4 hour observation patients

[Tiki_Torch]

My new hospital seriously lacks policies and procedures as compared to my previous hospital. This morning a term meconium baby was born with 3/6/9 apgars and there was a big debate as to whether he should go on to the Well Baby Nursery or come to the NICU for 4 hours of observation under the care of his pediatrician. As I understand it, he came out with a whimper of a cry and by 10 minutes he was vigorous. He wasn't intubated because the respiratory therapist didn't arrive in time for the precipitous delivery, although no one feels he would have needed to be intubated and suctioned at birth anyway. Blow by O2 pinked him up after a minute or two. (I thank God I am in orientation and didn't attend the delivery!!) After much hullaballoo the baby was eventually brought to the NICU for observation because of the 5 minute apgar of 6 making him an "at risk" baby. In my old hospital this would have bought him a ticket to an observation bed right away. This hospital doesn't have such parameters so each shift/nurse seems to do what they feel is best for each baby on an individual case basis. There was a lot of complaining about no policy (the WBN nurse didn't want to accept the baby and the NICU charge nurse felt the baby was vigorous and could be watched in normal transition in WBN until we all considered the 5 minute apgar of 6). I blame our administration for not having policies in place for situations like this so that everyone knows what should be done in most every situation. (By the way, in the NICU the baby was satting 100, not tachypneic and looked great. Of course all of this happened close to the end of our shift... isn't that always the case?!!!) Anyway, the baby was placed on Oxygen Saturation monitor and then came the debate about placing him on Cardio-Respiratory monitor too. The oncoming shift said observation babies are not supposed to be placed on C-R monitors because of something to do with "charges". Of course there was no policy to back up this claim either. In my old hospital the observation babies were put on C-R and SpO2 monitors for 4 hours.

On the basis of this experience I'm wondering how your units handle observation patients:

If your NICU admits at risk newborn babies for observation, do you have a policy to put them on Cardio-Respiratory and Oxygen Saturation monitors, only Oxygen Saturation monitor, no monitors, or wait for your Neonatologist or Nurse Practitioner to order which types of monitors to hook them up to?

Also, do you have a policy to clarify exactly which babies constitute being brought to NICU for an observation period, and if so, what are they?

How many hours do you keep them as "Observation" status before either being admitted as "NICU" status or transferred to your "Well Baby Nursery" status?

Thanks in advance for any input you may share!!!

[iceNICUnurse]

In my NICU we only put them on SpO2 monitors mostly b/c the cardio/resp electrodes do not stick wery well to new babies.

The MD goes to all risk births (we never go to the delivery rooms) so it is his call wich baby comes to Nicu and wich can stay with mum.

We dont have any policy on which babies come to us for observation, just if the MD does not like the look of the baby or if it is grunting or flaring he takes it to us.

The nurses then take over and take the vital signs and give O2 if needed.

As soon as the baby looks ok to us, resps are under 60, sats good and blood sugar ok, we page the MD and ask him to discharge the baby. We can have the well baby nurses take a few vital signs and blood sugers after we dishcarge the baby but they dont like to do that:(

We have 3- 4 hours max for obs. and if they are not ok by then they have to be admitted to the NICU and stay at least untill the next morning. Also if we have to give IV fluids the baby has to be admitted.

I think this is all...it would be nice to hear from you all and maby you culd tell me if there is a policy on how many gests can come and look at the baby while in for observaton, we have a problem with that the whole family and friends sometimes comes barging in on us!

Love from iceNICUnurse!

[Tiki_Torch]

Thank you for you reply iceNICUnurse!

To answer your question about observation patient visitors:

My previous hospital treated the baby as if it was a NICU baby: At delivery the mother and father (or significant other person the mom chooses) each receive an armband with numbers matching the two the baby wears. Only these people are allowed into the NICU and each may bring one person with them, but only two people are allowed at the bedside at any one time.

For the observation patients, if they were C-sections, we generally didn't see the mom during the first 4 hours unless she was wheeled into the NICU on her stretcher after leaving the recovery room on her way to her room. Mostly those babies had made their way out to the Well Baby Nursery by the time mom felt up to seeing her baby. If they were lady partsl deliveries with no bleeding or other problems, the Moms would often visit in a wheelchair, but again many times they'd wait until the baby had left the NICU.

As far as visitors wanting to see the baby... grandparents, aunts, uncles, siblings, etc... after we got the baby settled in (admission labs done, etc.) the Father would be allowed to bring the other visitors in one at a time for a few minutes each. This was the policy for all babies in the NICU... No more than two people at the bedside at a time and the visitor must be with someone wearing an armband. Children who are siblings of the baby could come in if they were screened for contagious illnesses first. Everyone must wash their hands for 2 minutes.

My new hospital seems to be pretty much the same as far as visitors and armbands go. The unit is too small for a stretcher to come in with Mom on it so all she can get is a photograph until the baby is able to go to her room or she can get in a wheelchair and come to the nursery. This is the first time I've seen an observation patient in my new hospital and since I left my shift to go home before any visitors came, I can't tell you now exactly how that works in this place.

Thanks again for your post!

:kiss

[Mimi2RN, ASN, RN]

We frequently have observation babies, put them on monitors , and see what they do. All kinds of reasons...babies who have had PPV, sugar babies, ones with tachypnea. 35/36 weekers that could go either way. We can give them four hours to show their true colors. Sometimes, they are back with mom in an hour, and depending on what else we have to do, we will give them a bath before they go out to the floor. Other babies buy a ticket to be admitted, lab results, such as a CBC or blood sugar, or more resp distress etc.

We allow the father and grandparents to visit, with sometimes a quick look by other relatives.

We get no credit for babes like that, it's not even a patient charge, except for small disposable items.

It is a level II nursery, we don't have a normal newborn area.