NICU - Neonatal Intensive Care Units


This Website was designed to be revised. Anyone is encouraged to build on this knowledge in hopes that it will spread to others involved in the design of NICU's. Please add comments or additional information to any of the pages, specifically to the case studies. The greater number of case studies available will help to develop NICU design through experience. Thank you for your participation!

US Davis Neonatal Intensive Care Unit

Overview

No consensus national standard of what constitutes a NICU exists. Some states have defined levels of care, while other states have informal or no systems for classification. The American Academy of Pediatrics has defined NICU levels and sub-levels of care based primarily on availability of specialized equipment and staff.

Newborn intensive care can be defined as care for medically unstable or critically ill newborns requiring constant nursing, complicated surgical procedures, continual respiratory support, or other intensive interventions.

Intermediate care includes care of ill infants requiring less constant nursing, but does not exclude respiratory support. Many NICUs often encompass both intensive and intermediate or step-down care. In general terms, Intensive Care is referred to as Level III and Intermediate care as Level II.

History

Neonatology was established as a specialty in the 20th century. The initial shift of newborn care from non-hospital settings to hospital settings occurred in 1914, as newborn baby-tents on the bays of Lake Shore Drive were replaced by the Sarah Morris Hospital in Chicago, becoming the first premature infant center in the United States--a significant advancement in concern for ill infants.

The 'First Generation' of NICU design was onset with the first American newborn intensive care center at Grace New Haven Hospital in Connecticut, opened in 1960. This design included large, open brightly lit rooms, each allotting 20-24 square feet/infant (less than the amount allocated to adult intensive care patients). This generation was noted for producing the published document, Toward Improving the Outcome of Pregnancy, encouraging the regionalization of neonatal care and the use of levels of NICU care.

The 'Second Generation' of NICU design continued to produce literature, ultimately evolving into codes and standards. The 'Perinatal Bible' was the first edition of Guidelines for Perinatal Care, published in 1983 to provide design guidelines. Additional publications encouraged more state agencies to enforce minimum design standards. Such standards included provisions for family space within the NICU, equipping of every delivery room for neonatal resuscitation, and facility guidelines for planning intensive care nursery bedside space. These standards were primarily developed in response to higher numbers of premature infants. This increase was primarily due to the use of surfactant, a treatment which decreased mortality for premature infants with respiratory issues.

The 'Third Generation' of NICU design was the first to transform facilites to support changes in relationships among caregivers, families, and infants. New designs were being implemented in regional birth centers, progressive children's hospitals, and community hospitals to offer a level of care between the newborn nursery and comprehensive NICUs.
With this new generation, the number of NICUs in the United States nearly doubled from 350 to 825. Among these, two NICU's led the innovation design for this generation:

Children's National Medical Center converted to six bays for their 40-bed unit in 1988. Six bays contained six beds each, with two of the bays enlarged to provide two private isolation rooms. The design allowed for control of the environment with less noise and flexible lighting conditions. This design provided personalized care for each patient and enabled efficient staffing organization by integrating intensive and nonintensive care patients. The design also included a parent sleep room in which a parent and infant could room together before leaving the facility. This concept of allowing parents to practice caring for fragile babies in a 'homelike' environment prior to returning home has become common in hospital practice. The most important lesson learned was the need to have all disciplines contribute to the design process, in addition to the use of a bedside mock-up before construction.


The NICU in Northern Virginia at INOVA Fairfax Hospital opened in 1992, inlcuding 50 beds arranged in 10 bed pods with seven two-bed rooms interspersed. These smaller rooms were initially intended to provide isolation and flexibility in the event of an infectious outbreak. Through time the rooms were being used to hold infants for longer periods of stay or families with special social needs. This was the beginning of single and double bed room units. Fairfax also demonstrated several other innovative design features, including access to natural light, a dispersed air handling system, consistent and flexible headwall design, the absence of structural obstacles, and adequate storage provided in three tiers (centralized, adjacent, and bedside).

Recent Developments

Much research and study has gone into the NICU environment as it influences and affects the high-risk infant. Such milestones are the investigations into the effects of sound and noise on the post-natal development of the pre-term infant. Studies have conclusively shown that early iterations of NICUs had high noise levels that had debilitating effects on babies development. Other research examined the consequence of bright light in the NICU. The result of these studies indicate that very pre-term babies need to be shielded from light. There is evidence that 28 week gestation age babies can benefit from a diurnal lighting scheme. Further studies into lighting in the NICU have revealed that caregivers performance is influenced by the lighting levels and that their needs are different that those of the babies.

The benefit of family-centered care in the NICU is borne out in research, as well. Many studies cite the postive effects on parent-infant bonding when families participate in the care of the infant. An important method of parent-infant bonding is skin-to-skin touch, known as "kanagroo care".

Early NICU's were in open bay (sometimes called "warehouse") configurations. As the research noted above began to influence the design on NICU's the desire to have more individualized control at each patient care station emerge.

Terminology

Surfactant: A substance composed of lipoprotein that is secreted by the alveolar cells of the lung and serves to maintain the stability of pulmonary tissue by reducing the surface tension of fluids that coat the lung.

Pre-term Infant: A baby born before 38 weeks of gestation.

Full-term Infant: A baby born 38 weeks after gestation.

Gestation: The period of development in the uterus from conception until birth; pregnancy.