The Difference Between Different Level NICUs (and Why it Matters)

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If you’re reading this post you’re probably in nursing school trying to figure out if you want to work in the Neonatal Intensive Care Unit (NICU), you’re an experienced nurse thinking about switching into the NICU, or you might even be a parent trying to navigate this new and scary world.  This post is going to explain what each level NICU is/means plus why it matters to you.  I’ve been a NICU nurse for 6+ years now and it took me a while to get my footing.  Now I’m going to share everything that I know so that you can navigate the world of neonatal nursing better (and faster) than me.

 


Before reading any further, make sure to check out this post first to better understand the language in the NICU, and therefore better understand this post!


 

What are the Different Level NICUs?

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To start, there isn’t one NICU level that is “better” than the rest.  Quite frankly speaking, if you work in a “lower-level” NICU or your baby is in a “lower-level” NICU it simply means that the babies aren’t as sick and don’t require as much advance care.  It doesn’t mean that the NICU is bad or worse, it just doesn’t offer as much as a “higher level” NICU would.

You should also know that NICU levels vary between states.  While one NICU in Kansas could be referred to as a level III, the same NICU in Washington could be referred to as a level IV.  This post is GENERALLY speaking and isn’t to provide specifics on any one NICU.  Instead, it’s aimed to give you a rough idea of the NICU setting.

NICU levels vary from 2-4 and sometimes a “well-baby” nursery can be referred to as the lowest tier nursery or a level I.  Typically NICU trained nurses don’t staff well-baby nurseries but will float there if needed or will get called down there for any issues (can’t get an IV, worried about a baby getting sick, etc).  I’m not going to go into detail in this post about well-baby nurseries because this is aimed more towards the ICU setting.

 

Please note:  The NICU levels work opposite of the ER levels.  For instance, a level IV NICU is the most advanced NICU setting and a level I ER is the most advanced ER setting.

 

Level II NICUs

A level II NICU is also referred to as a “special care nursery”.  NICU-trained nurses staff the unit, but if the baby were to get sicker and need more advanced care then he/she would need to be transported to a higher level NICU setting.  Typically this means the baby will go to whatever Children’s hospital is closest, or to a hospital within the same hospital family that offers more advanced care.

Level II NICUs typically care for premature babies >32 weeks, or full-term babies who need IV antibiotics, phototherapy, or other non-invasive procedures.  If a baby that is very sick or very premature is born at a hospital that offers a Level II NICU, the staff members are trained to stabilize and transport out.  All NICU nurses have to have their Neonatal Resuscitation (NRP) to work in the NICU regardless of what level of NICU they work in.

If you’re an expecting mother and you’re a high-risk pregnancy, chances are you won’t be delivering at a hospital with a Level II NICU.  You’re more than likely going to be delivering at a hospital with a Level III or IV NICU.

If you are a new nurse and eventually want to be a travel nurse, I highly encourage you to search for jobs that are higher than a Level II setting.  Instead, I encourage you to work in a Level III or IV setting to get more experience so that you’re more favorable when you begin traveling.

 

Level III NICUs

Level III NICUs offer everything that Level II NICUs offer, plus more.  Level III NICUs are usually staffed with nurses, doctors, respiratory therapists, occupational therapy, physical therapy, and more.  The babies are typically sicker so they require more intervention and closer follow-up with each specialty.  Depending on what hospital you’re at, Level III NICUs begin saving babies around 22-weeks of life.  However, this is rule is not set in stone and instead is specific to the situation.  Some babies may not be eligible to be saved that early (too small, severe developmental issues, etc); this will be a talk that the neonatologist will have with the parents.

Some Level III NICUs offer surgery, but not all of them.  The Level III NICUs that offer surgery typically offer basic surgeries such as g-tubes, hernia repairs, shunt placements, gut repairs; but typically won’t offer heart surgery – those babies would be transferred to a Level IV NICU.

If you’re a new nurse and looking to work in the NICU I would highly suggest beginning in a Level III hospital.  This is because they are usually “birthing” hospitals – meaning that there is a Labor and Delivery unit.  And because the babies are sicker than the Level II babies.  If you want to eventually be a travel nurse I recommend trying to get a job in a birthing hospital that also has a surgical NICU.

 

Level IV NICUs

Level IV NICUs offer all that Level II and III NICUs offer, plus more.  They have every specialty on hand and offer every life-saving intervention.  Typically, the sickest of the sick babies end up in Level IV NICUs OR babies that are full-term and can’t seem to get off of the ventilator.  These babies are known as babies with BPD (Bronchopulmonary Dysplasia).

If you’re a nurse wondering if you should work in a Level IV NICU I would say to prepare to have fewer premature babies and more full-term babies.  Also, prepare to have tons of surgical patients plus deal with more ethical cases.  Working in a Level IV NICU can oftentimes be emotionally draining, however, it’s where you’ll sharpen your skills and learn a lot.  Level IV NICUs are oftentimes teaching hospitals meaning that you should have tons of learning opportunities.

Level IV NICUs have sicker babies, but they usually aren’t birthing hospitals.  If there is a high-risk patient that needs to be transported in, they will deliver at a different hospital and then come via ambulance.  There are SOME Level IV NICUs in hospitals with birthing units.  These beds are for high-risk mothers with babies that will need immediate intervention.

 


If you do work on a level IV unit, you may be required to obtain your PALS certification.  Either way, read Why You Should Receive Your PALS Certification As a NICU Nurse.


 

If you’re curious about a hospital offering a certain level of NICU, make sure to check out this website from the American Academy of Pediatrics.

 


For more information about the NICU, don’t miss these posts:

10 Things I Wish I Knew Before Becoming a Neonatal Nurse

How to Become a Neonatal Nurse


 

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passportsandpreemies
passportsandpreemies

Kylee is a traveling Neonatal Intensive Care (NICU) nurse with a love for solo travel, wine, and Taylor Swift. Inspiring nurses to travel both near and far, Kylee began Passports and Preemies in 2017 while volunteering in Skopje, North Macedonia. Passports and Preemies was created as a way to reach nurses and advocate for the prevention of nurse burnout by traveling. Kylee is the original creator of the “8 Day Vacay” – a vacation geared towards nurses who aim to take advantage of the potentially 8 days off between work weeks with no need to use PTO.

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