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NORMSANDSTANDARDSFORESSENTIALNEONATALCARE

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

EssentialNewbornCare:Normsandstandards

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TABLEOFCONTENTS

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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INTRODUCTIONTORECOMMENDEDSTANDARDS

Astandardisastatementaboutadesiredandacceptablelevelofcare.ThestandardsforessentialnewborncarearederivedfromSouthAfricanNationalandProvincialstandards,globalstandardsandtheexperienceofseniorcliniciansworkinginneonatalcareinSouthAfricaformanydecades.

Webelievethattheyformagoodbaselinefromwhichtoworkandwouldliketorecommendthatyouusethesestandardsasastartingpointfortheprovisionofessentialnewborncare.Yourdistrictorprovincemaywanttoadjustthestandardstoyourparticularservice.

1.ESSENTIALNEWBORNCARE

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

1.1ESSENTIALMATERNALCARE

Adiscussiononnewborncarecannotleaveoutmaternalcare.Ifthemotherisnotwellandhasnotaccessedessentialmaternalservices,thebabymaybeaffectedintheneonatalperiodandlaterinlife.Essentialmaternalcareincludes

• AttendanceatAntenatalClinicfromthefirsttrimesterofpregnancyandforatleast5goodqualityantenatalvisits

• Identificationofhighriskmaternalandneonatalsituationswithaccesstoappropriatecare• RecognitionofHIVpositivewomen,assessmentandcareofthemotherincludingantiretroviral

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

Diseaseinthebaby• Monitoringandcareinlabourtopreventfoetalhypoxiaandneonatalasphyxia• EarlyreferralofthemothertolevelIIorIIIcentresifadifficultmaternalorneonatalcourseis

anticipated

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1.2ESSENTIALNEWBORNCARESERVICES

1.2.1NEONATALRESUSCITATIONATBIRTH

Mostbabieswillnotneedhelptobreathe,but6–9%doandcanbehelpedtobreathewithin1minuteofbirth.

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

1.2.2ROUTINECARE

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

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

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

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

Routinecareofthenewbornisprovidedbythestaffthatprovidesthematernalcaretothemotheratprimaryhealthcarefacilitiesorhospitals.Ifrisksorillnessareidentified,thebabyisreferredtothepaediatricandneonatalservice.

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1.2.3INPATIENTCAREOFSICKANDSMALLNEWBORNS

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

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

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

STANDARDINPATIENTNEONATALCARE

Standardinpatientcareisthecareofababywhohasbeenidentifiedassickorsmallandreferredtotheneonatalunitforspecialcare.Itincludesthecareofbabieswhoarelessthan2kilogramsatbirth,thosethathaveasphyxia,infectionsoracongenitalabnormality.StandardcareincludesKangarooMotherCare.

KANGAROOMOTHERCARE(KMC)

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

NEONATALHIGHCARE

NeonatalHighcareisthecareofsickerbabiesandincludesthosewhorequirecardiorespiratorymonitoring,oxygentherapyofmorethan40%,NasalprongCPAP,thosewhohaverecurrentapnoeaandconvulsions,orwhomayneedanexchangetransfusion.

INTENSIVEANDHIGHLYSPECIALIZEDCARE

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

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TABLE1. LEVELSOFNEWBORNCAREATFACILITIES

ROUTINECARE(RC)

STANDARDINPATIENTCARE(SIC)

HIGHCARE(HC)

INTENSIVEANDHIGHLYSPECIALISEDCARE(NICU)

Category of baby requiring

care

• Most Full term infants • Most low birth weight

infants > 2kg

Babies with • Low Apgars • Congenital

abnormalities • LBW 1500 – 1999g • Gestational age 32

– 36 wks • Birth weight

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

Babies with • LBW < 1500g • Gestational age <

32wks • Encephalopathy • Meconium

aspiration • Septicaemia /

meningitis • Recurrent apnoea • Moderate and

severe respiratory distress

• Convulsions • Severe jaundice • Simple neonatal

surgical problems

Babies with • A need for assisted

ventilation • Complex Surgical

problems • Persistent

hypoglycaemia • Cardiovascular

problems • Multisystem

problems • Problems requiring

specialist intervention e.g. ambiguous genitalia

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

resuscitation ∗ Initiation of Breast

feeding at birth and further support

∗ Maintenance of warmth ∗ Emergency care before

referral ∗ Vitamin K, eye care,

immunisation, cord care, measurement,

∗ Examination of newborn ∗ Care to baby whose

mother has HIV, TB or syphilis

∗ Skin to skin care and KMC

IN addition to routine care • Maintenance of

thermo-neutral environment.

• Oxygen administration and monitoring

• Monitoring glucose and correcting abnormalities

• IV Fluid administration

• Tube feeding • Bilirubin monitoring

and Phototherapy • Drug administration

In addition to routine and standard care • Cardio-respiratory

monitoring • Oxygen therapy

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

transfusion

In addition to other neonatal care • IPPV, and advanced

techniques for respiratory support

• Total parenteral Nutrition

• Arterial catheterization

• Therapeutic cooling • Advanced

neurological monitoring

• Ultrasound and Echo-cardiography

• Sophisticated diagnostic investigation

• Sub-specialist consultation

• Neonatal surgical intervention

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2.HOSPITALFACILITIES:NEONATALUNITANDMATERNITY

2.1POSITIONOFTHENEONATALUNIT

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

2.2SIZEOFTHENEONATALUNIT

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

Thecurrentshortageofregionalhospitalnewbornfacilitiesandstaff,anddifficultyintransportingbabiesmeanthatdistricthospitalsinruralprovinces,needtoplanforsomehighcareservices.

Beforeplanningthenumberofbedsandconfigurationofthebedsaskyourselfanumberofquestions

ü Howmanydeliveriesinthehospital,clinicsandathome?ü Isthenumberofdeliveriesexpectedtoincreaseordecreaseovertheyears?ü Istherearegionalhospitalserviceinthedistricttoreferhighcarepatientsorshouldwebe

planningforsomehighcarebeds?

Example:Ifadistricthospitaldelivers3000babiesinayearthehospitalwillrequire(12inpatientneonatalbeds.

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

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

AhospitalthissizewouldusuallybeaLevelIIhospital

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

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

Regionalservicesarebestplannedas36,48and60bedunits.A48and60bedunitwouldalsoprovidesomeintensivecareservice,butnotneonatalsurgeryandhighlyspecializedcare,asthespecialistsrequiredforthisserviceareusuallyonlyatthetertiaryhospital.

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

InadistricthospitalapproximatelyathirdofbedswillbeHC,athirdSICandathirdKMC.

EXAMPLESOFDISTRIBUTIONOFBEDS

DISTRICTHOSPITALS

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

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


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



(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.

15�

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

17�

2013



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



AdvancedResuscitationtrolley

1perhealthcentre1per6labourwardbeds

1perunit 1per6HC/ICbeds 1per6HC/ICbeds

Neopuff

1perICUunit 1perICUunit

Laryngoscope,straightmillerbladesize00,0,sparebatteriesandbulb

1perhealthcentre1per6labourwardbeds




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

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



Introducer 1peradvancedresuscitationtrolley




Mcgillsforceps 1peradvancedresuscitationtrolley




Suctioncatheters Size103ateachresuscitaire

Size103ateachresuscitaire



18�



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


Ventilatorcircuits 4circuits/machineavailableforreuse



Neonatalsaturationprobes

2permachineavailableforreuse




Neonatalincubatorprobes

6perincubator 6perincubator 6perincubator

Infusionsets* 5x60dpmset 5x60dpmorCorrectsetforinfusioncontroller

5x60dpmorCorrectsetforinfusioncontroller

5x60dpmorCorrectsetforinfusioncontroller

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

5inlabourward,andpostnatalward

Infusioncontrollersarepreferable



Consumablesforbilicheck

Ivfluids 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

19�

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.

21�

2013

FURTHERDIPLOMATRAINING

VariousuniversitiesofferdiplomatraininginNeonatalIntensivecareorPaediatrics.Regionalhospitalsshouldarrangestudyleavefornursestoundergothistraining.DoctorsareencouragedtostudyforthediplomainChildHealth.

ATTENDANCEATCONFERENCESANDUPDATES

Avarietyofconferencesareheldeveryyear,thatwillencouragelearning.Theseinclude

1. Perinatalprioritiesconference2. Biannualpaediatricconference3. Paediatricrefreshercourse4. Variousupdates

Guidelines,trainingmaterialsandresourcesareattached.xxx

MENTORINGANDSUPPORTIVESUPERVISION

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

4.5NURSINGNORMSFORMATERNALCARE

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

MATERNITYSTAFFING

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

Theneonatalunitrequiresaseparatestaffing,unlessthehospitalisverysmallandtherearefewerthan1000deliveriesayear.

22�

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

ENROLLEDNURSESANDENROLLEDNURSINGASSSISTANTS10–12enrollednursesper100deliveriespermontharerequiredonthestaffestablishment.Thisallowsfor1tobeworkinginthelabourwardand1tobeworkinginthepostnatalwardtoprovide24-hourcover.

DOCTORSTheremustbeadesignateddoctorresponsibleforpatientcareinthematernitywardashis/herfirstresponsibility.Doctorsdoingtheircommunityserviceyeardonotneedtobe“rotated”.Theyaremedicalofficersasanyother.

STAFFINGFORPHCCLINCIS

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

23�

2013

5.INFECTIONPREVENTIONANDCONTROLINTHENEONATALUNIT

Newbornsareathighriskofacquiringinfection,thisisduetotheirimmatureimmunesystem.Theyareusuallyprotectedfrominfectionthroughexclusivebreastfeeding,andlimitedcontactwithotherindividuals.

Theneonatalunitoranyfacilitypredisposesthebabytoinfection.Inthisenvironmentthebabyishandledbymanypeople,exposedtodifferentsurfacesandprobes,andtheintegrityoftheirskinormucousmembranemaybebrokenbyprocedures.Mostorganismsaretransmittedbyhandsontothebabyorequipmentintheenvironment.

ThisguideappliestoalllevelsbutisintendedmainlyforlevelIandIIfacilitieswithunitsfrom6–36beds.LargerlevelIIandLevelIIIfacilitiesmayrequireadditionalinfectioncontrolmeasurestobeputinplace.

HAND WASHING IS THE SINGLE MOST IMPORTANT WAY TO PREVENTINFECTION.

• Stricthandwashing,beforetouchingababy

• Adequatesoap,waterandpapertowels

• Preventovercrowding

• Feedbabiesbreastmilkonly

• Beobsessivewithhousekeepingandasepsis

5.1FACILTIES:SPACE,STAFFING,POLICIES

5.1.1SPACE

Infectionisreducedifthereisadequatespacefornursing,andonlyafewpeoplewithcleanhandstouchthebaby.Adherencetothenormsandstandardsforstaffandfacilitiesthatareoutlinedwillpreventinfection.Thekeyfactorsthatpreventinfectionare

• Adequatespaceforeachincubatororbassinettesothatthereisspaceforthemother,themedicalstaffandtherequiredequipment

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

• Theunitisair-conditionedandthatthisiskeptbetween24and25degreesCelsius• Adequateventilationintheunit

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.

25�

2013

5.1.5ADMISSIONCRITERIA

Babiesareusuallybornwithoutinfectionsandaregraduallycolonisedbyorganismsfromtheirmothersandtheenvironment.Babieswhohavebeenhomemaybecolonisedbycommunity-acquiredorganismthatmaybelessproblematictotreatthanthosewithhospitalacquiredinfections.Thereisnojustificationtoexcludingbabieswhocomefromhomeorotherenvironmentsornursingtheminaseparatearea.

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

TheseincludebabieswithstaphylococcalskinsepsisandpossibleRSVinfection

Washyourhandsbeforeandaftertouchingababy

5.1.6VISITINGCRITERIA

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

5.1.7Clothing

Theroutineuseofgownsisofnoprovenvalue.Studieshaveshownthatroutineuseofgownsdoesnotreducecolonisationorinfectioninnewborns

Personnelshouldwearcomfortableshort-sleevedcleanclothesdaily,andmaychoosetowearauniformscrubdressorsuit.

Doctorsmustremovewhitecoatsastheyenter,asthesemaybecontaminatedfromotherareasinthehospital

Gownsareonlyusedforsterileprocedures,e.gexchangetransfusion.

Lodgermothersshouldwearcleanclotheseveryday.

5.2CLINCALPROCDURESFORINFECTIONCONTROL

5.2.1HANDWASHING

Washhandsforoneminuteonenteringtheneonatalunit

Washhandsfor30secondsordoanalcoholrinsebetweentouchingeachbaby.

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.

27�

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.

29�

2013

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.

30�

6.STANDARDCLINICALCARE

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

Standardclinicalguidelineshavebeendevelopedinordertofacilitatestandardcare.Hospitalsneedtoadoptthenationalstandardclinicalguidelines.Adjustmentstotheguidelinesmaybemadeintoprotocolstofacilitatelocalimplementationoftheguidelines.

Examplesofstandardclinicalguidelinesinclude

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

Theseguidelinesareattachedtothetoolkit,inhardcopyandontheCDROM

Tertiaryunitsdeveloptheirownstandardclinicalguidelines.Whilethesearenotforuseindistricthospitals,wehaveincludedelectronicversionsofsomeoftheseguidelinesforreference.

Supportfortheimplementationofstandardcareisimportant.Waystodothisinclude

• Clinicalsupportvisitsbyapaediatrician• Clinicalaudit• Clinicsupervision• Recordreviews• Mortalityaudits

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7.NEONATALTRANSFERS

Referralofpatientoccursin2directions:

Acriticallyillneonatereferredfromadistricttoatertiaryserviceeg:Neonatebornatadistricthospitalrequiringsurgeryforacongenitalabnormalityatatertiaryhospital.

AhighriskneonatebornatatertiaryhospitalreferredfromatertiaryserviceoncestabletoadistricthospitaltoreceiveKangaroomothercare.

Thedecisiontoreferapatientshouldbetelephonicallydiscussedbetweenthedoctorfromthereferringhospitaltothedoctoratthereceivinghospital.

Forcertaincriticallyillnewbornstransferandreferralmaynotbethebestformofmanagement.Thesenewbornsmightbeservedbetterbyprovidingcomfortorpalliativecareatthebirthingunit.Babiesbornattheextremeendofviabilityorwithcongenitalabnormalitiesincompatiblewithsurvivalaresomeexamples.

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

Thefollowingguidelinesaresuggestionstofacilitatethereferralandtransferofthecorrectpatienttothecorrectlevelofcare.Theymaynotbeapplicabletoeverydistrictandprovince,andlocalguidelinesforreferralarenecessary.ThereisinequitableaccesstostandardcarefornewbornsinSouthAfricaandequityacrossprovincesneedstobediscussed.

7.1FROMACLINICTOALEVEL1DISTRICTHOSPITAL

Indicationsforreferraltoadistricthospitalarethesameasforanybabyreferredtotheneonatalunitfrommaternityandincludethefollowing

• BabieswithApgarscoreslessthan8• Babieswithbirthweight<2kg• Babywithaprioritysignorcongenitalabnormality• Babywithariskfactorthatcannotbeadequatemanagedatclinicleve

7.2FROMALEVELITOALEVELIIHOSPITAL

SomeoftheindicationsforreferralfromLevelItoLevelIIcare.

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

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

92%orababyonCPAPishavingrecurrentapnoearequiringmaskventilation.

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• Babywithuncontrolledseizures• Hypoglycaemianotrespondingtotreatmentin1hour• Jaundicewithbilirubinlevelsindicatingimminentexchangetransfusion• Persistentvomiting• AsphyxiatedpatientsarenotusuallyconsideredbutsomeinfantswithaThompsonHIEscoreof10

–15,orSarnatgrade1–2maybenefitfromtherapeuticcoolingstartedwithin4hoursofbirth,ifthisserviceisavailable.

• DysmorphicbabiesneedtobeseenbyapaediatricianbutthisisnotareasonforurgenttransfertoalevelIIorlevelIIIhospital

7.3FROMLEVELIORIITOLEVELIIIHOSPITAL

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

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

Whenthebedcapacityatthereferralhospitalhasbeenreached,thereceivingdoctorwillneedtobeinvolvedtoidentifyanalternativebedattheappropriatelevelofcare.Ifnobedisavailablethepatientmayhavetostayatthereferringhospitaluntilsuchtimethatabedbecomesavailable.

7.3LIMITATIONOFCAREGUIDELINES

“Limitationofcare”isadecisiontonotofferactiveresuscitationorcontinuedventilation.Itmayincludethelimitationofescalationofcareorwithholdingofantibiotics,oxygenandmonitoring.

Thedecisiontolimitcareisbasedonacombinationoflimitedresourcesandexpectedlongtermoutcome.Theseguidelinesaresubjecttochangedependingonavailabilityifresourcesandfurtherinformationregardingtheprognosisoftheclinicalcondition.Itisdifficulttogiveabsoluteguidelinesbutitisimportanttorecognizewhentheofferedtherapyisfailingandthesituationisnowfutile.Itiscriticaltotreatthepatientsandtheirfamilieswiththeutmostrespectandempathyandtoaccommodatebaptismorotherreligiousorculturalceremonieswherepossible.

PreferablytwonameddoctorsshouldagreeonaDECISIONtolimitcareanditshouldbecondiseredinthefollowingscenarios

• ChronicIPPV>14daysandnotsteadilyimprovingintheabsenceofaknowntreatableconditionwithexpectedgoodlongtermoutcome

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

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

haemorrhage(IVH)orunilateralperiventricularleucomalacia(PVL)intheparietal/occipitalregions

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

• SevereHypoxicIschaemicEncephalopathy(HIE)ie:Sarnatgrade3orThompsonHIEscore15ormore.

• Prolongedprofoundhypoxia/acidosis/seizuresnotrespondingtotreatmentwithin6hours(andmetabolicdiseaseunlikely).

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8.NEONATALTRANSPORT

InSouthAfricacriticallyillneonatesarebornatalllevelsofcare.Wherethereiseffectivescreeningandreferralofhigh-riskmothersantenatallytoLevelllorlevellllservices,theseinfantshaveabetterchanceofsurvivalastheyaredeliveredwherethereisaspecializedneonatalunitstaffedbyspecialistpaediatricianorneonatologist.

Criticallyillneonateswhoarebornatadistrictfacilityhavetobetransferredtoasecondaryortertiarycentreandaredependantuponemergencytransferstoareferralhospital.Theneonataloutcomeisdirectlyrelatedtoefficientandrapidtransporttime,andthecarethattheyreceivebeforeandduringtransport.

Vehiclesforgroundtransportofneonatalpatientshavehistoricallybeengeneral-purposeambulances,withorwithoutatransportincubator.

Weneedtoworktowardsdedicatedneonatalambulanceservices,withvehiclesfittedwithspecializedneonatalequipmentandskilledneonataltrainedemergencymedicalpersonneltostaffthem.

Therearetwomaincomponentsinvolvedinthetransportofapatient.Theseare:

8.1THEREFERRALSERVICE

Thereferralsystemconsistsofthepersonnel,vehicles,andprotocolsfortransfer

8.1.1PERSONNELThereare

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

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

8.1.2MODEOFTRANSPORT

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

8.2CAREOFTHENEWBORNDURINGTRANSPORT

COMMUNICATION Thedoctorwhohasbeenlookingafterthebabyshouldmakearequestfortransferofasickbabytothereceivingdoctor.Thisshouldbeasearlyaspossiblebeforethebabydeteriorates.ThemostseniordoctorshouldmakethedecisionaboutreferralThereceivingdoctorwill

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

PRE-DEPARTURESTABILIZATION

Theconditionofthebabymustbestabilisedbeforetransportation.Thefollowingaspectsofcareareessentialforthebaby:

• Thebabymustbekeptwarm.• Ensurethatthebabyisgettingsufficientoxygen.Theoxygensaturationshouldbekeptbetween

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

specialinvestigations)mustbereadyforthetransportteamwhentheyarrive.

CAREOFTHENEONATEINTHETRANSPORTENVIRONMENT

PERSONNELNEEDED

Themostreasonableoptionistohaveasuitablyqualifiedparamedicaspartofthetransportteam.This,inSouthAfrica,ismostoftennotpossible.

Thealternativeistosendaqualifiednursewiththebaby.Thisusuallyresultsinthestaffingofthereferringhospitalbeingdepleted.Thenursealsoneedstobereturnedtoherhospital.Thisisafarfromidealsituation.

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EQUIPMENT

Theambulanceneedstohavebasicequipmentfortransportingnewborns.Thisconsistsof:

• Atransportincubatorwhichcanplugintothevehicle’selectricalsystem• Asourceofoxygen,usuallyacylinder,withameansofcontrollingtheflowandthepercentage

beingadministered.Theformerisusuallypresentonthecylindergaugehead,butthepercentageadministeredwillneedventuris,ifaheadboxisbeingused.

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

ontheway.

THERMALCONTROL

Thermoregulationisvitaltobothmorbidityandmortalityinthecriticallyillneonate.Waysofkeepingababywarmduringtransport

• Transportincubator:Thetemperatureofthebabymustbechecked½hourlyandtheincubatortemperatureadjustedaccordingtothebaby’stemperature.

• Usingapolythenebagor“sheet”.Thiscanbeusedevenifthebabyisinanincubator,asitreducestheheatlossfromthebaby.

• KeepingthebabyintheKMCposition.Unlessthereisaspecialreasonfornotbeingabletodothis,itisasafemethodofkeepingthebabywarmduringtransport.Itwillbeessentialtodothisifatransportincubatorisnotavailable.

• ThetemperatureofbabieswithHIEshouldbekeptbetween34–350Cforthedurationofthetransport.

VENTILATIONANDAIRWAYMANAGEMENT

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

Ifventilationisneededoranticipated,thebabywillneedtobeintubatedwithanendotrachealtube,beforethejourney,andatransportventilatorisrequiredwithpersonnelwhocansupportventilation.

MONITORINGDURINGTRANSPORT

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

ARRIVALATTHEREFERRALHOSPITAL

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

8.3QUALITYASSURANCE

Regularmeetingsneedtobeheldbetweentheneonatalserviceandthetransportservice,andguidelinesformonitoringqualityassuranceputinplace.

8.4THECASEFORANEONATALRETRIEVALTEAM(NRT)

Paramedics,nursesanddoctors,havetheroleofrapidlystabilizingcriticallyillnewbornpatientsforimmediatetransfer.Theservicesofaspecializedneonataltransportteamhasbeenshowntobeassociatedwithreductionsinhypothermiaandacidosis,aswellasreducedmortalityinlowbirthweightinfants.

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

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9.REFERENCES

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

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

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

EasternCapeHospitalDesignGuideVer2.1May2011

InfectionPreventionandControlinthenursery,Chapter24ofKZNHealthManual

GuidelineforNeonatalCare.June2008.DepartmentofHealth,RepublicofSouthAfrica

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

NewbornCareCharts:Managementofthesickandsmallnewbornsinhospital.2008.LimpopoInitiativeforNewbornCare

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

Servicestandardsforhospitalsprovidingneonatalcare.3rdedition2010.BritishAssociationofPerinatalMedicine.

ToolkitforSettingUpSpecialCareNewbornUnits,StabilisationUnitsandNewbornCareCorners,Unicef,India

Download - Chapter 2 Norms and Standards for Essential Newborn Care ...lincare.co.za/wp-content/uploads/2016/06/Chapter-2-Norms-and... · NORMS AND STANDARDS FOR ESSENTIAL NEONATAL ... The standards

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