December 22, 2012

MH0052 [Hospital Organisation Operations & Planning] Set1 Q6

Q6. If you are called be the infrastructural consultant for setting up a NICU in a 5 year old multispecialty hospital, what are the planning considerations of NICU that you would present to the Managing Board?

Neo-natal ICU

Childbirth is an occasion for joy. However, on some occasions this joy is tainted with concern about the health of the newborn. The threat of serious illness or death of a newborn places serious responsibilities on health care providers to respond appropriately with effective therapy. Disorders and diseases in the neonatal period pose a greater risk to life and health than which occur during any other period of postnatal life. This burden of illness is measured not only in terms of neonatal mortality and morbidity but also in terms of disability and handicap among survivors and in terms of high economic costs for acute and continuing medical care, special education and other supportive services. The recognition of the need for provision of intensive care to the newborn, led to the birth of the concept of Neonatal Intensive Care Units/ Special Care Neonatal Units/ Intensive Care Nurseries.

The idea of having a special intensive care unit for newborns represented a developmental milestone in the field of neonatology. The establishment of the first premature infant center at Sara Morris Hospital in Chicago in 1920s marked a new era of concern for the sick newborn. Dr. Louis Gluck established the first newborn center at Grace New Haven Hospital at New Haven, Connecticut in 1960. At the turn of the 20th century, a French physician named Pierre Constant Budin discovered that incubator care was associated with improved survival of premature infants. Martin Couney is credited with advances in incubator design as well as premature feeding techniques. The use of ventilators in infants with respiratory distress began in 1961. Much of what is now known as intensive care, the use of intravascular catheters; blood gas monitoring; arterial pressures; heart rate; temperature monitoring and a myriad of other facets of care were developed as a result of research, after the success of assisted ventilation.

Newborn intensive care is defined as care for medically unstable or critically ill newborns requiring constant nursing, complicated surgical procedures, continual respiratory support, or other intensive interventions. 

Neonatal Intensive Care Unit (NICU) is a special unit of the hospital set up to provide extraordinary surveillance and support of vital functions and definitive therapy for infants having acute or potentially reversible life threatening impairment of a vital system. 

Classification of Neo-natal Intensive Care Unit 
There is a lack of consistent definition of levels of care in neonatal care units. The advantages of having uniform definition would include the ability to compare outcomes, utilization, and costs among institutions; develop NICU standards; inform the public of NICU capabilities; minimize the perceived need for businesses to develop NICU standards.

The proposed levels of care are:
Level 1. Newborn Nursery
- Can perform neonatal resuscitation at every delivery
- Care for healthy term newborns and for infants 35-37 weeks gestation who remain physiologically stable.
- Other newborns would be stabilized and transported to a unit with the appropriate higher level of care.

Level 2a. Special Care Nursery 
- Can provide Level 1 care plus can care for infants > 32 weeks gestation and > 1500 grams birth weight.
- Have physiologic immaturity (apnea, poor feeding, temperature instability), but not requiring mechanical ventilation or Continuous Positive Airway Pressure (CPAP)
- Have medical problems that are anticipated to resolve rapidly and not require urgent sub-specialty care
- Are convalescing after intensive care.

Level 2b. Special Care Nursery
- Can provide Level 2a care, and 
- Can provide mechanical ventilation for brief duration (<24 hours) or CPAP.

Level 3a. Neonatal Intensive Care Unit.
Can care for infants > 28 weeks gestation and > 1000 grams birth weight.
Can provide sustained life support with conventional mechanical ventilation.
May perform minor surgical procedures, such as placement of central venous catheters or repair of inguinal hernias.

Level 3b. Neonatal Intensive Care Unit
Can provide comprehensive care for infants < 28 weeks gestation and 
< 1000 grams birth weight.
Can provide advanced respiratory support such as high-frequency ventilation or inhaled nitric oxide.
Can perform major surgical procedures on neonates (excluding ECMO and repair of complex congenital heart defects requiring cardiopulmonary bypass). 
Requires prompt and on-site access to a full range of paediatric sub-specialty consultants, as well as paediatric surgeons and anesthetist.
Requires availability of advanced imaging support on an urgent basis, including CT, MRI, and echocardiography.

Level 3c. Neonatal Intensive Care Unit.
Has the capabilities of a level 3b NICU 
Can provide ECMO and surgical repair of complex congenital heart defects requiring cardiopulmonary bypass. 

The rationale for this three-tier approach is:
A reasonable geographic coverage is ensured.
A high throughput for the level III units enables the maintenance of clinical skills.
High levels of bed occupancy in level III units permits efficient use of expensive resources.
In our country, 80-85% of all babies need only primary or level I care, 
15-20% needs level II care and only 5% need level III care. Level II and level III care are woefully inadequate, in both the government and non-government sectors and level I care, though available, is of very poor quality. If newborn care has to improve, all three levels of care have to be well developed and a good referral system should be in place.

Neonatal Intensive Care Unit Environment:
The environment within the NICU is completely new to the preterm infant, who until the time of birth, has been protected within an intra-uterine environment. Increasing amount of research shows a relationship between the NICU environment and the physiological and neurological development of the infants. An environmentally sensitive unit can enhance growth, shorten the duration of mechanical ventilation, lead to early oral feeding, reduce incidence of complications, shorten hospital stay and reduce hospital costs.

Giving birth to a premature or sick infant is not usually the familys expectation, and the intimidating environment of the NICU can provide reassurance to the shock and sense of loss that families feel. Therefore in planning and designing a neonatal unit, the goal should be to provide an environment which is conducive to family-centered developmental care of sick newborns, decreasing stress for the family and the healthcare providers, improving short and long-term outcomes.

Physical Facilities and Space Requirements:
Core physical requirements include, continuous supply of running water, uninterrupted power supply, central supply of medical gases and suction facilities.

Geographic access:
Level III neonatal intensive care services should be available within 2 hours by road, under normal traffic conditions for 90 % population in a district.

Location within the hospital:
The NICU should be in a distinct area within the health care facility, with controlled access. Movement to other services should not pass through this unit. It should be located close to the labour room and operation theatre, to facilitate prompt transfer of sick and high-risk infants. It is suggested that units receiving babies from other hospitals should have ready access to the hospitals transport receiving area or hospitals ambulance entrance. NICU should be easily accessible from emergency room, laboratories and radiology suite.

NICU Unit configuration:
Hospitals proposing a level III NICU should propose a unit of at least 15 beds and should have 15 or more level II NICU beds. According to Putsep concept, a 28 bassinet unit might have 3 intensive care spaces (10.7%), 20 intermediate care spaces (71.4 %) and 5 transitional care spaces (17.9 %) for short-term observation. The unit should be in a square area so that open, unencumbered space is available. A split-unit, on either side of the hospital corridor should be avoided for ease of mobility and prevention of infections. 

The NICU design may range from an open ward to an individual cubicle or room configuration. Open unit configuration offers maximum flexibility for patients, staff, equipment movement and better patient view; individual cubicles design gives less noise and patient movement and reduced cross-infection rate.

Size of the unit 
The size of the unit planned, depends on the number of deliveries in the hospital per year; whether it is a referral maternity center or babies born in other hospitals are admitted. At present the recommendation is that 1.5-2 intensive care beds and 2 special care beds should be provided for every 1000 births (can be modified according to the workload of the unit). Extra provision has to be made for babies in other hospitals. 

Infant care space
Each infant care space should contain a minimum of 11.2 square meters, excluding sinks and aisles. Intensive care beds may require 14 square meters per infant. An estimated 50 square feet of floor space is needed per patient bed, for intermediate care. 

There may be an aisle adjacent to each infant care space with a minimum width of 1.2 meters in multiple bedrooms and 2.4 meters in case of single patient rooms or fixed cubicle partitions. This is to facilitate easy movement of all equipment, which may be brought to the babys bedside. 

In multiple bedrooms, there should be a minimum of 2.4 meters between infant care beds. This is because the provision of less than 8 feet between beds limits the ability of a family to stay at a babys bedside without interfering with staff activities. Each room should have a minimum of one door of width 48 inches, for X-ray equipment.

Electrical, Gas supply and Mechanical Needs:
Mechanical requirements at each infant care bed, such as electrical and gas outlets, must be organized to ensure safety, easy access and maintenance. There should be a minimum of 20 simultaneously accessible electrical outlets for intensive care infants positioned to maximize access and flexibility. Standard duplex electrical outlets are not suitable, as each outlet may not be simultaneously accessible for oversized equipment plugs. The outlets must be installed at a height of three feet. There should be a mix of AC power supply and UPS for all electrical outlets. At least fifty percent of the outlets should be connected to an uninterrupted power supply. All life support and monitoring equipment should be connected to UPS. In addition, the area needs a special outlet to power portable X-ray machines. The use of adaptors and extension boards should be discouraged. The electrical equipment must be checked, at least once a month for leakage of power supply and grounding adequacy. Voltage supply to the NICU must be stabilized with a voltage stabilizer.

Minimum number of accessible gas outlets recommended is: Air; Oxygen; Vacuum; 3 out lets per infant bed. In case of intermediate care infants, two oxygen outlets, two compressed air outlets and two suction outlets should be provided for each bed. A flow rate of 20 liters per minute, at a pressure of 3.5 to 4.0 bars is satisfactory for oxygen supply. Each vacuum point should allow free airflow of 40 liters per minute at vacuum pressure of 500 mm of mercury. The suction outlets should be equipped with a unit alarm to signal loss of vacuum. Installations should be at a height of 3 feet.

Airborne Infection Isolation Room(s)
It is desirable to have an isolation room for every 6-10 beds. In most of the cases, this is ideally situated within the NICU; but, in some circumstances, utilization of a similar isolation room elsewhere in the hospital (example, in a pediatric ICU) would be suitable. Infants with open sepsis should be cared for by different nursing and resident staff. A work-area for hand washing, gowning and storage of clean and soiled materials, may be provided near the entrance to the room. The room must have a minimum of 150 square feet of clean space, excluding the entry work area. Single and multiple bed configurations are appropriate based on use. Ventilation systems for isolation room(s) should be engineered to have negative air pressure with 100 % air exhaust. There should be a minimum ventilation of 12 air-changes per hour in the isolation room and 10 air-changes per hour in the work-area. 

The walls, ceiling, floor must be sealed tightly so that air does not infiltrate the environment from outside or from other air spaces. An emergency communication system should be provided within the room and remote monitoring of an isolated infant should be considered. When not used for isolation, these rooms may be utilized for care of non-infectious infants and other clinical purposes.

Procedure room
A procedure room may be incorporated into the NICU but is preferably sectioned off to reduce patient traffic and to allow better control of techniques such as exchange transfusion, umbilical vessel catheterization. This room should be a minimum of 120 square feet in size, equipped with a hand washing section, oxygen outlet and vacuum outlet and about 
4 electrical switches. The ventilation of the room should provide a minimum of 6 air-changes per hour.

The entrance to the neonatal unit should be planned as a lobby with double doors; an airlock, which allows some control of the airflow within the unit. Corridors in NICU should be at least 1.8 meter wide.

Scrub area
At least 150 square feet of space at the main entrance, must be assigned as a scrub area with provision for hand-washing, hanging coats, stethoscopes and for leaving footwear. It should have hands-free sinks large enough to contain splashing. Blade handles at the sink should be minimum six inches long. Space must be provided, for donning of protective clothing and a bench to facilitate wearing of over-boots. About ten air-changes per hour are recommended for this area.

General support space
Storage areas A three level storage system is desirable. The first storage area should be the central supply department of the hospital. The second storage zone is the clean utility area for the storage of supplies frequently used in the care of newborns. It should be adjacent to or within the infant care area. There should be at least 0.22 cubic meters of space for each infant, for secondary storage of syringes, needles, intravenous infusion sets and sterile trays. 

A medical equipment store should be provided; 1.7 square meters of floor space for equipment storage per infant in intermediate care and 2.8 square meters per infant in intensive care. Easily accessible electrical outlets are desirable in this area for recharging equipment. All supply and medical equipment rooms should have convenient access to at least one sink. A minimum of 4 air-changes per hour are recommended for the clean utility and equipment storage rooms.

The third storage zone is for items frequently used at the newborns bedside. There should be shelf space available for placing respirators, monitors, infusion pumps and feeding pumps. Bedside cabinet storage should be 0.45 cubic meters per infant in intermediate care area and 0.67 cubic meters per infant in intensive care area. 

Family entry and reception area
The NICU should have a clearly identified entrance and reception area for families. Families shall have immediate and direct contact with staff when they arrive at this entrance and reception area. The design of this area should be impressive. Facilitating contacts with staff will also enhance security for infants in the NICU. This area should have storage facilities with a lock for families personal belongings.

Floor surfaces
Floor surfaces should be such that they can be easily cleaned, should minimize growth of microorganisms and should be highly durable to withstand frequent cleaning and heavy traffic. Floors should be slip resistant. Consideration should also be given to the density of materials used and acoustical properties. Materials suitable to these criteria are resilient sheet flooring (medical grade) and carpeting with an impermeable backing, chemically welded seams with antimicrobial and antistatic properties.

Walls and surfaces
As with floors, the ease of cleaning, durability and acoustical properties of wall surfaces must be considered. Acceptable materials include scrub paint, vinyl wall covering, vinyl covered sound absorbing panels and sheet materials that have fused joint systems. Walls may also be made of washable glazed tiles. There should be protection at points where contact with movable equipment is likely to occur. Walls must be painted white or slightly off-white to permit prompt detection of jaundice and cyanosis. 

Glossy finish create glare that is harmful to newborn eyes; matt finish in dark colors absorb too much light, increasing the need for artificial light sources. Doors should be provided with automatic door closers.

Ceiling should be cleaned easily and should prohibit the passage of particles from the cavity above the ceiling into the clinical environment. It should either be a monolithic ceiling or have ceiling tiles that are clipped down and washable. It should have a noise reduction coefficient (NRC) of at least 0.903. Standard hospital tiles have a NRC of 0.6519.

Ambient temperature and ventilation:
The NICU should be designed to provide an air temperature of 22-26oC and a relative humidity of 30-60 %. This is best achieved by air-conditioning with small package units rather than centralized air-conditioning. Portable radiant heater and infrared lamp can be used to provide additional heat to an individual infant.

Effective ventilation is essential to reduce nosocomial infections. The most satisfactory ventilation is achieved with laminar airflow. In a vertical type system, the air flows from above downwards and it is recommended for use in NICU. A constant positive air pressure should be maintained, to prevent contaminated air entry from the corridors into the NICU; the vertical flow of filtered air maintains positive pressure of 15 mmHg. Millipore filters (0.5m) or high efficiency particulate aggregate (HEPA) filter may be used (to filter out bacteria). Air delivered to the NICU should be filtered with at least 90 % efficiency. A minimum of 6 air changes per hour is required, with a minimum of 2 air changes from outside air. The ventilation pattern should prevent particulate matter from moving freely in the space; intake and exhaust outlets should be situated as to minimize drafts near infant beds. Fresh air intake should be located at least 25 feet (7.6 meters) from the exhaust outlets of ventilating systems, combustion equipment stacks, plumbing vents, or areas that may collect vehicular exhaust or other noxious fumes.

Noise abatement
The noise level in a NICU affects the infants, staff and families. Excessive noise may lead to hearing loss, physiological and behavioral disturbances like sleep disturbances, crying, hypoxia, tachycardia and increased intracranial pressure. Equipment should be selected with a noise criterion (NC) rating of 40 or less. However, once the unit is in operation, much of the transient sound in a nursery is under the control of personnel. Hence, the personnel should devise simple strategies to reduce noise in the nursery (no tapping / writing on incubator hoods, careful closing of incubator doors, soft shoes, etc.). 

Communication system
The NICU should be provided with an intercom system. A direct external telephone is mandatory for parents to inquire about their infants.

Infant security
The NICU should be designed to minimize the risk of infant abduction. Care should be taken to limit the number of exits and entrances to the unit. Control station / clerical area should be located in close proximity and direct view of the entrance to the newborn area, so that all visitors will have to pass in front of the nursing station to enter the unit. In addition, for security reasons, parent-infant room(s) should be situated within an area of controlled public access.

Ancillary services 
Distinct support space should be provided for respiratory therapy, laboratory, pharmacy, radiology and other ancillary services when these activities are routinely performed in the unit. Satellite facilities may be required to provide these services. Hospitals providing Level III neonatal intensive care services should provide at the site, X-ray and clinical laboratory services capable of performing micro studies. This requirement is essential in order to carry out investigations on blood samples in small quantity from preterm babies in whom, frequent biochemical investigations are needed, collecting venous blood is difficult and hazardous. Anesthetist should be available. There should also be access to ECG, EEG and blood bank services. 

Equipment requirements 
During the last decade, a large number of devices for diagnostic and therapeutic application for the high-risk newborn infants have evolved. The fundamental needs of the unit are availability of adequate space, presence of sufficient number of trained nurses and continuous in-service training. It should be ensured that company supplying the equipment undertakes to train all staff in the unit. 

Maintenance of existing equipments in proper working condition is more important than acquiring new ones. After expiry of warranty period, yearly maintenance contract must be made for preventive maintenance and emergency repairs. Essential spares must be purchased and kept in stock. Photocopies of working and service manuals should be available in the NICU. Equipments must be charged when not in use. The in-charge nurse should maintain a register with equipment name, company address and contact number, date of installation, warranty period, problems and repairs pertaining to all the equipments, along with record keeping of equipment quality assurance. There should be a budget for purchasing, maintaining, replacing and upgrading of equipments for neonatal care. 

Equipments needed may be classified into following groups:
Supportive systems: incubator, open care systems, transport incubator, infusion pump, phototherapy unit, ventilator, nebulizer.
Monitors: The monitors with facility to display, heart rate, respiratory rate, blood pressure, oxygen saturation
Laboratory and imaging equipment

The various equipments in the neonatal unit are listed below
Emergency tray( containing Ambu bag and mask, infant laryngoscope, oral airways and tracheal tubes of different sizes, connectors for tracheal tubes, sterile suction catheters, oral mucus suction, emergency drugs like epinephrine 1:10,000, naloxone hydrochloride, sodium bicarbonate, IV fluids and pediatric stethoscope); Bag and mask resuscitator; Suction equipment; Catheters, syringes and needles; Weighing machine; Bassinets; Incubators; Perspex heat shield; Oxygen head box / Oxygen hood; Oxygen analyzer/ambient oxygen monitor; Heart rate monitor; Respiratory rate and apnea monitor; Thermometers; Blood pressure monitor; Invasive blood gas monitoring; Non-invasive blood gas monitoring; Pulse-oximeter; Transcutaneous blood gas monitor; Capnography or End Tidal CO2 (EtCO2) monitor; Multi-channel vital sign monitor; Ventilator; CPAP (Continuous Positive Airway Pressure) apparatus; Infusion pump; Phototherapy unit; Transcutaneous bilirubinometer; Portable X-ray and ultrasound machine; Laboratory equipment; Feeding equipment; extra corporeal membrane oxygenator (ECMO)

Discharge policy in a neonatal unit
The discharge policy statement is put forward by the first formal statement of the American Academy of Pediatrics on the issue of hospital discharge of the high-risk neonate. It has been developed, on the basis of scientifically derived information. 

Four categories of high risk neonate are identified: 
Preterm infant
Infant who requires technological support
Infant primarily at risk because of family issues
Infant whose irreversible condition will result in an early death.

The unique home care issues for each are reviewed within a common framework. Recommendations are given for four areas of readiness for hospital discharge: infant, home care planning, family and home environment, community and health care system. The need for individualized planning and physician judgment is emphasized.

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Quality Management (11) OM0016 Set1 (8) OM0016 Set2 (3) OM0017 - Advanced Production and Planning Control (11) OM0017 Set1 (3) OM0017 Set2 (8) OM0018 - Technology Management (9) OM0018 Set1 (7) OM0018 Set2 (2) PM0010 - Introduction to Project Management (26) PM0010 Set1 (14) PM0010 Set2 (12) PM0011 - Project Planning and Scheduling (25) PM0011 Set1 (14) PM0011 Set2 (11) PM0012 - Project Financing and Budgeting (26) PM0012 Set1 (14) PM0012 Set2 (12) PM0013 - Managing Human Resources in Projects (26) PM0013 Set1 (13) PM0013 Set2 (14) PM0014 (1) PM0015 - Quantitative Methods in Project Management (14) PM0015 Set1 (8) PM0015 Set2 (6) PM0016 - Project Risk Management (14) PM0016 Set1 (7) PM0016 Set2 (7) PM0017 - Project Quality Management (14) PM0017 Set1 (7) PM0017 Set2 (7) PM0018 - Contracts Management in Projects (14) PM0018 Set1 (7) PM0018 Set2 (7) Project (1) QM0010 - Foundations of Quality Management (4) QM0010 Set1 (2) QM0010 Set2 (2) QM0011 - Principles and Philosophies of Quality Management (4) QM0011 Set1 (2) QM0011 Set2 (2) QM0012 - Statistical Process Control and Process Capability (4) QM0012 Set1 (2) QM0012 Set2 (2) QM0013 - Quality Management Tools (4) QM0013 Set1 (2) QM0013 Set2 (2) QM0014 (1) QM0015 - ISO/QS 9000 Elements (2) QM0015 Set1 (1) QM0015 Set2 (1) QM0016 - Managing Quality in the Organization (2) QM0016 Set1 (1) QM0016 Set2 (1) QM0017 - Quality Management System (2) QM0017 Set1 (1) QM0017 Set2 (1) QM0018 - Quality Development Methods (2) QM0018 Set1 (1) QM0018 Set2 (1) SC0001 - Supply Chain Management (4) SC0001 Set1 (2) SC0001 Set2 (2) SC0002 - Outsourcing (4) SC0002 Set1 (2) SC0002 Set2 (2) SC0003 - Food Supply Chain Management (4) SC0003 Set1 (2) SC0003 Set2 (2) SC0004 - Inventory Management (4) SC0004 Set1 (2) SC0004 Set2 (2) SC0006 - Global Logistics and Supply Chain Management (2) SC0006 Set1 (1) SC0006 Set2 (1) SC0007 - Category Management in Purchasing (2) SC0007 Set1 (1) SC0007 Set2 (1) SC0008 - Purchasing and Contracting for Projects (2) SC0008 Set1 (1) SC0008 Set2 (1) SC0009 - Supply Chain Cost Management (2) SC0009 Set1 (1) SC0009 Set2 (1) SMU BBA Subjects (1) SMU MBA/PGDBA Subjects (1)

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