Status of neonatal intensive care units in India.A Fernandez, JA Mondkar
Dept. of Paediatrics, LTMG Hospital, Bombay, Maharashtra.
Neonatal mortality in India accounts for 50% of infant mortality, which has declined to 84/1000 live births. There is no prenatal care for over 50% of pregnant women, and over 80% deliver at home in unsafe and unsanitary conditions. Those women who do deliver in health facilities are unable to receive intensive neonatal care when necessary. Level I and Level II neonatal care is unavailable in most health facilities in India, and in most developing countries. There is a need in India for Level III care units also. The establishment of neonatal intensive care units (NICUs) in India and developing countries would require space and location, finances, equipment, staff, protocols of care, and infection control measures. Neonatal mortality could be reduced by initially adding NICUs at a few key hospitals. The recommendation is for 30 NICU beds per million population. Each bed would require 50 square feet per cradle and proper climate control. Funds would have to be diverted from adult care. The largest expenses would be in equipment purchase, maintenance, and repair. Trained technicians would be required to operate and monitor the sophisticated ventilators and incubators. The nurse-patient ratio should be 1:1 and 1:2 for other infants. Training mothers to work in the NICUs would help ease the problems of trained nursing staff shortages. Protocols need not be highly technical; they could include the substitution of radiant warmers and room heaters for expensive incubators, the provision of breast milk, and the reduction of invasive procedures such as venipuncture and intubation. Nocosomial infections should be reduced by vacuum cleaning and wet mopping with a disinfectant twice a day, changing disinfectants periodically, maintaining mops to avoid infection, decontamination of linen, daily changing of tubing, and cleaning and sterilizing oxygen hoods and resuscitation equipment, and maintaining an iatrogenic infection record book, which could be used to study the infection patterns and to apply the appropriate antibiotics.
Keywords: Developing Countries, Health Services Needs and Demand, Human, India, Infant Mortality, Infant, Newborn, Intensive Care Units, Neonatal, organization &administration,trends,Intensive Care, Neonatal, organization &administration,trends,
A neonatal intensive care unit is a unit that provides high quality skilled care to critically ill neonates by offering facilities for continuous clinical, biochemical and radiological monitoring and use of life support systems with the aim of improving survival of these babies.
The concept of neonatal intensive care came into existence in the developed world in the mid-60's and 70's. With the availability of excellent maternal and child health services resulting in survival of practically all normal newborns, their attention was then focussed on improving survival rates in the high risk group of newborns like very low birth weight babies especially those with problems like hyaline membrane disease, babies with severe birth asphyxia, those with organ system failure leading to shock, coma, cardiac failure, babies with severe metabolic derangements or babies with major congenital malformations requiring surgery.
Though the infant mortality rate (IMR) in our country has dropped from 144 per thousand live births to 84 per thousand five births in the past few decades, the neonatal mortality rate still accounts for over 50% of the IMR, What are the factors responsible for these demoralising figures? The deficiency starts with inadequate antenatal care. Over 50% of women have no access to basic antenatal care. Over 80% of deliveries are still conducted at home with poor facilities for a safe and clean delivery by unskilled dais. Basic neonatal care (Level I) is not available at a majority of centres where neonates are delivered or admitted. Even larger hospitals with a high delivery rate do not have access to Level II neonatal care and the basic equipment required. Thus, a substantial decline in the neonatal mortality rate in our country can be achieved by improving components of neonatal care that do not require high levels of sophistication and technology. These include facilities for clean delivery and for resuscitation at birth, adequate temperature regulation, feeding of exclusive breast-milk, prevention of infection and early detection and prompt treatment of minor problems. Current emphasis therefore should be on improvement of Level I and if care so as to ensure survival of normal neonates and those with maximal chance for intact survival.
The question then arises whether neonatal intensive care units have a role in developing countries like ours, taking into consideration the fact that neonatal intensive care is among the more expensive services that any health care system can provide. Though sufficient data on the 'per patient' cost is not available in our country, in the USA the estimated average hospital cost of smallest surviving preterms exceeds US $ 1 lakh per year. Is it then justifiable to spend enormous sums of money to save a few babies when a majority of babies have no access to primary care?
The common cause of neonatal mortality in our country are asphyxia, prematurity and low birth weight, infections like pneumonia and gastroenteritis and a variety of surgical problems. Though improved Level I and II care can bring down the mortality rates, simultaneous availability of good Level III care units are needed for the large number of critically ill neonates that flood the few units where such facilities are available. Level III care areas therefore must be set up in those areas where Level II facilities have been operative successfully for quite some time. The setting up of such NICUs at apex institutions on a regional basis should run concurrently with programmes aimed at promoting Level I and II care in the community. As per current recommendations, about 30 NICU beds are recommended per million population.
The NICUs could be made responsible for training doctors and nurses working at Level II units and to evaluate and recommend modern technology in the Indian setting. Lastly, if family planning programmes in our country have to be effective, we should be able to ensure survival of the 'very sick neonates' which may only be possible with good intensive care.
Currently, there are only a few neonatal intensive care units in the country, majority of which are attached to teaching institutions. Over the past few years, a few privately run NICUs have mushroomed in some of the major cities. However, these are inadequate for the number of babies requiring intensive care and few babies can avail of these services because of the high costs. Despite the fact that establishing and maintaining NICUs in a developing country are beset with a number of problems, the fact remains that there is a need for such units which should be developed in suitable institutions on a regional basis.
While setting up an NICU in a developing country, one has to face a number of problems and is bound down by many constraints. Very often, these problems can only be surmounted by making need based modifications as may be required:
Space and location: The ideal method would be to allocate space for setting up NICU in the planning and constructions phase of an institution. This would ensure that the unit is appropriately located near the delivery room and Obstetric OT to facilitate prompt transfer of babies. Besides, one can ensure that an average floor area of 50 square feet per cradle is available. Availability of some form of air handling units, airconditioners or a suitably placed exhaust fan is essential for air exchange to occur in the unit without the occurrence of air draughts. Installation of the systems should be done at the inception of the intensive care unit. However, majority of NICUs in our country are not preplanned and therefore we may need to fit into the space made available.
Finances: The basic requirement for the development of any specialised care is the availability of sufficient finances. Unfortunately, in the distribution of finances in any given institution, the lion's share are diverted to adult care in ICCUs and MICUs with least preference for neonatal intensive care.
Equipment: A large part of the budget for an NICU is utilized for purchase of various types of equipment. Most of this equipment needs to be imported. Frequent breakdowns and poor maintenance and repair facilities result in a lot of equipment lying idle. Besides basic equipment for resuscitation, infusion, phototherapy and thermoregulation, a well equipped NICU needs a variety of sophisticated equipments like cardiorespiratory, apnea monitors, blood pressure monitors, ventilators, infusion pumps, pulse oximeter and other equipment. However, the purchase of equipment should be in a phased manner and as per the need of the unit. Before finalizing a purchase, one should ensure that the equipment is sturdy, easy to clean, simple to operate user friendly and preferably indigenously manufactured. The company should have engineers offering prompt after sales service in the city, The availability of trained technicians and biomedical engineers in the hospital helps to prolong the life of the instrument.
Staff: The quality of services offered by an ICU depends not on the number of sophisticated incubators and ventilators but on the availability of clinical expertise round-the-clock, backed up by monitoring devices and equipment. Well-trained nurses and medical staff form the backbone of the service. Trained neonatal medical staff on call round-the-clock alongwith residents trained in neonatology for a minimum period of six months, are necessary. In order to render adequate nursing care, the nurse-patient ratio should be 1:1 for babies on ventilator and 1:2 for all other babies, Inadequate number of trained nursing staff, frequent transfers of existing staff coupled with overcrowding of NICU, interfere with the proper delivery of Level III care.
The shortage of nurses can be eased in part by encouraging entry of mothers into the NICU and involving them in the care of their baby. They can be entrusted with simple tasks like changing their baby's diapers, assisting in feeding, even monitoring for colour and respiratory movements. No staff can be more dedicated than a mother helping to monitor her own baby's respiration, output or other parameters.
In addition, facilities for referral in the hospital to paediatric surgery, plastic surgery, cardiology and neurology are needed.
Protocols of care: Though the term 'Intensive Care Unit' conjures the image of baby surrounded by a variety of beeping monitors and a mesh of wires, the term 'intensive care' need not be synonymous with ' invasive care'. In fact, the high incidence of nosocomical infections and iatrogenic problems necessitates that care in newborns be intensive in nursing skills but conservative in protocols of management'. For example, use of open care system of nursing under radiant warmers alongwith room heaters in winter in preference to incubators which are expensive, difficult to maintain and may be a source of infection. Avoiding use of parenterai fluids unless mandatory. Feeding all babies breastmilk by gavagelwati and spoon if unable to breastfeed and avoiding use of formula and bottles. Minimizing invasive procedures like venelarterial punctures, intubation catheterisation, etc. are some of the measures found to be cost effective as they reduce need for higher antibiotics as well as the cost of long hospital stay.
Infection control measures: Increased use of invasive interventions in critically ill neonates has made the hovering spectre of nosocomial infection a dreaded reality.
Prevention and control of nosocomial spread requires a multi- disciplinary committee of administrator, microbiologist and clinicians, etc. of whom at least one of the persons in the committee supervises the day-to-day measures for infection control. These include:
Vacuum cleaning the area followed by wet mopping of the floors at least once every shift (thrice a day) with a disinfectant.
* Periodic changes in disinfectants to avoid resistant strains from emerging.
* Proper maintenance of mops which could otherwise be a source of organisms.
* Policy for decontamination of linen.
* Daily changing of suctian and oxygen tubings, cleaning and sterilizing of oxygen hoods, resuscitation equipment.
* Maintaining an iatrogenic infection record book and the organisms; cultured, etc. so as to study the type of colonising organisms and to change usage of antibiotics according to the sensitivity pattern.
In conclusion, the high neonatal mortality rates pose a special problem in developing countries. The immediate need is to reduce these rates by improving Level I and II care for the neonates. In addition, neonatal intensive care should be developed concurrently at few apex institutions that serve as referral training and research centres.