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1

DISCLAIMER
These handouts are compiled from various
sources to assist health care professionals.
It should not be regarded as complete and
could vary in different units.

foreword
India has witnessed rapid growth of facility-based care for sick neonates in recent years. The goal is to save
newborn lives and provide quality care. The special care and intensive care newborn units are home to premature
and sick newborn infants. These vulnerable babies need nurturing with utmost holistic care and safe practices
that minimize the probability of harm. Health care providers need to stay updated with current evidence in
literature. Working together as a team, physicians and nurses can follow standard evidence-based protocols to
improve care. In a neonatal unit, a team of physicians, nurses and other healthcare staff carry out a number of
complex multi-step healthcare procedures.
From aviation sector to operation theatres, checklists have proved useful in decreasing errors at key steps in a
high-stress environment. Checklists and bundles when applied to neonatal units can help in avoiding break in
asepsis during various care procedures and decrease the risk of acquisition of health-care associated infection.
Recent study from Karnataka by World Health Organisation reported that introduction of simple checklist improves
practices of health workers during childbirth. This safety checklist is being tested in 100 centres in North India for
mothers and babies.
Andhra Pradesh neonatologists under the able leadership of Fernandez Hospital team have taken a lead in this
direction by conceptualizing safe practices checklist and bundle approaches using evidence based practices
for reducing catheter-related blood stream infections, ventilator-associated pneumonia and other healthcare
associated (nosocomial) infections. Evidence from developed countries supports the use of checklists in avoiding
medication errors and nosocomial infections.
Challenge is now to create institutions and network within each state where best unit practices can be replicated
and documented. Proven interventions are relatively inexpensive and easy to perform but the unfortunate disparity
between knowledge and practice has constituted a major barrier to improving outcomes. Such innovative ideas
will have far reaching effects in improving quality of care in healthcare delivery in the region, reduce economic
burden and also serve as model for other disciplines of Medicine.

Dr. Ashok Deorari, FAMS FNNF


Professor, Department of Pediatrics
AIIMS, New Delhi

preface
Quality of care is a new paradigm in Neonatology. Team concept, standardization of care and building up processes
are the keys to quality care. In an effort to improve quality of care, we at Fernandez Hospital collated a checklists,
bundles and infection control practices with ___________. This is a reference manual and not a standard

INDEX
CHECKLISTS

Admission Checklist

Checklist for discharge of healthy newborn

10

Discharge from NICU

11

TRANSPORT CHECKLIST
CHECKLIST FOR PREPARATION OF FORMULA FEED
Denominators for Neonatal Intensive Care Unit (NICU)
LEVEL- 3 DAILY FORM
LEVEL- 2 DAILY FORM
CHECKLIST SETTING UP NICU (8 16 BEDS)
CHECKLIST FOR SURGERY
CENTRAL LINE INSERTION CHECKLIST
SURFACTANT ADMINISTRATION
CHECKLIST FOR INTUBATION
Peritoneal Dialysis
Checklist Exchange Transfusion
Exchange Transfusion Monitoring Form
Checklist for Umbilical Line
Checklist for Peripherally Inserted Central Venous Line
Checklist for Intravenous Cannulation
Infection Control Audit Checklist
Lumbar Puncture Checklist
Aseptic Non-touch Technique Audit Checklist
Requirements for Ventilated Beds
Infection Control Practices
Hand Hygiene
Handrub Procedure
Handwash Procedure
Housekeeping Procedures in the NICU
Bundles
Ventilator Associated Pneumonia (VAP) Bundle
Central Line Associated Blood Stream Infection (CLABSI) Bundle
Nutrition Bundle
Prevention of Hypothermia in ELBW and VLBW Infants

12
16
17
18
19
22
23
24
26
27
29
31
32
33
35
37
39
40
41
43
44
45
46
47
54
55
56
57
58

ADMISSION CHECKLIST

Yes

No

Things to be Checked in an Anticipated Admission

Warmer on Manual Mode

Crib made ready

Standby Ventilator / CPAP with New Circuit and Humidifier

On arrival

Baby Name Tagged

Suction if Required

Oxygen by Hood/ Prongs

Nasal Prongs

Temperature Probe Attached

Warmer Mode Shifted to Servo

Pulse Oximeter Probe Attached

IV Cannula Inserted and Dated

GRBS on Arrival Checked

Necessary Investigations Collected

UVC / UAC / PICC Lines

NIBP

X-ray Chest and Abdomen

IV Fluids Started

Feeding Tube Inserted

Urine Collecting Bags

Inj. Vitamin K- given

Time of First Dose of Antibiotic after Arrival Noted

Weight, Length, OFC Checked and Documented

Any Injuries, Previous Cannula Extravasations Noted and Documented

Admission Formalities and Counselling Done

Need of Admission

Expected Complications

Duration of NICU Stay

Financial Counselling

Explained about Daily Visiting Hours, Time of Daily Counselling

Explained regarding Feeding Plan and Expression of Milk and Storage of Milk

Visitors Cards Issued

Written Informed Consent taken Regarding Initial Support, Invasive Procedures

Baby shown to Attendants after Initial Stabilisation

Admission Slip, Medication Slip given to Attendants

Checklist for discharge of healthy newborn

Day of Life

Weight at Discharge and Percentage of Weight Loss*

Establishment of Breast Feeds

YES / NO

Passage of Meconium

YES / NO

Passage of Urine

YES / NO

Eye Examination (Cataract)

Cleft Palate

Murmurs & Femoral Pulses

Hip Examination (DDH)

Genitals

Examination of the Back

New Born Screening

Bilirubin Levels (Any value > 6 mg/dL on day 1 No discharge)

SpO2 (< 95% needs evaluation)

BCG / OPV / Hepatitis B (1)

Complaints from Mother

Review on

Name of the Doctor

* (Of concern weight loss : > 5% on day 1 and day 2 and > 10% after day 3)

10

_______grams (_____%)

(TSB / TCB) _____ mg/dl


_____________%
YES / NO

Discharge from NICU


Yes

Weight, OFC at birth and at Discharge

Temperature Stability

Accepting Spoon/Palade or Breast feeds

IV lines removed

Newborn screening (basic or Expanded)

Mother confident of Handling the Newborn

Mother Trained on Spoon feeds

No

Medication advise- how to give/ when to stop


Multivitamins/Iron/Calcium supplementation
Adding HMF
Any other oral medication
Danger Signs Explained
Skin/Cord care Explained
Sponge bath till 2.5kgs
Oil massage
Cap, Socks, Mittens
Powder with puff
No oil instillation or blowing of Ears/Nose

Explain about need for practicing KMC at home

Summary Explained and given to Parents

Follow up dates-when/purpose of follow up Explained


(Anthropometry/Jaundice/BERA/NSG/ROP)

Inform about Vaccination dates/ Immunisation schedule

11

TRANSPORT CHECKLIST
Baby Name : ___________________________________

M. R. No. _________________________

Age: ______________

Birth weight : ________gms

Sex: M / F

Gest.Age: _________wk

Transport Doctor :_______________ Transport Nurse:_______________ Date & Time of call : _____________
Yes
Transport Kit

12

Endotracheal Tubes #2.0, #2.5, #3.0 & # 3.5

Laryngoscope

Blade Size #0 & #1

Face Mask Pre-term and Term

Laryngoscope with Extra Batteries 2 in number

Nasal Prongs

Oxygen Tubes

Prediluted Drugs (Adrenaline 1:10,000, NaHCo3 , Dopamine, Dobutamine,


Calcium gluconate).

IV fluids (2 in number) : Pediadrip Set, Normal Saline, 10% Dextrose, 5% Dextrose, Sterile Water for Injection

Feeding Tubes

Mucus Sucker

Suction Catheters

Portable Suction

Glucometer with Strips

Stethoscope

Pulse Oximeter (Battery charged) with Extra Set of Probes

Syringe Pump (Battery Charged)

Syringes (5 in number) 1 cc, 2 cc, 5 cc, 10 cc

3 way Extension

Blood Pressure Cuff

Sterile Towel, Head Cap

IV Cannula 24 No. (5 in number)

IV Cannula and ET Plasters

Sterile Cotton, Diapers

Oxygen Source (in the ambulance)

Incubator / Thermostat

Transport Ventilator, Neopuff

New Set of Ventilator Tubings

No

Yes

No

Procedure Checklist

Temperature

HR

RR

GRBS

Blood pressure

SPO2

CFT

Respiratory Support CPAP / Oxygen / Ventilation

Vitamin K given

Medications Received, Dose, Timings, Route

Any Investigations Sent

X-ray Chest Done

Any Relevant History

IV Cannula (No. of days)

Counselling of Parents done Regarding Need for Transport

Written Informed Consent Taken for Transport from Attendants

Copy of Maternal Records

Copy of Neonatal Treatment Record

Receiving Team Informed about the Baby

Interventions done during Transport

Stabilization post transport

Temperature

GRBS

Handover given to Doctor : _________________________

Nurse : _________________________

Time of handover : ________________________________

13

CHECKLIST FOR PREPARATION OF FORMULA FEED


Preparation of Formula Feed

Hands Washed before Cleaning and Sterilizing Feeding Utensils

Dedicated Sink used for Cleaning Feeding Utensils

Cleaning
Feeding & Preparation Utensils (E.g. Palada, Cups, Spoons, bottles) washed
in Hot Soapy Water. Dedicated Soap and Sponge/Brush Used for Cleaning.

After washing, Utensils Rinsed Thoroughly in Safe Water.

Sterilizing
Washed Utensils Completely Submerged In Large Pan Filled with Water,
Pan Covered with a Lid, Brought to a Rolling Boil and kept Covered Until
Utensils Needed.

Surface Cleaned & Disinfected before Feed Preparation

Hands Washed before Utensils are Removed with a Sterilized Forceps

Sterilized Cheatle/Forcep used to Remove Utensil has a date < 24 hours old

Kettle Filled With At Least 1 Litre Fresh Safe Drinking Water (Water Boiled Previously Not Re Used).

Safe Drinking Water Boiled Until a Rolling Boil. (Bottled Water Preferably not
used, if used its also Boiled)

Water used Within 30 Minutes of Boiling (So that it Remains at a Temperature of


at least 70C )

Appropriate Amount of Boiled Water Poured into Sterilized Feeding Vessel


(30ml for Every Scoop). Formula powder added to the Water. (If a Batch Made in a
Larger Container, the Container Used is Cleaned and
Sterilized and Maximum 1 Litre Prepared at one time).

Mixed Thoroughly with a Cleaned and Sterilized Spoon

Formula Cooled By Holding the Bottom Half of the Utensil/Bottle Under


Cold/Tap Water without Contaminating Contents

Labelling
Type of Formula, Infants Name or ID, Time and Date of Preparation,
and Preparers Name.

14

Temperature of Formula Feed Tested on inside of wrist before giving to


Baby

Left over feed Thrown away

Yes

No

Denominators for Neonatal Intensive Care Unit (NICU)


Month :

Year :
A 750 g

Date
Pts

IVF

CL

Vent

B = 751-1000 g
O2

IV

TPN

Pts

IVF

CL

Vent

O2

C = 1001-1500 g
IV

TPN

Pts

IVF

CL

Vent

O2

IV

TPN

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

15

Denominators for Neonatal Intensive Care Unit (NICU)


Month :

Year :

Date

D = 1501-2500 g
Pts

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

16

IVF

CL

Vent

O2

Weight >2500gm
IV

TPN

Pts

IVF

CL

Vent

O2

Total
IV

TPN

Pts

III

II

KMC

LEVEL- 3 DAILY FORM


Baby of :

IP: No .
DAY

10

11

12

13

14

15

DATE
GESTATION
WEIGHT
RESP

VENTILATION
CPAP
OXYGEN

FLIUIDS

IV CANNULA
CENTRAL LINES
IV FLUIDS
TPN
EBM
FORMULA
HMF

DRUGS

ANTIBIOTICS
ANTIFUNGALS
INOTROPES
ANTI
CONVULSANTS
SEDATIVES

BLOOD
PACKED RBC
COMPONENTS
PRP / SDP
FFP
IMAGING

ECG
NSG
ECHO
X-RAY

ROP

ROP Screening
NEXT REVIEW

Notes :

17

LEVEL- 2 DAILY FORM


Baby of :

IP: No .
DAY
DATE
GESTATION
WEIGHT
LENGTH
OFC
CALORIES (kg/day)
PROTEIN (kg/day)

RESP
FLIUIDS

OXYGEN
IV CANNULA
CENTRAL LINES
IV FLUIDS
TPN
EBM
FORMULA
SUPPLEMENTS
HMF

DRUGS

VITAMIN A
CAFFEINE
3 % SALINE/BICARB
ANTIBIOTICS

BLOOD
COMPONENTS
LABS

PACKED RBC

PCV
Na
CALCIUM
ENBS /NBS

IMAGES

NSG
2D ECHO
X-RAY

ROP Findings:
Notes :

18

10

11

12

13

14

15

CHECKLIST SETTING UP NICU (8 16 BEDS)


Location and size

Restricted Access

Isolation Room

Temperature, Humidity and Pressure in each level of care

Proximity to Labour Room/Transport Area/Imaging Facility

Ramp/Passage/Lift for Transport of Newborn

No Thoroughfare / No Access to Other Facilities Through NICU

Self Closing Device On Door

100 Sqft Clear Space Per Bed (50 Sqft Baby Areas + 50 Sqft Ancillary Areas).

Baby Care Divided Into 2 or 3 Sections. Visibility from Nurses Station

Ancillary service area

Reception Area

Parents Waiting Lounge

Counselling Room

Examination Room

Side Lab

Office /Administration Room- Near Entrance/ Electronic Data Recording

Mothers Area For Breast Milk Expression/ Feeding Area- Breast Pump

Milk Bank

Autoclave Facility

Change Room/ Rest Room/Toilets

Store Room

Linen Washing/Laundry Room- Automatic Washing Machine And Dryer

Dirty Utility Room

Yes

No

Yes

No

19

CHECKLIST SETTING UP NICU (8 16 BEDS)


NICU Area

Hand Wash Area

Hands Free Elbow Operated Taps

Stainless Steel/ Porcelain Sink with Size 24 Wide x 16 front to Back x 10


Deep Designed to avoid Splashing and water Stagnation.

Adjacent Wall Non- Porous And Non-Absorbent/ Tiles

Soap Dispenser With Liquid Soap

Hand Dryer or Disposable Towels or Tissues

Trash Bin

Pictorial Chart For Hand Wash

Additional Hand Washing Within 20 Feet Of Every Bed Minimum 3 Feet Away
One Washbasin for Every 4 Beds

Clean Utility Area

Space For Holding Sterile Trays/Syringes/Infusion Set/ IV Fluid/Diapers etc.

Dirty Utility Area

Electrical Needs

24 Hour Uninterrupted Supply

A Generator With 25-50 KVA Capacity And a Servo Stabiliser (3 Phase)

6-8 Central Voltage Stabilised Outlets Per Bed: 5 Amps (4) and 15 amps (4)

Lighting Cool White Fluorescent Tubes, Preferably CFL or LED (Light-Emitting Diodes)

Mechanical Needs

20

Flooring : Durable, non-porous, non-teretogenic

Walls Glaze Tiles up to 7 feet

24 Hours Water Supply

Glazed Windows at Least 2 Feet Distance away from Baby Bed

Visible Day Light

Avoid Bright Light/Separate Procedure Lighting

Supply and Exhaust Ventilation/Air Temp 26-28 c

2-Oxygen Outlet/2-Compressed Air Outlet/1- Suction Outlet- Per Ventilated Bed

1-Oxyegn Outlet/1- Compressed Air Outlet/1- Suction Outlet Per Non Ventilated Bed

Fire Safety Plan- Fire Exits/Dampeners/Safety Certificate

Sewer And Water Connection And No Objection Certificate

Yes

No

CHECKLIST SETTING UP NICU (8 16 BEDS)

Equipment list

Ventilator and Appropriate Circuits

CPAP Machine

Laminar Flow for IV Fluid Mixing & TPN Preparation

Phototherapy Unit, Single Head, High Intensity

Infusion And Syringe Pump

Oxygen Hood, S & M Sizes Including Connecting Tubes

Thermometer, Clinical,Digital,32-43C

Scale (Baby, Electronic) 10 kg (<5g Sensitivity)

Hub Cutter, Syringe

Irradiance Meter For Phototherapy Units

ECG Unit 3 Channel, Portable/Set

Infantometer, Plexi, 105 cm

X-Ray, Mobile

Mobile Ultrasound Machine

Transport Incubator, Basic, With Battery & O2

Autoclave ( Steam, Bench Top) 20L Electrical

Laundry Washer Dryer 5kg Capacity

Wall Clock/Seconds Hand Display

Refrigerator-110L

Lab equipment

Drum Steriliser 165mm

Centrifuge, Hematocrit, Benchtop Up to 12000 rpm, Including Rotor

Microscope, Binocular, With Illuminator

Bilirubinometer (Total Bilirubin) Capillary Based

Glucometer With Dextrostix

Urine Multistix

Staff

Consultant With Neonatal Experience

Trained Duty Registrar Doctor Per Shift

Bed to Staff Nurse - 1 : 1 Ratio

In-Charge Nurse : One

Class IV Employee Per Shift - 1 Person

Ward Aide - 1 Person And Dayas

Data Operator - 1 Person

Social Worker/Relation Manager - 1 Person

Lactation Assistant - 1 Person

Security Per Shift-1 Person

Yes

No

Yes

No

Yes

No

21

CHECKLIST FOR SURGERY


Yes
Pre-operative

Informed Consent Taken

High Risk Consent Taken

Case Sheet Prepared (Shifting Notes)

Procedure Risk Explained By Pediatrician / Neonatologist


By Pediatric Surgeon / Anaesthetist

Basic Investigations : Blood Group, CBP (Lavender top), Sr. Electrolytes, Bl. Urea,
Sr. Creatinine (Red top) PT, APTT (Blue top), BT, CT

Inform Anaesthetist for Pre Anaesthetic Check-up

Inform Operation Theatre

Prophylactic Antibiotic before Surgery

Reserve Blood Products (PRBC/FFP) along with Cross Matching Sample in Blood
Bank

Blood Products Needed for Surgery at least 3 hrs before Surgery

Proper IV Access to Baby

ET Tube Positioned

Shift with Warmer

Operative

Case Sheet sent to OT

Thermoregulation during Surgery Planned

Blood Products sent to OT

Post-operative

22

Bed Ready before Baby Arrives in NICU

Ventilator (if necessary) kept Ready

ET Tube Position Confirmed

Operation Notes

Post-operative Counselling

Advice by Surgeon

Analgesics

Time of Feeding

Time of Suture Removal

No

CENTRAL LINE INSERTION CHECKLIST


Babys Name : __________________________________ M. R. No. _______________ Date : ________________
Start Time : ______________ Procedure Performed By: __________________Assisted by : _________________

Yes

No

Date

Date

Before the procedure

Perform Hand Hygiene

Wear Cap, Mask, Sterile Gown and Sterile Gloves

Prepare the Insertion Site as Per Protocol


Skin Prepared With Chlorhexidine in 70% Isopropyl Alcohol

Solution Generously Applied by Back and Forth Friction Rub for around 30 Seconds

Solution Allowed to Dry for 2 minutes Before Skin Is Punctured

Cover Entire Patient with a Sterile Drape

Did Physician Maintain a Sterile Field during the Procedure

Sterile Dressing Applied to Cover Insertion Site

Site specific insertion

Umbilical

Upper Limb

Saphenous

Others

Rationale

Form Completed by

Central line Maintenance Bundle


Goal

Date

Date

Date

Date

Daily review of line necessity


(During Consultant Rounds)
Dedicated Lumen for TPN
0700 1300 hrs.
1300 1900 hrs.
1900 0700 hrs.
Aseptically accessing hub
and scrubbing hub with 2%
Chlorhexidine +
70% alcohol
0700 1300 hrs.
1300 1900 hrs.
1900 0700 hrs.
Check entry site for inflammation
with every change of dressing

23

SURFACTANT ADMINISTRATION
Baby's Name __________________________________ M. R. No. _______________ Date : ________________
Gestation Age__________wk

Weight ___________ gm

Time : ________________

Dr. ______________________________________

Nurse In-charge __________________________

Consent taken from parents : YES / NO

X-ray done : Yes / No

ET tube size used _____________________ Surfactant administered at :_____________________Hours of life


Pre-surfactant Fio2 _________%

PEEP_________cmH2O

Surfactant brand Curosurf / Survanta / Neosurf

Volume__________

PIP __________cmH2O
No. of Aliquots __________

Time taken to finish procedure __________minutes


Yes

No

Yes

No

Equipment list

Surfactant of Desired Brand

Desired Volume / Number of Vials Ordered

Syringes 5 ml, 10 ml, 2 ml

Surgical Blade

Infant Feeding Tube 5 Fr, 6 Fr

Endotracheal Tube of Sizes 2, 2.5, 3, 3.5

Functioning Laryngoscope with Straight Blade of Size 00, 0, 1

Ambu Bag with Reservoir

Masks of different Sizes

Oxygen Connection Tubes

Sterile Gloves / Cap / Mask / Gown

Midazolam

Tegaderm / Duropore

Scissors

Stethoscope

Suction Catheter

Pulse Oximeter

Procedure checklist

24

Laryngoscope Function Checked

Cap / Mask

Hand-washing Done

Gloves put on

Oxygen Tube Connected

Suction Catheter Connected

Pressure of Vacuum Set 100 cmH2O

Infant Feeding Tube Cut at Desired Length

Surfactant Loaded in Syringe

Sedation Given

Positioning of Infant

Intubated with Correct Size ET Tube

Air Entry Checked

Saturations Checked

ET Tube Fixed at Lip with Duropore

Surfactant given Aseptically

Connected to CPAP / Ventilator

Pressure / FiO2 Reset

Procedure Notes Written on Case Sheet

25

CHECKLIST FOR INTUBATION


Baby Name : ___________________________________

M. R. No. _________________________

Age: ______________ Gest.Age: _________wk Birth weight : ________gms Date & Time : _______________

Indication : Emergency / Elective
E. T. No. __________________
E.T. Fixed at _____________ cms
Yes

No

Yes

No

Equipment list

Functioning Laryngoscope with Straight Blade 00, 0, 1

Ambu Bag with Reservoir

Masks of Different Sizes

Oxygen Connection Tubes

Sterile Gloves

Endotracheal Tubes of Different Sizes (Based on Infant Weight )

Cap / Mask / Gloves

Midazolam

Syringes 5 ml

Tegaderm / Duropore

Scissors

Suction Catheter

Orogastric Tube

Pulse Oxymeter

Stethoscope

Procedure checklist

26

Laryngoscope Function Checked

Cap / Mask / Hand wash / Gloves

Oxygen Tube Connected to Central Oxygen

Suction Catheter Connected and Pressure Set to 100 cmH20

Sedation

Positioning of Infant

Procedure Done

Saturation Maintained

Air entry checked

ET Tube Fixed at Lip with Duropore

Extra Length of ET Tube Cut

X-ray Chest Ordered / ET Tube Position Rechecked and Repositioned

ET Tube Card Filled / Date and Time Noted

Connected to Ventilator

Procedure Notes Done

PERITONEAL DIALYSIS
Baby's Name __________________________________ M. R. No. _______________ Date : ________________
Gestation Age__________wk

Weight ___________ gm

Dr. ______________________________________

Time : ________________

Nurse In-charge __________________________

Consent taken from parents : YES / NO


Indication : Hyperkalemia / Anuria

Last creatinine: ____________

Urine output last 24 hrs: ____________


Yes

No

Yes

No

Equipment list

Vygon Polypropylene Catheter 12 Fr with Trocar and Connector

Scalpel

IV Cannula 20 G

Peritoneal Dialysate Fluid (1.7%)

IV Set 2

Empty Bottle for Draining

3 way Connector

Xylocaine (2%)

2 ml, 10 ml Syringes

Dressing set with Sterilium, Betadine

Silk Thread and Needle for Suture

Peritoneal Dialysis Chart

Cap / Mask / Gown

Latex Glove 2 Pairs

Fixing Tape

Nasogastric Tube No. 5 Fr / 6 Fr

Drapes 2

Procedure checklist

Cap / Mask worn

Hand-washing Done

Gown and then Gloves put on

Pre procedure Decompression of Abdomen

Catheterisation of Bladder

Skin preparation with 2% Chlorhexidine

Dressing and Draping

Site of Insertion Properly Selected Right / Left

27

28

Catheter Inserted and Fixed

PD Fluid Connected

Heparin Added into PD Fluids

Hemostasis Maintained

Check for Obstruction, Bleeding, Dislodgement, Leakage, Extravasation, Infection

PD Chart Properly Prepared and Nurses Explained on Documentation

Volume of PD Fuid per Exchange

Frequency and Duration of Exchanges Recorded

Fill Time, Dwell Time, and Drain Time Clearly Written

Weight Charting Daily

Signs of Peritonitis Explained to Duty Nurse

Mention When to Stop PD

Electrolyte Monitoring / Renal Profile Monitoring Chart

Peritoneal Dialysis Procedure Notes Written

CHECKLIST EXCHANGE TRANSFUSION


Baby's Name __________________________________ M. R. No. _______________ Date : ________________
Gestation Age__________wk

Weight ___________ gm

Time : ________________

Dr. ______________________________________

Nurse In-charge __________________________

Consent taken from parents : YES / NO

Indication : ______________________________

Max TSB : _______ mg/dL

TSB before Exchange : ______ mg/dL

Volume of Blood Exchange_______ ml (2 x 80 x Birth Weight in kgs)


Number of Aliquots : _________

Babys Blood Group : __________

Aliquot Volume _______ ml


Mothers Blood Group_________

ABO/Rh Incompatibility : Yes / No If YES, Specify__________________________________________________


Start Time : __________
Donor Bag no.

Date of collection

Pre Exchange Condition


Pallor : Yes / No
Bilirubin Encephalopathy : Yes / No

Group

End Time : _________


Cross checked by

If Yes, Stage _____________________________

Findings : __________________________________________________________________________________
Respiratory Support : Yes / No

Sickness Status : Healthy / Sick

Medications : 1_______________________ 2 _________________________ 3 ______________________


Yes

No

Equipment list

Blood Ordered

Mother Sample Obtained for Cross Match

Umbilical Catheter 3.5 Fr, 5 Fr, 6 Fr, 7 Fr

Gloves Latex (2 Pairs)

Dressing Set

Cap / Mask / Gown (2 Pairs)

Spirit / Betadine / Chlorhexidine 2%

Drapes (2)

Syringe 5 ml (2), 10 ml (2), 2 ml (2)

IV Cannula 24 No. (1)

Three Way Stop Cock (2)

Blood Transfusion Set

IV Set (2)

Plastic or Glass Bottle for Disposal of Blood

Saline / Sterile Water

Transparent Dressing

29

Paper Tape / Tegaderm / Duropore

Surgical Blade

Sucrose Analgesia

Exchange Cycle Chart Prepared

Cycle Volume and Cycle Number Determined


Yes

No

Procedure Checklist

Umbilical Cannulation Done

Umbilical Catheter in-situ

Proper Aseptic Precautions taken during Cannulation

Back Flow Checked

Need of Peripheral Artery

Phototherapy Continued During Procedure

Blood Bag No. and Blood Group Cross-checked

Three Way Connected to Umbilical Catheter

Blood Bag Sufficiently Warm

Transfusion Set and IV Set Properly Connected

Cycle Started with Pull Out

Same Volume Pushed In

Bag Mixing done Intermittently

Hemodynamics Monitored

Desired Number of Cycles Done

Blood Volume was Sufficient for Cycles

IVIG Dose Administered

Last Aliquot sent for PCV, TSB and Calcium

Procedure Notes Written

Complications During the Procedure:_____________________________________________________________


Post Exchange Transfusion: HR _____ RR ______ SpO2 ________ Blood Pressure _______
Respiratory Support ______________ Other Remarks _________________________
Instructions: Post-Exchange Transfusion
1. Start feeding after _____ hours

2. RBS at _____ TSB at _______hours

3. Injection vitamin K 1mg IM stat

4. Medications : _____________

5. Monitor

a) HR________ hourly

b) RR________hourly

c) SpO2______hourly

d) BP_______ hourly

6. Preserve Blood sample for a) Cross-match


b) DCT and Reticulocyte Count
c) Donor blood for next 24 hours (in case of reaction report to blood bank)

30

EXCHANGE TRANSFUSION monitoring form


Cycle
No.

Time

Volume
Out

Volume
In

Heart
Rate

SpO2

Breathing

BP

Temp

Remarks

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30

31

checklist for Umbilical line


Baby Name : ___________________________________

M. R. No. _________________________

Age: ______________ Gest.Age: _________wk Birth weight : ________gms Date & Time : _______________
Dr. ________________________ Assisting Nurse : ________________ Time taken __________________ mins

Yes

No

Yes

No

Equipment list

Umbilical Catheter 3.5 Fr, 5 Fr, 6 Fr, 7 Fr

Gloves Latex (2 pairs)

Dressing Set

Cap / Mask / Gown (2 pairs)

Spirit / Betadine / Chlorhexidine 2%

Measuring Tape

Drapes (2)

Syringe 5 ml (4), Saline / Sterile Water

Transparent Dressing

Paper Tape / Tegaderm / Duropore

Surgical Blade

IV Fluids Prepared (Dextrose 10%, TPN etc) / IV Set

Sucrose

Procedure checklist

32

Length of Insertion from Shoulder to Umbilicus Length and Chart

Cap Mask Worn / Handwash / Gown / Gloves

Site Preparation with Spirit and Betadine

Site Covered with Drapes

Proper Size Umbilical Catheter Inserted Depending on Size of Vein and Artery

Back Flow Checked

Fixed at Measured Length with Transparent Tape and Tegaderm

Flushed with Saline

X-ray Ordered or Position Checked with Ultrasound and Fixed

Position of UVC / UAC Noted Down on Card

Vital and Temperature of Infant Checked

Haemostasis Secured

Bionecter Used and IV Fluids Connected

Heparin Connected to Umbilical Artery Line

Periodical Checks for Local Signs of Inflammation / Swelling

Watch for Lower Limb Colour and Perfusion

Hub of Line Covered with Sterile Gauze

Procedure Notes Done

CHECKLIST FOR PERIPHERALLY INSERTED CENTRAL VENOUS LINE


Baby Name : ___________________________________

M. R. No. _________________________

Age: ______________ Gest.Age: _________wk Birth weight : ________gms Date & Time : _______________
Dr. ________________________ Assisting Nurse : ________________ Time taken __________________ mins
Site :

Antecubital Right Arm / Left Arm

Saphenous Right / Left

Popliteal Right / Left


Yes

No

Yes

No

Equipment list

PICC Line Size (Depending upon Site of Insertion)

Gloves Latex (2 pairs)

22 Gauze Cannula

Dressing Set

Cap / Mask / Gown (2 pairs)

Measuring Tape

Drapes (2)

Spirit / Betadine / Chlorhexidine 2%

Syringe 5 ml (2)

Saline / Sterile Water

Transparent Dressing

Paper Tape / Tegaderm / Duropore

IV Fluids Prepared (Dextrose 10%, TPN etc) / IV set

Sucrose

Procedure checklist

Site Selection for Insertion

Length of Line to be Inserted Measured

Cap Mask Worn

Hand Scrub Performed

Gown and then Gloves Worn

Site Preparation with Spirit and Betadine/ Chlorhexadine

Site Covered with Drapes

Cannula Inserted at Selected Site

Guide Wire Passed (Seldinger Technique)

PICC Line Inserted Taking Care of All Aseptic Precautions

Guide Wire Removed

Back Flow Checked

Fixed at Measured Length

33

34

Fixed with Transparent Tape and Tegaderm

Flushed with Saline

X-ray Ordered or Line Tip checked with Ultrasound

Position Rechecked and Fixed (Line Tip in SVC or IVC)

Vitals and Temperature of Infant Checked

Haemostasis Secured

Limb Checked for Signs of Ischemia

Bionecter used and IV Fluids / TPN Connected

Hub of Line Covered with Sterile Gauze

Procedure Notes Done

Periodical Checks for Local Signs of Inflammation / Swelling

CHECKLIST FOR INTRAVENOUS CANNULATION


Yes

No

Yes

No

Equipment list

Sterile gloves

24 G Cannula Preferably 2 in Number

Antiseptic Solution (2% Chlorhexidine in 70% Isopropyl Alcohol) / Betadine

Syringe 5 ml and 2 ml

Three Way with 10 cm Extension

2 2 Gauze / Cotton Balls

Vacuum Collection Tubes and Adaptor

Blood Culture Bottle (if blood culture to be taken)

Saline or Heparin Lock

Transparent Dressing

Paper Tape / Tegaderm / Duropore

IV Fluids Prepared (Dextrose 10%, TPN etc) / IV Set

Procedure Checklist
Cannula Placement

Trained Person

Document Reason Emergency / Planned / Number of Attempts Made

Maximum 2 Attempts per person

Plastic Tray Cleaned with Soap and then Cleaned with 70% Alcohol Wipe

Operator and Baby to be Comfortable

Sucrose or Breast Milk for Baby to Relieve Pain

Hand Hygiene WHO 5 steps

Check Baby Identity

Choose Appropriate Size Cannula and Appropriate Vein Site

Gloves

Torniquet not too Tight (if used)

Clean site with 2% Chlorhexidine + 70% Propyl Alcohol Working Outwards and
Allow to Dry for 30 60 seconds

Do Not Palpate Vein After Disinfecting Skin

Stylet Removed from Cannula to be Placed back in Tray

T-clamp / 3-way to be Used at End Port

Fresh Cannula to be Taken for Every Attempt

After Cannula is Placed Flush with 1 ml of 0.9% Saline

Safe Disposal of Stylet

35

Yes
Cannula Dressing
Secured Using Sterile Clean Polyurethane Dressing (Tegaderm)
Occlusive / Opaque / Adhesive Dressing (Preferably not to be used)
Steristrips Used before Dressing to Secure Cannula
Cannula Care
Daily Once Inspection and Documentation of Cannula Site for Signs of Phlebitis i.e.
Erythema / Redness / Swelling
Remove Cannula if Signs of Phlebitis Present or iv Therapy not Required
IV Flow Rates Cross Checked
Potential Irritant Infusions Given in Bigger Calibre Veins
Preferable to Avoid Blood Sampling from Cannula
Change Dressing if Visibly Soiled or Soaked
Before and After Administration of Drug Flush 1 cc 0.9% Saline
For Giving Injection and Boluses Follow Hand Hygiene / Clean Port or Hub of Cannula
with 2% Chlorhexidine and Allow to Dry
For Boluses or Injection Use 5 or 10 cc Syringes and Not 2 cc Syringe
Change IV Infusion Set Daily
Infusion / Syringe Pump to Administrate IV Fluid Therapy

36

No

INFECTION CONTROL AUDIT CHECKLIST


General

Does the organization have written Procedures and Policies for Infection Control

Is there enough IEC (Information, Education and Communication) material


(e.g. Hand Hygiene, Waste Segregation)

Yes

No

Yes

No

Facility checklist for correct hand washing: Percentage of hand washing


encounters with all components adhered to

Overall appearance of the environment is tidy and uncluttered with only


appropriate, clean and well maintained equipment and furniture
The environment and equipment smells clean, fresh and pleasant

The following items are clean and free from splashes, soil, film, dust, fingerprints, and spillage

The complete floor, including edges and corners


Baby weighing scales
Resuscitation Equipment : AMBU Bag, Laryngoscope, Suction Bottles,
Oxygen and Suction Tubes
Equipment : Warmers / Incubators, Monitors, Infusion Pump, Ventilator /
CPAP
Mattress on Warmer / Incubator is free of rips and tears and is visibly clean
Waste receptacles are clean
All high and low surfaces are free of dust
Fans are clean and free from dust

There is an identified area for the storage of clean and sterile equipment

A dirty utility is available

A separate sink is available for decontamination of patient equipment

Use of Personal Protective Equipment

No

Facility checklist for hand washing station supplies: Percentage of sinks fulfilling all the criteria

Yes

Do healthcare workers have appropriate supplies (materials for hand


decontamination, sharps containers, personal protective equipment)

Environment

No

Has the staff received any training on infection control (E.g. Trained in hand
decontamination, the use of personal protective equipment, the safe use and
disposal of sharps) Ask a member of medical, nursing and ancillary staff

Hand Hygiene

Yes

Sterile and non-sterile gloves (powder free) are available in all clinical areas
Observation of glove uses of atleast one healthcare (Includes correct
indication, correct method of wearing gloves, hand hygiene before and after
wearing gloves)

Are aprons available (Autoclaved reusable linen/ Disposable plastic aprons)

Are clean face masks and eye protection equipment available

37

Safe use and disposal of sharps

Is the sharp container appropriate (Size, shape, material) for its use

Is the sharp container located in a safe position that avoids spillage

Is the sharp container used for any purpose other than the disposal of sharps

Is the sharp container not filled above the fill line/ more than 3/4 full

Is the sharp container disposed of every 3 months even if not full

Is the sharp container temporarily closed when not in use

Waste disposal

Is there clinical waste signage (posters) identifying waste segregation available


in all areas

Is there evidence that the waste contractor is registered with a valid licence
(check records)

Is waste segregation happening with colour coded bins and colour coded
plastic bags lining the containers

Is the waste storage area clean and tidy

There is no storage of waste in corridors or in other inappropriate areas inside/


outside the facility whilst waste is awaiting collection.

All waste bins are visibly clean externally and internally

There are no overfilled bags. Bags are no more than 2/3 full.

Spillage and/or Contamination With Blood/Body Fluids

Sodium hypochlorite solution in the strength 1:10,000ppm (1%) is available

Staff is aware of how to preprare 1% Hypochlorite solution.

Feeding

Is a Water sterilizer available and functioning with hot water?

Is there a clean area for preparation of feeds and a sink available for
decontamination and cleaning of used feeding vessels?

Observe whether feeding utensils are allowed to remain in boiling water for
atleast 5min

Aseptic Non Touch Technique

38

Atleast 1 aseptic technique observed by using the Aseptic Non Touch


Technique (ANTT) Tool. (E.g. blood sampling, IV line insertion, IV fluid
preparation and attachment to IV port etc) Percentage of absolute compliance
to all 10 steps

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Lumbar Puncture Checklist


Baby Name : ____________________________________________

M. R. No. _________________________

Procedure done by _______________________________ Assisted by ________________________________


Date & Time : ____________________

No. of Attempts : ___________________________

Yes

No

Yes

No

Equipment list

Neonatal Lumbar Puncture Tray (drape, needle holder, cotton, guaze)

22 G and 24 G Needles

Surgical Masks

Sterile Gloves

2 x 2 Gauze

Cotton Balls

Sample Labels with Sterile Bottles

Sharps Container

Procedure checklist

Informed Consent from Parent

Blood Sugar Measured

No Active Bleeding

Platelet > 50000 / mm3

Infection at Lumbar Puncture Site

No Evidence of Raised ICP (posturing, bulging AF)

Hand wash, Cap, Mask, Gown and Gloves

Baby Positioned Lateral Decubitus with no Flexion of Neck

Site Cleaned with Betadine and Spirit

Puncture Site Identified (L4 and L5, ischeal spine )

Bevel up and Needle Advanced into the Subarachnoid Space

Needle Advanced towards Navel

CSF Collected into Four Sterile Bottles (Biochemistry, Cell Counts, Gram Stain,
Culture)

Puncture Site Cleaned to with Spirit to Remove Betadine

Pressure Applied to Site

Procedure notes Documented

39

Aseptic non touch technique checklist: Audit

Steps of Aseptic Non Touch Technique

40

Two Persons doing the Procedure

Hand Hygiene before the Procedure

Hand Hygiene for the Assistant

Cleaning the Trolley / Surface where Equipment kept

Assistant Opening the Equipment Appropriately

Appropriate Glove use during the Procedure

Sterile Field for the Procedure

Cleaning of the Site of Procedure (wait for 30 seconds)

Protection of the Key Parts all the Time

Hand Hygiene after the Procedure

Adherence to all 10 steps

Cannulation

Blood
Sampling

Drug
Making

Requirements for ventilated beds


Requirements for ventilated beds

Open Care Radiant Warmer/Ventilator/Humidifier

Electric Sockets- 5 Ampere-4 / 15 Ampere-4

UPS Sockets

Central Oxygen- 2 Port

Compressed Air- 1 Port

Central Suction- 1 Port

Suction Catheter- Ch 8/6 With Suction Adapter

Mucus Aspirator- 1

Laryngoscope Blade Size 00/0

Infant Resuscitator 250ml/500ml-1

ET Tube Size 2.5/3.0/3.5/4.0

Multipara Monitor

Syringe Pump

Infusion Pump

Hand Rub Dispenser

Disposable Sterile Gloves

Infant Feeding Tube Fr 8/6

Hood Box /Oxygen Cannula

Disposable Syringes

Sterile Gauze And Cotton

Sterile Water

Umbilical Catheter

ICD Catheter

Gown/Cap Mask

Measure Tape- Duropore / Transpore / Dynaplast /Tegaderm

Binaural Stethoscope And BP Cuff

Glucometer With Strips

Trash Bins

PICC Line

Venflon 22 no.

Dressing Sets

Sterile Towel Bins

Forceps

Spirit

Betadine

Surgical Gloves

ABG Machine

EG7

CG4

Inj.Heparin And Heploc

Yes

No

41

Requirements for Non-Ventilated bed

Open Radiant Warmer

Oxygen Port - 1

Electric Socket 5 Ampere- 1 & 15 Ampere-1

Hand Rub Dispenser

Syringe Pump

Infusion Pump

Spo2 Monitor

Mucus Aspirator

Infant Feeding Tube

Palade/Gavage

Syringes

Measuring Tape

Binaural Stethoscope

Sterile Cotton/Gauze

Trash Bins

Emergency Equipment and Medicine Tray

Resuscitator/Ambu Bag

Laryngoscope With Blade 00/0

ET Tube Sizes 2.5/3.0/3.5/4.0/1

IV Cannula Nos 23/24

2 Each

Feeding and suction tube Fr 6/7/8

1 Each

Syringes 5/10cc

2 Each

3-way connect- 100cm &10 cm

Surgical Blade

Suture Material

Adhesive Tapes

Needle Holder

ICD Trocar/Under Water Seal Bag

Artery Forceps

42

Quantity

Medicines- Adrenaline, Calcium Gluconate,


Atropine, Midazolam, Dopamine,
Dobutamine,Normal Saline , Phenobarbitone

Yes

No

Yes

No

43

Hand Hygiene
For Hand Washing

Running water with large washbasins which require little maintenance, with anti splash devices and
hands-free controls.

Soap or antiseptic depending on the procedure.

Facilities for drying without contamination (disposable towels if possible)
For Hand Disinfection

Alcoholic rubs with antiseptic and emollient Gels which can be Applied to Physically Clean Hands.
Hand Rub Should Contain Minimum 60% Alcohol and Preferably 70% or More Alcohol.

Hand Care

Take Care of your Hands by Regularly Using a Protective Hand Cream or Lotion, atleast Daily.

Do not Routinely Wash Hands with Soap and Water Immediately before or
after using an Alcohol-Based Hand Rubs.

Do not use Hot Water to Rinse your Hands.

After Hand Rubbing or Hand Washing let your Hands Dry Completely before putting on Gloves.

Do not Wear Artificial Fingernails or Extenders when in Direct Contact with Patients.
Keep Natural Nails Short.
Personal Hygiene

All Staff must Maintain Good Personal Hygiene. Nails must be Clean and Kept Short.

False Nails Should not be Worn.

Hair must be Worn Short or Pinned Up.

Beard and Moustaches must be Kept Trimmed Short and Clean.

44

45

46

Housekeeping procedures in the NICU


To Minimize The Transmission of Microorganisms From Equipment and the Environment, Adequate Methods for
Cleaning, Disinfecting and Sterilizing must be in Place.

Few Definitions
Cleaning
Removing Foreign Material (Soil, Organic Matter, Microbes) from an object. It is Best Done with Clean and Cold
Running Water. Sometimes Mild Disinfection With 0.5% Chlorine Is Required Before Cleaning. Most Environmental
Objects (Floors, Walls, Sinks) Require Only Mild Disinfection and then Cleaning. All objects in the NICU Require
Cleaning.
Disinfection
Disinfection Is Removing all Pathogenic Microbes Except Spores. All Objects must be Cleaned before Disinfection.
This is Required for all objects that come in Contact with Baby (Warmers, Equipment, Linen, Cotton, Gauze, Baby
Belongings Etc.). Disinfection is done with moist heat (70 to100 C) or with Chemicals (2% Glutaraldehyde, 6%
Hydrogen Peroxide, 0.2 -0.3% Peracetic Acid). When using Chemicals for Disinfection, These Should not Come in
Contact with the Newborn.
Sterilization
This is Removal of All Living Microbes Including Spores. This Is Required for all objects that Invade the Body
(Orogastric tube, Catheters, and Ventilator Circuits). Sterilization is done with Autoclave/Dry Heat/Ethylene Oxide
Gas.
Decontamination
It involves Cleaning, Disinfection and Sterilization
Responsibility of Housekeeping Staff

Cleaning Floors-(Including Counseling room, Handover, Triage, Changing and Feeding Rooms)
Floor Mopping. Once per shift and as and when needed in case of spill.
Surface Cleaning - Daily (Horizontal Surfaces, Window Sills, Doorknobs, Light Switches, Furniture in Nursing
Station, Racks).
Surface Cleaning , When Soiled (Walls, Window Blinds, Window Curtains.)
Suction Jars, Oxygen Humidifiers, Suction Tubing.
Main Scrub Area & Sinks
Slippers
Collecting Soiled Linen
Waste Emptying
Cleaning Waste Disposal Bins
Cleaning of Toilets

Once a Shift
Floor Cleaning, Surface Cleaning, Disposal Of Waste
Once daily
Scrub Areas and Sink, Suction Jars, Oxygen Humidifier, Slippers and Waste Bins, Soiled Linen, Toilets

47

Housekeeping Procedures In The NICU


Order of
Cleaning

48

Responsibility

Cleaning Method

Frequency

Suction Jars, Oxygen


Humidifiers, Suction Tubing.

Removed & Washed with Soap


and Water. Sent for Sterilization 2 Times/Week
With ETO or In 2% Cidex for 8
Hours

Surface Cleaning (Horizontal


Surfaces, Window Sills, Top
of Doors, Doorknobs, Light
Switches, Lights, Furniture in
Nursing Station, Racks.)

[0.5% Chlorine+ Detergent


Cleaning solution.] Only Wet
Dusting With Cleaning Cloth.

Daily and Whenever Visibly


Soiled.

Procedure and Examination


Rooms

Wipe Horizontal Surfaces With


[0.5% Chlorine + Detergent
Cleaning solution.]

After Each Procedure and


Whenever Visibly Soiled.

Walls, Windows, Ceilings,


Window Curtains, Window
blinds, Doors.

[0.5% Chlorine+ Detergent


Cleaning Solution]

Main Scrub Area & Sinks

Scrub with a Separate Brush


and [0.5% Chlorine+ Detergent
Cleaning Solution.] Rinse With
Water.

Daily

Soiled Linen

Collect Soiled Linen in Closed,


Leak Proof Containers.

Daily (or More often as


Needed)

Waste

Collect Waste from all Areas.

At least Daily (or more


Frequently as Needed). Avoid
Overflowing

Floor Mopping

0.5% Chlorine Cleaning +


Detergent Solution, Only Wet
Mopping

Once Per Shift (3 Times / Day)


and When Soiling or Spill
Occurs.

Slippers

Detergent solution

Every Night

10

Waste Disposal Bins

[0.5% Chlorine + Detergent


solution] and Scrub to Remove
Soil and Organic Material.

Clean Contaminated waste


containers Daily And Non
Contaminated Containers
When Visibly Soiled And At
Least Once a Week.

11

Toilets

Scrub With a Separate Brush


and Harpic.

3 times/day (At the End of


Every Shift.)

Spot Cleaning Only When


Soiled

HOUSEKEEPING PROCEDURES IN THE NICU


The Formula for Making a Dilute Chlorine Solution From Any Concentrated Hypochlorite Solution Is:



Check Concentration (% Concentrate) of the Chlorine Product You are Using.


Determine Total Parts Water Needed Using the Formula Below.
Total Parts (TP) water = [%Concentrate ] - 1 % Dilute
Mix 1 part concentrated bleach with the total parts water required.

Example: Make a dilute solution (0.5%) from 5% concentrated solution


STEP 1: Calculate TP water: [ 5.0% ] - 1 = 10 1 = 9
0.5 %
STEP 2: Take 1 Part Concentrated solution and add to 9 parts water.
The Formula For Making a Dilute Solution From a Powder of Any Percent Available Chlorine Is:
Formula for making Chlorine Solution from Dry Powders:



Check concentration (% concentrate) of the powder you are using.


Determine grams bleach needed using the formula below.
Grams/Liter = [ % Dilute ] X 1000
% Concentrate
Mix measured amount of bleach powder with 1 litre of water.

Example: Make a dilute Chlorine-releasing solution (0.5%) from a Concentrated Powder (35%).
STEP 1: Calculate grams/litre: x 1000 = [ 0.5% ] X 1000 = 14.2 g / L
35%
STEP 2: Add 14.2 grams (Approximately 14 g) to 1 litre of water.

WHO (1989) recommends 0.5% Chlorine Solution for Decontaminating Instruments and Surfaces Before Cleaning. In addition, Because of the Potentially High Load of Microorganisms And/Or Other Organic Material (Blood
or Other Body Fluids) On Soiled Items, Using a 0.5% Solution for Decontamination Provides a wider Margin of
Safety.

49

HOUSEKEEPING PROCEDURES IN THE NICU


Cleaning Methods Of Housekeeping Surfaces
Cleaning Should Start with the Least Soiled Area and move to the most soiled area and from High to Low
Surfaces.
Wet Mopping
Is the Most Common and Preferred Method to Clean Floors.
Double-Bucket Technique
Two Different Buckets are used, One Containing a Cleaning Solution and the other Containing Rinse Water.
The Mop is always Rinsed and wrung out before it is Dipped into the Cleaning Solution. The Double-Bucket
Technique Extends the Life of the Cleaning Solution (Fewer Changes are Required), Saving both Labor and
Material Costs.
Dusting
Is Most Commonly Used for Cleaning walls, Ceilings, Doors, Windows, Furniture and Other Environmental
Surfaces.
Clean Cloth or Mops are Wetted with Cleaning Solution Contained in a Basin or Bucket. The Double-Bucket
System Minimizes the Contamination of the Cleaning Solution.
Dry Dusting should be avoided and Dust Cloths and Mops Should Never be Shaken to avoid the Spread of
Microorganisms.
Dusting Should be Performed in a Systematic way, Using a Starting Point as a Reference to Ensure that all
Surfaces Have been Reached.
Using Care when wet Dusting Equipment and Surfaces above the Patient to avoid Patient Contact with the
Detergent/Disinfectant.
When Doing High Dusting (Ceiling Tiles And Walls), Check for Stains that may Indicate Possible Leaks. (Leaks
Should be Repaired as soon as Possible because Moist Ceiling Tiles Provide a Reservoir for Fungal Growth.)
Part of the Cleaning Strategy is to Minimize Contamination of Cleaning Solutions and Cleaning Tools.
Another source of contamination in the cleaning process is the cleaning cloth or mop head, especially if left
soaking in dirty cleaning solutions. Laundering of cloth and mop heads after use and allowing them to dry before
re-use can help to minimize the degree of contamination. A Simplified Approach to Cleaning Involves Replacing
Soiled Cloths and Mop Heads with Clean Items Each Time A Bucket of Detergent/Disinfectant is Emptied and
Replaced with Fresh, Clean Solution.)
Cleaning Solution Should be Prepared Daily Since another Reservoir for Microorganisms in the Cleaning Process
may be Dilute Solutions of the Detergents Or Disinfectants, Especially if the Working Solution is Prepared in a
Dirty Container, Stored for Long Periods of time, or Prepared Incorrectly. Application of contaminated cleaning
solutions, particularly from small quantity aerosol spray bottles or with equipment that might Generate Aerosols
during operation, should be avoided, Especially in High-Risk Patient areas.
Making Sufficient Fresh Cleaning Solution for Daily Cleaning, Discarding any Remaining Solution, and Drying out
the Container will help to Minimize Containers that Dispense Liquid as Opposed to Spray-Nozzle Dispensers (e.g.,
Quart-Sized Dishwashing Liquid Bottles) can be used to apply Detergent/ Disinfectants to Surfaces and then to
Cleaning Cloths With Minimal Aerosol Generation.
Cleaning Strategies For Spills of Blood and Body Substances:
Clean Spills with a 0.5% Chlorine Solution.
Clean Spills of Blood, Body Fluids and other Potentially Infectious Fluids Immediately:
For Small Spills
While Wearing Utility or Examination Gloves, Remove Visible Material Using a Cloth Soaked in a 0.5% Chlorine
Solution, then wipe Clean with a Disinfectant Cleaning Solution.
For Large Spills
While Wearing Gloves, Flood the Area with a 0.5% Chlorine Solution, Mop up the Solution and then Clean as
usual with Detergent and water.

50

How to Clean Soiled and Contaminated Cleaning Equipment


Step 1: Decontaminate cleaning equipment that has been contaminated with blood or body fluids by
soaking it for 10 minutes in a 0.5% Chlorine Solution or other locally available and approved
disinfectants.
Step 2: Wash cleaning buckets, cloths, brushes and mops with detergent and water daily, or sooner if visibly
dirty.
Step 3: Rinse in clean water.
Step 4: Dry completely before reuse. (Wet cloths and mop heads are heavily contaminated with
microorganisms.).

Chemical

Autoclave

Dry Heat

Soak
10 24 minutes

Pressure : 106 kpa


(15 lb/inch sq)
Te m p e r a t u r e
:121 C
(250 F)

170 C

Boil
or Steam

Chemical
Soak 20 minutes

An alternative to disinfection for environmental cleaning for some objects is hot water
Disinfection with hot water
1. Sanitary Equipment
2. Linen

Temperature
80 Celsius

Duration
4560 seconds

70 Celsius
or 95 Celsius

25 minutes
10 minutes

51

Housekeeping Procedures In The NICU


Cleaning schedule for Nursing Staff:
1

Object

Disinfection Method

Warmer/Incubator When In Use

Soap & Water

Sterilizer

Soap & Water

Oxygen hood

Soap & Water

Feeding Utensils (Paladay, Spoon, Katories etc.)

Soap and water & Boil For 10 Minute

Refrigerator

Defrost & Soap & Water

Stethoscope/Thermometer/ Measuring Tape

Alcohol/Spirit

Feeding Utensils Shelf/Bathing Tray Shelf

1% Bacillocid*

TPN Room ( Laminar Flow, Dressing Trolley)

1% Bacillocid

10

Infusion Pump /Monitor/Bedside Table

1% Bacillocid

11

Warmer/Incubator When Not In Use

1% Bacillocid & Rinse Well With Water

12

Unused Biomedical Equipment

1% Bacillocid

13

Crash Trolley/Other Plastic Trays

1% Bacillocid

14

Ambu Bag & Mask

Soap & Water and Etio or 2% Cidex

15

Nasal Canula Oxygen

Soap & Water & Etio

16

Oxygen & Suction Bottles

Soap & Water & Etio

17

Oxygen & Suction Tubes

Etio Sterilization

18

Swab Container, Injection And Medicine Tray

Wash With Soap & Water / Autoclave

19

Sets For Procedures

Wash With Soap & Water/ Autoclave

20

Cheatle Forceps

Autoclave

21

Steel Drums

Autoclave

22

Baby Linen, Blanket, Blanket Cover

Wash & Autoclave

23

Cotton Gauze

Autoclave

*1% Bacillocid is Prepared By Adding 50ml Bacillocid + 5 Litre Water


Soap and Water to be used Instead of Bacillocid after the Initial Outbreak of Infection Subsides.

52

Housekeeping procedures in the NICU


Time Schedule For Cleaning And Disinfection
Once A Day - Morning

Once A Day - Night

Once A Day - Evening


Once Or Twice - Weekly

After Every Use

Sterilizer
Swab Container, Injection & Medicine Tray
Cheatle Forceps
Steel Drums
Baby Linen, Blanket & Blanket Cover
Cotton Gauze

Warmer Or Incubator
Bed Making
Infusion Pump /Syringe Pump
Stethoscope, Measuring Tape, Cotton, Syringe, Gauze,
Thermometer
Weighing Scale
Ambu Bag
Laryngoscope
Oxygen Hood, Oxygen Tube, Suction Tube
Change Water in Oxygen And Suction Bottle

TPN or Drug Preparation Area


Unused Medical Equipment, Incubator, Warmer
Crash Trolley, Files, Nursing Stations

Ambu Bag To Be Sterilized


Refrigerator
Procedure Trays (Exchange, LP, ICD, Central Line Kit)

Stethoscope, Thermometer, Laryngoscope, Feeding Utensils

53

54

Ventilator associated Pneumonia (VAP) Bundle


Hand Hygiene

Wash Hands with Soap and Water (Follow all 6 Steps for Minimum 60sec )

Wear Mask, Cap and Gloves

Do Not Touch Baby /Babys Environment with Gloves.

Handwash / Handrub After Removing the Gloves
Endotracheal Tube Care

During Intubation Aseptic Technique to be Maintained, Mask And Gloves to be Worn

Oral Intubation is Preferred over Nasal
Humidification

Heated Humidifier is a Must

Inspired Gas At 370C and 100% Relative Humidity

Use Distilled Water in the Humidifier.

Always use the Auto-Fill Technique for the Humidifier to fill water.

No Condensation in Inspiratory Limb

Drain Condensate to Water Trap

Consider Condensate as an Infectious Waste and Discard accordingly

Handwash after Contact with Condensate
Respiratory Equipment Care

Ventilator Circuits and Oxygen Therapy Equipment Should be Readily Available

CPAP Systems Allowed to remain on Stand-By for no Longer than 12 hrs

Resuscitation bags not to be Laid on bed, to be Hung Outside Of Bed.
Resuscitation Bags Should be Replaced Once a Week

The Circuit to be Positioned Parallel to the Baby and in Dependent Position
Position of Infant

30 degree elevation of the head end

Lateral Decubitus is the Preferred Position

Frequent Change in Position
Stress Ulcer Prophylaxis

Acid Gastric Content Prevent Bacterial Colonisation

Avoid Using Antacids-Such as Ranitidine

Sucralfate is Preferred over Ranitidine when required
Oral Hygiene

Oral Suction to Prevent Pooling of Secretions

Always Suction Nose before the Mouth

Moisten the Lips with Saline

Avoid Reusable Suction Tubes for Oral Suction

Mucus Bulb Suction Avoided for Oral Suction

Chlorhexidine Oral Application is optional
Enteral Feeds

Encourage Oral Feeds through the Orogastric Tube

Prefer EBM over formula

Trophic Feeds if not on Enteral Feeds
Shorten Duration of Intubation and Ventilation

Consider Use of Non Invasive Ventilation

Wean Off Invasive Ventilation as soon as possible

Prevent Unplanned Extubation

Avoid Unnecessary Re-Intubation
Post Extubation

Frequent Change in Position

Oral and Nasal Suction

Nebulisation SOS

Watch for Respiratory Distress

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Central line associated blood stream infection (CLABSI)


Insertion Bundle

Establish a Central Line Kit or Cart to Consolidate all Items Necessary for the Procedure
Perform Hand Hygiene with Hospital-Approved Alcohol-Based Product
or Antiseptic-Containing Soap before and After Palpating Insertion Sites and before and after
Inserting the Central Line Use Maximal Barrier Precautions (Including: Sterile Gown, Sterile Gloves,
Surgical Mask, Cap, & Large Sterile Drape)
Disinfect Skin with Appropriate Antiseptic (2% Chlorhexidine, 70% Alcohol)
before Catheter Insertion
Minimize the Number of Access Ports
Keep Connecting Ports with UVC/UAC away from Diaper Area
Use Either a Sterile Transparent Semi-Permeable Dressing or Sterile Gauze to Cover The Insertion
Site
Prefer Upper Limb Veins over Lower Limb Veins
Ensure the Catheter Tip at Proper Position
No Blood Stains around the Insertion Site

Maintenance Bundle

Perform Hand Hygiene with Hospital Approved Alcohol-Based Product or Antiseptic Containing
Soap Before and After Accessing a Catheter or Before and after Changing the Dressing
Evaluate The Catheter Insertion Site Daily for Signs of Infection and Dressing Integrity
If the Dressing is Damp, Soiled, or Loose Change Dressing Aseptically and Disinfect
the Skin around the Insertion Site with an Appropriate Antiseptic
Develop and Use Standardized Intravenous Tubing Setup and Changes
Maintain Aseptic Technique when Changing Intravenous Tubing
and when Entering the Catheter Including Scrub the Hub
Daily Review of Catheter Necessity with Prompt Removal when No Longer Essential

Hub Care Bundle









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Cleanse Hands with Soap and Water


Put on Gloves
Establish Sterile Field Under Access Port
Place Syringes on Edge of Sterile Field
Scrub Access Port with Chlorhexidine for 10 Seconds and Allow to Dry
(Clean Outside and on top but not inside the Hub)
Pick up Syringe Keeping Tip Sterile
Attach Syringe to Hub, Keeping Connections Sterile
Administer Flush Solution Keeping Connections Sterile

Nutrition Bundle
Parenteral Nutrition





Start Aminoacids atleast 1g/Kg/Day on Day 1


Increase Aminoacids to 3 to 4 G/Kg/Day on Day 2 And Lipids to 3g/Kg/Day on Day 2 or ASAP
Continue TPN till Enteral Feeds 100ml/Kg/Day
Always Use Central Line for Giving Parenteral Nutrition
Heparin 1U/ml in the TPN solution
Both Lipid and Amino-Acid Solutions to be protected from Sunlight

Enteral Nutrition






Early Trophic Feedings


Strategies to Improve Rates of Maternal Lactation (Early Pumping by the Mother,
Mothers Entry into the NICU, Mother involved in Baby Care Activities, Relieve Pain and Stress,
Lactation Counselor, Galactogogues)
Improved Use of Human Milk Preferentially, both in the NICU and beyond Discharge.
Mothers own Milk the ideal choice.
Colostrum a Must
For VLBW Infants Fortification of Human Milk Should be done with Multi-Component Human Milk
Fortifiers (HMF) once the Infant is on 150ml/Kg/Day of Enteral Feeds

For Infants On Formula Feeds













Asepsis on Preparation of Feeds


Actual Powder to Water Ratio
Water at 80oC during Preparation of Feeds
One feed, one preparation. left over thrown out
Early Non Nutritive Sucking (NNS) on Empty Breast of the Mother
Increased Emphasis on Growth as part of Daily NICU Care
Daily Weight, Weekly Length and OFC
Promote Kangaroo Mother Care During Intermediate Care and During NNS
Appropriate nutritional support during the transition to home phase of care; (i.e. Sharing Growth
Charts, Kangaroo Mother Care, Specific Post-Discharge Nutritional Recommendations,
Access to Pediatric Dietician, Etc.)
Vitamin A Prophylaxis In Infants With A Birth Weight Less Than 1250 Grams
To Prevent Chronic Lung Disease

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Prevention of Hypothermia in ELBW and VLBW infants


Call Received >30mins Before Impending Premature Delivery
Open Warmer Preparation In Labour Room OT

Pre Warm Open Warmer At 100% For >10min Before Arrival


Warm 2 Sets of Linen for >10mins

Incubator Preparation In NICU




Warm Transport Incubator to 36 Degree C


Warm NICU Incubator to 36 Degree C
Incubator Humidity >60%

Equipment Preparation In NICU




Ventilator or CPAP, Oxygen, Suction Apparatus


Resuscitation Kit / Intubation Trolley
Weighing Scale, Pediatric Drip Set, SpO2 Monitoring

Resuscitation Of Baby As Per NRP









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Place Baby in Zip-Lock Or Cover Entire Body Except the Face with Plastic Wrap
after Initial Assessment Of Heart Rate, Breathing And Color
Shift Baby To Pre-Warmed Transport Incubator Post Resuscitation
Receive Baby In Nicu In Transport Incubator And Covered In Zip-Lock/Plastic Wrap
Weigh The Baby Before Transferring From Transport Incubator To Nicu Incubator
Temperature On Admission Within 10 Minutes : Axillary
Recheck Hourly till Euthermic and then after 6hrs
If Normal Temperature, Remove Zip-Lock/Plastic Wrap

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Conference Secretariat
Fernandez Hospital Pvt. Ltd.
Bogulkunta, Hyderabad 500001.
Phone : 91-40-40632569 Mobile : 8886360023
Dr. Srinivas Murki : 9392470351
Fax : 91-40-24753482
Email: iapneocon2012@gmail.com
Website :www.iapneocon2012. org

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