Internship Survival Guide

2014-2015

University of Florida College of Medicine

Department of Pediatrics

50
 Table of Contents

Section Page
Important Phone Numbers 3
Patient Safety Report 7
Vitals by age, Top 10 Reading List 8
EPIC/ Home Access, List of Order Sets 10
Florida Map 12
Presentations/PBAR 13
I-PASS for Patient Hand Offs 14
PEWS 16
Responding to a Code 18
NICU 19
Newborn Sepsis Guidelines 20
Hyperbilirubinemia 21
PICU 22
Vents and ABG Interpretation 23
Asthma 24
Bronchiolitis Score 26
CF 27
Heme/Onc 28
Transfusion Tips 29
EKG 31
FEN 32
Clinic and immunizations 33-35
Development Chart 36
Duty Hour Logging 37-39
Chain of Command, When to Call ? 40
Procedures 42-44
Important Login Information 45
SMART Goals 47

2 49
 General Numbers
Admissions 50236
Bed Control 50233
Blood Bank 50377
Cardiology
- ECHO lab (reads) 392-2500
- ECHO 258-1927
- EKG (PICU) 413-0175
- EKG (Floor & NICU) 413-0174
- Heart Station (Holters) 50047
Child Life 46470
- Text pager 413-5068
Dialysis (peds) 50255
EEG 50334
ED Break Room 93517
Hospital (main) 265-0111
iHIRM 59375
Laboratory - Main 47737
- Chemistry 44869
- Hematology 44857
- Immunology 45328
- Microbiology (open 8am-5pm) 50165
- Rocky Point (main) 50172
- Rocky Point (chemistry) 72202
- Send Out 72200
- Virology 44778
Lactation (Brenda) 50317
Medical Records 44796
MRI 50106
MRI anesthesia 49982
OR Front Desk 50023
Pathology 50208
Pharmacy
- Inpatient (PICU) 42754
- Inpatient (Floor & NICU) 43401
- Outpatient (atrium/med plaza) 50405/58270
Pre-op 50076
PFTs (pulmonary) 50275
Poison Control 800-222-1222
Peds ID consults/ outpt scheduling 294-5481/294-5480

48 3
 IMPORTANT PHONE NUMBERS
Radiology 50101
- PEDS Reading Room 44297/44294
- Body (night reads) 44385
- Bone 273-7159
- Chest 42820
- Interventional/Specials 50116
- File Room 50107
- Fluoroscopy 50102
- Neuro Reading Room 46570/44334/44381
- Nuclear Medicine 57050/46211
- Ultrasound 44363
- Vascular 50399
Recovery Room (PACU) 50038
Psychology clinic & consult fax 50294/50096
Peds Surgery pager 413-0746
Senior Phone 672-0953
TPN 44248
Transfer Center 50559
Transport (ShandsCair) 50222

Clinics
CMS
- Front Desk 334-0206
- Resident Room 334-0237/334-0207
- Resident Room 334-0242
- Adolescent 334-0297
- Fax 334-4041
Tower
- Front Desk 733-1770
- Backline 27534/27536/27537
- Fax 372-5164
PAH
- Front Desk 265-0724
- Backline 88236
Specialty Clinics (Med Plaza) 265-8250

Code blue 66
Security Stat 50911/nonstat 50109
4 Needle stick injury 1-866-477-6824 47
 Outpatient Departments
Important Information Allergy 265-8250
How to Access Log in Name Password Cardiology 273-7770
Pedalink www.pedialink.org or via AAP ID # Set up yourself
Child Psychology 413-3338
- ILP www.aap.org CPT 334-1300
- PREP questions
Dental (peds) 273-7643
Nelsons Online http://site.ebrary.com/lib/ None-must be on VPN None-must be on VPN - Backline 273-7645
univflorida/
docDetail.action? Endocrinology 334-1390
docID=10567389
Gastroenterology 273-9350
The Harriet Lane Hand- http://site.ebrary.com/lib/ None-must be on VPN None-must be on VPN Genetics 294-5050
book univflorida/
docDetail.action? Hematology/Oncology 392-5633
docID=10567408
Immuno/Rheum/ID 392-2961
Lactation Clinic (Marys cell/pager) 219-2335/413-4302
Nephrology 392-4434
FL Shots www.flshots.com Organization ID: UFPC01 Set up yourself
(for CMS) and UFPC02 (for Neurology 273-8920
Tower)
Username: Last name plus Ortho Clinic 273-7001
first letter of first name in all
caps (i.e. Al Gator would be - Backline (Teri Rhodes) 273-7379
GATORA)
Pulmonology 392-4458
CANVAS Gatorlink username Gatorlink password Inpatient Floors & Workrooms
4200 50042 (fax 265-0946)
4400 50044 (fax 265-0467)
Genetics Patient Protocols http://www.peds.ufl.edu/ Patient Protocols - then Gatorlink password
divisions/genetics/ enter Gatorlink username 4500 50045 (fax 265-0793)
fellowship.htm
4433 Conference Room 44013
New Innovation Www.new-innov.com First letter of first name Set up yourself Blue Workroom (4530) 43450/47325/44057
and then last name
Green Workroom (4270) 48208/43449/46200
Med student eval Medinfo.ufl.edu Gatorlink username Gatorlink password Orange Workroom (4437) 43934/45259
ER 265-5437 (KIDS)
- Charge Nurse 745-8280
- Peds Resident Phone 51256 or 51257
- Peds Attending 745-8278
Mother/Baby (3500) 50035
Newborn Nursery 44097
NI2 50352
NI3 50033
- Fishbowl 44348/44124
PICU 51004/51005
- Fellow phone 494-8383
- Resident phone 745-8027
Housekeeping 50480
46 5
 Housestaff Numbers
Important Information
Pediatric Chairs Office 273-9001
Pediatric Med Ed 273-8234 How to Access Log in Name Password
Tammy/Amy 273-8466/273-8594
Peds E-mail www.mail.ufl.edu Gatorlink username Gatorlink password
- Fax 273-8593
Chief Pager 888-980-3608 Shands Portal Home screen for most Shands ID
Chief Office Nora 50912 my.portal.shands.ufl.edu computers, otherwise use
(Shands homepage) link to left
Chief Office Kendall 50919
Clinical pharmacists Citrix/EPIC Can access directly on Shands ID
citrix.shands.org most computers, via link
- Brian Kelly 45868/413-4054 to left, or via Portal
- Lisa Taylor 413-1892 Stentor - Radiology On portal page (after Shands ID (to get onto
Dr. Black 50915/413-2048 logging in), middle area Portal)
under Clinical Applica-
Peds IT/Shands IT 273-5808/265-0526 tions

SUF On-Call Schedule On portal page (after Shands ID (to get onto
PCCP 413-1454 (calling consults) logging in), middle area Portal)
under Clinical Tools

Drug Reference On portal page (before No log-in needed

Pediatric Team Phones logging in), bottom left in
Clinical Links
Green Team 317-5326
Senior Phone 672-0953 New Innovations www.new-innov.com Institution Login: ufl Set up yourself
- Call Schedule Username: first letter of
Outside Hospitals - Work Hours Log-in WEEKLY for first name and entire last
- Evaluations work hrs & MONTHLY name (i.e. Al Gator would
Halifax (Daytona Beach) 386-254-4000 - Procedure Log for evals be agator)
Leesburg Regional Medical Center 352-323-5762 - Schedule

Munroe Regional Medical Center 352-351-7200 Text Paging www.myairmail.com ufpeds gator

N. FL Regional Medical Center (NFRMC) 352-333-4000 REMOTE remote.peds.ufl.edu Gatorlink username Gatorlink password
Ocala Regional Medical Center 352-401-1000 (do it from home!)

Putnam Community Medical Center (Palatka) 386-328-5711 SHAREPOINT www.peds.ufl.edu ufad\gatorlink username Gatorlink password
-List -Faculty & Staff
Seven Rivers (Crystal River) 352-795-6560 -PCP list -Faculty & Staff Re- If 3 blanks, put UFAD in
Tallahassee Memorial 850-431-1155 -Intern guide sources domain
-Click Housestaff after
logging in for information

Quest 800-282-6613

6 45
 Procedure Log Patient Safety Report
Remember to update frequently on New Innovations.
Required Procedures: Date Location/Supervisors Signature
Bag-mask ventila- How to Submit a Patient Safety Report
tion
Bladder catheterization
Note: Do not pr ess [enter ], always use [tab] or the
Giving immunizations mouse to go to the desired field.
Incision and drainage
of abscess
Lumbar Puncture To report a new event, log in to the Shands portal (homepage on
Neonatal endotracheal hospital computers):
intubation
Peripheral intravenous Click Patient Safety Report UF&Shands
catheter placement
Reduction of simple
dislocation
Select Report an Event: follow prompts
Simple laceration
repair
Simple removal of
foreign body
There is an option to place an Express Report or you can
Temporary splinting of find the category of the incident and report it that way
fracture
Umbilical catheter
placement
Venipuncture
Simulated placement
of intraosseous line
Medical Knowledge Date Location/Supervisors Signature
of the following:
Arterial line place-
ment
Arterial puncture
Chest tube
placement
Circumcision
Endotracheal intuba-
tion of non-neonates
Thoracentesis

44 7
 Normal vital signs by age PROCEDURE GUIDE
Temperature The procedures listed below and levels of ability in performing them are the
36 38.5 UNLESS under 3 months, immunocompromised or minimum r equir ed by the Pediatr ic RRC. You will be exposed to and do
HEME/ONC - fever is 38 for them! many other procedures during residency and you should document them all in
your procedure log on the ACGME website.
Heart Rate
RRC training requirement
Age Sleeping Awake Patient Care and Procedural Skills: Residents must be able to competent-
Term -3 mo 80-160 85-205 ly perform procedures used by a pediatrician in general practice, including
3 mo-2 yrs 75-160 100-190 being able to describe the steps in the procedure, indications, contraindica-
tions, complications, pain management, post-procedure care, and interpreta-
2-10 yrs 60-90 60-140
tion of applicable results. Residents must demonstrate procedural competence
>10 years 50-90 60-100
by performing the following:
Bag-mask ventilation
Bladder catheterization
Respiratory Rate Giving immunizations
Age Respiratory rate Incision and drainage of abscess
Birth-6 weeks 30-60 Lumbar puncture
Infant 24-40 Neonatal endotracheal intubation
2-6 years 22-34 Peripheral intravenous catheter placement
6-10 years 18-30
Reduction of simple dislocation
Simple laceration repair
Over 10 years 12-20 Simple removal of foreign body
Temporary splinting of fracture
Blood Pressure Umbilical catheter placement
Venipuncture
Age Wt SBP DBP Complete training and maintain certification in PALS including
Preterm 1 40-60 20-36 simulated placement of an intraosseous line and Neonatal Resusci-
tation
Term Newborn 2-3 60-70 30-45
1 month 4 70-100 30-62 Medical Knowledge: Residents must be competent in the under standing
6 months 7 70-118 50-70 of the indications, contraindications, and complications for the following:
1 year 10 70-126 41-91 Arterial line placement
Arterial puncture
2-3 years 12-14 74-124 39-89 Chest tube placement
4-5 years 16-18 79-119 45-85 Circumcision
6-8 yrs 20-26 80-124 45-85 Endotracheal intubation of non-neonates
10-12 yrs 32-42 90-135 55-88 Thoracentesis
>14 >50 90-140 60-90 http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-
1-10 y/o 50thPercentile SBP=90 + (Age x 2) PIF/320_pediatrics_07012013.pdf
5th Percentile SBP=70 + (Age x 2)
Find BP norms by age and height percentile at:
http://www.cc.nih.gov/ccc/pedweb/pedsstaff/bp.html
8 43
 PROCEDURE NOTES: Top 10 Reading ListCommon Pediatric Diagnoses
Lumbar puncture
Date/Time: Pneumonia
Indication: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3202323/
Consent on chart: Asthma
http://pedsinreview.aappublications.org/content/30/10/375
Infant draped and prepped in sterile fashion. 22 g myelonate Acute bronchitis/bronchiolitis
spinal needle inserted between L 4-5. http://pedsinreview.aappublications.org/content/30/10/386
On attempt #; yielded approximately ______ mL clear/ se- Skin and subcutaneous tissue infections http://www.uptodate.com/
rosanguiness/xanthochromic CSF. contents/evaluation-and-management-of-suspected-methicillin-
resistant-staphylococcus-aureus-skin-and-soft-tissue-infections-in-
Pt tolerated procedure well with minimal blood loss and no children?
complications. source=search_result&search=soft+tissue+infections&selectedTitl
Labs sent for: e=9%7E150
Tube 1: G-stain, Cult, AFB/fungal stain Epilepsy
Tube 2: Glucose, protein http://pediatrics.aappublications.org/content/127/2/389.full.html
Tube 3: Special (HSV PCR) Urinary tract infections
Tube 4: Cell count, diff. http://pediatrics.aappublications.org/content/early/2011/08/24/
peds.2011-1330
Intubations: Otitis Media
Date/Time: http://pediatrics.aappublications.org/content/early/2013/02/20/
peds.2012-3488.abstract
Infant intubated with ______ETT and _____ blade on _____ Pharyngitis
attempt. Equal breath sounds heard bilaterally and color change http://circ.ahajournals.org/content/119/11/1541.full.pdf
seen on CO2 detector. ETT taped at _____ cm at lip. CXR ADHD
obtained to confirm placement. http://pediatrics.aappublications.org/
content/128/5/1007.full.pdf+html?sid=f19cb249-15a2-429b-9860-
Circumcision: 92f2231d079b
Date/Time:
Indication: Phimosis, unwanted foreskin
Consent: Obtained and on chart

Time out preformed. 1% lidocaine (1.5 ml) used for DPNB.

Infant prepped and draped in sterile fashion. Gomco 1.1/1.3
used to perform circumcision. Estimated blood loss < 5 ml.
Infant tolerated procedure well. Aftercare instructions given to
mother.
42 9
 Partial EPIC Dictations Supervision/When to Call?

1) Use the headset placed at dictation/PC terminal
2) In New Note or Notewriter, place cursor in area you want to
dictate
3) Click the Blue microphone on the toolbar
4) Click the Record button the player that appears
5) State and spell the patients full name, date of service, and
CSN
6) Dictate the partial dictation (Note: If you rewind and record,
you will overwrite you dictation)
7) Click Accept on the player. Dictation link will appear on
the document.
Typing H&Ps/Discharge Summaries/Progress Notes
1) Log into patients chart and click on Note tab on left side
2) Find appropriate tab for work type (H&P, D/C Summary, etc)
3) Click on either New Note or Notewriter
4) Select appropriate template for work type - most have the
phrase SH IP PED _________(work type). Some services
have their own templates
SUPERB - Guide for Attending Supervision
S - Set expectations for when to be notified
U - Uncertainty is a time to contact
P - Planned communication
E - Easily available
R - Reassure resident not to be afraid to call
B - Balance supervision and autonomy for resident
___________________________________________________________
SAFETY - Resident Guide for Attending Input
S - Seek attending input early (prevents delays, quicker results)
A - Active clinical decisions (surgery, invasive procedure, etc)
F - Feel uncertain about clinical decisions
E - End of life care or family/legal discussions
T - Transitions of care (PICU, discharges, hospital transfers)
Y - You need help with the system/hierarchy (attending to attend-
ing discussions, etc)
Farnan, J.M. et al. Strategies for Effective On-Call Supervision for Internal Medicine Resi-
dents: The SUPERB/SAFETY Model. Journal of Graduate Medical Education. 2010 March; 2
(1): 4652

5) Fill out entire template being sure to not miss any *** or
{bracketed areas}
6) You may use the partial dictation function (see above) at any
point
7) Indicate service team at the top of note, along with co-signing
physician (if you dont indicate a co-signing physician your
note cannot be finalized)
8) Click Accept at bottom of note to finalize - if you click
Pend you can return and make changes without having to
create an Addendum but your note will remain hidden from
others
9) If you have any questions you may call 265-0526 (50526) at
any time for IT/EPIC assistance

10 41
 Resident Concern Flow sheet EPIC HELP emr .med.ufl.edu/tr aining

EPIC from Home http://net-services.ufl.edu/provided_services/

vpn/anyconnect/

https://mycitrix.shands.org

EPIC Order sets for Pediatrics:

Failure to Thrive Physicians Orders IP UF

Pediatric Bronchiolitis Physician's Orders IP UF
Pediatric Acute Gastroenteritis Physicians Orders IP UF
Discharge Pediatrics UF
Pediatric Cellulitis Physicians Orders IP UF
ALTE (Acute Life Threatening Event) Peds
Pediatric Fever without a Source: Infants 0-28 days old and high
risk infants 28-90 days old
Pediatric Pain Intervention Orders (Admission Supplement) IP UF
Pediatric Admission Order Set for Asthma IP UF
Pediatric IMC and Floor Admission Orders IP UF
Pediatric PICC Orders IP UF
Pediatric UTI (Urinary Tract Infection)/Pyelonephritis
Pediatric Pneumonia/Empyema
Pediatric NAT (Nonaccidental Trauma)
Pediatric Hyperbilirubinemia Order Set (for the floor
Failure to Thrive Physicians Orders IP UF
Pediatric Bronchiolitis Physician's Orders IP UF
Pediatric Acute Gastroenteritis Physicians Orders IP UF
Discharge Pediatrics UF
Pediatric Cellulitis Physicians Orders IP UF

Patient Safety Risk Hotline: (352)538-2635

40 11
 Rotation/Shift Duty Hour Type
4200 days without overnight call Shift
4200 days with overnight call 1st 24 hours = Call
Hours 24-30 = Call/No new patients after 24
hours
Cards/GI Selective Shift
Time off between shifts (i.e. Acute AM Break during shift/rotation
then PAH at night)

City County Lake Butler Union

Alachua/Archer Alachua Lake City Columbia
Bell Gilchrist Lawtey Bradford
Belleview Marion Leesburg Lake
Cedar Key/Chiefland Levy Live Oak Suwannee
Cross City Dixie Mayo Lafayette
Crystal River Citrus Melrose Alachua/Putnam
Deland Volusia Micanopy/Newberry Alachua
Dunnellon Mareion Ocala /Oklawaha Marion
Fort White Marion Old town Dixie
Hawthorn/ High Springs Alachua Palatka Putnam
Interlachen Putnam Starke Bradford
Inverness Citrus Trenton Gilchrist
Jacksonville Duval Waldo Alachua
Jasper/Jennings Hamilton Wildwood Sumter
LaCross Alachua Williston Levy
12 39
 Duty Hour Type by Rotation
Rotation/Shift
Wards-Weekday, short Call
Wards-Weekday, no short call
Wards-Weekend, long call
Wards-Weekend, Sunday NF
Wards-Weekday Night Float
NICU-Weekday
NICU-Weekday NF
NICU-Weekend (Friday or Saturday)
NICU-Weekend, Sunday NF
Daily Presentations
Duty Hour Type
Shift Presentations can be problem-based vs system-based (varies from
Shift attending to attending and from service to service)
1st 24 hours = Call For all general patients, please use the PBAR format:
Hours 24-30 = Call/No new patients after 24 hours
- P = Pr oblem (Chief complaint/pr oblem)
1st 24 hours = Call - B = Backgr ound (Histor y, over night events, PE, labs)
Hours 24-30 = Call/No new patients after 24 hours - A = Assessment (Assessment of how patient is doing)
Shift - R = Recommendations (Plan)
Shift Each patient can have multiple problems, so go through each one
Shift individually (always include disposition as the last problem)
1st 24 hours = Call
Hours 24-30 = Call/No new patients after 24 hours New admissions will still need more information (what led up to
st
admission, HPI, etc), compared to those that have been in the hos-
1 24 hours = Call
pital for a couple days
Hours 24-30 = Call/No new patients after 24 hours

PICU-Weekday Shift
PICU-Weekday NF
PICU-Weekend (Friday or Saturday)
Shift
1st 24 hours = Call
The new patient vs. The old patient
Hours 24-30 = Call/No new patients after 24 hours

PICU-Weekend, Sunday NF 1st 24 hours = Call

Hours 24-30 = Call/No new patients after 24 hours The New Patient The Old Patient
Newborn Nursery-Weekday or Weekend Shift
Back-up Call, not called in Back-up 1 line: Identifying 1 line: Identifying
Back-up Call, called in Log according to what you were called in for information and reason information and recap
Annual Leave Vacation/Leave
for admission of hospitalization
Sick Leave Sick
Conference Leave Education Leave HPI
Continuity Clinic Continuity Clinic
PBAR PBAR
Acute clinic Shift
The last problem is always The last problem is always
PAH, no phone calls Shift
disposition disposition
PAH, with phone calls Shift (log only the hours you were in clinic, do not
log phone call hours)
ED Shift
Adolescent Rotation Hours
Development Rotation Hours
Advocacy Rotation Hours This is similar to the SBAR format nurses use to communicate to
Elective Rotation Hours
one another and should be using to communicate with physicians
Moonlighting (PAH or Abstracting) Moonlighting
(S = Situation instead of Problem)
Administrative Time (i.e. Time between Rotation Hours
adolescent clinic in the AM and AR at Medical students are taught the PBAR method, so model this
night, etc.) while they rotate through Pediatrics

38 13
 How to Log Duty Hours?

Log-on to www.new-innov.com and click Client Login

Enter ufl for Institution, username and password are same
as your Gatorlink
Select either Log My Hours on the middle-right side of the
I Illness Severity Stable, watcher, unstable screen or from the drop-down menu (under Main), select Du-
ty Hours
Enter Duty Hours corresponding to the rotation/shift you
Patient Summary Summary statement worked (see key on next page)
P Events leading up to admission Enter Duty Hours on a daily basis
Hospital course If there are any work hour violations, residents must leave a
Ongoing assessment comment explaining why the violation occur r ed (it will
Plan then be reviewed by Chief Residents and Program Director)
Residents not entering their duty hours by Tuesday of each
week, will start to receive reminder emails that will also be
To do list
sent to the Chief Residents and Program Directors
A Action List Timeline and ownership
Please be truthful when entering duty hours - we all must
abide by the ACGME Work Hours and want to know if there
Situation Aware- Know whats going on are rotations/areas where residents arent meeting the require-
S ness & Contin- ments
gency Planning Plan for what might happen

Synthesis by Re- Receiver summarizes what was

S ceiver heard

Asks questions

Restates key action/to do items

2011 I-PASS Study Group/Childrens Hospital Boston

All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu

14 37
36
Age Language Fine motor Gross motor Psychosocial
1 Alerts to sound, cries Hands tightly fisted Head up in prone Regards face, follows
mo
2 Smiles socially Retains rattle (briefly) if placed Chest up in prone, Holds head smiles socially, tracks past
mo in hand midline midline, regards hands
3 Coos Holds hands open at rest Supports on forearms in prone Reaches for objects, antici-
mo position, holds head up steadily pates feeding
4 Laughs, orients to voice Grasps & retains, brings hands No head lag, rolls front to back, Enjoys looking around, smiles
mo to midline rolls back to front by 5 mo spont. by 5 mo
Babbles, ah-goo, razz, lateral Transfers object hand to hand, Sits-props on hands, puts feet in Recognizes mother, looks to
6 orientation to bell immature rake mouth, sits without help by 7 mo floor when object drops
mo

Mama/Dada nonspecific, Cube held with thumb & finger Pulls to stand, creeps on hands Stranger anxiety, takes solids,
9 Gestures, understands "no" tips, immature pincer grasp, & knees, pivots when sitting, waves by-bye by 10 mo, peek
mo holds bottle, throws objects cruises at 10 mo, stands at 11 -a-boo
12m 2 words (not ma/dada), one- Fine pincer grasp, marks with Walks Separation anxiety, drinks
o step command with gesture crayon, releases voluntarily from cup with help
15m 3-5 words, mature jargoning, 2 cube tower at 14 mo & 3 Walks well at 14 mo and back- Solitary play, drinks from cup
o points to body part cubes at 16 mo ward/runs at 16 mo cooperates with dressing
18m 10-25 words, points to 3 body 4 cube tower, scribbles, turns Throws ball, handedness devel- Hugs parents, uses spoon
o parts 2-3 pages at a time ops
Development Chart

1/2 of speech is intelligible, 2 6 cube tower, can draw, unzips Kicks ball, throws overhand, Kisses with pucker, removes
2 word sentences, 2 step com- zipper walks down stairs garment, parallel play, opens
yrs mands, 50+ words door, copies parents in tasks
3/4 speech is intelligible, 3 10 cube tower, can draw circle, Broad jump, rides tricycle, Puts on some clothing, group
3 word sentences, names 1 dries hands if reminded balances on one foot for 1-2 sec, play, takes turns, undresses,
yrs color, 250+ words up stairs with rail/alt. feet knows full name, gender, age

100% intelligible speech, 4 Can draw +, draws a person Walk up & down stairs with rail & Dresses without help, plays
4 word sentences, knows colors, with 3 parts alternating feet, balance 1 foot cooperative games, buttons,
yrs knows 4 prepositions for 3-4 sec, hop, catch ball tells a story
5 word sentences, counts 5-10 draw triangle/person (5-6 Walks up & down stairs without Plays board games, follow
5 blocks, defines 5 familiar parts), prints a few letters/ first rail, balances on one foot for 5- rules, likes to help in house-
yrs words, knows opposites name, ties shoes 10 sec, skips hold chores
Patient Summary
Use IPASS mnemonic

Be concise and focused

Include semantic qualifiers

Establish working diagnosis
Supplements verbal handoff

Articulate chain of command

May import elements from EMR

Ensure check-back with receiver

Identify most worrisome patients

Employ closed loop communication
Begin with overview of entire service

Problem solve before things go wrong

Keeps information current with updates

Know potential therapies or interventions

Contingency Plans If this happens, then
High Level Skills
Need proper environment limit interruptions
Structured Verbal Handoff

Printed Handoff Document

I-PASS Handoff Essentials
Better handoffs. Safer Care

2011 I-PASS Study Group/Childrens Hospital Boston

All Rights Reserved. For Permissions contact ipass.study@childrens.harvard.edu

15
16
Category 0 points 1 point 2 points 3 points

Lethargic or
Playing
Sleeping Irritable or agitated & is confused
Behavior Appropriate for
Irritable & consolable not consolable Reduced pain
patient
response

Grey & mott-

led
Grey Capillary refill
Pink Capillary refill 4 sec- 5 seconds
Pale
Cardiovascular Capillary refill 1-2 onds Tachycardia
Capillary refill 3 seconds
seconds Tachycardia of 20 30 above nor-
above normal rate mal rate
Bradycardia
for age

>10 above normal parame- 5 below nor-

> 20 above normal
ters mal parameters
Within normal parameters
Using accessory muscles with retractions
Pediatric Early Warning Score (PEWS) System

Respiratory parameters Retractions

24-40% FIO2 or 2 L/min Grunting
No retractions >40% FIO2 or 3 L/min
O2 50% FIO2 or
O2
Any initiation of O2 8 L/min O2
(non-CLD)
Synagis Guidelines

35
34
2014 -15 UF PEDIATRIC CLINIC VACCINE SCHEDULE
Birth/
2 mo 4 mo 6 mo 12 mo 15 mo 18 mo 2 yrs 4-6 yrs 11-12 yrs 15 yrs 18 yrs
Nursery
Tdap
Pediarix Pediarix Pediarix
Kinrix Adacel (> 11
HBV (DTaP+IPV+ (DTaP+IPV+ (DTaP+IPV+H DTaP Tdap catch up > 12yrs
(DTap+IPV) yrs) Boostrix
HBV) HBV) BV)
(> 10 yrs)
Hib with
Pediarix (Not
Hib with Hib with
needed if Hib MMR
Pediarix Pediarix Proquad
PedvaxHIB at
2 and 4 month) (MMR+Variv
ax)
Varivax Catch up > 6 yr of age
Prevnar Prevnar Prevnar Prevnar
Varivax (3 mths apart till age 13 yrs then 4 wks
(PCV13) (PCV13) (PCV13) (PCV13)
apart)
Rotarix 1/
Rotateq 3 Hep A
Rotateq 1 Rotarix 2/
(< 8 months 0 Hep A (6 mths after Hep A catch up > 2 yrs
(6 wk -14 wks Rotateq 2
days) 1st dose)
6 dys)
Menactra (MCV4) Booster
- at 16 yrs, if first dose be-
Menactra
tween 11-12 yrs - at 16-
(MCV4)
18 yrs, if first dose between 13
-15 yrs
Gardasil
[Girls &
Boys]
(HPV) 0-2-6
mths
(24 wks
between
dose 1 and
3)
Flu-Mist: IN, 2 - 49 yrs healthy, July - May, 0.1 ml each nostril
Flu-Shot: IM > 6 mths, Sep - May, 0.25 ml for 6 mths Flu-Shot: Sep - May, 0.5ml for > 3 years
Flu vaccine: 2 doses at least 4 wks apart for children < 9 yrs receiving for the first time. One dose if (received 2 doses of seasonal flu last year/1 dose of
seasonal flu in two previous seasons) and any 2009 H1N1 monovalent vaccine

6 pts
5 pts
3 pts

4 pts
Total
Score

0 - 2 pts

Code Blue Team: Call # 66

minutes

Any category 3 call a SWAT

Call SWAT
Notify MD resident

Notify CN to assess patient

Notify CN to assess patient
Notify CN to assess patient
Notify CN to assess patient
PEWS Action Plan

Notify MD Attending on service

No additional interventions required

Increase vital signs q1 hr with PEWS

PEWS Action Plan

Increase vital signs q1 hr x 3 with PEWS

Increase vital signs q1 hr x 3 with PEWS

Rapid Response Team: Condition H - Call #61 or SWAT - Call #69

Notify MD resident, senior resident/fellow STAT
Notify MD resident to assess patient within 15 minutes
Notify MD resident to assess patient within 15 minutes

Notify MD senior resident/fellow to assess patient within 15

17
 Clinic Tips
Car seats:
Infants - Rear-facing seats until 2 years of age (or until
highest weight/height allowed by car seat manufacturer
reached)
Toddlers/Preschoolers - Forward-facing seats (5-point
harness) until outgrows (typically around age 4)
School-aged children - Booster seats (belt-positioning)
until 49 tall and between 8-12 years old
Older children - Seat belts (lap and shoulder); children
younger than 13 years old should ride in the back seat

FLSHOTS.com (keep log-in in your email!)

___________________________________________________

Anemia
Anemia = Hgb
Age 2 SD below Mean
mean
6mo-6yr 10.5 12

7-12yo 11 12.5

>12 12 14

>12 13 16

Eyes: refer if >10 difference between eyes or worse than

Age 4 = 20/40
Age 5 = 20/30
Age 6 = 20/20

18 33
 FEN:
NICU/NBN
Intubations:
Fluids- (Gener al r ules, does not always apply) Blade Size: 1 for term, 0 Term-30 wks, 00 < 30wks
4ml/kg for each kg between 1-10kg +
2ml/kg for each kg between 11-20kg + <1kg 1-2 kg 2-3 kg 3+ kg
1ml/kg for each kg over 20kg or ETT size 2.5 cm 3.0 cm 3.5 cm 3.5-4cm
Quick version for over 20 kg- just add 40 to weight Tape at: 6+ weight (kg)

Most of time use D5 NS + 10-20 meq KCl/L Lines:

- Exceptions: NS for brain tumors; no KCl for Onc pts UAC (Weight(kg) x 3) + 9 for T6-T9
- NS for neonates Weight + 7 for L3-4
- NS is 154 meq/L Na and Cl UVC UAC length /2 + 1
(Weight(kg) x 1.5) +5.5
Maintenance Electrolytes-
Na+: 3meq/kg/day K+: 2meq/kg/day
FEN:
Kcal/kg/day calculations:
Important Formulas Dextrose: ml/kg/day x % dextrose x 0.034
Lipids: ml/kg/day x 2
Anion Gap: Na (Cl + HCO3) AA: g/kg x 4

Corrected Na : Na + [(glucose 100) x 0.016] Formulas:

20 kcal/oz 0.67 kcal/ml
Osmolality: 2x Na + glucose/18 + BUN/2.8 22 kcal/oz 0.73 kcal/ml
24 kcal/oz 0.80 kcal/ml
FE Na: Cr clearance:
Urine Na x serum Cr Urine Cr x urine Vol (ml) GIR (glucose infusion rate): % dextrose x 10 x rate in ml/hr
Serum Na x urine Cr Serum Cr x time (min) 60 x weight (kg)
Acid correction: For pH<7.2 OR Base deficit >10
NaHCO3 2mEq/kg/dose or correction:
GFR estimated: PC x height (cm)/ ser um Cr Base Deficit x 0.6xWt (kg)/2 Given over 30-60 minutes
(Proportionality Constant = 0.33 in LBW infants < 1 yo, 0.45 in Na Correction: Give over 12-24 hours
term infants < 1 yo, 0.55 in children 2-12, 0.55 in girls 13-21, [Na deficit Na value] x weight(kg) x 0.6
0.70 in boys 13-21)
ROP Guidelines: At 6 weeks. <30wks or <1500g
GIR (glucose infusion rate): % dextrose x 10 x rate in ml/hr Car Seat Guidelines: <4 lbs= car bed, <37 wks Car seat test
60 x weight (kg) HUS/MRI Guidelines: HUS 1 wk, MRI PTD. <30wks or <1250g
Synagis Guidelines: See next page

32 19
 Adapted from MMWR Nov 19, 2010/Vol EKG
Sepsis GuidelinesUF 59/No. RR-10 & AAP COFN May 2012 &
July 2013, Pediatrics. I. Rate: divide 300 by # of boxes
Revised 1/2014 Donald Fillipps, MD
Medical Director Newborn Nursery
II. Rhythm: Ps, Qs, 3 Rs
P waves upright in II = sinus rhythm
History/symptoms Immediate Subsequent
Management Management QRS wide or narrow
Rate, regular rhythm, related P waves
Blood cultures, CBC w/ diff,
Consider transfer to NICU III. Intervals
Yes
+/- CRP (CRP optional) Length of therapy determined by
clinical response, cultures, labs,
PR: ~ 1 large box
Signs of sepsis? LP if sepsis strongly suspected.
and physician judgment. QRS: ~ large box
CXR if respiratory symptoms
QT: ~ the RR interval (drugs, lytes, CNS)
No Start Ampicillin and Gentamicin
QT/square root (R-R)
Repeat CBC w/ diff, +/-
Blood cultures immediately. CBC CRP(CRP optional) at 48 hr. IV. Axis: I and aVF
Maternal Yes
w/ diff, +/- CRP(CRP optional) at
age 6-12 hrs
D/C home if baby healthy, blood
cultures (-), and lab/s normal.
Normal: QRS + in I and aVF
Chorioamnionitis &
Start Ampicillin and Gentamicin Prolonged antibiotic therapy if
RAD: QRS in I and + in aVF
Baby Healthy
Order vitals with hands-on nursing
suspicion high for sepsis or if LAD: QRS + in I and in aVF
No blood cx(+), or lab/s abnormal
assessments Q 4 hrs Intermediate: QRS in I and aVF
Maternal GBS
prophylaxis indicated? No
Routine newborn care
V. Hypertrophy
(GBS+, or GBS unknown LVH: deep S in V1-2 + tall R in V5-6 = 35
with any of the following:
<37 weeks or ROM>18hrs * If GBS is negative but has risk factors of either <37 wks or ROM RAA: prominent, peaked, pul. Leads (II, III, aVF)
or sibling with GBS) >18hrs, the following options should be considered if baby appears LAA: p waves M in mitral leads (I, II, aVL)
healthy: (Q 4 hr vitals and hands-on assessments for all)
(Scheduled c-section or c-
section for maternal indications, 1) Observe for 48 hrs without obtaining cultures or lab evaluation RVH: tall R waves in V1 and RV strain
prophylaxis NOT indicated) 2) Blood culture, CBC w/ diff, +/- CRP(CRP optional) at age 6-12 hrs;
start Amp & Gent if lab/s abnormal
*Strain: asymmetric ST depression and T wave inv.
If both risk factors present obtain blood cx, CBC w/ diff, +/- CRP at VI. Infarct (QRST )
Yes age 6-12 hrs; start Amp & Gent if lab/s abnormal
Normal for Peds
Received penicillin,
ampicillin or cefazolin
Yes
Observation in hospital for 24-48
If discharged home in <48 hrs,
Q wave: small and narrow normally seen in
4 hr before delivery?
hrs.
should have follow-up I, aVL, V5, V6
appointment within 24 hours.
No Observation in hospital for 48 hrs.
R wave progression: btwn V2 and V4
Yes
Order vital sign checks ST seg: smiley or frowny
37 weeks and ROM (Temp/HR/RR) with hands-on If antibiotics are started &
<18 hrs? (Inadequate nursing assessments Q 4 hrs baby remains healthy: T wave: normally inverted in III, aVF, aVL, V1
IAP and no other risk
Option 1: Consider D/C home
factors)
Blood cultures, CBC w/ diff, at 48 hrs if baby healthy and
No +/- CRP(CRP optional), at age 6- blood cultures negative
Yes
12 hrs.
Option 2: Repeat CBC, diff, +/-
Either <37 weeks or
Begin vital sign checks CRP(CRP optional) at 48 hrs.
ROM > 18 hrs and
(Temp/HR/RR) and hands-on D/C home if blood culture
well appearing
nursing assessment Q 4 hrs negative and repeat lab/s
normal
If baby develops symptoms of
sepsis or lab/s abnormal, start Prolonged antibiotic therapy if
Ampicillin and Gentamicin 48 hr lab/s abnormal

20 31
 Transfusion Guidelines Hyperbilirubinemia
Guidelines for therapy >35 weeks gestation
Pre-Meds:
Only if history of reaction to blood products
Most febrile reactions occur with platelets

Blood (PRBC) Transfusion:

10 15 mL/kg
In a stable patient with normal cardiac function, 10 mL/kg can be
transfused over 2 hours
For patients with Hct less than 15 or Hgb less than 5 and stable, rule
of thumb is to give blood slowly. The transfusion volume is
patients Hgb x wt in kg over 2-3 hours. Wait a few hours and
reevaluate Hct and Hgb and cardiac status; base next transfu-
sion on new data.
For patients with Hct less than 15 or Hgb less than 5 and unstable
contact Heme/Onc before transfusing
For volume depleted patients who are unstable secondary to blood
loss, infuse as rapidly as possible. Nomogram for designation of risk >36 weeks gestation
This patient should be in PICU!

1 unit PRBCs = 250 mL (at least, sometimes as much as 500ml)

1 unit PRBCs ~ 3 pedisplit units
1 pedisplit = ~80 mL

Platelets:
10mL per kg
1-2 apheresis units is the maximum
Single donor (apheresis unit) = ~ 8 random donor units
Pre-pooled platelets are the equivalent of 6-8 different donors. For
infants and toddlers random donor units are acceptable. Once
patient is getting equivalent of 4 or more random donors,
apheresis unit should be ordered.
Average volume of apheresis unit = ~200-250 mL
Platelets are normally hung by gravity over ~15-20 min

30 Risk of hyperbilirubinemia: Bilitool.org 21

 PICU
INTUBATION
ETT SIZE = 4 + (pts age in yrs/4)
Cuffed ETT tube = 3 + (pts age in yrs/4)
ETT position (cm) at lip = 3 x ETT size (mm)
INITIAL VENTILATOR SETTINGS (volume mode)
Attributes for PRBCs and Platelets:
Leuko-reduced products:
Used to remove leukocytes.
Leukocytes are a primary source of HLA antigens and filtering decreases devel-
oping alloimmunity.
Decreases febrile reactions.
Filters majority of CMV out of product if donor is CMV +
Irradiated:
Leuko-reduction does not filter all lymphocytes out of products, so all immune
compromised patients and must receive irradiated products.
Used to prevent graft versus host disease.

CMV Negative:
TV = 7-10 mL/kg Donor is CMV
PEEP = 5 cm H20 Used only in patients who are CMV and candidates for allogenic transplant
Fi02 - 0.4 to 1 (Adjust to keep 02 sat>90%)
IMV=15/min for child & 20-30/min for infants Washed:
PIP less than 35 cm H20, usually <25 cm H20 if normal lungs Removes majority (~99%) of plasma proteins, electrolytes, and antibodies.
Used for patients with history of allergic or febrile reaction to plasma compo-
Inspiratory time = 0.5 0.6 sec infant; 0.7-0.8 sec child;
nents of blood products
0.8 1.0 sec adolescent May be used for patients with IgA deficiency
Used in bone marrow transplant patients see ABO/Rh compatibility chart
HYPOVOLEMIC / SEPTIC SHOCK:
Packed:
10-20 mL/kg as rapid bolus of an isotonic, non-glucose contain- Only an option for platelet products
ing solution (i.e. lactated ringers or normal saline). Repeat PRN Reduces volume
based on distal pulses, blood pressure, capillary refill. There is Used in bone marrow transplant patients see ABO/Rh compatibility chart
___________________________________________________________________
no maximum; the amount given is determined by the needs of
Sickle Cell Patients:
the patient. Leuko-reduced
Sickle cell (Hgb S) negative
MINIMAL BLOOD PRESSURE VALUES Preferably less than 5 days old or freshest available if blood that recently
donated is available. (This is to reduce the amount of iron patient receives.
As RBCs break down and age iron builds up in the blood unit. Because of
frequent transfusions Sickle Cell patients are at risk for developing iron
0 to 1 month Systolic pressure > 60mmHg overload.)
1 month to 1 year Systolic pressure > 70mmHg Does not need to be irradiated
Greater than 1 year Systolic pressure > 70mmHg + 2x (Age)
10 yrs Systolic pressure > 90mmHg Oncology Patients:
Leuko-reduced
Irradiated
Other attributes per pt (i.e. CMV -, washed)
If patient has had Bone Marrow Transplant refer to ABO/Rh compatibility chart
for that patient

22 29
 Hematology/Oncology How to adjust the vent 101
In General: RATE P PEEP iTIME FiO2
- GI prophylaxis (ex: Prevacid) if pt is NPO/on steroids/NSAIDS
- Check the medication record (MAR) in the bedside chart to see times To N/A N/A N/A
chemo, antibiotics and if prn pain meds were given QAM. Make sure PaCO2
they actually got the medicine! To N/A N/A N/A
PaCO2
To N/A
Sickle Cell Disease:
PaO2
- Pain crisis: pain control, hydration, anemia management
To N/A N/A
- With PCA or scheduled opiates, use continuous pulse ox and a laxa- PaO2
tive (ex: Colace); know PCA settings (basal amt, on demand amt and
frequency, lockout) and PO medication frequency.
- Toradol given for only 5 days, then Motrin PaO2 PaCO2 pH HCO3 BE
- Chest pain or fever: get CXR to look for acute chest syndrome
Term 80-95 35-45 7.32-7.38 24-26 3
- If SCD and fever: culture Q24 with fever. Antibiotic of choice for
new fever is Ceftriaxone 75 mg/kg/day. 30-38 60-80 35-45 7.30-7.35 22-25 3
- Penicillin prophylaxis if pt 5 yo or asplenic wks
- Transfusions: < 30 wks 45-60 38-50 7.27-7.32 19-22 4
Know pts transfusion criteria, often 20/20 (Hct/platelets).
Consider consenting for blood transfusion during your H&P
pRBCs attributes: leukoreduced, sickle negative, <5 day old

Cancer patients: ABG Interpretation

- Absolute Neutrophil Count = total WBC x (% bands + % segs).
I. Acidemia v. Alkalemia
ANC normal >1500 pH: 7.38-7.42
1000 1500 mild neutropenia II. Respiratory v. Metabolic
PaCO2 = 40 HCO3- = 24
500 1000 mod neutropenia III. Anion Gap
< 500 severe neutropenia AG = Na+ - (Cl- + HCO3-) normal=10
IV. / Ratio
- Fever and Neutropenia: GO EXAMINE ANY neutropenic patient / Ratio = (AG 10)/(24 [HCO3-])
with a fever! Bacter ial cultur es Q24hr , Cefepime (usually until 1 alk; 1 acid
counts recover), Add Vanc, if sick or if pt w/ AML. Consider fungal V. Resp Component
cultures. Winter Formula:
- If long term antibiotics or steroids needed, add fungal prophylaxis Expected CO2 = 1.5[HCO3-] + 8 2
(ex: Fluconazole), especially if neutropenic. VI. Resp: Acute v. Chronic
- Chemo Roadmap = what chemo drugs a patient is receiving, when Acute: CO2 of 10 = pH of 0.08
they are due and what they have gotten in the past, only the attending Chronic: CO2 of 10 = pH of 0.03
can sign chemo orders (due by 5pm) VII. A-a Gradient
A-a = PIO2 - (PaCO2/0.8) - PaO2
PIO2 = (760 - 47)*0.21 (on room air)

28 23
 ASTHMA Cystic Fibrosis
Asthma Score 6-12:

Continuous neb
Print CF patient care form (on the portal)
Q 1h assessment Look at past H&P, D/C summaries for medication history, sputum
culture results
Airway clearance QID (Vest, CPT, IPV ask pt what they use or
Give albuterol Hold therapy
Q1hour assessment Q 1h assessment look at past hospital course/clinic notes)
Move if score is still Move if score is still Sputum culture labeled CF sputum, extended sensitivities
highX2 low X 2
Notify MD Notify MD Remember annual labs (prealbumin, LFTs, PT/PTT, vitamin lev-
els) and monitoring labs (BMP if pt on Vanc, Vanc trough,
Asthma Score 2-5: Tobra 2/8 hr levels)
Spirometry (pre- and post-bronchodilator) usually at the time of
Q2h neb
Q2h Assessment admission (sometimes done in clinic) and then usually every
1-2 weeks until improvement seen
Consults to the appropriate services (Endo if pt has CFRD, GI/
Give albuterol Hold therapy Liver if pt has CF liver disease, Nutrition for help with nutri-
Q 2h assessment Q 2h assessment
Move if score is still Move if score is still tional supplementation, and Pharmacokinetics if pt has drug
high X 2 low X 2 levels that will need adjusting)
Notify MD Notify MD
PICC line consent at the time of admission (1-2 weeks of IV Abx)
nd then fax PICC consult sheet and call PICC team (dont
Asthma Score 0-1: fax consult sheet w/o obtaining consent)
Hold therapy CXR following PICC line placement, if placement is delayed con-
Q2h assessment sider earlier CXR
assessment
Everyday: ask pt to cough as par t of lung exam (pr oductive?),
Move if patient did not
if CPT is in progress STOP IT with pause button to do exam.
Continue protocol if require albuterol For 4
discharge criteria not hours
fulfilled
Notify MD

Discharge Home if:

Asthma Education
Asthma Action Plan
Follow up

Escalate Stable Descalate

Flowsheets available in EPIC:
Asthma Scoring System
ED PACE Asthma History
ED PACE Asthma Scoring System
24 27
 Bronchiolitis Score ASTHMA
Out-patient:
New Diagnosis: determine if it is asthma (if they respond to bronchodila-
tor treatment), and what type of asthma it is (intermittent or persistent)

Classification:
Mild Mild Moderate Severe
Intermittent Persistent Persistent Persistent
Day 2 days/wk >2/week Daily Continual
but
<1/day
Night 2 nights/ >2 nights/ >1 night/ Frequent
month month wk
FEV1 80% 80% 60-80% 60%

Treatment:
Mild Intermittent-
No daily medication
Only short acting beta agonist (Albuterol)
Mild Persistent
Low-dose inhaled corticosteroid daily (Flovent)
Short acting beta agonist (Albuterol) as needed
Moderate Persistent:
Low-dose inhaled corticosteroid (Flovent) AND long acting beta
agonist (Advair)
OR Medium dose inhaled corticosteroid
Short acting beta agonist (Albuterol) as needed
Severe Persistent
High dose inhaled corticosteroid
Long acting inhaled beta agonist

**If pt has ever been in the PICU for an asthma exacerbation

they should be followed by Pulmonary**

26 25