Resident Roles and Responsibilities
Clinical Rotations for Residents
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 located outside of F2, in the main hallway between Stanford and Lucile Packard Children's Hospital (LPCH).
Occasionally, an infant will be physically present in the nursery, but usually babies are cared for in the rooms with their mothers on units F-1 or F-2. We care for about 16 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.
For safety and security, 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.
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 monitor with a "+" 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 (but not initiated) 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 electronic "WBN note" for admits, discharges, and progress notes. Medical students may choose to use either electronic or paper charting, but should also have the senior resident start an electronic "WBN note" for their patients.
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 1:00pm, 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 for 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.
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
- following the daily progress of the baby (use "24 hour" and "flowsheets" tabs for RN information)
- 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 neonatal intensive care unit (NICU) or Packard intermediate care nursery (PICN). 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 PICN should be managed by the senior resident or attending with clear communication to the NICU fellow or attending. The decision of whether the infant will be admitted to the NICU or PICN will be made by the NICU physician.
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 and clinical 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.
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.
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, any required tests or therapies should be discussed with the private physician before instituting them unless the patient would be harmed by the delay.
- 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 a language other than English). 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