Neonatal Intensive Care Unit

 

Neonatal Intensive care unit

            Neonatal Intensive care is also considered synonymous with providing Advanced Life Support to critically sick babies.

Goal :

1.      To improve the clinical are of the critically ill neonate

2.      To reduce the Neonatal Mortality and Morbidity

3.      To provide continuing in-service training of Medical and Nursing personnel into care of newborn

Levels of care

·         The first step towards organization of neonatal intensive care is the recognition of existing neonatal care facilities.

·         It is prime importance to first strengthen Level-I care facilities

·         Priority order for developing the units should be

o   Basic level –II

o   High Level –II

o   Level –III

·         The ratio is 15:5:1

LEVEL- I CARE

• The minimal care
• Provided by the mother under the supervision of basic health professionals.
•  Neonates weighting more than 2000 gm or having gestational age maturity of 37 weeks or more belong to this care.
• This care can be includes care of delivery, provision of the warmth, maintenance of asepsis, and promotion of

LEVEL II CARE

• This care includes requirement for resuscitation, maintenance of thermo neutral temperature, intravenous infusion, gavage feeding phototherapy and exchange transfusion.
• 10-15 percent of the newborn require this care
•   This care s is anticipated for the infants weighing in between 1500 & 1800 gm or having gestational age maturity of 32 to 36 weeks.

LEVEL III CARE

•         This care includes life saving support system like ventilator and best suited special intensive neonatal care. 

•         Three to five percent of newborn require care of this level. 

•         This level of care is for critically ill babies, for those weighing less than 1500 gm or having gestational age maturity of less than 32 weeks.

INDICATIONS FOR THE ADMINSSION TO NICU

• Babies less then 30 weeks
• Very low birth weight baby of less then 1500 gms
• Cardiopulmonary monitoring
• Surfactant therapy
• Convulsions
• Severe birth asphyxia
• Assisted ventilation
• Total parenteral  nutrition
• Major surgery

 Physical facilities required for NICU

Physical facilities

Location and Space requirement

·         Traditional design NICU is of “Multiple bed NICU”, where a single big area is designed with multiple beds.

·         Current and most popular concept is of ‘Single family Room NICU’ where the mother stays with baby in NICU. This type of NICU needs more space and more staff.

·         It should be located preferably next to labor ward or delivery room

·         To pick up referral babies , it should be within easy access from ambulance entrance and should have separate elevator

·         One intensive care bed is generally required for 1000 deliveries provided  the prematurity rate is about 8%

·         NICU design should allow 500 – 600 gross square feet per bed. It includes patient  area, storage area, office area, seminar room, laboratory room, space for doctors, nurses, other staffs and space for families.

·         For level -3 multiple bed NICU , infant space should be 120square feet of unobstructed space  is required

·         The distance between the two baby beds should be 8-12 feet, so that the adjacent to each infant space will have minimum width of 4 feet .

Floor space

·         Floors should be easily cleanable and washable should minimize the growth of micro -organisms.

Wall surfaces

·         As with floors, the ease of cleaning , durability and acoustic properties of wall surfaces must be considered.

Hand Washing Stations

·         It should be 3 feet away from an Infant bed or clean supply area

·         The sink should be large enough to control splashing and should be designed to avoid standing or retained water.

·         The minimum dimensions for hand washing sink are 24 inches wide X 16 inches front to back X 10 inches deep from bottom of the sink.

Electrical, Gas supply and Mechanical Need

·         Electrical gas outlets near each infant should be organized, to ensure safety, easy assess and maintenance

·         There should be minimum 18 -20 simultaneously accessible electrical outlets

·         Minimum number of the

Family support area

·         Adequate space is required immediately adjacent to NICU for families

·         The family area should have space for gowns, hand washing, secured storage for their belongings, a small pantry and toilet.

Staff support area

·         Adequate space should be provided within the NICU to meet the professional , personal and administrative needs of the staff

Mother’s room

·         The room should be within or immediately adjacent to the NICU. These rooms should within or immediately adjacent to the NICU

·          

Temperature of the NICU

·         The air temperature of the should be 20 to 26*C and relative humidity of 30 to 60%

·         A minimum 6 air exchanges per hour is required with the minimum of two changes being the outside air.

Ventilation

·         A minimum of six air exchanges per hour is required

·         Ventilation air delivered to the NICU should be filtered with at least 3 micron HEPA filters. Filters should be located outside the infant care area so that they can be changed easily and safely.

Lighting

·         The whole unit must be well illuminated and painted white

·         The lighting arrangement should provided uniform shadow-free, illumination of 100 foot candles at the baby’s level

·         To perform procedures, separate lighting capable of providing 2000 lux is required. 

Noise

·         The permissible noise criteria of an hourly Leq is 45db and hourly L10 is of 50 dB.

·         Transient sound should not cross 65dB

Nurses

·         A nurse : patient ratio of 1:1 maintained thought out day and night is absolutely essential for babies on multi system support including ventilator therapy.

·         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 overall in-charge

·         In addition to basic nursing training for level-II car, 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 of 3 years work experience in special care neonatal unit in addition to having 3 months hand-on-training in an intensive care neonatal unit.

 Other staffs

·         Respiratory therapist

·         Laboratory technician

·         Public health nurse or social worker

·         Biomedical engineer

·         Clark

Equipment Need for NICU

•         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 & skills are used efficiently.

•         There should be servo-controlled incubators and open care systems for providing adequate warmth

 EQUIPMENT FOR LEVEL III NURSING – 6 BED

Sl.No	Item	Nos
1	Resuscitation set	6
2	Open care system	4
3	Incubators	2
4	Infusion pumps	12-18
5	Positive pressure ventilators	6
6	Oxygen hoods, oxygen analyzers	6
7	Heart rate – apnea monitors with scope	6
8	Phototherapy unit	6
9	Electronic weighting scale	1
10	Pulse oxymeters	6
11	End tidal CO2 monitor	6
12	Transcutaneous PO2 & PCO2	2-3
13	Noninvasive Bp monitors	1-2
14	Invasive Bp monitors	1-2
15	ECG monitor with defibrillator	1
16	Intra cranial pressure monitor	1
17	Portable radiographic machine	1
18	Portable ultrasound machine	1
19	Blood gas analyzer	1

DISPOSABLE ARTICLES REQUIRED FOR THE NICU

•         IV Catheters

•         IV sets

•         Micro burette sets

•         Bacterial filters

•         Feeding tubes

•         Endotracheal tubes

•         Suction catheters

•         Three-way stopcocks

•         Extension tubing

•         Umbilical arterial and venous catheters

•         Syringes, needles

•         Trocar and cannula

Laboratory Facilities

•         Microchemistry laboratory

•         Well equipped to provide   quick and reliable

•         Facilities for creative protein, total leukocyte counts and microscopic examination of peripheral blood

TOWARDS A GENTLE AND FRIENDLY NICU ENVIRONMENT

•         It has been realized that physical and social environment of nursery affect the recovery and long term morbidity of the neonate.

•         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.

•         Parent 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.