LEVELS OF NEONATAL

INTENSIVE CARE UNIT

By:-
Prerna sharma
M.SC Nursing, second
semester
 INTRODUCTION

A neonatal intensive-care
unit (NICU), also known as
an intensive care nursery (ICN), is
an intensive-care unit specializing in
the care of ill or pre-mature newborn 
infants.
The first American newborn intensive
care unit, designed by Louis Gluck,
was opened in October 1960 at 
Yale-New Haven Hospital,
 The term neonatal comes from neo,
"new", and natal, "pertaining to birth
or origin".

Fig:1 NEWBORN INFANT SLEEPING

IN AN INCUBATOR
 History

As early as the 17th and 18th

centuries, there were scholarly
papers published that attempted to
share knowledge of interventions. 
It was not until 1922, however, that
hospitals started grouping the
newborn infants into one area, now
called the neonatal intensive care unit
(NICU).
In the mid-nineteenth century, the
infant incubator was first developed,
based on the incubators used for
chicken eggs.
Dr. Stephane Tarnier is generally
considered to be the father of the
incubator (or isolette as it is now
known), having developed it to
attempt to keep premature infants in a
Paris maternity ward warm.
 Nursing and neonatal
populations
 
Master of Science in Nursing (MSN)
and various doctorates.
A nurse practitioner may be required
to hold a postgraduate degree. 
The National Association of Neonatal
Nurses recommends two years'
experience working in a NICU before
taking graduate classes
Registered nurse, local licensing or
certifying bodies as well as employers
may set requirements for continuing
education.

FIG-2 a pediatric nurse checking

recently born triplets in an incubator
at ECWA Evangel Hospital, Jos,
Nigeria
 Increasing technology
Admission policies gradually changed
special modification for small babies,
whose bodies were tiny and often
immature.
The key is prevention. Money can be
spent on programs educating mothers
on staying healthy during their
pregnancy.
Not only careful nursing but also new
techniques and instruments now
played a major role.
Neonatal intensive-care unit from
1980
Neonatal intensive-care unit in 2009.
 Changing priorities

NICUs now concentrate on treating

very small, premature, or congenitally
ill babies.
Premature labour, and how to prevent
it, remains a perplexing problem for
doctors.
parents are encouraged to help with
care as much as possible.
Cuddling and skin-to-skin contact,
also known as Kangaroo care,
A premature infant weighing 992 grams
(35 ounces), intubated and requiring 
mechanical ventilation in the
neonatal intensive-care unit
 common diseases cared for in a
NICU include perinatal asphyxia,
major birth defects, sepsis, 
neonatal jaundice, and
Infant respiratory distress syndrome
 due to immaturity of the lungs. In
general, the leading cause of death in
NICUs is necrotizing.
 Levels of care

Levels in the United States are

designated by the guidelines
published by the 
American Academy of Pediatrics In
Britain, the guidelines are issued by
The British Association of Perinatal
Medicine (BAPM), and in Canada
they are maintained by The Canadian
Paediatric Society.
Level 1: Basic neonatal care

Level 1a: Evaluation and postnatal

care of healthy newborn infants; and 
Phototherapy
Provide neonatal resuscitation at
every delivery, as needed
•Provide care for infants born at 35-37
weeks who are physiologically stable
•Stabilize infants born <35 weeks or
who are ill until transfer to a higher
level of care facility
Neonates weighing more than 1800
grams or having gestational maturity
of 34 weeks or more are categorized
under level I care. The care consists
of basic care at birth, provision of
warmth, maintaining asepsis and
promotion of breastfeeding. This type
of care can be given at home,
subcenter and primary health centre.
 Level 1b
Care for infants with corrected gestational
age greater than 34 weeks or weight
greater than 1800 g who have mild illness
expected to resolve quickly or who are
convalescing after intensive care
Ability to initiate and maintain intravenous
access and medications
Nasal oxygen with oxygen saturation
monitoring (e.g., for infants with chronic
lung disease needing long-term oxygen
and monitoring).
Level 2: special care newborn
nursery
Level 2a:
Care of infants with a corrected gestational age of
32 weeks or greater or a weight of 1500 g or
greater who are moderately ill with problems
expected to resolve quickly or who are
convalescing after intensive care
Peripheral intravenous infusions and possibly
parenteral nutrition for a limited duration
Resuscitation and stabilization of ill infants before
transfer to an appropriate care facility
Nasal oxygen with oxygen saturation monitoring
(e.g., for infants with chronic lung disease needing
long-term oxygen and monitoring).
Level 2b: Mechanical ventilation for
brief durations (less than 24 h) or
continuous positive airway pressure.
Intravenous infusion, total parenteral
nutrition, and possibly the use of
umbilical central lines and
percutaneous intravenous central
lines.
GUIDELINE FOR PERINATAL CARE
(GPC) 6th Edition
•IIA – assisted ventilation on a limited
basis
•IIB – mechanical ventilation for ≤24
hours or CPAP
 
GPC 7th Edition – Combined II A
and II B
•II -assisted ventilation for ≤24 hours
or CPAP
GPC 6th and 7th Edition. Personnel
and equipment continuously
available:
Neonatologists, NNPs
Specialized nurses, respiratory
therapists
Radiology and laboratory technicians
Portable x-ray machine
Blood gas analyzer
Level 3: Intensive neonatal
care
Level 3a: Care of infants of all
gestational ages and weights;
Mechanical ventilation support, and
possibly inhaled nitric oxide, for as
long as required Immediate access to
the full range of subspecialty
consultants.
Level 3b: Comprehensive on-site access to
subspecialty consultants; Performance and
interpretation of advanced imaging tests, including
computed tomography, magnetic resonance
imaging and cardiac echocardiography on an
urgent basis
Performance of major surgery on site but not
extracorporeal membrane oxygenation,
hemofiltration and hemodialysis, or surgical repair
of serious congenital cardiac malformations that
require cardiopulmonary bypass.
Level 3c: 
Extracorporeal membrane oxygenatio
n
, hemofiltration and hemodialysis, or
surgical repair of serious congenital
cardiac malformations that require a
cardiopulmonary bypass.
Neonates weighing more than 1800 grams or
having gestational maturity of 34 weeks or more
are categorized under level I care. The care
consists of basic care at birth, provision of warmth,
maintaining asepsis and promotion of
breastfeeding. This type of care can be given at
home, subcenter and primary health centre.
Provide neonatal resuscitation at every delivery, as
needed
•Provide care for infants born at 35-37 weeks who
are physiologically stable
•Stabilize infants born <35 weeks or who are ill
until transfer to a higher level of care facility
GPC 6th Edition
•Provide sustained life support
−III A – infants >1000 g or >28 wk,
conventional ventilation (no HFV),
minor surgical procedures
−III B – infants <1000 g and <28 wk,
severe and/or complex illness, HFV,
iNO
−III C – ECMO, CHD surgery
requiring bypass
GPC 6th Edition (III B)
Prompt and on site access to a full
range of pediatric medical
subspecialists
Pediatric surgical specialists and
pediatric anesthesiologists on site or
at a closely related institution
GPC 7th Edition
•Provide sustained life support and
comprehensive care for infants <32
wk and <1500 g, and all critically ill
infants
Provide a full range of respiratory
support which may include
conventional and/or HFO and iNO
GPC 7th Edition (III)
Prompt and readily available access to a
full range of pediatric medical
subspecialists, pediatric surgical
specialists, pediatric anesthesiologists and
pediatric ophthalmologists on site or at a
closely related institution by pre- arranged
consultative agreement

GPC 6th and 7th Edition

•Capability to perform advanced imaging
with interpretation on an urgent basis,
including computed tomography, magnetic
resonance imaging and echocardiography
Level-4 sub speciality care

GPC 6th Edition (III C)

•Located within an institution with the
capability to provide surgical repair of
serious congenital heart anomalies
that require cardio-pulmonary bypass,
and/or ECMO for medical conditions.
GPC 6th Edition (III C)
•Urgent access to pediatric medical
subspecialists
•Pediatric surgical specialists on site
or at a closely related institution
GPC 7th Edition (IV)
•Located within an institution with the
capability to provide surgical repair of
complex congenital or acquired
conditions.

GPC 7th Edition (IV)

•Immediate on-site access to pediatric
medical and surgical subspecialists,
and pediatric anesthesiologists
Collaboration on Innovation and
Improvement Network (COIN)

•Infant Mortality Reduction

Strategies
–Perinatal Regionalization
–Prevention of Elective Deliveries <39
weeks
–Prevention of SIDS/SUID
–Smoking Cessation in Pregnancy
–Preconception and Interconception
 Approach
A. Define Hospital Levels using new
AAP guidelines
a. Caring for infants less than 35 weeks
gestation?
b. Providing > 24 hours of CPAP?
c. Providing advanced respiratory
therapy?
d. Available pediatric subspecialists?
e. Surgical care of complex conditions?
f.Transport systems in place?
B. Clarify/refine definitions with state AAP
perinatal section leaders and ACOG
leaders
C. Measure number (percent) of births by
facility
–Live births
–500 grams or more
–Births < 1500 grams
D. Calculate VLBW mortality rate by
facility
–Neonatal (<28 days) or in-hospital deaths
– deaths/1,000 live births
E. Create collaborative forums to
share information confidentially
–State perinatal advisory group
–AAP/ACOG representative groups
F. Learn from other stakeholders
–Parents
–Support groups
G. Acknowledge challenges  
–Challenges to transport
•Funding
•Geography
•Antenatal transport
•Reverse transport
-Policy issues
•Certificate of Need
Financial challenges
•Unmet needs
•Misaligned incentives
Roles OF NEONATAL
NURSE
. A Level I is usually a healthy newborn nursery—largely
nonexistent now because mothers and babies have a very
short hospital stay these days and often share the same
room.

2. Level II is an intermediate care or special care nursery

where the baby may be born prematurely or may be
suffering from an illness; these babies may need
supplemental oxygen, intravenous therapy, specialized
feedings, or more time to mature before discharge.

3. The Level III neonatal intensive care unit (NICU) admits all
neonates (during the first 28 days of life) who cannot be
treated in either of the other two nursery levels. These
babies may be small for their age, premature, or sick term
infants who require high technology care, such as
ventilators, special equipment or incubators, or surgery. The
Level III units may be in a large general hospital or part of a
children’s hospital. Neonatal nurses provide the direct
patient care to these infants.
 Basic Skills

Each institution establishes practice skills for

neonatal nurses, but most expect the nurse to be
able perform math calculations -- an infant often
needs a fraction of the dose of medication an adult
would require.
Other basic skills are management of intravenous
lines, cardiopulmonary resuscitation and the use of
specialized equipment such as ventilators and
incubators.
A neonatal nurse must be technically proficient
with skills such as starting intravenous lines or
using feeding tubes on very tiny infants
Other Duties
Nursing infants is very different from nursing
adults. Infants cannot communicate verbally when
in pain, their bodies respond differently to
medications and treatments and they must be
protected from potential dangers.
In addition, the neonatal nurse must educate and
support the infant’s parents, who may be stressed
or frightened.
A neonatal nurse should have excellent
interpersonal skills, with the ability to establish
rapport and provide compassion and empathy to
parents. She must also understand and be vigilant
to prevent harm from risks that specifically affect
newborns, such as temperature changes or
excess oxygen.
Advanced Practice

Many neonatal nurses are staff nurses, but others

may be advanced practice nurses such as nurse
practitioners or clinical nurse specialists who also
work in the neonatal arena.
These highly educated nurses have a least a
master’s degree and are authorized to provide
physician services such as medications, or to
order treatments and diagnostic tests.
A clinical nurse specialist, for example, might
assume responsibility for the care of ventilator-
dependent infants or assist with special
procedures such as the use of heart-lung bypass
machines.
 Summary

Today we have discussed how can

we reduce the mortality and morbidity
rate by efficient care by proper level
of neonatal intensive unit.
And how being a nurse we should be
active, basic skill to work efficiently in
neonatal intensive unit