fellowship training program section of newborn · pdf fileskills in rendering initial...

2011 Hospital Accreditation Manual Section of Newborn Medicine, UP-PGH

FELLOWSHIP TRAINING PROGRAM

Section of Newborn Medicine

UP-Philippine General Hospital

OBJECTIVES

I. General Objectives

To provide intensive training and education of high quality in the acquisition of

knowledge and skills which are required of a specialist in the pediatric subspecialty of

Newborn Medicine in order to systematically and rationally approach the prevention,

diagnosis and treatment of the diseases of the newborn

II. Specific Instructional Objectives

A. Service

1. To develop clinical based skills in the care of normal, problematic and

critically ill neonates by actual management of cases.

2. To develop awareness that management of newborn diseases extends the

care to the parents, specifically the mother.

3. To develop proficiency in various competencies in the clinical practice of

neonatology.

B. Training

1. To provide learning materials in acquiring basic and clinical knowledge

required to make a Neonatologist more specialized than a general

pediatrician.

2. To offer opportunity to actively participate in the teaching of the basic and

academic aspect of the subspecialty to undergraduates, interns and allied

medical staff.

3. To develop managerial potentials through active participation in the

planning, organization and evaluation of the existing training program.

C. Research

1. To expose to basic research techniques and encourage research relevant to

the practice of neonatology

2. To provide opportunities for encouraging research related to neonatal

medicine

3. To develop an attitude of lifetime study and research.

D. To help the trainee meet the necessary requirements for accreditation by the

corresponding subspecialty board.


FELLOWS ADMISSION POLICIES / PROCESS

I. Applications to the Neonatology Fellowship Program are accepted for a position

which opens every month of July. In special circumstances, positions may be offered

in the month of January.

A. Applicant eligibility and procedure

1. All applicants should be a Diplomate in Pediatrics as certified by the

Philippine Pediatric Society. Applicants who are graduates of the

Philippine General Hospital who have not taken the Pediatric boards may

be admitted to the program but should become a diplomate during the

fellowship program.

2. Eligible applicants should submit the following documents to the Office of

the Department of Pediatrics

a. Fully accomplished application form obtained from the Office of

the PGH Deputy Director for Training.

b. Letter of Intent

c. Medical School Transcript of Records

d. Medical Diploma

e. Certificate of Graduation from an accredited Residency Program

3. A written examination will be given by the Department of Pediatrics.

4. Each applicant will be interviewed by the members of the subspecialty

section.

a. A pre-fellowship of 3-4 weeks is required of each applicant. The

purpose of the pre-fellowship are dual:

i. Assessment of clinical skills by the members of the section

ii. Orientation of the applicant to the NICU procedures and

policies

b. Tools for evaluation for acceptance to the program

i. Written examination -25%

ii. Interview – 25%

iii. Pre-fellowship exposure – 30%

iv. Oral case presentation – 20%

c. After deliberation by the members of the subspecialty section, the

name/s of the qualified applicant/s will be submitted to the

Fellowship Training Committee of the Department of Pediatrics.

5. Letters will be sent to all applicants to inform them of the results of their

application to the program.


COMPETENCIES EXPECTED OF FELLOWS

I. YEAR LEVEL I

Emphasis on acquiring basic knowledge in the care of a newborn (Normal fetal

and Neonatal physiology, fetal monitoring, physiology during extrauterine adaptation and

pathophysiology of common newborn problems, etc)

A. Competencies desired:

1. Skills in obtaining adequate communication capabilities with emphasis on

perinatal history.

2. Knowledge in fetal monitoring

3. Skills in anticipating neonatal problems based on perinatal events and fetal

monitoring

4. Skills in performing complete physical and neurologic examination on the

newborn, observing thoroughness and gentleness in the procedure.

5. Skills in performing pediatric aging and assessing state of nutrition and

rate of intrauterine growth.

6. Skills in anticipating problems by thorough knowledge and understanding

of high risk perinatal factors

7. Skills in rendering initial management at the delivery room and the

nursery with emphasis on:

a. Resuscitation

b. Temperature regulation

c. Respiratory support

d. Metabolic support

e. Nutritional support with skills in promoting breast-feeding

f. Aseptic techniques

8. Skills in performing the following procedures with confidence:

a. Intubation

b. CPR

c. Umbilical cannulation, venous and arterial

d. Exchange transfusion, double and partial

e. Blood extraction (external jugular puncture) and peripheral arterial

puncture for ABG: Radial and Temporal

f. Lumbar puncture

g. Paracentesis / thoracentesis / pericardiocentesis

h. CTT insertion / needling

i. Supra-pubic bladder aspiration

j. Intraosseous insertion

k. PICC insertion


l. Use of monitoring device

m. Use of devices for ventilatory support

n. CPAP/Respirator

o. Central venous pressure

p. Subdural tap

q. TPN

r. Use of trancutaneous bilirubinometer

s. Cranial ultrasound

t. Heart ultrasound (depending on the training module)

9. Skills in interpreting accurately results of diagnostic tests including blood

gases

10. Skills in communicating and relating to parents of sick and problematic

neonates with compassion and understanding

11. Skills in preparing research proposal

12. Skills in acting decisively in case of emergency and skill in providing

stabilizing treatment promptly

13. Skills in interpreting assessment of fetal distress in coordination with the

perinatal team of the Department of Obstetrics and Gynecology

II. YEAR LEVEL II

In addition to the competencies listed in Year Leve I, competencies desired:

A. Skills in prescribing and monitoring parenteral nutrition

B. Skills in diagnosing and managing newborn complications involving different

organ systems (Cardiac, pulmonary, endocrine, etc.)

C. Skills in handling high technology equipment

III. YEAR LEVEL III

In addition to the competencies listed in Year Level I, competencies desired:

A. Skills in handling problems in staff relationship

B. Skills in maintaining equipment

C. Skills in applying management principles in the managerial functions of planning,

organizing, staffing, leading and controlling delivery of newborn care.

D. Skill in reviewing literature, collecting data and interpreting research results

E. Skill in implementing techniques for the quality control of newborn care

F. Skill in identifying priority areas for research

G. Skill in writing and evaluating research protocols and in choosing appropriate

research method


H. Skill in implementing proper steps in the research process and applying basic

statistical techniques in analyzing data.

I. Skill in presenting the findings of his research in the form of a scientific paper.

ROTATIONS OF FELLOWS

The fellows are required at least the following rotations per year level:

Rotation First Year Second Year Third Year

NICU III 6 4 2

NICU II 2 2 2

OBAS/DRI 2 2 2

Gen Ped 2(outborn)/EINC 1 2 2

Pay 1 2 2

Elective 0 0 1

Research (optional) 0 0 1

FELLOWS’ DUTIES

Each fellow is expected to go on 24 hour duties every three to five days. During

his / her shift, she mans all the areas together with the Pediatric residents. From 8am to 5pm, the

fellows are expected to make rounds on the areas assigned for their monthly rotation.

FELLOWS ASSIGNMENTS AND RESPONSIBILITIES

I. NICU

A. Supervises the clinical duties of the residents.

B. Must examine and evaluate all critically ill infants daily and as often as necessary

and writes progress notes and orders in the chart.

C. The fellow holds endorsement and teaching rounds at 8 am and 4 pm.

D. The fellow performs neonatal procedures and may supervise the

residents/students in the procedures.

E. The fellow, in the absence of the consultants, ensures the proper administrative

procedures with regards to patient care and their families, nursing personnel and

support staff.

F. Coordinates with other subspecialties and interdepartmental referrals.


G. The fellow ensures that patient safety is observed at all times.

H. Make sure that the charts are in order, progress notes are written, laboratory

results are followed up and entries are made in the logbook.

I. The fellow should always confer with the patient’s family with regards to his

problems, current health status, prognosis and other related matters.

J. Makes discharge plans on patients, ensures all laboratories are done, and schedule

OPD follow up.

K. The fellow ensures that the residents and interns arrives on time, wears proper

attire and behaves professionally towards colleagues, nurses and patient’s family.

L. Must make sure that the residents, interns and students observe and follow the

NICU policies.

II. Direct Rooming In and High Risk DRI

A. Supervises residents and interns in the management of the well newborn and in

detection and disposition of abnormalities and problems.

B. Makes rounds on the patients at the High Risk DRI.

C. Teaches residents and interns regarding normal newborn care with emphasis of

early latching, improving lactation, proper breastfeeding, immunization and

prophylaxis.

D. Teaches residents and interns regarding advice to mother on feeding, jaundice,

bathing and cord care. Warning signs for readmission of the infant should also be

discusses.

E. Assigns and supervises residents and interns on mothers’ classes being held

weekly.

F. Supervises BCG immunization done by resident and students.

III. Delivery Areas (OBAS and LCB)

A. Must be aware of all high risk mothers in the labor room, the progress of their

labor, and the status and ongoing OB management of their high risk condition(s);

and plan anticipatory management accordingly.

B. Must attend all anticipated high risk deliveries.

C. Must be readily available for all DR emergencies.

D. Supervises the DR resident, intern students in the proper resuscitation and DR

stabilization and transport of the high risk neonate.

E. Makes sure that the DR resuscitation supplies are replenished and all equipements

are working properly.

F. Answers referrals for prenatal counselling and attends perinatal conferences.


G. Supervises the residents and interns on the proper procedure for the EINC.

IV. Outborn neonates ( General Pediatric Service 2 and Kiko’s room)

A. Makes daily rounds on newborn infants in the service with the service residents

and interns; and examines and evaluates the critically ill infants with them.

B. Joins the General Pediatrics service 2 consultant’s rounds.

C. Conducts teaching rounds for the residents and interns.

D. Supervises the residents on the diagnosis and management of sick neonates.

E. Checks adequacy and completeness of progress notes and charts entries.

F. Makes discharge plans with the resident and interns for optimal follow up care of

the patients.

G. Assigned to attend meetings for the EINC and Milk bank

V. Pay services

A. Makes rounds on all pay patients of the section consultants.

B. The fellow goes on rounds with the attending neonatologist.

VI. Electives

A. A month rotation, wherein a fellow may choose among the following rotations:

1. PICU

2. Cardiology

3. Neurology

4. Genetics

5. Developmental Pediatrics

6. Radiology

VII. Conferences

A. Pediatric conferences

1. House staff conferences during Mondays, Wednesdays and Fridays

2. Monthly Grand Audit

3. House staff teaching hour

4. Pediatric research fora


B. Section conferences

1. Weekly CATS

2. Mid-month catchers’ audit

3. Monthly section audit

4. Fellow’s, resident’s and student’s report

5. Consultant lectures

C. Interdepartmental conferences

1. Annual peristatistics

2. Quarterly peristatistics

3. Multidisciplinary conferences

4. Interdepartmental research forum

D. Outside the hospital (duty fellow is left to man the areas)

1. Quarterly fellow’s forum

2. Annual PSNbM convention

3. Annual PPS convention

TRAINING ACTIVITIES FOR FELLOWS

I. Patient rounds with service consultants

Bedside discussion of each patient’s case is done three to four times a week with

the service consultant scheduled for the week. All fellows, residents, and students are

required to attend. The student or resident in charge presents the case, and the fellows

present the management. The fellows also presents complicated cases to the consultant.

The consultant gives additional input and feedback on the management of the patient.

II. Departmental conferences

Every Monday and Wednesday at 8 – 9AM, the department holds its house staff

conference where consultants from different subspecialties give timely lectures. While

Fridays are reserved for grand audits and case presentations by the residents. All fellows,

residents, and students are required to attend these departmental activities which are held

at the Emergency Room Conference hall.


III. Fellows’ reporting

Each fellow is assigned a topic to report on every first and third Tuesdays of the

month. Reporting is based on modules per organ system using Fanaroff’s and Martin’s

Neonatal and Perinatal Medicine, Diseases of the Fetus and Infant, 9th

edition; Polin and

Fox’es Fetal and Neonatal Physiology, 3rd

edition and Avery’s Neonatology,

Pathophysiology and Management of the Newborn, 6th

edition as references.

IV. Fellows’ case conference

Each fellow is required to present an interesting case every end of the month,

admitted at NICU. He / She is expected to incorporate journals and newest updates on

the disease.

V. CATS

Each fellow is required to critically appraise a journal or an article on issues about

diagnosis, therapy and prognosis. The article should answer a dilemma encountered at

the NICU. CATS presentation is usually held every 4th

Tuesday of the month.

VI. Monthly Audit

Fellows and residents have monthly audit with the service consultant which is

held every first Tuesday of the month. Morbidity and mortality cases are discussed;

status of nosocomial infections is also talked about. Strategies to improve patient’s

services are likewise part of the agenda.

VII. Catchers’ Audit

Mid month census are presented by DRI fellow and second year residents who are

rotating at the OBAS, LCB and DRI. All admissions from day 1 to 15 of the month were

talked about to monitor issues on resuscitation, with emphasis on complicated deliveries.


TRAINING RESPONSIBILITIES TO RESIDENTS AND STUDENTS

A total of nine (9) residents rotate at the NICU every month. The first and third

year residents are assigned to rotate on NICU 3, NICU 2, and COHORT while the second

year residents are assigned to OBAS, LCB, DRI and High Risk OPD.

I. Resident orientation

Residents are to be oriented prior to assuming posts. At present we are using a

general orientation for residents in a learning-and-competency-based format.

Algorithms on policies for admission, including OB AS policies, are included in the

orientation. Templates for the census used in the monthly audit, as well as various forms

to be filled up by the residents are also part of the orientation. These include the

following: Database Forms, Anthropometric Forms, OBAS forms. Duties and

responsibilities of residents have to be clearly emphasized. A general orientation is given

by the fellows, but a separate orientation per service should also be done.

II. Endorsement rounds

The fellows are required to conduct daily morning teaching endorsement rounds

with the residents and students. New patients are usually presented by the residents while

the fellows discuss the theoretical aspect of the case and give inputs on the management.

III. Supervision of Resident Reporting

Each resident is required to have a reporting about cases they have encountered in

the NICU. Service fellows assign these cases to residents and make the schedule of

reporting. While the resident is presenting, the fellow asks questions relevant to the topic

and sees to it that the resident will be able to correlate his lecture with the patient’s

clinical course.

IV. Supervision in the neonatal procedures

The fellows guide the residents in doing certain procedures such as intubation,

umbilical cannulation, lumbar puncture, and double volume exchange transfusion.


V. Supervision in the High Risk Clinic

High risk clinics are held during Mondays which are attended by fellows (except

NICU rotators) and second year rotators and students. Fellows supervise the students and

the residents in their work. They checks on their findings on assessment and

management of babies on follow up. Residents are required to present problematic

patients to fellows for proper disposition. The fellows see to it that all patients scheduled

on that day are seen and advised properly.

VI. Supervision in high risk deliveries

The fellows attend deliveries, together with the second year resident (catcher), of

patients classified as high risk: the preterm infant, the infant who requires technological

support, the infant primarily at risk because of family issues, and the infant whose

irreversible condition will result in an early death. The fellows see to it that these

patients are admitted to NICU for further evaluation and management.


SCHEDULE OF SECTION ACTIVITIES

WEEKLY TEMPLATE OF ACTIVITIES

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY

7:30- 8:00

AM

Endorsement Endorsement

and Teaching

Rounds

Endorsement

Endorsement

and Teaching

Rounds

Endorsement

8:00-9:00

AM

House Staff

Teaching

Hour

Vignettes

*PGH Flag

Ceremony

Endorsement

and Teaching

Rounds

Fellow’s

reporting with

consultant (1st

and 3rd

Tuesday)

Staff

Conference

Grand Audit

(2nd

week)

Business

Meeting

Multi-

Disciplinary/

Interesting

Case

Conference

Case

dilemmas

Special

lectures

Subspecialty

updates

Research

Activities

Endorsement

and Teaching

Rounds

I-CATCH at

Pandacan (3rd

Thursday)

Staff

Conference

Business

Meeting

Multi-

Disciplinary/

Interesting

Case

Conference

Case

dilemmas

Special

lectures

Subspecialty

updates

Research

Activities

9:00-12:00

PM

High Risk

Clinic

Rounds with

consultant

Section Audit

with

consultants(1st

Tuesday)

(Quarterly)

Perinatology-

Neonatology

Statistics(2nd

Tuesday)

Fellows Case

Presentation

with

consultant

Written

examination

(4th

Wednesday)

Rounds with

consultant

Resident’s

CATS

presentation

with

consultant

(4th Friday)


Catchers Audit

with

consultants(3rd

Tuesday)

Fellow’s

CATS/

journal report

with

consultants(4th

Tuesday)

1:00-3:00

PM

Rounds Rounds with

consultant

Rounds with

consultant

Neonatology

Review with

Dr. Isleta

Rounds with

consultant

3:00-4:30

PM

Resident’s

Lecture

Rounds Resident’s

Lecture

Neonatology

Review with

Dr. Isleta

Resident’s

Lecture

4:30 PM Endorsement Endorsement Endorsement Endorsement Endorsement


SUMMARY OF TRAINING PROGRAMS OFFERED BY THE SECTION OF

NEWBORN MEDICINE

I. NEONATAL RESUSCITATION PROGRAM COURSES

The Section of Newborn Medicine, in coordination with PSNbM, is regularly

conducting courses in neonatal resuscitation program courses catering to pediatric

residents, nurses, and general pediatricians of different hospitals in Metro Manila and

other parts of Luzon. The NRP is an education program that introduces the concepts and

basic skills of neonatal resuscitation performed by a designated and coordinated team.

The full-day course is conducted by NRP-trained Neonatology consultant staff of the

Section and invited NRP- trained guests from other hospitals.

II. S.T.A.B.L.E. COURSE

Yearly a S.T.A.B.L.E. course which is an educational program provides general

guidelines for the assessment and stabilization of sick infants in the post-resuscitation /

pre-transport stabilization period is offered by the Section of Newborn Medicine. A

uniform, simple, standardized process of care and comprehensive team approach can

improve the infant’s overall stability, safety and outcome. This covers important elements

of newborn care, namely: Sugar, Temperature, Airway, Blood Pressure, Laboratory, and

Emotional support (hence, the mnemonic STABLE). This program which caters to

general pediatricians, pediatric residents, emergency staff and nurses, is designed to

provide important information about neonatal stabilization for maternal/infant healthcare

providers in all settings – from community hospitals and birth centers, to emergency

rooms and more complex hospital environments. The workshop is conducted by

STABLE-certified staff of the Section and invited STABLE- certified guests from other

hospitals.

III. ANNUAL ROUND TABLE DISCUSSION ON NEONATOLOGY

The Round Table Discussion in Newborn Medicine was the brain child of Dr.

Enrique M. Ostrea Jr. in his desire to provide a venue for a dialog among neonatologists

regarding controversial issues and new developments in the field. From 3 participants

during the first RTD (2001) held in the clubhouse of Dr. Ostrea’s Tagaytay home, it

evolved to become a yearly endeavor by the Institute of Child Health and Human

Development- NIH and the Section of Neonatology, UP-PGH, attended by an increasing

number of audience which now include pediatricians from different parts of the


Philippines as well as nurses and other allied medical professionals. Through the years, it

continues to provide a forum for academic discourse of topics pertinent in the field of

Neonatology in the hope of improving the survival and quality of life of the Filipino

newborn infant.

IV. INTENSIVE HANDS-ON COURSE ON NEONATAL VENTILATION

In November 2006, the Section of Newborn Medicine offered its 1st Intensive

Neonatal Ventilator Workshop, an intensive hands-on course that was intended to teach

practitioners how to effectively ventilate newborns. A series of lectures in the morning

was followed by an interactive “hands-on” teaching by stations in the afternoon

conducted by the Neonatology consultant staff. Topics include basic pulmonary neonatal

physiology, different oxygen delivery systems, CPAP, basic principles in neonatal

ventilation, blood gas interpretation and chest radiograph readings in the newborn. This

course is being offered by the Section every other year and caters to general

paediatricians, paediatric residency trainees, nurses, and respiratory therapists.

V. INTENSIVE COURSE IN NUTRITION MANAGEMENT OF HIGH RISK

NEONATES

In November 15 and 16 of this year, the Section of Newborn Medicine will offer

its 1st neonatal nutrition workshop, an intensive hands-on course that is intended to teach

practitioners how to effectively manage the nutrition of high risk newborns. A series of

lectures in the morning will be followed by an interactive “hands-on” teaching by stations

in the afternoon conducted by the Neonatology consultant staff. Topics include basic

neonatal gastrointestinal physiology, optimizing nutrition of low birthweight infants,

breastfeeding problems and solutions, feeding post-operative neonates, feeding neonates

with inborn error of metabolism, among others. This course will be offered by the

Section every other year and will cater to general paediatricians, paediatric residency

trainees, and nurses.

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