Evidence-based design for infants and staff in the neonatal intensive care unit

Color and newborn intensive care unit design: executive summary

Research on color in the design of healthcare settings is minimal. This paper provides an executive summary of a recent review on this topic, focusing on application to newborn intensive care units. The review focuses on the following question: Does the use of color in the design of the newborn intensive care units impact health outcomes in infants, families, and/or staff? We employed a structured review process, resulting in four studies involving the use of color in NICUs. The search was expanded to include general research on responses to color and studies in other healthcare settings. The literature clustered around preferences and psychobiological impact of color on infants and adults in NICUs, the interaction of color and light, and the impact of color on adults in general medical settings. Recommendations are made regarding the importance of modifiability and flexibility in the use of color in NICUs and colors that are associated with stress reduction and stimulation.

Color and NICU Design

PURPOSE

The appropriate use of color in healthcare settings has been a topic of interest for designers and researchers, and the need for evidence-based standards evident. The purpose of this article is to summarize recent research on color as applicable to neonatal intensive care units and to propose standards for color in these settings.

BACKGROUND

Research on this topic is limited due to difficulties associated with constructing research protocols, challenges in setting parameters for the independent variable (color), and the need to simultaneously address infants, families, and caregivers.

METHODS

For our literature review, the following research question was developed: Does the use of color in the design of the neonatal intensive care units (NICUs) impact health outcomes in newborn infants, families, and/or staff? Using Arksey and O'Malley's framework for conducting a structured literature review, we (1) identified the research question, (2) identified relevant studies, (3) selected studies, and (4) collated and summarized the results. Only four papers were found regarding NICUs, so the search was expanded to include related healthcare and authors reporting on best practice.

RESULTS

Overall, the primary research focused on behavioral or physiological outcomes including the role of wayfinding and art, the impact of lighting on color, and tools for evaluating the impact of color. Best practice recommendations sometimes reflected the primary research but occasionally provided contradictory advice.

CONCLUSIONS

Based on the reviewed literature, five topics are addressed: palette malleability; the use of the primary colors, blue, red, and yellow; and the relationship between light and color.

Comparing light and noise levels before and after a NICU change of design

OBJECTIVE

To compare light and sound levels before and after a change of design and evaluate these levels considering recommended NICU standards.

STUDY DESIGN

A pre-test/post-test design. Light and sound levels were compared between the former open ward (OW) NICU of 34 beds and the current 40-bed unit composed of both pods and single-family rooms (SFR).

RESULT

Light levels were significantly higher in the pod/SFR unit for all levels of care, days of the week and time of the day. These findings could be attributed to the number and configuration of windows in the new pod/SFR unit allowing for more daylight entry compared to the OW. Sound levels were significantly lower in the current NICU (pod/SFR) compared to the former OW.

CONCLUSION

Following the change of design, the pod/SFR unit are less noisy than the OW, although light levels are higher indicating the necessity to measure light levels.

Mothers' experiences expressing breast milk for their preterm infants: does NICU design make a difference?

PURPOSE

This study examined differences in outcomes of provision of mothers' milk before and after implementation of a single-family room (SFR) neonatal intensive care unit (NICU) and described issues related to long-term milk expression.

SAMPLE

The sample included 40 mothers (15 in the original NICU and 25 in the SFR NICU).

DESIGN

Descriptive comparative.

METHODS

Mothers were recruited 2 months before and 3 months after opening an SFR NICU. Nutritional data were collected throughout hospitalization. Mothers used a milk expression diary during hospitalization and completed a survey, "My Experiences With Milk Expression" immediately before infant discharge.

RESULTS

Seventy-five percent of mothers planned to express breast milk or breastfeed before delivery. The majority of the mothers (55%) were most comfortable pumping in their own homes because of the increased privacy. There were no statistically significant differences between the 2 groups regarding the place where they were most comfortable pumping or where they usually pumped, although more mothers pumped in their babies' rooms in the SFR NICU. The majority of the mothers reported concern about their milk supply at some time during hospitalization and 47.5% reported having breast problems. At discharge, 71.8% of the total group was providing some breast milk and 44.7% of the total group was providing breast milk exclusively. There were no significant differences between the groups in outcomes concerning the provision of breast milk.

CONCLUSIONS

Individual mother's needs for privacy need to be determined and interventions to support mothers' feeding plans throughout hospitalization and at discharge need to be developed.

Impact of the design of neonatal intensive care units on neonates, staff, and families: a systematic literature review

Newborn intensive care is for critically ill newborns requiring constant and continuous care and supervision. The survival rates of critically ill infants and hospitalization in neonatal intensive care units (NICUs) have improved over the past 2 decades because of technological advances in neonatology. The design of NICUs may also have implications for the health of babies, parents, and staff. It is important therefore to articulate the design features of NICU that are associated with improved outcomes. The aim of this study was to explore the main features of the NICU design and to determine the advantages and limitations of the designs in terms of outcomes for babies, parents, and staff, predominately nurses. A systematic review of English-language, peer-reviewed articles was conducted for a period of 10 years, up to January 2011. Four online library databases and a number of relevant professional Web sites were searched using key words. There were 2 main designs of NICUs: open bay and single-family room. The open-bay environment develops communication and interaction with medical staff and nurses and has the ability to monitor multiple infants simultaneously. The single-family rooms were deemed superior for patient care and parent satisfaction. Key factors associated with improved outcomes included increased privacy, increased parental involvement in patient care, assistance with infection control, noise control, improved sleep, decreased length of hospital stay, and reduced rehospitalization. The design of NICUs has implications for babies, parents, and staff. An understanding of the positive design features needs to be considered by health service planners, managers, and those who design such specialized units.

Evaluation of the Built Environment: Staff and Family Satisfaction Pre- and Post-Occupancy of the Children's Hospital

Objective:

To evaluate and compare the impact of an existing and newly built hospital environment on family and staff satisfaction related to light, noise, temperature, aesthetics, and amenities, as well as safety, security, and privacy.

Background:

The United States is engaged in an unprecedented healthcare building boom driven by the need to replace aging facilities, understand the impact of the built environment on quality and safety, incorporate rapidly emerging technologies, and enhance patient- and family-centered care. More importantly, there is heightened attention to creating optimal physical environments to achieve the best possible outcomes for patients, families, and staff.

Methods:

Using a pre-post descriptive survey design, all nursing, social work, therapy staff, and families on selected inpatient units were invited to participate. A demographic form and Family and Staff Satisfaction Surveys were developed and administered pre- and post-occupancy of the new facility.

Results:

Pre/post mean scores for staff satisfaction improved on all survey subscales with statistically significant improvement ( p < .05) in most areas. The most improvement was seen with layout of the patient room, natural light, storage and writing surfaces, and comfort and appeal. Family satisfaction demonstrated statistically significant improvement on all subscales (p ≤ .01), especially for natural light, quiet space, parking, and the child's room as a healing environment.

Conclusions:

Families and staff reported greater satisfaction with the newly built hospital environment compared to the old facility. Study results will help guide future architectural design decisions, attract and retain staff at a world-class facility, and create the most effective healing environments.

Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design

OBJECTIVE

To compare perceived workplace quality in an open-bay neonatal intensive care unit (NICU) and a single-family room (SFR) NICU.

STUDY DESIGN

Prospective non-randomized, non-controlled cohort study.

RESULT

Staff workplace quality perceptions assessed included the following: the quality of being a Sanford Health System employee (NS-not significant), the quality of the NICU physical work environment, the quality of NICU patient care, the job quality in the NICU, the quality of health and safety in the NICU (NS), the quality of safety and security in the NICU, the quality of interaction with other members of the NICU health-care team (NS; in subanalysis nurse scores significantly declined), the quality of interaction with NICU technology and the off-job quality of life (NS). Scores for each category and the total scores were statistically greater in the SFR, except as noted (NS).

CONCLUSION

Staff perceptions of workplace quality were significantly greater in the SFR than the open-bay NICU.

Transition to an individual-room NICU design: process and outcome measures

Redesign of a neonatal intensive care unit is a major budget undertaking, demanding accountability for its equipment and feasibility of design. It must be philosophically based and driven by research supporting best practice. The NJCU at the Magee-Womens Hospital of the University of Pittsburgh Medical Center, a Level III, 74-bed unit, has made the change from a ward design to an individual-room design suitable for family-centered, developmentally supportive care. This article presents the design process as it occurred. Unique to this process are the involvement of NJCU-graduate families and the use of transition teams. Guidelines and recommendations are offered to others interested in designing and practicing in an individual-room NJCU. Outcome data demonstrate staff adjustment to the new design and practice model. A comparison of this NICU design is made with the Recommended Standards for Newborn ICU Design.

The development of potentially better practices to support the neurodevelopment of infants in the NICU

OBJECTIVE

To review the existing evidence used to identify potentially better care practices that support newborn brain development.

STUDY DESIGN

Literature review.

RESULT

Sixteen potentially better practices are identified and grouped into two operational clinical bundles based upon timing for recommended implementation.

CONCLUSION

Existing evidence supports the implementation of selected care practices that potentially may support newborn brain development.

Noise in contemporary neonatal intensive care

Weekly sound surveys (n = 63) were collected, using 5 s sampling intervals, for two modern neonatal intensive care units (NICUs). Median weekly equivalent sound pressure levels (LEQ) for NICU A ranged from 61 to 63 dB (A weighted), depending on the level of care. NICU B L(EQ) measurements ranged from 55 to 60 dB (A weighted). NICU B was recently built with a focus on sound abatement, explaining much of the difference between the two NICUs. Sound levels exceeded 45 dB (A weighted), recommended by the American Academy of Pediatrics, more than 70% of the time for all levels of care. Hourly L(EQ)s below 50 dB (A weighted) and hourly L10s below 55 dB (A weighted), recommended by the Sound Study Group (SSG) of the National Resource Center, were also exceeded in more than 70% of recorded samples. A third SSG recommendation, that the 1 s L(MAX), should not exceed 70 dB (A weighted), was exceeded relatively infrequently (< 11% of the time). Peak impulse measurements exceeded 90 dB for 6.3% of 5 s samples recorded from NICU A and 2.8% of NICU B samples. Twenty-four h periodicities in sound levels as a function of regular staff activities were apparent, but short-term variability was considerable.

Room for improvement: nurses' perceptions of providing care in a single room newborn intensive care setting

Theoretically, single patient room newborn intensive care units are designed to optimize the developmental outcomes of critically ill infants by providing individual patient environments with decreased stimulation and noise. This article reports the perceptions of 127 neonatal intensive care nurses after the move into a single room neonatal intensive care unit (NICU). The observations of the nurses were obtained using a questionnaire to identify some of the benefits, risks, and specific patient safety concerns related to the single room NICU design. The results suggest that in this setting the single patient room concept was deemed superior for patient care and parent satisfaction when compared to the large open unit. However, the nurses emphasize that the success of single room care model primarily depends on providing sufficient staff coverage, given the decreased patient visibility and greater distances between patients. Larger units also present unique communication, staff education, and quality improvement challenges. To further evaluate the impact of single room designs we evaluated data on important clinical issues, specifically noise levels and catheter-related infections provide objective measures of important improvements. Noise levels decreased from an average of 63 to 56 decibels and catheter-associated bloodstream infections fell from 10.1 per 1000 device days to 3.3 per 1000 device days in the 9 months after the move to single patient rooms. This article provides pragmatic design suggestions that should be prospectively considered to minimize staff isolation and stress.