Private room vs open bay for the NICU. Can always get a quote from a parent saying it is great but….? At what cost? Impact on staff? Is parent time in those NICUs greater now? Other alternatives?
Included in the post was an article discussing the benefits of such a design. Below I will look at the benefits and risks and conclude with an answer to his last question.
The NICUs of the 1970s through late 1990s have been described as “barn like” or “open concept” but in recent years the belief that single patient rooms (SPR) would offer greater benefit to infants led to the adoption of such a unit design across North America. The imagined benefits would be related to improved parent comfort, creating a desire for families to spend more time with their children. As we move to a “family centred” approach to care, a key goal of all units should be to make their families as comfortable and stress free as possible in order to have a positive experience.
Detractors meanwhile, speak of concern regarding isolation of such infants when families do not visit and moreover a risk that such infants deprived of sensory experience will have impaired development. Last year a paper was published that did not help quell such fears; Alterations in Brain Structure and Neurodevelopmental Outcome in Preterm Infants Hospitalized in Different Neonatal Intensive Care Unit Environments (full article in link). This study which compared infants cared for in SPR to an open unit (the hospital in this study had a mixture of both in their NICU) found a worrisome finding at 2 year follow-up in that the infants in SPR had lower scores on language and a trend towards lower motor scores as well. Additionally, partly explaining such findings may have been differences noted at term equivalent age in both the structure and activity of the children’s brains compared to those cared for in an open environment. We were starting construction on a new NICU at the time this paper was published and I can tell you the findings sent shockwaves through our hospital as many wondered whether this was the right decision.
Devil Is in The Details
Looking further into this study, the urban population bore little resemblance to our own. In our hospital all women are taught how to perform skin to skin care and the majority of our mothers spend a great deal of time with their infants. To see how successful have a look at our recent Kangaroo Care drive results! The families in this study however the average hours per week of parent visitation over the length of stay ranged from 1.8-104 hours with a mean of 19+/- 19 hours. The average number of days held per week over the length of stay was 0-6 days with a mean of 2.4 +/-1.5 days. The average number of days held skin-to-skin over the length of stay ranged from 0-4 days, with a mean of 0.7 +/- 0.9 days. In short they were hardly there.
Statistically significant results (all Ps ≤.05) showed that infants in the SPR NICU weighed more at discharge, had a greater rate of weight gain, required fewer medical procedures, had a lower gestational age at full enteral feed and less sepsis, showed better attention, less physiologic stress, less hypertonicity, less lethargy, and less pain.Nurses reported a more positive work environment and attitudes in the SPR NICU.
This study in fact demonstrated greater maternal involvement in a SPR with improvement in outcomes across the board. It would seem then that in a SPR environment, provided there is enough family visitation and involvement this model truly is superior to the open concept. Furthermore despite concerns by some nurses that the loss of line of sight to their patients will make for a more stressful working environment this does not seem to be the case.
What About Families Who Cannot or Simply Aren’t Visiting Frequently?
The reality is that there are many reasons for parents to be absent for long periods during their newborns stay. Having a home outside of the city with other children to care for, work obligations, or loss of custody and abandonment due to apprehension are just some of these reasons. In our hospital, at least 15-20% of all patients admitted are from outside Winnipeg. The evidence as I see it supports the move to a SPR but what do we do for those children who need more visitation? The solution is a cuddler program. In our new hospital we are grateful for the generosity of our Children’s Hospital Foundation who secured a donor to pay for a coordinator of such a program. The veteran parent who is leading this program ensures that no infant goes beyond a set period of time without feeling the touch or hearing the sound of a voice. Such a program is in fact already in place at our other tertiary hospital and was featured in a lovely article attached here. Taking all the information together that is out there I think that if we can provide the necessary stimulation from both touch and auditory stimuli as well we can provide these infants with the developmental needs that each of them requires.
The SPR is the right design in my mind for families with many benefits that spring forth in such an environment. This need not be a win-lose scenario for your hospital. Do not underestimate the power of a cuddler and don’t hesitate to seek support to initiate such a program. It could mean the difference from going from good to great!
Neonatology is a team sport if there ever was one. It can be very confusing though to families as they go along their journey. The descriptions below are not meant to be exhaustive and if you are functioning in one of these roles and would like be to add something to your description please chime in! I thought it would be helpful to have a primer of who’s who in the NICU and what do they do exactly? Bear in mind that depending on where you are in the world the person caring for your baby may be different based on staffing models but here is a quick primer to the most common medical staffing positions in Canada. In Neonatology we also tend to like using abbreviations a lot so where there is a common one used I have indicated that in parentheses next to the name.
Attending Neonatologist (NEO)
This is a doctor who has done special training in newborn intensive care. Like me, they will have gone through a residency first in Pediatrics and then done anywhere from 2-3 years of extra training specific to the care of sick newborns. The Neonatologist is commonly seen leading morning rounds and will be the one typically asked to speak with parents when there is something important to share. We may not always be seen front and centre but when not on rounds we are in continual communication with the other “front line medical staff” and stay on top of what is happening with all the babies on the clinical service. You will typically see us in the hospital during day time hours but for the sickest of patients we will come in from home when on call to provide expert guidance on care. Many Neonatologists will have been certified by a national organization such as the Royal College of Physicians and Surgeons of Canada. Not all will however as there are other pathways to taking on this role.
House Medical Officer (HMO)
HMOs are members of the team will have also done a Pediatrics residency. They will have done a Neoatology fellowship as well. These individuals typically will do a mixture of day and night call. You will get to know them over time as they are on the front line and will be seen day and night in the units.
A fellow has done a Pediatric residency and is now doing specialized training in NICU. In their first year they do an abundance of clinical work as they try and learn the core knowledge of the specialty and obtain expertise in all the common procedures needed in the field. As they move into their second and optional third year they take on additional responsibilities and typically will do a “junior attending” role on a few occasions. in this capacity they act as the Neonatologist and run the NICU. The Neonatologist who is on with them continues to be appraised of the patients in the unit but will not be always on rounds during these weeks. This graduated responsibility is part of the development of the Neonatal fellow.
Residents are training to become a Pediatrician. They do a mandatory number of rotations in NICU which varies depending on the province you are in. As residents they are learning and in many cases will not yet have mastered all the procedural skills in the profession such as intubation and putting in umbilical catheters but they are on their way to obtaining those skills. These are people though who have comprehensive training in all areas of Pediatrics and will be familiar with the ability of the wards to care for your infant if they are transferred potentially to a hospital ward.
Clinical Assistant (CA)
CAs as they are also know will typically not have had a full Pediatrics Residency but in most cases have come VERY close. They function in a capacity very similar to the HMO. Do not be fooled by the lack of a complete residency in the eyes of the local College of Physicians and Surgeons. Many of these individuals are exceptional and would be impossible to distinguish in performance from an HMO.
Nurse Practitioner (NP)
NPs or Neonatal (NNPs) are nurses who have gone through a very advanced program and function as part of the medical team. If you reside in Alberta, NNPs have been the dominant form of housestaff support in Neonatal units for many years. They are meticulous care providers who by virtue of their nursing background have a very holistic approach to care of infants. Their plans always factor in impacts on nursing and in many respects their care is similar to that provided by their MD counterparts. NNPs are capable of performing all the procedural skills as their MD counterparts and it has been a real pleasure to work with them over the years both in Alberta and Manitoba.
Nurse managers are responsible for the day to day operations of the NICU. They are also the person to which all of the nurses working in the NICU report. If you have concerns about your experience in the NICU they will eventually filter there way through to this person and sometimes the medical lead for Neonatology. This person can also be of great help sometimes when you don’t feel like you are getting the answers you need as they have a great birds eye view of the unit and are well versed in policies and accepted practices.
This position is many respects is the nursing equivalent of the Neonatologist. The Charge nurse will co-lead with the Neonatologist on rounds and is involved in bed management as well. The person in this position is aware of all events that occured overnight and often serves as an advocate for the night staff who may have expressed concerns overnight that need to be dealt with on days.
If you are in the NICU as you read this already you will be very familiar with this position. The bedside nurse is who you will have the most contact with. This person provides direct nursing care to your infant and is often the person you will speak most to during your day. They also wil one day help transition you to home but in the meantime you will bond with many of those you come across. With the sheer amount of time you will be exposed to each other you won’t be able to help bonding.
Registered Respiratory Therapist (RRT)
RRTs as they are known provide a great deal of support to our babies who are having difficulties with breathing. The RRT is the person who will be called when a baby is in need of CPAP or a ventilator and is also the one who takes blood for analysis to check oxygen and carbon dioxide levels amoung other things. They are experts in the airway and breathing and will often be the one seen providing breaths with a bag and mask at the head of the bed if your baby needs support getting in each breath, They also possess the skill to intubate babies so much like the residents, fellows and HMOs you may hear that if your baby needed a breathing tube they were the ones to place it.
Occupational therapist (OT)
These inividuals can perform many tasks but one of the things that has really developed into a strong role is the assessment of feeding. Many ex-preterm infants have challenges after the initial period when they were quite ill, establishing full oral feedings. Many OTs have developed exceptional skills at assessing infant sucking and swallowing. They may recommend pacing strategies to help your baby achieve full oral feedings faster than they would have otherwise.
PTs as they are often called specialize in assessing infant tone and posture. They are very helpful when it comes to helping your infant with their musculoskeletal system. They may provide devices or recommend stretching exercises to help with their limb positioning or muscle tone. Some babies can develop what are called contractures where a limb is quite flexed and they will provide recommendations to help lessen these.
You will already know what a pharmacist is but when it comes to the NICU they provide a very important role. Unlike the adult world where dosing is pretty standard for drugs, in babies the dose is typically measured out per kg of body weight. Moreover, as many studies are not done yet in babies in order to determine proper dosing, the pharmacist helps us determine what drug and at what dose is best to maximize benefit and reduce risk to your infant. Almost all drugs have side effects and by keeping track of the drugs your baby is on they remain vigilant to look for drug interactions and advise us if any are likely.
Registered Dietician (RD)
You would think that nutrition should be an easy thing to manage. Give a baby milk and they will grow. Unfortunately, while this approach works for most babies as they are born term, the preterm infant provides a lot of challenges. Considerations of calories, fat, carbohydrates and protein need to be considered and adjustments made over time. The RDs keep a very close eye on your infant and help advise us about adjustments needed in order to optimize growth and achieve the right balance for weight, length and head circumference. These people are meticulous in their monitoring of nutritional intake and the addition of them to our team has meant more babies going home with the right proportions!
NICU can be a stressful time for anyone. After you come to find the expected outcome of pregnancy has not gone as planned there is no doubt that you will experience stress. You may have other children that you are worried about or have been displaced from your home and traveling long distances to visit. In addition to the bedside nurse the social workers are here to talk to you and to help you access programs and resources that may be of help to you.
In our unit we have a person who experienced the journey through NICU firsthand. Having had a preterm baby in the NICU they are very much in tune with the needs of parents. This person may organize information sessions for families or parent groups. The veteran parent and the veteran parent volunteers that she coordinates provide direct one-on-one support to families. They also are responsible for arranging baby cuddlers as mentioned below to help ensure that your baby is not deprived of that important contact time when you can’t be there. The nurses of course help with this as much as they can but with multiple babies to care for having a dedicated person to help coordinate this.
A recent addition to the team are baby cuddlers who have volunteered their time to be with your baby when you can’t be. Parents often worry about who will be with their baby while they are gone. This service which also includes reading to the infants helps to reduce the isolation many babies would otherwise experience in particular when families are needed back home and need to take a few days to be with their family. There may be a coordinator in the unit as we have for this program who will also help families by providing information sessions and opportunities to get together and share experiences and let you know that you are not alone.
Spiritual Health Services recognizes and celebrates diversity. WE provide care to all whether you identify as spiritual, atheist, religious or agnostic. We are available to journey with you and support the values and belief that are important to you. Spiritual Health Practitioners are professional members of the health care team, specifically trained to provide support for your emotional and spiritual well being especially during times of difficulty and crisis. We also arrange for ceremonies, smudge, sacraments and rituals.
If you have a baby in the NICU there is a pretty good chance there will be at least one piece of plastic inserted into your child at some point. We have all sorts of “lines” and tubes that may be present depending on the conditions your baby develops. What follows is a primer on what they are all for.
I thought I would start with the easiest one since when you gave birth the team delivering you put one in you as well. The IV in the neonate is typically put in a hand or foot rather than the crease at the elbow as we like to save the bigger veins for something that we will talk about later on. Typically the IV provides sugar water (D10 most typically which is 10% sugar in water) to provide your baby with enough sugar to satisfy their metabolic needs. If a baby is older at birth but has difficulty breathing, having this type of access allows us to give them sugar and energy while not feeding them and letting their breathing settle. Putting food in the belly may sound like a necessity but they will be fine for awhile on dextrose which will allow their breathing to settle without having a full stomach pushing up on their diaphragm.
These come in two forms; the umbilical venous and arterial catheters. The easiest way to think of these are as long IVs like the one you may have had in your hand during delivery. These are long and on the venous side allow us to provide nutrition to your child either with sugar water (dextrose) or total parenteral nutrition (TPN). We can also give medications which can be tough on small veins in the hand or feet such as those to help with boosting blood pressure. The arterial catheter on the other hand allows us to monitor your baby’s blood pressure continuously. It also gives us a way of drawing blood when we need to test a number of things such as how your baby is breathing (an art gas) or checking their biochemistry such as when you hear us order “lytes” which checks salt and water balances in the body. By the way, putting these lines in does not hurt as there are no nerve endings in the umbilical cord.
These plastic tubes go from the nose (or mouth if it is an orogastric tube) into the stomach. When your baby is too preterm to know how to suck, swallow and breathe without inhaling their food it is safest to provide their milk through one of these tubes. They are very common!
When your baby is unable to breathe on their own they may need to be put on a ventilator. The ventilator attaches to an endotracheal tube and helps your baby get oxygen in and carbon dioxide out. These tubes can also be used very briefly to administer surfactant which makes it easier for your baby’s lungs to open and take air in. You may hear the medical team refer to the INSURE approach when using the tube in this way which stands for Intubate, Surfactant, Extubate.
Thankfully these tubes are not needed as much as they used to be. When air gets in between the lung and the chest wall we call that a pneumothorax.
This air can build up and make it very difficult for the underlying lung to open and fill with air. When that happens your baby’s oxygen levels drop and the carbon dioxide rises. These tubes will be put in to drain the air and relieve the pressure. Once they stop “bubbling” the tube will be clamped and then pulled out if no air reaccumulates. You may also see these tubes placed when a baby develops fluid in the same space called a pleural effusion. In that case you are trying to get rid of the fluid rather than air that has found its way in between the lung and the chest wall.
It’s Father’s Day so why not put out a post about a role for father’s in resuscitation. Given that we are talking about a parent being present for resuscitation after delivery and the mother will have just delivered, what follows is a discussion about having the other parent present at the ensuing resuscitation if needed. This will of course not always be a father as in female same sex parenting so what follows could apply to any situation in which there are two parents present and one has just delivered.
Since I was a resident this question has been batted around. During a resuscitation is it better to have families present or not? Certainly work has been done in this area which has demonstrated that from the families perspective this is a worthwhile pursuit. Families wish to be present and as a parent myself I would say it would be far more frightening to be kept out of the room than invited in to see what is going on. A mind can often conjure up scenarios that are far worse than actually exist if left to ourselves. I think in many centres now this is the case that families are invited into the room when their infant is being resuscitated but looking at things from another standpoint the question becomes what effect this has on the team doing the work? Does the team perceive that their workload is increased and if so could this affect performance?
An Answer to this question?
Dr. Schmölzer and his team in Edmonton (my former place of work) have atttempted to answer this question by looking at initial resuscitations in the delivery suite. Their study Does parental presence affect workload during neonatal resuscitation? used a tool I was unfamiliar with called the multidimensional National Aeronautics and Space Administration Task Load Index (TLX) survey to assess workload. After a resuscitation team members were invited to fill out the survey anonymously and in total 204 submissions were done. Degree of intervention after delivery included requiring stimulation 149 (73%) and suction 130 (64%), 120 (59%) continuous positive airway pressure, 105 (52%) positive pressure ventilation, 33 (16%) intubation, 10 (5%) chest compression, and 4 (2%) reported administration of epinephrine during resuscitation.
Results and Thoughts
Looking at the raw scores on the TLX the difference was highly significant in favour of having a parent present.
When further subdividing by apgar scores an interesting finding emerges in that as the apgar score increases the workload decreases. Even in the lowest apgar range the workload though appears to be equivalent.
I wonder if the finding results from being able to kill two birds with one stone? Part of the duty for any health care provider performing a resuscitation is to inform the parent of what is happening. When a patient is not doing well a provider might feel distracted and torn between providing the immediate care required and keeping the family abreast of what is happening. Having the family member present to see exactly what is going on reduces the amount of communication using descriptions and having to explain what they mean. Being able to point at an infant on CPAP and having respiratory distress for example is far easier with the parent present to point at the finding of indrawing than taking the time to explain it. I suppose the number of questions might even be lower in that circumstance. If a baby is quite ill at birth though and receiving chest compressions or epinephrine I would imagine it would be difficult to educate the family concurrently so explaining in detail what has been happening might be deferred to a later time point and hence the workload might be no different. What the data does suggest to me though is that in addition to previous research demonstrating benefits of families being part of the resuscitation for themselves, the team is no worse off in terms of workload and might even benefit from having them there as well.
The next logical study will look at resuscitations on the unit rather than in the case room but I think the question that was talked about as a resident can be put to rest.
If you have had a baby born prematurely and are reading this blog post you may have been told that the medical team is looking for a PDA. The PDA stands for Patent Ductus Arteriosus and the last two words Ductus Arteriosus really helped your fetus as it was growing in the womb. In order to understand how it can cause a problem after birth it is first important to understand what it did and why it exists in the first place.
Act I – The Womb
When your baby was developing its lungs the tissue was busy branching into airways that ended in little air sacs called alveoli. Each of those alveoli was next to a capillary which is our smallest blood vessels in the body. One day these units (alveolus and capillary) will happily exchange oxygen that is breathed in for carbon dioxide that needs to be breathed out. In the womb though the lungs were filled with fluid and air was nowhere to be seen. As such, most of the blood (about 90%) that came back from all the veins in the body to the right side of the heart had no business going to the lung. There was just not really any point in sending blood to the lung when it couldn’t pick up any oxygen there. The fetus by having a ductus arteriosus had a “pop off valve”. Since the pressure in the lung was high instead of sending blood to the lung, the 90% went from the right ventricle in the lower part of the heart to the pulmonary artery and from there across the ductus arteriosus to the aorta. The blood following this path therefore basically bypassed the lung and went from the “right” side of the heart to the “left” side that normally sends blood with oxygen to the rest of the body. The oxygen in this case came from the placenta. This fetal ciruculation is shown in the figure below.
Act II – Life on the outside
After birth the lungs fill with air containing oxygen and the resistance to blood flowing into the lung decreases which is a good thing as it allows oxygen to move from the alveolus to the capillary and back to the left side of the heart. As oxygen in the blood stream rises this usually leads to closure of the ductus arteriosus. In preterm babies though the ductus may not shut and this is what we call a Patent Ductus Arteriosus or PDA. This becomes a problem when the blood pressure in the aorta is high and the pressure in the lungs falls with breathing of air. Eventually, instead of the right to left flow of blood that occurred before, you now get blood flowing from the aorta to the pulmonary artery going to the lung and as more and more blood flows to the lungs they start to look white on chest x-rays and it gets harder and harder for your baby to breathe. The mixing is shown below.
Act III -So what do we do about it?
If we suspect that there is a PDA your doctor will order a test called an echocardiogram. This is an ultrasound of the heart and may be done by a specialist in the heart called a Cardiologist or may be done by a Neonatologist trained in doing such tests. Either way if the doctors believe the PDA is causing problems they will suggest a treatment plan to deal with it. The problems that would tend to motivate us to treat would most commonly be that your baby is needed support to help their breathing although problems related to poor blood supply to the kidneys might also lead us to treat.
The mainstays of treatment are two very common drugs and one that you may not have heard of. Indomethacin is a drug that was first used to help close PDAs and is a non steroidal anti-inflammatory (NSAID) drug that is in the same class as ibuprofen (advil) which is another drug that is used. In some centres another very common drug acetaminophen (tylenol) is employed. Most centres at this point are using one of the first two. Regardless after the medicines are given the doctors will order another echocardiogram to see if the PDA has closed and if not may repeat a course of the same medicine or choose a different one.
Act IV – What do you do if it just won’t close?
The next steps depend on how your baby is tolerating the PDA. If your infant is breathing on their own and their kidney function is working well many doctors will just observe and not offer more treatment. Babies though who are on a ventilator or are having significant issues related to their kidneys may rarely need to have a surgeon put a clip on the PDA to close it. These days this is quite rare and there are some centres that choose to not treat the PDA with medicine or surgical closure at all and just wait it out until they are gone. Almost 90% of them will close on their own if you leave them alone but again it depends on how sick your infant is in order to determine if this is reasonable.
If you are reading this and have a baby in the NICU with respiratory distress syndrome (RDS) otherwise known as hyaline membrane disease you might be surprised to know that it is because of the same condition that modern NICUs exist. The newspaper clipping from above sparked a multibillion dollar expansion of research to find a cure for the condition that took the life of President Kennedy’s preterm infant Patrick Bouvier Kennedy. He died of complications of RDS as there was nothing other than oxygen to treat him with. After his death the President committeed dollars to research to find a treatment and from that came surfactant and modern ventilators to support these little ones.
What is surfactant and what is it’s relationship to RDS?
When you take a breath (all of us including you reading this) oxygen travels down your windpipe (trachea) down into your lung and goes left and right down what are called your mainstem bronchi and then travels to the deep parts of the lung eventually finding its way to your tiny air sacs called alveoli (there are millions of them). Each alveolus has a substance in it called surfactant which helps to reduce the surface tension in the sac allowing it to open to receive oxygen and then shrink to get rid of carbon dioxide that the blood stream brings to these sacs to eliminate. Preterm infants don’t have enough surfactant and therefore the tension is high and the sacs are hard to open and easily collapse. Think of surface tension like blowing up those latex balloons as a child. Very hard to get them started but once those little balloons open a little it is much easier! The x-ray above shows you what the lungs of a newborn with RDS look like. They are described as having a “ground glass” appearance which if you recall is the white glass that you write on using a grease pencil when you are using a microscope slide. Remember that?
Before your infant was born you may have received two needles in your buttocks. These needles contain steroid that helps your unborn baby make surfactant so that when they are born they have a better chance of breathing on their own.
Things we can do after birth
Even with steroids the lungs may be “sticky” after birth and difficult to open. The way this will look to you is that when your baby takes a breath since it is so difficult the skin in between the ribs may seem to suck in. That is because the lungs are working so hard to take breath in that the negative pressure is seen on the chest. If your baby is doing that we can start them on something called CPAP which is a machine that uses a mask covering the nose and blows air into the chest. This air is under pressure and helps get oxygen into the lungs and gives them the assist they need to overcome the resistance to opening.
Some babies need more than this though and will need surfactant put into the lungs. The way this is done is typically by one of two ways. One option is to put a plastic tube in between the vocal cords and then squirt in surfactant (we get it from cow’s or pigs) and then typically the tube is withdrawn (you may hear people call it the INSURE technique – INtubate, SURfactant, Extubate). For some babies who still need oxygen after the tube is put in they may need to remain on the ventilator to help them breathe for awhile. The other technique is the LISA (Less Invasive Surfactant Administration). This is a newer way of giving surfactant and typically involves putting a baby on CPAP and then looking at the vocal cords and putting a thin catheter in between them. Surfactant is then squirted into the trachea and the catheter taken out. The difference between the two methods is that in the LISA method your baby is breathing on their own throughout the procedure while receiving CPAP.
Even if no surfactant is given the good news is that while RDS typically worsens over the first 2-3 days, by day 3-4 your baby will start to make their own surfactant. When that happens they will start to feel better and breathe easier. Come to think of it you will too.