NICU (Level III neonatal care) is a facility for critically sick and premature babies requiring the highest level of professional competence to save and sustain their fragile lives.
Although, the outcome of care in the neonatal intensive care unit depends a lot on the specific problem and the clinical condition of the patient, a high quality care can often make a difference between life and death.
The services are highly specialized, requiring specially trained neonatologists, nurses and sophisticated high precision equipment to effectively manage the most common threats to lives of neonates viz. infections/septicemia, hypothermia, hypoglycemia or hypoxemia.
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Since in neonates, especially low birth weight babies, the body defenses have not yet developed, their condition deteriorates very fast if the hospital does not have the requisite well trained staff round the clock or the requisite equipment to provide the life support, the safety of these fragile lives will be in serious danger.
In addition to the technical, disease related hazards, there are other threats also threats of malfunctioning equipment, incubator fires and physical injuries due to negligence or accidents.
Safety Measures:
1. The NICU must have adequate space for various activities so as to prevent overcrowding and chances of infection. The patient area should have minimum 3.5 sq m per bassinet and the bassinets should be at least 1.2 meter apart.
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Adequate space should be available around the bassinet for the equipments and free movements for various procedures.
The patient area should have separate cubicles for high risk, septic and premature babies. There should be adequate arrangement for isolation/barrier nursing.
2. There should be a separate room for procedures (exchange transfusion, umbilical vessel catheterization), a formula room and a breast feeding room. Wash hand basins should be conveniently located for washing the hands before examining the babies.
3. The department should be headed by a qualified experienced neonatologist and should have adequate staff as per the norms (depending upon the neonatal beds authorized) including NICU trained residents for round the clock cover. NICU trained nurses should be available in the ratio of 1:1 in every shift.
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It is important that all the staff is specially trained in the neonatal intensive care and have age specific competence of handling the neonatal cases. They should be put on independent duty only after credentialing and privileging, as per their level of competence.
4. Availability of high quality/ reliable equipments such as bed side monitors, ventilators, C-PAP, incubators, defibrillator, phototherapy systems, radiant warmers, infusion pumps, digital weighing machines, blood gas analyzer, glucometer, piped gas (100%, 50% oxygen) and vacuum supply at the right pressure (for each incubator) for the neonates, crash carts, end tracheal tubes/oxygen hoods of the right size and adequate shelf space for keeping equipments such as infusion and feeding pumps.
5. There should be facility for microchemistry (micro methods to limit the blood loss for investigations). Availability of a reliable neonatal transport system, if possible, can add value to the services.
6. Availability of stable uninterrupted power supply, potable water supply, an efficient system of temperature/ventilation/humidity control with AC filters regularly cleaned/ replaced and the hand washing facilities.
7. Availability of a quality manual with documented policies and procedures for the care of neonates in accordance with the national and international guidelines.
8. Availability of documented standard protocols for:
i. Patient’s assessment including detailed nutritional, growth and immunization assessment
ii. Monitoring the cardiac activity, temperature, respiratory rate, skin color, fluid intake/output, weight, nutrition
iii. Management of neonates of high risk obstetric cases
iv. Management of common emergencies such as hypothermia, hypoxemia, hypoglycemia.
9. A documented protocol for prevention and control of infections in the NICU including:
i. Arrangement for keeping infected/suspected cases in septic nursery separate from the other non infected cases
ii. Compliance of infection preventive measures such as hand washing, use of gloves/ mask/soap/disinfectants is monitored
iii. Disinfection of oxygen hoods/masks/cots/after discharge of the patient
iv. Planned periodic disinfection of ventilators/humidifiers other equipment
v. Safe disposal of Biomedical waste as per the rules
vi. A documented antibiotic policy
vii. Being a high risk area, a program of active surveillance for detection of infections
viii.A policy and procedure for screening and restricting entry of those (including the staff) suffering from respiratory/other infections
ix. A documented and strictly implemented policy about entry of mothers /other relatives in the nursery. Ideally, even mothers may not be allowed inside the nursery.
10. A procedure for obtaining informed consent from the appropriate legal representative.
11. There should be a laid down procedure for recording and communicating to parents, the sex of the babies at birth.
It can be ensured by taking the entire body photograph of the baby along with the face of the mother and her particulars, and the date and time of birth.
12. A documented fool proof procedure for identification of the neonates to avoid medication/sampling/other errors or mixing/swapping of babies.
The standard procedure being followed at good hospitals is to tie the identity bands right after the birth.
The bands contain the band number, the mother’s name, the date of birth, the time of birth and the sex of the infant.
One band is tied around the left ankle and left wrist of the baby. One band is tied around the left ankle of the mother. Another similar band is kept as a record.
13. A system of planned preventive (and break down) maintenance and recalibration to ensure optimal operational reliability and fault free functioning of all equipments, especially the incubators, oxygen therapy equipment so as to eliminate the chances of incubator fires or burns caused by radiant warmers or hypo/hyperoxaemia.
14. Documented policies and procedures are in place for prevention of abduction/change of babies or any physical harm to them.
15. The ward should have experienced security personnel round the clock to check the entry of unauthorized persons in the area.
16. Ensuring the standard practice of educating the parents about nutrition, breast feeding, immunization and safe parenting and documenting the same in the medical records.
Quality of services in NICU is particularly important because patients in this ward are not only critically sick, but are ill equipped to fight the infections because of underdeveloped immune system.
They are so vulnerable that fluctuations in temperature, oxygen or glucose level (which may not affect the adults much) can imperil their lives.
High quality care in NICU requires sophisticated equipment and highly skilled/ specialized staff. It also requires an efficient system of care delivery.
The department must have documented policies and protocols for every important activity and the same must be implemented to give these fragile lives, a chance for survival.
There is also the problem of physical security of the babies. Instances of change of babies with those of opposite sex, and theft of babies from nursery are not uncommon due to lack of proper system of identification and safety of babies in some hospitals. They not only bring a bad name to the hospital, but may also lead to legal liability of the hospital for failing to ensure safety and security of the patient.