Neonatal intensive care unit
A neonatal intensive care unit, an intensive care nursery, is an intensive care unit specializing in the care of ill or premature newborn infants. The NICU is divided into several areas, including a critical care area for babies who require close monitoring and intervention, an intermediate care area for infants who are stable but still require specialized care, and a step down unit where babies who are ready to leave the hospital can receive additional care before being discharged.
Neonatal refers to the first 28 days of life. Neonatal care, a.k.a. specialized nurseries or intensive care, has been around since the 1960s.
The first American newborn intensive care unit, designed by Louis Gluck, was opened in October 1960 at Yale New Haven Hospital.
An NICU is typically directed by one or more neonatologists and staffed by resident physicians, nurses, nurse practitioners, pharmacists, physician assistants, respiratory therapists, and dietitians. Many other ancillary disciplines and specialists are available at larger units.
The term neonatal comes from neo,, and natal,.
Roles and tasks
A neonatal nurse practitioner is a registered nurse who has been specially trained to help with the care of a newborn. A dietician helps ensure the baby gets enough nutrients for healthy growth. A respiratory therapist helps with managing oxygen and breathing machines. A physical or occupational therapist watches the baby's development.Nursing and neonatal populations
Healthcare institutions have varying entry-level requirements for neonatal nurses. Neonatal nurses are registered nurses, and therefore must have an Associate of Science in Nursing or Bachelor of Science in Nursing degree. Some countries or institutions may also require a midwifery qualification. Some institutions may accept newly graduated RNs having passed the NCLEX exam; others may require additional experience working in adult-health or medical/surgical nursing.Some countries offer postgraduate degrees in neonatal nursing, such as the Master of Science in Nursing and various doctorates. A nurse practitioner may be required to hold a postgraduate degree. The National Association of Neonatal Nurses recommends two years' experience working in a NICU before taking graduate classes.
As with any registered nurse, local licensing or certifying bodies, as well as employers, may set requirements for continuing education.
There are no mandated requirements to becoming an RN in an NICU, although neonatal nurses must have certification as a neonatal resuscitation provider. Some units prefer new graduates who do not have experience in other units, so they may be trained in the specialty exclusively, while others prefer nurses with more experience.
Intensive-care nurses undergo intensive didactic and clinical orientation in addition to their general nursing knowledge in order to provide highly specialized care for critical patients. Their competencies include the administration of high-risk medications, management of high-acuity patients requiring ventilator support, surgical care, resuscitation, advanced interventions such as extracorporeal membrane oxygenation or hypothermia therapy for neonatal encephalopathy procedures, as well as chronic-care management or lower acuity cares associated with premature infants such as feeding intolerance, phototherapy, or administering antibiotics. NICU RNs undergo annual skills tests and are subject to additional training to maintain contemporary practice.
History
The problem of premature and congenitally ill infants is not a new one. As early as the 17th and 18th centuries, there were scholarly papers published that attempted to share knowledge of interventions. It was not until 1922, however, that hospitals started grouping the newborn infants into one area, now called the neonatal intensive care unit.Before the Industrial Revolution, premature and ill infants were born and cared for at home and either lived or died without medical intervention. In the mid-nineteenth century, the infant incubator was first developed, based on the incubators used for chicken eggs. Stephane Tarnier is generally considered to be the father of the incubator, having developed it in 1880 to attempt to keep premature infants in a Paris maternity ward warm. Other methods had been used before, but this was the first closed model; in addition, he helped convince other physicians that the treatment helped premature infants. France became a forerunner in assisting premature infants, in part due to its concerns about a falling birth rate.
After Tarnier retired, Pierre Budin, followed in his footsteps, noting the limitations of infants in incubators and the importance of breastmilk and the mother's attachment to the child. Budin is known as the father of modern perinatology, and his seminal work The Nursling became the first major publication to deal with the care of the neonate. The incubator was improved in 1890 in Marseilles by Alexandre Lion, who founded in 1891 the Œuvre Maternelle des Couveuses d'Enfants in Nice and in January 1896 in Paris.
Another factor that contributed to the development of modern neonatology was Martin Couney and his permanent installment of premature babies in incubators at Coney Island. A more controversial figure, he studied under Budin and brought attention to premature babies and their plight through his display of infants as sideshow attractions at Coney Island and the World's Fair in New York and Chicago in 1933 and 1939, respectively. Infants had also previously been displayed in incubators at the 1897, 1898, 1901, and 1904 World Fairs.
Early years
Doctors took an increasing role in childbirth from the eighteenth century onward. However, the care of newborn babies, sick or well, remained largely in the hands of mothers and midwives. Some baby incubators, similar to those used for hatching chicks, were devised in the late nineteenth century. In the United States, these were shown at commercial exhibitions, complete with babies inside, until 1931. A. Robert Bauer, at Henry Ford Hospital in Detroit, Michigan, successfully combined oxygen, heat, humidity, ease of accessibility, and ease of nursing care in 1931. It was not until after the Second World War that special-care baby units were established in many hospitals. In Britain, early SCBUs opened in Birmingham and Bristol, the latter set up with only £100. At Southmead Hospital, Bristol, initial opposition from obstetricians lessened after quadruplets born there in 1948 were successfully cared for in the new unit.Incubators were expensive, so the whole room was often kept warm instead. Cross-infection between babies was greatly feared. Strict nursing routines involved staff wearing gowns and masks, constant hand-washing, and minimal handling of babies. Parents were sometimes allowed to watch through the windows of the unit. Much was learned about feeding—frequent, tiny feeds seemed best—and breathing. Oxygen was given freely until the end of the 1950s, when it was shown that the high concentrations reached inside incubators caused some babies to go blind. Monitoring conditions in the incubator, and the baby itself, was to become a major area of research.
The 1960s were a time of rapid medical advances, particularly in respiratory support, that were at last making the survival of premature newborn babies a reality. Very few babies born before thirty-two weeks survived and those who did often had neurological impairments. Herbert Barrie in London pioneered advances in resuscitation of the newborn. Barrie published his seminal paper on the subject in The Lancet in 1963. One of the concerns at this time was the worry that using high pressures of oxygen could be damaging to newborn lungs. Barrie developed an underwater safety valve in the oxygen circuit. The tubes were originally made of rubber, but these had the potential to irritate sensitive newborn tracheas: Barrie switched to plastic. This new endotracheal tube, based on Barrie's design, was known as the "St Thomas's tube". In 1964, pediatric radiologist William Northway – while conversing with neonatologist Philip Sunshine at Stanford University Medical Center – noted a consistent pattern of cystic changes in the lungs on the radiographs of premature babies. Northway found that all of the babies had received high concentrations of oxygen and mechanical ventilation, causing damage. His 1967 paper in which the term bronchopulmonary dysplasia was coined described the disease and comorbidities. This led to worldwide reductions in supplemental oxygen levels and ventilation pressure, improving the health outcomes of premature infants. The paper has been called "one of the most important, most cited, and influential articles in the history of neonatology".
Most early units had little equipment, providing only oxygen and warmth, and relied on careful nursing and observation. In later years, further research allowed technology to play a larger role in the decline of infant mortality. The development of pulmonary surfactant, which facilitates the oxygenation and ventilation of underdeveloped lungs, has been the most important development in neonatology to date.
Increasing technology
By the 1970s, NICUs were an established part of hospitals in the developed world. In Britain, some early units ran community programs, sending experienced nurses to help care for premature babies at home. But increasingly technological monitoring and therapy meant special care for babies became hospital-based. By the 1980s, over 90% of births took place in hospitals. The emergency dash from home to the NICU with the baby in a transport incubator had become a thing of the past, though transport incubators were still needed. Specialist equipment and expertise were not available at every hospital, and strong arguments were made for large, centralized NICUs. On the downside was the long traveling time for frail babies and parents. A 1979 study showed that 20% of babies in NICUs for up to a week were never visited by either parent. Centralised or not, by the 1980s few questioned the role of NICUs in saving babies. Around 80% of babies born weighing less than 1.5 kg now survived, compared to around 40% in the 1960s. From 1982, pediatricians in Britain could train and qualify in the sub-specialty of neonatal medicine.Not only careful nursing but also new techniques and instruments now played a major role. As in adult intensive-care units, the use of monitoring and life-support systems became routine. These needed special modification for small babies, whose bodies were tiny and often immature. Adult ventilators, for example, could damage babies' lungs and gentler techniques with smaller pressure changes were devised. The many tubes and sensors used for monitoring the baby's condition, blood sampling and artificial feeding made some babies scarcely visible beneath the technology. Furthermore, by 1975, over 18% of newborn babies in Britain were being admitted to NICUs. Some hospitals admitted all babies delivered by Caesarian section or under 2500 g in weight. The fact that these babies missed early close contact with their mothers was a growing concern. The 1980s saw questions being raised about the human and economic costs of too much technology, and admission policies gradually became more conservative.