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This work is licensed under a CC BY 4.0 International License. NORMS AND STANDARDS FOR ESSENTIAL NEONATAL CARE Recommended norms and standards for providing Essential Newborn Care in South Africa. Standards for clinical services, infrastructure, equipment, human resources, and infection control, clinical care, transfer and transport of newborns. Essential Newborn Care: Norms and standards

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ThisworkislicensedunderaCCBY4.0InternationalLicense.

NORMSANDSTANDARDSFORESSENTIALNEONATALCARE

RecommendednormsandstandardsforprovidingEssentialNewbornCareinSouthAfrica.Standardsforclinicalservices,infrastructure,equipment,humanresources,andinfectioncontrol,clinicalcare,transferandtransportofnewborns.

EssentialNewbornCare:Normsandstandards

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TABLEOFCONTENTS

INTRODUCTIONTORECOMMENDEDSTANDARDS...........................................................................3

1.ESSENTIALNEWBORNCARE............................................................................................................3

1.1ESSENTIALMATERNALCARE...................................................................................................................31.2ESSENTIALNEWBORNCARESERVICES.....................................................................................................41.2.1NEONATALRESUSCITATIONATBIRTH...................................................................................................41.2.2ROUTINECARE...................................................................................................................................41.2.3INPATIENTCAREOFSICKANDSMALLNEWBORNS..................................................................................5

2.HOSPITALFACILITIES:NEONATALUNITANDMATERNITY...........................................................7

2.1POSITIONOFTHENEONATALUNIT..........................................................................................................72.2SIZEOFTHENEONATALUNIT.................................................................................................................72.3CONFIGURATIONOFTHENEONATALUNIT...............................................................................................8STANDARDINPATIENT(SIC)AREA...............................................................................................................9KANGAROOMOTHERCARE(KMC)AREA.....................................................................................................9HIGHCARE(HC)AREA................................................................................................................................9INTENSIVEANDHIGHLYSPECIALISEDCARE(NICU)........................................................................................9ADMINISTRATIVEWORKAREAS...................................................................................................................9STORAGE,UTILITYANDPREPARATIONAREAS...............................................................................................10NURSESANDDOCTORSRESTAREAS...........................................................................................................10FAMILYFACILITIES....................................................................................................................................10ADDITIONALFACILITIES..............................................................................................................................112.4.ENVIRONMENTALDESIGN...................................................................................................................112.4.1HANDWASHFACILITIES......................................................................................................................112.4.2ELECTRICALNEEDS............................................................................................................................112.4.3LIGHTING.........................................................................................................................................112.4.4FLOORINGANDWALLS......................................................................................................................112.4.5WINDOWS......................................................................................................................................122.4.6VENTILATIONANDTEMPERATURE......................................................................................................122.4.7SOUNDCONTROL.............................................................................................................................122.4.8SECURITY........................................................................................................................................12EXAMPLEOFANEONATALUNITDESIGN......................................................................................................132.5MATERNITYFACILITIES.........................................................................................................................142.5.1CLINIC,COMMUNITYHEALTHCENTREORMIDWIFEOBSTETRUCUNIT.....................................................142.5.2HOSPITALMATERNITYFACILITIES.......................................................................................................14

3.EQUIPMENTANDRENEWABLERESOURCESFORNEONATALCARE...........................................15

4.HUMANRESOURCESFORNEWBORNCARE..................................................................................19

4.1NEONATALUNITNURSINGNUMBERS...................................................................................................19

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4.2NURSESKILLS,TRAININGANDDEVELOPMENT........................................................................................194.3DOCTORS...........................................................................................................................................194.4SKILLSDEVELOPMENT........................................................................................................................20MENTORINGANDSUPPORTIVESUPERVISION...............................................................................................214.5NURSINGNORMSFORMATERNALCARE................................................................................................21MATERNITYSTAFFING...............................................................................................................................21STAFFINGFORPHCCLINCIS........................................................................................................................22

5.INFECTIONPREVENTIONANDCONTROLINTHENEONATALUNIT.............................................23

5.1FACILTIES:SPACE,STAFFING,POLICIES...................................................................................................235.1.1SPACE..............................................................................................................................................235.1.2PERSONNEL....................................................................................................................................245.1.3HANDWASHINGFACILITIES...............................................................................................................245.1.4ISOLATION......................................................................................................................................245.1.5ADMISSIONCRITERIA........................................................................................................................255.1.6VISITINGCRITERIA.........................................................................................................................255.1.7CLOTHING........................................................................................................................................255.2CLINCALPROCDURESFORINFECTIONCONTROL......................................................................................255.3CLEANINGEQUIPMENT.........................................................................................................................275.3.3OXYGENTUBINGANDRESPIRATORYCIRCUITS......................................................................................275.4HOUSEKEEPING..................................................................................................................................285.5NOSOCOMIALINFECTIONSANDOUTBREAKS.........................................................................................29

6.STANDARDCLINICALCARE............................................................................................................30

7.NEONATALTRANSFERS...................................................................................................................31

7.1FROMACLINICTOALEVEL1DISTRICTHOSPITAL.....................................................................................317.2FROMALEVELITOALEVELIIHOSPITAL...........................................................................................317.3FROMLEVELIORIITOLEVELIIIHOSPITAL...........................................................................................327.3LIMITATIONOFCAREGUIDELINES........................................................................................................32

8.NEONATALTRANSPORT................................................................................................................34

8.1THEREFERRALSERVICE.......................................................................................................................348.2CAREOFTHENEWBORNDURINGTRANSPORT........................................................................................35COMMUNICATION...................................................................................................................................35PRE-DEPARTURESTABILIZATION...............................................................................................................35CAREOFTHENEONATEINTHETRANSPORTENVIRONMENT...........................................................................35ARRIVALATTHEREFERRALHOSPITAL.......................................................................................................378.3QUALITYASSURANCE....................................................................................................................378.4THECASEFORANEONATALRETRIEVALTEAM(NRT)................................................................37

9.REFERENCES...................................................................................................................................38

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INTRODUCTIONTORECOMMENDEDSTANDARDS

Astandardisastatementaboutadesiredandacceptablelevelofcare.ThestandardsforessentialnewborncarearederivedfromSouthAfricanNationalandProvincialstandards,globalstandardsandtheexperienceofseniorcliniciansworkinginneonatalcareinSouthAfricaformanydecades.

Webelievethattheyformagoodbaselinefromwhichtoworkandwouldliketorecommendthatyouusethesestandardsasastartingpointfortheprovisionofessentialnewborncare.Yourdistrictorprovincemaywanttoadjustthestandardstoyourparticularservice.

1.ESSENTIALNEWBORNCARE

Essentialnewborncareisthecarerequiredbyallnewbornsinthefirst28daysoflife,iftheyarehealthy,oriftheyaresickorsmall.Itincludesthecaretheyrequiretopreventillnessinthenewbornperiodandlateroninlife.Thiscaretakesplaceathome,inclinics,andinhospitals.Somenewbornsrequireintensiveorspecialisedcareinatertiaryunit.Westriveforequalaccesstoessentialandspecialisednewborncare.

1.1ESSENTIALMATERNALCARE

Adiscussiononnewborncarecannotleaveoutmaternalcare.Ifthemotherisnotwellandhasnotaccessedessentialmaternalservices,thebabymaybeaffectedintheneonatalperiodandlaterinlife.Essentialmaternalcareincludes

• AttendanceatAntenatalClinicfromthefirsttrimesterofpregnancyandforatleast5goodqualityantenatalvisits

• Identificationofhighriskmaternalandneonatalsituationswithaccesstoappropriatecare• RecognitionofHIVpositivewomen,assessmentandcareofthemotherincludingantiretroviral

treatmentorprophylaxis• Recognitionandtreatmentofsyphilis• Prenatalfolateadministrationandadequatematernalnutrition• Recognitionandtreatmentofmaternalillness,e.g.diabetes,pregnancyinducedhypertension• PreventionofprematurityandcareofthemotherinpretermlabourtopreventHyalineMembrane

Diseaseinthebaby• Monitoringandcareinlabourtopreventfoetalhypoxiaandneonatalasphyxia• EarlyreferralofthemothertolevelIIorIIIcentresifadifficultmaternalorneonatalcourseis

anticipated

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1.2ESSENTIALNEWBORNCARESERVICES

1.2.1NEONATALRESUSCITATIONATBIRTH

Mostbabieswillnotneedhelptobreathe,but6–9%doandcanbehelpedtobreathewithin1minuteofbirth.

Everyclinic,casualty,emergencyserviceandlabourwardmustbepreparedforababyatdelivery,andensurethatthebabybreatheswithinthefirstminuteoflife.AllstaffneedtraininginBasicNeonatalresuscitationandneedregulardrillstoensuretheskillsaremaintained.Basicessentialequipmentisrequiredateverylabourwardbed,andanadvancedresuscitationtrolleyintheunit.HelpingBabiesBreathe,atrainingprogrammeoftheAmericanAcademyofPaediatricsisanexampleoftrainingthatshouldberolledouttoallstaff.Advancedmidwivesanddoctorsrequireskillinadvancedneonatalresuscitation.

1.2.2ROUTINECARE

Routinecareatbirthisallthecareanapparentlywellnewbornrequirestobehealthy.Itexcludesthecarethatisrequiredforthoseidentifiedassickandsmallbabies.Routinecarehappensinthematernalserviceatclinics,inlabourward,andpostnatalward,andisprovidedbythesestaffinconcurrencewiththemotherscare.

Inlabourwardroutinecareisnewbornresuscitation,triageofbabiestoidentifythosesickorsmallbabiesneedingmorecare,initiationofbreastfeedingwithin30minutesofbirth,administrationofeyeprophylaxisandadministrationofVitaminKtopreventhaemorrhagicdiseaseofthenewborn.ThefirstdoseofantiretroviraltreatmenttoHIVexposedinfantsisgiveninlabourward.Documentationofcareisinthematernalrecord.

InpostnatalwardroutinecareincludesafullassessmentofthebabytodetectandmanageriskfactorssuchasHIV,anypredispositionforjaundice,andathoroughexaminationtolookforillnessandabnormalities.Babies’roominwiththeirmothers,thereisno“wellbabynursery”.Additionalscreeningmaybedoneaccordingtolocalprotocolse.g.saturationmeasurementforcyanoticcongenitalheartdiseaseandthyroidandhearingscreening.Breastfeedingissupportedforallbabies,exceptinrarecases,wheremedicallyindicated,themotherwillbeassistedwithformulafeeding.InformationisdocumentedinthenewbornsectionofthematernalrecordandtheRoadtoHealthBooklet.Ifwell,thebabyisreferredtothePrimaryHealthCareserviceforfollowuponthethirdday.

A3-dayvisit–eitherbythemothertotheclinic,orclinictothemother,isessentialtosupportfeeding,reinforcepreventivecareandfurtherscreenforjaundiceandillness.

Routinecareofthenewbornisprovidedbythestaffthatprovidesthematernalcaretothemotheratprimaryhealthcarefacilitiesorhospitals.Ifrisksorillnessareidentified,thebabyisreferredtothepaediatricandneonatalservice.

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1.2.3INPATIENTCAREOFSICKANDSMALLNEWBORNS

Atbirthbabiesareexaminedinlabourwardandagaininpostnatalwardtoassessthecaretheyrequire.Babieswhoarelessthan2kgaswellasbabieswhoaresick,e.ghaveneonatalasphyxia,respiratoryproblems,infectionoramajorabnormalityareadmittedtotheneonatalunitforfurtherassessmentandmanagement.

Inpatientneonatalcareisprovidedintheneonatalunitofahospital.AsmostbabiesinSouthAfricaarebornindistricthospitals,districthospitalsneedtohavetheservicesandaskilledteamtomanagesickandsmallbabies.Certainbabiesrequirefurthercareatregionalandtertiaryhospitals.Wherepossible,neonatalproblemsareanticipatedinutero,sothatthebabycanbebornattheappropriateleveltoreceivethecaretheyrequire.

About10–15%ofbabieswillrequireinpatientneonatalservices.ThisisinthehospitalNeonatalUnit.Allhospitalsmusthaveaneonatalunitforsickandsmallbabies,butnotforwellbabies.ThisdocumentreferstotheNeonatalUnitthatmaybesynonymouswith,orinclusiveof,thefollowingterms,nursery,prematureunit,NICU,KMC.

STANDARDINPATIENTNEONATALCARE

Standardinpatientcareisthecareofababywhohasbeenidentifiedassickorsmallandreferredtotheneonatalunitforspecialcare.Itincludesthecareofbabieswhoarelessthan2kilogramsatbirth,thosethathaveasphyxia,infectionsoracongenitalabnormality.StandardcareincludesKangarooMotherCare.

KANGAROOMOTHERCARE(KMC)

KMCiscaretolowbirthweightandpretermbabies,whohavebeenstabilizedinstandardinpatientcare,NICUorhighcareandarenowreadytoreceivecareintheKangaroopositionwiththeirmothers.KMCispartofStandardInpatientCare.TheKangaroopositionprovides,warmth,stability,nutritionandinfectionpreventiontothelowbirthweightbabies.AlllowbirthweightbabiesoncestabilizedwillreceiveKMCuntilthebabyiswellandbigenoughtobedischargedhome.TheKangarooMotherCareUnitispartoftheNeonatalUnit.

NEONATALHIGHCARE

NeonatalHighcareisthecareofsickerbabiesandincludesthosewhorequirecardiorespiratorymonitoring,oxygentherapyofmorethan40%,NasalprongCPAP,thosewhohaverecurrentapnoeaandconvulsions,orwhomayneedanexchangetransfusion.

INTENSIVEANDHIGHLYSPECIALIZEDCARE

Intensivecareisrequiredforbabieswhoneedmechanicalventilation,totalparenteralnutrition,orwhohaveacomplexproblemrequiringfurtherinvestigationandmanagementorwhohaveaneonatalsurgicalproblem.Advancedcareisascarceresource,andmuchmoneycanbespentonmanagingbabieswhoareverysmallandimmature,orwhoselongtermoutcomemaybepoor.Limitingcareneedsconsiderationandisdiscussedunderreferral.Essentialcareincludesguidelinesonwhichbabiesshouldaccessadvancedcare.

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TABLE1. LEVELSOFNEWBORNCAREATFACILITIES

ROUTINECARE(RC)

STANDARDINPATIENTCARE(SIC)

HIGHCARE(HC)

INTENSIVEANDHIGHLYSPECIALISEDCARE(NICU)

Category of baby requiring

care

• Most Full term infants • Most low birth weight

infants > 2kg

Babies with • Low Apgars • Congenital

abnormalities • LBW 1500 – 1999g • Gestational age 32

– 36 wks • Birth weight

>4000g • Meconium staining • Wasting • Possible infection • Jaundice

Babies with • LBW < 1500g • Gestational age <

32wks • Encephalopathy • Meconium

aspiration • Septicaemia /

meningitis • Recurrent apnoea • Moderate and

severe respiratory distress

• Convulsions • Severe jaundice • Simple neonatal

surgical problems

Babies with • A need for assisted

ventilation • Complex Surgical

problems • Persistent

hypoglycaemia • Cardiovascular

problems • Multisystem

problems • Problems requiring

specialist intervention e.g. ambiguous genitalia

Care provided ∗ Safe, clean delivery ∗ Apgar score ∗ Basic newborn

resuscitation ∗ Initiation of Breast

feeding at birth and further support

∗ Maintenance of warmth ∗ Emergency care before

referral ∗ Vitamin K, eye care,

immunisation, cord care, measurement,

∗ Examination of newborn ∗ Care to baby whose

mother has HIV, TB or syphilis

∗ Skin to skin care and KMC

IN addition to routine care • Maintenance of

thermo-neutral environment.

• Oxygen administration and monitoring

• Monitoring glucose and correcting abnormalities

• IV Fluid administration

• Tube feeding • Bilirubin monitoring

and Phototherapy • Drug administration

In addition to routine and standard care • Cardio-respiratory

monitoring • Oxygen therapy

> 40% Head box • Nasal prong CPAP • Short term IPPV • Blood transfusion • Chest drains • Exchange blood

transfusion

In addition to other neonatal care • IPPV, and advanced

techniques for respiratory support

• Total parenteral Nutrition

• Arterial catheterization

• Therapeutic cooling • Advanced

neurological monitoring

• Ultrasound and Echo-cardiography

• Sophisticated diagnostic investigation

• Sub-specialist consultation

• Neonatal surgical intervention

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2.HOSPITALFACILITIES:NEONATALUNITANDMATERNITY

2.1POSITIONOFTHENEONATALUNIT

Theneonatalunitisideallylocatedasastand-aloneunitbetweenthelabourwardandpostnatalward.Whenmakingalterationstoexistingbuildings,plantoincorporateasmanyoftheelementsoftheserviceinonegeographicalarea,butthismaynotalwaysbepossible.Inmostdistricthospitalstheneonatalunitislocatedinthepostnatalward.Thisisacceptableifthereisadequatespaceforallcomponentoftheunit.Ifthereisinadequateairandoxygensupplyorspace,neonatalhighcarebedsmaybeplacedinthehospitalhighcareorICU.

2.2SIZEOFTHENEONATALUNIT

Thenumberofdeliveriesinthecatchmentareathatthehospitalservesdeterminestheprojectedsizeoftheneonatalunit.Ahospitalrequires3-4bedsper1000annualdeliveriestoprovidelevelIinpatientnewborncareservices.Thedeliverynumbersincludeallthedeliveriesinthecatchmentorsub-districti.e.inthehospital,feederclinicsandhomedeliveries.Anadditional2–3bedsper1000deliveriesarerequiredforhighcareand0.5bedsper1000deliveriesforintensiveorhighlyspecializedcare.Highcareandintensivecareareusuallyprovidedatregional(LevelII)andtertiaryhospitals(LevelIII).

Thecurrentshortageofregionalhospitalnewbornfacilitiesandstaff,anddifficultyintransportingbabiesmeanthatdistricthospitalsinruralprovinces,needtoplanforsomehighcareservices.

Beforeplanningthenumberofbedsandconfigurationofthebedsaskyourselfanumberofquestions

ü Howmanydeliveriesinthehospital,clinicsandathome?ü Isthenumberofdeliveriesexpectedtoincreaseordecreaseovertheyears?ü Istherearegionalhospitalserviceinthedistricttoreferhighcarepatientsorshouldwebe

planningforsomehighcarebeds?

Example:Ifadistricthospitaldelivers3000babiesinayearthehospitalwillrequire(12inpatientneonatalbeds.

• 4/1000x3000deliveries=12bedsWehaveused4not3perthousanddeliveries,ashomeandclinicdeliveriesareprobablyabout20%ofdeliveriesinSouthAfrica.Ifthehospitalalsoprovideslimitedhighcaretothecatchmentpopulation,thehospitalmayrequireanadditional1per1000highcarebedsi.e.3additionalhighcarebeds.

• 1/1000x3000deliveries=3bedsThehospitalwillrequire15inpatientneonatalbeds.Efficiencydictatesthatdistricthospitalsshouldnothavelessthan9bedsormorethan24beds.Thefollowingmodelisgivenasaguidetohospitals,basedonthenumberofdeliveries.

AhospitalthissizewouldusuallybeaLevelIIhospital

<2000deliveries 9beds2000–<3000deliveries 12beds3000–<4000deliveries 18beds4–<5000deliveries 24beds>5000deliveries 36beds*

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Aregionalhospitalwillrequire4inpatientbedsforeach1000deliveriesinthesub-districtand2inpatientbedsforevery1000deliveriesinthewholedistrict.Ifthehospitaldelivers4000babiestheyneed16bedslevel1beds,andifthedistrictdelivers20000babies,theyneedandadditional40levelIIbedsforthedistrict.Theythusneed56beds.Ifthedistricthospitalsareprovidinghighcare,theymayrequirefewerbeds.

Regionalservicesarebestplannedas36,48and60bedunits.A48and60bedunitwouldalsoprovidesomeintensivecareservice,butnotneonatalsurgeryandhighlyspecializedcare,asthespecialistsrequiredforthisserviceareusuallyonlyatthetertiaryhospital.

ThebedsintheneonatalunitaredividedintoStandardInpatientCare(SIC),KangarooMotherCare(KMC),HighCare(HC)andIntensivecare(NICU).LodgermotherbedsareneededformothersnotinKMCandnotthemselvesadmittedinpostnatalward.

InadistricthospitalapproximatelyathirdofbedswillbeHC,athirdSICandathirdKMC.

EXAMPLESOFDISTRIBUTIONOFBEDS

DISTRICTHOSPITALS

9bedNeonatalUnit=3SICbeds+2HCbeds+4KMCbeds+(3lodgermotherbeds)

12BedNeonatalUnit=3SICbeds+3HCbeds+6KMCbeds+(4lodgermotherbeds)

18BedNeonatalUnit=6SICbeds+4HCbeds+8KMCbeds+(6lodgermotherbeds)

24BedNeonatalUnit=8SICbeds+6HCbeds+10KMCbeds+(10lodgermotherbeds) s

REGIONALHOSPITALS

36bedNeonatalUnit=4NICUbeds+8HCbeds+12SICbeds+12KMCbeds+(16lodgerbeds)

48bedNeonatalUnit=6ICUbeds+12HCbeds+12SCbeds+18KMCbeds+(24lodgerbeds)

60bedNeonatalUnit=12ICUbeds+12HCbeds+24SCbeds+12KMCbeds+(36lodgerbeds)

2.3CONFIGURATIONOFTHENEONATALUNIT

Thedesignoftheneonatalunitmaydependonthespaceavailabletobuildormakealterationsandthepreferencesofindividuals.Whatevertheopportunitiesorconstraintsthefollowingshouldbeconsidered.Workflowpatternsshouldallowforefficientpatientandstaffmovements

• Theneedforconstantsurveillanceofeachbedfromthenurses’station.• Allsectionsoftheneonatalunitinonephysicalarea,includingtheKMCareawherepossible• Areashouldberestrictedtogeneraltraffic• Adualcorridorratherthanacentralcorridorisideal• Allmothersshouldlodgeneartheneonatalunit• Babiespartitionedintofunctionalunitsof4–8babiesperarea.• Accessformothersonwheelchairs• AccessforportableXrayandultrasoundmachines

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Theneonatalunitincludesanumberofareas

STANDARDINPATIENT(SIC)AREA

Thestandardinpatientcareareaoftheneonatalunitrequiresaminimumspaceof5m2perbed.Theservicepanelrequiresoxygenandsuctionand6plugs.Infantsareusuallynursedinaclosedincubatororabassinette.Nomorethan6babiesshouldbeinonestandardinpatientcarearea.

KANGAROOMOTHERCARE(KMC)AREA

IntheKMCareababiesarenursedskin-to-skinwiththeirmothersintheKMCposition.Eachmotherrequiresabed,with7.2–10m2ofspace.Eachcubiclecanaccommodate2-6beds.Aloungeanddiningareawithtelevision,fridge,microwaveandkettlehelpmaketheunithomely.Ablutionsarerequiredaswellasawashingareawithwashingmachineandtumbledryer.

EachKMCbedrequiresaservicepanelwithlights,oxygen,andsuctionand4plugs.TheKMCareaisideallyadjacenttotheneonatalunitwithaninter-leadingdoor.IftheKMCunitisadistanceawayfromtheneonatalunit,itwillrequireadditionaladministrativeandutilityareasaswellasanemergencyresuscitationarea.

HIGHCARE(HC)AREA

Thehighcareareaisforunstablebabiese.gthoserequiringcardio-respiratorymonitoring,onmorethan40%headboxoxygenandbabiesonCPAP.Inasmallneonatalunittherewillbedesignatedhighcarebedsintheneonatalunit.Inalargerneonatalunit,therecanbeahighcarecubicle.Highcarebedsrequireaspaceof7.2–10sqmandtheservicepanelrequires6-12electricplugsaswellasmedicalair,oxygen,ablenderandsuction.

INTENSIVEANDHIGHLYSPECIALISEDCARE(NICU)

Intensivecarewillbeinregionalandtertiaryhospitalonly.IntensivecareisforinfantsrequiringIPPV,arterialcatheterization,thosethathavecomplexmedicalproblemsandneonatalsurgicalproblems.Eachbedrequiresaminimumof10-15m2ofspace,andtheservicepanelrequires12-24plugs,2oxygenpoints,2airpointsandasuctionpoint.

ADMINISTRATIVEWORKAREAS

RECEPTIONAREA

Largerneonatalunitsrequireareceptionarea,whichistheorganisationalcentreforwelcomingpatients,anddoingadministrativework.Thereceptionneedsaworkareafor2to4people,telephones,computeranddatapointsaswellasstoragespaceforstationary.

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THENURSINGSTATIONANDUNITOFFICE

Thenursingstationissituatedsothatpatientscanbeseenandtrafficcontrolled.Spaceisrequiredforworkstationsappropriatelyequippedwithcomputersandinternetconnections.Storageisrequiredforrecordsandstationary.

Largerunitsrequireaunitofficeandadoctor’sofficewithworkarelevantnumberofworkstations.

COUNSELLINGROOM

Acounsellingroomwhereyoucantalktoparentsandfamilyaboutthechild’sconditionisneeded.Itshouldbecomfortablyandtastefullydecorated.Smallerunitsmayshareaspacewithmaternity.

STORAGE,UTILITYANDPREPARATIONAREAS

Multiplestorageandutilityspaceisneeded,largeunitsneedaseparateroomforeachfunctionwhereassmallunitsmaycombinespaceorutiliseacupboard.Thefollowingareasarerequired.

• Alockabledrugtrolleyorcupboardtostoremedication.• ACleanutilityareatostoreconsumablesandsupplies• Alinencupboardforcleanlinenandnappies• Anequipmentstoretocleanandkeepequipmentreadyforuse• Adirtyutilityareafordirtylinen,sothatdirtylinencanberemovedwithoutgoingthroughthe

neonatalunit.• Acleanersroomtoplaceandkeepcleaningmaterials• Amilkpreparationorstoragearea.Smallerhospitalswillhavea24hourcentralmilkkitchen,that

candelivertheoccasionalformulathatmayberequired,largeunitsmayhavetheirownunit.Ifflashheattreatmentisdone,amilkkitchenisrequired.Largerhospitalsmayhavebreastmilkbanks.

NURSESANDDOCTORSRESTAREAS

Arestroomwithcomfortablechairs,lockersandadiningareawithfridge,microwaveandkettlearerequiredforstaff.

Regionalhospitalsandlargeunitsrequireadoctor’sovernightroomfor24-hourmedicalofficercover.Theovernightroomshouldincludeabed,tableandchair,internetconnection,televisionanden-suitebathroom.

FAMILYFACILITIES

MotherswhoarenolongeradmittedtothepostnatalwardornotprovidingKMCneedroomsandfacilitieswheretheycanlodgeuntiltheirbabiesarereadytogohome.Thefacilityneedsablutions,adayroomandlaundryarea.

Avisitor’sloungeisrequiredforfamilyandvisitorstosupportthemother.Comfortablechairs,hotandcoldwaterarerequired.

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ADDITIONALFACILITIES

MobileXrayfacilitiesrequirestorageandinbiggerunitsaplacetoprocesstheXRay.

Anoutpatientareaforbabiestobeseenatfollowupisrequiredinbiggerunits.

Alaboratorysideroomisrequiredinlargerunitsforbloodgasanalyser,microscopyandbilirubinmeasurement.

2.4.ENVIRONMENTALDESIGN

2.4.1HANDWASHFACILITIES

Ahandwashbasinisplacedattheentrancetotheneonatalunitandeachbabyshouldbewithin6metresofahandwashbasin,andthereshouldbeatleast1basinforevery4–6babies.Thehandwashbasinmusthaveelbowoperatedtapsandbelargeenoughtocontainsplashing,butnotbetoodeep.Thereshouldbenosurroundingcountersurfacebutspaceforsoap,toweldispensersandtrashreceptacles.

2.4.2ELECTRICALNEEDS

Theunitshouldhavea24houruninterruptedpowersupply,aswellasabackuppowersupply.

Inordertohandleequipmenteachbedneedsanumberofcentralvoltagestabilizedoutlets.

• Intermediatecarebeds:4–6perbed• Highcarebeds:6–8perbed• ICU:12perbed• KMC:4perbed

Eachareashouldhave2additionalplugsforcleaningequipmentandmobileXrayunits.

Thewardairconditioningductedsystemoncentralsupplyandswitchedonpermanently.

2.4.3LIGHTING

Lightingshouldbecarefullyplanned.Planfortheabilitytohaveadequateprocedurelightaswellastoachievedarkness.Eachlightmustbeindividuallyswitchcontrolled.Theunitshouldhaveadequatedaylight,andartificiallightshouldbeindirect,lightsshouldbedirectuptoilluminatetheceiling.Thenewborn’sdirectlineofsighttothefixtureshouldbeprotectedtopreventretinaldamage.Eachbedrequiresaprocedurelightwithadjustabledirection,intensityandfieldsize.Lightingshouldprovideadequateskintonerecognition,usuallyawhitelight,andbefreeofglare.Lightfixturesshouldbeeasytoclean.

2.4.4FLOORINGANDWALLS

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Floorsurfacesshouldbeeasilycleanablewithoutuseofchemicals,andbehighlydurable,imperviousandjointless.Wallsalsoneedtobedurablewithwashablepaintortiles.Wallsshouldbewhiteorlightforskintonerecognition.Acousticpropertiesneedtobeconsideredforfloorsandwallstodiminishnoise.

2.4.5WINDOWS

Atleastonesourceofdaylightshouldbevisiblefromthebabyarea.Externalwindowsshouldideallybeglazedtoavoidheatgainorloss,andshouldbesituatedatleast0.6mfromaninfantsbedtominimizeradiantheatlossorgain.

2.4.6VENTILATIONANDTEMPERATURE

Temperatureandhumiditycontrolintheneonatalunitisextremelyimportant.Theairconditioningsystemneedstobeofthehighestqualityandmustbeonethathasair-mixerssothattheaircomingintotheroomisattherighttemperature,andhotorcoldairisnotblownacrossthebabies.Theairconditioningmustbeabletokeepthetemperatureoftheunitatbetween22and26degreesatalltimes.Theairconditionershouldsupply6airchangesperhourminimum,thehumidityshouldbebetween30and60%,thereshouldbeminimaldraftandfiltrationshouldbe90%efficient.

2.4.7SOUNDCONTROL

Noisegeneratingactivities,phones,staffareas–shouldbeawayfromthebabiestoreducenoise.Theunitneedstobequietandstaffshouldbeabletoheareachotherwithoutraisingtheirvoice.Alarmsshouldbeappropriatelysetfornew-bornsandattendedtoimmediately.Softmusicmaybeplayed.

Walls,floors,sinksandceilingscanallbedesignedtoabsorbsound.

2.4.8SECURITY

Carefulconsiderationshouldbegiventosecurity,withaccesscontroltoprotectthesecurityoftheinfantsfamilyandstaff.Closedcircuittelevisionaccesscanbeconsidered.

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2013

EXAMPLEOFANEONATALUNITDESIGN

12BedNeonatalUnit=3SICbeds+3HCbeds+6KMCbeds+(4lodgermotherbeds)

24BedNeonatalUnit=8SICbeds+6HCbeds+10KMCbeds+(10lodgermotherbeds)

(stilltobeinserted)

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2.5MATERNITYFACILITIES

2.5.1CLINIC,COMMUNITYHEALTHCENTREORMIDWIFEOBSTETRUCUNIT.

Clinics,CommunityHealthCenters’orMidwifeObstetricUnits’require1labourwardbedforevery500deliveriesayearand1postnatalbedforevery300deliveriesperyear.Mostclinicsdeliverlessthan500babiesayear,buttheyareusuallydesignedtohave2maternitybedsforlabourandpostnatalcare.Aspaceofatleast10–12m2(3mx3.5–4m)isrequiredforeachbed.Eachserviceunit/bedrequiresoxygenandsuctionpoints,2electricplugsand1light.Theroomneedstohaveairconditioning.

Aspaceforresuscitationofthenewbornof7.2m2perisrequired.Thereshouldbeoneresuscitationareaforeachlabourwardbed,usuallyoneperclinic.Theresuscitairerequiresoxygenandsuctionpointsand2electricplugs.

Atransport,orstandardclosedincubatorisalsorequired,shouldtheinfantbesmallandsickandneedmonitoringbeforetransfer.

2.5.2HOSPITALMATERNITYFACILITIES

LABOURWARD

Hospitalsrequire1labourwardbedforevery500deliveriesamonth.EachcontrolpanelrequiresOxygenwithadoubleflowcontrollerandsuction,4electricplugsandanextraelectricplugforcleaningequipment.Airconditioningisneeded.Thespacerequiredperbedis10–12m2(3mx3.5–4m)

Eachlabourwardbedrequiresaresuscitairewithbasicresuscitationequipmentandanadvancedneonatalresuscitationtrolleyforevery6beds.Theatresrequirearesuscitairewithadvancedneonatalresuscitationequipment.Thetheatreshouldbeabletoaccommodateanadditionalmobileresuscitaireinthecaseoftwindeliveries.Regionalandtertiaryhospitalsrequiremedicalairandoxygeninthelabourwardhighcarearea

Foreachresuscitationareathereshouldbeatransportincubatorforthecareofthesmallorsickbabywholewaitingtobemovedtotheneonatalunit.

POSTNATALWARD

Hospitalsrequire6postnatalbedsper1000deliveriesperyear.Standardcarebedsrequire4electricplugsperbedandalight.Spacerequiredis7.2–10m2perbed.Thebabyroomsinwiththemotherandcan“liein”withthemotherorbeinabassinettenexttothemother.Bathingfacilitiesarenotrequiredforbabies,neitherisatransitionalorwellbabynurseryarea,asthebabyshouldeitherbewiththemother,orintheneonatalunit.Ifphototherapyisrequiredthiscanbegivennexttothemothersbed.

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2013

3.EQUIPMENTANDRENEWABLERESOURCESFORNEONATALCARE

Equipmentisneededintheneonatalunittoassistinthecareofnewbornse.g.

• Toadministeroxygen,monitoroxygenationandprovideventilatorassistance• Toadministerfeedsandfluids• Tomonitorvitalsigns• Toprovidewarmththroughanincubatororothersource• Tomonitorandmanagejaundice

Whenpurchasingequipmentfortheneonatalunitconsider:

• Thequantityrequiredbasedonthecurrentandprojectedbedspace• Theelectricalormechanicalrequirementstooperatetheequipment• Anypre-purchaseinstallationrequirements• Aftersalessupportincludinginstallation,training,andimmediatebackupandrepair• Maintenancecontractsfortheequipment• Consumablesthatthedevicewillrequireinordertofunction,lookatcostandavailabilityand

comparewithalternativeoptions• Specificationsrequired,andspecificationsoftheitem• Durabilityoftheitem.Anitemmaycostlessthananotheritem,butthedurabilityofsomeitems

makesthemmorecosteffective.• Theadviceofpaediatriciansandneonatalnurses

Table2liststheequipmentandconsumablerequirements.Calculatewhatyouneedforyourfacility.

Additionalspecificationsforequipment,listsofmanufacturersandpricesareincludedinAppendix2.

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TABLE2:EQUIPMENTFORNEWBORNCARE

Equipment Labourunitandpostnatalward

LevelINeonatalUnit LevelIINeonatalUnit LevelIIINeonatalUnit

Incubators,bassinettes,andgeneralneonatalequipmentClosedincubator

1perSICbed 1perSICbed 1perSICbed

Bassinette(Washable)

4per1000deliveries/month

1perSICbed

Transportincubator 1per3LWbeds2perTheatre

Overheadservoincubator

0 1perHCbed 1perHC/ICUbed 1perHC/ICUbed

HeatShield

0 1perHCbed 1perHC/ICUbed 1perHC/ICUbed

Wallsuctionunit 1persuctionpoint 1persuctionpoint 1persuctionpoint 1persuctionpointPhototherapyunits 1/Healthcentre

1/6PNbeds1per2NNUbeds 1per2NNUbeds 1per2ICandHC

bedsTranscutaneousbilirubinmeter

1/Healthcentre1/Postnatalward

1perNNU

1forKMCandSC1forHCandICU

1forKMCandIC1forHCandICU

Electronicscale 1per6LWbeds1per6PNbeds

1perNNUcubicle 1perNNUcubicle 1perNNUcubicle

EquipmentforrespiratorysupportandoxygentherapyVentilators(Complete)

0 1–2forshorttermventilation

1perICUbed

NasalCPAP(Complete)

1perHCbed

1perHCbed 1perHCbed

Headboxes 1forLW/clinic1forPostnatalWard

1perSICandHCbed

1perSICandHCbed 1perSICandHCbed

Pulseoximeters* 1perHealthCentre1forLabourward1forpostnatalward

1perHCbeds1per2SICbeds

1perHCbeds1per2SICbeds

1perHC/ICUbeds1per2SICbeds

Oxygenflowmeter 1doubleperoxygenpoint

1doubleperNNUbed

1doubleperNNUbed 1doubleperNNUbed

Oxygenblender 1perHCbed 1perHCbed 1perHCbedOxygenanalyser 1per2HCbed 1per2HCbed 1per2HCbedApnoeamonitors 1per2HCbed 1per2HCbed 1per2HCbedTrans-illuminationlight

1perNNU 1perHCunit1perICUunit

1perHCunit1perICUunit

Chestdrainkit 1perNNU 1perNNU 2perNNUFluidcontrollersandcardiacmonitorsIntravenousinfusioncontrollers

1perNNUbed 1perNNUbed 1perNNUbed

Multi-parametermonitors

1perHCbed 1perHC/ICUbed 1perHC/ICUbed

BPmonitor-portable

1 1 1

Syringepumps

1perICUbed 1perICUbed

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Equipment Labourunitandpostnatalward

LevelINeonatalUnit LevelIINeonatalUnit LevelIIINeonatalUnit

Otherequipment PortableSuctionapparatus

1perclinic1perlabourward

1perNeonatalunit 1per6beds 1per6beds

MobileXRay 1inthehospital 1intheunit 1intheunitUltrasoundmachine 1mobilewithneonatal

andechoprobeavailableinhospital

1inNNUwithneonatalandechoprobes

Bloodgasanalyser 1inlargehospitals 1inthehospital 1intheunit ResuscitationequipmentResuscitaire 1perlabourwardbed

2pertheatre1perpostnatalward

1perunit 1perunit 1perunit

Self-inflatingneonatalbagandmaskandmasks00,0/1,2

2perresuscitaire2peradvancedresuscitationtrolley

2peradvancedresuscitationtrolley

2peradvancedresuscitationtrolley

2peradvancedresuscitationtrolley

AdvancedResuscitationtrolley

1perhealthcentre1per6labourwardbeds

1perunit 1per6HC/ICbeds 1per6HC/ICbeds

Neopuff

1perICUunit 1perICUunit

Laryngoscope,straightmillerbladesize00,0,sparebatteriesandbulb

1perhealthcentre1per6labourwardbeds

1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

Endotrachealtubes 3size2.5,3.0,3.5and4,0perresuscitationtrolley

3size2.5,3.0,3.5and4,0perresuscitationtrolley

3size2.5,3.0,3.5and4,0perresuscitationtrolley

3size2.5,3.0,3.5and4,0perresuscitationtrolley

Introducer 1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

Mcgillsforceps 1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

1peradvancedresuscitationtrolley

Suctioncatheters Size103ateachresuscitaire

Size103ateachresuscitaire

Size103ateachresuscitaire

Size103ateachresuscitaire

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Equipment Labourunitandpostnatalward

LevelINeonatalUnit LevelIINeonatalUnit LevelIIINeonatalUnit

Consumables Oxygentubing* 2peroxygenpoint 2peroxygenpoint 2peroxygenpoint 2peroxygenpointNasalprongs* 2neonatal/preterm

peroxygenpoint2neonatal/pretermperoxygenpoint

2neonatal/pretermperoxygenpoint

2neonatal/pretermperoxygenpoint

Venturi’s* 1fullsetperoxygenpoint

1fullsetperoxygenpointinSC/HC

1fullsetperoxygenpointinSC/HC

1fullsetperoxygenpointinSC

CPAPcircuit 4circuits/machineavailableforreuse

4circuits/machineavailableforreuse

4circuits/machineavailableforreuse

Ventilatorcircuits 4circuits/machineavailableforreuse

4circuits/machineavailableforreuse

4circuits/machineavailableforreuse

Neonatalsaturationprobes

2permachineavailableforreuse

2permachineavailableforreuse

2permachineavailableforreuse

2permachineavailableforreuse

Neonatalincubatorprobes

6perincubator 6perincubator 6perincubator

Infusionsets* 5x60dpmset 5x60dpmorCorrectsetforinfusioncontroller

5x60dpmorCorrectsetforinfusioncontroller

5x60dpmorCorrectsetforinfusioncontroller

IVcannulas 5x24and22G Many24and22G Many24and22G Many24and22GDial–a–flow 5perclinic

5inlabourward,andpostnatalward

Infusioncontrollersarepreferable

Infusioncontrollersarepreferable

Infusioncontrollersarepreferable

Consumablesforbilicheck

Ivfluids 10%Neonatolyte,NSaline,10%dextrose5%dextrose

10%Neonatolyte,NSaline,10%dextrose5%dextrose

10%Neonatolyte,NSaline,10%dextrose5%dextrose

10%Neonatolyte,NSaline,10%dextrose5%dextrose

Feedingequipment Breastpumps Notrecommendedinclinicsandhospitalsastheyaredifficulttocleanandsterilise.Expressmilk

byhandintoacupEquipmentforflashheattreatingmilk2platestove,aluminiumpots

Nil 1per12beds 1per12beds 1per12beds

200mland50mlfeedingcup

4per10deliveries 8perbed 8perbed 8perbed

Forconsumableequipment,thisisthenumberthatmustbeavailableeveryday,ensureadequatestocksforthistohappen

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2013

4.HUMANRESOURCESFORNEWBORNCARE

Guidelinesaregivenfornursinganddoctornorms,aswellascompetenciesandsuggestedtrainingandlearning.

4.1NEONATALUNITNURSINGNUMBERS

Aneonatalintensivecareshouldhave1professionalnurseperpatient.Itisacceptabletohaveonenursefor2patients.

Ahighcareunitrequires1ProfessionalNurse(PN)per2patientsbutoneper3patientsisacceptable.IfyouhaveonePNandoneEnrolledNurse(EN)for4babiesthisisalsoacceptable,aslongastheENisexperiencedinnewborncare.

AstandardinpatientcareunitandKMCunitshouldhaveonePNforeach6babiesaswellasoneENforeach6babies.HavingonePNtocover12standardandKMCbabiesduringthedayisacceptable,ifthereare2Enrollednurses.

Aneonatalunitrequiresaunitmanager.Inasmallerunit,theunitmanagermaybepartofthestaffcomplement,butinlargerunitsanadditionalpostisnecessary.

Toprovide24-hourcovereverydayforeachnursingshift,6postsarerequiredforeachposition.

4.2NURSESKILLS,TRAININGANDDEVELOPMENT

AdiplomainneonatalICUorpaediatricsisrecommendedfortheprofessionalnursesintheintensivecareunitandtheunitmanager.

AsaminimumrequirementPN’sshouldundergoin-servicetraininginnewborncaresuchastheoneweekLINCtrainingandbeengagedinself-studyoranongoingin-servicetrainingprogrammeatthefacility.e.g.PerinatalEducationProgramme.

Non-rotationofprofessionalnursesintheneonatalunitisessential.Workinginaneonatalunitrequiresspecificskills,andnurseswithapassionandinterestinnewbornsareneeded.Onceyouhavefoundgoodnurses,developtheirskillsfurther,anddonotrotatethem.

4.3DOCTORS

Theremustbeadoctorresponsiblefortheneonatalunitinthehospital.Thedoctormustdoadailywardround,andaproblemroundintheafternoonandevening.Thelargertheunit,themoreofthedoctorstimewillbespentintheneonatalunit.Largeneonatalunitswith18ormorebedsrequireamedicalofficertobepresentatalltimesduringtheday.

Aregionalhospitalneonatalunit,requiresapermanentmedicalofficertobeallocatedtoevery18babies,andapaediatriciantoprovideadvice,supportandtraining.A24hourpaediatricmedicalofficercoverfortheneonatalunitisneeded.

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Doctorsshouldhaveaninterestinnewborns,shouldhaveundergoneasaminimumaneonatalresuscitationcourseandthe2-dayLINCtraining,andshouldparticipateinon-goinglearning.DoctorsatregionalhospitalsareencouragedtoworktowardsaDiplomainChildHealth.

4.4SKILLSDEVELOPMENT

Thereareanumberofcompetenciesrequiredtoworkwithnewbornsandanumberofwaystoassistyourhealthworkersinacquiringthesecompetencies.Thesearelistedintheresourcechapterandsummarisedhere.

ADVOCACY.

Beforeembarkingonanyskillsdevelopmentensurethatstaffareinterestedinnewborncare,committedtolearning,andwanttofurthertheirskills.Youcandothisbyintroducingthemtonewborncarethroughadvocacymaterials,preparingtopicsandbringinginanoutsideexperttotalkaboutnewborncare.

NEONATALRESUSCITATIONTRAINING

HelpingBabiesBreathe(HBB)trainingisabasicresuscitationtrainingrequiredbyallnursesanddoctorswhoworkinthematernityandneonatalunit.Doctors,advancedmidwivesandneonatalnursesshouldhaveskillinadvancedneonatalresuscitationthatcanbeachievedbysendingthemonaNRPcourse,ortrainingyourprovinceprovides.HBBtrainingcanbedoneon-siteineachfacility.Ongoingon-sitedrillsandskillsrevisiononneonatalresuscitationisrequiredatfacilities.

BASICNEWBORNCARECOURSES

LINChasdevelopedbasicnewborncarelearningandtrainingmaterialsandsuggestionsforcoursesorin-servicetraining.

AModuleonRoutinecarecanbetaughtasaoneortwodaycourseoraspartofin-servicetraininginthefacility.TheRoutineCareassumesthatparticipantshavealreadydoneanHBBcourse.Itisbestthatthislearningisfacilitybased.

Chartsandmodulesthatcanbeadaptedtoteachnurses,doctorsandenrollednursescoverthemanagementofsickandsmallbabies.A5-daycourseschedulefornursesisprovidedthatincludesinteractiveadultlearningandpractical.Thiscoursecanberunasa5daycourse,asselflearningorasafacilitybasedin-servicetrainingprogramme.

DISTANCEBASEDLEARNING

Thereareavarietyofdistancebasedlearningmaterialsfornursesanddoctors.ThePerinatalEducationProgrammeissuchacourseandcanbeusedasselflearningorgrouplearninginafacility.

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2013

FURTHERDIPLOMATRAINING

VariousuniversitiesofferdiplomatraininginNeonatalIntensivecareorPaediatrics.Regionalhospitalsshouldarrangestudyleavefornursestoundergothistraining.DoctorsareencouragedtostudyforthediplomainChildHealth.

ATTENDANCEATCONFERENCESANDUPDATES

Avarietyofconferencesareheldeveryyear,thatwillencouragelearning.Theseinclude

1. Perinatalprioritiesconference2. Biannualpaediatricconference3. Paediatricrefreshercourse4. Variousupdates

Guidelines,trainingmaterialsandresourcesareattached.xxx

MENTORINGANDSUPPORTIVESUPERVISION

Clinicalmentoringisanimportantwayoflearning,andtraditionallythisishownurses,internsandjuniordoctorsdomostoftheirlearning,fromexperiencedcolleagues.Manyinstitutionshaveexperiencedalossofskilledhealthworkers,andhealthworkershavenotalwayskeptuptodate.Intheseinstances,outsidementorscanassistwithskillsdevelopment.MoreinformationcanbefoundinChapter3.

4.5NURSINGNORMSFORMATERNALCARE

Newborncarestartsduringpregnancy!Pregnancyisabouthavingababy,anditistheresponsibilityofeveryoneinvolved–parentsandhealthworkerstodoeverythingpossibletoensurethat,attheendofthepregnancy,thereisahealthybaby.Thisalsomeansthattheremustbeahealthymother.Thekeytoagoodoutcomeofpregnancyisthecarethatthemothergetsduringpregnancyandlabour.Theremustbesufficientstaffavailableforthiscaretobeprovided.Allstaffprovidingmaternitycare,frombookingtodischargeafterdelivery,mustnotbe“rotated”.Theymustbepermanentlyallocated,unlessthestaffmemberhimorherselfrequeststobemoved.

MATERNITYSTAFFING

Thisstaffingreferstohospitalstaffingofantenatalclinic,labourwardandpostnatalward.Itdoesnotincludestaffingfortheneonatalunit.Thematernitystaffareresponsibleforthecareofthemotherinthehighriskantenatalclinic,inthelabourwardandinpostnatalward,aswellastheroutinecareofthebabyinutero,inlabourwardandpostnatalward.

Theneonatalunitrequiresaseparatestaffing,unlessthehospitalisverysmallandtherearefewerthan1000deliveriesayear.

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MIDWIVESThestaffestablishmentrequires16midwivesforevery100deliveriespermonth.Aunitmanager,whoisclinicallyinvolved,isneededinadditiontothisnumber.Inordertohave1nurseonduty24hoursintheday,theremustbe5nursesonthestaffestablishmentThereshouldbeanadvancedmidwifeonduty24hoursperdayaspartofthisnumber–thereforeatleast5advancedmidwivesonthestaffestablishment.

ENROLLEDNURSESANDENROLLEDNURSINGASSSISTANTS10–12enrollednursesper100deliveriespermontharerequiredonthestaffestablishment.Thisallowsfor1tobeworkinginthelabourwardand1tobeworkinginthepostnatalwardtoprovide24-hourcover.

DOCTORSTheremustbeadesignateddoctorresponsibleforpatientcareinthematernitywardashis/herfirstresponsibility.Doctorsdoingtheircommunityserviceyeardonotneedtobe“rotated”.Theyaremedicalofficersasanyother.

STAFFINGFORPHCCLINCIS

NormscannotbespecificallyprovidedformaternitycareatPHCclinicsasthisisintegratedintotheworkdoneaPHCfacility.ManyPHCclinicsconductfewerthan5deliveriesamonth.Whereclinicsarebiggerortherearehealthcentresthatdodeliveriesthesamenormwillapplyforprofessionalnurses,i.e.16midwivesforevery100deliveriesamonth.

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2013

5.INFECTIONPREVENTIONANDCONTROLINTHENEONATALUNIT

Newbornsareathighriskofacquiringinfection,thisisduetotheirimmatureimmunesystem.Theyareusuallyprotectedfrominfectionthroughexclusivebreastfeeding,andlimitedcontactwithotherindividuals.

Theneonatalunitoranyfacilitypredisposesthebabytoinfection.Inthisenvironmentthebabyishandledbymanypeople,exposedtodifferentsurfacesandprobes,andtheintegrityoftheirskinormucousmembranemaybebrokenbyprocedures.Mostorganismsaretransmittedbyhandsontothebabyorequipmentintheenvironment.

ThisguideappliestoalllevelsbutisintendedmainlyforlevelIandIIfacilitieswithunitsfrom6–36beds.LargerlevelIIandLevelIIIfacilitiesmayrequireadditionalinfectioncontrolmeasurestobeputinplace.

HAND WASHING IS THE SINGLE MOST IMPORTANT WAY TO PREVENTINFECTION.

• Stricthandwashing,beforetouchingababy

• Adequatesoap,waterandpapertowels

• Preventovercrowding

• Feedbabiesbreastmilkonly

• Beobsessivewithhousekeepingandasepsis

5.1FACILTIES:SPACE,STAFFING,POLICIES

5.1.1SPACE

Infectionisreducedifthereisadequatespacefornursing,andonlyafewpeoplewithcleanhandstouchthebaby.Adherencetothenormsandstandardsforstaffandfacilitiesthatareoutlinedwillpreventinfection.Thekeyfactorsthatpreventinfectionare

• Adequatespaceforeachincubatororbassinettesothatthereisspaceforthemother,themedicalstaffandtherequiredequipment

• Having4-8babiesperfunctionalarea,evenwithoutdividers,sothatthereisonehandwashbasinforeach4–8babies,andthatthenursingstaffworkonlywith4–8babieseach

• Theunitisair-conditionedandthatthisiskeptbetween24and25degreesCelsius• Adequateventilationintheunit

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• Limitthenumberofpeoplecomingintotheunit• Swingdoors,ornodoorsbetweensectionstopreventhavingtohandledoors

5.1.2PERSONNEL

Personnelwithairborninfectionsandskininfectionsshouldnotworkdirectlywithpatientsuntiltheyarebetter.

Personnelshouldbeallocatedtopatientsnottasks,andshouldideallynotcareformorethan6babies.

Personnelshouldbeimmunetomeasles,rubella,andvaricella.

Personnelshouldreceiveannualinfluenzavaccinations.

5.1.3HANDWASHINGFACILITIES

Handwashingfacilitiesneedtoinclude

• Ahandwashbasinwithelbowoperatedtapsattheentrancetotheneonatalunit• Eachcubicleof4–8babiestohaveahandwashbasinwithelbowoperatedtaps,andeachbaby

shouldbelessthan6metresfromahandwashbasin• Ahandwashingposterwithclearinstructionspostedaboveornexttoeachbasin• Antisepticsoapandcleandisposabletowelsateachbasin• Alcoholhandspray• Apeddleoperatedrefusebinateachbasin

5.1.4ISOLATION

• Mostinfectionsinnewbornsdonotrequirespecialisolationprecautions• Generalnewborncaremeasureswillpreventtransmissionofmostinfectionsbetweennewborns• Examplesofbabieswhomayneedspecialprecautionsareababywithinfectivediarrhoea,RSVor

staphylococcalskinsepsis.Theycanbenursedinaclosedincubator,andadistanceof1metreshouldseparatethemfromotherpatientsinthenursery.

• Babieswhoaredeemedtohaveaseriousinfectiousrisk,e.g.varicellaormeaslesrequireisolationoutsidetheneonatalunit.

• Nospecialrestrictionsshouldbeappliedtobabiesbornoutsidethehospital.Theyshouldbetreatedthesameasbabiesborninthehospital.

• Ifthereisanoutbreakofaninfection,thenthestaffandbabiesinvolvedintheoutbreakarekeptasacohortinasinglecubicleuntildischarge.

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2013

5.1.5ADMISSIONCRITERIA

Babiesareusuallybornwithoutinfectionsandaregraduallycolonisedbyorganismsfromtheirmothersandtheenvironment.Babieswhohavebeenhomemaybecolonisedbycommunity-acquiredorganismthatmaybelessproblematictotreatthanthosewithhospitalacquiredinfections.Thereisnojustificationtoexcludingbabieswhocomefromhomeorotherenvironmentsornursingtheminaseparatearea.

• Allneonatesirrespectiveofwheretheyareborn,orhavebeen,areadmittedtotheneonatalunit• Other“infectedbabies”canbenursedinaclosedincubatorwithattentiontoinfectioncontrol.

TheseincludebabieswithstaphylococcalskinsepsisandpossibleRSVinfection

Washyourhandsbeforeandaftertouchingababy

5.1.6VISITINGCRITERIA

Parentsarefreetovisitatanytime.Theyneedtoadheretohandwashingguidelines.Othervisitorsincludinggrandparents,importantcaregiversandsiblingscanvisitforshortperiods,aslongastheyhavenorespiratoryinfection,washtheirhandsandtheunitisnotovercrowded.

5.1.7Clothing

Theroutineuseofgownsisofnoprovenvalue.Studieshaveshownthatroutineuseofgownsdoesnotreducecolonisationorinfectioninnewborns

Personnelshouldwearcomfortableshort-sleevedcleanclothesdaily,andmaychoosetowearauniformscrubdressorsuit.

Doctorsmustremovewhitecoatsastheyenter,asthesemaybecontaminatedfromotherareasinthehospital

Gownsareonlyusedforsterileprocedures,e.gexchangetransfusion.

Lodgermothersshouldwearcleanclotheseveryday.

5.2CLINCALPROCDURESFORINFECTIONCONTROL

5.2.1HANDWASHING

Washhandsforoneminuteonenteringtheneonatalunit

Washhandsfor30secondsordoanalcoholrinsebetweentouchingeachbaby.

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HANDWASHINGPROCEDURE

• Rollsleevestoelbow• Removewatch,bangle• Usewaterandsoapandwashhandsinthefollowingsequence

o Palmsandfingersinwebspaceso Backsofhandso Fingersandknuckleso Thumbso Fingertipso Wristsandforearmstoelbowso Keepelbowlowerthanhands

• Closethetapwithelbow,orwithpaperoncehandsaredry• Dryhandswithsingleusecleanpaper• Discardinthepeddlebin

Whenusingalcoholhandspray,followthesameprocedure

5.2.2SEPARATEBASICEQUIPMENTFOREACHBABY

Thefollowingequipmentandsuppliesshouldbeassignedtoasinglepatientandkeptbelowtheincubatororbassinette

• Stethoscope• Tapemeasure• Cottonwoolswabs• Swabs• Thermometer• Alcohol

Cleanwithalcoholbetweenpatients.

Keeprecords,filesandX-raysonthenurses’station,notontheincubator

5.2.4SKINANDUMBILICALCORDCARE

Cleanumbilicalcordandumbilicuswith70%alcohol4timesaday

5.2.5MANAGINGIVIINFUSIONS,OXYGEN,MEDICATIONS

• ChangeIVlinesafter72hours• Changeallvacolitresafter24hours• Labelthebagwithdateandtimeofopening• Changeburetrolsafter24hours• Changesuctionbottlesafter24hours• Donotusehumidificationbottlesunlessthepatientisgettingnasopharyngealoxygen.

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• Changeoxygenhumidificationbottlesandwatereverydayandreplacewithcleanbottles,andsterilewaterdaily.

• ChangeventilatorandCPAPcircuitsonceaweek• Changenasalprongsandcannulasevery3days• Changedportholecuffseverydayordonotuse• Discardantibioticvialsafter24hours• Usesyrupsforoneweekafteropeningandthendiscard

5.3CLEANINGEQUIPMENT

5.3.1SMALLEQUIPMENT

Wipedownswabcontainer,injectionandmedicinetrayeachdaywithsoapandwater

Cleanthefollowingdailywithspiritsifusedforthesamepatient

• Stethescope• Measuringtape• Thermometer• BPcuffs• Radiantwarmerprobes• Pulseoximeter

Ifusedfordifferentpatients,wipewithspiritsbetweenpatients.

Oxygenhood:wipewithsoapandwatereachday,andcleanwith0.5%chlorhexidenebetweenpatientsandafter7days

5.3.2INCUBATORSANDBASINETTES

Cleanincubatorseverydaywithadampclothsoakedinmilddetergent,don’tusechemicalsorspirits

Cleanincubatorsthoroughlywith0.5%chlorhexideneafterusebyapatientandafter7days.Allowtodrybeforeusing.

Replacewaterproofmattresseswhenwaterproofingisbroken

Disinfectbasinettesdailyusingdetergentsolutionordisinfectantsolutions

5.3.3OXYGENTUBINGANDRESPIRATORYCIRCUITS

Ifbabyhashadagramnegativeinfectiondiscardoxygentubingandrespiratorycircuits

OTHERWISE

• Cleanoxygentubingandrespiratorycircuitswithsoapandwater• Rinsewithcleanwater

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• Drythoroughlybyhangingtodryfor24hoursorblowdrywithairoroxygen• Packandgassterilise

OR

• Soakinhibiscrub(4%chorhexidenegluconate)for30minutes• SoakinCydex(10%isopropylalcohol)mixedwithabucketofwaterfor30minutes• Rinseinwater,hangonastandandallowtodry

5.3.4CPAPGENERATORSANDNASALPRONGSFORCPAP

• Washwithsoapandwatertoremovesecretions,bloodanddirt• Rinseanddrythoroughly• Pack• Gassterilise

5.3.5HUMIDIFIERCHAMBERS

• Fillwithsterilewaterdaily• Aftereachbabyorafteroneweek,washwithsoapywater,rinse,drythouroughly• Gassterilise

5.3.6INFANTFEEDINGCUPS

• Washandsterilisecupsusedforfeeding• Discarddisposablesyringesafteruseifusedforfeeding

5.4HOUSEKEEPING

5.4.1CLEANING

• Keepthenurserycleananddustfree.• Cleaningmethodsthatminimisedustdispersalshouldbeused.• Haveahousekeepingschedule• CleanfloorsandhorizontalsurfacesonceortwicedailywithanEPAapproveddisinfectant.

Phenolicsolutionsshouldnotbeused.• Cleananddustwindowsandblindsweekly• Cleanfromtoptothebottom• Ensurethatafreshbucketcontainingdisinfectantsolutionisavailableatalltimes;• Immediatelycleanupspillsofbloodorbodyfluidwithdisinfectantsolution(0.5%chlorhexidene• Dustbinsshouldbewasheddailywithsoapandwater,andthebagschangeddailyorwhenfull.

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5.4.2LINEN

• Washlinenat60degreescelsiusandinfectedlinenat93degreescelsius• Cleanlinenmustbeavailableatalltimes• Linentobetransportedincoveredlaundrybags• Newlinentobelaunderedpriortouse• Contaminatedlinentobeplacedinayellowplasticbagandtakentothelaundrytwiceaday

5.4.3WASTEHANDLING

• Soilednappiesandmedicalwastetobecollected3hourlyaftereveryfeedinground• Separatecontaminatedwastefromnon-contaminatedwaste• Useapunctureproofcontainerforcontaminatedsharps,andemptywhen2/3full

5.5NOSOCOMIALINFECTIONSANDOUTBREAKS

Apresumptiveepidemicistwoormorebabieswithinaneonatalunitwiththesameconditionatthesametime.Strictcontrolmeasuresneedtobeputinplaceandmonitoredtoresolvetheproblem.

• Isolatethebabyandmotherinaprivateroomorplaceinaclosedincubator• Orplaceallbabieswiththesameinfectioninthesameroom• Ordonotadmitnewbabiestothatroom

Whenenteringtheroom

• Wearcleanglovesandchangeglovesaftercontactwithinfectiousmaterials(secretions,gauze)• Wearacleangownwhenincontactwiththebaby• Removethegownandglovesaftercontactwiththebaby• Washhandswhenleavingtheroom• Avoidtouchingpotentiallycontaminatedsurfaces

• Reservenoncriticalequipmentforuseonlywiththeinfectedbaby

ReviewCompliancewithinfectioncontrolprocedures.

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6.STANDARDCLINICALCARE

Newborncareistobeprovidedaccordingtosetstandards.Thesestandardscanbemadeintoguidelines,protocolsandpoliciesforcare.Theyrequireimplementationstrategies,training,supportandmonitoring.

Standardclinicalguidelineshavebeendevelopedinordertofacilitatestandardcare.Hospitalsneedtoadoptthenationalstandardclinicalguidelines.Adjustmentstotheguidelinesmaybemadeintoprotocolstofacilitatelocalimplementationoftheguidelines.

Examplesofstandardclinicalguidelinesinclude

1. StandardclinicalguidelinesandEDLforPaediatricCare2. LINCguidelinesfordistricthospitals(Limpopo)3. LINCChartsonroutinecareandthecareofthesickandsmallnewborn.

Theseguidelinesareattachedtothetoolkit,inhardcopyandontheCDROM

Tertiaryunitsdeveloptheirownstandardclinicalguidelines.Whilethesearenotforuseindistricthospitals,wehaveincludedelectronicversionsofsomeoftheseguidelinesforreference.

Supportfortheimplementationofstandardcareisimportant.Waystodothisinclude

• Clinicalsupportvisitsbyapaediatrician• Clinicalaudit• Clinicsupervision• Recordreviews• Mortalityaudits

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7.NEONATALTRANSFERS

Referralofpatientoccursin2directions:

Acriticallyillneonatereferredfromadistricttoatertiaryserviceeg:Neonatebornatadistricthospitalrequiringsurgeryforacongenitalabnormalityatatertiaryhospital.

AhighriskneonatebornatatertiaryhospitalreferredfromatertiaryserviceoncestabletoadistricthospitaltoreceiveKangaroomothercare.

Thedecisiontoreferapatientshouldbetelephonicallydiscussedbetweenthedoctorfromthereferringhospitaltothedoctoratthereceivinghospital.

Forcertaincriticallyillnewbornstransferandreferralmaynotbethebestformofmanagement.Thesenewbornsmightbeservedbetterbyprovidingcomfortorpalliativecareatthebirthingunit.Babiesbornattheextremeendofviabilityorwithcongenitalabnormalitiesincompatiblewithsurvivalaresomeexamples.

Inasituationwherenobedmaybeavailableatthetimeofreferral,on-goingmanagementoftheneonatemustbecontinuedattheplaceofdeliveryinliaisonwiththespecialistatthereceivinghospital.Itisthedutyofthereferringdoctortoupdatethedoctoratthereceivinghospitalofthepatient’scondition.Transfershouldhappenonceabedbecomesavailable.

Thefollowingguidelinesaresuggestionstofacilitatethereferralandtransferofthecorrectpatienttothecorrectlevelofcare.Theymaynotbeapplicabletoeverydistrictandprovince,andlocalguidelinesforreferralarenecessary.ThereisinequitableaccesstostandardcarefornewbornsinSouthAfricaandequityacrossprovincesneedstobediscussed.

7.1FROMACLINICTOALEVEL1DISTRICTHOSPITAL

Indicationsforreferraltoadistricthospitalarethesameasforanybabyreferredtotheneonatalunitfrommaternityandincludethefollowing

• BabieswithApgarscoreslessthan8• Babieswithbirthweight<2kg• Babywithaprioritysignorcongenitalabnormality• Babywithariskfactorthatcannotbeadequatemanagedatclinicleve

7.2FROMALEVELITOALEVELIIHOSPITAL

SomeoftheindicationsforreferralfromLevelItoLevelIIcare.

• Babieswithabirthweightof1000g-1500gwhoareunwellatDISTRICThospitals• BabieswithRespiratorydistresswithsaturations<80%onHeadBoxoxygenat>60%oxygenin

headbox,andCPAPisnotavailable• Babywithsevererespiratorydistress,grunting,severeindrawingandRR>70• ThebabyisreceivingCPAP,andtheinhaledoxygenis>60%tomaintainoxygensaturationat88–

92%orababyonCPAPishavingrecurrentapnoearequiringmaskventilation.

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• Babywithuncontrolledseizures• Hypoglycaemianotrespondingtotreatmentin1hour• Jaundicewithbilirubinlevelsindicatingimminentexchangetransfusion• Persistentvomiting• AsphyxiatedpatientsarenotusuallyconsideredbutsomeinfantswithaThompsonHIEscoreof10

–15,orSarnatgrade1–2maybenefitfromtherapeuticcoolingstartedwithin4hoursofbirth,ifthisserviceisavailable.

• DysmorphicbabiesneedtobeseenbyapaediatricianbutthisisnotareasonforurgenttransfertoalevelIIorlevelIIIhospital

7.3FROMLEVELIORIITOLEVELIIIHOSPITAL

Level3spaceisalimited,acostlyresource,andnotavailableinallprovinces.ThedecisiontoreferapatienttoatertiaryhospitalmustbediscussedwiththespecialistintheNICU.Somepatientse.g.patientswithsurgicalproblemssuchasgastroschis,willbenefitfromgoingdirectlytoatertiaryunit.Somepatientswhomayqualifyinclude

• FailedCPAPifnoventilationisavailableatlevelll• AllVLBWrequiringventilationbeyond72hours• Congenitalabnormalitiesrequiringsurgery• LongtermfeedingproblemsrequiringTotalParenteralNutrition(TPN)• SeverePersistentPulmonaryHypertension(PPHN)requiringventilationandinotropicsupport

Whenthebedcapacityatthereferralhospitalhasbeenreached,thereceivingdoctorwillneedtobeinvolvedtoidentifyanalternativebedattheappropriatelevelofcare.Ifnobedisavailablethepatientmayhavetostayatthereferringhospitaluntilsuchtimethatabedbecomesavailable.

7.3LIMITATIONOFCAREGUIDELINES

“Limitationofcare”isadecisiontonotofferactiveresuscitationorcontinuedventilation.Itmayincludethelimitationofescalationofcareorwithholdingofantibiotics,oxygenandmonitoring.

Thedecisiontolimitcareisbasedonacombinationoflimitedresourcesandexpectedlongtermoutcome.Theseguidelinesaresubjecttochangedependingonavailabilityifresourcesandfurtherinformationregardingtheprognosisoftheclinicalcondition.Itisdifficulttogiveabsoluteguidelinesbutitisimportanttorecognizewhentheofferedtherapyisfailingandthesituationisnowfutile.Itiscriticaltotreatthepatientsandtheirfamilieswiththeutmostrespectandempathyandtoaccommodatebaptismorotherreligiousorculturalceremonieswherepossible.

PreferablytwonameddoctorsshouldagreeonaDECISIONtolimitcareanditshouldbecondiseredinthefollowingscenarios

• ChronicIPPV>14daysandnotsteadilyimprovingintheabsenceofaknowntreatableconditionwithexpectedgoodlongtermoutcome

• InfantswithNecrotisingEnterocolitis(NEC)whofailconventionalventilation• Multisystemdiseaseanddeterioratingafteraweekoftreatment• Congenital/Metabolicabnormalitieswithaknownorexpectedpooroutcome

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• Chronicneuromusculardisorderswithexpecteddurationofventilatorysupport>30days.• Expectedpoorneurologicaloutcome,eg:Bilateralgrade3orunilateralgrade4intraventricular

haemorrhage(IVH)orunilateralperiventricularleucomalacia(PVL)intheparietal/occipitalregions

• Aspyxiatedinfantswhodonotestablishsustainedspontaneousrespirationby20minutesoflifeorwhohavecontinuous,persistentprofoundbradycardia<60bpmbeyond10minsoflifedespitetheusual,appropriateresuscitativemeasures(Intheabsenceofreversiblematernalmedicationinfluence)

• SevereHypoxicIschaemicEncephalopathy(HIE)ie:Sarnatgrade3orThompsonHIEscore15ormore.

• Prolongedprofoundhypoxia/acidosis/seizuresnotrespondingtotreatmentwithin6hours(andmetabolicdiseaseunlikely).

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8.NEONATALTRANSPORT

InSouthAfricacriticallyillneonatesarebornatalllevelsofcare.Wherethereiseffectivescreeningandreferralofhigh-riskmothersantenatallytoLevelllorlevellllservices,theseinfantshaveabetterchanceofsurvivalastheyaredeliveredwherethereisaspecializedneonatalunitstaffedbyspecialistpaediatricianorneonatologist.

Criticallyillneonateswhoarebornatadistrictfacilityhavetobetransferredtoasecondaryortertiarycentreandaredependantuponemergencytransferstoareferralhospital.Theneonataloutcomeisdirectlyrelatedtoefficientandrapidtransporttime,andthecarethattheyreceivebeforeandduringtransport.

Vehiclesforgroundtransportofneonatalpatientshavehistoricallybeengeneral-purposeambulances,withorwithoutatransportincubator.

Weneedtoworktowardsdedicatedneonatalambulanceservices,withvehiclesfittedwithspecializedneonatalequipmentandskilledneonataltrainedemergencymedicalpersonneltostaffthem.

Therearetwomaincomponentsinvolvedinthetransportofapatient.Theseare:

8.1THEREFERRALSERVICE

Thereferralsystemconsistsofthepersonnel,vehicles,andprotocolsfortransfer

8.1.1PERSONNELThereare

• thepersonnelmanningtheofficeatthe“ambulance”callcentre,• theclinicalstaffatthehospital• thepersonnelmanningtheambulance.

Thecallcentrestaffreceivethecalltofetchapatientandpassthisontothestaffmanningthevehicles.Thesecallsareprioritisedaccordingtoalist.Neonataltransfershouldbehighontheprioritylist.Clearprotocolsfortransportingnewborninfants,whichincludeurgencymustbeinplaceandbeavailabletothe“ambulance”staff.Theambulancepersonnelusuallyconsistsofthedriverofthevehicleandacolleaguewhomay,orsometimesmaynot,havehadonlybasicfirstaidtraining.Fortransportingnewbornbabies,thereisaneedtohaveapersonwhohashadtraininginthecareofanewbornbabyduringtransport.Thedoctoratthereceivinghospitalisinthebestpositiontoadvisetheambulancepersonnelontheurgencyoftransportandanyspecialmanagementwhichthebabycouldneedduringtransport.Itisessentialthatallthreecategoriesofstaffmeetonaregularbasistodiscussproblems,developprotocols,andformplanstoimprovetheservice.

8.1.2MODEOFTRANSPORT

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Groundambulancesareusedforrelativelyshort-distancetransportwhensurfacetransportationismoreefficientandoftenmorerapidthanairtransport.Itmustalsobeusedwhenclimacticconditionsprecludeairtransport.Helicopterorfixed-wingairplanetransportmaybeusedformedium-distancetransfers.Theyresultinrapidtransferbutarecostly,andweatherdoesnotalwayspermittheiruse.

8.2CAREOFTHENEWBORNDURINGTRANSPORT

COMMUNICATION Thedoctorwhohasbeenlookingafterthebabyshouldmakearequestfortransferofasickbabytothereceivingdoctor.Thisshouldbeasearlyaspossiblebeforethebabydeteriorates.ThemostseniordoctorshouldmakethedecisionaboutreferralThereceivingdoctorwill

• Giveadviceonpre-transportstabilizationpriortothearrivalofthetransportteam.• Decidewhethertransferisappropriate• Ifindicated,authorizesorrecommendsamodeoftransport• Advisethetransportteamonthecareneededduringtransport.• Informthenurseinchargeoftheneonatalunitthatthebabyisbeingtransferredin

PRE-DEPARTURESTABILIZATION

Theconditionofthebabymustbestabilisedbeforetransportation.Thefollowingaspectsofcareareessentialforthebaby:

• Thebabymustbekeptwarm.• Ensurethatthebabyisgettingsufficientoxygen.Theoxygensaturationshouldbekeptbetween

88and93%(preterminfant)or94–96%(terminfant).• Thebloodglucoselevelmustbemaintainedinthenormalrange.• Thebabymusthaveasecuredairway.Thismaymeanendotrachealintubation.• Allthedocumentation(copiesofallthepatientnotes,observationcharts,andtheresultsof

specialinvestigations)mustbereadyforthetransportteamwhentheyarrive.

CAREOFTHENEONATEINTHETRANSPORTENVIRONMENT

PERSONNELNEEDED

Themostreasonableoptionistohaveasuitablyqualifiedparamedicaspartofthetransportteam.This,inSouthAfrica,ismostoftennotpossible.

Thealternativeistosendaqualifiednursewiththebaby.Thisusuallyresultsinthestaffingofthereferringhospitalbeingdepleted.Thenursealsoneedstobereturnedtoherhospital.Thisisafarfromidealsituation.

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EQUIPMENT

Theambulanceneedstohavebasicequipmentfortransportingnewborns.Thisconsistsof:

• Atransportincubatorwhichcanplugintothevehicle’selectricalsystem• Asourceofoxygen,usuallyacylinder,withameansofcontrollingtheflowandthepercentage

beingadministered.Theformerisusuallypresentonthecylindergaugehead,butthepercentageadministeredwillneedventuris,ifaheadboxisbeingused.

• Apulseoximeter(oxygensaturationmonitor)• Adripstand• AnIVinfusionratecontroller,orsuitablealternative• Aplaceforthebaby’smother,andtheaccompanyinghealthprofessionaltosit.• Adequateresuscitationequipment–aminimumofabagandmask.• Transportventilatorsareavailable,andwilldefinitelybeneededifababyneedstobeventilated

ontheway.

THERMALCONTROL

Thermoregulationisvitaltobothmorbidityandmortalityinthecriticallyillneonate.Waysofkeepingababywarmduringtransport

• Transportincubator:Thetemperatureofthebabymustbechecked½hourlyandtheincubatortemperatureadjustedaccordingtothebaby’stemperature.

• Usingapolythenebagor“sheet”.Thiscanbeusedevenifthebabyisinanincubator,asitreducestheheatlossfromthebaby.

• KeepingthebabyintheKMCposition.Unlessthereisaspecialreasonfornotbeingabletodothis,itisasafemethodofkeepingthebabywarmduringtransport.Itwillbeessentialtodothisifatransportincubatorisnotavailable.

• ThetemperatureofbabieswithHIEshouldbekeptbetween34–350Cforthedurationofthetransport.

VENTILATIONANDAIRWAYMANAGEMENT

Thefirstlevelofinterventionisbag-valve-maskventilation.Thisisacceptableforshorttransfersiftransferredbyunskilledtransportstaff.However,itisanunacceptablepracticeforprolongedairwaymanagementduringtransport.

Ifventilationisneededoranticipated,thebabywillneedtobeintubatedwithanendotrachealtube,beforethejourney,andatransportventilatorisrequiredwithpersonnelwhocansupportventilation.

MONITORINGDURINGTRANSPORT

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Monitoringthevitalsignsofaneonateinanambulancehasitschallenges.Thefollowingobservationsneedtobedone:Temperature,Respiratoryrate,Heartrate,Oxygensaturation,IVlinerunningcorrectly(Checkdripsite)Theseobservationsmustberecordedandtherecordputwiththebabiesdocuments.

ARRIVALATTHEREFERRALHOSPITAL

Onarrivalatthereferralhospital,thebabyshouldbetakendirectlytotheNeonatalUnit,andNOTviatheout-patientdepartmentorcasualty.Allthenecessaryobservationsmustbecommencedimmediatelyonarrival.Assoonasthebabyhasbeensettledintoanincubator,theresponsibledoctormustbecalledtoassessthebaby.Thereshouldbeareportbacktothereferringdoctorbythereceivingdoctorwithin24hoursofthebabyarrivingatthereferralhospital.Thisshouldinitiallybebytelephone,andabriefwrittennotealsosent.

8.3QUALITYASSURANCE

Regularmeetingsneedtobeheldbetweentheneonatalserviceandthetransportservice,andguidelinesformonitoringqualityassuranceputinplace.

8.4THECASEFORANEONATALRETRIEVALTEAM(NRT)

Paramedics,nursesanddoctors,havetheroleofrapidlystabilizingcriticallyillnewbornpatientsforimmediatetransfer.Theservicesofaspecializedneonataltransportteamhasbeenshowntobeassociatedwithreductionsinhypothermiaandacidosis,aswellasreducedmortalityinlowbirthweightinfants.

Anumberoftransportteamconfigurationsareusedforneonataltransport.Criticalcaretransportteamsarenotcommoninthepublicsector.However,intheprivatesector,themostcommoncrewconfigurationisanexperiencedprofessionalnurseworkingwithaparamedic,andanemergencyspecialistoradoctorifrequired.However,indevelopedcountries,manyneonataltransportprogramsincludearespiratorytherapistasthesecondcrewmemberbecauseofairwaymanagementexpertise.AddingaspecialisttotheteamisverycostlyandSouthAfricahastakentherouteofprovidingadvancedtrainingforparamedicsinneonatalconditionsasacosteffectivealternative.

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9.REFERENCES

BarlowHJ.AnEvaluationofNeonatalNursingCareinSelectedHospitalsintheWesternCape,2003.MCurThesis,UniversityofStellenboschBryanLOhming.GuidelinesandTransferProtocols–MaternityandNeonatalTransfers,ChildHealthNetworkfortheGreaterTorontoArea2010–2011GreenfieldDH.MidwiferyStaffingNeedsinaMaternityWard.Proceedingsofthe25thConferenceonPrioritiesinPerinatalCareinSouthAfrica,ChampagneSportsResort,KwaZulu-NatalMarch2006

Laing,I,DuckerT,LeafA,NewmarchP.DesigningaNeonatalUnit.ReportfortheBritishAssociationofPerinatalMedicine.May2004

MalanA,WoodsD,CooperP,AdhikariM.HealthPlanforNeonatalCare.1997PrioritiesinPerinatalCareConference.

EasternCapeHospitalDesignGuideVer2.1May2011

InfectionPreventionandControlinthenursery,Chapter24ofKZNHealthManual

GuidelineforNeonatalCare.June2008.DepartmentofHealth,RepublicofSouthAfrica

ManagingNewbornProblems:Aguidefordoctors,nurses,andmidwives:WorldHealthOrganisation2003(IntegratedManagementofpregnancyandchildbirth)

NewbornCareCharts:Managementofthesickandsmallnewbornsinhospital.2008.LimpopoInitiativeforNewbornCare

Qualitystandardsforspecialistneonatalcare:Standardsforhospitalsprovidingneonatalintensiveandhighdependencycare(SecondEdition)NICE/BAPM(inconsultation)

Servicestandardsforhospitalsprovidingneonatalcare.3rdedition2010.BritishAssociationofPerinatalMedicine.

ToolkitforSettingUpSpecialCareNewbornUnits,StabilisationUnitsandNewbornCareCorners,Unicef,India