**6. Recycling own old incubators**

The successful clinical trials of the initial RIT systems paved the way to the present in-depth study on neonatal thermoneutral control in this African tropical climate. The cost of producing an RIT system from a hospital's fleet of carcasses was demonstrated to be less than 20% of the cost of purchasing one state-of-the-art (STA) incubator (Amadi et al., 2007). This made the idea of incubator re-equipping of the SCBUs an attractive project to administrators of many of the tertiary hospitals that participated in the study. More hospital centres were later attracted to participate in Nigeria when the government approved the supply of STA Draeger Caleo system at a unit cost equivalent to the cost of recycling 7.5 old incubators. It was important to strategically tackle the provision of adequate number of functional micro-environments (housing) for the teaming population of the neonates within the limits of the available funding. It was well-understood that the STA systems have got the excellent finishing of modern technology and sophistication, however, it was necessary to consider the number of babies the same amount of money could house per unit time. RIT approach was hence the easy way of populating the SCBUs with many functional incubators

The successful clinical trials of the initial RIT systems paved the way to the present in-depth study on neonatal thermoneutral control in this African tropical climate. The cost of producing an RIT system from a hospital's fleet of carcasses was demonstrated to be less than 20% of the cost of purchasing one state-of-the-art (STA) incubator (Amadi et al., 2007). This made the idea of incubator re-equipping of the SCBUs an attractive project to administrators of many of the tertiary hospitals that participated in the study. More hospital centres were later attracted to participate in Nigeria when the government approved the supply of STA Draeger Caleo system at a unit cost equivalent to the cost of recycling 7.5 old incubators. It was important to strategically tackle the provision of adequate number of functional micro-environments (housing) for the teaming population of the neonates within the limits of the available funding. It was well-understood that the STA systems have got the excellent finishing of modern technology and sophistication, however, it was necessary to consider the number of babies the same amount of money could house per unit time. RIT approach was hence the easy way of populating the SCBUs with many functional incubators

Fig. 5. RIT Assembly Block Diagram (Amadi et al, 2007)

**6. Recycling own old incubators** 

using the available meagre funding. This would hence create the platform to properly study thermoneutral application in a tropical busy centre. In order to keep the project focused and on course, some of the collaborating hospitals Managements were advised to adopt a 'slow but steady batch-by-batch' recycling approach. This approach allowed a hospital to put a time frame vision for the completion of the recycling of all available carcasses of incubators. The Lagos University Teaching Hospital, for example, had no functional incubators at the start of the project. Ten incubators were initially recycled; there after the Hospital Management recycled 5 more each year to achieve a fleet of 25 functional incubators in three years. This boosted patient flow and staff enthusiasm for work thereby enabling better investigations of the objects of this study in the Centre (Amadi et al., 2010).

The good dedication of most of the collaborators soon led to the successful recycling of all available old incubators in most of the participating hospitals. However, the drive to provide adequate number for the SCBUs meant that some of the hospitals had to take another step of procuring more incubators from the market. The confidence already reposed on RIT made it possible for the Hospitals Managements to use available funds to purchase affordable systems they could easily re-power with RIT component when these failed. This hence secured a sustainable fleet of functional incubators required for the study in each of the participating Centres. The Centres were also encouraged and assisted to add one or more transport incubators in the fleet. This helped to reduce the distress some of the neonates suffered during intra-hospital transports using inappropriate and crude techniques.

#### **6.1 Incubator routine maintenance and functionality auditing**

The high neonatal admission delivery in these hospitals coupled with high influx of referrals resulted in extensive demands on the incubators. Many of these functioned continuously for weeks and months without break except when they were to be cleaned for another waiting baby. There was then need to initiate another supportive programme to guarantee sustainability of the functional status of the incubators and freedom from frequent unexpected system failures. This was ensured by the introduction, in each Centre, of a routine maintenance culture. By this the Hospital Managements allowed all the RIT systems to undergo professional functionality auditing and thorough system servicing by qualified RIT in-country technicians once in every 6 months. Some employees of the hospital's engineering department were deployed to be trained to assist in the technical upkeep of the recycled systems. This programme ensured the replacement of any damaged or damaging part of the incubator before this could lead to the system being run to a stop.

#### **7. Paediatrics incubation technique course**

It was discovered that generations of medical students and staff had come and passed on from the Units without ever practicing with a really functional incubator. This created generations of staff who knew no better than how to crudely improvise cages to do the work of an incubator. This hence meant an absolute lack of the fundamental knowledge of how to operate and nurse babies in proper incubators. There was initial 'general' staff training on how to operate the newly recycled systems. This basically familiarised the systems to the nurses, clinical staff and the engineering technicians, demonstrating the various assemblies of the machine and how it worked. The course was basic enough to introduce the system with the assumption that the attending staffs were already trained in various aspects of

Neonatal Thermoneutrality in a Tropical Climate 525

compartment. Some apply affixed probes to independently monitor baby's temperature,

The module explained why some infant incubators were designed as "Transporters" or "Rescue" Units; discussing the kinds of "Power Sources" that keep the system functional whilst on transit. The power source could be assemblies incorporating a lead-acid accumulator (car battery) or rechargeable uninterrupted power supply (UPS) units. Transporter designs are used for ambulatory services, i.e. to move premature babies, for example, from the labour room to the neonatal intensive care unit. During such transport operation, the machine power source would be switched to battery or UPS. In cases where the baby arrives in a distant hospital or maternity, the transport incubator could be interphased with the car or ambulance electrical systems for operation throughout the drive or flight. More sophisticated transport incubators are designed with integral neonatal ventilators for life support and to minimize the possibilities of successful apnoea attack. Transporter units are designed to also make use of the conventional electric mains supply during normal operation in the ward. Diagrams and photos of different models of transport incubators were used to buttress on the diversity of transporter designs where none was

The ability of the incubator to make artificial (programmed) decisions was explained. This facility is installed in incubators at different capacity levels depending on the taste and design constraints of the manufacturer. The intelligence is mostly installed take care of a. Incubator over-heating through 'air' temperature sensors or baby over-heat through

b. Electric Current leakages which can cause electric shock and hence harmful to both the

c. Humidity control for the comfort of the baby. Most of the earlier designs incorporated

Other primary allowable design capabilities, either automatically operated through its artificial intelligence or manually were explianed. These included Weighing features for checking baby's weight gains; Oxygen supplies through inbuilt oxygen concentrators or direct feed through independent oxygen cylinders or supply plants. The need and necessity for incorporation of cooling facility in tropical incubator designs to aid heat extraction for

Participants were also taken aback in history to trace the origin of modern neonatal incubation. This segment of the course endeavoured to show the progress in the development of the ideas and technologies that led to the design and production of the modern systems that could be seen today. The contributions of early players were discussed, including: the early Egyptian applications, the 1588 Giovanni Battista della Porta's idea, the 1609 Cornelius Drabbel's 'Athenor incubator' with thermostat, the 1770 John Champion's London design and patent of 1846. Other pioneering works examined were those of 1837 work of Dr Crede of Leipzig, Odile Martin's 'Couveuse' at Paris Maternity Hospital and the remarkable 1896 Earl's Court exhibition in London [Drebbel,

The course isolated different basic assembly modules of an infant incubator and practically demonstrated these features to intimate students on the operational links of these to achieve regulated warmth for the baby. This includes: (a) Power source/input assembly (b) Electromechanical/Electronic compartment (c) Compressor/fan assembly (d) Thermal generation assembly (e) Humidity assembly (f) Incubation chamber/Neonate's

breathing, heartbeat rates and weight-gains.

physically available in the hospital.

'skin' probes on baby.

attendance and the premature baby inside it.

climatically overheated incubators was also explained.

manually operated humidity controls.

2011; Neonatalogy on the web, 1897].

new-born management including incubator care. Over the succeeding months and across the peculiarities of the various participating hospitals in the region, there was continuous monitoring of how the nursing and clinical staff (care providers) attended to the patients with the incubators. Practice errors were thus identified; building up what was later to form the contents of a proper course work that would treat the fundamentals of incubator care in the tropical climate. This was to collate environmental, socio-cultural, human and technical factors as observed to design an elective course to demonstrate a customised approach to neonatal incubation within the climatic setting. This was to demonstrate to the attending care-providers how various wrong practices could have contributed to the mortalities in their Units. The second aspect of the course concentrated on educating participants on the 'dynamics of neonatal thermoneutral control' based on the best practice approach for achieving a steady body temperature for babies in incubators in the tropical climate. This two-graded elective course coined 'Paediatrics Incubation Techniques' thus had level 1 as 'fundamentals of neonatal incubator care' and level 2 as 'dynamics of neonatal thermoneutral control'. The general aim of level 1 was to apply theories and on-the-spot practical demonstrations to explain the basic physics of incubation and how the incubator achieved this. This also demonstrated how familiar wrong practices could have prevented the incubator from properly achieving its aims thereby delimiting the overall neonatal care quality. Level 2 was a short course that taught participants how to interactively set and re-set the incubator set-point to avoid the common confusions encountered when using the incubator to thermally stabilise the baby. The contents of these courses are briefly set out below.

#### **7.1 Fundamentals of neonatal incubator care**

The course was started with an introductory segment that was aimed at making participants to understand the general make-up of the incubator. This presented its features and mode of operation in a way as to simplify any complexities that would make care-providers see this as a mystery machine. This emphasised that Newborn babies were precious and generally delicate while the premature, among them, were much more delicate to nurse, especially during the first few days of their arrival. The premature baby, during the first few days of its arrival, needed above every other thing, controlled and regulated warmth that could provide it with a comfortable environment in its struggle for survival. The Incubator, in doing this job, becomes the obvious best friend of the premature baby during this period. A mishandling of the Incubator would mean everything DANGER to the precious premature baby inside it. Therefore a carefree attitude towards an incubator on duty could expose the child to suffocation, electric shock and many other dangers that could claim its life. Hence it was necessary that every nurse and clinician was adequately informed and trained before he/she could effectively nurse a baby with it. This emphasized that the incubator was precious and delicate just like its best friend and hence must be handled with care.

The course module explained some differences in designs of infant incubators, describing these as diverse and versatile, pointing out probable constraints necessitating the design variations. Although there is a generally acceptable basic programme of operation of an incubator, different manufacturers enhanced their designs over others with automation technology that improved their values. Modern designs incorporate microprocessors that aid automatic operation of the machine, enabling it to do much more than what older analogue and hybrid systems could do. The microprocessors fostered advanced artificial intelligent systems that regulated the humidity of the incubation chamber or neonate's

new-born management including incubator care. Over the succeeding months and across the peculiarities of the various participating hospitals in the region, there was continuous monitoring of how the nursing and clinical staff (care providers) attended to the patients with the incubators. Practice errors were thus identified; building up what was later to form the contents of a proper course work that would treat the fundamentals of incubator care in the tropical climate. This was to collate environmental, socio-cultural, human and technical factors as observed to design an elective course to demonstrate a customised approach to neonatal incubation within the climatic setting. This was to demonstrate to the attending care-providers how various wrong practices could have contributed to the mortalities in their Units. The second aspect of the course concentrated on educating participants on the 'dynamics of neonatal thermoneutral control' based on the best practice approach for achieving a steady body temperature for babies in incubators in the tropical climate. This two-graded elective course coined 'Paediatrics Incubation Techniques' thus had level 1 as 'fundamentals of neonatal incubator care' and level 2 as 'dynamics of neonatal thermoneutral control'. The general aim of level 1 was to apply theories and on-the-spot practical demonstrations to explain the basic physics of incubation and how the incubator achieved this. This also demonstrated how familiar wrong practices could have prevented the incubator from properly achieving its aims thereby delimiting the overall neonatal care quality. Level 2 was a short course that taught participants how to interactively set and re-set the incubator set-point to avoid the common confusions encountered when using the incubator to thermally stabilise the

The course was started with an introductory segment that was aimed at making participants to understand the general make-up of the incubator. This presented its features and mode of operation in a way as to simplify any complexities that would make care-providers see this as a mystery machine. This emphasised that Newborn babies were precious and generally delicate while the premature, among them, were much more delicate to nurse, especially during the first few days of their arrival. The premature baby, during the first few days of its arrival, needed above every other thing, controlled and regulated warmth that could provide it with a comfortable environment in its struggle for survival. The Incubator, in doing this job, becomes the obvious best friend of the premature baby during this period. A mishandling of the Incubator would mean everything DANGER to the precious premature baby inside it. Therefore a carefree attitude towards an incubator on duty could expose the child to suffocation, electric shock and many other dangers that could claim its life. Hence it was necessary that every nurse and clinician was adequately informed and trained before he/she could effectively nurse a baby with it. This emphasized that the incubator was

precious and delicate just like its best friend and hence must be handled with care.

The course module explained some differences in designs of infant incubators, describing these as diverse and versatile, pointing out probable constraints necessitating the design variations. Although there is a generally acceptable basic programme of operation of an incubator, different manufacturers enhanced their designs over others with automation technology that improved their values. Modern designs incorporate microprocessors that aid automatic operation of the machine, enabling it to do much more than what older analogue and hybrid systems could do. The microprocessors fostered advanced artificial intelligent systems that regulated the humidity of the incubation chamber or neonate's

baby. The contents of these courses are briefly set out below.

**7.1 Fundamentals of neonatal incubator care** 

compartment. Some apply affixed probes to independently monitor baby's temperature, breathing, heartbeat rates and weight-gains.

The module explained why some infant incubators were designed as "Transporters" or "Rescue" Units; discussing the kinds of "Power Sources" that keep the system functional whilst on transit. The power source could be assemblies incorporating a lead-acid accumulator (car battery) or rechargeable uninterrupted power supply (UPS) units. Transporter designs are used for ambulatory services, i.e. to move premature babies, for example, from the labour room to the neonatal intensive care unit. During such transport operation, the machine power source would be switched to battery or UPS. In cases where the baby arrives in a distant hospital or maternity, the transport incubator could be interphased with the car or ambulance electrical systems for operation throughout the drive or flight. More sophisticated transport incubators are designed with integral neonatal ventilators for life support and to minimize the possibilities of successful apnoea attack. Transporter units are designed to also make use of the conventional electric mains supply during normal operation in the ward. Diagrams and photos of different models of transport incubators were used to buttress on the diversity of transporter designs where none was physically available in the hospital.

The ability of the incubator to make artificial (programmed) decisions was explained. This facility is installed in incubators at different capacity levels depending on the taste and design constraints of the manufacturer. The intelligence is mostly installed take care of


Other primary allowable design capabilities, either automatically operated through its artificial intelligence or manually were explianed. These included Weighing features for checking baby's weight gains; Oxygen supplies through inbuilt oxygen concentrators or direct feed through independent oxygen cylinders or supply plants. The need and necessity for incorporation of cooling facility in tropical incubator designs to aid heat extraction for climatically overheated incubators was also explained.

Participants were also taken aback in history to trace the origin of modern neonatal incubation. This segment of the course endeavoured to show the progress in the development of the ideas and technologies that led to the design and production of the modern systems that could be seen today. The contributions of early players were discussed, including: the early Egyptian applications, the 1588 Giovanni Battista della Porta's idea, the 1609 Cornelius Drabbel's 'Athenor incubator' with thermostat, the 1770 John Champion's London design and patent of 1846. Other pioneering works examined were those of 1837 work of Dr Crede of Leipzig, Odile Martin's 'Couveuse' at Paris Maternity Hospital and the remarkable 1896 Earl's Court exhibition in London [Drebbel, 2011; Neonatalogy on the web, 1897].

The course isolated different basic assembly modules of an infant incubator and practically demonstrated these features to intimate students on the operational links of these to achieve regulated warmth for the baby. This includes: (a) Power source/input assembly (b) Electromechanical/Electronic compartment (c) Compressor/fan assembly (d) Thermal generation assembly (e) Humidity assembly (f) Incubation chamber/Neonate's

Neonatal Thermoneutrality in a Tropical Climate 527

c. Mains Input: There was always insufficient power sockets on the walls of nursery wards to take up all electrical appliances required to be on at the same time. This was an observed failure common to all participating neonatal centers without an exception. This deficiency in the nursery electrification often causes care-providers to multiply power ports by the use of 'cabled extension'. Unfortunately, this indiscriminately run all over the place, staying in the way for movement and potentially posing the hazard of a staff tripping over them. This might result in injury to the staff or the baby such may possibly be carrying. The use of extensions causes care-providers to innocently overload these cables and the host power sockets causing electrical sparks and shocks, endangering lives and damaging equipment. This was therefore labeled a hazardous and unprofessional practice that must be discouraged. New wiring designs were

d. Humidity Reservoir: The care of the humidity reservoir was a segment that highlighted on the effective management of the incubator humidifiers. This explained how the reservoir might be kept from becoming nursery for infection-causing micro plants and organisms. Hence, humidifier tank must be drained of water whenever the machine was discharged of a neonate and kept dry if not in use. The tank should however be refilled with distilled water whenever the machine was to be used again. Water could be boiled and stored in a clean plastic container for use as an alternative to the use of

e. Thermometer: The operator must closely monitor the temperature of the incubator with the thermometer provided to probe the microenvironment. This helps to notice when the temperature might be indicative of unfavorable condition inside. This is important

f. Voltage Stabilizer: Use of single incubator-specific automatic voltage regulator (AVR) sets was introduced and encouraged to be applied. Erratic, poor quality and incessant power failures in these tropical countries often exposed the incubators to power surges and under voltage supplies that crippled their effective function (Figure 7). The functional inadequacies of this phenomenon were demonstrated diagrammatically to enable self-appreciation of the problem by the trainees so as to have personal drives to

g. Earthed Lines: Trainees were encouraged to carefully inspect incubators being delivered for use before acceptance. It was important to reject incubators with obvious electrical hazards such as un-fused systems and the absence of the 'earthing line' pin (E) on the plug head, whether the system was a new product from a supplier or repaired system from the maintenance workshop. Cartooned illustrations were used to demonstrate how these related to the general building earthing and how these served as safety devices to protect baby and care-providers from 'static' and 'mains' electric

cleaning standards that would be professionally acceptable.

proposed and implemented in each Centre to correct this deficiency.

especially for cases when there is a thermostatic assembly failure.

distilled water if unavailable.

protect the systems during use.

shocks (Figure 8).

low-paid casual workers were recruited to mop floors, clean windows and dust chairs. These also went ahead to handle the incubators, often with neonates inside, the same way as they cleaned chairs using same filthy and smelly rags. What a perfect way of introducing bugs that reduce neonatal survival and also cause damages to the incubator! The course stressed the need for hygiene around the neonates and the incubators and to keep off such infection vendors as outside visitors, improperly masked staff and mothers. Participants were encouraged to use their improved understanding of the neonatal microenvironment during the course to ensure effective

compartment (g) Thermostatic assembly and (h) External communication assembly. Cartoon illustrations were applied in some instances to ensure fair understanding of the ideas behind these various assemblies (Figure 6).

Fig. 6. Cartooned illustration of thermostatic operation

[This assembly is the thermal policeman of the incubator. It controls and gives the thermal generators instructions on when to supply heat and when to stop. It always checks up the temperature of the incubation chamber and compares it with the operator's input (set point). The thermostat's 'ON and OFF' or 'REDUCE and INCREASE' commands to the thermal generators help it to keep a check and guard against an under- or over -shoot of incubation temperature. It does this by what is known as "feedback control mechanism"]
