The NICU: Small patients pose big infection risks

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Neonatal ICU (NICU) patients are at the top of the list of patients at high risk of developing infections. "Neonates are incredibly vulnerable [to infection]," says Alicia Budd, an ICP at The Children's Center of Johns Hopkins Hospital in Baltimore. Most of the children in the NICU are very premature, very low-birth-weight babies with immature immune systems. And as part of their treatment, these patients often need invasive devices that put them at further risk for infection.

The following are some important issues you should focus on in the NICU to help reduce the risk of infection:

Make hand hygiene a priority. Proper hand hygiene is the most important precaution against infection for the NICU staff members at The Children's Center. They begin their day by performing a surgical hand scrub, says Budd.

"Staff that work on the NICU understand how vulnerable the population is that they're caring for, and they're very aware of the importance of hand hygiene," she says.

Cut down on transmission. Anytime equipment is shared among patients, the risk of infection increases. To avoid this problem, ensure that each child has his or her own designated stethoscope, thermometer, and other high-use equipment, says Budd. At The Children's Center, each NICU patient also has his or her own stock of disposable supplies.

Adopt NICU-specific policies and procedures and enforce them. Respiratory virus season is a critical time of year for patients in the NICU. Neonates, who often have immature lungs, have difficulty weathering common viruses, so you should design your policies and procedures to protect them from this risk factor.

Your policies should include provisions to prevent ill visitors and staff members from transmitting these viruses to neonates. In its policy, The Children's Center states that:

Visitors with an illness should avoid the unit.

No one younger than 18 years, including siblings, is permitted to visit the NICU during respiratory virus season.

When siblings are permitted to visit during other times of the year, staff members must screen them to make sure that they are up to date on their various vaccinations and that they are not currently symptomatic.

Adults should not visit the unit if they have a fever and should wear a mask if they are afebrile but have lingering respiratory symptoms.

Staff members who have a fever must not come to work. Those with a lingering cold must wear a mask when working with patients.

The Children's Center also offers free flu vaccines to healthcare workers, says Budd. Compliance is high because healthcare workers understand the importance of getting vaccinated, she adds.

Focus on MRSA. The Children's Center's NICU regularly screens patients for MRSA through a process similar to that of the adult ICU.

However, any NICU patient that tests positive for MRSA colonization undergoes decolonization, says Polly Ristaino, an ICP and director of IC at The Children's Center.

"This is unique to the NICU because, if they do get infected, it's much more difficult for them to fight the infection," Ristaino says.

Target central line-associated bloodstream infections. Because neonates have so many invasive devices, bloodstream infections are a real risk in this population. The Children's Center has implemented a central-line bundle to ensure that staff members use best practices related to central-line insertion and care, says Budd.

Zap ventilator-associated pneumonia (VAP). VAP is also a real risk in this population. Again, your strategies to reduce the risk of pneumonia should be similar to those used in the adult population.

Wipe out environmental risks. This patient population is vulnerable to environmental organisms, such as waterborne pseudomonas aeruginosa, which might not be a problem for other hospitalized patients.

At a prior facility, Ristaino said an outbreak of pseudomonas in the NICU originated in a sink drain. To prevent this occurrence, Hopkins facilities treat all of the water in the facility with chlorine dioxide.

However, keep in mind that if you have a sink that doesn't get much use, you'll need to have procedures in place to make sure the faucets are run for five minutes each day so the chlorine dioxide gets through the pipes, says Ristaino. Reducing potential environmental contaminants can help reduce the risks at your facility.