Intern Survival Guide:
NICU Edition
Outline
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Introduction
Schedules
Prep work
Division of labor
Where things are
When things happen
Crunching numbers
Rounding with the
attending
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IHI
Orders
Med Rounding
The DR/OR and
Admissions
Progress notes and
Updating the list
Discharges
Signing Out
Call
2
So you’re starting NICU…
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NICU is located on 8S – hang a right from
the elevators.
The resident call room is across from the
entrance. The code is 145 and the door
sticks. Keep trying. No one locked you out.
We promise.
Scrubs are cool to wear every day, but if
you’re wearing long sleeves under your
scrub top, make sure you can push them
above your elbows easily.
No eating or drinking at all on the unit.
There’s a break room to the left when you
walk in and a fridge in the call room.
3
Scheduling
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If there are only three residents on for the block, you
will follow a Q3 schedule.
If there are four residents on, you can decide amongst
yourselves if you want to be Q4 or have a nightfloat
week (one week sun night through thurs night, plus one
additional 24 Friday and 24 Saturday). Make sure to email the chiefs in advance to let them know.
There is no scheduled continuity clinic during the NICU
month.
The resident on call will be the designated “labor and
delivery” person and given the resident baby-baby pager
each day. That resident is the one who will go to all the
deliveries, so stay on your toes.
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Schedule Access
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To access your personal schedule, go to:
– New Innovations:
https://rms1.newinnov.com/Login/Login.aspx
– After logging in, hit
– View:
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Take a couple of hours one day and just
browse through new innovations. It does
take some getting used to.
5
Preparation
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If it’s July and NICU is your first rotation,
you’ll have a nice orientation during
orientation week and you can get sign-out
from the departing intern then.
If it’s not July, the day before the rotation
starts, make your way up to the NICU and
get sign-out from one of the interns. If
they’re really nice, they’ll show you around
and teach you how to do numbers.
If not, or if you’re still confused, just
continue reading this presentation.
6
Division of Labor
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NICU patients are divided into three teams, first by
color (red and green) and then by covering
practitioner (resident or NP). There is no NP on the
red team.
The NNPs are amazing so be really nice to them…
I’ve heard they like chocolate.
When you’re on call at night and over the weekend,
you’re responsible for all the resident babies, red
and green. It’s hard to know all of the opposite
team’s patients very well, since you don’t round on
them daily, but try to pay close attention to the
history and management of the patients on your
own team, even if they’re technically not “your
patients.” It really helps.
7
Where Things Are: The
Binders
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The big yellow (red team) and blue (green team)
binders will be your team’s filing cabinet.
Here is an overview of what’s inside:
– Yellow binder only:
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Rounding information
Tips, tricks and Suzanne’s “So you’re starting NICU”
document, also posted on fellinahole
Dictation template
– Blank daily flowsheets and progress notes
– Admission face sheets and H&P (for admission and
discharge) forms
– Ballard scoring (front) with growth curves (back)
– Current patient information separated neatly by handmade
dividers (using sticker pages).
– Recently discharged patient information – we keep them
8
for a few days.
Where Things Are:
Bedside Charts
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There are a couple things that are important to you
in the thin, blue bedside chart:
– Apnea/Brady log (usually right at the front.)
– IHI (we’ll get back to this later)
If you take a bedside chart out of a room, tell the
nurse. Even better, ask that nurse if he or she
minds that you take it. They’ll appreciate the
consideration.
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Where Things Are: Big
Red Charts
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The big red charts sit behind the clerk. Things that
will there that are important to you:
– Progress notes
– Consults
– Admission paperwork (after it’s done)
– DR/OR summary (in the OR section)
– Outside institution/lab information
All charts are thinned once a week. Old charts
can be found in the big filing cabinets where the
printer is, behind the clerk’s desk.
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Where Things Are:
Consents
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Mom is the consenting parental unit always unless there is a
CPS issue. Dad can never give consent.
There are a bunch you should get when the baby is first
admitted:
– NICU – give permission to be in the NICU
– JHACO – acknowledges we gave her info on privacy
– HepB – if baby is >2kg.
– Circ – if mom is interested.
They will either be clipped in the blue chart (usually when
patient is first admitted) or in the “consent” section of the red
chart. If the consents are in neither of those places, just ask
the clerk to print them out for you.
If you don’t get the consents right away, it’s fine. Moms will
usually visit when they recover, before they make the crosscountry trek to mother-baby. If they don’t, just grab the forms
and head over to L&D. Moms will want to know about what’s
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going on anyway, so it’s good chance to update them/ask
questions/get consents signed.
Where Things Are: Daily
Sign-Out
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The first computer right as you walk in is our
resident computer. Here you can find the
hard drive with the sign-outs… but only if
you have access.
Make sure to e-mail Peter Vecere and ask
him for UHMC Peds Access. This will give
you access to floor sign-outs, too.
The pediatrics drive is on the desktop. The
most recent sign-out will be in the “NICU”
folder.
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Where Things Are: Misc
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Optho Book – On top of the cabinet that houses
the green team red charts.
Extra stickers
– Big Red Charts
– Thin Blue Charts
– “Red” or “Green” (literally labeled as such) clerk’s binder,
usually on the inside left corner of the desk.
– In the large reservoir of what clerks can print for you. I’ve
heard they like chocolate.
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Linens – To the left, on the way out of the NICU by
room 114.
Med room – code is 2001.
Ophthalmoscope – Usually in the med room.
Vaccine Information Sheets (VIS) – Lower right 13
desk drawer in front of room 112.
When Things Happen
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Weekly Labs (H&H, retic) – Order on
Tuesday for AM Wednesday
Weekly length, head circumference
– Order on Tuesday for AM Wednesday
– Don’t forget to plot these!
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Optho exams – Wednesday
Fluid, drip, TPN renewal – Every day
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When Things Happen TPN
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TPN must be ordered before 11 every day.
Fellows like to order TPN before rounding, so
try to catch them so you can do it together.
For more information on formulas and other
things to know when ordering TPN, review the
NICU manual @
http://www.fellinahole.com/chartdata/nicu/tpn.
html
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A Day in the Life
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7am is the usual designated start time. Throw your
things in the call room and come on in.
You should pull your sleeves up and scrub, surgical
style, at the big sink when you get here.
Find the resident who was on call and get sign-out
from the night before. That should include all labs
and films that were designated for the AM, which
makes your life a LOT easier.
The most senior resident on your team will
distribute the overnight admissions – don’t forget to
get vitals on the new admission, too.
All Is and Os are computerized now, so find one
and start your numbers.
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Crunching Numbers
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Your most important
job in the morning is to
get the “numbers” on
all of your patients.
For the first week of
life (days 1 through 7),
all numbers are based
on birth weight.
Starting day 8, you can
use actual weight.
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Crunching more
numbers…
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It’s important to keep meds
and levels updated. Be
sure, even if your kid has
been off caffeine for a
week, a covering attending
will want to know the last
caffeine level. You don’t
have to list ALL of the result
as you make sheets, just
the most recent.
The last big box is for the
plan, which you can scribble
in on rounds. (We’ll get to
rounds later.)
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Back to crunching
numbers…
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Little kids need fluids. Their total fluids will
vary with their gestational age and issues.
Most kids will either start with 100cc/kg/day
(little kids) or 80cc/kg/day (bigger) and we’ll
work up from there.
You care about two things
– 1. How many cc/kg/day the baby is getting
– 2. How many kilocals/kg/day the baby is getting
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Kids get fluids in 2 ways: parenteral and
enteral. Enteral is easy so we’ll do that first.
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Calculating PO fluids
Total fluid volume
cc/kg/day = total ccs PO
weight in kg
Total calories
 The number designation of formula
(E20, S24) denotes how many kcals
per ounce a formula has.
 You don’t really care about ounces,
though. You want ccs. And there
are 30cc to an ounce.
 Therefore the general rule is that:
kcals in formula = kcals/cc
30cc
 It then follows that:
Hints, tips and tricks
• rice is 1 kcal/cc
• breast milk is 20kcal/30cc or
0.67kcal/cc
kcals/kg/day = kcals/cc x total cc PO
weight in kg
20
Our running total
PO
cc/kg/day
kcal/kg/day
PE24 (215cc) / 1.85kg =
116
(215cc)(0.8) / 1.85kg =
93
116
93
CHO
Protein
Lipids
Other
Total
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TPN: Dextrose
Total fluid volume
cc/kg/day = total cc TPN
weight in kg
Total calories
• First you need to figure out how
many kcals per cc your dextrose is
giving you. This formula is true
for all formulations of TPN:
(% dextrose)(3.4) = kcals/cc
100
Hints, tips and tricks
• Lipids don’t count in the total
volume of TPN (they run in their
own bag) but protein does!
Therefore, protein adds additional
calories without adding additional
fluid.
kcals/kg/day = (kcals/cc)(cc TPN)
weight in kg
22
Our running total
cc/kg/day
kcal/kg/day
PO
PE24 (215cc) / 1.85kg =
116
(215cc)(0.8) / 1.85kg =
93
CHO
D10 (81.8cc) / 1.85kg =
44
(81.8cc)(0.34) / 1.85kg =
15
160
108
Protein
Lipids
Other
Total
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TPN: Protein
Total fluid volume
0
Total calories
• First you need to go to the TPN bag itself
and note two things: order volume and
trophamine (protein).
• Amount of protein is dependent on how
much is in the bag and how much of the
bag the baby got.
Kcals/kg/day = Trophamine x total cc TPN x
order volume
4
weight in kg
24
Our running total
cc/kg/day
kcal/kg/day
PO
PE24 (215cc) / 1.85kg =
116
(215cc)(0.8) / 1.85kg =
93
CHO
D10 (81.8cc) / 1.85kg =
44
(81.8cc)(0.34) / 1.85kg =
15
0
(14/500) x 81.8 x (4/1.85) =
Protein
5
Lipids
Other
Total
160
113
25
TPN: Lipids
Total fluid volume
cc/kg/day = total cc lipids
weight in kg
Total calories
• First you need to figure out how
many kcals per cc your lipids are
giving you. This formula is simply:
kcals/kg/day = (2)(cc of lipids)
weight in kg
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Our running total
cc/kg/day
kcal/kg/day
PO
PE24 (215cc) / 1.85kg =
116
(215cc)(0.8) / 1.85kg =
93
CHO
D10 (81.8cc) / 1.85kg =
44
(81.8cc)(0.34) / 1.85kg =
15
0
(14/500) x 81.8 x (4/1.85) =
Protein
Lipids
5
IL (44cc) / 1.85 kg =
22
(44cc)(2) / 1.85kg =
46
Other
Total
183
159
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Numbers: Other
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Anything dripping in (morphine, sodium
acetate, etc.) counts for cc/kg/day but
provides no calories.
Anything being put out (ie OG, repogel)
must be subtracted from cc/kg/day
For those who are a little more high-tech,
check out the NICU calculator (peds drive 
NICU folder  NICU documents.)
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Rounding with the
Attending
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It’s usually attending dependent, but expect to round every
day at around 9am. (Dr. Shah is the exception – he rounds
early and fast, so stay on your toes!)
Attendings will either round with residents and NNPs
altogether or separately. It varies from attending to attending
and day to day.
Verbal presentations follow the flow sheet exactly:
– One liner on history – “Ex 331/7-weeker with resolving RDS,
status post ROS.”
– DOL, weight, and weight change
– What the baby is feeding (PE24), how much (27.5-30cc), how
often (Q3H) and route (nipple vs. NG tube).
– Then just read off the remaining columns (cc/kg/day,
kcal/kg/day, UOP, stools) all the way to As/Bs.
– A good order for the rest is meds  new labs  new films/other
studies  other changes made the day before  any new
developments.
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– As the plan is discussed, write it in the lower right box.
IHI/Daily Goals
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While you’re presenting,
another resident (or the fellow)
will get the “IHI” form – NICU
daily goals and plan of care –
from it’s section in the thin blue
bedside chart.
Nurses fill out the left side, it’s
our job to fill out the right side.
Everyone present at the bedside
should sign the form on page 2.
There is an “IHI fellow” who will
round on patients under 1500g.
The nurses read off the IHI and
a more in-depth interdisciplinary
discussion takes place. Formal
“IHI rounds” usually happen
before attending rounds. You
should attend if the IHI rounds
are happening on one of your
patients.
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Orders
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During rounds, while you’re presenting, another resident (or
fellow) will usually put in orders for you depending on what is
being discussed. Don’t forget to come back and check to
make sure those orders were actually picked up. People get
busy.
Even though orders are written on the computer, you have to
show all (virtual) math. When ordering Zantac, you should
pick the “2mg/kg” option so the computer does the math for
you.
Zantac (2mg/kg/day)(1.04kg) = 2.08; round to 2mg PO
Qday.
Every time TPN is sent from pharmacy (usually 3 in the
afternoon every day) you’ll need to set a rate.
Make sure to tell a nurse when you’ve written an order. It
should pop up on her task list but you never know.
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Order Rewrites
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CPOE makes order rewrites obsolete.
However, it is prudent and necessary
to check every order every day to
make sure that you haven’t hit a
soft stop and it hasn’t fallen off of the
nurse’s MAR.
Compare active orders to what the
patient should be getting to exactly
what the patient is getting (MAR)
every day.
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Med Rounding
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The NICU has
standardized drug
dosing by instituting
rounding policies on
specific drugs.
These are also found in
the front of red team’s
yellow binder.
Highlighted drugs are
very commonly
prescribed, so if you’re
going to remember any
off the cuff, it’s these.
Adapted from NICU Manual, Annie Rohan, NNP
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The Delivery Room and
Operating Room
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Go to lots of deliveries. You’ll learn a lot and staff
is very eager to each.
At first, you’ll attend all deliveries with someone
more experienced – a fellow or an NP.
After attending three, you’re certified to go to
uncomplicated deliveries alone (just you and the DR
nurse). However, if you’re uncomfortable attending
a delivery by yourself, someone will always be
there to go with you. You’re never truly alone.
You’ll never go to complicated deliveries on your
own.
When you go to the OR and you’re the one
catching the baby, you’ll have to scrub in surgical
style. Don’t forget your hat and mask.
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Responsibilities in the
DR/OR
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The attendings, NPs and fellows will go over DR/OR
proceedings in more depth. However, be aware
that your primary role is airway – which puts you at
the head of the radiant warmer. Review your
neonatal resuscitation handbook – it helps.
You also will need to assign the APGAR score and
write a very brief note in the birth report detailing
why you were called and what kind of resuscitation
took place (even if it was only stimulation and bulb
suction.)
If the baby comes back to the NICU with you, take
the yellow copy of the birth report. If the baby
goes to newborn, you don’t have to take anything
back with you.
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NICU Admission Criteria
From from NICU Manual, Kathy Gilsbach, RN, MS
The following babies must be admitted to NICU:
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Babies less than 351/7 weeks as documented on the yellow 'Birth
Record' and less than 2000 gms. These babies must come to the NICU
for a period of observation to ensure normal transition.
Infants >35 weeks have no specific length of time they must stay in the
NICU. In general the transition period should be no less than 4 hours.
Infants <35 weeks must stay for a minimum of 24 hours of
cardiopulmonary monitoring.
Any baby who shows signs of delayed transition/physiologic instability,
including tachypnea, grunting, flaring, etc., should come to NICU for
observation and monitoring, but as above, do not have to stay once
normal transition is ensured. Keep in mind that normal newborn nursery
has limited ability to monitor babies, both in terms of equipment and staff.
5 minute APGAR < 6
Hypoglycemia
Maternal temp >100.4 and/or any documented diagnosis of
chorioamnionitis
Infants who receive naloxone (Narcan) at delivery (for 24 hrs of
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monitoring)
NICU Admission Orders
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When a baby is admitted to the NICU, after he or she
is stabilized, the most important thing to do is write
the admission orders – now made super simple with
CPOE’s power plans. Pick the one that fits your
patient the best (“Full term infant with congenital
heart disease”) and all you have to do is check what
you want.
One of the fellows or one of the fabulous respiratory
therapists will be on hand to show you how they like
to do respiratory orders. For every change in vent
settings or mode of support, you’ll have to write a new
order.
Unlike on the floor, residents don’t write an admission
note. The fellow will take care of that. However, that
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doesn’t mean you don’t have work to do.
Admission Paperwork:
Important Info to Know
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Maternal History
– Mom’s chart/Mom herself (best)
– The CIS system
 The computer closest to the clinicians room with the rolly mouse is the CIS
computer. Your login is whatever you use to check your mail (ie LSmith)
and the password is “baby.”
 Select the mom that you’re interested in and surf around to see what you
can find.
 It will, at the very least, have her age, her parity notation and her prenatal
labs.
 How to: security  login  select a patient
– Powerchart/Eclipsys
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Birth History
– Birth report – yellow copy
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Vitals
– The Nurses’ Admission packet will detail the initial vitals and their physical.
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Blood Type/Antibody Information
– Cord Blood pH – Mom’s Powerchart under “Last 48 hours” tab
– Baby’s blood type/antibody – Baby’s Powerchart ONLY if cord blood 38is
released
Admission Paperwork:
Your Arsenal
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The following goes into the appropriate
team’s binder:
– Divider: Take a sheet of stickers and make a
divider.
– Facesheet
– Flowsheet
– Ballard Score and Growth Chart
– Initial Physical
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Attending must sign this
Add the new patient to the appropriate
team list.
Don’t forget to consent the mom.
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The Daily Grind: Progress
Notes and Updating the List
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Progress Notes
– There are post-call days, lecture days, etc. that make
note-writing difficult, but do the best you can.
– Examine your babies every day regardless of how
busy it is. Try to coordinate your exam with “handson” nursing so you don’t disturb the baby too much.
Updating the list
– If you’re not the person on call, you should update
the list before you leave. A good habit to have is to
update the list twice – once after rounds and once
before you leave.
– If you’re the person on call, you’ll end up updating
the list a hundred times. It’s inevitable.
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Discharge Checklist
 Discharge Summary
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In thin blue bedside chart or have the clerk print one
Fill in all pertinent info and all newborn screens done (not just the most recent)
Fill in ALL follow-up appointments with the name of the physician, phone number and
time-frame.
Attendings must sign the bottom
 Discharge Physical

Same form as admission physical, just circle “discharge” on top.
No need to fill out the history section again, just cross it out and write “see admission
physical.”
Once again, check for a red reflex and have the attending sign at the bottom.

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The pediatricians appreciate a heads up about the patients before they are seen.
Call the PMD and give a brief history.
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Write the dictation confirmation number on the facesheet
Move the patient’s paperwork from the “admission” section of your binder to the
“discharge” section.
Remove the patient from the list.

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 Informing the PMD
 Discharge Orders
 Dictation and Beyond
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Signing Out
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If you’re not on call, you should be able to sign out
to the on-call resident as early as 3pm, as long as
all your work is done and there’s nothing else going
on.
Update the list and give the on-call resident a copy.
Make sure to sign-out anything pending overnight
and for the AM.
If the on-call resident is on a different team, it’s
probably prudent to give a little background on
your patients, especially new ones (admitted in the
last 3 days).
There is no “formal” sign out. Just find the on-call
resident and ask if he or she minds you signing out.
Remember to also sign out your patients to a
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teammate before you leave for clinic.
Call: Weeknights
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Weeknights
– You’re in charge of all the red and green
resident babies from sign-out until 7am the next
morning.
– There will be an attending, an NNP and a fellow
on with you at night. However, you’re first in
line if there’s an issue with a resident baby – the
call will come to you.
– You and the NNP will alternate delivery and
admission responsibilities.
– You should wake up early enough in the
morning to get all of the pending labs, update
the list and do all of your numbers before the
rest of the team gets there at 7am.
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Call: Weekends
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Friday
– Same as weeknights, except before signing out to the
resident on Saturday morning, you should do all the
numbers for every patient on your team.
Saturday
– Saturday is the most labor intensive day.
– Saturday morning, you’ll have to do the numbers for the
patients that the Friday night resident didn’t take care of.
– Then, on Sunday morning, you should do the numbers for
every patient on your team, as well as getting the labs,
updating the list, etc.
Sunday
– Sunday morning numbers for patients the Saturday
resident didn’t do.
– Monday morning, you can just do your own patients’
numbers.
44