ORGANIZATION OF NEONATAL INTENSIVE CARE UNIT

INTRODUCTION
Newborn intensive care approach developed from the concept that a more intensive approach
to neonates who require special care would result in a significant decrease in neonatal
mortality and morbidity. A neonatal intensive care unit (NICU) is an intensive care unit
specializing in the care of ill or premature newborn infants. The first official ICU for neonates
was established in 1961 at Vanderbilt University Mildred Stahlman, officially termed a NICU
when Stahlman used a ventilator off-label for a baby with breathing difficulties, for the first
time ever in the world.

DEFINITION OF NICU
It is very specialized unit where critically ill neonates are cared to reduce the neonatal
morbidity and mortality.

INDICATIONS FOR ADMISSION IN NICU

 Low birth weight
 Large babies
 Birth asphyxia(APGAR score less than or equal to 6)
 Me conium aspiration syndrome
 Severe jaundice
 Infants of diabetic mother
 Neonatal sepsis/meningitis
 Neonatal convulsions
 Severe congenital malformation
 O2 therapy/parenteral nutrition
 Immediately after surgery
 Cardio respiratory monitoring
 Exchange blood transfusion
 PROM/foul smelling liquor
 Mother of Hepatitis B carrier
 Injured neonate.

AIMS /GOALS OF NICU

The goals of neonatal intensive care unit are
 To improve the condition of the critically ill neonates keeping in mind the survival of
neonate so as to reduce the neonatal mortality and morbidity
 To provide continuing in-service training to medicine and nursing personnel in the care
of newborn.
 To maintain the function of the pulmonary ,cardiovascular, renal and nervous system
 To monitor the heart rate, body temperature, blood pressure,central venous pressure
and blood by non invasive techniques.
 To measure the oxygen concentration of the blood by oxygen analysers
 To check/observe alarms systems signal ,to find out the changes beyond certain fixed
limits sets on the monitors.
  To administer precise amounts of fluids and minute quantities of drugs through I.V
infusion pumps.

CATAGORIES OF NICU: -
LEVEL 1
 Evaluation and postnatal care of healthy newborn infants;
 Phototherapy
 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
 Normal new born care
LEVEL 2
 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
 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
 Mild to moderate respiratory distress syndrome
 Suspected neonatal sepsis
 Hypoglycaemia
 Infants of diabetic mother
LEVEL 3
 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 consultation
 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
haemodialysis, or surgical repair of serious congenital cardiac malformations that
require cardiopulmonary bypass.
 Severe respiratory distress syndrome
 Persistent pulmonary HTN
 Sepsis
 Prematurity at<32 weeks
Major congenital malformations
ORGANISATION OF NICU
 Physical Organization
 Personal Organization
 Equipment Organization
PHYSICAL ORGANISATION
The neonatologist and nurse in charge must be involved while planning the unit. The intensive
area should be localized preferably next to labor ward and delivery rooms. For economizing
costs it would be preferably to have combined with level 2 facilities, through both the areas
there must have separate and adequate staff and single administrative control. the neonatal
unit can be conceptualized in terms of four elements which exist in a concentric layering inside
outwards with designed work traffic flow pattern.
a) Clinical care areas
b) Clinical support areas
c) Administrative zones
d) Family support area
a) Clinical care areas
 Scrubbing areas
 Storage spaces
 Hand washing scrub zones
b) Clinical support areas
 Laboratory
 X ray machine
 Formula preparation
 TPN preparation
 Breast milk expression
 Equipment storage
 Clean and dirty utility areas
c) Administrative and staff support areas
 Central reception area
 Separate unit office for ward master, resident doctor,and nursing staff
 Staff changing room
 On call duty doctor room
 Staff rest room
 Counselling room
 Seminar rooms
 Library
d) Family support area
 Children play area
 Nourishment area
 A lounge
 Lockable storage
 Education area

PHYSICAL ENVIRONMENT CHARACTERSTICS:

1. Bed strength
The NICU can be in a single area or it can be in multiple rooms with a capacity of 2-4 infants
each. One intensive care bed is generally required for 100 deliveries provided the prematurity
ratio is around 8 percent and hence for a population of one million,30 intensive care beds
would be required for our country. It would be uneconomical to have a NICU of less than 6-
8bed.
 2. Space between the patient
 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 of about 6 feet between two incubators for adequate circulation
and keep the essential lifesaving equipment, space needed about 120 square feet.
 Each patient station should have 12-16 central voltage stabilized electrical outlets
 2-3 oxygen out lets
 2 compressed air outlets
 2 compressed air outlets
 2-3 suction outlets
 Additional power plug point would be required for the portable x-ray machine close to
the patient care area

3. TEMPERATURE AND HUMIDITY CONTROL OF THE UNIT

 In case of controlling the environmental temperature, the NICU should not be located
on the top floor, but there must be adequate sunlight for illumination
 The unit must have a fair degree or ventilation of fresh air through central air
conditioning is must. The temperature inside the unit should be maintained at 28+_2deg
c while the humidity must be above 50%.

4. WATER-HAND WASHING
 The unit must have an uninterrupted clean water supply and each patient care area must
also have a wash basin with foot or elbow operated tapes. Neat wash basin, placing
paper towel and receptacle.
 The unit should be equipped with laminar air flow system, however alternatively air
conditioned with multipore filters and fresh air exchange of 12 per hours should be
provided.

5. COLOUR
The walls of the whole unit should be washable and have a white or slightly off white colour for
better colour appreciation of the neonates.

6. LIGHTING
The lighting arrangement should provide uniform, shadow free illumination. In addition spot
illumination should be available for each baby for any procedure. A generator back up is
mandatory where there are frequent power fluctuations or power failures.

7. SOUNDS
The acoustic characteristics should be such that the intensity of light kept below 75 decibels.
The unit should also have an intercom and a direct outside telephone so that the parent of the
patient can have an easy access to the medical personnels in case of an emergency.

8. ROOMS
Apart from the patient care area including rooms for isolation and procedures, her e is need of
space for certain essential functions, like a room for scrubbing and gowning near the entrance, a
side laboratory mothers room, adequate stores for keeping consumable and non-consumable
articles
  A room for keeping x-ray and ultrasound machines
 One or two rooms each would be needed for doctors and nurses on day and night duties
 There is space available for a biomedical engineer to provide essential periodic
preventive maintenance of costly equipments.
 Additional space will be required for educational activities and storing of data.

9. VENTILATION
Minimum of six air changes,2 air changes should be outside for filtering the inner air.
 Effective air ventilation of nursery is essential to reduce nasocomial infections
 The air conditioning ducts must be provided with Millipore filters(0.5H) to restrict
passage of microbes

10. ENVIRONMENTAL DESIGN:

WALL SURFACES
 Easily cleanable, protect at point with moveable equipment, made with sound
absorbable material
FLOORS
 Easily cleanable without use of hazardous material, minimize microbial growth
CEILINGS;
 Easily cleanable, noise reduction

11. COMMUNICATION:
 One emergency call bell in each room connected to doctors room

12. DATABASE AND RESEARCH ENVIRONMENT:

 Computer ports with internet access should be readily available to maintain database
and data analysis.
 Database of all NICU information, teaching aids like X rays, ECG, and ABG reports must
be maintained for future training and research.

13. SEPTIC NURSERY

14. SECURITY

15. HEAD WALL SYSTEM

Refers to the array of the medical gas outlet+electrical+data outlet at each patient care station
 Electric environment
 Medical gases
 Data outlets

16. Toilets
It is important to plan the number and position of water closets in the Neonatal Unit. Parents’
bedrooms, Transitional Care, medical on-call rooms, and the area dedicated to counselling
(Parents’ Quiet Rooms) should all have separate toilet facilities. In a large Neonatal Unit there
should be at least 3 further toilets for staff and the general public.
17. Transport incubator store
Transport incubators are bulky and should not be stored in public corridors. There should be a
designated area for storing them within the Equipment Store.

18. Pneumatic tube system

Careful thought should be put into how specimens can be transferred urgently to central
laboratories in the Hospital. If a pneumatic tube system is chosen, it should be easily accessible,
robust and reliable. The outlet might be best positioned at the central station next to the Unit
Office. Readily available personnel can then identify problems if the system were to fail to send
an urgent specimen.

19. Stationery
Although some NNUs are striving towards becoming paperless, most will not achieve this in the
next five years. There should therefore be a room of 12 sqm with extensive shelving for storage
of all the paper sheets and forms necessary for the efficient running of the NNU.

20. CLINICAL
Pendants, gantries, cabinetry or head-rails?
Choosing to equip the rooms with pendants, gantries or cabinetry is a crucial early decision.
Pendants descend from the ceiling and are single-armed or double-armed. The pendants
contain intensive care facilities including electrical outlets, oxygen and air pipes and a vacuum
facility for suction. The clinician has the opportunity of specifying the number of electric
sockets, and the number of shelves which are fixed to the pendant arms. These shelves can hold
ventilators, monitors, syringes drivers, and indeed any intensive care equipment required to
service the infants in the incubator.

Gantries
Gantries have many of the advantages of pendants containing internally all the pipin and wiring
required to provide the oxygen, air, vacuum and power points as well as the computer
networks. The clinicians again have the opportunity of specifying the number of sockets and
the number of shelves. Many of the gantries allow movement laterally of the hangars and
ventilators, monitors and syringe drivers can all be attached to the gantry.

Cabinetry
If designed carefully, cabinetry is fully consistent with the demands of intensive care. All
intensive care and high dependency cots can be contained in spacious bays. Electric sockets,
computer and piped gas outlets can all be positioned so that there is no interference with the
movement of staff caring for the infant. It is recommended that all such bays be identical in the
Unit, so that staff can be familiar with the work area no matter which room or cots have been
allocated to them. The size of the bays is critical. Each must accommodate an incubator, a
mother and father with comfortable seating, two members of nursing staff, and it should be
possible to maneuver all machinery (e.g. for taking X-rays) within the allocated space. Such bays
should be at least 3.2m wide and the bay walls may extend 2-3 cm in room

Head-rails
It is possible to combine cabinetry systems with horizontal rails at the head of the incubator.
These rails then carry most of the intensive care monitoring equipment
WORK FLOW PATTERN AND ATMOSPHERE
The NICU should be designed to allow efficient patient and staff movements within the unit. The
following should be included.
• Ready access of the NNU to Labor Suite including Operating Theatres
• All doors between Labor Suite and NNU, and also those within NNU, should be designed to
maximize safety and convenience. Automatic opening, push pad opening, swipe-card access,
punch-code access and manual opening may all be appropriate in individual circumstances
• Positioning of Neonatal intensive care cots closest to the Labour Suite
• Access for mothers on trolleys or in wheelchairs. Widths of doors, corridors and corners
should be considered so that mothers have access to all clinical areas
• Access to all cots in all clinical areas for X-ray, ultrasound and other mobile equipment. An
MRI scanner ideally should be available nearby on the same floor
• Clinical support areas should be as close as possible to clinical care areas. Such supports
include near patient testing laboratory, pharmacy, equipment storage, milk storage, clean and
dirty linen store
• Family access to the waiting area, counseling rooms, support services (e.g. social work and
community neonatal nursing) and recreational facilities
• Positioning of the Clinical Manager’s office on the NNU floor, easily available to all staff and, by
arrangement, to families
• Attending consultant’s office should be in the NNU so that family interviews and staff
interviews can take place readily
• Doctors’ on call rooms should be in the NNU, sound-proofed, and sufficiently distanced from
busy corridors and extraneous noises to allow adequate rest opportunities
• Consultant and research offices can be positioned further away from the clinical care area
• Ideally there should be ready access to the mortuary, a viewing area for the bereaved, and to
the autopsy suite.
Atmosphere
The NNU should be thought of as “baby’s first home”. It must have a welcoming atmosphere.
This is achieved by thinking of the comforts of the infant and family. Natural lighting and where
possible views of the surroundings outside are beneficial. Internal decoration can convert a
clinical area into a room which is appealing to families, and encourages all members of staff to
treat the care area as the infant bed room.

PERSONAL ORGANISATION
MEDICAL STAFF-The unit should be headed by a director who is full time neonatologist with
special qualification and training in neonatal medicine.
 He should be responsible for maintenance of standard of patient care
 Development of operating budget
 Equipment evaluation and purchase
 Planning and development of education programme
 Evaluation of effectiveness of perinatal care in the area
 He should devote time to patient care services,research and teaching as well as co-
ordinate with level 1 and level 2 hospital in the area .

STAFF REQUIREMENTS
 Neonatal physician 6-12 in the continuing care, intermediate care and intensive care
areas.
  He should be available for 24 hrs basis for consultation
 A ratio of one physician in training to every 4-5 patient who requires intensive care ideal
round the clock
 Services of other specialists like micro biologists, hemtologists, and radiologists
cardiologists and should be available on call.
 An anaesthetist capable of administering anaesthesia to neonate
 Paediatric surgeon and paediatric pathologists should be available.

NURSES RATIO
 Nurse patient ratio of 1:1 maintained throughout the day and 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 2 carer, tertiary care requires dedicated
committed and trained staff of the highest quality
 The training must include training in handling equipment, use of ventilators and the use
of mask resuscitations and even endotracheal intubation, arterial sampling and so on

EXPERIENCE
The staff nurse must have a minimum of three 3yrs experience in special neonatal care unit in
addition to having three months training in a intensive care unit.

OTHER STAFF
 One sweeper should be available round the clock
 Laboratory technician
 Public health nurse/social workers
 Respiratory therapist
 Bio medical engineer
 Ward clerk can help in keeping track of the stores.

EQUIPMENT ORGANISATION
 Equipment and supports should include all that is necessary to resuscitation and
intermediate areas
 Supply should be kept to the patient station so that nurse does not have to go away from
the neonate unnecessarily and nurses time and skills are used efficiently
 There should be controlled incubators and open air system for providing adequate
warmth
 Adequate number of infusion pumps for giving fluid and parenteral nutrition solutions
and drugs should be available
 Infant ventilators capable of giving pressure ventilation and various cardiopulmonary
monitor.

EQUIPMENT REQUIRED FOR ANY NEONATAL ICU

1. Radiant warmer
2. Incubator
 3. Radiography
4. Oxygen catheter
5. Infusion pumps
6. Positive pressure ventilator
7. Oxygen analyser
8. Phototherapy
9. Electronic weighing machine
10. Transcutaneous PO2 and PCO2 monitor
11. Noninvasive BP monitor
12. Invasive BP monitor
13. Intracranial pressure monitor.
14. Microdrips
15. Suction apparatus
16. Open care system
17. ECG monitor
18. Pulse oxymeter
19. Resuscitation set
20. Oxyhood
Disposable articles
21. Nasogastric tubes
22. Feeding bottles and cups.
23. Diapers.
24. Specimen bottles
25. I.V catheter
26. IV set,
27. Bacterial filters.
28. Three way stop cocks,
29. umbilical arterial and venous catheter,
30. syringes, needles,
31. ventilator tubes,
32. Cannula,
33. Catheters suction, urinary ET tube, nasal catheters.

DOCUMENTATION IN NICU
The unit should have printed problem oriented stationary for maintaining records, admission
and discharge slips
Record of all admission should be maintained in a register or on a computer
The information should be analyzed and discussed at least once a month to improve the
effectiveness of the nicu in providing the services.

EDUCATION PROGRAMME AT NICU

 There should be continuing medical education programmes for physicians and nurses in
the form of lectures, demonstrations and group discussions.
 This should cover important issues like resuscitation, steralisation to be maintained for
critically ill babies, putting in arterial catheters, conducting exchange transfusions,
maintenance of ventilators.
  Educational programmes covering the nurses and physicians in the community should
be developed.
 There should be regular discussion with the obstetrician to discuss the perinatal care
and condition Individual high risk cases
 Education and follow up is necessary.

ROLE OF A NURSE IN NICU

A Neonatal nurse job role involves working in a specialist neonatal baby care unit
(within maternity or children’s hospitals) or in the local community.
Neonatal nurses care for new-born babies who are premature or are born sick. There are a vast
number of conditions that can affect a new-born baby and require treatment from specialists
within the healthcare team. As a neonatal nurse its important to be sensitive to the needs of
others, have a caring attitude. As a neonatal nurse has an important role of supporting parents
of the sick baby at a time when they themselves are frightened of losing their child, very
anxious and stressed or upset seeing baby coupled up to wires and monitors. As far as possible,
the parents and occasionally other family members are encouraged to take an active role in the
care of the baby.

ESSENTIAL DUTIES:
 Managing patient care of newborns and pediatrics, assisting with the admission assessment
discharge of these patients;
 Providing health education and counselling to patients;
 Maintaining medical records
 Participating in nursing and unit staff meetings and patient care conferences;
 Performing other related duties as assigned/required.
 Provides and/or manages the nursing plan of care for neonates with complex problems;
 Provides education, training, information, and consultation services to physicians, registered
nurses, and other members of the clinical team;
 Interprets, coordinates, and implements new and existing policies, methods and procedures
for neonatal nursing in the Perinatal areas;
 Keeps informed of current practices and trends and incorporates them into practice
 Works in cooperation with other members of the multidisciplinary health teams;
 Makes professional contacts with a variety of public, private and professional
institutions/organizations;
 Performs other related duties as assigned/required.
 The duties for a neonatal nurse may vary slightly at each hospital, but overall their care tasks
are the same. A neonatal nurse is one of the primary caregivers of a baby in the intensive
care unit, and often becomes the saving grace to worried parents who have plenty of
questions and few answers about their situation.

General Care
One of the main duties for a neonatal nurse is the general care of the infant. Babies, even tiny
ones or those with physical ailments, need regular changes, feedings and cuddles. Customarily,
the NICU will assign each baby "care times" throughout the day and night, usually about 3 or 4
hours apart from each other. At each care time, the nurse will change the baby's diaper, take his
temperature, and feed him breast milk or formula. If a baby is receiving any medications, these
may also be administered during these times.
If the parents of an infant are able to visit regularly, a neonatal nurse will teach them how to
perform these basic cares. With time, nurses will help parents to feel equipped in all aspects of
meeting their little one's needs and will continue to serve as a basic support system during the
hospitalization.

Special Needs
Sometimes babies are too fragile or small to eat directly from breast or bottle. When this
is the case, they are fed either intravenously, or through a gavage tube, which is a small tube
that goes from the nose or mouth into the stomach. Nurses will carefully place the correct
amount of formula or dietary supplementation if a baby is not yet eating, into either of these
methods of nutrition, and monitors the baby for any positive or negative changes in the infant.
The duties for a neonatal nurse also include inserting and changing IVs, administering blood
transfusions when necessary, and drawing blood for various testing. Nurses are able to perform
many other procedures as well, and it fully depends upon each hospital's individual protocol, as
well as the nurse's experience level and staff rating.

Technical Duties for a Neonatal Nurse

Regardless of their other responsibilities, all neonatal nurses do a fair bit of charting on
each of their patients. This may be on a paper sheet, or more commonly every year, completed
electronically via a special hospital computer system. The details logged into the online chart
allow doctors, other nurses, and anyone else within the baby's medical care team to view a
baby's updated health records.
A nurse may also be responsible for emailing the neonatologist (NICU doctor) or calling the
parents with specific requests or information. While a neonatal nurse's priorities are found in
caring for the child assigned to them, they often also spend a large portion of their shift charting
and getting messages out to those who need to receive them.

Emotional Support
A neonatal nurse often gets to know the families of infants very well, especially if they
happen to have a primary baby they take care of. A primary nurse will care for the same infant
for the duration of his hospital stay, whenever he/she is on shift. This works well, as the nurses
become very familiar with their babies and can in turn provide them with the best care
possible. In building relationships with these families, they can often provide emotional support
and comfort during scary times. If a baby has to go through surgery or is exceptionally ill,
nurses are great for reassuring the parents and providing as concrete of answers as they are
permitted to.
Neonatal nurses are often the unsung heroes to families and able to give the earliest of
lives a fighting chance. Their daily duties add up to countless miracles and a rewarding career
at the same time.

CONCLUSION
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 premature newborn infants. A NICU is
typically directed by one or more neonatologists and staffed by nurses, nurse practitioners,
pharmacists, physician assistants, resident physicians, and respiratory therapists, dietitians.
Many other ancillary disciplines and specialists are available at larger units. Neonatal intensive
care is costly not only to the individual but also to the family. These cost increase with
decreasing birth weight and gestational age. Therefore neonatologists must include parents in
any discussion about whether to continue the extreme measures being provided to their
extremely low birth weight preterm infants. Development of neonatal intensive care unit
requires careful planning with the joint efforts of physicians, nurses and architects. The plan
should be based on functional efficiency. Neonatal intensive care unit ideally should be next to
the obstetric suite.