How to establish nicu

nicu establishment

1. Dr.N.Vinay kumar Junior resident HOW TO ESTABLISH NICU

2. Newborn or neonatal care unit is an intensive care unit designed for premature and ill newborn babies. HISTORY Mid 19 th century: Dr.Stephane tarnier designed incubator and he is called as father of incubator . Dr.Budin :father of perinatology . DEFINITION

3. AIM Reducing the neonatal mortality and improving the quality of life among the survivors. OBJECTIVES ICU Services. Reduce neonatal mortality & morbidity. Meeting the special needs of the neonates. Maternal Bonding. To meet the nutritional needs of the neonate. Continuing in-service education.

4. TERMINOLOGY Newborn Care Corner (NBCC) NBCC is a space within the delivery room in any health facility where immediate care is provided to all newborns at birth. This area is MANDATORY for all health facilities where deliveries are conducted. Newborn Stabilization Unit (NBSU) NBSU is a facility within or in close proximity of the maternity ward where sick and low birth weight newborns can be cared for during short periods. All FRUs/CHCs 1 need to have a neonatal stabilization unit, in addition to the newborn care corner.

5. Special Newborn Care Unit (SNCU) SNCU is a neonatal unit in the vicinity of the labor room which will provide special care for sick newborns. Any facility with more than 3,000 deliveries per year should have an SNCU (most district hospitals and some sub-district hospitals would fulfil this criteria).

6. Level – III - High – Intensive -Tertiary Level – II - Ideal - Specialised Level – I - Adequate – Basic LEVELS OF NEONATAL CARE

7. LEVEL 1 LEVEL 2 LEVEL 3 80 percent babies require minimal care provided b mothers under supervision. Neonates >1800 gm and >34 week gestation. Care can be provided at home, subcenter and phc . Basic care at birth Provision of warmth Maintainence of asepsis Exclusive breast feeding 10-15 percent babies require specialised care Supervised by trained nurses and pediatricians Neonates between 1200gm-1800gm or 30-34 weeks gestation. Care provided at FRU,dist hospitals,nursin homes. Equipment for resusitation,maintainence of themoneutral environment,iv infusion,gavage feeding,phototherapy,exchange blood transfusion 3-5 percent babies require intensive care Supervised by skilled nurses and neonatologists Neonates <1200gm or<30 weeks gestation. Care provided at apex institute or regional perinatal centers Centralised O2, suction ,servo controlled incubators,monitors,ventillators,inusion pumps.

8. Adequate space. Availability of running water round the clock. Centralized oxygen and suction facilities. Maintenance of thermo neutral environment. Availability of plenty of linen and disposables. Facilities for availability to treat common neonatal problems. BASIC REQUIREMENTS

9. 1.PHYSICAL FACILITIES( Space,Location,Floor Plan,Ventilation,Lightings,Temperature and Humidity, Handling and Social Contacts, Communication Systems, Electrical Outlets) 2.PERSONNEL 3.EQUIPMENTS 4.LABORATORY FACILITIES 5. PROCEDURE MANUAL 6. TRANSPORT OF SICK INFANTS MAIN COMPONENTS TO BE CONSIDER WHILE ORGANIZING A NICU

10. Newborn Care Corner Earmark an area about 20-30 sqft in size within the labor rooms of all health facilities for establishing a newborn corner. For FRUs and district hospitals, also set up newborn corners in operation theatres where caesarean sections are conducted. Equip the corner with a radiant warmer and resuscitation kits Steps in setting up newborn care facilities

11. Newborn Stabilization Unit For setting up a 4-bedded stabilization unit, at least 200 sqft of floor space is required. The unit should be located within or in close proximity to the maternity ward. In addition, two beds in the postnatal ward should be dedicated for rooming in. Civil work. Basic civil work required to set up a stabilization unit are: Power supply: The unit should have 24 hr uninterrupted stabilized power supply

12. Water supply: The unit should have 24 hr uninterrupted running water supply. Lighting: The unit should be well lit, preferably with compact fluorescent light (CFL) panels. Floor surfaces: The floor surfaces should be easily cleanable thus minimizing the growth of micro-organisms. Walls: As with floors, the ease of cleaning, durability, and acoustical properties of wall surfaces needs to be considered. Equipment: The equipment for maintaining temperature and conducting resuscitation are required

13. LOCATION – Close to labour room, Operation Theaters. It should be situated in the Ground Floor. Good ventilation should be there. It should be located on to one side of the corridor. Split unit should be avoided. It should be located with in nursery complex for the promotion of breast feeding and expression of breast milk and storage. Special Newborn Care Unit

14. 1. Project the bed demand . minimum recommended number of beds for an SNCU at the district hospital is 12. if the district hospital conducts more than 3,000 deliveries per year, 4 beds should be added for each 1,000 additional deliveries. 2. Estimate the required space and identify the space. An average floor area of 50 sqft per bed should be available for a patient care area with an additional 50 sqft to be utilized as ancillary area. Therefore, on an average, a total area of 100 sqft per patient is required. For example, for a 12-bedded SNCU, 1,200 sqft floor area is required.

15. Additional space will be required for the step-down area which will have beds for babies rooming-in with the mothers after the acute phase of illness is over. The number of beds (adult beds would be required for rooming-in babies with mothers) is 30% of the SNCU beds. For example, a 12-bedded unit will require 4 additional adult beds for the step down. 3. Design the unit Patient care area Ancillary area Step-down area

16. Patient care area For a unit of 12 beds, the patient care area would be 600 sqft (50 sqft per bed). The patient care area can be designed to have two interconnected rooms separated by transparent observation windows from the nurses' working place in between. While one room can be used for intramural newborns (those born within the health facility), another room can be used for extramural newborns (those born outside the health facility).

17. Ancillary area: 600 sqft ancillary area should include separate areas for hand washing and gowning area , nurses' work station, clean area for mixing intravenous fluids and medications, doctors duty room, computer terminal, mother's area for expression of breast milk and learning mother crafts, unit store and side lab. It is desirable to have areas for portable x- ray, boiling and autoclaving and laundry room.

18. a)Hand washing and gowning areas Should be located at the entrance of the unit. Elbow operated taps should be there for hand washing Sink should be made of stainless steel with no counter tops. Walls surrounding the sinks should be made of nonporous material. Handwashing instructions should be displaed .

19. b)Mother area It should be comfortable to the mother for breast feeding their babies and expression of breast milk. c)Nurse station It should be located in central area from where all the neonates are visible. d) Handwashing stations Should be 20 feet distance to each infant. Sinks should be large and deep(24*16*10). e)preparation of iv fluids Separate area should be earmarked for preparation of enteral feed,medications ,preparation of tpn .

20. f)Examination area There should be a table with comortable seating good light and warmth should be there Every baby before admission assesed and cleaned in this area. g)Staff rooms Chaning room should be there for nurses. Separate room should be there or resident doctors Step-down area The SNCU design should include the step-down unit. The step-down could be within the premises or in close proximity.

21. Power supply : The unit requires 24 hr uninterrupted stabilized power supply, sufficient to take the load of equipment.There should be a generator facility as power backup. Floor surfaces: The floor surfaces are made of glazed tiles which can be easily cleanable and minimize the growth of micro­organisms. Walls : walls should be painted white or off white,and walls should have the properties of heat and sound insulation. Water supply : The unit should have 24 hr uninterrupted running water supply. An overhead tank of appropriate size should be provided for. Lighting: Light sources should be as free as possible of glare or veiling reflections. No direct view of the electric light source or sun should be permitted in the newborn space. 4. Identify and provide for civil, electrical and mechanical requirements

22. Temperature : The unit should be designed to provide an air temperature of 78.8°F to 82.4°F (28 ± 2°C). temperature can be maintained with the help of A/C. sound: Should not exceed 75 db (decibels) Excessive Sound leads to Hearing loss , Startle ,Sleep Disturbance , Hypoxia ,Crying episode , Tachycardia raised ICP . Telephone rings & Equipment alarms should be Replaced by blinking Lighting

23. Electric Outlet Adequate numbers of electrical points should be there attached to common ground. Each bed – 8 electrical outlets (four-5amp and four-15amp) Do not use adopter or extension board. Safety devices must be installed. UPS system should be available for the sensitive equipment. 5. Procure and install equipment SNCU equipment include equipment for resuscitation, phototherapy and thermoregulation such as radiant warmers and phototherapy units etc

24. 5)Personnel 1 full time pediatrician 1 senior resident 1 junior resident for 8babies round the clock 1 social worker Nurses-1:4 Lab tecnician Phsiotherapist Biomedical tecnician Pathologist

25. 6 .INFECTION CONTROL Hand washing is essential and needs to be monitored regularly steps of hand washing posters should be displayed near the sinks. 7. DOCUMENTATION Unit should have -printed form of admission and discharge slips Records of all admission should be maintained in regular

26. 8.COOPERATION BETWEEN THE OBSTETRICIAN AND NEONATOLOGIST Antenatal care and foetal diagnosis Perinatal hypoxia Promotion of feeding with human milk Supervised care of low birth weight babies

27. EQUIPMENT REQUIRED AT VARIOUS CENTERS

28. IV Catheters IV Sets Feeding Tubes ET Tubes Suction catheters Umblical central venous catheter Syringes Needles splints extention Gloves DISPOSABLE ARTICLES REQUIRED

29. Cost of setting up newborn care facilities

30. NBCC One doctor and one sister required for NBCC. All doctors and nurses attending deliveries should attend training in Navjaat Shishu Suraksha Karyakram (NSSK). Human resources for newborn care service

31. NBSU: One trained doctor is required for the stabilization unit. At least one full-time staff nurse trained in newborn care per shift should be available. This would require at least 4 fulltime staff nurses per unit. The staff at NBSU must be trained in facility based IMNCI (F-IMNCI).

32. SNCU : It is proposed that one paediatrician trained in neonatology should be posted at the unit, supported by two or three medical officers trained in FBNC. Three nurses in each shift, round-the-clock. In addition to doctors and paramedics, support staff should be available to clean the nursery at least once during every shift and more often depending on the need. In addition, a part-time lab technician and a data operator will be required for the unit. The Doctors and nurses posted at the SNCU need to further undergo training in FBNC

33. NBCC NBSU SNCU MO 1 1 3 – 4 MOs (including 1 Ped ) SN 1 4 (1 / shift) 10 (3/ shift) Training NSSK F-IMNCI FBNC

34. NSSK addresses important interventions of care at birth, that is basic newborn resuscitation, prevention of hypothermia, prevention of infection, early initiation of breast feeding, and equips the staff with appropriate knowledge and skill to provide essential newborn care in primary health care settings. Navjaat Shishu Suraksha Karyakram (NSSK)

35. Capacity building of service providers at NBSUs is essential to ensure quality care for normal and sick newborns. Keeping in view the non-availability of specialists ( paediatricians ) at many FRUs, it becomes important to build skills of medical officers and staff nurses at these facilities. It is recommended that all NBSU staff at FRUs is trained in F-IMNCI, which includes the package on 'facility based care of sick newborns and children'. F-IMNCI is skill-based training, based on a participatory approach combining classroom sessions with hands-on clinical sessions. Facility based IMNCI (F-IMNCI)

36. FBNC Training in 3 steps Step I: Training of Trainers from the sites selected for FBNC training minimum 2-3 Trainers from each site who will be involved in training Professors, Asso -Professors, lecturers, Chief resident, Senior Staff Nurses with good communication skills. Depending on the sites 2-3 TOTs will be done preferably at State collab . Centers. Facility based newborn care training programme

37. Step II: Actual training for personnel's working in SNCUs 4 Days classroom training Batch Size: 20 Participants Facilitators: 04 (ratio of 1:5) Participants: MO/ Pediatricians/ Staff Nurses Duration : 4 days Step III: Observer-ship for 12 days At a time 3 -4 participant in each training site for Hands-on training in developing skills

38. The manual should contain detailed instructions regarding care of baby in labour room. Indication for admissions in to nicu . Detailed description for the prevention of infections,temperature control,incubator care,keeping babies warm,nurses observation and working knowledge of various equipments. The policy regarding mother baby contact, discharge,what to do after baby dies should be clearly defined. guidelines for mangement of birth asphyxia,RDS,jaundice,sepsis,bleeding . P rocedure manual

39. THANK YOU