FM Unassigned Newborn Service

Welcome to the Family Medicine newborn inpatient service! We admit most “unassigned” babies (no pediatrician selected, or one selected that does not have permissions at St. Agnes). We are working on a list for inclusion and exclusion criteria for our service. Remember, nothing is set in stone and this will all likely change as the rotation evolves.

Written by Arianna Crediford, MD (PGY1) 

• On your first Monday morning, report to the FM rounding room at 7:00 AM to receive sign out from the night resident. Check Amion for who your attending will be and find out when they’d like to round. 
  
  

• Your best view for the list will be the LD grease board (accessed by clicking the red EPIC button in the top left corner → Patient Care → LD Grease board; can click the thumbtack on the right side to pin it). Once on the LD grease board, head to the → Nursery tab to see all the newborns, either located on 4 Main or 6 Main. You can sort by attending to see which babies are assigned to us, if any. Alternatively you can favorite the SAFR Nursery 4 Main and SAFR Nursery 6 Main lists which can be viewed on mobile unlike the greaseboard. When in baby’s chart, mom’s chart is linked at the bottom left in green and vice versa. You will need to check her chart for more in-depth OB history. The “delivery” tab (which is identical in mom and baby’s chart) has most of the other info you will need. 
  
  

• Important: Once sign out is received for the morning, go to the 6th floor main newborn nursery and introduce yourself to the nurses, leave a post-it with your name and attending’s name for the week so they know who to Haiku with the admission sheets known as “pink sheets” for new babies. 

  • Nurses may call the Newborn phone (phone by printer in FM rounding room) prior to Haiku. Make sure to intermittently check the LD grease board to ensure babies are not assigned to our attending without our knowledge.

  • Weekday AM shifts we work with our FM attendings, no cross coverage. You can always contact the pediatrician on call for complicated babies/questions. (Amion- ED CALL- Unassigned Newborn)

  • Weekend AM shifts + all PM shifts we work with the pediatricians as attendings. If our service still has babies on the weekend, keep them assigned to our attending (DO NOT reassign to pediatrician to avoid confusing the services). Round with the pediatrician and discuss with them how they would like notation to be handled.

  • We don't take new admissions on weekends or nights; instead we cross cover for all pediatricians; all new babies are assigned to the pediatrician, healthy babies do not need to be seen unless concerns or calls. Contact the on-call pediatrician so they have your number and ask for any additional instructions, e.g. which babies to watch out for overnight.

  • When Dr. Thampy is on she has a nurse practitioner Frances Cipolla who is not on AMION but can be reached at 559-285-3985. She has been working 25+ years and is a brilliant resource

Useful Tips

Admissions: .NBHPFAM (EPIC, if it doesn't auto populate, search Phillip Kim in Personalization and use the SHARE ICON for access)

• Wait for pink sheets to be sent by nurses via haiku for new admissions. Nurses do a mini-triage to decide if the baby is healthy enough for our service; if not it will be assigned to the pediatrician. 

• Make sure to do your own triage for missed warning signs/risks; if concerns can call pediatrician and reassign baby to them or even NICU as indicated. Do not give back to nurses/reject baby. 

• Pink sheets sent usually about 30-45 min after birth: includes all delivery info, maternal risk factors, most highlights that you would want to know but always double check chart
  
  

• Generally we don’t put in orders unless Bili work up, sepsis work up, or sometimes to add formula. 
  
  

• May need to check mom’s chart for patient location since it is not always updated on baby’s chart; check mom’s chart for OB history as well. Ensure mom is RPR neg x 2 (one prenatal, one at delivery). 
  
  

• Try to see baby within 2 hours of being born: full physical exam, find out who pediatrician is (if none selected try to recruit to our clinic by messaging Deb mom’s MRN and she will call pt and make appt), find out feeding plan (breast vs formula vs both), and parental concerns. Baby must be seen absolutely no later than 24 hours after birth. Mom and baby will be on 6th floor at first then moved to 4th floor. May be in the recovery room (RR) which is on 6th floor especially if C-section. On 4th floor, nurse takes care of mom and baby so can answer questions about both for you. 
  
  

• Note templates: submit to FM attendings on weekdays. Find out if the pediatrician wants you to write notes on weekends. No notes or admissions at night.  

• .NBHPFAM : H&P template for new admissions

• .NBPNFAM: Progress note template

• .NBDCFAM : Discharge summary template

• Please add additional issues to assessment and plan as appropriate e.g. maternal GBS positive or GDM, LGA/SGA, systolic murmur, sacral dimple, etc. 

Cap: 12 total notes or 6 total admissions for the day. No more than 12 INTERACTIONS/NOTES per day. So if you start the day with 12 babies on the list and you discharge 6, you don't have to admit 6 more.  This will likely change as the rotation evolves.

Progress Notes: .NBPNFAM

• If baby is LGA or SGA, maternal GDM, mom got labetalol, or other glycemic risk factors nurses will put orders to monitor POC glucose automatically. If POC glucose low per UTD chart (in rounding room) can check serum glucose, consider treating per serum glucose.
  
  

• If SGA or preterm, may need car seat challenge prior to d/c which nurses will automatically do
  
  

• Sepsis work up: Blood cultures x 2, CBC, CRP if indicated (can use EOS to assist)
  
  

• Screenings: At 24 hours of life three screenings are performed: hearing screening, pre and post ductal O2 sat for congenital heart defect screening, and bilirubin screening (transcutaneous Tc). If normal, most babies are clear for discharge. If Tc Bili is elevated per bilitool, can order serum bili (total and direct) since Tc Bili tends to overestimate bilirubin. If baby has jaundice risk factors (direct coombs positive, ABO incompatibility) or visible jaundice/ruddiness on exam, can do Tc bili earlier @ 6 hours or 12 hours of life. 

• Can check screenings under chart review- →  single click on current encounter → flowsheets → screening

• Alternatively, flowsheets tab can be used and newborn screening can be pinned- can discuss with Arianna or Dr. Kim to have pinned

• Indirect coombs is done with mom’s blood and can be seen on mom’s chart or pink sheet as “Maternal Ab” status positive or negative. Baby’s blood type and direct coombs are assessed from cord blood gas, usually results back by 24 hours of life. 

• NICU is on 4th floor, can discuss cases with their attendings at any time.
  
  

• Make sure red reflex is done prior to D/C- ophthalmoscope can be found at 4th or 6th floor nursing stations

Discharges: .NBDCFAM

• NSVD births: max stay is 24 hours unless complications
   

• C-Section births: max stay is 72 hours unless complications
  
  

• Ensure red reflex is done
  
  

• Cannot leave without pediatrician selected and documented, ensure car seat, ensure screenings are done (hearing, heart, bili as above)
  
  

• Nurses will let you know when mom is clear for d/c and ask if baby is good to go but you can also check mom’s chart
  
  

• Can consider adding vitamin D drops in discharge orders upon D/C (can find in Dr. Kim’s preference list)
  
  

• Discharge summary has a hospital course template generated for ease but please read through and add additional complications/findings as appropriate; remove sentence about blood sugar checks if not performed.