Introduction

Application of These Standards

Substantive changes to 8^th Edition

The Newborn Intensive Care Unit

Standards:

Delivery Room Standard

Newborn ICU Standards

1. Unit Configuration
2. Location within the Hospital
3. Family Entry and Reception Entry
4. Safety/Infant Security
5. Minimum Space, Clearance, and Privacy Requirements for the Infant Space
6. Single Family Room Space
7. Airborne Infection Isolation Area
8. Operating Rooms Intended for Use by Newborn ICU Patients
9. Electrical, Gas Supply and Mechanical
10. Ambient Temperature and Ventilation
11. Handwashing
12. General Support Space
13. Staff Support Space
14. Support Space for Ancillary Services
15. Administrative Space
16. Family Support Space
17. Family Transition Room(s)
18. Ceiling Finishes
19. Wall Surfaces
20. Floor Spaces
21. Furnishings
22. Ambient Lighting in Infant Care Area
23. Procedure Lighting in Infant Care Area
24. Illumination of Support Areas
25. Daylighting
26. Access to Nature and other Positive Distractions
27. Acoustic Environment

Glossary

References

The creation of formal planning guidelines for newborn intensive care units (NICUs) first occurred when Toward Improving the Outcome of Pregnancy was published in 1976¹.  This landmark publication, written by a multidisciplinary committee and published by the March of Dimes, provided a rationale for planning and policy for regionalized perinatal care, as well as details of roles and facility design. Since then, the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) have published several editions of their comprehensive Guidelines for Perinatal Care², and The American Institute of Architects has likewise published several editions of their Guidelines for Construction of Hospital and Healthcare Facilities³. In 1993, Toward Improving the Outcome of Pregnancy was revised⁴. The second TIOP reviewed medical and societal changes since the original document and formulated new recommendations in recognition of these developments, particularly the ascendance of managed care.

The purpose of this committee is to complement the above documents by providing health care professionals, architects, interior designers, state health care facility regulators, and others involved in the planning of NICUs with a comprehensive set of standards based on clinical experience and an evolving scientific database.

With the support of Ross Products Division / Abbott Laboratories, a multidisciplinary team of physicians, nurses, state health planning officials, consultants, and architects reached consensus on the first edition of these recommendations in January 1992.  The document was then sent to all members of the American Academy of Pediatrics Section on Perinatal Pediatrics to solicit their comments, and we also sought input from participants at the 1993 Parent Care Conference and at an open, multidisciplinary conference on newborn ICU design held in Orlando in 1993.   Subsequent editions of these recommended standards were then developed by consensus committees in 1993, 1996, 1999, 2002, 2006, and 2007 under the auspices of the Physical and Developmental Environment of the High-Risk Infant Project. 

Various portions of these recommended standards have now been adopted by the American Institute of Architects/Facilities Guidelines Institute Guidelines³, the AAP/ACOG Guidelines², and by standards documents in several other countries.  In the future, we will continue to update these recommendations on a regular basis, incorporating new research findings, experiences, and suggestions.

It is our hope this document will continue to provide the basis for a consistent set of standards that can be used by all states and endorsed by appropriate national organizations, and that it will also continue to be useful in the international arena.

While many of these standards are minimums, the intent is to optimize design within the constraints of available resources, and to facilitate excellent health care for the infant in a setting that supports the central role of the family and the needs of the staff. Decision makers may find these standards do not go far enough, and resources may be available to push further toward the ideal.

Unless specified otherwise, the following recommendations apply to the newborn intensive care built environment, although most have broader application for the care of ill infants and their families.

Where the word shall is used, it is the consensus of the committee participants that the standard is appropriate for future NICU constructions. We recognize that it may not be reasonable to apply these standards to existing NICUs or those undergoing limited renovation.

We also recognize the need to avoid statements requiring mandatory compliance unless a clear scientific basis or consensus exists. The standards presented in this document address only those areas where we believe such data or consensus is available.

Individuals and organizations applying these standards should understand that this document is not meant to be all-encompassing.  It is intended to provide guidance for the planning team to apply the functional aspects of operations with sensitivity to the needs of infants, family and staff. The program planning and design process should include research, evidence-based recommendations and materials, with objective input of experts in the field in addition to the internal interdisciplinary team that includes families who have experienced newborn intensive care.  The design should creatively reflect the vision and spirit of the infants, families and staff of the unit.  The program and design process should include:

Development of vision and goals for the project

Education on design planning and processes for changing organizational culture

Review of articles on patient- and family-centered care, individualized developmentally supportive care, teambuilding, evidence-based design, facility planning, and other relevant aspects of clinical practice.

• Visits to new and renovated units
• Vendor Fairs
• Program Planning
• Space planning, including methods to visualize 3-D space
• Operations planning, including traffic patterns, functional locations, and relationship to ancillary services
• Interior planning
• Surface materials selection
• Review of blueprints, specifications, and other documents
• Construction of mock-ups
• Preparation and planning for change in practice for staff and families in the new unit
• Building and construction
• Post-construction verification and remediation
• Post-occupancy evaluation

General changes:  The Standards have been re-numbered to allow similar topics to be positioned together in the document.

Standard 5:  This Standard now explicitly states that space must be provided at the bedside to allow for extended, intimate parental contact with the infant.

Standard 6:  The minimum clear floor space for single patient rooms has been increased to 165 square feet, based on extensive experience with NICUs that have incorporated this feature and found that rooms any smaller than this are universally considered to be too small.  The Standard now also specifies that a recumbent sleep surface be provided for at least one adult in these rooms.

Standard 11:  In light of the efficacy and increased use of waterless hand cleansers, the requirement that each single patient room have a handwashing station has been removed.  Each patient bed must still be within 20 feet of a handwashing sink so most designers will choose to place a sink inside a private room, but this change gives designers the option of situating the sink just outside the room based on their evaluation of the benefits and disadvantages of having a sink within the patient room.

Standard 14:  Unless provided elsewhere in the hospital, space must be provided in the NICU for feeding preparation, which should no longer be performed at the bedside.

Standard 22:  A requirement has been added to describe the allowable level of flicker in luminaires.

Standards 25 and 26:  The requirements for daylighting and access to nature have been clarified so that it will be clear that windows are not required for each patient room.  Our intent is to assure that daylighting and access to nature are readily accessible to families and staff.  These features are acceptable, even desirable in private rooms, but designers should not strive to provide windows in each private room if this means being unable to provide them in spaces frequented by adult caregivers and families.

No consensus national standard of what constitutes a NICU exists. Some states have defined levels of care, while other states have informal or no systems for classification.  The American Academy of Pediatrics has defined NICU levels of care based primarily on availability of specialized equipment and staff, but many NICUs often encompass both intensive and step-down or intermediate care. The recommended minimum standards we have written encompass Level III subspecialty care in general, rather than distinguish criteria for each sub-level.

For the purposes of this document, newborn intensive care is defined as care for medically unstable or critically ill newborns requiring constant nursing, complicated surgical procedures, continual respiratory support, or other intensive interventions.

Intermediate care includes care of ill infants requiring less constant nursing, but does not exclude respiratory support. When an intensive care nursery is available, the intermediate nursery serves as a “step down” unit from the intensive care area. When hospitals mix infants of varying acuity, requiring different levels of care in the same area, intensive care design standards shall be followed to provide maximum clinical flexibility.

Infant Resuscitation/Stabilization Areas

Space for infant resuscitation/stabilization shall be provided within operative delivery rooms and within Labor/Delivery/Recovery (LDR), Labor/Delivery/Recovery/Post-partum (LDRP) rooms, and other non-operative delivery rooms. Delivery rooms may directly connect to nursery or Newborn ICU (NICU) space via pass-through windows or doors. The ventilation system for each delivery and resuscitation room shall be designed to control the ambient temperature between 72-78 degrees Fahrenheit (22-26 degrees Centigrade) during the delivery, resuscitation, and stabilization of a newborn. 

Specific recommendations for each location where infant resuscitation or stabilization occurs are as follows:

Operative Delivery Rooms

Recommendations for operating rooms intended for use by NICU patients (Standard 8) shall be followed with these exceptions: 

• A minimum clear floor area of 80 square feet (7.5 square meters) for the infant shall be provided in addition to the area required for other functions.
• 3 oxygen, 3 air, 3 vacuum and 12 simultaneously-accessible electrical outlets shall be provided for the infant and shall comply with all specifications for these outlets described in NICU Standard 9.
• The infant space may not be omitted from the operative delivery room(s) when a separate infant resuscitation/stabilization room is provided.

LDR, LDRP or other Non-operative Delivery Rooms 

• A minimum clear floor area of 40 square feet (3.7 square meters) shall be provided for infant space. This space may be used for multiple purposes including resuscitation, stabilization, observation, exam, sleep or other infant needs.
• 1 oxygen, 1 air, 1 vacuum and 6 simultaneously-accessible electrical outlets shall be provided for the infant in addition to the facilities required for the mother.
• The infant space may not be omitted from the LDR, LDRP or non-operative delivery room when a separate infant resuscitation/stabilization room is provided.

Pass-Through Windows and Doors

•  Windows and doors shall be designed for visual and acoustical privacy and shall allow easy exchange of an infant between personnel.
• When an operative delivery room is equipped with a pass-through window or door, it shall have positive pressure so that air flows out to the infant room when the window or door is opened.

Interpretation:  Today’s delivery rooms (operative and non-operative) are required to have separate resuscitation space and outlets for infants. This space includes an acceptable environment for most uncomplicated term infants, but may not support the optimal management of infants who will become NICU patients.

Some term infants and most preterm infants are at greater thermal risk and often require additional personnel, equipment and time to optimize resuscitation and stabilization.  They are essentially NICU patients from the time of delivery and would therefore be optimally managed in space designed to NICU standards.  The appropriate resuscitation/stabilization environment should be provided.   Providing it in each delivery room allows parents to be aware of staff’s efforts to revive and care for their infant before transport to the NICU.  Providing ongoing support in a designated admission room or within the NICU with infant transfer via pass-through windows or doors offers efficiencies for staff, an environment designed for infants, and immediate access to all necessary equipment and supplies.  Infectious concerns for an opening into an operative room from a non-sterile (NICU) area are addressed by designing airflow out of the sterile room when windows and doors are opened.

Provision of appropriate temperature for delivery room resuscitation of high-risk preterm infants is vital to their stabilization.  While lower temperatures are often more comfortable for gowned attendants, the needs of the high-risk infant must take priority.  It is also essential that these appropriate ambient temperatures can be achieved within a short time frame, since many high-risk deliveries occur with little warning.

Since many of the higher risk patients are delivered in operative delivery rooms, the operative room minimums should be greater than the minimum standards for LDRs or LDRPs.  If a hospital serves a predominantly high-risk perinatal population, the hospital is encouraged to exceed the minimum standards.    

Equipment storage may be best provided by a wall-hung board or other suitable technique to allow ready visibility and access to all needed resuscitation equipment.

The NICU design shall be driven by systematically developed program goals and objectives that define the purpose of the unit, service provision, space utilization, projected bed space demand, staffing requirements and other basic information related to the mission of the unit. Design strategies to achieve program goals and objectives shall address the medical, developmental, educational, emotional, and social needs of infants, families and staff. The design shall allow for flexibility and creativity to achieve the stated objectives.

The NICU shall be configured to individualize the caregiving environment and services for each infant and family, including families of twins or higher-order multiples.

 Interpretation: Program goals and objectives congruent with the philosophy of care and the unit’s definition of quality should be developed by a planning team.  This team should include, among others, health care professionals, families whose primary experience with the hospital is as consumers of health care, administrators and design professionals.

The program goals and objectives should include a description of those services necessary for the complete operation of the unit and address the potential need to expand services to accommodate increased demand.

The specific approaches to achieve individualized environments are addressed in subsequent sections.

The NICU shall be a distinct area within the health care facility, with controlled access and a controlled environment.

The NICU shall be located within space designed for that purpose. It shall provide effective circulation of staff, family, and equipment. Traffic to other services shall not pass through the unit.

The NICU shall be in close and controlled proximity to the area of the hospital where births occur. When obstetric and neonatal services must be on separate floors of the Hospital, an elevator located adjacent to the units with priority call and controlled access by keyed operation shall be provided for service between the birthing unit and the NICU.

 Units receiving infants from other facilities shall have ready access to the hospital’s transport receiving area and shall designate a space for transport equipment.

Interpretation:  The purpose of this standard is to provide safe and efficient transport of infants while respecting their privacy.  Accordingly, the NICU should be a distinct, controlled area immediately adjacent to other perinatal services, except in those local situations (e.g., free-standing children’s hospitals) where exceptions can be justified.  Transport of infants within the hospital should be possible without using public corridors.

The NICU shall have a clearly identified entrance and reception area for families.  Families shall have immediate and direct contact with staff when they arrive at this entrance and reception area.

Interpretation:  The design of this area should contribute to positive first impressions for families and foster the concept that families are important members of their infant’s health care team, not visitors. Facilitating contact with staff will also enhance security for infants in the NICU.

This area should have lockable storage facilities for families’ personal belongings (unless provided elsewhere), and may also include a handwashing and gowning area.

The NICU shall be designed as part of an overall security program to protect the physical safety of infants, families and staff in the NICU. The NICU shall be designed to minimize the risk of infant abduction.

 Interpretation:  Because facility design significantly affects security, it should be a priority in the planning for renovation of an existing unit or a new unit. Care should be taken to limit the number of exits and entrances to the unit.

Control station(s) should be located within close proximity and direct visibility of the entrance to the infant care area. The control point should be situated so that all visitors must walk past the station to enter the unit. The design should provide for maximum visibility of the nursery from the workroom or charting area. However, security considerations should not adversely affect the quality of spaces for families in the NICU. The need for security should be balanced with the needs for comfort and privacy of families and their infants.

 Technological devices can be utilized in flexible and innovative manners within the design of the multiple-bed or single infant room NICU schematic.  Such technology, when utilized in conjunction with the thoughtful planning of the traffic patterns to/from and within the NICU space, support areas and family space, can facilitate a safe, yet open family-friendly area.