Sick Newborn Care Unit

Sick Newborn Care Unit

Document No: Date of Issue : ---------------

Version/Issue No: 01 Effective Date: -------------------

Edition : 01 Document Pages: Page 2 of 39

1. About the Department: Scope of services

Timings

Types of patients served

2. Organogram

3. Quality Policy

4. Quality Objectives





5. Patient registration and admission S.No Activity Responsibility Record

1. Registration & Admission for walk –in cases

- Registration shall be done at registration counter during OPD

hours and at emergency department during non OPD hrs.

- Every patient who is registered shall be provided with a unique

identification number mentioned in the OP case paper and

directed either towards the OPD/emergency department based

on the working hours.

- A written order for hospitalization by the doctor at the paediatric

OPD during OPD hours or the Medical officer at the emergency

department shall be provided at the registration desk for

initiating admission formalities.

Doctor / Casualty

Medical Officer

OP ticket & Admission

slip

2. Registration and admission of referral cases

- Referred-in cases for out born admission shall be directly guided

to SNCU.

- As per physical assessment of the baby the doctors shall either

advice for hospitalization or prescribe medication/stabilizes and

send back.

- In case of advice for hospitalization, the admission formalities

shall be fulfilled at the SNCU itself.

SNCU - Incharge,

Doctor

Admission slip &

Infant case sheet

3. Inborn cases

- For inborn babies, they shall be transferred to SNCU from the

ward and no separate admission formalities shall be required,

only a separate case sheet for the baby will be developed. The

order for admission shall be given by the concerned doctor on

the mother’s case sheet.

SNCU- Incharge,

Doctor

Infant case sheet at

SNCU

4. Criteria for admission in SNCU

General criteria

- Birth weight < 1800g or gestation < 34 weeks

- Large baby (> 4.0 kg)

- Perinatal asphyxia

SNCU nursing

staff and doctor

Nil





- Apnea or gasping

- Refusal to feed

- Respiratory distress(Rate > 60/minute or grunt/retractions)

- Sever jaundice (Appears > 24 hours/stains palms & soles/lasts >

2 weeks)

- Hypothermia < 35.40 C or hyperthermia > 37.50 C

- Central cyanosis

- Shock ( Cold periphery with CFT > 3 seconds and weak and fast

pulse)

- Coma,convulsion,encephalopathy

- Abdominal distension

- Diarrhoea / Dysentery

- Bleeding major malformation

5. For observation after delivery

The following infants should be observed in the SNCU for at least 24

hours after delivery:

- Infants depressed at birth

- Meconium - stained infants

- Infants born after a traumatic delivery

- Infants of diabetic mother

- Infants small for gestational age, and / or < 2.4 kg

- Large for gestational Age > 4.0kg

- Infants born by emergency LSCS

Nursing staff &

Incharge of

Labour room &

SNCU

Mother’s case sheet,

SNCU register

6. Immediate admission after delivery

The following infants are immediately admitted after delivery

- Infants severely depressed at birth, e.g. APGAR score less

than or equal to five at five minutes.

- Any respiratory distress.

- Infants less than 34 weeks gestation or less than 1800g at

birth or SGA.

Nursing staff &

Incharge of

Labour room &

SNCU

SNCU admission

register, Infant case

sheet, Inter-dept

transfer register





- Infants with meconium aspiration.

- Infants with major or severe congenital anomalies (does not

include, for e.g. Down Syndrome)

7. Admission from postnatal ward to SNCU

The following signs and symptoms signify a sick infant and should

therefore be admitted from postnatal ward

- Delayed or persistent respiratory distress

- Apnoeic or cyanotic spells

- Abnormal behaviour or activity including recurrent vomiting,

abdominal distention, lethargy, hypotonia, Seizures

- Suspected sepsis

- Evidence of bleeding or excessively pale infants.

- Jaundice if it occurs before 24 hours of age or bilirubin is

equal to or exceeds a level of 15 mg/dl before 48 hours or if

considered to be in phototherapy range according to

reference charts.

- Persistent hypothermia not responding to simple measures.

- Hypoglycaemia –severe / recurrent / non- responding to

feeds alone.

Nursing staff &

Incharge of

maternity ward &

SNCU

SNCU admission

register, Infant case

sheet, Inter-dept

transfer register

In any of the above situations, the concerned doctor needs to be

contacted at the earliest.

Nursing staff

SNCU

Nil

Reference standard - ME E1.1, ME E1.3





6. In-case of non-availability of beds S.No Activity Responsibility Record

1. All efforts shall be made to accommodate the baby, extra baby

bassinets and baby warmers shall be available to accommodate the

new admissions.

Management ,

S.N.C.U – Incharge

Nil

2. In case of non-availability of beds, limited refer-in cases shall be

accepted or baby stabilized and referred to another centre.

S.N.C.U – Incharge S.N.C.U register

3. On phone calls received for refer-in cases, the problem of lack of beds

should be clearly intimated to the caller at the other end.

S.N.C.U –

Incharge, Nursing

staff

Nil

Reference standard - ME E1.4

7. Patient receiving, initial assessment, regular re-assessment S.No Activity Responsibility Record

1. Baby receiving from labour room/ward/OT

- For sending the baby to SNCU, prior information to the SNCU-

Incharge shall have to be sent.

- The SNCU nursing staff shall take handover of the baby, complete

necessary formalities in the SNCU register and receive the baby

covered in a sterile towel in the baby receiving tray for transfer to

SNCU.

- Baby bassinets whenever available shall be used for transfer

purpose.

Nursing staff of labour room, ward, OT, SNCU

Inter-dept

transfer register ,

SNCU register

2. Initial assessment

Initial assessment of the baby shall be done on the following

parameters

- Weight, Temperature , general condition

- Airway & breathing

- Circulation

- Convulsion

Nursing staff , duty doctor, specialist

Initial asessment form

Initial assessment and treatment should be provided immediately and

timely documented, preferably within 2 hours

Nursing staff , duty doctor, specialist

Initial asessment form

3. Re-assessment

Re-assessment shall be done by treating doctor at least once a day. Treating doctor Infant case sheet





The frequency can be augmented based on the clinical condition.

The following parameters shall be reassessed in routine for all the

patients by the staff nurse.

- Temperature, Pulse and Respiration

- Airway and breathing,

- Any feeding problems

- Any signs & symptoms of infection or any other developing

illness

Staff nurse Nursing note,

Infant case sheet

The treating doctor shall regularly check and scrutinize the notes

made on the case sheet to ensure that all the relevant information

about the sign and symptoms, daily progress or detoriation, notes of

investigations are entered on the case papers and evaluate the baby’s

condition accordingly.

Treating doctor Infant case sheet

The re-assessment done shall faithfully reflect the patient’s clinical

condition, response to treatment and inputs to plan further line of

treatment or discharge.

Treating doctor Infant case sheet

All clinical re-assessments shall be recorded and signed with name,

date and time in the medical record by the staff making entry

Nursing staff,

doctor

Infant case sheet

Reference standard – ME E2.1

8. Criteria for transfer to step down

S.No Activity Responsibility Record

1. The following criteria shall be used for baby transfer to step down unit

- Babies whose respiratory distress is improving and do not require

oxygen supplementation to maintain saturation

- Babies on antibiotics for completion of duration of therapy

- Low birth weight babies (less than 1800g) who are otherwise

stable 9for adequate weight gain)

- Babies with jaundice requiring phototherapy but otherwise stable

- Babies admitted for any condition but are now thermodynamically

and hemodynamically stable

SNCU nursing staff

and doctor

Reference standard – ME E2.1





9. Triage of new born

- Hypothermia

(temp< 360C)

- Apnea or gasping

respiration

- Severe respiratory

distress (rate > 70,

severe retractions,

grunt)

- Central cyanosis

- Shock (cold

periphery, CFT>3

secs, weak & fast

pulse)

- Coma, convulsions

or encephalopathy

- Cold stress (temp

36.40C- 360C)

- Respiratory distress

(rate > 60, no

retractions)

- Irritable/restless/jittery

- Abdominal distension

- Severe jaundice

- Severe pallor

- Bleeding from any sites

- Major congenital

malformations

- Weight less than 1800 g

or more than 4 kg

- Transitional stools

- Posetting

- Minor birth trauma

- Superficial

infections

- Minor

malformations

- Jaundice

- All cases not

categorized as

Emergency/Priority

Emergency signs

Priority signs Non-urgent

signs Classify Initiate

Emergency

treatment

Assess and act

rapidly

Assess and

act rapidly

Act

Triage of a sick newborn or at-

risk newborn who presents at

SNCU

Reference standard: ME.11.1





10. Assessment and treatment of newborns displaying emergency

signs

ASSESS FOR EMERGENCY SIGNS

(In all cases)

TREAT EMEREGNCY SIGNS

TEMPERATURE Cold to touch (Abdomen) Rewarm hypothermic babies

Rapidly re-warm if there is sever

hypothermia(<320C) upto 350C and

then gradual re-warming

Make sure young infant is warm

IF + ve

AIRWAY &

BREATHING

Not breathing or gasping or

Central synopsis or

Severe respiratory distress

- Respiratory rate 70/min

- Severe lower in-chest

drawing

- Apnoeic spells

- Grunting

- Unable to feed

ANY SIGN

+ ve Manage airway

Provide tactile stimulation if apnoeic

If still apnoeic or gasping – provide PPV

Give oxygen

Make sure neonate is warm

Capillary refill longer than 3

seconds and

Weak and fast pulse (>160)

Convulsions

CIRCULATION

CONVULSIONS

IF + ve

IF CONVULSING

Give oxygen

Insert IV line and give 20ml/kg normal

saline over 30 min

Proceed immediately to full assessment

and treatment


Manage airway

Check and correct hypoglycemia

Give anticonvulsant


Reference standard: ME.G4.2





11. Neonatal transportation and referral from unit


1. Criteria for referral

2. Referral of Patients

If the baby requires further care or any surgical intervention that

cannot be provided at the hospital then the patient shall be referred to

a higher centre for specialist care.

Doctor,

Staff nurse

Referral slip

Ambulance shall be provided by the hospital for quick transportation

of patients.

Nursing staff ,

ambulance driver

Nil

An advance telephonic communication with the referral centre shall

be done to ensure the required service is available and intimate the

staff of the higher centre about the referral.

Staff Nurse List of contact details

of ambulance

The staff nurse shall document the referral details and coordinate for

the referral process.

Staff Nurse Refer In-Out register

The baby along with the referral slip and case sheet shall be referred

to the higher centre.

Staff Nurse Referral slip

The nursing staff shall also contact the referral centre and follow up

about the condition of the patient post referral.

Staff Nurse Refer In-Out register

Reference standard - ME G4.2





12. Requisition for diagnostics, collection & transfer of samples and

receiving of reports


1. Treating doctor shall prescribe the investigations in the requisition

form/doctor’s note and counter sign the same with name, date and

time.

Doctor Investigation requisition

form/doctor’s note

2. For laboratory test, the sample shall be collected by Nursing staff

following aseptic procedure. The sample shall be transported to

the lab by the ward boy/aaya by the use of transportation boxes.

The samples shall be labelled with the patient name, ID and test

name.

Nursing staff Sample dispatch register

3. For emergency test requisitions the labels shall be marked with

EM. and lab staff shall be intimated over the phone too.

Nursing staff Sample dispatch register

4. After all tests are done, reports shall be received from the

concerned diagnostic area as per the turnaround time for test.

Nursing staff Test Report

5. The reports received should be discussed with the doctor during

his/her rounds. In case of any critical results the doctor shall be

immediately intimated through phone or by a messenger

Nursing staff Test Report






13. Thermoregulation of newborns


1. Prevention of hypothermia

Baby must be kept warm at all times , the following measures

should be followed for maintaining the warm chain

- Ensuring warm transportation during receiving at SNCU

- Warm resuscitation

- Adequate temperature maintenance inside the SNCU

- Ensuring timely Breast feeding

- Appropriate clothing and bedding

Skin-to skin contact with mother when required

Nursing staff Nil

2. Assessment of temperature and grading of hypothermia

Normally axillary temperature : 36.5 - 37.50C

Cold stress : 36.4 - 36.00 C

Moderate hypothermia : 35.9 - 320C

Severe hypothermia : < 320C

The warm and pink feet of the baby indicate that the baby is in

thermal comfort, but when the feet are cold and abdomen warm, it

indicates that the baby is in cold stress. In hypothermia, both feet

and abdomen are cold to touch.

Nursing staff Infant case sheet

3. Management of hypothermia

A hypothermic baby has to be re-warmed as quickly as possible

Set radiant warmer at 37- 380 C

Once baby’s temperature reaches 340C the re-warming process

should be slowed down.

Continue re-warming till temperature reaches normal range.

Monitor every 15-30 minutes

Monitor B.P, heart –rate, temperature and glucose

In addition

- Take measure to reduce heat loss

- Start IV 10% dextrose

- Give inj Vit K 1 mg I/M to term neonates & 0.5 mg I/M to

preterm






- Provide oxygen

4. Fever

- Fever (temp > 37.50C) can be a sign of infection, In all febrile

neonates, a diligent search for possible infection should be

made.

- In summer, Hyperthermia may occur due to raised

environmental temperature. For treating the same, move the

baby into colder environment.

- When the temperature is 37.50C- 39

) C, undress and expose

the neonate to room temperature.

- If the temperature is above 390

C, the neonate should be

undressed and sponged with tepid water at approximately 350C

until the temperature is below 380C.

- Monitor the temperature every hour.


Reference standard – ME G4.2





14. Nursing care


1. Correct Identification of patient

The correct identification of the baby shall be ensured at all point

of care and especially before initiating any invasive procedure.

Nursing staff Nil

Identification tag enlisting name of mother, and id no shall be

placed near newborn feet.

Nursing staff Sure tag

2. Timely and accurate nursing care

Treatment charts shall be maintained and updated. Drugs given

shall be documented in case sheet. The drug dosage given

should Co-relate it with drugs, time and doses prescribed.


3. Ensuring accuracy of verbal/telephonic orders

Verbal or telephone orders shall be accepted only on emergency

when it is impossible or impractical for the physician to write

them.

Nursing

staff , doctor

verbal order register,

Infant case sheet

Abbreviations should not be used when an order is given or

received.

Nursing

staff , doctor

verbal order register

Read back the order to the physician including the patient’s

name, treatment order/drug name and spelling of the drug to

avoid an error due to sound alike drugs, Dosage, pronouncing it

in single digits (e.g. 15 mg should be read as one five), route,

frequency (e.g. three times daily, not TID).

Nursing

staff


Document the order immediately including the date, time, and

physician’s name. Receiver’s name and signature.

Nursing

staff


Ensure the order is countersigned by the same doctor within 24

hours of communication of the verbal order.

Nursing

staff , doctor

verbal order register,

Infant case sheet

4. Nursing Hand-over

The nursing staff shall follow handing over formalities after every

shift. A Nursing hand-over register shall be maintained for the

same.

Nursing staff Nursing hand-over

register

During change of each shift, patient handover shall be given; A

practice of giving bedside patient handover shall be carried out.


register





All details of baby’s condition, treatment given and care to be

given next shall be explained to the next nursing staff on-duty.


register

All details explained shall be documented in the nursing hand-

over register and signature of the nursing staff giving and taking

handover shall be documented in the register.


register

Reference standard - ME .E 4





15. Safe Drug Administration


1. Drug orders should be in capital letters, with dose and frequency of

administration mentioned. Error prone medical abbreviations should be

avoided.

Nursing staff Drug chart

2. Following parameters shall be verified before administration of drugs by

the person administering the drug

Written medication order (For verbal order refer the document ‘written

orders for medications’

General appearance (physical incompatibility) of the medicine for

administration (for e.g. melting, clumping etc.)

Patient identification

Dosage of medication

Route of administration

Time of administration

Nursing staff Drug chart, Nursing notes

3. All the medications administered in In-patients shall be documented in

drug order sheet and nurses chart


4. In case of any adverse reactions, the treating doctor shall be notified as

soon as possible and details of the event shall be documented in the

incident reporting form.


5. Any high risk medication shall be administered by/under the supervision

of a senior Nursing staff only.


6. Close monitoring of the patient after the drug administration shall be

carried out.


7. Safety of high alert drugs

- High alert drugs available in department shall be identified and a list

displayed near the medication tray.

- Electrolytes like Potassium chloride, Opioids, Neuro muscular

blocking agent, Anti thrombolytic agent, insulin, warfarin, Heparin,

Adrenergic agonist etc. as applicable.

- The list displayed should enlist name of high alert drugs available in

department, value for maximum doses as per age and prescribed

for.

- A system of independent double check of drugs should be followed

before administration.

Nursing staff List of high alert drugs

Reference standard - ME E.7.1





16. Fluid Management


1. Babies requiring IV fluid therapy

- Neonates with lethargy and refusal to feed

- Moderate to severe breathing difficulty

- Babies with shock

- Babies with severe asphyxia

Abdominal distension with bilious or blood stained vomiting


2. Choice of fluids

Give 10% dextrose for the initial 48 hours of life

After the age of 48 hrs if the baby is passing urine 5-6 times a day,

use commercially available IV fluid, such as IsolyteP.

If the premixed solution is not available or baby requires higher GIR

(Glucose Infusion Rate).

- Add normal saline (NS) 20ml/kg body weight (which

contains 3 meq of Na/kg) to required volume of 10%

Dextrose. Add 1ml KCl/100ml of prepared fluid.

- To calculate the necessary fluid volume, determine the

volume of fluid required for day of life. Provide this as

20ml/kg of NS and the remaining as 10% dextrose.


3. Administration of IV fluid

Use of micro drip infusion set which has a micro dropper (where 1ml

= 60 micro drops)

In this device, number of drops per minute is equal to ml of fluid per

hour e.g. If a baby needs 6 mL/hr provide 6 microdrops/minute

Before infusing Iv fluid check

- The expiry date of the fluid

- The seal of the infusion bottle

Calculate the rate of administration, and ensure that the micro

dropper delivers the fluid at the required rate.

Change the IV infusion set and fluid bag every 24 hours; even if the

bag still contains IV fluids (this can be a major source of infection).


4. Volume of fluids

Fluid requirement of neonates (ml/per kg body weight)

Day of life Birth weight >1500g Birth weight <1500g

1 60 80

2 75 95






3 90 110

4 105 125

5 120 140

6 135 150

7 150 150

5. Monitoring of baby receiving IV fluid

- Inspect the infusion site every hour

- Look for redness and swelling around the insertion site of the

canula, which indicates that the canula is not in the vein and fluid is

leaking into the subcutaneous tissues.

- If redness or swelling is seen at anytime, stop the infusion, remove

the canula, and establish a new IV line in a different vein.

- Check the volume of fluid infused and compare to the prescribed

volume, record all findings.

- Measure blood glucose every nursing shift i.e.6-8 hours.

- If the blood glucose is less than 45mg/dl, treat for low blood glucose

- If the blood glucose is more than 150 mg/dl on two consecutive

readings, change to 5% dextrose solution and measure blood

glucose in three hours.

- Weigh the baby daily, if the daily weight loss is more than 5%

increase volume of fluid by 10ml/kg body weight for one day

- If there is no weight loss or weight gain in the initial 3 days of life, do

not give the daily increment, keep fluid rate same as previous

- In case of excessive weight gain (3-5%) decrease fluid intake by 15-

20 ml/kg/day.

- Check the urine output, normally a bay passes urine 5-6 times every

day.







17. Enteral feeding


1. Allow the baby to begin breastfeeding as soon as the baby’s

condition improves.


2. If the baby cannot be breastfeed, expressed breast milk shall be

given using an alternative feeding method


3. If the baby tolerates the feed and there are no problems, continue to

increase the volume of feed by 20-30nl/kg/day, while decreasing the

volume of IV fluid to maintain the total daily fluid volume according to

the baby’s daily requirement.


4. Feed the baby every two hours, adjusting the volume at each

feeding accordingly.


5. Discontinue the infusion of IV fluid when the baby is receiving more

than two-thirds of the daily fluid volume by mouth and has no

abdominal distension or vomiting.


6. Encourage the mother to initiate breastfeeding as soon as possible. Nursing staff Infant case sheet






18. Neonatal Resuscitation


1. - Transfer the baby to a warm clean, flat and dry surface.

- Provide warmth

- Position the baby

- Clear the airway

- Stimulate and reposition

For detailed procedure refer GoI’s work protocol for newborn

resuscitation.

Staff Nurse GoI’s work protocol for newborn resuscitation

2. Key to successful resuscitation Anticipation

Preparation

Call for help

Document /record

Be Fast

Be Gentle

Provide warmth

Maintain Hygiene

Staff Nurse GoI’s work protocol for newborn resuscitation






19. Maintenance of Infrastructure of SNCU


1. SNCU shall have the following minimal infrastructure

- Waiting area

- Sitting area for patient relative

- Separate inborn & out born units

- Nursing station with receiving and examination room

- Ancillary areas like washing area, dirty & clean utiliy rooms, staff

room, staff and visitor changing area and breastfeeding room

Management, SNCU

In-charge

2. Safety of infrastructure

2.a. Seismic Safety

The SNCU shall ensure the seismic safety of the infrastructure.

Non structural components shall be properly secured.

SNCU In-charge, Nil

Fixtures and furniture like cupboards, cabinets, and heavy equipments, hanging objects shall be properly fastened and secured.

SNCU In-charge Nil

2.b. Safety of electrical establishment

SNCU shall not have temporary connections and loose hanging

wires

SNCU In-charge Nil

Periodical check / test of all electrical installation by electrical

Engineer/ maintenance staff shall be done once a week

SNCU In-charge &

maintenance staff

Maintenance

checklist

ICU shall have a dedicated earthling pit system available SNCU In-charge Nil

Wall mounted digital display shall be available in ICU to show earth

to neutral voltage

SNCU In-charge Nil

Quality output of voltage stabilizer will be displayed in each stabilizer

as per manufacturer guideline

SNCU In-charge Nil

Power boards shall be marked as per phase to which it belongs SNCU In-charge Nil

Floors of the ICU shall be non slippery and even and daily cleaning

done

SNCU In-charge &

housekeeping -Incharge

Nil

Windows/ ventilators if any shall be intact and sealed SNCU In-charge Nil

2.c. Fire safety

The I.C.U shall have a fire exit to permit safe escape to its occupant

at time of fire.

Management Nil





Fire exits shall be clearly visible and routes to reach exit clearly

marked.

Management Nil

Smoke and heat detectors and fire extinguishers will be placed at

strategic locations in I.C.U for ensuring fire safety.

Management & SNCU

Incharge

Nil

3. Maintenance

The Incharge of the SNCU shall ensure the SNCU is adequately

maintained.

SNCU Incharge Nil

The in-charge shall check that there is no seepage, cracks, chipping

of plaster, window panes, doors and other fixtures are intact.

SNCU Incharge Nil

No condemned/Junk material in the SNCU SNCU Incharge Nil

For any infrastructural damage or problems like breakage, seepage

etc the maintenance staff & PWD shall be informed for repair

SNCU Incharge Nil

Reference standard - ME D4.1





20. Maintaining, updating of patients’ clinical records, their storage

and retrieval


1. Maintaining and updating of records

All the assessments, re-assessment, investigations, , treatment

and medication details shall be recorded and updated.

Nursing staff Associated forms and

formats

Standard forms and formats like treatment charts, surgery notes,

investigation chart, medicine register, nursing handover register,

referral register, transfer in-out register etc shall be maintained

Nursing staff Associated forms and formats

All records maintained shall be legible and complete in terms with

name and signature of staff making entry along with date and

time of entry.

Nursing staff Associated forms and formats

All registers/records shall be identified and numbered. Nursing staff Associated forms and

formats

2. Storage of records

All medical records of the patient shall be complete & legible with

proper name & signature of the author with date & time.


The patient information shall only be shared amongst the care

providers. While on use the files should be stored in nursing

station under the custody of the ward nursing staff.


On patient discharge the file shall be checked for completion and

sent to MRD for storage. Only copy of the discharge summary

shall be handed over to the patient during his discharge.


3. Retrieval of records

Access to clinical records of patient is allowed to entitled

personnel only on request. Whenever the clinical record of a

follow up patient is sought after by the treating doctor, he/she

shall fill in a record requisition register at MRD for availing the

same.

Nursing staff Record requisition

register

Reference Standard: ME.E8





21. Discharge from S.N.C.U to home


1. Discharge planning involves the following activities:

- Development of a care plan for post discharge care.

- Arranging for the provision of services, including

patient/family education and referrals.

- The Nurse in charge as well as the duty doctor shall be

responsible for coordinating the discharge with other team

members.

Treating Doctor Infant case sheet ,

investigation results,

nurses notes etc.

2. The following criteria shall be met by baby for discharge

- Baby is able to maintain temperature without radiant warmer

- Baby is hemodynamically stable (normal CFT, strong

peripheral pulses)

- Baby accepting breast feeds well

- Baby has documented weight gain for 3 consecutive days

and the weight is more than 1.5 kg

- Primary illness has resolved

- In addition to the above, mother should be confident of

taking care of the baby at home.

Treating Doctor Infant case sheet ,


nurses notes etc.

3. The Discharge process shall be planned in consultation with the

family members.

Treating Doctor,

Nursing staff

Infant case sheet ,


nurses notes etc.

4. Discharge planning shall be initiated on the basis of assessment

of baby’s condition.

Treating Doctor Doctor’s notes

5. Assessment of the baby shall be made for being ‘medically

stable’ and fit for discharge. This may include assessment of

functional, medical, medication, and nutritional needs.

Treating Doctor Patient vital sheets,


nurses notes etc

6. The Treating doctor shall write the discharge orders in the case

paper to initiate the necessary formalities for discharge.

Treating Doctor Doctor’s note

7. A Discharge Summary shall be prepared and signed by the

treating doctor or doctor on duty (in case of non availability of

treating doctor) and given to the parents/family members.

Treating Doctor/

Medical officer on

duty

Discharge Summary





8. A copy of discharge summary shall be attached with IP case

paper

Nursing staff Patient case sheet

9. Details of the discharge shall be entered in the discharge register Nursing staff Discharge register

10. The discharge summary shall contain the following information

- Details of the patient including Hospital IP Number

- Date of admission and date of discharge

- Name of the doctor in charge of the case

- Patient history

- Reason for admission.

- Significant findings.

- Diagnosis

- Investigation results.

- Details of any procedure performed.

- Medication.

- Other treatment given.

- Course in the hospital

- Follow up

a. Advice.

b. Medication

- Instructions regarding when and how to obtain urgent care

Management Discharge summary

form

11. During discharge, the parents should be counselled on

Medication intake, care at home, diet & nutrition, any medical

precautions & infection control measures and identifying

symptoms requiring immediate medical care.

Nursing staff Patient discharge

checklist

Reference Standard: ME.9.1, ME.9.2, ME.9.3, ME.9.4





22. Equipment Management


Calibration of Equipments

1. All the measuring equipments/ instrument shall be

calibrated.

SNCU –Incharge Nil

2. An ISO certified calibration agency shall be identified to

calibrate the equipments/instruments.


3. Calibration labels/stickers shall be placed on the

equipment denoting the date of calibration and indicating

the status of calibration/ verification when recalibration is

due.

SNCU –Incharge Equipment register

4. All calibration certificates shall be maintained by the

Incharge or centrally stored by the Store-Incharge of the

hospital.

SNCU –Incharge Calibration certificate

5. The ward shall maintain an equipment register to

document details of equipment and calibration status.


6. It shall be the duty of the Incharge to ensure updation of

calibration for all equipments as per their schedule.


General Maintenance

7. Up to date manufacturer’s instructions for operation and

maintenance of equipments shall be kept in the

department so that the same can be readily available to

staff when required.

SNCU –Incharge Manufacturer’s instruction

8. Defective/Out of order equipments shall be labelled and

stored appropriately away from traffic area, until it has

been repaired

SNCU –Incharge

9. Daily dusting/ dry wiping of equipments shall be done by

housekeeping staff. The laboratory technician shall do a

daily check on the functioning of equipments every

morning before commencement of testing procedure.


10. An equipment register shall be maintained to document SNCU –Incharge Equipment register





details of equipment - name, hospital code, and date of

installation, name of manufacturer, maintained in A

house/maintained by external agency or manufacturer,

Warranty Period, under AMC/CMC.

Preventive and Breakdown Maintenance

Preventive Maintenance

11. All equipments shall be covered under AMC/CMC

including Preventive maintenance.


12. The lab-Incharge shall maintain an updated record on

AMC & Preventive maintenance in equipment register this

should include details like :

o Frequency of Preventive Maintenance/Calibration

- As per manufacturer guidelines

- Presently being followed

o Preventive Maintenance/Calibration Done On

o Preventive Maintenance/Calibration Due On

o Expenditure with cost and details

o Remarks with Functional Status


13. Preventive maintenance shall be carried out as per

Maintenance Schedule for each individual equipment

based on manufacturer’s recommendations.


14. The following shall be checked during a preventive

maintenance-

Physical condition of the equipment/ facility

lubrication, calibration, cleaning or replacing parts that

are expected to wear or which have a finite life

Maintenance report verification

Maintenance / Service report shall be obtained from

service agency and after verification marked as O.K. /Not

O.K.

SNCU –Incharge Equipment Service Report

Breakdown Maintenance

15. Faulty or defective equipment shall not be used regardless

of how minor is the problem and must be reported in the

first instance to the in-house maintenance engineer






/outside agency hired for maintenance as soon as

possible and seen that the problem is attended to as soon

as possible.

16. A label of “out of order” shall be attached to the equipment

and information regarding breakdown shall be passed to

all staff including any shift changes.


17. On restoration of the equipment, the Equipment

Breakdown Record should be updated. This indicates that

the breakdown/maintenance is performed of the

equipment.

The “out of order” sticker shall be removed after the

restoration of the equipment.


18. All the breakdowns occurring in the department should be

maintained in the equipment register and include the

following

Breakdown Date and Time

Breakdown Details (Technical fault or other reasons)

Date and Time of Rectification

Total Time Taken (Rectification Time – Breakdown

Time)

Rectification Details with expenditure including cost (if

any)

Remarks with functional status

Reasons for delay if any


Reference Standard: ME G4.2





23. Storage and Inventory management of drugs and consumables


Inventory Management

1. All drugs and consumables to be used shall be stored under the

supervision of ward Incharge in cupboards at ward store

room/nursing station.

SNCU -Incharge,

Nursing staff

Stock register

2. The stock stored shall be kept in original packages/labelled containers

on labelled racks.

SNCU -Incharge,

Nursing staff

Stock register

3. Stock level shall be daily checked and updated in a stock register. The

expiry date for each batch of drugs shall also be mentioned in the

register.

Ward-Incharge,

Nursing staff

Stock register

4. A system of timely forecasting and indenting of drugs and

consumables shall be practiced .The ward Incharge shall ensure there

is a buffer stock available for emergency use before putting an indent

for new stock.

Ward-Incharge Stock register

5. A crash cart for storage of emergency drugs equipment and

consumables shall be maintained and a crash cart checklist shall be

used for daily (in very shift) stock checking and updation of the same.

Ward-Incharge,

Nursing staff

Crash cart

checklist

Storage of drugs and consumables for daily use

6. All drugs and consumables required for daily use shall be kept neatly

arranged in a medicine trolley.

Nursing staff Nil

7. The all drug and consumable containers shall be labelled. Nursing staff Nil

8. A medicine trolley register shall be maintained to record details of

usage.

Nursing staff Medicine trolley

register

Reference Standard: ME D.2.1, ME D.2.5

24. Purchase of external services & supplies

Refer SOP in pharmacy & store manual





25. Infection control practices


1. Linen Management

For linen management refer SOP Auxiliary services Linen & Laundry

6.3.1,6.3.2,6.3.3

Nursing staff SOP Auxiliary

services

2. Hand Hygiene

- Availability of wash basin with running water, soap, clean

towel/tissue paper/hand dryer shall be ensured at the casualty.

- Poster depicting steps of hand washing shall be displayed near all

wash basins.

- All staff involved in patient care shall be trained on hand hygiene

practices.

- The Infection control nurse shall monitor for adherence to hand

hygiene practices.

- Alcohol based Hand rubs shall also be made available .

- Mothers shall be educated to practice hand washing with soap.

Nursing staff Hand hygiene

monitoring

checklist

3. Standard practices and materials for antisepsis

- Antiseptic solutions shall be made available at all patient care

points.

- Proper cleaning of procedure site with antisepsis like before giving

IM/IV injection, drawing blood, putting Intravenous lines.

Nursing staff Nil

4. Use of PPE

- The staff should always adhere to the use of PPE like gloves,

uniform. Apron, mask, shoe cover/sterile slipper & caps.

- No reuse of disposable gloves, masks, caps and aprons shall be

practiced.

- Compliance to correct method of wearing and removing the gloves

should be practiced

Nursing staff Nil

5. General cleaning

- Wet mop floor using detergent and standard

disinfectant/0.5%chlorine solution.

- Clean all furniture and lights using warm water, detergent and

Housekeeping

staff

Housekeeping

checklist





disinfectant/0.5% chlorine solution every morning.

- Clean the toilets and corridor daily with detergent water and

disinfectant.

- Prepare cleaning solutions daily or as needed, and replace with

fresh solution frequently.

- Cleaning equipments like broom shall not be used in patient care

areas.

- Three bucket system for mopping should be used.

- Unidirectional mopping from inside out should be practiced.

- Any cleaning equipment leading to dispersion of dust particles in air

should be avoided.

Terminal cleaning

- Use vacuum cleaner to clean the AC Vent and ducts if available,

once in a month.

- Wet-dust horizontal surfaces by moistening a cloth with a small

amount of a recommended hospital detergent/disinfectant.

- Avoid dusting methods that disperse dust (e.g., feather-dusting).

Housekeeping

staff

Housekeeping

checklist

6. Waste Management

The following colour - coding system shall be used in waste

management segregation.

Blue Bag:

Syringes

Tubings

Saline bottles

Puncture Proof containers: White

Broken glass articles

Medicine vials

Needles (to be disposed only after burning)

Scalpels

Metal articles, like forceps to be disposed.

Yellow Bag:

Blood stained bandages, gauze, cotton, tissues, and gloves

Housekeeping

staff

Nil





Infectious wastes

Black Bag:

Paper

Plastic & other general waste

8. Microbiological surveillance

As an infection control measure to check the sterility of the environment

and surfaces in S.N.C.U, swabs shall be collected from patient care

surfaces,utilities,floor,instruments & A.C vent to be sent for

microbiological culture surveillance .

Infection control

nurse/

SNCU- Incharge

Culture

sensitivity report

9. Water testing

Once in a month overhead water tank cleaning and water testing shall

be done to check sterility of water.

Infection control

nurse/

SNCU-Incharge

Water testing

report

10. Processing of equipments and instruments

- Procedure surface like baby basiinets, warmers, phototherapy units,

laryngoscope, oxygen hood and other instruments used shall be

wiped with 5% chlorine solution.

- Instruments like ambubag, suction canula, Surgical Instruments

shall be decontaminated by Soaking in 0.5% Chlorine Solution/

Wiping with 0.5% Clorine Solution or 70% Alcohol as applicable.

- Contact time for decontamination shall be maintained to 10 minutes.

- The instruments should be cleaned after decontamination with

detergent and running water.

- Cleaned instruments shall be sent to TSSU/CSSD for autoclaving

and sterilization.

Infection control

nurse/

SNCU -Incharge

11. Use of standard disinfectants

- Standard disinfectants like chorine solution, sodium hypochlorite

solution, phenyl , formaldehyde/gluteraldehyde should be used

Infection control

nurse/

FP OT-Incharge

12. Restricted entry

- Taking into consideration infection control measures and prevention

of overcrowding only one attendant at a time shall be allowed to

meet the patient.

Incharge, nursing

staff

Nil





- Visitors shall be allowed entry only during visiting hours as per the

visiting policy

- Keeping in purview the infection control practices the attendant shall

have to change into sterile gowns, mask & slippers before entering

into the patient zone

- Hand washing shall be advocated before and after visiting the ICU

for the visitors.






26. Prevention of Child Abduction


Restricted Entry in SNCU

1. The SNCU shall at all times ensure limited entry inside SNCU, i.e. only

identified SNCU staff shall be available at SNCU. The staff should

always wear their Id tag. No outsiders shall be allowed. In any

exceptional case if required, visitors are permitted entry only on

approval of Incharge/duty doctor and shall have to be accompanied by

a SNCU staff during the visit.

SNCU –Incharge,

Duty doctor

Staff duty roaster

Visitor register

2. The baby’s family members shall be allowed entry inside the SNCU

during visiting hours only.

SNCU –Incharge,

nursing staff

Visitor register

3. Aside from the visiting hours, only the baby’s mother can be allowed to

meet baby for feeding.


4. Family members shall be allowed to visit the baby only when

accompanied by any one of the parent or if identified by the parents as

their family member. However entry of only one family member at a

time shall be allowed inside SNCU.

SNCU –Incharge Visitor register

Correct identification

Baby identification at labour room/OT

5. Correct identification of the newborn shall be initiated immediately

after birth at labour room/OT.

Labour room/OT

nursing staff

Labour room/OT

register , Patient

case sheet

6. Immediately after Baby birth details shall be entered in the case sheet,

(Recording date and Time of Birth, Weight of baby). An identification

tag shall be placed on baby’s ankle. Mother shall be shown the baby

and family members intimated about the baby’s birth and shown the

baby.

Labour room /OT

nursing staff

Labour room/OT

register, Patient

case sheet

Baby identification at SNCU

7. The SNCU staff should verify the details on the baby tag and that on

the mother’s case sheet during receiving the baby.

SNCU nursing

staff

SNCU register

8. The nursing staff at SNCU shall ensure the baby tag is intact at all times, if any damage the same shall be immediately replaced with a new one by verifying details with the baby’s case sheet.

SNCU nursing

staff

SNCU register,

infant case sheet






27. Quality assurance


1. Department Incharge shall be vigilant about the key characteristics.

Based on the observation, every month Department-Incharge shall

record his / her remark against the key characteristics as to whether

the key characteristics meet the acceptance norms or not. Specific

comments for the key characteristics may also be written.

Incharge Nil

2. All reports shall be verified and signed by the radiologist/sonologist

and then dispatched.

Incharge Reports

3. These quality indicators relating to productivity, efficiency, safety,

service etc shall be maintained by the technicians and reviewed by the

Incharge:

- Inborn admission rate - Proportion of admissions which are out born - Bed Occupancy Rate - Proportion of female babies admitted - LAMA rate for female babies - Proportion of BPL Patients - Proportion of very low birth weight babies - Down time Critical Equipments - Bed Turnover Rate - Referral Rate - Survival rate - No. of drug stock out in SNCU - Average waiting time for initial assessment of newborn - Proportion of newborn deaths among inborn - Proportion of newborn deaths among outborn - Case Fatality Rates - Proportion of asphyxiated newborn babies admitted out of

deliveries conducted at facility - Average length of stay - No of Adverse events reported - % of environmental swab culture reported positive - Average length of stay

- Antibiotic use rate

Incharge Indicator register

4. Internal Audits

o Audits shall be conducted as per pre scheduled audit plan and

organized and carried out by designated internal auditors.

o While planning Audit it should be ensured that the internal

auditors do not audit their own activities.

Auditor & Auditee Internal Audit

report

CAPA report





o A Quality management system procedure for Internal Audit

shall include the following

Selection of Internal Auditors.

Criteria for Internal Auditors.

Audit Planning and methodologies.

Audit recording, non-conformance and summary report

preparation.

o Where audit findings indicate deficiencies or the opportunity for

improvement corrective or preventive action is promptly taken,

this is documented and carried out within an agreed upon time.

Note: Refer Internal Audit procedure in Lab Manual for details

Reference Standard: ME G4.2





Annexure:

I. Housekeeping protocol









II. Clinical protcols

Documents

Sick Newborn Care Unit