UNM FAMILY MEDICINE RESIDENCY

ROTATION INFORMATION

INTERMEDIATE CARE NURSERY (ICN3) ROTATION

 

Rotation name: Intermediate Care Nursery (ICN3)

 

Year: R2

 

Rotation Contact information: 

• Pediatric Chief Coord 2-3909 hsc-pedschief@salud.unm.edu

 

Important notes about this rotation/updates to rotation:

AGME Requirements are met for pediatrics by completing 4 weeks of ICN and meeting continuity clinic requirements you will have 3 half days of clinic per week.

ICN Website (with helpful information, updated by Nicole Urrea):   https://sites.google.com/view/unm-icn3/home

 

Location: UNMH 

 

Pre-requisites: none

PLEASE REVIEW: New algorithm for opioid exposed babies per Dr. Leeman (3/21/2024):UNM-NOWs-symptom-based3-1-24 .docx

Description of rotation:

 

Schedule:

 

	Sun	Mon	Tues	Wed	Thu	Fri	Sat
AM	ICN3	ICN3	ICN3	ICN3	ICN3	ICN3	ICN3
PM	ICN3	Continuity Clinic	Continuity Clinic	Resident School	ICN3	Continuity Clinic	ICN3

 

ICN3 Reminders and Calculators

 

GENERAL OBJECTIVES

 

The goal of the Intermediate Care Nursery curriculum is to provide residents with learning opportunities that will enable them to develop or refine knowledge, skills and attitudes necessary to

 

1. Show competency in obtaining and interpreting maternal history; performing the neonatal physical exam; interpretation of common screening and diagnostic tests performed in neonates; and performing common neonatal procedures.

2. Understand the normal physiologic changes in the transition period and the first few weeks of life, identify signs of complications during this period, understand issues which alter normal progress in newborns, and demonstrate management of newborns with complications.

3. Use medical evidence from resources such as literature, consultants, and peers to provide the best possible patient care.

4. Effectively communicate with all members of the healthcare team.

5. Develop a professional identity that emphasizes individual, practice and system improvement

6. Advocate for patients within the larger medical system, emphasizing continuity of care.

 

OBJECTIVES BY ACGME COMPETENCY

 

PATIENT CARE

IMPORTANT NOTE: It is expected that the resident will come to the ICN 3 rotation having gained most of the patient care skills needed for normal term newborn care while on NBN rotation, including maternal and newborn history taking, familiarity with maternal and neonatal screening tests, examination skills for the term newborn, gestational age and weight assessment, ability to recognize and manage common term newborn signs and symptoms, and ability to perform common procedures, such as circumcision and bag-mask-ventilation, as outlined in UNM NBN Goals and Objectives. Residents not comfortable with any of these skills should notify the ICN 3 attending as soon as possible after arrival on the rotation.

 

GOAL 1: RESUSCITATION AND TRANSITION CARE

The resident will learn to assess late preterm infants for the type of resuscitation and/ or supportive care required during the transition to extra-uterine life and to provide that care in an effective, timely manner.

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Hands-on experience with support of experienced clinician and bedside teaching by attending.

EVALUATION METHOD: Observation by attending.

 

GOAL 2: CARE OF PATIENTS WITH COMMON SIGNS AND SYMPTOMS ENCOUNTERED IN ICN3

For the following conditions, the resident will learn to rapidly recognize signs or symptoms of disease onset, perform a pertinent history and physical, formulate an appropriate differential diagnosis, understand indications for admission to ICN 3 and transfer of care among other newborn units (NBN, NICU), and recognize indications for emergent intervention and stabilization. These conditions will often, but not always, be associated with late prematurity:

Respiratory distress

Apnea and bradycardia

Sepsis

Hypoglycemia

Jaundice

Temperature instability

Growth and feeding disorders and problems maintaining maternal milk supply

Hypothermia

Developmental abnormalities

Neonatal abstinence syndrome/intrauterine substance exposure

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Hands-on experience with support of experienced clinician, bedside teaching by attending, didactic sessions, and independent reading.

EVALUATION METHOD: Accuracy and completeness of oral patient presentations and of written patient notes, and observation by attending.

 

GOAL 3: ORDERING AND INTERPRETATION OF TESTS COMMONLY USED IN ICN 3

The resident will order and interpret laboratory tests and radiologic images, taking into account the patient’s gestational age, related physiology, medical condition, prenatal imaging, and maternal antenatal labs

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Hands-on experience with support of experienced clinician and bedside teaching by attending.

EVALUATION METHOD: Oral patient presentations, written notes, and observation by attending.

 

GOAL 4: APPROPRIATE PHYSIOLOGIC MONITORING OF PATIENTS REQUIRING 1CN3 ADMISSION

The resident will learn appropriate use, interpretation, and response to the results of the following physiologic monitoring modalities as appropriate for the patient’s gestational age and condition:

Vital signs and NAS scores

Continuous cardiorespiratory and pulse oximetry monitoring

Blood glucoses

Continuous temperature monitoring

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Hands-on experience with support of experienced clinician and bedside teaching.

EVALUATION METHOD: Oral patient presentations, discussions during patient care, and observation by attending.

 

GOAL 5: UNDERSTANDING AND IMPLEMENTING THERAPEUTIC MODALITIES COMMONLY UTILIZED IN ICN3

For the following therapies, the resident will learn the physiology, appropriate utilization, and appropriate monitoring of the response to and the complications of each therapy:

Temperature maintenance and use of newborn warmers

Oxygen administration

Intravenous fluids, glucose, and electrolytes, including relevant calculations

Gavage feeds

Phototherapy

Antibiotics and antiviral therapies

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Hands-on experience with support of experienced clinician, bedside teaching, didactic sessions, and independent reading.

EVALUATION METHOD: Observation by attending.

 

GOAL 6: MANAGEMENT AND DECISION MAKING

The resident will develop patient management skills for late preterm infants and infants with the conditions listed under Goal 2, as well as the ability to recognize the strengths and limits of their knowledge in this area.

PRIORITY: Essential.

LEVEL OF MASTERY: Working knowledge

TEACHING METHOD: Hands-on experience with support of experienced clinician, bedside teaching, and didactic sessions.

EVALUATION METHOD: Completeness and accuracy of oral and written patient presentations, observation by attending.

 

GOAL 7: FAMILY-CENTERED CARE, PATIENT SUPPORT, AND ADVOCACY

The resident will provide comprehensive, family centered, culturally appropriate care to patients, recognizing the particular stress placed on families by ICN3 admission and its associated diagnoses.

PRIORITY: Essential.

LEVEL OF MASTERY: Working knowledge.

TEACHING METHOD: Modeling by attending physician.

EVALUATION METHOD: Observation by attending.

 

MEDICAL KNOWLEDGE

GOAL 1: The resident will demonstrate knowledge of the physiology of the transition to extrauterine life.

PRIORITY: Important.

TEACHING METHOD: Bedside teaching by attending. Didactic sessions. Independent reading.

EVALUATION METHOD: Ability to answer questions during patient care, patient presentations, and didactic sessions.

GOAL 2: The resident will demonstrate knowledge of the physiology and management of feeding and growth in late preterm infants including

1. Methods and behaviors for supporting breastfeeding.

2. Methods for determining adequate volume/calorie intake and weight gain at various degrees of prematurity and stages of growth.

3. Expected patterns of weight loss and gain

4. Appropriate support of nutrition, for any given clinical situation, including need for

1. Gavage feeding

2. Supplemental feeds with EBM or formula

3. Increased caloric density feeds

4. Parenteral nutrition

PRIORITY: Essential.

LEVEL OF MASTERY: Working knowledge.

TEACHING METHOD: Bedside teaching by attending, didactic sessions, and independent reading.

EVALUATION METHOD: Ability to answer questions during patient care, patient presentations, and didactic sessions, and ability to justify feeding plans for patients.

GOAL 3: For each of the conditions listed under patient care goal 2, the resident will demonstrate knowledge of the pathophysiology of the condition, and its stabilization, evaluation, management, complications, and appropriate level of care (ie NBN, ICN3, or NICU).

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Hands-on experience with support of experienced clinician, bedside teaching, didactic sessions, and independent reading.

EVALUATION METHOD: Accuracy and completeness of oral patient presentations and written patient notes, and ability to answer questions during patient care, patient presentations, and didactic sessions.

 

PRACTICE-BASED LEARNING AND IMPROVEMENT

The resident will:

1. Recognize his/her own strengths and limitations.

2. Apply medical evidence to inpatient clinical situations, using a logical approach that is inclusive of the individual patient.

3. Use appropriate resources such as literature, consultants and peers to provide best patient care.

4. Ask questions as an engaged, critical learner.

PRIORITY: Essential

LEVEL OF MASTERY: Working knowledge

TEACHING METHOD: Modeling by and feedback from attending.

EVALUATION METHOD: Observation by attending.

 

INTERPERSONAL AND COMMUNICATION SKILLS

The resident will:

1. Make organized and effective oral presentations.

2. Communicate with the patient, family and primary care or follow-up physician in a timely, developmentally and culturally appropriate manner.

3. Communicate clearly and respectfully with medical team members, consultants, nursing, social work, discharge planning, and other staff.

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Modeling from and feedback by attending.

EVALUATION METHOD: Accuracy and completeness of oral patient presentations and observation of attending and staff.

 

PROFESSIONALISM

The resident will:

1. Accept responsibility for patient care.

2. Never misrepresent patient care information.

3. Be punctual, reliable and collegial.

4. Demonstrate dress, hygiene and manner of speech that consistently reflect appropriate standards.

5. Demonstrate sensitivity towards patients’ and colleagues’ gender, age, culture, disabilities, ethnicity and sexual orientation.

6. Demonstrate sensitivity to the stressors and needs of the family with a premature or ill newborn.

PRIORITY: Essential.

LEVEL OF MASTERY: Proficiency.

TEACHING METHOD: Modeling from and feedback by attending.

EVALUATION METHOD: Observation of attending.

 

SYSTEMS-BASED PRACTICE

The resident will:

1. Practice patient advocacy and use system resources to minimize discomfort or confusion.

2. Recognize that the patient is part of greater system and provide care in a manner that supports continuity.

PRIORITY: Important.

TEACHING METHOD: Modeling from and feedback by attending.

EVALUATION METHOD: Observation of attending

 

EXPLANATION OF PRIORITIZATION TERMS:

Each goal has a level of priority associated to assist residents in allocating time and resources to learn different skills. The levels are defined as:

1. Essential—All residents completing the rotation must achieve these goals.

2. Important—Residents with a strong interest in this patient population will want to achieve these goals.

3. Supportive— These goals will add to expertise, but achieving them may be limited by their infrequent occurrence or level of complexity.

For “essential” goals, level of mastery is further defined as:

1. Proficiency—Residents will be able to independently recognize these conditions, determine a management plan, and implement the plan by the conclusion of the rotation.

2. Working knowledge—Residents will be able to independently recognize or evaluate this condition, but may need assistance in formulating and carrying out a management plan.

Understanding—Residents will be familiar with the condition/procedure and should be able to discuss it with a consultant and describe it to family members, but will need assistance for full evaluation and implementation.