Neonatal intensive care unit organisation

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1. ORGANIZATION OF NEONATAL CARE, SERVICES ( LEVELS ), TRANSPORT

2. Introduction The infant mortality rate and neonatal mortality rate is very high in India. The organization of a good quality special care unit and paediatric ward is essential for reducing the high mortality and improving the quality of care being given to children. During the past three decades, improvements in diagnostic and therapeutic approaches in the care of high risk infants have influenced their prognosis favourably.

3. Cont.. Unfortunately, many neonatal care centres in developing countries are unplanned and merely improvised. The organization of a good quality special care neonatal unit (SCNU) is essential for reducing the neonatal mortality and improving the quality of life among the survivors.

4. DEFINITION Newborn or neonatal intensive care unit, an intensive care unit designed for premature and ill newborn babies.

5. AIM OF ESTABLISHING NICU Reducing the neonatal mortality and improving the quality of life among the survivors

6. OBJECTIVES Govt. of India has launched an initiative to establish SCNU’s at district hospitals to provide: Care at birth including resuscitation of asphyxiated newborns. Management of sick newborns. Referral and transport services for babies needing mechanical ventilation and major surgical interventions. Post-natal care and immunization services Follow-up of high risk newborns.

7. Planning the Neonatal Intensive Care Unit During planning of paediatric wards, the paediatrician, and the nurse – in – charge of paediatric services should be taken into confidence, so that the special care neonatal units and paediatric wards are based on their opinions for meeting the needs of infants during hospitalization.

8. Emphasis should be laid on the following factors : Asepsis Warmth or thermo neutral environment Adequate nutrition with human milk Non – stimulating, noise free ward Safety from all biological, physical and chemical hazards The establishment of an ideal paediatric ward requires professional expertise and sound infrastructure. The philosophy of specialized conservative management of high risk new born babies should be fully exploiting to bring down the mortality rate in children

9. An ideal NICU should have facilities like : Adequate space Centralized oxygen and suction facilities Maintenance of thermo neutral environment Running water round the clock Linens and disposables like gloves, mask etc., Equipment's and articles of general and special use like IV stands, various procedure trays, stethoscopes, torch, syringes, bowels, kidney tray, feeding cups, jugs, basin etc., Machines like incubator, phototherapy unit, ventilator, monitors, etc., Stationary as per need. Toilets and bathrooms.

10. PHYSICAL FACILITIES Location Space Floor plan Ventilation Lighting Environmental Temperature Humidity Communication System Electric Outlets Staffing Other specialization staff Equipment's Disposable articles Laboratory Facilities

11. Location Neonatal unit should be located as close as possible to the labour room and obstetrics theatre. Adequate sunlight for illumination. Fair degree of ventilation of fresh air

12. Space 500 to 600 gross square feet per bed. Space includes patient care area, storage area, space for doctors, nurses, other staff, office room a rea, seminar room area, laboratory area, and space for families. 6 feet gap between two incubators for adequate circulation and keeping the life saving equipment.

13. Ventilation Effective air ventilation. Central air conditioning.

14. Floor plan Open encumbered space. The walls should be made of washable glazed tiles and windows should have two layers of glass panes. Wash basin with elbow or floor operated taps facility having constant round the clock water supply should be provided. The doors should be provided with automatic door closers. Isolation room should be present.

15. Lighting The whole unit must be well illuminated and painted white. The lighting arrangements should be provided uniform shadow free, illumination of 100 foot candles at the baby’s level.

16. Environmental temperature & humidity The temperature inside the unit should be maintained at 28’c +/- 2’c, while the humidity must be above 50 %. Portable radiant heater, infra red lamps can be used .

17. Communication system The unit should have an intercom facility & a direct outside telephone facility.

18. Staff pattern A direct who is a full time neonatologist One neonatal physician is required for every 6 – 10 patients One resident doctor should be present in the unit round the clock Anaesthetist – paediatric surgeon and paediatric pathologist are essential persons in establishment of a good quality nicu Other staff : Respiratory therapist Laboratory technician Public health nurse Social worker Biomedical engineer Clerk

19. Acoustic characteristics : The ventilation system, incubators, air compressors, suction apparatus and many other devices used in the nursery produce noise. Sound intensity in the unit should be not exceed 75 decibels. Telephone rings and equipment alarms should be replaced by blinking lights.

20. Electrical outlets Each patient station should have 12 to 16 central voltage – stabilized electrical outlets sufficient to handle all pieces of equipment. An additional power plug point should be preserved. There should be round the clock power back up including provision of ups.

21. Nurses staffing pattern A nurse : patient ratio of 1:1 maintained through out the day time and night time is absolutely essential for babies on multi system support including ventilator support. For special care neonatal unit and intermediate care nurse to patient ratio of 1:3 is ideal but 1:5 per shift is manageable. Head nurse is the over all in-charge. In addition to basic nursing training for level-II care, tertiary care requires, staff nurse need to be trained in handling equipment, use of ventilators and initiation of life support like use of bag and mask resuscitation, endotracheal intubations, arterial sampling and so – on. The staff must have a minimum 3 years work experience in special care neonatal unit in addition to having 3 months hand on training in an intensive care neonatal unit.

22. Equipment Equipment and supplies should including all that is necessary for resuscitation and intermediate care areas. Supplies should be kept close to the patient station so that nurses do not have to go away from the neonate unnecessarily and nurses time & skill are used efficiently There should be servo – controlled incubators and open care systems for providing adequate warmth Equipment's required as per the census of the unit and the level of care providing facility

23. Equipment's required Resuscitation sets Incubators Infusion pumps Positive pressure ventilators Oxygen hoods Oxygen analysers Heart rate monitors Apnea monitors with scope Phototherapy unit Electronic weighing scale

24. Contnd ., Ecg monitors Defibrillators Intra cranial pressure monitors Portable radiographic machine Portable ultrasound machine Blood gas analyser Pulse oximetry Invasive blood pressure monitors Non-invasive blood pressure monitors

25. Disposable articles required : Iv catheters Iv sets Micro burette sets Suction catheters Ryles tube Infant feeding tubes Urinary catheters Urine collection bags Three way adaptors Syringes & venflans & needles Endotracheal tubes Extension tubing's

26. Laboratory facilities Micro chemistry laboratory Well equipped to provide quick and reliable Facilities for creative protein, total leukocyte counts and microscopic examination of peripheral blood

27. Babies less than 30 weeks Very low birth weight baby of less than 1500 grams Cardiopulmonary monitoring Surfactant therapy Convulsions Severe birth asphyxia Assisted ventilation Total parenteral nutrition Major surgery Babies need to be on special vigilance care Opthalmia neonatrum babies Congenital syphilis babies Congenital malformation babies Jaundice affected babies Indications for the administration to NICU

28. LEVELS OR GRADES OF NEONATAL CARE Level I Level II Level III

29. Level – I (or) primary care of new born Primary care is simple care of new born who is normal (or) mild sick. This can be provided by mother, care taker (or) I level health workers, Trained Birth Attendant, Multi Purpose Health Workers, Auxiliary Nurse Midwives. Such care can be provided at home, Primary Health Centre, Sub Centre, Community Health Centre, Nursing Homes, Taluk Hospitals. The aim is to provided optimal care based on physiological needs of new born.

30. Component of primary care of new born Preparation during Antenatal Period Preparation of delivery & intra natal care Resuscitation at birth Physical examination & categorization of risk neonates Maintenance of warmth to neonates Breast feeding Prevention of infection Routine monitoring and management of minor ailments Identification of danger signal indications of referral case during transport Follow up, growth monitoring, immunization

31. 1.Basic neonatal care Good nutrition includes iron & folic acid for pregnant mother in order to prevent malnutrition and to improve the growth of fetus Immunization and adequate rest 2.Care of newborn at birth : All deliveries should be at institution (or) attended by Trained Birth Attendant Sterile disposable kit can be used Trained Birth Attendant can assess the new born at birth: cry, breathing, color Mouth to mouth resuscitation can be done when required O2 cylinder must be available at centre Weighing the baby to be done If any emergency immediate referral service

32. The hospital worker must be taught to dry the baby immediately after birth. Remove wet cloth wrap the baby in pre warmed cloth. Head should be covered with cap. Mother and hospital should be taught to keep the babies warm by touching the trunk and extremities with the back of their palm. No bath should be given soon after birth. At home room can be warmed by vacuum method. At Centre over head lamp electrical bulbs can be very effective in keeping the baby warm. The best method of warmth is skin to skin, kangaroo method. 3.Warmth to neonates

33. Mother must be educated about the importance of the breast feeding The baby must be put on to breast feeding after ½ hour of delivery if normal & there is no complication in lscs :4-6 hours Mother are encouraged to drink extra fluids and addition 50% in order to maintain health 5. prevention of Infection Inj.TT 2 doses during AN period Using aseptic precaution during delivery to prevent infection Keep delivery room clean, periodically cleaning and fumigation of room is necessary 4.Promotion of breast feeding

34. Neonates below 1800 grams (or) more than 34 weeks of gestation should be taken care at home. If there is no sucking reflex feed with spoon. Strict asepsis should be followed at home itself. No self medication is encouraged at home. 7.identification and referral of high risk neonates: Hospital worker to be taught to identify high risk babies so that timely referral can save life of the neonate. Neonate at high risk are less than 1800 grams, less than 34 weeks of gestation, pale, cyanosed, rapid breathing more than 60/minute, persistent vomiting/ diarrhoea , seizures, who fails to pass urine / meconium with in 24 hours. 6.Home care of LBW neonates

35. The concept of participating mother in the case of new born under the supervision of doctor, nurse are relevant the case they learnt at hospital can be practiced at home confidentially. The main care taken in level – II care needs physical space, trained manpower. Location : The level – II care should be close to the labor and delivery room. There should be facility for new born unit so that sick babies can be transferred quickly. Nursery should not be located in first floor. There should be adequate sunlight and illumination at nursery. L evel II care ( or) Secondary of new born

36. A wall clock with seconds Warmer with radiant heat source Mucus extractor, suction apparatus Infant laryngoscope with neonatal size blade Proper neonatal size e.t. tubes Facility for bag and mask ventilation Mechanical ventilators O2 supply with flow meter Umbilical vein canulation set Thermometer Essential drugs needed for resuscitation such : adrenaline. i.v.fluids , epinephrine, Hco3 Facilities for neonatal resuscitation in labor room

37. Pre term babies less than 33 to 36 weeks of gestation Babies with 1500 to 2000 grams and less than 4000 grams Babies with birth asphyxia Meconium aspirated Respiratory Distress Syndrome Infant with abnormal behavior (or) weight pattern Infant with metabolic, hematologic problems Neonatal hyperbilirubinaemia needs phototherapy (or) exchange transfusion High risk babies Function at level – II nursery :

38. Well developed written protocol. Admission discharge advice. Orientation to new health personnel. Patient care routine and proceeds. In service training and education. Written instruction about handling of vacuum equipment in the unit. Instruction about the filling of preformats discharge summary and follow up. Ongoing collection of monthly and annual statistical data. Administrative aspects :

39. New born less than 1500 grams less than 32 weeks, critically ill babies. Level III care requires neonatal care experts, maternal – fetal medicine experts. Any children who needs intensive care such : hydrofetalis, congenital heart disease, diaphragmatic hernia, abdominal wall defects, neural tube defects, should be delivered level – III care. Approximately 3-5% requires this type of care. Level – III (or) Tertiary care of the new born

40. Resuscitation facilities ( all equipment's ). Diagnosis and interventional therapy, fetal imaging and prenatal diagnosis of fetal distress. Development of fetal medicine to diagnose fetal disorders. Continuous medical education for doctors, nurses in the form of lecture, seminar, group discussion. Documentation, records of all babies should be maintained. Well equipped lab facilities for 24 hours. Equipment facilities: open care system, infusion pumps, ventilators, monitors, ecg , nibp, invasive monitors, pulse- oxymeter . Pediatrics under graduate and post graduate education. Transport facilities – ambulance. Follow up care. Functions of level – III nursing care :

41. LAY OUT DIAGRAM – N I C U

42. LAYOUT DIAGRAM – P I C U

43. Neonatal transport

44. Definition Newborn transport is used to move premature and other sick infants from hospitals without specialist, intensive care facilities require for optimal care of the baby to hospitals with neonatal intensive care and other specialist services.

45. Out born newborns A significant number of neonates require emergent transfer to a tertiary care center, often because of medical, surgical, or rapidly emerging postpartum problems. These are termed “outborn” neonates, because they have been born somewhere besides the facility to which they’ve been transferred.

46. TRANSFER Transfer can be within the hospital; to ICU Transfer can be to other hospital

47. NEONATAL TRANSFER TYPES Emergency: unplanned Elective : planned and informed

48. How can we transfer? The short distance transport within the hospital can be accomplished in a transport incubator. The use of plastic basket with perforated sides coupled with careful placing of hot water bottles is recommended for use in the rural setting.

49. The baby can be wrapped in tin foil or covered with several layers of cotton. Themocele (polystyrene) box is an effective insulator and can be used in community. Skin to skin contact with mother or a care taker is a useful modality of transport in rural areas or resource poor settings.

50. INDICATIONS OF NEONATAL TRANSPORT Preterm infant with a birth weight <1500g or gestation <32 weeks Respiratory distress requiring CPAP or assisted ventilation Severe hypoxic-ischemic encephalopathy Life threatening sepsis Intractable seizures Bleeding neonate

51. Cont… Congenital anomalies or surgical neonate Inborn errors of metabolism Severe jaundice Procedures or diagnostic facilities unavailable at parent hospital.

52. TRANSPORT EQUIPMENTS Transport incubator with multi channel vital signs monitor for recording temperature, heart rate, NIBP, oxygen saturation CPAP facility with nasal prongs and portable ventilator Airway equipment: suction devices, oral airways, bag and mask, laryngoscopes (size 00,0 and 1 blades)

53. Infusion facilities: infusates, infusion pumps , glucometer . oxygen, compressed air cylinder, oxygen mask, hood, heat and light, sources of electric powers and adapters. disposables: catheters (5,6,7,8,10,12Fr), syringes, needles, feeding tubes (8 & 10Fr), alcohol, betadine swabs, micropore tape, gloves etc.

54. 7. Instrument tray for ET intubation, vascular access, insertion of chest tubes, NG tube etc . 8. Life saving drugs.

55. No t e All the equipment should have a battery back up and should be kept fully charged all the time. Enough O 2 supply should be carried which should last during the period of journey.

56. TRANSPORT TEAM The neonate needing special or intensive care should be transported by a skilled transport team. Teams include at least, One senior resident One specially trained neonatal nurse

57. PRINCIPLES OF SAFE TRANSPORT S ugar T emperature A irway B lood pressure L ab work E motional support

58. S ugar A rterial circulatory support F amily support E nvironment R espiratory support

59. T emperature O xygenation (airway and breathing) P erfusion S ugar

60. PROTOCOLS Maintain airway, oxygenation, thermal stability and tissue perfusion . Stop oral feeding and start parenteral feeding with 10% of dextrose. Ensure umbilical or peripheral venous access . Insert an NG tube and decompress the stomach . Maintain adequate blood glucose level .

61. Obtain culture samples and administer first dose of antibiotics. Obtain a recent chest skiagram as a base line and to check the position of catheters and tubes. Take the family member or parents along with the baby whenever feasible. When required transport team should undertake life saving procedures (like ET tube insertion, chest tube insertion etc)

62. A dminister life saving drugs like surfactant and prostaglandins The referring hospital should prepare a detailed transport note including copies of obstetric and neonatal charts for the transport team. Monitor the baby’s color and temperature.

63. ARRIVAL AT THE RECEIVING NICU The transport team should remain in constant touch with the referral NICU during the course of journey. The team should brief the NICU care givers regarding the status of the baby and immediate clinical concerns. Hand over all the documents.

64. The referring hospital and parents should be informed about the safe arrival and latest condition of the baby. The inventory of transport equipment should be checked, medications and essential supplies should be restocked for the next transport service.

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