PANPACIFIC UNIVERSITY NORTH PHILIPPINESUrdaneta City, Pangasinan

College of Nursing

CHALLENGING DESIGNS IN NEONATAL INTENSIVE CARE UNITS

In Partial Fulfillmentof the

Requirements inNCM 104

Related Learning Experience(NICU)

Submitted by:

Garcia, Neil A.BSN 4-D Group 14

Submitted to:

Ma. Psyche C. Antonio RN, MANClinical Instructor

September 2010

I. Introduction

Intensive care units expressly built for newborn infants are a relatively new type of hospital unit. As recently as 30 years ago, most neonatal intensive care units (NICUs) were located in converted patient rooms. These converted spaces were rooms strung down a hallway; their only modification was the elimination of walls to create units. It was not until the late 1970s and 1980s that NICUs designed and built for the specific purpose of caring for critically sick neonates became commonplace. These units were designed as multi-patient wards. Obstetric units designed at that same time were eliminating shared spaces, from the labor rooms to the postpartum rooms. Under the influence of the consumer advocacy movement in obstetrics, private labor-delivery-recovery rooms and labor-delivery-recovery-post-partum rooms appeared in the 1970s and rapidly became the norm by the end of the 1980s.Pediatric intensive care units (PICUs) also were moving away from multi-patient rooms. By the late 1970s, PICUs with private rooms were replacing the open multi-patient spaces that preceded them, including the PICU at Children’s Hospital Los Angeles built in 1979.

Children’s Hospital Los Angeles is currently replacing the existing acute inpatient facility. During the planning phase, the NICU team was challenged to develop a new unit that would meet both existing and future needs. The team had to make decisions about unit layout that included whether or not to continue with the multi-patient room plan, modify the plan adding some separations for privacy, or develop a lay-out that would give neonates and their families private and semiprivate rooms. The team decided to replace the existing unit with private and semiprivate rooms. The hospital based their decision on the historical context of NICU design.

Ii. Historical Perspective

The first great technological breakthrough in survival of preterm infants was the invention of the incubator for infants in France in 1878.This invention, based on a chick incubator, allowed preterm infants born in the hospital to be kept warm. Nonetheless, the survival of preterm infants was uncommon because no treatments were available for infections or for respiratory distress syndrome. Survival was so unique that in 1896 when Martin Couney displayed preterm infants in incubators at the World Exposition in Berlin, the "exhibit" was a tremendous success. The exhibit traveled to London the following year and then to a series of world exhibits from North America to Paris. Dr Couney settled in the United States, where preterm infants were exhibited to the public on Coney Island and at various world fairs until as late as 1939. The reports of survival in this exhibit were impressive for the time. As a result, Dr Couney was considered an expert in the care of preterm infants, and many were sent from all over New York State to receive his care. The care given was typified by separation of the infant from the mother, care by nurses and wet nurses, banishment of children from visiting, multi-patient rooms for the infants, and large viewing windows for the public.

The influence of Couney’s model of care can be illustrated by the Dionne quintuplets. In 1934, the Dionne quintuplets were born approximately 2 months early and weighed a mean of 0.9 kg (2 lb).They thrived at home for weeks under the care of their parents supervised by visits from

the local physician. They were subsequently removed from their parents by the government so the infants could be cared for by experts and displayed to the public. This action was largely unquestioned at the time, and millions viewed the quintuplets during the next 10 years. The Dionnes’ experience underscores how deeply Couney’s exhibits of preterm infants had impressed the public perceptions of care of preterm infants. Expectations for preterm care continued to be influenced by these famous events well into the modern period of neonatology. This influence is evidenced by the NICUs designed with large viewing windows, open units, and the once-routine practice of severely limiting time that parents could "visit" their sick infants.

Although displaying patients to the public was unique to newborns, care in multi-patient wards was the standard during the 19th and early 20th centuries (Figure 6 ). In that time, private rooms were for patients with infections or for patients with the financial resources to afford private duty nurses. As early as the 1920s, some hospitals began to experiment with using a larger proportion of semiprivate and private rooms. This trend changed after World War II when private and semiprivate rooms became the dominant room type even though multi-patient wards were often still included in the mix of rooms built during that period. Multi-patient rooms were eliminated from new construction in the late 1970s, and private rooms predominated within 10 years. Children’s hospitals tended to mirror the design trends of general hospitals. Only NICUs remained untouched by these trends; of the hundreds of NICUs nationally, only 12 facilities have published designs for the use of private and semiprivate rooms.

Public expectations were not the only influence for maintaining the old NICU design. In the 1980s, a marked increase in the number of NICU patients occurred, caused, at least in part, by the gains in survival of very-low-birth-weight infants. Because of the overflow of patients, units that allowed flexibility in the number and placement of beds seemed ideal to staff caring for what seemed like an endless influx of critically sick infants. Hospital building programs in the late 1980s and early 1990s attempted to relieve the NICU bed crisis, but essentially no breakthroughs in NICU design occurred in that time.

Among the other reasons for resistance to eliminating the open multi-patient space is the traditional standard that infants must be observed at all time so that any changes in their physiological condition can be noted. Developments in precise physiological monitoring and the capacity to integrate equipment alarms with other technology prompted reexamination of the traditional approach to monitoring infants’ conditions, allowing the consideration of the private-room model. In the 1990s, the feasibility of private and semiprivate rooms for NICU patients was recognized. The first published recommendation to consider some private rooms for neonates appeared in 1992. The first unit described as being built to this recommendation with separate rooms for neonatal patients was opened in 1997.

III. NICU Design and Developmental Care

As survival of infants born preterm improved dramatically in the 1980s, concern about intact survival (i.e., survival without disabilities) also increased. Developmental research began to emerge that created a new focus on the environment inhabited by preterm infants in their first months of life. Research and recommendations on light and noise control heavily influenced the design choices made for NICUs.

IV. Light in the NICU

One of the design changes for NICUs recommended by the American Academy of Pediatrics evolved from concerns about the effect of light exposure on preterm infants. Because fetuses normally develop in total darkness, light exposure in the NICU was an early topic of environmental research. As early as the 1950s, it was known that direct exposure to bili lights (300–400 foot-candles [ft-c]) or sunlight (1000 ft-c) could cause retinal damage. In 1985, Glass et al reported that NICU room lights between 50 and 100 ft-c might increase the risk of retinopathy of prematurity. This report initiated a trend toward dimming NICU lights. The observation of Glass et al has not been supported by more recent research, but light exposure continues to be examined. Currently, the American Academy of Pediatrics states that adjustable lighting between 0.5 and 60 ft-c is appropriate for general lighting levels in NICUs and that new NICUs should be built with indirect room lighting to avoid having room lights shine directly into an infant’s eyes. This amount of light is markedly less than the 100 ft-c recommended by earlier groups and reflected in current California State Health Department Code of Regulations.

In addition to its effects on vision, light is a key physiological regulator. Light regulates the circadian rhythm, which can be calculated by measuring specific hormones, which in turn regulate most if not all bodily systems. During fetal life, light regulates fetal physiology through maternal light exposure and the subsequent changes in the maternal hormones that the fetus is exposed to. A study on the effects on newborns of cycling light to mimic daylight and nighttime patterns indicated that cycled lights may have a positive effect on variables such as amount of sleep time, weight gain, and behavior in preterm infants. In an early investigation, Mann et al studied the effect of day-night cycled lights compared with continuous bright lights on 42 preterm infants. The infants in the cycled-light environment spent less time awake and had significantly greater weight gain than did the control group. Brandon et al compared the effect of near darkness to cycled light on 62 preterm infants and found that weight gain was significantly faster in the early cycled-light group. Blackburn and Patterson found that decreasing light levels in the evening decreased motor activity and stabilized heart and respiratory rates. These studies all indicate that cycled light is beneficial and that continuous, bright lighting, once the norm in NICUs, reduces growth and increases physiological instability.

A report about the adverse effect of light exposure on unborn chicks illustrates another emerging area of developmental research. Exposing chicks to light while they were still in the egg led to their subsequent inability to respond normally to their mother’s voice. This experiment indicated that stimulating systems out of sequence, or while the systems are immature, may result in

subtle but critical impairments in learning and behavior. This finding is yet to be confirmed in humans, but it raises concerns that improperly timed light stimulation may impair the development of another seemingly unrelated system.

Although light cycled to mimic a normal day-night pattern is more beneficial than continuous light, the wide range of lighting that the American Academy of Pediatrics recommends (0.5–60 ft-c) reflects that lighting levels have not yet been precisely defined for developing preterm infants. Despite a lack of certainty about the specific safety of light levels, as discussed, available evidence supports a concern by caregivers that intense, direct, and continuous light exposure should be avoided in preterm infants. Preventing excess light exposure to infants in multi-patient rooms is very difficult. Procedure lights, bili lights, and heat lamps can all produce more than 100 ft-c.

Although eye pads are routinely used to protect the eyes of any infant who is directly under intense clinical lights, the amount of light exposure for adjacent infants is often both continuous and greater than the American Academy of Pediatrics recommended maximum of 60 ft-c. Because the safety of blocking all visual cues for non-therapeutic reasons has not been established and, at least, violates the recommendations for cycled light, blocking all visual cues cannot be recommended as a remedy for infants who neighbor a patient who needs intense clinical lights. Semiprivate and private rooms, on the other hand, greatly improve the likelihood that individual infants can be provided an individualized lighting environment.

V. Sound in the NICU

Unlike light, noise is a normal aspect of fetal development. Fetuses normally mature in utero accompanied by a variety of noises generated by the maternal viscera and voice. These uterine noises are rhythmic and familiar and are generally low frequency, at a mean of 50 dB. In the past, noise levels inside isolettes have been measured in excess of 90 dB, the level at which the Occupational Safety and Health Administration requires ear protection in adults to prevent hearing loss. Newer models of isolettes now meet the recommended standard that motor noises not exceed 50 dB. However, infants in isolettes can still be exposed to high levels of noise. Something as simple as abruptly closing a solid plastic porthole can generate in excess of 100 dB inside an isolette. Although normal NICU room noise, which averages less than 70 dB, has not been proved to cause classic hearing loss, a link has been established between exposure to constant room noise and loss in frequency and pattern discrimination essential to understanding the spoken word. Loss of an ability to discriminate speech can cause profound developmental delay in survivors with no other disabilities by interfering with language acquisition.

In addition to the connection between noise levels and deficits in hearing discrimination, clear connections also exist between noise and physiological instability. Preterm infants can experience repeated apneic episodes and clinically important reductions in oxygen saturation and bradycardia when exposed to normal adult activities in a NICU. Limiting neonates’ exposure to adult activities can decrease the number of alarms that represent physiological decompensation. One result of private and semiprivate rooms is that fewer adults are in the

room and a natural decrease occurs in the noise generated by activity and conversation. In a study by Robertson et al, decreasing conversation had the greatest effect on decreasing noise levels in the NICU.

VI. Variations in Infants’ Ages

Further complicating the developmental environment in a NICU is the routine of caring for preterm infants along with full-term infants. An infant born at 25 weeks’ gestation is far less mature and has quite different developmental needs than an infant born at 40 weeks’ gestation. Additionally, some infants admitted to our NICU stay for up to 1 year, and older infants have vastly different requirements than do newly born infants of any gestational age. In multi-patient rooms with infants of greatly different ages, any single routine for light or sound exposure most likely is inappropriate for one or more of the patients. The good intention of separating infants by age groups in multi-patient rooms can be forced to a low priority because of the requirements for intensity of care, therapeutic regimens, and the availability of beds. Thus, caring for infants of widely different ages increases the need for separate rooms in order to provide individualized developmental environments.

VII. Financial and Operational Issues

The cost of a new unit design was taken into account by the team at Children’s Hospital Los Angeles. According to estimates, the cost of caring for very-low-birth-weight infants during the infants’ first year of life accounts for nearly one third of all the healthcare dollars spent each year in the United States. Added to these direct costs are the realities of increasing overhead costs related to maintaining additional square footage that requires additional energy, housekeeping, and maintenance. Additionally, neonatal care, like the rest of the healthcare specialties, faces a severe shortage in nurses. All of these concerns (i.e., staffing, treatment costs, and facility operational costs) create pressure to keep open multi-patient space design for neonatal care under the assumption that these spaces are a more cost-effective design.

However, evaluations by health-care economists do not support the assumption that use of multi-patient rooms decreases costs. In several analyses, 60% to 70% of the cost of NICU care was attributed to daily room charges, making length of stay the single most important variable contributing to the cost of NICU care. Complications that increase the length of stay adversely affect costs; inversely, therapies that reduce the intensity of illness decrease the costs of care.

Reducing the rate of hospital-acquired infections is a well-known method of decreasing the mean length of stay. Hospital-acquired infections contribute significantly to neonatal mortality and can increase the cost of care on the average by $10000, nearly a 20% increase in the cost of "uncomplicated" care for a premature infant. Close contact between patients is one way that hospital-acquired infections can occur. Although multi-patient rooms do not per se cause overcrowding, during long stays in NICU, infants may have their beds pushed together briefly, resulting in cross-contamination. Accidentally using the same equipment to treat more than a single infant is also possible in multi-patient rooms. The essential principle of safety engineering

is that the optimal design will eliminate any possibility of user error. Placing a patient alone or with only one other patient fits that model.

In addition to providing potential gains in intact survival, developmental care can have a positive effect on length of stay. Developmental care that emphasizes the individual requirements of a preterm infant has resulted in earlier initiation of feedings, more rapid weight gain, and overall shorter lengths of stay and lower hospital costs.

Although NICU staff members are generally enthusiastic about applying new therapies to their vulnerable patients, the realities of a poorly designed unit can markedly undermine their best intentions. As described earlier, the available evidence convinced us to conclude that private or semiprivate rooms for sick neonates would allow us to meet the operational goal of maximizing care in a manner that was achievable with available financial resources.

Finally, when considering the redesign of their work environment, we could not ignore the effects of any new design on NICU staff. Staff concerns about efficiency of work, the effect on work relationships, and the ability to observe patients are a reality when considering a major redesign of a NICU. Clearly, staff morale also must be an important consideration, because recruitment and retention are essential to continuing to provide care in all the hospitals in the United States. As reported by Brooks of Alta Bates Summit Medical Center, Berkeley, California, moving from a traditional NICU multi-patient space to semi-private rooms required a significant adjustment by the staff. However, once the adjustment was made, overall staff satisfaction increased, at least in part because of the calmer environment created by separating patients. Brooks also reported that despite initial staff resistance, the semiprivate design was so successful that private rooms are now planned for an upcoming expansion.

VIII. Summary

The aging healthcare infrastructure, population growth, and changes in healthcare code requirements have all converged to create a demand for new facilities nationwide. At Children’s Hospital Los Angeles, we are replacing our now 40-year-old building with a 280-bed facility. One of the key units we have is our NICU. Early in the design process, we had to face the basic question now facing many other facilities: do we keep the open unit design or do we move to private and semiprivate rooms? The healthcare team in the NICU opted for the latter. Our new facility will include 10 private and 15 semiprivate rooms. We think that this decision is well grounded in the evidence currently at our disposal, the needs of our patients, and the goals of our professional staff. As is true in most building projects, we will not be able to validate our decision until after we have moved in. Surveys of the parents of our patients before and after the new NICU is occupied, staff questionnaires, and quality assurance and quality control data will help us determine if we have, in the end, made the right decision.

Figure 1 A patient’s room converted for use as a neonatal intensive care unit.

Figure 2 Neonatal intensive care unit designed and built in the 1980s