3  Physician Operations

3.1 Launch remote session

  • Click on the Epic pull-down menu on the left upper corner
  • Select Launch Sessions
  • Click on the magnification glass to select the session to launch

Each session has a designated two-letter code. Use the following table to find the session for the hospital to launch:

Hospital ID Hospital Location Session Code
954 Downey TC
197 LAMC ML
200 SDMC SD
337 OCMC - Anaheim OC
393 Panorama City VA
391 Baldwin Park TC
199 Fontana IE
338 West LA ML
201 Wooden Hill VA
392 Riverside IE
400 South Bay TC
893 OC - Irvine OC
1072 Ontario IE
1433 MoVal IE



3.2 Census and extra duty

  • < 7 patients: no extra duty
  • 8-11 patients: 0.5W
  • ≥12 patients: 1W



3.3 Secure Chat

Secure Chat can be accessed inside Health Connect. Instructions as follows:



3.4 Daily Rounds Process

Checklist

  • NICU accordion summary
  • Review labs
  • Review meds
  • Review growth and flowsheet
  • Revise the problem list
  • Orders
  • E&M coding
  • Progress note
  • Call parents to provide update, or update at bedside



3.5 Quality Management

P-score process map


Important notes:

  1. P scoring is based on POTENTIAL FOR HARM.
  2. P2 is the serious and will require corrective actions.
  3. If you receive P2, you can appeal and ask for independent review.
  4. Standard for care = is the COMMUNITY STANDARD, not department standard.
  5. It’s ok to discuss the case with the physician under review to get their thought process.
  6. Any learning experience will be shared to the Neo group without naming the physician under review.
  7. Any request for case review can be submitted to me or directly to QM regardless of department, e.g radiology, nursing, peds etc.


References

Click to Download Peer Preview Training Slides

Click to Download Level 3 Audits Pearls & Tips



3.6 Interdepartmental Agreements

Escalation process

Each agreement is reviewed on a yearly basis by its agreement owners. Non-compliance with an agreement is escalated on a case-by-case basis and in real time, per the Patient Care Issue Resolution Process:

Step Action
Service issue (peer-to-peer) Have a conversation with physician or peer (involve a manager if you need to)
Resolution Level 1 Involve Manager or Director
Resolution Level 2 Involve Physician Leader, Physician-in-Charge, or Chief
Resolution Level 3 Involve AAMD, Area Administrator, or COO
Resolution Level 4 Involve AMD, CAO, or Executive Director


Radiology

Service Level Agreement (SLA), Riverside Medical Center. Agreement owners: Dr. Heather Le (Chief of Diagnostic Imaging Services), Sukhvinder Puri (Director of Diagnostic Imaging Services), Dr. James Washington (Chief of NICU Services, Riverside area), Maria Rodriguez (Director of NICU Services, Riverside area). Signed July–September 2026.

Study Agreement
IV contrast studies (CT/MRI/MRA/MRV as examples) Radiology techs to be trained to inject contrast for NICU studies only for babies with peripheral IV access (trained to scope of practice)
Emergent UGI to rule out malrotation Okay with upper GI/SBFT during work hours, M–F 8 am to 5 pm. Other situations transfer out
VCUG Should be available at RMC/MVMC, M–F 9 am to 4 pm. Teams and email Dr. Le for real-time escalations
RUS with doppler study Transfer out if the study is needed for a NICU baby
MRA/MRV/MRI of the body Transfer to pediatric institute of excellence if these studies are needed
MRI without contrast of head and brainstem Can be performed at both RMC and MV with confirmed compatible EKG and respiratory machines

Real-time escalation: contact the radiologist on call; Teams and email the Radiology Chief; Radiology manager on call.


Pediatrics–Neonatology: FCC Coverage

Pediatrics–Neonatology FCC Coverage Interdepartmental Agreement, Riverside Service Area.

We share responsibility for providing an outstanding care experience for our new parents, outstanding clinical care for our newborns, and an outstanding working experience for our team. As a team, we will proactively identify potential needs/problems and suggest solutions. We will communicate to the team if we observe something team members may do to make the day more efficient, take better care of our members or each other. Continuous role clarification is encouraged to enhance partnership of team.


Moreno Valley (MVMC) FCC

Pediatrician FCC coverage: 8 AM – 12 PM

  • Complete the discharge summary/order for newborns discharged before 12 PM. Write a conditional order/discharge summary for newborns that are being discharged after 12 PM. The pediatrician will communicate with the on-call neonatologist items that will need to be followed prior to discharge.
  • Complete the H&Ps for newborns that were delivered after 8 PM the night prior and for newborns that have been delivered by 10:00 AM.
  • Perform all circumcisions.
  • Not responsible for attending deliveries.
  • Will sign out to the neonatologist at 12 PM if there are any items pending of patients that are being discharged after 12 PM and for the other newborns in which laboratory/radiological studies are pending. The pending items will be noted in the “Write Handoff” section in Health Connect.
  • Prioritize discharges, circumcisions, then progress notes and H&Ps.
  • Work that is not completed will be signed out to the neonatologists (if this occurs, usually will be the H&Ps).
  • Pediatricians will place future outpatient orders for hip ultrasounds, renal ultrasounds, thyroid labs, etc.
  • If possible, pediatrician can attend board rounds in Moreno Valley at 8:30 to discuss any issues/questions, concerns and patient management.
  • Pediatrician can contact the neonatologist via the most convenient method for the pediatrician (Vocera, paging or calling their office/call room).

Neonatologist FCC coverage: 12 PM – 8 AM

  • Follow up on the newborns being discharged after 12 PM with pending items.
  • Will need to complete the discharge order/summary for newborns that were not anticipated to be discharged. This should happen rarely.
  • Complete the H&Ps for newborns that are delivered from 10:00 AM to 8 PM.
  • Will be responsible for managing any abnormal results from the hypoglycemia protocol and for serial TCBs for ABO incompatibility.
  • If nursery nurse has concerns about an infant on FCC, they are to call the neonatologist, who will determine if the NICU team/RN can first evaluate the infant.
  • Will need to follow up on serum bilirubin for patients seen in Moreno Valley Great Starts clinic when results are not back by 5 PM. Based on the result, may need to order Bili Blanket, repeat serum bilirubin, and schedule a follow-up with PCP or another pediatrician.
  • Neonatologist is expected to write the late preterm admission orders if asked by nursing for late preterm infants who are in observation in the NICU in Riverside and Moreno Valley. If not under observation, the pediatrician is expected to write the late preterm admission orders.
  • Neonatologist is expected to write a note for any infant in observation in the NICU, for infants requiring resuscitation, and for deliveries they attended in person (physical exam by neonatologist is not necessarily required on the infants that transition back to FCC).
  • If anticipatory discharge is cancelled, neonatologist is expected to cancel the discharge order and leave a note or write handoff with the reason for cancellation.
  • Neonatologists can attend board rounds in Moreno Valley at 8:30 to discuss any issues/questions, concerns and patient management.
  • Neonatologists are not expected to perform circumcision consents but can do so if time allows, as it is helpful to the pediatrician’s workflow.
  • Neonatologist is expected to provide discussion and anticipatory guidance with the parents on hospital-specific diagnoses such as congenital hydronephrosis, late preterm infants required to stay 48 hours, labs due to maternal Graves disease, staying for 24 hours for Accuchecks (SGA, LGA and GDM infants) and TCB checks for ABO/Rh incompatibility, discussing nirsevimab with parents who refused at birth, etc.
  • Neonatologists are responsible for all the critical lab results from the regional lab between 7:30 PM – 6:30 AM (this is currently being managed by the Moreno Valley ED team).
  • Neonatologists are to manage bilirubin labs from MV Great Starts and Palm Desert patients that result after 5 PM (these are not to be managed by the Riverside DOD or ED team).
  • Neonatologists are responsible for pharmacy calls from 7:30 PM – 6:30 AM (currently being managed by the MoVal ED).
  • May be consulted by the Emergency Department to assist in the management of children less than 30 days of age.
  • Will sign out to the pediatrician at 8 AM if there are any urgent items that need follow-up. The pending items will be noted in the “Write Handoff” section in Health Connect. Discuss with the incoming pediatrician the plan of treatment regarding the critical labs that were received.
  • Pediatrician can contact the neonatologist via the most convenient method for the pediatrician (Vocera, paging or calling their office/call room).


Riverside (RMC) FCC

Pediatrician FCC coverage: 7 AM – 7 PM

  • Complete the discharge summary/order for newborns discharged before 7:30 PM. Write a conditional order/discharge summary for newborns that are being discharged after 7:30 PM. The pediatrician will communicate with the neonatologist items that will need to be followed prior to discharge.
  • Complete the H&Ps for all newborns.
  • Perform all circumcisions.
  • Available for emergency room consults (note is expected; please contact hospitalist directly if admission is recommended).
  • Available for Urgent Care consults.
  • Not responsible for attending deliveries.
  • Responsible for critical lab results between 6:30 AM – 7:30 PM (except for MoVal Great Starts and Palm Desert bili labs).
  • Responsible for general pharmacy calls between 6:30 AM – 7:30 PM.
  • Responsible for Home Health calls (not NICU related).
  • Will sign out to the neonatologist at 7:30 PM if there are any items pending for patients that are being discharged after 12 PM and for the other newborns in which laboratory/radiological studies are pending. The pending items will be noted in the “Write Handoff” section in Health Connect.

Neonatologist FCC coverage: 7 PM – 7 AM

  • Follow up on the newborns being discharged after 7:30 PM with pending items.
  • Will need to complete the discharge order/summary for newborns that were not anticipated to be discharged.
  • Will be responsible for managing any abnormal results from the hypoglycemia protocol and for serial TCBs for ABO incompatibility.
  • Neonatologist is expected to write the late preterm admission orders if asked by nursing for late preterm infants who are in observation in the NICU in Riverside and Moreno Valley. If not under observation, the pediatrician is expected to write the late preterm admission orders.
  • Neonatologist is expected to write late preterm admission orders for infants born between 7:30 PM – 6:30 AM.
  • Neonatologist is expected to write a note for any infant in observation in the NICU, for infants requiring resuscitation, and for deliveries they attended in person.
  • May be consulted by the Emergency Department to assist in the management of children less than 30 days of age.
  • Will sign out to the pediatrician at 8 AM if there are any urgent items that need follow-up. The pending items will be noted in the “Write Handoff” section in Health Connect.


Shared clinical agreements

Hyperbilirubinemia

  • Agreement among the pediatricians and neonatologists for newborns with hyperbilirubinemia risk factors (such as ABO incompatibility) to initiate phototherapy 2 below phototherapy threshold based on bilitool.org or peditools.org.
  • In certain cases, infants who can no longer remain on FCC due to maternal discharge, but still need phototherapy, may need admission to the NICU.
  • If the infant is on full phototherapy, the pediatric group can transition to a bili-blanket and order a follow-up bilirubin 6–8 hours later.
  • If rate of rise (ROR) is > 0.2/hr, then admit to the NICU as they have failed the bili-blanket.
  • If ROR is < 0.2/hr, then OK to discharge home with bili-blanket and follow up in 1 day with repeat total serum bilirubin prior to their appointment.
  • If mother has been discharged and there is space on postpartum, OK for infant to stay on FCC service while in FCC and under phototherapy.
  • If there is bed shortage, infant would then need to be transferred to NICU for management (under NICU service).
  • Please reference the 2022 AAP guidelines on management of hyperbilirubinemia.

Maternal Graves/hyperthyroidism

  • For infants born to mothers with history of Graves disease or hyperthyroidism, please initiate thyroid labs ASAP per algorithm and consult with Endocrinology as necessary.
  • Please reference the MVH Neo/FCC Team channel for the algorithm.

Positive maternal UDS

  • For mothers with positive THC on UDS (no other drug positive), do NOT need to order UDS on baby.

Trisomy 21 infants

  • Any unstable infant will be admitted to the NICU directly.
  • Team huddle for these infants, to include the pediatrician, neonatologist, charge nurses and bedside nurses.
  • If they fail 3 feedings, transfer to NICU (with flexibility if close).
  • Monitor these infants at least 48–72 hours on FCC prior to discharge.
  • If mother is being discharged and infant not ready, they will be transferred to the NICU.
  • Multiple major congenital anomalies will be admitted to the NICU. If NICU and Peds do not agree on this admission, Peds can ask for a formal consult.
  • Infant does not need to be seen by OT prior to discharge if they are feeding well (as OT only comes one day/week).

Pediatrician/neonatologist:

  • Evaluate Trisomy 21 or suspected Trisomy 21 babies soon after birth and talk to parents about the diagnosis or suspected diagnosis.
  • Please be responsive to nurse or family concerns.
  • Trisomy 21 workflow: TSH, echocardiogram, chromosomes, genetics consult outpatient, etc. Neonatologist/peds is expected to order the echo at the time of exam and H&P to expedite the study taking place (not urgent, only for it to be done next day).
  • In the first 12–24 hours, the nurse caring for these infants should have a 2 couplet ratio (max 3). If this ratio is not possible due to staffing issues, infant should go to NICU.
  • Social work consult, reason: IRC referral.

Problem list: common diagnoses

  • Newborn, single liveborn, in hospital by vaginal delivery
  • Newborn, single liveborn, in hospital by cesarean section
  • Newborn, single liveborn, born outside of hospital prior to admission
  • Circumcision Consultation (or Elective Circumcision)
  • Immunization Counseling
  • Prophylactic Immunotherapy for Respiratory Syncytial Virus
  • SGA
  • LGA
  • Infant of Diabetic Mother
  • ABO incompatibility reaction
  • Rh incompatibility reaction
  • Prematurity of Newborn, completed 36, 35, 34 weeks… or Preterm infant, unspecified completed weeks gestation
  • Screening for congenital hip dislocation, breech presentation
  • Screening for congenital dislocation of hip (for multiple births)
  • Screening for thyroid disorder (for twins, Trisomy 21, etc.)
  • Congenital Hydronephrosis

Under the diagnosis of Newborn, single liveborn…:

  • Please include GA, mother’s blood type and GBS status, and infant’s blood type if done.
  • Can also mention any other relevant information, such as history of maternal depression/anxiety, mother with pre-eclampsia, oligo, etc.
  • There is a smart phrase some physicians use to autopopulate this: .birth or .birth1 (can copy from the smartphrase list of Dr. Garabedian, Dr. Song or Dr. Chen).

Outpatient bilirubin management

  • You get TSB calls from labs done at the Moreno Valley hospital, which includes Iris Great Starts and the Palm Desert labs.
  • Please call parent with the result and plan, which can be no further follow-up, repeat the bili the next day, etc.
  • Please order any follow-up TSB “stat”.
    • Stat laboratories are Iris, Murrieta and Riverside (not Heacock).
    • Please let parent know which specific lab to go to. If they go to the Heacock lab it will not be run stat and will result after 5–9 PM.
  • Ordering the biliblanket: order is “phototherapy, light, including supplies”.
    • Apria will deliver to their house within 4 hours of order.
    • If after 5 PM, can call the ER Case Manager to let them know of the order, and they can call Apria to confirm they received the order.
    • Can also inform parent that if they don’t receive the biliblanket within 4–6 hours, to call the L&D secretary to speak with the neonatologist on call.
  • Med Advice: can call them or send them a message to book a follow-up in-person appointment or TAV.
    • Routing pool is “P Pedririv Med Advice” (10139)
    • Med Advice phone number: 951-353-4354
    • Weekend follow-up for bili: can book into Riverside or Murrieta clinics for in-person follow-up. Does not need to wait until Monday.

Anticipatory discharges

  • If mother is staying, discharge order needs to be cancelled for infant, with a note acknowledging the cancelled discharge and reason.
  • If a parent decides they want to be discharged after the pediatrician has left, neonatologist can discharge the infant if all criteria are met.
    • Great Starts clinic is available on weekdays.
    • On weekends or holidays, we book into the Pediatric “After Hours” clinic, which is in Riverside and Murrieta.
  • Conditional discharge note (also in Section B.2.2.7):

Infant may be discharged home today after *** once all of the following criteria have been met:
A. Vital Signs are within Normal Limits (Temp 36.5–37.9 °C, HR 100–160, RR less than 60)
B. Infant has voided and passed stool
C. Infant has passed CCHD screening with O2 sat greater than 94%
D. Newborn screening is complete
E. Hearing Screening is complete; if referred, CMV buccal swab has been obtained and outpatient audiology follow-up has been scheduled
F. Hepatitis B vaccine has been given, and if indicated, HBIG has been given. If parents refused hep B vaccine, declination waiver has been signed.
G. Transcutaneous bilirubin levels have not exceeded the threshold to require a serum bili level
H. If infant is being evaluated for hypoglycemia, all blood sugars have been completed and infant has not required any dextrose gel OR infant has had 3 serial glucose POCT levels greater than or equal to 45 mg/dL.
I. Infant has had a recent repeat weight, with ≤ 6% weight loss from birth weight on day 1 or ≤ 8% weight loss from birth weight on day 2 or 3. If breastfeeding, a LATCH score of 8 or more is documented and mother has demonstrated ability to latch baby independently OR mother has worked with lactation and a discharge feeding plan has been documented.
J. Follow-up appointment(s) scheduled per unit policy: 1) in Great Starts in 2 days, 2) at 3 weeks with PCP, and 3) at 2 months with PCP.
If above criteria have not been met then please cancel discharge and notify MD on call.

Miscellaneous

  • Please document red reflex in your H&P if it can be done. If not done, please write it in sign-out so the pediatrician is aware.
  • Please contact any of us with questions; we are all happy to help.
  • Can also call the DOD in Riverside with questions.


Open items

Items in the agreement that are still being worked out:

  • Workflows: Dr. Garabedian has created a Microsoft Teams channel (MVH Neo/FCC team) with links to workflows and guidelines for:
    • Sacral dimple
    • Congenital hydronephrosis/pelviectasis
    • DDH (please order hip ultrasound to be done at 6 weeks of age)
    • Bilateral undescended testis
    • Maternal Graves disease
    • Maternal syphilis
    • Vascular birthmarks
    • Other…
  • Trisomy 21: Can NICU staff/nurses help with feeds on FCC? (sharing resources)
  • Donor breast milk: TBD



3.7 Moreno Valley NICU


Family care center coverage

FCC coverage, H&P timing, and outpatient (Great Starts) bilirubin follow-up are covered in the Pediatrics–Neonatology FCC agreement (Section 3.6.3).


Problem List

  • Create an overview for the “LIVE BORN……” problem to include the following information:
    • GA
    • Birth weight
    • GBS status
    • Maternal/Infant blood type
    • Coombs status