New Born Care Unit ( Part 3 )

 

Levels of care

The concept of designations for hospital facilities that care for newborn infants according to the level of complexity of care provided was first proposed in the United States in 1976. Levels in the United States are designated by the guidelines published by the American Academy of Pediatrics In Britain, the guidelines are issued by The British Association of Perinatal Medicine (BAPM), and in Canada, they are maintained by The Canadian Paediatric Society.

Neonatal care is split into categories or “levels of care”. these levels apply to the type of care needed and is determined by the governing body of the area .

India

India has 3-tier system based on weight and gestational age of neonate.

Level I care

Neonates weighing more than 1800 grams or having gestational maturity of 34 weeks or more are categorized under level I care. The care consists of basic care at birth, provision of warmth, maintaining asepsis and promotion of breastfeeding. This type of care can be given at home, subcenter and primary health centre.

Level II care

Neonates weighing 1200-1800 grams or having gestational maturity of 30–34 weeks are categorized under level II care and are looked after by trained nurses and pediatricians. The equipment and facilities used for this level of care include equipment for resuscitation, maintenance of thermoneutral environment, intravenous infusion, gavage feeding, phototherapy and exchange blood transfusion. This type of care can be given at first referral units, district hospitals, teaching institutions and nursing homes.

Level III care

Neonates weighing less than 1200 grams or having gestational maturity of less than 30 weeks are categorized under level III care. The care is provided at apex institutions and regional perinatal centers equipped with centralized oxygen and suction facilities, servo-controlled incubators, vital signs monitors, transcutaneous monitors, ventilators, infusion pumps etc. This type of care is provided by skilled nurses and neonatologists.

United Kingdom

The terminology used in the United Kingdom can be confusing because different criteria are used to designate 'special' and 'intensive' neonatal care locally and nationally.

Level 1 Neonatal Units

Also known as 'Special Care Baby Units' (SCBU). These look after babies who need more care than healthy newborns but are relatively stable and mature. SCBU might provide tube-feeding, oxygen therapy, antibiotics to treat infection and phototherapy for jaundice. In a SCBU, a nurse can be assigned up to four babies to care for.

Level 2 Neonatal Units

Also known as 'Local Neonatal Units', these can look after babies who need more advanced support such as parenteral nutrition and continuous positive airway pressure (CPAP). Confusingly, they may also look after babies who need short-term intensive care such as mechanical ventilation. Babies who will need longer-term or more elaborate intensive care, for example extremely preterm infants, are usually transferred to a Level 3 unit. Babies in a Level 2 unit may be classified for nursing purposes as 'Special Care', 'High Dependency' (HDU) (in which a nurse will be assigned up to two babies) or 'Intensive care' (where nursing is one-to-one, or sometimes even two-to-one).

Level 3 Neonatal Units

Also known as 'Neonatal Intensive Care Units' (NICU) - although Level 2 units may also have their own NICU. These look after the smallest, most premature and most unwell babies and often serve a large geographical region. Therapies such as prolonged mechanical ventilation, therapeutic hypothermia, neonatal surgery and inhaled nitric oxide are usually provided in Level 3 Units, although not every unit has access to all therapies. Some babies being cared for in Level 3 units will require less intensive treatment and will be looked after in HDU or SCBU nurseries on the same site. NHS England recommended in December 2019 that these units should care for at least 100 babies weighing less than 1.5 kg, and usually perform more than 2,000 intensive care days per year.

United States

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1. Level I, Well newborn nursery
2. Level II, Special care nursery
3. Level III, Neonatal intensive-care unit (NICU)
4. Level IV, Regional neonatal intensive-care unit (Regional NICU)

Level I (well newborn nursery )

Level I units are typically referred to as the well baby nursery. Well newborn nurseries have the capability to provide neonatal resuscitation at every delivery; evaluate and provide postnatal care to healthy newborn infants; stabilize and provide care for infants born at 35 to 37 weeks’ gestation who remain physiologically stable; and stabilize newborn infants who are ill and those born less than 35 weeks’ gestation until transfer to a facility that can provide the appropriate level of neonatal care. Required provider types for well newborn nurseries include pediatricians, family physicians, nurse practitioners, and other advanced practice registered nurses.

Level II (special care nursery)

• Provide care for infants born ≥32-week gestation and weighing ≥1500 g who have physiologic immaturity or who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis
• Provide care for infants who are feeding and growing stronger or convalescing after intensive care
• Provide mechanical ventilation for a brief duration (<24 h) or continuous positive airway pressure
• Stabilize infants born before 32-week gestation and weighing less than 1500 g until transfer to a neonatal intensive-care facility
• Level II nurseries are required to be managed and staffed by a pediatrician, however many Level II special care nurseries are staffed by neonatologists and neonatal nurse practitioners.^[36]

Level III (neonatal intensive-care unit)

• Provide sustained life support
• Provide comprehensive care for infants born <32 wks gestation and weighing <1500 g
• Provide comprehensive care for infants born at all gestational ages and birth weights with critical illness
• Provide prompt and readily available access to a full range of pediatric medical subspecialists, pediatric surgical specialists, pediatric anesthesiologists, and pediatric ophthalmologists
• Provide a full range of respiratory support that may include conventional and/or high-frequency ventilation and inhaled nitric oxide
• Perform advanced imaging, with interpretation on an urgent basis, including computed tomography, MRI, and echocardiography

Level IV (regional NICU

• Are located within an institution with the capability to provide surgical repair of complex congenital or acquired conditions
• Maintain a full range of pediatric medical subspecialists, pediatric surgical subspecialists, and pediatric anesthesiologists at the site
• Facilitate transport and provide outreach education.