Transcript Style C 36 by 48 wide - University of Chicago

Optimizing Resident Learning Resources in the NICU:
The Development of a Computer-Based and Pocket Size Handbook
Jeanette Hoenig, M.D.
The University of Chicago Comer Children’s Hospital
INTRODUCTION
DISCUSSION
Resident Survey: 82% Response rate (50/61)
74% reported the current resource is not always accessible
36% reported the current resource is hard to use
78% reported they would read 1-2 pages of a topic review
As ideas and technology advance, information can be
made more accessible and easy-to-use. This is especially
important when teaching residents, as there is a significant
amount of self-directed learning that occurs.
M ost frequently used source of information when
a resident learns about a topic
Format of a NICU Handbook most likely to be
used by a resident
44%
Repsonse Rate (%)
48%
Response Rate (%)
Residents manage complex patients in the Neonatal
Intensive Care Unit (NICU) starting from intern year. Due
to the fast pace and highly-specialized nature of the field,
there is a need for an accessible, easy-to-use resource for
resident self-directed learning. The current resource is
provided as an 8 ½ x 11” packet of NICU topics without
page numbers, which limits its accessibility and ease of
use. Studies have shown that students are now also
using computers as learning tools and that this resource
is an effective mode of teaching.
RESULTS
28%
22%
34%
14%
6%
4%
Pocketbook
PDA
Online
8x11 packet
Computer
Format
OBJECTIVE
To facilitate resident self-directed learning in the NICU:
1. Evaluate the current NICU resource for house staff
and identify areas for improvement
2. Develop a new NICU house staff resource provided in
multiple formats, designed to meet a wide range of
resident needs
METHODS
1. Resident survey conducted via email to evaluate the
current NICU resource and identify learning needs
2. Authorship of a new NICU house staff resource
a) Extensive literature review
b) Interviews (unstructured) with topic experts
c) Attendance at specialized topic review courses
d) Content review by a panel of experts:
3 Neonatology attendings and 1 Neonatology fellow
Our survey revealed that more residents (48%) use a
computer vs. another person (34%) or a book (4%) when
learning about a topic. However, many residents (44%)
report that they would be most likely to use a pocketbook
reference in the NICU.
Person
PDA
Book
Source of Information
A New NICU House Staff Resource:
Pocket NICU: A Handbook for House Staff
1. Provided in multiple formats to improve accessibility
a) Pocketbook version
b) Online version will be available on Chief’s website
c) 8 ½ x 11” packet
2. Designed to improve ease-of-use
a) 47 Topic reviews: each review is 1-2 pages in length
b) Page numbers provided in the pocketbook and packet
c) Online version with links to each topic
TABLE OF CONTENTS
NECROTIZING ENTEROCOLITIS
Introduction
Definition: Necrotizing enterocolit is (NEC) is a disorder that involves inflammation and necrosis of the intestinal walls.
NICU Basics
Pulmonary Topics
Prenatal Testing and Fetal Monitoring
Delivery Roo m Preparation
Delivery Roo m Management
Algorith m for Newborn Resuscitation
Admission Criteria Guidelines
Admitt ing to the NICU – Init ial Steps
Plan fo r the Day
Discharge Planning
Lab/Study Monitoring Guidelines
Facts and Formulas
Emergencies
Preterm Infant
Retinopathy of Prematurity
Ventilator Basics
Ventilator Management
High Frequency Oscillatory Ventilation
Respiratory Distress Syndrome
Transient Tachypnea of the Newborn
Bronchopulmonary Dysplasia
Meconium Aspiration Syndro me
Apnea
Procedures
Drawing Blood
Umbilical Artery Catheterization
Umbilical Vein Catheterization
Endotracheal Intubation
Chest Tube Placement
Lu mbar Puncture
Neurologic Topics
Seizures
Intraventricular Hemorrhage
Periventricular Leuko malacia
Sedation and Analgesia
Hematologic Topics
Anemia of Prematurity
Hyperbilirubinemia – Unconjugated
Endocrine Topics
Infant of a Diabetic Mother
FEN Topics
Nutrit ion
Flu ids – Daily Orders
Flu ids – In Detail
TPN – DOL # 1
TPN – DOL # 2
ID Topics
Cardiovascular Topics
Gastroesophageal Reflu x
Necrotizing Enterocolitis
Sepsis – Early Onset
GBS
Gastrointestinal Topics
Patent Ductus Arteriosus
Persistent Pulmonary Hypertension of the
Newborn
ECM O Basics
Congenital Heart Disease
2005 First Edition
Written by Jeanette D. Hoenig, M.D.
Email [email protected] with any questions or suggestions
Online version of this handbook is available at http://pediatrics.uchicago.edu/chiefs
Reviewed by Dr. William Meadow, Dr. Jaideep Singh, Dr. Leslie Caldarelli and Dr. Bree Andrews
It is the most common gastrointestinal emergency in the newborn and may lead to death in severely affected infants.
Characteristic findings include abdominal distension, blood in the stools and pneumatosis intestinalis (air in the bowel wall)
on abdominal x-ray.
Epidemiology: Incidence is 1-3 per 1,000 live births. The incidence is highest in preterm infants, with most cases
occurring in patients < 34 weeks gestation and BW <1500 grams. Appro ximately 10% of cases occur in fu ll term infants.
Most affected infants have been enterally fed.
Pathophysiology
The exact etiology of NEC remains unclear. The initial event may involve injury to the intestinal mucosa by ischemia,
reperfusion injury, infect ious agents or mucosal irritants. Bacteria may then proliferate on the substrate provided by enteral
feeds and invade the vulnerable mucosa. Eventually, gas accumu lates in the mucosal wall. Further in jury, invasion and
inflammat ion lead to necrosis and possible perforation of the bowel. Preterm infants are believed to be susceptible due to
immaturity of the GI tract and immune system.
Risk factors: prematurity, enteral feeds (though breastmilk may be protective), hyperosmolar solutions, rapid advancement
of feeds (controversial), circulatory instability, bacterial overgrowth and polycythemia
A new NICU house staff resource has been developed to
meet a variety of resident needs. Multiple formats have
been provided to maximize learning opportunities. The
computer has been utilized as a teaching tool. In the
future, this NICU resource can be expanded in content and
in format - for example, a PDA version can be developed.
The ultimate goal is for an improved knowledge base and
comfort level of residents in the NICU.
REFERENCES
1. Carroll AE, Schwartz MW. A comparison of a lecture
and computer program to teach fundamentals of the
draw-a-person test. Arch Pediatr Adolesc Med.
2002;156:137-140.
2. D’Alessandro DM, Kreitner CD, Peterson MW. An
evaluation of information-seeking behaviors of
general pediatricians. Pediatrics 2004;113:64-69.
3. Potts MJ, Messimer SR. Successful teaching of
pediatric fluid management using computer methods.
Arch Pediatr Adolesc Med. 1999;153:195-198.
Clinical Presentation
In full term infants, symptoms present early, i.e. first 1-3 days of life. Affected preterm infants are often the “feeders and
growers” with symptoms developing weeks to months after birth. Pat ients may present with GI-related sympto ms
including feeding intolerance (vo miting or large residuals, possibly bilious), bloody stools (gross or occult blood),
hypoactive bowel sounds or abdominal d istension, tenderness, discoloration or “loopy” appearance. Patients may also
present with nonspecific symptoms including lethargy, temperature instability, apnea, bradycardia or poor perfusion.
Diagnostic Evaluation
 CBC3 – concerning values include a high or lo w WBC, left-shift, lo w platelet count
 BM P – concerning values include lo w Na, h igh K
 Blood gas – concerning value includes low pH
 Blood culture
 AXR – order supine view and either cross-table lateral or left lateral decubitus (L side down) as well. Look for bowel
wall thickening, air in the wrong place such pneumatosis intestinalis (air in the bowel wall), portal air, free air, or the
“football sign” (a hyperlucency overlying the mid-abdo men on a supine film representing air in the anterior abdomen).
Also look for signs of obstruction including dilated bowel loops or a “sentinel loop” (bowel loop fixed in the same position
on serial films).
Management
 NPO, NG suction, IVF with electro lytes, TPN, heme-check stools, respiratory and cardiovascular support
 Antibiotics: A mpicillin and Gentamicin, consider adding Clindamycin or Flagyl in severe cases
 Pediatric surgery consult if perfo ration suspected. Examp les of surgical interventions may include exploratory
laparotomy, d rain p lacement or removal of necrotic bowel.
 In the acute phase of the illness, serial labs and abdominal x-rays are ordered frequently, i.e. Q6-12 hours
 Medical management of NEC o ften involves maintaining the pt NPO, on TPN and antibiotics for 10-14 days
Prognosis
With earlier d iagnosis and treatment, the mortality rate has decreased to 20-30%.
ACKNOWLEDGEMENTS
Special thanks to those who made this project possible:
William Meadow, Madelyn Kahana, Jaideep Singh, Leslie
Caldarelli, Bree Andrews, Tom Shimotake, Alyna Chien,
Jeremy Hoenig, Ellen Newton and Toni Payne