Inpatient Experiences

RNICU OBJECTIVES AND GOALS

The Sub-Specialty Resident completes a month-long rotation in the RNICU.
The Sub-Specialty Resident assists the attending physician in the supervision, teaching, and evaluation of the two residents and any medical students assigned to service.
The Sub-Specialty Resident is responsible for the supervising of all patients assigned to the residents in lieu of themselves being assigned to specific patients.
The Sub-Specialty Resident participates in the management and discussion of patients with the attending physician during rounds.
Throughout the day, the Sub-Specialty Resident participates in stabilizing admissions to the RNICU, order writing, diagnostic and therapeutic procedures, troubleshooting, and delivery room resuscitation.
 All surgical pre- and post-operative management is by the neonatal team with advice from the pediatric surgeons.

 

 The on-call sub-specialty resident is on-site with one of the residents and shares the same responsibilities with the addition of having a supervisorial role.

 

CORE SKILLS TO BE MASTERED

Core competencies listed in brackets as follows: Patient Care [PC], Medical Knowledge [MK], Interpersonal and Communication Skills [ICS], System-Based Practices [SBP], Professionalism [P], Practice-Based Learning and Improvement [PBLI].

 

BY END OF YEAR 1:

Fellows are responsible for mastering the management of straightforward disorders of neonatology, including respiratory distress syndrome, fluid and electrolyte abnormalities, sepsis, jaundice, feeding disorders, seizures, etc. [PC, MK].

Their responsibilities include the stabilization and instrumentation of sick neonates (surfactant administration, intubation, umbilical line insertion, spinal and bladder taps, chest tube insertion, etc.) [PBLI, PC].
The Fellows are expected to learn the indications and contraindications for the common modes of assisted ventilation including synchronized ventilation, assist control, high-frequency oscillatory ventilation, volume ventilation, time cycled and pressure regulated modes, CPAP with and without SNIPPV, SiPAP, NAVA, and high and low-flow nasal cannula in neonates [PC, MK, PBLI].
Fellows should become experienced in the use of nitric oxide and ventilator management of persistent pulmonary hypertension. Become familiar with non-ventilatory management of PPHN (blood pressure support, renal monitoring, cardiac support, head/body cooling, etc. [PC, MK].
Fellows should master delivery room/perinatal stabilization of low birth weight, very low birth weight, extremely low birth weight infants and infants with malformations [PC, MK, ICS, P].

 

They should also master the initial management of extremely low birth weight infants, including the principles of thermal and fluid regulation [PC, MK].
Subspecialty residents should become familiar with the utility and limitations of antenatal ultrasound, cord blood gasses, and other diagnostic and fetal monitoring modalities [PC, MK].
They should understand the benefits of breast milk feeding and ways of supporting mothers desiring to breastfeed. They should know the more common medications the cross the breast milk and learn to counsel parents accordingly. [MK, PC, ICS].
Fellows should develop skills as a counselor for families with impending delivery of preterm infants and of infants with prenatally diagnosed conditions [MK, PBLI, ICS, P].
They should become familiar with concepts of individually based developmental care in the NICU environment, and its impact on outcome [PC, MK, PBLI].
They should recognize and manage disorders in the newborn arising from legal and illegal substance abuse by the mothers [PC, MK, ICS, SBP, P].
 Residents must learn the basic use of electronic medical record-keeping and web-based learning programs [SBP, PBLI, MK].
 They must also learn to interact in a constructive way with a variety of health-care workers on the patient management team [P, SBP, ICS, PC, PBLI].

 

BY END OF YEAR TWO:

By the end of year 2, the Fellows should continue to master and improve on all the previously mentioned skills [MK, PC, P, ICS, PBLI, SBP].
Fellows should develop the skills and philosophies designed to prevent long-term complications of prematurity, including bronchopulmonary dysplasia, retinopathy of prematurity, nutritional rickets, necrotizing enterocolitis, and infections [MK, SBP, PC, PBLI]. 
They should become knowledgeable about the impact of antepartum and intrapartum conditions affecting pregnant women (e.g. diabetes, congenital heart disease, and autoimmune disorders) on the fetus [MK, PC].
They should become familiar with the management of common surgical problems arising in the neonatal period, including the pre-, peri- and post-operative care of such infants [PC, MK, PBLI].
They should further develop skills as a teacher of neonatal-perinatal physiology and pathophysiology to medical students and residents and other health care workers [MK, ICS, PBLI].
Their knowledge base should expand to develop skills as a diagnostician of genetic, polygenic and environmentally-induced malformation syndromes, including immediately life-threatening birth defects, such as craniofacial anomalies and neural tube defects [MK, ICS, PC].
They should become knowledgeable about the effects of maternally administered medications on the fetus and newborn infant [MK, PC, ICS].
They should be able to independently manage all problems related to special nutritional needs of low birth weight, very low birth weight and extremely low birth weight infants during the first months of life.  This includes the strengths and limits of human milk and complications of parenteral nutrition [MK, PC].
They should be prepared to provide the relevant information, to assist and support families in making informed decisions regarding the care of critically ill newborns within the ethical and legal constraints of the community [P, PC, SBP, ICS].
They also should be familiar with the art of subspecialty consultation by telephone and in person, including consultation with obstetricians, pediatricians, and family practice physicians about common issues of perinatal management [P, MK, ICS, SBP].
Finally, they should begin to have the training and experience to understand true evidenced-based practice and be able to critically read and bring to practice appropriate new care practices [PBLI].

 

 

 BY END OF YEAR 3:

By the end of year 3, the Fellows should continue to master and improve on all the previously mentioned skills [MK, PC, P, ICS, PBLI, SBP].
In addition, the Fellows should become familiar with principals of extracorporeal membrane oxygenation (EMO), including indications, risks, and short-term and long-term outcomes associated with the use of ECMO, including safe preparation for transport of patients /MK, PC/.
The Fellows should become experienced in the diagnosis and management of cardiac problems arising in the newborn period, including the pre- and post-surgical care of such infants [MK, PC, SBP, PBLI].
They should be able to independently manage and act as team leader, for all problems arising in the delivery suite [PC, MK, ICS, P].
They should become expert at the utility and pitfalls of the legally mandated newborn screening program and prudent use of community recourses for follow-up and management of infants with abnormal test results [ICS, SBP, MK].
Fellows should understand costs of care – actual and projected, and of care expected to be needed in the future including the role of private health insurance companies and government-sponsored agencies like Medicaid, Medicare and Children’s Special Health Care Services [SBP].
They should become expert at recognizing the unique problems of neonatal transport by land [SBP, MK, PC].
Finally, they should become skilled and charismatic teachers to allied health professionals, medical students and residents [ICS, P, PBLI].



Faculty Supervision

All faculty working with neonatal fellows are required to do the following:

  • Provide direct supervision for all fellows during any inpatient or outpatient clinical activities. This includes daily rounding, key procedures, and neonatal resuscitation skills.
  • Be available as backup for any questions or crises when on-call.
  • Foster in Fellows critical thinking skills and independent decision-making processes.
  • Help senior Fellows resolve issues of workload and clinical care, as necessary.
  • Provide Fellows with constructive feedback while identifying specific areas of improvement, and developing methods to improve the Fellows' performance.
  • Address any patient care, clinical decision-making, and basic knowledge concerns directly related to the Fellows.
  • Model professional behavior in any interactions with trainees, medical staff, patients, families, and colleagues.
  • Provide research training to fellows, including direct mentoring, teaching biostatistics, research design, ethical concerns, technical procedures, and critical thinking.
  • Review evaluations with fellows.