Neonatal Intensive Care Unit
Goals and Objectives
The goal of the MGH NICU rotation is to develop the ability of residents to evaluate and manage critically ill infants with a broad range of medical and surgical problems. The rotation is based in an 18-bed level III neonatal intensive care unit. Learning will occur in a multidisciplinary team-based system. Residents will be the primary caregivers for their patients, under the close supervision of staff neonatologists and intensive care fellows. The objectives of this rotation are designed to further the residents’ development of competency in the following six areas:
I. Patient Care
II. Medical Knowledge
III. Practice-Based Learning and Improvement
IV. Interpersonal and Communication Skills
V. Professionalism
VI. Systems-Based Practice
I. Patient Care
Residents will take a detailed perinatal history when possible, review the prenatal records, and perform a complete infant physical examination upon the patient’s admission. After evaluating the patient, they will formulate a differential diagnosis and plan appropriate diagnostic and therapeutic interventions, in coordination with the attending neonatologist, intensive care fellow, respiratory therapist, and primary neonatal nurse.
Through thoughtful review of diagnostic results and frequent reassessment of the patient, residents will reconsider the clinical status of the patient, along with the differential diagnoses on a continuing basis, making changes to management plans as appropriate.
At all times, it is the residents’ responsibility to educate and work with the patient and family, maintaining a strong therapeutic alliance.
Residents will be mindful of routine health care maintenance for infants under their care. They will order Massachusetts newborn screening, hearing screens, active and passive immunizations, car seat testing , and ophthalmologic examinations as indicated.
As medically indicated, residents will perform appropriate diagnostic and therapeutic procedures after obtaining informed consent from the patient and/or family, with supervision from the attending neonatologist and intensive care fellow. Residents will document procedures in the chart and in their personal logbooks. On this rotation, these may include:
- arterial puncture
- endotracheal intubation
- intravenous catheter placement
- lumbar puncture
- thoracentesis and chest tube insertion
- umbilical catheter placement
- venipuncture
II. Medical Knowledge
Residents will draw from the wide range of patient diagnoses requiring admission to a level III neonatal intensive care unit to broaden their exposure to a wide range of complex disease processes. In developing a differential diagnosis, the resident will demonstrate his ability to apply analytical thinking to the clinical situation.
The patient population at this referral center is based on a high-risk metropolitan obstetrical service, as well as infants transferred from outside hospitals for higher levels of care, including nitric oxide therapy, extracorporeal membrane oxygenation, specialized ophthalmologic surgery, and pediatric surgical interventions.
During this rotation, it is expected that residents will manage infants diagnosed with, but not limited to:
- Congenital abnormalities
- Congenital pneumonia
- Hyperbilirubinemia
- Meconium aspiration
- Necrotizing enterocolitis
- Neonatal infectious diseases caused by bacteria, viruses, and parasites
- Persistent pulmonary hypertension of the newborn
- Pneumothorax
- Prematurity (including apnea of prematurity, retinopathy of prematurity)
- Respiratory distress syndrome
Residents will learn about the principles and application of parenteral and enteral nutrition, as well as fluid and electrolyte therapy in neonates.
Residents will work with respiratory therapists and other team members to manage conventional and high frequency mechanical ventilation of sick neonates.
III. Practice-Based Learning and Improvement
In caring for patients, residents will utilize a broad range of published medical information available through web-based resources, as well as print textbooks and the hospital library. It is expected that decisions about patient care will be informed by review, synthesis and application of studies available in the literature. Daily work rounds will include discussion of information gathered from the literature by residents and other team members.
Residents will attend regular lectures on topics important to the care of neonates given by the neonatology staff.
Residents will take part daily in radiology rounds, reviewing radiologic imaging of their patients with pediatric radiology attendings and the neonatology team.
All residents will take an active role teaching fourth year Harvard and visiting medical students rotating on the neonatology service.
IV. Interpersonal and Communication Skills
Residents will take part in daily collaborative interdisciplinary team rounds. They will provide innovative, state-of-the-art clinical care through a collaborative team of neonatologists, neonatology and intensive care fellows, neonatal nurse practitioners, neonatal nurses, respiratory therapists, pharmacists, medical students, social workers, dietitians, lactation specialists, occupational and physical therapists, chaplains and other support staff.
Residents will meet regularly with parents to listen to their concerns and keep them updated on their child’s condition and care plan.
Residents will coordinate consult services and facilitate discussion among clinician members of the team and the family.
Daily notes in the chart clearly documenting patients’ progress, diagnostic results and ongoing plan will be completed in order to maintain an accurate medical record and share information among team members. When leaving the rotation, an off-service summary will be prepared and made part of the medical record.
Residents will provide feedback to their co-residents, students and attendings on an ongoing basis throughout the rotation, completing written evaluations at the completion of the rotation. Similarly, they will receive regular verbal feedback and a final written evaluation from the attending neonatologist that will be placed in their permanent record. Residents will use constructive feedback to guide their efforts in ongoing learning and self-improvement.
V. Professionalism
Residents will interact with an extremely ethnically and socio-economically varied patient population that is treated in this referral intensive care unit. Patients will include those living in local communities, as well as those delivered at MGH because of high-risk pregnancies and those transferred for complex disease of the neonate. Residents will care for patients independent of their ability to pay for services.
Residents will provide compassionate, empathic and culturally sensitive communication with parents. They will be particularly sensitive to the unique situation of parents of premature or severely ill infants. They will demonstrate sensitivity and responsiveness at all times to parents’ culture, gender, sexual orientation and disabilities.
Maintenance of family confidentiality will be of highest priority.
Residents will at all times demonstrate ethical and professional behavior. During this rotation, in particular, residents will deal with issues of end of life care and withdrawal of support, potential for long-term disabilities and chronic illness. Residents will take part in discussions between attending physicians and patients/families about end of life care decisions.
When appropriate, residents will utilize the MGH Ethics Consultation Service to facilitate team meetings to discuss difficult issues.
Residents will ensure that families give informed consent for all aspects of care.
VI. Systems-Based Practice
Residents are expected to provide high quality, but cost-effective health care. They will collaborate with case managers and other team members to implement appropriate discharge plans.
Residents will help arrange follow up with the Massachusetts early intervention program, the NICU follow up clinic and subspecialists as indicated, in addition to the patient’s primary care provider. Residents will communicate with the patient’s primary care physician, especially near the time of discharge.
At all times, residents will act in accordance with the legal mandate in the Commonwealth of Massachusetts to report any suspicions of child abuse or neglect, being familiar with the process by which such suspicions are reported. The MGH Child Protection Consultation Team will be a unique resource for residents working in the complex referral atmosphere of this rotation
