neonatal intensive care unit years of education

How to Become a Neonatal (NICU) Nurse

What is a nicu nurse.

• Career Outlook

How to Become a NICU Nurse

• Neonatal Nurse vs Nurse Practitioner

Neonatal Nurse Jobs

Neonatal Intensive Care Unit (NICU) nursing is a specialty of nursing that deals with the care of sick or premature babies and babies with birth defects. NICU nurses are registered nurses who have gained experience working with neonatal patients and potentially also become certified in an area related to this. You can have either an ADN or a BSN to work as a neonatal nurse.

It takes a special person to become a nurse, but that's even more true for those who go on to become Neonatal Intensive Care Unit (NICU) nurses. These dedicated professionals care for the most fragile patients: sick and premature newborns. In addition, they are on the front lines when it comes to helping scared parents through what is often a traumatic experience. 

Find out more about what it takes to become a NICU nurse and why those who choose this track are doing society a special service.

There are many specialty nursing careers , some of which deal with a particular type of patient. That is the case for neonatal intensive care unit (NICU) nurses. Their primary patients are sick and/or premature babies or babies with various forms of birth defects. These patients need to be cared for and monitored, sometimes for weeks or months, until they are hopefully healthy and developed enough to go home.

What I Love About Being a NICU Nurse "As a NICU Nurse, I have always had a deep awareness of how my actions deeply touch the experiences of mothers in a very vulnerable time of their lives. I strive every day to be a light of trust, knowledge, and hope to mothers with babies in intensive care."

According to the National Association of Neonatal Nurses (NANN), approximately 40,000 low-birth-weight infants are born each year in the United States. Thanks to advances in medicine, highly skilled NICU nurses, and other healthcare professionals, survival rates are improving. In fact, the survival rate is now 10 times better than it was 15 years ago. 

>> Show Me Neonatal Nursing Programs

What Does a Neonatal Nurse Do?

NICU stands for neonatal intensive care unit, and the patients nurses care for in the NICU are often in acute or critical condition. So, in addition to hands-on patient care, monitoring, and feeding the babies, NICU nurses also work intimately with moms and dads who are going through this emotional experience with their newborns. Neonatal nurses provide comfort and education to help families get through this trying time.

According to NANN, NICU nursing generally involves care for newly-born infants in crisis. It also encompasses neonates who suffer from long-term problems related to being born early or from some severe illness encountered soon after birth. Some NICU nurses may even care for babies up to about 2 years of age.

However, NICU nurses' responsibilities reach beyond their infant patients. They also care for the entire family unit. Neonatal nurses act as a shoulder to cry for distraught parents, assist new mothers with breastfeeding, and provide lasting memories to new parents. 

Day in the Life of a NICU Nurse

A day in the life of a NICU nurse is demanding and can range from basic newborn care to monitoring seriously ill patients. NICU units operate 24/7, so most neonatal nurses work 12-hour shifts, which include some nights and weekends. Most large private and public hospitals have a NICU, while smaller facilities or medical centers may not have a full department or any at all.

A neonatal nurse will, at times, have more “downtime” than a typical bedside nurse. Because sleep and rest are so important to growth in the neonatal population, a NICU nurse will generally provide hands-on care to patients every three to four hours and monitor in between.

NICU nurses will monitor the vital signs of the more seriously ill or premature infants day and night to make sure they are breathing and developing properly. They also administer medications, record the newborn’s progress and recovery, change diapers, and calm babies in distress.

NICU Levels of Care

There are four levels of NICU nursing care that may impact a neonatal nurse's daily duties. Working in a neonatal intensive care unit is considered level three, while level one is for healthy infants and level two is for less serious neonatal cases. Here's a breakdown of the different levels of neonatal care:

• Level I: Basic newborn care
• Level II: More advanced newborn care 
• Level III: Neonatal ICU (Where most NICU nurses will work)
• Level IV: This is the most intense level of newborn care for babies born with serious birth defects. Usually found at children's hospitals, university hospitals, or destination centers.

How Many Patients Does a Neonatal Nurse Work With?

Depending on the status of the patients and how many babies are born in a given period of time, a NICU nurse may work with just a few infants at a time. If there are serious medical issues, the more experienced NICU nurses in a team might focus on just one or two cases.

NICU Nurse Required Skills

It takes a specialized set of skills–beyond just medical ones–to work in the NICU. Neonatal intensive care units are fast-paced, stressful, and emotional, especially when working with family members.

In general, having strong communication skills and a calm, empathetic demeanor are paramount. In addition, because the patients are so tiny and even the smallest error can be life-threatening, precise attention to detail cannot be understated.

Neonatal Nurse Scope of Practice

Like other RNs, NICU nurses work under a scope of practice, a set of state laws that define your rights and responsibilities as a nurse and authorize you on how to function when providing various aspects of medical care.

You can find your state’s Nurse Practice Act via the National Council of State Boards of Nursing. 

This content used under license from "Ask Nurse Alice."

Neonatal Nurse Salary

A reliable way to estimate nursing salaries is to use the RN salary as a baseline and understand that specialty nursing roles will have slightly higher compensation. Though that isn't true for every specialty, NICU nursing does conform to this rule of thumb. Due to the complexity and acuity of neonatal nursing patients, NICU nurses tend to earn more than bedside RNs and even other nursing specialties.

The baseline RN salary in the US is $81,220 per year or $39.05 per hour, per the US Bureau of Labor Statistics . In comparison, ZipRecruiter reports the average NICU nurse salary as $136,592 per year or $66 per hour as of July 2023.

But location may also increase or decrease salary expectations. For example, New York neonatal nurses make an average of $163,945 annually, while those in Ohio make $127,140 ( ZipRecruiter ). 

The highest paying states for NICU nurses, according to ZipRecruiter, are:

It’s fair to say that NICU nurses–and in all areas of nursing–salary is commensurate with experience, and large cities and well-known medical institutions will pay higher salaries.

Opportunities for overtime, bonuses, and other financial perks will also vary by employer. However, in most cases, when working for a hospital or medical facility, neonatal nurses receive a generous benefits package to go along with their salary.

What Is the Career Outlook for Neonatal Nurses?

The job outlook for nursing professionals of all types is expected to be strong. As reported in The Atlantic, about one million registered nurses (RNs) working today (about a third of the workforce) are over the age of 50. Nearly 700,000 nurses are projected to retire or leave the labor force by 2024. The U.S. Bureau of Labor Statistics estimates that the healthcare sector has lost nearly half a million workers since February 2020. While the number doesn’t specifically identify the number of nurses that have left - an overwhelming number are bedside nurses.

As they begin retiring over the next decade, new RNs will be in demand to fill those roles; in fact, there are expected to be 1.2 million vacancies between 2014 and 2022. As such, the BLS projects that the employment of registered nurses should grow 6 percent from 2022 to 2032. Making a nursing career an excellent choice. 

For NICU nurses specifically, that demand may even be slightly greater. Anytime specialized credentials and skills are involved, it can be more challenging to keep the talent pipeline full. In other words, RNs who become neonatal nurses are equipped with a skill set that will be in demand for years to come.

Why I Became a NICU Nurse "For the longest time, I had a weird interest in the works of the human reproductive system. I wanted to understand it and help myself and other women thrive, specifically during the reproductive period."

Before you can begin working as a NICU nurse, you must meet certain neonatal nurse requirements. These include earning your RN licensure and gaining relevant experience. The steps you can take to become a NICU nurse are as follows:

1. Become an RN

To become an RN, you must first attend an accredited nursing program to earn an ADN or BSN degree. Then, you will sit the NCLEX-RN exam and, upon passing, apply for RN licensure with your State Nursing Board.

2. Gain Experience

You cannot begin working as a NICU nurse without gaining relevant clinical experience. So, you must work for two or more years with neonatal patients before applying to take a certification exam for NICU nursing. Some relevant nursing units you can work in to earn this experience include:

• Pediatric Nursing
• Maternal-Child Nursing
• Well Baby Nursing
• Labor and Delivery Nursing

3. Take a Certification Exam

Although you don't necessarily need a neonatal nursing certification to work in a NICU, earning one will help with career advancement and qualify you for higher-level positions.

There are several certifications available to NICU nurses. These include:

Top Neonatal Nurse Programs

Methodology

We ranked the top NICU nursing programs based on several factors, including:

• NCLEX pass rate
• Acceptance rate, when available
• Only ACEN or CCNE-accredited schools are eligible

Nurse Panel

Our selection panel is made up of 3 Registered Nurses with years of experience and multiple degrees:

• Tracy Everhart, MSN, RN, CNS
• Tyler Faust, MSN, RN
• Kathleen Gaines, MSN, BSN, RN, BA, CBC

There are numerous registered nursing programs, and our panel of nurses ranked them based on factors mentioned in the methodology. Because individual nursing pathways and careers take various forms, the top 10 neonatal NICU nurse programs are ranked in no particular order. 

1. University of Massachusetts Boston

Annual In-State Tuition: $14,905 | Annual Out-of-State Tuition: $36,581

Program Length: 4 years

The University of Massachusetts Boston, located on the water right next to the John F. Kennedy Library and Presidential Museum, offers a prime combination of excellent location and low cost for MA residents. The BSN program takes 2.5-4 years to complete (depending on whether students select direct entry or transfer in), and students get to enjoy clinicals at excellent locations across the area, including the renowned Boston Children's Hospital. This could help students gain early NICU exposure, preparing them for their future careers. Also, all NE region residents receive a discounted tuition rate, so students in the area should consider this program.

2. University of Pennsylvania

Annual Tuition: $58,620

A private, Ivy League school located in Philadelphia, the University of Pennsylvania might have the best all-around nursing school in the nation. Students who enroll in the BSN learn important nursing skills with an emphasis placed on cultural awareness and community involvement.

Those planning on becoming NICU nurses could benefit from the great clinical locations, including the Children's Hospital of Philadelphia, the nation's first-ever hospital devoted entirely to children. The cost of this private school is steep, but BSN students would have a hard time finding a better program. 

3. University of Washington

Quarterly In-State Tuition: $4,215 | Quarterly Out-of-State Tuition: $13,999

Located in Seattle, the University of Washington is one of the best schools in the state. Perhaps best known for its research degrees, UW still boasts an excellent BSN program that sees students complete over 1,000 clinical hours at sites across the region.

Aspiring neonatal nurses could get placed at Seattle Children's Hospital, one of the best children's hospitals in the West. Over 98% of nurses in the program graduate, and UW boasts an above-average NCEX pass rate for first-time test-takers. 

4. University of Colorado Denver

In-State Tuition Per Credit Hour: $472-$588 | Out-of-State Tuition Per Credit Hour: $1,019

With its main campus located in downtown Denver, the University of Colorado Denver is the state's only public, urban research institution. However, students enrolled in the BSN will attend courses at CU Denver's nearby campus in Aurora.

Students can choose from various BSN routes, though most students choose the traditional BSN, a two-year program that accepts students who completed two years of prerequisite courses. The program uses a cohort system, so nursing students work closely with one another. Also, the university might place students in clinicals at Children's Hospital Colorado, a top-ranked children's hospital. 

5. Georgetown University*

Tuition: $32,448 Per Semester, Full-Time | $2,704 Per Credit, Part-Time

Georgetown University* , located in Washington, D.C., is one of the nation's top research universities. The university also happens to be private, meaning students don't get access to discounted tuition rates.

While costly, nursing students do get to earn one of the best BSN degrees in the nation. The BSN allows for direct entry, and students begin clinicals during their first year. By the end of the program, students will have earned over 850 clinical hours at excellent sites in the area, including Children's National Hospital. Graduates of the program end up in a variety of positions, including neonatal nursing. 

6. Xavier University

Tuition: $23,948 Per Semester

A Jesuit university located in Cincinnati, Xavier University is a mid-sized school with just 4,500 undergraduate students. The small size might make the nursing school more exclusive, but Xavier's 98% of graduates find a healthcare role within six months of graduating.

Many graduates also end up working at Cincinnati Children's Hospital Medical Center, a great place to earn NICU experience and one of Xavier's top clinical rotation sites. Xavier may have a high private school cost, but many students secure some form of financial aid. 

7. University of California Los Angeles

Annual In-State Tuition: $11,928 | Annual Out-of-State Tuition: $42,954

Known for its great location and excellent sports, the University of California Los Angeles also has some of the top academic programs in the region, including its BSN. A great choice for anyone who wants to become a nurse in California, UCLA's BSN includes plenty of clinical experience and a clinically-based scholarly project at the end of students' fourth year.

UCLA nursing students enjoy clinicals at great sites, including Children's Hospital Los Angeles. The early exposure to working with children and UCLA's location could help graduates secure a NICU position in California. 

8. University of Pittsburgh

In-State Tuition: $8,412 Per Term | Out-of-State Tuition: $15,650 Per Term

Founded in 1787, the University of Pittsburgh now teaches nearly 23,500 undergraduate students. Pitt strives to give nursing students an all-around education, requiring courses through the Dietrich School of Arts and Sciences as students also take nursing courses.

Students get clinical exposure during their first year through a skills lab, then get placed in rotations during their second year. Clinical sites include many of the best regional healthcare facilities, including Pitt's own UMPC Children's. Graduates could end up finding a position at UMPC Children's or other great spots in the area.

9. University of Houston

Annual In-State Tuition: $11,150 | Annual Out-of-State Tuition: $23,110

With over 46,000 students, the University of Houston is one of the largest on this list. However, UH's size doesn't detract from the quality of its nursing program. BSN students earn over 900 hours of clinical experience through rotations and labs, and those interested in neonatal nursing could gain experience at Texas Children's Hospital.

Nursing students complete the first two years of the BSN in Houston, followed by two years at the Katy instructional site. On top of the low in-state tuition rate, students can also secure financial aid and scholarships.

10. The Ohio State University

Annual In-State Tuition: $12,859 | Annual Out-of-State Tuition: $38,365

The Ohio State University, a top public university located in Columbus, enrolls over 68,000 students, making it the largest school on this list. Despite the university's large size, OSU's BSN program is highly competitive, particularly for Ohio residents looking to secure in-state tuition.

Graduates end up finding excellent careers, and gaining clinical experience at Columbus' Nationwide Children's Hospital could help prepare students for a career in NICU nursing. Overall, OSU offers relatively low tuition rates for a great education, making this a good pick for anyone looking to become a NICU nurse. 

What Are the Continuing Education Requirements for Neonatal Nurses?

NICU nurses do not innately have specific requirements beyond state-mandated continuing education. However, advanced certifications such as the CCRN and RNC-NIC do require specific CEUs.

All neonatal nurses are required to maintain an RN license regardless of advanced certification.

Continuing education requirements for the license differ for each state. Monetary fees and other state-specific criteria are also associated with all license and certification renewals.  

Examples of continuing education requirements for RNs are as follows: 

• California - 30 CEUs every two years
• Florida - 24 CEUs every two years
• Hawaii - 30 CEUs every two years
• Oklahoma - 24 CEUs every two years
• Pennsylvania - 30 CEUs every two years

 A comprehensive list can be found here .  

Certification CEU requirements are specific to the certification. It is important to check the certification body prior to the renewal date to ensure all requirements are being met. For example, the CCRN Neonatal requires the following for recertification:

• CERPs are a specific type of continuing education
• Clinical practice hours are required. Practice as an RN or APRN for 432 hours in the direct care of acutely/critically ill neonatal patients during the three-year certification renewal period, with 144 of those hours accrued in the 12-month period prior to the scheduled renewal date, is required.

What is the Difference Between a Neonatal Nurse and a Neonatal Nurse Practitioner?

Neonatal Intensive Care Unit Nurses and Neonatal Nurse Practitioners are similar roles, but the difference is in the education requirements and scope of practice. A Neonatal Nurse is a Registered Nurse that works in the NICU and works under the supervision of physicians and Neonatal Nurse Practitioners. Neonatal Nurse Practitioners have completed either a Master's or Doctorate level of education and become certified.

For more on what a Neonatal Nurse Practitioner is and what they do, check out our Neonatal Nurse Practitioner Career Guide . 

Where Can I Learn More About Neonatal Nursing?

To learn more about Neonatal and NICU nursing, take advantage of the resources provided and consider joining the following professional associations:

• Neonatal (NICU) Nurse Salary Guide
• Academy of Neonatal Nursing
• Association of Women's Health, Obstetric, and Neonatal Nurses
• Council of International Neonatal Nurses, Inc. 
• National Association of Neonatal Nurses

The more advanced your degrees and/or certifications are, the more likely you are to get the position you want as a Neonatal Intensive Care Nurse. 

The best opportunities will be in large hospitals that have a full-fledged NICU department that provides both level II and level III care. 

NICU nurses play perhaps one of the most important roles in our healthcare system in that they are there when life begins and are often instrumental in helping high-risk newborns survive and thrive. They also act as a great source of comfort and information to the parents who spend those first few days or weeks as parents in the NICU.

For aspiring nurses who love the idea of working with infants to improve their health and get them home, NICU nursing is not only a high-demand specialization but also a fulfilling career choice. Check out NICU nurse jobs hiring now on our  job board . 

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Home / Nursing Careers & Specialties / NICU Nurse

What Does a NICU Nurse Do?

Becoming a nicu nurse, nicu nurse faqs, where do nicu nurses work, nicu nurse salary & employment, helpful organizations, societies, and agencies.

What Is a NICU Nurse?

Neonatal Intensive Care Unit (NICU) nursing is a field sub-specialty where nurses work with newborn infants who have a variety of medical ailments, such as premature congenital disabilities, cardiac malformations, dangerous infections, and other morphological or functional problems. Medical literature defines the first month of life as the neonatal period. NICU nursing typically encompasses care for infants with complications proximately after birth; however, that isn't to say that it excludes care for infants experiencing chronic long-term problems following their birth. NICU nurses will typically care for infants from the time of their birth until they're discharged from the hospital.

What Are the Educational Requirements for a Neonatal Intensive Care Nurse?

To become a neonatal intensive care nurse, you first must be a registered nurse (RN) with either an Associate's Degree in Nursing (ADN) or a Bachelor's of Science in Nursing (BSN) . Hospitals hiring for neonatal intensive care appointments will give priority to RNs who have obtained their BSN over those with only an ADN. Although certification is not always required for RNs to work in NICU settings, many NICU nurses must meet the requirement of having a minimum number of years of clinical experience in institutional contexts.

• Neonatal Nurse Practitioner Programs
• Post-Master's Neonatal Nurse Practitioner Certificate Programs

Are Any Certifications or Credentials Needed?

After obtaining an ADN or BSN, individuals are then eligible to sit for the National Council Licensure Exam (NCLEX-RN). Upon taking and passing the NCLEX-RN examination , individuals are subsequently able to apply for their registered nursing license.

The National Certification Corporation (NCC) requires the following credentials for individuals to be eligible to take the RNC-NIC examination specific to neonatal intensive care nursing:

• Must currently be a registered nurse in the U.S. or Canada
• Must have been employed in a neonatal-related field during the last two years
• Must have at least one of the following: at least 2,000 hours of neonatal specialty experience in direct patient care, administration, education, or research. Or, at a minimum, two years of experience working directly with severely afflicted infants as a registered nurse

Read more for further clarification on neonatal nurse certifications .

What's a Day in the Life of a NICU Nurse Like?

A day in the life of a NICU nurse is unpredictable, and can be both overwhelming and rewarding. At the start of the shift, you walk through secure doors to a locked unit. You’re required to first stop at the sink area to scrub your hands and arms from fingertips to elbows for a full minute with antiseptic, antimicrobial soap as if you are about to perform surgery. 

Most NICU assignments consist of one to three patients, depending on the acuity of the baby. You may have three “feeder growers” or one very ill baby on life support. Some days, you may find you are the admission nurse and start your day attending a very premature delivery. 

The NICU has a strict schedule for feedings and checking vital signs while minimizing the number of disruptions. NICU days are typically divided into three or four-hour periods, depending on “hands-on” care for the baby. Babies that are eating by mouth usually eat every three to four hours, whereas sicker babies or very premature infants receive less hands-on care to reduce overstimulation. All babies are continuously monitored in the NICU, and each baby is placed on a cardiorespiratory monitor to measure their heart rate and respiration. Other babies may require constant pulse ox monitoring, invasive blood pressure monitoring, and temperature or CO2 readings. 

How Many Babies Will a NICU Nurse Be Responsible for at Once?

Since more focused care is needed for acutely ill newborns, NICU nurses typically have a lower nurse-to-patient ratio than floor nurses. The number of babies a NICU nurse is responsible for can vary depending on state regulations as well as the facility. For example, mandatory nurse-to-patient ratio laws determine the maximum number of patients a nurse may care for at a given time. In California, for example, nurses in the neonatal care unit may only care for a maximum of two babies.

However, some facilities implement their staffing ratios based on acuity systems. NICUs classify patient acuity by “levels” usually 1-4. For example, neonates with more care needs (level 3 or 4) may be the only patient assigned to a NICU nurse. Intubated or post-op babies may even have two nurses assigned, depending on the case. Babies with less acute needs (i.e. “feeders and growers”) may be one of two or three patients per nurse.

Being that intensive care requires more attention and bedside care, nurses should be aware of their state’s ratio laws as well as their facility’s ratio standards. Asking for help and speaking up for unsafe assignments is essential in an intensive care area, especially with vulnerable newborns.

What Are Some of the Challenges of Working in a NICU?

It takes a special type of person to face the day-to-day challenges of working in a NICU. One of the most significant challenges, especially in the higher-level NICUs, is caring for babies who are struggling to survive. Sometimes, even when the most cutting-edge technology is employed, babies may not survive. Nurses and NPs establish a relationship with not only the baby but the parents and family. When a baby dies, the grief and loss felt by nurses can be significant. Nurses must be able to provide comfort to families and seek comfort from their support systems as well.

Caring for critically-ill infants is also emotionally draining. The challenge of caregiver stress and burnout is also significant. Nurses may feel depressed, anxious, or irritable at home. Being able to identify caregiver burnout and finding healthy outlets for stress is crucial for the mental well-being of NICU nurses.

Alarm fatigue is another challenge. Nurses and NPs work long hours. NICUs have multiple alarms sounding to guide caregiver interventions. While the alarms are set up to keep patients safe, sometimes alarm fatigue places patients at risk. Over time, caregivers can become desensitized to sounding alarms, risking them to be overlooked, ignored, or missed. Many times, repetitive alarms lose the urgency to caregivers who hear them for hours at a time. Luckily, many facilities employ strategies to reduce alarm fatigue among caregivers.

NICU nurses will find employment in both privately owned as well as public hospitals. Once in a while, although infrequently, NICU nurses can be found working in home-health service settings or even as a part of medical emergency teams. Here is a list of the most common locations you will find NICU nurses:

• Neonatal Intensive Care Units
• Community Health Organizations
• Medical Evacuation and Transport Services
• Home Health Services

Neonatal intensive care nurses typically take on the following duties:

• Provide comfort, support, and care to newborn infants who may have serious health conditions
• Communicate and cooperate with other healthcare professionals as part of a larger NICU team
• Administer treatments and medication that have been prescribed by physicians
• Educate the mothers and other family members of patients about infant care
• Use cutting-edge equipment and technological machines and devices

What Are the Roles and Duties of NICU Nurses?

The following describes the distinct levels of neonatal care and the kind of work involved at each level:

• Level I NICUs (Basic Newborn Care): RNs specialize in providing postnatal care for healthy newborn infants. In these facilities, RNs help to maintain the stability of newborn infants at 35 to 37 weeks' gestation who are physiologically sound. They help to stabilize infants who are born at less than 35 weeks' gestation and/or sick until they can be transferred to a healthcare facility that can provide an acceptable level of neonatal care.
• Level II NICUs (Advanced Neonatal Care): RNs working at this level care for less critically ill newborns who may require breathing and feeding support, or special medication. Level II NICU units are found in smaller healthcare facilities called special care nurseries.
• Level III NICUs (Sub-specialty Newborn Care): RNs working at these NICUs care for infants that have been born at less than 32 weeks' gestation and newborns suffering from severe afflictions at any gestational age. Typically, level III NICUs offer patients access to a complete spectrum of pediatric sub-specialties, respiratory support systems, and advanced imaging technologies.
• Level IV NICUs (Regional NICU; Highest Level of Neonatal Care): These facilities provide the care for infants who are born as young as 22 to 24 weeks' gestational age. Level IV NICUs provide mechanical ventilation, including high-frequency ventilation, and a wide range of advanced surgeries including "open-heart" surgeries needed to correct congenital heart defects. Some level IV NICU facilities provide ECMO or extracorporeal membrane oxygenation.

According to Payscale , RNs that work in the Neonatal Intensive Care Unit (NICU) make an average annual salary of $60,375, while Neonatal Nurse Practitioners make an average annual salary of $93,122. Individuals should be aware that salaries of NICU nurses and nurse practitioners can vary extensively depending on a wide variety of factors.

The demand for RNs is robust. The Bureau of Labor Statistics cites that RNs holding at least a Bachelor's of Science in Nursing (BSN) are more inclined to have better job prospects than those with an Associate's Degree in Nursing (ADN). Between 2012-2022, job growth for RNs in general is expected to grow by 19%.

• National Association of Neonatal Nurses
• Association of Women’s Health, Obstetric, and Neonatal Nurses
• Academy of Neonatal Nursing

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How to Become a Neonatal (NICU) Nurse

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• It takes 4-6 years to become a NICU nurse.
• Neonatal nurses need a college degree and a state-issued license.
• Certifications can help professionals qualify for more career opportunities.
• The typical neonatal nurse practitioner salary exceeds $110,000 as of June 2022.

The nursing field features many specializations, making the career appealing to workers with different professional interests. Neonatal nurses treat one of the most vulnerable groups — infants born prematurely or with a life-threatening condition. This fulfilling career requires a college education, licensure, and certification.

The best neonatal nurses need more than extensive healthcare knowledge. They must also offer patients and their families compassion and level-headedness during an emotionally stressful time. The career also requires physical stamina and an eye for detail. The typical neonatal nurse salary exceeds the U.S. median salary significantly. This advantage lets professionals live comfortably in most parts of the country. Keep reading to learn how to become a neonatal nurse.

What Does a Neonatal Nurse Do?

Neonatal nurses care for infants with exceptional medical needs. Like other healthcare careers, experience, certification, and additional education affect day-to-day responsibilities.

Gaining experience lets workers pursue professional certifications. Benefits may include qualifying for more jobs and keeping up to date with the latest nursing best practices.

Like a certification, an MSN with a specialization in neonatal care may qualify graduates for a career change or advancement. Neonatal nurse practitioners with this degree provide advanced care and perform other specialized roles.

Neonatal Nurse Responsibilities

• Caring for infants who are critically ill, born prematurely or with a birth defect, or older infants who require longer term critical care
• Collaborating with other medical professionals in a neonatal intensive care unit (NICU)
• Reviewing and maintaining patient paperwork
• Communicating medical information to family members and other stakeholders

Neonatal Nurse Not For You? Check Out These Related Careers.

Related nursing programs for you.

Learn about start dates, transferring credits, availability of financial aid, and more by contacting the universities below.

How to Become a NICU Nurse

Becoming a neonatal nurse license begins with education. Aspiring neonatal nurses should earn a bachelor's to make themselves more competitive. Other steps include passing the NCLEX-RN, applying for a license, and working in a hospital's NICU.

Licensed nurses use their education and training to qualify for a professional certification. Certification may result in a higher neonatal nursing salary and more career paths.

Step 1: Earn a BSN

A bachelor's in nursing features the education and hands-on training states require for licensure. Typical classes in a four-year program include human physiology, clinical pharmacology, and mental health nursing . Students also take general education classes emphasizing transferable skills .

Prospective students unsure about their career path should consider earning an associate in a science-related subject before transferring. They can speak with an academic counselor to choose the right major .

In addition, consider affordability when comparing ADN, RN-to-BSN, and BSN programs. In-state public schools may offer the lowest tuition rates.

Degree-seekers can make the most of their education by speaking with their school's career counselors . These professionals help learners prepare for interviews and develop a resume.

Step 2: Pass the NCLEX Exam

States' licensure requirements include passing the National Council of State Boards of Nursing (NCSBN) NCLEX-RN exam. Licensure candidates take this exam at a Pearson VUE testing center. The NCLEX-RN costs $200 as of August 2022.

The NCLEX-RN uses a computer-adaptive format, meaning the number of questions varies by test-taker. They answer 75-145 questions over a maximum five-hour testing window. The NCSBN uses a passing standard formula rather than a traditional score cutoff.

Visit the NCSBN website to access exam-preparation materials, such as a free practice test.

Step 3: Obtain RN Licensure

Aspiring nurses who pass the NCLEX-RN exam can start the licensure application process. Requirements vary by state but include official transcripts, exam scores, and a criminal background check.

Licensure applicants pay a fee when they submit their application. Individuals in Delaware pay $170 as of April 2022. California charges $300.

Licensed nurses also pay for continuing education classes necessary for licensure renewal. States charge renewal fees, as well.

Step 4: Work in a Neonatal Setting

Newly licensed nurses gain neonatal nursing experience by working in their hospital's NICU. Many professionals spend 1-2 years in an entry-level role before pursuing certification.

July 2022 Payscale data reports that entry-level nurses made almost $28 per hour. Students approaching graduation may find a better-paying position by developing their interviewing skills and working with their school's career counselors. Recent graduates can get their first job by custom-tailoring their resume and cover letter for each position.

Step 5: Apply for Certification

Nursing organizations that include the American Association of Critical-Care Nurses (AACN) award certification to experienced neonatal nurses. Professionals with 2-5 years of experience may qualify for the CCRN (neonatal) certification.

Earning the CCRN (neonatal) involves passing a comprehensive exam. Question topics cover six core areas, such as body systems and typical medical conditions. AACN members receive a $115 certification discount as of August 2022.

The National Certification Corporation awards the RNC certification for neonatal intensive care nursing to nurses who hold at least two years of experience and pass an exam. The exam costs $325 as of August 2022.

What to Know Before Becoming a Neonatal Nurse

Accreditation.

Prospective students limit their school search by checking schools' accreditation status . The benefits of attending an accredited school include transferring credit, accessing federal financial aid programs, and qualifying for more educational opportunities. Avoid schools lacking accreditation.

Online programs need the same accreditation as on-campus programs. Check accreditation status on a school's consumer information page.

According to a BestColleges data report, tuition and fees at four-year schools cost an average of $19,020 per year in 2020-2021. Many learners must also pay hidden college costs , such as travel and housing. Students may save money by attending a public or online school .

According to the National Center for Education Statistics , the average graduate tuition and fees in 2020-2021 cost $19,749 per year. Learners pursuing a master's degree may save money by comparing on-campus and online program costs .

The Bureau of Labor Statistics reports that registered nurses earned a median salary of $86,070 per year in May 2023. Top-paying employers included government agencies, hospitals, and ambulatory healthcare services. California nurses made the highest median salaries in the nation, at $137,690 per year.

Professionals may increase their salary potential with a graduate degree. Nurse practitioners with a master's or doctorate earned a median salary of $126,260 per year in May 2023.

Frequently Asked Questions About Becoming a Neonatal Nurse

What qualifications do you need to become a neonatal nurse.

Neonatal nurses need an associate or bachelor's degree from a state-approved nursing school. Both degrees require rigorous coursework and supervised clinical experience. Nurses-in-training qualify for a state license by passing the NCLEX-RN exam and meeting other requirements.

Newly licensed nurses enter the neonatal nursing field by gaining experience and professional certifications. They work under experienced nurses in their hospital's NICU before pursuing certification.

People interested in how to become a neonatal nurse should explore ADN and BSN programs in their area. These programs' in-person coursework and hands-on training let workers explore neonatal nursing and other specialties.

What is the fastest way to become a neonatal nurse?

Some nursing programs awarding an ADN take only two years to complete. However, some hospitals may prefer applicants with a bachelor's degree. Degree-seekers spend their 2-4 years in school learning nursing fundamentals, such as anatomy and physiology, chemistry, and psychology.

New nurses spend about two years gaining experience in neonatal nursing. Working under experienced neonatal nurses lets them develop knowledge and skills related to general pediatrics and maternal-child nursing. Professionals then earn one or more neonatal nursing certifications.

Some aspiring neonatal nurses need more than 4-6 years to achieve their career goals. Neonatal nurse practitioners must hold a master's degree. A typical master's program takes full-time learners an extra two years to finish.

How do I become a neonatal nurse without a degree?

People researching how to become a licensed neonatal nurse will discover the profession requires at least an associate degree. States regulate the nursing profession with this and other requirements. Visit a state's board of licensure website to learn more about the process.

Although registered nurses hold a degree, other nursing professionals do not. These licensed professional nurses (LPNs) and licensed vocational nurses (LVNs) need only a diploma to practice. Diploma programs take less time than an associate or bachelor's degree.

Becoming an LPN or LVN lets workers explore the nursing profession without committing to a degree. Their diploma may transfer to an ADN program, as well.

Can I become a neonatal nurse with an online degree?

Aspiring neonatal nurses without college experience may enroll in a hybrid program. Hybrid programs combine the hands-on experiences states require for licensure and some online coursework. As a result, college applicants should apply to hybrid programs within commuting distance.

RNs with an associate degree may explore fully online RN-to-BSN programs . These degrees let learners continue working while in school. Other advantages may include the ability to study full or part time.

Experienced nurses with a bachelor's can select from online MSN and DNP neonatal nursing programs. These programs feature the same advantages as online RN-to-BSN degrees.

How much money does a neonatal nurse make?

As of June 2022 Payscale data, neonatal nurses earn over $20,000 more annually than the typical U.S. worker. Some professionals make more than $100,000 per year.

Many factors affect salary, such as degree level. Payscale reports that the average neonatal nurse practitioner salary exceeds $117,000 as of March 2024. This salary potential may make earning an MSN or DNP degree a wise investment for some experienced nurses.

Where nurses live may also impact their salary. The BLS reports that registered nurses in California, Hawaii, and Oregon made at least $20,000 more per year than the profession's median salary in May 2023. Other top-paying locations included Washington, D.C. and Alaska.

Explore More College Resources

6 reasons to pursue a career in nursing.

In a Survey, 90% of Nurses Said They Are Considering a Career Change Within the Year

RN License Requirements by State

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Health Encyclopedia

The neonatal intensive care unit (nicu).

The birth of a baby is a wonderful and very complex process. Many physical and emotional changes occur for both the birth parent and the baby.

A baby must make many physical adjustments to life outside the birth parent's body. Leaving the uterus means that a baby can no longer depend on the birth parent's blood supply and placenta for important body functions.

Before birth, the baby depends on functions from the birth parent. These include breathing, eating, elimination of waste, and immune protection. When a baby leaves the uterus, its body systems must change. For instance:

The lungs must breathe air.

The cardiac and pulmonary circulation changes.

The digestive system must begin to process food and excrete waste.

The kidneys must begin working to balance fluids and chemicals in the body and excrete waste.

The liver and immune systems must begin working on their own.

Your baby's body systems must work together in a new way. In some cases, a baby has trouble making the transition outside the uterus. Preterm birth, a difficult birth, or birth defects can make these changes more challenging. But a lot of special care is available to help newborn babies.

What is the neonatal intensive care unit (NICU)?

Newborn babies who need intensive medical care are often put in a special area of the hospital called the neonatal intensive care unit (NICU). The NICU has advanced technology and trained healthcare professionals to give special care for the tiniest patients. NICUs may also care for babies who are not as sick but do need specialized nursing care. Some hospitals don’t have the staff for a NICU. In these cases, babies must be moved to another hospital. Babies who need intensive care do better if they are born in a hospital with a NICU than if they are moved after birth.

Some newborn babies will need care in a NICU. Giving birth to a sick or premature baby can be unexpected for any parent. The NICU can be overwhelming. This information is to help you understand why a baby may need to be in the NICU. You will also find out about some of the procedures that may be needed for the care of your baby.

Which babies need special care?

Most babies admitted to the NICU are preterm (born before 37 weeks of pregnancy), have low birth weight (less than 5.5 pounds), or have a health condition that needs special care. In the U.S., about 1 in 10 babies are born preterm. Many of these babies also have low birth weights. Twins, triplets, and other multiples often are admitted to the NICU. This is because they tend to be born earlier and smaller than single birth babies. Babies with health conditions, such as breathing trouble, heart problems, infections, or birth defects are also cared for in the NICU.

Below are some factors that can place a baby at high risk and increase the chances of being admitted to the NICU. But each baby must be assessed to see if they need the NICU. High-risk factors are detailed below.

Birth parent factors include:

Being younger than age 16 or older than age 40

Drug or alcohol use

High blood pressure (hypertension)

Sexually transmitted diseases

Multiple pregnancy (twins, triplets, or more)

Too little or too much amniotic fluid

Premature rupture of membranes (also called the amniotic sac or bag of waters)

Delivery factors include:

Changes in a baby’s organ systems due to lack of oxygen (fetal distress or birth asphyxia)

Buttocks delivered first (breech birth) or other abnormal position

The baby's first stool (meconium) passed during pregnancy into the amniotic fluid

Umbilical cord wrapped around the baby's neck (nuchal cord)

Forceps, vacuum, or cesarean delivery

Baby factors include:

Baby born at gestational age of less than 37 weeks or more than 42 weeks

Birth weight less than 5 pounds, 8 ounces (2,500 grams) or over 8 pounds, 13 ounces (4,000 grams)

Small for gestational age

Medicine or resuscitation in the delivery room

Birth defects

Respiratory distress, including rapid breathing, grunting, or stopping breathing (apnea)

Infection such as herpes, group B streptococcus, chlamydia

Low blood sugar (hypoglycemia)

Need for extra oxygen or monitoring, IV (intravenous) therapy, or medicines

Need for special treatment or procedures, such as a blood transfusion

Who will care for your baby in the NICU?

Some of the specially trained healthcare providers who may care for your baby include:

Neonatologist. This is a pediatrician with extra training in the care of sick and premature babies. The neonatologist (often called the attending physician) supervises pediatric fellows and residents, nurse practitioners, and nurses who care for babies in the NICU.

Neonatal fellow. This is a pediatrician getting extra training in the care of sick and premature babies. They may do procedures and direct your child's care.

Pediatric resident. This is a healthcare provider who is getting extra training in the care of children. They may do or assist in procedures and help direct your child's care.

Neonatal nurse practitioner. This is a registered nurse with extra training in the care of newborn babies. They can do procedures and help direct your child's care.

Registered nurse (RN). RNs care for your baby 24 hours a day. They carefully watch for any changes and give medicines. They can show you how to take part in your baby's care.

Respiratory therapist. This is a person with special training in giving respiratory support. This includes managing breathing machines and oxygen.

Physical, occupational, and speech therapists. These types of therapists make sure a baby is developing well. They also help with care, including positioning and soothing methods. Speech therapists help babies learn to eat by mouth.

Registered dietitian nutritionist (RDN). RDNs make sure the babies are growing well and getting good nutrition. They watch your baby's intake of calories, protein, vitamins, and minerals.

Lactation consultants. These are healthcare providers with extra training and certification in helping women and babies breastfeed. They can help with pumping, maintaining milk supply, and starting and continuing breastfeeding.

Pharmacists. Pharmacists help the healthcare providers in the NICU choose the best medicines. They check medicine doses and levels. They keep the team aware of possible side effects and monitoring that may be needed.

Social workers. Social workers help families cope with many things when a child is ill. They give emotional support. They help families get information from healthcare providers. They support the family with other more basic care needs, too. These can include money problems, transportation, or arranging home healthcare.

Hospital chaplain. This may be a priest, minister, lay pastor, or other religious advisor. The chaplain can give spiritual support and counseling to help families cope with the stress of the NICU.

NICU team members work together with parents to create a plan of care for high-risk newborns. Ask about the NICU's parent support groups and other programs designed to help parents.

Medical Reviewers:

• Donna Freeborn PhD CNM FNP
• Stacey Wojcik MBA BSN RN
• Tracy C. Garrett RNC-NIC BSN
• Ask a Medical Librarian Make an Appointment Physicians & Services Physicians who treat newborn infants

• Medicine >
• Education & Training >
• Medicine-Pediatrics Residency >
• Curriculum >
• Rotations >
• Pediatric >

Neonatal Intensive Care Unit (NICU)

Function as the primary care physician for sick neonates.

Sick and premature infants are evaluated, examined, and under the close supervision of attendings and fellows, therapeutic and diagnostic management plans are formulated.

During this rotation, you will assume increasing responsibility for the care of sick and premature infants and are primarily responsible for the care of all patients. There are full-time attending neonatologists who round daily with the house staff. There are also neonatal fellows involved with neonatal care and who are available to assist in the care of sick neonates.

You will be the first one to evaluate the presenting neonate. Abnormal physical findings, complications and therapeutic implications are discussed in depth. The input of the perinatal staff and neonatal nurse practitioners is sought. Discussions with parents about prognosis and anticipatory guidance is encouraged and guided by the attendings.

Conditions Seen

Common diagnoses or problems seen during this rotation are:

• congenital malformations
• prematurity
• hypoglycemia
• chronic lung disease
• meningomyelocele
• hypoxic ischemic encephalopathy

Rotation One

By the end of the first rotation you will be expected to be able to:

• extract from the perinatal record relevant information to develop a differential diagnosis and initiate a plan of management for sick newborns
• detect major functional and morphologic abnormalities based upon physical examination of the newborn
• understand and apply the general principles of nutritional and thermal requirements of newborn infants
• interpret microbiological, biochemical, hematological and pharmacological lab values in the monitoring and management of the newborn patient
• participate in the delivery room resuscitation of high-risk newborns following AAP/AHA Neonatal Resuscitation Program Guidelines
• demonstrate knowledge of the indications and complications of common neonatal procedures including umbilical catheterization, peripheral arterial sampling, percutaneous central venous lines, needle thoracenthesis, endotracheal intubation and achieve some success at umbilical venous catheter and peripheral IV insertion

Rotation Two

At the end of the second rotation, you should, in addition to the previous achievements, be able to:

• communicate the pertinent positive and negative historical information to support an assessment or differential diagnosis and communicate this evaluation and plan as appropriate to the neonatal health care team, the parents and the primary care physician
• elicit the pertinent physical and laboratory findings that pertain to the assessment of differential diagnosis
• initiate appropriate management regimen for newborn patients with the common disorders of the respiratory, cardiovascular, metabolic and nervous systems
• interpret blood gas results and routine chest and abdominal x-rays to initiate appropriate changes in patient management
• provide initial delivery room resuscitation of high-risk newborns, including bag mask ventilation and management of the meconium stained amniotic fluid delivery
• successfully place peripheral IV’s and umbilical venous catheters, obtain peripheral arterial blood samples, and gain experience in placement of umbilical arterial catheters, needle thoracocentesis and endotracheal intubation
• independently evaluate the sick newborn infant to develop and implement an appropriate plan of care
• efficiently and effectively utilize time in focused patient care evaluation, documentation and communication
• analyze complex information, evaluate response to initial support management and develop procedures for altering the plan of care in a broad range of acutely ill neonatal patients
• appropriately monitor the plan of care to assure appropriate utilization of resources and response to intervention
• manage the cardiopulmonary resuscitation of the newborn infant in the delivery room including endotracheal intubation, vascular access, emergency medications, needle thoracocentesis and external cardiac massage
• successfully place umbilical artery catheters and participate in chest tube placement for tension pneumothorax
• provide for the initial resuscitation and stabilization of high-risk newborns
• recognize and determine which neonatal patient can be effectively managed based upon the neonatal care services available and provide for timely initiation of referral
• become knowledgeable in the appropriate post-discharge follow-up and care needs of the high-risk neonatal patient and family
• provide leadership, direction and teaching to junior members of the health care team in a constructive and academic manner
• utilize the various pediatric medical, surgical, nursing and allied health specialists in optimizing the care for the patient and family
• improve knowledge and care through independent review of the medical literature and apply this knowledge to patient care

Didactics/Rounds

Work rounds.

Patient care rounds occur daily (seven days) with the neonatal attending and fellow. Patients are presented and discussed in detail. Other members of rounds can include a nutritionist, clinical pharmacist, respiratory therapist and neonatal nurse practitioner.

Attending Rounds

These are made every day with assigned attendings and formal presentations done ad hoc.

Nursery Didatics

Topics relating directly to the potential problems or complications of premature infants are discussed weekly, and on an ad hoc basis daily.

About 10 patients per day.

Years Taken

• PGY-1: required
• PGY-2: required
• PGY-3: possible elective

Length of Rotation

Clinical site.

• 5/21/19 Oishei Children’s Hospital

Patient Population

• premature, as young as 23 weeks
• sick full-term infants

Oishei Children’s Hospital NICU is a Level III referral center; patients may be on a liquid ventilation oscillator.

• Second Opinion

The Neonatal Intensive Care Unit (NICU)

The birth of a baby is a wonderful and very complex process. Many physical and emotional changes occur for both mother and baby.

A baby must make many physical adjustments to life outside the mother's body. Leaving the uterus means that a baby can no longer depend on the mother's blood supply and placenta for important body functions.

Before birth, the baby depends on functions from the mother. These include breathing, eating, elimination of waste, and immune protection. When a baby leaves the womb, its body systems must change. For example:

The lungs must breathe air.

The cardiac and pulmonary circulation changes.

The digestive system must begin to process food and excrete waste.

The kidneys must begin working to balance fluids and chemicals in the body and excrete waste.

The liver and immune systems must begin working on their own.

Your baby's body systems must work together in a new way. In some cases, a baby has trouble making the transition outside the womb. Preterm birth, a difficult birth, or birth defects can make these changes more challenging. But a lot of special care is available to help newborn babies.

What is the neonatal intensive care unit (NICU)?

Newborn babies who need intensive medical care are often put in a special area of the hospital called the neonatal intensive care unit (NICU). The NICU has advanced technology and trained healthcare professionals to give special care for the tiniest patients. NICUs may also care areas for babies who are not as sick but do need specialized nursing care. Some hospitals don’t have the staff for a NICU and babies must be moved to another hospital. Babies who need intensive care do better if they are born in a hospital with a NICU than if they are moved after birth.

Some newborn babies will require care in a NICU. Giving birth to a sick or premature baby can be unexpected for any parent. The NICU can be overwhelming. This information is to help you understand why a baby may need to be in the NICU. You will also find out about some of the procedures that may be needed for the care of your baby.

Which babies need special care?

Most babies admitted to the NICU are preterm (born before 37 weeks of pregnancy), have low birth weight (less than 5.5 pounds), or have a health condition that needs special care. In the U.S., nearly half a million babies are born preterm. Many of these babies also have low birth weights. Twins, triplets, and other multiples often are admitted to the NICU. This is because they tend to be born earlier and smaller than single birth babies. Babies with health conditions such as breathing trouble, heart problems, infections, or birth defects are also cared for in the NICU.

Below are some factors that can place a baby at high risk and increase the chances of being admitted to the NICU. But each baby must be assessed to see if he or she needs the NICU. High-risk factors include the below.

Maternal factors include:

Being younger than age 16 or older than age 40

Drug or alcohol use

High blood pressure (hypertension)

Sexually transmitted diseases

Multiple pregnancy (twins, triplets, or more)

Too little or too much amniotic fluid

Premature rupture of membranes (also called the amniotic sac or bag of waters)

Delivery factors include:

Changes in a baby’s organ systems due to lack of oxygen (fetal distress or birth asphyxia)

Buttocks delivered first (breech birth) or other abnormal position

The baby's first stool (meconium) passed during pregnancy into the amniotic fluid

Umbilical cord wrapped around the baby's neck (nuchal cord)

Forceps or cesarean delivery

Baby factors include:

Baby born at gestational age of less than 37 weeks or more than 42 weeks

Birth weight less than 5 pounds, 8 ounces (2,500 grams) or over 8 pounds, 13 ounces (4,000 grams)

Small for gestational age

Medicine or resuscitation in the delivery room

Birth defects

Respiratory distress including rapid breathing, grunting, or stopping breathing (apnea)

Infection such as herpes, group B streptococcus, chlamydia

Low blood sugar (hypoglycemia)

Need for extra oxygen or monitoring, IV (intravenous) therapy, or medicines

Need for special treatment or procedures such as a blood transfusion

Who will care for your baby in the NICU?

Some of the specially-trained healthcare providers who may care for your baby include:

Neonatologist. This is a pediatrician with extra training in the care of sick and premature babies. The neonatologist (often called the attending physician) supervises pediatric fellows and residents, nurse practitioners, and nurses who care for babies in the NICU.

Neonatal fellow. This is a pediatrician getting extra training in the care of sick and premature babies. He or she may do procedures and direct your child's care.

Pediatric resident. This is a doctor who is getting extra training in the care of children. He or she may do or assist in procedures and help direct your child's care.

Neonatal nurse practitioner. This is a registered nurse with extra training in the care of newborn babies. He or she can do procedures and help direct your child's care.

Respiratory therapist. This is a person with special training in giving respiratory support. This includes managing breathing machines and oxygen.

Physical, occupational, and speech therapists. These types of therapists make sure a baby is developing well. They also help with care including positioning and soothing methods. Speech therapists help babies learn to eat by mouth.

Dietitians. Dietitians ensure the babies are growing well and getting good nutrition. They watch your baby's intake of calories, protein, vitamins, and minerals.

Lactation consultants. These are healthcare providers with extra training and certification in helping women and babies breastfeed. They can help with pumping, maintaining milk supply, and starting and continuing breastfeeding.

Pharmacists. Pharmacists help in the NICU by assisting the care providers choose the best medicines. They check medicine doses and levels. They keep the team aware of possible side effects and monitoring that may be needed.

Social workers. Social workers help families cope with many things when a child is ill. They give emotional support. They help families get information from healthcare providers. They support the family with other more basic care needs, too. These can include money problems, transportation, or arranging home healthcare.

Hospital chaplain. The hospital chaplain may be a priest, minister, lay pastor, or other religious advisor. The chaplain can give spiritual support and counseling to help families cope with the stress of the NICU.

NICU team members work together with parents to create a plan of care for high-risk newborns. Ask about the NICU's parent support groups and other programs designed to help parents.

Supporing each delivery with nurturing care and outstanding comfort

Related links.

• Neonatology Care
• Neonatal Intensive Care Unit
• Parent Support
• Road to Home
• Care of the Baby in the Delivery Room
• Prematurity

Developmental Care for Babies in the NICU

Related Topics

Equipment That Is Used in the NICU

Intravenous (IV) Line and Tubes

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• Neonatal Intensive Care Unit (NICU)

• Resources for Families in the NICU
• Parenting in the NICU

NICU Postpartum Support Program

• Choosing a NICU

Family Resources

If you have a sick or premature infant, you want and need the best possible care. You'll find that care at Children's National Hospital, where our specialized team of pediatric subspecialists and nurses use the latest technology and equipment to ensure that babies in our care have the opportunity to grow up stronger. Our neonatology program continues to be recognized with high rankings from U.S. News & World Report, including our current ranking as the number 2 neonatology program  in the country.

Our Providers

Our pediatric specialists provide personalized care for your child’s physical, mental and emotional health needs.

Contact Information

For appointments, please call 1-888-884-BEAR (2327) and for information, call NICU administration at 202-476-5448.

At Children’s National, our neonatal intensive care unit (NICU) is a Level IV NICU.  As a Level IV NICU, we offer the highest level of care for premature and ill newborns, as designated by The American Academy of Pediatrics. This means we can:

• Offer the full range of pediatric medical subspecialists, pediatric surgical subspecialists and pediatric anesthesiologists on site. Learn more about our team .
• Perform complex surgical procedures to repair complex congenital or acquired conditions
• Arrange for babies to come to the NICU and provide education for parents and families

Understanding NICU Levels

All neonatal intensive care units care for babies who need special help, but different NICUs offer different levels of care. Learn more about the different levels of NICU care  (PDF).

Level 1: Basic Care

Level I NICUs provide care for healthy, full-term babies. They also stabilize near-term babies to get them ready to be moved to specialized facilities.

Level 2: Advanced Care

Level II NICUs offer care for babies born at or after 32 weeks and babies who are recovering from more serious health problems.

Level 3: Specialized Care

Level III NICUs care for very sick babies and offer access to a wide range of pediatric specialists and equipment, such as X-rays and ventilation support. The babies in these nurseries are generally born earlier than 32 weeks or have critical illnesses.

Level 4: Highest Level of Care

Level IV NICUs provide the highest level of neonatal care. They have a full range of healthcare providers, including pediatric subspecialists, specialized nurses and equipment to care for very sick babies.

What to Expect in Our NICU

Who will be caring for my child in the nicu, what should i know about the nicu nursing staff, what should i expect from the nicu patient rooms, what programs and resources are available for my child and family.

We know that your family is a core part of your baby’s recovery and healing. That is why we offer unique programs and services, like:

• Daily participation in rounds with the team of doctors and nurses caring for your baby
• Private rooms with comfortable rockers where we teach you to care for your child safely and comfortably, when you are both ready
• Child development specialists who will evaluate and design therapies to help your baby, when ready
• Social workers, chaplains and Child Life Specialists who can help different members of your family, including your infant’s siblings
• Our NICU Postpartum Support Program , a behavioral health program designed to support parents of babies in the NICU

Your baby is our focus, but the emotional and physical health of your entire family is our goal. Learn more about our Specialized Programs  or visit our Resources for Families , where you will find information about what to expect while in the NICU, feeding and bonding resources and a list of supportive services we offer.

What are the NICU visiting hours?

• Visitation hours are 9 a.m. to 9 p.m. for designated visitors (ask your nurse or social worker for more information).
• Parents or caregivers are able to be in the NICU 24 hours a day.
• Only two visitors are allowed to be at the bedside at a time.
• Siblings who visit must be 10 years of age or older. The hours for visits from siblings are also 9 a.m. to 9 p.m.
• If you have symptoms of any illness, we ask that you do not visit until you are well and wear a mask in the building. Masks are available at the front desk.

How can I transition from the NICU to my home with my child?

Explore our dedicated NICU Family Resources page where you'll find helpful resources and supportive programs created to help families with loved ones in the NICU.

The NICU Postpartum Support Program is an integrated behavioral health program designed to support parents of babies in the NICU at Children’s National Hospital.

Additional Contact Information

For specific inquiries, please see additional phone numbers below. NICU Administration: 202-476-5448 Admission to NICU (24/7): 202-476-5040 Admission Fax: 202-476-3459 Neonatal High Risk Follow-Up Appointments: 202-476-5405 Evenings and Weekends: 202-476-5000 For comments and questions, we welcome you to email the unit director.

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Take a Tour of Our NICU

Learn more and take a look around our Level IV Neonatal Intensive Care Unit (NICU) at Children's National Hospital. As a Level IV NICU, we offer the highest level of care for premature and ill newborns.

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• Published: 21 February 2024

Improving attitudes toward trauma-informed care in the neonatal intensive care unit through comprehensive multi-disciplinary education

• Patricia A. Davis   ORCID: orcid.org/0000-0001-6469-9365 1 ,
• Dena Hubbard   ORCID: orcid.org/0000-0002-0183-7852 2 , 3 ,
• Tiffany Gladdis 2 , 3 , 4 ,
• Chris Nitkin   ORCID: orcid.org/0000-0001-5718-4523 2 , 3 ,
• Kara Hansen 5 ,
• Erin Keith-Chancy 6 ,
• Jennifer Godwin 2 , 3 ,
• Vincent Staggs 7 , 8 ,
• Shilpa Babbar 5 ,
• Michelle Hardy 9 ,
• Jacqulin Ashbaugh 9 &
• Brian S. Carter   ORCID: orcid.org/0000-0003-0539-9164 2 , 10  

Journal of Perinatology ( 2024 ) Cite this article

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Metrics details

• Health services
• Neuroscience

This study measured staff understanding and integration of trauma-informed care following comprehensive education.

Study design

This mixed method design used the validated Attitudes Related to Trauma-Informed Care (ARTIC) scale and open-ended survey questions via REDCap optional surveys. Trauma-informed care education was made available to staff members in a level IV NICU. Pre- and post-intervention ARTIC scores were compared and post-intervention REDCap surveys were analyzed.

There were 245 multi-disciplinary NICU team members who completed the ARTIC survey before and/or after the educational intervention; and 764 REDCap surveys were completed throughout the study time. ARTIC scores increased from pre- to post-training both for participants with data at both time points (0.5 SD mean increase) and among those with data at only one time point (0.4 SD mean increase). Content analysis of the REDCap survey corroborated the ARTIC results.

System-wide trauma-informed education can achieve measurable effect in a NICU setting.

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Data availability.

The majority of datasets generated and analyzed during this study are included in this published article [and its supplementary information files]. The complete brainstorming dataset generated and analyzed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We gratefully acknowledge assistance from study team Clinical Investigators, Grace Asaad, RN, Shelbi Polasik, MT, and Liesel Stephens, MT, who served as scientific advisors by coding and analyzing study participant responses for qualitative data interpretation. We particularly appreciate the assistance of the additional members of the Children’s Mercy Kansas City NICU Trauma-Informed Care workgroup, who served as Participating Investigators aiding in multi-disciplinary collaboration and data collection including Kaylee Hurt, Parent on Staff, Elisa Loughman, MD, Courtney Becker, RN, Becky Palmer, QI, Marni Scott, LCSW, Carissa Thompson, LCSW, Megan Cope, RN, John Lantos, MD, Brooke Ratliff, CLS, Erin Perez, LCSW, Nicole Hutcheson, DNP, Dianne Wilderson, MSN, and Mary Henley, CCRN. We especially valued the assistance of Chris Kennedy, MD, pediatric emergency medicine, Children’s Mercy Kansas City, in helping to create the on-line distribution of the ARTIC survey. The authors would also like to thank the members of the NICU healthcare team members who participated in our study.

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Department of Social Work, Children’s Mercy-Kansas City, Kansas City, MO, USA

Patricia A. Davis

Division of Neonatology, Department of Pediatrics, Children’s Mercy-Kansas City, Kansas City, MO, USA

Dena Hubbard, Tiffany Gladdis, Chris Nitkin, Jennifer Godwin & Brian S. Carter

Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA

Dena Hubbard, Tiffany Gladdis, Chris Nitkin & Jennifer Godwin

Division of Developmental and Behavioral Medicine, Department of Pediatrics, Children’s Mercy-Kansas City, Kansas City, MO, USA

Tiffany Gladdis

Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Children’s Mercy Kansas City, Kansas City, MO, USA

Kara Hansen & Shilpa Babbar

University of Kansas School of Nursing - Undergraduate Faculty, Kansas City, MO, USA

Erin Keith-Chancy

Biostatistics & Epidemiology Core, Children’s Mercy-Kansas City; School of Medicine, University of Missouri-at Kansas City, Kansas City, MO, USA

Vincent Staggs

Statistical Consulting & Research, IDDI, Inc., Raleigh, NC, USA

Neonatal Intensive Care Unit, Children’s Mercy-Kansas City, Kansas City, MO, USA

Michelle Hardy & Jacqulin Ashbaugh

Pediatric Bioethics Center, Children’s Mercy-Kansas City, Professor of Pediatrics, School of Medicine, Kansas City, MO, USA

Brian S. Carter

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Researchers Davis, Hubbard, Hansen, Nitkin, and Keith-Chancy conceptualized and designed the paper, drafted the initial manuscript, and reviewed and revised the manuscript. Investigator’s Staggs, Carter, Gladdis, Godwin, Ashbaugh, Hardy, and Babbar critically reviewed and revised the manuscript for important intellectual content and data interpretation. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Correspondence to Patricia A. Davis .

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Davis, P.A., Hubbard, D., Gladdis, T. et al. Improving attitudes toward trauma-informed care in the neonatal intensive care unit through comprehensive multi-disciplinary education. J Perinatol (2024). https://doi.org/10.1038/s41372-024-01897-4

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DOI : https://doi.org/10.1038/s41372-024-01897-4

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Neonatal Intensive Care Unit celebrates 50 years of caring for Mayo’s tiniest patients – including those of a NICU nurse

Mayo Clinic Staff

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When Connor and Colson Kasper arrived at 32 weeks gestation, their mother, Alli Kasper, was better prepared than most parents for a stay in the  Neonatal Intensive Care Unit  at Mayo Clinic: She's the unit's interim nurse manager.

But her role had changed. She was now a mom, not a nurse. And her colleagues recognized that.

"Even though I was their colleague, everyone in the NICU treated me as my twins' mom and not their nurse," Kasper says. "The providers talked to my husband and me in plain language terms to ensure we both understood what was happening and what the plan was. The nurses were phenomenal and provided excellent care, kept me updated on any changes, and were genuinely kind and loving toward my babies."

That gave Kasper comfort.

"I had a sense of peace knowing my sons were getting the best care," she says.

50 years of caring

Fifty years ago, premature babies like Kasper's might not have lived past a few days. Now, thanks to new technology and scientific discoveries, even the smallest babies born as early as 22 weeks have a chance of surviving.

"We are commonly asked to consult with a mother who may be experiencing premature labor to describe care options for her newborn and family. The goal is to deliver a healthy baby with developmental outcomes optimized," says  Christopher Colby, M.D. , a neonatologist at  Mayo Clinic Children's Center . 

The Neonatal Intensive Care Unit at Mayo Clinic began as a four-bed pilot project in 1973, spearheaded by the late Robert Feldt, M.D., a pediatric cardiologist, and Lloyd Harris, M.D., a pediatrician. The pilot was a success, quickly demonstrating the need for more space and personnel to care for the hospital's most fragile patients.

Fredric Kleinberg, M.D., was the original board-certified neonatologist at  Mayo Clinic  in 1977. Dr. Kleinberg credits medical advancements, including more sophisticated ventilation devices, with improved rates of survival at less mature gestational ages.

"Technology has come a long way since the days of using 5-foot-tall compressed air and oxygen tanks to help premature babies breathe," says Donna Hanks, who was a nurse in the Neonatal Intensive Care Unit for 43 years.

As Hanks notes, medical equipment has been refined to support newborns — some of whom weigh less than a pound at birth. These mechanical advancements include high-frequency ventilation and continuous positive airway pressure machines.

In addition to better equipment and new technologies, medication discoveries have improved the survival rates of premature babies.

"Administering the antenatal steroid known as betamethasone to the mother at least 48 hours before delivery has been demonstrated to improve survival and long-term outcomes for premature babies," says  Stephanie Mavis, M.D. , a neonatologist at Mayo Clinic.

Mayo Clinic's original four-bed Neonatal Intensive Care Unit has grown to include two Neonatal Intensive Care Unit locations in Rochester, where 879 newborns received care in 2022.

A  neonatal telemedicine service  introduced in 2013 serves even more patients, placing a neonatologist virtually at the bedside of any newborn across the entirety of Mayo Clinic Health System. This service assists local care teams with the stabilization of critically ill babies and has supported nearly 1,000 newborns since its inception.

All of the tiny tots who receive care at Mayo Clinic are invited to an annual NICU family reunion, an event that has taken place for 39 years.

Kasper and her family attended this year's event, which she experienced as both a mother and a nurse. At the event, a former patient thanked her for taking care of him when he was a baby — a gesture that brought tears to her eyes.

"It makes the long and exhausting shifts worth it," Kasper says. "More than a gathering, the reunion is proof that our work in the NICU truly makes a difference."  

That's something she knows firsthand: Kasper herself was born at 32 weeks.

"My parents always raved about how amazing the nurses who took care of me were," she says. "I knew from a young age that I wanted to work in a NICU to give that same level of comfort and compassion to my patients' parents."

• Pass the turkey — and your family health insights — this Thanksgiving Mayo Clinic Minute: How to make healthy holiday food choices

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Neonatal care expert: 'Vulgar' narrative on NICU deaths hurting babies' parents

NEONATOLOGIST Dr Petronella Manning-Alleyne has condemned what she described as a vulgar narrative being pursued in the media with respect to the babies who died at the neonatal intensive care unit (NICU) at the Port of Spain General Hospital (PosGH) and the NICU's staff.

She claimed this narrative is being pursued by people who are attempting to exploit the vulnerabilities of the babies' parents and the NICU staff, for their own benefit.

Seven babies died from a bacterial infection at the NICU between April 4 and 9.

The parents of these babies have since initiated legal action against the North West Regional Health Authority (NWRHA) over their babies' deaths.

They are being represented by Freedom Law Chambers, which is led by former attorney general Anand Ramlogan, SC.

The PosGH falls under the NWRHA's jurisdiction.

The parents of other babies who died at the NICU have also joined the lawsuit against the the NWRHA by Freedom Law Chambers.

In a video that was posted on her Facebook page and subsequently sent to Newsday, Manning-Alleyne said she had turned down requests from the media to be interviewed about the deaths of babies at the NICU and events related to that.

She gave her reason for declining these requests.

"I would like to suggest that the vulgar interest that we seem to have in what is going on in the neonatal unit at PosGH is just that. It's vulgar. It does not help anybody, and I would suggest that we should feel a little bit more for the parents who have lost children. They are angry because they have lost their children."

Manning-Alleyne had a message for anyone pushing such a narrative or trying to exploit the parties involved in this matter for their own benefit.

"I want them to stop it, because this is not how life works."

In addition to being a neonatologist, Manning-Alleyne is also experienced in death counselling.

She said there are stages of grief that people go through when someone close to them dies, and failure to come out of any stage of the grief process negatively affects one's ability to heal.

The first stage is denial and this is followed by anger.

Manning-Alleyne said these two stages of grief are what the babies' parents are going through now. The latter, she continued, will see the parents blaming everything and everyone for their babies' death.

Manning-Alleyne said it is wrong for anyone trying to keep the parents in this state of anger so they could benefit from it.

"We need to support them. We don't need to bury them in a big barrel of anger. When we do that. we hurt them to the extent that they are going to be having a lot of difficulty recovering from that."

Manning-Alleyne, who played a key role in the establishment of the PoSGH's NICU and worked there for 28 years, called for similar consideration to be given to the feelings of the unit's staff.

As a neonatologist, Manning-Alleyne said, "I have lost babies, and it is not a good feeling. It is not a good feeling for the parents."

She added it is also not a good feeling for the NICU staff who still have to care for the other babies in the unit.

Manning-Alleyne said it takes a particular type of person to work in neonatal intensive care.

"We who do intensive care and we who do neonatal intensive care, you have to have a certain kind of interest and and certain kind of expertise in order to work with children of that kind of age group."

Manning-Alleyne said it is a difficult thing for a doctor or nurse to tell a parent their child is dead.

She recalled one such case that was very traumatic for her.

"I had to go home and cry for the whole day and I had to get somebody to talk to me and I had to come back to the hospital and show the parent a straight face."

Manning-Alleyne left the PoSGH in 2008.

Referring to the bacterial infection the seven babies died from earlier this month, Manning-Alleyne said, "I don't know anything about those organisms. They did not exist when I was working in the hospital."

She added that certain things could have happened over the last 15 years when it came to certain bacteria and their evolution.

Manning-Alleyne made a comparison to the covid19 virus which developed a resistance to initial vaccines used to treat it and new vaccines had to be created to successfully combat the virus.

She said bacterial organisms could have developed a resistance to antibiotics initially used to treat them and different antibiotics have to be used on them now.

Manning Alleyne added that in situations such as this cluster problems happen and there is international literature on this subject which shows these problems are not unique or pertinent to PoSGH alone.

She reiterated her call for a proper understanding of matters happening at the NICU and for people seeking to benefit from this situation to desist immediately.

Auditor General asks AG to pay her legal costs

Post news is dead, man shot dead in jackson hill, east port of spain, wi retired players foundation receives us$500,000 after ten-year wait, west: new complex will help point fortin, "neonatal care expert: ‘vulgar’ narrative on nicu deaths hurting babies’ parents", more in this section, contractor ordered to pay $12m for work done on red house, president's house projects, beetham gardens' 2-week stink – raw sewage flows along 24th street, tha secretary appeals to ema: 'havoc' at turtle nesting site, offices of chief secretary and deputy chief secretary merged.

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Introduction, central line–associated bloodstream infections, epidemiology, pathogenesis, microorganisms, risk factors, ventilator-associated pneumonia, catheter-associated urinary tract infections, blood-borne infections and hospital-acquired viral infections, multidrug-resistant organisms, nosocomial infection prevention, antimicrobial stewardship, economic impact of nosocomial infections.

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Nosocomial infections are relatively common in the NICU. These infections increase morbidity and mortality, particularly in the smallest and most fragile infants. The impact of these infections on long-term outcomes and health-care costs is devastating. Worldwide efforts to decrease the incidence of nosocomial infections have focused on implementing specific prevention protocols such as handwashing, central line teams, care bundles, and antimicrobial stewardship. This review summarizes common nosocomial infections in patients in the NICU.

Neonatologists need to recognize that surveillance, good hand hygiene practices, care bundles, and antimicrobial stewardship are effective in preventing nosocomial infections.

Describe the clinical features and pathophysiology of nosocomial infections in the NICU.

Explain the etiologies and prevention strategies of nosocomial infections in the NICU.

Recognize the economic impact of nosocomial infections on the health-care system.

Nosocomial infections are infections acquired during the process of receiving inpatient health care. They are also known as health care–associated infections (HAIs). ( 1 ) Nosocomial infections are common in the NICU and lead to higher mortality, morbidity, and prolonged hospital stays. ( 2 ) In the past 2 decades, there has been a significant improvement in the survival rates of extremely preterm infants, which has led to an increase in nosocomial infections in the NICU. ( 3 ) HAIs pose a significant burden on health-care costs. ( 4 ) Global efforts to decrease nosocomial infections have focused on antimicrobial stewardship and developing care bundles.

The Centers for Disease Control and Prevention (CDC) and National Healthcare Safety Network define a central line–associated bloodstream infection (CLABSI) as a primary infection in a patient with a central catheter. ( 5 ) The central catheter must have been placed and accessed at least 48 hours before or removed within 24 hours before the development of the infection. The definition of a CLABSI also requires that the bloodstream infection (BSI) cannot be attributable to an infection at another site. Types of central catheters qualifying for the National Healthcare Safety Network–reportable CLABSIs include permanent central catheters such as venous or arterial umbilical catheters, temporary central catheters, tunneled catheters (eg, dialysis catheters), and implanted catheters (eg, ports). ( 6 )

CLABSIs are the most common HAIs in the NICU. ( 7 )( 8 ) Approximately 80,000 CLABSIs are reported annually across all intensive care units in the United States. ( 9 ) The incidence of CLABSIs in neonates ranges from 3.2 to 21.8 per 1,000 central venous catheter days. ( 10 ) Despite worldwide efforts to eliminate CLABSIs, recent reports indicate a plateauing of NICU CLABSI rates. The CLABSI incidence rates are higher among very-low-birthweight infants. ( 11 ) Mortality rates associated with neonatal CLABSI vary widely and are estimated to be between 4% and 20%. ( 12 )

The risk of BSIs is higher with central catheters due to the multiple entry points they provide through the skin barrier. These entry points can be found both on the external surface of the cannula and within the lumen. ( 13 ) Typically, the sources are endogenous skin flora of the patient or extrinsic organisms from the environment. Several potential pathways can lead to a CLABSI. The initial catheter insertion procedure has the potential to serve as a port of entry for organisms. Secondly, the entry site can become infected during catheter hub operation and maintenance. Contamination of intravenous fluids or drugs may occur during the preparation process. It is also possible for a catheter to be colonized and infected from hematogenous dissemination of bacteria from a distal site. ( 13 )( 14 )

One study examining bloodstream infections in the NICU revealed that coagulase-negative Staphylococcus (CoNS) was the most common organism responsible for infections, accounting for 34.1% of all NICU infections. ( 15 ) Enterococci accounted for 16% of cases, whereas Staphylococcus aureus was responsible for 9.9% of cases. ( 15 ) Gram-negative organisms like Klebsiella, Enterobacter, Pseudomonas, Escherichia coli, and Acinetobacter were less common, accounting for 5.8%, 3.9%, 3.1%, 2.7%, and 2.2% of infections, respectively. ( 15 ) Candida species accounted for about 11.8% of infections. ( 15 )

Similar organism involvement was reported in other studies, with gram-positive organisms identified in up to 50% of cases, whereas gram-negative organisms were less common, accounting for about 36% of infections. ( 16 ) In another study, S aureus accounted for 25% of cases, followed by CoNS at 21%, E coli at 11%, Enterococcus faecalis at 8.8%, and other organisms like Candida, Enterobacter spp, Pseudomonas aeruginosa, Serratia , and group B Streptococcus accounting for less than 5% of cases. ( 17 )

Central catheters are necessary for the administration of medications and parenteral nutrition, as well as for hemodynamic monitoring and frequent blood draws; however, these lines increase the risk of infections. The NICU population is particularly prone to CLABSIs for various reasons. NICU patients undergo frequent procedures disrupting the epidermal barrier (eg, punctures for blood sampling), which create ports of entry for invasive organisms. Premature infants have decreased innate immune function and fewer antibodies acquired in utero, further increasing the risk for CLABSIs. ( 18 )

Low-birthweight infants and lower gestational age are the primary risk factors for developing a CLABSI. ( 18 )( 19 ) In a recent meta-analysis, independent risk factors for CLABSIs included prolonged need for total parenteral nutrition, use of multilumen catheters, an impaired immune system, and number of central catheter days. ( 20 ) Additional risk factors identified in critically ill neonates include length of stay over 14 days and blood transfusions. ( 21 ) Postnatal growth failure has also been shown to be an independent risk factor for HAIs. ( 19 ) Several studies have noted that gastrointestinal conditions such as abdominal surgery, bowel obstructions, dysmotility, and ischemia-reperfusion injuries lead to increased risk of CLABSIs. The proposed mechanism involves translocation of gastrointestinal flora into the bloodstream, which can then colonize a central line catheter. ( 19 )( 21 ) Less common risk factors for CLABSIs include underlying metabolic conditions, extracorporeal life support, and genetic malformations. ( 18 )

Ventilator-associated pneumonia (VAP) is the second most frequent type of nosocomial infection in NICUs after CLABSIs. ( 22 ) VAP is commonly defined as bacterial pneumonia occurring after 48 hours of mechanical ventilation. However, establishing a clear and objective definition of VAP in neonates has been a persistent challenge. The CDC VAP prevention guidelines provide the most commonly used formal criteria illustrated in Table 1 . ( 23 )

CDC Diagnostic Criteria for Neonatal VAP

CDC=Centers for Disease Control and Prevention, Fi o 2 =fraction of inspired oxygen, HR=heart rate, VAP=ventilator-associated pneumonia, WBC=white blood cell.

WBC < 4,000/µL (<4 × 10 9 /L).

WBC > 15,000/µL (>15 × 10 9 /L) with a left shift (>10% band forms).

Tachypnea, retractions, grunting, nasal flaring.

HR < 100 beats/min.

HR > 170 beats/min.

Adapted from Goerens A, Lehnick D, Büttcher M, et al. Neonatal ventilator associated pneumonia: a quality improvement initiative focusing on antimicrobial stewardship. Front Pediatr . 2018;6:262. ( 24 )

The reported incidence of VAPs in the NICU varies widely between 2.7 and 37.2 per 1,000 ventilator days. ( 24 ) The wide range of incidence is likely related to the lack of a standardized VAP definition. Mortality rates from VAPs in patients in adult, pediatric, and neonatal intensive care units were reported to be as high as 28.4% in the 2020 report of the International Nosocomial Infection Control Consortium. ( 25 ) Neonatal VAP is associated with higher rates of bronchopulmonary dysplasia, retinopathy of prematurity, longer hospital stays, and higher hospital costs. ( 26 )

The risk factors for VAP include the presence of an artificial airway; low birthweight; under-resourced medical settings; bronchopulmonary dysplasia; and need for sedation, reintubation, and blood transfusions. ( 27 ) The etiology of VAPs is typically a single bacterial pathogen. However, polymicrobial infections are on the rise. The 2 most common organisms are S aureus and P aeruginosa , followed by other gram-negative organisms, such as Klebsiella and Enterobacter species. ( 28 ) In addition, Enterococcus species and group B Streptococcus are important NICU-specific organisms causing VAP. ( 28 ) Prevention of VAPs, like other nosocomial infections, is best optimized by bundled care practices, such as head-of-bed elevation, re-enforcement of hand hygiene, sterile suction, and daily evaluation for readiness for extubation. ( 29 )

Catheter-associated urinary tract infections (CAUTIs) are less common in neonates due to decreased use of urinary catheters in NICUs. However, the most common pathogens are E coli and P aeruginosa . ( 11 )( 30 ) Prevention strategies include judicious use of catheters and multimodal approaches such as care bundles and checklists. ( 31 )

Infectious agents, such as viruses, bacteria, protozoa, and other pathogens, can be transmitted by blood transfusions in neonates. The risk of transmitting infection via a red blood cell transfusion is low because of extreme precautions taken to prevent contamination and transmission by these microorganisms. Since the introduction of nucleic acid amplification testing for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus, the risk of transmission of these viruses has decreased significantly from 1 in 1 million to 1 in 10 million. ( 32 )( 33 )

Cytomegalovirus (CMV) is the most common pathogen transmitted via blood transfusions. Approximately 50% to 80% of blood donors in the United States are CMV seropositive. ( 34 ) CMV infection can remain dormant in the leukocytes of blood donors, and consequently be transmitted via cellular blood products. Premature seronegative neonates weighing less than 1,250 g at birth and fetuses receiving intrauterine transfusions are at heightened risk for transfusion-transmitted CMV. ( 35 )( 36 ) Ensuring the use of CMV-seronegative blood for transfusions is crucial in preventing transfusion-transmitted CMV infections; however, obtaining seronegative products is challenging because of the high prevalence of CMV-seropositive donors. The use of leukoreduction filters is currently recommended for neonatal transfusions. In a prospective multicenter study of 539 very-low-birthweight infants, the transfusion-transmitted CMV infection incidence was 0.0% (95% confidence interval, 0%–0.3%) when CMV-seronegative and leukoreduced blood products were used. ( 37 ) Leukoreduction of blood has also decreased the risks of transmission of other viruses, such as human T‐lymphotropic virus I/II, Epstein-Barr virus, and human herpesvirus 8. ( 38 )

Platelet transfusion–associated infection is rare; however, bacterial contamination of platelet products has been reported. Compared with other blood products, platelet transfusion poses a greater risk of sepsis and death. ( 39 )( 40 ) Bacterial contamination can be from the donor’s skin or from the environment. The recommended storage temperature for platelets is 71.6°F (22°C), which can facilitate bacterial growth. ( 41 )( 42 ) The Food and Drug Administration has approved the use of pathogen reduction technologies as an additional measure to maintain safety in platelet transfusions, reducing the risk of transfusion-transmitted bacterial infections and transmission of other agents such as human immunodeficiency virus, malaria, babesiosis, Chagas disease, and Zika virus. ( 43 ) This technology has been used mainly for platelet transfusions in adults. Additional studies are necessary to assess the effects of pathogen reduction technologies in platelet transfusions in the neonatal and pediatric populations.

There are limitations to the surveillance of multidrug resistant organism (MDRO) colonization in the NICU setting. The MDRO rates in the NICU are lower than in other pediatric units. ( 30 ) S aureus was reported to be the second most frequent cause of late-onset sepsis in very-low-birthweight infants after CoNS. ( 44 ) Methicillin-resistant S aureus (MRSA) was isolated in 8% to 28% of cases. ( 45 ) Effective infection control measures, such as decolonization, cohorting, and the use of personal protective equipment, have led to a recent decline in MRSA colonization and infection rates in the NICU. ( 46 )( 47 ) The prevalence of extended-spectrum β-lactamase–producing Enterobacteriaceae , Candida auris , and carbapenem-resistant Enterobacteriaceae (CRE) is rarely reported in NICUs in the United States. Reports of infections with C auris and CRE are increasing among neonates in low- and middle-income countries. ( 48 )( 49 )

According to a study that analyzed data from 3,381 cases of pediatric BSIs worldwide between 1996 and 2013, the incidence of MDRO was estimated to be 9%, with an annual increase of 3.2%. ( 50 ) The prevalence of MDRO was higher among neonates (11%) than among children older than 28 days (5%). ( 50 ) This study found that Africa (15%), South America (12%), India (11%), and the rest of Asia (7%) had higher rates of MDRO than Europe (4%). ( 50 )

Given the significant morbidity, mortality, and costs associated with nosocomial infections, infection prevention measures are of utmost importance in the NICU. Proper hand hygiene, standard precautions, and transition-based safeguards, as well as staff and family education, are pillars of prevention. ( 5 ) Implementation of care bundles is also an effective practice in hospital settings and should be applied to all NICU patients. Care bundles use multiple concurrent evidence-based best practice measures and provide a standardized approach to infection prevention. Studies investigating the use of bundles to prevent neonatal VAP and CLABSI have shown significantly reduced rates of these infections. ( 29 )( 51 )( 52 )( 53 ) One study demonstrated a decrease in VAP episodes from 11.79 to 1.93 episodes per 1,000 ventilator days, with a number needed to treat of 9 infants to prevent 1 case of VAP with a neonatal VAP bundle. ( 47 ) A systemic review of 27 studies described the benefit of care bundles for preventing CLABSIs in NICUs. After the introduction of the bundles, 17 of 27 studies showed a significant decrease in CLABSI rates. ( 54 ) Furthermore, a meta-analysis of 24 neonatal care bundle studies revealed a 60% decline in CLABSI rates. ( 52 )

An example of a CLABSI prevention bundle in our institution is shown in the Figure . This bundle was designed by a multidisciplinary team of physicians, nurses, administrators, and pharmacists. The CDC and The Society for Healthcare Epidemiology of America published updated evidence-based guidelines to reinforce efforts to reduce central catheter infections in the NICU. ( 55 )( 56 ) Table 2 includes more details.

Example of a central line-associated bloodstream infection (CLABSI) NICU prevention bundle. PICC=peripherally inserted central catheter.

Prevention Standards for Nosocomial Infections

CDC=Centers for Disease Control and Prevention.

Adapted from Centers for Disease Control and Prevention. CDC’s core infection prevention and control practices for safe healthcare delivery in all settings. www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html . ( 5 )

When nosocomial infections occur, rapid detection of MDROs is imperative. Treatment should be modified and further transmission prevented with the use of measures such as isolation and additional personal protective equipment. ( 57 ) A multimodal approach is needed to assign active benchmarks, embrace quality improvement partnerships, and apply updated evidence-based practices to prevent nosocomial infections. ( 58 ) In addition, all team members should be empowered to halt nonemergent procedures if an interruption in sterile technique is observed. ( 58 )

Antimicrobial agents reduce neonatal morbidity and mortality from infections. However, inappropriate and lengthy regimens have been linked to increased rates of late-onset sepsis, multidrug resistance, fungemia, necrotizing enterocolitis, and death. ( 59 )( 60 )( 61 )( 62 )( 63 ) Improper and excessive use of antimicrobials can also lead to an increased risk of adverse drug events and persistent microbiome dysbiosis. ( 61 )( 62 )( 64 )( 65 )

Antimicrobial stewardship has become an essential tool in NICUs. This approach reduces inappropriate antibiotic use, decreases antimicrobial resistance, saves resources, and improves patient safety. ( 66 ) Using a multidisciplinary approach and quality improvement measures, antimicrobial stewardship diminishes unwarranted antibiotic use and targets therapy with the narrowest spectrum drug for the shortest duration. ( 5 ) One of the most common applications of neonatal antimicrobial stewardship includes the development of evidence-based guidelines using unit-specific antimicrobial resistance patterns that help direct which antimicrobials to choose and when. Additional examples of neonatal antibiotic stewardship are listed in Table 3 . ( 57 )

Antimicrobial Stewardship in the NICU ( 66 )( 67 )( 68 )

Nosocomial infections lead to significantly increased health-care costs. HAIs are estimated to afflict approximately 2 million patients annually in the United States, leading to 90,000 deaths and 28 to 45 billion dollars in direct costs to hospitals. ( 67 )

Most costs for nosocomial infections come from increased length of stay. One study of HAIs in NICUs in Belgium found that the cost of accommodations, laboratory fees, and radiology services accounted for 94% of the additional charges. ( 68 ) Case-control studies have shown variable increases in NICU length of stay due to HAIs, ranging from 5.2 to 24.0 days. ( 68 )( 69 )( 70 ) In a meta-analysis examining CLABSIs in neonates and children, the pooled mean attributable increase in NICU length of stay was 11.37 days. ( 71 )

Reducing nosocomial infections has a clear health benefit. However, in a competitive health-care market with decreasing margins for acute care hospitals, the cost of improvement programs also must be considered. Ideally, an improvement program should improve health and reduce costs significantly more than the program’s expense. Both the Neonatal Intensive Care Collaborative Quality Project of the Vermont Oxford Network and the Ohio Perinatal Quality Collaborative investigated the return on investment of multihospital collaborative quality improvement projects. The Vermont Oxford Collaborative demonstrated an average savings per hospital of $2.3 million for VLBW infants, for an average investment of $68,206. ( 72 ) The Ohio Collaborative invested approximately $600,000 over 2 years for a cost avoidance of $2,343,592. ( 73 ) Therefore, hospitals are well suited to investing in nosocomial infection prevention programs.

Nosocomial infections pose a significant threat to NICU patients. CLABSIs are the most common HAIs in the NICU, followed by VAPs and CAUTIs. Preventing these infections relies on proper surveillance, hygiene practices, and care bundles. In addition to increased mortality and morbidity, nosocomial infections add substantial strain on health-care–associated costs in the NICU. Multidisciplinary evidence-based preventive bundles and antibiotic stewardship help to significantly reduce the burden of HAIs in neonates.

Know strategies to prevent and manage central line-associated bloodstream infections and understand their complications.

Know strategies to prevent ventilator-associated pneumonia.

Know the effective techniques for control of health-care–associated infection in the nursery, neonatal intensive care unit, and obstetrical unit.

Know the pathogenesis and prevention of transmission of infections with multidrug-resistant bacteria.

AUTHOR DISCLOSURES Dr Smith has received payment for expert testimony from Kelly & Ignoffo Law Group. Drs Marty, Sorum, Nicoski, Al-Sayyed, and Amin have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

bloodstream infection

catheter-associated urinary tract infection

Centers for Disease Control and Prevention

central line–associated bloodstream infection

cytomegalovirus

coagulase-negative Staphylococcus

carbapenem-resistant Enterobacteriaceae

health-care–associated infection

multidrug-resistant organism

methicillin-resistant Staphylococcus aureus

ventilator-associated pneumonia

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• Published: 26 April 2024

Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China

• Xiaoyan Yu 1 , 3 ,
• Lin Ouyang 1 , 3 ,
• Jinxiu Li 1 , 3 ,
• Ying Peng 1 , 3 ,
• Dingming Zhong 1 , 3 ,
• Huan Yang 2 &
• Yanyan Zhou 1 , 3  

BMC Nursing volume  23 , Article number:  281 ( 2024 ) Cite this article

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Metrics details

Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation.

This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests ( α  = 0.05) were employed.

A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department.

ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.

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Continuous renal replacement therapy (CRRT) is a widely utilized method of renal replacement therapy (RRT) within intensive care unit (ICU) due to its ability to facilitate precise volume control, stabilize acid-base and electrolyte levels, and maintain hemodynamic stability [ 1 ]. CRRT serves as the initial choice of RRT for 75% of critically ill patients [ 2 , 3 ]. Beyond renal replacement, CRRT finds extensive application across various critical clinical scenarios, including sepsis, poisoning, rhabdomyolysis, volume management, burns, multiple injuries, organ failure, and heatstroke [ 1 , 4 , 5 , 6 , 7 , 8 , 9 ]. Notably, CRRT has garnered attention amidst the Coronavirus Disease 2019 (COVID-19) pandemic, further underscoring its versatile utility within the ICU setting [ 10 , 11 , 12 , 13 , 14 ]. Consequently, CRRT exhibits a promising scope of application within the ICU [ 15 ].

Real-world studies have shown significant variation in the quality of CRRT [ 16 , 17 ]. The quality of CRRT is closely linked to the level of expertise possessed by the ICU staff [ 18 , 19 ]. For example, inadequate anticoagulation can result in clotting, leading to unplanned treatment interruptions, while excessive anticoagulation may lead to anticoagulant toxicity or bleeding events [ 20 ]. Failing to implement the anticipated CRRT plan can result in wasted medical resources and increased costs. Untreated disturbances in internal environmental balance, such as hyperkalemia and acidosis, can precipitate cardiac arrest [ 21 ]. Failure to achieve targeted fluid removal contributes to fluid overload and may compromise patient outcomes requiring CRRT [ 22 ].

In the ICU, a specialized CRRT team (SCT) composed of physicians and nurses, playing pivotal roles in administering CRRT [ 21 ]. Physicians are tasked with evaluating patients’ eligibility for CRRT, formulating comprehensive treatment protocols, and establishing vascular access, while nurses undertake the actual execution of CRRT. During CRRT, physicians and nurses must jointly monitor the patient’s condition and the equipment, adjusting treatment as needed to ensure optimal outcomes. This inter-professional collaboration is instrumental in the successful deployment of CRRT, significantly enhancing patient outcomes and safety [ 21 , 22 ].

Numerous studies have shown that the quality of CRRT can be effectively improved by mastering all CRRT-related knowledge, ensuring its correct management, and standardizing its implementation [ 21 , 22 , 23 ]. People have been trying to improve quality through various educational training programs [ 23 , 24 ]. However, there is a paucity of evidence-based research on joint training and management strategies. When available, they are often one-sided surveys of doctors or nurses, with little focus on teamwork and cognitive unity [ 25 ]. To bridge this gap, we have developed a Knowledge, Attitude, and Practice (KAP) questionnaire tailored to CRRT. The aim is to thoroughly evaluate the shared knowledge and operational competencies of ICU physicians and nurses throughout the CRRT management continuum. Additionally, it seeks to pinpoint educational needs, preferences, and the current state of CRRT application. These findings will inform the creation of more specialized CRRT educational and training programs.

Materials and methods

Study design and setting.

This study conducted a cross-sectional survey of ICU physicians and nurses in China. The questionnaire was distributed to ICU medical staff at a number of hospitals in China. The Initial data collection period 1.5 months, from February 6 to March 20, 2023).

Participants

Study participants comprised conveniently selected ICU medical staff from Central and South China. Each of the seven provinces in Central and South China designated one liaison officer, responsible for their respective liaison tasks. These liaison officers communicated with qualified ICU staff within their province via phone and WeChat to elucidate the study’s objectives.. Upon obtaining consent, a link to the questionnaire was sent for survey completion. Subjects received timely guidance if they encountered any issues while completing the questionnaire. Initially, the questionnaire was disseminated through WeChat, with participants encouraged to share the link with other ICU medical staff. In cases where an insufficient number of responses were received, reminders were sent via voicemail, video, or phone calls. To ensure participant data confidentiality and anonymity, researchers assigned numerical codes instead of names. At the outset of the survey, participants were informed that their completion of the questionnaire implied “consent to participate”.

It is generally accepted that the survey sample size should be at least 5–10 times the number of variables included in a multiple linear regression [ 26 ]. Drawing from relevant regulations and both domestic and foreign literature, this study identified 15 variables that likely to influence the KAP of CRRT in the ICU. Considering a 20% attrition rate, a minimum of 180 respondents were deemed necessary.

Inclusion criteria: (1) Registered physicians and nurses in the ICU; (2) Individuals with at least 1 year of experience working in the ICU; (3) Participants who provided signed informed consent (included in the questionnaire). Exclusion criteria: (1) Individuals on leave during the investigation; (2) Regular training students.

ICU medical staff were invited to participate in an anonymous survey about CRRT. The researchers utilized a self-made structured questionnaire, with the variable assignments included (see Supplementary File  1 ). The questionnaire comprised two sections: general information and knowledge, attitude, practice.

General information questionnaire

The demographics and institutional information included gender, age, educational level, professional title, hospital grade, teaching hospital or not, years of CRRT practice, administrative role, ICU category, and CRRT specialist panel membership or not. Professional titles were classified as junior, intermediate, and deputy senior or above. Hospital grades were divided into Tertiary Grade A general, secondary specialized, secondary or other [ 27 ] (Table  1 ).

The knowledge, attitudes, and practices questionnaire

The knowledge component was scored using a 5-level Likert scale, with a score of “1” indicating very unfamiliar and “5” indicated very familiar. This section comprised 14 items, allowing for a maximum score of 70 points. A higher score reflected a higher self-rated knowledge level. Similarly, the attitude component was evaluated using a 5-level Likert scale, with “1” indicating highly disagree, and “5” indicating highly agree. With a total of 15 items, this section permitted a maximum score of 75 points, with higher scores indicating a more positive attitude. Regarding the practice component, respondents were presented with two options: “no” and “yes,” scored as 1 and 2, respectively. This section comprised 10 items, totaling 20 points, with a higher score indicating a higher self-rated practice level. Prior to data collection, the questionnaire underwent testing and validation.

The questionnaire was tested and validated before data collection. First, 10 clinical experts assessed the content validity of the questionnaire, and the total content validity of the questionnaire was 0.9. Further, the researchers selected 20 ICU medical staff members meeting the inclusion criteria were selected as a sample. Two questionnaire surveys were conducted on them, with a one-week interval between surveys. The correlation coefficient for the test-retest method was calculated, revealing a high stability with a correlation coefficient of 0.87. Meanwhile, Cronbach’s α was used to test the internal consistency, resulting in a total questionnaire Cronbach’s α coefficient of 0.903. For the sub-questionnaires, the Cronbach’s α coefficients were 0.956 for the knowledge component, 0.831 for the attitude component, and 0.751 for the practice component, indicating excellent reliability and validity.

The hierarchical method of mean distribution was used to classify the knowledge component into three levels: low [ 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ], moderate [ 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ], and high [ 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 ]; the attitude component into: low [ 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ], moderate [ 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 ], and high [ 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 ]; and the practice component into: low [ 10 , 11 , 12 , 13 ], moderate [ 14 , 15 , 16 ], and high [ 17 , 18 , 19 , 20 ] [ 28 , 29 ].

It is important to keep the survey as concise and straightforward to reduce the burden on ICU medical staff. The survey consisted of 39 questions and typically required 10–15 minutes to complete.

This study was approved by the Institutional Ethics Committee of the Second Xiangya Hospital of Central South University (No. 2022224). We informed participants in the beginning of the questionnaire that completion of the survey considered “consent to participate”.

Statistical analysis

Prior to data analysis, data were coded in SPSS (IBM SPSS V.25.0, IBM, Armonk, New York, USA). The Kolmogorov-Smirnov test was applied to assess normality, revealing that the dataset pertaining to knowledge, attitude, and behavior exhibited a normal distribution ( p  > 0.05). Categorical variables and items from the questionnaire with Likert scale items were presented as frequencies and percentages. T-tests were used to compare two subgroups. Analysis of variance (ANOVA) was used to compare more than 2 subgroups. Pearson correlation coefficients was used to analyze correlation between knowledge, attitude, and practice. Multiple linear regression analyses were used to analyze the influence of various demographic and occupational factors on KAP. A p -value < 0.05 was considered statistically significant.

Demographic and professional characteristics of participants

Out of 405 ICU medical staff from 66 general or specialized hospitals who participated in the survey, 395 provided valid responses after excluding 10 incomplete questionnaires, resulting in an effective response rate of 97.53%. Among the respondents, 56.4% were female, with a slight majority of doctors over nurses at a ratio of 1.079. The distribution of respondents was nearly even between Central China and South China, with a ratio of 0.984. A significant majority, 89.9%, held a bachelor’s degree or higher. In terms of employment, 74.7% were affiliated with tertiary general hospitals, and a substantial 82.9% had over 5 years of experience working in an ICU. Regarding CRRT practice, more than three-fifths of the participants had over 3 years of experience, and 44.3% were members of a CRRT specialist panel. Detailed general information and occupational background data are presented in Table 1 .

Knowledge status

The mean knowledge score was 51.46 ± 5.96 (out of 70). Based on this classification, 61.8% ( n  = 244) of respondents had good knowledge and 4.3% ( n  = 17) had poor knowledge (Table  2 ).

ICU medical staff knowledge regarding CRRT is presented in Fig.  1 . More than 60% of participants were familiar/very familiar with all knowledge items except for CRRT machine maintenance. Basic CRRT principles (65.82% + 12.66%), the timing of CRRT initiation (68.10% + 11.14%), and treatment mode selection (65.09% + 11.39%) were the top three knowledge items. CRRT machine maintenance (4.05% + 14.68%), pausing treatment self-circulation (3.29% + 11.39%), differences between different dilution modes (3.54% + 7.09%) were the top three unfamiliar or very unfamiliar options. Detailed data are presented in Supplementary Table  1 .

Knowledge of ICU staff toward CRRT. ICU: intensive care unit; CRRT: continuous renal replacement therapy

Table  3 compares the mean knowledge scores of ICU staff based on their demographics and work characteristics. Significant differences were seen in the distribution of knowledge scores between different subgroups, including gender, age, professional title, hospital grade, working years, years of CRRT practice, administrative personnel, ICU category, and CRRT specialist panel membership.

Attitude status

The mean attitude score was 58.71 ± 2.19 (out of 75). The higher the score, the more positive the respondent’s attitude toward CRRT. 73.9% ( n  = 292) of respondents had a positive attitude and no respondent scored below 35 (Table 2 ).

The attitude of ICU medical staff toward CRRT is presented in Fig.  2 . More than 90% of participants highly agreed or agreed with these 5 points: (1) The CRRT management in the ICU should adopt a collaborative model involving physicians and nurses. (35.44% + 58.73%); (2) When nurses find problems with CRRT treatment orders, they should provide timely feedback to doctors (35.95% + 59.75%); (3) Systematic CRRT training can improve the professional ability of medical staff (33.67% + 60.76%); (4) Medical staff who use CRRT need to pass an examination before performing CRRT (25.32% + 65.57%); and (5) Pay attention to CRRT alarms and treatment (21.77% + 68.61%). The two most highly disagreed or disagreed views were: (1) During CRRT, nurses can regulate the citrate infusion rate independently (5.82% + 25.57%); and (2) Nurses can regulate the ultrafiltration rate independently (3.04% + 20.25%). Detailed data are presented in Supplementary Table  2 .

Attitude of ICU staff toward CRRT. ICU: intensive care unit; CRRT: continuous renal replacement therapy

Table  3 compares the mean attitude scores of ICU staff based on their demographics and work characteristics. There were significant differences in the distribution of attitude scores between different subgroups, including age, educational level, professional title, working years, years of CRRT practice, administrative personnel, and CRRT specialist panel membership.

Practice status

The mean practice score was 18.15 ± 0.98 (out of 20). The higher the score, the more appropriate the practice. When ranges of 10–13, 14–16 and 17–20 were defined as low, moderate, and high, respectively, 85.1% ( n  = 336) had a high practice score and only 3.5% ( n  = 14) had a low practice score (Table 2 ).

The practices of ICU medical staff regarding CRRT are present in Fig.  3 . Over 90% of participants indicated they would monitor hemodynamics during CRRT (93.92%) and believed that the CRRT plan should be adjusted at any time according to the patients’ condition (90.89%). During CRRT, when the vascular access flow was poor, 90.38% of respondents would first adjust the position of the catheter. Regarding decision-making, 87.34% of respondents believed that doctors and nurses should make joint decisions on the formulating anticoagulation methods and goals, while 87.09% believed that ICU doctors and nurses should work together to solve alarms. Similarly, when clotting occurred, 87.34% of respondents recognized that CRRT settings may need to be examined and adjusted rather than solely blaming the care process. A CRRT specialist panel was established at 70.89% of the participants’ departments. However, it is concerning that 32.15% of respondents still use a uniform CRRT prescription, only 57.47% regulated the ultrafiltration rate hourly, and 18.23% did not calculate the therapeutic dose and filtration fraction when prescribing. Detailed data are presented in Supplementary Table  3 .

Practice of ICU staff toward CRRT. ICU: intensive care unit; CRRT: continuous renal replacement therapy

Table 3 compares the mean practice scores of ICU staff based on their demographics and work characteristics. There were significant differences in the distribution of practice scores between different subgroups, including educational level, hospital grade, and teaching hospital employment.

Correlation analysis

Pearson correlation coefficient tests showed a significantly positive correlations between knowledge and attitude ( r  = 0.431, p  < 0.001), knowledge and practice ( r  = 0.250, p  < 0.001), and attitude and practice ( r  = 0.176, p  < 0.001). Detailed data are presented in Supplementary Table  4 .

Multiple linear regression analysis

After multiple linear regression analysis, we found that: Gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected knowledge score. Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected attitude score. Education level and teaching hospital employment independently affected practice score. Detailed data are presented in Table 4 .

CRRT educational pathways and needs

CRRT information was acquired by 82.03% of participants through department knowledge training, 81.01% through work experience, and 76.46% through communication within the hospital. Only 33.42% of respondents reported education through professional papers (Fig.  4 A).

CRRT education pathway and the needs of ICU staff. A Education pathway of CRRT, ( B ) Training and learning content needs. ICU: intensive care unit; CRRT: continuous renal replacement therapy

Educational needs were CRRT liquid management (92.15%), prevention and treatment of vascular access complications (89.97%), common alarm causes and handling methods (89.11%), and basic CRRT principles (82.28%) (Fig. 4 B).

CRRT implementation status

Volume assessment.

Monitoring vital signs remained the primary method for assessing volume during CRRT (92.15%), followed by monitoring arteriovenous blood gas analysis (91.90%). Assessments were more commonly by ultrasound (70.38%) than empirical assessment (63.8%). It should be noted that this section was multiple choice, so the above four methods could have been used in combination (Fig.  5 A).

Investigation of CRRT in ICU medical staff. A Volume assessment methods, ( B ) Commonly selected CRRT mode, ( C ) Frequency of CRRT circuit clotting, ( D ) Frequency of unplanned interruption, ( E ) Frequency of hypotension in CRRT. ICU: intensive care unit; CRRT: continuous renal replacement therapy; CVVH: continuous venovenous hemofiltration; HP: hemoperfusion; CVVHDF: continuous venovenous hemodiafiltration; SCUF: slow continuous ultrafiltration

Mode selection

Continuous venovenous hemofiltration (CVVH) (84.56%) and continuous venovenous hemodiafiltration (CVVHDF) (81.27%) were the most commonly selected modes, followed by continuous venovenous hemodialysis (CVVHD) (55.95%) and slow continuous ultrafiltration (SCUF) (36%) (Fig. 5 B).

Circuits clotting, unplanned interruption and hypotension

Occasional circuit clotting during CRRT was reported by 81.77% of the participants while 12.41% had frequent circuit clotting (> 3 cases in 1 month) (Fig. 5 C). Similarly, 84.05 had occasional unplanned interruptions during CRRT and 11.9% had frequent unplanned interruptions (> 3 cases in 1 month). (Fig. 5 D). Occasional hypotension during CRRT was reported by 83.54 while 13.4% reported frequent hypotension (> 3 cases in 1 month) (Fig. 5 E).

CRRT is an important organ support method that has been widely used in the field of critical care medicine [ 5 , 6 , 9 , 11 , 13 , 30 ]. To ensure patients receive precise and high-quality treatment, comprehensive investigations into all aspects of CRRT have been conducted. The timing, mode, therapeutic dose, anticoagulation method, hemodynamic monitoring, and various special modes represent focal points of research [ 31 , 32 , 33 , 34 , 35 , 36 , 37 ]. The applications of CRRT have expanded beyond traditional ward to various surgeries, particularly organ transplantation procedures [ 35 , 38 , 39 ]. Additionally, CRRT plays a role in temperature control for critically ill patients, such as rewarming individuals experiencing severe accidental hypothermia-systematic [ 40 ]. The quality of CRRT can affect patient prognosis [ 41 , 42 ].

CRRT is a medical procedure necessitating close cooperation between doctors and nurses, and the involvement of highly skilled SCT professionals can enhance its implementation success rates [ 20 , 21 , 22 ]. The following six steps had aligned with the theme of promoting high-quality CRRT through precision medicine methods, as proposed by the 17th International Acute Dialysis Quality Initiative (ADQI) [ 17 , 43 ]. They were: 1) Close collaboration between critical care medicine and nephrology; 2) Define the primary goal of CRRT daily; 3) Keep CRRT running; 4) Review the appropriateness medication dosing daily; 5) Ensure appropriate nutrition support during CRRT; 6) Avoid CRRT-related complications. The lack of KAP studies of CRRT on both physicians and nurses in critical care, especially in terms of care collaboration and knowledge sharing, has prevented us from developing more efficient and targeted measures to improve CRRT quality. To fill this gap, we designed a KAP questionnaire. The design of this KAP survey focuses on steps 2, 3, and 4. In view of the importance of cooperation among SCT members in the implementation of CRRT [ 21 ], we focused on understanding the answer choice of physicians and nurses for the same question, so as to provide more basis for the improvement of the integration cooperation.

The survey population has a well-representation

The high completion rate (97.53%) of this questionnaire indicates that the participants were willing to participate and their careful consideration of each question. Data from Table 1 suggest that our survey results are a reasonably represent the target population. Subgroup analyses and comparisons could be conducted with similar sample sizes to investigate the influence of various factors on knowledge, attitude, and practice.

ICU staff have good knowledge of CRRT

More than two fifths of participants exhibited good knowledge, with the top three areas being basic CRRT principles, the timing of CRRT, and treatment mode selection. Since the first continuous arteriovenous hemofiltration (CAVH) treatment was performed in 1977 [ 44 ], researchers have constantly explored methods to enhance CRRT. The timing of CRRT initiation has long been a research focus [ 45 , 46 , 47 , 48 , 49 ], leading to the development of various CRRT modes, including continuous arteriovenous hemodiafiltration (CAVHDF), continuous arteriovenous hemodialysis (CAVHD), CVVH, CVVHD CVVHDF and integrated technology [ 50 ].

The lowest three knowledge scores were observed in CRRT machine maintenance, pausing treatment self-circulation, and differences between different dilution modes.. Medical staff primarily function as users, requiring the assistance of professional engineers for machine-related issues. “Pausing treatment self-circulation” refers to the machine entering a self-circulation state during the CRRT process due to a temporary interruption, resuming treatment when conditions permit [ 51 ]. Many hospitals in China lack mobile bedside computed tomography and magnetic resonance imaging, necessitating patients to leave the ICU to complete these examinations. Hence, it’s crucial to fully comprehend pausing treatment self-circulation. Dilution modes are closely related to the therapeutic dose, filtration fraction, and filter life span, even affecting the patency of the entire CRRT circuit [ 1 , 52 , 53 ]. Dilution modes are dynamic and complex processes. A lack of in-depth understanding may be the reason for the poor familiarity with these.

Based on Table 3 , it seems that male, age, hospital grade, extended working years and CRRT practice time, administrative personnel, CRRT specialist panel membership, and working at a general ICU were positively correlated with knowledge scores. However, our multiple linear regression analysis found that only male sex, extended CRRT practice time, working at a general ICU, and CRRT specialist panel membership were positively associated with knowledge scores. Surprisingly, there was a negative correlation between age and knowledge scores. There are several explanations for these findings. Firstly, this study relied on subjective surveys, allowing participants to self-assess their knowledge levels. A study on confidence in pediatric endotracheal intubation found that male interns reported higher initial confidence levels compared with females [ 54 ]. This confidence wasn’t linked to prior experience in airway management or intubation performance [ 54 ]. Similarly, our results showed that males exhibited higher confidence levels in their knowledge compared to females. Secondly, longer CRRT practice duration provides staff with more opportunities to deepen their knowledge. Additionally, CRRT specialist panel members benefit from regular study sessions and increased peer communication. Thirdly, compared to specialized ICUs, general ICUs encounter a broader range of diseases, necessitating staff to possess more comprehensive professional knowledge. Lastly, the observed positive correlation between age and knowledge level (Table 3 ) initially suggested that older participants, who had longer work experience and CRRT practice, possessed higher knowledge scores. However, upon controlling for these variables using multiple linear regression analysis (Table 4 ), it became evident that advancing age was associated with lower knowledge scores. This discrepancy could be attributed to the decline in working memory (WM) capacity with age. As individuals age, their WM capacity diminishes, leading to slower reaction times and reduced accuracy [ 55 ]. Consequently, the capacity to acquire, process, and retain knowledge, as well as cognitive functions, gradually diminishes [ 55 , 56 ].

The attitude of ICU staff toward CRRT were very positive

The mean attitude score of ICU staff was high. It is noteworthy that 73.9% of participants had a positive attitude toward CRRT. Additionally, 90% of ICU staff reported timely handling of CRRT alarms, along with doctor-nurse integration, pre-job assessment, systematic training, and timely feedback adjustment between doctors and nurses.

31.39% of the participants expressed a negative attitude toward ICU nurses independently regulating the citrate infusion rate. Citrate serves not only as an anticoagulant but also plays a role in energy metabolism through the tricarboxylic acid cycle, impacts acid-base balance, and involves a variety complex metabolic sites [ 57 , 58 ]. The regulation of citrate infusion rate is intricate and cannot rely on a single index for monitoring. Incorrect monitoring regulation may lead to poisoning or inadequate anticoagulation [ 59 ], thus contributing to ICU staff’s lack of confidence in this practice. Similarly, 23.29 of the participants disagreed with allowing nurses to independent regulate the ultrafiltration rate. The regulation of the ultrafiltration rate must consider various factors, including the patient’s hemodynamics, fluid balance, and organ function [ 60 ]. A net ultrafiltration (NUF) rate > 1.75 mL/kg/h was associated with increased mortality compared with an early NUF rate < 1.01 mL/kg/h [ 61 ]. The complexity of the mechanism leads participants to think that it is difficult.

According to Table 3 , age, educational level, professional title, extended working years and CRRT practice time, administrative personnel, and membership on a CRRT specialist panel showed positive correlations with attitude scores. However, multiple linear regression analysis identified only three remaining factors: education level, extended CRRT practice time, and joining a CRRT specialist panel. Several reasons account for this observation. Firstly, higher educational attainment and longer CRRT practice duration correlate with increased exposure to CRRT information, thereby fostering a more positive attitude among staff. A study examining parental knowledge and attitudes toward epilepsy similarly found that higher education levels correlated with greater awareness and positivity towards epilepsy [ 62 ]. Secondly, belonging to a CRRT specialist panel may enhance medical staff’s perception of CRRT. Research on nurses indicated that a strong professional identity positively influences emotional regulation, social support, and professional success [ 63 ]. Additionally, participation in specialist panels often involves setting career goals, which can bolster self-efficacy and enthusiasm, contributing to a more positive attitude [ 64 ].

The above results indicated that upgrading educational level, extended CRRT practice time, and joining a CRRT specialist panel could improve the attitude of ICU staff.

The appropriateness of ICU staff CRRT practice was good

The mean practice score high. Most (85.1%) participants scored high, the level of practice matched knowledge and attitude.

We were pleased to note that the vast majority of medical staff (> 90%) monitor hemodynamics during CRRT and advocate for real-time adjustments based on change in the patient’s condition. Hemodynamic instability related to renal replacement therapy (HIRRT) can increase mortality rates and delay renal function recovery [ 34 ]. Understanding the mechanisms of HIRRT and strategies to mitigate its occurrence has been a recent research focus [ 34 , 65 , 66 ]. Medical staff should adjust the ultrafiltration rate, treatment time, dose, dialysate sodium concentration, dialysate calcium concentration, dialysate temperature, and buffer system according to the patient’s condition to reduce the incidence of HIRRT [ 66 ].

Despite their practice scores, nearly 1/3 of participants currently use a uniform CRRT prescription (same parameters for all patients). This practice poses risks due to the heterogeneity of critically ill patients. Prioritizing understanding individual patient requirements for renal support, such as electrolyte imbalance, fluid overload, or systemic removal of inflammatory mediators, is crucial before prescribing a tailored treatment plan [ 67 ].

Only 57.47% of participants adjusted their ultrafiltration rate hourly, despite over 90% being hemodynamically monitored during treatment. This discrepancy may stem from the heavy workload and inadequate energy levels among ICU staff. ICU staff. Additionally, those adjusting the ultrafiltration rate may not fully grasp the necessity of precise hourly adjustments, indicating a need for further training in this area.

In contrast to knowledge and attitude, the practice scores of CRRT specialist panel members were not higher than those of non-specialist group participants ( p  = 0.180, Table 3 ). The reasons for this may be as follows: 1) mastering CRRT requires extensive practical experience. Mere membership in a CRRT specialist panel, without significant practical experience, may lead to quicker improvements in knowledge and attitude but does not necessarily enhance practical skills; 2) the absence of a CRRT specialist panel in 29.11% of participant departments may prevent individuals with strong practical abilities from joining such panels. Encouraging the establishment of specialized groups and reinforcing practical training is imperative.

Both educational level and employment in teaching hospitals independently influence practice scores. Previous research suggests that the educational level of nurses plays a crucial role in fostering professional awareness and integrating professional values into practice [ 68 ]. Nurses with higher educational levels demonstrate greater proficiency in detecting adverse reactions during treatment [ 69 ]. Teaching hospitals are associated with superior quality of care [ 70 ], improved postoperative outcomes [ 71 ], and reduced in-hospital mortality rates [ 72 ]. Additionally, medical staff at teaching hospitals assume teaching responsibilities alongside their clinical duties, leading them to subconsciously ensure practice standardization. Moreover, teaching hospitals implement more rigorous assessment systems, further enhancing practice standardization.

The above results indicate that by upgraded educational level and further study at a teaching hospital can improve the practice quality of ICU staff.

Good knowledge and a positive attitude may lead to correct practice

Our correlation analysis revealed significant associations among knowledge, attitude, and practice. Correlation coefficients < 0.35 were considered low or weak correlations, 0.36 to 0.67 modest or moderate correlations, and 0.68 to 1.0 strong or high correlations [ 73 ]. The correlation between knowledge and attitude was moderately positive ( r  = 0.431). Both knowledge ( r  = 0.250) and attitude ( r  = 0.176) exhibited weak positive correlations with practice, with knowledge demonstrating a stronger correlation than attitude. These results suggest that while possessing a good level of knowledge and a positive attitude is beneficial, they alone may not suffice for ensuring good practice. Implementation of standardized processes, stringent systems, and scientific assessment mechanisms are also imperative for fostering and sustaining good practices.

Department knowledge training and work experience are the main ways to receive CRRT education and training

The condition of critically ill patients can change rapidly, necessitating uninterrupted monitoring and treatment by ICU staff 24 hours a day [ 74 ]. In-department training is the most effective approach, as it allows staff to integrate learning into their daily routines without requiring additional time or a change in location. Consequently, when developing training programs, it is crucial to consider both time and location to enhance participation willingness among ICU staff.

Training sessions should focus on topics of interest to the participants, including CRRT liquid management, prevention and treatment of vascular access complications, common alarm causes and handling methods, and the basic CRRT principles.

Volume assessment was not precise enough, CVVH and CVVHDF were the mainstream modes

Our study showed that volume assessment primarily relied on monitoring vital signs and arteriovenous blood gas analysis, which are considered macro assessment methods. However, only 70.38% of respondents reported using critical ultrasound for volume assessment during CRRT. Ultrasound offers intuitive, real-time, and accurate measurements, making it widely applicable throughout the ICU. Dynamic monitoring of the inferior vena cava diameter (IVCD) and variability via ultrasound can assess volumetric status, guide dehydration adjustment during CRRT, and expedite relief of heart failure symptoms in patients with renal and acute heart failure [ 75 ]. Additionally, Lung ultrasound score assess pulmonary edema in pediatric acute respiratory distress syndrome patients undergoing CRRT [ 76 ].. Furthermore, echocardiography can be used to identify pulmonary hypertension and left and right ventricular systolic dysfunction in patients with CRRT [ 77 ]. Promoting the use of critical ultrasound in CRRT can enhance the precision of volume assessment and fluid management.

More than 4/5 of participants preferred CVVH and CVVHDF modes. Mode selection varied depending on therapeutic objectives, solute removal, hemodynamic conditions, and the medical staff’s familiarity with CRRT modes. CVVHDF, combining convection and diffusion, emerged as the most prevalent mode, boasting an extended cardiopulmonary bypass life [ 43 , 78 ].

Limitations

Firstly, the survey content did not involve interdisciplinary cooperation, nutritional support, or medication regulation, which are integral to the implementation of high-quality CRRT [ 20 ]. Secondly, the survey did not inquire about the annual number of CRRT procedures performed by the participating departments, a factor that may better correlate with professional experience than years of CRRT practice. Thirdly, the questionnaire did not involve the combination of artificial intelligence and CRRT. The development of CRRT has been upgraded from a simple technological revolution to the cross-field cooperation between artificial intelligence and CRRT [ 79 ]. Suggestions have been made regarding the utilization of chemical sensors for maintaining acid-base balance and electrolytes, facilitating continuous adjustment of dialysate and replacement fluid composition [ 79 ]. Additionally, there is potential for the development of miniaturized wearable or implantable devices for monitoring and treating critically ill ICU patients requiring blood purification [ 80 ]. Fourthly, the survey lacks comparisons with other countries and regions. Regrettably, there remains a notable dearth of comprehensive KAP surveys pertaining to CRRT. Existing surveys predominantly targeted either physicians, nurses, or patients, neglecting a holistic perspective [ 25 , 81 , 82 ]. This study primarily emphasized the optimization of CRRT quality within the ICU context, rather than delving into patient prognosis, the selection of kidney replacement modalities, or the intricacies of chronic patient self-management. Fifthly, We indeed employed a “convenient” rather than “random” method for selecting ICU staff for this survey. This could lead to bias in the study results, as participants who volunteer for the survey may have a more positive attitude. Finally, the survey did not assess the economic development status of the participants’ regions. Limited resources may cause clinicians to encounter various barriers to CRRT, including a limited number of ICU staff and trained personnel, knowledge gaps, poor machine availability, cultural and socio-economic aspects, high-cost treatment without reimbursement, and administrative and governmental barriers [ 18 ].

Conclusions

ICU medical staff exhibit good knowledge, a positive attitude and appropriate practices for CRRT. Males were more confident in their knowledge compared to females. Extending CRRT practice time, pursuing further study at a general ICU or a teaching hospital, joining a CRRT specialist panel, and increasing overall educational level can enhance ICU staff’s knowledge, attitude, and practice levels towards CRRT. CVVH and CVVHDF are the predominant modes in Central and South China ICUs. Department training and accumulation of work experience are primary methods for acquire CRRT-related knowledge. Considering the convenience of training programs will enhance ICU staff’s willingness to participate. Training sessions can focus on CRRT liquid management, prevention and treatment of vascular access complications, common alarm causes and handling methods, and the basic CRRT principles.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to the sensitive nature of the interview questions but are available from the corresponding author on reasonable request.

Abbreviations

• Continuous renal replacement therapy

Renal replacement therapy

Intensive care unit

A specialized CRRT team

Knowledge, attitude, and practice

Analysis of variance

Coronavirus disease 2019

Statistic package for social science

International business machine

The United States of America

Continuous venovenous hemofiltration

Continuous venovenous hemodiafiltration

Continuous venovenous hemodialysis

Slow continuous ultrafiltration

Acute dialysis quality initiation

Continuous arteriovenous hemofiltration

Continuous arteriovenous hemodiafiltration

Continuous arteriovenous hemodialysis

Working memory

Net ultrafiltration

Hemodynamic instability related to renal replacement therapy

Inferior vena cava diameter

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Acknowledgements

The authors would like to thank Dr. Ying Xia for his help in the statistical analysis. We also wish to express a special thanks to all participants who found the time to share their experiences with us and contribute to this study.

This study was financially supported by Scientific Research Project of Hunan Provincial Health Commission (W20243060) and Natural Science Foundation of Hunan Province (2023JJ30808), awarded to the corresponding author. The funding sources were not involved in the study design; in the collection, analysis and interpretation of data; or in writing the report.

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Department of Critical Care Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China

Xiaoyan Yu, Lin Ouyang, Jinxiu Li, Ying Peng, Dingming Zhong & Yanyan Zhou

Blood Purification Center, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China

Hunan Provincial Center for Critical Care Medicine and Clinical Research in Smart Healthcare, Changsha, Hunan, China

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Contributions

XY and YZ helped with conceptualization, writing of the original draft, data curation, formal analysis, methodology, organization of results. LO, YP and DZ performed data collection. XY, HY and YZ analyzed the data. JL and YZ assisted with conceptualization, fund acquisition, supervision, and writing (review and editing). All authors contributed to the article and approved the submitted version.

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Correspondence to Yanyan Zhou .

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Studies involving human participants were reviewed and approved by the Institutional Ethics Committee of the Second Xiangya Hospital of Central South University (No. 2022224). Participation in this study was voluntary, and informed consent was obtained. All methods were performed in accordance with the Declaration of Helsinki guidelines.

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Yu, X., Ouyang, L., Li, J. et al. Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China. BMC Nurs 23 , 281 (2024). https://doi.org/10.1186/s12912-024-01953-6

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Received : 18 October 2023

Accepted : 19 April 2024

Published : 26 April 2024

DOI : https://doi.org/10.1186/s12912-024-01953-6

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Early stress during NICU stay and parent-reported health-related quality of life after extremely preterm birth: an exploratory study with possible targets for early intervention

Affiliations.

• 1 Divison of Neonatology, Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
• 2 Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
• 3 Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
• 4 Environment and Health, Youth Health Care, University of Leuven, KU Leuven, Leuven, Belgium.
• PMID: 38650996
• PMCID: PMC11033392
• DOI: 10.3389/fped.2024.1381008

Introduction: The association between neonatal intensive care unit (NICU) related stress in preterm infants and their health-related quality of life (HRQoL) in the first year following preterm birth remains unexplored. Understanding this association is crucial for enhancing preventive and supportive measures for infants and parents within and beyond the NICU.

Methods: From a single center observational cohort study, we included infants with gestational ages below 30 weeks and/or birth weights under 1,000 grams. HRQoL was quantified using the Infant Quality of Life Instrument (IQI) at 3-, 6-, 9- and 12-months corrected age, covering seven domains. NICU stress was quantified using the Neonatal Infant Stressor Scale (NISS) for the first week of life. We performed Spearman's correlation analyses to test this association.

Results: Of the 45 included infants, the IQI was completed for 27 (60%) at 3, 15 (33%) at 6, 14 (31%) at 9 and 15 (33%) at 12 months. The HRQoL sum scores were related to neonatal stress at 9 and 12 months ( ρ = 0.643 and 0.591, p = 0.013 and p = 0.019, respectively) but not at 3 and 6 months ( ρ = -0.001 and -0.077 respectively, p > 0.05). Higher NICU stress tended to be associated with more respiratory and mood problems throughout the first year.

Discussion: From a parental perspective on infant HRQoL, extremely preterm infants with higher stress exposure show more problems in the second half-year of life, mainly breathing and possibly mood-related problems. This knowledge may help improve our neonatal care, both during NICU stay and in follow-up clinics, by implementing targeted interventions.

Keywords: NICU-related stress; extremely preterm infants; health-related quality of life; neonatal intensive care unit; parental perspectives.

© 2024 van Dokkum, Bos, Kraft, Bouma, Reijneveld, Krabbe and de Kroon.

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