Neonatal intensive care (Provisions and costs)

INTENSIVE CARE NURSING, t;Longman Croup 1986

1986, I, 204-209

TECHNICAL

Neonatal Intensive Care (Provisions and costs) S. M. Lindsay Whilst a student, doing the JBCNS400 course for Neonatal Intensive Care as my project, I looked at some of the costs involved when providing neonatal intensive care. I was intrigued by the amount of equipment necessary to care for the sick or preterm neonate. ( 1978/ 1980) which examined Neonatal and Guided mainly by the Short Report Perinatal Mortality, then gave recommended guidelines for equipment, facilities, medical and nursing cover and levels of care, I priced equipment per cot at 1984 costs, then I briefly set out provisions made by the North East Thames Regional Referral Unit estimated at 1981 prices, when plans were made to expand and update the unit to care for 34 neonates. Finally, drugs, disposable and single-use items were priced over a twelve-hour period for a full term neonate who suffered birth asphyxia and required intensive care. Although standards of care are always being improved the costs are high, but the results surely worthwhile.

AWARENESS

OF NEEDS

Over the past 2 decades Neonatal

has become a highly skilled and care, especially since the advent ventilation and oxygen monitoring is aimed at minimising mortality thus enabling the preterm or attain full adult potential. In 197771978 the largest

obstetric

portion

Intensive Care complex field of of mechanical facilities. Care and morbidity sick neonate to

inpatients

of the estimated

were taking Maternity

Sadie M. Lindsay, 35 Manor Road, Smethwick, Midlands Manuscript

breakdown

(Short:

1978/1980.)

(although on

actual

there

was

no

expenditures).

In April 1978, kc‘52 million

were injected into the hospital and health services to improve them, priorities being the provision of better facilities for mothers and babies. Various committees

have

since

been

set up to review

maternity and neonatal services and make appropriate recommendations. I looked at some of these recommendations and the costs involved in neonatal intensive care provision.

REQUIREMENTS 27 Feb.

FOR CARE

1986

Although the costs itemised in this article are already out of date it is a thought-provoking reminder of the economic costs of this kind of service, and of equipment which is sometimes used without thought as to its price and whether use of each disposable item is really necessary. PAT ASHWORTH. Editor

204

expenditure

West

B67 6SD accepted

Services detailed

The Sheldon Report examined infant care then set out, as a guideline, a schedule ofrecommended equipment for a Special Care Baby Unit (SCBU)of 30 cots inclusive of five Intensive Care cots caring for 5000 babies per year. (Sheldon,

INTENSIVE

CARE

NURSING

205

6

--L II II

Fig. 1. Equipment per intensive care cot as recommended in the Sheldon and Short Reports

197 11 The equipment

per cot is shown in Figure 1,

and listed in Table I are related costs at June

1984

prices. All are exclusive of Value Added Tax. In 1978 the British Paediatric Astociation and

Royal

College

gists Liaison

of Obstetricians Committee

and Gynaecolo-

stated

that,

‘In major

units I:6 special care cots should be designated for intensive care, and units with 3000-4000

List of Equipment and Costs 1.

Infusion

2.

Phototherapy

pump and stand

3.

Oxygen

4/5.

Apnoea monitor

and pad

335

6.

Servo controlled

incubator

7.

Ventilator

3400 2750

.

.

light for use over incubator

ic; 720 or cot

700 450

analyser and sensor

8.

Humidifier

9.

Ventilator

and probe

lo/l1

Ohio overhead radiant heat includes phototherapy

12. 13.

Transcutaneous

1100

tubing circuit

270 light

oxygen monitor with chart recorder

14.

Transcutaneous oxygen probe Open cot for use under radiant heat

15/16. 17.

(converted from old Vickers 59 incubator) Heart rate and E.C.G. recorder Temperature recorder

lSj19. 20.

Respiration and blood pressure Chart recorder

3500 6500 440 200

3650

deliver-

206

INTENSIVE

CARE

NURSING

cot during any 24 h period, optimum

Table I Equipment figure 1

and costs additional

to those shown

in

BABIES

f 2850 650

Infant resuscitaire Syringe pump Alarm cut out boxes (3 per intensivecare set up) Skin temperature probe Heat shield with humidified circuit Intravascular Oxygen monitor Blood pressure monitor with cuff Transilluminator Heat pad Oxygen headbox Stethoscope Penlon bag Weighing scales Breast pump Fully equipped transport incubator

REQUIRING

INTENSIVE

CARE:

A) Those receiving assisted ventilation, Positive Airway Pressure (CPAP)

150 100 400 1000 1802 300 80 50

24 h following total

its withdrawal.

parenteral

Constant

and in the first Babies

receiving

nutrition.

B) Babies with unstable cardiorespiratory including

recurrent

attention.

Those

f 136275.5

apnoea

48 h after birth. transported travel.

surgery,

Babies having

during the first

convulsions.

Babies

by the staff of the unit on the day of

Babies

cedures,

constant

who have had major

below 30 weeks gestation

Babies

disease,

requiring

in the first 24 h post-operatively.

particularly

~00.50 350 510 5345

Total (exclusive of VAT)

ratio being

5:l.

undergoing

e.g. arterial

major

pro-

medical

catheterisation

or exchange

transfusion.

ies or more immediate

per year

provision

care facilities

should

qualify

for the

of full long term intensive

including

appropriate

Paediatric

and Nursing cover’. . . Recommended

equipment,

facilities and medi-

Special Care

Care

is given

treatment

in a special

exceeding

nursery

providing

the normal routine care but

falling short of Intensive

Care. Sufficient

staff should be available

to allow a ratio of 1.25

cal and nursing cover as set out in the Sheldon

nurses

Report,

during a 24 h period, optimum ratio being 1.5 : 1.

were reiterated

in the Short Report

also by the British Paediatric British

Association

(BPA/BAPP, The

for

Association

Perinatal

Report

also

recommended

that

funds be set aside annually

by the Regions

replace

equipment

above k5000,

and

deficient

to

costing

and Districts should replace equip-

ment below ;c15000. No specification to what constitutes

neonatal

was given as

‘old’ or ‘deficient’.

SPECIAL

CARE

The BPA/BAPP

care as follows: (BPA/BAPP:

to each

cot

monitoring

transcutaneous

oxygen

ing

tube

having

feeds and

Oxygen,

ARE:

(TCP02). intravenous

Phototherapy,

special blood monitoring glucose or serum bilirubin.

Babies requir-

i.e. of heart

rate or

Babies receivfluids.

Those

Antibiotics

procedures,

or

e.g. blood

Those who have had

minor surgery in the previous 24 h. Babies with a Those

requiring

physiotherapy,

X-ray investigations or other methods ofimaging. Babies needing constant supervision i.e. babies

OF CARE defines and categorises

BABIES

ing continuous

tracheostomy.

CATEGORIES

experience

and the

Paediatrics

1984.)

Short old

and

with

nursing

whose mothers levels of

1984)

are drug addicts.

Dying babies.

Babies who are barrier nursed. Some units may subdivide Special Care into high and low dependency to audit the workload.

Intensive

Care

Care is given in a nursery providing COntinUOUS skilled supervision by medical and nursing staff. Nurses should be sufficient to allow a ratio of 4 (trained in neonatal and intensive care) to each

Provision Referral

in

a

Regional

Neonatal

“nit

The designated North East Thames Referral Unit averages 2500 deliveries per year and has 18

INTENSIVE

neonatal Unit and

cots. Since

(NNU) taken

(UCH

history,

made

and

1983).

submitted

funding,

to expand

Hospital

and

and

guidelines,

approximately

L514247

ties

=

L54772

and

Care

hospitals

(LO.21),

the baby

Region

for

comply

with

at 1981),

additional

at

facili-

and 2 1 Special

The

was duly

1982 and officially HRH

Princess

Since

opened

has almost 1983

professional tive,

unit

with

carried

full intensive

cleared

from and

Chlorhexidine

1982 by

and

of regional

ried

out

leads

admission

ancillary,

works)

and

administra-

non

staff

initially

in

1000,

cascade

con-

0.02” 11(LO.5 1 /.

0.5

and umbilical sepsis

(40.64)

an autolet

and

platform

lancet

(LO.33).

Head

and

and equipment, tely fin- more the

the unit is unable than

allocated

Ll32.15

to care adequa-

28 cots and still remain

funding.

Cost

at

,cJ48238,

per day.

Costs

estimated

space

and

and length

within

per cot per

year

is

approximately

do not include

measure

were measured (LO.05).

the paediatrician

mainte-

analysis bottles

Cost of drugs and disposable equipment

he was electively

baby

who

required

suffered

intensive

severe

bonnet

at birth

because

of intrapartum distress mode of delivery. He was intubated (ETT) LO.75) and

asphyxia

and

Dextrose low

the baby had shown

signs

trose

were to be the

at birth (endotracheal tube a mucus extractor (,C;O.lS)

were

to obtain

gastric

which

was put in

from a heel stab with

a disposable circumference

using a disposable

tape by

for investigations

and blood

gas

butterfly

cannula,

specimen

condition

re-intubated and

attached

mucus

remained (ETT,

poor, collar

extractor,

25”,

(LO.33)

(LO.29) a peripheral

secretions

disposable

was commenced.

and

so and

to the ventilator. to remove

LO.30). Blood sugar level was rechecked, initial result was low, requiring a bolus

were

and forceps

(LO.24)

were taken

baby’s

(LO.80)

(catheter,

and Paediatrician

was synthe-

a naso-

chest

The ETT was then suctioned

care was calculated:

12.40h: The Obstetrician present

birth

&O.l6j

(g0.41).

13.15h: The

The cost of drugs and single use or disposable items used during the first 12 h oflife for a full term

skin discs)

Blood specimens

(syringes,

nance.

and

and

analysis,

using

staff,

ml

swabs

passed

for laboratory

car-

iECG)

screening

complexity

more

then

to aid prothrombin

a sterilin pot (LO.08). Blood sugar level was checked

requiring

were

electrode

averaged kl640 100 per year for 34 cots (UCH Report: 1983/1984) but in 1984, due to increased of care,

was

extractor

(&0.0211 for adhesive

Konakion

tube

secretion

Mucus

a mucus

procedures TCP02

for routine

gastric

costs

complete

Electrocardiogram

probe

attached,

taken

equipment. with

nappy

heater

solution

given intramuscularly

nursing,

to

gamgee

disposable

nursed

as follows:

sis, ear, throat (medical,

clamped

transferred

via a Bennetts

x 3 (Al.62),

were

from 54 in 1981-158

costs

care

he was

a radiant

his mouth

taining

of 1983.

staff

the Ohio

(high and

out in 1981L

the number

trebled,

and

humidified

in December

and technical,

clerical

(LO. 15), under

temperature

in the first 11 months In

(El.87)

(60.16)

Diana.

the expansion,

referrals

pad

Routine

expansion

and

12.45 h: The baby was laid on a soft warm

oxygen

low- dependency).

respiratory

was

Unit.

=

Care

a

cord

extubated

207

NURSING

(L3.27’1

umbilical

for 34 cots,

equipment

to cater

the Neonatal wool

Obstetric

costs were estimated (prices

This was estimated

13 Intensive

The

to the To

Naloxone

stimulant.

1970s plans

the

and

per year

In the

Unit.

recommended

L459475.

referring

update

Neonatal

acidosis

the Neonatal

for 450 babies

2-3 per week from

Short

were

the mid-sixties

has cared

CARE

because

gloves as the dose of

it remained

infusion

of lo”,,

Dex-

At the same

time,

it was

decided to insert umbilical artery and vein catheters (see table 2) to enable intravascular monitoring venous

of vital pressure,

signs

(blood

pressure,

central

used to clear secretions from the oropharynx and a suction catheter (,C;O.O9) to clear the air passages

arterial oxygen and carbon dioxide tension). Chest and abdominal X-ray-s were ordered, to confirm ETT and catheter

around the Bicarbonate

positions and to observe the lung fields. 14.30h: Blood sugar levels remained low (LO.33 j

vocal cords. 5O,, (L0.18)

Intravenous was given

Sodium to correct

208

INTENSIVE

CARE

NURSING

Neonatal These perspex daily.

Emergency

Drug Box

drugs are kept on the resuscitaire box so they can be clearly They

have pre-set

in a sealed

seen and checked

doses with specified

expiry

dates, by which date they are destroyed ifnot used. They are also wasted if opened

and not required,

and are

usually discarded. Adrenaline Naloxone

1: 1000

2 x lOm1

neonatal

Isoprenaline

2 x 2ml O.O2mgs/mls

sulphate

Calcium Gluconate

10::

Diazepam

20mcgmj2ml 2 x 1Oml

Al.26 6.54

x 2

.96 .46

2 x lOmg/2ml

Sodium bicarbonate Phenobarbitone

57,

sodium

.50

2 x 20ml

1.56

2 x 15mg/ml

.lO

Phytomenadione

2 x lmg/0.5ml

.32

Dextrose

1 x 25ml

.26

25”,

Ll1.96

Table II

Peripheral Infusion Giving set Intravenous cannula Infusion solution 3-way tap Syringe 5mls. Gallipot and wool swabs Sodium chloride 2mls

Umbilical artery Infusion f 2.50 0.55 0.80 0.27 0.06 10

Giving set Artery catheter Infusion solution Heparin sodium Intravascular electrode Tape measure 0.03 Disposable surgeon’s gloves Dressing pack

f 4.31

f 2.50 0.62 0.80 0.33 20.75 0.06 0.35 0.66

f26.07

Umbilical vein Infusion Solution manometer line 60ml. syrine and extension Heparin sodium 3-way tap umbilical catheter rubbish bag

f 0.80

0.97 2.00 0.33 0.27 0.62 0.05 f 5.04

so the sodium chloride solution via the umbi!ica! artery was changed for a glucose solution (L3.30). The baby’s central venous pressure was elevated to 20cm. H20 (normally 7-10 cm H20) and with X-ray findings plus clinical signs, the medical team agreed on a diagnosis of congestive cardiac

failure due to circulatory overloading, secondary to a huge transplacental transfusion. Venesection was performed four times over a period of8 h with strict monitoring of vital signs, until the central venous pressure stabilised below 1Ocm H20. Total cost ofitems x four (L4.04) 20ml syringe (L0.44)

INTENSIVE

sterile

disposable

surgeon’s

gloves

the

above

and

procedures

given

hourly;

Gentamycin and needles

16.00

h, 20.00

routine

care

mucus

extractor

and

were suction

gallipot, disposable

test

wool

balls

bag

inserted movements ments

Blood catheter

was

with

a catheter

urinary to

some

to cerebral

Phenobarbitone

x 5 from from

the

umbilical

was

until

The services

the laboratory

technicians

in the unit’s

h for scanfunds)

of intraventricular of the radiologist

and

were used (services

equip-

cases

may argue

and

units the

cost

The

are media

that it is not cost-effective more

money

for

equipment,

but when

of maintaining

a handi-

in the community - ,C;50000000

in his document,

all, the baby

Care.

to request

sophisticated

person

of handicap

for the duration

(as estimated

Newborn then

surely

standards

has the whole

by Dr.

Care in England it is worth-

of care? After

of the rest of his life to

live fully and effectively.

References BPA/BAPP 1984 Statement of the British Pardiatric Association and the British Association for Perinatal Pardiatrirs on Categories of Babies receiving N’conwtal

not

Sheldon 1971 Report of the Expert Group on Special Care for Babies, Sheldon Report 1971, H51SO Short 1978 Second Report of the Social Services Committee, Short Report 1978-1980, Perinatal and Neonatal Mortalit), Volume 1 and Volume V HMSO University College Hospital 1883-1983 A Short History p.33 University College Hospital 1983 Report on the Regional Neonatal Unit, January 198311984

budget). items and drugs

iOO” Ij care by a trained

medical

24.00

research

By aged 12 h this baby had incurred for disposable

artery

The Ultrasound

the medical

haemorrhage.

constant

oedema,

(FO.10)

admission (&0.30).

of their

Care

from

was used to look for evidence

required

move-

the baby.

ner (purchased

L60.08

abnormal

convulsive

were attributed

taken

East

Medical

output. have

generalised

blood gas analysis

included

(LO.09)

some

Intensive

to improve

began

to sedate

some

on Neonatal

1978,1980),

intravenous

given

capped

where

conclusion,

for neonatal staffing

North

an excellent

is manufactured.

1978 (Short,

and

which

department

has

while striving

(L0.48)

baby

Physics In

also

Fruse-

to measure

The

Region

a small

! 20 mg/2 ml) was given (LO. 15) and a urine

mide

collection

Thames

only

passed

the

Value

may vary depend-

so a dose of the diuretic

had

from

include

The

the

of his lifetime

for urinalysis

not

and items priced

Dunn

By 17.30 h the baby

&o

sodium

obtained

do

manufacturers.

on

considering

& rubbish

syringe,

were and

'Lo9

ing

and society

catheter

quoted

NURSING

Added Tax. Equipment

blamed

sugar gloves

2 ml

out:

disposable

= LO.21. of urine

prices

department

ment

suction,

carried

3 x LO. 16 = kO.48;

3 x LO.06 = LO. 18; labstix

amount

and

6

syringes,

h: ETT

observations

3 x LO. lO= LO.30;

3 x &07

LO.09

AO.21)

h, and 24.00

3 x LO.33 = AO.99; 3 x LO. 11 = LO.33; chloride

with

ordered

18 hourly;

3 x LO. 15 = LO.45; nappy 3 x LO.09 = LO.27; blood

hags

were

(Penicillin

LO.58

The

small

associated

antibiotics

intravenously

swabs

(1.40))

stores

dressing pack (L2.20). Because of the risk of infection

CARE

attention.

expenses

of

and he had nurse,

and

Acknowledgement I would relevant

like to thank information.

everyone

who kindly

helped

to gather

the