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How medical staff can be utilised effectively to provide effective medical care for clinical incidents in the neonatal intensive care unit

Introduction
The neonatal intensive care unit is undoubtedly one of the most critical and significant sectors of any nation’s health system. Any possible critical situation involving a neonate automatically translates to a situation or condition which has a high probability of disabling or immediately life-threatening consequences and which requires immediate intervention. It is significant to realise that such situations are of utmost importance for the whole medical environment and that neonate intensive care management is a very significant aspect of general health-care. Especially, when a neonate is presented to the intensive care unit, this can present a challenge to even the most experienced clinician. The purpose of this paper is to review and critically evaluate the resource management of the intensive care unit relevant to care offered to neonates. The main theme of this paper will be centred around the issue of how resources can and should be effectively utilised in the intensive care unit, in order to provide the most effective treatment/care possible to the neonate.

Effectiveness in the health care sector
Effectiveness in health care has been defined as the production of health benefits for patients when an intervention or service is provided. Much of the focus on recent resource utilisation in the health care sector has been on the efficiency and effectiveness of the NHS. Considerable political and public attention has been devoted to these matters (Wright and Hill, 2003).

The intensive care unit/department and the neonate
Although the intensive care unit is of great importance in itself, and there are a great deal of issues and preparations that have to be made for it to function effectively. When it comes to treating the neonate, there are a number of special considerations that must be looked into and catered for. These unique features are vital if the neonate is to be treated effectively.

Following the correct medical procedures
First of all, it is important that all incidents arising that include neonates must first go through the triage process. During this process, a registered nurse or another type of physician assigns the neonate a level of acuity, how serious the condition of the neonate is. This decision almost certainly predetermines in which area and at what time frame the neonate will be seen and cared for. During this procedure, the rectal temperature of the neonate is measured and the triage personnel usually go through vital signs and the ABCs (airway, breathing, and circulation). If the neonate is considered in the high levels of acuity then it is immediately taken to a bed and registered at bedside. Different categories and levels have been predetermined for neonate emergencies and it is according to these that it is designated how serious the condition of the neonate is and if it must be looked into immediately. For example, the most serious level is the level 1, which translates to the neonate having respiratory failure, shock, coma, or cardiopulmonary arrest, or generally any neonate which requires continuous assessment and intervention to maintain physiological stability. Saying this, it is very frequent that any neonate taken to the intensive care or the emergency department, to be assigned to this category, due to its very young age, whereas elder children are assigned to other less serious levels.

Adequate Staff Training
One other aspect, very important to effective resource management that must be catered for in any neonate intensive care department, is that the staff must be adequately trained for this specific patient group. Neonate / paediatric nursing are recognised specialties. The assessment skills necessary for appropriate triage, ongoing assessment and neonate care are critical for good outcomes in the neonate intensive care department. It is very common for nurses to be educated through years of experience on a neonate / paediatric unit, through formal education in professional schools, or through specific continuing medical education.

Availability of Equipment
Furthermore, it is vital that neonate and paediatric facilities have the relevant equipment available, if they are to function effectively and be able to carry out the functions purposefully. A plethora of equipment is vital for such specialised departments, ranging from ventilation and airway equipment to injury prevention equipment and the relevant medications. Infant pulse oximetry probes should be available, together with appropriate supplies for vascular access, including intraosseous needles.

Keeping the Neonates away from Infections
One other issue that must be taken care of in critical circumstances which include neonates is following procedures which will protect the neonate from possible infections. Although immunologic immaturity and altered cutaneous barriers play some role in the vulnerability of neonates to nosocomial infections, clearly, therapeutic interventions that have proven to be lifesaving for these fragile infants also appear to be associated with the majority of infectious complications resulting in neonatal morbidity and mortality. Rates of infections in neonatal intensive care units have varied from 6% to 40% of neonatal patients, with the highest rates in those facilities having larger proportions of very low-birth-weight infants (birth weight ≤1000 grams) or neonates requiring surgery (Cutfield et al., 2004). Efforts to protect the vulnerable NICU infants include the following: (1) optimal infection control practices, especially good hand hygiene and good nursery design; (2) prudent use of invasive interventions with particular attention to early removal of invasive devices after they are no longer essential; and (3) judicious use of antimicrobial agents, with an emphasis on targeted (narrow spectrum) rather than broad-spectrum antibiotics and appropriate indications (proven or suspected bacterial infections).

As with other settings in which critically ill patients receive care, infants hospitalized in neonatal intensive care units are at risk for health care-associated infections because of their profound physiologic instability and exposure to invasive devices and broad-spectrum antibiotics. However, this group of infants has some unique host risk factors that make them particularly vulnerable for acquiring health care-associated infections, as well as experiencing more severe illness as a result of these infections. Whether the infant is born prematurely or at full term, many components of the immune system exhibit diminished functional capacity (quantitative and qualitative) when compared with older children and adults. (Grandi, Tapia and Marshall, 2005). Most of the differences are based merely on an age-related intrinsic immaturity, which is more profound the earlier during gestation that the infant is born. In addition, the protected environment of intrauterine life prevents any significant immunologic exposure that would be necessary to prime many valuable protective immune responses.

Therefore, it is vital that nurses provide very delicate and deliberate care once the child has just been born, as in that period the child is out of the protective growth environment and is out in the world and can be infected very easily. This is one of the prime responsibilities and duties that nurses have to face right after the birth of the neonate.

Utilising Parental Presence
Another issue that must be taken care of in any neonate department is the issue of effectiveness in parental presence. It has been found that families and even very young patients benefit from having family members present during procedures and cardiopulmonary resuscitation. Even in cases where there is a fatal outcome, families feel comforted and have an easier time with the grieving process when they have witnessed the resuscitation (Eichhorn, Meyers, Mitchell, and Guzzetta, 1996). Saying this, it is vital that all neonate intensive care departments have a clearly defined and practised policy that describes the circumstances under which family members are permitted to be present during such procedures. Furthermore, it is important that any additional intensive care unit/department staff, such as social workers, clergy, and volunteers help so that the families are comforted and have the procedures explained to them.

Psychological support of the families of the Neonates
One aspect that must be catered for through effective resource management is if there is going to be effective holistic treatment of the neonate and its family, is offering professional psychological support to the family of the neonate.

Parents find it very stressful when their baby is admitted to the neonatal unit for many reasons. Different sources of stress have been identified, and certain occasions (such as discharge from hospital or bereavement) are particularly difficult. These experiences impact on families in positive and negative ways, and people adopt a range of coping mechanisms. Staff should adopt a holistic approach to care that acknowledges the uniqueness of each family and supports them appropriately (McHaffie and Fowlie, 1996). During pregnancy, most women and their partners do not give serious consideration to the possibility of preterm delivery or illness in their newborn baby. In most cases admission of an infant to the neonatal unit is unexpected and is stressful for the parents. If a problem is diagnosed antenatally, parents can be forewarned. For most admissions to the neonatal unit, however, there is little or no time to prepare the family. Parents are unfamiliar with the potentially complex problems their infant is facing and they are unsure of the future (Smith, Bajo and Hager, 2004). Incomprehension and uncertainty are major sources of stress. In addition, maternal health is often compromised at this time. A better understanding of the sources of stress and how parents might try to cope allows appropriate care of the family. When designing neonatal units, great emphasis is placed on effective layout, lighting, and noise reduction (Johnson, Abraham and Parish, 2004). Facilities for families to stay close to their baby are usually provided, and parent rooms allow mothers and fathers to relax and meet other parents. Play areas for siblings can be incorporated into some units. This more “family-orientated” approach to care is helped by less restricted visiting policies in neonatal units. Most units will allow parents and siblings open access to their baby if they comply with local infection control measures. Having transitional care areas as an integral part of the neonatal unit or as a separate area (for example, as part of the postnatal ward) minimises the separation of mother and baby (Smith, Bajo and Hager, 2004). When time permits, members of the neonatal team will often meet with parents before the birth to discuss any likely admission. Parents may visit the unit before their baby is born to familiarise themselves with the environment and some of the staff. After delivery, it is good practice to discuss medical and nursing issues in detail with parents and to involve them in decision making from an early stage (Johnson, Abraham and Parish, 2004). Parents will often have immediate access to recordings, results, and clinical notes. They can also help care for their preterm baby. This care may extend beyond simple but important measures, such as “skin to skin” contact, to providing skilled care such as tube feeding, oral toileting, and intensive “developmental care” programmes (Affleck and Tennen, 1991).

Utilising an effective team
As Wright and Hill (2003) very accurately state, ” in the modern NHS, with medicine and health care increasing in complexity. High quality care for patients will increasingly depend on high quality teamwork, so the quality of clinical teams has become an important clinical governance issue “. This is very true as in most health scenarios, especially critical ones; effective care depends highly on effective collaboration between many people. Especially in the case of a critically ill neonate, it is necessary for such care to be delivered through a multidisciplinary team. Reason (1995) has found that by providing the staff with professional training in team management and communication skills, significant improvements in human performance can be achieved. Irvine (1997) has extensively researched the performance of doctors and the characteristics of effective teams and has found that effective teams are those which show leadership, have clear values and standards, are collectively committed to sustaining and improving quality, foster learning through personal and team professional management, care for each member, function through a ‘no blame’ culture, are committed to the principle of external review, and are open regarding their professionalism.

Distribution/Allocation of the necessary resources
One of the major public health factors that seriously influence the short and long term health and welfare of neonates attending any hospital is the allocation of resources to that specific health care setting. This is highly dependent on the national health policy. In certain countries, the national health policy may be directed towards overspending in a specific disease while distributing much fewer resources on another disease. So, depending on the disease, the critically ill neonate could be better or worse off according to his country’s national health policy.

Also, a very well organised and programmed national health policy is definite to contribute to a better organisation on the micro scale. One lucid example is the National Health Service in countries like the UK, which now increasingly place a major role in evidence when forming a policy (Hewison, 2003). They will take into account Cost-of-illness (COI) analyses, Cost-effectiveness analyses (CEA), Cost-minimisation analyses (CMA), Cost-benefit analyses (CBA), and Cost-utility analyses (CUA) when formulating their policy. This is very significant because it means that the policy will not be based on subjective opinions, but on facts, and thus will lead to a more effective health system.

Furthermore, it is widely known that the health system in each different country differs to a great extent. This happens even between very developed countries. The Hussey et al. (2004) study compared health care quality data on 21 indicators (including survival rates for 9 conditions) in 5 countries (Australia, Canada, England, New Zealand and the US). It found that every country ranks both worst and best on at least one measure. For example, Canada was found to have the highest 5-year survival for childhood leukaemia as well as for kidney and liver transplants. On the other hand, it also had the highest acute myocardial infarction 30-day case fatality rates. Data such as this shows that effectiveness regarding health care provision can vary enormously between countries.

Patient Accessibility
Another factor which is dependent on effective resource utilisation is to what extent a health care system is accessible to its patients. Delays for access to care plague our healthcare systems. These delays have been found to cause patient dissatisfaction, to contribute to staff dissatisfaction, and also, they may lead to worsening clinical outcomes (Murray, 2000). Apart from this, they are also expensive: patients often consume scarce resources while waiting, there is a cost in maintaining any waiting list; the longer the wait the higher the “fail to show” rate, which represents unused capacity; and, finally, there is the risk that patients waiting will arrive with a more costly clinical condition. Therefore, it is clear that effective utilisation regarding patient accessibility to the neonate intensive care unit, which achieves relatively timely accession to treatment or diagnosis, would definitely lead to better long term prospects for neonate patients.

Psychosocial Factors
A plethora of studies regarding effective resource management have to date documented the role of psychosocial factors in the quality of life of child patients and their families. On the one hand, high levels of trust and density of group membership have been found to be associated with reduced mortality. On the other hand, lack of control, lack of self esteem, and poor social support have been found to contribute to increased morbidity (Kawachi and Kennedy, 1997).

There is now a substantial body of evidence that indicates that the extent to which social relationships are strong and supportive is related to the health of individuals who live within such social contexts. Berkman (1995) conducted a review of population-based research on mortality risk over the last 20 years and found that people and families who were isolated were at increased mortality risk from a number of causes. For example, in the occasion of a neonate who is fostered by a single mother, not offering any type of psychosocial support to them could lead to very negative consequences.

For social support to be health promoting, it must provide both a sense of belonging and intimacy and must help people to be more competent and self-efficacious. Acknowledging that health promotion rests on the shoulders not only of individuals but also of their families and communities means that, if we are to achieve the most effective states through correct and efficient resource management, we must commit resources over the next decade to designing, testing, and implementing interventions in this area.

Conclusion
It is evident that the handling of the intensive care department in cases where the neonate is in a critical condition is one of the most vital and important aspects of general health care. In such situations, the staff must be adequately trained in order to be able to handle effectively such specialised conditions, and also be able to give the necessary psychological support to the parents and families of the neonate.

Especially, it is very vital to have adequate provision of effective teamwork, adequate patient accessibility and adequate resource allocation, because it is only in this way that the neonate’s condition can be adequately evaluated and assessed, and therefore, the most accurate and effective therapeutic modality will be taken into consideration, and this will lead to better outcomes, both in the short term, as well as the long-term. Concluding, the current literature is continuing to study extensively the great variety of complications that can arise in the neonate and it is quite predictable that in the near future, all neonate intensive care procedures will be improved and they will be much more effective than they are today. Such improvement in therapy will involve better evaluation, specific and holistic treatment of the neonate patient, as well as better physical, medical, and psychological care.

References
Affleck, G. and Tennen, H. (1991) The effect of newborn intensive care on parents’ psychological well-being. Child Health Care 20, 6-14.

Berkman, L. (1995). The role of social relations in health promotion. Psychosomat Med 57, 245-254

Cutfield, W., Regan, F., Jackson, W., Jefferies, C., Robinson, E., Harris, M. and Hofman, P. (2004) The endocrine consequences for very low birth weight premature infants. Growth Hormone and IGF Research 14(1), 130-135.

Eichhorn, D., Meyers, T., Mitchell, T. and Guzzetta, C. (1996) Opening the doors: family presence during resuscitation. J Cardiovasc Nurs 10(4), 59-70.

Grandi, C., Tapia, J and Marshall, G. (2005) An assessment of the severity, proportionality and risk of mortality of very low birth weight infants with foetal growth restriction. J Pediatr 81(3), 198-204.

Hewison, A. (2003). Modernizing the British National Health Service (NHS). Some ideological and policy considerations: a commentary and application. J Nurs Manag. 11, 91.

Hussey, P., Anderson, P., Osborn, R. et al. (2004). How does the quality of care compare in five countries? Health Affairs 23, 89-99.

Irvine, D. (1997) The performance of doctors. II:Maintaining good practice, protecting patients from poor performance. BMJ 314, 1613-1615.

Johnson, B., Abraham, M. and Parrish R. (2004) Designing the neonatal intensive care unit for optimal family involvement. Clin Perinatol 31(2), 353-382.

Kawachi, I. and Kennedy, B. (1997). Health and social cohesion: why care about income inequality? BMJ 314, 1037-1040

McHaffie, H. and Fowlie, P. (1996) Life, death and decisions: doctors and nurses reflect on neonatal practice. Hale: Hochland and Hochland.

Murray, M. (2000). Modernising the NHS. BMJ 320, 1594-1596

Reason, J. (1995) Understanding adverse events: human factors. In: Vincent, C. (ed) Clinical Risk Management. London: BMJ Publishing Group.

Smith, J., Bajo, K. and Hager, J. (2004) Planning a developmentally appropriate intensive care unit. Clin Perinatol. 31(2), 313-322.

Wright, J. and Hill, P. (2003) Clinical Governance Churchill Livingstone Press.

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