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DEPARTMENT PROFILE HISTORY

I.

Era of Conception When the hospital opened its doors to the public in 1967, there was already a Department of Pediatrics, ably chaired by Dr. Gracia Fernandez-Ramos with 2 other consultants in the staff: Dr. Narcisa Quaioit-Fajardo and Dr. Aida Mariano-Castro. They had 2 general practitioners on 24-hour duty shifts to specifically care for pediatric patients. Slowly, the number of consultants grew with Dr. Priscila Reyes joining the staff in 1969 and Drs. Iole Rabor and Librada Manaligud following soon after.

II.

Era of Struggle In 1974, Dr. Fernandez-Ramos relinquished her position to Dr. Fajardo who took over as Chairman of the Department. Dr. Mariano-Castro, likewise, left for abroad. With a handful of pediatricians left in the department, Dr. Fajardo felt it was time to take in new medical graduates whom they could train in the field of Pediatrics. Dr. Rabor assumed the role of the Residents Training Officer. Regular department conferences and rounds were essential in the training program. The residents also provided service to hospital dependents through well-baby check-ups. In 1978, the Metro-Manila Integrated Residency Training Program (later, to be SEC registered in 1992 as the First Integrated Residency Training Pediatric Program or F.I.R.S.T.), was created. It was formed by The Medical City General Hospital with three other neighboring private hospitals that eventually became PPS-HAB IIa/b accredited, namely: Cardinal Santos Medical Center, Our Lady of Lourdes Hospital, and Polymedic General Hospital (now known as Victor R. Potenciano Medical Center). A program of conferences, workshops and lectures, organized by the consultants of each member hospital, provided the residents exposure to a wider and more diverse field for teaching and learning that complemented the hospitals individual training programs. At about this time, the Philippine Pediatric Society (PPS) was implementing the rules of the Hospital Accreditation Board (HAB), responsible for maintaining the quality and elevating the status of pediatric residency training programs all over the country. As Dr. Rabor was a member of the PPS-HAB Specialty Board, she encouraged Dr. Emelita Lazaro-Leh, then incumbent Chief Resident, to work for the departments accreditation. The department achieved accreditation to a Phase I status in October 1981. In 1984, Dr. Rabor passed away. It was a big loss for the department for she was a well-loved academician, a compassionate and idealistic practitioner, who served as an inspiration to all those who were privileged to train under her wings. On that same year, Dr. Fajardo begged off from the chairmanship.

III.

Era of Growth Dr. Priscila C. Reyes then embraced the role of Chairman of the Department in 1985, with Dr. Carmelo A. Alfiler as Training Officer.

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Accreditation was upgraded yearly to Phase IIa and then Phase II a/b. This consequently qualified our resident graduates to take the pediatric specialty board examinations given biannually by the PPS. The department increased its resident staff from the initial 1-2 to 9-12 staff members (having 3-4 doctors per training year). The consultant staff likewise grew; diplomats, fellows and invited subspecialists of the PPS joined the distinguished roster of pediatricians. With excellence achieved in academic performance, in addition to award winning research output acknowledged in intra- and inter-departmental as well as inter-hospital research paper contests, it was no surprise that The Medical City was cited as Outstanding Hospital within the FIRST. With recognition abounding, Dr. Priscilla Reyes fondly called this time as our Golden Period. IV. Era of Sustainable Development In 1996, Dr. Carmelo A. Alfiler took over as Chairman of the department. He appointed Dr. Elizabeth Palmero-Reyes, a former Chief Resident, as Training Officer. Armed with a vision-mission statement and trailblazing plans, Dr. Alfiler carried the department into a bold new era in its history. The consultant staff grew to 41 regular and 44 visiting staff members, with a good balance of general and sub-specialty pediatricians among the consultant staff. Just as importantly, 15 sub-specialty sections were filled up with at least two sub-specialists each, all ready to develop and conduct their own fellowship training programs and have 15 faculty members with post-doctoral degrees who can offer masters programs in the future medical school. The number of slots for residents increased to 22, including plantilla for a 4th year (as Chief Resident, for the very first time in 2003 and again in 2004), to cover five service areas --- Pedia ER, NICU, Ward, OPD/community and PICU. Numerous scientific activities and medical symposia provided extensive exposure for consultant and resident staff. Out-patient well-baby and sick child services, pediatric emergency room rotations and cases admitted to the hospitals Divine Mercy Program for service/charity patients provided additional opportunities for learning and handling of pediatric patients. In-house preceptorships for general and subspecialty pediatrics for our residents began in 2001 and 2002, respectively. V. Era of Expansion Into the new millennium, The New Medical City, once only a dream became a reality, relocating to its new site and structure along Ortigas Avenue in Pasig City by early 2004. By then, Dr. Alfiler, who had worked passionately to achieve the departments goal of Phase III accreditation status, had moved on to become the Medical Director of the countrys premiere state-run hospital, the UPPGH, and passed on the baton to Dr. Elizabeth Palmero-Reyes, the departments first graduate ever to become Department Chairman. The past chairman of the RTC, Dr. Carlos Paguio was then appointed Training Officer. Under its new and young chairman, the department was more than ready to thrust its best foot forward, having achieved Phase III status and working to maintain this seal of excellence. Plans are being organized to prepare for a future affiliation with the Ateneo University School of Medicine and Public Health. Presently, the staff includes 45 regular and 66 visiting consultants and 18 residents. Achievements of its staff in academics and research and accomplishments of its distinguished staff that pursue further studies here and abroad have been duly recognized and hailed by the hospital and the whole medical community, as well.

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To date, the department boasts of 75 graduates, 12 of whom have trained further in their respective sub-specialties and 5 of whom hold Masteral Degrees in Health Professions Education, Health Services Administration and Health Care. Ninety-four percent (94%) of graduates have been duly board-certified by the Philippine Pediatric Society and forty-two percent (42 %) of graduates are now currently on the staff. It is not typical of the department to remain complacent in its present status, but rather, it is in its character to strive and achieve more than what it set out to be. As this history unfolds, the department has come up with pioneering and showcase programs (e.g. Comprehensive Health of Adolescents Program or CHAP, Barangay Ugong Community Development Program), and other services integrated with the hospitals niches (Cardiovascular, Neurosciences, Cancer, Organ Transplantation), all of which will certainly prove that the Department of Pediatrics is indeed a vibrant player in The Medical City. VI. Administration The Philippine Pediatric Society Hospital Accreditation Board (PPS-HAB) has duly accredited the Medical City Department of Pediatrics as Phase II A/B hospital since 1986. It has since been accredited as a Phase III hospital with an effectivity date of January 1, 2004 to December 30, 2007 (please refer to Attachment A). It has since been revisited at the new site in Ortigas Ave. last March 1, 2005.

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DEPARTMENT THRUST

I.

Vision We envision to provide optimum quality pediatric care, staffed by highly competent pediatricians, duly certified by the Philippine Pediatric Society, collectively working to pursue academic & patient service programs for the benefit of the hospital and the community, specially, the children we serve.

II.

Mission We commit ourselves to fulfill our vision by: Aligning our strategies with those of The Medical City, anchored on the principle of Keeping our patients on center stage and service of greater worth. Continuously developing and implementing feasible and sustainable strategies that will promote & realize the highest of academic, training & service-oriented goals in every section of our department. Establishing mutually beneficial relationships with agencies & institutions, both here & abroad, that are similarly focused on child advocacy & child health. Generating resources for the optimum & sustainable implementation of departmental policies. Inculcating the highest moral and ethical standards into all our department practices and personnel.

III.

Strategic Thrusts of the Department of Pediatrics A. Staff Development 1. Upgrade consultants and Junior consultants capabilities through: CME and research, local and international Professional development, including post-doctoral studies Up-to-date and relevant library and information technology materials 2. Recruit and train needed professional manpower Eligible general and subspecialty consultants Eligible junior consultants and, in the future, residency and post-residency fellowship candidates. 3. Generate funds for staff curricular requirements B. Service Delivery Improvement 1. Acquire and upgrade essential pediatric equipment 2. Initiate and maintain service networks 3. Review and make relevant service policies C. Department Camaraderie 1. Develop new and sustain existing group activities designed to foster interpersonal understanding. 2. Participate in seminars/ workshops that cater to ethics, values and group dynamics.

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D. Intra/Extra-Hospital Recognition 1. To work on the status as the leading clinical department in The Medical City Iloilo. 2. Devise unique programs worthy of acknowledgement by The Medical City, Philippine Pediatric Society (P.P.S.), Philippine Medical Association (P.M.A.) and various local / international institutions. IV. Developmental Plans The department is planning to work on the fulfillment of its short and long-term goals. Proposed programs and activities are always consistent with this developmental plan, which is in turn, aligned with the hospitals developmental plans.

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V.

Organizational Structure The departments organization structure was revised during the first quarter of 2007. The Management Committee was expanded with the addition of the Operations Division head. All the divisions are under the headship of the Department Chair.
Board of Directors

Chief Executive Officer

Medical Director

Clinical Services Director

Department Chairperson

C&P

Management Committee

Executive Committee

Coordinator, Continuing Pediatric Education

Coordinator, Office of Research & Extension Consultants

Coordinator, Operations

Coordinator, Patient Care In-patient Svcs Newborn Services Intensive Care PICU

Finance

Consultants Junior Consultants Junior Consultants Human

Advocacy & Training Publication

Marketing

NICU Ambulatory

Emergency Out Patient

Adolescent
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Community

VI.

Services Offered A. Adolescent Medicine 1. Adolescent Growth & Development 2. Consent, Confidentiality, and other related issues 3. Transition to Adulthood 4. End-of-life Issues in adolescent health care 5. Medical Health Issues a. Obesity and other Eating disorders b. Rheumatic disorders c. Endocrine disorders - Thyroid problems diabetes d. Genitourinary and Renal disorders e. Cardiovascular disorders f. Malignant diseases g. Disorders of the skin h. Infectious diseases i. EENT disorders j. Neurologic disorders k. GIT Disorders l. Adolescent Hematology m. Musculoskeletal disorders 6. Sexual and Gynecologic health a. STD b. Menstrual disorders c. Breast disorder d. Contraception in the adolescent e. Sexual abuse in the adolescent f. Adolescent pregnancy 7. Sports Medicine 8. Mental health a. Depression b. Suicide c. Substance abuse d. Disruptive behavior & other mood disorders e. ADHD f. Schizophrenia in adolescents g. Psychosomatic disorders 9. Preventive Health & Maintenance a. Immunization b. Counseling Issues and techniques c. Health risk behavior assessment d. Caring for adolescents in the clinic/ office B. Allergy and Clinical Immunology 1. Mastery of the Immune System a. Anatomy and Physiology b. Immune Response 2. Clinical Evaluation of a child with allergic or immunologic disease a. History b. Physical examination

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3. Performance and Interpretation Diagnostic Procedures: a. Aeroallergen Skin Testing b. Food Allergen Skin Testing c. Insect Allergen Skin Testing d. Vaccine Testing e. Anesthetic Agent Testing f. Patch Testing 4. Interpretation of Laboratory and Radiologic Diagnostic Procedures: a. Peak Flow Reading / Spirometry b. UNICAP Allergy Tests c. Immunologic work up d. X-rays and CT Scans 5. Administration of Therapeutic Modalities: a. Immunotherapy b. Allergic emergency management c. IVIG Treatment 6. Primary and Secondary Immunodeficiency Diseases 7. Systemic Reactions and Anaphylaxis 8. Allergic Disorders of the Upper Respiratory Tract 9. Allergic Disorders of the Eye 10. Atopic Dermatitis 11. Bronchial Asthma 12. Adverse Reactions to Food 13. Adverse Reactions to Drugs 14. Allergic Reactions to Insect Stings 15. Urticaria and Angioedema 16. Patient Education C. Ambulatory Pediatrics 1. Health supervision visit principles to include anticipatory guidance and biomedical and psychosocial risks 2. Developmental, behavioral and educational surveillance 3. Child abuse and neglect 4. Community pediatrics/social pediatrics 5. Basic principles of research 6. History taking skills from newborns to adolescents 7. Physical examination skills from newborns to adolescents 8. Managerial skills for children with acute and chronic illnesses or disability 9. Teaching/mentoring/counseling skills 10. Communication/interpersonal skills with parents and trainees D. Pediatric Cardiology 1. Mastery of: a. Normal anatomy and physiology of the cardiovascular system b. Pathogenesis and pathophysiology of cardiovascular diseases and its complication in infants, children and adolescents All acyanotic heart diseases All cyanotic heart diseases
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Rheumatic fever/rheumatic heart disease Other acquired heart diseases Others c. Diagnostic and therapeutic principles of cardiovascular diseases and their complications 2. Expertise in the performance or interpretation of the following: a. EKG and chest X-ray b. Two dimensional echocardiography c. Stress testing d. 24 hour EKG e. cardiac catheterization data 3. Competence in managing all cardiovascular disease most especially: a. CHF b. Cardiac cyanosis in the newborn c. Arrhythmia d. Cardiovascular cases in an ICU setting e. Post op management of cardiac surgery E. Collagen Vascular and Other Multisystem Disorders 1. Systemic Lupus Erythematosus 2. Juvenile Rheumatoid Arthritis 3. Dermatomyositis 4. Scleroderma 5. Other arthritis syndromes a. Ankylosing spondylitis b. Postinfectious arthritis c. Arthritis of inflammatory bowel disease 6. Vasculitis syndromes a. Henoch-Schonlein Purpura b. Takayasu arteritis c. Polyarteritis Nodosa d. Kawasaki Syndrome F. Pediatric Dermatologic 1. Anatomy and Physiology of the Skin a. Skin development b. Structure and function of neonatal, infant & adult skin 2. Principles of diagnosis in pediatric dermatology a. Dermatologic history and P.E. b. Clinical Diagnostic test 3. Principles of therapy in pediatric dermatology a. Topical treatment b. Systematic treatment c. Cosmetic treatment d. Simple surgical techniques excision & punch biopsy electrocautery of superficial skin lesions e.g. warts curettage of superficial skin lesions manual extraction of superficial cysts & warts Cryotherapy with the use of liquid N2 (nitrogen) 4. Pediatric dermatology disorders
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a. b. c. d. e. f. g. h. i. j.

Neonatal skin disorders Genodermatosis Disorders in keratinization Diseases of the mucosal membranes and skin appendages Reaction patterns Neoplasm and systemic diseases Infections and infestations Drug eruptions Physical injuries and environmental hazards Psychosocial Development in children with cutaneous disease

G. Developmental and Behavioral Pediatrics 1. Mastery of: a. Normal growth and development: Principles of child development Theories of human development from prenatal to adolescent stage b. Brain development and learning c. Growth, behavior and learning problems d. Developmental disabilities: Autism, Mental Retardation, Communication Disorders, Multiply handicapped (visually impaired, hearing impaired etc) 2. Knowledge and understanding of: a. Psychological aspects of acute, chronic and terminal illnesses b. Special issues like child abuse and neglect, genetic counseling c. Giftedness d. Problems in Adolescence e. Community pediatrics f. Family counseling and support g. Community resources and support groups for families 3. Expertise in performing and/or interpreting: a. Developmental assessment testing (Griffiths or CAT-CLAMS or other developmental assessment tool) b. Psychometric evaluations (Wechsler intelligence test etc) 4. Competence in managing all developmental disabilities and behavioral/learning problems: a. Autism b. Communication Disorders c. Global developmental delays and Mental retardation d. Attention Deficit/Hyperactivity disorder Sensory impairments (visual, hearing) and multiply-handicapped Learning problems and disabilities (reading, comprehension, math etc) Networking with other professionals and community resources to support interventions H. Pediatric Endocrinology 1. Carbohydrate metabolism a. Diabetes mellitus (type 1, type 2, transient) b. Hypoglycemia c. Hyperglycemia d. Others 2. Bone and Mineral Metabolism a. Calcium and Phosphorus metabolism b. Vitamin D related disorders
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c. Parathyroid hormone disorders d. Rickets and osteomalacia` e. Osteoporosis Diseases of the thyroid gland a. Goiter b. Hypothyroidism c. Hyperthyroidism d. Others Adrenal Disorders a. Congenital Adrenal Hyperplasia b. Adrenal tumors c. Others Diseases of the Pituitary/ Hypothalamus a. Tumors of the pituitary/ hypothalamus b. Pituitary/ hypothalamic dysfunction secondary to chemotherapy/ irradiation c. Others Growth disorders Diseases of the reproductive endocrine system a. Precocious Puberty b. Delayed Puberty c. Polycystic Ovarian Diseases d. Others Lipoprotein and lipid disorders Other hormones

I. Pediatric Gastroenterology 1. Knowledge in the following diseases: a. Congenital GI anomalies b. Metabolic liver diseases c. Diarrheal diseases, acute and chronic d. Neonatal cholestasis e. Viral hepatitides f. GI infections g. Pancreatitis h. Biliary tract diseases i. Portal hypertension j. GI bleeding k. Acid peptic diseases including peptic ulcers l. Abdominal mass m. Inflammatory bowel diseases n. Functional GI disorders o. Nutritional disorders p. Enteral and parenteral nutrition 2. Knowledge of GI physiology and anatomy 3. Knowledge of GI drugs, nutritional products 4. Diagnostic and therapeutic/interventional endoscopy a. Gastroscopy b. Foreign body removal c. Variceal sclerotherapy d. Variceal legation e. Percutaneous endoscopic gastrostomy
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f. Colonoscopy 5. Percutaneous liver biopsy 6. Paracentesis J. Genetics 1. Principles a. Human embryology b. Normal growth and development c. Mechanisms of abnormal morphogenesis Malformations Deformations Disruptions Dysplasias d. Fetal pathology regarding congenital anomalies e. Teratology f. An approach to the diagnostic recognition of patterns of malformations g. Principles of human genetics 2. Practice a. Performance of a careful, detailed physical examination to ascertain normal and abnormal morphogenesis: major anomalies, minor anomalies, normal variants b. Collection of a detailed history with respect to both prenatal and postnatal periods Family history and pedigree construction History of potential teratogenic exposure Prenatal and postnatal growth and developmental histories c. Information synthesis Pedigree interpretation Interpretation of medical history and physical examination Differential diagnosis of single primary defects or multiple malformation syndromes Critical analysis of the medical literature and computerized databases Diagnostic synthesis Longitudinal follow up of patients d. Information transfer Counseling of patients and families K. Pediatric Hematology 1. Expected competencies: a. Skill in peripheral blood smear preparation and bone marrow aspiration and/or biopsy b. Interpretation of peripheral blood smear, bone marrow aspiration, bone marrow imprints (optional: core biopsy) c. Interpretation of common hematologic test (i.e. osmotic fragility test, sucrose lysis test, PT, Aptt, TT, fibrin degradation product, coagulation assays hemoglobin and serum electrophoresis, etc.) d. Research e. Proficiency in blood banking and transfusion medicine f. Understanding of methods, principles and interpretation of immunopathologic tests, immunophenotyping, flow cytometry, immunoelectrophoresis, cytochemistry, cytogenetics g. Emphasize on the development of patient management skill h. Bioethics i. Research
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2. Acquired basic knowledge in: a. Pathophysiology, diagnosis and management of hematologic and oncologic diseases b. Child and adolescent diseases c. Congenital and acquired disorders of red cells, white cells, and platelets; coagulation defects d. Bone marrow failures, myeloproliferative diseases e. Nutritional anemias f. Disturbances of iron metabolism g. Hemoglobinopathies h. Immunodeficiency i. Leukemias j. Thrombocytopenias and thrombasthenia k. Histiocytic disorder 3. Knowledge in related basic sciences: a. Structure of hemoglobin, iron metabolism and bilirubin b. Coagulation and platelet functions c. Cell kinetics d. Phagocytic system e. Spleen, its function and the reticulo-endothelial system f. Immunology-immunohematology g. Genetics h. Principles of radiation therapy i. Blood group and transfusion j. Characteristic, pharmacology/pharmacokinetics of chemotherapeutic agents k. Microbiology and anti-infective agents in the compromised host l. Tissue typing m. Bone marrow transplantation and graft versus host n. Malnutrition o. Learn the staging and classification of tumors, complete knowledge of the application of multimodal therapy, learning to function as member of the team, cancer and blood disorders making good observations and keeping accurate patient data p. Experience in the support of patient, family and staff in dealing with terminal illness with development of skills in communication and counseling. L. Infectious Disease 1. Immunization 2. Knowledge of anti-infectives 3. Management of : a. Bacterial Infections b. TB c. Viral Infections d. Fungal Infections in Immuno-compromised hosts e. CNS Infections f. Nosocomial Infections g. FUOs M. Pulmonary Diseases 1. Anatomy and Physiology of the lungs 2. Clinical evaluation of a child with pulmonary disease a. History and physical examination 3. Diagnostic and therapeutic procedures
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4. 5. 6. 7. 8. 9.

a. Bronchoscopy b. Chest imaging c. Pulmonary function tests d. Thoracentesis/bottle system e. Oxygen supplementation f. Mechanical ventilation Respiratory disorders in the newborn Pleural diseases Respiratory tract infections Non-infectious disorders of the respiratory tract Acute respiratory failure Chest tumors

N. Pediatric Neonatology 1. Normal Newborn a. Antenatal Identifying antenatal conditions associated with high risk deliveries and know the impact of these illnesses on the fetus and newborn Know the methods of assessment of fetal well being Identify the commonly used maternal drugs and their effects on the fetus b. Perinatal Anticipation of low and high risk deliveries Familiarization with the equipments needed for resuscitation and their proper usage (e.g. radiant warmers, suction machine, incubation set) c. Know delivery room management Evaluation, decision making and prompt action Goals of resuscitation Inverted pyramid of resuscitation Sequence of resuscitation as recommended by the Neonatal Resuscitation Program (NALS) 2. General care of the newborn a. Know how to perform a thorough physical and neurological examination b. Know gestational age assessment by Ballard/ Dubowitz and correlate with obstetric estimate c. Know routine newborn care Temperature regulation Proper umbilical cord care Vitamin K prophylaxis Nutrition emphasis on breastfeeding Rooming in d. Identify the components of the newborn screening tests and its clinical implication e. Know the difference between physiologic and pathologic jaundice. 3. Abnormal newborn a. Know the diagnosis and management of: Deviation from normal intrauterine growth (e.g. SGA, LGA, IUGR) b. Respiratory RDS and its complication (BPD, IVH, retinopathy, etc.) Air leaks (pneumothorax, pneumomediastinum) Persistent pulmonary hypertension Apnea Meconium aspiration
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Transient tachypnea of the newborn c. Infection (e.g. sepsis, pneumonia, meningitis) d. Major cardiac anomalies (cyanotic and acyanotic heart disease) e. Neurological (e.g. hyponatremia, hypoglycemia, hypocalcemia) f. GI ( e.g. NEC, atresia) g. Hyperbilirubinemia conjugated and unconjugated h. Endocrine/Metabolic Disorders 4. Others a. Know the basic principles of mechanical ventilation and recognition of respiratory failure and the need to ventilate b. Interpret blood gas analysis and be able to correlate clinically c. Interpret chest x-ray studies d. Perform the following: intubation, thoracostomy, I and D O. Pediatric Nephrology 1. Knowledge in the following diseases a. 10 syndromes in Nephrology Acute nephritis Nephrotic syndrome Asymptomatic bacteriuria Acute renal failure Urinary tract infection Urinary obstruction Tubular diseases Hypertension Nephrolithiasis b. Fluid and electrolyte problems c. Acid-base disorders 2. Must be equipped in doing: a. Acute and chronic peritoneal dialysis b. Acute and chronic hemodialysis c. Kidney biopsy 3. Has interest in research and has output of at least one retro and prospective study while on fellowship 4. Knowledge and understanding of: a. Elements of normal anatomy and physiology of the kidneys b. Pathogenesis and pathophysiology of renal disease c. Diagnostic and therapeutic principles of renal disease d. Basic principles in peritoneal dialysis and hemodialysis e. Transplant immunology and knowledge of indications and contraindications of transplantation f. Basic knowledge of transplant related medical problems 5. Must have clinical exposure in a. Chronic peritoneal dialysis catheter insertion b. Dual lumen, jugular, subclavian or femoral catheter insertion c. Extracorporeal dialysis modalities P. Pediatric Neurology 1. Competence in the diagnosis and management of common pediatric neurological disorders/ conditions such as: a. Paroxysmal disorders in infants and children
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Headaches Seizures, including febrile seizures, epilepsy, and symptomatic seizures Pseudoseizures and non-epileptiform disorders such as Tics, movement disorders, syncope b. CNS infections c. Brain tumors (medical management of complications) d. Head injury - accidental and non-accidental traumatic brain injury e. Neurometabolic disorders f. Neurological manifestations of systemic illness g. Alterations in consciousness h. Motor weakness i. Problems with balance and coordination (ataxia) j. Psychomotor retardation k. Increased intracranial pressure 2. Expertise in the interpretation of common diagnostic procedures/laboratory results such as: a. Neuroimaging procedures Brain CT scan Brain MRI Cranial ultrasound Skull and vertebral x-rays b. Electroencephalography c. Electromyogram/Nerve conduction studies d. Cerebrospinal fluid examination e. Evoked potentials (VER, BAER) 3. Exhibits an competent level of skill in the performance of common neurological diagnostic procedures such as: a. Lumbar puncture b. Subdural taps for evacuation of subdural effusions/empyema Q. Clinical Toxicology 1. Knowledge a. Basic Pharmacology and Toxicology of Drugs and Chemicals b. Principles of Clinical Toxicology c. Characteristics of specific and common poisons Household agents Over-the counter drugs Pesticides Heavy metals Plant and Animal/Marine Toxins Drug abuse Chemical warfare Hazardous wastes d. Basic Principles of Environmental Health and Toxicology e. Basic Analytical and Forensic Toxicology f. Adverse drug reactions / drug interactions 2. Skills a. General approach to management of poisoning cases Emergency stabilization Clinical evaluation Limitation of absorption Enhancement of elimination and excretion
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Use and administration of specific antidotes Supportive management Sound disposition b. Identify toxidromes especially for unknown poisoning c. Management and detoxification of drug abuse patients d. Rational use and proper interpretation of toxicologic screens and analytical laboratory examinations e. Management of chemical incidents f. Identify and manage adverse drug reactions g. Do research as databases for common poisoning cases and case reports for interesting/uncommon toxicities h. Share knowledge through lectures/ rounds/discussions of poisoning cases 3. Attitudes a. Wholistic approach in the management of suicidal patients and drug abusers b. Awareness of bioethical and medico-legal implications of poisoning cases c. Practice toxicovigilance through poison prevention programs and information dissemination R. General Pediatrics 1. Must have general knowledge on: a. Growth and Development Anthropometric Behavioral b. Nutrition and Nutritional disorders Normal nutritional requirements Infant feeding Deficiency states c. Genetics/Dysmorphology Different patterns of inheritance General clinical principles in counseling for genetic disorders Common chromosomal abnormalities d. Newborn General care of the newborn Diagnosis and management of common diseases of the newborn e. Allergy, Immunology and Related disorders The major components of the immune system Signs and symptoms and the basic management of a potentially immunodeficient child General and specific diagnostic tools in allergic disorders General preventive measures for allergic disorders Principles of management for allergic disorders Pathophysiology, diagnosis and management of asthma f. Infectious Diseases Immunizations Diagnostic approach to FUO, occult bacteremia Pathogenesis, diagnosis, complications and treatment for sepsis General spectrum of infectious diseases in children including etiology, incidence, incubation period, transmission, clinical manifestations, diagnosis, complications, management, prevention and prognosis Common viral, bacterial, fungal and parasitic infections

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Indications/contraindications, preparations, dosages, mode of administration and major adverse effects for each group of anti-infectious agents Respiratory Disorders Common diseases of the respiratory tract: upper airway, lower airway, parenchyma General signs and symptoms of respiratory disorders Gastrointestinal Disorders General signs and symptoms of digestive tract disorders Common diseases of the gastrointestinal tract Fluids and Electrolytes Composition of body fluids Acid-base physiology Electrolyte abnormalities Basic principles of fluid and electrolyte therapy Renal disorders Normal function of the kidneys General signs and symptoms of renal disorders Common specific disorders Renal failure Cardiovascular disorders Common clinical manifestations of cardiovascular disorders and their onset Ancillary procedures which are useful in the initial evaluation Treatment of CHF and other related medical complications Congenital heart diseases Acquired heart diseases Metabolic and endocrine disorders Signs and symptoms of the more common errors of metabolism/endocrine disorders Screening tests in the neonatal period Specific metabolic conditions Growth Disorders of the blood/neoplasms Erythrocyte, leukocyte and platelet disorders Coagulation disorders Tumors Neurologic disorders General signs and symptoms of neurologic disorders and their management Infections Developmental malformation/static neurologic deficit Seizures Spinal cord diseases Musculoskeletal disorders Common manifestations attributable to musculoskeletal disorders: gait, limping, pain Developmental disorders Congenital disorders Acquired disorders Skin disorders General principles of diagnosis and treatment of skin disorders: infectious. Vascular, pigment, neurocutaneous disorders Disorders of eye, ear, nose and throat Common disorders and their management Adolescent medicine/gynecology
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Adolescent development Sexuality Cognitive and moral development Social development Health issues of the adolescent s. Critical Care General signs and changes of impending systemic failure Emergency life support Recognition and management of shock, respiratory and cardio-pulmonary failure t. Emergency care Trauma Burns Seizures Near-drowning Bites and stings Anaphylaxis/shock Poisoning u. Others Sports medicine Environmental health Ethical issues in pediatrics

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STAFF QUALICFICATIONS, DUTIES AND RESPONSIBILITIES A. Executive Committee The Executive Committee is the highest body in the organizational structure of the Department of Pediatrics. It was formed in 1996 and is tasked with the formation and execution of departmental guidelines, among other things, training, patient service, research, non-scholastic affairs and administration. It serves as a policy-making and decision-setting committee. The members of the Executive Committee are the following: 1. Department Chair The voice of the department in the hospital community and in the Philippine Pediatric Society. (PPS) Approves the policies and guidelines formulated by the Department (Executive Committee) and the other committees of the department. Assigns specific duties and responsibilities to departmental consultants. Approves the acceptance of new junior consultants. Represents the department in intra-hospital and inter-hospital meetings. The overall training coordinator-in-charge of the departments academic programs. Implements the academic policies and guidelines formulated by the Executive Committee. 2. Coordinator of the different areas FORMULATE DUTIES & RESPONSIBILITIES

3. Liaison Officer In-charge of communications between the department and the hospital, and between the department and organizations outside of the hospital. The Department Chair and Executive Committee assigns special tasks, which ultimately redound to departmental and hospital welfare.

4. Junior Consultant Is the voice of the residents in the Executive Committee Fulfills administrative, clinical and miscellaneous functions. Helps the Chair and the Executive Committee implement and monitor departmental projects. FORMULATE DUTIES & RESPONSIBILITIES

The active staff meets regularly and as the need arises.

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B. Management Committee The Management Committee was formed in 1996 and is composed of the members of the Executive Committee and the Coordinators for Training, Service, Research, Non-scholastic Activities and Nursing Services. It was expanded in 2003 with the addition of the Administrative Services Division and the Subspecialty Sections. This committee convenes regularly to discuss updates, plans and problems in the different sectors of the department. The members of the Management Committee are the following: 1. All the members of the Executive Committee 2. Administrative Services Coordinator a. She is responsible in ensuring the proper functioning of the following components. Physical Facilities Committee - Pediatric Office Complex - Pediatric Staff Assistance Office - IT office Networking Special Projects Committee - Comprehensive Adolescent - Health Maintenance Program - Ad Hoc PPS HAB Accreditation - Skills Training 3. Subspecialty Sections Coordinator a. She is in-charge of giving recommendations for further staff development in the different subspecialties (as reviewed and approved by the Academic Personnel Board). b. She coordinates with the head of each section, regarding their program activities and needs. c. Each section is responsible for program development, implementation, monitoring and evaluation. Adolescent Medicine Allergy & Immunology Ambulatory Pediatrics Cardiology Endocrinology Hematology-Oncology Infectious Disease Nephrology Neonatology Neurology Pulmonology Developmental Genetics Gastroenterology 4. Training Coordinator a. He represents the department in intrahospital and interhospital academic affairs b. He coordinates with the different component committee heads under this service c. Each committee is responsible in developing, implementing, monitoring and evaluating programs proposed in their areas of specialty.
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Graduate Programs Committee Post Residency Training Committee Residency Training Committee Internship Training Committee

5. Patient Services Coordinator a. She makes sure that all the service units are functioning as expected. b. She coordinates with the heads of component committees. c. Each service unit is free to recommend projects that redound to the upgrading, improvements and maintenance of patient service facilities/needs. The heads of each unit periodically evaluates the efficiency of his area of responsibility. Ward Service PICU Service Newborn Services Division Pediatric Emergency Room Service OPD Committee - TMC - Ugong Community Service Special Service - Patient Education 6. Research Coordinator a. She is the over-all coordinator for residents research b. She represents the department in intra-hospital and inter-hospital research activities c. She coordinates with the heads of the Research Committee, Learning Research Center, each with the function of disseminating or propagating researches in appropriate for a: Intrahospital Research Committee Interhospital Research Committee Scientific Publications Committee Library Service Committee 7. Nonscholastic Activities Coordinator a. She is responsible for coordinating non-scholastic activities within and outside of the hospital b. The heads of the different sub-committees are: Personality Development Committee Sports and Physical Fitness Committee Socio-cultural/Religious Committee Resource Generation Alumni Relations

DEPARTMENT POLICIES AND PROCEDURES I. Objectives A. Service To provide excellent health care to all pediatric patients with the availability of the proper equipment and diagnostics To ensure quality of care by maintaining a competent medical staff

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To be able to extend medical assistance to those in need through our Divine Mercy Program

B. Training To provide our trainees with sufficient clinical cases that will complement the lectures given by consultants II. Background The Medical City has a total of 500 beds. To provide specialized quality care, the floors are departmentalized. The 9th & 10th floors are dedicated for pediatric patients. The 9th floor has a total of 35 beds while the 10th floor has 33 beds. Separate Gastrointestinal Ward and Respiratory Ward with six beds each are found at the 6th floor. Each floor has its own fully equipped treatment room, residents call room and conference room. Although our floors are departmentalized, pediatric patients may still be admitted in other floors as needed. A. Staff Profile It is required that our staff should either be certified diplomates or fellows of the Philippine Pediatric Society. All subspecialists should be board certified. At present, we have 41 Active Consultants and 71 Visiting Consultants. We have a full complement of subspecialists and associates who work as a team in caring for our patients. Our residents are divided into three services based on geographic locations of the patient. Service 1 resident handles patients on the 10th and 11th floor. Service 2 residents handle patients from 9th and 8th floors. The rest of the floors (other floors) are handled by the Service 3 resident. A group of consultants is assigned as preceptors for each of the services who conduct teaching rounds or small group discussions with their service residents. During these teaching rounds, residents are graded using the following criteria: Grading Sheet 1. 2. 3. 4. 5. 6. History taking Performance of a good physical examination Interpretation of laboratory results Diagnosis and differential diagnosis Management and rationale Complete laboratory results, nutritional chart and flow chart of labs 7. Progress notes 8. General knowledge 9. Punctuality and courtesy 15% 15% 10% 10% 10% 10% 10% 15% 5%

B. Duties of the Core Group 1. Head The responsibilities of the Core Group Head are as follows: a. Oversees all the activities of the service

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b. c. d. e. f.

Teaching Rounds - conduct weekly teaching rounds with the service residents and supervise the members of the core group Mini Audit moderates the discussion of cases encountered by the service for the month Divine Mercy Program - encourage more consultants to admit more patients under the program Makes sure the services are running smoothly. (e.g. all medications needed should be available in the wards and are administered correctly) Regularly checks on ward equipments to make sure that they are complete and functioning properly. (Nebulizers, pulse oximeter, weighing scale, etc.) Gives suggestions to improve the service Assigns consultant moderator for the service Grand Audit Delegates tasks as necessary

2. Core Group Co-Head The responsibilities of the co-head are as follows: a. Conducts weekly teaching rounds with the service residents and supervise the members of the core group with the goal of teaching the residents their b. Supervises the monthly mini-audit of the service, and also make sure at least five consultants of the service are present during the mini-audit. The co-head may assign a resident in the service to be in charge of informing the service consultants of the miniaudit c. Encourages the consultants of the service to admit patients under the Divine Mercy program d. In the absence of the service head, takes over his/her responsibilities 3. Core Member The responsibilities of the core member are as follows: a. Meets with the service residents for their chart rounds touching on the history, physical examination and laboratory examinations. If the management of the case will be discussed, this will be done with the knowledge and consent of the attending physician. The goal is to make the service residents know their cases by heart, make sure the history and physical examination are complete and done properly and that the management of cases are guided by clinical practice guidelines if applicable. (Please see Appendix A OPC No. 97 A Securing of Patients Inform Consent) b. Randomly checks the completeness of charts c. As a group, determines the interesting cases which can be presented for discussion during Grand Audits d. Gives suggestions on anything concerning the ward service and if problems are encountered, discuss them with the head of the service and head of the ward.

IN-PATIENT SERVICES (FLOORS AND WARDS) I. General Policies 1. All the physicians who see the patient should indicate their complete assessment and plan of management in the chart, which could be seen and understood by the consultants and residents involved in the care of patients
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2. Diagnostic tests to ascertain need for admission shall be ordered according to the needs of the individual patient based on the assessment of the Attending Physician. 3. Medical, nursing and other services responsible for patient care collaborate to analyze and integrate the different assessments. These are all recorded, the needs of the patient are prioritized, and the family is made aware. 4. Physicians involved in caring for the patient have access to the patients record. Their notes are written on the chart after each visit to the patient. Parents may look at the chart upon the attending physicians approval. 5. Admission Criteria Laboratory-blood - Serum sodium < 130 mEq/L or > 150 mEq/L - Serum potassium< 2.5 mEq/L or > 5.5 mEq/L - Serum calcium< 7.0 mg/dL (for ionized calcium values see newborn criteria) - Serum bilirubin> 15.0 mg/dL indirect or total bilirubin CO2 combining power shows non-compensated acidosis/alkalosis by arterial blood gas documenting either HCO3 < 20 mEq/L or > 36 mEq/L or PaCO2 < 30 mmHg or > 50 mmHg - Arterial blood pH < 7.30 or > 7.55 (identified within the last 48 hours) - Hemoglobin (Hgb) 10 g/dL or less with active bleeding or a 3 g/dL drop from baseline - Toxic drug level as evidenced by laboratory report - White blood count < 3,000 /L or > 16,000 /L - Hemoglobin (Hgb) < 9 g/dL or > 20 g/dL with signs of volume depletion - Hematocrit (Hct) < 24% or > 55% - Positive blood culture - Metabolic acidosis with venous lactate level > 2 mEq/L Functional impairment (identified within last 72 hours) - Unconsciousness - Disorientation - Delirium - Motor function loss--any body part - Loss of sensation--any body part - Severe articular restriction and somatic dysfunction - Change in mental status from baseline or an abrupt deterioration over previous functional level - Fall with inability to ambulate, in a previously ambulatory person Physical findings - Penetrating wounds - Continuous hemorrhage from any site - Wound disruption (requiring closure) - Dehiscence/evisceration - Seizures uncontrolled by medication - Congenital abnormality admitted for surgical intervention requiring hospitalization - Documentation of malignancy and admitted for treatment requiring hospitalization - Generalized edema - Clinical signs of dehydration to include two or more of the following: altered mental status, lethargy, light-headedness, syncope, decreased skin turgor, dry mucous membranes, tachycardia, or orthostatic hypotension and other symptoms of dehydration including sunken eyes or fontanels, weight loss > 5% and/or decreased urine output < 1ml/kg/hr - Present or potential respiratory depression - *Observation for head trauma
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Vomiting and/or diarrhea with dehydration Shock or potential shock *Physician documentation must substantiate the need for greater than twenty-four hours monitoring, treatment, and/or observation post procedure. Vital signs (taken at rest) - Temperature: Pediatric values reflect rectal or tympanic temperature readings. To convert rectal temperatures to an oral value, subtract one degree. Pediatric: < 8 weeks > 100.4 F (38.0 C) 8 weeks - 1 year > 101 F (38.3 C) > 1 year - 3 years > 102 F (38.9 C) with WBC > 15,000/L > 3 years - 17 years > 104 F (40 C) with WBC > 16,000/L - Pulse: beats per minute (bpm) Pediatric: < 6 weeks < 80 or > 200 bpm 6 weeks - 1 year < 70 or > 180 bpm > 1 year - 3 years < 60 or > 170 bpm > 3 years - 12 years < 60 or > 160 bpm > 12 years - 17 years < 50 or > 140 bpm - Respirations: Pediatric: Newborn (first 12 days of life) > 60/minute sustained or Pa O2 < 50 mmHg on room air with O2 saturation < 90% > 12 days - 1 year < 25 or > 60/minute > 1 year - 3 years < 15 or > 40/minute > 3 years - 12 years < 15 or > 40/minute > 12 years - 17 years < 12 or > 30/minute - Blood pressure: Systolic (mmHg) Diastolic (mmHg) Pediatric: birth to 1 year < 65 or > 100 < 30 or > 65 > 1 year - 3 years < 75 or > 110 < 45 or > 75 > 3 years - 6 years < 80 or > 115 < 50 or > 80 > 6 years - 12 years < 80 or > 130 < 50 or > 90 > 12 years - 17 years < 80 or > 170 < 50 or > 100 Related areas - Suspected or proven child abuse/neglect - Failure to thrive - Suspected or known ingestion of foreign body - Suspected apnea > 20 seconds (0 - 1 years) Others - Admitted for surgical procedure which required hospitalization (indication for the surgery is documented) - Admitted for day surgery procedure (indication for procedure is documented) and patient has American Society of Anesthesiologists (ASA) Classification of Physical Status of III, IV, or V, or Classification of Heart Disease III or IV

6. Patient Identification a. Patient Identifiers shall be used in verifying a patients identity for all transactions and services/procedures (i.e. patient admission, patient inquiry, performing procedure, collection of specimen/blood samples, charging of procedure/medications, administering of medications, results printing, etc.) b. Patient Identifier shall be as follows:
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Patients Complete Name Birth Date Patient Identification Number (PIN) c. To confirm a patients identity, at least two (2) of the identifiers should be used. Patient identifiers shall not be confirmed with patients using questions answerable by YES or NO. 7. Ordering of tests a. When ordering a test/procedure or medication, the Attending Physician/Prescribing Physician shall note the corresponding clinical indication. 8. Diagnostic Tests Required a. Diagnostics tests to ascertain need for admission shall be ordered according to the needs of the individual patient based on the assessment of the Attending Physician. b. Service residents should follow up official x-ray readings, laboratory results of their patients themselves and make sure that these are incorporated in the chart. c. All initial laboratory results have to be relayed to the consultants ASAP e.g. CBC, platelet count in dengue patients, serum electrolytes in dehydrated patients, etc. 9. Informed Consent a. For diagnostic tests and procedures that require an informed consent, the Attending Physician (AP) shall be the one to explain with the patient or patients guardian prior to the conduct of the test/procedure. (For the detailed policy guidelines, please refer to Appendix A OPC No. 97-A Securing of Informed Consent) 10. Treatment Room a. Treatment room can be used for procedures such as lumbar tap, difficult IVF insertion, etc. All the treatment rooms are properly equipped. 11. Medication a. Medicine prescriptions should comply with OPC No. 166 on Prescription Writing and No. 175 on Medication Management System. (For detailed policies and procedures, please refer to Appendix B - OPC No. 166 Prescription Writing and Appendix C OPC No. 175 Medication Management and Use) 12. Handling verbal and telephone communications In cases where verbal or telephone communication is necessary, the individual/physician communicating the result/order , must ensure/confirm that the relayed information was understood and heard correctly by the receiving staff-in charge by requesting the receiving staff to repeat or read back the information. Any incorrect or unclear information must be clarified by both parties immediately. 13. Handling of Complaints Involving professional attitude and behavior shall be referred to Appendix D - OPC No. 168 Complaint Management and Appendix E OPC No. 103-B Classifying, Reporting and Analyzing Unanticipated Clinical Events and Near Misses. 14. Transport and Transfer of Patients a. General Guidelines Transfer to other organizations will be guided by the following principles: Patients will be transferred to other healthcare organizations if the hospital does not have the requisite staff and/or facilities to provide the needed service. Patients will be transferred to other healthcare organizations based on individual preference. b. Intrahospital In cases where the patient is requiring additional care or procedure (e.g. MRI, CT scan, 2D Echo) not readily available at the patients location, transporting the patient should be given high level of care and consideration. There should be a written order from the
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physician that the patient needs to undergo a certain procedure and it should be properly coordinated to the receiving unit by the nurse-in-charge. The nurse-in-charge must schedule the patient to special services where the test or desired management is to be done. During transport, the patient should be accompanied by the orderly/ auxiliary or nurse in charge, as well as the patients record. If the patient is for transfer to the Pediatric ICU, then utmost care should also be observed. There should be a written order from the physician that the patient would be transferred to the ICU. This should be properly coordinated with the receiving unit. The service resident should contact the PICU resident and properly endorse the patient which would include the patients diagnosis and present health condition, medications and other management measures. During transport, the patient should be accompanied by the senior resident, the nurse-in-charge, the orderly/auxiliary, necessary equipment and the patients records. c. Interhospital In cases where the patient is for transfer to another institution, there should be an order from the attending physician to do so and would be based on the patients needs for continuing care. The service resident should endorse the patient to the receiving institution, which would include the patients history, diagnosis, management received, existing problems and present condition. The patient should have a stable medical condition that would allow for transfer. If the patient would be transferred via ambulance conduction then the service resident should endorse the patient to the resident in charge of ambulance conduction. The patient would be accompanied by the resident to the receiving institution. If the conduction would be made through an outside ambulance service, then the patient would not be accompanied by the resident but the designated medical or paramedical staff of that ambulance service. The patient should be properly endorsed to the receiving staff. (For detailed policies and procedures, please refer to the OPM No. 1 Emergency Department - Ambulance Conduction). 15. Policy on Out-On-Pass a. Patients requesting for out on pass shall seek approval from their Attending Physician (AP). Based on the Attending Physicians assessment, patients shall be granted out-on-pass privileges for a period not to exceed 24 hours unless otherwise indicated. Orders will be documented in the patient chart. 16. Discharge Criteria and Procedures a. Criteria Vital signs Vital signs within the following limits for age for 24 hours prior to discharge or an abnormal reading within 24 hours, followed by a subsequent normal reading

Temperature (all ages): Blood pressure:

Oral Rectal Systolic (mmHg)

< 101 F (38.3 C) < 102 F (38.9 C) Diastolic (mmHg)

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Pediatric: birth to 1 year > 1 year - 3 years > 3 years - 6 years > 6 years - 12 years > 12 years - 17years Pulse: Pediatric: < 1 year > 1 year - 3 years > 3 years - 6 years > 6 years - 12 years >12 years - 17 years Respirations: Pediatric: < 1 year > 1 year - 3 years > 3 years - 12 years >12 years - 17 years

65 - 100 75 - 110 80 - 120 90 - 130 80 - 140

30 - 65 50 - 70 50 - 80 60 - 80 70 85

Beats per minute (bpm)

80-160 bpm 80-130 bpm 70-120 bpm 70-110 bpm 50-105 bpm per minute

30-50 20-40 15-30 12-25

Patient education Patient and/or family competent for care, patient having received maximum benefits of education in hospital Functional Infant (Below 1 year old): - Infant has grown or shown a steady weight gain on po or tube feedings - Infant has demonstrated good sucking mechanism - Infant able to maintain body temperature in an open crib - No apnea for 24 hours - Responsible caretaker demonstrates ability to care for infant/child Above 1 year old to below 19 years old: - Prescribed diet tolerated for last 12 hours prior to discharge without nausea/vomiting, excluding chemotherapy patients Self-initiated and self-effected activities of daily living or documented provision for such in an alternate setting Voiding or draining urine without difficulty for last 12 hours or arrangements have been made for drainage of urine, voiding activities in an alternative setting, or hemodialysis/continuous ambulatory peritoneal dialysis (CAPD) - Parenteral analgesic administration not to exceed one dose within 3 hours prior to discharge, excluding patients expected to require regular analgesic administration for a persistent condition b. Procedures (For detailed policies and procedures, please refer Appendix F - OPC No. 28-B Servicing of Patient Discharge)
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17. Divine Mercy Program (For detailed policies and procedures, please refer to OPM No. 8 Corporate Services Department).

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ADMISSION AND CARE OF PEDIATRIC PATIENTS I. Objectives To establish standard policies and procedures in the admission of pediatric patients To ensure efficient flow of communication and coordination among the medical staff involved in the process

II.

Policy Guidelines A. General Policies 1. All patients aged 0-18 years and 364 days shall be admitted under a pediatrician duly licensed and accredited by the Philippine Pediatric Society. 2. Residents and Interns being trained at The Medical City shall be allowed to assess and admit Pediatric patients. 3. Pediatric patients who are not candidates for admission at the pediatric intensive care unit (PICU) are preferably admitted at the assigned pediatrics floors or wards (9th, 10th or 6th floors). 4. Guidelines for floors or wards admission are the following: Patients with stable hemodynamic, neurologic and respiratory status Patients who do not need very close monitoring However, if the said floors are filled up, they may be admitted at the other floors. Those requiring isolation because of the infectious nature of their illness are admitted at the 14 th floor, which is the assigned Infectious unit. 5. Admission of patients at the Pediatric Intensive Care Unit (PICU) is based on the critical care admission criteria 6. Management of patients is based on existing local and international clinical practice guidelines from the Philippine Pediatric Society, Department of Health, and American Academy of Pediatrics or World Health Organization, if applicable. These guidelines are adapted to individual patients resources. The guidelines include those on pneumonia, febrile seizures, acute gastroenteritis, eye examination, etc. Through regular updates by the PPS, these guidelines are reviewed yearly by the subspecialists. Clinical Pathways are also being developed by the hospital on the following diseases: Pneumonia, Acute Gastroenteritis B. Emergency Room (ER) Admissions 1. Admitted patients shall be endorsed to the floor resident by the ER resident who admitted the patient. 2. The floor residents shall make their own admitting notes and assessment of the patient upon arrival in the room. 3. Admitted patient shall be seen within 30 minutes by the service residents or the residentson-duty. After seeing the patient, the floor residents shall immediately update the Attending Physician. Service residents are required to do their own In-service notes and this shall be incorporated in the chart within 24 hours. 4. For problematic patients, they shall be initially managed and stabilized by the ER resident. The senior service or floor resident shall be informed immediately so that he/she can assess and manage the case with the ER resident until the patient is stable enough to be transferred to the floors or the PICU. The admitting notes shall be completed and in order. 5. ER residents shall inform consultants of all admissions the soonest possible time.

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6. The admitting notes shall contain the following: History of the present illness Birth history Past medical history Social, nutritional, economic, immunization developmental Psychological and physical exam Diagnosis Management 7. The doctors admitting orders shall include frequency of vital signs monitoring, input and output monitoring, intravenous fluids, medications, and diagnostic exams. All these shall be written down on the chart. 8. Patients who were initially seen at other institutions shall have their referral notes attached to the chart. If no referral notes are available, previous assessments done outside are verified by phone or fax. These assessments done outside should not be older than 30 days. Any changes from the previous report are noted on the patients chart. C. Direct Admissions 1. Direct admissions are admissions straight from the attending physicians office with admitting orders. 2. Service residents shall assess the patient within 1 hour upon arrival at the floors. 3. Attending physicians shall be immediately informed by the service or floor resident of their admissions. 4. Consultants shall inform the senior residents when they have problematic cases to be admitted. These patients shall be advised to go directly to the ER with their admitting orders for immediate implementation. D. HMO Admissions 1. Each HMO has its own roster of consultants. Official referral to a pediatric consultant is necessary before the pediatric resident admits a patient to the floors. In the event that the coordinating physician has been encoded as the attending physician during admission and there is a transfer of service of attending physician who is the primary physician orchestrating the planning and delivery of care of the patient, the nurse in charge shall inform the admitting office and allied services of the transfer of service. 2. Pediatric residents should see patients admitted or referred to the pediatric consultants only. The senior resident is required to make notes regarding the referral. 3. When there is a need for a subspecialty referral, patients are referred to subspecialists affiliated with the HMO but if there are none, patients are referred to a subspecialist with the consent of the family. E. Ward/Chart Rounds 1. For non problematic cases, service junior residents together with the senior residents should make their rounds once in the morning and once in the afternoon. For problematic cases they should make their rounds as often as needed. 2. All service residents should make rounds with their service consultants. However, the residents will be excused when teaching rounds or conferences are on-going. But if a patient is problematic and warrants immediate attention, this of course will take precedence.

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3. After office hours, residents on duty make rounds in the evening and early morning the following day. 4. Doctors orders are written on the doctors order sheet. This is written by the attending physician, other doctors caring for the patient, and the service or duty residents. All orders written by other doctors are carried out upon the approval of the main attending physician. If with conflict, orders of the attending physician will take precedence. 5. Reassessment of problematic patients is done as often as deemed necessary by the attending physician or the resident in charge. All the reassessments are documented and written down on the left side of the doctors order sheet. All patients are reassessed at regular intervals, at least twice a day by the service resident. The attending physician visits the patient daily during the acute phase and is reassessed before until discharge, or more frequently as needed. Assessment should be written on the patients charts. The physicians name in print and signature should be written on the chart. 6. Results of laboratory or other ancillary procedures done on the patient should be attached to the chart. 7. Progress notes must be done on all patients daily. The notes take on an SOAP format (subjective findings, objective findings, assessment and plan). F. IV Insertion 1. For patients >2y/o, pediatric interns are allowed to attempt once. 2. If unsuccessful, the 1st year resident can try 2x before referring to the senior resident. 3. For children less than 2 years-old, rotating interns are not allowed to insert IV. If in cases where the residents have difficulty in inserting IV, a referral to the Department of Anesthesia can be made. G. OGT/ NGT Insertion 1. Five successful supervised OGT, NGT insertion, umbilical cannulation must be done before 1st year residents are allowed to do the procedure independently. H. ECG 1. All ECG ordered for the day shall be initially read by the senior resident. 2. Furthermore, the Cardiology rotator shall read all ECGs done during the day and shall refer to the Cardiology consultant. All ECG tracings are officially read by the cardiology consultant on the same day. I. Referrals 1. Referrals to other subspecialties shall be written down either by the Attending Physician or the service or floor resident. These should be complete with history, physical examination, present status of the patient, present assessment and reason for referral. Replies to the referral should be written down as well by the resident or the subspecialty consultant. 2. The patient should be assessed first by the resident subspecialty rotator. He/she is required to write his/her referral notes, then inform and update the subspecialty consultant. 3. In case of patients referred for opinion, the physician should see the patient at least once, and he or she should indicate his or her complete assessment, which includes the history, physical examination, impression and suggestions.

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4. For patients referred for co-management, the patient must be managed in collaboration with the attending physician so long as the need arises. 5. If there are more than 4 consultants in a case, all the consultants should meet with the main AP as needed for the diagnosis and other issues. Discussions among them are also recorded in the chart. The consensus reached by all the consultants is explained and relayed to the patient and his/her family. J. Initial Assessment 1. The Patient Database Form (PDF) is a tool used in assessing and examining patients upon admission at The Medical City (please refer to Attachment B). 2. The elements of assessment are the following: a. Chief complaint b. History of present illness c. Review of systems d. Past medical history e. Family history f. Birth Maternal g. Nutritional h. Medication i. Immunization j. Developmental state k. Physical examination findings l. Neurological Examination m. Assessment n. Plan 3. Initial assessments must be conducted by physicians within 2 hours for emergency cases and 12 hours for elective admissions. Re-assessments are conducted by physicians at least once every 24 hours. K. Patients for Preoperative Evaluation 1. Children admitted for surgery should have a preoperative evaluation no more than one week before the scheduled operation. 2. In emergency cases, medical assessment may be performed by the senior pediatric resident on duty with the approval of the attending physician. In elective cases, the attending physician should have a medical assessment prior to the procedure. 3. A pre-operative diagnosis is written down on the chart, including all diagnostic test results done prior to surgery. 4. The anesthesiologist also determines if the patient is a good candidate for the planned operation, and is re-evaluated just before the procedure. An anesthesia assessment is recorded before the use of anesthesia. L. Nutritional Assessment 1. All admitted patients have a nutritional assessment using The Department of Pediatrics Nutrition Screening Form accomplished by the parent/guardian and the resident upon admission. The form is attached to the patients record. 2. Based on the Nutrition screening form, patients are classified as priority 1, 2 or 3. Priority 1 High risk to develop malnutrition. Dietician to assess patient within 24 hours of admission
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Priority 2 Moderate risk to develop malnutrition. Dietician to assess patient within 48 hours of admission. Priority 3 Low risk to develop malnutrition. No action taken. Patient is reclassified as priority 2 if not discharged by day 8. 3. For patients classified as priority 1 or 2, the resident refers the patient to the Dietary service (For complete policy guidelines, please refer to OPM No. 72 Nutrition Management Services) M. Pain Assessment and Management 1. All admitted patients would have a pain assessment. It is considered as the fifth vital sign. Assessment of pain is done using appropriate assessment tools. The Wong-Baker Faces Scale and Visual Analogue Scale (see below) is used to assess pain. A score from 0-10 is obtained depending on the presence and severity of pain. The pain score is recorded in the standard vital signs monitoring sheet.
Visual Analog Scale (VAS) Wong-Baker Faces Scale

0 1 2 3 4 5 2. Monitoring of the presence and severity of pain is done by the nurses depending on the frequency of monitoring determined by the attending physician or resident. Pain is also monitored by the resident or attending physician during their ward rounds. 3. The type of pain medication would depend on the severity of the pain (pain score). The type of medication to be used would be recorded in the patients chart. For mild pain (1 in Faces scale or VAS score 1-3), oral paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) are given. For moderate pain (2-3 in Faces scale and VAS score 4-6), oral paracetamol/opiod combinations or IV Ketorolac are given. For severe pain (4-5 in Faces scale or VAS score 7-10), IV opiods are given. Patients are referred to the pain specialist shall be considered for pain score 5 and above. 4. Non-pharmacologic approaches could also be used to manage pain. These approaches include distraction techniques, guided imagery and comfort measures. (For detailed policies and procedures, please refer to OPM No. 18 - Pain Management Clinic) III. Procedures (For detailed policies and procedures on patient admission, please refer to OPM No. 34 Admission and Allied Services Department).

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CARE OF HIGH-RISK PATIENTS I. Policy Guidelines A. Preoperative Evaluation 1. Goals of Preoperative evaluation: a. To acquire the pertinent medical information, consultations and laboratory tests necessary to assess preoperative risk. b. To optimize the patients medical condition and develop an appropriate preoperative plan. c. To inform the parents and the rest of the surgical team of potential risks, to allow for management strategies that will minimize known risks. (Please refer to Attachment C - Preoperative Evaluation Forms) 2. Preoperative Basic Health Assessment: a. Medical History Age Religion e.g. Jehovas witnesses History of Present Illness (duration of illness, degree of incapacitation or compromise) Past and Current Medical History Cardiopulmonary status Acute /recent URTI/allergies Asthma Congenital/ Acquired heart disease/signs or symptoms pertaining to heart problems - Hemostasis status: Each ASA classification has a required hemostatic blood exam. - Severe (symptomatic) anemia: - Neuromuscular conditions seizures (controlled, anticonvulsants) cerebral palsy hydrocephalus meningomyelocoele myopathies hypotonia - Genetic/Metabolic conditions Any syndromes - Endocrine conditions Diabetes Thyroid conditions Obesity Adrenal insufficiency - Prematurity Age of gestation History of ventilator support Bronchopulmonary dysplasia History of apnea - Medications: last intake
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- Known allergies: to medications? Latex? Balloons? - Pregnancy - Smoking/alcohol history - Drugs (Substance abuse) Surgical Procedure - indication or type - duration Anesthesia - anesthetic agent - technique/manner of delivery - airway device - duration - depth of anesthesia - known allergies/reactions to previous anesthesia Family history (malignant hyperthermia? Allergies) Physical Examination (Complete PE): Laboratory Tests In most cases, children at risk can be identified by a detailed history and physical examination without the need for additional laboratory studies or other investigations. However, it is suggested that a complete blood count (CBC) be done on ALL PATIENTS CBC is specially important for: - infants - growers/ premature infants - patients with chronic illness - patients with recent blood loss Coagulation studies (complete) are suggested for: - patients with history of hemostatic defects - tonsillectomy / CNS surgery cases - cases where coagulation system is particularly needed for hemostasis - cases where minimal postoperative bleeding is critical - patients on anticoagulants - patients with anticipated large blood losses Note: The most reliable factors for detecting bleeding disorders were a history of bleeding from minor wounds, frequent bruising and the use of NSAIDs or platelet function antagonists. Therefore coagulation studies should be considered with those with a positive bleeding history, in those who have underlying medical conditions that increase the risk of coagulopathy (e.g. liver disease or malabsorption) or in those receiving anticoagulants or other medications that increase the risk of a bleeding disorder. Chest radiography for: suspected acute cardiopulmonary disease stable chronic cardiopulmonary disease without a recent chest x-ray within 6 months Electrocardiography is done for: - patients with irregular rhythm, palpitations, murmur, congenital or acquired heart disease and other cardiac symptoms
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- patients with new or unstable cardiac disease Note: If there is any question of a significant structural cardiac abnormality, preoperative echocardiography and evaluation by a pediatric cardiologist are mandatory. The presence of an abnormal murmur, cyanosis, decreased exercise tolerance, poor weight gain, sweating, decreased femoral pulses, or a precordial heave necessitates a more complete preoperative evaluation (hematocrit, ECG, chest radiograph, oxygen saturation and cardiology consultation). Serum electrolytes: - renal failure - intake of diuretics - enteral feeding and GI disturbances 3. After preoperative evaluation, classify patient as to the American Society of Anesthesiologists (ASA) classification for risk and physical status: Class I: No underlying physical or metabolic disturbances Class II: mild to moderate disturbances that do not interfere with daily routines (<1 year of age, anemia, mild renal insufficiency, asymptomatic heart disease, moderate obesity, well controlled asthma) Class III: severe disturbances that interfere with ordinary daily activities (chronic lung disease, TOF, insulin-dependent diabetes, compromising physical abnormalities such as morbid obesity, Pierre-Robin syndrome) Class IV: severe disturbances that are a constant threat to life (extreme prematurity, intractable congestive heart failure, advanced renal, pulmonary or endocrine dysfunction, critical airway obstruction. Class V: moribund condition in patient who is likely to succumb in 24 hours, whether or not surgery is undertaken. Surgery is attempted as last hope to prevent death and is usually part of ongoing resuscitation E (suffix): physical status classification appended with an E when surgery is undertaken as an emergency an acknowledgment of additional physical risk factors associated with absence or pre-operative stabilization like NPO or evaluation Example: Physical Status I E: healthy child with testicular torsion for Emergency operation ASA Task Force Recommendations: Guidelines in giving food and liquids 8 hrs solids 6 hrs milk formula 4 hrs breast milk 2 hrs clear liquids 4. General Guidelines: a. All patients undergoing surgery should undergo a preoperative evaluation by a pediatrician and an Anesthesiologist.
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b.

Emergency cases would have a preoperative evaluation by the attending physician or the third year pediatric resident and the anesthesiologist. c. All elective surgical procedures should have a preoperative evaluation at least 3 days before the procedure. Note: In the event that the attending physician could not come in to do the preoperative evaluation, he/she could request the walk-in consultant for that week to perform the evaluation. The walk-in consultant is free to refuse and in that case, the attending physician could request another consultant to perform the evaluation. The attending physician could also request the senior (third year) pediatric resident to perform the evaluation on his/her behalf. B. Resuscitation Resuscitation procedures shall be based on the Pediatric Advanced Life Support (PALS) and Neonatal Advanced Life Support (NALS) guidelines.

C. Administration of Blood and Blood Products (For detailed policies and procedures, please refer to OPM No. 63 - Blood Bank and Transfusion Services) D. Infection Control (For detailed policies and procedures, please refer to Hospital Operations and Procedures (HOP) No. 3 - Hospital Infection Control Committee Manual) E. Peritoneal Dialysis The peritoneal membrane acts as a semi permeable membrane to allow solute and water removal from the blood in children with renal failure. Solutes move by passive diffusion and convection across a concentration provided by dialysis fluid containing 132 mEql1 Na; 96 m Eql Cf.' 1.8 mE'l11 Ca, 0.25 mE'l11 Mg and 40 meq lactate. Fluid is removed by creating an osmotic gradient between the dialysis fluid and blood using varying glucose concentrations. The usual dialysate solutions contain 1.5% glucose (osmolality = 346 mosm), with 2.5% glucose solutions (osmolality = 395 mosm) used to remove extra fluid. 0.55% glucose solution (osmolality = 298 mosm) is available if the child is dehydrated as this allows fluid to be absorbed from the peritoneum. A 4.25% glucose solution (osmolality = 484 mosm) is available if the child is fluid overloaded and a 2.5% solution does not remove sufficient fluid. A 4.25% bag should be used once and the fluid status reassessed to prevent too rapid fluid removal and hypotension. A second cycle of 4.25% solution should not be given without discussion with the nephrologists on call. NB: Extreme care should be taken using a 4.25% dialysis fluid in a child with a fistula as hypotension may result in thrombosis of the fistula. 1. Access a. Tenckoff catheter
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b. Double cuffed catheter implanted surgically into the peritoneal cavity c. Antibiotics are given as single doses preoperatively to reduce the risk of wound infection and peritonitis. d. The catheter should not be used for 48-72 hours to reduce the risk of leakage e. An op site dress silk is applied to the catheter at the time of surgery. This should remain intact for 5-7 days unless there is discharge from the exit site, in which case the op site should be removed, the exit site is cleaned with disinfectants and another op site applied f. The catheter exit site should not be allowed to become wet for 4-6 weeks. g. For acute PlJ catheter, in acute renalfailure this may need to he inserted urgently, usually in lCU. h. The catheter exit site should not be allowed to become wet for 4-6 hours. 2. Types of Peritoneal Dialysis Continuous Ambulalorv Peritoneal Dialvsis CAPD The Free line Solo system involves 3-4 exchanges/day. This has 2 lines, an inflow line with a fresh bag of dialysis fluid connected and an outflow to allow drainage. There is a single connection for the system to be attached-to the Tenckhoff catheter with each exchange. b. Continuous Cvcle Peritoneal Dialvsis (CCPD) CCPD is the preferred form of peritoneal dialysis for children at home. An automated cycler deliver set amounts of fluid into the peritoneal cavity and drains this automatically afler a set dwell time. a. This provides an increased number of cycles and only one connection and disconnection. Most children have a "last bag option" where fluid is left to dwell before they are removed from the machine. The last bag option allows a different volume to be delivered for the final cycle e.g. 1500 mls x 4 and a last bag option of 750 mls. Dry Weight Most children commencing dialysis are salt ailed water overloaded. "Dry weight" is a clinical assessment of the weight at which the children are euvolaemic and normotensive. (Occasionally antihypertensive medication is also required). Since weight is closely related to nutrition, the dry weight should be regularly reassessed in light of improved or inadequate caloric intake. Volume of Cycles 30-40 mL/kg is the volume of dialysis fluid which a child can comfortably tolerate In a child starting dialysis, the volume should initially be 15-20 mlslkg and graded over 7-10 days to prevent leakage

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F. Use of Restraints 1. Objective The objective of this policy is to provide a consistent, clear documentation of the care and management of patients requiring restraints. Restraints are used to ensure patient safety. The indications for restraints include: (Source: Maccioli, GA et al. 2003. Clinical Practice Guidelines for the maintenance of patient safety in the ICU: Use of restraining therapies. Crit care Med Vol. 31 (11): 2665-2676.) a. To decrease the risk of deliberate or inadvertent removal of an essential medical device(circulatory assist devices, endotracheal tubes, tracheotomy tubes, intracranial catheters, nasogastric or orogastric tubes, enteral feeding tubes, central venous catheters, arterial catheters, chest tubes, surgical drains, intravenous lines and urinary catheters. b. To limit the patients movement if movement might lead to a new or exacerbate an existing injury. c. To facilitate the performance of bedside procedures in patients who cannot cooperate d. For patients with primary behavioral or psychiatric disorders. 2. General Policies a. Physician must put the date and time and sign restraint order form. b. Nurse must sign and verify order for use of restraint c. Document clinical justification for use of restraint d. Document type of restraint used such as hand mittens, soft wrist restraints, soft ankle restraints or vests e. Renew restraint order every 24 hours f. Document attempted alternatives to restraint g. Assess every 2 hours and document patients mental status in flow sheet. Document patients mental status on restraint forms every shift. h. Document restrained patient care in nurses notes or flow sheet i. Date and sign documentation 3. Assessment, Care, and Monitoring a. Document assessment and care on the monitoring form b. For limb restraints, patient should be assessed every hour for skin integrity and circulation. The limb restraints should be removed every four hours and range of motion (ROM) exercises should be done. c. All patients should be assessed every two hours for mental status, safety and needs related to hydration, elimination and nutrition. d. The following aspects of patient assessment and care should be monitored: Position: Proper alignment of the restrained limb(s) is maintained Circulation: The affected limb(s) has been checked and device application has been determined not to impair circulation to the extremity: - Nail bed blanched in less than 3 seconds - Pulse is present above and below restraint Skin Integrity: Skin integrity has been checked under and around the device(s), and at all bony prominences and no pressure or reddened areas have developed. Privacy: The patient is covered either by gown, sheet, or curtain and is protected from public view.

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Temperature: The patients skin is comfortable to the touch. The patient's body temperature is checked as ordered by the physician, and the room temperature is maintained as appropriate to patients condition (generally 2022oC on the room thermostat). Device Application: The device is applied according to the manufacturers guidelines and in a manner that is secure but not tight. Straps are secured to bed or chair frame (never to side rails or other moveable parts); and quick release is possible. Fluid Needs: Fluids are administered as ordered by the physician. If the patient is not on fluid restriction, oral fluids are offered at least every two hours. If the patient is nothing-by-mouth (NPO), oral care is provided at least daily to maintain integrity of oral mucosa. Toileting Needs: Elimination needs are attended to, either by foley catheter (Only if ordered for other medical necessity) or by offering the patient the bed pan or assistance to bathroom or bedside commode chair. Nutrition Offered: Nutritional needs are met as ordered by the physician. If oral intake is allowed, the patient is offered and assisted with meals and snacks. Range of Motion: Active or passive range of motion in the affected limb(s) is completed either by the patient or the caregiver. For patients requiring limb restraints, ROM exercise is recommended at least every 4 hours. Evaluation for Restraint Reduction or Removal: Need for the use of restraint(s) is evaluated frequently (at least every two hours) and restraints are discontinued at the earliest possible time.

4. Procedures Issuing Orders for Restraint and Patient Monitoring Attending Physician a. A physicians order is required to restrain a patient. The following are the guidelines for ordering the use of restraint: Indicate date and time of order Indicate period for which restraint is to be used Indicate alternative interventions employed prior to the restraint order Renew restraint order every 24 hours after assessing for continued need for restraints Verbal/telephone orders for restraints must be signed by the attending physician within 24 hours In case of emergency, restraints may be applied prior to a physicians order, however a physician must be contacted to obtain an order for restraint within an hour of starting restraints b. Writes down in the doctors order sheet the following: Date and time of order Indication or reason for the use of restraint Type of restraint to be used Location of the restraint Alternatives attempted to avoid restraint Criteria necessary for release of restraint c. Informs and explains to patients family members reason for the restraint

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Nurse-in-Charge Carries out doctors order accordingly Monitors patient using the Monitoring Flow sheet Files flow sheet in the patients chart Discontinuing Restraint Attending Physician a. Writes on the doctors order sheet the order to discontinue/stop the use of restraint to include Narrative note that explains patients change in condition related to the decision to discontinue the use of restraints. This is written on the progress notes section of the patients chart. Nurse-in-Charge a. Carries out doctors order accordingly b. Writes down on the Nurses Notes the completion of the task G. Care of the Comatose Child (Please refer to policy on the Care of the Comatose Child under Patient Intensive Care Unit)

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THE MEDICAL CITY (TMC) NEWBORN SERVICES DIVISION QUALIFICATION AND RESPONSIBILITIES OF THE STAFF A. Attending Physician (General Pediatrician or Neonatologist) 1. Qualifications: Must be an active consultant of The Medical City or a certified TMC Visiting pediatrician For General Pediatrician- A diplomate of the Philippine Pediatric Society (PPS) For Neonatologist - A diplomate of the Philippine Pediatric Society - Must be certified as diplomate by the PPS Sub board of Neonatal Medicine. 2. Responsibilities: a. Makes daily rounds on all babies admitted under his/her service and in-charge of the over-all care and management of patients b. Informs mother/father of the conditions/problems of the babies, medications given and procedures being done c. Gives instructions to mothers on daily care, feeding, bathing and follow-up of newborns prior to hospital discharge d. Responsible for teaching the residents and other medical staff e. Makes appropriate referrals to other subspecialties when needed f. Supervises completion of patients charts g. Gives the final diagnosis h. Signs telephone orders as early as possible (within 12-24 hours) i. Attending physician reads daily the residents progress notes for level II and III patients. B. Residents 1. Qualifications Must be an accredited pediatric resident staff of The Medical City PPS Certification in Pediatric Advanced Life Support and Neonatal Resuscitation Program 2. Responsibilities: First Year Resident a. Normal Newborns 1. Admit all normal newborns delivered vaginally. 2. Do immediate newborn appraisal. Have complete maternal and obstetrical data in the newborn chart and do the admitting orders and progress notes 3. To be able to identify normal variants and deviation from normal and refer accordingly 4. Inform consultants of admissions 5. Make daily rounds on all babies in the transition nursery b. In case of abnormal developments 1. Answer calls for IV insertion, blood extraction, and gastric lavage 2. Perform umbilical cannulation, lumbar punctures and cardio-pulmonary resuscitation upon the supervision of a senior resident and the attending physician 3. Inform consultants of problems regarding admitted babies

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a. Inform attending physicians of mothers discharge. b. Make rounds on all roomed in babies and refer problems to the senior NICU resident. c. Observe and assist the senior resident in the care and management of problematic babies. d. Prepare the monthly audit of normal newborns: NSD, normal CS, and roomed in babies. e. Follow-up consent for newborn screening for inborn errors of metabolism and for hearing screening tests. f. Perform procedures for newborn screening for inborn errors of metabolism. Second Year Resident a. Attend to all babies delivered by Caesarean section. b. Abnormal / Problematic Newborns: 1. Attend all abnormal / problematic deliveries and manage perinatal problems arising there from under the supervision of a 3rd year resident or attending physician 2. Do the complete history and admitting orders, neonatal history, maternal and obstetrical history, and progress notes of all problematic newborns 3. To be able to identify and manage basic pathologic conditions in the newborn 4. Monitor critically ill neonates and perform, if needed, all essential procedures related to their care 5. Accompany babies for diagnostic procedures and / or transfer to other hospitals 6. Update the attending physician and subspecialist on problems or new developments arising during their NICU duty 7. Inform subspecialist of referrals made to them c. Supervise and teach the First Year residents, interns, and nurses in the NICU d. Check and update the logbook of NICU Referral, Isolation Room, and NICU proper admissions and discharges. Prepare the monthly audit e. Complete the infectious surveillance form of congenital / nosocomial infection and submit it at weekly basis f. Keep data and update logbook for newborn screening for inborn errors of metabolism Normal Newborns: a. Admit all normal newborns delivered vaginally b. Do immediate newborn appraisal. Have complete maternal and obstetrical data in the newborn chart and do the admitting orders and progress notes c. Inform consultants of admissions d. Make daily rounds on all babies in the transition nursery In case of abnormal developments: 1. Answer calls for IV insertion, blood extraction, and gastric lavage 2. Perform umbilical cannulation, lumbar punctures and Cardiopulmonary resuscitation upon the supervision of a senior resident and the attending physician 3. Inform consultants of problems regarding admitted babies 4. Inform attending physicians of mothers discharge g. Make rounds on all roomed in babies and refer problems to the senior NICU resident. h. Observe and assist the senior resident in the care and management of problematic babies. i. Prepare the monthly audit of normal newborns: NSD, normal CS, and roomed in - babies. j. Follow-up consent for newborn screening for inborn errors of metabolism and for hearing screening tests. k. Perform procedures for newborn screening for inborn errors of metabolism.

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Third Year Resident a. NICU / Isolation Room / NICU Referral: 1. Take care of newborns admitted to the above-mentioned 3 areas 2. Refer all problems regarding critical care and management directly to the attending physician 3. To be able to identify and manage basic pathologic conditions independently and more complex pathologic conditions with supervision 4. Make rounds and progress notes on all problematic neonates 5. Endorse all problematic cases and procedures to the senior residents on duty at the end of the day 6. Assume command responsibility over junior residents and interns during her tour of duty or rotation 7. Supervise the training and service activities of residents and interns in the whole NICU 8. Perform duties of the second year if no junior resident is available

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GENERAL GUIDELINES

I.

Policy Guidelines A. Decision Points 1. If not sure about the level of care needed by the baby, consult attending physician/ neonatologist/ NICU director or assistant director as to where the baby will be admitted. 2. Any baby less than or equal to 5 kg in weight, who may be greater than 4 weeks in age should be considered for admission to the newborn services. 3. Newborns <28 days not requiring intensive care maybe admitted to the other areas of the hospital if the patient cannot be accommodated in the NICU. 4. Newborns admitted to various levels of the nursery, require written admitting orders from the admitting physician or resident on duty who pers the consultant. 5. If outborn, the baby could be admitted from the ER or the attending physician can write admitting orders and the baby could be admitted at the outborn unit. B. Level I Normal Newborn Nursery, 5th floor 1. Normal newborns are admitted here immediately after birth for transitional care until transfer to mothers room for rooming-in. 2. Rooming-in: Normal Spontaneous Delivery (NSD) Package within 6hrs Caesarian (CS) Delivery Package within 24 hours Non package deliveries (NSD/CS) 6-24 hours 3. Normal baby whose mother has ongoing obstetric or medical problem/s cannot be roomedin. C. Level II Intermediate or Special Care (Inborn) Nursery, 5th Floor 1. Stable high-risk infants with the following diagnosis are admitted here Hyperbilirubinemia Fever R/O sepsis (Any infant from the delivery room suspected of having sepsis should be isolated in an incubator. Infants who meet criteria for isolation should be admitted/transferred to the Isolation Room) Babies completing IV antibiotics/medications Premature babies >2000g not needing NICU care Growing premature babies on full nipple feedings who are not ready for discharge Congenital birth defects not meeting NICU admission criteria. D. Level II (Outborn), 5th Floor 1. Same as level II criteria plus the following: 2. All neonates born outside The Medical City Obstetric Delivery Rooms who need admission to the hospital are admitted here after (all levels of care) and being stabilized in the ER. 3. Babies already roomed-in with the mothers who are previously discharged who need to be re-admitted to the NSD written admitting orders are also required.

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E. Level III Neonatal Intensive Care Unit, 5th floor 1. Unstable high-risk non-infectious infants with the following diagnosis or conditions are admitted here: Premature babies <2000 g Respiratory distress conditions requiring O2 / Respirator support Apnea Seizures Acute life-threatening event (ALTE) Cardiac conditions Acute surgical conditions pre and post-op (except those with colostomy who will be admitted to isolation) Babies on hyperalimentation Babies for exchange transfusion Surfactant replacement therapy Blood transfusion Congenital birth defects needing NICU care 2. The condition requires continuous cardiopulmonary monitoring plus at least one of the following: Congenital Anomalies causing functional impairment: - Life threatening, major malformations - Congenital malignancy - Congenital icthyosis Pulmonary Distress: - Persistent cyanosis, grunting, retracting, flaring, true apnea which requires O2 for >1 hour - Persistent altered respiratory rate as defined - Persistent oxygen saturation <94% in room air after 1 hour of life - Needing ventilatory support Metabolic Distress: - Severe hypoglycemia or hyperglycemia - Na, K, Ca imbalances - Hyper/hypothyroidism - ABG imbalances - Inborn error of metabolism - Adrenal insufficiency Cardiac Distress - Circulatory abnormalities as previously defined - Poor perfusion, hypotension - Persistent tachypnea - Heart murmur after 24-49 hours in presence of symptomatology - Cardiac arrhythmia such as supraventricular tachycardia or congenital heart block - Cyanosis Neurologic Distress: - Seizures - Intracranial hemorrhage - Lethargy/ irritability - Asphyxia - Hypotonia/ rigidity - Apnea
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- Hydrocephalus GIT Abnormalities - Inability to establish feeding, voiding, stooling within 24 hours - Unstable blood sugar - Presence of congenital abnormalities (eg. cleft lip/palate) - Significant vomiting or abdominal distention requiring NPO status with IV fluid administration Sepsis - Requiring IV antibiotics and CP monitoring - Presence of clinical symptoms with abnormal CBC (admitted at the isolation room) - High risk for sepsis (eg. Chorioamnionitis) Prematurity or significant IUGR - <1800 grams - <34 weeks gestation Condition requiring surgery within 48 hours after birth - Must need NPO status, IV line - Laboratory and cardiopulmonary monitoring. Persistent: defined as symptoms - lasting > 1 hour - demonstrated more than once

Reference: South Dakota Medical Assistance NICU F. NICU-Isolation Unit 1. Infectious neonates whether inborn or outborn who fulfill isolation criteria are admitted or transferred from other areas of the nursery Culture positive sepsis Culture positive pneumonias Omphalitis Meningitis Congenital infections (Toxoplasmosis, Rubella, CMV, Herpes, Syphilis) Maternal AIDS Maternal Chicken pox Staphylococcal skin diseases Culture negative sepsis who are clinically septic (sclerematous, neutropenic, leukocytosis, etc.) Acute diarrheas (It is recommended that babies who do not require close monitoring be admitted to private room of choice. If admission to the NSD cannot be avoided, then strict isolation guidelines should be followed.) Babies with Ostomies Post-operative patients needing intensive monitoring Babies with audible cough 2. All babies delivered at TMC OR-DR under potentially septic conditions (e.g. without proper aseptic preparations) shall also be admitted in this unit. G. Progress Notes Policies 1. Daily progress notes in SOAP format shall be written for level 2 and 3 babies by the pediatric resident assigned to the patient. 2. Progress notes should also be written after any significant event or change in management
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3. Pediatric residents shall be assigned to each patient. 4. Any procedure done on the patient shall be written on the order sheet.

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ADMISSION OF THE NEWBORN I. Policy Guidelines A. General Policies 1. All patients admitted into the Unit shall be assessed by the Pediatric resident-on-call within 15-30 minutes and the Attending Physician within 12-24 hours. 2. The appropriate hospital forms for history, physical examination, and maturity testing shall be filled up by the admitting resident under the supervision of the Attending Physician. 3. Subsequent management of patients will conform to accepted standards of care. Clinical practice guidelines shall be used to guide patient assessment and reduce unwanted variation. Protocols on Newborn screening, hearing screen, Hepatitis B immunization, and Infection Control procedures are based on existing recommendations of the Philippine Pediatric Society, Pediatric Infectious Diseases Society of the Philippines, Pediatric Ophthalmology Society of the Philippines and the American Academy of Pediatrics. B. Admission to the Level I Nursery 1. A bassinet with droplight shall be prepared for the admission. 2. Gloves shall be worn by the nurse or midwife when the newborn is received from the OR/DR staff. 3. The ID band and data sheet shall be checked for the date, time of delivery, sex, mothers name and attending physician and shall be compared with the newborn record. 4. Erythromycin eye ointment shall be applied on both eyes from the inner to the outer canthus. 5. Cord dressing shall be done by cleaning the base of the cord with povidone-iodine followed by 70% isopropyl alcohol in a circular and upward motion. The cord shall be cut one inch from the base and a sterile disposable clip cord shall be used to clamp the stump. 6. The anthropometric measurement of the baby shall be taken as follows: Head circumference: from the occiput to the glabella and the supraorbital ridges Chest circumference: taken at the level of the xiphoid cartilage or substernal notch Abdominal circumference: taken at the level of the umbilicus Length: from the tip of the toe to the top of the head 7. Foot printing shall be done at the back of the babys newborn record. 8. Vitamin K injection shall be given thru IM at the left thigh as follows: For babies >1 kg: 1 mg IM For babies < 1 kg: 0.5 mg IM 9. Hepatitis B immunization at birth shall be given by the Pediatric Resident-On-Duty (PROD) on the right thigh. 10. Babies delivered via Normal Spontaneous Delivery (NSD) shall be placed in a bassinet under droplight while Caesarean Section (CS) deliveries shall be placed in a prewarmed incubator with O2 or in a warmer. 11. Nurse-in-charge shall fill up the admitting checklist and shall accomplish the data sheet and diploma. These data sheets shall be incorporated in the babys chart within 24 hours. 12. Vital signs monitoring shall be done and recorded on admission, at 15 minutes, 30 minutes 45 minutes, 60 minutes, then every hour thereafter for 4 hours 13. Consent for admission to Newborn Services Division shall be signed by parent or legal guardian. This could include consent for newborn screening for blood and hearing tests. This could include consent for newborn screening for blood and hearing tests.

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C. Admission to the Level II Nursery (SCN) 1. Babies shall be placed in a pre-warmed incubator or could remain in a bassinet as indicated. The management depends upon the condition of the baby and the order of the attending physician. 2. Admission checklist, data sheet and diploma shall be filled up and accomplished by the nurse-in-charge. 3. Consent for admission to level II should be signed by the parent or legal guardian. This could include consent for newborn screening for blood and hearing, if not yet accomplished. 4. Routine monitoring includes HR, RR, every 2 hours and BP monitoring every 4 hours is standard unless otherwise ordered D. Admission to the Level III Nursery (NICU) 1. Babies are placed directly in pre-warmed incubator. The management depends upon the condition of the baby and the order of the attending physician. 2. Admission checklist, data sheet and diploma shall be filled-up and accomplished by the nurse. 3. Consent for admission to level III shall be signed by parent or legal guardian. This could include consent for newborn screening for blood and hearing, if not yet accomplished. 4. Routine VS monitoring includes continuous HR, RR, and O2 sat and BP hourly unless otherwise ordered E. Admission Orders The following format is useful for writing admission orders for babies admitted to Level II and III Nursery: 1. Admit. The location of the patient (eg. level II or III nursery) and the attending physician in charge and resident in charge shall be specified. 2. Diagnosis. The admitting diagnosis shall be listed. 3. Condition. Whether the patient is in stable or critical condition shall be noted. 4. Vital Signs. The desired frequency of monitoring of vital signs shall be stated. Axillary temperature shall be specified. Other parameters include blood pressure, pulse, and respiratory rate, weight, length and head circumference shall also be obtained on admission. 5. Activity. All are at bed rest but one can specify minimal stress or hands-off protocol here. This notation is used for infants who react poorly to stress by dropping their oxygenation, such as those patients with persistent pulmonary hypertension. At most centers, this means to handle the infant as little as possible and record all vital signs off the monitor. 6. Nursing procedures. Respiratory care (ventilator setting, chest percussion and postural drainage orders and endotracheal suctioning with frequency.) Also require that a daily weight and head circumference be recorded. The frequency of Hgt testing is included in this section, since it is a bedside procedure. 7. Diet. All infants admitted to the neonatal intensive care unit are usually made NPO (nothing by mouth) for at least 6-24 hours, until they are assessed and stabilized. When appropriate, specific diet orders shall be written. 8. Input and output (I and O). Request that nursing staff record accurate input and output of each baby. This record is especially important for infants on intravenous fluids and those just starting oral feedings. How often you want the urine tested for specific gravity and glucose shall be specified.
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9. Specific Drugs. State drugs to be administered, giving specific dosages and routes of administration. It is useful to also include the milligrams per kilogram per day dose of the drug to allow cross-checking and verification of the dose ordered. 10. Symptomatic drugs. These drugs are not routinely used in a neonatal intensive care unit and would include such items as pain and sleep medications. 11. Extras. These are any other orders required but not included above, such as x-rays, ECG and ultrasound. 12. Laboratory data. Laboratory data drawn on admission, plus routine laboratory orders with frequency shall be included 13. Every medication or fluid order should include current weight of the infant.

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ASSESSMENT OF NEWBORN I. Policy Guidelines A. Level I Complete obstetric and maternal histories shall be obtained by the first year pediatric resident on duty from the mother or a reliable informant. These histories shall be done within two hours of admission of the mother and shall be incorporated in the chart. Obstetric and maternal histories shall include the following: Name of the mother and the father Address of the parents Pertinent history of the present pregnancy History of previous pregnancies and their outcomes Personal and Social History Family History History of past illnesses Significant maternal factors should be duly noted on the chart. The following factors should be documented: fetal bradycardia or tachycardia meconium staining maternal fever time of rupture of membranes any signs of maternal infection signs of chorioamnionitis pertinent laboratory abnormalities in the mother On admission at the nursery, complete assessment of the baby shall be done by the first year pediatric resident-on-duty and appropriate referral to the attending physician shall be done within 30 minutes of admission. Physical examination findings are documented using the standard physical examination form upon delivery. Monitoring of the patient using standard monitoring form (See attached form) shall be done by the nurse in charge, initially every 30 minutes until stable then every 2-4 hours until discharge. Any abnormal finding shall be referred immediately to the resident on duty and the attending physician. All normal babies shall be roomed-in with the mother. Daily physical examination shall be done by the nursery resident and attending physician, and any deviation from normal shall be duly noted. Discharge physical examination findings shall be documented using standard discharge physical examination form. This form shall be accomplished by the resident in charge. B. Level II & III 1. Complete history and physical examination of the baby shall be done by the senior resident on duty. 2. Follow policy guidelines of item A, numbers 2 and 3. 3. Complete assessment of the admission is to be done by the senior pediatric resident on duty and appropriate referral to the attending physician is to be done within 30 minutes of admission.

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4. Physical examination findings are documented using the standard physical examination form (See attached physical examination form) 5. Monitoring of the patient is done by the nurse in charge every 2 hours for level II and hourly for level III and duly noted on the monitoring form. 6. Daily physical examination and progress notes must be done by the senior resident until discharge and any abnormal findings must be duly noted and referred to the attending physician. 7. Discharge physical examination must be done on all patients by the senior resident and all findings documented on the standard physical examination form. All patients in Levels I-III will be assessed periodically as deemed necessary. Second year residents are required to make daily problem-oriented progress notes on all patients, indicating the assessment and plan of management as discussed with the Attending Physician.

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CARE OF PATIENTS I. Policy Guidelines 1. The division head and/or staff physicians shall hold monthly meetings involving the nurse manager to address current patient care issues and insure uniformity of patient care. a. The division shall utilize the same protocol for each procedure in its various settings. b. The division has designed policies and procedures to ensure uniform care and reflect relevant laws and regulations. These are documented in the Policy and Procedure Manual of the Division of Newborn Services. 2. The residents, attending physician/physician-in-charge, and nurse in charge shall perform daily rounds on each patient admitted under the Division of Newborn Services. Current problems shall be discussed and a specific care plan shall be designed. a. The daily plan for each patient shall be documented in the chart in the Attending Physicians Progress Note or Residents Progress Note. The progress note is written in problem-oriented format and is written at least daily. These notes shall be documented in the Progress Note section of the patients chart. b. The patients care plan shall be carried out by the physicians, nurses and ancillary staff involved. Plans carried out shall be documented in the Progress Note section, the Nurses Notes section, and/or the Medication Sheet in the patients chart. c. The specific aspects of care provided to the patient shall be documented in a timely manner in the appropriate forms in the patients chart as noted above d. In complicated cases, or cases where consulting services are involved, discussions between services shall be documented in the patients record under the Progress Notes section. All plans and resolutions arising from patient care team meetings, including formal meetings with family members shall also be documented in the chart in the same section. 3. All orders shall be documented/written as soon as possible under the Order Section in the patients chart. Verbal orders shall be documented by the resident in charge or nurse in charge in the same section, noting the time the order was given and the time the order was carried out. Late orders shall be noted as Late entry. a. Only Pediatric residents rotating in the Newborn Services Division and the attending physician involved in the case are permitted to write orders in the Order Section of the patients chart. Consulting services shall be asked to document their suggested plan of management under the Progress Note section of the chart. These are then reviewed by the primary physician and written in the Order Section once a decision is made to carry out the suggested plan. b. All orders shall be written in the Order Section of the patients chart. Only orders written in the Order Section of the chart shall be carried out. 4. All major procedures such as endotracheal intubation, chest tube placement, umbilical catheter placement, central line placement, peripheral arterial line placement, lumbar puncture, and resuscitation shall be documented in the Progress Notes Section of the patients chart as a specific Procedure Note. This note describes the patients condition prior to, during, and immediately after the procedure, the type of procedure, the process involved, and any complications occurring at the time the procedure is performed. a. The Procedure Note shall include results or immediate outcomes (such as resolution of pneumo/hemothorax in the case of chest tube placement, or successful intubation with ET tube in appropriate position in the case of endotracheal intubation) 5. The patients chart, which contains all notes relating to the patients care, shall remain at the patients bedside at all times. All persons involved in the patients care shall have access to the patients chart.
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a. A care provider may access other providers care notes by viewing them in the Progress Notes section of the patients chart. 6. The patient shall be evaluated on a regular basis throughout the day and throughout his/her hospital stay. The patients needs and condition shall be constantly evaluated and the plan shall be adjusted accordingly. Changes in plan shall be documented in the Progress Notes section and the Orders section of the chart. 7. Clinical Practice Guidelines for certain conditions in the newborn have been designed by the Division of Newborn Services and are used as a guide to patient care. In the absence of clinical practice guidelines, care is based on universally accepted standards of practice 8. The Division of Newborn Services has designed specific clinical pathways for certain conditions in the newborn. These shall be used as a guide to patient care. In the absence of clinical pathways, care shall be based on universally accepted standards of practice.

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CARE OF LEVEL II AND LEVEL III AND PROVISION OF LEVEL II AND LEVEL III SERVICES I. Policy Guidelines 1. The division has designed policies and procedures to ensure uniform care for high-risk patients. These are documented in the Policy and Procedure Manual of the Division of Newborn Services under the section for High-Risk Patients and Services. a. Patients and services considered as High-Risk have been defined in items B, C and D of The Medical City Newborn Services Division on page 37. b. The Divisions physicians discuss and develop new policies and procedures as needed during its monthly meetings. Minutes of these meetings are documented and filed. c. The Divisions staff is trained in the use of its policies and procedures as a guide to patient care. All neonatal staff involved in patient care is oriented to new policies and procedures prior to implementation. 2. Specific policies and procedures pertaining to the care of emergency patients have been designed by the division and are contained in the Policy and Procedure Manual of the Division of Newborn Services. Such procedures include Endotracheal Intubation, Umbilical Vessel Catheterization, Peripherally Inserted Central Catheter Placement, Peripheral Arterial Catheter placement, and Exchange Transfusions. Resuscitation is guided by policies of the Neonatal Resuscitation Program. 3. Care provided to emergency patients in the Newborn Intensive Care Unit is according to its policies and procedures as noted above, or in the absence of such, is in accordance with universally accepted standards of emergency care. Care provided in emergency situations is documented in a timely manner in the Progress Note and Orders sections of the patients chart. 4. Resuscitation services in the Newborn Services Division are provided according to the guidelines created by the Neonatal Resuscitation Program. 5. The handling, use and administration of blood and blood products are guided by The Medical City Blood Banks Policy on the Handling, Use and Administration of Blood and Blood Products. This is documented in the patients chart in the Consent for Blood Transfusion, the Orders section, and the Blood Transfusion Form. 6. The care of vegetative patients is guided by universally accepted standards of care a. The care of patients on life support is guided by policies and procedures as documented in the Nursing Manual of the Newborn Services Division. Certain specific guidelines, such as a guideline for Do Not Resuscitate are included in the Policy and Procedure Manual of the Division of Newborn Services. 7. The care of patients with a communicable disease is guided by the Isolation Rooms Infection Control Guidelines for the Newborn Services Division. a. The care of immune-suppressed patients is guided by the Isolation Rooms Infection Control Guidelines for the Newborn Services Division b. Orders regarding infection control are to be written in the Order Section in the patients chart as soon as an infant is diagnosed with a communicable disease or as being immunesuppressed. These orders are based on the above-mentioned policies and procedures. 8. Policies and procedures guide the care of patients on dialysis. 9. Policies and procedures guide the use of restraint and the care of patients in restraint. a. Situations in which physical restraints may be used are written in the Policy and Procedure Manual of the Newborn Services Division under Special Considerations: The Use of Restraints b. The use of restraints is based on the above policy/procedure and is documented in the Order Section as well as the Nurses Notes section of the patients chart.
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10. The care of young, dependent children is guided by universally accepted standards of care. Parents are asked to consent for minors in the event of necessary procedures/interventions. a. Young, dependent children receive care according to universally accepted standards. 11. The Division of Newborn Services has created a Policy on Moderate and Deep Sedation, which is contained in the divisions Policy and Procedure Manual. a. The Policy on Moderate and Deep Sedation states that Deep Sedation must be performed by a qualified anesthesiologist, while moderate sedation may be performed by a licensed neonatologist, an anesthesiologist, or with the assistance of a qualified nurse. As stated in the Policy on Moderate and Deep Sedation, an infant undergoing moderate sedation must be monitored by a licensed physician training in Pediatrics or a more senior physician, as well as a qualified nurse. An infant undergoing deep sedation must be monitored by an anesthesiologist. 12. A preanesthesia evaluation is performed prior to administration of anesthetics and is documented in the patients chart in the Anesthesiologists Pre-Operative Note. a. This evaluation is performed by an Attending Anesthesiologist, or by an anesthesiologistin-training, under supervision of an Attending Anesthesiologist, prior to administration of anesthetics. 13. The anesthesia care of each patient is planned by the anesthesiologist after an evaluation of the patient and discussion with the surgeon and/or the patients primary physician. This plan is documented in the Anesthesiologists Pre-Operative Note. a. The risks, potential complications, and options are discussed by the anesthesiologist with his/her family and documented in the consent for anesthesia. 14. The anesthesia used and anesthetic technique are entered into the patients record by the anesthesiologist in the Anesthesia Sheet of the Operative Record in the patients chart. 15. The patients physiologic status is continuously monitored during anesthesia according to protocols of the Department of Anesthesiology. a. The results of monitoring during administration of anesthesia are documented in the Anesthesia Sheet of the Operative Record in the patients chart. 16. Patients are monitored during the immediate post anesthesia recovery period as dictated by protocols of the Department of Anesthesiology. Once the patient is transferred to the Neonatal Intensive Care Unit, monitoring is a routine for patients requiring intensive care. a. Monitoring findings are entered into the Vital Signs Record of the patients chart. 17. Each patients surgical care is planned by the Surgeon-in-Charge, in coordination with the patients primary Attending Physician, as well as the patients family. a. Surgical planning is performed based on all clinical findings and available laboratory information. b. The surgical plan is documented in the patients chart under the Surgeons Consultation Note in the Progress Note section of the chart. c. A preoperative diagnosis is an essential part of the Surgeons Consultation Note. 18. The patients family/decision-makers are educated on the risks, benefits, potential complications and options related to the planned surgical procedure in the process of obtaining consent for the procedure, as well as prior to this, during physician discussions with the family regarding the patients condition. a. As part of the discussion regarding surgery, the need for transfusion of blood/blood products, its attendant risks and possible alternatives, are discussed. b. This pre-operative discussion is performed by the surgeon and/or primary attending physician. 19. A postoperative diagnosis is documented in the surgeons Operative Note. a. The Operative Note shall also contain a description of the surgical procedure, any findings, and any surgical specimens obtained. This note is contained in the Operative Record in the patients chart.
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b. The names of the surgeon and surgical assistants are documented both in the Operative Record and in the Anesthesia Record in the patients chart. c. The surgical record is placed in the patients chart within 6 hours of completion of the surgical procedure. 20. Each patients physiologic status shall be monitored continuously and documented as written above. 21. Each patients medical, nursing and post-surgical care shall be planned by his/her primary physician in coordination with the anesthesiologist, surgical team, and bedside nurse. This plan shall be documented in the Progress Notes and Orders sections of the patients chart.

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DAILY CARE OF THE NEWBORN I. Policy Guidelines A. Anthropometric Measurements 1. Anthropometric measurements (Head circumference, chest circumference, abdominal circumference, weight and length) shall be taken upon admission and shall be plotted on the percentile graph adapted from Lubchengco LC, Hansman and Boyde and shall be incorporated in the babys chart (see attached sample). 2. For babies who are not roomed-in, daily weight shall be taken and recorded accordingly. Unusual weight gain or loss shall be reported to the resident on duty that will recheck the weight and will then look for the underlying problem. B. Temperature 1. The neonates temperature is maintained between 36.5-37.5C. The axillary temperature is preferred over the rectal temperature. 2. For babies inside isolettes, skin temperature should be ideally maintained at skin temperature of 36.5C with the probe located over the area of the liver. C. Bathing 1. After delivery, once thermo regulated, all normal and non-septic babies shall be given their first bath using a mild antiseptic soap/solution. 2. Thereafter, all normal babies are bathed daily using a mild soap. Premature and critically ill babies shall be given daily sponge baths inside their isolettes in the presence of the resident on duty. D. Cord Care 1. The umbilical cord is cleaned daily with 70% alcohol followed by Betadine paint. Cord clips are removed prior to discharge, but not earlier than the second day of life. E. Diaper Change 1. Disposable diapers shall be used on all infants. 2. The perineum shall be cleansed with water with each diaper change and disposed off immediately into the dirt utility. They shall not be placed in trash cans inside the nursery.

REFERRALS, SPECIAL PERMISSIONS AND COVERAGE

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I.

Policy Guidelines A. Referrals 1. Referrals to other pediatric subspecialties shall be made when needed. 2. The subspecialty consultant referred to must be a Diplomate of the Philippine Pediatric Society and Board Certified by their corresponding subspecialty society. 3. The hospital policy on referrals is followed: a. An active consultant of the Medical City may refer to either an active or visiting consultant staff. b. A visiting attending pediatrician must refer to an active staff. In subspecialties where no active staff is available, a visiting attending pediatrician may refer to a visiting subspecialist. c. The list of active and visiting staff are updated and listed in the office. d. Referrals must be seen within 12-24 hours and in cases of emergencies, as soon as possible. e. Referral form must be accomplished prior to the referral. It becomes part of the chart once completed. B. Special Permissions 1. Special visiting privilege may be granted for a single occasion. 2. Special permission for visiting privilege in the nursery may be granted to the following: Fellow emeritus of the Philippine Pediatric Society and other subspecialty societies under the Philippine Pediatric Society. Certain Pediatricians and Subspecialist referred by the Department Chair or Hospital Administration. However, he/she must be PPS board-certified and certified by their appropriate subspecialty board of the PPS. 3. Special visiting privileges given should have the written approval of the Department Chair. 4. Special permission form must be completed and signed by appropriate authority and becomes part of the chart. C. Coverage There will be occasions when the attending pediatrician and subspecialist referred to have to go on leave. During these times, the policy on coverage or transfer of responsibilities is as follows: 1. The attending pediatrician must transfer responsibility for care and management of the newborn to another pediatrician or neonatologist who is either a staff or visiting pediatrician of the hospital. 2. When a subspecialist goes on leave, she must transfer responsibilities for care and management of the newborn to another subspecialist who is either a staff or visiting consultant of the hospital. 3. In instances when there is no subspecialist available to take over the responsibilities of the subspecialist going on leave, a subspecialist who is not a visiting staff may be asked to take over. However, this subspecialist must be certified by their corresponding subspecialty society and must have written approval from the Department Chair.

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TRANSPORT OF BABIES I. Policy Guidelines

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A. Transport of Babies Within the Hospital 1. Babies admitted at the Newborn Services Division (Level I-III) who require procedures that will be done outside NICU have to be accompanied by a junior/senior resident, senior nurse and any ancillary personnel needed. 2. The chart is brought with the baby and necessary equipment. 3. Mode of transport outside the Newborn Services Division will depend on the patients level of care. B. Transport of Babies Outside of the Hospital 1. Babies for transfer to another unit for certain procedures or for admission should be accompanied by medical personnel. 2. If the baby will be conducted by a TMC ambulance, a junior or senior resident and a NICU nurse should accompany the patient. 3. If the baby will be conducted using other ambulance services, a medical personnel from the ambulance service should accompany the baby. 4. Transport of patients using private vehicles is not allowed. 5. All babies for transport should have adequate coordination and preparation with the receiving unit in The Medical City or other hospitals. 6. All necessary paper work shall be accomplished (e.g. transfer summary, summary of labs, copy of x-rays, etc.) C. Transport of Babies for Surgery 1. During pre- and post-op transport for surgery, the baby must be accompanied by the Senior Pediatric Resident, the anesthesiologist and a NICU nurse.

ROOMING-IN POLICIES AND PROCEDURES

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Rooming-in is encouraged among mothers giving birth in this hospital. This arrangement of placing the newborn infant in the same room as the mother encourages early maternal bonding and facilitates breastfeeding. At the same time, the father is given a chance to take care of the child early. The cost of hospitalization is minimized because mothers are encouraged to breastfeed early, avoiding the use of prelacteals and expensive milk formula. I. Policy Guidelines 1. All expectant mothers should be primed and encouraged to room-in early by their obstetricians; policies and procedures are explained during the early prenatal visits. Those parents who want to room-in will sign consent for rooming-in upon admission to the hospital. The obstetrician will in turn refer to and coordinate with the pediatrician of choice for rooming-in instructions. 2. All babies born by normal spontaneous delivery (cephalic and breech) and Lamaze methods, without any complications or problems can be roomed-in depending on the assessment of the attending physician. 3. Routine newborn care is given to the baby upon admission to the Newborn Services Division. This includes: Bathing Cord dressing Administration of Vitamin K Credes prophylaxis Weight and anthropometric measurement Suctioning and oxygen if needed Hepatitis B vaccine Newborn and Hearing Screening test 4. Babies for rooming-in may be placed with their mothers in the Baby Friendly unit or any private room in the hospital. 5. The attending pediatrician will give the orders for the care of the baby. The neonate will be observed in the Level I area for 6-24 hours. After reassessment by the pediatrician, or a duly authorized pediatric resident, the baby maybe transferred to the mothers room. 6. Upon rooming-in, the nursery staff endorses the baby to the floor nurse for identification. A member of the nursery nursing staff makes daily rounds on all roomed-in babies where cord care, bathing, and breastfeeding advice is given. Routine vital signs monitoring or roomed in babies will be the responsibility of the floor nurses. 7. The hospital will provide a bassinet for each baby. Mothers are required to provide for all the babys needs (clothes, mittens, blankets, clips, etc.) Feeding, burping and diaper change will be done by the mother or the watcher. 8. In case the baby develops problems while roomed-in, the baby may be transferred back to the Newborn Services Unit in the appropriate division (Level II or III or Isolation). 9. All babies who are roomed-in are to be breastfed. When breast milk is not available, the attending pediatrician may recommend other forms of feeding. 10. All roomed-in mothers and babies will have limited visitors. Only one watcher or visitor will be allowed to stay in the room at any one time. Babies and children are not allowed to stay or visit. All visitors must observe proper hand washing before handling the baby. 11. The attending pediatrician makes daily rounds on all roomed-in babies. Proper instructions about the care and follow-up are given prior to discharge. 12. For babies who are roomed-in, the Newborn Screening test will be done in the mothers room or the procedures room on the floors by the resident assigned to the Newborn Services Division prior to the babys discharge if the test was not done prior to rooming-in.

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13. Babies already roomed-in with mothers with hearing screening test results of refer will be bought back to the Newborn Services Division for repeat hearing screening test prior to discharge. 14. The Newborn Services Division resident will inform the attending pediatrician of discharges of roomed-in babies. 15. Home instructions for babies will follow the standard Home Instructions Form.

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POLICY FOR BOARDERS I. Definition of Terms 1. Boarder - defined as a sick baby who stays in the NICU after the mother goes home, or a well baby whose mother has been discharged. II. Policy Guidelines 1. Mothers who leave their babies as boarders will have to accomplish duplicate copies each of the NICU Boarders Data and Boarders Contract. 2. Well-babies and growing preemies stay shall be limited only up to the age of 3 months. 3. Names of persons who may view the baby boarder will have to be indicated by the parents. 4. Parents will sign the guidelines for viewing and visiting of boarders.

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CONSENT AND WAIVERS I. Policy Guidelines A. Consent 1. A consent form is required for the following procedures: Ear piercing Circumcision Release of tongue tie Blood transfusion Exchange transfusion Lumbar tap Newborn and hearing screening tests Surgical or other invasive procedures Invasive radiographic procedures 2. Only parents or legal guardians are authorized to give these consents. 3. Circumcision shall be done in the Operating Room by the mothers Obstetrician or Surgeon. Other procedures can be done at the Newborn Services Division. B. Waivers/Refusal 1. For babies not undergoing Newborn Screening test for inborn errors, a waiver/refusal form has to be signed. (See attached waiver/refusal form.) 2. Parents shall need to sign for refused procedures 3. Parents who refuse rooming in shall sign a waiver (For detailed policies and procedures on securing informed consent, please refer Appendix A OPC NO. 7-A Securing of Informed Consent).

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POLICY FOR VIEWING I. Policy Guidelines 1. Level I Nursery will be open for viewing daily only on specified times of the day: Monday to Sunday, 11:00 AM to 12:00 NN and at 5:00 PM to 6:00 PM. 2. Babies admitted at Level II, III, NICU Outborn Unit or Isolation rooms, have no specified time for such visits, however, they will be advised to limit their visits to 10 to 15 minutes at any one time, 2-3x a day. They are allowed to touch their babies after proper hand washing. Gowns and slippers are provided for the parents of these sick neonates. Routine visit from parents should be one at a time. 3. Mothers doing kangaroo care for preterms and growers are allowed to stay longer but must be situated in the Breastfeeding Room. Fathers are allowed to visit in the evening after viewing hours. 4. Only parents/ legal guardians/ grandparents are allowed to view their baby at the NICU on a case to case basis, limited to 5 minutes, one person at a time.

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DISCHARGE I. Policy Guidelines A. Discharge Instructions 1. Prior to discharge of each baby, the attending physician will give the instructions regarding the care of their baby and follow-up. 2. In the event that the AP cannot give the home instructions, he/she may delegate this duty to an approved representative, either another consultant or a senior resident. 3. Nurses or midwives are allowed to give instructions on routine baby care 4. Other instructions pertaining to special medical care (medications, and other therapy) and follow up should be given by attending physician or duly appointed representative 5. Discharge instructions should be written, one copy for the mother one copy for the file. (use discharge forms) B. Discharge Policies 1. There must be a written doctors order in the patients chart. 2. Subspecialist(s) in the case of discharged babies will be informed and will give their discharge order. 3. The Newborn Services Division staff will encode the patients discharge notice to the billing section together with the professional fee of the attending pediatrician and subspecialist(s). The appointment slip is given to the parent. 4. When the bill is settled, the clearance will be presented at the Newborn Services Division for the release of the baby. 5. Mothers will provide the layette of the baby. Proper identification of the baby is done by the staff before dressing the baby. 6. Foot printing is done at the back of the newborn record prior to discharge. 7. The mother presents her hospital ID tag to the nurse before the baby is given. Proper identification of the baby is done in front of the mother by checking the foot tag which should correlate with the crib tag. The sex is also checked and is also shown to the mother. 8. The contents of the admission kit, hepatitis B vaccine card, babys blood type is given and instructions with regards to the hearing screening test and availability of newborn screening test are given to the mothers. Home instructions on newborn care and follow up are given by the attending pediatrician or authorized resident. 9. The mother shall then sign the discharge logbook. 10. Staff Midwife will bring the baby to the lobby using a crib. 11. Staff Nurse will fill up the discharge checklist. 12. In cases where the mother sends a representative to bring home the baby from the nursery, the representative should bring the following: Letter of Authority Hospital name tag of the mother and ID of the mother One ID with picture of authorized representative 13. For level II and III babies, a discharge summary is written and included in the chart. 14. The information sheet must be duly accomplished with final diagnosis and signed by the attending physician. Newborn screening date done and newborn hearing screening is found there. 15. Phil Health form should be completed if needed.

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C. Discharge Summary 1. The following information is written at the time of discharge and provides a summary of the infants illness and hospital stay. This is a sample discharge summary for babies admitted to level II and III nursery. Date of admission Date of discharge Admitting diagnosis Discharge diagnosis. List in order of occurrence or severity. Attending physician and service caring for the patient Referring physician and address Procedures. Include all invasive procedures Brief history, physical examination and laboratory data on admission. Use the admission history, physical examination and laboratory data as a guide. Hospital course. The easiest way to approach this section of the discharge summary is to discuss each problem in paragraph form. Condition at discharge. A complete physical examination is done at the time of discharge and is included in this section. It is important to include the discharge weight, head circumference and length so that growth can be assessed at the time of the patients initial check up. Also include the type and amount of formula the patient is on and any pertinent discharge laboratory values. Discharge medications. Include the name(s) of medication(s), the dosage(s), and length of treatment. If the patient is being sent home on an apnea monitor, it is helpful to include the monitor settings and the planned course of treatment. Disposition. Note where the patient is being sent (e.g. to an outside hospital, home or to a foster home.) Discharge instructions and follow up. Include instructions to the parents on medications and when the patient is to return to the clinic (and its exact location). It is helpful to indicate tests that need to be done on follow-up and any results that need to be rechecked. Problem list. Same list as the discharge diagnosis list. (For the complete policies and procedures, please refer to Appendix F OPC No. 28-B Servicing of Patients Discharge)

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IDENTIFICATION OF THE BABY I. Policy Guidelines 1. ID bracelets shall be placed on the babys ankle. If ever a newborn is admitted whose tag is placed on the wrist, the baby shall be brought back to the delivery room where the tag is changed. 2. During endorsement, there shall be proper identification of babies by checking the ID bracelets and crib tags. On rooming-in, proper identification of the baby shall be done by checking the ID and crib tags of the baby and the mothers bracelet. The same shall be done for babies brought to the breastfeeding room and those for viewing. Particular attention shall be given to the mothers given name in cases where the babies family names are the same. 3. On discharge of babies, ID bracelets shall go with the baby. 4. The criteria for changing ID bracelets are as follows: Loose tag Illegible handwriting Soiling Constricting tags 5. If there is a need for a change of ID bands, the attention of the head nurse or senior NOD is called. She will be the one responsible for changing the tag. 6. Appropriate entries should be made on the babys chart by the nurse in charge when there is a need to change the babys ID tag.

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NO CODE OR DO NOT RESUSCITATE (DNR) GUIDELINES Rationale Among the therapeutic modalities, Cardio-Pulmonary resuscitation (CPR) is unique in that it is initiated without a physicians order when cardiac or respiratory arrest is recognized. A specific instruction if necessary is CPR is not to be started. I. Definition of Terms 1. No code or Do Not Resuscitate (DNR) - an order which communicates to the nursing or hospital staff that resuscitative measures are not to be taken in the event that a patient goes into cardio-pulmonary arrest. II. Policy Guidelines A. General Policies 1. Every necessary measure shall be taken to promote the patients comfort and dignity. 2. A licensed pediatrician in training shall obtain the concurrence of the attending physician (or department chief if needed) and the parents of a legal guardian before initiating a No code order. 3. The parents shall be offered informed options. The Bioethics Committee stands ready to assist in any case where clarification of options is necessary. Parents are the decision makers concerning treatment for the sick infant, based on the advice and reasonable medical judgment of their childs physicians. 4. A referral to the Bioethics Committee and Legal Office shall be made if there is a need for it. B. Documentation for NO CODE 1. The no code or DNR order shall be written on the patient care order sheet and signed by the parents and attested to by 2 licensed physicians (attending/resident). 2. The parents or legal guardian shall be requested to sign the DNR form. 3. A DNR progress note is required. The progress note of the physician must include: A summary of the medical situation The name and opinion of the physician who is the senior physician (attending, division, department chief) to the physician in training Two signatures of licensed hospital staff members present at the conference when the patient, family, guardian, or conservator agreed to the DNR order. Witness/es signature 4. The no code or DNR order shall be appropriately reviewed to ensure that the order remains current and consistent with the familys desire and with the patients medical condition. 5. A new DNR order shall be written on each admission for those patients who are readmitted more than once. 6. The DNR Code can be cancelled by the parents at anytime. (We need to tailor the DNR form to neonate.)

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POLICY FOR NON-VIABLE INFANTS I. Definition of Terms Preterm Infant 1. Very-low-birth-weight (VLBW) infants = birth wt <1500 g (3 pounds, 5 ounces) 2. Extremely-low-birth-weight (ELBW) infants = birth wt < 1000 g (2 pounds, 3 ounces) 3. Incredibly-low-birth-weight (ILBW) infants = birth wt < 750 to 800 g (1 pound, 1ounce). Reference: Schaeffer & Avery Taeusch and Ballard II. Policy Guidelines 1. All live born infants who are non-viable (< 24 weeks and < 400 gms.) shall be admitted to the NICU, unless they expire after delivery (they do not respond to full resuscitation in 30 min. and a licensed physician pronounces them dead at the Delivery Room). 2. On situations where the viability of the infant is in question, an immediate assessment by an experienced physician will be done. If an immediate assessment is not feasible, then medical intervention including resuscitation will be done until the assessment is complete. 3. In situations where a DNR is appropriate, the DNR guidelines will be followed (see DNR guidelines). It is unacceptable for a physician to tell the nurse that an infant is non-viable and not write the appropriate orders. Orders for these infants should include: DNR where the infant should be nursed (crib, incubator) monitoring instructions whether or not a CPR monitor should be placed on the infant (this is a decision that the MD will make on an individual basis) feeding or IV fluids provision of oxygen, etc.

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POLICY FOR HEPATITIS B IMMUNIZATION AT BIRTH The prevention of Chronic HBV infection is a high priority globally. In 1991, WHO/ EPI recommended that HB vaccine be included on the National Immunization Programs in all countries with an HBV carrier rate of 8 % or over by 1995 and in all other countries (regardless of HBSAg prevalence) by 1997(1). Babies who become infected at birth have a 90 percent risk of chronic infection and may die of chronic liver disease as adults. Hepatitis B vaccine is one of the most effective vaccines available. Studies have shown that infants of the most highly infectious mothers (HBSAg+ and HBeAg+) who received postexposure prophylaxis with only hepatitis B vaccine (without HBIG) at birth are protected in 90 95 % of cases(2). The Medical City believes that the best way to prevent perinatal transmission of hepatitis B is by routine immunization of all babies born at The Medical City Newborn Services Unit. This practice has been going since 1997. I. Policy Guidelines 1. The following schedule is followed for Hepatitis B Immunoprophylaxis: a. For Term Babies Infant Born to Mother known to be HBSAg Positive Age Birth (within 12 hrs.) Birth (within 12 hours)

First Vaccine Dose HBIG

Infant Born to mother with Unknown HBsAg Status Age Birth (within 12 hrs.) Maternal screening for Hepa B is recommended. If mother is found to be HBsAg (+) following screening, give 0.5 ml HBIG as soon as possible not later than 1 week after birth.

Vaccine Dose First vaccine dose HBIG

b. For Preterm Infants The optimal time for initiating hepatitis B immunization in premies weighing less than 2 kgs is still undetermined. Seroconversion rates in VLBW infants in whom immunization was given shortly after birth have been shown to be lower compared to term infants. The following are recommendations for hepatitis B Immunoprophylaxis for preterm and LBW infants (< 2 kg.).

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Infants born to HBsAg Positive Mothers - PT and LBW infants must receive Hepatitis B vaccine and HBIG with 12 hours after birth regardless of gestational age or birth weight. - Infants weighing < 2 kgs. Should not have the birth dose of HBV counted as part of HBV Immunization series. - 3 additional doses of hepatitis B vaccine starting at 1 month of age should be given Infants Born to HBsAg Negative Mothers - First dose can be delayed until just before hospital discharge of infants or once the weight is > 2 kgs., or - Wait until infant is approximately 6-8 weeks of age when routine immunization is given. Infants born to Mothers whose HBsAg status is Unknown - First dose of HBV should be given at birth (within 12 hours). - Maternal screening for HBsAg is recommended. If mother is HBsAg (+), give 0.5 ml as soon as possible not later than 1 week after birth. - Three additional doses of Hepatitis B starting at 1 month of age should be given following 0, 1, 6 schedule.

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NEWBORN HEARING SCREENING PROGRAM PROTOCOL I. Policy Guidelines 1. Hearing screening using the otoacoustic emission (OAE) machine is done by trained technician (midwife, nurse, etc.) before the childs discharge once consent is given by the caregiver. It is a routine procedure done for all admissions at the Newborn Services Division (NSD). 2. The test is best done 24 hours or more after birth, when the child is sleeping or just resting quietly and when he/she has recovered from any health problems (infections, low birth weight, respiratory difficulties, etc.) It is usually performed by the Hearing and Dizziness Personnel. On the days when they are not available, a midwife trained in doing the test performs the procedure. 3. The babies for screening are identified by the midwife on duty for that day to assist the Hearing and Dizziness personnel. This will aid in the ease and speed in performing the test. The baby is wheeled into the hearing screening room by the technician and the test is done there. (The Otoacoustic emission machine works performs best when charged for a few hours before the start of hearing screening. The screening technician for that day will be responsible for this task.) The best fit ear probe is used on the most available ear of the child to prevent him/her form waking up. Then the head is turned gently to test the other ear. 4. If the child does not pass the screen, he/she can be screened again either immediately, a few hours or the next few days (as long as the baby is not yet discharged). This will definitely reduce the refer rate of the hearing screening procedure and is advisable. 5. The technician writes down all the pertinent data and completes the OAE results form. This form is forwarded on the same day to the Hearing and Dizziness Unit and a copy is given to the mother if the child refers on at least one ear. If the baby passes on both ears, the mother is informed by the physician or nurse-in-charge of the results but is advised to pick up the results in a few days since even if the baby passed the test, a re-screen may be warranted as explained later. 6. The preliminary test is done by the technician and the result is also documented in the Newborn Hearing Screening Form. 7. Final results (of those who passed the hearing screen) are brought to the NICU within 3 working days by the staff of the Hearing and Dizziness Unit for filing. The preliminary results will tell you that the test was done and whether the infant passed the screening test or not. The final result will include, besides the result, recommendations for re-screening if needed. 8. For babies who referred or did not pass the initial screening, they are (as previously mentioned) given a copy of the properly accomplished OAE results form and advised to have the baby re-screened in 1-3 months time. 9. For babies who are discharged before 48-72 hours with a refer result, a repeat testing will be done after 30 days by the ENT Pediatric Consultant in-charge of the Hearing and Dizziness Unit (call for scheduling). 10. For the babies whom the hearing screening test were not done prior to discharge and babies who want to avail of the same procedure, a referral to the ENT Pediatric Consultant in-charge of the Hearing and Dizziness Unit will be given for the said procedure. 11. The patients that are important to re-screen are all patients who are high risk for hearing loss (whether or not they passed the initial test) and all those who are non-high risk but did not pass the initial screening. They are best re-screened in 1 to 3 months time. If a patient does not pass the screen it does not mean that the child is deaf. There are many factors that can cause a child not to pass (refer). Vernix caseosa, a noisy baby, noisy environment and very small ear canals (some premature infants) may all potentially cause a baby not to pass the test.

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12. High risk factors include an illness or a condition requiring admission of >48 hours to a NICU, stigmata or a syndrome associated with hearing loss, family history of childhood sensorineural hearing loss, craniofacial anomalies and in-utero infection. 13. A re-screen should be scheduled. The parents/caregiver of the child shall be informed that the test is best done with the child asleep. The parents shall also be advised not to feed the infant 2 to 4 hours prior to the test (unless medically unacceptable if the child is taking medication, for example) but to bring his/her food to the test site. The test will be done after feeding the child and will definitely take longer if the child is awake/crying/active during the test. 14. The resident-on-duty at the Newborn Services Division must inform the attending physicians of all babies with a hearing screening result of refer prior to the babies discharge. 15. For babies who fail the repeat hearing screening test done by the ENT consultant in-charge of the Hearing and Dizziness Unit and requires a BAER, will be issued by the ENT consultant and sent to the Attending Physician. 16. The Hearing Screening Test is performed daily. II. Procedures A. Prior to the Newborn Hearing Screening Midwife-on-Duty 1. Requests patient to fill up the information sheet completely 2. Prepares the patient in advance by lining him/her up for the test B. During the Test Hearing and Dizziness Staff-in-Charge 1. Makes sure that the baby is asleep or is quiet during the test. 2. Makes sure that the environment is quiet. Suggestions are: a. Remove the paging system along the hallway of the examination room. b. Minimize conversation and noise along the reception area, corridor and the locker room while the test is ongoing. 3. Performs the test C. After Newborn Hearing Screening Attending Physician 1. Explains properly to the parents the result of the test so as not to unduly upset them. 2. Follows up patients who refer to make sure they undergo a repeat screening. D. Care of the Machine Hearing and Dizziness Staff-in-charge 1. Adds a lock on the Newborn and Hearing Screening Room to minimize moving the machine in and out of the table and also to minimize rolling of the thin probe cable which may lead to damage to the machine and delays in testing 2. Cleans the ear probes properly. a. Washes it thoroughly with water
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b. Wipes dry, not with needle 3. Order new earprobes as necessary (For detailed policies and procedures, please refer to Appendix G OPC No. 140 - Servicing of Patient Availing of Newborn Screening Procedure)

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NEWBORN SURGERY PROTOCOL

I.

Policy Guidelines All newborns for surgery will be medically evaluated before administration of anesthesia and/or surgical treatment. A. Elective Procedures 1. Newborns undergoing an elective procedure will be assessed as to cardio-pulmonary physiologic status by the Attending neonatologist not longer than 24 hours prior to the said procedure. This assessment as well as a pre-operative diagnosis shall be based on recorded results of diagnostic laboratory tests requested (CBC, chest x-ray). Tests done outside the TMC are verified at admission. 2. The attending anesthesiologist makes an initial pre-op assessment and a re-evaluation right before the induction of anesthesia. 3. These assessments are recorded in referral sheets. 4. Outborn patients of surgeons may be referred to the Unit for clearance by the neonatologist, intra-op monitoring and/or post-op care as specified in the referral sheet. 5. Patient for surgery is transported to the Surgery Suite accompanied by the Pediatrics resident-on-call and nurse-in-charge. Post-operatively patient is transported back to Level III accompanied by the PROD and the anesthesiologist. B. Emergency Surgical Procedures 1. A clearance is not required. The attending neonatologist stabilizes patients hemodynamic status prior to surgery. 2. Intra-op monitoring is provided on request by the surgeon.

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TMC NEWBORN SERVICES NURSING STAFF SUGGESTED ACUITY GUIDELINES Revised January 1995 A. Nursing Care 1. 1: 1 Acuity Patient who are hemodynamically unstable with multiple IV infusions (ie. Low BP) Patient with multiple chest tubes who is unstable (ie. Vital signs which require frequent ABGs, and ventilatory changes Q 1-2 hr) Patient receiving peritoneal or hemodialysis Multiple transfusions of blood products greater than 3/shift Post-op cardiac for first 24 hr, e.g. B-T shunts (eg: PDA) During exchange transfusions Seizures not controlled by anticonvulsants On IV drip with unstable chemistries Infants who are to go for cardiac catheterization Infants whose respiratory status is unstable (e.g. conventional vent, multiple ABGs and multiple chest tube insertions) 2. 1:2 Acuity Trach/Intubated (not meeting 1:1 criteria) who are on a respirator + ABG determinations Stable BP on vasopressors or other drips for cardiac effects (PGE, Dopamine, Dobutamine) Unstable Nasal CPAP patients (ie. Frequent oxygen changes, frequent A & Bs, multiple IV drips) Unstable IDM (i.e. frequent chemstrips, frequent IV changes) Post-surgical patients on a respirator 3. 1:3 Acuity Continuous IV infusions containing calcium Two or more piggyback medications IDM with frequent chemistries Pulse oximeter with titration of oxygen Chronic patients requiring more than twelve oral medications per shift Scheduled complex discharge instructions taught to parents or primary care giver Suctioning required more than twice per shift Stable Nasal CPAP babies (less than 4 A&Bs per shift and FiO2 of 35% or less) Tracheostomy with CPAP or sprinting to collar Frequent ostomy appliance changes, dressing changes, wound care or complex skin care

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4. 1:4 Acuity Stable hyperbilirubinemia patient Tolerating feeds Q 3-4 hr Infant receiving 2 or less piggyback medications (ie. heplock, Ampicillin and Gentimicin) per 12 hour shift Infants on continuous oxygen who are stable Chronic babies who are on less than 12 oral medications

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EQUIPMENT RECOMMENDED FOR DIFFERENT LEVELS OF NEONATAL INTENSIVE CARE A. Special Care Nursery (Level 2) The following equipments are recommended for babies under special care: incubator or cot adequate for temperature control ambient oxygen analyzer (not available) apnea alarm (not available) heart rate monitor infusion pump phototherapy unit access to frequent blood gas analysis using micromethods access to biochemical analysis using micromethods access to equipment for radiological examination

B. Neonatal Intensive Care Unit (Level 3) The following equipments are recommended for care of the critically ill: intensive care incubator or unit with overhead heating respiratory or apnea monitor (not available) heart rate monitor intravascular blood pressure transducer or surface blood pressure recorder (not available) transcutaneous pO2 monitor (available) or intravascular oxygen transducer (not available) transcutaneous pCO2 monitor (not available) syringe pumps infusion pumps ventilator continuous temperature monitor pulse oximeter phototherapy unit ambient oxygen monitor (not available) facilities for frequent blood gas analyses using micromethods facilities for frequent biochemical analyses including glucose, bilirubin and electrolytes by micromethods access to ultrasound equipment for visualization of organs such as the brain access to equipment for radiological examination

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RECORDS A. Data sheets for all babies admitted in the NSU should be arranged as follows: 1. Patients Data Sheet- furnished by the Admitting office and based on the babys data slip forwarded to them by the NSU. 2. Consent Forms- include consent forms for Newborn and Hearing Screening tests. 3. Newborn Record- accompanying record of the baby from the Delivery Room; contains the Apgar score and delivery data as furnished by the Obstetrician. 4. Maturity Testing and Anthropometric Measurement Form 5. Admission and Discharge PE Sheet- a record of the babys physical evaluation by the Pediatrician/Resident upon admission and prior to discharge. 6. Residents Admitting NICU history and Physical Examination 7. Doctors Progress Notes- babys progress and observation report done by the residents 8. Laboratory Report- a blank sheet of paper where results of the laboratory examinations are pasted. 9. NSU Monitoring Sheet for Level II and III patients. 10. Temperature Chart- used by the nurses and midwives for recording vital signs, weights, urine and stool scores. 11. Doctors Order Sheet- written orders for feeding, medication, treatment, disposition and other instructions are entered by the AP/ resident. 12. Medication Chart- accomplished by the nurses in recording the medications given. 13. Nurses Notes- babys progress and observation report done by the nurses. 14. Input and Output form

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PROTOCOL FOR PATIENTS SUSPECTED TO HAVE MSUD

DAY 1 1. Routine evaluation 2. Newborn care 3. Once feeding is started, feeding schedule for the next 24 hours should contain: a. Natural protein at 1g/kg/day using regular infant formula. b. Special MSUD formula 1.5 g/kg/day of protein free BCAA. c. Rest of the requirement to be given as protein free formula (Energivit). 4. Please monitor strictly intake and output. 5. Observe for vomiting, poor suck, unusual odor, lethargy or any neurologic deterioration while on feeding.

DAY 2 1. Evaluate protein intake for the last 24 hours. 2. Collect blood spots on filter card and send for leucine level at Newborn Screening Laboratory, National Institutes of Health. 3. Collect 20-30 cc of sterile urine, freeze and submit for High Voltage Electrophoresis (HVE) at Biochemical Laboratory, NIH. 4. Maintain natural protein at 1g/kg/day until the results of the above tests are in. 5. Please maintain MSUD formula at 1.5g/kg/day. 6. Evaluate status of the patient and refer accordingly. 7. Continue strict input and output monitoring.

DAY 3 1. 2. 3. 4.

Evaluate protein intake for the last 24 hours. Collect blood spots for leucine level. Collect urine for HVE. Once the results of the above tests are normal, may increase natural protein intake to 1.5g/kg/day. Maintain MSUD formula at 1g/kg/day. 5. Evaluate status of patient and refer accordingly. 6. Strict I and O monitoring.

DAY 4 1. 2. 3. 4.

Evaluate protein intake for the last 24 hours. Collect blood spots for leucine level. Collect urine for HVE. Once the results of the above tests are normal, may increase natural protein intake to 2g/kg/day. Maintain MSUD formula at 1g/kg/day. 5. Evaluate status of patient and refer accordingly. 6. Strict I and O monitoring.

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DAY 5 1. 2. 3. 4.

Evaluate protein intake for the last 24 hours. Collect blood spots for leucine level. Collect urine for HVE. Once the results of the above tests are normal, may increase natural protein intake to 2.5g/kg/day. Maintain MSUD formula at 1g/kg/day. 5. Evaluate status of patient and refer accordingly. 6. Strict I and O monitoring.

DAY 6 1. 2. 3. 4.

Evaluate protein intake for the last 24 hours. Collect blood spots for leucine level. Collect urine for HVE. Once the results of the above tests are normal, may increase natural protein intake to 3g/kg/day. Maintain MSUD formula at 1g/kg/day. 5. Evaluate status of patient and refer accordingly. 6. Strict I and O monitoring.

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PROTOCOL FOR PATIENTS WITH FAMILY HISTORY OF NEONATAL DEATHS/POOR OB HISTORY Among the genetic conditions that can present with neonatal deaths are chromosomal abnormalities and inborn errors of metabolism presenting with acute encephalopathy such as: aminoacidopathies, organic acidopathies, mitochondrial disorders, fatty acid oxidation defects and urea cycle defects.

DAY 1 1. 2. 3. 4.

Routine evaluation. Newborn care. Evaluate for dysmorphic features. Once feeding is started, feeding schedule for the next 24 hours should contain: a. Natural protein at 0.5g/kg/day using regular infant formula b. Rest of the requirement should come from a protein-free formula (Energivit) 5. Collect the following samples: a. 20-30 cc of urine (keep frozen) for urine organic acid and high voltage electrophoresis and submit to Biochemical Laboratory, NIH b. Collect blood spots on filter card for leucine level at Newborn Screening laboratory, NIH c. Collect 3 ml of blood on lithium heparinized tube and send on wet ice immediately to Biochem Lab, NIH d. Blood gas e. Serum ammonia f. Urine ketones g. Serum lactate (as needed) 6. Observe for vomiting, poor suck, unusual odor, lethargy or any neurologic deterioration 7. Strict input and output monitoring

DAY 2 1. If the results of the above tests are normal, may increase natural protein to 1g/kg/day. Continue protein free formula (Energivit) 2. Evaluate status of patient and refer accordingly 3. Continue strict I and O monitoring

DAY 3 1. Collect the following samples: a. 20-30 cc of urine (keep frozen) for urine organic acid and high voltage electrophoresis and submit at Biochemical laboratory, NIH b. Collect blood spots on filter card for leucine level at Newborn Screening Laboratory, NIH c. Collect 3 ml of blood on lithium heparinized tube, send on wet ice immediately to Biochem Lab, NIH d. Blood gas e. Serum ammonia f. Urine ketones g. Serum lactate (as needed)
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2. Evaluate status of patient and refer accordingly. 3. Continue strict input and output monitoring.

DAY 4 1. If the results of the test done on day 3 are normal, may increase natural protein at 1.5g/kg/day. Continue Energivit. 2. Evaluate status of patient and refer accordingly. 3. Continue strict input and output monitoring.

DAY 5 1. Collect the following samples: a. 20-30 cc of urine (keep frozen) for urine organic acid and high voltage elctrophoresis and submit at Biochemical Laboratory, NIH b. Collect blood spots on filter card for leucine level at Newborn Screening Laboratory, NIH c. Collect 3 ml of blood on lithium heparinized tube, send on wet ice immediately to Biochemical Laboratory, NIH d. Blood gas e. Serum ammonia f. Urine ketones g. Serum lactate (as needed) 2. Evaluate status of patient and refer accordingly. 3. Continue strict input and output monitoring.

DAY 6 1. If the results of the test done on day 3 are normal, may increase natural protein at 2g/kg/day. Continue Energivit. 2. Evaluate status of patient and refer accordingly. 3. Continue strict input and output monitoring.

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QUICK GUIDE TO GENETIC TESTING SERVICES Institute of Human Genetics National Institutes of Health Phone: (632) 5261710 / 5261725 Fax (632) 5269997 Website: http://www.humangenetics.com.ph Office Hours: Monday Friday (8:00 am to 5:00 pm)

info@humangenetic.com.ph

UNIT BIOCHEMICAL GENETICS Metabolic Profile Organic Acid Analysis Amino Acid Analysis Plasma Cerebrospinal Fluid Quantification

Sample Requirements

Transport Requirements

Turn Around Time (Working Days) Routine Urgent* 7 days 2 weeks 2 days 1 day

30 cc of random urine in sterile container. Store in freezer 30 cc of random urine in sterile container. Store in freezer

Transport in ice. Transport in ice.

Total Homocysteine Analysis Urine Ketones Reducing Sugars CYTOGENETICS Karyotyping Peripheral Blood + High Resolution + Fragile X Screening Bone Marrow
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1 cc plasma from blood collected in green top blue. Collect 3 cc blood, centrifuge at 2700 rpm for 10 minutes. Store in plasma freezer 1 cc of cerebrospinal fluid in plain tube. Store in freezer 1 cc plasma from blood collected in purple top blue. Collect 3 cc blood, centrifuge at 2700 rpm for 10 minutes. Store in plasma freezer 10 cc of random urine in sterile container. 10 cc of random urine in sterile container. 3 4 cc of blood in green top tube * sent immediately 3 4 cc of blood in green top tube * sent immediately 3 4 cc of blood in green top tube * sent immediately 2 3 cc of bone marrow aspirate in green top blue
91

Transport in ice.

4 weeks

2 days

Transport in ice.

4 weeks Special Arrangement 1 day 1 day

2 days

Transport in ice.

Transport in ice. Transport in ice. Transport in ice. Transport in ice.

2 3 weeks 2 3 weeks 2 3 weeks 3 4 weeks

4 days 4 days 4 days

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* sent immediately Tissue a. Solid Tumor b. Product of Conception MOLECULAR GENETICS DNA Extraction With DMD / BMD Testing Fish BCR ABL DiGeorge PWS / AS Her 2 (Breast CA) NEWBORN SCREENING Newborn Screening Panel G6PD Confirmatory Amino Acid Thin Layer Chromatography dried whole blood spotted on filter paper * sent immediately 2 3 cc of blood in purple top tube plus dried blood Transport in ice spot dried whole blood spotted on filter paper 5 days 7 days 7 days 1 day 3 4 cc of blood in green top tube immediately 3 4 cc of blood in green top tube immediately 3 4 cc of blood in green top tube immediately 3 4 cc of blood in green top tube immediately * sent * sent * sent * sent 3 4 weeks 3 4 weeks 3 4 weeks 3 4 weeks 2 3 cc of blood in purple top tube immediately 2 3 cc of blood in purple top tube immediately * sent * sent 2 7 days 2 3 weeks 1 2 cm2 tumor in transport medium * sent immediately 1 2 cm2 product of conception in transport medium * sent immediately 4 5 weeks 4 5 weeks

NOTE: green top tube: Heparin Vacutainer; purple top tube: EDTA Vacutainer * Please call IHG for urgent samples

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PEDIATRIC EMERGENCY ROOM

I.

Introduction The New Medical City Emergency Department is a 24-hour, 7-day service department principally dedicated to the immediate and competent first contact care of patients whose conditions require prompt attention. The Pediatric Emergency Room housed inside the main ER complex, with its complement of skilled and competent medical staff and appropriate equipment and supplies, aims to provide immediate and adequate appraisal and care to pediatric ambulatory patients as well as to the critically ill and the injured. As patient as well as visitor expectations for upgraded and efficient emergency services grow, this manual shall serve as an aid in the implementation of effective and efficient health care operations at the pediatric emergency room and shall guide the performance of duties and responsibilities of the emergency room staff.

II.

Definition of Terms 1. Emergency - An emergency is any condition that, in the opinion of the patient, his family of whoever assumes the responsibility of bringing the patient to the hospital, requires immediate medical attention. This definition continues until a determination has been made by a health care professional that the patients life or well-being is not threatened. 2. True Emergency - A true emergency is any condition clinically determined to require immediate medical care. Such conditions range from those requiring extensive immediate care to those that are diagnostic problems and may or may not require admission after work-up and observation. 3. Triage - Prompt, brief medical evaluation of all incoming patients to determine the nature of the problem, the level of urgency, the identification of the kind of service needed, and assignment for emergency attention.

III.

Classification of Patients Presenting at the Emergency Department 1. Emergent - Requires immediate medical attention. Delay is harmful to the patient. Disorder is acute and potentially threatens life or function. 2. Urgent - Requires medical attention within a few hours. In danger if not attended. Disorder is acute but not necessarily severe. 3. Non-urgent - Does not require the resources of an emergency service. Disorder is minor or non-acute.

IV.

Services and Facilities 1. The Pediatric Emergency Room, as the first point of contact with the medical system, renders immediate medical assessment and initiates treatment. Among its particular capabilities are: Consultation and initiation of diagnostic work-up Cardio-pulmonary resuscitation Initial management of burns, injuries, fractures and poisoning Generation of initial orders for patients requiring emergency admission Short-stay holding for observation, treatment, drug administration and monitored stay prior to admission or transfer to another facility
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2. V.

The facilities include: 4 main pediatric cubicles (4 beds with cubicle 1 as acute care bed) 1 hydration room with 3 beds 1 isolation rooms (total of 7 beds) 3 waiting rooms behind nurse station(total of 6 beds) 2 rooms for out patient consult 1 nebulization room with 2 chairs machines for suction, cardiac monitoring, defibrillation and respiratory support emergency medications and supplies accommodations and amenities for the 24-hour staff internal and external communications in proper working order

Clinical Reference Materials Clinical reference materials relating to general pediatrics, pediatric decision-making, pediatric basic and advanced life support, pediatric critical care, pediatric emergency room procedures, acute management of poisoning, and initial treatment of burns shall always be immediately accessible to the pediatric ER staff. These references are not to leave the premises and shall always be kept at a designated place. (For complete policies and procedures, please refer to OPM No. 1 Emergency Department)

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VI.

General Staff Organization

Chairman, Emergency Room

AVP, Special Diagnostic& Treatment Services

Pediatric Emergency Room Coordinator

ER Consultant

Nursing Supervisor/ Coordinator

Pediatric ER Committee on Training, Service and Administrative Concerns

Head Nurse Pediatric ER Residents Charge Nurse Pediatric Intern

Pediatric ER Staff Nurse

Pediatric ER Clerk

Pediatric ER Clerk

ER Auxiliary

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Pediatric ER Committee 2005

Ma. Neva Luna Batayola, MD Team Leader

Florianne Valdes, MD Adviser

Member

Administration & Operations Deanna Lacson, MD Elizza Senseng, MD Arcelie Teano, MD

Training Easter Joy Dionio-Lim, MD Felita Lucena, MD Fatima Gimenez, MD

VII. General Staff Responsibilities A. Chairman The ED Chairman has the overall responsibility for the professional activities conducted within the emergency department. The Physician Coordinator for Pediatric Emergency Services may either be a specialist in pediatric emergency medicine, pediatric intensive care, or general pediatrics. The Physician Coordinator is responsible for: 1. Ensuring adequate skill and knowledge and the continuing medical education of staff physicians, rotating residents and interns in emergency care and resuscitation of infants and children. 2. Overseeing ED pediatric quality improvement, performance improvement and clinical care protocols. 3. Overseeing the development and periodic review of ED medications, equipment, supplies, policies and procedures. 4. Facilitating pediatric emergency education for ED health care providers. The Pediatric ER Committee on Training, Service and Administrative Concerns is composed of pediatricians with special interest in emergency medical care and who are dedicated and committed to the training and supervision of rotating residents and interns to ensure the delivery of quality pediatric emergency care. They are either regular or visiting staff of the

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Department of Pediatrics. As part of the ER committee, they are encouraged to regularly update their certification in pediatric basic and advanced life support. 1. ER consultants go on-service on a weekly basis. The chief resident of pediatrics shall provide them a copy of the schedule on a monthly basis and shall remind them a week before they are decked to go on-service. The schedule shall be posted at the pediatric ER. 2. The on-service consultant is responsible for conducting daily morning endorsement/teaching rounds with all the rotating pediatric ER residents and interns. Morning endorsements start at 7 a.m. and end at 8 a.m. All pediatric ER residents and interns are required to attend the endorsement rounds. 3. ER consultants conduct daily chart rounds with the rotating pediatric residents.

DAILY CHART ROUNDS SCHEDULE Mondays Tuesdays Wednesdays Thursdays Fridays Saturdays Dr. Arcelie Teano Dr. Elizza Senseng Dr. Felita Lucena Dr. Josephine dela Pena Dr. Deanna Lacson Dr. Florianne Valdes Dr. Jocelyn Bondoc Dr. Fatima Gimenez Dr. Lourdes Tanchanco

4. The on-service ER consultant may be called upon by the pediatric ER-ROD for advice on problems that may arise in relation to patient care and ER management concerns. 5. The committee shall periodically evaluate the rotating residents in terms of clinical competence and work attitude. B. Nursing Supervisor The Nursing Supervisor/Coordinator must have special interest, knowledge and skill in emergency care and resuscitation of infants and children as demonstrated by training, clinical experience, or focused continuing nursing education. She is responsible for: 1. The day-to-day administration of the ED on the authority of the ED Chairman and the AVP for Special Diagnostic and Treatment Services, like a. Scheduling, organizing, disciplining and evaluating the ER nursing staff. b. Reporting incidents and deviations from policies and procedures to the ED Chairman and the AVP for Special Diagnostic and Treatment Services. c. Implementing nursing service policies as they apply to the ER nursing staff. d. Providing the ER Consultant/ROD with the necessary administrative support to ensure prompt and efficient patient care at the ED. e. Identifying matters that require the attention or decision by higher authorities. 2. Coordinating pediatric quality improvement, performance improvement and clinical care protocols with the Physician Coordinator.
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3. Facilitating ED nursing continuing education in pediatrics and providing orientation for new staff members. 4. Assisting in the development and periodic review of policies and procedures for pediatric care. 5. Monitoring pediatric equipment and medication availability and authorizing the request for purchase of supplies, repair or replacement of equipment. C. Emergency Department Head Nurse 1. Assists the Nursing Supervisor in the day-to-day administration of the ED a. Coordinates activities and recommends changes in schedules. b. Performs inventories of all equipment and supplies. c. Reports minor and major problems in the ED, analyzes the source of the problem and makes recommendations to the Supervisor. d. Monitors staff compliance to hospital rules and regulations (i.e., uniform code, attendance, adherence to policies on patient care delivery). 2. Assesses plans and organizes therapeutically effective, safe as well as cost-effective ER activities related to patient care delivery. D. Rotating Pediatric ER Residents 1. Pediatric ER Residents are 2nd year Residents who have the necessary skill, knowledge, and training (including basic life support and pediatric advanced life support) to provide emergency evaluation and treatment of children of all ages. 2. Residents go on monthly rotation at the Pediatric Emergency Room and are under the direct supervision of the Pediatric ER Committee and the Pediatric Consultant staff. Competencies are evaluated on a regular basis. 3. Two Second Year Residents go on 24-hr duty every 3 days. Their tour starts from 7 a.m. until 7 a.m. of the next day when their relievers shall have reported for duty and after the morning endorsement rounds with the on-service ER consultant. 4. Pre-duty ER residents shall be called as backup in situations of heavy patient flow at the pediatric ER. Otherwise, they shall go to their designated areas of assignment in the pediatric floors. 5. Post-call ER Residents shall be given the day off after they have completed the daily logs and documentations and after the morning endorsement rounds with the ER consultants. Functions: The Pediatric ER-ROD shall Promptly (in less than 15 minutes) attend to all pediatric cases with due regard to logical and reasonable prioritization of activities and resources. Take a concise and accurate clinical history and perform a complete physical examination on all pediatric patients consulting at the ED, with the rotating intern in attendance whenever possible. For admitted patients, the ER-RODs admitting history should accompany the patients record upon transport from the emergency room to the unit. However, in circumstances of high patient load at the ER, clinical histories may be completed within 4 hours for critically ill patients and within 12 hours for those who are not critically ill.

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Make a diagnosis or a clinical impression and decide on the management and disposition (send home/admit/observe at short stay area) of all pediatric patients. All orders made shall be properly recorded, reviewed and signed.

No orders shall be made by the rotating intern. Promptly inform the attending physicians of admissions to their service and inform them if any of their patients has been seen at the ER for outpatient consultation. Refer any case that in his/her judgment requires referral to other specialties. Such referrals can either be to another member of the house staff or to a member of the consultant staff. Referrals should be made directly to the specialty resident and never to the intern. All gynecologic referrals should be seen and initially assessed by the OB-ROD at the Pediatric Emergency Room. All psychiatry cases are referred to the psychiatry resident after initial assessment of disposition and management. Pediatric patients for surgical clearance should be seen and examined at the pediatric ER by the surgical resident-on-duty and the Emergency Medicine Consultant. Properly endorse patients for admission to the pediatric units to the receiving floor residenton-duty. Critically ill patients should be endorsed directly to the senior of the service during office hours or to the senior resident-on-duty after office hours. Attend morning endorsement/teaching rounds with the ER consultant-on-deck whatever his/her duty status may be (on-duty, post-call, pre-duty) The Pediatric ER-ROD shall directly supervise the rotating interns. Under no circumstance shall patients be initially assessed and treated by an intern. The ER-ROD is authorized to assign duties and tasks to interns, oversee their performance, make evaluations, recommend disciplinary measures, and monitor compliance with existing policies and standards. He/she shall make a formal report on an interns performance and shall submit said report to the interns monitor. Complete the daily ER census prior to post-call status. E. Emergency Department Staff Nurses Nurses manning the pediatric ER must have the necessary skill, knowledge, and training (including basic life support and pediatric advanced life support) to provide nursing care to children of all ages. Responsibilities 1. Related to Patient Care a. Acts as triage nurse ( with the necessary competence and qualifications) b. Interviews patients, obtain personal data and history c. Takes and records weight, anthropometric measurements, vital signs d. Immediately/promptly reports abnormal conditions, sudden deviations and significant e. Assists in physical examination, treatments and procedures ant changes in the patient f. Accompanies patients to diagnostic/treatment procedures g. Brings the patient to the unit and make the necessary endorsement to the receiving nurse 2. Related to Administrative Support a. Transcribes doctors orders b. Completes forms to carry out doctors orders for diagnostic procedures c. Receives patients valuables for safekeeping.
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3. Related to General Support a. Accomplishes charge slips when the ED clerk is not available b. Maintains ED records c. Assists in preparing supplies such as cotton balls, etc. d. Assists in periodic inventories of supplies, instruments and equipment e. Assists in orienting new nurses, orderlies, clerks and visitors f. Assists in handling patients complaints or inquiries g. Reports undue incidents and problems h. Assists in complying with existing policies and procedures F. The Pediatric ER Interns Two (2) pediatric interns go on 24-hr duty at the pediatric ER. The tour-of-duty starts at 7 a.m. and ends at 7 a.m. the next day when their relievers shall have reported for duty. Interns on duty do not leave the area at any time. Pediatric ER interns go on 24-hr duty every 3 days on a monthly rotational basis. In case of heavy patient flow at the pediatric ER, the pre-duty pediatric ER interns shall be called to assist in patient care. All interns assigned to the ED shall sign in and sign out in the attendance logbook. The interns monitor in coordination with the ER Surgery ROD will regularly check the logbook. Functions: The pediatric ER intern shall 1. Assists the pediatric ER-ROD in the diagnosis, management and disposition of patients 2. Performs patient care functions after initial assessment by the resident, i.e. a. History taking b. ECG taking c. Blood extraction d. Insertion of intravenous lines, nasogastric tubes and foley catheters e. Gastric lavage and catheter flushing f. Monitoring of critically ill patients g. Any other related activity on orders of the resident-on-duty Patient care functions are done under the direct supervision and express approval of the pediatric resident-on-duty. 3. Attends the daily morning endorsements / chart rounds with the on-service consultant and the rotating ER residents G. Pediatric Emergency Room Clerk Function: The pediatric ER clerk performs clerical functions necessary in an emergency room service. Apart from the activities assigned by the ER-ROD, interns and staff nurses, the ER clerk has the following activities: 1. Acts as receptionist-secretary-clerk of the pediatric ER
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2. 3. 4. 5. 6. 7.

Takes custody and maintains ER records Prepares charges according to approved rates Maintains supply of forms and office supplies Communicates with consultants, residents and other hospital units regarding ER activities Keeps track of purchase requisitions, job orders, and borrowing for proper disposition Prepares reports, communications, schedules and other written documents pertaining to ER activities 8. Assists in all other staff activities H. Pediatric Emergency Room Orderly Function: The orderly assigned in the pediatric ER assists in providing nursing and general support in patient care for emergency patients. He assists in carrying out mechanical tasks, physically strenuous work and other activities requiring strength and speed. Apart from assignments and instructions issued by the ER-ROD, interns and staff nurses, the orderly performs the following activities: 1. Assists in physically supporting and carrying non-ambulatory patients to and from beds, stretchers, tables and wheelchairs 2. Assists nurses in all their activities 3. Runs errands such as obtaining supplies from the pharmacy and other units 4. Changes, collects and returns soiled linen 5. Prepares deceased patients and transports them to the morgue 6. Cleans and packs instruments for sterilization at the central supply room 7. Refills oxygen tanks and cylinders 8. Cleans and arranges equipment, stock room, cabinets, and other work areas of the ER 9. Checks regularly the functional integrity of the ER equipment An orientation program is provided for new employees, rotating residents and interns and shall include an introduction to the overall physical setting of the pediatric emergency room as well as the whole ER complex; an overview of the goals and standards of the hospital, its departmental plan and organization, policies and procedures, personnel policies and evaluation procedures. Pediatric ER residents and interns shall be oriented by the pediatric ER coordinator.

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GENERAL POLICIES ON THE CONDUCT OF ER PERSONNEL 1. On Time Reporting For Duty: All personnel assigned to the pediatric ER shall report on their scheduled time of duty. 2. No Absence: The full complement of ER staff should be fulfilled 24 hours a day, 7 days a week. 3. No Check Out Until Relieved: At no time should personnel check out of duty until the reliever has checked in and endorsements have been made. 4. Proper Attire: All personnel should report for duty in proper attire with the identification badge properly displayed. Male Doctors Shirt and tie with appropriate colored pants and prescribed white coat with the hospitals logo. Female Doctors Semi-formal outfit with the prescribed white coat bearing the hospital logo. No denims or flowered pants are allowed. Nurses Prescribed white uniforms

5. Professional Handling of Comments and Inquiries: All personnel should deal with comments and inquiries by patients and relatives in a professional manner. 6. Waiving of ER Charges: No personnel can waive charges incurred by patients.

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PATIENT FLOW AT THE EMERGENCY DEPARTMENT Entrance of:


Parent/Guardian Patient

ER clerk for patient data and medical information

Triage Nurse

Non-emergent (OPD)

Urgent/Emergent

Pedia-ER Nurse Pedia-ER Nurse (Vital signs) ER Resident ER Resident/Intern

Admission

Resident for discharge Instructions

Resident for interpretation of results

With accredited Pediatrician

Walk-in (No AP or AP not accredited)

HMO prescription

Need not be admitted

Needs admission Admitted under accredited Pediatrician Decked to walkin consultant Decked to coordinator

Back to clerk for billing

HOME

Ward clerk for admitting slip

To Unit

To admitting section room assignment


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1. Upon entry of the patient to the ER, the security personnel directs him to the triage area where he is classified by the triage nurse as non-emergent, urgent or emergent after his vital signs are taken. The vital signs are noted down in the ER sheet. 2. Meanwhile, the parent or the guardian fills up the medical information sheet under the guidance of the ER clerk. The ER clerk determines if the patient has an accredited attending pediatrician, is a walk-in patient or an HMO patient. After all pertinent information is provided; the clerk encodes the data in the computer. 3. If a patient is classified to be urgent or emergent, he is immediately wheeled in to the pediatric emergency room, brought to a bed and endorsed to the ER nurse. 4. The ER nurse calls the ER resident who performs a brief medical history and a thorough physical examination. Initial/Emergency medical treatment is instituted based on the patients clinical condition and the residents assessment. The resident then facilitates admission after he writes down the admitting orders in the patients chart. He then informs the parent or guardian of the need for admission then notifies the attending pediatrician. 5. The nurse carries out the admitting orders. A signed consent for admission and diagnostic procedures (when indicated) is obtained from the parent or guardian. The nurse then endorses the chart to the ER clerk who provides an admitting slip to the parent or guardian. She instructs the parent or guardian to proceed to the admitting section for arrangements and room assignment. 6. The patient is ready for transport to the pediatric unit after all orders for initial treatment and diagnostic examinations are carried out. 7. If a patient is classified as non-urgent, he shall follow the pathway presented below:

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FLOW OF ER CONSULTATION (Non-Urgent; Outpatient)


Patient

Triage area Security personnel directs patient

Triage nurse Takes chief complaint and vital signs; Clerks lets parent fill-up data sheet

Patient is directed to a cubicle at the pedia ER and waits to be attended to

Intern gets patients chart Takes an initial history and Physical exam

Intern refers to Resident Resident takes history and P.E

Lab tests needed

No lab test needed Patient for discharge

Resident orders lab tests in the chart (3rd sheet of the data sheet & endorses to nurse)(5 min max)

Resident fills up discharge instruction Writes prescription for home meds (5mins)

Nurse carries out order while clerk makes the charges for the test (5mins)

Explains home instructions and meds to parents (5min)

Phlebotomist arrives 5-10 min to get blood sample (if stool/urine sample are needed, pt is given a specimen cup for collection. Nurse submit specimen to lab once available.

Endorsed to nurse (5min)

Chart endorsed to clerk; charges or billing prepared (5min)

Patient waits for results (1-1.5 hrs)

Directed to billing section for settlement of bills Admit HOME Discharge


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Resident explains lab result to parents; determines final disposition (10min)


OPM No. 23 Department of Pediatrics

ADMISSION GUIDELINES AT EMERGENCY DEPARTMENT

A. Determination of the Need for Admission 1. In the course of providing emergency care, the ER-ROD shall determine whether or not there is a medical need to admit the patient. 2. Patients refusing admission and who have been properly advised by the attending resident shall be made to sign a waiver. The attending pediatrician shall be personally notified by the resident. 3. All patients requesting admission, regardless of medical need, shall be admitted. The admitting resident shall then indicate that the patient was admitted per request. B. Attending Physician of Admissions 1. The patients doctor is a member of the regular staff The patient shall be admitted under the service of the regular consultant regardless of the nature of the case while proper communication is made by the admitting resident as soon as possible. The consultant will be responsible for proper interdepartmental or intradepartmental referrals. 2. The patients doctor is a member of the visiting staff The patient shall be admitted under the service of the consultant and proper communication is made as soon as possible. The visiting consultant will be responsible for proper interdepartmental or intradepartmental referrals. 3. The patients doctor is not an accredited physician of the hospital The parent or guardian shall be informed that the physician is not an accredited staff. If the parent or guardian consents, arrangements shall be made and the patient shall be considered as a walk-in patient. C. Classification of Patients 1. The patient is a walk-in patient. A walk-in patient is a patient coming to the hospital with no attending physician or whose attending physician is not an accredited member of the regular or visiting staff. The walk-in patient shall be admitted under the service of the regular consultant on deck for the day. If the consultant on deck is not available, the consultant on deck for the following day shall be designated as the attending physician. The schedule of walk-in consultants is posted at the pediatric emergency room. Whenever a patient is referred to a consultant other than the one scheduled, a notice of deviation on the prescribed form shall be sent to the consultant on deck and to the Auditing Department. 2. The patient is a member of a health maintenance organization duly accredited at The Medical City.

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An HMO cardholder shall be admitted under the service of the HMO coordinator. The coordinator shall be responsible for interdepartmental or intradepartmental referrals. The pediatric ER ward clerk checks the validity and expiration date of the HMO ID card at all times. A Letter of Authorization is required. 3. The patient is a referral from an outside physician, a private or public agency/hospital. The preceding guidelines on assignment of attending physicians shall apply. Letters of referral from outside physicians and institutions shall be attached to the patients medical record.

(For detailed procedures on handling patient admission at Emergency Department, please refer to Appendix H - OPC No. 27 Handling of Patient Admission at Emergency Department and OPM No. 34 Admission and Allied Services Department)

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GENERAL GUIDELINES ON HANDLING OF EMERGENCY DEPARTMENT PEDIATRIC PATIENTS I. Policy Guidelines A. Patients under Observation 1. Patients whose initial medical assessment calls for a short period of direct observation to allow frequent reassessment by the ER resident-on-duty in terms of response to treatment shall be accommodated in the short stay or holding area. 2. Whenever possible, the ER resident shall inform the attending pediatrician that his patient is at the short stay area for observation and shall relay results of diagnostic tests and subsequent assessments to determine whether or not the patient should be admitted, referred or discharged. If the patient has no accredited attending pediatrician, all matters that concern treatment and continued care shall be brought to the attention of the walk-in consultant for the day. 3. Patients who are discharged after observation are provided a home instructions sheet. 4. Patients who are subsequently admitted are endorsed by the ER resident to the service resident-in-charge (during office hours) or to the resident-on-duty (after office hours).The attending pediatrician is informed of the admission. B. The Pediatric Trauma Patient 1. All trauma or multiply injured pediatric patients shall be seen, assessed and treated directly by the trauma service. 2. They shall be admitted under the surgery service who shall determine if a referral to the pediatric service is necessary. C. Patients Referred for Clearance Prior to Any Surgical or Diagnostic Procedure 1. Walk-in patients shall be formally referred to the regular consultant on-deck for the day. 2. Charity patients or patients for admission under the Divine Mercy program shall likewise be cleared by the regular consultant on-deck for the day. 3. Existing policies apply for patients with accredited pediatricians or patients who are members of accredited health maintenance organizations. D. Direct Admissions (Patients with Admitting Orders from their Attending Pediatricians ) 1. Patients with direct orders for admission from their attending pediatricians who pass through the pediatric emergency room shall be seen initially and assessed by the pediatric ER-ROD before endorsement to the receiving service resident or the floor resident-on-duty. 2. If the patient does not need emergent treatment, he shall be directed to the admitting section for arrangements on admission and shall be transported to the unit where he shall then be received by the corresponding service. The receiving service resident or on-duty floor resident shall be responsible for informing the attending physician of the admission and carrying out all orders made.
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3. However, should the patients condition require immediate attention and management, he shall become the responsibility of the ER-ROD and shall be admitted from the emergency room where all orders shall be carried out prior to transport to the unit. It will be the responsibility of the ER-ROD to inform and update the attending pediatrician. E. Non-Emergent Patients not For Admission 1. All patients not requiring admission or not needing laboratory work-up shall be sent home within the hour after having been seen and assessed by the ER-ROD. 2. The patients out-patient record must be complete and factual and a complete physical examination shall be made by the ER-ROD. 3. If laboratory tests were requested, results shall be obtained at the soonest possible time for appropriate disposition. 4. Upon discharge from the emergency room, the patient/parent/guardian should be given explicit instructions on follow-up care. The patient/parent/guardian should provide assurance that these are clearly understood. Oral instructions should be confirmed in writing. A copy of the written instructions, signed by the patient/parent/guardian to indicate receipt, co-signed by the attending resident, preferably witnessed by the attending nurse, shall be included in the patients out-patient record. 5. If the patient leaves the pediatric emergency room against medical advice the patient/parent/guardian shall sign a waiver to release the hospital and the attending doctor from all responsibility. If he/she refuses to sign the waiver, the facts shall be entered in the record and witnessed if possible. 6. The pediatric ER-ROD shall inform the attending pediatricians if any of their patients were seen in the emergency room as outpatients. F. Conduct of Emergency Room Procedures 1. All diagnostic, clinical and treatment procedures in the emergency room shall be accompanied, whenever applicable, by a written consent from the patient/parent/guardian. The consent shall be attested to by a witness. 2. If a patient/parent/guardian refuses to give consent for a procedure or treatment after adequate explanation by the attending resident of the consequences, he/she shall sign a waiver. If he/she refuses to sign the waiver, the facts should be entered in the patients record and attested to by a witness. G. Do Not Resuscitate Orders in the Emergency Room 1. For the critically ill, the standard of care in any institution is to perform cardiopulmonary resuscitation (CPR). The two general situations that justify withholding CPR are: a. When CPR is judged to be of no medical benefit b. When the patient with intact decision making capacity or someone designated to make decisions for him/her when he/she lacks such capacity clearly indicates he/she does not want CPR 2. The DNR order can be entered for a child with the consent of the childs parent or guardian. If the child is old enough to understand or decide about CPR, the childs consent shall also be required for a DNR order.

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3. The DNR order shall be written or co-signed by the attending ER physician, who in this instance is the ER resident-on-duty. If a standard hospital DNR form is available, this shall be properly filled up and signed by the parent or guardian, co-signed by the attending resident and attested to by a witness. 4. The DNR order shall be removed at anytime upon the request of the parent or guardian or the patient. 5. The ER-ROD must inform the attending pediatrician or the walk-in consultant (for patients without attending physicians) if such a situation arises.

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FLOW ON HANDLING OF SUSPECTED CHILD ABUSE/CHILD NEGLECT PATIENTS

SUSPECTED CHILD ABUSE/NEGLECT PATIENT PER/OPD

INITIAL ASSESSMENT BY TRIAGE

EMERGENT/URGENT

NON-URGENT

Shock/Instability, Acute Abdomen, Fractures, Suicidal Patient, Poisoning IC Bleed or increased ICP Mental status changes, etc.
CPU CONSULTANT ON-CALL STABILIZE REFER TO APPROPRIATE SPECIALTY

Emergency Assessment by CPU (Child Protection Unit) Consultant for the following: 1. History of inappropriate sexual contact within 72 hrs.

CPU CONSULTANT

2. Acute Vaginal or Rectal bleeding 3. Inability to provide safe environment 4. Severe physical abuse 5. Social emergencies (from the province, police emergencies)

* For poisoning cases, coordinate with the National Poison Control Center (trunkline 521-84-50)
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HANDLING PEDIATRIC EMERGERGENCY ROOM RECORDS I. Policy Guidelines 1. ER/Treatment Room Record All cases seen at the pediatric ER-TR shall be documented in specific pre-numbered, loose-leaf forms containing personal and medical information related to the care of the emergency room patient. 2. ER/TR Patient Logbook this logbook shall contain the following information: Patients name Date when seen Patients record number HMO/Company ID numbers Diagnosis Medicine/Treatment given Charge Slip Number 3. Record of Operative Procedures in the ER-OR this form shall be accomplished in duplicate by the surgical consultant. The original copy shall be forwarded to the Medical Information Department (MID). The duplicate copy and the patients chart shall be kept in the ER for billing and filing purposes. Any request by surgeons or patients for copies of these records shall be coursed through the Medical Records Section. 4. Filing All ER-TR patient records shall be filed in numerical sequence. Daily records shall be put in one folder. 5. Custody of Records The ER-TR shall keep patient records on a weekly basis only. Folders containing older records shall be sent to MID for custody and storage. The ER-TR shall keep patient logbooks for the current and past year only. The rest of the logbooks shall be forwarded to MID for custody.

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PEDIATRIC OUTPATIENT CLINICS AND CHILD HEALTH SERVICES I. Rationale The Department of Pediatrics of the Medical City has been operating an Out Patient Service section since 1974. The Pediatric residents manned this clinic. The patients who availed of the services at that time were dependents of TMC employees and their relatives. This service then fulfilled the minimum requirements set by the Hospital accreditation board of the Philippine Pediatric Society, Inc. (PPS-HAB) to be a training hospital. From the basic Phase I, TMC was then further elevated to a higher level of accreditation, Phase II a and b. This was in 1986. Aligned with the Vision of The Medical City, the Department of Pediatrics aimed for the highest accreditation of the PPS Hospital Accreditation Board, which is a Phase III. In preparation for this bid, innovations and changes were instituted in our department. One of these was the intensified and enhanced OPD/ER services initiated in 1999, with the set up of our own OPD clinic within the ER complex. The patients were relative and dependents of TMC employees and the patients from the recruit program of the Department of Obstetrics and Gynecology. In 2004, the Department of Pediatrics was finally awarded the Phase III status. Last March 2005, the PPS-HAB revisited The Medical City in its new home to reaffirm our position as a Phase III hospital. The strengths of the department were as follows: (1) infrastructure and facilities offered by the hospital were of high quality and of international standards, (2) strong support from the central administration focused in fulfilling the departments short and long-term goals, (3) research and faculty development. However they recommended the following improvement in our training program, particularly, (1) increase the number of Divine Mercy patients which is being addressed with more vigor by the Central Administration and the department, and (2) increase in-hospital OPD census. Together with the fact that pediatric practice would involve 70-80% out patient cases, the department realized the need to intensify and improve the trainees exposure in out patient care. In March 2005, the new out patient clinic of the department was opened. The objectives of the opening of the service are: 1. To provide training and exposure to our house staff, this includes residents and interns in health supervision of children in the ambulatory setting. Training in health supervision includes diagnostic and therapeutic management of common out patient diseases, anticipatory guidance which includes health promotion, preventive pediatrics and family and patient education. 2. To serve as the in-house comprehensive ambulatory care of the department in fulfillment of the PPS HAB requirement. II. Introduction The outpatient department of the Department of Pediatrics will serve as the comprehensive Ambulatory Care Section of the department. This section will also function as the teaching venue for the house staff, which includes the residents and interns. It offers complete health supervision service in an outpatient clinic setting. This section will also function as an educational and training arm of the house staff in the form of hands on supervision by consultants, weekly conferences and audits. This will help fulfill the requirements set by the Philippine Pediatric Society, Inc. for Phase III accreditation of the Residency Training program of the hospital.

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III. Organization A. Residents 1. First year resident 2. Second/Third year resident 3. Qualifications: Must be a duly licensed physician Must be an accredited Pediatric resident of the Department B. Interns 1. Assigned interns to the department 2. Qualifications: Must be an accredited intern of The Medical City C. Consultants 1. General pediatricians, both active and visiting, function to provide direct supervision and training of residents and rotating interns 2. Subspecialty consultants supervise the clinics in the following specialties: Pulmonology Cardiology Neurology 3. Qualifications: Must be an accredited medical staff of The Medical City Must be a diplomate or fellow of the Philippine Pediatric Society D. Social Worker 1. Qualifications: Must be an accredited social worker of The Medical City Must have a degree in BS Social Work E. Nurse 1. Qualifications: Must be a registered nurse with a BSN degree Must be an accredited nursing staff of The Medical City

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ORGANIZATIONAL CHART Department Chair

Head, Ambulatory Services

OPD Committee Head

OPD Committee Co-Head

OPD Committee Members IV. Target Patients 1. 2. 3. 4. All patients aged 0-18 years old and 364 days can be seen in the pediatric outpatient department. Well babies from the recruit program of the Department of Obstetrics and Gynecology who may avail of free consultation and OPD immunization program. Patients referred by the Barangay Ugong Health Center. Patients from the Divine Mercy Program approved by the hospital. This would include patients for follow-up after admission from the Divine Mercy ward and patients for clearance prior to any operation under the Divine Mercy Program. Qualified indigent pediatric patients referred by the Department of Social Welfare and Development (DSWD) of Pasig City.

5.

A memorandum of agreement will be signed by both The Medical City through the Department of Pediatrics represented by Dr. Elizabeth Palmero-Reyes and the Department of Social Welfare and Development head of Pasig, Mrs. Francisca Delleva, and another representative from the City of Pasig. The Department of Pediatrics of The Medical City will accept indigent pediatric patients from the municipality of Pasig who have passed the minimum requirements for eligibility for issuance of a DSWD White Card. a. Minimum requirements to be eligible for the issuance of a White Card: Voters identification number Barangay Certificate of residency in Pasig City or in the other involved municipalities for at least 6 months Combined salary of all family members residing with the pediatric patient of not more than Five Thousand Pesos (PHP 5,000.00) per month Accomplishment of screening form

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Only children of holders of the DSWD White Card can avail of the OPD program coupled with a referral letter signed by their city hospital officers addressed to the section head of the Section of Ambulatory Pediatrics. The DSWD of Pasig City has the responsibility to strictly screen, check and verify the indigent status of the patients referred to the OPD. The number of patients to be accepted per day will be limited to those that can be accommodated in the OPD-Pediatric Clinic and only during the clinic hours provided. V. Mechanics A. Location The Outpatient Department clinic of the Department of Pediatrics is located at the Lower Ground of the Podium of The Medical City. B. Clinic Hours 1. General Pediatric Clinic: Monday to Friday: 9:00 AM to 12:00 NN Monday, Wednesday and Thursday 2:00 PM to 4:00 PM 2. Immunization Day: Wednesday, 9:00 AM to 12:00 NN 3. Subspecialty Clinic (Pulmonology, Cardiology and Neurology) Pulmonology: Monday and Friday AM Cardiology: Wednesday and Thursday PM Neurology: Thursday AM The OPD will be closed every Saturday, Sunday, Legal and Special Holidays. C. Fees 1. No consultation fee will be charged. 2. Necessary laboratory work up may be done at The Medical City at the expense of the patient or any government hospital. 3. Vaccines under EPI are free as long as they are available (BCG, DPT, OPV, Hepatitis B, Measles). 4. Vaccines not under the EPI may still be given as long as they are available and will be at the expense of the patient. D. Others 1. All patients will be evaluated and managed by the resident under the supervision of the consultant on deck. 2. The following documents must be completed by the OPD Resident: Patients Chart (General Data, History, Immunization, Developmental Milestones, Past Medical History, Physical Examination, Diagnosis and Management) Growth Charts / Nutrition Charts / Immunization Charts
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Logbooks 3. Only eligible patients with White Cards and referral letters issued by partner municipalities, those for follow up from the Divine Mercy Program and well babies from the recruitment program of the Department of Obstetrics an patients referred by the Barangay Ugong Health Center shall be seen at the TMC OPD clinic. 4. All patients will be seen on a first come first serve basis. However, priority will be given to children whose illness necessitates immediate attention. Workflow for Consultation at the Pedia OPD
Patient comes in for OPD result Social worker

screens patient for eligibility Nurse triages patient Patient is assessed by the physician (resident or consultant)
Well baby

Sick baby Gen. Pediatrics consult Refer to Pedia subspecialti es

Well baby check up

Immunization

Refer to other subspecial ties The Outpatient Department of The Medical City Department of Pediatrics is composed of the following:

1. General Pediatrics Clinic 2. Subspecialty Clinics Cardiology Neurology Pulmonology The objectives and policies for each of the clinics will be discussed in the succeeding sections.

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SPECIFIC CLINIC GUIDELINES GENERAL PEDIATRICS CLINIC (GPC) I. Objectives To acquire thorough knowledge and skills in the care of infants and children (immunization, health education and nutrition) To provide training opportunities for residents in the care of acute and chronically-ill patients in the outpatient setting To provide the post-graduate interns the necessary exposure to common pediatric illnesses in the outpatient setting To be a venue for educating patient/ parents on primary health care To serve as screening area for patients needing referrals to pediatric subspecialty clinics or other appropriate specialty clinic/s To provide continuity of care to discharged patients from the Divine Mercy Program To deliver free health services to qualified indigent pediatric patients from selected municipalities and from Barangay Ugong Health Center and to babies from the Recruit Program of the Department of Obstetrics

II.

Policy Guidelines A. General Policies 1. Consultation Hours: Monday to Friday: 9:00 AM to 12:00 NN Monday, Wednesday Thursday: 2:00 PM to 4:00 PM 2. The OPD-General Pediatrics Clinic is manned during clinic hours by 2 residents (1 first year and 1 second or third year resident), 1 intern and 1 social worker or nurse. A General Pediatrician is also available to provide direct supervision of the residents and interns. 3. All pediatric patients who consult at the OPD are assessed first by the social worker or nurse, or if unavailable, an assigned intern, if they are eligible to avail of the OPD Program. Well babies from the recruit program of the Department of Obstetrics Patients referred by the Barangay Ugong Health Center Patients from the Divine Mercy Program Children of holders of the DSWD White Card with a referral letter from their Municipal Health Officer. 4. Patients are then referred to the intern and/or resident for initial assessment. The elements of the outpatient assessment are as follows (please refer to Attachment C): a. General Data b. History c. Immunization d. Developmental Milestones e. Past Medical History f. Physical Examination g. Diagnosis h. Management 5. Priority is given to patients who manifest with grave illness and who are weak, febrile and restless. The resident and/or intern should

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a.

b. c. d.

e.

f.

Write a comprehensive pediatric/neonatal history, perform a complete physical examination, give an impression and outline the management for the patient. All patients should be seen by the resident and assigned consultant before discharge. Patients for pre-surgical evaluation are seen by the Senior Pediatric resident then referred to the consultant of the day. Referrals to subspecialty Pediatric clinics or other specialties like Surgery, Obstetrics and Gynecology, Otolaryngology and Ophthalmology are done if deemed necessary. Patients requiring admission should be referred to the senior resident. Patients may then be referred to government hospitals such as Pasig City General Hospital for admission or to TMC Divine Mercy if patient meets all requirements for admission. Patients who are suspected Child Abuse cases are immediately referred to the senior resident and consultant-on-deck accompanied by an intern. This will provide comprehensive and immediate care for the patient without the trauma of repeated interviews. Patients may avail of free immunization (EPI vaccines: DPT, OPV, Hepatitis B, Measles) on scheduled days and subject to availability of vaccines.

B. Work-Ups 1. No laboratory work-up is required prior to referral to the General Pediatric Clinic, unless the patient is for pediatric clearance prior to surgery. 2. Residents may request for laboratory work-up if necessary, however, expenses incurred for these laboratory examinations will be shouldered by the patient. C. Referrals 1. To other Pediatric Subspecialty Clinic a. All cases should be seen and examined by the Pediatric Resident rotating at the General Pediatric Clinic following all the requirements set by the subspecialty clinic/s b. All laboratory examinations required by the Specialty Clinic should be done prior to their appointment with the subspecialty clinic c. Resident to resident endorsement should be done on all referrals d. Difficult or problematic cases should be referred to the consultant on deck at the subspecialty clinic 2. To other Non-Pediatric OPD Clinics (Surgery, Ophthalmology and ENT) a. All referrals should be seen and examined by the Pediatric Resident rotating at the General Pediatric Clinic. b. The referral is made by the pediatric resident to the resident of the different departments. 3. To other hospitals/private physicians a. Patients for referral/transfer to other hospitals should be given clinical abstracts duly noted and signed by the GPC resident. b. The reason for referral/transfer should be indicated. All cases should be properly endorsed to the hospital or private physician. D. Schedule of Follow-Ups 1. Intervals in the follow-ups are up to discretion of the GPC resident. 2. Unscheduled patients coming to the GPC shall either be seen last or, in case there are already too many patients, shall be rescheduled depending on the clinical status of the patient.
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3. Each resident has an assigned clinic hour at the OPD during the week that serve as their continuity clinic. Patients may follow-up with the resident during their specified clinic schedule. E. Responsibilities of the Staff 1. Consultants a. There is an assigned Consultant-of-the-day at the GPC from the pool of Pediatric Consultants. (see page 132) b. All patients should be referred to them for proper assessment and disposition c. Should there be any problems encountered at the GPC for the day, whether clinical or administrative, the consultant should be informed by the senior resident d. Conduct teaching rounds for the rotating residents and interns e. Conduct weekly admitting conferences and monthly audits with the residents and interns f. The admitting conferences are held every Friday at 9:00 to 10:00 AM. The audit is held every 1st Friday of the month at 9:00 to 10:00 AM g. Evaluate the performance of the residents and interns using standard evaluation tools 2. Second/Third Year Residents At least one 2nd or 3rd year Pediatric Resident is assigned at the General Pediatric Clinic as scheduled by the Chief resident. The following are their expected duties and responsibilities: a. Duration of rotation is one month b. Should be at the GPC at 8:30 AM c. Oversees the day to day running of the OPD Clinic d. Attends to Pediatric Clearances of patients for surgery referred to the GPC on an outpatient basis e. Guides and helps the first year residents f. Holds teaching rounds with the post-graduate interns g. Evaluates all patients for referral to other clinics and countersigns the charts of these patients prior to the referral h. Ensures that all charts are complete i. Refers all patients to OPD consultant for the day 3. First Year Residents At least one 1st year Pediatric Resident is assigned at the GPC as scheduled by the Chief resident. The following are their expected duties and responsibilities: a. Duration of rotation is one month b. Obtains a complete history and does a thorough physical examination of each patient at the OPD Clinic c. Makes a complete assessment and formulate a diagnostic and therapeutic plan d. Assists the senior residents in checking and countersigning the charts of the patients seen by the interns e. Supervises the work of the post-graduate interns f. Accomplishes requests for laboratory examinations and gives appropriate instructions to the parents/guardians/patients g. Checks that all charts bear their printed name and signature
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h. Checks that all prescriptions have the printed name, signature, physicians license number and/or S2 number for prohibited drugs, in accordance with the Generics Law 4. Post-Graduate Interns a. Charts new cases and is expected to write a complete history, perform thorough physical and neurologic examination, give a logical assessment and make an appropriate management plan for the patient b. Refers all cases seen to the resident c. Attends the required scheduled activities of the section 5. Nurses a. Should be at the GPC by 8:00 AM b. Makes sure that all equipments and materials needed at the clinic are in good working condition c. Confirms eligibility of the patient based on the OPD requirements d. Gets anthropometrics and vital signs of patients e. Serves as the triage officer f. Prepares the patients database and other forms that needs to be filled up by the intern and resident g. Endorses the patient to the intern for initial assessment h. Prepares medications and other materials for procedures 6. Social Worker a. Assesses eligibility of patients b. Assists patients to be referred out (ex. other hospitals, for laboratories, for admission) F. Equipment and Physical Plant Requirements 1. Standard Equipment Weighing scale Lengthometer Thermometer Measuring tape BP apparatus with cuffs of different sizes Diagnostic set Negatoscope Equipment rolling tray Growth charts Nutrition charts Immunization charts Logbooks Reference books 2. Emergency equipment and drugs, for emergency situations like an anaphylactic reaction or neurogenic shock. Ambu-bag (2 sizes) pediatric & neonatal Laryngoscope Endotracheal tubes Suction Machines
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Oxygen tank / O2 mask & tubings/O2 catheters I.V. fluids Venosets and butterflies Emergency drugs (Extra batteries & laryngoscope, syringes), Epinephrine, NaHC03, Hydrocortisone, etc (Such specific emergency equipment and/or drugs should be kept in readiness at the GPC)

G. Rotating General Pediatric Consultants 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Dr. Alma Bie Dr. Marthony Basco Dr. Cristina Bernardo Dr. Josephine Bondoc Dr. Anna Crucillo Dr. Gee Serafica-Diaz Dr. Josephine Dimayuga-Dela Pena Dr. Jocelyn Echiverri Dr. Fatima Gimenez Dr. Rosario Isada Dr. Sally King Dr. Anne Orendain Dr. Xeres Luz Dr. Edna Morada Dr. Elizza Senseng Dr. Heidi Villanueva

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SUBSPECIALTY CLINICS CARDIOLOGY CLINIC I. Objectives A. Service To deliver holistic care to children with cardiac problems To provide initial consultation for patients suspected with CHD, Rheumatic Fever and RHD To give specific care (advice) for children with CHD, RF and RHD To monitor status of children with RHD

B. Training To provide training for pediatric residents and interns in the recognition, diagnosis, management, and rehabilitation of Congenital Heart Disease, Rheumatic Fever and Rheumatic Heart Disease To provide post-graduate interns an opportunity to gather data and examine patients with cardiac disease To provide a venue for developing and reinforcing teaching potentials of the rotating cardiology residents and other personnel To recognize and practice the role of pediatricians in implementing the multidisciplinary approach in the care of chronically ill children especially those with heart disease

C. Research To encourage research on pediatric cardiology diseases seen in the clinic

II. Policy Guidelines A. Clinic Schedule & Venue 1. The Cardiology Clinic is held every Mondays and Wednesdays 2:00 PM to 4:00PM at the Lower Ground of TMC. B. Patient Quota 1. The Cardiology Clinic can assess and manage a maximum of 5 patients (follow-ups and new cases) per clinic day. Unscheduled patients from the General Pediatric Clinics may be seen on a case to case basis. C. Admission Criteria 1. All patients perceived to have cardiac problems should be referred to the Cardiac Service. D. Referrals 1. Patients seen for the first time in the clinic should be registered and a registry form incorporated in their charts.
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2. Follow-up patients are examined, evaluated and will have their names recorded in a special follow-up logbook. 3. Referral Protocol for all patients: a. Chart with clinical abstract b. Patients with referral letters from physicians outside of TMC may go directly to the Cardiology Clinic without being seen at the General Pediatrics Clinic. c. Results of the ECG and Chest x-ray need not be in for the patients to be seen by the Cardiology service 4. Criteria for referral to the Cardiology Service: Children suspected to have congenital heart disease with any of the following findings: - Murmurs - Cyanosis - Irregular rhythm - Multiple congenital anomalies - Syncope - Abnormal cardiac findings on ECG and Chest x-ray 5. Patients with cyanosis aged < 1 year, cardio-respiratory distress, hyper cyanotic spells, heart failure, symptomatic arrhythmias and syncope on exertion are to be referred as emergency cases. They should be referred immediately to the senior resident and consultant-on-deck. 6. Children diagnosed elsewhere to have CHD. 7. Patients discharged from the Divine Mercy Program and diagnosed to have cardiac anomaly. 8. Children who have undergone close heart and open-heart surgery. 9. When CHD needs to be ruled out against RHD. 10. Age limit: birth to 18 years and 364 days E. Diagnostics 1. All diagnostic procedures will be referred to Pasig General Hospital. 2. For patients to be seen for the first time: History and P.E. including BP in all extremities CBC for cyanotic patients ECG- for difficult cases, ECG should be done immediately at the PER by the Resident in Charge Chest x-ray ESR, CRP, ASO for patients where CHD is to be differentiated from RHD or whose presence of both is suspected such as in Lutembacher (ASD & Rheumatic MS) 3. For follow-up patients: ECG as needed Chest X-ray as needed CBC every 6 months and as needed for cyanotic patients, as needed for the acyanotic patients Echocardiography every 12 to 18 months or earlier as needed For pre-op hemodynamics presentation: ECG, Chest x-ray & Echocardiography should have been done within the last 3 months before presentation

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F. Discharge Criteria 1. All patients seen at the Cardiology clinic should be continually followed up by the residents and as such, no patient will be discharged from the clinic except for patients who reach adulthood.

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NEUROLOGY CLINIC I. Objectives A. Service To follow-up neurology patients discharged from the TMC Divine Mercy Program who would need continuity of care To evaluate and manage patients with neurologic problems referred from the General Pediatrics Clinic (GPC) and other Specialty Clinics

B. Training To provide opportunities for Residents to diagnose and manage neurologic disorders in the out-patient setting To provide a venue for postgraduate interns to acquire skills in data gathering and examination of patients with neurologic problems

C. Research To establish a database or registry of neurologic cases seen at the clinic for future studies by residents and interns

II.

Policy Guidelines A. Clinic Schedule & Venue 1. The General Neurology Clinic is held every Thursday from 9:00AM 12:00 NN. The clinic is held at the Lower Ground, Podium, TMC. B. Patient Quota 1. The Neurology Clinic can assess and manage a maximum of 5 patients (follow-ups and new cases) per clinic day. 2. All patients seen per clinic should be previously scheduled except for emergencies or patients needing immediate referral. In these cases, direct referral from the resident of the GPC or subspecialty clinic should be done. C. Admission Criteria 1. Patients who may seek admission to the clinic are as follows: Patients referred from the GPC and other subspecialty clinics needing neurologic evaluation and/or management. All neurologic cases discharged from TMC Divine Mercy Program who will need continuity of care by the neurology service are seen at the clinic. However, schedule of follow-ups should be done prior to discharge of the patients. In addition, these patients should have been previously referred to the service for evaluation. In cases where close follow-up is necessary, the resident rotator should coordinate with the clinic nurses to give such patients priority in scheduling.

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D. Referrals 1. Patients referred to Neurology Clinic should be screened first at the GPC or other Subspecialty Clinics. 2. Referrals from other departments may, however, be directly seen at the Neurology clinic. 3. Requirements prior to a referral include: Complete history, physical examination as well as a neurologic examination A working impression The reason for referral 4. All neurologic cases requiring clearance for a surgical procedure may be cleared at the GPC except if with seizures. However, if the patient is co-managed by Neurology Service, Neurology will give the clearance. E. Diagnostics 1. No laboratory work-up is required prior to referral. 2. Work-ups of patients depend on the discretion of the referring resident. 3. In addition, treatment may be started right away even in the absence of an EEG except for questionable seizures. F. Follow-up Schedule of Patients 1. Patients regularly seen at the Neurology clinic will have the below follow-up schedule: Thursdays at 9AM to 12NN. G. Discharge Criteria 1. Patients having the following specific conditions may be discharged from the Neurology clinic: Uncomplicated suppurative meningitis Simple febrile seizures GBS with return of some motor power and reflexes Viral encephalitis without complications 2. Patients who are beyond 21 years old may be discharged from the clinic and referred to adult neurology clinic if further follow-up is necessary.

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PULMONOLOGY CLINIC I. Objectives A. Service To render optimal care for patients with pulmonary diseases To educate parents and patients on the nature and progress of the pulmonary illness

B. Training To provide opportunities for Residents to diagnose and manage pulmonary disorders in the out-patient setting To provide a venue for post-graduate interns to acquire skills in data gathering and examination of patients with pulmonary problems

C. Research II. To encourage research on pediatric pulmonary diseases seen in the clinic

Policy Guidelines A. Clinic Schedule & Venue 1. The Pulmonology Clinic is held every Tuesday at 9 to 12 noon and Thursdays at 2 to 4 PM. All are held at the Lower Ground, Podium (Hospital Building), TMC. B. Patient Quota 1. The Pulmonology Clinic can assess and manage a maximum of 5 patients (follow-ups and new cases) per clinic day. 2. Unscheduled patients coming to the clinic shall be seen last. 3. However, in case there are already too many patients for the day, rescheduling shall be done. C. Admission Criteria 1. Patients who may seek admission to the clinic are as follows: Patients referred from the General Pediatric Clinic needing pulmonary evaluation and/or management All pulmonary cases discharged from the TMC Divine Mercy Program who will need continuity of care by the Pulmonary service are seen at the clinic. However, schedule of follow-ups should be done prior to discharge of the patients. In addition, these patients should have been previously referred to the service for evaluation. In cases where follow-up is necessary, the resident rotator should coordinate with the clinic nurses to give such patients priority in scheduling. This includes in-patients as well as patients at the OPD. 2. Unscheduled patients coming to the clinic shall either be seen last or in case there are already too many patients, shall be scheduled for another clinic day.

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D. Referrals 1. All out-patients with pulmonary problems shall initially be seen and screened at the GPC. 2. Patients from other specialty clinics may be referred directly to the Pulmonary clinic with the accompanying results of the initial laboratory work-up and the signature of the specialty clinic residents. 3. Referrals from other departments may be directly seen at the clinic. 4. Requirements prior to a referral include: Complete history and physical examination A working impression The reason for the referral 5. Patients for referral to other services will be referred using the standard referral policies with an abstract and referral slip. 6. Patients for admission may be referred to Pasig City General Hospital or to TMC Divine Mercy Program. E. Diagnostics 1. All diagnostic procedures will be referred to the Pasig City General Hospital. 2. Mandatory work-ups at the GPC for patients referred to the Asthma Clinic shall include: Spirometry Exercise challenge test (optional) Chest x-ray AP-L view for moderate to severe persistent asthma 3. Patients referred to the Pulmonary clinic should have an initial Chest x-ray prior to the referral. 4. The following diagnostics are needed prior to pulmonary clearance: CBC Chest x-ray Spirometry (obstructive/restrictive) F. Discharge Criteria 1. Patients will be discharged from the clinic only with the discretion of the senior resident and with the approval of the Service Consultant on a case to case basis.

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MANAGEMENT OF SUSPECTED CHILD ABUSE PATIENT IN THE EMERENCY DEPARTMENT, NURSING UNITS, AND OUTPATIENT CLINICS I. Policy Statement Suspected child abuse patients who come to the Emergency Department, Nursing Unit, and outpatient clinics will be managed according to the law (Republic Act 7610: Special Protection of Children against Child Abuse, Exploitation and Discrimination Act). II. Policy Guidelines 1. This policy as governed by Republic Act 7610: Special Protection of Children Against Child Abuse, Exploitation and Discrimination Act defines children as follows: Persons below eighteen (18) years of age or Those over eighteen years of age but are unable to fully take care of themselves or protect themselves from abuse, neglect, cruelty, exploitation or discrimination because of a physical mental disability or condition; 2. "Child Abuse" refers to the maltreatment, whether habitual or not, of the child which includes any of the following: Psychological and physical abuse, neglect, cruelty, sexual abuse and emotional maltreatment. 3. A suspected child abuse patient presenting at the ER may include the following: a. A patient brought to the ER for the purpose of examination of alleged child abuse b. A patient who during the course of evaluation at the ER for another concern has medical examination findings that indicate child abuse c. Suspicious child death d. A patient admitted at the floors and assessed to be a suspected child abuse patient 4. A suspected child abuse patient may also include the following: a. A patient seen at TMC for the purpose of management of alleged child abuse b. A patient who during the course of evaluation at TMC for another concern has medical examination findings that indicate child abuse. These may include but not limited to the following: Diagnosis of N. gonorrheae, Chlamydia, Syphilis, HIV or other sexually transmitted infections not perinatally acquired. Pregnancy in or delivery by a child who is less than 13 years old Pregnancy in or delivery by a child with disclosure of abuse or rape Suspicious physical injuries with incompatible history such as pattern burn injuries, multiple fractures, fractures of different ages, intracerebral hemorrhage, etc. Retinal hemorrhages in an infant Unexplained head trauma Suspicious child death Any disclosure of abuse by the child 5. Any suspected child abuse patient will be referred to the Department of Social Welfare and Development (DSWD) as required by law, to wit: The head of any public or private hospital, medical clinic and similar institution, to the DSWD within 48 hours of learning of the abuse. (R.A. 7610, I.R.R., Reporting and Investigation of Child Abuse Cases, Sec. 4; P.D. 603, Art. 166) 6. The suspected child abuse report (please refer to Attachment E) should be prepared by the Attending Physician and faxed to one of the following :

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a. Department of Social Welfare and Development DSWD Bldg., Constitution Hills, Batasan Complex, Q.C., Philippines Tel. (632)931-81-01 to 931-81-07 b. DSWD-NCR Ugnayan Pag-asa Crisis Intervention Center Legarda, Manila (02) 734-8617 to 18 c. DSWD Social Protection Unit Quezon City (02) 931-9133/932-2573 d. DSWD (Pasig City) (02)643-5010 7. The management of these patients with regards suspected abuse would also be referred to a child protection specialist (Regular and Visiting Staff of the Medical City Department of Pediatrics).

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MANPOWER PLANNING I. Proposed Staffing Pattern ANALYSIS ELEMENTS Professional Manpower Consultants SHORT TERM (2005-2007) Please see attached recruitment targets 21 27 Nurses 1:2-3 1:7 1:1 NICU(80-100 beds) and PICU (14 beds) 1:1 Pediatric Floor/Wing 1:4 LONG TERM (BY 2015) Please see recruitment targets (table below) JUSTIFICATION/REMARKS

Residents 45

6 residents each for 5 independent service areas (WARDS, ER, OPD, NICU, PICU), 1 resident for Community Pediatrics, Adolescent Clinic Aside from full NICU and 12bed PICU complement, provision for one whole wing/ floor for Pediatrics

The department aims for a balanced staffing of highly qualified clinicians, with at least 2 recruited general pediatricians or sub specialists in each of the 18 focus subspecialties. The proposed staffing pattern until year 2010 is as follows: ACTIVE & VISITING General Pediatrics Adolescent Medicine Allergy & Immunology Ambulatory Pediatrics Cardiology Dermatology Developmental Pediatrics Endocrinology & Metabolic Gastroenterology & Nutrition Genetics Hematology Infectious Disease Intensive Care Neonatology Neurology Nephrology Oncology Pulmonology Toxicology CURRENT 62 3 3 3 6 1 3 2 (1) 2 2 4 3 2 5 2 2 4 1 2006 2 2007 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2008 2 2009 2 1 2010 2

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II.

Strategy Action Plan STRATEGY ACTION STEPS TIME FRAME April UNIT RESPONSIBLE APB Section Head Chair

Review/ Update of Profile current manpower Medical Manpower complement Requirements (NEEDS ANALYSIS) Determine current service areas Updated Manpower Plan Determine current manpower complement per service area Determine future service areas requiring additional manpower complement and project manpower needs Determine future events requiring additional manpower (medical school and new hospital wing) and project manpower needs Determine baseline service utilization/ patient load and revenue generation of current manpower complement Project future service utilization/ patient load and revenue generation for the department and determine additional manpower required to meet projections Project manpower requirement

April

April

April

April

April

April

May

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STRATEGY Creation and maintenance of a recruitment database Database is created and maintained

ACTION STEPS

TIME FRAME

Determine database content April April Design and produce information sheet April List ten major target hospitals as source of April and every recruit January if each year thereafter Obtain list if new pediatric residency graduates from 10 major target hospitals End of April and after every PPS convention Obtain list of new each year diplomats and fellows from PPS April

UNIT RESPONSIBLE Department

Obtain a list of pediatricians from medical society of Pasig, Mandaluyong, Quezon City, and the Rizal towns Obtain a list of pediatricians in mall based practices in the Ortigas, Eastwood, Mandaluyong area Verify list and data gathered Encode database Verify current database Obtain new entries

April

May June January of every year January of every year

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STRATEGY Tracking and recruitment of top TMC trainees

ACTION STEPS Ask all graduating residents to accomplish information sheet for database Review and verify graduates database

TIME FRAME September

UNIT RESPONSIBLE Department

September

September Establish and maintain an e-group of TMC graduates Start an annual registration and update of database of all TMC graduates through egroup Identify top 20% of specialty and subspecialty board passers Special recruiting teams Send invitation and brochure of TMC Identify team members Meet teams to set objective and make plans June June

September

ID and recruitment of topnotch MDs

May (PPS) May onwards (subspecialties)

June onwards

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RECRUITMENT PROCESS

SELECTION OF INCOMING RESIDENTS Every year, the Residency Training Committee undergoes a tedious and thorough process of selecting applicants for the training program. Application starts every September of each year. Applicants are required to take the qualifying written examination composed of questions submitted by the members of the RTU and selected generalists and subspecialists. They are then interviewed by a panel of RTU members using the unified interview questionnaire formulated in 1997 by The Medical Citys Committee on Medical Education and Professional Development under the leadership of Dr Mediadora Saniel. Qualified applicants undergo a one-month pre-residency training program. I. Policy Guidelines A. General Policies 1. Only applicants with good moral character and who have never been convicted of any crime shall be admitted to this department. 2. Only applicants with attitudes suitable for pediatrics will be accepted. 3. Only applicants with good academic records will be admitted. 4. Filipino citizens will be given priority for admission to the program. Foreign graduates shall only be admitted based on the rules and regulations set by the Professional Regulation Commission and The Medical City. 5. Qualified applicants who are not admitted may re-apply in any succeeding academic year. 6. Other relevant hospital policies on admission shall also apply. 7. Application forms are available at the Medical Training Office at the 2nd floor of Podium Building anytime starting June until September 31. B. Entrance Requirements 1. Entrance requirements shall be as follows: Doctor of Medicine degree from an accredited college or university Completed internship from an accredited hospital Passed the Physicians Licensure Examination conducted by the Board of Medicine of the Professional Regulation Commission Satisfactorily completed pre-residency Must undergo interview by a panel designated by the Residency Training Committee C. Admission Policies 1. An applicant must submit to the Medical Training Office a complete application. A complete application includes: Completely accomplished application form of The Medical City Application letter addressed to the Department Chair (2) 2x2 Colored I.D. picture with red background (2) Letters of recommendation Resume Class ranking Transcript of Records (certified true copy) Diploma (certified true copy)
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2. 3. 4. 5. 6. 7.

Certificate of Internship (certified true copy) Board Rating PRC License Card Birth Certificate Marriage Contract The Medical Training Office will forward complete applications to the Department of Pediatrics. Qualified applications will be asked to take the written examination. A panel interview will be conducted by the Residency Training Committee members. Selected applicants will be asked to undergo pre-residency training for one month. At the end of the pre-residency, applicants will be required to do a case management presentation. Members of the Residency training Committee will evaluate the presentation. The Department of Pediatrics and the Residency Training Committee reserve the right to refuse admission to any applicant for any due cause.

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DEPARTMENT STAFF PROFILE The department hosts a staff of one hundred twelve (112) pediatricians (42 and 70 active and visiting consultants, respectively). Fifty four (54) consultants belong to 17 subspecialty sections, most of which still continue to practice general pediatrics, exclusive of the sixty-three (62) general clinicians in the faculty. Sixteen (16) other consultants were recognized as affiliate subspecialists. Sixteen (16) pediatricians have pursued masters and post doctorate studies. Fourteen (14) pediatricians belong to the Satellite clinics, located in the areas of Sta. Lucia, Antipolo, Cainta, Fairview, Pasig and Congressional Avenue. (For Current Roster of Subspecialty Consultants, General Pediatricians and Affiliate Subspecialties please refer to Attachment F) (For list of consultant development programs please refer to Attachment G)

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STAFF TECHNICAL TRAINING REQUIREMENTS

DEPARTMENT OF PEDIATRICS MENTORSHIP PROGRAM To ensure that every resident receives appropriate professional and personal guidance during his/her residency training, each resident who enters the Department of Pediatrics is assigned to a mentor at the beginning of the training program. The chosen mentor remains in charge of the trainee for the entire 3 years of residency training. All Consultants of the Department of Pediatrics are eligible to become mentors. A. Duties of the mentor include but are not limited to: 1. Receive a summary of evaluations from the Residency Training Unit and discuss this with the trainee quarterly. 2. Supervise/approve all formal presentations to be given by the trainee during the course of residency. 3. Provide/facilitate research opportunities for the trainee. 4. Provide/facilitate subspecialty exposure 5. Facilitate professional advancement/opportunities for continuing training/education. 6. Act as liaison between the Residency Training Unit and the trainee as needed. 7. Inform the Residency Training Unit of any commendations or special concerns regarding the trainee. B. Responsibilities of the Pediatric Resident/Trainee: 1. Meet with his/her mentor at least once every quarter to obtain an evaluation as well as give feedback regarding his/her training experience 2. Inform his/her mentor of all assigned formal presentations and have the mentor evaluate presentations beforehand 3. Discuss with the mentor his/her areas of interest (clinical and research) 4. Discuss with his/her mentor any significant untoward events that may occur 5. Disclose any personal issues that may interfere with his/her residency training and clinical obligations.

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GUIDANCE AND COUNSELING SERVICES FOR RESIDENTS Each resident is assigned a specific consultant mentor who monitors and supervises the residents performance and well being while in the department. It is the duty of the specific consultant adviser to counsel the resident in terms of academic growth, relationship with peers and adjustment to the residency program. In cases where a resident is not performing at par, the Residency Training Committee, headed by Dr. Carlos E. Paguio, coordinates with the consultant adviser so as to provide a stronger support system.

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GUIDELINES FOR PRECEPTORSHIP I. Department of Pediatrics Clinical Preceptorship Program A. Objectives: To provide a formal venue for regular clinical teaching To provide an objective basis for evaluating the pediatric residents clinical skills and knowledge B. Policy Guidelines 1. Preceptorship Assignment a. Each division of the Department of Pediatrics (Ward, NICU, PICU, ER) will have a designated group of preceptors b. One preceptor is assigned to each division/service every 2 weeks. c. The assigned preceptor will perform teaching rounds with all residents presently rotating in the unit/division at least once in the assigned 2-week period, and as often as everyday. d. All consultants of the Department of Pediatrics, including those whose practice is mainly out-patient based, are eligible to become clinical preceptors. 2. Conduct of Preceptorial Session a. One or two patients from those currently admitted in the unit/division will be selected for discussion during each preceptorial session. These patients need not be personal patients of the preceptor. Any patient currently admitted can be chosen for discussion, unless otherwise indicated by the patients Attending Physician. b. The session is conducted in a private area (family conference room/division conference room) to ensure patient privacy. c. The resident-in-charge is asked to present the patients history and course, though all residents are encouraged to join in the discussion. d. The discussion should include: complete history, complete physical exam findings, differential diagnosis, appropriate diagnostic tests and proper interpretation of results, appropriate course of management including clinical practice guidelines (if any), prognosis, prevention, anticipatory guidance and any implications on public health. e. Each preceptorial session should last no longer than 1 hour. 3. Residents Evaluation Each resident who is present during the preceptorial session is to be evaluated using the Clinical Skills Evaluation form. (See Attachment D) As indicated in the form, the basis of evaluation is the residents ability to obtain a complete but concise and directed history, perform a complete targeted physical examination, come up with reasonable differential diagnosis based on history and physical exam, determine the appropriate diagnostic tests to be performed, accurately interpret test results, make the correct diagnosis, discuss the pathophysiology and natural course of the disease, discuss appropriate management, formulate a discharge and follow-up plan, and identify any long-term implications of the patients disease/condition. Should the preceptor feel that he/she is unable to evaluate a resident for a particular session, the resident should be informed. It then becomes the responsibility of the resident to schedule another preceptorial session in order to obtain an evaluation. 4. Evaluation of Preceptors Each preceptor will receive an evaluation from the residents presently rotating in his/her service/division at the end of the rotation
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II.

Pre-Residency Training Program A. Objectives 1. To learn basic pediatric knowledge regarding: The common disease in the pediatric age group, their manifestation, pathophysiology, clinical course, diagnosis and management Basic pediatric skills: - Intravenous insertion - Nasogastric tube insertion/ gastric lavage of the newborn - Endotracheal intubation - Blood extraction in patients less than 1 year old - Umbilical cannulation - Lumbar puncture To learn how to make a concise but comprehensive clinical history and physical examination To learn the proper decorum and bedside manners toward pediatric patients To provide the Residency Training Committee an opportunity to evaluate applicants During the pre-residency period, the applicants have to present at least one case management report. They are expected to go on duty under the direct supervision of the first year and senior residents on duty. The consultant staff will give lectures on selected topics. At the end of the pre-residency period, the Residency Training Committee evaluates the performance of the pre-residents and chooses those will go into the regular residency program.

III.

Pediatrics Research Program One of the departments thrusts as far as its academic growth is to encourage and contribute to research output. It is the departments aim to produce 2-4 winning papers a year, with an end goal of having at least 1 published paper per year. The department has organized its own Research Committee, headed by Dr. Susanna L. Lopez. The members are Drs. Olympia O. Malanyaon, Agnes Alarilla-Alba, Cynthia B. Gomez, Teresita N. Rabanal, Jacqueline O. Navarro and Cynthia A. Aguirre (RTC representative). It functions to gather research materials, review submitted protocols and assist in the proper conduction of researches. The department has adapted the policies formulated by the hospitals Research Committee. In compliance with the PPS-HAB requirements on Research, the department requires all its residents to formulate a research question, submit a protocol, conduct the research and submit a research paper before graduation from the three-year training program: The first year residents are required to develop and submit a research protocol prior to promotion to the next year level.

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The second year residents are required to perform the actual research, present it in department research contest and submit a completed research paper before they are promoted to third year residency The third year residents are expected to make final revisions on their research papers.

The department has been receiving full support from The Medical City, organizing research workshops facilitated by distinguished members of the Committee on Medical Education and Professional Development. The Medical City also has a full complement Ethics Review Board which approves researches involving patients. In its desire to stimulate a positive attitude and develop the skills in research utilization and development among the residents, the hospitals Committee on Research organized an annual research workshop on Evidence-based Medicine & Protocol Development, concluded last February 2004 at the MSD Office in Philam Towers, Makati City. First year residents from all departments participated in this. For 2005, the department sponsored a protocol development workshop in January for the second year residents which the first year residents also attended. Included in its program of activities is participation in a series of research for a held at various months of the year. Cash grants provided by the hospital, the department and the F.I.R.S.T are available and awarded to deserving protocols. Researches submitted annually are first entered in the intradepartmental research paper presentation, scheduled during the last quarter of the training year. Winning papers are later submitted in several other for a, such as interdepartmental, intra- and interhospital research paper contests (e.g. F.I.R.S.T) as well as pediatric societies research presentation. IV. Pediatrics Research Division A. Mission Promotion, publication and utilization of quality, relevant and ethical research those benefits The Medical Citys pediatric patients, professional staff and communities it serves engaging the departments strategic partners who share the departments vision and passion. B. Objectives To motivate and train consultants and residents to do research To guide consultants and residents in the conduct of the research To advocate for research publication and utilization To generate funding for research To establish, manage and sustain relationship with research grantors C. Strategies 1. Coordinate with the hospitals research committee regarding research training. 2. Provide opportunities for consultants and residents to engage in research related training and activities. 3. Identify potential sources of funding both locally and internationally and outline processes and requirements for a funding/grant application 4. Identify venues/ journals for publishing research papers and obtaining requirements for these 5. Identify venue for presentations(e.g. subspecialty for a) of research papers both locally and internationally

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D. Policies 1. The first year resident should have a research protocol co-authored by a pediatric board certified consultant of the TMC 2. The second year resident should conduct, analyze data of his/her research 3. The third year resident will revise and fine tune written manuscripts for submission to PPS and international and regional journals. 4. All researches shall be guided by the policies of the Hospitals Research Committee as stated in The Medical City Operations and Procedures Manual No. 17. Likewise they have 5. to comply with the TMC Pediatric Department Research Policies 6. All researches would be reviewed and approved by the departments technical review board (TRB), hospitals institutional review board (IRB) and the ethics review board (ERB). 7. Each resident will have consultant co-author/s, one of whom is a member of the research division. 8. The second year resident must complete the conduction, analysis and presentation of research before the end of the second year as a prerequisite for promotion to the 3 rd year of residency. The 2nd year resident should have been issued a certificate of participation in the annual research presentation/ contest E. Procedures 1. The first year residents will receive training through the hospitals research committee on the following topics: a. Research methodology b. Sample size and stat analysis c. Writing scientific paper d. Evidence-based medicine e. Metaanalysis f. Economic Analysis 2. Once protocols are made, they are submitted to the department of pediatrics technical review board (TRB) and the Hospitals Ethics Review Board (ERB). If needed, the Hospitals Institutional Review Board (IRB) will also review the paper. 3. The resident with their respective co-authors will present the research protocol to the ERB. 4. If funding would be requested, a grant application would be submitted to the hospitals research committee 5. The conduct of research would be done from January to July of the second year level. The data analysis and paper writing would be done on August and September and presented in appropriate for a on October onwards. 6. The revised written paper would be submitted to the Research Division for review by the Research Publications Unit. The author together with the Research Publications Unit would assist the researcher in finding the appropriate venue/journal for its publication or the appropriate subspecialty forum where it could be presented. 7. The co-authors are to sign the completed written research paper before submission to PPS as part of the pediatric diplomat exam requirement. F. Budget The resident upon submission of research protocol must indicate budget or expenses for said research and may apply for support from a research funding body.

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G. Evaluation Research is evaluated through several ways: 1. Through the departments TRB, hospitals IRB and ERB using the research proposal checklist (please refer to Attachment H) and the evaluation used for judging papers (please refer to Attachment I). 2. If for publication then the research is submitted to appropriate journals as guided by journal requirements for authors H. Venue for Research presentation 1. Departments Annual Scientific Paper Presentation 2. The FIRST annual research paper contest 3. The Medical Citys Interdepartmental Research Contest 4. The TIPPS research contest 5. PPS and subspecialty society for a and regional and international conventions (Please refer to Attachment J Sample Unit Work Plan, Attachment K for the List of Research Papers and OPM No. 17 Research Office for the detailed policies and procedures) V. Community Pediatrics A. Rationale of Community Pediatrics With the Philippine Pediatric Society (PPS)-Hospital Accreditation Board (HAB) thrust of community exposure and development for all accredited hospitals, the Department of Pediatrics of The Medical City embarked on a regular community program, two years after the inception of its training program in 1980. Pariancillo Health Center in Pasig City was the pioneer site for such an activity. This was later moved to Ugong Health Center, Pasig City, a site that is easily accessible to the hospital. Since then, the consultants and residents of the department have continued to serve the health needs of the children in the community. It has been a fertile ground for achieving the desired census for the departments well baby/well child clinics. Several years have passed. The children are growing up to adulthood. Health maintenance and disease prevention remain to be the goals of community pediatrics. However, these goals cannot be the single responsibility of the health care providers alone. In June 2003 the Community Health Program (CHP) was conceptualized wherein partner agencies have been invited to participate in the childs well-being and health. This gigantic task is being shared with the government, non-government, and socio-civic organizations. B. Vision and Mission VISION To be an exemplary Phase III Community Health Program (CHP) geared towards improving the child health status of communities and empowering these through the collaborative partnership of the Department of Pediatrics of The Medical City and other socially-responsible agencies. MISSION The Department of Pediatrics of The Medical City is committed to developing more appropriate responsive CHP that will: 1. Promote child survival and well-being in the identified community.

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2. Work together with other advocacy groups that will hasten the development and empowerment of the community towards self-reliance and self-sufficiency. 3. Enhance social awareness and learning opportunities for the pediatric residents and other trainees. C. Consultants Job Description 1. Subcommittee on PROGRAMS Community organization / coordination of working groups Operations review Responsible for the activities Map out plans / job description of interns, residents and consultants Development of modules Monitoring and evaluation function of program / activities Weekly lectures didactic and activity workshops Community integration / social integration identifies person in the community whom TMC people go to; orients residents to community program / work, their way of living, beliefs, etc.; integrates program to be part of the residents training program. Involvement of subspecialties in COMPEDS referrals (setting up referral system); link to involving subspecialties as community generalist consultant. 2. Subcommittee on OPERATIONS Human resource planning; scheduling of residents / consultants; activity secretariat. Preparation of logistic support, transportation, materials, equipment, etc. Documentation of all activities (pre, actual and post-activity); archiving Budget preparation / tracking Financing Internal and external evaluations and monitoring to assign another person / group Hiring of social worker who can act as administrative officer Set up the system hire staff, create documentation system, data base costing, communication (meetings) like setting up venue, materials needed such as laptop, LCD, etc. 3. Subcommittee on LIAISON Setting meetings with partner agencies Resources Meeting with residency training committee Coordinate projects / programs with partner agencies D. Residents Job Description 1. One resident rotator is assigned to the community for two successive months. 2. He is expected to be at the community from 9:00 AM to 3:00 PM. 3. He is expected to finish paper works from 3:00 PM onwards when he is back in the hospital. 4. He is required to have at least one mini-paper/project during his rotation. 5. He holds health education encounters with the community. 6. He becomes manager, social mobilizer, clinician, reasearcher, and educator during his stay at the community.

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E. Resident Rotation in Community Pediatrics WEEKLY SCHEDULE Monday Tuesday Wednesday Thursday Friday

A.M. Nutrition Health Education (BHW) Health Education (Mothers & Caregivers) Sick Child Clinic Health Education (BHW)

P.M. Health Education (School) XXXXX** Individual Project Implementation Health Education (School) XXXXX**

* Monday to Friday

9:00 3:00 P.M. Community Work 3:00 5:00 P.M. Back in hospital doing integration of data / paperwork

** Tuesday P.M. (Not in community) FIRST Activity Friday P.M. (Not in community) Department Mini-audit and Grand audit (1st and 2nd Fridays) F. Community Health Program YEAR PLANNER Theme for the Month (In cooperation with DOH thrust) JANUARY Orientation to residents Orientation to consultants (members of Community Pediatrics committee) IMCI Dental Health BHW Survey Injury Prevention Nutrition Nutrition Physical Fitness (Annual physical check-up in Francisco Legaspi Memorial Elementary School)

FEBRUARY

MARCH APRIL MAY JUNE

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JULY AUGUST SEPTEMBER OCTOBER NOVEMBER DECEMBER G. Community Diagnosis 1. Introduction

Dengue Awareness Tuberculosis EPI Food Safety Awareness Substance Abuse IMCI

Barangay Ugong is one major community that makes up the City of Pasig. Barangay Ugong , (Purok 1-6), is the adopted community of the Department of Pediatrics, The Medical City. It is located at the bank of the Marikina River, which also borders the barangays South-Southeastern margin. On the north side is part of Quezon City (Barangay Ugong North) and Valle Verde occupies the western side of the community. Surrounded by large factories and industrial buildings, Barangay Ugong (Purok 1-6) has a total land area of 394 hectares, with an Internal Revenue Allocation of Php34 million. The present Barangay was created by virtue of Presidential Decree No. 557 signed on September 21, 1974. Barangay Ugong is divided into 6 smaller communities (Table 1), with a total population of 24, 791 (year 2003). Table 1 Estimated Population per community in Barangay Ugong Pasig City (2003) Barangay Ugong Population Total Percent Purok 1 2025 8361 33.73 2 1535 3 1511 4 1325 5 1326 6 639 Valle Verde 1 2450 10143 40.91 2 1750 3 980 4 595 5 2982 6 1386 Landmark 1 434 1239 5.00 2 805 Barangay Ugong Population Total Percent Casa Verde 889 889 3.59 Las Villas 3189 3189 12.86 Kaimitoville 970 970 3.91 Total 24791 24791 100.00
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2. Demography of Barangay Ugong: Puroks 1-6 Among the six puroks, Purok 4 contributes to 25% of the total population, followed by Purok 1 with 23%. The least populated purok is Purok 6 contributing to only 5% of the total population of the Barangay. Barangay Ugong has a male: female ratio of 1:1 in all ages. Figure 1. Population per Area, Bgy. Ugong Puroks 1-6 (Nov. 2003)

Purok 5 16% Purok 4 16%

Purok 6 7% Purok 1 25%

Purok 3 18%

Purok 2 18%

The majority (60%) of the eligible working force of the Barangay (ages 18-59) belongs to Purok 4 (23%), Purok 1 (23%) and Purok 2 (21%). In contrast with the countrys 67% of children in secondary school, only 18% of the population in Barangay Ugong was eligible for schooling. Purok 4 contributes to 27% of the eligible children for schooling, and Purok 1 has 24% of these children. Sixteen percent (16%) of the population in Barangay Ugong belong to the under 6years of age bracket. Majority of this age group is found in Purok 4 (23%), Purok 2 (21%) and Purok 1 (19%). Table 2 Age-Gender distribution Barangay Ugong (Nov. 2003) 0-2 3-6 7-17 18-59 >60 total M F M F M F M F M F Purok 1 68 46 87 75 170 167 501 550 49 47 1760 2 40 64 69 86 136 119 466 487 28 38 1533 3 30 32 52 49 74 62 237 248 32 34 850 4 59 66 75 79 191 188 499 530 37 55 1779 5 34 35 50 55 109 121 373 362 26 21 1186 6 15 10 16 16 46 37 127 129 6 5 407 Total 246 253 349 360 726 694 2203 2306 178 200 7515

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Figure 2. Age-Gender Distribution, Bgy. Ugong (Nov. 2003)


>60 18-59 7-17 3-6 0-2
-2500 -2000 -1500 -1000 -500 0 500 1000 1500 2000 2500 Female Male

3. Socio-Economic Characteristics of Barangay Ugong As of 2003, Barangay Ugong has a registered household of 2084 families, 22% of which are residing at Purok 1, 21% at Purok 2 and 18% in Purok 4. More than half of the families (61%) have an average of 4 household members and only 8% of the total families registered have more than 7 households. Majority of families with more than 7 households are found in Purok 3 (29%). Table 3 Family Size per area Barangay Ugong (2003) Purok 1 2 3 4 5 6 Total 1-4 306 284 155 247 218 68 1278 Number of Households 5-6 >7 123 41 125 20 160 48 116 23 87 26 29 8 640 166

Total 470 434 363 386 331 105 2084

Houses in Barangay Ugong are of mixed materials, made of concrete, wood and steel. As of the type of ownership, 55% of the houses are privately owned, and most of these houses are found in Purok 1 (22%), Purok 5 (21%) and Purok 2 (19%). Almost one third of the houses in the Barangay are being rented by its inhabitants and majority of these types are found in Purok 1 (22%), Purok 2 (22%) and Purok 4 (21%). There are also sharers of rooms (boarders) that comprise 14% of the total and majority of these types are found in Purok 1 (27%), Purok 3 (23%) and Purok 2 (22%).

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Table 4 Distribution of Families by Type of Housing, Barangay Ugong (2003) Purok 1 2 3 4 5 6 Total Owned 249 220 169 199 244 57470 1138 Rented 139 140 124 131 67 32 633 Caretaker 1 1 0 1 3 1 7 Sharer 81 68 70 55 14 14 302 Total 470 429 363 386 328 104 2080

With regards to water supply, 100% of the houses in Barangay Ugong have access to water. Ninety-six percent (96%) are type 3 and majority of this type is found in Purok 1 (23%) and Purok 2 (22%). The remaining four percent (4%) of the community have access to deep well and this type is found in Purok 6 (84%) and Purok 4 (16%). Table 5 Distribution of Water Supply, Barangay Ugong (2003)
Purok 1 2 3 4 5 6 Total Type 1 Type 3 Total 470 470 434 434 363 363 373 13 386 328 328 34 70 104 2002 83 2085

Majority of the eligible population in Barangay Ugong are employed. Manufacturing and Industrial type of work are the major types of employment (35%). Majority of the employed class are found in Purok 1 (25%) and Purok 2 (17%). Despite the high proportion of working class, 18% are found to be unemployed and 4% are underemployed. Unemployment is high in Purok 2 (37%), Purok 3 (18%) and Purok 4 (18%).

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Table 6 Source of Income, Barangay Ugong (2003) Livelihood 1 2 3 4 5 Agriculture 4 Livestock 7 6 2 14 4 Food processing 8 Cottage Industry 4 Trade & Commerce 31 18 8 28 48 Services 87 70 40 52 Industrial 198 56 76 74 101 Others 43 114 126 75 108 Unemployed 27 126 62 62 39 Underemployed 65 2 9 Total 470 392 314 309 309 Figure 3 Employment, Barangay Ugong (2003)

Total 4 33 37 4 159 259 534 529 342 76 1977

26 10 29 63 26 154

4% 18% 78%
employed unemployed underemployed

The eligible population of school children (age 7-17 years) in Barangay Ugong is 1420. Ninety-seven percent (97%) of this group is presently enrolled in schools; the remaining 3% are out of school. Majority of school children (54%) are in the elementary level, 29% in high school and 17% in college. The majority of out of school children can be found in Purok 1 (50%) while Purok 6 contributes to 30% of the group. Figure 4 Educational Attainment Per area and Level, Barangay Ugong (2003)

Purok 1 2 3 4 5 6 Total

No shooling

64

64

Elem in 243 120 83 205 200 55 906

out 11 4 2 1 2 6 26

HS in 104 84 55 102 98 36 479

out 42 11 5 1 4 16 79

College in 71 59 51 50 44 9 284

Graduate Vocational out 50 18 16 30 4 118 33 4 18 34 31 7 94 10 7 50

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4. Health Status of Barangay Ugong The crude death rate (CDR) in Barangay Ugong is 1.6/1000 population, in contrast to the national level of 7.0/1000. Like the general trend in developing countries, the leading causes of mortality in the Barangay are mainly due to lifestyle related diseases (58%). It is noteworthy, however, that the infant mortality rate (IMR) in Barangay Ugong was registered at 5.9/1000 live births, though most of the deliveries (69%) were conducted in hospitals and attended by doctors. Acute Upper Respiratory tract infections ranked first among the leading causes of morbidity in Barangay Ugong. Majority of the cases are communicable in nature. Infant morbidity (age 0-2 years) in Barangay Ugong was 25.21/1000 population. It is noticeable that majority of cases have subsequent programs on health for prevention, case finding, treatment and referrals.

Table 3. Selected Vital Indices, Barangay Ugong (2003) Total Population Total Registered Births Crude Birth Rate Total Registered Deaths Crude Death Rate Registered Infant Deaths Infant Mortality Rate 24791 505 20.37 (per 1000 population) 40 1.6 (per 1000 population) 3 5.9 (per 1000 live births)

Table 4 Leading Causes of Mortality (all ages), Barangay Ugong (2003) Cases Cardio respiratory arrest Pneumonia Hypertensive Vascular Disease Acute Myocardial Infarction Tuberculosis Birth Injury Infant death Cancer Diabetes mellitus Total cases Total Population Number 9 7 5 5 4 3 3 2 2 40 24791 Rate (per 10,000) 3.6 2.8 2.0 2.0 1.6 1.2 1.2 0.8 0.8 16.13

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Table 5 Leading Causes of Morbidity (all ages), Barangay Ugong (2003) Cases Acute Upper Respiratory tract infection Bronchitis Hypertension Pneumonia Dermatitis Diarrhea Diabetes Parasitism Arthritis Infected wound Total Number 2917 473 388 287 194 173 135 123 116 110 4916 Rate 106.11 (per 1000) 19.08 15.65 11.57 7.82 6.98 5.44 4.96 4.68 4.44 198.30

Table 6 Infant Morbidity (0-2 years), Barangay Ugong (2003) Cases Acute Upper Respiratory tract infection Diarrhea Pneumonia Bronchitis Dermatitis Bronchial Asthma Infected wound Impetigo Influenza Otitis Media Roseola Infantum Total cases Number 421 59 55 39 33 5 4 3 2 2 2 625 Rate 16.98 (per 1000) 2.38 2.22 1.57 1.33 0.20 0.16 0.12 0.08 0.08 0.08 25.21

Figure 5 Percent Distribution of Place of Delivery, Barangay Ugong (2003)

31%

69%

hospital home

Figure 6 Percent Distribution of Deliveries by Attendance, Barangay Ugong (2003)

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31% 69%

doctors midwives

5. The Barangay Ugong Health Center Barangay Ugong is provided with a local health center attended by 1 physician, 1 dentist, 1 nurse, 1 nutritionist, 1 midwife and 30 health workers. The facility has 2 rooms for consultation and a dental clinic. Barangay Ugong Health Center schedule of medical and dental services are as follows:

Wednesday

Thursday

Tuesday

Monday

MEDICAL SERVICES Sick baby Feeding program National TB program Outreach (Purok 6) Immunization Post-partum check up Feeding program Prenatal check up DENTAL SERVICES Adult Outreach (Purok 6) Pres-schoolers School Children Pregnant Women 6. Existing Health Programs in Ugong Health Center

Friday
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a. b. c. d. e. f.

Blood sugar screening Blood cholesterol screening ECG Bone scanning 24 hour rescue and ambulance service Physical examination 1. Physical fitness program 2. Medical clearance for Public School teachers 3. Public grade school, kinder, day care pupils 4. Barangay and Public School participants g. Free Physical Therapy h. Botika sa Barangay i. Salt testing for Iodine j. Garantisadong Pambata k. National TB Program 7. Political Profile: The Barangay Ugong Council Mission Statement To make efficient, effective and economical governance, enforce all laws and ordinances, maintain public order, administer the operation of the Katarungang Pambarangay, enforce laws and regulations relating to pollution control and protection and assist the city council in the performance of their duties and functions.

Vision Statement To be the model political unit that will serve as the primary planning and implementing unit of government policies, plans, programs, projects and activities in the community, and as a forum wherein the collective views of the people may be expressed, crystallized and considered, and where disputes may be amicably settled VI. Internship Training Program The Internship Training Program (ITP) of The Medical City is a program accredited by the Association of Philippine Medical Colleges (APMC) according to the guidelines by the Board of Medical Education. Using a combination of patient care duties delegated by consultants and residents, bedside teaching in daily rounds, clinical conferences and didactic sessions, the Program seeks to make interns familiar with the thinking habits, values and techniques necessary in the professional practice of medicine. The Program provides principally two elements for training the intern, namely: the opportunity to encounter a variety of patients and a variety of diagnostic and treatment methods; and the structure under which discipline and insight can be acquired or inculcated. The Program demands of each intern time and participation to make full use of the opportunities and willingness and enthusiasm to adhere and utilize the structure provided.

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A. General Objective At the end of the 8-week rotation, the intern should be able to acquire the basic knowledge, attitude and skills necessary in the recognition and management of common pediatric conditions encountered in general practice. B. Specific Objectives 1. Ward To diagnose correctly common pediatric conditions based on a complete and accurate history and physical examination To select appropriate diagnostic work-ups based on initial diagnosis To interpret results of common diagnostic work-ups and correlate with clinical findings To know the management of common pediatric conditions including emergency care To refer uncommon and complicated pediatric conditions To interact with patients and co-workers showing respect for human values To perform accurately basic skills necessary in patient care To develop interest in continuing medical education 2. Newborn Services Division To obtain a comprehensive and accurate newborn history including maternal history To perform complete and accurate physical examination of the newborn including APGAR score and Dubowitz maturity testing To know the proper steps in newborn resuscitation in an uncomplicated labor and delivery To render routine care to normal newborns To know the management of common newborn problems To refer uncommon and complicated newborn problems To perform accurately basic pediatric skills necessary in neonatal care To work harmoniously with colleagues and other paramedical personnel as well as relatives of patients while rendering neonatal care To accomplish accurate and concise newborn records 3. Emergency Room To know the proper management of common emergency pediatric conditions To know the correct indications and dosages of emergency drugs To perform accurately basic emergency procedures like CPR To interact harmoniously with colleagues and other paramedical personnel as well as relatives of patients while rendering emergency care To show genuine concern and compassion for patients and their relatives. 4. Outpatient Department To monitor growth and development of all patients seen using standard growth charts To assess the nutritional status of all patients using Waterlow classification To advise mothers on proper feeding and nutrition of infants and children To determine a complete immunization schedule for infants and children To know the proper management of common pediatric conditions in an outpatient setting To accomplish completely and accurately the outpatient records of all patients seen C. Training Program Profile (For the list of training staff, please refer to Attachment L) D. Teaching Learning Activities 1. The intern must attend and actively participate in the following activities:
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a. Daily endorsements (A.M. and P.M. endorsements) b. Intra-departmental conferences c. Inter-departmental conferences/lectures d. Journal Club e. Monthly audits f. Inter-hospital conferences (F.I.R.S.T.) 2. The interns have the following specific activities: a. Interns Hour (every Wednesday 1-3 P.M.) b. Teaching rounds with Consultants c. Teaching rounds with the Interns Monitor d. Oral Revalida (last week of rotation) e. Grand Rounds (last Wednesday of rotation) (Please refer to Attachment M Intern Grand Rounds Evaluation Form) E. Duties of Interns 1. General Duties a. Interns rotate for the duration of eight (8) weeks in the Department of Pediatrics. b. All interns will rotate in the following areas: Ward, N.I.C.U., or ER-OPD c. All interns MUST sign in their attendance logbook daily and must state their posts and duty. Regular non-duty hours: Mon-Fri 7:00 am - 5:00 pm Saturday 7:00 am - 12:00 nn Mon-Fri 5:00 pm - 7:00 am Saturday 12:00 nn - 7:00 am Sun/Holidays 8:00 am - 7:00 am d. Requests for exchange of duties must be duly approved by the Interns Monitor and a typewritten request must be filed at least three (3) days from the duty date. 2. 24-Hour Duty a. Each intern goes on a 24-hour duty every 3 days. On exceptional occasions, he may be required to go on a 24-hour duty every other day. b. During Sundays, holidays and after regular working hours, the intern-on-duty assumes the role of the Ward, NICU and ER intern and shall perform the tasks specified for each area. c. He endorses assigned patients to the incoming intern-on-duty. 3. Duties in Each Rotation a. Ward Rotation 1. It is the task of the intern to do admitting histories and P.E. on all patients admitted to the ward (E.R. and direct admissions, referrals to the service excluding those for CP clearance). Histories and P.E. must be accurate and complete and must include the Birth, Feeding, Immunization, Developmental history as well as Nutritional Status. All admitting data bases must be inserted in the chart not later than 24 hours for those not critically-ill and not later than 6 hours for critically-ill patients. The Interns Monitor must check and countersign all admitting histories and P.E. and make the necessary corrections. (Please refer to Attachment B - Patient Data Base Form) 2. Ward interns are encouraged to accompany residents during their daily rounds as well as to accompany the consultants during their rounds. They are also tasked to read the patients charts, especially those whom they admitted on their duty. 3. The following are the skills allowed of a ward intern: Duty hours as follows:

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4.

5.

6.

7. 8.

IV insertion = for those patients 2 years old; only two (2) attempts are allowed; after which such task will be referred to the PROD/Service resident. All insertions must be with the assistance of the nurse-in-charge. NGT/OGT insertion) Catheter insertion) under the supervision of the resident IV medication push) Skin test interpretation = if results are doubtful, prompt referral to the resident As described in the Pediatric Manual for Undergraduate education the following are the procedures that an INTERN must know at the end of the pediatric rotation: - Otoscopy - Transillumination - Blood pressure measurement - Peak expiratory flow rate determination - Nasogastric/ orogastric tube insertion - Gastric lavage - Collection of blood specimen - Infusion of fluids - Infections - Venostomy - Closed chest massage - Endotracheal tube intubation - Urine collection - Needling - Rumple-Leede (tourniquet) test - Exchange transfusion - Umbilical catheterization - Subdural puncture - Thoracentesis - Abdominal paracentesis - Nasotracheal intubation The ward intern obtains a complete history, performs physical examination, gives admitting diagnosis, and differential diagnosis on all pediatric cases directly admitted to the ward. This should be incorporated in the chart within 24 hours after admission or within 6 hours for critically-ill patients. Data bases of patients referred to the pediatric Service (e.g. Surgery, ENT and Ophthalmology) for cardiopulmonary clearance purposes will be done by the referring service. Data bases of patients referred to the pediatric service through HMOs (e.g Medicard) will be accomplished by the pediatric ward intern as stated in section B1. Pediatric interns make daily ward rounds with consultants and service residents-on-duty. During non-duty working hours, he will be in charge of all ward calls namely: IV insertion for patients >2 years old IV push with permission from the service resident-in-charge Skin test interpretation Tourniquet test HGT monitoring NGT/Catheter insertion (under supervision of the resident)

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9. He checks the completeness of the chart (presence of data bases, laboratory results, monitoring) on all ward patients. 10. He makes the necessary clinical abstracts and referral papers for some designated patients. 11. He accompanies ward patients for transfer to other hospitals via ambulance conduction (excluding critically-ill patients). 12. He endorses all pending ward work to the incoming intern-on-duty after the afternoon endorsements by the residents. 13. He follows up all pertinent laboratory exams and relays them promptly to the resident-in-charge. 4. NICU Duties a. He abides by the existing rules and regulations of NICU upon entry (e.g. wearing scrub suits and strict infection control). b. He is aware of all potential deliveries for the day in the OR-DR and must make the NICU resident/s aware of such. c. He secures a good OB-Maternal history on all deliveries, and relays promptly to the NICU resident/s for proper disposition. d. He makes sure that the necessary equipment and resuscitation kit for the impending delivery are complete, available, and well-functioning at the OR-DR. e. He assists the resident/s in the assessment and resuscitation of the newborn. f. Under the residents supervision, the intern does the initial appraisal of the newborn and makes the admitting orders. g. During non-duty hours, the NICU intern is on call for all procedures to be done under the supervision of the residents. He must perform cord dressing (at least 10/rotation) of the newborn under supervision of the residents. h. He makes daily rounds on all normal patients and reports any untoward problems to the resident. i. He accompanies NICU patients to other hospitals for diagnostic purposes and for transfer to other hospitals (excluding critically-ill patients). j. He checks the completeness of the charts (admitting orders, laboratory exam) 5. ER/OPD Duties a. It is the task of the intern to do admitting histories and PE on all patients admitted in the ward (ER and OPD).

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DEPARTMENT ACTIVITIES
MONDAY Endorsement Evidencebased Medicine (Journal Club) Service Rounds 9:00 12:00nn TMC-OPD Clinic TUESDAY Endorsement WEDNESDAY Endorsement UGONG/ THURSDAY Endorsement FRIDAY Endorsement SATURDAY Endorsement NICU Module

7:30 9:00 am

Service Rounds TMC-OPD Clinic

Service Rounds Interns Hour TMC-OPD Clinic

Service Rounds ER Module/ Chart Rounds TMC-OPD Clinic CORE PEDIATRIC (Modular Lectures in General Pediatrics and/or Subspecialties Subspecialty Clinic Chief Resident/ Seniors Rounds Endorsement

Service Rounds TMC-OPD Clinic Monthly Mini- or Grand Audit/ Morbidity & Mortality Business Meeting Case Management / Grand Rounds Conference Endorsement Service Rounds

1:00 2:00 pm

Nelsons Club FIRST Conference

CORE PEDIATRIC lectures (Modular Lectures in General Pediatrics and/or Subspecialties)

2:00 4:00 pm

Subspecialty Clinic

Subspecialty Clinic

4:00 5:00 pm

Endorsement

Endorsement

Endorsement

I.

Instructional Activities A. Intradepartmental 1. Regular Activities Evidence-based Medicine (Journal Club) weekly, as scheduled Teaching Rounds - Consultants endorsement (walk-in) weekly, as scheduled - Chief/ Senior Residents - Every Thursday Service Consultants Teaching Rounds - weekly, as scheduled Case Management/Grand Rounds every third and fourth Friday of the month Audit, Mortality and Morbidity Conferences - Mini-/ Service Audit every first Friday of the month - Grand Audit every second Friday of the month Business Meeting Subspecialty Hour/ Pharmacology Series twice a week, as scheduled Modular lectures on General Pediatrics every Wednesday/ Thursday afternoons ER Modules/ Chart Rounds daily, as scheduled NICU Modules twice a month, as scheduled NICU audit every 2nd Wednesday of the month Interns Hour every Wednesday afternoon

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Nelsons Club every first Monday of the month Interesting Case Presentation Newborn Services once a month ER Audit 1st Thursday of the month

B. Interdepartmental 1. Lectures 2. Perinatology Conference joint lecture with the Department of Obstetrics and Gynecology 3. Tumor Board Conference/ Lecture (every 2nd Thursday of the month) 4. Therapeutics Committee Meeting (every 3rd Thursday of the month) 5. Residents Organization 6. In collaboration with the Department of Obstetrics and Gynecology, the Newborn Services Division of the Department of Pediatrics regularly conducts Parents Class. Parents Class This is held every third Saturday of each month to provide a venue where expectant or new mothers and fathers can learn more about the techniques and advantages of breastfeeding from the medical experts (consultants and residents from the Department of Pediatrics and Obstetrics & Gynecology) and from testimonials of celebrities and guests, who have breastfed their own children. The Medical Citys Center for Patient Education is officially promoting this lay forum, by offering it as a half-day course entitled Parenting 101. Topics discussed range from prenatal and postnatal maternal and newborn care. Consultants from the Department of Anesthesia and Psychiatry likewise contribute by giving lectures on Lamaze or anesthesia and postpartum blues, respectively. C. Inter-hospital 1. F.I.R.S.T. component hospitals Cardinal Santos Medical Center, Our Lady of Lourdes Hospital and Victor R. Potenciano Medical Center Lectures 2 Tuesday afternoon/ month Grand rounds 1 Tuesday afternoon/month Clinicopathologic Conference 1 Tuesday afternoon / month N.A.L.S. Neonatal Advanced Life Support Course P.A.L.S. Pediatric Advanced Life Support Course Post Graduate Courses/ Research Workshop 2. The Integrated Pediatric Program Secretariat (T.I.P.P.S.) Grand Echo of selected topics from the American Academy of Pediatrics Annual Convention 3. Philippine Pediatric Society (PPS) Grand Echo of selected topics/ scientific lectures Terminal Competencies of Residents (Second and Third) After the Two-Month Rotation in the Outpatient Clinics A. Competencies on Basic Pediatric Primary Care 1. To elicit a complete, comprehensive and accurate pediatric history 2. To perform a complete and appropriate for age physical examination on all pediatric age groups

II.

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3. To measure all the necessary anthropometric parameters accurately and how to use these data to asses the nutritional status and growth and development patterns of the patients 4. To judicially screen all patients in the following aspects: a. Newborn metabolic disorders (if the patient was delivered outside of The Medical City) b. Routine screening for hypertension at age three c. Routine screening for TB for all patients via tuberculin test d. Routine screening for anemia and iron deficiency, optimally from 12 months to 24 months of age e. Subjective visual testing for all visits and objective visual testing at age 3-4 years f. Subjective hearing tests at all visits and objective hearing tests and/or audiology referrals when certain problems are perceived, (e.g. language delay, chronic ear problems, bacterial CNS infections, family history of hearing loss, marked prematurity, low APGAR scores). g. Screen for common developmental disorders/lags by evaluating the developmental status at all visits. h. Screen for common pediatric illness. i. Screen for common renal pediatric illness. 5. To implement the recommended immunization schedule 6. To provide anticipatory guidance and counseling for caretakers, for all age groups. 7. To be trained to detect signs and symptoms of non-medical problems like child abuse, behavioral problems, school problems. B. Competencies on Pediatrics Diagnosis and Management 1. To create a logical algorithm for common pediatric signs and symptoms, including differential diagnosis and cost effective diagnostic plans 2. To formulate and institute therapeutic plans for common pediatric conditions 3. To know when to refer cases to the subspecialty clinics and other ancillary services 4. To be able to distinguish urgent, non-urgent, and emergent cases (to prioritize patients and send to the Emergency Department those who warrant Emergency care) C. Competencies on Health Education/Preventive Medicine 1. To include health maintenance, preventive medicine in all dialogues with the caretakers/ mothers of all patients of all age groups (newborn, infancy, toddler, child, adolescent). These should include the following concerns: a. Parenting b. Nutrition and proper diet c. Dental health d. Hygiene e. Feeding problems f. Immunizations g. Accident and injury prevention h. Disease prevention and transmission i. Sex education/ substance abuse/alcohol j. Importance of follow up and continuity of care 2. To develop an effective manner of establishing rapport and communication with the caretakers (parents or guardian) of the patients

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D. The Resident as a Manager, Teacher and Researcher 1. To maintain complete, accurate and comprehensive medical records for each consultation 2. To be able to present cases in a logical, concise manner as a model for the interns and clerks rotating at the OPD 3. To serve as preceptors for the clerks and interns rotating at the OPD 4. To be able to utilize the OPD pool of patients and data for research purposes E. Basic Procedures the Resident Should Master at the End of the OPD Rotation 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Anthropometric measurements Tourniquet test Skin tests for drugs, e.g. Penicillin Administration of the immunizations/Mantoux test Minor wound care Neurologic exam of all patients Sexual maturity rating and pelvic exam of adolescent Developmental evaluation (behavioral and fine motor skills) Screening for eye problems (Snellens chart, E-game) Screening test for hearing and speech problems

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NEWBORN SERVICES DIVISION RESIDENCY LEARNING OBJECTIVES A. First Year Resident Duration of Rotation: Minimum of 2 months 1. Entry knowledge and skills Must know the components of complete maternal and newborn history Must able to identify perinatal/antenatal conditions associated with high risk deliveries Must be able to render delivery room management (preparation of equipment for and sequence of basic neonatal resuscitation) Must be able to provide general care of the newborn (temperature regulation, umbilical cord care, vitamin K prophylaxis, breastfeeding, rooming-in) Must be skilled in peripheral vascular access insertion and umbilical cannulation Must be able to Identify components of newborn screening and its interpretation Must recognize deviations from normal intrauterine growth Must be able to recognize disorders of the newborn not usually requiring intensive care (not all inclusive) - Uncomplicated prematurity - R/O sepsis short term antibiotic administration - Minor infections - Transient respiratory distress - Transient hypoglycemia: SGA, IDM - Hyperbilirubinemia/ anemia not requiring exchange transfusion - Malformations and common birth injuries not requiring intensive care - Infant of substance abusing mother

2. Terminal competencies Expected Clinical Skills At the end of their rotation, the first year resident is able to: a. Elicit a complete and appropriate clinical history (maternal and perinatal history) and to perform a thorough physical examination b. Interpret and correlate gathered data and formulate a primary diagnosis and differential diagnosis c. Interpret and correlate basic laboratory results with clinical diagnosis including ABGs, x-rays d. Prioritize appropriate diagnostic studies e. Recognize and manage the following problems: common respiratory disorders of the newborn, congenital sepsis, common congenital malformations or anomalies f. Perform the following procedures under the supervision of the senior resident or consultant, e.g. umbilical cannulation, lumbar tap, endotracheal intubation, urinary catheterization, blood extractions, gastric lavage in cases of abnormal developments As teacher / discussant is able to:
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a. Present clinical data of patient during rounds / conferences b. Discuss basic diagnosis and management of patients among interns c. Conduct basic lectures for interns As Researcher, is able to: a. Prepare the monthly census of normal newborns and records hearing screening test, hepatitis B vaccinations as done per month as part of data collection b. Critically appraise literature c. Present / write a case report d. Formulate a research question 3. Evaluation: Written and oral examinations at the end of each rotation will be given. B. Second Year Resident Duration of Rotation: Minimum of 2 months 1. Entry knowledge and skills: The second year resident should have the expected terminal skills of a first year resident and: a. Should be able to recognize the need to intervene with Oxygen Bag and mask ventilation Intubation Chest compressions Initiation of IV fluids Management of meconium deliveries NG/OG tube placement Umbilical cannula placement Evaluation of progress of resuscitation b. Should be knowledgeable with moderate to serious neonatal problem, eg: Respiratory distress Neonatal sepsis Common congenital malformation Apnea of prematurity Anemia Infections Nutrition and growth in the premature infant Chronic lung disease Post-operative congenital heart disease GI problems that affect growth and nutrition Screening issues (e.g. retinopathy, hearing, ICH) Developmental follow-up and early intervention 2. Terminal competencies Expected Clinical Skills At the end of their rotation, the second year resident is able to: a. Obtain a concise history and thorough physical examination b. Make correct decisions surrounding delivery room management. c. Do ventilator management beyond initiation stage. d. Perform diagnostic and therapeutic management to a neonate with:
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Extremely low birth weight Respiratory distress Suspected congenital heart disease Possible inborn error of metabolism Surgical problem Hyperbilirubinemia requiring an exchange transfusion Suspected neurological injury or condition. e. Manage more specific NICU diseases RDS/TTNB/Pneumonia/Aspiration syndromes Pulmonary hypertension Patent ductus arteriosus BPD or CLD and associated problems Necrotizing enterocolitis Sepsis and shock Intra-uterine and perinatal asphyxia and consequences Various congenital anomalies Congenital heart defects Inborn errors of metabolism f. Perform special procedures (umbilical cannulation, exchange transfusion, needling, endotracheal intubation, lumbar puncture, urinary catheterization, gastric lavage) As a Teacher is able to: a. Teach / supervise first year residents and interns b. Present lectures / case discussions on assigned topics / patients c. Present monthly morbidity and mortality census As a Researcher is able to a. Formulate a research proposal to be approved by the Research Committee b. Prepare monthly census for: sick and problematic babies congenital disorders surveillance for nosocomial infections 3. Evaluation- written examinations and skills performance evaluation will be given. C. Third Year Resident Duration of rotation: Minimum of 2 months 1. Entry knowledge and skills: The third year resident should have the expected terminal skills of a second year resident and is able to: a. Recognize respiratory failure and apply the basic principles of assisted ventilation and its appropriate intervention b. Interpret arterial blood gas result and give appropriate management c. Have increasing leadership responsibilities.

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2. Terminal competencies Expected Clinical Skills At the end of their rotation, the third year resident is able to: a. Obtain concise and organized clinical data (complete history and physical examination) b. Formulate an assessment / diagnosis based on clinical data c. Formulate a diagnostic and therapeutic management plan for each patient d. Carry out special procedures e. Correlate clinical and laboratory findings f. Formulate preventive care g. Care for the post-operative cardiac patient As Teacher / Manager is able to: a. Act as a preceptor or trainer for first and second year as future medical students b. Present monthly morbidity and mortality if there is no 2nd year resident c. Evaluate the 1st and 2nd year rotators of their skills and knowledge d. Conduct daily teaching and chart rounds to nurses, interns and junior residents As a Researcher is able to: a. Ensure that data collection by 1st and 2nd year is done accurately and is up to date b. Guide the 1st and 2nd year in their research 3. Evaluation a written examination and performance evaluation will be given.

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FIRST INTEGRATED PEDIATRIC RESIDENCY TRAINING PROGRAM (F.I.R.S.T)

The Medical City is one of the member-hospitals of FIRST. Other member hospitals include Cardinal Santos Medical Center, Our Lady of Lourdes Hospital and Victor R. Potenciano Medical Center. The member hospitals have weekly CME activities which include the following: lectures or updates, grand rounds or clinico-pathologic conferences. An annual research contest is also held. In addition, the residents of the four hospitals take 2 examinations per year (midyear and year-end), the coverage of which include the topics discussed during the FIRST conferences. (Please refer to Attachment N Grand Rounds Evaluation Form)

First Integrated Residency Training (F.I.R.S.T.) PEDIATRIC PROGRAM INC. THE MEDICAL CITY Secretariat 2007

DATE January 9 16 23 30 February 6 13 20 27 March 6

ACTIVITY Lecture 1 Grand rounds Lecture 2 CANCELLED Lecture 3 Grand rounds Lecture 4 Grand rounds Lecture 5 UTI

TOPIC

HOSPITAL Dr. Agnes Alarilla-Alba CSMC Carol Hernandez

Basic Pediatric Nutrition

Acute Abdomen Nephritis

Dr. Delfin Cuajunco VRPMC Dr. Victor Doctor TMC Dr. Germana Gregorio Dr. Joel Elises OLLH TMC CSMC

Infectious GIT Diseases Renal Failure

17 20 27 April & May June 5 12 19 26

Lecture 6 Grand rounds CPC Grand rounds

Grand rounds Lecture 7 MID YEAR EXAM CPC

ERD, Dyspepsia & related diseases

TMC Dr. Mary Jean Guno

OLLH
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July 3 10 17 24 31 August 7 14 21 28 September 4 14 18 25 October 2 9 16 23 30 November 6 13 27

Lecture 8 Grand rounds Lecture 9 Grand rounds Lecture 10

Obesity Newborn screening Diabetes Mellitus

Dr. Sioksoan Cua CSMC Dr. Carmencita Padilla TMC Dr. Sylvia CapistranoEstrada Dr. Eva Maria CutiongcoDelaPaz VRPMC Dr. Carmela Kasala CSMC

Lecture 11 Grandrounds Lecture 12 CPC Lecture 13 Grandrounds Lecture 14 CPC Lecture 15 Grandrounds Lecture 16 Grandrounds Lecture 17

Genetic & Dysmorphic Child Treatment & Diagnosis of Atopic Diseases

Food Intolerance vs Food Allergy Adverse drug reactions and anaphylaxis

Dr. Eileen AlikpalaCuajunco OLLH Dr. Michelle DeVera VRPMC

Anemias Blood components: use and abuse Child Abuse & Medicolegal Issues

Dr. Vincent Alba VRPMC Dr. Maria Beatriz Gepte OLLH Dr. Stella Guerrero-Manalo

Research Paper Presentation YEAR END EXAM Endorsements

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TRAINING PROGRAM FOR RESIDENTS (PICU) A. Goals Resuscitation and Stabilization Understand how to rapidly resuscitate and stabilize the critically ill child in the PICU setting. Common Signs and Symptoms Understand how to evaluate and manage common signs and symptoms seen in critically ill children, including when to transfer to an intensive care setting. Common Conditions Understand how to manage certain common diagnoses (reasonably expected of general pediatricians) in the PICU setting. Diagnostic Testing Understand how to use and interpret laboratory and imaging studies in the PICU which can be reasonably expected of general pediatricians. Monitoring and Therapeutic Modalities Understand the application of physiologic monitoring and special technology and treatment in the PICU setting. Management and Decision Making Develop case management skills for complex multi-problem patients under high stress situations, under the supervision of an intensivist, using principles of decision-making and problem solving and understanding ones own limits. Teamwork and Consultation Understand how to function effectively as a team member in the PICU. Patient Support and Advocacy Understand how to provide comprehensive and supportive care to the PICU patient and his family. Medical Ethics and Legal Issues Become familiar with ethical and medical-legal considerations in the care of critically ill children. Financial Issues and Cost Control Understand key aspects of cost control in the PICU. PICU Medical Records

Understand how to maintain accurate, timely, and legally appropriate medical records on complex and critically ill children. B. Skills / Competencies At the end of the rotation in the PICU, the resident must be able to: Explain and perform steps in resuscitation and stabilization, particularly airway management and resuscitative pharmacology Describe the common causes of acute deterioration in the previously stable PICU patient. Function appropriately in codes and resuscitations as part of the PICU team. Rapidly recognize the sign or symptom as heralding the onset of disease or injury and perform a directed pertinent history and physical examination Formulate an age-appropriate differential diagnosis Discuss indications for admission to and discharge from the PICU, and indications for emergent intervention, as well as procedures for stabilization prior to transport to the PICU. Devise a plan for stabilization, further evaluation, and definitive management, and be able to describe the physiologic basis for therapies.
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Discuss the pathophysiologic basis of the disease or injury. Explain potential acute and long-term consequences and complication of the disease and treatment, and be able to evaluate prognosis. Develop and maintain a detailed problem list with accurate prioritization. Coordinate with multiple consultants involved in the care of the patient. Describe the indications and general technique and appropriately interpret the results of invasive procedures performed in the PICU (CVP, PAP, PCWP, intracranial monitoring, among others). For the common therapies listed, integrate understanding of physiology and pathogenesis to determine the appropriate use of therapy and how to monitor its effect and describe its potential complications: - oxygen administration by cannula, mask, hood - positive pressure ventilation - basic ventilator management - analgesics, sedatives and paralytics - enteral and parenteral nutrition - blood and blood product transfusions - vasoactive drugs (pressors and inotropes) Coordinate orderly transfer of care to another provider when intensive care is no longer needed. Consistently act responsibly and adhere to professional standards for ethical and legal behavior. Recognize the limits of ones knowledge, skills, and tolerance for stress level; ask for help when needed. Communicate well and work effectively with fellow residents, consultants, nurses, ancillary staff and referring physicians. Know how to assist referring physicians in preparing a patient for transport to the PICU. Provide pediatric consultation to surgeons and other specialists who manage children in the PICU. Recognize and evaluate the psychosocial need of acutely ill children and their families, both during the immediate illness and during recovery. Demonstrate respect, sensitivity, and skill in dealing with death and dying with the child, the family, and other health care professionals. Communicate well with children and families. Identify problems and risk factors in the child and family, even outside the scope of this ICU admission; appropriately intervene or refer (i.e., injury prevention; importance of anticipatory guidance in teaching parents about the early signs and symptoms of serious, life-threatening disease). Discuss concepts of futility, withdrawal and withholding of care. Define brain death and describe criteria for organ donation. Describe hospital policy on Do Not Resuscitate orders. Demonstrate awareness of cost of PICU care and its impact on families; refer families for social services support as needed. Use consultants and resources appropriately. Maintain daily, timed notes, with update as necessary, clearly documenting the patients progress and details of the ongoing evaluation and plan. Prepare appropriate and timely discharge and transfer notes.

Three second or third year residents rotate at the PICU for 2 months with each resident going on 24hr duty every 3 days. Tour of duty starts at 7:30 am and ends at 7:30 am the next day.

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Endorsements from the post-call ICU resident starts promptly at 7:30 am. The patients charts are reviewed prior to bedside endorsements. All rotating residents are required to attend morning endorsements. Attendance is logged. The on-call PICU resident is primarily responsible for all the patients during her tour of duty. She is never to leave the ICU for any reason without endorsing the patients to the pre-call resident who shall take over patient care. The pre-call PICU resident shall assist the on-call resident in patient care during office hours. She shall be responsible for transporting patients for diagnostic procedures. She shall accompany patients who are for transfer to other institutions. The post-call resident after endorsements will be given the day off to rest and complete required documentations. Time off may also be spent for research or reports. No resident shall be allowed to go on leave during the intensive care rotation. Regular Activities (Venue: ICU conference room) First Friday of the month Second Fridays Third Fridays Fourth Fridays Every 2 weeks End of Rotation Audit Case Management Journal Report Lecture (PICU consultant or PICU rotator) Radiology Rounds Written Exam Consultants Evaluation

Rotating residents shall present the ICU census at the department grand audit. EVALUATION written exam presentation during rounds with the consultant presentation during the grand audit evaluation form

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PEDIATRIC EMERGENCY ROOM RESIDENT ROTATION A. Overview The second year pediatric resident rotates at the ED for 4 weeks for a total of 3 months. The pediatric emergency care rotation is designed for the resident to develop the ability and skills to triage, evaluate and manage children aged 0 to 18 years and 364 days presenting at the ED with a variety of medical as well as surgical problems. Rotating residents will work closely with other team members including other pediatric residents, residents from other specialties (surgery, ENT, ophthalmology, anesthesia, obstetrics & gynecology, psychiatry), emergency room consultants, pediatric attending, subspecialists, nurses and support staff to triage and care for these patients. B. Goals and Objectives of the ER rotation: Develop competence in the assessment and care of the pediatric patient especially in determining the need for emergent or urgent evaluation. Concentrate on the foundation of basic medical science and clinical knowledge integral to pediatric disease. Develop skills in the performance of pediatric emergency procedures. Continue to develop methods of scientific investigation and critical review of scientific literature. Continue to develop interpersonal as well as communication skills as a member of the medical team with emphasis on physician-patient and physician-parent relationships. Continue to develop an understanding of health delivery in the emergency room setting.

1. Rotating Pediatric Residents: Qualifications Second year pediatric residents who have the necessary skill, knowledge, and training to provide emergency evaluation and treatment of children of all ages. Certified in neonatal resuscitation and pediatric basic and advanced life support. Certification is updated every 3 years. Duties & Responsibilities Residents go on monthly rotation at the Pediatric Emergency Room and are under the direct supervision of the Pediatric ER Committee and the Pediatric Consultant staff. Two second year residents go on 24-hr duty every 3 days. Their tour starts from 7 a.m. until 7 a.m. of the next day when their relievers shall have reported for duty and after the morning endorsement rounds with the on-service ER consultant. Pre-duty ER residents shall be called as backup in situations of heavy patient flow at the pediatric ER. Otherwise, they shall go to their designated areas of assignment in the pediatric floors. Post-call ER Residents shall be given the morning off after they have completed the daily logs and documentations and after the morning endorsement rounds with the ER consultants. In the afternoon they shall go to their designated areas of assignment in the pediatric floors or report back to the ER as backup in situations of heavy patient flow. He shall promptly (in less than 15 minutes) attend to all pediatric cases with due regard to logical and reasonable prioritization of activities and resources. He shall take a concise and accurate clinical history and perform a complete physical examination on all pediatric patients consulting at the ED, with the rotating intern in attendance whenever possible.
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For admitted patients, the ER-RODs admitting history should accompany the patients record upon transport from the emergency room to the unit. However, in circumstances of high patient load at the ER, clinical histories may be completed within 4 hours for critically ill patients and within 12 hours for those who are not critically ill. He shall make a diagnosis or a clinical impression and decide on the management and disposition (send home/admit/observe at short stay area) of all pediatric patients. All orders made shall be properly recorded, reviewed and signed. No orders shall be made by the rotating intern. He shall promptly inform the attending physicians of admissions to their service and inform them if any of their patients has been seen at the ER for outpatient consultation. He shall refer any case that in his/her judgment requires referral to other specialties. Such referrals can either be to another member of the house staff or to a member of the consultant staff. Referrals should be made directly to the specialty resident and never to the intern. - All gynecologic referrals should be seen and initially assessed by the OB-ROD at the Pediatric Emergency Room. - All psychiatry cases are referred to the psychiatry resident after initial assessment of disposition and management. - Pediatric patients for surgical clearance should be seen and examined at the pediatric ER by the surgical resident-on-duty and the Emergency Medicine Consultant. He shall properly endorse patients for admission to the pediatric units to the receiving floor resident-on-duty. Critically ill patients should be endorsed directly to the senior of the service during office hours or to the senior resident-on-duty after office hours. Attendance to morning endorsement/teaching rounds/chart rounds with the ER consultant-ondeck is mandatory whatever an ER residents duty status may be (on-duty, post-call, preduty). He is required to attend the monthly mini-audit and is expected to be adequately prepared for it. He shall attend the monthly ER mini audit and all meetings set by the committee when resident attendance is specified. The Pediatric ER-ROD shall directly supervise the rotating interns. Under no circumstance shall patients be initially assessed and treated by an intern. The ER-ROD is authorized to assign duties and tasks to interns, oversee their performance, make evaluations, recommend disciplinary measures, and monitor compliance with existing policies and standards. He/she shall make a formal report on an interns performance and shall submit said report to the interns monitor. He shall make the daily ER census and complete all patient charts/documentations prior to post-call status. He shall document procedures in the patient chart and in his personal procedure logbook. The procedure log is filled out after a procedure is successfully performed and should be signed by the supervising consultant. At the end of the ER rotation, the procedure log is reviewed as part of the evaluation.

C. Competencies At the end of the rotation, residents will be assessed based on the following competencies: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice. 1. Patient Care a. Competence in triaging and the rapid assessment of urgent / emergent patients
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b. Competence in the performance of a problem-based pediatric history and physical examination and in the formulation of a differential diagnosis after initial evaluation of the patient c. Competence in planning and performing appropriate diagnostic and therapeutic interventions in consultation with the emergency room consultant or the primary attending and after obtaining informed consent from the patient, parents or the primary caregiver. All procedures will be documented in the patients chart and in the residents individual procedure logbooks. Procedures will include arterial punctures bladder catheterization / suprapubic aspiration endotracheal intubation intraosseous line placement intravenous catheter placement lumbar puncture nasogastric tube placement gastric lavage umbilical cannulation procedural sedation and pain management venipuncture urethral catheterization burn debridement suturing and wound care d. Competence in determining need for admission or readiness to discharge after thoughtful review and accurate interpretation of diagnostic results and reassessment of the patient during interventions. e. Competence in acute pediatric care including cardiopulmonary resuscitation, initial stabilization and resuscitation of the critically ill, management of shock f. Competence in the logistics of transporting a critically ill or wounded pediatric patient. g. Ability to work closely with a multidisciplinary team in the immediate stabilization of the multiply injured pediatric patient h. Ability to provide compassionate, developmentally / age-appropriate and effective familycentered care and encourage proactive involvement in medical management through counseling and education. D. Medical Knowledge 1. Ability to demonstrate knowledge on basic sciences and clinical principles that are important in the practice of pediatrics. 2. Demonstrate investigatory as well as analytic thinking in the approach to clinical situations 3. Demonstrate competence in research skills and methods of scientific design and investigation through ongoing research and completion of faculty monitored research program. 4. Ability to manage patients diagnosed with Fever Cardiac arrest Sepsis Dehydration & electrolyte imbalance Fractures Burns Seizures Respiratory distress/failure
177

Suicidal ideation/attempts Toxic ingestions/poisoning Trauma Near drowning Bites and stings Shock / anaphylaxis

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E. Practice-based Learning and Improvement 1. Competence in using evidence-based medicine in patient care practices and in the improvement of patient care practices. 2. Ability to use information technology to manage information, access on-line medical information and further their own education and learning 3. Facilitate the learning of other members of the health care team (interns, nurses, auxiliary staff) F. Interpersonal & Communication Skills 1. Ability to establish rapport with patients and relatives. 2. Ability to create and sustain a therapeutic and ethically sound relationship with patients and their families 3. Ability to work effectively with others as a member of the team. G. Professionalism 1. Competence in demonstrating respect, compassion and integrity in dealing with patients. 2. Ability to demonstrate a commitment to high legal and ethical principles (patient confidentiality, informed consent, provision or withholding of care, etc.) as well as a commitment to excellence and ongoing professional development 3. Ability to demonstrate professional attitude and behavior in dealing with superiors and peers. H. Systems-based practice 1. Ability to practice high quality but cost-effective health care and resource allocation 2. Ability to rally for quality patient care and assist patients in dealing with system complexities. I. Supervision Pediatric emergency room residents are directly supervised by the ER coordinator and members of the ER committee, the junior ER consultants, the attending pediatricians as well as the senior pediatric residents. J. Evaluation 1. Formative evaluation Observed history taking and physical examination skills by the members of the ER committee during their weekly supervision schedule. Feedback is given about strengths and weaknesses. 2. Clinical competence ( history taking and physical examination, clinical judgment, technical skills, professional attitudes and behavior, moral and ethical behavior) Residents are evaluated by the ER coordinator and the members of the ER committee on these components of clinical competence at the end of the rotation. 3. End of rotation written examinations ( passing score = 75 )

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ROTATING INTERNS A. Qualification: He shall have fulfilled the requirements of the internship program Duties & Responsibilities: 1. Two (2) pediatric interns go on 24-hr duty at the pediatric ER. The tour-of-duty starts at 7 a.m. and ends at 7 a.m. the next day when their relievers shall have reported for duty. Interns on duty do not leave the area at any time. Pediatric ER interns go on 24-hr duty every 3 days on a monthly rotational basis. In case of heavy patient flow at the pediatric ER, the pre-duty pediatric ER interns shall be called to assist in patient care. 2. All interns assigned to the ED shall sign in and sign out in the attendance logbook. The interns monitor in coordination with the ER Surgery ROD will regularly check the logbook. 3. Interns shall assist the pediatric ER-ROD in the diagnosis, management and disposition of patients 4. Perform patient care functions after initial assessment by the resident, i.e. a. History taking / Physical Examination b. ECG taking c. Blood extraction d. Insertion of intravenous lines, nasogastric tubes and foley catheters e. Gastric lavage and catheter flushing f. Monitoring of critically ill patients g. Any other related activity on orders of the resident-on-duty Patient care functions are done under the direct supervision and express approval of the pediatric resident-on-duty. Attend the daily morning endorsements / chart rounds with the on-service consultant and the rotating ER residents

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PERFORMANCE QUALITY MONITORING

The sections heads shall identify and monitor the key performance indicators of each section. Each KPI are detailed in the Balance Scorecard and shall be reported on an annual basis to the department chairman and the head of Medical Quality Improvement Office. (Please refer to Attachment O for the Balance Scorecard Matrix)

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RETENTION OF RECORD A. Purpose This policy provides for the systematic retention of documents, data and materials received or created by the Section in connection with the operation of its services. This policy also to ensure that all record and documents are adequately safe kept, maintained and properly discarded when the retention period exceeded. (To identify the retention periods and manner of disposal of records and documents please refer to Attachment P - List of Documents for Disposition and Appendix I - Guidelines in Accomplishing List of Documents for Disposition)

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