NEONATAL-PERINATAL MEDICINE SUBSPECIALTY TRAINING PROGRAM THE UNIVERSITY OF TENNESSEE HEALTH SCIENCE CENTER

Transcription

1 1 NEONATAL-PERINATAL MEDICINE SUBSPECIALTY TRAINING PROAM THE UNIVERSITY OF TENNESE HEALTH SCIENCE CENTER NEONATOLOGY FACULTY SUPERVISORS Ramasubbareddy Dhanireddy, M.D. Sheldon B. Korones Professor of Pediatrics and Obstetrics and Gynecology Chief, Division of Neonatology American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) Mohamad Tammam El Abiad, MD Assistant Professor of Pediatrics American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) John Ferguson, MD Assistant Professor of Pediatrics American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) Raquel Gomez, MD Assistant Professor of Pediatrics A. Joi Goodwin-Samson, MD Assistant Professor of Pediatrics Ravi Kudumula, MD Assistant Professor of Pediatrics Ramesh Krishnan, MD Assistant Professor of Pediatrics American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) Massroor Pourcyrous, M.D. Professor of Pediatrics, Obstetrics and Gynecology and Physiology American Board of Pediatrics Certified (Neonatal-Perinatal Medicine)

2 2 Carole Perry, MD (part time) Fr-Assistant Professor of Pediatrics American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) Divya Rana, MD Assistant Professor of Pediatrics American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) Marilyn Robinson, MD (Site Director, Le Bonheur NICU) Assistant Professor of Pediatrics American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) Ajay J. Talati, M.D. Associate Professor of Pediatrics and Obstetrics and Gynecology Program Director, Neonatal-Perinatal Medicine Fellowship American Board of Pediatrics Certified (Neonatal-Perinatal Medicine) GENERAL DESCRIPTION The Neonatal-Perinatal Medicine subspecialty program is a 3-year program that provides training in clinical neonatology, research, and teaching. Upon completion of subspecialty residency, the trainee will have acquired an in-depth knowledge and necessary clinical skills to recognize and manage most neonatal clinical conditions and to teach others involved in neonatal care in the areas of neonatal stabilization, transport, and delivery of intensive care. The training in research will impart knowledge in hypothesis testing, study design, data collection, and analysis of results utilizing appropriate and commonly used statistical methods. PROAM GOAL The goals and objectives of the residency training in Neonatal-Perinatal Medicine subspecialty are expected to be achieved by the end of the three-year training program. Upon completion of the subspecialty training in Neonatal-Perinatal Medicine, the trainee will achieve the following goals: 1. Develop and acquire the competencies required in the clinical practice of Neonatology 2. Develop the necessary knowledge in the area of Neonatology practice to be able to share and disseminate information with other providers, medical and those in the other disciplines and involved in the care of the ill neonate and post discharge 3. Develop competencies to become competitive and successful if choosing an academic career

3 3 GENERAL OBJECTIVES By the end of the 3-year Neonatal-Perinatal training program, the residents are expected to expand and cultivate knowledge and skills developed during previous training and to achieve the following objectives based on the six general competencies. Under the supervision and guidance of faculty, the residents will assume graded responsibility as educational experience and procedural skills increase. KEY Teaching Methods Evaluation Methods CT=Clinical Teaching =Global Rating Form (monthly) NRC=Neonatal Resuscitation Course = degree evaluation (every six months) MMC=Morbidity & Mortality Conference =in-training exam (annual) BSC=Basic Science Conference PLR=Procedure Log Review (annual) NPC=Neonatal-Perinatal Conference =Self Evaluation (annual) STC=Biostatistics Course CL= case logs (annual) BEC=Bioethics Conference CE = Conference evaluation (per conference given) JC=Journal Club INF = informal feedback during meetings and discussions SBL=Systems-Based Lecture SCR= scholarly committee report (yearly) RM=Role Modeling ME=Mentoring CAC= Clinical Anomaly Conference RLS = resident lecture series RC = Radiology conference FM = faculty and administrative meetings NL = Nursing Lectures GME-Mod = web-based modules by GME Competency Required Skill(s) Teaching Formative Evaluation Patient Care GENERAL OBJECTIVES Provide patient care that is compassionate, appropriate, and effective for the treatment of neonatal health problems and the promotion of health. CT, NPC, RM Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families. CT, NPC, RM Gather essential and accurate information about their patients. CT, NPC, RM Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical CT, NPC, RM judgments. Develop and carry out patient management plans. CT, NPC, RM Counsel and educate patients and their families about various neonatal disorders. CT, NPC, RM

4 4 Competency Required Skill(s) Teaching Formative Evaluation Use information technology to support patient care decisions and patient education. CT, NPC, RM Perform competently all medical and invasive procedures considered essential for neonatology. Provide health care services aimed at preventing health problems or maintaining health. CT, NPC, RM Work with health care professionals, including those from other disciplines, to provide patient-focused care. CT, NPC, RM Gather pertinent patient information from records and from interview about maternal medical history, pregnancy history, labor complications, and events in the first hours CT, NPC, RM or days of life prior to admission Clinically assess signs of disease and pertinent physical examination findings and correlate these objective findings with information gathered regarding patient history CT, NPC, RM Synthesize information gathered to reach a working impression for diagnostic and management plan CT, NPC, RM Formulate plans for monitoring patient conditions short term and long term management CT, NPC, RM Use available technology for diagnosis, management, and monitoring treatment CT, NPC, RM Perform procedures for monitoring, diagnostic and/or therapeutic intervention CT, NPC, RM PLR Stabilize neonates in the delivery room, for transport, and during transport NRC See individual rotations for a more detailed list of patient care objectives Medical Knowledge GENERAL OBJECTIVES Demonstrate knowledge about established and evolving biomedical, clinical, and cognate sciences and the application of this knowledge to patient care. CT, NPC, JC Demonstrate an investigatory and analytic thinking approach to clinical situations. CT, NPC, JC Know and apply the basic and clinically supportive sciences which are appropriate to their discipline. PLR

5 5 Competency Required Skill(s) Teaching Formative Evaluation Practice Based Learning and Improvement Describe how normal and abnormal pregnancies and maternal conditions will affect fetal well-being Demonstrate in-depth knowledge of fetal-neonatal physiology and pathophysiology of common neonatal disorders and apply this knowledge in the work up and management of neonatal disorders Demonstrate in-depth knowledge of the causes, manifestations and treatment of neonatal disorders or systems disorders encountered in Neonatology Develop an in-depth understanding of the complications of various neonatal disorders and the impact or consequences of these complications later in life Demonstrate familiarity with the short-term and the long-term outcomes of low-birth weight babies, premature infants, and high-risk neonates and the screening or identification of those who demonstrate developmental delay, neurologic problems, neurosensory deficits, language disorders, and mental retardation See individual rotations for a more detailed list of medical knowledge objectives. GENERAL OBJECTIVES Investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Analyze practice experience and perform practice-based improvement activities using a systematic methodology. Locate, appraise, and assimilate evidence from scientific studies related to their patients health problems. Obtain and use information about their own population of patients and the larger population of patients from which their patients are drawn. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness. Use information technology to manage information, access on-line medical information; and support their own education. CT, NPC, JC, CAC CT, NPC, JC,BSC MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC, RLS

6 6 Competency Required Skill(s) Teaching Formative Evaluation Facilitate the learning of students and other health care professionals. MMC, JC, CT, NPC, RLS Evaluate patient care, clinical management, and diagnostic assessment practices, discuss how they meet standards, and develop ways to improve these practices. Demonstrate ability to perform literature search related to a planned research, formulate questions and then the hypothesis to be tested and apply for approval to IACUC or IRB. Compare clinical practice, patient safety, and quality of care with evidence based medicine. Demonstrate the ability to use information from mortality and morbidity conferences to further search for information and or to change practice based on lessons learned from these activities Implement new scientific advances and clinical approaches from a variety of sources into current patient care practices. Analyze and evaluate medical literature and examine alternate sources for information that pertains to their patient s health problems. MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC MMC, JC, CT, NPC Take responsibility for lifelong learning. MMC, JC, CT, NPC, RM Use information technology to gather information needed to support decisions in diagnosis and management and to provide education to other trainees Demonstrate competency as educator at bedside for residents, fellows, and other students in the sub-specialty of Neonatology. This objective is achieved when a fellow achieves his/her objective in the clinical competency related to medical knowledge. Maintain appropriate records documenting practice activities (such as transport logs, procedure logs). MMC, JC, workshops CT, MMC, RM, NPC MMC, JC, CT, NPC, SCR, INF CE PLR

7 7 Competency Required Skill(s) Teaching Formative Evaluation Interpersonal and Communications skills Demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates. CT, RM, NPC, ME Create and sustain a therapeutic and ethically sound relationship with patients. CT, RM, NPC, ME Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills. Work effectively with others as a member or leader of a health care team or other professional group. Carefully listen to patients to assess the patient s health problems including their verbal and non-verbal communications. Demonstrating respectful and considerate attitudes, effectively communicate with patients, families, and other health care personnel, when addressing management plans, patient issues, and especially end-of-life decisions. Accurately present (verbally and written) a case to attending physicians, fellow residents, and other health care professionals. Deliver lectures in both small and large groups of audience at all levels of learning and of various disciplines Provide timely, legible, and thorough medical record documentation - histories and physical examinations, admission notes, progress notes, procedure notes and discharge summaries. Provide education and counseling to patients, and families using non-technical and clear language. (Use non-verbal and verbal communication skills) Spend adequate time with patients and families addressing their questions and concerns. Work well within team consisting of students, residents, attending physicians, nurses, and patients. CT, RM, NPC, ME CT, RM, NPC, ME CT, RM, NPC, ME CT, RM, NPC, ME CT, RM, NPC, MMC, RC CT, RM, NPC, RLS, NL CT, RM, CT, RM, NPC, ME CT, RM, NPC, ME CT, RM, NPC, simulations, INF, CE, INF

8 8 Competency Required Skill(s) Teaching Formative Evaluation Function effectively as a consultant for specialty and subspecialty care. CT, RM, NPC,CAC Represent the Neonatology staff in interactions with patients and their families, acting with compassion and consideration at all times. Professionalism GENERAL OBJECTIVES Demonstrate a commitment to carrying our professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients, society that supercedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care confidentiality of patient information, informed consent, and business practices. Demonstrate a sensitivity and responsiveness to patients culture, age, gender, and disabilities. Demonstrate respect, compassion, integrity, punctuality, reliability, and honesty with regards to patients and colleagues. CT, RM, NPC, ME CT, RM, BEC, SBL, ME CT, RM, BEC, SBL, ME CT, RM, BEC, SBL, ME CT, RM, BEC, SBL, ME CT, RM, BEC, SBL, ME Show regard for the opinions of others. CT, RM, BEC, SBL, ME Display initiative and leadership. CT, RM, BEC, SBL, ME Acknowledge errors, alert patients and appropriate health care providers about the errors, and create a plan of action to minimize them. CT, RM, BEC, SBL, ME Demonstrate concern for the educational development of students and residents. CT, RM, BEC, SBL, ME Ask for help when needed and accept constructive feedback. CT, RM, BEC, SBL, ME

9 9 Competency Required Skill(s) Teaching Formative Evaluation Systems-Based Practice Demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Maintain patient confidentiality. Compassionately respond to issues of culture, age, gender, ethnicity, and disability in patient care. GENERAL OBJECTIVES Demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources. Practice cost-effective health care and resource allocation that does not compromise quality of care. Advocate for quality patient care and assist patients in dealing with system complexities. Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance. CT, RM, BEC, SBL, ME CT, RM, BEC, SBL, ME GME-Mod CT, RM, BEC, SBL, ME CT, RM, SBL, MMC CT, RM, SBL, MMC CT, RM, SBL, MMC CT, RM, SBL, MMC, JC CT, RM, SBL, MMC, FM CT, RM, SBL, MMC, FM Demonstrate ability to deliver high-quality medical care in a private, government, and inner city hospital setting NICU. Demonstrate the knowledge of different types of NICU practices and health care delivery systems and understand how this affects patient care. Demonstrate knowledge of business aspects of medical practice including coding, billing, and insurance. Work with ancillary team members (discharge planners, case managers, and social workers) to provide high quality cost-effective care. CT, RM, SBL, MMC CT, RM, SBL, MMC CT, RM, SBL, MMC, FM CT, RM, SBL, MMC, FM

10 10 Competency Required Skill(s) Teaching Formative Evaluation Use systematic approaches to reduce errors. CT, RM, SBL, MMC, FM Practice effective allocation of health care resources to avoid compromising quality of care. CT, RM Serve as a patient advocate in the outpatient and inpatient setting. CT, RM, SBL, MMC Demonstrate knowledge of how the health care system including other physicians, nurses, and health care professionals affect their patient care practices. CT, RM, SBL, MMC Neonatal Intensive Care Unit Rotation Sheldon B. Korones Newborn Center Regional Medical Center ROTATION GOAL Through hands-on experience, supervision of house staff, nurse clinicians and physician assistants, individual reading, attendance at conferences, and presenting at lectures/conferences, the residents will gain in-depth knowledge of fetal/neonatal physiology, pathophysiology of neonatal disorders, and will gain experience in diagnosing and managing neonatal disorders. SPECIFIC OBJECTIVES First Year Neonatal-Perinatal Resident During the first year of training, subspecialty faculty members will closely supervise the resident as he/she demonstrates knowledge in differential diagnosis, patient management, and utilization of available resources in the NICU and hospital. At this time, the resident will learn most bedside NICU procedures such as umbilical venous and arterial catheterization, lumbar puncture, supra-pubic puncture, chest thoracostomy or chest tube insertion, arterial puncture for blood gas sampling and phlebotomy for blood sampling for laboratory determination and blood culture. By the end of the NICU rotation at the MED, first year subspecialty residents are expected to expand and cultivate skills and knowledge learned during previous training and to achieve the following objectives based on the six general competencies. The resident should exhibit an increasing level of responsibility and independency as he or she progresses throughout the year. Competency Required Skill(s) Teaching Formative Evaluation Patient Care Recognize problems of infants in the delivery room and provide appropriate management of the neonate to include understanding of anesthesia for labor and delivery, delivery room resuscitation of the neonate, physical examination and care of the newborn, birth injuries, and congenital malformations Recognize, diagnose, and manage the following neonatal diseases/conditions including but not limited to: NRC, simulations JC, MMC PLR

11 11 Competency Required Skill(s) Teaching Formative Evaluation General considerations in providing neonatal care The physical environment/thermoregulation neonatal monitoring nutrition and metabolism enteral feeding parenteral nutrition fluid and electrolyte balance acid-base balance PLR The respiratory system developmental biology pulmonary function respiratory distress syndrome (surfactant deficiency) assisted ventilation other lung disorders (TTN, MAS, CF) persistent pulmonary hypertension chronic lung disease air leak syndromes ECMO and other therapies The cardiovascular system cardiac development postnatal cardiopulmonary adaptation neonatal cardiac assessment and assessment of cardiac function patent ductus arteriosus common cardiac defects cardiac medications The neonatal gastrointestinal tract development (anatomical, physiological, and biochemical) upper GI disorders disorders of digestion GI anomalies and intestinal obstruction GI hemorrhage necrotizing enterocolitis

12 12 Competency Required Skill(s) Teaching Formative Evaluation Diseases of the liver bilirubin metabolism unconjugated hyperbilirubinemia conjugated hyperbilirubinemia The immune system developmental immunology bacterial infection viral infections fungal and protozoal infections disorders of white blood cells therapies (IVIG, granulocytes, etc.) Central nervous system disturbances development of the nervous system disorders of development assessment of neurologic function intracranial hemorrhage seizures hypoxic-ischemic encephalopathy neuromuscular disorders Blood and the hematopoietic system disorders of the red cell disorders of platelets and coagulation blood component therapy Metabolic and endocrine disorders carbohydrate disorders disorders of calcium and magnesium thyroid disorders other metabolic disorders (adrenal disorders, SIADH) abnormalities of sexual differentiation inborn errors of metabolism Kidneys and the urinary tract

13 13 Competency Required Skill(s) Teaching Formative Evaluation renal development and physiology renal failure urinary tract malformations Diseases of the eye diagnosis and evaluation retinopathy of prematurity other eye diseases The skin neonatal skin morphology diseases of the skin Orthopedic problems neonatal musculoskeletal disorders bone and joint infection congenital deformities of the extremities Infants of durg-addicted mothers Under direct supervision, perform or interpret the following specialized clinical procedures, monitoring, and techniques and providing adequate documentation including status and patient tolerance of procedures performed including but not limited to: Cardiopulmonary monitoring Phototherapy Conventional mechanical ventilation High frequency ventilation Inhaled Nitric-oxide therapy Serologic Studies and other studies for transplacental and congenital infection Radiographic examination for line placement, detection of air leak, effusion, etc. Radionuclide scanning Under supervision acquire the necessary skills to perform taking into consideration aseptic and sterile techniques, avoiding or minimizing complications from the procedures and document, the following NICU PLR PLR

14 14 Competency Required Skill(s) Teaching Formative Evaluation procedures: Venipuncture Arterial stick Peripheral vein or arterial cannulation Percutaneous line insertion Umbilical vein catheterization Umbilical arterial catheterization Endotracheal Intubation Surfactant administration Nitric oxide therapy Lumbar puncture Suprapubic tap Exchange transfusion Partial plasma exchange transfusion Thoracocentesis Abdominocentesis Chest tube insertion Pericardial tap Ventricular reservoir tap Identify and gather relevant clinical data and develop history along relevant clinical lines MMC Interpret physical findings accurately and will repeat examination when findings are equivocal CT, NPC, RM Interpret laboratory findings/results correctly most of the times CT, NPC, RM Formulate sound diagnostic impression that is specific to the clinical problem encountered CT, NPC, RM Common neonatal disorders and issues include but not limited to preterm birth of varying gestational ages, surfactant deficiency syndrome, patent ductus arteriosus, anemia of prematurity, necrotizing enterocolitis, neonatal nutrition, fluid and electrolyte balance, and initial medical and surgical management prior to surgical procedure CT, NPC, RM Demonstrate a familiarity with the stabilization, logistics and management of infants during transport who are referred in to the tertiary medical center for further management. Start to recruit and provide follow-up of infants for developmental testing for continuing follow-up through the fellowship. CT, NPC, RM CT, NPC, RM

15 15 Competency Required Skill(s) Teaching Formative Evaluation Demonstrate compassion when dealing with families and will obtain history from families in a culturally competent manner. CT, NPC, RM Utilize available resources in the community and demonstrate appropriate planning for discharge of patients in the NICU CT, NPC, RM Participate in the development of clinical protocols in the NICU FM Respond to consultation requests from the Labor and Delivery Floor and from the prenatal clinics under the supervision of the assigned attending CT, NPC, RM Medical Knowledge Demonstrate an in-depth understanding of fetal-neonatal physiology and patho-physiology of common neonatal disorders and utilize this information in the management of infants. CT, NPC, JC,BSC, RSL Understand the basics of evidenced-based practice; i.e., searching the literature, critical literature review and implementing evidence-based findings., RSL Describe fetal growth, maturation, and intrauterine development, RSL Analyze how the following pregnancy disorders impact fetal development, including but not limited to: Intrauterine growth retardation Toxemia of Pregnancy Other hypertensive disorders of pregnancy Diabetes in pregnancy and gestational diabetes Medical conditions and pregnancy (Lupus, maternal thrombocytopenia, maternal infections, etc.) Obstetrical management of preterm birth Complications of labor and anesthesia Fetal effects of autoimmune diseases Multiple gestation Post-term pregnancy Erythroblastosis fetalis Polyhydramnios, oligohydramnios, hydrops Perinatal infection Placental pathology (previa, abruptio, etc) / abnormalities in function Prenatal genetic counseling Screening for abnormal conditions, problems and management when there CT, NPC, JC,BSC, CAC

16 16 Competency Required Skill(s) Teaching Formative Evaluation Practice Based Learning and Improvement Interpersonal and Communication Skills is a positive or abnormal screen result Demonstrate an understanding of the embryonic development, anatomical, biochemical and physiological maturation and of the underlying pathophysiology Demonstrate an understanding of the technical and underlying physics or biochemistry in the development of these procedures/equipment as well as the application of these procedures for evaluation or treatment of the fetus or the newborn Professionalism Systems-Based Practice 2 nd Year Neonatal-Perinatal Resident By the end of the NICU rotation at the MED, second year subspecialty residents are expected to expand and cultivate skills and knowledge learned during previous training and to achieve the following objectives based on the six general competencies. The resident should exhibit an increasing level of responsibility and independency as he or she progresses throughout the year. Since competencies learned or mastered in the first year of fellowship are competencies required for a successful clinician, the second year fellow will demonstrate achieved objectives in year one with expanded knowledge, more efficiency in performance of procedures, and additional knowledge in pathophysiology encompassing more complex disorders. Competency Required Skill(s) Teaching Formative Evaluation Patient Care Recognize problems of infants in the delivery room and provide appropriate management of the neonate to include anesthesia for labor and delivery, delivery room resuscitation of the neonate, physical examination and care of the newborn, birth injuries, and congenital malformations and be able to supervise pediatric residents and NNPs Interpret laboratory results correctly all the time and order subsequent tests appropriately PLR

17 17 Competency Required Skill(s) Teaching Formative Evaluation With more efficiency and less supervision, perform the following NICU procedures (If able to perform procedures without supervision, then the fellow will be able to provide supervision for such procedures to be formed by the resident): venipuncture arterial stick peripheral vein or arterial cannulation percutaneous line insertion umbilical vein catheterization umbilical arterial catheterization intubation surfactant administration nitric oxide therapy lumbar puncture suprapubic tap exchange transfusion partial plasma exchange transfusion thoracocentesis abdominocentesis chest tube insertion pericardial tap ventricular reservoir tap PLR All other objectives as described for first year level Medical Knowledge Demonstrate an in-depth understanding of fetal-neonatal physiology and pathophysiology of common neonatal disorders. Understand and apply the basics of evidenced-based practice; i.e., searching the literature, critical literature review and implementing evidence-based findings. CT, NPC, JC,BSC Describe fetal growth, maturation, and intrauterine development Analyze and explain how the pregnancy disorders described above (first year level) impact fetal development CT, NPC, JC,BSC Demonstrate an understanding of the embryonic development, anatomical,

18 18 Competency Required Skill(s) Teaching Formative Evaluation biochemical and physiological maturation and of the underlying pathophysiology Practice Based Learning and Improvement Interpersonal and Communication Skills Demonstrate an understanding of the technical and underlying physics or biochemistry in the development of this procedures/equipment as well as the application of these procedures for evaluation or treatment of the fetus or the newborn. Professionalism Systems-Based Practice 3rd Year Neonatal-Perinatal Resident By the end of the NICU rotation at the MED, third year subspecialty residents are expected to expand and cultivate skills and knowledge learned during previous training and to achieve the following objectives based on the six general competencies. The resident should exhibit an increasing level of responsibility and independency as he or she progresses throughout the year. Since competencies learned or mastered in the first and second year of fellowship are competencies required for a successful clinician, the third year fellow will demonstrate achieved objectives in year one and two with expanded knowledge, more efficiency in performance of procedures, and additional knowledge in pathophysiology encompassing more complex disorders. Competency Required Skill(s) Teaching Formative Evaluation Patient Care Recognize problems of infants in the delivery room and provide appropriate management of the neonate to include anesthesia for labor and delivery, delivery room resuscitation of the neonate, physical examination and care of the newborn, birth injuries, and congenital malformations, lead the team and supervise other trainees Proficiently perform or interpret the specialized procedures, monitoring, and techniques described above at first year level (fellow should be able to provide supervision for such procedures to be performed by the pediatric resident): Proficiently perform the NICU procedures described above at first year level PLR

19 19 Competency Required Skill(s) Teaching Formative Evaluation (fellow should be able to provide supervision for such procedures to be formed by the resident): PLR Work-up and manage NICU patients including those with complex disorders and oversee as Junior attending the care of the patients in the NICU For clinical research projects, complete enrollment, analyze data, prepare presentation, and prepare manuscript for submission ME Demonstrate competency and to be a role model for other trainees ME Medical Knowledge Demonstrate an in-depth understanding of fetal-neonatal physiology and pathophysiology of common neonatal disorders. Practice Based Learning and Improvement Interpersonal and Communication Skills Understand and apply the basics of evidenced-based practice; i.e., searching the literature, critical literature review and implementing evidence-based findings. CT, NPC, JC,BSC Describe fetal growth, maturation, and intrauterine development Analyze and teach how the pregnancy disorders described above (first year level) impact fetal development, placental pathology (previa, abruptio, etc) / abnormalities in function Demonstrate an understanding of the embryonic development, anatomical, biochemical and physiological maturation and of the underlying pathophysiology Demonstrate an understanding of the technical and underlying physics or biochemistry in the development of this procedures/equipment as well as the application of these procedures for evaluation or treatment of the fetus or the newborn. CT, NPC, JC,BSC Demonstrate an improvement of scores for in training exams, STC SCR

20 20 Competency Required Skill(s) Teaching Formative Evaluation Professionalism Systems-Based Practice DESCRIPTION OF RESPONSIBILITIES The subspecialty resident serves as supervisor of the clinical team. He/she will see to it that patients are appropriately worked up and managed by the primary care residents, and neonatal nurse practitioners. The subspecialty resident will be under the direct supervision of the neonatology attending. a. Year 1: There will be close supervision by the faculty member of the subspecialty resident as the subspecialty resident demonstrates knowledge in differential diagnosis; patient management and he/she learn how to utilize available resources in the NICU and hospital. At this time, the resident will learn most bedside NICU procedures such as umbilical venous and arterial catheterization, lumbar puncture, supra-pubic puncture, chest thoracotomy or chest tube insertion, arterial puncture for blood gas sampling and phlebotomy for blood sampling for laboratory determination and blood culture. b. Year 2: The subspecialty resident will continue to supervise residents, will demonstrate skills as a teacher at bedside, will give the monthly orientation for the new interns and students, and will also teach residents various procedures (at this point the subspecialty resident will have mastered the routine NICU procedures). The fellow would be an NRP instructor by this level. c. Year 3: a month of clinical service will be devoted to being a junior attending. The extent of responsibility will highly depend on the attending and previous performance of the subspecialty residents. EVALUATION OF PROAM AND FACULTY Input regarding the subspecialty resident's performance during months of clinical service is obtained from residents, nurses, nurse practitioners. Evaluation of competencies and performance are discussed by attending faculty with the subspecialty resident during rotation. However, formal evaluation of program/faculty is once a year (see Evaluations).

21 21 NEONATAL INTENSIVE CARE UNIT/SURGERY/TRANSPORT ROTATION LEBONHEUR CHILDREN S MEDICAL CENTER ROTATION GOAL Through hands-on experience (direct patient care), supervision of nurse clinicians and physician assistants, individual reading attendance at conferences, and presenting at lectures/conferences, the residents will gain an in-depth knowledge of fetal/neonatal physiology, pathophysiology of neonatal disorders, and will gain experience in diagnosing and managing a common neonatal disorders. Residents will focus much of their training around surgical patients of all specialties (general, ENT, Neurosurgery, cardiac surgery, etc.) during this rotation. The will demonstrate confidence in management of pre and postoperative neonates in conjunction with surgeons. ROTATION OBJECTIVES First Year Neonatal-Perinatal Resident During the first year of training, subspecialty faculty members will closely supervise the resident as he/she demonstrates knowledge in differential diagnosis, patient management, and utilization of available resources in the NICU and hospital. At this time, the resident will learn most bedside NICU procedures such as umbilical venous and arterial catheterization, lumbar puncture, supra-pubic puncture, chest thoracostomy or chest tube insertion, arterial puncture for blood gas sampling and phlebotomy for blood sampling for laboratory determination and blood culture. By the end of the NICU rotation at LeBonheur, first year subspecialty residents are expected to expand and cultivate skills and knowledge learned during previous training and to achieve the following objectives based on the six general competencies. The resident should exhibit an increasing level of responsibility and independency as he or she progresses throughout the year. Competency Required Skill(s) Teaching Formative Evaluation Patient Care Recognize problems of infants arriving on transport with surgical/multispeciality problems and stabilize them after admission Recognize, diagnose, and manage the following neonatal diseases/conditions under supervision from the attending neonatologist and surgeon, including but not limited to: General considerations in providing neonatal care with focus on pre and postoperative infants The physical environment/thermoregulation neonatal monitoring nutrition and metabolism enteral feeding parenteral nutrition fluid and electrolyte balance acid-base balance The respiratory system

22 22 Competency Required Skill(s) Teaching Formative Evaluation assisted ventilation persistent pulmonary hypertension chronic lung disease air leak syndromes ECMO and other therapies The cardiovascular system patent ductus arteriosus common cardiac defects and needed surgery cardiac medications The neonatal gastrointestinal tract development (anatomical, physiological, and biochemical) disorders of digestion GI anomalies and intestinal obstruction GI hemorrhage necrotizing enterocolitis Diseases of the liver TPN-related cholestasis Hepatic malformations Central nervous system disturbances development of the nervous system disorders of development assessment of neurologic function intracranial hemorrhage seizures hypoxic-ischemic encephalopathy neuromuscular disorders Kidney and the urinary tract renal development and physiology renal failure urinary tract malformations Orthopedic problems

23 23 Competency Required Skill(s) Teaching Formative Evaluation neonatal musculoskeletal disorders bone and joint infection congenital deformities of the extremities Acquire the necessary skills to perform the NICU procedures as described previously PLR Identify relevant clinical data and develop history along relevant clinical lines Interpret physical findings accurately and will repeat examination when findings are equivocal Interpret laboratory findings/results correctly Formulate sound diagnostic impression that is specific to the clinical problem encountered Recognize and utilize contribution of others to total patient care and observe ancillary support services like wound care, tracheotomy care, stoma care etc. Demonstrate a familiarity with the stabilization, logistics and management of infants during transport who are referred in to the tertiary medical center for further management. Demonstrate compassion when dealing with families and will obtain history from families in a culturally competent manner. Medical Knowledge Demonstrate an in-depth understanding of fetal-neonatal physiology and pathophysiology of common neonatal surgical disorders and utilize this information in the management of infants. Understand the basics of evidenced-based practice; i.e., searching the literature, critical literature review and implementing evidence-based findings. Demonstrate an understanding of the embryonic development, anatomical, biochemical and physiological maturation and of the underlying pathophysiology Demonstrate an understanding of the technical and underlying physics or biochemistry in the development of these procedures/equipment as well as the application of these procedures for evaluation or treatment of the fetus or the newborn CT, NPC, JC,BSC TCL Practice Based Learning and

24 24 Competency Required Skill(s) Teaching Formative Evaluation Improvement Interpersonal and Communication Skills Professionalism Systems-Based Practice Second Year Neonatal-Perinatal Resident By the end of the NICU rotation at LeBonheur, second year subspecialty residents are expected to expand and cultivate skills and knowledge learned during previous training and to achieve the following objectives based on the six general competencies. The resident should exhibit an increasing level of responsibility and independency as he or she progresses throughout the year. Since competencies learned or mastered in the first year of fellowship are competencies required for a successful clinician, the second year fellow will demonstrate achieved objectives in year one with expanded knowledge, more efficiency in performance of procedures, and additional knowledge in pathophysiology encompassing more complex disorders. Competency Required Skill(s) Teaching Formative Evaluation Patient Care Manage infants admitted after transport and stabilize them effectively prior to surgical interventsions Recognize, diagnose, and manage the neonatal diseases/conditions described above, with minimal supervision from the attending neonatologist and surgeon With minimal supervision, perform or interpret the following specialized clinical procedures, monitoring, and techniques and providing adequate documentation including status and patient tolerance of procedures performed including but not limited to: Cytogenetics and molecular aspect of genetics Perinatal ultrasound estimation of monitoring of fetal growth and well-being Cardiopulmonary monitoring Phototherapy Conventional mechanical ventilation High frequency ventilation RC

25 25 Competency Required Skill(s) Teaching Formative Evaluation ECMO Cerebral Function Monitoring Cranial ultrasound and cerebral Doppler Direct and Indirect Coombs tests Serologic Studies and other studies for transplacental and congenital infection Radiographic examination for line placement, detection of air leak, effusion, etc. Computerized tomography as imaging modality With minimal supervision, perform the NICU procedures described in the previous table for first year objectives Identify and gather relevant clinical data and develop history along relevant clinical lines PLR Interpret physical findings accurately and will repeat examination when findings are equivocal Interpret laboratory findings/results correctly and reorder subsequent laboratory tests appropriately Formulate sound diagnostic impression that is specific to the clinical problem encountered Recognize and utilize contribution of others to total patient care, learn ancillary care like wound care, tracheostomy care, stoma care Common neonatal disorders and issues include but not limited to preterm birth of varying gestational ages, surfactant deficiency syndrome, patent ductus arteriosus, anemia of prematurity, necrotizing Enterocolitis, neonatal nutrition, fluid and electrolyte balance, and initial medical and surgical management prior to surgical procedure Demonstrate an expertise with the stabilization, logistics and management of infants during transport who are referred in to the tertiary medical center for further management. Demonstrate compassion when dealing with families and will obtain history from families in a culturally competent manner. Utilize available resources in the community and demonstrate appropriate

26 26 Competency Required Skill(s) Teaching Formative Evaluation planning for discharge of patients in the NICU Participate in the development of clinical protocols in the NICU Medical Knowledge Demonstrate an in-depth understanding of fetal-neonatal physiology and pathophysiology of more complex neonatal disorders and utilize this information in the management of infants. Practice Based Learning and Improvement Interpersonal and Communication Skills Understand the basics of evidenced-based practice and implement; i.e., searching the literature, critical literature review and implementing evidence-based findings. Demonstrate an understanding of the embryonic development, anatomical, biochemical and physiological maturation and of the underlying pathophysiology Recognize the need for surgical intervention in neonates when appropriate and demonstrate understanding in co- management of surgical patients with the surgeons Demonstrate an understanding of the technical and underlying physics or biochemistry in the development of these procedures/equipment as well as the application of these procedures for evaluation or treatment of the fetus or the newborn Professionalism Systems-Based Practice CT, NPC, JC,BSC CT, NPC, JC,BSC Third Year Neonatal-Perinatal Resident During the third year of training, subspecialty residents are expected to work-up and manage NICU patients including those with complex disorders and oversee as Junior attending the care of patients. The residents will demonstrate proficiency in performing all NICU procedures and provide supervision for junior residents. Third year residents will serve as role models for junior residents and other trainees. By the end of the NICU rotation at LeBonheur, third year subspecialty residents are expected to expand and cultivate skills and knowledge learned during previous training and to achieve the following objectives based on the six general competencies. The resident should exhibit an increasing level of responsibility and independency as he or she progresses throughout the year.

27 27 Competency Required Skill(s) Teaching Formative Evaluation Patient Care Recognize, diagnose, and manage with independence and be able to teach junior residents and NNPs, conditions described above in objectives for first year level With proficiency, perform or interpret and explain to the junior residents and students, the specialized clinical procedures, monitoring, and techniques as described at first year level Proficiently and competently perform all the NICU procedures as described at first year level and provide supervision to junior residents Identify relevant clinical data and develop history along relevant clinical lines Interpret physical findings accurately and will repeat examination when findings are equivocal Interpret all laboratory findings/results correctly Formulate sound diagnostic impression that is specific to the clinical problem encountered Recognize and utilize contribution of others to total patient care Common neonatal disorders and issues include but not limited to preterm birth of varying gestational ages, surfactant deficiency syndrome, patent ductus arteriosus, anemia of prematurity, necrotizing Enterocolitis, neonatal nutrition, fluid and electrolyte balance, and initial medical and surgical management prior to surgical procedure Demonstrate an expertise with the stabilization, logistics and management of infants during transport who are referred in to the tertiary medical center for further management. Demonstrate compassion when dealing with families and will obtain history from families in a culturally competent manner. Utilize available resources in the community and demonstrate appropriate planning for discharge of patients in the NICU Participate in the development of clinical protocols in the NICU and present data to the faculty Medical Knowledge Demonstrate an in-depth understanding of fetal-neonatal physiology and pathophysiology of all neonatal disorders and utilize this information in the management CT, NPC, JC,BSC, CE

28 28 Competency Required Skill(s) Teaching Formative Evaluation of infants. Understand and apply the basics of evidenced-based practice; i.e., searching the literature, critical literature review and implementing evidence-based findings. Practice Based Learning and Improvement Interpersonal and Communication Skills Describe fetal growth, maturation, and intrauterine development Demonstrate an understanding and be able to teach the embryonic development, anatomical, biochemical and physiological maturation and problems related to malformations Show an in-depth knowledge of the causes, manifestations and treatment of neonatal disorders encountered in practice of neonatal surgery and cardiovascular surgery Demonstrate an understanding of the technical and underlying physics or biochemistry in the development of these procedures/equipment as well as the application of these procedures for evaluation or treatment of the fetus or the newborn Professionalism Systems-Based Practice CT, NPC, JC,BSC DESCRIPTION OF RESPONSIBILITIES Through this rotation, the subspecialty resident will spend 4-5 months in a 3 year period at the NICU at LBCMC. The patients are mainly pre/post surgery, cardiac and multispecialty involvement. The residents will closely follow and manage these patients with the neonatologist and the surgeon or other subspecialist as the need arises. The resident will learn to identify neonatal surgical problems and manage it together with the surgeon. During these rotations the resident will also be a part of the transport team and learn stabilization of the infant during transport under supervision of the neonatologist. The resident is expected to develop a presentation/lecture unique to the patient population seen in this NICU and present at the Noon conference. EVALUATION Performance evaluation will be obtained from the attending neonatologist and or local site director and also from the members of the transport team for a evaluation of the resident and support staff at Le Bonheur NICU.

29 29 DEVELOPMENTAL FOLLOW-UP ROTATION REGIONAL MEDICAL CENTER ROTATION GOAL Through this rotation the resident will learn different developmental and behavioral measures or scales that are used to assess the development of graduates of neonatal intensive care. He/she will become familiar with normal developmental milestones as well as subtle and gross signs of developmental delay. Through this rotation the trainee will learn the associated morbidities related to prematurity and other newborn disorders or the influence of these medical conditions on the infant's long-term outcome. Emphasis is placed on the comprehensive, multidisciplinary assessment. SPECIFIC OBJECTIVES By the end of the Developmental follow-up rotation at the MED, first year subspecialty residents are expected to expand and cultivate skills and knowledge learned during previous training and to achieve the following objectives based on the six general competencies. The resident should exhibit an increasing level of responsibility and independency as he or she progresses throughout the year. Competency Required Skill(s) Teaching Formative Evaluation Patient Care Obtain a complete medical history, reviewing medical interval histories, and complete a comprehensive physical examination including growth parameters Perform or interpret the following medical evaluations and assessments to provide the most accurate and efficient follow up care: neurological evaluation (also includes gross and fine motor assessment and tests for reflexes) psychological assessment (includes evaluation of behavior, temperament, cognitive function derived from standard tests such as the Bayley Scales of Infant Development and the Stanford-Binet intelligence test) hearing evaluation ophthalmologic evaluation socioeconomic and environment assessment through interviews and questionnaires Make use of the results of the multidisciplinary assessments to determine when to optimally refer infants suspected or assessed to have developmental delay or problems to other subspecialties and early intervention services, to prescribe or recommend further or additional home health care services, to recommend additional developmental follow-up, and to recognize and to provide or refer for counseling the caretakers or families of infants who were discharged from the NICU. Demonstrate a familiarity with the community's referral services and will make use of these resources to provide optimal follow-up of infants at high risk for developmental delay or morbidity