 |
 Background
The care of premature and sick neonates has come a long way since
Dr. Martin Couney developed a controversial model in the late
nineteenth and early twentieth centuries of exhibiting and caring
for neonates at various expositions and fairs to raise money for
their care-hard to imagine in today's medical environment under
Health Insurance Portability and Accountability Act (HIPAA)
regulations. Neonatal Intensive Care Units (NICUs) were developed
in the 1960s as the emergence of new technologies such as
ventilators for mechanical breathing, fetal monitoring, and
amniocentesis required a special environment to care for neonates.
Since then, perinatal and neonatal medicine has advanced
exponentially, greatly decreasing the mortality rates for infants
with low birth weight and abnormalities.
Recent social and demographic trends have contributed to the
increase in the number of neonates needing special care. Teenage
pregnancies and pregnancies with drug abuse and neglected perinatal
care have led to neonates with abnormalities. Fertility medicine
techniques of implanting multiple eggs to boost the chances of
pregnancy have led to multiple births and low birth weight neonates
requiring critical care. There is also evidence of the benefits of
family-centered care. Technological advancements in perinatology
have affected the design of neonatal intensive care units.
Organizations such as the Newborn Individualized Developmental Care
and Assessment Program (NIDCAP) focus on educating NICU staff in
the skills needed to provide care in a neurodevelopmentally
supportive, individualized, and family-centered framework.
NICU, Levels of Care, and Current Standards Defined
The definition of NICU has been a matter of considerable
debate. The codes and standards that define the level of care for
the newborns include terms such as "special care nursery,"
"continuing care nursery," and "NICU." The recommended standards
for NICU design, endorsed by several neonatal and perinatal
organizations, define "newborn intensive care" as "care for
medically unstable or critically ill newborns requiring constant
nursing, complicated surgical procedures, continual respiratory
support, or other intensive interventions." NICU care is expensive
and requires the commitment of specialty physicians, staff, and
facilities. This has led to the regionalization of NICU locations
to serve the entire U.S. population.
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| Figure 1: An open plan
concept at Children's Medical Center of Dallas |
Evolution of NICU
Configurations
Open plan concept
Early NICU configurations incorporated open plans for up
to 30 neonates positioned along a service counter and headwall
system. Some designs divided the plan into two or three high-risk
and low-risk areas. The intent was to deliver as much care as
possible without moving the neonates. Access to the patient area
was restricted, keeping viewing corridors on the perimeter. Because
a neonate's immune system is fragile, parents were allowed inside
on a limited basis and only after scrubbing and
gowning.
Open modular plans with cubicle
curtains
NICUs of the next generation were designed with modules of
six to eight neonates, separated either by cubicle curtains or by
walls that allowed staff observation while offering some privacy.
The advantage of the modular layout was staffing efficiency, with
the ability to close and open modules as needed depending on the
census. One or two private rooms were provided for training the
parents for transition to home. Parents participated in the care of
their babies. However, their accommodations within the care area
were minimal and did not offer privacy.
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| Figure 2: A modular NICU
configuration at Baptist Medical Center, Montgomery,
Alabama |
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| Figure 3: Mother and
family spaces are provided through a modular plan with partial
walls at Utah Valley Regional Medical Center, Provo,
Utah |
Pinwheel configuration
The advent of test-tube babies (conceived either through in vitro
fertilization [IVF] or gamete intra-fallopian transfer [GIFT]) in
the 1980s and advances in reproductive medicine during the 1990s
increased the number of multiple births and low-birth-weight
babies. During this time, the desire for, and benefits of, family
participation in the care of their babies were realized. Infection
control issues were addressed with increased filtration and
frequency of air changes. The NICU configurations, using pinwheel
or other layouts with partitions and headwalls, provided more
privacy for the family and the neonates while allowing staff to
observe several neonates at a time. Overall space requirements
increased due to the need for additional circulation areas and
inclusion of family facilities such as lounges, parent teaching
areas, breast pump rooms. Parents' sleeping accommodations were in
a separate area, either in a dormitory style or with private
rooms.
A Case for Individual Private Neonatal Care
Rooms
A move toward family-centered care and a more consumer-focused
orientation have resulted in the widespread use of individual
private rooms for obstetrical services, universal patient rooms,
and outpatient surgical preparation and recovery. In the continuing
evolution of NICU design, there is a need to address infant and
family privacy and flexibility to provide the entire spectrum of
care without moving the baby. Individual private rooms provide the
best setting for the NICU of the future, with substantial benefits
according to many neonatologists, nurses, and support staff.
Compliance with patient and family privacy requirements
under HIPAA
The Health Insurance Portability and Accountability Act
(HIPAA) passed by Congress in 1996 has a speech privacy rule, "Standards for Privacy of Individually
Identifiable Health Information," that went into effect on
April 14, 2003. Acoustical and speech privacy at hospitals is a
significant issue that needs design consideration. This is
especially important for neonates who may potentially develop
disabilities. Individual private rooms are the only reasonable way
to meet the acoustical privacy requirements under HIPAA. Private
rooms also give families the privacy to participate in the care of
their neonates on a continual basis.
Flexible, adequate space to deliver specialized care to each
neonate in one place
The intent of single-room NICU design is to maximize efficiency by
enabling performance of all care and needed procedures in one room.
A single room provides adequate space and flexibility for critical
care as well as transitional care, which prepares parents for home
care of neonates. The single-room approach reduces costs related to
transporting the neonates and increases physician and staff
efficiency.
Infection control
The NICU is one of the highest-risk areas for developing
infections due to the babies' immature immune systems. Particulate
matter tends to move freely in an open space despite best efforts
in locating diffusers and exhausts. Isolating neonates from each
other and from outside sources of infections has proven to be most
effective for infection control in NICUs. A private-room NICU
provides the best isolation for neonates.
Complete control over environment
Constant bright lights in an open-plan NICU can be harmful
to babies. The NICU needs a variety of lighting levels to regulate
neonates' biological rhythms, perform procedures, and ensure the
psychological well-being of staff and families. Similarly, control
of background noise and temperature for each neonate and family is
desirable to suit their individual needs. A single- room NICU
provides complete environmental control, with an individual
thermostat to regulate temperature, a door to block the noise, an
exterior window, and blinds to control lighting levels.
Optimal family involvement in caring for babies on a
continual basis
Active participation of parents in the medical care and
decision making for their neonates fosters development of the
parent-child relationship and helps parents learn to take care of
their babies. Parental access to their newborns is recommended on a
24-hour basis. The traditional approach provides facilities for
parents to stay overnight adjacent or close to the NICU. Generally,
these limited facilities cannot accommodate every parent.
Single-room NICUs provide the best setting for family-centered care
by providing an area for each family adjacent to the neonate. The
increased area for the single room is offset by the elimination of
parent sleep rooms within or adjacent to the unit.
Improved clinical outcome and customer satisfaction
Limited experience with single-room NICUs has shown that
close participation of parents in their child's care has shortened
hospital stays and reduced readmission rates. More data are needed
to provide clear evidence of the positive clinical outcome of
single-room NICUs. Based on the customer satisfaction with, and
success of, single-room maternity care and outpatient surgical care
models, there is ample evidence that single-room NICUs will
increase customer satisfaction and become the industry norm in the
future.
Design Solution
While private rooms offer recognized benefits in terms of
family-centered care and comfort, use of single-room NICUs has been
limited, largely due to perceptions that they will increase space
requirements and decrease staff efficiency. A need exists,
therefore, to develop NICU configurations based on the private-room
model and using appropriate configurations and communication
technology to mitigate the perceived inefficiencies. Below are some
strategies to develop single-room NICU designs.
Size and configuration
A single NICU room of 200 square feet provides adequate space for
caregivers to deliver critical care while giving the family "a home
away from home." A room 9 to 10 feet wide with a flat headwall
provides enough space around the infant bed for equipment and
caregivers. Keeping the width to a minimum helps to achieve an
efficient layout, with rooms around the perimeter that provide
windows to each room. Experience has shown that the single-room
NICU configuration requires less circulation area than the pinwheel
or modular configuration. While the rooms are larger, the space
requirements are reduced because no parent sleep rooms are needed.
Overall, the single-room design does not increase the total space
needs significantly.
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| Figure 4: Plan for a
200-square-foot single NICU room at Clarian North Hospital,
Indianapolis |
Staffing efficiency
The greatest resistance to the single-room NICU is based on the
perception that it would require more staff because they could not
observe all neonates at all times. It is imperative that the
single-room NICU use communication technology to mitigate the
perceived need for more staff. Today's advanced monitoring,
surveillance, and nurse locator systems immediately notify staff of
patient activities and allow access to patient information-even
from a remote location. In addition, a nurse work alcove can be
provided outside each pair or group of rooms, allowing nurses to
interact and work together as a team.
Facilities for family-centered care
One of the important benefits of single-room NICU design
is that it allows the parents to participate in the care of their
baby in privacy to develop the parent-infant bond throughout the
critical care phase. This also prepares the parents to care for
their baby at home following discharge. Separate parent sleep rooms
are not necessary. However, a family lounge, kitchenette, laundry,
and toilets with shower facilities should be provided so that
parents can continue some of their routine activities.
Accommodation of multiple neonates
Some private rooms should be designed with a sliding door between
two rooms to create a suite accommodating multiple babies and the
family. This allows both parents to stay with their children on a
continuous basis.
Conclusion
The provision of individual rooms for at least some NICU
patients is an idea whose time has come (White 2003). The NICU of
the future will be based on family-centered care and the new
realities of HIPAA regulations to provide privacy and
confidentiality. Clarian North Hospital in Indianapolis, a
specialty hospital for women and children, is currently
incorporating the single-room NICU into its design. It will provide
24 200-square-foot, single-room NICUs, enhanced with exterior views
of nature. All of the rooms will provide distinct family, patient,
and caregiver zones allowing the best possible care.
References
Gartner, Lawrence M., M.D., and Carol B. Gartner, M.D.
1985. The Care of Premature Infants: Historical Perspective.
Presented at Neonatal Intensive Care-A History of Excellence: A
Symposium Commemorating Child Health Day, at the National Institute
of Child Health and Human Development, National Institutes of
Health, Bethesda, Md. Paper originally presented October 7, 1985.
NIH Publication No. 92-2786, October 1992.
Committee to Establish Recommended Standards for Newborn ICU
Design. 2003. Recommended Standards for Newborn NICU: Report of the
Fifth Consensus Conference on Newborn ICU Design. Presented January
2002 in Clearwater Beach, Fla. Journal of Perinatology 23
(Supplement 1):S1-S24.
White, Robert D., M.D. 2003. Individual Rooms in the NICU-An
Evolving Concept. Journal of Perinatology 23 (Supplement
1):S22-S24.
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