Feature 61 Nicu

2013.6.1 Copyright © SpaceMed www.spacemed.com of 5

Originally printed in the SpaceMed Newsletter Winter 2013 www.spacemed.com

Evaluating Different NICU Facility Configuration Concepts By Cynthia Hayward

BACKGROUND Specialty areas for caring for critically ill neonates — known as neonatal intensive care units (NICUs) — were first developed in the late 1970s and 1980s as medical advances increased the survival rate of preterm (low birth weight) infants. With sig-nificant growth in the number of NICU patients, the configuration of large open wards with multiple bassinets appealed to staff who were caring for an endless in-flux of ill infants. In addition to providing optimal flexibility in the number and place-ment of the bassinets, the infants could be readily observed so that any changes in their physiological condition could be noted. Historically, private rooms were pro-vided only for patients with infections.

Developments in precise physiological monitoring and the capacity to integrate equipment alarms with other technology prompted the reevaluation of the traditional approach to monitoring infants. At the same time, with the survival of infants born preterm improving dramatically in the 1980s, concern about survival without disabil-ities also increased. Developmental research began to focus on the preterm infants’ environment in their first months of life. The focus also shifted from the preterm in-fant alone to the parent-child dyad. Research and recommendations on light and noise control also began to influence the design of the NICU. In the past decade, the design of the NICU has shifted away from placing infants in an open-bay in a large ward to a single family room (SFR). These family-centered private rooms pro-vide greater privacy, environmental control, and space customization to the infant's individual medical and developmental needs.

NICU FACILITY CONFIGURATION CONCEPTS Today, NICUs are increasingly designed using either the SFR concept, semi-private rooms to accommodate two infants, or a combination of both. Open-bay de-signs are primarily deployed where the constraints of existing space do not permit the other two options. To compare the space requirements between the SFR, semi-private room, and open-bay facility configuration concept, a space planning model was developed using common support space assumptions while varying the patient care space. The total department gross square feet (DGSF) per bed for different sizes of NICUs was also evaluated.

Single family room (SFR). SFRs are typically designed with space for the infant bassinet and monitoring equipment, staff charting and work surfaces, staff handwashing sink, and supply storage. Additional family space includes a recliner chair for kangaroo (skin-to-skin) care, a recumbent sleep surface for at least one parent, a work surface for writing or use of a laptop, and a storage cabinet for per-sonal effects. In a private patient room, a minimum of 150 net square feet (NSF) is required excluding sinks and aisles. A SFR of 170 NSF was assumed in this space analysis.

Semiprivate room. Rooms to accommodate two infants generally provide the same dedicated amenities for each infant’s family (on opposite sides of the bassi-net area). However, the staff support space is consolidated which results in some


Evaluating Different NICU Facility Configuration Concepts Continued

space efficiency. A minimum of 120 NSF of clear floor area is required for each infant in a multi-bed room. A semiprivate room of 280 NSF was assumed in this analysis.

Open-bay units may be designed with the bassinets around the perimeter of a large room, aligned lineally along a wall, or placed in a “pinwheel” arrangement. The pinwheel is circular in shape and typically divided into four areas via partitions. Each partitioned area is like a mini-room with the bassinet, a chair for a caregiver, counter space, and its own light control. The pinwheel design provides enhanced privacy for the infant and parents without physical containment in an individual room. Hospitals have also implemented various hybrid designs as well.

In order to provide adequate space at the bedside for both caregivers and families in private and semiprivate rooms, these rooms need to be somewhat larger than an infant space in an open multi-bed room. They must have additional bedside storage and communication capabilities in order to avoid isolation or excessive walking of caregivers. Although desirable, it may not be possible to provide a window for each room due to a finite amount of outside wall area. The available window area is gen-erally used first for the gathering spaces used by family and caregivers, and then secondarily for patient rooms.

SPACE PLANNING ASSUMPTIONS The space required for each of the three NICU facility configuration concepts was also evaluated based on the unit size. Space was estimated for a single 12-bed unit, and 24 and 36 bed units with pods of 12 beds.

The space in a NICU can be organized based on its functional use and typical aggregation within the unit. Assumptions used for each category of space are as follows:

Patient care pod includes the patient care rooms or bays. In this analysis, two isolation rooms are included in each 12-bed pod regardless of the facility configuration concept. In larger units, there may be more than one patient care pod requiring a small amount of decentralized support space that is placed directly adjacent to the bedrooms or bays to minimize caregiver walking to a central area.

Staff support space includes a central administrative control center for the NICU with a workstation for the unit clerk, touch-down workstations for caregivers and ancillary staff, an office for the NICU manager, team conference space, and associated staff amenities.

Clinical support space includes a clean supply room, soiled utility room, space for the storage and preparation of medications and the storage of infant formula and equipment used on the unit.

Family support space includes a parent/visitor lounge and consult room as well as an overnight sleep room and kitchenette and toilet facilities. Space for lactation counseling is also included.

Optional space that could either be included on the unit or elsewhere in the hospital includes a treatment/procedure room, space for infant formula preparation/processing (if commercial formula is not used), laundry room, and staff sleeping facilities.



Generally, the unit support space does not increase proportionate to an increase in the number of beds. This is because there are minimum sizes for most support spaces — such as clean supply and soiled utility rooms — that can accommodate a fixed number of beds. A further increase in beds can usually be accommodated with the addition of a second supply cart, bin, or cabinet.

An example space program comparing the space required for a 24-bed NICU depending on the chosen facility configuration concept can be reviewed at www.spacemed.com/newsletter/news61.html.

ANALYSIS As shown in the bar chart below, for a smaller NICU with 12 beds, the semiprivate room and open-bay concepts require about the same DGSF and the SFR unit re-quires about seven percent more space. As the number of total beds increases the differential between the SFR and open-bay concepts narrows. For a 24-bed NICU, the SFR concept requires eight percent more space than with semiprivate rooms and only five percent more space than the open-bay concept. The SFR concept re-quires nine percent and four percent more space than the semiprivate room and open bay concepts, respectively for a 36-bed NICU.

Guidelines for the minimum clear floor area required for each open-bay have in-creased substantially in the past decade which reduces the variance between the DGSF per bed in the open-bay concept versus the SFR and semiprivate room op-tions. Also, in this analysis, additional parent/infant sleep rooms are provided in the open-bay concept because recumbent sleeping facilities for parents are not provid-ed at the bedside as in the SFR and semiprivate room concepts.

Comparison of Department Gross Square Feet (DGSF) by Facility Configuration Concept for Different Size NICUs



When the DGSF per bed is reviewed in this example, the economies of scale of a larger unit far outweigh differences in the facility configuration concept as shown in the chart below. NICUs with all single family rooms range from 544 DGSF per bed for a 12-bed unit and decrease to 465 DGSF per bed for a 36-bed unit. Likewise, a unit with semiprivate rooms requires 507 DGSF per bed for a 12-bed unit which de-creases to 428 DGSF per bed for a 36-bed unit. The space required for a traditional open-bay NICU with 12 beds calculates to 509 DGSF per bed which decreases to 445 DGSF per bed for a 36-bed unit. It should also be noted that the net-to-gross space conversion factor alone — assumed to be 1.50 in this example — represents one-third of the total DGSF per bed such that a more efficient layout could mitigate differences between the facility configuration concept and/or the number of NICU beds.

In addition to the basic support spaces included in the analysis, optional space which might be located either within the NICU or elsewhere in the hospital, could account for another 600 to 800 NSF depending on the functional program and space availability.

It should be noted that as the number of NICU beds decreases further (i.e., less than 12 beds), the DGSF per bed increases substantially because of the minimum sizes required for support spaces. For example, a six-bed NICU, using the space planning model described in this analysis, would require over 700 DGSF per bed.

Comparison of Department Gross Square Feet (DGSF) Per Bed by Facility Configuration Concept for Different Size NICUs

SUMMARY Premature birth costs society more than $26 billion a year (March of Dimes Foun-dation, 2013) and babies born just a few weeks early are at risk of severe health problems and lifelong disabilities. Based on current research, a single family room is generally considered the optimal environment for the infant and family. However, the isolation of neonates in separate private rooms prompts concerns about the relative safety of the SFR compared with the open-ward design and may require additional staff.



In some communities, parents may actually prefer the camaraderie developed in the open-bay or multi-bed room concept. In addition to the cost of constructing ap-proximately 10 percent more space, overhead costs related to maintaining addi-tional square footage (e.g., additional energy, housekeeping, and maintenance) could also increase as well as staffing costs when the SFR concept is implement-ed. Consequently, healthcare staff have met the challenge of this transition with mixed enthusiasm, varying with experience and employment position. All of these concerns create pressure to maintain the open-bay design for neonatal care under the assumption that this concept is a more cost-effective design.

However, there are other considerations when opting for the SFR concept. Length of stay is 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 also a well-known method of reducing the length of stay. Close contact between patients is one way that hospital-acquired in-fections can occur. Research also shows that private patient rooms decrease the number of medical errors. It appears that just as the all single-room concept for adult medical/surgical patient care is now considered the standard in the U.S., the SFR concept for neonatal intensive care will also become the norm.

See an example of a room-by-room space program for the different NICU facility configuration concepts at www.spacemed.com/newsletter/news61.html.

Cynthia Hayward, AIA, is founder and principal of Hayward & Associates LLC.

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