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Preventing ROP in the NICU

The key components in providing high quality care to preterm babies in the neonatal intensive care unit and reduce their risk of ROP.
The aim of neonatal care is to provide high-quality evidence-based care which leads to more favourable outcomes for sick and preterm babies.
These favourable outcomes include: Survival to first discharge from hospital, and no adverse long-term disabilities, such as visual impairment or blindness due to ROP Providing high quality care in the neonatal unit (or NICU) requires both a multi-professional clinical team and the involvement of parents. The clinical team should follow formal care guidelines which have been agreed at the local, national or international level. And each NICU should also maintain its own up-to-date protocols which clinical staff can easily reference and apply to implementation of care.
The importance of neonatal nurses in the clinical team cannot be overemphasised. They provide on-going care for the baby around the clock
and perform many crucial roles, including: monitoring and recording the baby’s vital signs, such as heart and respiratory rate, blood pressure and temperature, adjusting the concentration of supplementary oxygen, in response to the baby’s needs, minimising the risk of sepsis (blood poisoning), monitoring blood glucose and feeding, administering medicines, identifying and preparing babies for screening, and supporting and involving parents. The minimum requirements for high-quality neonatal care mean that ideally one experienced nurse should look after a maximum of 2 sick babies at any one time.
Nurses with advanced neonatal training can perform procedures and make clinical decisions which have traditionally been carried out by doctors.
The roles of doctors in the neonatal team include: performing practical procedures such as inserting umbilical catheters, making clinical management decisions, liaising with other specialists as required, such as cardiologists and leading the overall care provided for a baby. In some settings they also train junior doctors and nurses. Parents are often overlooked as a resource for providing care for their baby. With training and support from the neonatal team,
parents can be involved in providing routine tasks such as: Tube-feeding, changing nappies and bathing This allows nurses more time to perform other duties.
Parents must be supported and kept fully informed by neonatal staff about important management decisions which affect their baby. Other members of the team involved in
providing high quality neonatal care include: dieticians, pharmacists and physiotherapists. And, where available, occupational health therapists and speech and language therapists are also involved in providing care to babies at risk of feeding difficulties. To be able provide a high standard of care nurses and direct contact with sick babies need ongoing education and training. If this training is not formally available, a package called POINTS of Care can be used to address the training gap.
POINTS of Care training has six modules: 1.Pain control: Painful procedures, such as intravenous drips and taking blood, can destabilise a preterm baby and must be kept to a minimum. By giving the baby oral sucrose or a pacifier, neonatal nurses can also reduce the pain experienced. For very painful procedures, they can give the baby some form of analgesic medication
2.Oxygen management: Trained neonatal nurses are responsible for managing the 24 hour care required to control the concentration of supplemental oxygen given to preterm babies. This is to keep babies’ blood oxygen saturation levels within the target range, 90% - 94%.
To do this nurses use and maintain a number of essential items: oxygen, compressed air, blenders, flow meters, gas humidifiers, pulse meters and alarms to notify them if levels vary. 3.Infection control: Babies are susceptible to infection and nurses minimise the risk of cross infection and development of sepsis in a number of ways.
These include: thorough hand washing, not sharing equipment such as stethoscopes between babies and maintaining a high standard of cleanliness within the NICU. 4.Nutrition is essential for growth and helps to reduce risk of infection and ROP. Neonatal nurses ensure that babies’ nutritional needs are met, through the mouth or orogastric tube (enteral routes) or by intravenous feeding for very sick babies (parenteral route). 5.Temperature control: Preterm babies cannot shiver if they become cold. Neonatal nurses ensure that the baby’s body temperature is maintained between 36.5 and 37.5 degrees centigrade (the thermoneutral zone) by removing drafts, using incubators, hats and warm cots, and kangaroo care (skin to skin contact with parents). 6.Supportive developmental care.
Nurses promote preterm babies’ development by keeping the baby stable and warm, By, for example, by good positioning and kangaroo care. By reducing noise, bright lights and the number of procedures, they also allow the baby to be undisturbed and to sleep Most of the POINTs of Care practices have been shown to directly or indirectly affect the risk of ROP. Constant monitoring of babies’ vital signs and clinical outcomes is required. Regular team briefing meetings must be held to discuss information on outcomes for the whole NICU performance.
In summary: Quality of care in a NICU requires a multidisciplinary approach that includes parents, Nurses play a critical role in the NICU and must receive competency-based training, Quality of care using the POINTs training package provides a framework for reducing the risk of ROP.

In this video we describe the key components of providing high quality care to preterm babies which reduce the risk of ROP development – the roles of the neonatal team, the use of guidelines and the value of the POINTS of care training approach.

Equipment in the neonatal unit (NICU)

The equipment surrounding sick infants often produce a constant stream of beeps, alarms and flashing lights. At first, these can be daunting for parents but the equipment, together with the skills and experience of the trained neonatal team, is central to providing the necessary care to reduce mortality and morbidity in preterm babies.

This illustration highlights the key elements and layout of the NICU equipment needed to provide high quality care and prevent ROP.

(Click to enlarge) (Download as PDF)

An incubator [1] is a special cot used for the care of small and sick newborns. It may be open (as shown here) with an overhead heater or heated mattress or closed with a lid to keep the air around the baby warm and humid.

The overhead heater [2] on an open incubator provides heat that helps to maintain the baby’s body temperature.

Monitors [3] display the baby’s breathing rate, heart rate, blood pressure, and the amount of oxygen in the blood. It is important that upper and lower alarm limits for these vital signs are set on the monitors and that the alarms are not switched off. If the baby’s vital signs stray outside of the range of the alarm limits, staff will be alerted by the alarm and appropriate action can be taken.

The ambient oxygen analyser [4] sits inside the incubator and measures the ambient concentration of supplemental oxygen. This is only required if there is no other way of measuring the concentration of oxygen that the baby is breathing.

The intravenous (IV) drip [5] is a narrow tube and needle which provides the baby with fluids, nutrients and medication. If the baby needs a drip for a long time, the team might insert a catheter (also called a PICC line or long line) which doesn’t need to be changed so often. The long line is used to administer substances, for example, parenteral nutrition and some drugs, that cannot be safely given through a peripheral IV line.

Feeding tubes [8] are flexible plastic tubes through which milk is provided for babies who are unable to feed orally.

A power supply [7] is provided for the equipment. All hospitals must have back-up power in case of a power cut.

Some babies will be put on a ventilator [6a] – a machine that allows artificial ventilation of the lungs through an endotracheal tube using a mixture of air and oxygen that has been heated and humidified. Conventional ventilation delivers the gas mixture in ‘breaths’ while an oscillatory or high-frequency ventilator delivers it through tiny, rapid vibrations of the gas mixture in the respiratory circuit. The ventilator monitor displays the ventilator settings. Respiratory support can also be provided using continuous positive airway pressure CPAP [6b].

Reflect on the systems and teams that deliver care for preterm babies in your setting. **Are there specific priorities that need to be addressed? Or, are there examples from your setting of neonatal care provision working well? Share your experiences in the Comments.

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