Children’s Medical Center at Dallas

Guidelines for the Roles of
Fellows in Neonatal-Perinatal Medicine in the NICU at CMC

Donald  McCurnin MD, Luc P. Brion MD, Mambarath Jaleel MD, and Rashmin Savani MBChB

Revised 03/21/10

1. Fellows in Neonatal-Perinatal Medicine have, upon credentialing, status as annual rotators at CMC. They are credentialed in neonatal sedation upon completion of the sedation module and NRP (PALS is required for the CVICU rotation).
2. Fellows in Neonatal-Perinatal Medicine will work collaboratively with other members of the NICU team including but not limited to NNPs, nurses, respiratory therapists, pharmacists, nutritionists, occupational/physical therapists, speech therapists, psychologists, and social workers.
3. The following points define the role of the Fellow in the CMC NICU. The Attending will make final decisions on specific situations.
4. The Fellow on service or the Fellow on-call will be available at all time for questions, immediate backup or additional help to the NNPs when needed.
5. The assignment schedule will be placed on Amion.com at http://www.amion.com; password is “utswneo”. Fellow assignment to the unit will depend on the number of fellows in the program and will remain compliant with duty hour regulations.
6. Fellows’ duty hours are regulated by ACGME, UTSW, Children’s Medical Center and Neonatal-Perinatal Divisional policies. The 5 ACGME rules are: 30 hours = absolute max duration of continuous work; 10 hours = minimum interval between shifts; 1 day (24 continuous hours) = minimum period off duty per week on average for 4 weeks; every 3rd day call = max averaged over 4 weeks; 80 hours = max average work per week over 4 weeks.
7. Fellows will participate in divisional seminars listed in the series except the 8:00 Monday high-risk Pregnancy Conference and elective seminars (see below).
8. The Fellows in Neonatal-Perinatal Medicine will primarily serve as liaison between the team and consultants, referring physicians, and other disciplines. The fellow will call for consults and, with the Attending, keep communications open with the consultants.
9. Fellows will serve as liaison between the team and the Attending when the Attending is not physically present in the unit. Fellows will call the Attending every evening after the 20:00 NICU rounds to present a patient review, which includes a summary of every neonate in the unit.  Fellows need to discuss each neonate's status as well as all important aspects of their ongoing problems that require intensive care. Fellows will call the Attending for any transport call, new pending admission, and within 2-3h of any admission to the unit to present and discuss in detail the neonate's history, status and the plan. The fellows must call the on-call Attending for any substantial deterioration of a patient.
10. NNPs will be the primary care providers for NICU patients. Fellows will not replace NNPs in their role of primary care providers at any time unless specifically directed by the Attending Neonatologist. Fellows will be of assistance to the NNPs in optimizing patient care, running daily rounds and providing continuity of care. Work will be shared and divided between fellows and practitioners on a case-by case basis to optimize rounds, patient care and continuity of care. Fellows will help NNPs with their role as primary care providers, e.g., writing orders, checking labs, writing admission notes, documenting major changes in patient status, performing procedures, transporting infants to procedures, and providing urgent and routine care of patients.
11. Fellows will participate in morning report and will examine patients before Attending rounds.
12. Rounds: The fellow will participate with the Attending and the NNPs at 09:30 work rounds. The on-service fellows will participate with the on-service Attending and the on-call fellow and Attending at 16:00 checkout rounds. Fellows will call the Attending every evening to present a patient review (see iii.).
13. During calls, fellows will serve as liaison between the team and the Attending (see ii.), and will help NNPs render patient care as needed for unit acuity, patient load, or admission. They will examine patients as needed, including all admissions. Under highly exceptional demanding situations, the fellow may help the NNPs with writing admission notes.
14. NNP-fellow communications will be optimized to ensure that all changes in plans, decisions and updating information will be shared among team members in a timely manner.
15. Fellows will have a significant role in updating parents and referring physicians, and will document these conversations in the chart. Updates will be at least once after admission, upon major event or deterioration, before and after major procedure, weekly, and in anticipation of transfer.
16. The Attending physician will take all transport calls and accept transfers. Fellows will be involved in transports as outlined in a separate document entitled “UTSW Transports” (see xvii and xviii below). When accepting an infant all conversations should be recorded (call through the Access Center -6-7441). If needed, the fellow will call the Attending or primary care giver at the referring hospital to obtain additional information. All transport calls and potential admissions taken by the fellows or NNPs must be discussed with the Attending.
17. The fellow will participate in phone calls by the transport team, using conference calls or in presence of the Neonatal Attending, during rotations and calls at the CMC NICU. In the first year of training, the fellow will listen to the attending. In the second year the fellow will participate in the discussion. In the third year the fellow will speak and make decisions and give orders under the direction of the attending.
18. When available, the fellows will participate and collaborate with the transport team in some transports during the NICU rotations and calls at CMC. The selection of the transports will be done by the attending on service depending on the fellows’ number of transports, patient’s acuity and NICU activity. Each fellow will collect his/her own transport log with diagnosis and acuity level. The first transport will be a low-risk neonate. Next transports will be sick neonates. The role of the fellow is not to lead the team, which is self-sufficient for all transports, but to collaborate, learn and/or teach depending on the fellow’s experience, and to communicate with the attending. Decisions will be made as a collaborative group. Orders will be given by the attending.  Orientation to transport safety given in July by the transport team is a prerequisite to fellows’ participation in transport with CMC transport team.
    For transports between CMC and Parkland that are not done by CMC transport team, fellows are expected to accompany any infant on a ventilator and/or on a drip (prostaglandin or pressor). This does not apply to babies going to surgery, who are transported by anesthesiologists.
19. Discharge planning: The fellows will work closely with the team to develop discharge plans, and will communicate with the Case Manager before sending a baby back to the referring hospital (to ensure insurance approval/pre-certification). The fellow will contact the referring physician, the OTL and the transport team the evening before planned discharge. The Attending, NNP or fellow will sign the discharge orders before 09:00 on the day of discharge.
20. Fellows are expected to conduct Medline searches, read patient-related publications and present that information to the team during rounds.
21. The fellows will be the primary responsible team member for conducting the monthly CMC NICU case conference/M&M conference under the direction of Lina Chalak, MD. This conference will take place at the C11 or D7 conference room, on a Tuesday once a month.
22. The fellows will share with NNPs the responsibility of completing and updating the discharge/problem list (in the patient plan of care section) that will prepare the discharge summary. Information should include the list of important items pertinent to prenatal history, delivery room history, past medical history (all of which can be cut and pasted from the admission note), and relevant parts of the current hospitalization.
23. Procedure will be shared between NNPs and fellows. A maximum of two attempts (e.g., for endotracheal intubation) per provider is expected.