An in-depth Look at Neonatal Intensive Care Unit Design that Serves Parents and their Babies
If you’ve read our previous article on Current Trends in NICU Design, this is the second in a series of papers focusing on NICUs that care for babies requiring advanced, subspecialty support or the highest level of care. We will cover lessons learned about Single-Family Rooms and Cobedding Rooms, and Perioperative space design. We will also include personal insights into what families may experience in the NICU environment.
Defining Levels of Care
Before any NICU design project begins, we use these basic definitions to verify the types of newborns we will be designing the space for. Typically, we may have more than two or even three levels of care in the same department design. This triggers a set of questions on the training of the staff to manage those multiple options.
Level I: Basic Newborn Care
These nurseries care for healthy, full-term babies. Level I care stabilizes babies born near term to get them ready to transfer to facilities that provide advanced care.
Level II: Advanced Newborn Care
These nurseries care for babies born at 32 weeks gestation or greater who are recovering from more serious conditions.
Level III: Subspecialty Newborn Care
These NICUs care for babies born at less than 32 weeks gestation as well as babies born with critical illness, at all gestational ages. These facilities offer prompt and readily available access to a full range of pediatric medical subspecialties. They also offer a full range of respiratory support and perform advanced imaging.
Level IV: Highest Level of Neonatal Care
These NICUs provided the highest level, most acute care. These nurseries are located within a hospital that can provide surgical repair of complex congenital or acquired conditions. The facilities will have a full range of pediatric medical and surgical subspecialties as well as pediatric anesthesiologists on site. These NICUs also facilitate transport and provide education outreach. (Source: Rocky Mountain Hospital for Children)
Without a doubt, the evolution of the NICU environment has changed dramatically over the last twenty years. NICU design has moved from large designed spaces that cohorted infants in groups of up to 8 per open pod to pinwheel designs that grouped 3-4 infants around a pentagon design. More recent designs have created single-family rooms, cobedding rooms and Kangaroo care rooms that allow mother and infant(s) to share the same space.
Single-family rooms have been highly touted and researched to determine if it makes a difference in the quality of care while providing privacy for mother and infant. Previously, families would utilize screen partitions for privacy and intimacy with their newborn. Today, the popularity of the single-family room, has given families extended quality time with their newborn for skin-to-skin contact.
Benefits of skin-to-skin contact:
- Calms and soothes the baby
- Helps the baby maintain a healthy body temperature (it’s better than an incubator)
- Helps regulate the baby’s heart rate, blood sugar, and breathing
- Improves the baby’s sleep
- Helps the baby breastfeed
Recent research has shown that when families are not present on a regular basis in a single-family room, this absence may be the reason for less stimulation and reduced learning and development of the newborn. Other findings also suggest the single-family room reduces sepsis and improves breastfeeding rates during the hospital stay.(Lancet Child & Adolescent Health Journal, January 2015)
One of the primary goals of the single-family room is to humanize the intensive care environment and to promote healing for infant and family. Lighting, acoustics, size and proximity to nursing staff are all key factors to consider.
Lighting and the advent of LEDs has been one of the best technologies that is now affordable for all applications in healthcare design. The ability to provide full-spectrum lighting and to change the color-rendition throughout the day to simulate the effect of the sun’s natural color is exciting. Controls for the lighting are almost endless with programmable options for circadian and diurnal settings that care be managed by the care team allowing for individual managed options of care.
Acoustics within the NICU can not only control the overall noise level but can supplement the acoustic environment with the stimulating sounds of nature and the newborn environment. This area of discovery is in its infancy but offers many possibilities for individualized care as new studies reveal that the lack of stimulation in a single-family room may deter from the infants development. There will definitely be more to come on this subject matter as it evolves.
Overall Size of the Room
Determining the right size for the single-family room is critical for the future success of the room. Over time the recommended size for Level III care has steadily increased - the current minimum guideline standard from FGI states 120 square feet for Level III care. That number represents the immediate clear floor area required – it does not take into consideration the circulation required for transport or multiple family members that may need to be accommodated within the room. On a recent DesignGroup project for Nationwide Children’s Hospital the average single-family room area for a 42-bed NICU renovation project was 244 net square feet.
Observation by Nursing
Having nurses available immediately adjacent to the bedside is critical to the care of infants in the NICU, and parents that are learning how to care for their babies. In the above example at Dell Children’s, you can see the relationship between the outside corridor and the access directly into the room. The sliding glass ICU door allows it to break open for easy and convenient patient transfers.
DesignGroup’s Sr. Interior Designer, Annie Neumer recently gave birth to twin girls, Violet and Evelyn. Born at 32 weeks, the twins spent significant time in the NICU. Annie shares her experience below:
Preterm babies are born with under-developed lungs; learning basic functions such as how to breathe and eat on their own are only a couple of examples of the high level of care they need. The concept of ‘suck, swallow, breathe’ when learning how to take milk from a bottle is challenging for the infant, but also for the parent learning how to feed their own baby. I can remember a specific example of this: my husband was bottle feeding our daughter Evelyn and she began to choke on the milk. Preemie babies do not have a developed cough reflex; Evelyn’s oxygen levels plummeted and she began to turn blue.
The alarms sounded, and one of the nurses at the nurse workstation right outside of our room rushed in to assess Evelyn. She needed hard thumps on her back to initiate the cough to relieve the choking, and also an oxygen mask to initiate breathing on her own again.
I can’t imagine having a closed door to our room during that moment. It happened so quickly, and this was after weeks of feeding our twins by bottle every 2-3 hours without incident. Evelyn’s room was curtained (did not have a sliding glass door), which did not allow for a lot of acoustical privacy. However, in that moment – when she could have died – I was so thankful that the nurses were close by to provide immediate, life-saving care for our daughter.
Designing for Perioperative Care in the NICU
Congenital Heart Disease (CHD) is the most common type of birth defect affecting 8 out of every 1,000 newborns. Each year, about 35,000 babies in the Unites States are diagnosed with CHD. Nearly 25 percent of those are critical congenital heart defects that require surgery or other interventions within the first year of life to survive. Parents of these children often sit by their child's side in the hospital hoping and praying for their child. As a result of dramatic advances in the medical and surgical management of CHD, 85 percent of infants with CHD are now expected to survive to adulthood, and CHD is regarded as a chronic disease rather than a terminal one. However, survival rates for children with critical congenital heart defects is lower; they often need specialized medical care throughout their lifetime. (Healthy children.org May, 2016)
It is important to note that many preterm infants with some form of perioperative care go on to achieve a full recovery. For example, Milwaukee Brewers star Travis Shaw’s daughter Ryann, who was born with Hypoplastic Left Heart Syndrome continues to live a full and exciting life thanks to the care of Children’s Hospital of Wisconsin and her family.
Before we look at some of the technical aspects of designing these spaces, it’s also important to remember that families require privacy and time to manage their newborn when confronted with the difficulty of surgery. Having a single-family room to recover and heal is essential for all involved, especially the pre-term infant.
There are ongoing considerations for humidification air change requirements as it relates to the design and planning of NICUs for perioperative care. Be sure to consult your engineering consultant prior to starting your project.
Recently, many NICU designs have included the added option of larger semi-private or multiple birth rooms. In discussions with physicians and nurses, we uncovered the need for larger, more flexible room designs. These rooms are designed to handle several options – from multiple births to surgical procedures and even babies requiring heart and lung support through the use of providing oxygen into the bloodstream. A focus on larger semi-private rooms has been on giving hospitals the ability to co-bed preterm twins or multiple birth scenarios.
Research on the Cobedding model to determine on whether it promotes self‐regulation and sleep and decreases crying without apparent increased risk has been conducted and will continue for other areas as well. For now, having the flexibility within the NICU for multiple birth infants has proven very successful for the family and caregivers of those infants.
Annie talks about spending time in the NICU which reinforces these findings:
When our twin girls were born, they were placed in separate rooms within the NICU. This created a situation in which either my husband or I would each go to one of the girls’ rooms to sit by their side, feed or provide care. This separation left each of us feel very vulnerable and anxious - not able to fully understand how both of our daughters were doing at the same time. Each of the girls also had a separate team of nurses and doctors that were caring for them, which posed its own challenges for us:
- Rooms were not equipped for parents to sleep or stay the night. Every night as we went home, we were given a phone number to call and check in. Two separate teams of nurses would be caring for the girls; we would often have to call twice, waiting on hold until someone could assure us that our girls were ok. The amount of anxiety we felt cannot be described.
- During the day, my husband would be at work and I would go back and forth between rooms trying to provide each of my daughters the care so critical to their development. I often felt like I was failing them because I couldn’t be in two places at once.
After two weeks of being in the NICU, we were moved to a room that could co-bed our twins. This change significantly improved our experience. Instead of moving between rooms every couple of hours, I was able to stay in one room and offer kangaroo care to both of them at the same time. Kangaroo care has been proven to decrease crying, improve breathing and improve weight gain, all of which can lead to earlier hospital discharge. In addition, parents gain an increased sense of control and confidence. (Resource: The Cleveland Clinic)
After we were able to co-bed, we definitely saw improvements. Both Evelyn and Violet were experiencing less incidents of desaturation (when the blood does not have enough oxygen) and apnea (when the breathing stops and heartrate may increase). They were also able to start regulating their own body temperature, and could be moved out of the incubators they spent the first few weeks in, and into open cribs. As a parent, this was the first time that I had gained a small amount of control and felt *slightly* less anxious. I was able to be with both of my daughters in the same room, at the same time, and witness every single moment of both of their journeys to go home. They spent 44 days in the NICU – which my husband and I often refer to as the most emotional roller coaster of our lives. We will be forever grateful for the teams of doctors, nurses and specialists that provided life-saving care for our daughters.
While the definitive solution for all NICU design is not agreed upon, we do have compelling evidence that providing enough space in an intimate, private setting accomplishes several key objectives:
- Privacy for families to be intimate and provide critical contact with the developing preterm infant
- Space for equipment and minor surgical procedures
- A programmable environment where lighting and acoustics can be controlled
The complexities within the NICU continue to be demanding and rapidly changing. The rapid advancement in care may very well continue into the next 20 years. With the ability of medicine to make great strides in perinatal care, as is the case for the NICU and micro-preemies and the advancement of technology, who knows where we may be even in the next five years. For now, the design professional needs to stay at the forefront of this rapidly changing field and provide as much flexibility in the patient care room as possible.
Ken Redman, AIA, ACHA, LEED BD+C // Senior Healthcare Planner
Ken is a Senior Medical Planner who has dedicated most of his life to the design and planning of some of the most prominent healthcare organizations in the United States and Canada. Working on prestigious Pediatric facilities in his earlier career such as CHOP, CNMC, Nationwide Children’s Hospital, CHOC, Toronto Sick Kids, and British Columbia Children’s, Ken has been able transition those experiences into current projects that require extensive healthcare knowledge and background into complex forward-thinking places of healing.
Annie Nuemer // Senior Interior Designer
As a design professional, Annie has worked on projects within a diverse range of markets, including civic, higher education, and healthcare. She has worked in close collaboration with both small and large project teams during ideation and conceptualization through design development and construction documentation. Her role as interior designer includes the graphic development of supporting diagrams, 3D renderings, interior finish palettes and deployment strategies, furniture strategy, selection, and deployment documentation, construction documentations including construction administration, coordination with professional project consultants through the design process and presentation of design concepts to clients.