LPCH NEONATAL-PERINATAL MEDICINE ROTATION SUMMARY
Rotation Director: Alexis Davis, MD
alexis.davis@stanford.edu
750 Welch Road, Suite 315
(650) 723-5711
Administrator:
Meghan Stawitcke
meghans4@stanford.edu
(650) 723-5711
Introduction
Pediatric housestaff in the Department of Pediatrics in the Stanford University School of Medicine are offered the opportunity to
enrich their training in the 40-bed Neonatal Intensive Care Unit (NICU), located on the second floor of Lucile Packard Children’s
Hospital (LPCH). This state-of-the-art unit serves as a tertiary referral center for Northern California and offers an intensive
experience in the management of premature as well as sick term neonates. The patient population is diverse and includes preterm
newborns, sick term infants, and infants of any gestational age with various surgical, genetic, and/or metabolic issues. Housestaff will
be exposed to therapies such as extracorporeal membrane oxygenation (ECMO), inhaled nitric oxide, and high frequency ventilation.
The NICU is supported by an active Maternal-Fetal Medicine delivery service and a comprehensive panel of pediatric surgical and
subspecialty services. It is also the site for both applied basic science and clinical research protocols carried out by members of the
Divisions of Neonatal and Developmental Medicine and Maternal-Fetal Medicine. Housestaff participation in any of these areas is
welcome.
The focus of the housestaff experience is to train future pediatricians to anticipate and recognize the newborn in distress, perform
appropriate resuscitation and ongoing assessment and stabilization of such neonates, and recognize the special needs of NICU
graduates in order to deliver optimal follow up care.
Weekly Schedule
0630-0800
0800-0830
0900-1030
1030-1100
1100-1200
1200-1300
1300-1600
Monday
Pre-round
Tuesday
Pre-round
Wednesday
Pre-round
Thursday
Pre-round
Morning Report
Morning Report
Morning Report
Morning Report
NICU Rounds
X-ray Rounds
NICU Rounds
X-ray Rounds
NICU Rounds
X-ray Rounds
NICU Rounds
X-ray Rounds
Patient Care
Patient Care
Patient Care
Patient Care
Conference
Conference
Conference
Conference
Friday
Pre-round
Grand Rounds
(0800-0900)
NICU Rounds
X-ray Rounds
Patient Care/NICU
lectures
Perinatal M&M
(LPCH Auditorium)
1330: Genetics Rounds
Patient Care
Patient Care
Patient Care
1600
Sign-out
Sign-out
Sign-out
Sign-out
Sign-out
NOTE: There are recurring NICU conferences that housestaff are encouraged but not required to attend:
 Journal club (3rd Monday)
 Research seminar (1st Wednesday)
 Research club (4th Wednesday)
 Clinical consensus conference (4th Monday)
 NICU fellow didactic lectures (Fridays at 11am in NICU conference room)
Please consult the division calendar (www.neonatology.stanford.edu) for specific times and locations of these conferences. Please call
the division office (723-5711) to request a copy of the journal club article, if desired.
Patient Care
Patient Care
Orientation
Residents should receive a detailed sign-out before beginning the rotation so they are familiar with the patients on the first day. A
detailed orientation slide set is uploaded to the housestaff website (Rotations-> Core-> NICU) and will also be emailed directly to the
residents prior to the start of the rotation. Residents should expect to pre-round and present their patients on the first day of the
rotation. A NICU fellow will conduct an orientation beginning at 7:15am on the first day to introduce residents to the physical
environment of the NICU, pertinent personnel, procedures, and policies. A NICU hospitalist will also orient residents to the delivery
room procedures, equipment, and personnel as needed. The goals of this orientation are to provide you with:
 a clear understanding of the expectations placed on you while in the NICU
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LPCH NEONATAL-PERINATAL MEDICINE ROTATION SUMMARY
 the tools (knowledge, skills, attitudes) necessary to fulfill these expectations, and
 an appreciation for how you may enhance your education in neonatal medicine while working in the NICU
The NICU guide is available on the LPCH intranet and a copy is in the resident workroom. This guide summarizes the care and
protocols in the unit and serves as an excellent resource tool for all aspects of patient care.
Junior residents rotating through the NICU will participate in a simulation course to review aspects of neonatal resuscitation will take
place at the Center for Advanced Pediatric Education (CAPE). This will typically take place on the first afternoon of the rotation.
Team Structure in the NICU
While the team in the NICU consists of numerous individuals in a multitude of disciplines at various stages of training, all have a
common goal: to deliver the best possible care to the patients and their families. Support personnel such as maintenance workers,
unit secretaries, phlebotomists, radiology technicians, social workers and discharge planners play an extremely important role in the
day-to-day operation of the NICU and therefore should be treated with the same level of respect extended to fellow physicians. The
nursing staff and respiratory therapists are the heart and soul of the NICU, as they deliver the bulk of hands-on care. Neonatal Nurse
Practitioners and Neonatal Nurse Transport Specialists are highly trained personnel who are vital to the function of the NICU. As a
group, they have a tremendous amount of experience in neonatal care and are an important resource for the physicians. Third and
fourth year medical students from Stanford as well as visiting medical students rotate through the NICU for periods of up to one
month. Physicians in the NICU include the attending neonatologists, fellows in neonatal-perinatal medicine, visiting scholars, and
your fellow house officers. Even though the NICU is an intense environment and expectations for performance are high, the faculty in
the Division of Neonatal and Developmental Medicine prefer an informal and friendly atmosphere in which to work in order to create
as pleasant a working environment and educational experience as possible.
Each team in the NICU consists of a resident and three neonatal nurse practitioners to provide primary care of all NICU patients. One
nurse practitioner on each team will carry a reduced patient load while also serving to mentor the resident in patient care
duties and to provide coverage when the resident is post-call or in clinic. Allocation of patients will be determined by the onservice/on-call fellow to maintain a balanced census among teams and frontline providers, but residents are encouraged to follow
patients they admit while on call.
Rounds
Morning rounds will be conducted at the bedside by the red and blue teams during the weekdays beginning at 9:00am. Residents are
expected to succinctly summarize changes in their patient’s condition and present a plan of care to the team.
Daily x-ray rounds are conducted at 10:30am in the second floor reading room to review the radiographic studies performed over the
preceding 24 hours. Housestaff are expected to attend and provide the radiology team with a succinct, “one-liner” about their patient
and the indication for the study that was performed.
Genetics and dysmorphology teaching rounds will be conducted weekly on Wednesday afternoons at 1:30pm. This is an opportunity
to review interesting physical findings, the pathophysiology of metabolic disorders, and guidelines for follow-up of prenatal or
postnatal diagnoses.
Sign-out rounds are held in the NICU conference room beginning at 4:00pm and are intended to inform the on-call team of problems
they will likely encounter that night. Routine diagnostic and therapeutic procedures are to be performed by the primary housestaff and
are not to be signed-out to the on-call team. Residents are expected to stay until the end of sign-out rounds in order to attend
deliveries and admit patients while the remainder of the daytime and on-call NICU team completes sign-out.
Following sign-out rounds, the on-call team will conduct walk rounds to review the plan with the bedside nurses.
Pagers/Phones
In order to minimize ambient noise in the NICU, the primary mode of communication will be by text page or by phone. The NICU
has dedicated phones to alert for delivery room calls and to provide a direct line of communication for conducting patient care.
Delivery Room Attendance
Resuscitation skills are, arguably, the most important skill set for future general pediatric practice to be gained during the NICU
rotation. As such, delivery room attendance is a vital component of learning during the NICU rotation and should be a top priority;
residents should be prepared to attend deliveries every day and wear appropriate clean LPCH scrub attire. Residents are expected to
attend all deliveries requiring the presence of a pediatric team (day and night), with the following exceptions:
 Pre-rounding and morning rounds
 Morning report
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LPCH NEONATAL-PERINATAL MEDICINE ROTATION SUMMARY
 Noon conference
Residents may alternate daytime delivery room attendance to optimize the team structure and prevent overcrowding in the delivery
room and are encouraged to assume a supervisory role when the PICN intern is present at the delivery. Residents are expected to
attend ALL deliveries while on call. Please be cognizant of and minimize the noise level in the delivery room, particularly when
multiple providers are in attendance at the resuscitation. A delivery room note will be written for all deliveries and will
summarize pertinent prenatal information, the indication for delivery room attendance, description of resuscitation procedures, a brief
physical examination, and recommendations for disposition. Additionally, housestaff are required to complete a delivery room
attendance card that details their role and responsibility in each delivery attended. These cards can be used to review progress in
acquisition of delivery room resuscitation skills throughout the rotation and should be turned into the Associate Program Director’s
office at the end of the rotation.
Weekends
Weekend rounds will be conducted as two teams beginning at 9:30am. Pre-rounding duties will be allocated by the on-call NICU
fellow, and housestaff should expect to round on their own patients as well as others. The team will write as many orders as possible
during rounds, and the remainder of patient care duties (including TPN orders) will be divided among the on-call team. Residents will
provide a brief sign-out to the incoming on-call team at approximately 4:00pm in the NNP office.
Night Call
The on-call team consists of one resident (when scheduled), two nurse practitioners (or one nurse practitioner and one hospitalist), a
fellow, and a hospitalist. Residents will be the first contact for fielding patient care questions (except ECMO) and should attend
deliveries as requested throughout the night. Any issues not able to be addressed by housestaff are to be referred to the NNP, Gap
provider, or fellow for consultation. The on-call team will conduct rounds at midnight that will focus on the reviewing new lab results
or other physiologic parameters (as instructed during sign-out rounds) and to ensure that the appropriate tests are ordered for the
morning. Any significant change in patient status or procedures performed should be documented in the patient chart and signed out
to the daytime team. Patient care inquiries for the general unit will be referred to the on-call NNP or hospitalist (aka Gap coverage)
beginning at 6:00am to permit adequate time to pre-round and complete work. Residents are to be excused no later than 11am and
should sign out to the NNP assigned as the mentor the resident.
Documentation and Communication
H&Ps: A history and physical are required of all infants admitted to the NICU. There may be special circumstances where an infant
is admitted to the NICU for observation post-operatively. If the surgical team has dictated an H&P prior to admission, a written postop accept note with a physical examination will suffice. Infants transferred from the Packard Intermediate Care Nursery (PICN) who
already have an H&P only require an accept note. (NOTE: Infants transferred from the Well Baby Nursery require an H&P)
Transfers and Discharges: All patients leaving the NICU require a written report that summarizes the events of their NICU
hospitalization, regardless of length of stay. This is usually best accomplished through a systems- or problem-based approach;
however, less complicated patients may only merit a brief summary. Please document the status of newborn screening,
immunizations, hearing screening, or any other health surveillance issues in the report. When a patient is to be discharged or
transferred to another facility, a discharge summary should be completed and sent with the patient or faxed to the
receiving/follow-up physician. Also, a phone call to the follow-up pediatrician or receiving MD should be made (or at least
attempted) and documented on the discharge record form in Cerner. Any possible or anticipated discharge or transfer summaries
should be prepared before the weekend if the resident will not be on call.
Interim Summaries: Interim summaries serve as working documents to summarize the patient’s hospital course. They should be
updated on a weekly basis to facilitate the discharge summary, and in the event that unexpected transfers or discharges need to occur.
Communication: Housestaff will be expected to provide updates to the parents of their patients. They should also ensure that a
member of the NICU team makes direct communication with the receiving physician/private pediatrician at the time of transfer or
discharge. Discuss with your attending to determine which member of the team would be most appropriate to initiate this
conversation.
Resident Roles and Responsibilities
 Performs the primary patient care role
 Pre-rounds on patients and writes daily progress notes and orders
o NOTE: Progress notes should be submitted for attending review and signature in a timely manner,
ideally by 2:oopm and no later than the end of the workday (4:00pm). Some attendings may request
that notes be submitted earlier. Continued revision to incorporate results from testing performed after
rounds are over is not necessary.
 Participates in rounds and takes care of daily work associated with patient care
 Updates the sign-out sheet daily and while on call
 Performs history and participates in the stabilization of new admissions (on call or as allocated by fellow)
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LPCH NEONATAL-PERINATAL MEDICINE ROTATION SUMMARY
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Attends deliveries, provides supervision to intern in the DR when appropriate
Performs procedures, including but not limited to:
 Intubation
 Umbilical line placement
 Lumbar puncture
Plans discharges, facilitates follow-up appointments, and writes discharge medications
Supervises medical students caring for your patients, co-signs orders.
Attend weekly Perinatal Morbidity & Mortality Conference; present patient histories when applicable
Communicates with parents, consultants, and referring/receiving physicians
Above all, all House Officers are encouraged to ask for assistance from the Neonatal Nurse Practitioners, Neonatology Fellow and
Attending Neonatologist in any matter (procedure, patient care decision, family conference) for which he/she feels ill-prepared or illequipped. It is understood that this is a teaching program and that training of future pediatricians in neonatal medicine is a part of the
mission of the Division of Neonatal and Developmental Medicine.
Methods of Evaluation
House officers rotating in the NICU are evaluated in several ways:
 MedHub
 Patient/procedure logs
 Case discussion
 In-training exam
 Simulation-based activities
 Self-assessment
All house officers are encouraged to maintain patient/procedure logs as a component of their general residency training. These are to
be reviewed periodically by the house officers themselves and pertinent questions regarding proficiency or extent of experience raised
with the appropriate attending physician, advisor, or residency program director.
House officers take the in-training examination of the American Board of Pediatrics on an annual basis. Individual results are
reviewed by the house officer with his/her advisor and program director. Cumulative results (of all house officers) are reviewed by
the director of the NICU rotation, deficits noted and communicated to the Division of Neonatology.
Simulation-based training in neonatal resuscitation is carried out at the Center for Advanced Pediatric Education (CAPE) prior to and
during residency training. This immersive learning experience is a unique opportunity for house officers to gain experience and
confidence in handling difficult clinical situations without risk to themselves or their patients. House officers work through intense
scenarios using human patient simulators and are then debriefed by simulator instructors as they watch a videotape record of their
performance. More information on CAPE and its programs can be found at http://www.cape.lpch.org.
House officers are encouraged to solicit feedback from their on-service fellow and attending faculty at the mid-point of their rotation
to discuss areas for improvement and again at the end of the rotation to gain an overall evaluation. House officers are likely to work
with several different supervisors and hospitalists during their month-long rotation; hence, there is potential for feedback from a
variety of sources. Written evaluations will be provided through the MedHub system.
Finally, all house officers are expected to reflect on their performance using the self-assessment tool and discuss it with their attending
physician, mentor and/or residency program director.
References and Readings
1) Avery’s Diseases of the Newborn 9th Ed. (e-Book on Lane website) Gleason CA and Devaskar S.
2) Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. Fanaroff AA, Martin RJ.
3) Assisted Ventilation of the Neonate. Goldsmith JP, Karotkin EH.
4) Neonatology: Management, procedures, on-call problems, diseases, drugs. Gomella TL, Cunningham MD, Eyal FG.
5) Pediatric Care of the ICN Graduate. Ballard RA.
6) Smith’s Recognizable Patterns of Human Malformation. Jones KL.
7) Fetology: Diagnosis and Management of the Fetal Patient. Bianchi DW, Crombleholme TM, D’Alton ME.
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NEONATAL-PERINATAL MEDICINE: SELF-ASSESSMENT FORM
TOPIC/SKILL
ADEQUATE EXPOSURE
ADEQUATE COMPETENCY
1. recognition of complications of
pregnancy, labor and delivery
placing a neonate at risk
2. technical skills for
resuscitation & stabilization:
umbilical lines, intubation,
initiation of ventilation, etc.
3. recognition and treatment of
neonatal medical emergencies:
shock, meconium aspiration, etc.
4. recognition and treatment of
neonatal surgical emergencies:
congenital heart disease, bowel
obstruction/perforation,
meningomyelocele, etc.
5. familiarity with long-term
consequences of prematurity:
IVH, ROP, BPD, etc.
6. understanding of ethical
principles governing decisions to
initiate, terminate or modify
intensive care
7. organization of information
and prioritization of problems
8. treatment of stable
convalescent infants: apnea,
anemia, feeding problems, etc.
9. understanding of the effects of
prematurity on infant
development
10. familiarity with the discharge
planning process
11. normal newborn physical
examination
12. anticipatory guidance
counseling of new parents
13. treatment of medical
problems in the term newborn:
drug abstinence, TTN,
hyperbilirubinemia, etc.
14. recognition of the need for
referral to appropriate pediatric
subspecialist
15. stabilization and transport of
the critically ill neonate
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ADEQUATE EXPOSURE
INADEQUATE COMPETENCY
INADEQUATE EXPOSURE