The Neonatal Intensive Care Unit is part of the UF Health Shands Children’s Hospital. The Neonatal Intensive Care Unit (NICU) has a combined 72 ICU and IMC level beds. The ICU level (34 licensed beds) and the IMC level (38 licensed beds) provide tertiary care to infants from within Florida as well as other states based on diagnosis and availability of resources. Admissions come from Labor and Delivery, referring hospitals, and the Mother-Baby Unit.
The NICU is located on the 3rd floor of the Children’s Hospital adjacent to the Labor/Delivery and postpartum units. All patient bedsides are equipped with cardiorespiratory monitors that have the capabilities of monitoring heart rate, respiratory rate, blood pressure, and oxygen saturation levels. Support Technicians continuously monitor emergency alarms that are active at all bedsides.
In addition to patient care spaces, the NICU has numerous support spaces including a conference room, two consult rooms, a Human Milk Room, a reception area, and a parent activity area. Parent and visitor access is monitored for security reasons. All infants in open bassinets are banded with security devices that provide alarms and lock-down if the security doors are breached. Additionally, there is camera surveillance that monitors the primary entrance and all patient care areas.
Description of Patient Populations
Common medical diagnoses treated in the NICU are:
- Respiratory Distress
- Necrotizing Entercolitis
- Congenital Cardiac Disease
- Congenital Anomalies requiring surgical repair
- Primary Pulmonary Hypertension
- Bronchial Pulmonary Dysplasia
- Birth Asphyxia
- Feeding Intolerance
- Retinopathy of Prematurity
- Hypoxic Ischemic Encephalopathy
Procedures commonly performed in the NICUs include Umbilical Arterial/Venous Catheterization, Percutaneous Line Placements, Endotracheal Intubations, Sepsis work-ups including lumbar punctures, peripheral artery line insertions, central line placements, chest tube insertions, invasive and non-invasive monitoring of all vital parameters, electrolyte infusions, whole body cooling and ECMO cannulation and de-cannulation.
Nursing care is focused on the assessment, diagnosis, planning, treatment and evaluation of patients requiring acute care. Nursing interventions address alterations in the physiological function of the neonate and alterations in the family processes. The Job Description identifies the population served, equipment utilized, skills performed, and clinical parameters. Each nurse has the autonomy and accountability for decision-making and total care for assigned patients during their shift, which is typically 12 hours. The nursing staff is committed to patient advocacy and innovative patient care.
The staff is comprised of an all RN staff. The nurse to patient ratio is determined by the patient acuity and is typically 1:2 for ICU level patients and 1:3-4 for IMC level patients. There are two charge nurses per shift: a CN who supports patient flow, clinical assignments, and immediate operational issues and a CN who supports clinical care and staff nurse assignments.
Unit clerical coverage is also available 24 hours a day. In addition, there is a Milk Tech who manages the intake, storage and handling of all human milk in the NICU and other units in the hospital.
Health Care Team
The NICU is under the medical direction of a Neonatologist, a Nurse Manager, two Clinical Leaders, and a Unit Assistant who are typically present during the week. The Nursing Coordinators provide off-shift and weekend administrative assistance. The staffing plans for the Registered Nurse are consistent for all shifts. Direct care in the NICUs is provided by the registered nurses, physicians, neonatal nurse practitioners, occupational therapists, physical therapists, respiratory therapists, pharmacists, nutritionists, social workers, and families. Support Technicians provide support for the direct patient caregivers. Additional support services available for neonatal patients include Enterostomal Therapists and Patient and Family advocates.
Requirements for Staff:
The Clinical Leader and Management Staff of the Neonatal Intensive Care Unit coordinate the professional orientation of the nursing staff. This is accomplished with the assistance of the staff nurses who serve as Preceptors. The orientation consists of hospital and unit specific components.
The basic requirements for the Registered Nurse include:
- Current RN licensure in the State of Florida
- Completion the Neonatal Resuscitation Program
- Competence as defined by NICU RN Job Description
This foundation supports and facilitates caring for premature and term infants.
Basic requirements for the Support Technicians l Staff include:
- Competence as defined by the NICU Support Technicians Job Description
Nursing care responsibilities are assigned by the primary Charge Nurse. The primary Charge Nurses is responsible for the coordination of work flow, collaborating with the medical team regarding the coordination of unit admissions and transfers, facilitating adequate staffing for the oncoming shift, and making patient assignments. The second Charge Nurse is responsible for supporting staff and clinical decision making during the shift. Assignments are made based on the following considerations:
- The degree of supervision needed by the care giver and its availability
- Competencies of the caregiver:
- Orientees will be assigned patients of a complexity designated by their schedule plan
- Staff recently completing orientation will be assigned patient of a complexity comparable to their assignments at the end of their orientation period
- Specialty patients will be assigned only to experienced staff members who have demonstrated broad competency in neonatal nursing
- Staff supplement/float staff will be assigned patient congruent with the Pediatric float grid and will be assigned an NICU resource staff member
- Staff will be assigned patients congruent with completion of competencies of technology required for patient care.
- Patient’s status and complexity of condition as reflected in the Quadramed system, professional judgment, and frequency of procedures
- Location of patient with the respective units
- Previous day’s assignment to provide continuity of care.
Assignments are to follow practices outlined in the departmental policy. The Registered Nurse responsible for making these assignments will be familiar with these practices and will review them as necessary to keep his/her information current.
Direct care hours exclude the Nurse Manager, two Clinical Leaders, Nursing Staff, Administrative Assistant, and Unit Clerks. Budgeted hours per patient day for ICU level patients is 13.3 and 9.48 for IMC level patients. Adjustments are reflected in the Targeted Staffing projections in Concerro and are based on the census and acuity of the classified patients. Additional staffing needs are met as described in the Hospital Plan for Nursing Care. The Nurse Manager or designee, in accordance with the Hospital Plan for Nursing Care and the nursing policy, determines the need for extra shifts/overtime. A staffing Grid based on the budgeted HPPD identified below. Adjustments to this grid are reflected in the Targeted Staffing projections in Concerro and are based on the census and acuity of the classified patients (Quadramed Classification System).
Daily staffing requirements are made by using the following parameters: unit census, acuity, and experience and competence level of staff. Staffing needs are highly variable as reflected in the census and care needs of the neonatal patient.
The Nurse Manager/designee will make decisions concerning overall adjustment of staff according to the above. Additional staffing will be obtained by notifying the Central Staffing Office (CSO)/ scheduling available staff for extra hours or time and a half/ utilizing transport team/ and management staff. If census and/or acuity are decreased, the CSO will be notified of float availability. If additional staffing is not required within the Pediatric units, staff may request to work in other areas within the hospital based on their level of competence. Staff may be utilized on available projects or is granted time off on a rotating basis as determined by the use of the voluntary STOG log and calendar.
The NICU will use extra shifts/overtime based on periods of high census, patient acuity, and experience of staff members, open positions, or individuals on Unscheduled Time Off, Short Term Disability, or Long Term Disability. Coverage needs will be communicated to staff by posting available shifts through BESTSHIFT. This process will be the primary source of staffing available shifts.
Scheduled Time Off (STO):
Request for STO will be reviewed on a case-by-case basis and taking into account the variables listed in the extra shift/overtime section. Utilizing this approach will decrease the need for extra shift coverage due to high numbers of STO request during a given period of time. NICU employees are expected to request time off six weeks in advance of the new schedule. Request can be made a maximum of 6 months in advance. The holiday time is subject to holiday guidelines that are reviewed yearly. Guidelines will be posted. All STO requests are recorded by management team member on the vacation calendar that is located in the Managers office. Requests will be limited to no more than 180 hours per shift, on a first come first serve basis. During the peak vacation time (June – August) staff requests for vacation are typically limited to two weeks in order to accommodate as many individual requests as possible. If requests are greater than can be accommodated, switches can be arranged as long as they do not result in unnecessary overtime. Staff is encouraged to trade shifts for day to day STO needs after the above deadline for request has occurred. Trades should not incur overtime.
Staff are granted time for educational programs by requesting administrative leave for off-unit activities. Required programs sponsored by the unit are given during shift hours or overtime is paid. Staff are paid for meeting times and committees work with each staff member collaborating with each other for unit coverage during the meeting times.
NICU Coverage Plan For Charge Nurse (No CSO/Float Help Available):
Step 1: Review volunteer sign-up list for OT/Extra shift. Call personnel in if available. Call all staff that is off and request help. Be flexible with how staff can help out working 4/6/8 hour shifts.
Step 2: Negotiate for staff members currently working, to work extra in exchange for overtime or another shift off. Try to avoid Friday-Sunday switches when possible to avoid difficulty-covering weekends. Again, flexibility will help meet staff needs as well as personal needs; 4/6/8 will help out.
Step 3: Evaluate extra shifts, which may be over staffed and negotiate for someone to work in exchange for this shift off. This may require calling that are not on duty at the time.
Step 4: With census above 52 discuss with attending the situation and steps taken. In collaboration with the attending, CN, and Nursing Coordinator discuss census status of other PEDS units and consider patient movement within house. If none is available discuss option of moving some patients to other hospitals using our usual and customary criteria.
Step 5: Consider having the CN pick up an assignment, revert to whole team approach. Inform the staff that the CN has an assignment and staff will need to call the unit directly, as he/she will not have time to make usual rounds. Call on the nursing coordinator to help out as necessary.