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Admission and Discharge for Neonatal Intensive Care Unit (NICU) (2.1.30)

Admission and Discharge for Neonatal Intensive Care Unit (NICU) (2.1.30) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer

2.1.30


UW HEALTH CLINICAL POLICY 1
Policy Title: Admission & Discharge for Neonatal Intensive Care Unit (NICU)
Policy Number: 2.1.30
Category: UW Health
Type: Inpatient
Effective Date: October 20, 2017

I. PURPOSE
A. To ensure appropriate use of the Neonatal Intensive Care Unit (NICU).
B. The purpose of the NICU is to provide inpatient intensive and convalescent care to high-risk newborns in a
family-centered environment; optimize the developmental potential of each infant served; provide education,
counseling and support to families experiencing the birth of a high-risk infant; provide discharge planning for
families to manage continuing care needs after discharge.
C. Care is provided by a multi-disciplinary team of clinical and support staff that is responsible for the provision
of services in a professional technically expert and caring manner.
D. The NICU also serves as an educational setting for nurses, physicians, and other members of the health
care team. In addition, the NICU provides opportunities for research in the care of critically ill and
convalescing neonates.
E. Access to the NICU is limited to the physicians and employees who have appropriate business in the
NICU. Primary supports have open access to the NICU.

II. POLICY ELEMENTS
A. Singled Care Status
i. Some examples of patients admitted to NICU requiring singled care status include those with:
a. Respiratory Disorders:
1. High degree of respiratory instability requiring continuous assessment.
2. Invasive ventilation with or without, inhaled Nitric Oxide (iNO).
b. Cardiovascular Disorders
1. Severe hemodynamic compromise requiring continuous assessment.
2. Hemodynamically unstable requiring frequent interventions and multiple invasive
procedures.
c. Neurological Disorders
1. High degree of neurological instability requiring continuous assessment or
amplitude integrated electroencephalogram monitoring (aEEG).
2. Admitting patient requiring whole body cooling for treatment of hypoxic ischemic
encephalopathy.
3. Neurologic impairment including frequent seizures, mental status depression,
encephalopathy, or progressive neuromuscular changes requiring frequent
monitoring.
d. Metabolic, Renal, and Endocrine Disorders
1. Unstable endocrine, metabolic, or renal disease requiring frequent and rapid
laboratory evaluation and intervention.
e. Gastrointestinal disorders
1. Patients requiring acute surgical procedures of the abdomen that may lead to
cardiorespiratory compromise.
f. Patients requiring complex procedures
1. MRI.
2. Surgery.
g. Patients with active withdrawal of care/bereavement.
B. Intensive Care Status
i. Patients that are clinically more stable than singled care patients yet require a moderate level of
monitoring and/or treatment. Some examples of patients admitted to NICU in this category include
those with:
a. Respiratory distress or multiple apneas and bradycardias requiring interventions.
b. Respiratory support greater than or equal to 1.5L nasal canula.
c. Post-op status requiring increased monitoring and interventions.
d. Continuous neuromuscular blockade, sedation/pain control.



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge for Neonatal Intensive Care Unit (NICU)
Policy Number: 2.1.30

e. Patients stabilized on cooling blanket.
f. Patients requiring greater than 50 percent parenteral nutrition.
g. Stable tracheostomy patients who have not transitioned to home ventilator.
C. Intermediate Care Status
i. Patients that are progressing toward discharge, no longer requiring conventional ventilatory
support. Some examples of patients admitted to NICU in this category would include those with:
a. Hyperbilirubinemia.
b. Convalescing infants post intensive care.
c. Neonatal abstinence syndrome on medical taper.
d. Rule out sepsis.
e. Patients requiring less than 1.5 L nasal canula.
f. Patients tolerating at least 50 percent enteral feedings.
g. Stable tracheostomy patient on home ventilator for one week.
III. PROCEDURE
A. Admission
i. The level IV NICU at American Family Children’s Hospital (AFCH) can provide the most advanced
care for critically ill infants and premature infants.
a. The requesting provider or their designee will contact the Access Center. Access Center
will connect the referring provider to the Neonatologist, prior to acceptance to the NICU, to
discuss the patient's condition and management pending transfer to the NICU.
b. The Access Center attending NICU physician, and NICU Care Team Leader (or Senior
Team Member) will jointly determine placement and ability to transport.
c. Mode of transport will be determined jointly by the Neonatologist and the referring
provider.
ii. AFCH NICU Admission Guidelines
a. The attending neonatologist at AFCH will triage all access center calls to determine
appropriate neonatal placement between Meriter Level III NICU or AFCH Level IV NICU
(see related document: Appendix A, NICU triage decision tool)
1. Neonates requiring cardiac surgical intervention within one week of admission or
need for Extracorporeal Membrane Oxygenation (ECMO) will be admitted to the
pediatric intensive care unit (PICU) at AFCH.
2. Neonates within two weeks of NICU discharge, regardless of Post Menstrual Age
(PMA) should be admitted to the NICU if ongoing neonatal issues persist.
3. Neonates already discharged home, up to 48 weeks PMA. requiring l intensive
care can be admitted to the NICU with the exception of patients with suspected
viral illness or trauma. This includes direct admissions from a clinic, home birth,
or emergency department.
4. Infants outside of the previously stated parameters may be admitted to the NICU
at the discretion of the attending Neonatologist.
B. Assignment of Patients
i. All patients admitted to the NICU will be either primarily managed by the NICU team or co-
managed between the NICU team and the general pediatric surgical team.
a. NICU Team Managed Patients: The primary care is the responsibility of, and assigned to
the NICU attending staff and team. This includes all medical admissions to the NICU. The
NICU team will write all orders. Other services will remain as a consultant.
b. Co-managed Patients: General pediatric surgical patients will be co-managed. Together,
neonatology and surgery will discuss and approve major changes in patient plans of care.
Timely and respectful communications will occur between services regarding patient care
issues, orders written by each service will be communicated to the other service in a
timely fashion, and attempts should be made to round on patients jointly or to have a
representative from each team present during the respective patient care discussions.
C. Transfer out of NICU
i. Back transfer to birth hospital or referring NICU should be facilitated if appropriate level of care can
be provided and insurance approval is attained. The main objective of a back transport is to provide
a safe transition of care of a stable infant, who no longer requires level IV intensive care to a NICU
closer to home.



UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge for Neonatal Intensive Care Unit (NICU)
Policy Number: 2.1.30

a. Identifying infants
1. Candidates for back transport includes infants meeting the following criteria:
A. No longer requiring level IV intensive care.
B. Approval from subspecialists providing care.
C. Insurance approval obtained.
b. Determine receiving NICU
1. Neonatal return transports may occur when the care at the outside hospital is
appropriate to the level required by the infant. Additionally, care must be
transferred to an appropriate physician and the parents or legal guardian consent
to such transport.
c. Provider to provider communication
1. Attending provider at AFCH NICU must contact receiving provider to accept
transfer of infant care and assure NICU is able to admit patient.
d. Nursing report
1. Nurse caring for patient at time of transfer must call admitting unit and provide
detailed report on patient, including:
A. Medical history
B. Current physical assessment and vital signs
C. Laboratory and testing results
D. Current medications
E. Current respiratory support (if any)
F. Current feeding regimen
G. Discharge planning/follow-up care needs
H. Social history
e. Team providing back transport
1. Some hospitals have the skill level and capability to pick up back transports.
Attending providers and both hospital transports teams should be involved in this
decision making process, with infants safety as the top priority.
ii. If transfer out is not appropriate, every effort will be made for neonates to remain in the NICU from
admission to discharge.
a. Any patient transferred to the NICU will be managed under the Neonatology service.
b. In times of high census and/or decreased bed availability, internal transfers of AFCH NICU
patients will be made in collaboration with inpatient nursing managers and transferring and
accepting attending providers.
D. Discharge Criteria/Planning
i. When discharge from the NICU is appropriate the discharge planning process will be followed,
including discharge teaching and follow up appointments made as appropriate.
a. Discharge planning, including teaching should begin at time of admission
b. Follow-up appointments are scheduled prior to discharge
c. For patients and families meeting criteria an independent care session should be
completed prior to discharge. Variation to the suggested length of time for independent
care sessions will be determined by a team meeting (see related document: Appendix B,
Independent Care Session)
ii. On the day of discharge the patient should be evaluated and a decision to discharge should be
made prior to rounds so that the discharge can be performed in a timely manner.
E. Developmental Follow-Up
i. Developmental follow up needs are determined in weekly interprofessional discharge planning
rounds

IV. COORDINATION

Author: Nurse Manager, Neonatal Intensive Care Unit
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Medical Director, NICU; Clinical Nurse Specialist, NICU
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: September 18, 2017




UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge for Neonatal Intensive Care Unit (NICU)
Policy Number: 2.1.30

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

Hospital Administrative Policy #7.18-Admission & Discharge Criteria for Pediatric intensive Care Unit (PICU)
Nursing Patient Care Policy & Procedure #4.24P-Neonatal Whole Body Cooling (Pediatric)
Nursing Patient Care Policy & Procedure #14.36P-Neonatal Intensive Care Unit (NICU) Visitation and
Infection Control (Pediatric)

VII. REVIEW DETAILS
Version: Revision
Last Full Review: October 20, 2017
Next Revision Due: October 2020
Formerly Known as: UWHC policy #7.16, Admission & Discharge Criteria for Neonatal Intensive Care Unit
(NICU)


































UW HEALTH CLINICAL POLICY 2
Policy Title: Admission & Discharge for Neonatal Intensive Care Unit (NICU)
Policy Number: 2.1.30