Welcome to UVA Well Newborn and Breastfeeding Medicine Services 2015!
Dear New Pediatric and Family Medicine Residents,
As you begin to settle in to your new role at UVA Hospital, we wanted to make sure you are aware of a few very important resources available to you both on the Newborn rotation and elsewhere in the Health System to help you care for newborns and breastfeeding babies. These are things should be of use to you no matter what rotation you are on, and especially as you are working in the NICU covering newborns at night! Please take a moment to read through this information to help make sure you are off to a great start.
1) The Newborn Rotation
a. Diverse population—Medicaid, Private Insurance, non-English-speaking, Doctors, Professors, Community Leaders, Immigrants
b. The interns follow their own patients and function as a leader/educator on the team for third and sometimes fourth-year medical students
c. 2 Nurse Practitioners—coverage 6/7 days/week: Mary Jane Jackson and Diane Drame; serve as liaisons with nursing staff; continuity of care resources; will round on patients if more than 7 on one-intern days, or more than 14 on two-intern days; work on quality improvement projects; cover when you are in clinic for newborn follow-ups or continuity clinic
d. Hospital-medicine exposure—Newborn Medicine is a subset of Hospital Medicine and tends to be very protocol-driven (ex. There are protocols for Admission, glucose, bili, Neonatal Abstinence Syndrome, GBS, Later pre-term, etc.), and we utilize a continuous quality improvement model. See below for links to key protocols.
e. We have the highest patient turnover of any unit in the hospital, so much effort is made to ensure patients have the best quality experience while also keeping important items from falling through the cracks
f. We are starting the baby’s newborn medical record that will follow them to the PCP and beyond and strive to make the transition to their outpatient PCP as smooth as possible
g. We are “Baby Friendly” (a World Health Organization/UNICEF certification) and practice evidence-based, family-centered maternity care
h. There are multiple quality improvement project and research opportunities for those who may be interested. Contact Ann Kellams, MD for more information.
i. We function as a Multidisciplinary team: Nursing, Shift Manager, NICU, OB, Anesthesia, Social Work, Lactation consultants, Subspecialties
j. There are opportunities to get exposure/learn certain procedures such as frenotomies and circumcisions—let us know if you are interested and we will do our best to try to arrange these experiences
k. General Pediatric Attendings attend on the service and cover questions from the NICU night coverage team at night. We are present in the mornings for rounds and teaching and then have other responsibilities, but are always available by phone. The afternoons are an opportunity to have some autonomy, attend deliveries, do follow-up visits, and teach the medical students.
2) Newborn Follow-Up visits
a. As part of your newborn rotation, you will have two time slots per day in the Birdsong Pediatric Clinic in the Battle Building to see newborns who have just been discharged from the hospital
3) UVA Breastfeeding Medicine Program
a. There is 7 day/week lactation consultant coverage for the mother-baby and NICU units
b. We also have a Breastfeeding Medicine clinic in the Battle Building on weekdays that sees mothers and babies with a lactation consultant and a pediatrician, call 2-3316 to arrange or call the hospital operator and ask for Breastfeeding Medicine
c. We do inpatient consults for mothers or babies admitted anywhere else in the hospital, pager 1636, and order consult in Epic
d. Depending on availability, a lactation consultant can come to the Battle Pediatric clinic if you are seeing a family that is in need of help, page 1636. If we are unable to see them at that moment, we can arrange to speak with the mother by phone and/or to get them into the Breastfeeding Medicine clinic
e. We will soon be providing a NICU follow-up home visit for a breastfeeding evaluation, within a certain radius, with a pediatrician and a lactation consultant
f. IF you are interested in becoming an IBCLC or Internationally Board-Certified Lactation Consultant by then end of your training, contact Dr. Ann Kellams for more information
g. We strive to educate mothers prenatally and upon admission about the recommendation to breastfeed and also to try to avoid unnecessary formula use. It is normal for all mothers to worry about feeding their baby and whether they are making enough milk. The baby going to breast often is what tells the mother’s body to make more milk. If you get called about a family requesting formula at night, please try using motivational interviewing techniques, make sure the family is informed about whether or not there is a medical need for supplementation, why we would or would not recommend it at that time, and if they are going to use formula, how we would suggest doing a small amount and pumping when formula is used, and using an alternate method like cup, spoon, or syringe
h. About 80% of mothers at our hospital initiate breastfeeding, but there is a steep drop-off in the first two weeks. We need to be doing more to help mothers get through what can often be a bit of a bumpy start! It is very rare to truly not be able to produce enough milk, and breastfeeding should not be uncomfortable for mother or baby. Encourage them to get help, watch a feeding, assist with getting baby’s tummy more against mom, nipple aiming toward baby’s nose, wider mouth, etc.
i. Encourage all mothers of infants to watch for feeding cues in their babies and feed on demand
4) Deliveries and Calls for Assistance
a. If mom and baby are stable, the baby does not need to come to the warmer even if the NICU team was called to attend the delivery.
b. Please review the Delivery Response plan: (http://www.healthsystem.virginia.edu/docs/manuals/guidelines/womens-place-policies-protocols-guidelines/i-inpatient-womens-services/neonatal-care-l-d-and-newborn-nursery/newborn-delivery-team-response-plan/at_download/currentfile)
c. We practice skin-to-skin contact after delivery regardless of the mode of delivery; it should begin within 5 minutes and proceed for at least an hour and until after the first feeding. This is the “power hour.” All routine care and assessments like vitals and APGARS should be done on the mother’s chest.
d. Safe skin-to-skin involves someone observing the baby if mother is drowsy and making sure face and nose are clear and baby is pink and breathing comfortably.
5) Resources
a. The Newborn Intranet Site (http://www.healthsystem.virginia.edu/pub/newborn-nursery)
i. Orientation Manual
ii. A couple important videos
iii. Important articles and AAP statements
iv. Links to helpful websites
b. Newborn Policies and Procedures http://www.healthsystem.virginia.edu/newdocs/manuals/guidelines/womens-place-policies-protocols-guidelines
c. Bilitool: http://bilitool.org/
d. Bhutani curve for plotting bilirubins: http://newborns.stanford.edu/BhutaniNomogram.html
e. Kaiser Newborn Sepsis Calculator: http://newbornsepsiscalculator.org/
f. Newborn Admission Guidelines and other protocols: http://www.healthsystem.virginia.edu/docs/manuals/guidelines/womens-place-policies-protocols-guidelines#section-8
g. Newbornweight.org Newborn weight curves for vaginal and c-section deliveries
6) GME Milestones covered on Newborn Rotation:
1. Gather essential and accurate information about the patient—for newborns, this means a thorough review of the prenatal record/mother’s chart whether electronic, paper, or both
2. Organize and prioritize responsibilities to provide patient care that is safe, effective, and efficient—for newborns this means recognizing sick vs. not sick, red flags in the prenatal record, and learning to supervise medical students; it also means streamlining discharges and ensuring discharge prepping the day before
3. Provide transfer of care that ensures seamless transitions—for newborns, this means excellent communication with OB, nursing, night team, NICU, and infant’s PCP
4. Identify strengths, deficiencies, and limits in one’s knowledge and expertise—for newborn, this the only rotation in first-year without a senior resident, the residents must know when to ask questions, call the attending, double-check information, and supervise the medical students
5. Identify and perform appropriate learning activities to guide personal and professional development—for newborn, this means reviewing the Newborn Intranet sight, looking up information related to the care of your patients, completing the pre-test, self-assessment, and newborn screening activities in the packets, attending morning report, noon conferences, and grand rounds, and asking questions when you are unsure
6. Communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds—for newborns we see a huge racial, economic, and educational diversity and are charged with ensuring that they all leave the hospital knowing how to safely care for their babies
7. Professionalism—a sense of duty and accountability to patients, society, and the profession—for newborn, this means conscientious care of your patients and their families, careful sign-out at hand-off of care, assuming the ultimate responsibility for what occurs during their stay with the back-up of the attending, and thinking about health and prevention from a public health perspective as you screen for conditions and educate families to help keep them well
8. Trustworthiness that makes colleagues feel secure when one is responsible for the care of patients—for newborn, again, there is no senior resident, so it falls on the newborn resident to assimilate all information on their patients and communicate it to team members
9. Coordinate patient care within the health care system relevant to their clinical specialty—for newborns, this means starting the newborn’s medical record with family history and birth history and ensuring adequate documentation of prenatal history and hospital course
10. Work in inter-professional teams to enhance patient safety and improve patient care quality—for newborns this means keeping the sign-out and orders up-to-date and coordinating with nursing, NICU, OB, lactation, social work, any consultants, and the infant’s PCP
Again, Welcome! We look forward to working with you and taking great care of the mothers and babies in our Health System. Please let us know if there is anything we can do to make your experience more meaningful or enjoyable.
~The Newborn and Breastfeeding Medicine Team 2015-2016