NICU Infection Prevention

The hospital landscape—and indeed the entire world—has changed over the past few months since the arrival of the COVID-19 pandemic in the U.S., caused by the coronavirus called SARS-CoV-2.  Hospital administrators and healthcare workers have seen changes come at a near-breakneck speed as new evidence about the coronavirus becomes available and as local conditions evolve. These changes necessitate a great amount of attention to ever-shifting city, county, state, and national guidelines, including those of organizations such as the Centers for Disease Control and Prevention (CDC), American Academy of Pediatrics (AAP), and the American College of Obstetricians and Gynecologists (ACOG). Flexibility to adapt to these changing guidelines is required, as is patience in explaining them to staff while also maintaining morale in the midst of an environment where uncertainty, fear, and staff exhaustion can become pervasive.

Changes have come to the Neonatal Intensive Care Unit (NICU) as well, although those working in NICUs have long been well practiced in paying close attention to strict infection control standards. Because infants—especially those who are premature—have immune systems that are not fully developed, they are at an overall higher risk of infection than older children. As such, visitation in the NICU has always been closely regulated and monitored, and it is now even more so.

A key thing to understand is that policies in each hospital are variable, depending to a large extent on the local degree of community transmission of the coronavirus that causes COVID-19. Hospitals located in the middle of “hot spot” cities and towns where transmission of the virus is not well controlled will have more restrictive visitation policies than those where there are but a few cases. And in fact, visitation policies may need to be changed abruptly based on trends in local data.

Most NICUs are now limiting “visitors” (not the best label for a parent to have!) to just two—and sometimes only one—consistent people throughout the baby’s hospital stay. Typically, these would be the baby’s parents, or the mother and her designated support person, both of whom wear identifying hospital-issued bands. Unfortunately, some hospitals located in areas where COVID-19 infections are still prevalent have forbidden any visitors, once the mother has been discharged from the hospital after delivery. This type of severely restrictive policy should not be undertaken lightly, as much evidence has shown how important parent/baby bonding is to the infant’s development and parents’ mental health.

Visitors will typically be screened upon entering the hospital by answering a few brief questions about any current symptoms they may have, and their temperature may be taken; obviously, anyone who is showing symptoms of COVID-19 or who has an elevated temperature will not be allowed in. Visitors will be asked to don a hospital-provided face mask, and they may undergo repeat screening before entering the NICU. If approved for entrance, visitors will then engage in the usual routine of three full minutes of handwashing using soap and water with a scrub brush.

Visiting “hours” are usually not restricted, given the commitment in most NICUs to family-centered care, and again, the importance of both skin-to-skin (kangaroo) care and breastfeeding to the well-being of both mother and baby. We know that many parents already experience the NICU as being traumatic, and having a fragile or sick baby in the middle of a worldwide pandemic will only serve to heighten parents’ anxiety.

Practices among the nurses and doctors have changed as well. Whereas staff used to only wear face masks under certain conditions, such as when performing sterile procedures or attending deliveries, they are now wearing them throughout their whole shift. Many if not most NICUs have long required staff to wear non-sterile gloves when providing patient care. Now, in addition, more layers of protection are added to the recommended personal protective equipment (PPE) being used for certain procedures that have the potential to cause spread of the virus (such as intubating a patient, or treating them with continuous positive airway pressure). These include goggles or a face shield to protect the eyes (personal eye glasses have been deemed inadequate), and a gown, gloves, and N-95 face mask to guard against inhalation of respiratory droplets. Staff may also wear gowns over scrubs at deliveries.  A hospital’s supplies of PPE, in conjunction with the number of COVID-19 patients the hospital is caring for, have combined to determine the protocols for use and reuse of PPE locally.


References

  1. CDC. 2020. “Coronavirus Disease 2019 (COVID-19).” Centers for Disease Control and Prevention. February 11, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/inpatient-obstetric-healthcare-guidance.html.
  2. “Clinical Management of Severe Acute Respiratory Infection When COVID-19 Is Suspected.” n.d. Accessed May 9, 2020. https://www.who.int/publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected.
  3. “National Perinatal Association – NPA + NANN Joint Statement: Mothers with COVID-29 and Their Newborn Infants, Positin Statement #3069.” n.d. National Perinatal Association. Accessed May 9, 2020. http://nationalperinatal.org/NPAandNANN.
  4. Puopolo, KM, ML Hudak, DW Kimberlin, and J Cummings. 2020. “Initial Guidance of Infants Born to Mothers with COVID-19.” American Academy of Pediatrics Committee on Fetus and Newborn, Section on Neonatal Perinatal Medicine, and Committee on Infectious Diseases. https://downloads.aap.org/AAP/PDF/COVID%2019%20Initial%20Newborn%20Guidance.pdf.
  5. Stuebe, A. 2020. “Should Infants Be Separated from Mothers with COVID-19? First, Do No Harm.” Breastfeeding Medicine, April, bfm.2020.29153.ams. https://doi.org/10.1089/bfm.2020.29153.ams.