Q&A: COVID Presents Unique Challenges to NICUs

Giving birth can be difficult in even the best of circumstances. But what happens if the infant needs to be taken to the neonatal intensive care unit? And what happens if a mother or father tests positive for COVID-19? What if there are not enough isolation rooms? These are just some of the issues that have been confronted by NICUs across the country in the face of the COVID-19 pandemic. Jenny Hayes, MSN, RN, CIC, CAIP, CASSPT, is the infection prevention leader at the Hospital of the University of Pennsylvania. Hayes says that it all comes down to strategy. She recently sat down with Infection Control Today® to explain what she considers to be the best approaches to NICU care under the shadow of COVID-19. For instance: “All of our mothers are tested upon admission. They all come in whether they’re symptomatic or not symptomatic, they are all tested. Not all hospitals may have that capacity.”

Infection Control Today®: Two-part question. Could you tell us a little bit about the challenges of infection prevention in NICUs in general? And has COVID-19 presented a unique challenge there?

Jenny Hayes, MSN, RN, CIC: In the neonatal intensive care population, you can’t look at this population as a single entity. This is a combined population of maternal health, both prior to birth and after birth. You have your triage for labor and delivery. You have your labor and delivery staff and that setting. And then you have the birth of a child who perhaps needs emergent resuscitation. Is born prematurely and needs to go to the infant resuscitation bay and is subsequently admitted to the neonatal intensive care unit. Once that happens, you still have to have that consideration for the postpartum setting where the mother will be recovering from the delivery. So, remembering that delivery can take place as a vaginal birth in a labor and delivery room, or perhaps in an operating room as a C-section. Both of those settings have unique considerations for safety as far as COVID-19 is concerned.

ICT®: What are those?

Hayes: In labor and delivery, mom’s in labor. There may be heavy breathing involved. You may have more close contact with the face. Perhaps you’re holding the patient’s hand and assisting them in breathing. It can be a heavier breathing. Asking the patient to wear a mask, which is something that we do in our facility, can be challenging at that point, especially as labor progresses, and you’re to the point of pushing. That right there offers a set of unique challenges for both the patient and the staff in the room. And when you talk about aerosolization, sometimes you’re talking about if perhaps a mom screams during that delivery. She may aerosolized some particles that wouldn’t normally take place in a routine patient care setting. The patient in labor is going to have unique needs, as opposed to the patient who delivers by C-section. Now you’re looking at a perioperative setting. Now you have to consider the airflow exchange in an operating room. You want to make sure that you are meeting the correct guidelines for that.

ICT®: What about the fathers?

Hayes: We allow one partner in the room. One coach in the room with the parent. In the past, you could have more than one person, but with COVID-19 we are now have one person to assist with that labor. And yes, they would be masked as well. Everyone in the room is universally masked.

ICT®: What are the healthcare workers wearing?

Hayes: They’re wearing a paper surgical mask and they are wearing a face shield to protect them in addition to the mask, because that offers eye protection as well. The point of the mask, as I’m sure as you hear in the media, helps prevent transmission at the source. OK? Your patient is protecting you by wearing the mask. You’re protecting the patient by wearing a mask. That face shield is going to help you protect your eyes.

ICT®: Do you test the babies after they’re born for COVID?

Hayes: We do if the mom tests positive. All of our mothers are tested upon admission. They all come in whether they’re symptomatic or not symptomatic, they are all tested. Not all hospitals may have that capacity. And in that case, they need to prioritize their testing and they may want to prioritize that based on symptomatology. We did that initially, we only tested symptomatic patients. But then we discovered with the increases in the COVID rates that there was a lot of asymptomatic cases that were not being identified in the community at large. One of the challenges with testing with just symptomatic patients was that some of the patients were refusing testing because they were afraid of being separated from their baby. When we went to universal testing, that became part of their pre-admission education when they’re being followed by their obstetrician. They would understand that universal testing was required for all patients admitted to labor and delivery, whether you had symptoms or did not have symptoms. There was more education in the prenatal setting, so that they would understand what the signs and symptoms of COVID are. Practitioners, we’re following them for that, assessing them for that, doing telemedicine visits. In the last month of pregnancy, you would require ultrasounds or an internal exam. You would be coming into the office. And of course, there are outpatient settings, trying to really limit the volume of patients in the practices. Again, to prevent the spread of COVID-19. Part of that education through telemedicine or inpatient visits is universal testing protocols. So, it’s not a surprise when they come in that, yes, we’re going to test you for COVID-19. Fortunately, in our hospital, we’re able to get the results pretty quickly. If the mom tests positive, then yes, we will test the baby. When the patient delivers in labor and delivery, as I described some of the unique scenarios with that, as opposed to a C-section that’s a perioperative setting. Now that’s a little bit different. Your air exchanges need to be higher. In a normal patient room, you’re looking at a greater than 6 air exchanges per hour. In a perioperative setting, greater than 12. You really want to ensure that your air balancing is correct.

ICT®: Who checks the air balance?

Hayes: That would be facilities. There’s air direction. They usually have a contractor who can do their air balancing reports for them. Usually done annually. But if there’s any concern that there’s a change in the airflow, then they can always have their contractors come in and check it again. There’s filtration that takes place and there’s directional airflow that takes place. You have to have the correct checks and balances. And you do this really normally in a perioperative setting, but then you have to consider, “Oh mom tested positive.” So now this OR is isolated as a COVID OR. We have our supplies isolated in that OR. Some things stay outside of the room. Some things are inside of the room, depending on your policy and your hospital, how you want to handle that based on a risk assessment. And that risk assessment will be performed with nursing staff and leadership, physicians, anesthesia. What is it that you have to have in the room absolute at hands reach? What is it that occasionally you may use, that may say in a cart outside of the room?

ICT®: What concerns you the most about COVID-19 and the neonatal intensive care units?

Hayes: Open bay settings. A lot of intensive care units are designed with open bay settings, and limited isolation rooms. You may have seven or 10 beds in an open bay, and maybe only have one or two isolation rooms. But now what happens when you limit the number of isolation rooms you have? Perhaps you have two isolation rooms. Perhaps you have two babies whose mothers tested positive for COVID. So now they have to go into isolation. But now you have another mom who comes in and she’s a person under suspicion you have a pending test, and she delivers promptly. So now you have a baby who maybe…. You have to strategize where you’re going to place that baby. Perhaps at the end of the bay, closer to the isolation rooms. Waiting for that test result to come back to see, because they’re under investigation for possible COVID. You really kind of have to strategize placement of patients and prioritize those risks.

ICT®: What happened when you had more patients who tested positive for COVID-19 then you had isolation rooms? What did you do in that case?

Hayes: Well, that’s where you have to strategize. You have to really look and see what type of…. Are there any aerosol generating procedures? If the baby’s on CPAP or BiPAP, then that may be a greater concern because that’s an aerosol generating procedure. You’d want to put that baby in the isolation room. A baby that comes to you from the infant resuscitation bay, and they’re already intubated, it’s more of a closed setting. The other thing is you may have an isolette warmer that is closed. That’s going to help prevent some of that aerosolization that will happen. Rather than an open bassinet, you put that baby in an isolette.

ICT®: I guess in some cases the bonding between a newborn and mother wasn’t able to take place right away?

Hayes: That’s correct. We require two tests, 24 hours apart, to take mom out of isolation. The mom may deliver and may not be able to see the baby initially, during that time period, we’re trying to rule in or rule out COVID. And if [the mother has COVID-19 and the baby doesn’t] mom’s going to be going home, and then she’s going to have to follow the quarantine initiatives that are put out by the department of health before she’ll be able to come back and visit with the baby. Because the baby’s in the intensive care unit, their discharge is likely to be delayed due to their health issues. It becomes very challenging. And it’s heartbreaking for some of these families.

This interview has been edited for clarity and length.