CLINICAL SPECIALITY-I

SEMINAR
ON
ORGANIZATION,
TRANSPORTATION, SETTING
& MANAGEMENT OF NICU

SUBMITTED TO:
MRS. BAKKIYALATCUMI. P
TUTOR, CON JIPMER
SUBMITTED BY:
LIPI MONDAL
M.SC NURSING 1ST YEAR STUDENT
CON, JIPMER
 Organization, Management, Transportation of NICU

INTRODUCTION:

Neonatal intensive care unit (NICU) is a crucial one to take care of sick babies & low birth weight &
preterm babies. Three to five percentage of the newborns would need these services depending upon the
type of unit & percentage of high-risk population it caters for. NICU, like other patient care facilities,
requires a team approach with a high degree of high-tech inputs.

DEFINITION OF NICU:

Neonatal intensive care unit is defined as care provided for medically unstable & critically ill neonates
requiring constant nursing, complicated surgical procedures & continued respiratory support & other
intensive intervention.

AIMS & GOALS OF NICU:

 To improve the condition of the critically ill neonates keeping in mind the survival of neonate,so as
to reduce the neonatal morbidity & mortality.
 To provide continuing in-service training to medicine & nursing personnel in the care of newborn.
 To maintain the function of the pulmonary, cardio-vascular, renal & nervous system.
 To monitor the heart rate, body temperature, CVP & blood values by non-invasive techniques.
 To measure the oxygen concentration of the blood is by oxygen analyzers.
 To check/observe alarm system signals to find out the changes beyond certain fixed limits set on the
monitors.
 To administer precise amount of fluid & minute quantities of drugs through i.v infusion pumps.

LEVEL/CATEGORIES OF NICU:

i. Level-I : (Mild) – Basic neonatal care ( e.g. weight>= 1800gm, 34 weeks or more)
ii. Level-II: (Moderate)- Special baby care unit ( e.g. weight 1200-1800gm, 30-34 weeks of gestation)
iii. Level-III: (Critical)- Intensive care unit ( e.g. weight less than 1200gms, less than 30 weeks of
gestation)

DESIGN OF NEONATAL UNIT:

Designing a neonatal unit requires an understanding of categorization of levels of care, space &
environment, number of beds needed, size of the units, personnel, equipment, support services, education,
neonatal transport & quality assurance.

THE FACTORS TO BE CONSIDERED IN DESIGNING THE NEONATAL UNIT:

 Population
 Organization, Management, Transportation of NICU

 Birth rate
 Number of high risk newborn delivered per year
 Average number of newborn admitted in the unit
 Average number of newborn referred from outside
 Average length of the stay & occupancy level

INDICATIONS FOR ADMISSION IN NICU:

 Apnea
 Baby with respiratory distress
 Birth asphyxia
 Convulsion
 Low birth weight(less than 1500gms requiring intensive care)
 Neonatal jaundice requiring exchange blood transfusion
 Sepsis
 Meningitis

PHYSICAL SETUP & ADMINISTRATIVE SETUP OF NICU:

a. PHYSICAL SETUP:
i. Location:
NICU should be located near the labour/delivery room to facilitate transfer of sick neonates
quickly to the unit without any delay. It will be preferable that operation theatre also should
be located in the same floor closer to the unit.
ii. Space:
In India about 15-20% of newborn requires special care. A maternity centre having 2000
deliveries per year should have facility for special care bed for 8 high risk infants.
 For the patient care, 100 square feet is required for each baby as it is true for any adult
bed.
 There should be a gap about 6 feet between two incubators for adequate circulation &
keep the essential life saving equipments, space needed about 120 square feet.
 Each patient station should have 12-16 central voltage stabilized electrical outlets.
 2-3 oxygen outlets.
 2 compressed air outlets.
 Organization, Management, Transportation of NICU

 2-3 suction outlets.

 Additional power plug points would be required for the portable x-ray machine close
to the patient care area.
iii. Design:
The design may vary from an open ward to an individual cubicle with 2-4 beds in one
cubicle. The open ward allows for better coverage of nurses & disadvantage of this type is
noise pollution & excessive traffic.
iv. Floor space:
 Level-I : The space required is a minimum of 30 to 40 sq feet for each infant.
 Level-II : The unit should have 50 sq feet of floor space per baby. There should be at
least 4 feet between cots or incubators.
 Level-III : The minimum floor space for each NICU cot is 80-100 sq feet with 3 feet
on each of the three sides of the cot for movement of the staff, equipment & parents.
Current guideline recommends 100-150 sq feet per NICU bed.
v. Hand washing area:
 The unit must have an uninterrupted clear water supply & each patient care area must
also have a wash basin with foot or elbow operated tapes. Neat wash basin, placing
paper towel.
 The unit should be equipped with air flow system, however alternatively air
conditioned with multipore filters & fresh air exchange of 12 per hours should be
provided.
vi. Color:
The walls of the whole unit should be washable & have a white or lightly off white color for
better color appreciation of the neonates.
vii. Lighting:
The lighting arrangement should provide uniform, shadow free illumination of 100 foot
cardles at the baby’s level. In addition, spot illumination should be available for each baby
for any procedure.
A generable back-up is mandatory where there are frequent power fluctuation or power
failure.
viii. Sounds:
The intensity of sound should be monitored & should be kept within 45 db to protect hearing
ability of infants & staff.
ix. Ventilation:
 Organization, Management, Transportation of NICU

It is vital that the neonatal units are well ventilated to reduce nosocomial infection. This can
be achieved by centralized air conditioning or exhaust fan or laminar air flow system. All air
should be filtered at 90% efficiency. The recommended air exchange is 6 per hr/ 2 without
side air exchange.
x. Temperature & Humidity:
The ideal room temperature of the neonatal unit should be 26±2 degree Celsius & related
humidity should be kept between 40%-60%.
xi. Floor:
The floor should be non slippery & easily washable.
xii. Electrical outlet:
Electrical & gas outlet should be available at each bed side for easy access. Centralized
oxygen & gas is essential with alarm system to indicate fall in pressure. Each level II cot
should have 10-12 electrical outlets with uninterrupted power supply with provision of UPS
System for sensitive equipments.
xiii. Communication System:
A direct line external telephone is mandatory so that parents can call & get the information
about her baby. They should be in house communication system available to contact doctors
24×7 without leaving the baby/unit.
xiv. Safety:
Safety of all equipment used in the unit should be checked regularly & documented. The unit
door should be electronically operated to restrict the entry for strangers. Anti abduction
system should be in place to ensure safety of the newborn admitted in the unit.
xv. Evacuation Plan:
Evacuation policy should be in place & all staff working in the unit should be drilled
regularly to perform evacuation in the time of crisis. Safety advisors should be identified &
each one should know their roles & responsibilities. Floor plan should be available in the unit
for everyone to know the routes of evacuation.
xvi. Rooms:
Apart from patient care area including rooms for isolation & procedures, there is need of
space for certain essential functions, like a room for scrubbing & gowning near the entrance,
a side lab, mothers room, adequate stores for keeping consumable & non-consumable
articles.
 A room for keeping the x-ray & ultrasound machines.
 One or two rooms each would be needed for doctors & nurses on day & night duties.
 Organization, Management, Transportation of NICU

 There is a space available for a biochemical engineer to provide essential periodic

preventive maintenance of the costly equipments.
 Additional space will be required for educational activities & storing of data.
 Each room should have a separate basin facilities, it can be used for children.
 Sinks are regularly cleared by disinfectant.
xvii. Isolated Facilities:
Negative pressure room is desirable if the entire NICU is air conditioned.

xviii. Quiet Room:

Every NICU should have quiet room for the parents to spend time with their babies who
expired or terminally ill. This room will facilitate to provide end of life care.

b. ADMINISTRATIVE SETUP:

i. Medical Staff:

The unit should be headed by a Director who is full time neonatologist with special qualification
& training in neonatal medicine.

 He should be responsible for maintenance of standard of patient care.

 Development of the operating budget.
 Equipment evaluation & purchase.
 Planning & development of educational programme.
 Evaluation of effectiveness of perinatal care in the area.
 He should devote time to patient care services , research & teaching as well as co-ordinate
with level I & level III hospital in the area.
ii. Staff Requirement:
 Neonatal physician 6-12 patient in the continuing care, inter mediate Care & intensive
care areas.
 He should be available on 24 hours bases for consultation.
 A ratio of one physician in training to every 4-5 patients who requires intensive care ideal
round the clock.
 Services of other specialists like Microbiologist, Radiologists, Cardiologists & should be
available on call.
 An anesthesist capable of administering anesthesia to neonates.
 Pediatric surgeon & pediatric pathologists should be available.
 Organization, Management, Transportation of NICU

iii. Nurses Ratio:

 Nurse patient ratio 1:1 maintained throughout day & night.
 A ratio of one nurse for two sick babies not requiring ventilator support may be adequate.
 For an ideal nurse patient ratio, four trained nurses per intensive care bed are needed.
 Additional head nurse who is the overall incharge.
 In addition to basic nursing training for level-II care , tertiary care requires dedicated
,committed & trained staff of the highest quality.
 Their training must include training in handling equipment, use of ventilator & use of
mask resuscitation & even endotracheal intubation , arterial sampling & so on.

ACCORDING TO THE RECOMMENDATION OF NATIONAL NEONATOLOGY

FORUM OF INDIA

LEVEL -I
• 1 registered nurse can be alloted to provide for 6 babies.

LEVEL-II
• 1 registered nurse should be allotted for 3-4 babies.
• Sick neonates in this unit requires 6-12 hrs of nursing
care time each day.

LEVEL-III
• 1 chief nurse who had training of atleast 3 months in an
accreditable neonatal unit.

The staff /patient ratio should be 1:1. Bedside nurses one consultant neonatologist , one
registrar & two junior doctors should be available. One doctor should be available round the
clock on call.
 Organization, Management, Transportation of NICU

iv. Experience:

The staff nurse must have a minimum of 3 years work experience in special neonatal care unit in
addition to having 3 months hard on training in a intensive care unit.

v. Other Staff:

 There is a special need of motivated staff responsible for cleanliness of the unit.
 Special attention must also be made to train & educate other persons for their role in the
patient care.
 One sweeper should be available round the clock.
 Laboratory technician
 Public health nurse/ Social workers
 Respiratory therapist
 Biomedical engineer
 Ward clerk can help in keeping track of the stores.

PREPARATION OF NICU:

 Warm ( 33-36ºC) incubator

 Adequate light source
 Resuscitation & treatment trolly stocked
 History, Continuation sheet, Treatment & diet sheet, Problem list & flow charts
 Oxygen air & Suction apparatus
 Oxygen line connected to oxygen & air flow meter.
 Suction- complete suction unit tubing & various sizes of suction catheters.
 Vital sign monitors
 Specific equipment as indicated by diagnosis

Equipments required in NICU:

 Resuscitation equipment
( Bag & mask resuscitator, Laryngoscope, Endotracheal tubes, Catheters, Syringes, Needles
& Suction & Oxygen facilities.)
 Incubator
 Radiant warmer
 Organization, Management, Transportation of NICU

 Infusion / Syringe pumps

 Ventilator
 Cardiac monitor
 ECG monitor
 Pulse oxymeter
 Oxygen analyzer
 Invasive & non-invasive BP monitors
 Phototherapy
 Blood gas analyzer
 Digital weighing scale
 Breast pump
 Ultrasound scan machine
 Digital thermometer

This equipments should be purchased & maintained as per international standards & policy.

ADMISSION PROCEDURES IN NICU:

All babies admitted to the neonatal unit should have the following data recorded carefully within
24hours of admission.

a. History & Examinations:

 Maternal history
 Paternal history
 Previous obstetric history
 Details of present pregnancy
 Labour
 Delivery
 APGAR Score of the newborn

b. On Admission:
 Notify doctor & the nurse incharge.
 Resuscitate infant as necessary & maintain warmth.
 Check infant identification lebel.
 Organization, Management, Transportation of NICU

 Quickly examine the infant from head to toe for obvious abnormalities if the conditions
permit.
 Record weight, length & head circumference as soon as possible.
 Transfer to warm environment as soon as possible.
 Commonest observations are:
 Temperature ( Infant normal temperature ranges from 36c to 37c)
 Heart rate
 Respiration
 Color
 Activity
 Explain to parents
 Handover from transferring unit staff
 Record keeping
 Birth history
 Ward history contains- APGAR Score & Examination of newborn infant
sheet, Neonatal weight & fetal sheet, progress chart.
 Compiled history
 Patient registration form
 Progress chart/ sheet
 Intra uterine growth chart
 Oxygen flow sheet, fluid balance sheet etc.

MANAGEMENT OF NICU:

The NICU should be managed by head of departments & head nurse.

 Proper management of infection control.

 Proper arrangement of staffing pattern.
 Well management of physical & administrative set up.
 Equipments should be kept ready.
 Cleaning should be properly managed.
 Proper & holistic care should be provided.
 Health education to the mothers regarding newborn care.
 Management of staffs working in NICU.
 Organization, Management, Transportation of NICU

CONCLUSION:

With the organization & management of NICU, the skilled nurse will have a very detailed picture of the
organization & management of NICU, the nurse should take the opportunity to assure herself of having
adequate knowledge regarding organization pattern, knowing the organization & management regarding
Neonatal Intensive Care Unit.

JOURNAL ARTICLE:

RISK FACTORS FOR NOSOCOMIAL INFECTIONS IN NEONATAL INTENSIVE CARE UNITS

(NICU)

-Nanou Christina1, Paulopoulou Ioanna2, Liosis George3, Tsoumakas Konstantinos4 and

Saroglou Georgios4. (2015)

Abstract

 Background:

Nosocomial infections constitute one of the leading causes of morbidity and mortality in premature
neonates in Neonatal Intensive Care Units (NICUs) and affect the duration of their hospitalization, as well
as the quality of their care.

 Aim:

The study was carried out in order to record and describe the risk factors for nosocomial infections in
neonates hospitalized in NICUs.

 Method and material:

In this prospective cross-sectional survey, all the neonates (100%) who were admitted in the NICUs of a
General Pediatric (during 7 months) and a Maternity Hospital (6 months) (n=474), constituted the
population of the study. Data was collected by means of a record card including data about Demographics,
Consumption of antibiotics, Infections’ surveillance, Clinical Identification and Laboratory confirmations.
Analyses were conducted using SPSS statistical software (version 18.0).
 Organization, Management, Transportation of NICU

 Results:

301 neonates (63,5%) were premature. 40,9% of the neonates developed sepsis and 34,9% primary
bacteremia. Neonates hospitalized in open NICU were more likely to develop nosocomial infections
compared with those who were hospitalized in closed NICU (OR 3.37, 95% CI 1.94 to 5.86, p<0.001).
Premature neonates were more likely to develop nosocomial infections compared with those with a
normal duration of gestational age (OR 4.46, 95% CI 2.04 to 9.72, p<0.001). Proportionally, when the
duration of the intravenous therapy (OR 1.14, 95% CI 1.10 to 1.19. p <0.001) and of the hospitalization
were prolonged the likelihood of nosocomial infection increased.

 Conclusion:

Factors such as low birth weight, prematurity, intravenous therapy and mechanical ventilation were
associated with nosocomial infections. Limited use of invasive methods and devices and adherence to all
the principles and procedures of aseptic techniques could reduce the incidence of nosocomial infections.

Keywords: Infection; Nosocomial infection; NICU; Risk factors; Neonates

Organization, Management, Transportation of NICU

PHYSICAL SET UP OF NICU IN JIPMER:

 Organization, Management, Transportation of NICU

APPLICATION OF THEORY:

O OREM’S SELF CARE DEFICIT THEORY:

 Organization, Management, Transportation of NICU

BIBLIOGRAPHY:

 Mererstein & Gardner’s Handbook of neonatal intensive care.7th edition. Missouri. Mosby
Elsevier. 2011. P- 13-78.
 Guha’s Neonatology principles & practice. 3rd edition. New Delhi. Jaypee brothers. 2005. P-71-
90.
 Meharban Singh. Care of the newborn. 6th edition. New Delhi. Sagar publications. 2004. P- 20-37.
 Dorothy R Marlow. Textbook of pediatric nursing. 6th edition. Noida. Elsevier publication. 2012.
P- 248 -249; 387, 391.
 Jain S , Bhakoo ON, Singh M. Neonatal Monitoring. National Neonatology Forum. New Delhi.
1990.
 Fraser Cooper, A Margaret, Myles textbook of midwives. 15th edition. Churchill livingstone
publication. China. 2009. P- 917- 928.
 Acoustics in Healthcare Environments. (2010 October). Ceilings and Interior Systems
Construction Association. Retrieved from:
http://www.cisca.org/files/public/Acoustics%20in%20Healthcare%20Environments_CIS CA.pdf
 Brown, P., & Taquino, L. T. (2001). Designing and Delivering Neonatal Care in Single Rooms.
Journal of Perinatal and Neonatal Nursing , 15 (1), 68-83.
 Hardy, N. P. (2005). Cost and Design Analysis of Neonatal Intensive Care Units: Comparing
Single Family Room, Double-Occupancy, Open-Bay, and Combination Settings for Best Design
Practices. Retrieved from: http://etd.fcla.edu/UF/UFE0011780/hardy_n.pdf
 Johnson, B. H., Abraham, M. R., & Parrish, R. N. (2004). Designing the neonatal intensive care
unit for optimal family involvement. Clinics in perinatology , 31 (2), 353-382.
 Joseph, A. (2006). Impact of light on outcomes in healthcare settings. The Center for Health
Design. Retrieved from: http://www.healthdesign.org/sites/default/files/CHD_Issue_Paper2.pdf
 Joseph, A., & Ulrich, R. (2007 January 4). Sound control for improved outcomes in healthcare
settings. The Center for Health Design Issues. Retrieved from:
http://www.healthdesign.org/sites/default/files/Sound%20Control.pdf
 Shepley, M. (2004). Evidence-based design for infants and staff in the neonatal intensive care
unit. Clinics in perinatology , 31 (2), 299-311.
 Stevens, D., Helseth, C., Khan, M., Munson, D., & Smith, T. (2010). Neonatal intensive care
nursery staff perceive enhanced workplace quality with the single-family room design. Journal of
Perinatology , 30, 352-358.
 White, R.D. (2007) Recommended Standards for Newborn ICU Design. Report of the Seventh
Census Conference on Newborn ICU Design. Retrieved from: http://www.nd.edu/~nicudes/index.html
 Organization, Management, Transportation of NICU

 White, R. D. (2010). Single-Family Room Design in the Neonatal Intensive Care Unit -
Challenges and Opportunities. Newborn and Infant Nursing Reviews , 10 (2), 83-86.