Neonatal Intensive Care Unit. NICU. neonate

NICU. Neonate

1. NEONATAL INTENSIVE
CARE UNIT
(NICU)

2. Neonatal intensive care units (NICU) are
highly specialized area in a hospital that
caters to the needs of all types of sick
newborn babies.

3. Grades of Neonatal Care
India has 3-tier system of neonatal care based
on weight and gestational age of neonate.

4. Level I care
About 80-90% of neonates require minimal care.
For care of newborns more than 2000 grams or G.A.
> 37 weeks.
The care consists of basic care at birth, provision of
warmth, maintaining asepsis and promotion of
breastfeeding.
This type of care can be given at home, subcenter
and primary health centre.

5. Level II care
Neonates weighing 1500-2000 grams or G.A.
between 32–36 weeks are categorized under level
II care and are looked after by trained nurses and
pediatricians.
The equipment and facilities used for this level of
care include equipment for resuscitation,
maintenance of thermoneutralenvironment,
intravenous infusion, gavagefeeding, phototherapy
and exchange blood transfusion.
This type of care can be given at district hospitals,
teaching institutions and nursing homes.
Only 10-15% of all neonates require this care.

6. Level III care
Neonates weighing less than 1500 grams or having
gestational maturity of less than 32 weeks are
categorized under level III care.
The care is provided at apex institutions and
regional perinatalcentresequipped with centralized
oxygen and suction facilities, servo-controlled
incubators, vital signs monitors, ventilators, infusion
pumpsetc.
This type of care is provided by skilled nurses and
neonatologists.

7. ORGANIZATION OF NEONATAL
INTENSIVE CARE UNIT

8. The management of complex life-
threatening diseases, provision to intensive
monitoring & institution of life-sustaining
therapies in an organized manner to critically
ill children need separate neonatal and
pediatric intensive care unit (NICU and PICU).

9. The first consideration in establishing a new
NICU is to document the need for such a unit in
a given setup.
An assessment of its need should primarily be
based on the existing patient load & type of
illnesses cared for in that set-up.

10. SIZE:
The size of the unit is related to the expected
population intended to be served.
In a maternity unit having 2000 deliveries/year,
facilities for special care of 6-8 high risk infants
should be available.
Each infant should be provided with a minimum area
of a 100 sq ft (10 meter square).
There should be no compromise on space and its
adequacy is crucial for reduction of nosocomial
infections.

11. LOCATION:
The neonatal unit should be located as close as
possible to the labor room and obstetric
operation theatre to facilitate prompt transfer
of sick neonate.
The presence of an elevator in close proximity is
desirable for transport of out born babies.

12. Nursery Design
The unit design may be in a square space or
a single corridor based rectangular unit.
A split unit (on either side of the hospital
corridor) should be avoided, for prevention of
infections.

13. Baby Care Area
The unit should be provided with areas and rooms for
inborn or out born babies, examination area,
mother’s area for breastfeeding and expression of
breast milk, nurses station and charting area.
The infected infants with open sepsis (especially those
with diarrhea and abscesses) should be isolated in a
septic nursery, which should be located away from
the NICU and manned by different nursing and
resident staff.

14. Examination Area
A small comfortable room with examination
table, comfortable seating, sufficient light, and
warmth is needed for assessment of baby
before admission to the nursery.
Mother area-The room should be provided
with comfortable seating and privacy to the
mother to breastfeed and express the breast
milk with the help of a lactation nurse.

15. Handwashingand Gowning
Handwashingand gowning facility should be
located at the entrance. It should be provided
with abundant space with self closing doors.
Street shoes are changed with nursery slippers,
followed by handwashingand gowning.
Hand free elbow-operated handwashingsink
with liquid soap dispenser is recommended.

16. Cont..
Pictorial handwashinginstructions should be
provided on the wall next to the sink. Hands
should be dried with disposable napkins or hot
air dryer
The sink should be large and deep (24” wide
×16” front-back ×10” deep).
Antiseptic sanitizing solution (sterillium) can be
used for disinfection of hands in-between the
babies

17. Preparation of Intravenous Fluids
A separate area should be provided with a
laminar flow system for preparation of
intravenous fluids, parenteralnutritional
formulations, enteralfeeds and medications.

18. Nurses Station
Nursing station and charting area for nurses
and residents should be located in a central
area from where all the babies can be
observed.
Newborn charts, hospital forms, computer
terminals, telephone lines should be located in
this area.

19. Clean Utility and Soiled Utility Rooms
There should be enough space for stocking
clean utility items, disposal of dirty linen and
contaminated disposables.
The ventilation system in the soiled utility or
holding room should be engineered to have
negative air pressure with all air being
exhausted to the outside.

20. Staff Rooms
Space should be provided within the unit to meet
the professional, personal and administrative
needs of resident staff on duty.
Nurse’s Change room is required for changing
from formal street clothes to dress stipulated by
the NICU.

21. Ventilation
Effective air ventilation of nursery is essential to
reduce nosocomialinfections.
There should be no draughts of air on and near
the newborn beds.
The air-conditioning ducts must be provided with
milliporefilters (0.5 u) to restrict the passage of
microbes.

22. Lighting
The nursery must be well illuminated and
painted white or slightly off white to permit
prompt and early detection of jaundice and
cyanosis.
In places where electrical failure is frequent
and prolonged, the electrical system of the
nursery complex must be attached to a
generator.

23. Temperature and Humidity
The temperature of the nursery complex must
be maintained between 22 –26ͦC (72 -78°F)
and humidity 30%-60% in order to minimize
effects of thermal stress on the babies.
The air movement should be so designed that
draught is minimized.

24. PERSONNEL
1.Physician staff :
Consultant in charge (Neonatologist),
Resident doctor
Paediatricsurgeon
On call subspecialty pediatrician.

25. Cont..
2. Nurses:
The ideal nurse-patient ratio is 1:1; the minimum is
one nurse per 2 patients in the unit all the time.
3. Other members:
Biomedical engineer, Laboratory technician,
Physiotherapist and Sweeper should be assigned
specially for NICU.

26. Equipments
Emergency tray should be available in each
infant care room of NICU containing Ambubag
and mask, infant laryngoscope, tracheal tubes
of different sizes, sterile suction catheters and
emergency drugs.
Bag and Mask Resuscitator -Self-inflating bag
of 250 / 500 mLcapacity is ideal for
resuscitation of a newborn baby.

27. Cont..
Oxygen and suction facility
Catheter, syringes and needles
Feeding equipments-glass and stainless steel bowels of
adequate size
Weighing machine
Pulse Oximeter
Infusion or syringe pump
Blood Pressure Monitors
Incubator
Radiant warmer
Phototherapy unit

28. Prevention of neonatal
infections at NICU

29. Common Pathogens Causing
Neonatal Infections
Group B streptococcus
Staphylococcus aureus
Chlamydia
Gonorrhoea
Tetanus
Syphilis
Hepatitis B
Hepatitis C
Herpes simplex virus
Human
immunodeficiency virus
Human papillomavirus
Influenza virus
Rubella
BACTERIAL INFECTIONS VIRAL INFECTIONS

30. Types of hospital infections in the
NICU
Blood stream infections (BSI)
Central Venous Catheter
Umbilical catheter-associated blood stream
infections
Ventilator-associated pneumonia
Device associated infections

31. Prevention of Infection at The
Time of Birth
Keep the baby in a clean area and follow
standard precautions for newborn resuscitation.
Ensure that resuscitation team wears
appropriate PPE.
Wipe both of the new born’seyes with a sterile
gauze and discard the wet cloth. Use a
separate gauze for each eye and wipe from
the inner canthusto the outer canthus.

32. Cont..
Administer vitamin K and recommended
immunizations (birth dose of oral polio vaccine
and HBV vaccine), using safe injection practices
and sharps safety.
Apply relevant IPC precautions (Transmission-Based
Precautions and prophylaxis) to those who are
exposed or infected during or before birth (e.g.,
congenital syphilis, rubella, HIV, HBV, and other
infectious diseases).

33. Infection Prevention at Special
Care Unit
Comply with standard precautions at all times
and use transmission-based precautions
Keep the mother separated from the baby when
the mother has multi-drug resistant TB.
Follow patient spacing guidelines in the newborn
nursery.
Encourage exclusive breastfeeding
Manage expressing and storage of breast milk
carefully to prevent infection

34. Cont..
Use clean techniques for preparation of formula
feeds
Screen visitors and exclude for signs of infection-
fever, respiratory infection, diarrhoeaetc.
Hand hygiene before and after contact with
newborn
Not sharing equipment and supplies between
infants
Preventing the acquisition of infection from
contaminated feedings, water, or air

35. Cont..
Protecting the newborn from infected health
care workers and visitors
Using invasive medical devices carefully
Strictly adhering to aseptic techniques
Use of multi-dose vials should be discouraged, if
possible
Staff and parents should wear long-sleeved
gowns if they are handling the infant outside of
the bassinet/crib/warmer/incubator.

36. Cont..
Staff gowns should be discarded after care of
one infant and a new gown should be worn for
handling the next infant.
Parent gowns should be discarded at the end of
the visit.
Wrap or cover NICU linens during transport
from the laundry and store them in closed
cabinets to prevent contamination