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NORMSANDSTANDARDSFORESSENTIALNEONATALCARE
RecommendednormsandstandardsforprovidingEssentialNewbornCareinSouthAfrica.Standardsforclinicalservices,infrastructure,equipment,humanresources,andinfectioncontrol,clinicalcare,transferandtransportofnewborns.
EssentialNewbornCare:Normsandstandards
1�
2013
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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2013
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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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.
16�
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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2013
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
18�
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.
20�
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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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.
22�
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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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
24�
• 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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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.
26�
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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2013
• 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
28�
• 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.
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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