|NICUs nurse premature babies through their early stages of development. Many experience medical complications and require a lot of care—and a lot of instrumentation.|
Neonatal intensive care units (NICUs) are modern marvels. Here, babies as premature as 22 weeks—the youngest preemie to survive was born at 21 weeks and 6 days—are nursed through their early stages of development. These neonates are tiny, weighing as little as 1 pound, and sensitive to sound and light. Often, there are significant medical complications resulting from their underdeveloped organs and systems, necessitating a lot of care—and a lot of instrumentation.
Neonatal patients have special requirements, and so does their equipment. There are nearly 20 different types of equipment used in the NICU, including those for monitoring, warming, and treatment delivery (see sidebar below). Each one is critical and must be properly maintained, but the unique environment of the NICU can impose challenges that may require departmental, mechanical, and work style adjustments.
In general, biomeds rise to this challenge. A 2004 study by Suresh et al1 found that system failures were responsible for only 9% of 1,230 medical errors reported in the NICUs of 54 hospitals over two phases and 17 months. The category included equipment failure, inadequate equipment maintenance, unavailable necessary equipment, poor equipment design, and unfamiliar equipment.
The Usual Equipment and Care
With the large amount of equipment in the NICU, and the extended treatment times, maintenance and service can be a little tricky. “We have a 52-bed unit with eight six-bed pods and four isolation rooms,” says Nils Gurdin, project manager, Strong Health clinical engineering, Rochester, NY. The clinical engineering department is responsible for 751 pieces of NICU equipment, which does not include ventilators, which are the responsibility of the respiratory department.
In other facilities, such as Phoenix Children’s Hospital, in Phoenix, biomeds are responsible for the ventilators. At Texas Children’s Hospital in Houston, biomeds are responsible for everything. “We service all of the patient care equipment from the ECMO [extracorporeal membrane oxygenation] machines to thermometers, including ventilators, bedside monitoring, incubators, warmers, and bili lights,” says Ron Robb, manager of biomedical engineering at Texas Children’s.
Preventive maintenance (PM), particularly when it involves so many pieces, needs to be carefully planned. Some equipment maintenance is based on hours of usage, other PMs by the calendar. “Some equipment, such as incubators and ventilators, has actual preventive maintenance tasks that need to be completed, versus a performance verification,” says Curtis McFarland, Sodexho manager for biomedical engineering at Phoenix Children’s. “Incubators, warmers, and ECMOs are checked every 6 months. Scales and monitors have preventive maintenance performed once a year.”
Most departments base their PM schedules on manufacturer recommendations, but occasionally these are modified. At Strong, PM is done more frequently than recommended on blood gas analyzers—every 6 months rather than annually—due to the specific nature and quantity of the tests performed in the NICU. “We found that if we perform the PM more often, we have fewer unscheduled service calls,” says Marty Loftis, senior biomed technician at Strong Health.
Blood gas analyzers, however, are not among the most common service calls. Many problems are related to lead placement. “Electrodes are hard on the babies’ skin, which can start to dry out and impede conductance,” Robb says.
In addition, improper placement can affect measurement accuracy. “There have been instances where the pulse oximetry device could not produce a good reading because the team could not get good sensory placement,” Robb says.
New sensors, new software, and new packaging have all improved performance. “Our new lead wires are disposable, and combined with user training that addresses the importance of trading them out, the lead wire issues have improved,” Robb says. “The new pads are packaged so that open packages are not sitting on a shelf waiting to be used. And an update to the pulse oximetry software and hardware has addressed the artifact issues.”
Mechanical items can suffer simple failures. Incubators can be problematic “particularly if there are connectors for temperature probes and other items,” McFarland says. He adds that phototherapy lights must be replaced—not easily done by the operator. In addition, fans can break, drives can fail, and incubator heating elements can stop functioning. “These items are mechanical and will have failures,” he says.
User error can have some impact as well. Loftis sees a fair number of broken infusion pumps. “They get dropped a lot, and we have to do full rebuilds,” Loftis says. Investigation into a recent spate of broken corner brackets on radiant warmers found the cleaning crew needed retraining on how to handle the instruments due to a recent large turnover.
Generally, however, there is not a lot of user error in the NICU. “People in the NICU are much more acutely attuned to the equipment,” McFarland says. “There is occasional breakage—someone is in a hurry and forgets to move something out of the way before lifting an incubator hood, for instance, but in general, user error is minimal.”
In-House and In-the-Know
Most of the time, the work is handled in-house. “We will occasionally call a manufacturer, depending on the situation and whether the equipment is still under warranty, but most of the work is handled in-house,” McFarland says.
Robb estimates that about 95% of NICU equipment work is handled in-house at Texas Children’s, divided into areas of expertise. “We’ve got a large crew with respiratory experts, monitoring experts, and infusion experts who service the relevant instruments in-house, but that also means that PMs are broken [down] into many visits. There may be five or six people visiting the NICU,” he says.
Most work is done in the shop, although noninvasive tasks are completed on the floor. The team works with the department to determine which equipment can be cycled out for PM.
At Strong Health, the clinical engineering department works with the NICU departmental liaison to cycle equipment through PM. “A few of the departments have developed a position that is responsible for the equipment inventory and its location, but not the actual repairs,” Loftis says.
This staffer also provides detailed information for service calls.
Problems are reported using a central phone number and tagged information; the level of priority is also specified, such as stat or routine. The biomed department is divided into two teams—of eight and seven—with each team member cross-trained on the equipment the team services. Although the teams may be responsible for different areas (the seven-person team handles the NICU, the surgical ICU, endoscopy, and the ambulatory center, among others), each team member can generally perform the required service and maintenance. “When there is a breakdown in the NICU, any person on the relevant team can be assigned the repair,” Loftis says.
The larger teams work more effectively than Strong Health’s former approach of having smaller groups trained in specific departments. “We developed the cross-training program so we could get more people on the team involved in the NICU. One of our big issues was trying to spread out the technical knowledge,” Loftis says.
When one team member attends formal education, such as manu
facturer training, he or she shares the information with the rest of the team during an in-service scheduled after the team member’s return. “It permits us greater flexibility in managing our workflow. We can assign free technicians to any piece of equipment,” says Stephen Zigelstein, Strong Health’s manager of clinical engineering.
Sweat the Small Stuff
In many instances, the large volume of equipment does not pose as great a challenge as some of the NICU-specific limitations. Scheduling PMs, even with a staff member to track them, can still be challenging. “It’s difficult to normalize the use setting,” McFarland says. “You can never really predict when a woman will have a baby or when she will deliver five at once.”
Babies can remain in incubators for months, making some biomeds nervous about completing PMs within the required times. “In our facility, the nursing staff will bend over backward to help us, but they won’t endanger a patient for a PM,” McFarland says. At the same time, patient safety is also impacted by improperly functioning equipment, so if equipment cannot be cycled out conveniently for PM and the patient is stable, sometimes a neonate will be moved.
“We’ll have an incubator warmed to the levels the baby is presently in and placed next to the current incubator to swap everything over, but this happens very rarely,” says Loftus, crediting the NICU staffer who manages the inventory with limiting this need.
When anything does happen, particularly something as extreme as a move, it will likely involve parental input. “In the neonatal unit, parents are always potentially there and are very much advocates for their children—more so than visitors and relatives in the adult ICU,” says Texas Children’s Robb. The staff remains very cognizant of the parents and their anxiety.
“When we speak to other staff in front of parents, we let them know what we need in a way that will not alarm the parents,” Zigelstein says. Changes can create stress for everyone. McFarland concurs, saying, “When you treat neonates and children, you treat the entire family. It affects the family so radically when the child is a patient.”
The activity also affects the unit as a whole and contrasts with the peaceful, quiet atmosphere many NICUs strive to maintain. Neonates are easily startled, and stimulation can prevent rest and impede development. To maintain ideal quiet levels, Strong’s NICU unit employs sound-pressure measurement devices to monitor sound. “The system has an ear that changes color with noise to emphasize the need for a quieter environment,” Gurdin says.
McFarland notes that quiet time has been implemented at his facility to promote healing. For the biomed team, this quiet time determines when they have access to the equipment in the NICU.
Texas Children’s redesigned its NICU about 3 years ago and now employs new features designed to minimize sound, including phones that flash rather than ring, visual strobes for monitor alerts in the nurse’s stations, and low volumes set on monitoring equipment. Lights are also kept low, so biomeds carry small flashlights to enable them to read serial numbers and other items easily. “These limitations are easily dealt with, but they are not something the biomed will encounter in other units,” Robb says.
Other differences are a result of physiology. Neonates, particularly preemies, have their own set of parameters. “A heart rate of 180 is normal in a neonate, but in an adult, it would indicate a cardiac event or extreme exercise,” McFarland says. This means different default parameters and alarm settings as well as smaller tubing and other instrumentation. The basic devices, however, are the same, although some pieces, like the ECMO, are unique to the NICU.
Zigelstein notes that it can be a financial challenge to make sure the department has an adequate number of spares to provide backups when necessary, but the teams work together to limit all downtime. Communication is key to the effectiveness of any maintenance and service relationship, and many believe it is even more so in the NICU. “We’ve found communication to be our best advocate in being successful,” Zigelstein says.
Everyone wants to protect the neonatal patients, and awareness of their uniqueness helps to ensure good care. As McFarland reminds others, “These aren’t just little people. They are almost another species, and it’s important to understand the difference.”
1. Suresh G, Horbar J, Plsek P, et al. Voluntary anonymous reporting of medical errors for neonatal intensive care. Pediatrics. 2004;113:1609-1619.
Renee Diiulio is a contributing writer for 24×7. For more information, contact .
Equipment Needs in the NICU
It takes a lot to replace the womb. There are nearly 20 types of equipment in the neonatal intensive care unit (NICU), and many of them are critical to a neonate’s care. Below is a brief look at what biomeds service in the NICU:
- Blood gas analyzers measure pH, oxygen, and carbon dioxide levels and calculate bicarbonate levels, oxygen saturation, base deficit, and other values. The information can be used to determine gas mixtures and delivery patterns.
- Blood pressure monitors can take a baby’s blood pressure at intervals using a cuff, or continuously with catheters.
- Cardiorespiratory monitors provide information on heart rate and rhythm, breathing rate, arterial or central venous pressure, and other information collected by sensors on the baby’s skin. Various models offer different designs and functions, but alarms are often a common element.
- A drainage pump may be used to suction secretions and prevent them from accumulating in areas that could negatively impact the baby’s health.
- Extracorporeal membrane oxygenation (ECMO) provides both cardiac and respiratory support oxygen for babies without full heart and lung development. Blood is removed from the body, oxygenated separately, and returned to the body.
- Incubators isolate babies, keeping them warm while protecting them from noise, drafts, and infections. Isolette is actually a brand name for a particular incubator.
- Infusion pumps, more commonly known as IV pumps, deliver necessary solutions into the baby’s bloodstream with timing specific to the patient.
- Phototherapy lights, or bili lights, treat jaundiced babies, converting bilirubin into a less harmful substance using the wavelength in the blue portion of the spectrum (not the ultraviolet, which could carry risk).
- Pulse oximeters (pulse ox) measure the amount of oxygen in the baby’s blood using light technology.
- Radiant warmers keep unstable or extremely premature babies at a constant temperature. The design keeps babies warm but provides the care staff with access.
- Scales document baby weight, and are used to determine the necessary food, medications, and IV solutions. Accuracy is critical.
- Ventilators or respirators help the baby breathe, and newer models support multiple operational modes. Some technologies inflate and deflate the lungs while others, such as the high-frequency oscillatory ventilator, use pressure and vibration. Attached “blenders” create the gas mixtures with the appropriate ratios needed for the individual patient.
- Additional equipment includes transport incubators, lightboxes, and PACS instrumentation. Biomeds are often also responsible for more routine items, such as thermometers and monitor displays.