New Application: Neonatal-Perinatal Medicine

New Application: Neonatal-Perinatal Medicine

Review Committee for Pediatrics

ACGME

COMMON SUBSPECIALTY SECTION

Institutions

Using the table below, provide a summary of the program’s leadership and support staff, including the name and percent FTE protected time. 1.0 FTE is greater than or equal to 40 hours per week. Add rows as needed. [PR I.A.2.-3.]

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Program Leadership / Name / % FTE Protected Time for the Administration of the Program (excluding Scholarly Activity)
Program Director / Name / #%
Associate Program Director(s) / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Title / Name / #%
Administrative/Support Personnel / Number of Administrative Personnel / % FTE in This Fellowship Program for Each
e.g., Fellowship Coordinator / 1 / 100%
e.g., Administrative Assistant / 1.5 / 100%/50%
Title / # / #%
Title / # / #%
Title / # / #%
Title / # / #%
Title / # / #%

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Faculty Research

Complete the table below regarding the involvement of faculty members in research. Add rows as needed. [PR II.B.5-5.b).(3); II.B.5.f)-f).(2)]

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Name / # of Current IRB-Approved Research Projects / Total # of Current Funded Research Projects / # of Current Research Projects with Peer-Review Funding (Subset of Total # in Previous Column) / # of Presentations at National Scientific Meetings in Last 5 Years / # of Publications in Peer-Review Journals in Last 5 Years
Program Director:
Name / # / # / # / # / #
Physician Faculty Members within the Program Subspecialty (e.g., for a Pediatric Gastroenterology Program, Only List the Pediatric Gastroenterology Faculty Members):
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Non-Physician Research Mentors or Physician Faculty Members from Other Subspecialties:
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #
Name / # / # / # / # / #

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2.List active research projects in the subspecialty. Add rows as needed. [PR II.B.5.-5.b).(3); II.B.5.f).(1)-(2)]

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Project Title / Funding Source / Place An "X" if Funding Awarded by Peer Review Process / Years of Funding (Dates) / Faculty Investigator and Role in Grant (i.e., PI, Co-PI, Co-Investigator)
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /
Project title / Funding source / ☐ / Years of funding / Faculty investigator/role in grant /

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Research Resources

1.Does the program provide research laboratory space and equipment?...... ☐ YES ☐ NO

2.Does the program provide financial support for research?...... ☐ YES ☐ NO

3.Does the program provide computer and statistical consultation services?...... ☐ YES ☐ NO

Program Curriculum

Goals and Objectives

Are there goals and objectives for all training experiences? [PR IV.A.2.] / ☐ YES ☐ NO
Are these rotation- and level-specific? [PR IV.A.2.] / ☐ YES ☐ NO
How are they distributed? [PR IV.A.2.] / ☐ Hard copy ☐ Electronic or web-based
If not web-based, when are they distributed to fellows? [PR IV.A.2.] / ☐ Prior to each rotation☐ Annually
☐ Once in handbook☐ Other
If not web-based, when are they distributed to faculty members? [PR IV.A.2.] / ☐ Prior to each rotation
☐ Annually
☐ Other
If web-based, are reminders sent to access them? [PR IV.A.2.] / ☐ YES ☐ NO
If YES, when are the reminders sent? [PR IV.A.2.] / Click here to enter text. /

Collaboration among Programs

Are there meetings among the core program director and subspecialty program directors? [PR II.A.4.s)] / ☐ YES ☐ NO
How often do these meetings occur? [PR II.A.4.s).(1)] / Click here to enter text. /
Who typically participates in these meetings? (check all that apply) [PR II.A.4.s)] / ☐ Core program director
☐ Subspecialty program director for this specialty
☐ Program directors from other subspecialties

General Subspecialty Curriculum

Topic / Where Taught in Curriculum (Name Should Match Name in Conference List) / Number of Structured Teaching Hours Dedicated to Topic Area / Participants (Place An "X" in the Appropriate Column)
Fellows in this Discipline Attend / All Subspecialty Fellows Attend / Residents and Subspecialty Fellows Attend
e.g., Biostatistics / Research Course / 14 / X
Basic science as related to the application in clinical subspecialty practice [PR IV.A.6.a).(3)] / Click here to enter text. / # / ☐ / ☐ / ☐
Clinical subspecialty content [PR IV.A.6.a).(3)] / Click here to enter text. / # / ☐ / ☐ / ☐
For the topics below, if the topic is not appropriate for the discipline (e.g., lab research for fellows in developmental behavioral pediatrics), enter N/A in Column 2 (Where Taught…).
Biostatistics [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Lab research methodology (if appropriate) [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Clinical research methodology [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Study design [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Grant preparation [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Preparation of protocols for Institutional Review Board [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Principles of evidence-based medicine/critical literature review [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Quality improvement [PR IV.A.6.a).(6)] / Click here to enter text. / # / ☐ / ☐ / ☐
Teaching skills [PR IV.A.5.b).(1)] / Click here to enter text. / # / ☐ / ☐ / ☐
Professionalism/ethics [PR IV.A.5.e] / Click here to enter text. / # / ☐ / ☐ / ☐
Cultural diversity [PR IV.A.5.e).(5)] / Click here to enter text. / # / ☐ / ☐ / ☐
Systems-based practice (economics of health care, practice management, clinical outcomes, etc.) [PR IV.A.5.f)] / Click here to enter text. / # / ☐ / ☐ / ☐

Conferences

1.List regular subspecialty and interdepartmental conferences, rounds, etc. that are a part of the program. Identify the "Site" by using the corresponding number as it appears in the Accreditation Data System (ADS) portion of the application. Indicate the frequency (e.g., weekly, monthly) and whether conference attendance is required (R) or optional (O). List the planned role of the fellow in this activity (e.g., conducts conference, presents case and participates in discussion, case presentation only, participation limited to Q&A component). Add rows as needed. [PR IV.A.6.a).(2)-(4)]

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Conference / Site # / Frequency / Attendance Required (R) or Optional (O) / Role of the Fellow
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /
Conference / Site # / Frequency / ☐R
☐O / Role of fellow /

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2.Describe the mechanism that will be used to ensure fellow attendance at required conferences. State the degree to which faculty member attendance is expected, and how this will be monitored. [PR IV.A.6.a).(2)]

(Limit response to 50 words)

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Scholarship Oversight Committee

1.Will there be a Scholarship Oversight Committee for every fellow? [PR IV.B.2.b)]...... ☐ YES ☐ NO

2.If YES, how often will the committee meet with the fellow? [PR IV.B.2.b)]...... # times per year

Fellow Research Activities

1.Describe how the program will ensure a meaningful supervised research experience for fellows beginning in their first year and extending throughout their training. [PR IV.B.2.a)]

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2.Identify any research mentors outside the division that will be actively involved in mentoring fellows, and describe how liaisons will be used between these mentors and the fellows to allow for meaningful accomplishment of research. [PR IV.B.2.c)]

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The Learning and Working Environment

Night Float/Night Shift

If the program requires night experiences, indicate the frequency of these experiences each year, and describe how they are structured to ensure educational value to fellows. [PR VI.F.6.a)]

(Limit response to 200 words)

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SPECIALTY-SPECIFIC SECTION

Program Personnel and Resources

Other Professional Personnel [PR VIII.B.]

Indicate with a check mark the personnel who will interact regularly with fellows at each participating site. [PR: VIII.B.]

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Team Members / Site #1 / Site #2 / Site #3
Respiratory therapists assigned to NICU / # / # / # /
Pathologists skilled in placental and perinatal pathology / # / # / # /
Mid-level providers (NNPs, PAs, etc) / # / # / # /
Nutritionists skilled in the management of enteral and parenteral nutrition / # / # / # /
Physical and occupational therapists skilled in developmentally appropriate care and feeding problems / # / # / # /
Specialists in the assessment of hearing in infants / # / # / # /

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For categories of personnel that are unavailable, describe how that function will be addressed in the program.

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Faculty Disciplines for Pediatric Subspecialties

In the table below, indicate the number of faculty that are present in each of the required disciplines [PR: II.B.2.e)-II.B.2.e).(2); VII.A.; VIII.A.2.a; VIII.A.3.a)]:

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Discipline / Number of Essential Faculty
Site #1 / Site #2 / Site #3 / Site #4 / Site #5
PEDIATRIC SUBSPECIALTIES
Pediatric cardiology / # / # / # / # / # /
Pediatric critical care medicine / # / # / # / # / # /
Pediatric emergency medicine / # / # / # / # / # /
Pediatric endocrinology / # / # / # / # / # /
Pediatric gastroenterology / # / # / # / # / # /
Pediatric hematology/oncology / # / # / # / # / # /
Pediatric infectious diseases / # / # / # / # / # /
Pediatric nephrology / # / # / # / # / # /
Pediatric pulmonology / # / # / # / # / # /
Pediatric rheumatology / # / # / # / # / # /
SPECIFIC TO NEONATAL-PERINATAL MEDICINE
Anesthesiology / # / # / # / # / # /
Thoracic surgery / # / # / # / # / # /
Child and adolescent psychiatry / # / # / # / # / # /
Neurology with specialty qualification in child neurology / # / # / # / # / # /
Maternal-Fetal Obstetrics / # / # / # / # / # /
Medical Genetics / # / # / # / # / # /
Neurodevelopment Disabilities / # / # / # / # / # /
Neurological surgery / # / # / # / # / # /
Ophthalmology / # / # / # / # / # /
Orthopaedic Surgery / # / # / # / # / # /
Otolaryngology / # / # / # / # / # /
Pathology-Anatomic and Clinical / # / # / # / # / # /
Pediatric Radiology / # / # / # / # / # /
Pediatric surgery / # / # / # / # / # /
Urology / # / # / # / # / # /

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Facilities and Resources [PR VIII.C.]

Indicate whether the following services are available:

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/ Site #1
(Yes/No) / Site #2
(Yes/No) / Site #3
(Yes/No)
Available 24 hours a day
Portable x-ray
[PR VIII.C.1.a).(1)] / Choose an item. / Choose an item. / Choose an item. /
Ultrasound imaging
[PR VIII.C.1.a).(1)] / Choose an item. / Choose an item. / Choose an item. /
ECG
[PR VIII.C.1.a).(1)] / Choose an item. / Choose an item. / Choose an item. /
Neonatal echocardiography
[PR VIII.C.1.a).(1)] / Choose an item. / Choose an item. / Choose an item. /
EEG and interpretive services
[PR VIII.C.1.a).(1)] / Choose an item. / Choose an item. / Choose an item. /
Microchemistry and hematology laboratories
[PR VIII.C.3.a)] / Choose an item. / Choose an item. / Choose an item. /
Blood gas analysis
[PR VIII.C.3.b)] / Choose an item. / Choose an item. / Choose an item. /
Diagnostic bacteriology and virology laboratories
[PR VIII.C.3.e)] / Choose an item. / Choose an item. / Choose an item. /
Blood Bank
[PR VIII.C.3.f)] / Choose an item. / Choose an item. / Choose an item. /
Accessible CT and/or MRI facilities
[PR VIII.C.3.g)] / Choose an item. / Choose an item. / Choose an item. /
Available in a reasonable time
Screening laboratory for inborn errors of metabolism
[PR VIII.C.4.a)] / Choose an item. / Choose an item. / Choose an item. /
Clinical toxicology laboratory
[PR VIII.C.4.b)] / Choose an item. / Choose an item. / Choose an item. /
Nuclear medicine facilities
[PR VIII.C.4.c)] / Choose an item. / Choose an item. / Choose an item. /
Cytogenetics laboratory
[PR VIII.C.4.d)] / Choose an item. / Choose an item. / Choose an item. /
Audiology services
[PR VIII.C.4.e)] / Choose an item. / Choose an item. / Choose an item. /
Pathology services, including those for evaluation of placental pathology
[PR VIII.C.3.d)] / Choose an item. / Choose an item. / Choose an item. /

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Neonatal Intensive Care Unit (NICU) Data

Provide patient data for the most recent 12-month period for which records can be obtained. Note the same timeframe should be used throughout the forms.

Inclusive Dates: / From: Click here to enter a date. / To: Click here to enter a date.

Indicate the availability of the following at each of the sites participating in the program. Use the appropriate response (i.e., a number or yes/no answer):

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Site #1 / Site #2 / Site #3
1.Number of births per year / # / # / # /
2.Number of neonatal ICU admissions per year / # / # / # /
a)Number of admissions in NICU. Of these, how many had a birth weight< 1500 grams / # / # / # /
b)Number of admissions in NICU. Of these, how many had a birth weight < 1000 grams / # / # / # /
c)Number of admissions inborn / # / # / # /
d)Number of patients outborn/transported / # / # / # /
3.Average daily census in NICU: / # / # / # /
4.Average Length of Stay in NICU / Length / Length / Length /
5.Number of patients requiring ventilatory support: / # / # / # /
a)CPAP only (without mechanical ventilation) / # / # / # /
b)Ventilator / # / # / # /
c)Extra corporeal membrane oxygenation (ECMO) / # / # / # /
6.Number of neonatal surgical cases / # / # / # /
a)cardiac / # / # / # /
b)general / # / # / # /
7.Total number of residents in NICU (excluding neonatology fellows) during a block rotation / # / # / # /
a)Number of pediatric residents / # / # / # /
b)Number of other residents / # / # / # /
c) Number of primary, non-resident providers / # / # / # /

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2.If all or most admissions are outborn/transported, explain how fellows will obtain sufficient experience in resuscitation and stabilization for deliveries.

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3Provide the following information for the most recent 12-month academic or calendar year for each site used to provide a specific required experience, such as transplant, cardiology, intensive care, etc. Duplicate this table as necessary.

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Site #1 / Site #2 / Site #3
Name of service: / Click here to enter text. /
Total number of fellows and residents on the service / # / # / # /
Total number of admissions to the service / # / # / # /
Number of new patients admitted each year (“new” refers to those who are seen by members of the service for the first time.) / # / # / # /
Average length of stay of patients on the service / Length / Length / Length /
Average daily census of patients on the service, including consultations / # / # / # /

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List of Diagnoses

List 100 consecutive admissions. Identify the time period during which these admissions occurred. The date range should occur within the same 12-month period used in previous sections. The dates must begin on the date the first patient on the list was admitted, and end with the date the 100th patient was admitted, (e.g., July 1, 2014 through October 20, 2014). Submit a separate list for each site that provides required rotations. Duplicate tables as necessary.

Site Name: / Click here to enter text. /
Total number of patients admitted in most recent 12-month period / # /
Inclusive Dates: / From: Click here to enter a date. / To: Click here to enter a date.

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Patient ID / Number of days in Hospital / Up to three most significant Discharge Diagnoses
Number / Gestational Age / Birth Weight
# / Age / Weight / # / Click here to enter text. /
# / Age / Weight / # / Click here to enter text. /
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# / Age / Weight / # / Click here to enter text. /
# / Age / Weight / # / Click here to enter text. /

Neonatal-Perinatal MedicineUpdated 4/2016

Outpatient Experiences [PR VIII.C.6.]

Provide the following information for the same 12-month period. The date range should occur within the same 12-month period used in previous sections.

Inclusive Dates: / From: Click here to enter a date. / To: Click here to enter a date.

Indicate the following at each of the sites participating in the program. Use the appropriate response, (i.e., a number or yes/no answer)

Clinic Data
Is there a NICU follow-up clinic for patients discharged from the NICU? Yes or No / Choose an item. /
Number of NICU follow up clinic sessions per week: / # /
Number of NICU follow up visits per year: / # /
Year 1 / Year 2 / Year 3
Number of NICU high-risk follow-up clinics a subspecialty fellow attends while in the program: / # / # / # /
Average number of NICU follow up patients per fellow per session: / # / # / # /

If there is no separate NICU follow up clinic, explain below where the NICU follow up patients are seen (e.g., offices, clinics)? If the experience is in a private office, provide full details including name and credentials of supervisor, numbers and types of patients, degree of fellow responsibility for their care and how the director will monitor the experience and fellow performance.

Limit response to 250 words

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Describe how and by whom the fellows will be supervised during the provision of outpatient care, and identify the way in which the program ensures that the NICU follow up clinic has staff with expertise in performing developmental assessments and skilled neonatal or pediatric faculty as teachers.

Limit response to 250 words

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Inpatient Experiences

1.Describe the responsibilities the fellows will have for inpatients when assigned to inpatient services.

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2.Describe how and by whom the fellows will be supervised in the inpatient setting.

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3.Explain how fellows will be directly involved in the care of critically ill surgical patients to acquire the requisite knowledge and skills to attain competence in evaluation, diagnosis and pre/post operative management of such patients. Also describe the coordination of care between the pediatric surgeons and the neonatologists concerning the management of medical problems in these patients. [PR IX.A.1.]