Children’s Hospitals and Clinics of Minnesota NICU - St. Paul Campus
CHAPTERS
1. Introduction
2. Respiratory Management
3. Fluid-Electrolytes-Nutrition
4. Pharmacology
5. Discharge Information
6. Clinical
CHAPTER 1. GENERAL INTRODUCTION FOR RESIDENTS
I. Introduction
II. Goals of Resident Rotation
III. Careteam Roles
IV. Rounds
V. Resident On-Call/Weekend Expectations
VI. Neonatology On-Call
VII. Notes
VIII. Consultations
IX. Conferences
X. Supplemental curriculum
XI. Infection Control
XII. Miscellaneous NICU Information
I. INTRODUCTION
Welcome to the NICU at Children’s Hospitals and Clinics of Minnesota, St. Paul
Campus. We are a regional perinatal center serving primarily the greater St.
Paul area, as well as western Wisconsin. Although most of our babies are
delivered at United/Children’s Perinatal Center, about 15% of our babies are
transported in from other hospitals. We provide level II and level III neonatal
diagnostic and supportive care including mechanical ventilation, high frequency
ventilation, nitric oxide therapy and pediatric surgery. This does not include
ECMO; for this therapy, patients are referred to the NICU at the Minneapolis campus. In
addition, we are offer a regional Infant Apnea Program and staff the NICU
developmental Follow-Up Clinic.
II. GOALS OF RESIDENT ROTATION
1. Understand pathophysiology and treatment of common newborn diseases;
2. Develop procedural skills in newborn resuscitation and emergency
intervention;
3. Recognize clinical and laboratory signs of a sick newborn and develop
appropriate treatment plans;
4. Recognize common congenital malformations and syndromes;
5. Identify high-risk obstetrical factors.
6. Understand normal newborn physiology and examination findings.
III. RESIDENT ROTATION OBJECTIVES
A. Patient Care
1. Gather essential and accurate information regarding patients for daily
rounds
2. Make informed clinical decisions about diagnostic and therapeutic
interventions based on patient information and preferences, upt-to-date
scientific evidence, and clinical judgment (in consultation with the
attending neonatologist or neonatology fellow).
3. Develop and carry out patient management plans in daily rounds with
attending neonatologist and neonatology fellow.
4. Counsel and educate patient families.
5. Use information technology to support patient care decisions and patient
education.
6. Perform competently all medical and invasive procedures considered
essential for Level II Nursery care including newborn resuscitation,
endotracheal intubation, umbilical artery and vein catheterization, and
lumbar puncture.
7. Provide health care services aimed at preventing health problems or
maintaining health in the Level-II Nursery setting, including anticipatory
guidance and teaching for parents.
8. Work effectively with a multidisciplinary team of NICU professionals to
provide patient-and family-centered care.
B. Medical Knowledge
1. Demonstrate an investigatory and analytic thinking approach to clinical
situations.
2. Utilize core reading list, online media, and self-assessment tools provided
at course website to develop core knowledge base for the practice of Level
II Nursery care and management of common neonatal problems and
conditions as described below:
a. Recognize features of prematurity, common minor and major
anomalies and birth defects, in contrast to normal newborn exam
findings.
b. Recognize special nutritional needs of the sick or preterm infant.
c. Understand benefits of breast milk and breastfeeding.
d. Recognize signs of feeding intolerance and intestinal obstruction
and provide appropriate intervention.
e. Understand the importance of neonatal jaundice and its timely
evaluation and treatment.
f. Describe the impact of maternal diabetes on the physiology of
the fetus and newborn infant.
g. Identify and manage common respiratory problems such as
respiratory distress syndrome (RDS), transient tachypnea of the
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newborn (TTN), pneumonia, meconium aspiration, and
pneumothorax.
Recognize the signs and symptoms of congenital heart disease.
Describe the epidemiology, signs and symptoms, and
management of early- and late-onset neonatal sepsis.
Describe the etiology and first line management of neonatal
seizures.
Understand the clinical associations and management of apnea of
prematurity and other forms of newborn apnea as well as sudden
infant death syndrome (SIDS).
List newborn emergencies commonly encountered in the first
month of life and describe typical management of each.
Describe the correct technique for the placement of umbilical
catheters, endotracheal intubation, and lumbar puncture.
C. Communication Skills
1. Make daily contact with each patient family to create and sustain a
therapeutic and ethically sound relationship.
2. Use effective listening skills and elicit and provide information using
effective nonverbal, explanatory, questioning and writing skills.
3. Work effectively with others as a member of the health care team.
4. Facilitate learning of medical students.
D. Professionalism
1. Demonstrate respect, compassion, and integrity along with a
responsiveness to the needs of patients and society that supersedes selfinterest.
2. Demonstrate accountability for patient care.
3. Demonstrate a commitment to ethical principles pertaining to provision
or withholding of clinical care and confidentiality of patient information.
E. Systems-based Practice
1. Understand neonatal care within the larger context of the profession of
pediatrics and practice within a pediatric hospital and health care
community and effectively call upon available resources to optimize
value.
F. Practice-based Learning and Improvement
1. Continuously self-assess own patient care, appraisal and assimilation of
scientific evidence, and improvements in patient care.
III. ROLES
A. Fellow and Attending
In general, both the fellow and attending will make daily rounds on every patient. On
occasion, rounds will be under the direction of the fellow. No significant change in plans
made during rounds should be made without consultation with the fellow or attending.
The on-call fellow or attending should be notified of all admissions (day or night). The
fellow is available for supervision of all procedures during the daytime. There is an inhouse attending 24/7 that can provide supervision of all patient care and procedures.
B. Neonatal Nurse Practitioners
Neonatal nurse practitioners are nurses with advanced education/training and
certification in neonatal resuscitation and stabilization. They function as care
providers in collaboration with staff physicians. They are skilled at NICU invasive
procedures. They are present 24 hours per day in-house and will assist you in attending
all deliveries, providing daily patient care and performing procedures as needed.
C. Pediatric Interns
Pediatric interns are MDs in their first year of pediatric specialty training. They will
provide care to patients in the NICU in collaboration with the fellow and staff physicians.
They will attend deliveries as well as perform common neonatal procedures during their
rotation in the NICU. Pediatric interns will work a 6 day/week rotation throughout their
NICU month, with no overnight call responsibilities. Each intern will always have one
day per week off, with the day off being scheduled on either Friday, Saturday, or Sunday.
They will sign-out their patient population at 5:30pm each day to the overnight on-call
coverage team.
D. Charge Nurses
The charge nurse decides where the infants will be placed in the NICU and makes the
assignments for RN staffing of the unit. The charge nurses are the “go-between” for
staff RNs and the providers. Charge nurses are extremely valuable in making sure
the day-to-day operations run smoothly.
E. Social Workers
Social workers provide support to families while their babies are hospitalized in
the NICU. In general, this includes emotional support as families adjust to
having an ill or premature baby, assisting with finding resources in the hospital
or community, and helping the families understand communications with the
medical team. NICU social workers are also committed to supporting staff
members, realizing that families’ experience is directly affected by the resiliency
of those caring for their baby.
F. Care Managers
Care managers coordinates the pre-discharge, discharge and follow-up experience for the
NICU patients. They deal with various insurance issues, and also is involved with predischarge education of families. They also coordinate transfers back to referral hospitals
when medically appropriate.
IV. ROUNDS AND PATIENT ASSINGMENT
Residents should arrive at the NICU each morning in time to be updated on their
patients by the previous on-call team, typically no later than 7:30am. It is expected that
you will have examined all patients who are critically ill prior to rounds, with any noncritical patients to be examined during rounds. Rounds commence at 8:15 am in the
Radiology Department where x-rays are reviewed prior to formal rounds in the NICU.
On weekends, rounds begin in the NICU typically between 7:30 and 8:00 am and X-ray.
rounds will take place once the on-call radiologist arrives.
Patients will be added to interns’ census at the discretion of the neonatologist/fellow from
appropriate patients admitted during the course of day and interns will have the
opportunity to participate in the admission process including H&P and admission orders.
Patients will also be assigned overnight after being admitted by the NNP for the intern to
assume care the following morning.
V. WEEKEND WORKLOAD EXPECTATIONS
Each intern will be assigned to work one day of the weekend, with the other day being
off. The weekend workday will function the same as the weekday, however, one intern
will cover ALL of the resident patient population since the other resident will have the
day off.
VI. DAILY NOTES
1. “SOAP” format progress notes should be written in the EMR each day your
patients.
2. A procedure note must be completed in the EMR for all procedures.
3. A “Change in Status” note must be written in the EMR any time a major change in
patient status occurs.
4. A Post-Op note must be completed in the EMR when a patient returns from
surgery.
VII. CONSULTATIONS
Only the attending neonatologist or fellow can decide to obtain a subspecialty
consult, and choose the designated consultant. Typically, the attending or fellow will
contact the consultant, however, this should be clarified during rounds regarding who will
be responsible for making the call to the consultant, as occasionally, residents are asked
to contact consultants.
VIII. CONSENT/PARENT NOTIFICATION
A general consent to treatment is signed by the parents upon admission to the NICU for
all admission and subsequent NICU treatments and procedures. However, out of
courtesy, all parents should be informed of any procedures that are happening to their
baby. Parents should be notified of any consults, major test results, or significant
changes in their infant’s condition. Parents should be informed prior to any blood
transfusion (PRBC, FFP, Platelets, etc). The transfusion order will ask if consent has
been obtained; once informed consent is obtained you do not need to obtain informed
consent for each transfusion (unless that is an issue with that family), but out of courtesy,
the family should still be informed that a transfusion will take place.
IX. CONFERENCES/DIDACTIC TEACHING SESSIONS
1. On the third Thursday of each month there is a Mortality Conference where all NICU
and delivery room deaths or adverse events will be discussed as well as review of all
autopsies with Pathology
2. The NICU Fellows will give several didactic lectures in the afternoons, after rounds,
on specific topics.
X. SUPPLEMENTAL EDUCATIONAL CURRICULUM
1. A 4-week educational reading series is posted on our website,
WWW.NEWBORNMED.COM, and it is the expectation that you read each
week’s assigned readings during your rotation and complete the post-test after
each reading to demonstrate completion. Completion of the reading series is
mandatory and will be a part of your evaluation. The reading lists can be found
under the resident/fellow tab on the website and the password is “meconium”.
2. OPTIONAL: It is recommended that you register for CLIPP Cases (computer
assisted learning in pediatrics project). To register, go to www.clippcases.org,
and click on “CLIPP Pediatric” cases. Click on “go to cases”. “You are new
user?”  click “register”. Fill in your information using your university x500
email address. Your user name and password will be emailed to you.
a. The following Pediatric CLIPP cases should be reviewed during your
month in the NICU: #1 (Eval of newborn infant), #2 (prenatal and
newborn visits), #7 (newborn resp distress), #8 (jaundice), #9 (lethargy),
#15 (vomiting), #18 (poor feeding), #25 (apnea), #26 (not gaining weight),
#29 (hypotonia). The following Family Medicine CLIPP cases are
pertinent: #24 (fussiness).
XI. INFECTION CONTROL
1. Follow posted isolation procedures on the doors of patient rooms
2. Wash hands and arms up to elbows thoroughly upon entering the NICU each day.
Foam-in and foam-out of all patient rooms (up to elbows).
3. Wear gloves for all patient contact (no exceptions!)
4. No rings, watches, bracelets are allowed in the NICU.
5. No painted or artificial fingernails are allowed in the NICU
6. There is no specific dress code in the NICU. However, parents and staff
7. appreciate a neat appearance if you wear street clothes. Arms should be bare below
the elbow to promote good hand hygiene when examining patients. Feel free to
wear scrubs daily, if you want. If you are attending deliveries you should wear
scrubs or place appropriate gowns over your street clothes.
XII. MISCELLANEOUS NICU INFORMATION
1. TPN orders need to be completed by 2:00 pm daily because the TPN is formulated
in the Minneapolis campus central pharmacy and has to be couriered over to our
campus in the late afternoon.
2. Routine “AM” labs are drawn between 0600-0700. Standing lab order times should
be 1500, 2200, and 0300. Please try to place lab orders at the scheduled times,
unless clinical status requires deviation.
3. When ordering labs, specify date and time of lab as well as if the nurse will obtain
the specimen (eg. Patient has central access) or if laboratory will draw specimen
(capillary stick or venipuncture).
4. When infant has a Broviac catheter labs should be ordered for 2000 as this is when
the line will be “broken/opened” when new TPN is hung.
5. Weekly nutrition labs, when indicated, are ordered for Monday mornings. These
typically include prealbumin, alkaline phosphatase, hemoglobin, and reticulocyte
count. Occasionally, if the infant has severe osteopenia or malnutrition,
assessment of Ca, Mg, Phos will be included. If the infant is on diuretics or TPN,
a basic metabolic panel should be ordered.
6. By convention, we consider the birth date = day of life 1.
7. Drug dosing should be reported as mg/kg/day.
8. Intake should be reported as “XX” ml/kg/day and “XX” calories/kg/day.
9. Urine output should be reported as “XX” ml/kg/hr.