SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY

Transcription

1 PS1006 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: NEONATAL INTENSIVE CARE UNIT: ADMISSION AND TRANSFER PROCEDURE AND ACUITY GUIDELINES Job Title of Reviewer: EFFECTIVE DATE: REVISED DATE: POLICY TYPE: Director, Women s and Children s Services (neonatal) (respiratory care) 3/85 1/16 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 7 PURPOSE: POLICY STATEMENT: EXCEPTIONS: To establish guidelines for levels of care in the NICU, admission procedure and transfer procedure of an infant in the Neonatal Intensive Care Unit (NICU) for a different level of care. The following guidelines and procedures will be used to assess the appropriate level of care to infants in the NICU. 1. The Neonatologist and the director of Women and Children s or designee(s) will jointly agree upon any other exceptions. Levels of Care and acuity: 1. Critically Ill Infant (PC4) (1.) include: Requiring frequent multiple clinical interventions. Exchange Transfusions. Multiple lines with multiple meds (at least 1 central line). Unstable chest tubes. Paralytics Unstable neonate requiring high levels of ventilator support on conventional or high frequency oscillating ventilator. 2 or more Vasopressors. Neonate receiving eye surgery. Neonate requiring Nitric Oxide (Initiation of and or unstable) 2. Acutely Ill Infant (PNA) (0.5) include: Weight Less Than 1000 gm. Admission of hypoglycemia, non-intubated TTN, RDS, or r/o sepsis. Stable assisted ventilation CPAP, humidified high flow N.C. +5 cm H2O, non-invasive pressure ventilation (NIPPV) or Stable neonate requiring ventilation on Conventional ventilator or high frequency oscillator, or Bubble C-PAP. Stable Neonate requiring Nitric Oxide weaning Central lines - UAC, UVC, PAL. Chest tubes with other complicating factors. Post extubation x 24 hours and/or frequent bradycardia.

2 2 of 7 PROCEDURE: 1. All Infants: Blood transfusion of unstable infant. Post exchange transfusions. Vasopressor maintenance. Repogle tube Stable chest tube maintenance without other complications 3. Stable Intermediate Infant (PNI) (0.33) include: Weight > 1000 gm. May have feeding difficulties. May have NG/OG tube, abdominal girth, or frequent I & O s. Continuous IV therapy. Infant requiring titration of oxygen on nasal cannula, Bubble C- Pap or humidified high flow N.C. +5 cm H20 PICC or peripheral, No arterial lines Post-op hours from PNC category. Infant requiring isolation. Transfusion of stable infant. NAS patient on morphine and phenobarbital 4. Stable Infant (PNC) (0.25) include: Weight > 1000 gm. Grower-feeder. May be on CR monitor, home monitor and/or pulse oximeter. Infants on stable continuous oxygen per nasal cannula. Receiving 2 or less IV medications in a 12-hour shift, i.e., PRN adapter for Ampicillin/Gentamycin. Apnea/bradycardia with minimal interventions. Nippling/breastfeeding all feedings. NAS patient on only morphine or phenobarbital a. Admission care: 1. The physician will be notified of the impending admission and report of all available information will be given. 2. Prepare for the infant s arrival with: a) Respiratory supplies appropriate for infant needs. b) IV and central vein/artery supplies. c) Neonatal procedure tray and accessory supplies, NG/OG if indicated. d) Cardio-respiratory equipment, pulse oximeter and alarms. f) Suction equipment. g) Transilluminator. h) For developmentally supportive care guidelines see NUR 32. j. For skin care guidelines see NUR 26

3 3 of 7 3. At delivery, if infant s condition allows, he/she will be weighed. 4. Infant will be admitted to the most appropriate bed for gestation and diagnosis. Refer to skincare policy (nur 26) for humidity and care guidelines. 5. The initial assessment of the infant will be done, and includes: a) Vital signs, including temperature, pulse, O 2 saturations, pain, respirations and 4-point blood pressure, if able. b) Obtain blood glucose checks and start PRN adapter per MD order. c) Apply cardio-respiratory monitor leads. d) Cardiac Monitor alarm limits will be set according to the appropriate parameter ie: <34 weeks,>34 weeks, PPHN, Comfort Care or NAS unless otherwise indicated and documented. e) Assess Blood pressure per admission orders. f) Systems assessment including head, chest circumference, abdominal circumference and length measurements. g) Document in EMR, Admission Profile completed within 4 hours of admission. h) Verify ABG, CBG orders with RT. 6. In an emergency, the NICU Registered Nurse and/or Registered Respiratory Therapist will activate the staff emergency or code blue button. 7. As soon as the infant is stabilized, Erythromycin eye therapy will be administered, if not previously done. Vitamin K will be administered per admission orders after CBC results are reported and platelet count is greater than 100,000. b. Ongoing Care: 1. Continuous cardio-respiratory monitoring will be done, unless otherwise ordered. 2. Vital signs, including blood pressure and pain assessment will be documented per MD order and nursing protocol. Follow NUR 30 for VS for the micro premi. 3. Hourly intake of both IV s and PO fluids will be monitored. Output will include diaper weights for infants on IV fluids or <1000g. a) PIV location needs to be documented when location is changed. b) Site condition must be assessed and charted hourly. 4. F i O 2 reading will be recorded every hour and with each oxygen adjustment and charted on the EMR. 5. O 2 saturation readings will be done at least every hour and charted on the EMR.

4 4 of 7 a) Pulse ox probe location needs to be charted when location is changed only (minimum of every 4-6 hours) 6. See NUR 34 for guidelines on Kangaroo Care. 7. Position will be changed every (3-6) hours, if possible, unless otherwise ordered. 8. Initial blood glucose checks will be done according to MD order, after dextrose fluid changes and/or every 12 hours and PRN until off IV fluids. 9. Suctioning will be done as needed. Endotracheal tubes will be suctioned PRN and/or as ordered per VAP bundle. 10. Infants < 32 weeks refer to NUR26 for skin care and humidity guidelines. 11. Supportive care and explanations of equipment or condition will be given to mother and support person to facilitate bonding and understanding of infant s progress. 12. A bath will be given when the infant s vital signs are stable and thermoregulation is established. Refer to skin care policy (nur26) for the low birth weight infant 13. Daily weight will be obtained, unless condition warrants otherwise or MD order. c. Infants with IV s and central lines: 1. For neonatal intravenous therapy refer to policy # and procedure (nur19). 2. For infants with central lines Refer to procedure nur16 d. Infants on oxyhoods, CPAP, Hi-flow nasal cannula, and/or mechanical ventilation will have an oral-gastric or nasogastric tube inserted to straight drainage. Feeding tube will be changed every 30 days, unless otherwise ordered. Replogle tubes will be changed every 48 hours. Output will be measured and charted by means of diaper weight, unless otherwise ordered (i.e., indwelling catheter). e. Weekly head circumference and length measurements will be obtained. f. Follow lighting, positioning and bedding guidelines NUR 31) 2. Infants admitted for transitional care a. Admission of a patient for observation will follow the MD Transition Order set. 1. Can be observed up to 6 hours before being admitted to NICU or transferred to MBU. 3. Infants readmitted to NICU a. Obtain MRSA screen per MD order.

5 5 of 7 4. TRANSFER FROM THE NEONATAL INTENSIVE CARE UNIT INFANT TO A DIFFERENT LEVEL OF CARE b. Infants may be transferred to the Newborn Nursery, upon receipt of an order from the neonatologists. c. Infant born in-house and has been in NICU < 72 hours may be transferred to MBU, and the Pediatrician will be notified of transfer by the Neonatologist, otherwise the infant will be discharged from the NICU. d. Infants may be transferred to Pediatric floor upon receipt of an order from the physician. e. Neonatologists will speak to admitting physician to accept transfer. f. NICU will notify unit that infant will be transferred to 1. Infants transferred to a different level of care (excluding transfer from L&D) will have the following completed: Complete set of admission/transfer orders Physician progress notes/transfer notes Flow sheet complete Nurses Notes with pertinent observations and/or interventions Nurse transfer notes Identification sheet/labor and Delivery data sheets Two (2) ID bands on infant from L&D. One patient ID band on all infants at all times Completed admission sheet Verbal Hand off communication Patient Transfer Record 2. Parents or guardian should be notified of transfer by transferring unit. 3. Transfer can occur 24 hours a day. High Patient Volume RESPONSIBILITY: REFERENCE (S): During times of high utilization, neonates requiring intensive treatment will be placed according to Policy: High Patient Volume: NICU It will be the responsibility of the Director of Women s and Children s Services to see that all personnel are aware of, and adhere to, this policy. American Academy of Pediatrics, American College of Obstetricians and Gynecologists. (2007).5 th edition Guidelines For Perinatal Care. Evanston, IL; Washington, DC: Author. The Nurses Association of the American College of Obstetricians and Gynecologists. (2005). Standards For Obstetrical, Gynecological And Neonatal Nursing. Washington, DC: Author.

6 6 of 7. REVIEWING AUTHOR (S): Deb Harman, MSN RNC, Clinical Manager, NICU Heather Graber, RNC-NIC, BSN, Clinical Coordinator, NICU Heike S. Bucken RNC-NIC,CLC Clinical Coordinator, NICU Donetta Dangleis RRT, Respiratory Care Manager Kathleen Duffy, RRT, NPS, Respiratory Care Team Leader

7 7 of 7 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy: Date Title: Mark Pellman, Director, Respiratory Care Services Title: Pam Beitlich, Director, Women s and Children s Services Title: Title: Committee/Sections (if applicable): Clinical Practice Council 1/7/16 Title: Jan Mauck, Vice President, Chief Nursing Officer