NICU Research Articles

US Davis Health System: US Davis Neonatal Intensive Care Unit Recieves Design Award from Modern Healthcare

Sage Journals Online:Lighting for Neonatal Intensive Care Units: Some Critical Information for Design

Bio-Medicine: Design of Neonatal Intensive Care Units Critical to Infant Health

NACHRI: Hope and Healing Through Design

Lipshutz, Lisa Naide. Planning the Private-Room NICU. Inside ASHE, February 2008.

Article Summary:

-Evidence-based design, improved medical practice, and advances in technology have significantly evolved NICU design in the recent decade.
-With advances in communications technology-specifically staff communications systems, digital charting, the ability to link neonate monitors with staff communication systems, and staff locators-hospital decision-makers have become comfortable with advancing toward the private-room model.

The Decision-Making Process:
-Multidisciplinary Team: departmental and program administrators: clincians, including physicians, nurses, and ancillary staff, including respiratory therapists; experienced NICU architects/planners; families should also become an integral part of the decision-making process.
-The process:
-Analyze the projected number of patients, average length of stay, and acuity level to identify the number of units. -Address the issue of centralization versus decentralization (or both), the need for collaboration space, and the need for bedside electronic charting with the staff (area most impacted by the transition to single-room design).
-Minimize footsteps in every process, and develop touch-points for more efficient coverage.
-Consider bedside charting to provide direct access to information, as well as reduce transition time.
Family Input into Design:
-Hospitals are involving family members in the planning process to gain firsthand knowledge of their experiences, good and bad, and learn what families value in terms of support space, such as in-room sleeping arrangements and sibling accommodations including play space.
-Family input can be gathered in various ways:
-The hospital might conduct a family focus group, conduct individual interviews, or provide questionnaires to current and former patients' families during hte early planning phase.
-A few family representatives might be invited to attend design team meetings at the start of each major planning and design phase to comment on proposals. -Plans might also be posted in the hospital for comment.
Roadmap for Site Visits:
-Because there have been so many advances in NICU design in the recent few years, its is wise to plan site visits to other NICUs to tour the facilities and talk with administrators, clincians and families about their experiences.
-Plan ahead:
-Identify tour participants from the core design team who represent a variety of skill sets (administrators, clincians, staff).
-Architects/Planners, Interior Designers, and the Owner should also attend the tour in order to hear reactions of the core design team.
-Assign team members to assess specific areas, ask specific questions about each area, and document the tour in photographs.
Test Driving the Design and Mock-Ups:
-During conceptual design, architects develop 'test-fits' -sample floor plans of potential layouts- to determine if a particular facility is appropriate for the renovated NICU. The approved layout is then developed into a schematic plan.
-A mock-up can be employed as early as the schematic design phase, when the room has been sized and designers are starting to lay out functional elements. More often this task is completed during the design development phase where actual materials and equipment have been selected.
-It is important for staff to understand how the room is zoned to provide adequate caregiver space, infant care space, and family space.
-The mock-up continues to evolve as the design progresses, inclding locations of switches, medical gases, monitor, electronic charting station, etc.
-Environmental services staff should be invited to test durability and ease of maintenance using the manufacturers' recommended methods and products.

Impact of NICU Design on Staffing Levels:
-Administrative, nursing and medical staff are hesitant to adopt the private-room model, due to staff efficiency and isolation, increased square footage requirements, and inadequate window walls for rooms. For these issues, some facilities are still implementing the traditional pod configuration.
-In cases where the private-room model cannot be adopted, spaces to accommodate for parent privacy, new paretn education and training, reflection, and consultation can provide many of the same benefits.

-The private-room NICU provides high-quality care for newborns, a nurturing experience for families, and an efficient, team-oriented work environment for clinical staff. These benefits are made possible with careful planning and appropriate use of today's communication technology.

The Third Generation of Newborn Intensive Care Unit Design. Smith Hager Bajo, Inc. NICU White Paper, August 2003.

Article Summary:

-Neonatology was established as a specialty in the 20th century.
-NICU facilities have evolved to respond to higher family expectations, recent clinical research results, staffing shortages, smaller budgets and new technologies related to monitoring, clinical care and communication.
-Innovative design concepts:
-Single-bed rooms
-Angled headwalls to enable privacy
-Addition of 'family villages'
-Windows may be darkened using a remote-control
-The shift of newborn care from non-hospital settings to hospital settings (drastic change in short period of time).
-Early newborn care took place in incubators on the Midway at the Pan-American Exposition in Buffalo, NY and baby-tents on the bays of New York and Lake Shore Drive in Chicago.
-Sarah Morris Hospital in Chicago became the first premature infant center in the United States in 1914, marking significant advancement in concern for ill infants.
First Generation NICU design:
-In 1960, the first American newborn intensive care center at Grace New Haven Hospital in Connecticut set a standard resembling today's NICUs.
-Large, open brightly lit rooms
-Twice the usual 20-24 square feet allocated per baby in nurseries for healthy infants, but less square footage than the amount allocated to adult intensive care patients.
-In 1976, the March of Dimes published Toward Improving the Outcome of Pregnancy, a document encouraging the regionalization of neonatal care and the use of levels of NICU care.
Second Generation NICU design:
-The 1980's brought the use of surfactant, which ultimately decreased mortality for premature infants with respiratory issues. This advancement required hospitals to accommodate higher numbers of premature infants, as babies with gestational ages of 23-25 weeks were now surviving.
-'Perinatal Bible'
-The first edition of Guidleines for Perinatal Care was published in 1983 to provide design guidelines.
-Additional publications encouraged more state agencies to enforce minimum NICU design standards. For example:
-The required equipping of every delivery room for neonatal resuscitation.
-Hospital facility guidelines for planning intensive care nursery bedside space.
-Recognition that families and family space should be part of the NICU.
-By the late 1980's thirty states had minimum standards for intesnive care nurseries but these standards were inconsistent and not necessarily appropriate
-For example, square footage minimums as low as 24 net square feet/infant.
-Today's norm for new construction requires a minimum of 120 net square feet/infant.
Third Generation NICU design:
-Members of this generation are the first to transform facilities to support changes in relationships among caregivers, families and infants.
-Third generation NICUs are primarily located in regional birth centers while others are in progressive children's hospitals. A new group of NICUs have been located in community hospitals to offer a level of care between the newborn nursery and comprehensive NICUs.
-From 1982 to 2002 the number of NICUs in the United States nearly doubled from 350 to 825.
-NICUs that led the innovative design for the third generation:
-The Washington DC area produced several innovative NICU designs, which would ultimately provide evidence of what does and does not work.
-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, adn adequate storage provided in three tiers (centralized, adjacent, and bedside).
-Components of Third Generation NICU design:
1. Involve family and hospital staff in the design process.
-Results include small changes, such as the use of the term 'newborn intensive care' rather than 'neonatal intensive care'.
2. Privacy is a priority.
-Increase the number of single-bed rooms. -Include visual and audible controls. -Remove large public viewing windows. -Use video-viewing for family and friends who are not permitted into the unit.
3. Investigate Advanced Communications Technology and Monitoring Systems.
-Communications technology provides safer environments and a better connection among staff, family and infant. -Question the traditional belief that babies should be constantly visually watched by a nurse during all hours, as well as the belief that all babies must be clearly seen from a central station.
4. Provide flexible infant care support space.
-Design a universal patient care space with a standard setup that will support several levels of acuity, never less that 120 square feet for intensive care.
-When the staff are educated to care for multiple levels of infant acuity, the nurse scheduling process becomes much simpler.
-Document to prove lower-risk patients require the same amount of space as babies on ventilators, primarily due to the use of therapy devices.
-Prove that designing for flexibility is more cost-effective due to staffing issues, etc.
-Separate low and high acuity babies when the appropriate amount of privacy and space cannot be provided for these patients in unit design.
5. Provide social spaces.
-Although unit design accommodates more space for socialization, separate space should be dedicated to support social interaction among families and staff.
6. Design efficient non-revenue generating space.
-Replace large, loud, central "nurse stations" with more decentralized or mobile work stations.
7. Provide family space.
-Allow the family to personalize the infant care space, especially at the bedside of the patient room.
-Provide a space to sleep beside or near the bedside. -Provide space and technology for the familty to access the computer or web-cameras.
-Provide additional support spaces, including waiting, lounge, sleep, shower, laundry, toilet and nourishment.
8. Include access to natural and flexible likght.
-Enable staff and family access to natrual light; however, excessive heat gain or loss should be considered, especially near the infant beds.
-Exclude large bays of fluorescent lights above infant beds.
-Add rheostats to electric lights, darkening controls to windows, and additional lamps for staff when natural light is limited.
9. Control sound.
-Use texture, carpet, ceiling tiles, silent alarms, and quiet equipment to conrol the environment.
-Reduce sound, vibration, touch, light, etc. in order to avoid infant stimulation.
10. Use evidence-based design.
-Conduct research to ensure that the new design idease are data and experience-based.
11. Use interior decoration to connect with the community, families and staff.
-Use themes and replace traditional pink and blue decoration with meaningful design.
12. Design controls to regulate temperature.
-Eliminate air drafts and provide adequate thermostat and humidity controls to maintain a stable temperature.
13. Design sufficient storage space.
-Re-design storage space to accomodate supplies, equipment, medicine, breastmilk, furniture, etc.
-Anticipate furture change in storage needs.
-Use three-tiered storage space (centralized, unit-based and bedside).
14. Leaders should be consistent in the profession, with an interest and passion for the innovative potential of NICU design. 15. Use proven planning tools.
-Conduct pre- and pos-occupancy evaluations.
-Use methods that enable precise prediction of needs.
-Use change management processes so that innovation and operations drive the design rather than the other way around.
-Use tools such as site visit checklists, full-scale construction mock-ups and benchmarking.
-The universal goal of good NICU design should simply be to not add stress to the family's experience. Each facility should have a team planning committee including representatives from several disciplines to challenge staff, architects, and others to think beyond the traditional to the innovative.
Third Generation Planning Tools:
-Simulation modeling:
-Useful in predicting the approximate number, type and mix of patient beds and staff for NICUs. This method allows the testing and alaysis of the impact of practice changes on bed and staffing needs. Stakeholder input and space constraints have been primary determinants of bed accomodations in the past, but are more dependable when validated by proven methods. The simulation model provides the ability to compare results using different operational pattenrs, models of care, and volumes.
-Other proven planning tools include pre-and post-occupancy evaluations, site visit checklists, full-scale construction mock-ups and operational improvement methodology.
The Status of Single Room NICU Design:
-According to a 2003 estimate, Nearly twelve hospitals had converted a significant number of their NICU beds into single rooms. This number is expected to continue to grow through the next ten years, but is not expected to become the norm.
-The single family room is the result of evolution, rather than a new invention. The pattern of evolution is similar to adult adn pediatric intensive care units, which have tansitioned from open wards to single and double bed rooms during the past few decades. As several hopsitals have implemented the single infant room concept, the transition is not required. The closest attempt to a requirement is found in the Texas Department of Health code stating that "hospitals providing a neonatal critical care unit must provide at least one enclosed private room per every six cribs, with at least 100 square feet of clear space for each".
-Single infant room results:
-Hospitals with a large portion of single rooms have reported they did not increase nurse-staffing ratios, but did report that concerns about staff isolation need to be addressed in planning.
-More hospitals seem to be moving toward designing 'universal' NICU patient rooms to accommodate multiple levels of acuity. This design has enabled staffing flexibility, accommodate fluctuating patient numbers, and respond to families' requests.
-Some NICU management believes that when census peaks, lower risk patients can double-up in one room, leaving more room for intensive patients. Other management believes that all acuity level infants require the same amount of space, due to therapy equipment and family accommodations.
-Co-bedding is an option for multiple births. An expandable headwall and clustering of patient care areas are two solutions to the twin and triplet situations.
-Developmental care is linked to the idea of single rooms. A recent study indicates that 64% of NICUs in the United States reported they had developmental care in place.
-Technological advances will continue to support design innovations. Technology will support the global dissemination of information in thie field and at a fast pace. Evidence of this dissemination may be found in the implementation of the single room NICU at a hospital in New Zealand, or the provision of cots for parents between infant beds in a European hospital. Several NICU's even used a Scandinavian benchmark indicating appropriate family sleep space. Guidelines will continue to be explored, updated and shared among the disciplines. A multidisciplinary committee has begun the document, Recommended Guidelines for Newborn Intensive Care Unit Design, and continues to update the document for public use.

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