NEONATAL ORGANIZATION.pptx

neonatal organization

1. ORGANIZATION OF NEONATAL CARE UNIT, SERVICES,TRANSPORTATION , MANAGEMENT OF NURSING SERVICES IN NICU

2. What is the neonatal intensive care unit (NICU)? New-born babies who need intensive medical care are often put in special area of the hospital called the neonatal intensive care unit (NICU). The NICU has advanced technology and trained healthcare professionals to give special care. NICUs may also care areas for babies who are not as sick but do need specialized nursing care.

3. AIMS/GOALS OF NICU

4. MATERNAL FACTOR

5. DELIVERY FACTOR

6. BABY FACTOR

7. NICU TEAM

8. India has 3-tier system of neonatal care based on weight and gestational age of neonate . LEVEL OF CARE

9. INDICATIONS

10. PHYSICAL FACILITIES   The NICU can be in a single area or multiple rooms with a capacity of 2-4 infants each . The physical facilities include:

11. SPACE Serve as a referral unit for the infants born outside the hospital. Each infant should be provided with a minimum area of 100 sq. ft. or 10 m2. There should be separate space for breastfeeding 500-600 gross square feet /bed. 6 feet gap between two incubators for adequate circulation and keeping the essential lifesaving equipments . There should be no compromise on space and its adequacy is crucial for reduction of nosocomial infections. Space should be allocated within the nursery complex for promotion of breast feeding, expression of breast milk and its storage.  

12. LOCATION Located as close possible to the labor rooms and obstetric operation theatre The presence of an elevator in close proximity is desirable for transport of outborn infants. In tropical countries, the nursery should not be located on the top floor of the hospital but there should be feasibility for the sunlight to peep into the nursery to enhance brightness and provide ultraviolet rays to augment asepsis FLOOR PLAN: The unit facility should preferably be in a square space so that abundant open unencumbered space is available , walls should be made of washable glazed tiles and windows should have two layered glass panes. Wash basins with foot or elbow operated taps having round the clock water supply should be provided. The doors should be provided with automatic door closure. There should be an isolation room.

13. A SINGLE-CORRIDOR TYPE LAYOUT PLAN

14. VENTILATION There should be effective air ventilation and central air conditioning. Provision of exhaust fan A constant positive air pressure should be maintained in the nursery Do not use chemical air disinfection and ultraviolet lamps LIGHTING Well illuminated and painted while or slightly off white. Cool white fluorescent tubes The number and exact location of fixtures can be worked out taking into account size of the nursery, height of ceiling, and availability or otherwise of sunlight. Spot illumination for various procedures can be provided by a portable angle-poise lamp having two 15 watt fluorescent bulbs The nursery light should be dimmed at night to simulate day-night pattern to promote hormonal surge and growth of babies. Bed side lights with dimmer switches should be provided to create specialized microenvironment for each baby.  

15. ACOUSTIC CHARACTERISTICS: 1. Sound intensity in the unit should not be exceeded 75 decibles . 2. Telephone rings, equipment alarms should be replaced by blinking lights . 3. It is desirable to have effective sound proofing of ceilings, walls, doors and floor when a new nursery is designed.   ENVIRONMENTAL TEMPERATURE AND HUMIDITY 1. 26-28◦C in order to minimize effect of thermal stress on the babies and humidity must be above 50%. 2. The external windows of nursery should be glazed to minimize heat gain and heat loss and baby beds should be located at least 2 feet away from the wall and windows.   COMMUNICATION SYSTEM: The unit should have an intercom and a direct outside telephone line. No mobile phones should be allowed in the inborn and out born area.  

16. ELECTRICAL OUTLETS : There should be adequate number (8-12 electrical points at the height of 4-5 feets ) of light and power electrical points attached to a common ground. Each infants must be provided with at least eight electrical outlets. The use of adapters and extension boards should be discouraged. The electrical equipment used in the nursery must be checked at least once a month for leakage of current and adequacy of grounding. The voltage supply to the nursery should be stabilized with the help of a voltage servo-stabilizer.

17. NURSES STATIONS. 1. Central area 2. New-born charts, hospital forms, computer terminals, telephone lines should be located in this area CLEAN UTILITY AND SOILED UTILITY HOLDING ROOMS Stocking clean utility items and sterile disposables, and for disposal of dirty linen and contaminated disposables.

18.   STAFF ROOMS A comfortable room with intercom, telephone, computer facility. It is the space provided within the NICU.  Nurses staff room  Residents duty room  Nurses changing room MOTHER AREA Comfortable seating and privacy to mother to express breast milk with the help of lactation nurse.

19. PERSONNEL 1. Availability of sufficient number of adequately trained personnel 2. Nurse patient ratio in special care Medical personnel One independent senior resident doctor + 1 junior resident round the clock for 8 babies requiring special care . NURSING STAFF The NNFI (National Neonatology Forum of India ) has recommended that at least 1:4 ratio of babies in the special care neonatal unit. According to AAP, 1:3 for special & inter mediate nursery care, 1:1 for intensive care .The allowance should be kept for additional 25% staff to provide for exigencies of day off & leave. The nurse must be imparted continuous in service training in the art of neonatal nursing.

20.   Para medical personnel Respiratory therapist- -If ventilatory facilities are established, 1 respiratory therapist to monitor ventilatory settings, do tracheal suction & CPT. One paediatric pathologist to conduct and interpret autopsies. Other Staff 1. Maintenance staff: 1 sweeper should be there for 24hrs and 1 laundry boy 2. 1 Lab technician- One lab technician to operate glucometer, bilirubinometer , micro centrifuge, CRP kits & blood gas analyser . 3. 1 Social worker attached to NICU care

21. EQUIPMENTS   Equipments required of NICU for 6 patients include:

22. ENVIRONMENTAL EQUIPMENT   Environmental equipment include the following:   Incubators Radiant warmer  

23. MONITORS   Monitors include:   1. Blood Pressure Monitor.   2. Cardipulmonary Monitor   3. Transcutaneous oxygen/ carbondioxide monitor   4. EEG monitor   5. ECG monitor   6. Pulse oximeter

24. DIAGNOSTIC EQUIPMENT   Diagnostic equipment include : 1. X-ray   2. Ultrasound   4. MRI   3. CT scan X-ray : X-rays use electromagnetic energy beams to create images of bones, tissues, and organs. Ultrasound : Ultrasound machines use high fre quency sound waves to create images of organs, tissues, and blood vessels.   3. CT scan: A CT scan is a diagnostic imaging proce dure that uses a combination of X-rays and com puter technology to produce horizontal, or axial, images (often called slices) of the body ..

25. TREATMENT EQUIPMENT   Treatment equipment include:   Bili lights/ Phototherapy lights   Intravenous line Continuous Positive Airway Pressure ( CPAP Extracorporeal Membrane Oxygenation ( ECMO

26. Central line Umbilical catheter Endotracheal tube ( ET   Respirator or mechanical ventilator   Oxygen Hood   Nasal Cannula or Nasal Prongs   Feeding tube Peripherally Inserted Central Catheter (PICC) or Percutaneous Central Venous Catheter ( PCVC

27.   LABORATORY FOR NICU   A micro chemistry laboratory attached to the unit and providing round the clock service should be available. This should be well equipped with necessary equiments to provide quick and reliable test results.  

28. DOCUMENTATION   The unit should have printed problem oriented stationary for maintaining records, admission and discharge slips, etc. Records of all admission should be maintain in a register or on a computer. The information should analyzed and discussed at least once a month to improve the effectiveness of NICU in providing the services  

29. EDUCATIONAL PROGRAMME   There should be continuing medical education programmes for physicians and nursing personnel’s in t form of lectures, demonstrations, group discussions and panel discussions. These programmes should cour important issues like resuscitation, sterilization change transfusions, maintenance of equipment’s etc.

30. PROCEDURES THAT MAY BE NEEDED FOR THE CARE OF THE BABY . Warmth and Temperature Regulation   Nutrition for babies in the NICU Electrolyte and blood levels Some babies have too much or too little of certain electrolytes or other substances in the blood. As a result, some common problems include: Hypernatremia. This is high amounts of sodium (salt) in the blood. Hyperkalemia . This is high amounts of potassium in the blood. It can be diagnosed by blood test. Or it can be diagnosed by changes in the baby's heart rate pattern. Hyperglycemia . This is high amounts of glucose (sugar) in the blood. It is diagnosed by blood tests, often done by heel stick. Some babies may need insulin to control high glucose levels. Hypoglycemia . This is low blood sugar. It is usually treated with IV fluids that have dextrose. This is a type of sugar. Hypocalcemia . This is low calcium levels in the blood. It is usually treated with calcium in IV fluids .

31. Feeding These are some ways babies may be fed in the NICU: Gavage or tube feedings. Cup or spoon feedings.  Nipple feedings.   Testing and Lab Procedures for the New-born in Intensive   Intravenous (IV) Line and Tubes  Because most babies in the NICU are too small or sick to take full milk feedings, medicines, and fluids are often given through their veins or arteries. Babies may also need frequent lab tests and measurements of blood oxygen levels. There are several ways a baby may get fluids and medicines and have blood drawn. These include the following: Intravenous (IV) line. Umbilical catheter (UVC or UAC ). Percutaneous line.  

32. TRANSPORT OF SICK NEONATES The short distance transport within the hospital can be accomplished in a transport incubator.  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. When fragile neonates need to be moved to another facility, that move becomes the most important journey of the baby's life. For the smallest and most critically ill newborns , reduced transport time between facilities leads to improved outcomes. In utero transfer has better clinical outcomes for mother and infant than transfer after birth. However, in utero transfer is not always possible due to a number of reasons:   Accelerated birth due to baby's clinical condition. Need for treatment at a specialized hospital- extracorporeal membrane oxygenation Risk that could not be detected before birth Problems right after birth (for example respiratory distress syndrome)   :

33. In these instances, the critically ill newborns then rely on the hospital team and technology to provide the best possible environment for them during transportation. Depending on the region, hospital and situation, transfers can be done by ambulance or aircraft (fixed wing or helicopter).   The Baby needs to be protected from factors such as thermal change and vibrations, the caregiver needs fast access to the baby and life-supporting devices, and the transport team needs a transport system that is easy to move.   Transferring these infants at such a critical state poses many challenges to the clinicians and potential risks to the infant due to external factors including

34. In order to optimize transport and minimize discomfort to the infant, the effects of these factors have to be reduced as much as possible. Transportation requires skilled personnel and specialized equipment that is designed to meet the needs of neonates. The team set up varies from region to region and hospital to hospital. Equipment requirements also vary according to each situation but generally speaking the device needs the following:   Incubator with good access to the neonate   Vital signs monitor to observe oxygen saturation, ECG, respiration, C02 elimination, etc.   Ventilator to provide respiratory support Infusion pumps to administer medication.  

35. GOAL 1. The goal of every transport is to bring a sick neonate to a specialized neonatal centre in a stable condition. 2. To avoid complications during transport, the infant should be as stable as possible before leaving the referring hospital and a warm chain should be maintained. 3. The transport service gives high—risk patients timely access to the appropriate services without interrupting their care.  

36. ORGANISATION OF A NEONATAL TRANSPORT   The doctor in the referring hospital should,   Be aware of where to refer the sick baby   Contact the referral hospital   Provide clear history to the staff to enable early referral   Stabilise the infant before referral   Keep baby warm   Provide oxygen if hypoxic  

37. IV glucose if hypoglycaemia   Correct metabolic acidosis   Assist ventilation with bag & mask   Aspirate the gastric content & place b on CRTD   If sepsis, start apt antibiotics Ensure patent venous access   Explain the family the need for referral& get consent  

38. Components of a Newborn & Pediatric Critical Care Transport Program:   Transport dispatch system   Communication with neonatal intensivist   Response time   Critical care transport team  

39.   Interpretation of x-rays   Common lab investigations   Pharmacotherapy   Fluid therapy   Equipment training   Legal issues   Documentation   Transport physiology Infection control   Vehicle safety   Public relations   Continuous quality improvement   TRAINING & SKILLS FOR TRANSPORT TEAMS:

40. TRANSPORT PROCESS   Upon arrival at the referral institution   Consent   Assessment & stabilization   Call back to prepare the NICU/PIC  

41. STABILISATION DURING TRANSPORT Thermal care Glucose infusion Monitor color , respiration, and heart rate during the transport. Follow protocol during neonatal transport Monitor: HR, RR, RBS temperature Check for nasotracheal tube extubation Pneumothorax Any sudden change in status Contact to NICU to Report status of newborn State what is required for newborn During long-distance transport ➡ Monitor oxygen with a transcutaneous monitor → Consider the use of IPPV & CPAP

42. TRANSPORT EQUIPMENT & MEDICATIONS

43. Smaller Transport Equipment   Various sizes of:   chest tubes   cervical collar   IV cannula   central line sets   heparinized saline   Procedure manual   Co-operation between the obstetrician & neonatologists   Organisation of neonatal care services & its importance

44. NURSES ’ ROLE AND REPONSIBILITY To provide- continuing, comprehensive physical care and supportive treatment. Emotionally supportive care to acutely ill children. Empathetic support to parents and families of children in the NICU. To function effectively and safely, the ICU nurse should demonstrate the following capabilities : Good physical and emotional health Understanding or pathophysiology underlying diseases. Knowledge and understanding of sophisticated monitoring equipment and special apparatus. Ability to reason objectively and to judge and be aware of rapidly changing situations. Ability to interpret data and to take rapid, decisive action. Ability to perform complex technical skills correctly and organized manner. Understanding of the impact of illness and hospitalization on the life of the child. Understanding of parental responses and ways of coping with the stress of a critically ill child. Ability to record data concisely, accurately and thoroughly.    

45. PHYSICAL CARE OF THE CHILD Apply understanding of the pathogenesis of the disease. Perform complex technical skills to monitor and support the child. Apply general nursing measures for patient comfort and prevention of complications. Provide careful, continuous clinical observations of the child.

46. TOWARDS A GENTLE AND FRIENDLY NICU ENVIRONMENT Attempts should be made to reduce unnecessary noise and light. Avoid excess of light Handling should be gentle Neonates including pre terms feel pain and painful stimuli can cause deleterious physiological responses. Analgesia should be provided during all procedure including ventilation. Parents should be allowed unrestricted entry to the nursery They should be explained about various tubing and attachments to the baby and should be involved in care of their baby.

47. JOURNAL I mpact of the design of neonatal intensive care units on neonates, staff, and families: a systematic literature review Abstract Newborn intensive care is for critically ill newborns requiring constant and continuous care and supervision. The survival rates of critically ill infants and hospitalization in neonatal intensive care units (NICUs) have improved over the past 2 decades because of technological advances in neonatology. The design of NICUs may also have implications for the health of babies, parents, and staff. It is important therefore to articulate the design features of NICU that are associated with improved outcomes. The aim of this study was to explore the main features of the NICU design and to determine the advantages and limitations of the designs in terms of outcomes for babies, parents, and staff, predominately nurses. A systematic review of English-language, peer-reviewed articles was conducted for a period of 10 years, up to January 2011. Four online library databases and a number of relevant professional Web sites were searched using key words.

48. There were 2 main designs of NICUs: open bay and single-family room. The open-bay environment develops communication and interaction with medical staff and nurses and has the ability to monitor multiple infants simultaneously. The single-family rooms were deemed superior for patient care and parent satisfaction. Key factors associated with improved outcomes included increased privacy, increased parental involvement in patient care, assistance with infection control, noise control, improved sleep, decreased length of hospital stay, and reduced rehospitalization . The design of NICUs has implications for babies, parents, and staff. An understanding of the positive design features needs to be considered by health service planners, managers, and those who design such specialized units.  

49. REFERENCE Magon P. Textbook of child health nursing. Lotus Publishers: Pg 172- 181   Kurian S. Textbook of Pediatric Nursing. 1st Edition. Emmess : Pg 188-194   Pendita MH. A Textbook of child Health Nursing. Vit Med. Pg 317-325   Singh M. Came off the Newborn Sagan Publications. Pg. 20 20-30.                      

50. Thank you