<p>Neonatal Intensive Care (NIC) is elaborate, demanding and expensive. Neonates requiring intensive care (IC) are either very sick or below 1500 gm (VLBW). IC or level III care is required for only 3–5 percent of neonates, while 10–12 percent needs level II care and the remaining 85 percent level I care. Such categorization of level of neonatal care is essential since the nursing expertise, nursing coverage (i.e. nurse: patient ratio), level of technology and equipment required for monitoring and supportive care varies with the level of care and hence the difference in the cost of care. The cost of level II care is 5–10 times higher than the cost of level I care, while the cost of level III case is 5–10 times that of level II care. It is important to realize that NIC saves those lives which cannot be saved with level I or level II care. Moreover NIC is not more expensive than the intensive care of an adult, but saves a longer productive life and hence should be a social priority.</p></sec><sec id="sec002"><title>Setting up of Neonatal Intensive Care Unit (NICU)

JNNFI

Journal of Neonatology

0973-21870973-2179

National Neonatology Forum

jn-20-3-008

Commentaries

Challenges of neonatal intensive care in India

Bhakoo

O.N.

Ex Prof. and Head

Dept. of Pediatrics and Neonatology, PGIMER Chandigarh. E-mail: bhakooshukla@yahoo.co.in

7–92006

203256259

<p>Neonatal Intensive Care (NIC) is elaborate, demanding and expensive. Neonates requiring intensive care (IC) are either very sick or below 1500 gm (VLBW). IC or level III care is required for only 3–5 percent of neonates, while 10–12 percent needs level II care and the remaining 85 percent level I care. Such categorization of level of neonatal care is essential since the nursing expertise, nursing coverage (i.e. nurse: patient ratio), level of technology and equipment required for monitoring and supportive care varies with the level of care and hence the difference in the cost of care. The cost of level II care is 5–10 times higher than the cost of level I care, while the cost of level III case is 5–10 times that of level II care. It is important to realize that NIC saves those lives which cannot be saved with level I or level II care. Moreover NIC is not more expensive than the intensive care of an adult, but saves a longer productive life and hence should be a social priority.</p></sec><sec id="sec002"><title>Setting up of Neonatal Intensive Care Unit (NICU)

NIC requires a large space, lot of special equipment, a good laboratory support and a dedicated team. The equipment includes baby incubators, electronic monitors, phototherapy units, ventilators, infusion pumps and facilities for resuscitation and total parenteral nutrition. The laboratory support comprises of microchemistry, microbiology, hematology, imaging and drug monitoring. NIC team includes not only neonatologists and a large number of nurses, but also paramedical workers and super specialists trained to handle special needs of these babies. Such paramedical workers include respiratory therapists, nutritionists, biomedical engineers, social workers and physiotherapists. The super specialists comprise of perinatologist, neonatal surgeons, developmental pediatricians, ophthalmologists, otorhinolaryngologists and other system specialists. The first major challenge is to develop such a team, gather the desired equipment, have enough space and get the laboratories and the supper specialists interested in handling the special needs of the very sick and very small neonates.

It is important to follow NNF recommendations for setting up level III care neonatal unit. Depending upon the available facility, prepare the written up protocols for patient care, including nursing care and follow them in practice. These protocols may be reviewed and upgraded periodically depending upon the new literature and expanded facilities in the unit. It is logical to first develop good level II care facilities and then upgrade them gradually to level III care depending upon the demand and expertise of the team. During the developing period, one can improve the skills of team members and also convince the management for feasibility of higher allocation of funds for NIC. Pretty soon, the management starts appreciating that the good will generated through the availability of NIC in the institution often outweighs the profits generated. In due course of time, one may be able to develop a very large facility of NIC and relegate level II care to more peripheral units. It has been observed that under exceptional situations with highly supportive management and an aggressive team leader, one may be able to develop NIC facilities from the very start of the unit. Such situations are not unknown in our country.

The challenges

Since NIC is required for very high risk infants, it has a significant rate of uncertainty about their survival and intact survival. Hence there is continuing challenge to improve the survival as well as intact survival rates of such infants. Various challenges of NIC in our country are enumerated below:

Improving quality of care

The quality of NIC can be improved through the following means

All the NICUs should be accredited and re accredited every 5 years as per recommendations of NNF

Since the incidence of hospital acquired infections (HAI) among NICUs is particularly high in our country, it is important to be extra vigilant about its prevention. Prepare special protocols for infection control with continuing audit of HAI. Also have written down antibiotic policy and modify it from time to time depending upon the antibiotic sensitivity pattern of the isolated micro-organisms.

Ensure ongoing audit of all medical and nursing records of the patients for quality of care with special reference to complications like ROP, NEC, BPD, brain hemorrhages etc., and note if these complications could be prevented. In case of fatal out come, determine the cause of death and make a note of lessons, if any, for the future.

Ensure follow up of all NIC survivors as per prepared protocols. Carry out detailed analysis of preventable causative factors in those babies showing neurodevelopmental handicaps including ROP and deafness.

Compare your survival and intact survival rates with other good NICUs and analyze how they can be improved.

Reducing the cost of care

The cost of NIC can be reduced by adopting the following measures:-

Cutting down the cost of medical equipment: This is possible through indigenous manufacturing of quality equipment as well as by eliminating the taxes and duties levied by the state on such life saving equipments. For this NNF needs to play a pro-active role by interacting with the industry and helping Indian Standard Institute (ISI) to formulate standards for such equipment.

Optimal utilization of NIC facilities: Under utilization of such facilities increases the cost of care, since major cost factor is staff salaries and the cost of equipment. Hence it will be more economical to shift the patient from the level III care to level II care areas as soon as patient's condition warrants it, even if it means shifting the patient to another hospital with only level II care facilities, so that level III care facilities are optimally utilized for more sick patients. This is possible through inter hospital coordination or through regionalization of neonatal care. Availability of equipment on rent or taking it on loan from another unit may be considered a possibility to meet the temporary increase of work load of the unit.

Reducing the duration of hospitalization: There is need to collect information on preventable factors that prolong hospitalization e.g. hospital acquired infection. Similarly there may be factors related to nutrition and assisted ventilation. NNF should be able to play a major role in facilitating to collect and collate such information from various units of the country through collaborative studies.

Using the mother in NIC

While the role of the mother in level I and even level II care is well recognized, her role in level III care has not received much attention. Kangaroo mother care, even in intensive care settings has been shown to shorten the duration of hospital stay of the baby. The affect of such care is mediated through providing warmth, early stimulation and calming nerves. In our country, where there is perpetual shortage of nurses, mother can be trained to perform simple components of baby care beside breast feeding and providing breast milk. Hence, use of the mother in NIC is a challenge which is likely to yield rich dividends.

Improving patient satisfaction

Communication with the family is the most sensitive aspect of NIC. High cost of such care increases the expectations of the family and possibility of compromised outcome makes such a communication even more important. So, besides documenting the progress of the patients condition in the hospital records, it is important to inform the family about the patients changing condition truthfully and yet with guarded optimism if the circumstances so demand. Any possibility of adverse outcome may be told with sensitivity and compassion. Such an approach during counseling improves family's satisfaction and reduces chances of litigation. NNF should organize special sessions of discussion on counseling with examples of live experiences.

Health insurance-making NIC affordable

NIC can be made more affordable for middle income group families by persuading insurance companies in our country to introduce health insurance for NIC. For this NNF will have to interact with insurance sector and provide them hard data on the cost of NIC and the degree of risk for needing such a care.

Low income group families should be helped by the state through social welfare or the government health department. NNF can again play an important role by interacting with the government to increase NIC facilities in Govt. Hospitals.

Neonatal transport

Optimal care including IC during transport of a sick infant significantly reduces transport related morbidity, hence, improves outcome. It also reduces the stress of the family as well as of the referring doctor. Transport of such infants from the lower level to level III should be carried out by the team from level III care unit. At the present there is a great challenge to improve the state of neonatal transport in our country and in fact to create a model suitable to Indian conditions.

Expanding training facilities

Even if we calculate the need for NIC in the country as one 20 bedded NICU per million population, we need at least 3000 trained neonatologists. Currently we have less than 200 trained neonatologists in India and another 15 to 20 pediatricians per year graduate in neonatology through DM or Diplomat of National Boards or by training overseas. Hence there is a tremendous gap between the need and the availability of the doctors trained in NIC. This gap can only be filled by creating more training facilities.

We need at least 20 times more nurses trained in NIC than the number of neonatologists. There are no formal training programs in NIC for the nurses leading to certification or a degree in neonatal nursing in India. Moreover; there are no financial incentives for nurses performing NIC after having received inservice training. NNF and the neonatologist in our country need to encourage and support nursing colleges attached to big NICUs to start such formal training programmes. They also need to lobby with the hospital authorities to either give better pay scale or special allowances to the nurses trained in NIC and working in NICUs. This will result in attracting more nurses for neonatal intensive care.

In addition to all this, in service training of nurses and other team members of NICU should be carried out on continuing basis so as to improve their skills.

Outreach education

Outreach education means need based continuing education and training of the medical staff working in the peripheral units from where the patients are referred to level III unit. This education is conducted by the team from the referral centre mostly at the peripheral centre and partly at the referral centre itself. The topics for such CME should be related to the clinical problems faced during the proceeding months. Such outreach education improves the patient care and can be carried out with or without its being a component of Regionalization of neonatal care.

Regionalization of neonatal care

Networking and coordination of neonatal care between level I, II and III units in a small district level geographical area is called regionalization. It has improved neonatal survival with better utilization of community's resources wherever it has been implemented in the world. There is a need to try it at least in a limited way in our country. If the local neonatologists are enthusiastic, it may become possible in at least large cities with good infrastructure and reasonable number of neonatal care beds. Challenges during regionalization will include coordination of the private sector with the government sector, generating adequate funds and making it cost effective and the biggest challenge is to create an Indian model.

Role of NNF in NIC

At the current state of development of NIC in our country, there is a need to create a formal group of dynamic NNF members who are actively involved in NIC. Such a group can be designated NIC group and it should try to find solutions to identified problems specific to the NIC in our country. This can be done through sharing their experiences of the patient care data collected through collaborative efforts (like NNPD data). Depending upon their strengths, different NICU's can take leadership role in solving problems in certain defined areas of NIC. Such a group can also develop national guidelines on NIC in relation to specific needs of our country. Some of the aspects which can be deliberated upon by such a group can be as follows:-

Infection control

Neonatal audit

Reducing cost of care

Optimising use of NIC facilities

Neonatal transport

Outreach education

Counseling and handling litigation

Health insurance of NIC

Training in NIC

Collaborative research.

Indigenous development of equipment

Regionalization of neonatal care

The challenges of NIC in India are not insurmountable. I am sure the ability and courage of dedicated neonatologists will be more than a match for such challenges.

Acknowledgements

I thankfully acknowledge the critical comments of Prof Anil Narang, Dr Praveen Kumar and Dr Saurabh Datta of the Neonatal Unit, Advance Pediatric Centre, PGIMER Chandigarh.

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