Administrative space shall be provided in the NICU for activities directly related to infant care, family support, or other activities routinely performed within the NICU.

Interpretation:  A wide range of personnel are assigned to the NICU, many of whom require office or administrative space. When planning the NICU, administrative space should be considered for each discipline that provides service to the unit on a daily basis and needs a distinct area for carrying out their responsibilities, even if that individual has additional office space elsewhere.

Space shall be provided in or immediately adjacent to the NICU for the following functions: family lounge area, lockable storage, telephone(s), and toilet facilities.  Separate, dedicated rooms shall also be provided for lactation support and consultation in or immediately adjacent to the NICU. A family library or education area shall be provided within the hospital.  Access to the Internet and educational materials shall be provided via a computer station in the family lounge or at the infant’s bedside.

Interpretation:  Family Lounge Area: This should include comfortable and moveable seating, as well as a play area stocked with entertainment materials for children. A nourishment area should also be considered, as well as external windows or skylights.

Lockable Storage:  Secure storage for personal items should be provided at each infant space.

Lactation Support: Comfortable seating, a handwashing sink, and a means of communication to the NICU should be provided.

Family Education Area: This should include publications, audiovisual resources, and Internet access so that families can learn about health conditions, child development, parenting issues, and parent-to-parent support. This area might also include space and supplies to learn about and practice caregiving techniques.

Telephones: Telephones should be provided that offer privacy and that enable an individual to sit down while talking.

Consultation Room: This should include comfortable seating and allow complete visual and acoustic privacy.

Family-infant room(s) shall be provided within or immediately adjacent to the NICU that allow(s) families and infants extended private time together.

The room(s) shall have direct, private access to sink, toilet and shower facilities, emergency call and telephone or intercom linkage with the NICU staff, sleeping facilities for at least one parent, and sufficient space for the infant’s bed and equipment. Each room shall also have at least four electrical outlets for use and charging of the family’s electronic devices.

The room(s) can be used for other family support, educational, counseling, or demonstration purposes when unoccupied.

Interpretation:  Access to family-infant room(s) encourages overnight stays by parents and the infant in the NICU. The room(s) should be sufficiently equipped and sized to accommodate the parents, with additional space for a physician, nurse, social worker, chaplain, or other individuals who may need to meet with the parents and baby in private.

For security reasons, transition room(s) should be situated within an area of controlled public access.

The number of electrical, medical gas, and suction outlets specified will be dependent on the function(s) intended for this area.

Sufficient family-infant rooms should be provided to allow those families who wish to room in with their infants the opportunity to do so.  The appropriate number of rooms will depend on each hospital’s practice pattern, the number of single infant rooms with parent sleeping facilities, the availability of other rooms nearby, the size of the region served, and other variables.

Ceilings shall be easily cleanable and constructed in a manner to prohibit the passage of particles from the cavity above the ceiling plane into the clinical environment.

The ceiling construction in infant rooms and adult sleep areas and the spaces opening onto them shall not be friable and shall have a noise reduction coefficient (NRC) of at least 0.90 for 80% of the entire surface area or an average NRC of 0.85 for the whole ceiling including solid and acoustically absorptive surfaces.  To ensure protection from noise intrusion, ceilings in infant rooms and adult sleep areas shall be specified with a ceiling articulation class (CAC)-29.

Finishes shall be free of substances known to be teratogenic, mutagenic, carcinogenic, or otherwise harmful to human health.

Interpretation:  Since sound abatement is a high priority in the NICU, acoustical ceiling systems are desirable, but must be selected and designed carefully to meet this standard. In most NICUs, the ceiling offers the largest available area for sound absorption.  The Standard for ceiling finishes includes areas that communicate with infant rooms and adult sleep areas (e.g., hallways, corridors, storage, and staff work areas) when doors are opened in the course of daily activity.

Ceilings with high acoustical absorption (i.e., high NRC ratings) do not necessarily have a significant barrier effect (i.e., offer protection from sounds transmitted between adjacent areas).  A CAC-29 provides a moderate barrier effect and allows a broad range of ceiling products.  Poor barrier effects can result if room-dividing partitions are discontinued above the ceiling allowing room-to-room cross-talk or if there are noise-producing elements in the ceiling plenum.  If the ceiling plenum contains noise sources such as fan-powered boxes, in-line exhaust fans, variable air volume devices, etc. then a higher CAC than CAC-29 may be necessary.

VOCs and PBTs such as cadmium are often found in paints and ceiling tiles and should be avoided. Specify low- or no-VOC paints and coatings.

Wall surfaces shall be easily cleanable and provide protection at points where contact with movable equipment is likely to occur.  Surfaces shall be free of substances known to be teratogenic, mutagenic, carcinogenic, or otherwise harmful to human health.

Interpretation:  As with floors, the ease of cleaning, durability, and acoustical properties of wall surfaces must be considered. Although commonly used, many vinyl wall coverings contain PVC and will degrade indoor air quality, and thus should be avoided. VOCs and PBTs such as cadmium often are found in paints, wall-coverings, acoustical wall panels, and wood paneling systems and also should be avoided. Specify low- or no-VOC paints and coatings.

Floor surfaces shall be easily cleanable and shall minimize the growth of microorganisms.

Flooring material with a reflectance of no greater than 40%⁸ and a gloss value of no greater than 30 gloss units shall be used⁵, to minimize the possibility that glare reflected from a bright procedure or work-area light will impinge on the eyes of infants or caregivers.

Floors shall be highly durable to withstand frequent cleaning and heavy traffic.

Flooring materials shall be free of substances known to be teratogenic, mutagenic, carcinogenic, or otherwise harmful to human health.

Interpretation:  While ease of cleaning and durability of NICU surfaces are of primary importance, consideration should also be given to their glossiness (the mirror-like reflectivity of a surface)¹¹, their acoustical properties, and the density of the materials used.  Reduced glossiness will reduce the risks from bright reflected glare; acoustic and density properties will directly affect noise and comfort.

Materials should permit cleaning without the use of chemicals that may be hazardous, since it may not be possible to vacate the space during cleaning.

Transition surfaces that do not obstruct mobility, are durable, and minimize noise and jarring of equipment should be provided at the intersection of different flooring materials.

Materials suitable to these criteria include resilient sheet flooring (medical grade rubber or linoleum) and carpeting with an impermeable backing, heat- or chemically-welded seams, and antimicrobial and antistatic properties. Carpeting has been shown to be an acceptable floor covering in the hospital and the NICU and has obvious aesthetic and noise reduction appeal, but it is not suitable in all areas (e.g., around sinks or in isolation or soiling utility/holding areas). Small floor tiles (e.g., 12 inch squares) have myriad seams and areas of non-adherence to the sub-floor.  These harbor dirt and fluids and are a potential source of bacterial and fungal growth.

Much is known regarding the effects of chemicals such as mercury on human health and development. Additional efforts should be made to exclude persistent, bioaccumulative toxic chemicals (PBTs) such as polyvinyl chloride (PVC) from healthcare environments. PVC or vinyl is common in flooring materials including sheet goods, tiles, and carpet. The production of PVC generates dioxin, a potent carcinogen, and fumes emitted from vinyl degrade indoor air quality. Dioxin releases are not associated with materials such as polyolefin, rubber (latex), or linoleum.

Volatile organic compounds (VOCs) such as formaldehyde and chlorinated compounds such as neoprene also should be avoided when selecting adhesives or sealants for floor coverings. Specify low- or no-VOC and non-toxic and non- carcinogenic materials. Flooring containing natural rubber (latex) should be certified non-allergenic by the manufacturer.

Infants should not be moved into an area of newly installed flooring for a minimum of two weeks to permit off-gassing of adhesives and flooring materials.

Built-in and freestanding furnishings such as cabinets and carts, especially those in the infant care areas, shall be easily cleanable with the fewest possible seams in the integral construction. Exposed surface seams shall be sealed. Furnishings shall be of durable construction to withstand impact by movable equipment without significant damage.

Furnishings and materials shall be free of substances known to be teratogenic, mutagenic, carcinogenic, or otherwise harmful to human health.

Interpretation:  Countertops should have the fewest possible seams. Edges exposed to impact should be “soft” (i.e., bull-nosed). Corners created at wall or backsplash intersections should be coved. Intersections with sinks or other devices should be sealed or made integral with the top. Casework construction should not chip or flake when struck by objects in the normal routine of infant care, and should be of sufficient moisture resistance to prevent deterioration. 

Furnishings in the NICU are often composite pieces made of various parts and layers of materials that are assembled with glue or adhesives.  Materials and substances typically used in these furnishings often contain volatile organic compounds (VOCs) such as formaldehyde, which is frequently found in pressed wood products including plywood and particle board. Vinyl-based laminates, which often are applied to the surface of pressed wood products, also contain VOCs such as polyvinyl chloride (PVC). Specify low- or no-VOC materials, including urea-formaldehyde-free adhesives, for all furnishings in the NICU.

Specifying furnishings and materials from regional sources (within a 300 – 500 mile radius) not only provides support for the local community, but also reduces the amounts of fossil fuels necessary for transport.

Ambient lighting levels in infant spaces shall be adjustable through a range of at least 10 to no more than 600 lux (approximately 1 to 60 foot candles), as measured on a horizontal plane at each bedside. Both natural and electric light sources shall have controls that allow immediate darkening of any bed position sufficient for transillumination when necessary.

Electric light sources shall have a color rendering index (CRI)⁸ of no less than 80, and a gamut area index (GAI)⁹ of no less than 80 and no greater than 100.  The optical reflectors in the luminaires (light fixture) shall have a neutral finish so that the color rendering properties of the light source are maintained. The sources shall avoid unnecessary ultraviolet or infrared radiation by the use of appropriate lamps, lens, or filters⁵.

No direct view of the electric light source or sun shall be permitted in the infant space (as described in Standard 5): this does not exclude direct procedure lighting, as described in Standard 23.  Any lighting used outside the infant care area shall be located so as to avoid any infant’s direct line of sight to the fixture.

The electric light sources that are supplied by 60 Hz alternating current shall not flicker more than a common 40 W incandescent light source.  Specifically, the frequency and the depth of the light modulation produced by the source shall be no less than 120 Hz and no more than 13%, respectively¹⁰.

Lighting fixtures shall be easily cleaned.

Interpretation:  Substantial flexibility in lighting levels is required by this standard so that the disparate needs of infants at various stages of development and at various times of day can be accommodated, as well as the needs of caregivers.  In very preterm infants, there has been no demonstrable benefit to exposure to light.  After 28 weeks gestation, there is some evidence that diurnally-cycled lighting has potential benefit to the infant¹¹.  Caregivers benefit from moderate levels of ambient light in order to perform tasks and maintain wakefulness

Control of illumination should be accessible to staff and families, and capable of adjustment across the recommended range of lighting levels. Use of multiple light switches to allow different levels of illumination is one method helpful in this regard, but can pose serious difficulties when rapid darkening of the room is required to permit transillumination, so a master switch should also be provided.

Perception of skin tones is critical in the NICU; light sources that meet the CRI and GA values identified above provide accurate skin-tone recognition. Light sources should be as free as possible of glare or veiling reflections.  When the light sources to be used are linear fluorescent lamps, these color criteria can be met by using lamps that carry the color designation “RE80”.

Separate procedure lighting shall be mounted at each infant bed. The luminaire shall be capable of providing no less than 2000 lux at the plane of the infant bed, and must be framed so that no more than 2% of the light output of the luminaire extends beyond its illumination field. This lighting shall be adjustable so that lighting at less than maximal levels can be provided whenever possible.

Interpretation:  Temporary increases in illumination necessary to evaluate a baby or to perform a procedure should be possible without increasing lighting levels for other babies in the same room.

Since intense light may be unpleasant and harmful to the developing retina, every effort should be made to prevent direct light from reaching the infant’s eyes. Procedure lights with adjustable intensity, field size, and direction will help protect the infant’s eyes from direct exposure and provide the best visual support to staff.

It is preferable that the procedure light be either mounted on the headwall or incubator in lieu of a floor stand.  This will maximize the space around the infant work area and minimize trip hazards.

Illumination of support areas within the NICU, including the charting areas, medication preparation area, the reception desk, and handwashing areas, shall conform to IES specifications⁵.

Interpretation:  Illumination should be adequate in areas of the NICU where staff perform important or critical tasks; the IES specifications in these areas are similar to but somewhat more specific than the general guidelines recommended by AAP/ACOG².

In locations where these functions overlap with infant care areas (e.g., close proximity of the staff charting area to infant beds), the design should nevertheless permit separate light sources with independent controls so the very different needs of sleeping infants and working staff can be accommodated to the greatest possible extent. Care must be taken, however, to insure that bright light from these locations does not reach the infants’ eyes (see Standard 22).