NURSING PATIENT CARE POLICY & PROCEDURE
May 31, 2017
Nursing Manual (Red)
Policy #: 14.36P
Title: Neonatal Intensive Care Unit (NICU)
Visitation and Infection Control (Pediatric)
A. Outline guidelines for presence of primary support person(s) and visitors to the
Neonatal Intensive Care Unit (NICU).
B. Reduce transmission of infectious diseases to neonates.
C. Detect and prevent the spread of Methicillin-resistant Staphylococcus aureus
(MRSA) in the NICU by establishing a consistent screening and isolation
A. NICU Visitation
1. Primary Supports and Siblings
a. Primary supports are parents of the patient or persons designated
by the parents who are not necessarily blood relatives. In
collaboration with the healthcare team, they are encouraged and
supported to be involved in the care of the patient. Primary
supports are not visitors, rather they are recognized for the unique
role they play as a member of the patient's health care team, and as
such are integral to the patient's healing process.
i. Primary supports are encouraged to participate in patient care
and have unrestricted access to the NICU.
ii. Siblings of any age are welcome in the NICU following
infection control screening (refer to the Health Screening for
Visitors to the NICU document in the Related section on U-
a. Visitors are persons 16 years of age or older, identified by the
primary supports that are able to visit the patient. Primary supports
will identify these persons and indicate whether or not visitation
can occur when primary support person(s) are not present.
b. Up to four people may be at a patient bedside at a given time
i. The family lounge is available for additional visitors
ii. Considerations can be made for special circumstances
through care team leader (CTL) or nurse manager approval
on a case by case basis
3. Parent (Primary support) Overnight Rooms
a. Overnight room reservations are available through the NICU
health unit coordinator(HUC) for families who request and do not
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have a reserved room at Ronald McDonald House (RMH)
i. Room reservations need to be made daily
ii. Sleep room hours are from 6pm-9am
iii. Limit of two adults per sleep room and one sleep room per
iv. Considerations can be made for special circumstances
through care team leader (CTL) or nurse manager approval
on a case by case basis
b. Siblings are not able to sleep with parents in the overnight rooms
c. Parents who lose privileges to stay at RMH will also not be able to
use an overnight room
B. Infection Control
1. Infection Screening
a. Primary Supports and Visitors
i. Primary supports and visitors will complete a daily infection
screening tool (refer to the NICU Visitation Decision Tool
document in the Related section on U-Connect). This tool
will be administered in person by the NICU guest services or
nursing staff prior to unit entrance.
• Positive screen results should be reviewed by the
NICU care team leader using the NICU Visitation
Decision Tool to determine where visitation can
occur. If there are uncertainties, consult the
neonatologist on call. For specific infection
questions, contact the Infection Control
Practitioner on call.
i. Primary supports will complete daily infection screening tool
for each sibling entering the NICU.
• Positive screen results will follow same process
outlined above for primary supports and visitors.
ii. In addition, primary supports will complete the immunization
section on the infection screening tool one (1) time upon first
sibling visit, verifying accuracy with parental signature.
• Siblings who are not current on their
immunization schedule will be evaluated for
visitation on a case by case basis by the
• In extenuating circumstances (i.e., withdrawal of
life-sustaining treatment), exceptions to this may
be made on an individual basis in collaboration
with Infection Control.
iii. Siblings should be accompanied by primary support
person(s) at all times in the NICU and remain in the patient
• The NICU environment should be safe, quiet and
supportive for neonatal development. Primary
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supports will be educated by NICU staff to assure
sibling activity level meets these environmental
goals. The following behaviors interfere with this
environment and are not permitted:
o Touching medical equipment
o Loud noises
2. Hand Hygiene (refer to UWHC Administrative Policy 13.08, Hand
Hygiene). In addition, the NICU will adhere to the following (refer to
NICU Hand Hygiene Policy document in Related section on U-
a. Hand Hygiene for Primary Supports, Siblings, and Visitors
i. Soap and Water (two  minute hand wash)
• Required daily before initial entry in the unit, and
when hands are visibly soiled, or if Clostridium
difficile enterocolitis is suspected or confirmed.
• Hand wash should be repeated if primary support,
sibling, or visitor has left the hospital.
ii. Alcohol hand rub, after initial hand washing with soap and
• Use upon entry and exit of NICU, patient’s room
before and after touching patient, including in
between “dirty” and “clean” cares (i.e., after
diaper change, before feeding, etc.)and at staff or
b. Hand Hygiene for Support Personnel not entering the patient room
• Support personnel entering unit, without entering
patient room, will perform routine hand hygiene
with alcohol hand rub before entering the unit.
c. Hand Hygiene for Health Care Providers and support personnel
entering the patient room
i. All health care providers and support personnel who will
enter the patient room are required to perform a daily scrub
of hands and arms up to elbows (NICU hand scrub) at
designated scrub sinks outside the unit prior to unit entry.
Subsequent unit entry during the shift can be performed using
alcohol hand rub or soap and water if hands are visibly
• NICU hand scrub involves first cleaning under the
nails with a nail file and then selecting one of two
o Cleaning option #1: Waterless (Avagard®)
Use a 3-pump protocol:
▫ First – hand/forearm
▫ Second – hand/forearm
▫ Third – both
o Cleaning option #2: Hand and arm scrub
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with antimicrobial soap and water
Wash hands and arms with
antimicrobial soap with warm water.
Clean subungual areas with a nail
Start timing and scrub each side of
each finger, between fingers, back
and front of hand for two (2)
Proceed to scrub the arms, keeping
the hand higher than arm.
Wash each side of the arm to three
(3) inches above the elbow for one
Repeat the process on the other hand
and arm, keeping hands above the
elbows at all times.
Rinse hands and arms by passing
them through the water in one
direction, from fingertips to elbows.
Wipe hands dry with paper towel.
3. Cell phones and electronic devices for parents and healthcare providers
a. Cell phones and personal electronic devices should be cleaned
daily with available hospital approved electronic disinfectant wipes
4. Attire for all Persons Entering the NICU
a. Remove all hand and arm jewelry (i.e., rings, watches, bracelets,
b. All long-sleeved street clothes should be rolled up to the elbow.
c. Lab coats and jackets should be removed prior to unit entry.
i. Hooks are available at NICU entrance.
d. Lanyards should be made of non-cloth material.
e. No artificial nails or nail polish (including gel polish) of any kind
can be worn. Nails should be clean and trimmed. Persons who are
unable to remove jewelry (e.g., rings) must wear gloves before
entering patient room.
5. Food and Drink
a. Families and visitors can have covered drinks in the family area of
the patient room.
b. No food is allowed in NICU rooms.
i. Families will be given a bin in the family lounge to store
non-perishable food items.
C. Methicillin-resistant Staphylococcus aureus (MRSA) surveillance in NICU
1. Method of MRSA screening studies
a. MRSA polymerase chain reaction (PCR) will be the standard
method for screening.
b. Specimen for MRSA PCR will be one (1) swab of both the left and
2. Surveillance screening studies
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a. All patients will be screened upon admission. Patients admitted at
less than 48 hours of age will not be screened until they reach 48
3. In the event of any positive MRSA screen, all patients in the unit will be
screened every seven (7) days, on the same day (Monday), for at least
two (2) weeks or longer as necessary. If no new MRSA positive patients
are detected in this two-week period, the weekly screening will be lifted.
4. MRSA detection and documentation from outside facilities
a. If a patient transferred from an outside facility has previously
tested positive for MRSA, whether by screening culture or
otherwise, documentation of the site, date and method of testing
should be requested.
b. When feasible, testing for MRSA colonization by the transferring
hospital should be requested prior to transfer.
c. Patients with previous documentation of MRSA colonization
should be placed in contact isolation according to UW Health
Clinical Policy, 4.1.8 Standard Precautions and Isolation, upon
d. Maternal MRSA
i. Patients whose mothers have a history of MRSA colonization
or infection should be kept in isolation and patients will be
screened weekly for MRSA. Kangaroo care should still be
encouraged with these patient and mother pairs. Mothers
should cleanse upper body with chlorhexidine soap daily and
wear new cover gown with each hold.
5. Isolation standards for patients screened positive for MRSA
a. Patients with a positive MRSA screen shall be placed on standard
and contact isolation precautions according to UW Health Clinical
Policy 4.1.8, Standard Precautions and Isolation. This isolation
status will remain for the entire hospitalization.
b. On admission, patients without any prior MRSA history will not
require contact isolation while awaiting initial test results.
c. Patients admitted with prior proof of MRSA colonization or
infection will require contact isolation from the moment of arrival.
d. To the extent it is practical, staff cohorting should be practiced
such that each staff cares for only MRSA-colonized or only
uncolonized patients. Mothers of MRSA-colonized patients must
only use the breast pumps supplied in patient rooms and not those
in the shared lactation room.
6. Decolonization of MRSA-positive patients
a. Decolonization of a patient screened positive for MRSA may be
attempted by using daily intranasal mupirocin for five (5) days.
b. For children who are 48 weeks or older post menstrual age, with
mature skin, may also receive chlorhexidine baths for five (5) days.
c. Re-screening for MRSA in a positive-screened but otherwise
asymptomatic patient may be done after seven (7) days, regardless
of mupirocin use. MRSA isolation is to continue for the entire
admission, regardless of re-screening results.
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d. There is typically not a need for repeat decolonization, even if the
colonization recurs, unless patient is scheduled for surgery, and
requires preoperative decolonization.
D. Investigation of MRSA outbreaks
1. In the case of persistent positives screens despite attempted
decolonization or in the case of a cluster of positive MRSA screens in
the NICU, Infection Control will investigate for source and use whatever
lab techniques are available to ascertain the identity of the strain(s)
involved. Scope of investigation will include patients and staff based in
E. Routine cleaning
1. All high touch surfaces (i.e., computer key boards, workstations, bedside
carts, handles, etc.) in each patient room will be wiped down at the
beginning of each shift (every twelve  hours) with a hospital
approved cleaner and disinfectant wipe by the bedside RN or designee.
a. Incubators should be changed weekly for all infants requiring
humidity, for those with a central line or those requiring
respiratory support from a ventilator according to UWHC Nursing
Patient Care Policy 4.20P, Neonatal Thermoregulation (Pediatric).
b. All other incubator changes should occur every two (2) weeks.
III. UWHC CROSS REFERENCES
A. Health Facts For You 6415, Isolation Precaution for Pediatric Patients
B. Health Screening for Visitors to the NICU (see Related section on U-Connect)
C. UW Health Clinical Policy 4.1.8, Standard Precautions and Isolation
D. UWHC Administrative Policy 13.08, Hand Hygiene
E. NICU Hand Hygiene Policy (see Related section on U-Connect)
F. NICU Visitation Decision Tool (see Related section on U-Connect)
G. Nursing and Patient Care Policy 1.56 AP, Central Vascular Access Device Use,
Maintenance and Removal (Adult & Pediatric).
H. Nursing Patient Care Policy 4.20P, Neonatal Thermoregulation (Pediatric)
I. UWHC Clinical Practice Guideline Prevention of Ventilator Associated
Pneumonia (VAP) in the Pediatric and Neonatal/Infant Population (Birth-18
A. Association of Women’s Health, Obstetrics and Neonatal Nurses (2013).
Neonatal Skin Care Evidence-Based Clinical Practice Guideline (3
B. Centers for Disease Control and Prevention (2011). Guidelines for the prevention
of intravascular catheter related infections.
C. Delaney, H. M., Wang, E., & Melish, M. (2013). Comprehensive strategy
including prophylactic mupirocin to reduce Staphylococcus aureus colonization
and infection in high-risk neonate. J Perinatol, 33(4), 313-318.
D. Gerber, S. I., Jones, R. C., Scott, M. V., Price, J. S., Dworkin, M. S., Filippell, M.
B., Rearick, T., & et al. (2006). Management of outbreaks of methicillin-resistant
staphylococcus aureus infection in the neonatal intensive care unit: a consensus
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statement. Infection Control and Hospital Epidemiology, 27(2), 139-145.
E. Macnow, T., O’Toole, D., DeLaMora, P., Murray, M., Rivera, K., Whittier, S.,
Ross, B., & et al. (2013). Utility of surveillance cultures for antimicrobial
resistant organisms in infants transferred to the neonatal intensive care unit.
Pediatric Infect Dis, 32(12), e443-e450.
F. Milstone, A. M., Song, X., Coffin, S., & Elward, A. (2010). Identification and
eradication of methicillin-resistant staphylococcus aureus colonization in the
neonatal intensive care unit: results of a national survey. Infection Control and
Hospital Epidemiology, 31(7), 766-768.
G. Nelson, M. U., & Gallagher, P. G. (2012). Methicillin-resistant staphylococcus
aureus in the neonatal intensive care unit. Seminars in Perinatology, 36(6), 424-
H. Verklan, M. T., & Walden, M. (2015). Core curriculum for neonatal intensive
care nursing 5th Ed.). St. Louis, MO: Saunders Elsevier.
V. REVIEWED BY
Clinical Infection Control Practitioner, Infection Control
Clinical Nurse Specialist, Neonatal Intensive Care Unit (NICU)
Medical Director, NICU
Nurse Manager, NICU
Nursing Patient Care Policy and Procedure Committee, May 2017
Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive