Org of nicu

Organization of NICU

1. ORGANIZATION OF NEONATEL INTENSIVE CARE UNIT Ms. Kanchan Mehra M.Sc. (N) I yr PCNMS

2. INTRODUCTION The organization of a good quality neonatal intensive care unit, special care neonatal unit is essential for reducing the neonatal mortality and improving the quality of life among the neonates. Patient ratio of 1:1 maintained thought out day and night is absolutely essential for babies on multi system support including ventilatory therapy

3. DEFINITION - Andria Santiago Newborn or neonatal intensive care unit, an intensive care unit designed for premature and ill newborn babies .

4. LEVEL OF NICU According to American academy of pediatrics the neonatal care is devided into four categories. These are – LEVEL I- WELL NEWBORN NURSERY: - These are generally referred to as the well baby nursery. These kind of nurseries have the capability to provide neonatal resuscitation at every delivery. Evaluate and provide postnatal care to healthy newborn infants. Stabilize and provide care for infant born at 35to 37weeks gestation who remain physiologically stable. Stabilize newborn infants who are ill and those born less than 35weeks gestation until transfer to a facility that can provide the appropriate level of neonatal care

5. The care providers here include- Pediatrician Family physician Nurse practitioner Other advance practice registered nurse

6. 2) LEVEL II- SPECIAL CARE NURSERY:- These are also known as special care nurseries and have all the capabilities of a level I nursery These provide care for infants born at 32 weeks gestation or older and weighing more than and equal to 1500g who have physiologically immaturity and moderately ill with a problems that are expected to resolve rapidly. Provide care for infants who are feeding and growing stronger or recovering after intensive care. Provide mechanical ventilation for a brief duration or continuous positive airway pressure.

7. Stabilize infants born before a gestation period of 32 weeks and with weight less than 1500g until transfer to a neonatal intensive care facility. The care providers here include- Neonatologists Pediatric hospital staff Neonatal nurse practitioners and all the level I health care providers.

8. 3) LEVEL III- NEONATAL INTENSIVE CARE UNIT:- It provide sustained life support. Comprehensive care for infants born at all gestational ages and birth weight with critical illness. An immediate access to a full range of pediatric medical sub- specialties ,pediatric surgical specialties, pediatric anesthesiologist and pediatric ophthalmologist. Provide a full range of respiratory support that may include conventional and or high frequency ventilation. Performed advance imaging with interpretation on an urgent basis including Computed Tomography, MRI, Echocardiography. It include all the care providers of level I and level II

9. 3) LEVEL IV- REGIONAL NICU:- This is the unit which provides the highest level of neonatal care. These unit have pediatric surgical sub specialists and all the care providers for all level III unit. It include all capabilities of level I, level II, and level III. These are located within an institutional performing complex care and provide surgical repair of congenital or acquired conditions. Maintain a full range of pediatric medical subspecialists, pediatric surgical sub specialists anesthesiologists at the site. Facilitate transport and provide outreach education

10. ORGANIZATION OF NICU 1) SPACE :- 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. 2) 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. 3) FLOOR PLAN :- The walls should be made of washable glazed tiles and windows should have layers of glass panes. Wash basins 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 room should be there.

13. 4) VENTILATION : -Effective air ventilation of nursery is essential to reduce nosocomial infections. The most satisfactory ventilation is achieved with laminar air flow system which is rather expensive. When centralized air conditioning is used, minimum of 12 changes of room air per hour are recommended. A simple method to achieve satisfactory ventilation consists of provision of exhaust fan in a reverse direction near the ceiling for input of fresh uncontaminated air and fixation of another exhaust fan in the conventional manner near the floor for air exit.

14. 5 ) LIGHTING :- The nursery must be well illuminated and painted white or slightly off white to permit prompt and early detection of jaundice and cyanosis. It is best achieved by cool white fluorescent tubes or LED (light-emitting diodes) to provide at least 100 foot-candle, shadow free illumination at the infant’s level. Spot illumination for various procedures can be provided by a portable lamp having two 15 watt fluorescent bulbs which when held at a distance of about one foot from the infant, produce about 100 foot candle intensity of light. In places where electrical failure is frequent and prolonged, the electrical system of the nursery complex must be attached to a generator

15. 6) TEMPERATURE AND HUMIDITY: - The temperature of the nursery complex must be maintained between 26-28 ͦ C (78.8 - 82.4°F) in order to minimize effects of thermal stress on the babies. This is best achieved by centralized air conditioning having temperature control knobs in the nursery. In most parts of India, relative humidity averages above 50%, which is quite satisfactory for routine needs of newborn babies. Humidity level can be raised for preterm babies nursed in an incubator. High and effective humidity level is useful to reduce insensible water loss but is associated with increased risk of nosocomial infection.

16. 7) ACOUSTIC CHARACTERISTICS :- The ventilation system, incubators, air compressors, suction pumps and many other devices used in the nursery produce noise. Sound intensity in the nursery should not exceed 75 dB to protect hearing of nursery personnel and infants. Excessive noise may lead to hearing loss, physiological and behavioral disturbances, such as sleep disturbances, startles and crying episodes, hypoxia, tachycardia and increased intracranial pressure.

17. 8) ELECTRIC OUTLETS :- The electrical equipment used in the nursery must be checked at least once a month for leakage of current. Special fittings with safety devices should be installed. The unit should have round-the clock uninterrupted servo-stabilized power supply. There should be round-the-clock power back-up including provision of UPS system for the sensitive equipments.

18. 9) EQUIPMENT:- During past few years, a large number of sophisticated devices for diagnostic and therapeutic purpose have been developed. Acquisition of new equipment does not necessary mean better services and outcome. Machine can not replace men. The best monitors are dedicated nurses and resident doctors involved in the care of new born babies. The maintenance of existing equipment in proper working condition is more important than acquiring new and sophisticated gadgets. The equipments used in wards are-

19. Resuscitation equipments :- Through the children in ward are stable but emergency can arise any time. So an emergency tray should be available in each pediatric ward. The tray should contain pediatric ambu bag, and mask, infant laryngoscope, tracheal tube, suction catheters and emergency drugs.

20. Ambu and mask resuscitation :- Self-inflating bag of 250 / 500 mL capacity is ideal for resuscitation of a newborn baby.

21. Oxygen facility :- Oxygen is supplied through central Oxygen source or portable oxygen cylinders. Portable oxygen cylinders are expensive and not readily available in a district hospital or community health centre. Oxygen must be warmed (36.0 - 36.5°C) and humidified before administration to the baby. Oxygen concentrators are cost-effective and promoted by WHO in developing countries.

22. Catheter, syringe and needle :- Nasogastric feeding tube, suction catheter, umbilical vein catheter, small vein infusion set, and medications should be kept in ward. Only disposables syringes and needles should be used.

23. Feeding Equipment :- Glass or steel bowls of adequate size (120ml capacity) should be available in the nursery and ward for collection of expressed breast milk or mixing and preparing formula. Storage facility like refrigerator should be available in the nursery.

24. Weighing machine:- Accurate weight record of babies is a sensitive index of their well being. Different type of weighing machine should be available in NICU like electric weighing machine with a digital read- out. Thermometer: - Both oral and rectal thermometer should be available in the NICU , as babies are prone to hypothermia. If common thermometer of NICU is to be used for all babies, then must be properly disinfected.

25. Phototherapy Unit :- Phototherapy is now generally accepted as a safe and effective method for treatment of neonatal hyper bilirubinemia . A light source design between 400 -520 nm wave length range at the mattress is ideal. The infant may be exposed under a portable or fixed blue light source (425 to 475 nm) kept at a distance of about 18 inches (45 cm) from the skin.

26. Infusion pump:- In view of the fact that small quantities of fluid need to be infused and minor errors in rate of administration may prove lethal to low birth weight babies, the use of infusion pump with accurate control is essential to meet these requirements. When total parenteral nutrition is used for care of sick babies, use of infusion is obligatory.

27. Laboratory Facilities : Satisfactory facilities for routine radiological examination should be available in the nursery round-the clock. A side laboratory for routine analysis of blood, urine, glucose, bilirubin , hematocrit should be available . Facilities for analysis of serum sodium, potassium, calcium and total serum proteins, and albumin should be at hand.

28. ROLE OF MIDWIFE IN NICU Maintenance of Airway. Maintenance of breathing and circulation. Maintenance of thermoregulation. Prevention of accidents. Maintaining aseptic technique. Prevention of illness. Maintaining nutritional level of newborn Prevention of nosocomial infection. Properly checking of NICU equipments

29. REFERENCE h ttps://www.uptodate.com/contents/pathogenesis-clinical-features-and-diagnosis-of-thrombosis-in-the-newborn/abstract/15 Sharma Rimple , Essential Of Pediatric Nursing, Eddition 1 st , JP Brothers Medical Publisher(p)ltd 2013 page no 249- 256