Neonatal intensive care units (NICUs) can be breeding grounds for infection, but they also offer opportunities to provide better care through infection prevention. They do this, in part, by relying on infection preventionists (IPs) to perform one of the more delicate maneuvers in healthcare: Trying to educate laypeople about infection prevention.
It’s one thing to monitor and police fellow healthcare workers on the need to take extra precautions to prevent NICU infections. It’s quite another to try and stop family members from visiting these most vulnerable of patients. Parents or other relatives visiting in these units often hold the babies, as it is an important part of their care, but this can put the child into direct contact with infectious droplets or dirty hands.
That being said, any person going in and out of a NICU poses a challenge for infection prevention efforts. This can put the IP in a tough position. Although hand hygiene, isolation precautions, and staying home while sick are all practices emphasized among healthcare workers, family and visitors don’t often get that message. Educating anyone coming into the NICU about the vulnerability of the patients and their role in infection prevention efforts is vital.
Having conversations, empathy, and providing visitors/parents with the resources to avoid sharing germs goes a long way. Personal hand-gel containers, face masks, and requiring hand hygiene upon entrance can be helpful. Overall, there might be pushback and although you can’t prevent parents from visiting their children, working with them to understand the risks if they’re sick and giving them the tools to be a part of the care process through infection prevention can help empower them and reduce risk for the neonate.
Engaging family members and visitors in infection prevention efforts can help make them feel part of the care process while keeping the patient safe. However, that often requires 1 on 1 conversations and making accommodations.1 These are hospital units with extremely vulnerable patients, but they also provide a place for IPs to shine in their abilities to adapt and enhance measures without impacting patient care and family experiences.
Created in the 1950s, the use of NICUs has resulted in a neonatal mortality rate decline from 18.73 per 1000 live births in 1955 to 4.04 per 1000 live births in 2002.2 The use of these units has also been increasing. Overall NICU admission rates have grown from 64 per 1000 live births in January 2007 to 77.9 per 1000 live births in December 2012.3 Investigators analyzing 18 million live births in the US during this time period found the increase across all birth weight categories, noting that in 2012 there were 43 NICU admissions per 1000 normal birth weight infants, while the admission rate for very low birth weight infants was 844.1 per 1000 live births.1The March of Dimes reports that in 2018, 10% of all US live births were preterm.2Congenital malformations and low birth weight tend to account for the largest portion of infant mortality in the United States. Interestingly, neonatal mortality is higher in the US than in comparable countries like Canada or Switzerland.3
Since many newborns in the NICU are premature, their immune systems are not fully developed, which makes them susceptible to infections, especially opportunistic ones. Moreover, NICU patients are typically admitted for longer periods of time and often require invasive medical devices and/or procedures from central lines to ventilators and even Foley catheters, which increase the risk of healthcare-associated infections (HAI) and require the most diligent of infection prevention efforts. Infections in NICUs typically stem from methicillin-resistant Staphylococcus aureus(MRSA), and other bacterial pathogens. Prematurity inherently puts these patients at more of a risk as their natural defense systems—immune system and even skin—are not fully developed and more likely to have weaknesses.
The design of most NICUs is particularly unique and can create hurdles for infection prevention. NICUs are one of the few healthcare environments that allow for an open configuration, versus single-family room. The pinwheel configuration is unique in that it can include multiple neonates in several pods within a larger room. Although this setup may be helpful for nursing workflow, it also means that there is often more shared space and family/visitors are more likely to come into contact with surfaces/objects that are shared across babies. Studies have shown that those single-family rooms, despite being more costly, are more conducive to family-centered care and enhanced medical progress through reduced nosocomial sepsis and mortality.4Since neonates frequently require less space during the care process, this design not only makes patient care easier, but also utilizes less space. Ultimately, a single-family room is not only preferable, but helps reduce the risk that a sick visitor or healthcare worker would expose multiple babies.
There have been several NICU-centric outbreaks over the years that have offered hard lessons One 1997 outbreak of drug-resistant Enterobacter cloacaethat occurred in a NICU resulted in extensive screening and changes in care.5Ultimately, screening efforts identified ready-to-use “disinfected” thermometers as the probable cause of the outbreak, likely due to rushed disinfection practices that led to such contamination. In fact, investigators determined that, despite banning the use of these thermometers, newly admitted neonates in the NICU became colonized and the unit ultimately had to be temporarily closed. Extensive screening efforts were implemented that encompassed all thermometers and rectal temperature probes.
The research team there noted that “observation of disinfection procedures and a laboratory investigation revealed that ‘rushed’ disinfection with alcohol 80% led to a 1 in 10 chance of thermometers still being contaminated. Furthermore, alcoholic hand rub used for convenience disinfection failed to disinfect thermometers in 40% and 20% of the cases when done in a ‘rushed’ or ‘careful’ fashion, respectively.” Once adequate disinfection was enforced, the outbreak subsided and several months went by without additional cases. This is a prime example of not only the susceptibility of this patient population, but also how failures in environmental disinfection can be devastating to the entire unit.
Although all patients require vigilant infection prevention measures and the goal should always be zero infections, the stakes are sometimes higher in the NICU, as infections there have higher potential for death.
Saskia v. Popescu, PhD, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist. During her work as an infection preventionist, she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She holds a doctorate in biodefense from George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in infection control and has worked in both pediatric and adult acute care facilities.
1.Harrison W, Goodman D. Epidemiologic trends in neonatal intensive care, 2007-2012. JAMA Pediatrics. 2015 doi:10.1001/jamapediatrics.2015.1305.
March of Dimes. 2020. United States Preterm Data. Accessed on January 28, 2020 from https://www.marchofdimes.org/peristats/ViewSummary.aspx?reg=99&stop=60
2. MCG. Neonatal Care and the Neonatal Intensive Care Unit: Challenges & Opportunities, MCG. 2018. Accessed on February 1, 2020 from https://www.ahip.org/wp-content/uploads/2018/11/MCG-White-Paper-Neonatal...
3. Domanico R, Davis DK, Coleman F, Davis BO. Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. J Perinatol. 2011;31(4):281–288. doi:10.1038/jp.2010.120
4. Gastmeier P, Loui A, Stamm-Balderjahn S, Hansen S, Zuschneid I, Sohr D, et al. Outbreaks in neonatal intensive care units—They are not like others.
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5. Van den Berg RW, Claahsen HL, Niessen M, Muytjens HL, Liem K, Voss A. Enterobacter cloacae outbreak in the NICU related to disinfected thermometers. J Hosp Infect. 2000;45(1):29-34.