 Services (Levels)

ORGANIZATION OF NEONATAL INTENSIVE CARE UNIT

 Transport

 Neonatal intensive care unit

 Organization and management of nursing services in NICU

Neonatal intensive care unit,

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

The management of complex life threatening diseases,

provision of intensive monitoring and institution of life
sustaining therapies in an organized manner to critically
ill children in a separate pediatric intensive care unit.
Indication for the admission to nicu
■ Babies less then 30 weeks
■ Very low birth weight babies of less then 1500 gm
■ Cardiopulmonary monitoring.
■ Surfactant therapy
■ Convulsion
■ Sever birth asphyxia
■ Assisted ventilation
■ Total parenteral therapy
■ Major surgeries
 AIMS OF ORGANIZING OF NICU

Reducing the neonatal mortality and improving the quality of

life among the survivors
OBJECTIVES

■ To save the life of the sick new born

■ To prevent damage in infants with problems at birth and also

reduce morbidity in later life.

■ To monitor high risk newborns so as to reduce mortality and

morbidity in these babies
BASIC FACILITIES
■ Adequate space

■ Availability of running water

■ Centralized oxygen and suction facilities

■ Maintenance of thermo- neutral environment

■ Availability of plenty of linen and disposables

■ Facilities for availability to treat common neonatal problems

■ Equipment and articles of general and special use like iv
stands, various procedure trays, stethoscope, torch, syringes,
bowels, kidney trey, feeding cup, jugs, basin etc.

■ Machines like incubator, phototherapy unit, ventilator,

monitors etc.

■ Stationary as per need.

■ Toilets and bathrooms.

Emphasis should be laid on the
following:
■ Asepsis

■ Warmth and thermo neutral environment

■ Adequate nutrition with human milk

■ Non stimulating noise free ward

■ Safety from all biological, physical and chemical hazards.

NEONATAL CARE services

LEVEL - l
LEVEL - ll
NORMAL
NEONATAL LEVEL -lll
SPECIAL CARE
CARE NURSARY INTENSIVE
NEONATAL
CARE UNIT
LEVEL - I
■ 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 breast
feeding.
LEVEL - II
■ 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
■ 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.
Neonatal transport
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.
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 “out
born” neonates, because they have been born somewhere besides
the facility to which they’ve been transferred.
TRANSFER

■ Transfer can be within the hospital; to ICU

■ Transfer can be to other hospital

Neonatal transfer types

■ Emergency: unplanned

■ Elective : planned and informed

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.
■ The baby can be wrapped in tin foil or covered with several
layers of cotton.

■ Themocole (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.
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
■ Congenital anomalies or surgical neonate

■ Inborn errors of metabolism

■ Severe jaundice

■ Procedures or diagnostic facilities unavailable at parent

hospital.
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)
■ 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.
■ Instrument tray for ET intubation, vascular access, insertion of
chest tubes, NG tube etc.

■ Life saving drugs

Note
■ All the equipment should have a battery back up and should be
kept fully charged all the time.

■ Enough O2 supply should be carried which should last during

the period of journey.
Transport team
■ The neonate needing special or intensive care should be
transported by a skilled transport team.

■ Teams include at least,

1. One senior resident

2. One specially trained neonatal nurse

Principles of safe transport

STABLE

■ Sugar

■ Temperature

■ Airway

■ Blood pressure

■ Lab work

■
 SAFER
■ Sugar

■ Arterial circulatory support

■ Family support

■ Environment

■ Respiratory support
 TOPS
■ Temperature

■ Oxygenation (airway and breathing)

■ Perfusion

■ Sugar
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

■ 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)
■ Administer 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.

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

■ 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.
Organization of neonatal intensive care
unit
MAIN COMPONENTS TO BE
CONSIDER WHILE ORGANIZING A
NICU
1. Physical facilities

2. Personnel

3. Equipment

4. Laboratory facilities

5. Procedure manual

6. Transport of sick infants

7. Cooperation between the obstetrician and neonatologist

1. PHYSICAL FACILITIES

a) Location

b) Space

c) Floor plan

d) Lighting

e) Environmental temperature and humidity

f) Handling and social contacts

g) Communication system

h) Acoustic characteristics

i) Ventilation

j) Electrical outlets
A) LOCATION

■ Located as close as to labor room and obstetric

care unit

■ Adequate sunlight for illumination

■ Fair degree of ventilation for fresh air

b) SPACE

■ Serve as a referral unit for the infants born outside the hospital,
allowance should be made for additional physical facilities and space.

■ Each infant should be provided with a minimum area of 100 sq. ft. or
10sq. Meter. However , additional space would be needed to provide
for additional facilities

■ Space for promotion of breast feeding, expression of breast milk and

its storage.
■ 500-600 Gross square feet per bed.

■ Space includes patient care area, storage area, space

for doctors, nurses, other staff, office area, seminar
room area, laboratory area and space for families

■ 6 Feet gap between two incubators for adequate

circulation and keeping the essential lifesaving
equipment.
c) FLOOR PLAN

■ Ward should preferably be in square shape so that abundant open space is

available.

■ The walls should be made of washable glazed tiles and windows should
have two layers of glass planes to ensure the protection from heat and
sound insulation.

■ 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
■ There should be nursing station, doctor’s room, store room, a
procedure room, pantry, toilet and bathroom, milk storage
room and cleaning area.

■ The ward should have the clean area, infected area, separately
located where infants can be segregated.
d) VENTILATION

■ Effective air ventilation is necessary to reduce nosocomial infection.

■ The most satisfactory ventilation is achieved with laminar flow

system which is bit expensive.

■ A simple method for achieving satisfactory ventilation consist of

provision for exhaust fans in revers direction near ceiling for input of
fresh uncontaminated air.

■ Central air conditioning

E) LIGHTING

■ The whole unit must be well illuminated and painted white or

slightly off white to permit prompt detection of jaundice and
cyanosis.

■ The lighting arrangement should provided uniform shadow-free,

illumination of 100 foot candles at the infant’s level.

■ The number and exact location of fixation of lights depends upon

size of ward, height of ceiling and availability of natural light.
■ Spot illumination for various procedure can be provided by portable
angle poise lamp having two, 15 watt florescent bulbs.

■ In place where electric failure is frequent, the ward must be attached

with generator.
f) ENVIRONMANTAL TEMPERATURE AND
HUMIDITY

■ The temperature inside the unit

should be maintained at 28’ +_2’C,
while the humidity must be above
50%.

■ Portable radiant heater, infra red

lamp can be used.
g) ACOUSTIC CHARACTERISTICS

■ The ventilation system, incubators, air compressors, suction

pumps and many other devices used in the nursery produce
noise.

■ Sound intensity in the unit should be exceed 75 decibels.

■ Telephone rings and equipment alarms should be replaced by

blinking lights.
h) COMMUNICATION SYSTEM

■ The unit should also have an

intercom so that the ward is well
connected with other units of the
hospital, & a direct outside telephone
line so that the parents have easy
access to enquire about the wellbeing
about their child.
i) 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

■ There should be round-the-clock power

back up including provision of UPS
system
2. personnel

■ 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.

■ Anesthetist - pediatric surgeon and pediatric pathologist are essential

persons in establishment of a good quality NICU
k) NURSES
■ A nurse : patient ratio of 1:1 maintained thought out day and night
is absolutely essential for babies on multi system support including
ventilatory 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 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 of 3 years work experience in

special care neonatal unit in addition to having 3 months handon-
training in an intensive care neonatal unit.
OTHER STAFF
■ Respiratory therapist

■ Laboratory technician

■ Public health nurse or social worker

■ Biomedical engineer

■ Clark
3. equipment
During past few years, a large number of sophisticated devices for
diagnostic and therapeutic purpose have been developed.

Acquisition of new equipments does not necessarily mean better

services and outcome.

The maintenance of existing equipments in proper working

condition is more important then acquiring new and sophisticated
gadgets.
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
Medical Equipment in the NICU

Beds

Your baby will be admitted

to a radiant warmer or giraffe
bed, then changed into an
isolette or open crib
depending on age and medical
condition.
Monitor

Three sticky leads are placed on your baby’s skin to

monitor heart rate and breathing. A saturation probe is
placed on your baby’s hand or foot to read the oxygen
level. A temperature probe may be placed on the skin,
under the baby’s arm to measue the body temperature.
A blood pressure cuff will be placed on your baby’s leg
or arm to measure blood pressure.
■ Oxygen Saturation (blue line and number) is a measurement of how much oxygen the
blood cells are carrying and is described as a percentage of 100%, normal = 80 to 93 for
pre-term infants, 85 to 100 for term infants

■ Heart rate (green line and number) varies depending on infant

■ Temperature (orange number) normal is 36.2 to 37.6 Celsius or 97.2 to 99.7 Fahrenheit)

■ Respirations (white line and number) are your baby’s breaths, normal rate is 40 to 60

■ Blood pressure (purple number) varies depending on infant

■ Blood pressure cuff  (left leg) reads the baby’s blood pressure

■ Leads (purple hearts) read the baby’s heart rate and respirations

■ Saturation probe (right foot) reads the oxygen level the baby is receiving
Respiratory Equipment

Ventilator is a machine that provides

breathing support while the baby is unable
to breathe on his or her own

ET Tube is a tube that is placed in the

windpipe (trachea) and goes to the lungs to
help the ventilator provide breathing
support for the baby
CPAP is a machine that helps the baby breathe. CPAP prongs/mask will
be placed in/on the baby’s nose. The prongs/mask allow the CPAP
machine to provide breathing support to the baby.
■ Nasal Cannula are small tubes that go just inside your baby's nose to give oxygen
for breathing support.

■ Humidified Air for the nasal cannual helps keep your baby's nose from being
dried out.
■ The bag and mask set-up is at every
bedside. This emergency equipment is
used only temporarily until the ventilator
or CPAP machine is brought to your
baby.
■ A suction set-up is at every bedside.
Suction is used to clear collected
secretions/materials from airways to allow
babies to breathe easier. Suction is also
used to pull contents from the stomach or
the lungs. Babies with certain conditions
or breathing equipment may require
routine suctioning of their airway with
their care. Suction is readily available to
use in emergencies or with procedures
your baby may have done at the bedside.
IV Therapy
■ Infusion and IV pump are machines to
provide intravenous nutrition, IV fluids
and/or medications.

■ PIV or PICC are catheters that deliver

medications and IV fluid from the
medfusion and IV pump to the baby.
■ Phototherapy Some babies have an elevated bilirubin level which is referred to as
“jaundice”. Jaundice is a yellow-tinge in the baby’s skin or eyes. The bili-light
helps to reduce the bilirubin level in the baby’s body and will prevent side effects
associated with severe jaundice. The baby will have an eye mask to protect his or
her eyes from the bright lights of the bili-light.