JOHN HUNTER CHILDREN’S HOSPITAL
NEONATAL INTENSIVE CARE UNIT
JUNIOR STAFF – INTRODUCTORY HANDBOOK
January 2012
1
Contents
Topics
Page number
1. Introduction
4
2. Staff
2.1. Nursing & Allied Health
2.2. Medical
2.3. Other Staff
5
3. Rosters and Timesheets
3.1. Holidays
3.2. ADOs
7
4. Duties and Responsibilities
4.1. Neonatal Fellow
4.2. Registrar/NNP
4.3. Resident
4.4. Lines of communication
8
5. Daily Events
15
6. Clinical Care
6.1. Guidelines on contacting Neonatologist
6.2. Infection control
6.3. Clinical records
6.4. Guidelines on writing patient notes
6.4.1. Example note
6.5. Resuscitations
6.6. Baby checks
6.7. Blood products
6.8. Drug Manual
6.9. TPN
16
7. Investigations and Routine tests
7.1. Haematology & Biochemistry
7.2. Microbiology
7.3. Radiology
7.3.1. Head ultrasounds
7.3.2. Echocardiograms
7.3.3. Eye checks for ROP
22
2
17
Topics
Page number
8. Occupational Health & Safety
8.1. Safety glasses
8.2. Needles and Sharps
8.3. Footwear
8.4. Equipment
8.5. Transports
25
9. Educational Program
9.1. Orientation
9.2. Appraisal
9.3. Assessment
9.4. Education opportunities
9.5. Resuscitation Program on CD
9.6. Libraries
26
10. Checklist for Junior Medical staff/NNP
31
3
I. INTRODUCTION
Welcome to the John Hunter Children’s Hospital Neonatal Intensive Care Unit.
This document is an introduction to and provides some information about the running
of the neonatal unit at John Hunter Children’s Hospital. It is not about the medical
issues of care of neonates. The various guidelines dealing with medical issues can be
found in the unit protocol book or on the Kaleidoscope website.
The NICU at John Hunter Children’s Hospital is part of the New South Wales (NSW)
network of neonatal units serving the Hunter New England region of NSW. It is the
largest [41 total cots with 17 intensive care (12 ventilated; 5 non-ventilated)] and one
of the busiest NICU’s in NSW with approximately 3500 deliveries per annum and an
average annual admission rate of 1000 neonates. Of these, about 50% are premature
(< 37 weeks) ~ 15% are < 32 weeks, 15% less than 1500 grams and ~ 6% (45) less
than 1000 gms. Survival is of the order 30% at 23 weeks, 70% at 25 weeks and 90%
at 27 weeks. We support 200+ babies per year with some sort of respiratory support
(ventilation or CPAP) and have around 50 surgical cases per year. The results of our
care compare favourably with other units in NSW and with other NICUs within the
Australian & New Zealand Neonatal Network.
The unit also serves as the northern arm of the NSW Newborn and Paediatric
Emergency Transport Service (NETS) of NSW and conducts both road and air (rotary
wing only) retrievals from hospitals within the Hunter New England region. The current
number of retrievals is 120 per year and rapidly rising.
4
2.
STAFF
2.1
Medical
Director
Dr Chris Wake (pager: 5643)
Dr Rebecca Glover (pager: 5775)
Dr Ian Wright (pager: 6466)
Dr Paul Craven (pager: 5776)
Dr Javeed Travadi (pager: 5902)
Dr Koert DeWaal (pager 5778)
Dr Larissa Korostenski
Dr Anil Lakkundi
Dr Tejasvi Chaudhari
Neonatologists
Neonatal Fellow
Mary Wagner
Marilyn Owers
Mark Amey
Kym Pollock
Catherine Vickery
Neonatal Nurse Practitioners
Registrars
4 paediatric – 6-month rotation
1 ICU – 6 month rotation
Resident (SRMO)
2 paediatric –12 week rotation
2.2
Nursing – The NICU has a pool of 150 nursing staff.
Nursing Unit Manager (Grade 3)
Marie Mannion
Helene Anderson
Shirley Graham
Natalie Butchard
Nursing Unit Managers (Grade 2)
CNC Liaison Nurse
Susanne Wooderson
Denise Kinross
CNC Newborn care
Justine Parsons
Jo Kent Biggs
Julie Gregory
Vivienne Whitehead
Karen Endicott
Jenny Lamb
Jennifer Ormsby
Nurse Educator
Clinical Nurse Educators
5
Deborah Ireland
Shonnet Porter
Lactation Consultants
6
2.3
Allied Health Staff
Yasmine, Robyn, Jessica, Keisha,
Ward Clerks
Secretaries
Sylvia
Tara
Physiotherapist
Rosie Day (pager 2477)
Jane Lunn (Mon, Tues, Fri)
Brodie Warren (pager: 5582)
Speech Therapist
Dieticians
Yvette Anscombe
Elizabeth Webster
Social Work
Julie and Jan and Alison
Technical Assistants
Tracey
Nicole
John
Elaine
Drivers
Max, John and Gary
Using the paging system
To page any of the staff members, you need to dial 13955. Follow the prompts and
use the keypad to enter the numbers followed by the hash (#) key.
Alternately, you could use the computer LAN page system to leave a short message
on an alphanumeric pager.
7
Michelle
3.
ROSTERS AND TIMESHEETS
Consultant Neonatologists
The consultants rotate 1-2 weeks on clinical service then 2 weeks off service.
Two neonatologists are on service at any time, one for level 3 and one for level 2 +
postnatal wards. The on-service consultant will attend a daily morning ward round
with the appropriate day registrar, fellow and nursing coordinator (usually NUM 2).
Questions about patients should be directed to the appropriate neonatologist looking
after that baby. After hours (4pm to 8am) and on weekends, one consultant covers
the unit and is responsible for all babies.
Neonatal Fellows
Fellows are usually Advanced Trainees (or equivalent) supervised by the Royal
Australasian College of Physicians. The fellows’ work Mon – Fri, 8am to 4:30 pm,
rotating between level 3 and level 2. They also participate in the specialist on-call and
weekend roster with consultant back up. They will do at least one night per week and
one week end in 3-4. They will be expected to be on call at times for transports when
shifts are not adequately covered by unit staff.
Registrars and NNPs
The junior staffing is made up of 5 nurse practitioners, 3 paediatric registrars on
rotation to NICU for 6 months, an ICU registrar on NICU rotation. The registrars will
work 12 hour shifts unless recorded as an 8 hour day. One registrar will be based in
level 2 and one in level 3. In each side of the unit their will be a resident. After an initial
induction period residents may be rostered on nights and week ends and so some
days there may only be one resident. If a resident is on night or weekend duty they will
be the second person on for that day i.e. not 2 registrars and a resident
Resident
The SRMO is usually on a 12-week rotation from Paediatrics and works MonFri, 8am to 4:30 pm during the week, initially. One SRMO will be on the level 2 side of
the NICU and one on the level 3 side of NICU. Once an initial induction period has
passed the SRMO may be placed on nights and weekends as the second person
covering that shift, and hence some days during the week may only have 1 resident on
and there should always be a priority for level 2 cover. The main role of the SRMO is
participation in the level 2 rounds, management of babies on the postnatal wards &
level 2. Again if on level 3 the main role is similar to registrar/NNP roles. Taking an
ADO needs to be arranged in advance with the neonatologist on-service for level 2.
Rosters
Registrars and NNPs share a common roster. The roster is written by Ms.
Catherine Vickery (NNP), or a delegated NNP and circulated 2 weeks prior to
commencement. ADOs are written into the roster. Mutual equitable swaps on the
roster are agreeable in most cases provided timely approval has been obtained
from the on-service neonatologist. There are two registrars/NNP on duty per shift and
2 SRMO’s on shift. It is expected that the 2 registrars/NNP on duty share the workload
equitably with SRMO’s, with one resident and registrar in level 2 ands one in level 3.
Once 2 fellows are working one will be on for level 2 and one for level 3.
8
Leave / Holidays
Any leave (annual, study etc.) needs to be requested and approved by Dr
Javeed Travadi at least 4 weeks in advance to be guaranteed. All sick leave
notifications need to be made to the on-service Neonatologist at the earliest possible.
Sick leaves of >48hr duration require submission of duly signed sick certificate from a
GP.
Timesheets
Timesheets are filled in second weekly and given to the unit secretary.
Registrars on duty should claim the first 10 hours as ordinary time and hours beyond
that as overtime. All un-rostered overtime needs to be approved by a neonatologist.
9
4.
DUTIES AND RESPONSIBILITIES
4.1
Neonatal Fellow – Duties & Responsibilities
Hours: Monday to Friday, 0800 – 1630. On-call commitments for NICU 1 night/week and 1:4 weekends.
Also expected to participate in NETS retrieval where appropriate.
Clinical Duties:
1.
2.
3.
4.
Co-ordinate the morning registrar handover round
Daily ward round with Level 3/Level 2 consultant and registrar
Lead morning ward round (Level 3/Level 2) at least once/week
Oversee and assist registrar/resident with management of babies in Level 3
and Level 2 as required
5. Ensure that the consultant Neonatologist is aware of all problem babies and of
families who have concerns about their baby’s care
6. Be supportive of Level 2 registrar and resident for problems in Level 2 and
postnatal wards, especially when busy with paper work.
7. Attend all emergency calls when on duty
Clinics:
1. General outpatient: Wednesday: 2-5pm – supervised by Dr Paul Craven OR
consultant on duty for level 2
2. Neuro-developmental assessment: Thursday: 9.30-11am – supervised by
Drs. Anne Vimpani
NOTE: It is expected that the neonatal fellow will undergo training in
developmental assessment as required and be expected to complete a
minimum of 15 assessments (5 each of supervised, 12 month olds and 3 year
olds) during a 12 month appointment.
3. Antenatal counseling: Thursday: 3-5 pm – supervised by Drs Koert de Waal &
Rebecca Glover
4. Drug and alcohol withdrawal: Tuesday: 2-5 pm – supervised by Drs Chris
Wake & Dr J Travadi
NOTE: Rotations to above clinics (generally 2 clinics allocated per 6 month period)
will be determined at the initial appraisal meeting as per individual training needs.
10
On-call commitment:
Neonatal Fellows are expected to have a regular after-hours on-call commitment
acting as primary consultant for the NICU one-night/week and 1:4 weekends as part
of their training. During this time support will be provided in the form of a
Neonatologist who will act as secondary/back up consultant.
The back up on-call Neonatologist would expect to be contacted at any time that
extra support is needed and especially in the following circumstances:
1. Any life or death situations
2. Decisions involving stoppage of resuscitation in a delivery room situation
3. Inform regarding all 26 to 29 week gestation deliveries/admissions to the unit
at the earliest after admission and stabilisation
4. Inform for all <26-week gestation deliveries at the earliest possible. (The oncall Neonatologist may choose to be present for such a delivery)
5. Inform regarding any baby admitted with multiple congenital abnormalities or
antenatal undiagnosed Trisomy
6. Inform regarding any baby with difficult ventilation and requiring initiation of
HFOV or Nitric oxide
7. Inform if going “red” on the state-wide “bed-state”
8. Inform if going out on NETS retrieval and liase with the Neonatologist while on
the retrieval.
9. Inform about NETS calls if ANY concern about providing advice OR if ANY
doubt regarding patient transfer to JHH (Only a consultant can refuse a
transfer request).
10. The second on-call Neonatologist also needs to be informed and involved
when participating in a statewide conference call organised to discuss the bed
availability in NSW.
Neonatal Transport Duties:
The NICU at John Hunter Hospital functions as a branch of the NSW NETS transport
service currently doing approximately 120 transports per year within a 90-minute
travel time (ambulance or helicopter) of the unit.
The neonatal fellows are expected to undertake transports when on duty and when
on-call. When there are no members of the transport team on duty we may ask
fellows to respond during these periods to cover the service in addition but time will
be compensated by time in lieu if called out.
Educational:
1. Participate in orientation of new registrars and residents and ensure that they
are aware of unit protocols and research projects
2. Case presentations at monthly perinatal morbidity/mortality meetings
3. Attendance and active participation in Paediatric Grand rounds
11
4. Attend, participate in and organise internal teaching/tutorials/journal club for
NNPs, registrars/resident and nursing staff
5. Participate in outreach education sessions for GPs, paediatricians and
midwives in the HNE region
6. Regular review of own training program with supervisor/director including
performance appraisal
Research:
There is an active clinical audit and follow up program with data being collected for the
NICUS and ANZNN database. Research opportunities are also available in
conjunction with the Mothers and Babies Research Centre. The neonatal fellows will
have one rostered afternoon off clinical duties per week to pursue research
activities.
1. Expectation of involvement in own audit OR research project
2. Expectation of active participation in developing and reviewing unit guidelines
3. Expectation to complete and present at least one project at national level
meetings/conference
Administrative:
1. Supervision of NNP/registrars/residents in general
2. Ensure daily notes/tick sheets and discharge summaries (EDRS) are initiated
& completed by registrars or self as soon as possible
3. Organise teaching rosters for registrars/NNPs in training
12
4.2
Neonatal Registrar/NNP – Duties & Responsibilities
Level 3 – Day shift:
1. Handover round at change of shifts (supervised by Neonatal Fellow)
2. Daily ward round with neonatal fellow & consultant (start time 9-9.30 am
weekdays; 8 am weekends/public holidays)
3. Daily documentation on all babies including fluid chart, tick sheet and medical
notes (refer to guidelines for charting of daily notes Pg 17-20)
4. Day to day management of babies including IV insertion, arterial line
insertions, central venous and arterial catheter insertions, intubations,
arranging investigations and referrals as required
5. Reviewing all laboratory results & radiology
6. Management of new admissions in conjunction with neonatal fellow and
consultant
7. Complete TPN requests for pharmacy by 0930 hrs – Mon/Wed/Fri/Sun.
8. Ensuring entry and updating summaries on the EDRS
9. Completion of EDRS summary prior to transfer to level 2/discharge
10. Liase with consultant as appropriate (guidelines – pg 16)
Level 2 – Day shift: The registrar/NNP shall be responsible for and carry the 23172
DECT phone on their person at all times handing over to the next shift person as
appropriate.
1. Handover round at change of shifts (supervised by Neonatal Fellow)
2. Daily ward round (level 2/postnatal ward) with neonatal fellow OR consultant
(8.30 am)
3. Attend deliveries on labour ward and theatre as required
4. Attend all emergency calls (codes) immediately during shift
5. Regular documentation (medical notes, fluid charts & tick sheets) on all
babies including regular examination of each baby in level 2.
NOTE: For unstable/new babies – daily examination & for stable babies
examination every 2nd/3rd day.
6. Day to day management of babies including IV insertion, arranging
investigations and referrals and reviewing all laboratory results & radiology
7. Enter, maintain and complete EDRS summary for all babies prior to discharge
from NICU
8. Liaison with peripheral hospital paediatricians/GPs as appropriate prior to
transfer of baby for ongoing care
9. Be available for review of babies/problems on the postnatal ward
10. Oversee RMO with management of babies as required
11. Liase with neonatal fellow OR consultant as appropriate (guidelines – pg 16)
Afternoon & Night shifts:
Registrars/NNPs are expected to work in conjunction as a team sharing workload
and responsibilities as required ensuring appropriate care of babies across level 3
&2. It would be expected for both persons on duty to attend the combined handover
round.
13
1.
2.
3.
4.
5.
6.
Handover round at change of shifts
Equitable distribution and completion of work across level 3 and level 2
Attend deliveries on labour ward and theatre as required
Attend all emergency calls immediately during shift
Continuation of the management plan for each baby
Review all babies as requested by nursing staff promptly and discuss
significant problems with on-call consultant (see guidelines)
7. Night shift – Daily (nightly) examination and documentation in notes for
unstable/new babies.
8. Evening shift – Review all laboratory results & radiology results and organise
bloods/requests for the night/next day.
9. Night shift – Collect, send and review all laboratory results (0300 to 0600)
10. Enter, maintain EDRS summary for new admissions and complete EDRS for
babies where discharge from NICU anticipated the following morning.
11. Be available for review of babies/problems on the postnatal ward
12. Liase with neonatal fellow OR consultant as appropriate (guidelines – pg 16)
IMPORTANT NOTE:
The registrar/NNP shall be responsible for and carry the 23171 DECT phone on their
person at all times between 4pm – 8am.
Educational: (Also see Pg 26)
1. All registrars & NNPs are expected to attend and actively participate in
internal NICU teaching sessions (Journal clubs and tutorials) irrespective of
roster commitments (excluding night shift persons). The Neonatal Fellow will
carry your pager to enable participation
2. Attend Paediatric Grand rounds, Paediatric X-ray meetings and journal clubs
within Kaleidoscope when feasible
3. Regular review of own training program with supervisor / NICU director
including performance appraisal
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4.3
Resident Medical Officer – Duties & Responsibilities
Hours: Monday to Friday: 0800 – 1630
The main role of the RMO is participation in the level 2 and 3 rounds, management
of babies on the postnatal wards & level 2 and 3, Level 2 is always a priority if only
one resident is available. The RMO shall be responsible for and carry the 23171
DECT phone on his/her person.
1. Attend the combined handover round at beginning of shift (supervised by
Neonatal Fellows)
2. Daily level 2/postnatal ward round and level 3 consultant round with neonatal
fellow OR consultant (0830)
3. Attend deliveries on labour ward and theatre as required
4. Attend all emergency calls immediately during shift
5. Participate in daily documentation on all babies including fluid chart, tick sheet
and medical notes
6. Participate in day to day management of babies on level 2 and 3 (including IV
insertion, arterial line insertions, central venous and arterial catheter
insertions, intubations in conjunction with level 3 registrar)
7. Management of new admissions in conjunction with registrar/NNP and
neonatal fellow
8. Enter, update and complete EDRS summary in participation with the
registrar/NNP
9. Be available for review of babies/problems on the postnatal ward
10. Participate actively in the teaching activities on the unit (discuss with Neonatal
Fellow regarding participation on the journal club roster)
11. Liase with neonatal fellow OR consultant as appropriate (see lines of
responsibility – pg 14 & guidelines – pg 16)
15
4.4
Lines of communication and responsibility
Neonatologist on service for
level 3
Neonatologist on service for
level 2
Neonatal Fellow for level 3
Neonatal Fellow for level 2
Designated level 3
registrar/NNP
Designated level 2
registrar/NNP
As required
Main
responsibility
As required
Main
responsibility
Level 3 babies
Level 2 babies
As required
As required
RMO
After Hours/ Weekend:
Neonatologist on call
 Fellow
Reg/NNP/SRMO
L3/ L2/ Postnatal wards
16
Postnatal wards
5.
DAILY EVENTS
Level 3
0800
Combined handover round (attended by all on duty registrars,
NNPs RMO and Fellows)
0830-0930
Complete TPN orders
Chase and complete result book for the consultant round
Order Investigations - head U/S scans, Radiology etc.
0930 to1100
Consultant ward round
Recording management plan in charts (by Fellow)
Fluid and feed orders/medication charts updated
Post-rounds
Examine babies and update medical notes and tick sheets
Order appropriate investigations after discussion
fellow/neonatologist & review blood & radiology results
EDRS summaries
with
Besides the above – make a thousand decisions and do a hundred other things (save
lives, IVs, chest drains, arterial lines, long lines, intubations, have meals!)
2000 to 2030
Handover to night registrar/NNP
Overnight
In addition to duties described above – collect bloods (on TPN
day ensure bloods collected at least 4-6 hours after new TPN has
been put up)
Review all blood results UEC, FBC, blood c/s
Medical notes and examination of all unstable/acutely ill babies
Sunday night
All of above + Measure head circumferences and plot head and
weight on growth charts
Level 2
0830
Consultant/RMO + Fellow/Reg rounds to commence
Baby examinations, tick sheets, fluid orders
Order Investigations - head U/S scans, Radiology
Post-rounds
Completion of and EDRS summaries (as detailed on page 10)
Registrar to attend to postnatal ward calls/problems as required
Registrar/RMO to check with level 3 registrar/NNP and help out in
Level 3 as required
17
6.
CLINICAL CARE
6.1
Guidelines on contacting Fellow/Consultant for patient management
We appreciate that the neonatal unit will be a very confusing environment for the first
few weeks. The neonatologists are available to help. If in doubt ask, you will never be
criticised for calling but may well be for not calling!
The on-call consultant (Neonatal Fellow/ Neonatologist) would expect to be
contacted at any time support is needed and especially in the following
circumstances: (This is NOT an exhaustive list – if in doubt, CALL!)
1.
2.
3.
4.
5.
6.
7.
8.
Any life or death situations
Decisions involving stoppage of resuscitation in a delivery room situation
Inform regarding all admissions to the unit at the earliest
Admissions of all <29-week gestation deliveries at the earliest possible
Admissions that need ventilating
Inform regarding admissions with multiple congenital abnormalities or Trisomy
Inform regarding any case of severe asphyxia OR seizures
Inform regarding any baby with difficult ventilation and requiring initiation of
HFOV or Nitric oxide
9. Discuss all decisions involving major change in ventilation status
(intubation/extubation etc.)
6.2
Infection Control
Cross infection is a major issue in neonatal units. Briefly, the policy in the unit is:





Remove all rings (except wedding bands), watches, and other jewellery
from below your elbows.
Roll up sleeves to above the elbows
Wash hands on entering the nursery using chlorhexidine scrub.
Hand wash or use alcohol gel (Aquim) on hands before and after every
patient contact
If your hands can’t tolerate this regime talk to the neonatologist or nursing
unit manager
18
6.3
Clinical Records
Every unit has its own peculiarities for record keeping - we are no exception!
The Labour Ward Perinatal Database Summary sheet is (should be) available soon
after the birth. If not it can be obtained from the delivery suite. RMO/registrars/NNPs
should write a full admission in the baby's notes including a précis of the antenatal
problems. Please record the baby's weight, head circumference and the percentiles in
the admission note.
Flow Sheet (Tick Sheet)
These are kept at the baby's bedside. They should be filled in daily to keep them up to
date. They are invaluable for writing discharge summaries and provide the essential
information on the baby's past history for registrars, nurses and handovers etc.
Pathology Results
A separate book of pathology result flow sheets is kept in L3 and L2. These should be
kept up to date and are an essential part of each ward round.
Discharge Summaries
These are maintained on the EDRS system. Access to EDRS will be organised at time
of joining the department – if you do not have access please contact Ms Marie
Mannion (Nursing manager) ASAP. The EDRS should be started for every baby at
admission to the unit and maintained daily. Completed EDRS, forms part of the
transfer of babies from level 3 to level 2.
Progress Notes in L3 and for Acute Problems in L2
These are recorded daily by the day shift and at night if there are any significant
events. We encourage use of system notes (a separate heading for each system), as
these are much easier to read and follow at a later date. See guidelines below.
6.4
Guidelines on Writing Progress Notes
Daily notes in the chart clearly documenting patients’ progress, diagnostic results
and ongoing plan are required in order to maintain accurate medical records and
share information among team members.
Who & When?
Day shift registrar/NNP/Fellow/SRMO:

The day shift person should write a detailed progress note on all patients
as described subsequently. In level 2, we expect daily examination of sick
(example on CPAP) babies OR new admissions and daily record & for
stable babies an examination every 2nd to 3rd day.
19
Night shift registrar/NNP/SRMO:


A brief note is expected from the night duty person on all patients, even if
it is to say that observations during the shift have been stable and no
deviations from plan have occurred.
A more detailed note (as per day note) should be written for all unstable
and sick infants.
NOTE: Often, more than one note may be required (see below).
A note by the consultant does not mean that you do not need to write your
daily progress note!
 All procedures done should be timed, dated and noted. Stickers are
available on the trolley in L3 to record the procedures in the clinical notes
[Example – 12/08/2005, 1330 hrs – Lumbar puncture done under
aseptic precautions. 0.5 ml of clear (or otherwise) CSF collected and
sent for biochemical analysis and cultures. Infant tolerated procedure
well (as the case may be)].

All post-op patients returning to the NICU require a note documenting their
present condition, fluid, medication and pain relief requirements and
feeding plan. If intubated in theatre they will require a check CXR and may
require post operative bloods as discussed with the on call consultant

If you are called to see a baby for a problem by the nursing staff, write a
note indicating the problem you were called for, your assessment, and
what evaluation and/or therapy were done.
[Example: 25/08/05, 2330 hrs – asked to evaluate baby X for left eye
discharge. This has been noted for the first time. On examination, there
was no evidence of inflammation. Plan: Clean with normal saline.
Observe – inform if discharge recurs or if signs of inflammation].
GENERAL POINTS:
1.
2.
3.
4.
Write legibly.
Use black ink only (only black is allowed by medical records).
Always date and time notes.
All notes should have the last name of the person writing the note at the top –
“Dr Y (designation)” i.e. neonatal registrar, NNP etc.
5. Include pertinent physical examination in all progress notes. (Discuss with
the neonatologist/fellow to develop an understanding of what ‘pertinent
examination’ means - this would depend upon the patient and stage of
illness).
6. Avoid unusual abbreviations.
7. Ward round note – "W/R with Dr. X" at top (X being whoever the
Neonatologist/Fellow of the day is). Plan: note what the consultant wishes to
be done for the day. (Usually written by the Fellow)
20
Refrain from negative comments about patient care such as disagreements
between staff, etc. Also, check with senior medical staff before using
diagnostic labels like “asphyxia”.
STRUCTURE OF A PROGRESS NOTE:
1. Day of life
2. Gestation, current corrected gestation, current weight – note change from
previous recorded weight/birth weight
3. Current problems
4. Vital signs & ventilatory requirements
5. General examination noting colour, perfusion activity level, handling
6. Physical findings by organ system as pertinent to the patients underlying
problem(s). List in the following order:
a. Respiratory
b. Cardiovascular
c. Abdominal
d. Neurology
7. IV lines/ CVL/ arterial lines/ tubes/ ICC drains etc.
8. Fluid intake – recorded as mls/kg. Also record amount and type of enteral
feeds
9. Output – includes urine, gastric aspirates and wound losses.
10. Laboratory Tests: Relevant positive findings of blood tests/ urine/ other body
fluids/cultures (ideally list date and site from which obtained)/radiographic
tests/others (over past 24 hours OR as relevant to the current problem list)
11. Current medications and their duration/plan for their duration
12. Social – maternal condition, parental understanding/anxieties
13. Plans: list your plans for each diagnosis. Be as specific as possible.
6.4.1 Example: (For sake of communication, this is not as detailed as it
should be)
25th August 2005, 0930 hours; Dr. John Doe (Neonatal registrar/NNP)
Day 4, 29+2 wks GA, current/working weight 1020 (down 80 grams from
birth/previous weight)
Current problems:
1. RDS – ongoing, day 4 on CPAP
2. PDA – day 2, on indomethacin
3. Suspected sepsis – fresh problem from overnight, lethargic, mottled, poor
handling, feed intolerance, developing metabolic acidosis
4. Feed intolerance – large bile aspirates & abdominal distension noted at 0100
Respiratory support:
CPAP – 6 cm H2O, FiO2 45%
21
Examination:
Pale, well perfused (CFT<3secs), unstable on handling during cares.

RS – equal air entry, moderate recessions

CVS – grade 3/6 systolic murmur present

Abdomen – soft, distended flanks, minimal bowel sounds, bilious
aspirates present, bowels not opened since last 36 hours

Neurological – lethargic, AF normal
Input:
Restricted fluid intake as infant on indomethacin
1. TPN 100ml/kg/day; 10% dextrose (5.2mg/kg/min of glucose)
2. Nil orally
Output:
Urine: 3.4 ml/kg/hr; Gastric aspirates: 28 mls/24 hrs, predominantly dark bile
Labs:
UEC: Na 134, K 4.1, BSL 2.8mmol/L, FBC awaited, Blood C/s sent, LP clear, c/s
sent. ABG at 7 a.m. – ph 7.27, CO2 58, PO2 52, BE –7.9
Radiology:
AXR – s/o gaseous distension of ileal loops, no evidence of NEC
US head – day 3, grade 1 IVH bilaterally
Medications:
1. Flucloxacillin & Gentamicin – day 1
2. Indomethacin – last dose due at 1200 hrs
3. Miconazole – day 4
Social:
1. Mother still unwell, in ICU
2. Dad visited last night – needs to be informed regarding suspected sepsis
Plan:
1.
2.
3.
4.
5.
6.
Continue on CPAP at 6 cm H2O, monitor pH & CO2, watch for apnoea
Last dose of indomethacin at 12 noon – needs echo later today
Chase FBC and blood & CSF c/s
Continue antibiotics
Continue TPN at 100ml/kg/day
Continue nil orally
Signed/- (registrar/NNP)
22
6.5
Resuscitations
The Unit is usually advised beforehand of mothers and babies who are likely to require
resuscitation. The referral forms are left on the board behind the desk in Level 3
Nursery. It is accepted that everyone coming to the Nursery for the first time or after a
long absence may want help, guidance and reassurance from someone more skilled
than themselves. Please do not hesitate to ask for help.
For babies > 34 weeks' the Resident generally attends. For babies between 28 and
34 weeks, for babies with severe foetal distress or known congenital anomalies that
may affect resuscitation, the Registrar should also attend. For infants < 27 weeks, the
Neonatologists like to be notified and will often attend, though not necessarily to do the
resuscitation but to provide a further pair of hands for these infants as their first
minutes of life may have significant bearing on their outcome.
6.8
Baby Checks (The Blue Book)
By agreement with the Department of Obstetrics, where a baby has been admitted to
the L2 Nursery, the baby check will be done by the RMO/registrar on the Level 2
Nursery. At delivery whoever does the resuscitation needs to decide whether the
paediatric or obstetric resident needs to do the newborn examination and indicate this
in the resuscitation note or tick the appropriate box on the resus sheet.
6.7
Blood Products
Blood products must be ordered on the separate form for blood products. One cross
match is sufficient for 3 months in the newborn period. If there are no unusual
antibodies further blood can be issued without further cross match. The need for
blood transfusion should always be discussed with parents and consent
obtained on the appropriate form. Occasionally a parent will ask you if we can use
their blood for a blood transfusion. We actively discourage donor related transfusion
for a variety of reasons. There is a separate document about how this can be done
and the risks involved. The parents have to pay the cost. Blood for special purposes
eg. exchange transfusion or HPA negative platelets must be ordered from Sydney and
then delivered, this can cause significant delay – plan ahead in these situations!
Protocols & guidelines (Also see Appendix)
We have a few written protocols. The major one is the drug book (see below). Many
relevant protocols and procedures are documented in the Procedure & Protocols
Manual. Many new clinical guidelines are being developed as required and many of
the older guidelines are being updated – you are welcome to contribute to this
process. Many new guidelines are on the Kaleidoscope website under Professional:
Guidelines/policies/procedures-clinical-neonatal
http://www.kaleidoscope.org.au/professionals/guidelines_neo.htm#GL
23
6.8
Drug Protocol Manual
The Drug Book is in 3 versions, Level 2, Level 3 (lists of commonly used drugs in
those areas kept on the drug trolleys), and a master copy in level 3 above the
refrigerators. Dosage schedules should (generally) be strictly adhered to. This way the
nurses are readily able to double-check for inevitable prescribing errors. A drug
prescribing guideline from the John Hunter Hospital Drug Committee (as it was then
now the Quality Use of Medicines Committee) can be found in the Master Copy Drug
Book.
6.9
TPN
TPN scripts are generated on the computer in level 3 office. At weekends, the
Pharmacist on call will collect TPN scripts. The formula making process is
computerised and quite quick and easy to do. A guide to prescribing TPN is available
in level 3 nursery. TPN is usually ordered Monday, Wednesday, Friday & Sunday. The
first 3 days as 48-hour orders Sunday as a 24-hour order. TPN premix solutions have
been made available and where possible for stable babies, these should be used
rather than ordering patient specific TPN every time.
24
7.
INVESTIGATIONS & ROUTINE TESTS
7.1
Haematology and Biochemistry
Routine laboratory tests are taken by the Night Registrar between 0300 & 0600.
Ensure blood collection is done at least 4 hours after new TPN has been put up.
This is essential in ensuring results are available by the ward round. They can be sent
to the laboratory by the vacuum tube system in the store room behind the desk in level
3.
Follow collection protocols, i.e. what blood volume for particular tests, in particular
blood tubes. Be very careful not to put the wrong cap on a tube even very briefly,
claimed contamination of tubes by the laboratory is a common problem.
Label tubes/bottles properly. The person collecting the sample is responsible for
labelling the tube. If they are not labelled correctly they will be rejected by the
Laboratory. Be particularly careful with twins.
Give adequate information on Pathology forms (clinical notes).
Sign the form yourself.
If the blood volume you collect for a number of tests is small, then indicate the priority
of your test requirements on the form.
Coagulation tubes are collected immediately prior to use from the Laboratory (this
ensures fresh anticoagulant and accurate results).
Special tests, eg lactate, ammonia, can be done more quickly if the laboratory is
notified 10-15 minutes before blood is taken.
Long-term preterm infants in NICU (>1 month) should be considered for LFT's,
calcium, phosphate and a full blood count measured up to once/week.
7.2
Microbiology
Microbiology results are available on all computers (username: clinenq; password:
result). Dr John Ferguson is the clinical microbiologist we consult most frequently. He
usually does a round once a week (Monday, 12:30pm) to discuss current cases and
infection issues. At the weekend, negative results are not always entered into the
computer, eg if the 48 hour cultures were negative on Saturday, this will not be
entered until Monday. Positive results are entered. However, it often pays to make a
phone call.
25
7.3
Radiology
Examinations are now digital and available on the PACS system on all computers in
the NICU. You need to register for using the PACS – please contact Ms Marie
Mannion if you do not have access to PACS.
7.3.1 Head Ultrasound
Babies less than 34 weeks gestational age are at risk of subependymal haemorrhage
and intraventricular haemorrhage. We routinely ultrasound such babies on days 1-4,
day 7, day 28, and often monthly till discharge. Some babies need scanning for
specific indications. Ultrasounds are ordered by writing the form and then faxing it to
the radiology department. Some babies will of course have abnormal findings and will
need more frequent examinations, others somewhat less. The findings are written in
the Head Ultrasound book that is kept in level 3 (usually in a diary)
7.3.2 Echocardiograms
Very low birth weight infants are prone to patent ductus arteriosus. This may present
with hypotension or acidosis and not always a murmur. Dr Bruce Bastion and Dr Nick
Collins - cardiologists or Dr Gary Warner - paediatric cardiologist perform
echocardiographic scans. These can be organised by phoning the relevant office (see
roster of cardiology physicians on the L3 notice board) and arranging a time. Dr K De
Waal or Fellows will also provide functional echocardiography once a structurally
normal echo has been performed. If there is a problem getting a scan speak to the
fellow/neonatologist about it immediately so appropriate arrangements can be made.
7.3.3 Eye checks for ROP
All babies less than 34 weeks gestation at birth plus a few others with special
problems need to have their eyes checked while in the nursery for Retinopathy of
Prematurity. Dr Chris Challinor does this on Wednesday afternoons. Babies are
referred at 4 weeks post birth by putting their name in the EYE BOOK that is kept in
level 2. A very brief history is required. The findings are written in the eye book. In the
back of the eye book is the prescription for the drops required (to be charted) before
the examination is done (this can be done by nurses under standing orders).
26
8.
OCCUPATIONAL HEALTH AND SAFETY
The important occupational health and safety issues that come up from time to time
with respect to registrar and resident staff are the following:
8.1
Wearing safety glasses
Procedures involving body fluids require wearing of safety glasses. If you don’t have
safety glasses to wear please see the nursing unit manger (Ms Marie Mannion) and
she will arrange for some for you.
8.2
Needle Stick Injuries
The blood taking needles are the commonest culprits here. They are relatively small
and can be easily lost in the bedding or incubator and are sometimes found after a
needle stick injury to nurses changing the bed or the technical assistants cleaning the
incubator. Please be careful with their disposal.
8.3
Sharps
Sharps in general are a major concern in hospitals. We have a policy that whoever
uses the sharp is responsible for its disposal. This means that when you are putting in
an IV, chest drain or long line (PICC) for instance, you are responsible for disposal
of sharps. The nurses assisting may do this for you but it is still your responsibility to
make sure it has been done.
8.4
Shoes
It is the policy of the hospital to discourage open shoes in the hospital; we do the
same on NICU. However it is an absolute requirement (theatre policy) that open toed
shoes not be worn in theatre at all.
8.5
Equipment
Equipment in the nursery is maintained by the technical assistants and referred to
biomedical engineering if necessary. The technical assistants can help with advice on
setting up and using equipment and troubleshooting. They work in the nursery
morning and afternoon shifts most days.
8.6
Transports
The unit operates as one of the NETS teams and does emergency transports around
the Hunter New England region. Calls regarding transports should be directed straight
through to the consultant on call or to the NETS switchboard in Sydney.
Calls from GP’s or Paediatricians for advice should be directed straight through to the
Neonatal Fellow OR Consultant on call.
Always wear protective clothing, helmets and closed shoes if on helicopter retrieval
and protective clothes and closed shoes in an ambulance
27
9.
REGISTRAR EDUCATIONAL PROGRAM
9.1
Introduction
The training program is not a series of didactic lectures; this is not the format
appropriate for the full time registrar/ NNP and adult learner. Instead, a series of
learning opportunities is supplemented by facilities for extensive self-directed learning.
This will be reinforced by microteaching episodes on teaching ward rounds. Several
opportunities for the learner to teach will also be presented.
Subsequent pages describe the orientation an appraisal and assessment system, and
other educational opportunities.
9.2
Orientation
A lengthy orientation period is impossible due to the service needs of the NICU.
Where possible an experienced registrar/NNP will be rostered on nights and/or the
first weekend.
Ideally all new registrars will be rostered to enable a detailed (but short and perfectly
formed!) orientation to occur. Prior attendance at the hospital orientation covering all
aspects of general procedures is assumed. Orientation will include:
“This is your locker”: a tour of the unit and delivery suite.
“What now?” An introduction to ward routine (see attached timetable).
“Button pressing” The computers and how to use them.
“What’s for dinner” TPN and fluids
“Driver knowledge test” Using the ventilator - your L plates
“There’s always paperwork” Forms, fluids, notes and discharges – what
when and where.
7) “ABC” – The resuscitaire and how to use it. A refresher as most should be
familiar with ABC +/- recent ALS course.
1)
2)
3)
4)
5)
6)
The best place to learn is the neonatal unit and the best people to learn from are
there. The above program will be taught by a combination of consultants, fellows and
NNPs.
Post orientation sessions that will ideally be covered in the first week will include
Ventilator P Plates
High Frequency Oscillator P plates
Pneumothorax and chest drain insertion.
Use the educational material (“patients”) in front of you as triggers and the senior staff
as resources.
28
9.3
Appraisal
Appraisal is a 2-way reflective process between the registrar and the appraiser. It is
an opportunity to plan and subsequently monitor the progress of the acquisition of
knowledge and skills in this attachment. Most of the learning opportunities are
informal, but there is a wealth of possibilities available so it is important to review the
situation on a regular basis to maximise the learning for each individual registrar
within the service constraints.
The appraisal is separate from the assessment process at the end of every
attachment. However, the appraisal process and its outcomes can be used to inform
the assessment, especially as the appraiser(s) will always be involved in providing
information for the assessor. The specific discussions within the appraisal meetings
will remain confidential, even if the conclusions are not.
Appraisal meetings will take place at a minimum of 2 occasions. The first meeting
will be within 2 weeks of commencing on the NICU. The second will be towards the
end of the first half of the attachment followed by an assessment in the last few
weeks of the time on NICU. For those on a one-year attachment, a 3 to 4 monthly
meeting would be expected. Either the registrar or the appraiser can request more
frequent meetings.
The first meeting will establish expectations and opportunities. It is not intended as
an orientation (see separate sheet). Ideally the registrar will have completed the form
(SR3) to provide details of current experience and hopes for this attachment. This
will be discussed and will provide a basis for completion of the form (SR4) detailing
expectations and opportunities for the time on the neonatal unit. Often unrealistic
expectations, as well as opportunities the registrar may not have considered, will be
discussed at this time.
The next meeting will discuss progress based on the previously completed plan. Any
feedback on performance will be discussed and any new goals will be added to the
plan for the next period.
The final meeting will again review progress and discuss future aims in light of the
time in NICU. Finally feedback from the registrar about the attachment will also be
sought at this meeting.
These meetings would be held 6 monthly for NNPs and Fellows.
NOTE: Currently, appraisals are done by Dr Paul Craven. Dr C Wake may be
involved in the final assessment. Mini CEX assessments are available and will be
performed at the discretion of the registrar/SRMO approaching a suitably qualified
staff member
29
9.4
Assessment
This will be undertaken at the end of the rotation. It will be on a pre-determined form
with scales of attainment in various domains (see below). The Director (or Acting) of
the unit will do the assessment with input from at least 3 of the other consultants.
Information will also be obtained from senior nursing staff and the NICU fellows.
Results of the assessment will be provided to the registrar and an opportunity for
feedback will be available. This would usually be done by the Director (or Acting
Director) of the NICU. In the event of a satisfactory performance, the details will be
forwarded to the Director of paediatric Clinical Training (DCT) for their records.
In the event of an unsatisfactory performance the DCT would be invited to the
meeting to discuss the results of the assessment and subsequent remediation. The
registrar will be able to bring a support person (eg their paediatric mentor) should
they wish.
Assessment grid example
Personal Attributes
Reliability
Initiative
Reflective, learns from
experience, seeks help
appropriately
Motivation
Time management/Personal
organisation
Learning skills
Interpersonal Skills
Communication with patients
Communication with parents
Relationship with colleagues
Support to juniors
Relationship with colleagues
Team working
Clinical Skills
Patient assessment
Clinical judgment
Patient management
Practical skills
Consistently
Good
Normally
Acceptable
Sometimes
Inadequate
Often
Inadequate
Comments
Consistently
Good
Normally
Acceptable
Sometimes
Inadequate
Often
Inadequate
Comments
Consistently
Good
Normally
Acceptable
Sometimes
Inadequate
Often
Inadequate
Comments
Signed
Date
30
9.5
Education Opportunities
There are a number of learning opportunities, which are available to the
registrars/NNP on NICU. The availability depends on a number of factors including,
but not limited to, adequate clinical cover of the neonatal unit, sufficient interest for an
event to occur, appropriateness to the level of the learner.
Schedule of meetings and teaching sessions:
Monday
1330 Paediatric Education session
NICU Tutorial Room
Tuesday
1300 Paediatric Grand Rounds
RNC Lecture Theatre
Cases and a topic are presented and discussed; these are sometimes of interest to
Neonatology. Working lunch (1230–1300) provided.
Wednesday
1300 Paediatric X-ray meeting
Telehealth centre
1330 NICU Journal Club
NICU Tutorial Room
Neonatal topics are discussed and presented by registrars/NNPs/Fellows. The
Fellows will be drawing up the journal club roster – please choose your articles and
discuss them with the Fellow/Neonatologist 1 week in advance of presentation.
Thursday
0830 Perinatal Ward Round
Gum gallery, Delivery Suite
The obstetric staff comes to NICU to be updated on what has happened to the babies
they have followed in utero or have delivered. Forthcoming antenatal problems are
often discussed.
1330 Paediatric teaching Session
NICU Tutorial room
Friday
0930 Neonatal Grand Round
NICU seminar room (back of store)
Sitting round – presentation of babies in level 3 & problem/interesting cases in level 2
by respective registrars. Involves the Consultants, Registrar(s) &/or NNP of the day,
nursing & allied health staff.
NOTE: Attendance by all current residents/registrars/NNPs at the neonatal teaching
sessions on Tuesday and Thursday are expected irrespective of clinical roster
commitments (night shift excluded).
31
9.6
American Heart Association Resuscitation Program on CD
This is available on the computer in level 3 used for viewing x-rays. It is an excellent
program and what we recommend as the standard of care in resuscitation. Simulation
resuscitation courses are held bi-monthly- your attendance is expected
9.7
Library
There is a small library in the unit located in the nurse educator’s (Justine Parson)
office. There are a number of useful neonatal texts and journals located there. Most of
the computers in the unit have access to the CIAP site of the department of health
(MIMS, Medline & Cochrane).
The main library at John Hunter Hospital is the Gardiner Library Service located
across the courtyard from the HAPS building. Please see the librarian for issue of
library cards and guidelines on borrowing books and journals. Online access to the
library services including CIAP (OVID, MEDLINE) and Electronic Journals is available
through
the
library
link
from
the
hunter
health
homepage
(http://intranet.hne.health.nsw.gov.au).
9.8
Other educational opportunities
Further educational opportunities can be arranged in neonatal follow-up clinics and
developmental assessment clinics.
Clearly many of these opportunities require a fixed time period and this is not
possible within both the shift system, required for hours of work, and the service load
of the post. Therefore, as with continuing medical education, these learning
opportunities may need to be arranged outside rostered time.
32
10.
CHECKLIST FOR JUNIOR MEDICAL STAFF/NNPs IN NICU
1.
Do you know the:
a)
Neonatologists
b)
Senior Nursing Staff
c)
Unit Clerk
d)
Unit Secretary
e)
Other Registrars
f)
Delivery Area Staff
g)
Postnatal Ward Staff
2.
Have you got:
a)
The Registrar/Resident Orientation Protocol (this manual)
b)
Basic clinical guidelines for the NICU, John Hunter Hospital
3.
Do you know how to:
a)
Use the paging system
c)
Use the computer to get results
d)
Use the PACS system
e)
Use the EDRS system
f)
Use our Drug Book
g)
Find your way to the 4 quadrants of Labour Ward
h)
Find the Postnatal Wards
4.
Can you:
a)
Resuscitate a newborn
b)
Carry out a well baby check
c)
Take venous blood from a neonate
d)
Take capillary blood gases
e)
Take arterial blood gases
f)
Put in neonatal IV lines
g)
Put in umbilical arterial lines
h)
Put in peripheral arterial lines
i)
Put in peripheral central venous lines
j)
Do nasotracheal intubation
k)
Do orotracheal intubation
l)
Do nasopharyngeal CPAP
m)
Make up orders for TPN
5.
Do you know about?
a)
The Eye Book
b)
The Ultrasound Book
c)
The Results Folder
d)
The bedside flow sheet
e)
How to get a neonatologist very urgently to the unit
f)
The mobile phone numbers for the neonatologists
g)
Taking a call for a transport
h)
Unit educational activities
33