Michelle Ferrant, DNP, CNS, RN, RNC-NIC

The emergence of the SARS-CoV-2 virus swiftly effected change in every facet of society, with health care delivery being the frontline to the COVID-19 pandemic. This agent of change spared no population. Rapid process changes infiltrated neonatal intensive care units (NICUs) to protect the most vulnerable newborn babies who made their entry into the world during a global pandemic. Just as the virus has adapted to its global host with variant strains, health care delivery in the NICU has adapted with evolving and sustainable practices.

The NICU at the Hospital of the University of Pennsylvania provides care to a level 3 NICU patient population. The American Academy of Pediatrics defines a level 3 NICU as a hospital setting that offers expertise of care providers and specialized equipment needed to provide “comprehensive care for infants born < 32 weeks gestation and weighing < 1500 g and infants born at all gestational ages and birth weights with critical illness.”1 Four open bays comprise the 38-bed unit with only 2 negative pressure capable isolation rooms located in 1 of the bays. The NICU includes a separate resuscitation space adjacent to the labor and delivery (L&D) unit with 3 available bed spaces. To adapt to potential census fluctuations, many bed spaces are capable of accommodating overflow and multiple gestation infants in a single-bed space footprint.

Operational challenges in the NICU were quickly unveiled with the emergence of COVID-19. Staff illness or exposures to COVID-19 from community and workplace venues resulted in prolonged furlough periods.Severe supply chain shortages in personal protective equipment (PPE) and disinfectant products compounded these operational challenges, prompting conservation and reuse.2 The NICU was thrust into a crisis capacity mode from a baseline of conventional capacity operations.3 Unlike other areas of the hospital, the NICU could not reduce admissions or defer scheduled procedures. This prompted emergent planning for contingency operations.4

To continue safe delivery of care, immediate process changes were developed by a collaborative multidisciplinary team. Expert guidance was enlisted from the NICU and L&D nursing leadership and physician provider teams along with hospital partners from infection prevention and control, lab and pathology services, perioperative services, environmental services (EVS), facilities, and materials management (MM). Internal and external supply chain shortages of disinfectant products prompted EVS and MM to forge a plan to make and distribute disinfectant wipes.

Infection prevention in the NICU begins in the L&D setting. Prior to the availability of universal COVID-19 testing for the antepartum population upon admission, the patient history and physical (H&P) included screening for community exposure to COVID-19 and presence of signs or symptoms of COVID-19 infection.5 Any positive findings on the H&P resulted in a person under investigation (PUI) for COVID-19 status with laboratory testing to confirm diagnosis.6

Three negative pressure L&D rooms were designated for PUIs or COVID-19–positive patients. An operating room (OR) for cesarean-section deliveries was also designated for this patient population, with terminal cleaning commencing at the end of the case or upon discharge of the patient from the L&D room. A hospital nursing team of subject-matter experts (SMEs) was deployed to enhance PPE training with donning and doffing procedures as well as safe handling of N95 masks that were reused.7

An infant who was born to a mother who was a PUI required airborne and contact isolation pending the maternal COVID-19 result. This challenged the limitation of 2 NICU isolation rooms, prompting the conversion of the adjacent open bay to a negative pressure airflow to accommodate a third infant who would require isolation. Precipitous deliveries leave little time for the NICU to prepare for an admission, requiring airborne isolation resources to be in a state of readiness.

The admission of a third patient to the negative pressure bay requires imminent transfer of up to 4 other patients to other locations in the NICU. For this reason, the goal is to preserve this open bay for the most stable patients. Testing of the infant of the COVID-19–positive mother requires 2 negative COVID-19 tests 2 days apart. This time delay adds to the challenge of ensuring available isolation beds.

See the below slideshow for a demonstration of donning and doffing of PPE for the NICU (Photographer: Kelly Convery; Nurse donning and doffing: Christina Minnissale; Nurse in isolation room: Melanie Gabriel)

Donning and Doffing for the NICU

Because of the highly specialized nature of the neonatal population, the NICU adapted the hospital nursing SME model and implemented a unit specific team of SMEs. This core group of RNs served as trained observers for appropriate donning and doffing of PPE in the delivery room and during the admission and stabilization of the infant in the isolation bed space. This role quickly evolved into a dedicated resource for the interprofessional staff of the NICU. The acronym COPE was coined by a team member, Jennifer Roman, BSN, RN, CBC, to describe the team of COVID-19 operations and patient-care experts. In this role, nurses served as communication liaisons for unit leadership to disseminate the rapid evolution of guidance in the initial wave of the pandemic, which led to rapid process changes.

The COPE team was tasked with remaining knowledgeable on current processes, readily guiding the interprofessional team to unit resources and protocols and providing direct and indirect support to staff. In order to sustain preparedness, the COPE team created specific checklists and supply par levels that are utilized by all staff members to ensure isolation admission spaces are always at the ready. Identifying appropriate supply par levels and paring down admission supplies to the necessities also aided preserving supplies and minimizing waste during the terminal cleaning process of isolation spaces.

This population based SME team allowed for streamlined and systematic information communication to the unit staff members. The COPE team members were able to filter out the overwhelming volume of information being shared hospital-wide, much of which did not pertain to the specialized neonatal patient population, and provide concise, timely, and pertinent information to the neonatal team.

Ongoing assessments of patient and staff safety prevailed as more information about the transmission of SARS-CoV-2 virus and supply chain challenges became available. The interdepartmental collaboration and frequent virtual communications sustained the contingency plans and required resources through the peak of the pandemic, providing a pathway to a new conventional capacity operations model. Increased testing capacity and widespread vaccination for the SARS-Cov-2 virus has alleviated the contingency capacity operations with improved supply chain and decreased staffing burdens.

Sustained changes in the delivery of care in the NICU have forged new conventional capacity operations in the setting of the COVID-19 pandemic. Negative pressure in L&D rooms is no longer a requirement because updated information became available. A designated OR remains in use for COVID-19 positive patients as intubation may take place. Terminal cleaning procedures follow use of the L&D room or designated OR used for a COVID-19–positive patient. Infant resuscitation continues to be performed in the delivery room or in the OR. Delivery teams for COVID-19–positive patients continue to be limited to essential personnel with N95 masks used in aerosolizing procedures. The responding neonatal team has expanded to include pre-pandemic staff level participation.

Due to the increased potential for a neonate to require an aerosolizing procedure including initial resuscitation steps, neonatal responders continue to utilize N95 masks and viral filters for all neonatal respiratory equipment in L&D. Clean supply carts are maintained outside the room with a “clean” team member to hand off the supplies as needed to the delivery team. A daily checklist for supplies in each NICU isolation room is utilized to ensure capacity for airborne and contact isolation. Universal testing for hospital admissions continues. Visitors and employees are screened for symptoms of COVID-19 infection or exposure to sick contacts upon entry to the facility.

COPE team members continue to provide the necessary emotional support for the interprofessional staff during times of extraordinary stress and anxiety.8 The team serves as a sounding board for the other staff members and were able to bring forth staff concerns to unit based leadership for discussion and potential solution creation. Having dedicated “experts” who were specific to the unique population and space constrains of the NICU alleviated much of the staff worry, anxiety, and concern related to providing safe patient care. The COPE team continues to support the NICU interprofessional staff and has helped sustain unit readiness throughout several waves of COVID-19.

Surveillance for all hospital acquired infections as required by the state of Pennsylvania continued throughout the pandemic. No central line associated bloodstream infections (CLABSIs) were identified in over 400 days, nor were any other device-associated infections identified. There was no increase in nondevice–associated infections. Recent hand hygiene observations conducted by college co-op/volunteer students on all shifts revealed 95% compliance in 175 observations for 1 month.

This infection surveillance data indicates proven success in both contingency and new capacity models, with COVID-19 serving as an agent of change to facilitate improvement in infection prevention. A recently published study demonstrates the increased risk of maternal complications and preterm birth when COVID-19 infection occurs in pregnancy.9 This is a critical reminder that contingency planning and sustained operations are essential to the needs of our maternal and NICU population.

MICHELLE FERRANT, DNP, CNS, RN, RNC-NIC, ACCNS-N, CBC, is a clinical nurse specialist in the level III Intensive Care Nursery at the Hospital of the University of Pennsylvania.

JENNY HAYES, MSN, RN, CIC, CAIP, CASSPT, has 15 years of experience as an infection preventionist, serving both in-patient and ambulatory care populations in multidisciplinary settings. She is an infection preventionist at the Hospital of the University of Pennsylvania.

American Academy of Pediatrics Committee on Fetus and Newborn. Levels of neonatal care. 

 2012;130(3)587-597. doi:10.1542/peds.2012-1999

Summary for healthcare facilities: ​strategies for optimizing the supply of PPE during shortages. Centers for Disease Control and Prevention. Updated December 29, 2020. Accessed July 30, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/strategies-optimize-ppe-shortages.html

US Department of Health and Human Services. Hospital operations toolkit for COVID-19 patient care policies/processes: crisis standards of care.November 30, 2020. Accessed July 31, 2021. 

https://files.asprtracie.hhs.gov/documents/hospital-operations-toolkit-for-covid-19-patient-care-crisis-standards-of-care.pdf

COVID-19 sustainable response planning. Centers for Disease Control and Prevention. Updated January 4, 2021. Accessed July 30, 2021. 

https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/sustainable-response-planning.html

Altendahl M, Afshar Y, de St. Maurice A, Fajardo V, Chu, A. Perinatal maternal-fetal/neonatal transmission of COVID-19: a guide to safe maternal and neonatal care in the era of COVID-19 and physical distancing. 

Flannery DD, Gouma S, Dhudasia MB, et al. SARS-CoV-2 seroprevalence among parturient women. medRxiv. Published July 10, 2020. 

Andonian J, Kazi S, Therkorn J, et al. Effect of an intervention package and teamwork training to prevent healthcare personnel self-contamination during personal protective equipment doffing. 

Aloweni F, Ayre TC, Wong WHM, Tan HK, Teo I. The impact of the work environment, workplace support and individual-related factors on burnout experience of nurses during the covid-19 pandemic. 

 December 26, 2020. Accessed July 27, 2021. 

https://pragmajournals.com/journals/journal-of-nursing-and-patient-safety/fulltext/the-impact-of-the-work-environment-workplace-support-and-individual-related-factors-on-burnout-experience-of-nurses-during-the-covid-19-pandemic

Villar J, Ariff S, Gunier RB, et al. Maternal and neonatal morbidity and mortality among pregnant women with and without COVID-19 infection. 

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