How old is too old?

[Coffee Nurse, BSN, RN]

At what age do you tend to ship chronic babies off to PICU or the peds floor, and do you have a policy on this or just proactive charge nurses? At my hospital, my unit is rather lax about getting this ball rolling, and PICU tends to be less than cooperative in accepting it. As a result, we end up with kids who are 6+ months corrected, bored, and cranky. There was even a little guy who celebrated his first birthday in the NICU. I feel bad for them because we simply don't have the time or facilities to entertain/stimulate them as they should be -- and, selfishly, I went into NICU to take care of neonates, not small children, so I just don't have the mindset to interact with the latter. Our PT/OTs do what they can, but they're busy too. How do you manage these kids?

[prmenrs, RN]

IMO--these long term patients should stay in familiar surroundings as long as possible. They should have a primary team to bond w/. They should see the same faces every day. If the hosp has a peds unit, they likely have a Child Life Unit (teachers who work in the hospital and help patients w/activities and school work). One of those teachers should see the child daily to 'play' w/him/her. They should have OT, PT and speech therapies in place. All of these support systems will help the baby grow as normally as possible.

Put the baby on a schedule--wake, exam/labs/assess as approp, feed, bathe, dress, nap, play or therapy; feeding, afternoon nap; feeding, therapy/play and so on. Post the schedule and stick to it. If mom comes in, let her participate fully in the care.

Under NO circumstances should a chronic be assigned to a float!! (Don't laugh, it's been done. Disaster.)

These kiddos are going to have a hard enough time recovering long term, we shouldn't add to their trauma by shunting them hither, thither and yon.

Again, this my opinion; I've taken care of a LOT of chronics over the years, and I've seen good and bad outcomes.

[prmenrs, RN]

Re: OT/PT. In the past, our OT support came from the hospital wide rehab unit. Frequently, when the OT was scheduled to come and feed a baby who was having oral-motor issues, the main dep't could "pre-empt" his/her services and send her elsewhere to eval an adult pt. This happened a lot, and meant that the baby might wind up staying longer b/o poor feeding.

The NICU admin put a staff position for an OT full time. Since that therapist "belonged" to the NICU, the main dep't could not usurp our time! They (the main Rehab unit) no longer had a say, and the therapist was in the NICU all the time.

Don't know if that's an issue for you, but that is how we solved it.

[Coffee Nurse, BSN, RN]

IMO--these long term patients should stay in familiar surroundings as long as possible. They should have a primary team to bond w/. They should see the same faces every day. If the hosp has a peds unit, they likely have a Child Life Unit (teachers who work in the hospital and help patients w/activities and school work). One of those teachers should see the child daily to 'play' w/him/her. They should have OT, PT and speech therapies in place. All of these support systems will help the baby grow as normally as possible.

Put the baby on a schedule--wake, exam/labs/assess as approp, feed, bathe, dress, nap, play or therapy; feeding, afternoon nap; feeding, therapy/play and so on. Post the schedule and stick to it. If mom comes in, let her participate fully in the care.

Under NO circumstances should a chronic be assigned to a float!! (Don't laugh, it's been done. Disaster.)

These kiddos are going to have a hard enough time recovering long term, we shouldn't add to their trauma by shunting them hither, thither and yon.

Again, this my opinion; I've taken care of a LOT of chronics over the years, and I've seen good and bad outcomes.

I agree with the point about primary teams (our unit doesn't do primary nursing, which I have a problem with, although the logistics would be difficult given how we're set up), but surely a one-way transfer to PICU once the baby's old enough doesn't count as "shunting them hither, thither and yon." I suppose one of the problems is that if a baby is well enough to be put on the kind of schedule you suggest, then they're probably in our special-care baby unit, where nurses are expected to take care of up to four babies at a time. It would be lovely to play with them for an hour or two twice a shift, but just not feasible, and it seems unfair to either expect them to sleep all the time (as they shouldn't, because they're no longer neonates) or make the nurse choose between entertaining them and caring for her other patients.

[NicuGal, MSN, RN]

Never. Sometimes we send them

to Children's rehab across town, but our attendings hate our PICU and peds floor. We do try to only give one other kid with them and everyone pitches in to play. We also have cuddlers daily to play with them.

If they do have a schedule, it makes it easier. We also get portable DVD players from Child life and they love watching movies, etc. sometimes you have to make the best of it.

[prmenrs, RN]

Chronics are "high maintanence"--they require better staffing than 4 babes to one nurse. Allowances need to be made to staff them. A nurse could take care of one other STABLE baby, but that would be about it. If management cannot do that, then I guess you send them wherever is deemed appropriate.

I might add that staff frequently bonds with the baby as much as the baby bonds w/his or her team. So, even if you don't have primary nursing, a long term baby should get a "team"--a primary doc, therapists, and nurses that like that pt, and handle him well. They should get assigned as frequently as possible.

I could be way wrong, but it seems as if you've already determined that chronics should go, the only question is what age. My bias is that they should not.

[NicuGal, MSN, RN]

None of us sign on to take care of these older babies, but they are our patients and usually do better with a team that knows them. We have had 3 or 4 older kids on our unit and it feels like a daycare sometimes, but when that little person smiles at you because they know you, melts the heart!

If you truly don't like chronics ask not to take care of them, I find most people who don't like them do the least with them. Not fair to that baby.

[NICU Guy, BSN, RN]

We have about 6 long term chronic kids that have been on our unit for months, one celebrated his first birthday. Unfortunately, the outside facilities that handle long term peds on vents are chronically full.

[angrykitten]

We have had several patients celebrate their first birthdays in our NICU since I've been here - we never send them to the PICU. Our oldest patient right now is 1y9m. We do frequently send patients to a pediatric rehab hospital, but they have to be on a home ventilator and these particular patients are usually unable to tolerate the settings they would need to be on.

[Coffee Nurse, BSN, RN]

A bit belated, but:

prmenrs: When you have two units, one called the neonatal intensive care unit and one the pediatric, it seems reasonable to me that age would be the determining factor as to where a child resides, and that s/he should "graduate" if you will to the PICU once no longer an actual neonate. Yes, there is bonding of the staff with the baby and vice versa, but a normal child graduates from exclusively home/family to daycare to kindergarten, exchanging settings and familiar faces based on age, so I don't see why this would be different.

NicuGal: I don't not like chronics/older children, they're simply not why I chose to work in NICU. I don't neglect my patients.

angrykitten: Is that child an outlier, or is it common for you to have (presumably?) toddlers in your neonatal unit?

All: Never mind. I've only worked in three NICUs, and I see they must all have been the exception as opposed to what I assumed was the rule that pediatric-aged patients would be transferred to pediatric units. I still think that PICU is the best setting for around age 1+ (for our most recent chronic, impossible-to-manage-ventilation baby, only eight months old, we had PICU PTs coming over every day and were referring to their guidelines for fluids management, etc., so why keep him in the NICU), but clearly this is not the common practice that I thought it was.

[angrykitten]

angrykitten: Is that child an outlier, or is it common for you to have (presumably?) toddlers in your neonatal unit?

That child is definitely an outlier, but we've had at least four or five kids stay past their first birthdays in the past two years. There are many more chronics who have been over six months old when they have left. It does cause some controversy in out unit when they are over a year old. We do have child life and our docs do consult with the PICU docs, but what is usually decided is that the PICU wouldn't be doing anything differently for them than we do, so they should stay where they and their families are most familiar.

[NICUnurse21]

In our NICU, they move to PICU at one year.