Neonatal Intensive Care Unit (NICU) status survey in and around Hyderabad, Telangana

Introduction: Neonatal mortality rate (NMR) is considered a global burden. To decrease the NMR is a challenge, there are specific programs of maternal and child health focusing on reduction of neonatal mortality launched in recent years in our country. Aim: We conducted a study to evaluate the current status of neonatal intensive care units in the state of Telangana in terms of infrastructure, equipment, staffing, functioning and other facilities available. Methods: The survey was conducted from March 2014 to February 2015. Thirty three units participated in the study of which four were government and twenty seven were private. Results: Over last two decades there is humongous difference in the newborn facilities. Majority of the units had a wide range of equipments. Some units had the availability of support from the allied departments and sub-specialities. NNF accreditation criteria were not met in some of the units. Ventilation support was available in most of the units but was not found enough. Conclusion: There is scope of better achievements in future to further decrease the Neonatal mortality.


Introducion
Perinatal-neonatal period carries the highest risk of mortality and morbidity in the entire lifespan of a human being. It lays the foundations of the future health of individuals and determines the health and development of the nation as a whole. Poor neonatal care leads to high incidence of disabilities in the survivors. In fact, death and disease in the first month of life results in126 million disability adjusted life years (DALYs) lost annually, or 8.3 % of the global disease burden, compared to 63 million DALYs for ischemic heart disease [1].
India contributes to more than 25% of the global burden of 4 million annual neonatal deaths [2]. Currently, about 28% of babies are born LBW, thereby contributing 7.5 million LBW babies annually [3]. Premature delivery occurs in 13% of pregnancies in our country, accounting for 3.5 million preterm births per annum [4]. The neonatal mortality rate (NMR) in our country is 7 to 8 times higher as compared to the developed nations. The infant mortality rate (IMR) in the country has declined steadily from 165 per1000 live births in 1950s to 44 in 2011 [5]. On the other hand, NMR has shown a much slower fall in-spite of a surge of government interest in neonatal survival [6]. Two-thirds of neonatal mortality occurs within first week of life and is related to perinatal and birth events. As a result, the NMR has been forming an increasing proportion of IMR over the years and currently accounts for two-thirds of the infant deaths and more than half of under-5 mortality [7].
The specific programs of maternal and child health focusing on reduction of neonatal mortality have been launched only in the recent years. A prerequisite to decrease mortality is the availability of Neonatal Intensive Care Units (NICUs) and Special Care Newborn Units (SCNUs) for care of sick infants. In the last 2 to 3 decades, the number of NICUs and SCNUs in the country has increased exponentially. This has been due to the inputs provided by and progress made by the National Neonatology Forum (NNF) and in recent years the Government's drive to have at least one SCNU in each district with the help of National Rural Health Mission (NRHM), UNICEF and other agencies. An increasing number of neonatologists trained through subspecialty programs like Doctorate in Medicine (DM), Diplomate of National Board (DNB) and fellowships, and an easier availability of affordable neonatal care equipment have been the other catalysts for this growth. Even though the number of NICUs and SCNUs has increased, their actual operational status is not clearly known.
In this review, the authors describe the current status of NICUs in the country not only with respect to their infrastructure, staffing and equipment but also their functional aspects. Based on the findings of this survey, the authors also discuss the way forward.

Material and Methodology
The survey was conducted from March 2014 to February 2015 in Hyderabad, Telangana, India. A structured questionnaire was prepared by the researchers to extract all possible data from each NICU. The questionnaire includes the demographic details like location, district and organisation (private/government), structure of the unit, bed strength, infrastructure details like provision of side-lab, feeding room; separate kangaroo mother care (KMC) unit, out-patient department and area designated for counselling. The survey also looked at number of doctors, nurses, other supportive staff like lactation counsellors, infection control team, respiratory therapist, pharmacist, nutritionist, occupational therapist, biomedical engineer/ technician, quality control nurse/personnel, social worker/counsellors, data entry operator for patient data and their qualifications and experience.
We also looked at the infrastructure and equipment like open care systems, incubators, ventilators, continuous positive airway pressure machines (CPAP), high frequency nasal cannula, inhaled nitric oxide therapy, blood gas machine, laminar flow, in-house x-ray, ultrasound and Echocardiogram (ECHO)s, machines for therapeutic hypothermia, transilluminators and monitoring facilities like Electroencephalogram(EEG), invasive blood pressure, transcutaneous and total serum bilirubin measurements, hand held Oto Acoustic Emission (OAE)/Automated Auditory Brain stem Response (AABR), O2 blender and pulse oximeter in delivery room.
The survey also included the availability of paediatric sub-speciality care like paediatric surgery, cardiology, neurology, ophthalmology, audiologist, radiology, child psychology, blood bank, autopsy and genetics. The other facilities details are also included in survey like milk bank, transport facilities, total parenteral nutrition, unit protocols, blood transfusion facilities like pentabag, pedibag and CMV screens. The questionnaire also looked at the teaching, training and research facilities in each unit.
The research team has personally gone to each unit and filled the survey form. If some details are not available at the time of survey, then those details were later taken by phone facilities. The units have participated voluntarily and no undue influence was used to get the data. The data was collected from both government and private institutions. The governments units include medical colleges, district hospitals and special care newborn units (SCNU).  (Table 1).   (Table 3).  (Table 4). Transport services-All the units are transport facilities for shifting the sick neonates. However, only one unit have airtransport facility also while others transporting the neonates through ambulances by ground. Nine units have facility for transporting neonates needing mechanical ventilation (Table 5). However, this region caters too many of the districts in and around Telangana state. In view of these referrals, the number of beds needed will be more. According to NNF accreditation criteria, for unit to be labelled as level II, it should have a minimum of 12 beds, one unit Incharge with 4 medical officers, one nurse per bed and 100 sq feet area for each bed. If the unit have CPAP facility, then one CPAP for each 6 beds should be available [11]. For a level III unit, it should have 1:4 ratio of ventilator beds, doctor to bed ratio of 1:2.2, nurse to bed ratio of 0.66:1 and area of 150 square feet for each bed is mandatory [12]. In our survey, we found that though the total number of level III and level II beds are more, the personnel indicators of NNF accreditation criteria are not met by many units. There is gross mismatch of ventilator to bed and CPAP to bed ratios. Only few units are meeting these criteria.

Sub-speciality services-
Limitations-As this a survey, conducted by interviewing the administrators and senior consultants, the data may contain few errors. We were not able to calculate many parameters of accreditation due to paucity of data regarding, nurses and doctors per each shift and doctor responsibilities distribution among level II, level III and ward beds. Many of the units which are attached to pediatric services are sharing the ventilators and doctors for duties and care.