Newborn Nursery Intern Orientation April 2015 JH
NEWBORN NURSERY
Location: The NBN is located on the 5th floor of the NC Women’s Hospital. It is centrally located on the maternity care center, which is a locked unit.
Personnel:
· UNC Gen Peds faculty rotates weekly. Three NPs also rotate, with one present each day. They are Jamie Haushalter, Erin Burnette and Emily Freeman. They are an integral part of our team and a great group of clinician educators.
· Lizzy Burch, MSW is our social worker. She is a great resource for this rotation.
· Typically there are 2 interns in the nursery and 1-2 medical students.
· There are couplet nurses (caring for mother and baby), newborn nurses and lactation consultants available.
Daily Schedule:
7:00 am Pre-rounding:
· “Huddle” with the NP and NBN charge nurse to determine overnight events, admissions, and identify discharges. Assign patients between NP and interns.
· Collect data for rounds from Epic (TC/Serum bilirubin, voids, stools, feedings and weights with percent of total weight loss calculated using admission weight) and from mom’s chart/parents as needed. Use the pink and blue cards to collate your information; Identify late preterm infants (LPT) with a yellow sticker located with the cards and staple a purple LPT check list to the card.
· Most babies will be “rooming in” with their mother. However, you may examine babies that are located in the nursery. This is a great opportunity to teach PE skills with the students. Please wait to examine babies that are rooming in until you round with the attending to minimize interruption to mother-baby bonding.
· Begin work on notes as able. Attend morning conference unless there is a crisis or other special circumstances.
7:45 am Morning Report/Grand Rounds
8:30 am Rounds
· Opportunistic teaching will be done on Rounds. The resident assigned to the baby will perform the physical exam, obtain a history and provide education to the parents.
· Discharges should be seen first.
· Please take a laptop with you on rounds or use the computer in the patient’s room and enter discharge orders immediately after seeing the patient. All discharges should be seen and orders written if the patient is ready by 10am.
10:30-12:00 After rounds completed:
· Follow up with orders, issues that came up on rounds
· Write notes
· Pick up new admissions. Admissions can come at any time. Babies that are on the floor by early afternoon should be seen that day, their orders and notes written. Generally patients are divided between the interns and the NP in a “round robin” fashion attempting to have Interns see those infants wishing to follow up in UNC’s Resident Continuity clinic.
· Discuss afternoon plans with NP/Attending as they often have meetings in the afternoons.
12:00-1:00 Noon conference occurs daily; and on Wednesdays, PL-1s have intern support. You should attend these meetings. Your attending physician will make this a priority.
1:00-3:00 Follow up with any patient issues from the morning
· Continue to pick up new admissions. In general, we will see all infants born before 3pm Monday-Friday.
3:00-5:00 Teaching with the attending or the medical students
Complete rounds and notes on new patients that were admitted after morning rounds.
Follow up with patients as necessary.
Weekends:
· Discharge rounds begin at 7:30
· The attending will usually be covering NBN and Saturday morning clinic (until clinic is off site) Therefore, you will see the discharges first. You will then pre-round on new babies while the attending goes to clinic. New/interim babies will be rounded on late morning.
· One intern should be present each day; how these are arranged is up to you. Medical students do not come in on the weekends.
· NPs are usually present on the weekends; divide patients as during the week.
· Must complete an admission for all infants born before noon each day.
· Goal is efficiency.
Admissions:
· Collect data from maternal notes in EPIC and H+P with family, record on pink/blue infant cards. If NICU was present at delivery, you should find a “Delivery Attendance Note” in EPIC.
· Enter orders using the “newborn admission” order set, and remember to change the time for the newborn screen lab test for appropriate timed round (between 26-28 hrs of life), and Hepatitis B vaccine once parents are informed.
· Interns should spend time counseling parents on normal newborn care.
· During the Admission history you should ask about and discuss as needed:
o Pregnancy history, maternal meds, complications during pregnancy or labor
o Family history, especially childhood illness, jaundice, GBS
o Social history, care plan for baby, support at home, PCP selection
o Breastfeeding, LC support, or Formula Feeding if desired by family
o Hepatitis B vaccine is recommended by the CDC and we order on all newborns after informing parents of this practice. If they object more conversation should take place between provider and family.
o Safety
§ Car seat- backward for 2 yrs
§ guns in the home (if yes, are they locked?)
§ smoke detectors
§ passive smoke exposure/quit line information for parents
Example presentation:
Baby girl Smith was born yesterday at 11:13pm by induced vaginal delivery assisted by vacuum to a 26 year old G2P1001 mother at 38+4 weeks gestation. Labor was complicated by prolonged rupture of membranes but there was no maternal fever and she was GBS negative. The remainder of the prenatal labs were normal, and both mother and baby are O+. Pregnancy was complicated by maternal SSRI use for stable depression. No other maternal mediations and the family history is otherwise unremarkable. Apgars were 6, 9 and only bulb and stim were provided after delivery. ROM was 20 hours but there is no concern for maternal chorioamnionitis. She will live at home with mother, father, and a healthy 2 year old brother. There are no smokers or guns in the home, and PCP will be here at UNC with Dr Vincent who follows the 2 year old. Exam (if done yet) notable for….
Notes:
· See list of common newborn problem codes and “DOT” phrases we have made for admission/discharge/progress note templates.
· Breastfeeding/Formula: if infant is formula feeding please indicate the reason in the note (ie medically necessary due to hyperbilirubinenemia or wt loss, or formula is maternal desire).
· If a baby is seen for admission/discharge on the same day both an admission AND discharge note need to be completed in EPIC. Include PCP and route to your attending for co-signature. Be aware that if you are the one to start a note, you are the one who must finish it unless you “share” the note in EPIC.
· Students are NOT expected to write notes in the nursery but can help assure information in Epic is correct
Interim days:
· Update infant cards with information mentioned in above sections (weight, bili, etc). It is also helpful at this time to record any other significant events such as Hep B administration. (immunization tab)
· Screenings can be found in the “view only flowsheetà Infant daily cares” section of EPIC. Screenings include tc bili, hearing, metablolic and SpO2 screens.
· Make note if a circumcision was done, Mom’s RPR status from inpatient, etc.
· Update parents, answer questions, and provide appropriate teaching, guidance.
· Please make sure you address the problems list within your progress note.
Discharge Planning:
· On Discharge you should counsel on the topics listed on the attached discharge discussion topics sheet. In general, it covers:
o SIDS prevention
o Signs of illness
§ rectal temperature taking, fever=100.4 or greater, jaundice, poor feeding, etc.
o Sadness: postpartum depression
o Answer any remaining questions
· Discharge Orders
o May order “discharge today”
o If a baby needs a vaccine or other procedure prior to going home, you may write “discharge to home with parents after Hep B given” (for example).
o Nursing staff appreciate us putting follow up appointment in the discharge order text box.
o If follow up is at UNC Children’s clinic please review instructions on the back of pink/blue card for how to schedule appointments. The NBN interns (and NPs at times) will see all UNC newborn follow up visits in the first two weeks of life to help promote continuity and improve patient care. Give your business cards to the parents so they can have a name and contact information to schedule future appointments!
· Discharge Note
o Newborns with special conditions or requirements beyond regular newborn care warrant a call to the PCP prior to discharge.
o Be sure to route the note to the infants PCP and to the attending for co-signature. Inform NP if a PCP practice is not listed.
Other:
· Occasionally there will be infants admitted to NBN for palliative care. There is a notebook on the shelves in NBN with birth plans for these infants, as well as general palliative care information. It is a good idea to review this notebook and check the calendar during your time in the nursery to see if there are any of these deliveries pending. You may also review the nursing policy “Palliative Care of the Dying Infant”
· We are promoting intern continuity and family satisfaction by having the newborn interns see all follow up newborn visits in your clinic in place of a standing clinic day during your rotation. As we prepare for clinic to move off site we may make adjustments to how the intern NBN/clinic follow up schedule will work in the coming months. Please help us by being flexible J Use the newborn time to establish relationships with families and build your patient panel. Families with older children who are already established with another resident can also be scheduled with that person if a slot is open at the appropriate time. Work as a team to optimize patient care!
Pearls:
- Overnight- Please leave specific information regarding patients that need overnight follow up on the “Newborn Overnight” list. Please develop a plan and clearly state this in your sign out to the Hosptialist. Please be sure to check the list every morning and delete your patients after you have read the overnight developments. Please add all information to the list prior to 5:30. You are encouraged to contact the hospitalist for complicated issues (ie Palliative care)
· Call – there is no formal call for interns on the NBN rotation. If a child becomes ill overnight, the attending physician or Hospitalist will be notified.
· Please add your babies from the UNC Newborn Nursery list to the Newborn Resident List. This allows you to leave sign out to your fellow interns and the NPs regarding your patients. Sign out should go in Primary Team Sticky Note
· The newborn nursery has a well-stocked library—use it!
· UNC Newborn Nursery curriculum page can be found at https://pediatrics.med.unc.edu/education/current-residents/rotation-information/newborn-nursery PASSWORD is uncpeds
· Bring a stack of your business cards during your rotation to share with families who will be coming to your clinic.
Please ASK if you have questions. You are here to learn, not just work!! We want you to enjoy your time with us in the newborn nursery. Please let your attending or Dr. Seashore () know if you are having any problems.