As of March 2003, the Vanderbilt NICU joined the rest of the Vanderbilt hospital by converting from written orders to on-line computer order entry with physician decision support services.  Below is a brief guide to the many specialized features that were added for NICU use.

The Physician/NNP perspective

There are several special admission order sets which, properly selected, will facilitate the process of admission.  Options to choose from include: 

• General Admission Orders

• Birth Depression/Perinatal Asphyxia

• Multiple Congenital Anomalies

• Congenital Diaphragmatic Hernia

• Cyanotic Congenital Heart Disease

• Gastroschisis/Omphalocele

• Myelomeningocele

• Necrotizing enterocolitis

• Persistent Pulmonary Hypertension

• Suspected sepsis

• Low birth weight (prematurity)

• Pre-op cardiac surgery orders

• Patent ductus arteriosus

If the unit is expecting an undelivered patient or a patient is being transported in who needs to have fluids or drips awaiting their arrival, and the patient has not been entered in the computer system yet, there is a “Pre-admission order form” to fill out and send to pharmacy to order admission fluids and critical medications. 

New items that are important to enter during the process of admitting a NICU patient include the birth weight and the gestational age.  Wiz Order keeps daily track of the patients post-conceptual age, so enter the infants current PCA (not the EGA at birth) for a baby who is received several weeks old in transport.

For NICU order entry purposes, the issue of weight is a rather unique one.  There are four different weight variables which may be manipulated to optimize patient care. First, there is the birth weight. Then there’s the actual “daily” weight- this is the weight that the nurse measures on the scale every night at midnight and enters into WizOrder.  If there is clinical suspicion that the recorded daily weight is inaccurate or that the patient is dehydrated or fluid overloaded, the physician or NNP may create essentially an ideal body weight to use to calculate IV fluids or TPN; (i.e. the TPN weight.)  Also, upon first ordering a medication, the patient’s current weight will be used by the computer for calculations and will become the patient’s pediatric dosing weight.  The dosing weight will need to be updated as the patient grows and other medications are ordered. The pediatrics dosing weight is equivalent to the former “drip dosing weight.”

Although this sounds redundant, it is designed to allow the clinician the most flexibility with the critical issue of fluid and electrolyte management in the premature infant; while at the same time allowing for standardization in the pharmacy to decrease the risk of human error, medication error, pharmacy costs, and patient costs.

To facilitate medication dosage adjustments, medications in the Wiz orders will be labeled “Dose Outdated” when the patient’s actual weight differs from (usually exceeds) the dosing weight that drug was prescribed based upon by 20%.  This serves as notification that the dose should be recalculated and modified if the clinician wishes to continue the drug in the previously selected therapeutic range. If the patient is being allowed to “outgrow the dose,” no changes need be made.

Please note, that “dose outdated” is different from notification that a narcotic has “expired.” Orders about to expire are labeled with a ¶.  Narcotic orders expire after 72 hours and must be reordered using the Renew function if they drug is to be continued.

A final pharmacy feature is truly one of the strengths of WizOrder entry. For the 30 most commonly ordered NICU drugs (listed by type of activity under NICU common medications), the computer program is designed to recommend an appropriate dose in mg/kg based upon the patient’s weight, gestational age, and chronologic age.  When ordering these drugs, the computer will calculate the patient’s dose based on the pediatric dosing weight and round it to a safe and convenient amount for the pharmacy to measure.

Drug categories you will find under NICU common medications include: anticonvulsants, antimicrobials, cardiac meds, diuretics, electrolytes, endocrine meds, GI meds, hematology meds, neuromuscular blocking agents, respiratory meds, sedatives and analgesics, and vaccines.

Continuous infusions can be ordered using slightly modified versions of the PCCU drip pages. Typing PCCU drip infusions  from a NICU work station pulls up alprostadil (prostin), dobutamine, dopamine, fentanyl, insulin, midazolam, and vecuronium options, as well as an “other” box to access the PCCU’s more varied menu.  The drip pages assist the user in easily calculating the necessary pharmacologic recipe to run a desired concentration at a desired rate. 

Other new features:

Vent settings and orders are not entered into Wiz at this point.  For ventilated babies, select the order “PICU/NICU Ventilatory Support Order Sheet.” Babies with either ventilators or Aladdin CPAP at their bedsides will have on their respiratory clipboards a NICU Ventilatory Support Order Sheet.  On this sheet, physicians and respiratory therapists should write vent settings, record blood gases, and enter vent change orders.  Respiratory medications (surfactant, albuterol, etc.) should be ordered via WizOrder.

            Once a baby graduates to NCO2 or isolette O2, the NICU Ventilatory Support Order Sheet should be filed in the chart.  Continue to use it to record any blood gases obtained.

            Under NICU respiratory orders, there are orders for NCPAP, iNO, subatmospheric oxygen, albuterol, surfactant, racemic epi, extubation, and to teach parents CPR.  NICU oxygen therapy orders include nasal cannula oxygen (both high flow and low flow), head box, isolette O2, or O2 per trach collar.

To order clear IV fluids, go to the NICU IV Fluids page.  The first page that comes up has easy-to-select check boxes for all routine admission fluids (remember to check whether or not heparin should be added) and UAC and UVC fluids.  To create a more specialized fluid, go to the Custom IV Fluid page.  There is also a replacement fluid order screen for surgical or other patients with ongoing losses.

Please note on the IVF page, WizOrder instantaneously calculates the volume in ml/kg/d that any umbilical line fluids would provide the patient.  However, it does not automatically subtract that amount from the volume entered for IVF ml/kg/d; the user must take this into account.

TPN is now ordered on-line; housestaff are reminded to attempt to enter their TPN orders before 9am.  The NICU TPN program defaults to most necessary values depending on central vs. peripheral access and does most of the calculations, including calories.  Several points about the TPN page:

1.      Na and K are ordered as mEq/kg/day rather than mEq/L; remember most babies will need 2-3mEq/kg/day of Na and 2 mEq/kg/day of K, unless complications supervene such as renal immaturity or diuretic usage.

2.      The Intralipid volume is calculated separately and must be subtracted from the daily total fluid goal prior to entering TPN volume. (Remember: 1g/kg/d IL provides 5 ml/kg/d fluid; 2g/kg/d IL provides 10 ml/kg/d; and 3g/kg/d IL provides 15 ml/kg/d fluid.)

3.      Intralipid can be discontinued by entering 0 g/kg/d.

4.      TPN and IL rates come up separately under the IVF section of the Wiz orders and can be adjusted independently throughout the day as need arises.

5.      Once a baby has initial TPN orders, these orders can be regenerated the next day using the “Load previous orders” button and then adjusted as desired. 

6.      If a change needs to be made in the TPN recipe after the orders have been final accepted but the actual fluid has not yet been made, the orders can be modified on Wiz Order, but the ordering physician/NNP must also call the pharmacy to notify them.  WizOrder prompts this phone call.

7.      When TPN has been final accepted, a TPN Summary sheet will print in addition to the physician order sheets.  The TPN Summary is a more user-friendly account of the TPN recipe; it should be placed in the chart for the nurse to use to check the bag of TPN when it arrives.

8.      During “down-time,” there is a new down-time TPN form to fill out which mimics the on-line process rather than the old TPN form. The downtime TPN form is available on the Vanderbilt website e-docs.

9.      When the patient no longer requires parenteral nutrition, there is a “Discontinue TPN” order on a separate page to prevent inadvertent discontinuation, which the clinician should use to notify pharmacy that TPN/IL is no longer necessary.

Other order sets unique for NICU use include NICU thermoregulation orders, skin care orders, NICU line orders, NICU phototherapy orders, ECMO order sets, tube feeding/enteral nutrition nursing orders, and NICU discharge orders.

Feeding orders are divided into two parts.  First, click on NICU Enteral feeding orders, then select NICU common feedings/formulas.  Select the formula as well as the volume and frequency (continuous or bolus) and then click on the associated nursing orders for continuous or bolus gavage feeds, etc. under Enteral tube feeding orders.

      NICU line orders include line placement orders for UAC/UVCs, PICC lines, and CVCs (surgically-placed central venous catheters.)  There are orders for “infected central lines” which included various blood cultures and to culture the catheter tip.  There are also nursing/pharmacy orders for “heparin PICC line flush” and “heparinized saline for Broviac catheter flush” that are NICU-specific.

The NICU uses the same pediatric blood bank pages as the rest of the hospital; but when blood products are ordered for the NICU, it automatically defaults to “irradiated.”  The clinician should order the amount (s)he wishes to have transfused.  When the nurse sends the message to blood bank, (s)he should add 4-5 ml to the order to cover tubing losses.

The LBW admission order sets for premature infants are designed to assist with routine screening protocols.  Head ultrasounds will automatically be ordered for 7 days and 30 days.  A “dr. reminder” is generated regarding ROP exams and the Cyclomydril drops and 24% sucrose are automatically ordered.  However, the case managers still continue to track when individual ROP exams and follow-ups are due. A “dr. reminder” will also be generated regarding PT evaluations at 34 weeks PCA in appropriate populations. 

NICU patients will occasionally require very individualized orders that obviously are not available in WizOrder.  Such orders may be entered under Nursing: free text____, which allows the user to describe in detail any care strategy or treatment desired.  Similarly, one can enter descriptive orders under “Nutrition: free text____” for the NICU patient on a complicated formula recipe or feeding plan.

Regarding ECMO orders, since these highly complex patients are in the joint care of neonatology and pediatric surgery, orders may be duplicated or conflicting without good communication between the two teams.  To facilitate both communication and order entry, the surgeons have been notified that they may ask the neonatology fellow or senior resident to enter orders on ECMO patients.

Under discharge orders, most of the common orders pertinent to the ICN graduate can be found.  The “Discharge Wizard” used elsewhere in the hospital is also available but is less NICU-specific.  For back transport, click-on the order “Discharge Plan: Transfer to another hospital” and print out a sheet of transfer orders to accompany the patient and the discharge summary.

There are multiple different sites which can be used to order labs. Vanderbilt hospital administration encourages all labs to be ordered separately (rather than as panels) and discourages standing serial lab orders. Therefore, except in especially designed order sets, most labs must be “clicked-on” individually. 

For STAT labs (a sudden change in a patient’s condition) many urgent NICU labs can be found on the NICU One-Time Stat page.  For routine labs, often AM labs, ordered on rounds or pre-rounds, see the NICU Rounding labs.  NICU Rounding orders also includes access to TPN, the IVF page, blood gas/respiratory labs, NICU respiratory orders, enteral feeding orders, and X-rays.  By typing NICU Respiratory labs, a list of respiratory labs (ABG/VBG/CBG, Na, K, Cl, PCV, iCa metHgb) is obtained for quick access.  Most all labs can be found under NICU common labs which can be accessed through NICU lab orders which lists NICU one-time stat labs, NICU admission labs, rounding orders, common labs, common cultures, and drug levels. 

Under NICU diagnostic tests, orders can be found for CXR, KUB, Head U/S, Renal U/S, Echo, EKG, EEG, and the Brain Imaging advisor for CT or MRI. There’s also a section “NICU congenital anomaly radiographic studies” that includes both common and more unusual radiographic studies.

Routine X-rays should be ordered using the X-ray advisor; a pediatric CXR advisor is being designed which will provide more neonate-appropriate “reasons for CXR” than the current adult-based version does.  Urgent and Stat X-rays may be ordered on the NICU One-time STAT screen.

            When X-rays are ordered via WizOrder, Wiz will generate a printed requisition which will print in the unit.  This requisition is for the radiology tech and replaces the former yellow NCR page.  Films are viewed on the PACS system. 

The nursing/support staff perspective

            When a routine order is entered into WizOrder for a patient, the box beside the patient’s bedspace number on the “notification engine” computer screens will turn blue.  For a STAT order, the box will turn red.  The patient’s nurse should retrieve the copy of the order from the printer (the physician order sheet: POS) and acknowledge the order in the computer. 

All physician order sheets (POS) generated throughout the shift should be filed in the patient’s chart.  Orders are now filed in the NICU charts in chronological order to be consistent with the rest of Vanderbilt hospital. 

Around 5am and 5pm the MRs will print both a “Current Order Sheet (COS)” and a “Current Meds & Results (CMR)” to place in the chart in preparation for the next shift.  The COS and CMR may be useful for sign-out during shift change.

At night a batch print of each patient’s “Daily Order Sheet (DOS)” summarizing all the physician orders in the last 24 hours will print.  The night shift should compare the the POS vs. the DOS and sign “24 hour chart check” to verify orders.  If there are orders on the DOS that are missing from the POS, the nurse should verify that the order was completed.  The POS may then be discarded.  Discarded papers with patient information on them should be placed in the black bins in each room which will be emptied and shredded by the MRs every 2 hours.

Another common print out to identify in the morning is the TPN Summary sheet.  This sheet should print out with the physician order sheets giving the line listings of the TPN orders.  The TPN Summary is a more user-friendly account of the TPN recipe and is what should be used to check a patients TPN bag for accuracy when it arrives.

Orders for lab work print with the lab work requisition which should be sent to the lab with the sample.  Pre-printed labels are now available to place on specimens.   Recommendations regarding the necessary amount of blood should be carefully considered- each requested lab prints out individually, but if they are part of a panel, or they all require the same color tube, usually a single tube of blood can be sent with the multiple requisitions to receive all necessary results.

Requisitions for labs to be performed at a later time, for example “gent trough before 4^th dose,” should be filed in the chart in front of the MAR until time for its use and notation should be made on the MAR of when the lab is to be drawn.

Portable X-ray requisitions now print out in the NICU rooms as well.  These requisitions replace the former “yellow” duplicate copies of the Radiology order. 

For routine AM X-rays or screening head ultrasounds, the copy of the X-ray requisition that prints in radiology should be all that is necessary for the study to occur in a timely manner.  For urgent or emergent, unscheduled X-rays the MR should still call the radiology tech.  Unplanned ultrasounds, especially on weekends, should also generate a phone call to notify radiology.  The MRs should continue to call the respective departments for an EKG, Echo, or EEG.  CT scans and MRIs should be scheduled based on the requisition that prints in radiology alone.

To enter orders, nurses may type in either a “verbal” or “protocol” order and the attending of record’s name.  One order the nurses are asked to enter nightly is the baby’s actual weight as measured.  The initial entry should be entered as a “protocol” order and subsequent weights can be entered as a “nurse-to-nurse” order using either the Enter New or Renew function.  Length and head circumference are measured weekly and should still be entered on the bedside flowsheets, not in WizOrder.

Another order nurses are encouraged to enter as a “protocol” order is a lactation consult request for the breast-pumping or breast-feeding mother.  This order may be entered upon admission if overlooked by the physician or at any time during the patient’s stay when a need is identified.

            For verbal orders that were never entered by the physician, nurses may enter a “verbal” order and should remark in the comments field “Late Entry for (original time of order).”

            During “downtime” when the computers are unavailable for technical reasons, orders will again be written.  Once downtime has ended, the pharmacy will enter all on-going medication orders written during downtime; the nurse should enter any on-going non-medication orders written during downtime.  One-time orders written during downtime do not need to be duplicated.