NICU Resident Expectations and Tips
General Unit Information
I. Welcome to the NICU! This is an intensive care unit and we care for babies with a wide range of conditions and severity of illnesses. Be prepared to work hard and be flexible.
II. The NICU has 46 beds, including 2 isolation rooms.
III. Patient care is provided by neonatologists, fellows, pediatric and family medicine residents, hospitalist(s), neonatal nurse practitioners, nurses, case managers, social workers, occupational therapists, respiratory therapists, and numerous other ancillary health care personnel.
IV. There is always a fellow and an attending neonatologist on service. We have 24/7 in-house fellow or attending coverage for the NICU.
a. The neonatology fellow is an important resource for the NICU. In addition to supervising rounds/patient care, neonatology fellows take transport and consult calls, consult antepartum patients on Labor & Delivery, and have additional academic and research responsibilities. As you would on any other service, unless there is an urgent problem, evaluate the patient yourself, formulate an initial assessment and plan and then discuss with the fellow and/or attending. Interns should go to the senior resident or advanced practitioner with questions first. If you are ever worried about a baby acutely, however, do not hesitate to ask the fellow or attending for help.
V. Both 3rd and 4th year medical students frequently rotate through the NICU. You will be serving as supervisors for the medical students. Please review the assessment and plans for patients you share with them before rounds.
VI. The Family Medicine service can admit babies to the NICU with consultation from the attending neonatologist.
Hand Hygiene and Infection Control
I. Neonates are inherently immunocompromised. Meticulous hand hygiene is the most important aspect of nosocomial infection prevention.
II. Please remove all jewelry from hands and wrists when on the unit.
III. Thoroughly wash your hands at the beginning of your shift by scrubbing at a designated hand wash sink.
IV. Prior to touching ANY patient care area or patient, wash your hands or use the antiseptic hand solution (Avagard) stationed throughout each pod, and then put on gloves. Perform hand hygiene again after removing gloves. The monitors and IV pumps are not “clean”; you need to wash between touching these objects and touching the babies.
V. White coats should not be worn in the NICU. Sleeves need to be rolled up above the elbows when examining patients.
VI. Do not lean on incubators, warmers or cribs.
VII. Please be an advocate for the patients and remind other providers about our hand washing policies when necessary.
VIII. Each baby has a dedicated stethoscope at the bedside. Do not use your own stethoscope or carry them between beds.
Deliveries
I. At least one member of the resident team is expected to attend every delivery. This rotation is your opportunity during residency to obtain experience with NRP.
II. The Neonatal Resuscitation Team (NRT) is comprised of providers, specially trained nurses, and respiratory therapists. Members of the NRT carry resuscitation pagers used by Labor & Delivery to alert us when we need to attend a delivery.
III. Level of acuity: The page will have a number (1,2,3, or 5) followed by a room number for 12-C.
a. Level 1 is the lowest acuity and is called for >36 wks gestation, Cesarean delivery for failure to progress, mother on magnesium, or instrumented delivery. A resident should attend. 1st year residents should attend several deliveries with supervision prior to attending independently.
b. Level 2 is for “moderate risk” deliveries, such as meconium stained amniotic fluid, 35 weeks gestation or above, fetal distress, twins, IUGR, oligo- or polyhydramnios, suspected abruption. A provider experienced in securing advanced airways needs to attend these deliveries (a fellow or AP member), but the resident should be the primary provider and proceed with the resuscitation with guidance.
c. Level 3 = “high risk” including 30-34 weeks gestation, severe IUGR, minor fetal anomalies. A fellow and AP member will be in attendance in addition to the resident.
d. Level 5- “highest risk” including <30 weeks gestation, triplets, major fetal anomalies, severe fetal distress (e.g. cord prolapse, uterine rupture, loss of fetal heart tones/severe fetal bradycardia). In addition to the staff for the above deliveries, an attending will also be notified.
e. Unscheduled c-sections:
i. Yellow: will occur in >30 minutes, will page the resus pager again according to above levels
ii. Orange: will occur within 30 minutes, will page the resus pager again according to above levels
iii. Red: emergency c-section, delivery happening immediately.
IV. Codes: Each delivery room and the resuscitation suite has a code blue button near the warmer. This button is used by Labor & Delivery when a baby is unexpectedly in distress. Residents are encouraged also to call a code if a baby is not responding to initial NRP interventions. The code results in an overhead alarm as well as a code page to the resus pagers and will alert additional providers and nurses in the NICU to come assist.
V. All deliveries attended require a delivery note in the chart. This can be part of the H&P for babies admitted to the NICU. Babies not admitted to the NICU should have a brief progress note documenting the delivery. This should include the reason why NRT presence was requested, basic background information on the neonate and any relevant maternal history, the steps of NRP required, and any plans including disposition of the infant.
VI. If you find yourself needing extra training in resuscitation please contact Dr. Platteau at platteau@ohsu.edu or discuss with the neonatology fellow on service.
Teaching
I. Learning takes place in several forms in the NICU. On day shift, you can expect teaching from the fellow and attendings during rounds at the bedside in addition to learning from direct patient care, delivery experience, and procedures.
II. On your first few days on service, we will schedule a talk from the dietitians about neonatal nutrition. If one has not been scheduled for you, please reach out to the rotation director or the dietitians.
III. Interns should spend an hour with the resuscitation nurse on one of your nights on service when there is a senior resident on with you. After evening sign out, check in with the resus nurse and shadow them for an hour as they review deliveries and go through equipment check (~7pm-8pm).
IV. On night shift, the fellow will do additional teaching either at bedside or via didactics.
V. If you don’t understand a disease process, diagnosis, or treatment plan rationale, please ask.
VI. Attending your program noon conference is a priority. Please make sure the advanced practitioners know when you are leaving the unit for conference. As with any ICU rotation, critically ill patients or high risk deliveries may prevent you from attending conference sometimes but it is our hope that those scenarios are important learning opportunities.
VII. Review articles are available regarding common conditions in neonates. NeoReviews, which is available to you through OHSU, is another good resource.
Rounds
I. Morning sign-out begins at 7am every day. You may need to begin pre-rounding earlier in order to be prepared for rounds, depending on the census.
II. Daily rounds start promptly at 9am in the attending office. We will review xrays first, then start walk rounds by 9:15AM. Please have at least one computer on wheels available to help put in orders and pull up xrays. It is expected you have looked at your patient’s imaging studies prior to rounds.
III. Tell the fellow before rounds begin if you have clinic, didactics, or any other reason to be off the unit in the afternoon. You will need to sign out your patients before you leave to the remaining resident(s) and/or practitioners.
IV. Rounds on the cardiac patients in the NICU are done in conjunction with the Pediatric Cardiology team. When their team arrives on the unit, we will proceed with rounds on cardiology patients, then return to where rounds had been occurring to resume rounds on the non-cardiology patients.
V. Try to be as efficient as possible on rounds. Avoid repeating yourself. Here is an outline for how your presentation should be structured:
a. Patient ID “Sally is a 4 day old corrected to 29 5/7 days GA with primary problems being RDS and feeding intolerance”
b. Interval events- notable events since yesterday’s rounds. Include # of apnea/bradycardia spells requiring intervention. Other pertinent events include procedures (e.g. chest tube placed for recurrent pneumothorax) and changes in clinical status (e.g. extubated to CPAP; hypothermic prompting rule out sepsis, etc).
c. Vital signs- report only pertinent values to the particular patient and new trends or abnormalities
d. Respiratory support. Include ventilator settings, amount of CPAP/HHFNC and range of FiO2 in past 24 hrs.
e. Weight. Give the weight change from yesterday, % down from BW until they have regained.
f. Fluids and nutrition. State total fluids in mL/kg/day, what they are receiving (e.g. TPN of 14/3/2 at 60 mL/kg/day plus EMM at 80 mL/kg/day), and total kcal/kg/day. Give the type of fortification and additives to feeds.
g. Exam. Include pertinent positives and negatives as well as any changes from prior.
h. Labs and imaging. New results, including most recent blood gas. No need to read the entire CMP results, just mention the abnormal and/or pertinent values (e.g. CMP was notable for sodium stable at 132 and bilirubin of 11).
i. Assessment and Plans. Don’t repeat the day of life and cga here. Only focus on what is pertinent for the day. The rest can stay in your note.
- Go by systems: FEN/GI (what are you going to change in the TPN and/or feeds?), respiratory/apnea, CV, jaundice, Renal, ID, heme, neuro (next head US?), healthcare maintenance (immunizations) and follow-ups
j. PCP: Try to identify the PCP for your patients as soon as possible after admission. We send them weekly updates, and sometimes there are insurance issues so do not wait until the day before discharge to determine the PCP.
Documentation
I. Each patient should have an H&P, daily progress note, or discharge summary each day. If a patient is discharging, you do not need to do a progress note that day.
II. Notes should be completed on the day of service with goal for progress notes to be signed for attending attestation by 2pm.
a. Use spell check if you need to (isolette has 2 t's, for example). Remember your note is the main legal and medical daily document in the chart.
b. Only use exact dates for time reference (don't put "today", "yesterday" "Monday," "next week". e.g.: rpt HUS on 4/29.) Because we write a new interval history every day, that's the one place we will use "this morning" or "last night".
III. Discharge summaries should be signed the day of discharge so they can be routed to the PCP prior to the patient’s followup appointment.
a. Update the baby’s hospital course regularly. Patient assignments may change day-to-day, so even if you’re not the main provider for the patient, please update the hospital course any time your schedule allows.
IV. A procedure note should be written for any procedures performed or attempted, such as umbilical line placement, intubation, and lumbar puncture. The dotphrases for NICU procedures starts with .nicuproc_____.
V. All deliveries attended require a delivery room note in the chart to document what steps of NRP were required. This can be part of the H&P for babies admitted to the NICU. Babies not admitted to the NICU should have a brief progress note documenting the delivery.
Orders
I. When you write an order, notify the bedside nurse unless it was already discussed on morning rounds. The NICU nurses are busy and may not be able to check Epic in time to see an urgent order.
II. The radiology tech needs to be paged to come to the unit for x-rays ordered after 10:30pm. Often times the RNs or HUC will help with this.
III. The EKG tech needs to be paged during off hours to come to the unit for any EKG ordered. The HUC will help with this.
IV. The primary NICU team should be writing orders for all babies on the NICU service. If we are jointly managing a surgery patient with the Pediatric General Surgery team, it is expected to discuss the daily plan with them. You should expect to write fluid, TPN, lab, x-ray, and medication orders. There are times when it is more appropriate for that service to order a radiology study for coordination of care but be sure to confirm who will be writing the order.
V. The primary admission Order sets you will be using are:
Ped: NICU: Admission
Ped: NICU: Micropreemie Admission (for infants <30 wks GA)
VI. Other helpful Order sets:
NICU: Congenital heart disease
NICU: Cooling protocol
NICU: Electrolyte replacement
NICU: Fluid orders with amino acids
NICU: Gastroschisis
NICU: Hyperbilirubinemia
NICU: Immunizations
NICU: Neural tube defect
NICU: Post-op pain and agitation management
NICU: ROP: Bedside exam
NICU: ROP: Laser procedure
NICU: Surgical orders
NICU: Ventilator management
PED: NICU: Suspected sepsis
PED: Blood Product Transfusion
PED: Parental Nutrition: Neonatal
VII. Please use the Transfer Patient navigator when sending a baby to the MBU or transferring from the MBU to the NICU.
VIII. TPN orders.
a. TPN orders are due at 2PM every day.
b. To initiate TPN, go to the orderset Ped: Parenteral Nutrition: Neonatal.
c. To reorder TPN for the day (without or without changes), find the TPN orders and click “reorder”. Make changes to the TPN components as you would like. DO NOT click “modify” unless you want to discontinue the current TPN immediately.
d. Please ask for help from the NICU dietitians, your seniors, or members of the AP team if you have questions on how to write TPN.
Night Shift
I. Evening sign-out begins at 6pm in the AP office. The resident team signs out first on odd calendar days and the NP team signs out first on even calendar days.
II. Be prepared for night rounds at approximately 9pm. These are informal rounds in which the nighttime providers check in with each nurse about all patients, perform pertinent exams, and review orders and plans for the night. (E.g. confirm NPO time in pre-op patients, review morning lab orders, etc.)
III. Night shift is a time for patient care and learning. As we have transitioned to shift-work in the NICU, the expectation is now that the night team will be up all night to perform patient care and to learn. The night-time intern is the first call for babies in the MBU. Common calls include bilirubin levels, tachypnea, feeding issues, and temperature instability. Please answer the page, assess the baby if indicated, and discuss with the senior resident. If you think a baby needs to be admitted to the NICU, discuss with the fellow.
IV. Please alert the MBU resident before leaving in the morning to any babies that were observed in the NICU during the night or for whom there are other concerns.
Other helpful tips:
Go to the bridge to find in depth consensus documents on the most frequently encountered neonatal issues.
Fluid Calculations
I. We use a baby’s birth weight for calculations until they have regained it.
II. Total Fluids: Obtain total fluids In from I/O flowsheet in Epic. Divide total fluid volume by the reference weight (BW or daily wt) to give mL/kg/day.
a. Note: Trophic enteral feeds (<20mL/kg/day) are not included in total fluids
III. Calories: Present total kcal/kg/day in your note and on rounds
a. HA: [ total volume (ml) x dextrose conc (#/100) x 3.4 kcal/g dextrose ] / wt (kg)
b. Lipids: [total volume (ml) x 2 ] / wt (kg)
c. Feeds: [total volume (ml) / 30 ml/oz ] x [formula (kcal/oz) / wt (kg) ]
Feedings
I. There are a number of options for feeding babies in the NICU. The following are general guidelines. Use the NICU feeding order panel to order these various feeding options.
II. Human Milk:
a. Expressed Mother’s Milk (EMM): In early every case this is the best nutrition, best supports the immature immune system, and is important for preventing necrotizing enterocolitis. Our nurses and lactation specialists are available to help mothers with pumping and breastfeeding when the baby is mature enough. Premature infants usually need fortification added to get enough calcium, phosphorous, protein, and kcals.
b. Donor Breast Milk (DBM): We have access to donated, banked human milk via the Northwest Mothers Milk Bank. Women have been screened before donating and the milk is pasteurized. Some immunologic factors are lost during pasteurization but DBM has been shown to decrease risk of NEC compared with formula. DBM may be offered for neonates without available EMM or as a bridge to EMM supply and any of the following scenarios: <34 weeks gestation; babies with gastrointestinal disorders (e.g. gastroschisis, history of NEC); babies with cardiovascular disease, particularly those with risk of compromised systemic circulation (e.g. coarctation of the aorta); other ill infants as determined by the team. Assent must be obtained to order DBM and can be done by any member of the care team. Forms are at the HUC desk and are included in the admission packet.
III. Fortification:
a. Most premature infants will need additives to their milk to ensure adequate growth (remember goal is 10-15g/kg/day weight gain). There are several options, and we take into account the gestational age and how close a baby is to going home in order to decide.
b. Prolacta: human milk based fortifier. This is added to EMM/DBM to make feeds up to 30kcal. We reserve this for our smallest preemies.
c. Human Milk Fortifier (HMF): Similac HMF (SHMF) is the formulation available at OHSU. This is a cow milk based fortifier (with hydrolyzed protein) added to EMM/DBM and can be mixed to 22kcal/oz or 24 kcal/oz. They are not available as an outpatient, so babies need to be changed to a formula fortifier prior to discharge (e.g. Neosure).
d. Formula fortification: formula (powder or liquid) can be added to EMM/DBM for additional calories. Neosure is the formula of choice in the NICU for premature infants prior to discharge (in place of HFM), or added in with HMF to make 27 kcal/oz or 30 kcal/oz concentration. Term infants requiring more concentrated feeds can have their milk fortified with term formula (Similac advance) to 22, 24, 27 or 30 kcal/oz.
e. Protein Supplementation: Infants <1kg need additional protein even on full fortified feeds.
IV. Formulas:
a. There are a number of commercial formulas available. Again, breast milk is the preferred source of nutrition.
b. Preterm: Similac Special Care (SSC) is preferred as first line formula for premature infants (again can be mixed to several difference concentrations) but is not readily available for outpatients. Neosure is available for outpatient, so we switch to this a couple of days before discharge. Babies who are late preterm (and do not have EMM available) can start with Neosure.
c. Term: the standard formula is Similac Advance, though Similac Sensitive, hydrolyzed, and elemental formulas are also available.
V. Feeding Schedules:
a. Babies are typically set on a q3h feed schedule (PO+NG) until they are taking full feeds PO. Total fluids are typically set to 140-160ml/kg/day. Once they’re taking close to full volume PO feeds, babies can be liberalized to an ad lib feeding with a minimum, calculated out to 12h shifts (shift minimum). Daily minimums are typically 120-140ml/kg/day.
b. Trophic feeds (small volume, <20 mL/kg/day) are often started for premature infants to prime their intestine/induce maturation in preparation for higher volume feedings. It is crucial that these are with human milk (preferably mother’s colostrum) in the most immature patients.
c. Premature infants tend to have hypomotility and are additionally at risk for necrotizing enterocolitis. We advance their feeds cautiously. Please follow the feeding protocol which can be found on the NICU bridge website (bridge.ohsu.edu).
Discharge planning
I. NICU routine screening exams
a. ROP exams: BW <1.5kg or GA <31wks, first exam at 4 weeks of life or at 31 weeks CGA, whichever is later
b. Carseat test: BW <2.5kg or GA <37wks
c. CCHD: pre and post-ductal sats. Not needed if echo completed.
d. Newborn Screens: order via admissions ordersets.
i. Standard: #1 at 24hrs, #2 at 10-14 days old.
ii. Triplicate: #1 at 24hrs, #2 at 10-14 days old, #3 at 28 days. Get the 1st newborn screen before any blood transfusions. Otherwise, do not get newborn screens before they're due. If patients are discharged before their #2 or #3 screens, send the screens home to be done at their PCP's office.
II. NICU education resources
a. Hospital 2 home class: 3hr free class for family members. Goes through infant care, CPR, safe sleep, carseats, etc. Sign up sheets are at front desk.
b. YourNICUbaby.com. Family can login using NICU account for various parent-centered education materials.
III. Immunizations
a. Generally follows standard CDC guidelines, though we don’t give rotavirus vaccines inpatient.
b. 1st Hep B dose delayed to 1 month for babies <2kg. Babies >2kg should have the Hep B vaccine as soon as possible after birth.
c. Parent assent needed for vaccines - no signatures required but discussion with parents must have occurred.
d. Use the NICU immunizations orderset to order vaccines
e. Some babies qualify to receive Synagis (pavalizumab) for RSV prophylaxis per AAP recommendations. If it is during RSV season, patients should be given their first dose prior to discharge. All patients who qualify should have note of this on their discharge summaries.
IV. PCP identification
a. PCPs will receive weekly updates on their patients.
b. All babies must have PCP appointments made and documented (with date and time) for discharge
c. A member of the team that knows the patient well should contact the PCPs around discharge to give verbal patient handoff. Please discuss who should do this on rounds.
V. Discharge resources
a. Arnette Kayhani is our case manager. She assists with insurance, outpatient equipment and supplies, helps with selecting PCP, and assists with overall discharge planning.
b. Kathleen Bartell (45631) can schedule outpatient ROP exams at casey eye.
c. A list of various scheduling pools is posted in the workrooms to use for scheduling outpatient appointments.
d. Multi-disciplinary team discusses patients nearing discharge (2 week list) to assist with discharge planning. There are bedside rounds on the 2 week list patients every Tuesday morning, and there are sit rounds with the multidisciplinary team on Mondays and Thursdays at 11:30 in 12B13 conference room. Resident participation is optional but welcome.