Resident Roles and Responsibilities

Introduction

The Work Day

Patient Care

Supervision of Medical Students

Continuity Clinic Referrals

Requests from Private Physicians

Other Notes

INTRODUCTION

The pediatric residents are the primary providers for all babies on the Stanford Pediatric Clinic (SPC) service of the Newborn Nursery. The Newborn Nursery is temporarily located in unit F-1, between the front desk and the back nurse' station on the right.  Occasionally, an infant will be physically located in the nursery, but usually babies are cared for in the rooms with their mothers on units F-1 or F-2.  We typically care for about 17 patients per day, although there are wide fluctuations in census on a daily basis.  Approximately half of our families are Spanish-speaking.

A name badge is required to enter the nursery.  You should already be granted access to the door.   However, if security clearance has not yet been processed, a clearance request can be obtained through Gloria Santos, who has an office on F2, in the hallway between F2 and Labor and Delivery.  Once the signed form is turned in to the security office in the basement of SUH, access can be obtained.

For security purposes, all newborns are required to be in a crib when moved through the hallways, even if a parent or family member is transporting them.  Each baby also wears a security sensor that will alarm if out of contact with the skin or if the infant is taken out of the unit.  NOTE:  elevators are off limits for the alarms.  Badge activation for the nursery does NOT necessarily mean badge activation for the alarm in the elevator, so have a staff member or attending physician with you if you need to move an infant from floor to floor.

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THE WORK DAY

Early morning priority should be given to potentially sick newborns and newborns that are likely to be discharged that day.  Often, the mothers who are to be discharged will be identified on the unit white board with a star in front of the room number, but in general, babies born by vaginal delivery will have a 2 night stay and babies born by C-section will have 4 night stay.  The team should strive to examine the babies and complete teaching for the families who are going home that day, and if possible, have discharge orders completed before rounds. 

During rounds the team will review pertinent parts of the prenatal and delivery history, social and family history, physical findings, and discharge plans.  Frequently, the entire team will do "walk rounds" on patients who are going home or who have physical findings that present educational opportunities. If the census is high, the attending physician may independently round on some patients.

Residents should use the standard admission and progress note forms. Medical students may use these forms as guidelines for their notes, but should use blank progess note paper for both "Admission" and "Progress" notes.

After attending rounds, the team will continue visits with patients and families, attend to any infants with issues, examine new babies, and perform circumcisions.  Before noon the team should "tie up loose ends", call consultanting services, etc.  At 1 pm, the team will gather again to round on new patients, finish remaining procedures, review any problems encountered, and for educational discussion. 

The team is responsible for the evaluation, exam and physician orders or any newborn admitted to the SPC team throughout the day.  Newborns born after 10 am without active issues may be evaluated the following morning.

Residents should make all efforts to attend Morning Report and Noon Conference.

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PATIENT CARE

Main patient care responsibilities for the team, include the following:

• reviewing prenatal records to identify risks for the newborn (e.g. PROM, GBS status, HBsAg, Serology tests, substance abuse history, PPD, etc.)
• obtaining prenatal, birth, family, and social history from the parents and OB records
• performing admission and discharge physical exams (occasionally the length of stay is so short that these are the same exam)
• planning and arranging diagnostic tests and therapy
• arranging consultations or transfers
• reviewing appropriate newborn care issues with parents before discharge
• assuring that the family has a clinic designed for follow-up
• forwarding clinical information to the appropriate clinic or physician
• performing minor procedures, such as circumcision or frenotomy
• maintaining the medical record to document the following

  • prenatal history
  • birth history
  • physical exam
  • DAILY progress note
  • discharge plans including diet and follow-up (WIC forms if needed)
  • clear documentation of issues needing follow-up after discharge
  • clear documentation of follow-up appointment
  • orders and notes with dates, times and signature

Residents should inform parents of any significant change in the status of the baby, clinical or otherwise.  Examples include sepsis screening labs or CXR, initiation of phototherapy, or transfer to the intensive care nursery (NICU) or special care nursery (PSCN).  The purpose and procedure for any diagnostic evaluation should be explained directly to the infant's parents.

A transfer of a sick infant to the NICU or PSCN should be managed by the senior resident with clear communication to the NICU fellow or PSCN attending.  A brief transfer note should be written. 

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SUPERVISION OF MEDICAL STUDENTS

Medial students will be in the Newborn Nursery on Monday through Thursday mornings.   The senior resident and attending physician should bear the major responsibility for the didactic teaching of the students.  However, the intern can also play an important role, guiding them in such matters as history taking, the newborn physical exam, estimating gestational age of a newborn, and minor procedures.  Residents are not responsible for the routine evaluation of infants seen by students, as the attending physician will evaluate these babies.

Team members should expect to demonstrate for the student any abnormal or unusual findings identified on physical exams.

Orders and notes written by students must be co-signed by the senior resident or attending physician.

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CONTINUITY CLINIC REFERRALS

Though the initial follow-up of patients after discharge may not coincide with the intern's continuity clinic, residents can recruit nursery patients for subsequent continuity care.  Follow-up appointments should be made at the Acute Care Clinic 24 - 48 hours after discharge for otherwise healthy, term infants discharged 24 - 72 hours after birth.  Follow-up appointments after C-section or prolonged maternal stay may be made between 1 and 2 weeks after discharge for otherwise healthy, term infants.  Appointments may be required earlier on any infant regardless of delivery type to check on weight loss, feeding issues, jaundice, social situation, etc.

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REQUESTS FROM PRIVATE PHYSICIANS

When a private physician from the community has a request of a resident regarding patients in the nursery or delivery room, the private physician is expected to talk DIRECTLY with the house officer.  Nurses and clerks are NOT to be placed in the position of intermediary.  If you receive a call from a nurse or clerk, please ask for the physician's information and speak to them directly.

If a resident is asked to evaluate a private patient in the WBN, any required tests or therapies should be discussed with the private physician before instituting them unless the patient would be harmed by the delay.

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OTHER NOTES

• In couplet care, babies are rarely physically found in the Newborn Nursery .  Babies may be examined in the nursery, but this in no way replaces a visit to the mother to both give and receive information about the infant.

• Infants typically remain in mother's rooms for all assessments, and charts for both mother and baby will be located at the nursing stations closest to the room.  If privacy is needed for discussion with the family, consultation rooms are available on each floor.

• Many of our patients speak only Spanish (or another non-English language).  For that reason LPCH and SUH provide professional interpreters. It is recommended that if neither resident speaks the family's language fluently, the interpreter's service should be used.  Not obtaining history or giving inadequate information because of language barriers is not acceptable.

JAbyMD, ABurgosMD, 5/06

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