What the Difference Between NICU and PICU?

Within the last several months, I was having a conversation with a reviewer and he interchanged the words NICU and PICU several times and it became clear to me that he didn't really understand the difference between these two units so I thought I would clarify that here today.

A NICU, aka Neonatal Intensive Care Unit, is specifically for babies who have just been born and are having difficulties. This includes premature babies (23-24 weeks is considered viable) up to normal gestational age of 40 weeks. This is their area of specialty.

The problem becomes-- when can the babies go back to the NICU if they become sick? Often times, a NICU won't take a premature baby back once they've been discharged home for a couple of months (even if they are still an infant) because they could be "contaminated" with all sorts of other-worldly germs. So, if the infant is sick enough and needs an ICU admission they will likely (though not always) be admitted to the PICU.

The PICU, aka Pediatric Intensive Care Unit, is for infants the NICU won't take and all other kids up to about the age of 18 (some up to 21) or whatever age the pediatric hospital has decided to admit. Even this age cut-off is becoming blurred because patients with chronic diseases (cystic fibrosis or special needs kids) might stick with their children's hospital well into their 20's. This is becoming an area of concern for pediatric institutions-- how to transition adults into adult-centered care.

Another way an adult might end up in the Pediatric ICU is if they have had a repaired congenital heart defect. There really is a limited number of adult cardiac surgeons who are comfortable operating on adults with these defects. In all honestly, it's only been in the last couple of decades that these kids were living to adulthood but improved surgical techniques have changed all of that.

Apnea in Prematurity

Terri Forehand is back to discuss a common malady for premature infants. Good information for an author writing about this age group.

Welcome back, Terri!

Apnea is one of the most frightening symptoms for parents of premature infants. Apnea is a pause in breathing for 15-20 seconds.  It is associated with the infant’s color changing to a pale or bluish tint and with the heart rate slowing for a period of time. It can be alarming for those witnessing an episode of apnea for the first time and requires reassurance and education from the staff for those frightened parents.

The major reason premature infants experience apnea is their immature respiratory center of the brain. Preemies have bursts of big breaths followed by periods of short or shallow breaths or breathing pauses. It is most common in sleeping infants which is also reason for concern for new parents.

Bradycardia or the slowing of the infant’s heart rate is also a common symptom of prematurity and often goes along with the episode of apnea. Other causes for the premature infant to drop their heart rate include during or after a feeding and during a bowel movement.

Treatment for apnea may include medications such as caffeine or aminophylline to stimulate breathing and CPAP (continuous positive airway pressure) or oxygen by nasal cannula. Nasal cannula is the preferred way to administer this treatment and is done with little tubes into the baby’s nose. Mechanical ventilation may be used for very premature infants until they can manage breathing on their own with the assistance of CPAP only.

Most infants grow out of these symptoms close to their original due date as their brain centers mature. If premature infants still are having apnea spells but otherwise could go home, they can go home on an apnea monitor. Parents are trained to apply the monitor and to know how to use it as well as what to look for in their baby if the alarms go off.

Once the premature infant matures and the apnea resolves, it will not come back. Education and reassurance will help new parents of the premature infant to feel confident in caring for their infant during the last few days before discharge and when finally at home with their new baby.

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Terri Forehand is a pediatric/neonatal critical nurse and freelance writer. She writes both fiction and nonfiction, is the author of The Cancer Prayer Book released in 2011. Her picture book titled The ABC’s of Cancer According to Lilly Isabella Lane is due out in 2012. She writes from her rural home in Indiana which she shares with her husband of almost 30 years and an array of rescue animals.

The Bells and Whistles of a NICU

I'm pleased to welcome back Terri Forehand, NICU RN, and she explains the NICU environment. Great details for any author writing a NICU scene.

Welcome back, Terri!

Understanding the bells and whistles of a Neonatal Intensive Care Unit (NICU) is essential for the nurses and neonatologists that care for these tiny infants but it can be especially confusing for parents of a premature infant and down right mind boggling for those trying to write about a premature infant in their fiction. If you are a writer creating a plot or storyline around a NICU unit there are a few things you need to understand.

First, the NICU can be a unit where there are private rooms for each infant and where parents can spend long hours at the bedside in a more comfortable environment with the door closed. An open NICU unit is a huge room with stations or “patient areas” where there is room for the incubator for the baby, monitors, other medical equipment, and standing room around the incubator for the doctors and nurses to care for the infant. Many times you will see a rocking chair cleverly placed between the equipment so mom or dad can be only an arms length away from their baby. The overall feel of a busy unit may feel too close and crowded for many visitors.

A list of general equipment at each bedside regardless of whether it is an open unit or private rooms includes:

• Incubator or infant warmer sometimes called an island.
• Suction canister, tubing, and control gage usually attached to the wall used to assist in clearing the airway of an infant.
• Monitor and cords that attach to the infant’s chest that measure heart rate, respiratory rate, and another cord that attaches to the infant’s foot, toe, ear, or wrist that measures constant oxygen levels in the blood. The specific term for this particular probe is called oxcimetry.
• Supply cart or shelf that includes needles, blood collection supplies, extra respiratory equipment, diapers, pacifiers, and anything else the infant might need in a hurry.
• Blood pressure cords to measure the blood pressure of the infant.
• Feeding supplies.
• Many other items specific to each infant and the diagnosis including Intravenous pumps, bilirubin spot lights, and blood infusion pumps.

Advantages for the private room concept are privacy for parents and more room for staff to work on each infant. It is considered family centered and parents and grandparents seem more satisfied with these newer creative NICU units that at times can appear more like a plush hotel rather than an intensive care unit for sick babies. The biggest disadvantage for nursing staff is that you can only eyeball one baby at a time, feeling like you cannot keep the best eye on the infants in your care because of the walls between each incubator.

An advantage for the open unit style is easier management of patient care for the staff. It is easy to watch a monitor for one infant and be feeding an infant in close proximity. The nurse can see, hear, and know all about her babies because there are no barriers between patient care areas. This can also mean that private conversations between parents can be over heard by other parents making it more stressful.  The disadvantage is that it can be noisy and more overwhelming for parents not only with mixed conversations but the clanging of alarms from every direction is frightening.

A newborn between 23 and 36 weeks has no place to go but the NICU.  Gestational aged infants between 23 and 28 weeks have the additional complication of breathing issues many times requiring a ventilator. (More on that in another post) The need for extra equipment to support breathing takes up more room, adds more stress to the parents, and adds more alarms to the already frightening atmosphere. It can also be a complication in the plot of a good story.

Parents may be astonished at how complicated a NICU patient area can appear when they first see their tiny infant in that setting. Those of you writing a scene to include a NICU can appreciate how complicated the scene looks to an outsider. It also may offer the possibility for many clever or mysterious scenarios in combination with your imagined family relationships, after all babies are born to the rich, poor, good, bad, honest, and criminal characters both in real life and in the life of your imagination.

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Terri Forehand is a pediatric/neonatal critical nurse and freelance writer. She writes both fiction and nonfiction, is the author of The Cancer Prayer Book released in 2011. Her picture book titled The ABC’s of Cancer According to Lilly Isabella Lane is due out in 2012. She writes from her rural home in Indiana which she shares with her husband of almost 30 years and an array of rescue animals.

Inter-Hospital Transfer of the Pregnant Woman: 2/2

Dr. Tanya Goodwin concludes her two-part series on NICU designations and transfer of the OB patient. Excellent information for any author writing this scenario. You can find Part I here.

Welcome back, Tanya!

Prior to any transfer, the woman’s pre-term labor must be assessed. The OB performs a history and physical examination while the nurses attach a fetal Doppler and a Tocometer to record fetal heart beat and uterine contractions respectively, start an IV, and they or a lab tech draw blood.

MPR News

Typical blood work would include a complete blood count (for evidence of infection, anemia, or clotting problem) electrolytes (blood chemistry), type and screen (in case blood transfusion necessary or injection for blood type – Rhogam). If the woman is contracting then medications to stall labor are started (Magnesium Sulfate IV, Procardia orally).

Before the OB or labor nurse performs a vaginal exam to assess cervical dilation, a sterile speculum is inserted into the vagina and a special swab called fetal fibronectin is done (a positive result increases the risk that the woman will deliver pre-term). If ruptured membranes are suspected then a sample of fluid is evaluated for amniotic fluid. If the water hasn’t broken pre-term, then the OB does an internal exam to check for cervical dilation.

Antibiotics may be given to decrease the risk of neonatal Group B Streptococcal sepsis (severe and life threatening bacterial infection) Also a corticosteroid injection may be given to the woman between 26 – 32 weeks gestation to help accelerate fetal lung maturation.

Once the woman is assessed for labor, the OB must make a decision as to the probability that his/her patient will make it to another facility without giving birth en route or encounter a medical complication. The OB’s first obligation is to the mother, and then fetus. Stabilizing the pregnant woman is paramount. The fetus depends on the health of the mother.

A U.S./governmental code called EMTALA or Emergency Medical Treatment and Active Labor Act forbids rejection of care and transfer of an unstable patient to another facility. This applies to all hospitals that participate (or receive payment) from Medicare/Medicaid, which is virtually every U.S. hospital. Its original intention was to prevent hospitals from “dumping” indigent patients into “charity hospitals”.

The OB explains the situation to the woman and any family she consents to relay medical information to. This is typically the father of the baby. Risks and benefits of transfer are discussed with the woman and “family” and the woman must give consent to be transferred.

The OB then calls a “transfer center” relaying information regarding the woman’s status and the necessity for transfer to a higher level of care. The transfer center finds the nearest suitable facility and connects the admitting OB to the receiving/accepting OB. Medical information is exchanged. Once the patient is accepted, then depending on distance or urgency, the woman is transported via helicopter (weather permitting) or ambulance. If this is a neonate, then the pediatrician is in charge of obtaining appropriate transport. Nurses also give nurse-to-nurse report. Medical records generated are copied and go with the patient. Everyone involved keeps one another updated as to the outcome, hopefully a happy ending but unfortunately not always that way.

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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Inter-Hospital Transfer of the Pregnant Woman: 1/2

I'm pleased to host Dr. Tanya Goodwin as she discusses the difference between NICU's and their designation. This will be Part I of her post. Part II covering transfer specifics will be on Wednesday.

One thing I want to point out is the Trauma Center designations run opposite of NICU's. A Level I Trauma Center is where the most critical patients are taken if possible. Level II and Level III can always stabilize but may need to transfer the patient out.

Welcome back, Tanya!

Most pregnant woman will happily deliver their babies in a comfy hospital maternity unit. But for a few, their labor and delivery may need to be at a more specialized facility, or their infants may need to be transferred to an appropriate NICU or Neonatal Intensive Care Unit.

So how does this all happen?

Aside from a rare, life threatening maternal illness or a pregnant woman involved in a traumatic accident, transfer of the pregnant woman is usually based on the neonatal need.

A woman between 36 and 40+ weeks gestation (last month of pregnancy) can stay at a level I facility. Their babies will do quite well in a regular newborn nursery. Occasionally, a full-term baby may not adjust well to extrauterine life or have breathing problems or unforeseen medical or surgical issues that requires prompt transport to level II or III NICU (usually level III).

A level II nursery or special care nursery can accommodate those infants between 32 and 35 weeks. A 35 “weeker”, if doing well can stay at a level I /newborn nursery. Infants in a Level II are mainly there to feed and grow or receive a course of antibiotics.

Level III NICU’s are for babies that need long term care such as assistance with respirations via ventilators, medical or surgical issues. They may need to be fed through special nutritional intravenous fluids. These are the NICUs you usually see on TV.

A newer level, IV, has been touted as the place for extreme pre-term babies, between 22-25 weeks. Level III/IV are in urban centers (tertiary centers or teaching hospitals) where there are 24 hr neonatologists/sub-specialty neonatologists, physicians, surgeons, anesthesiologists, fellows, residents, and medical student. A very busy place!

Two of the most common scenarios requiring maternal transfer are pre-term labor (labor before completed 36 weeks pregnancy) and premature rupture of membranes (water breaking before 36 weeks). These conditions frequently co-exist, but not necessarily. If the OB is in a level I unit, then transfer of the woman is considered. If the OB is in a level II unit then depending on the gestation, the woman may stay or may be transported. No problem if already in a tertiary hospital.

More on this topic Wednesday.

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Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com

Micro Premies: Terri Forehand

I'm pleased to host neonatal nursing expert Terri Forehand. She will be doing several posts on the unique problems as it relates to gestational age. This is very important for writing medical accuracy into novels as to what these tiny charges and their parents face.

Welcome, Terri!

The neonatal intensive care unit is a frightening place for most visitors. Infants from 23 weeks gestation and older can be found attached to as many tubes and wires making the technical and medical environment confusing and overwhelming.

In the midst of the confusion of an NICU is an awesome atmosphere of healing and growth. The sole purpose of such a place is to mature these tiny creatures into healthy infants who suck, swallow, and breathe without mechanical assistance. In short, is nothing but amazing.

Follow us here to learn about each gestational stage of such infants whether for your own information or for details for your next novel. Today, we’re starting with micro premies.

Gestation: 23 weeks.

Most medical professionals consider a fetus over 23 weeks to be viable, meaning they can be assisted to grow and mature into a full term infant outside of the womb. No one that I know would ever guarantee an infant this young will mature without many hurdles and without the risk of complications that go along with prematurity. But there are many success stories over the course of years of researching neonatal care and progress is outstanding.

The fetus born at 23 weeks gestation will have loose thin skin. Skin grows faster than fat develops and at this stage the fetus doesn’t show much fat development so they are all skin and bones.

After 23 weeks the fetus will begin packing on pounds and increasing in weight. The fetus at 23 weeks is approximately 8 inches long and just over one pound and growth is rapid for the next few weeks.

The essential problem with survival of a 23 week fetus outside of the womb is breathing. Lung development at this age is very immature and the lining of the lungs is stiff making the exchange of oxygen more difficult. One of the main goals of the NICU team at this stage is to promote adequate oxygenation with supplemental oxygen and a variety of mechanical adjuncts to assist with breathing.

Another classic characteristic of a 23 week gestational infant is the eye lids most often are still fused closed. The combination of loose thin skin, extra hairy limbs, and fused eyelids make for increased anxiety for new parents and an overwhelming fear of what comes next.

Have you ever written a NICU scene for your novel?

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Terri Forehand is a pediatric/neonatal critical nurse and freelance writer. She writes both fiction and nonfiction, is the author of The Cancer Prayer Book released in 2011. Her picture book titled The ABC’s of Cancer According to Lilly Isabella Lane is due out in 2012. She writes from her rural home in Indiana which she shares with her husband of almost 30 years and an array of rescue animals.