Each infant space shall contain a minimum of 120 square feet (11.2 square meters) of clear floor space, excluding handwashing stations, columns, and aisles (see Glossary). Within this space, there shall be sufficient furnishing to allow a parent to stay seated, reclining, or fully recumbent at the bedside. There shall be an aisle adjacent to each infant space with a minimum width of 4 feet (1.2 meters) in multiple bed rooms. When single infant rooms or fixed cubicle partitions are utilized in the design, there shall be an adjacent aisle of not less than 8 feet (2.4 meters) in clear and unobstructed width to permit passage of equipment and personnel.

Multiple bed rooms shall have a minimum of 8 feet (2.4 meters) between infant beds.  There shall be provision for visual privacy for each bed, and the design shall support speech privacy at a distance of 12 feet (3.6 meters). 

 Interpretation:  These numbers are minimums and often need to be increased to reflect the complexity of care rendered, bedside space needed for parenting and family involvement in care, and privacy for families (see Standard 6).

The width of aisles in multiple bed rooms should allow for easy movement of all equipment that might be brought to the infant’s bedside, as well as easy access for a maternal bed.  The width of the corridors or aisles outside single infant rooms or infant spaces designed with permanent cubicle partitions should allow for simultaneous passage of two such items as mandated by state and federal architectural and fire codes.

The need for privacy for infants and families should be addressed not only in design of each bed space, but also in the overall unit design – for example, by minimizing traffic flow past each bed.

Rooms intended for the use of a single infant and his/her family shall conform to the requirements for infant spaces designated elsewhere in these standards, with the following exceptions:

• Minimum size shall be no less than 165 square feet (15.3 square meters) of clear floor area.
• An outside window is not required (see Standard 25 for further specifics).
• The requirement for wireless monitor and communication devices shall be identical to that described for isolation rooms (see Standard 7).
• Each room shall be designed to allow visual and speech privacy for the infant and family.
• Family space shall be designated and be able to include, at a minimum:
  • A comfortable reclining chair suitable for kangaroo/skin-to-skin care
  • A recumbent sleep surface for at least one parent
  • A desk or surface suitable for writing and/or use of a laptop computer
  • At least four electrical outlets for use and charging of electronic devices.
  • No less than 6 cubic feet (0.2 cubic meter) of storage space
• Staff space shall be designated and include, at a minimum:
  • A work surface of no less than 6 square feet (0.6 square meters)
  • A charting surface of no less than 3 square feet (0.3 square meters)
  • Supply storage of no less than 30 cubic feet (0.85 cubic meter).
    • NOTE: The above requirements can be met by any combination of fixed and portable casework desired, but all storage must be designed for quiet operation.                   

Interpretation:  Private (single-family) rooms allow improved ability to provide individualized and private environments for each baby and family when compared to multi-patient rooms.  In order to provide adequate space at the bedside for both caregivers and families, however, these rooms need to be somewhat larger than an infant space in an open multi-bed room design, and 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.  It is most important to utilize the available window area first for the gathering spaces used by family and caregivers, and then secondarily for patient rooms.

An airborne infection isolation room shall be available for NICU infants, and shall provide a minimum of 150 square feet (14 square meters) of clear floor space, excluding the entry work area. A hands-free handwashing station for hand hygiene and areas for gowning and storage of clean and soiled materials shall be provided near the entrance to the room. Ventilation systems for isolation rooms shall be engineered to have negative air pressure with air 100% exhausted to the outside, and shall meet acoustic standards for infant rooms (Standard 27). Airborne infection isolation room perimeter walls, ceilings, and floors, including penetrations, shall be sealed tightly so that air does not infiltrate the environment from the outside or from other airspaces.

Airborne infection isolation rooms shall have self-closing devices on all room exit doors. An emergency communication system and remote patient monitoring capability shall be provided within the airborne infection isolation room.

Airborne infection isolation rooms shall have observation windows with internal blinds or switchable privacy (opaquing) glass for privacy.  Placement of windows and other structural items shall allow for ease of operation and cleaning.

Airborne infection isolation rooms shall have a permanently installed visual mechanism to constantly monitor the pressure status of the room when occupied by a patient with an airborne infectious disease.  The mechanism shall continuously monitor the direction of the airflow.

Interpretation:  An airborne infection isolation room adequately designed to care for ill newborns should be available in any hospital with an NICU. In most cases, this is ideally situated within the NICU, but in some circumstances, utilization of an airborne infection isolation room elsewhere in the hospital (e.g., in a pediatric ICU) would be suitable.

At least one single-occupancy isolation room should be available for any infant with a suspected airborne infection.  A space within the NICU should also be available to safely cohort a group of infants infected with or exposed to a common airborne pathogen.

When not used for isolation, these rooms may be used for care of non-infectious infants and other clinical purposes.

Turbulence attendant to high air-exchange rates can result in unacceptable levels of background noise in airborne infection isolation rooms.  Such levels result in speech interference, annoyance, and physiologic responses typical of noise exposure for adults and infants.  Specific attention is required, therefore, to the design of noise-attenuating devices in the heating/ventilation/air-conditioning (HVAC) ductwork and to washable acoustic surfaces on the walls and ceilings to ensure that sound levels meet the Standard in these rooms.  Glass partitions should be limited to that which is actually necessary for safe visualization.  Proportional amounts of acoustically absorptive and acoustically reflective surfaces should be appropriate to achieve greater than 25% sound absorption.

Operating rooms in health-care facilities where infant procedures may be performed shall be constructed to operating room specifications except for the following modifications:

Assuming infant’s eyes are shielded (eye patches) while in the operating room, no changes to the IES guidelines for operating rooms⁵ are required.  However, light sources meeting the CRI and GA values identified in Standard 22 are recommended.

Laminar flow diffusers over the surgical bed shall be set at the low end of the air velocity range (approximately 25 ft/min) and balanced with the surrounding slot diffuser air curtain to minimize convective and evaporative heat and water loss from higher air flow onto the infant.  In addition, ambient temperature and humidity shall be adjustable into the range of 72-78° F (22 to 26° C) with a relative humidity of at least 30%.

The acoustic environment set forth in Standard 27 shall be the basis for all design choices except for the necessary hard (cleanable) room surfaces.  No effort need be made to achieve this standard in adjacent spaces if doors are expected to remain closed during most of the procedures.

Specialized Procedure Spaces or Rooms Within the Newborn ICU

Specialized procedure spaces or rooms within the NICU shall be constructed to achieve all of the above, as well as all of the requirements for an infant bed space elsewhere in these Recommended Standards, except for the following additional modifications:

Each procedure area must be physically separated from other areas so that during surgery or procedures patient and staff flow may be strictly controlled.  Air flow must be designed so as to not disrupt the air curtain around the surgical field, and shall be adjustable so as to be able to increase to 15 changes/hr during procedures, then return to baseline values set forth in Standard 10.   A scavenging system to vent waste inhalation anesthesia and analgesia gases is required.  HVAC equipment shall be of a type that minimizes the need for maintenance within the room.

Procedure rooms designed for surgery or ECMO shall have a minimum clear floor area of 360 square feet (33.5 square meters) with a minimum dimension of 16 feet (4.9 square meters) exclusive of built-in shelves or cabinets, hand washing stations, and columns.  These rooms shall be designed to comply with safety requirements for performance of laser surgical procedures.  The space requirements for these functions in multi-bed rooms shall have a minimum clear floor area of 225 square feet (21 square meters) exclusive of built-in shelves or cabinets, hand washing stations, columns and aisles.

It is assumed that infants having surgery in the NICU will be operated on and recover in their own beds and that surgical personnel will bring needed sterile surgical equipment and supplies to the NICU.  Therefore, no additional recovery or post-anesthesia areas are required nor are work areas for storage and processing of surgical instruments and separate corridors leading to the operative area.  However, support areas for storage of clean and sterile surgical supplies shall be provided, and a scrub station shall be provided near the entrance to each procedure room in a corridor limited to authorized personnel and patients.                                                                           

Ambient lighting recommendations set forth in Standard 22 shall be followed except where higher illuminances are required as set forth in IES recommendations for operating rooms⁵. Increased ambient lighting must still be adjustable and indirect

Interpretation: Standard operating room environments may be temporarily modified to better accommodate term infants requiring surgery, but cannot be made optimal for some term and preterm infants, nor can the problems associated with transporting less stable infants away from the intensive resources of the NICU be avoided.  There is now sufficient experience to conclude that certain procedures can be performed in the NICU without compromising patient safety or outcomes.

It is now also evident that the environment currently recommended for NICU design may have a positive impact on infant outcomes. This Standard now makes provision for infants requiring surgical procedures to be similarly benefited.

Mechanical requirements at each infant bed, such as electrical and gas outlets, shall be organized to ensure safety, easy access and maintenance.

There shall be a minimum of 20 simultaneously accessible electrical outlets. The minimum number of simultaneously accessible gas outlets is:

Air 3,
Oxygen 3, and
Vacuum 3.

There shall be a mixture of emergency and normal power for all electrical outlets per current National Fire Protection Association recommendations⁶.

Interpretation:  A system that includes easily accessible raceways for electrical conduit and gas piping, work space, and equipment placement is recommended because it permits flexibility to modify or upgrade mechanical, electrical or equipment features. All outlets should be positioned to maximize access and flexibility and minimize repetitive movements such as bending and stretching by the staff. Standard duplex electrical outlets may not be suitable, since each outlet may not be simultaneously accessible for oversized equipment plugs. The number of electrical, gas, and suction outlets specified is a minimum; access to more may be necessary for critically ill infants. This area should also include communication devices, supply storage, and charting space, resulting in an efficient, organized, and self-contained workstation around the infant.

The NICU shall be designed to provide an air temperature of 72°F to 78°F (22-26° C) and a relative humidity of 30-60%, while avoiding condensation on wall and window surfaces.

A minimum of six air changes per hour is required, with a minimum of two changes being outside air.

The ventilation pattern shall inhibit particulate matter from moving freely in the space, and intake and exhaust vents shall be situated to minimize drafts on or near the infant beds. Ventilation air delivered to the NICU shall be filtered with at least the efficiency specified in the FGI Guidelines³ .  Filters shall be located outside the infant care area so they can be changed easily and safely.

Fresh air intake shall be located at least 25 feet (7.6 meters) from exhaust outlets of ventilating systems, combustion equipment stacks, medical/surgical vacuum systems, plumbing vents, or areas that may collect vehicular exhausts or other noxious fumes.  Prevailing winds or proximity to other structures may require greater clearance.

Interpretation:  Heat sources near the exterior wall, if applicable, should be considered to ameliorate the “cold wall” condition, which in turn can be a source of convection drafts. This application of heat may also alleviate the conditions leading to condensation on these walls.

The air flow pattern should be at low velocity and designed to minimize drafts, noise levels, and airborne particulate matter.  A HEPA filtration system may provide improved infection control for immunocompromised patients.

Because a regular maintenance program is necessary to assure that systems continue to function as designed after occupancy, NICU design should attempt to maximize the ease of maintenance while minimizing its cost.

Every infant bed, whether in a single or multiple-bed room, shall be within 20 feet (6 meters) of a hands-free handwashing station.  Handwashing stations shall be no closer than 3 feet (0.9 meter) from an infant bed, clean supply storage, or counter/worksurface unless a splashguard is provided.

Handwashing sinks shall be large enough to control splashing and designed to avoid standing or retained water. Minimum dimensions for a handwashing sink are 24 inches wide x 16 inches front to back x 10 inches deep (61 cm x 41 cm x 25 cm) from the bottom of the sink to the top of its rim. Space for pictorial handwashing instructions shall be provided above all sinks. There shall be no aerator on the faucet.  Walls adjacent to handwashing sinks shall be constructed of non-porous material.  Space shall also be provided for soap and towel dispensers and for appropriate trash receptacles. Towel dispensers shall operate so that only the towel itself need be touched in the process of dispensing, and constructed in such a fashion as to control noise as per Standard 27.

Handwashing facilities located at a level where they can be used by people in wheelchairs shall be available in the NICU.

Separate receptacles for biohazardous and non-biohazardous waste shall be available.

Interpretation:  Proper hand hygiene is a key component in the prevention and reduction of spread of infection in health care settings.  Alcohol-based hand rubs (ABHR) have been shown to be more effective than soap-and-water handwashing in decontaminating hands that are not visibly soiled.  ABHR dispensers can be easily located at sites where hand hygiene is required.  Handwashing sinks are also required in close proximity to infant spaces to be used when hands or soiled or contaminated with body fluids.

Sinks for handwashing should not be built into counters.  Sink location, construction material and related hardware (paper towel and soap dispensers) should be chosen with durability, ease of operation, ease of cleaning, and noise control in mind. Non-absorbent wall material should be used around sinks to prevent the growth of mold on cellulose material.

Local, state, and federal regulatory agencies dictate what healthcare-generated waste is biohazardous or non-biohazardous and appropriate disposal methods that are dependent on the type of waste. Depending upon the jurisdiction, biohazard signage may need to be affixed.

Distinct facilities shall be provided for clean and soiled utilities, medical equipment storage, and unit management services.

Clean Utility/Holding Area(s): For storage of supplies frequently used in the care of newborns.

Soiled Utility/Holding Room: Essential for storing used and contaminated material before its removal from the care area. Unless used only as a holding room, this room shall contain a counter and a hands-free handwashing station separate from any utility sinks.  The handwashing station shall have hot and cold running water that is turned on and off by hands-free controls, soap and paper towel dispensers, and a covered waste receptacle with foot control.

The ventilation system in the soiled utility/holding room shall be engineered to have negative air pressure with air 100% exhausted to the outside. The soiled utility/holding room shall be situated to allow removal of soiled materials without passing through the infant care area.

A designated area for collection of recyclable materials used in the NICU shall be established.  This area shall measure at least one square foot per patient bed and be located outside the patient care area.

Charting/Staff Work Areas: Provision for charting space at each bedside shall be provided. An additional separate area or desk for tasks such as compiling more detailed records, completing requisitions, and telephone communication shall be provided in an area acoustically separated from the infant and family areas.  Dedicated space shall be allocated as necessary for electronic medical record keeping within infant care areas.

Interpretation:  Storage Areas: A three-zone storage system is desirable. The first storage area should be the central supply department of the hospital.

The second storage zone is the clean utility area described in the standard; it should be adjacent to and acoustically separated from the infant care area. Routinely used supplies such as diapers, formula, linen, cover gowns, charts, and information booklets may be stored in this space. There should be at least 8 cubic feet (0.22 cubic meters) for each infant for secondary storage of syringes, needles, intravenous infusion sets, and sterile trays.

There should also be at least 18 square feet (1.7 square meters) of floor space allocated for equipment storage per infant in intermediate care, and 30 square feet (2.8 square meters) for each infant bed in intensive care. Total storage space may vary by unit size and storage system.

Easily accessible electrical outlets are desirable in this area for recharging equipment.

The third storage zone is for items frequently used at the infant’s bedside. Bedside cabinet storage should be at least 16 cubic feet (0.45 cubic meters) for each infant in the intermediate care area and 24 cubic feet (0.67 cubic meters) for each infant in the intensive care area. Bedside storage should be designed for quiet operation.

Hospitals contribute significant waste each year to incinerators and landfills.  This creates not only an environmental hazard, but also conditions that are harmful to human health.  Providing a designated collection area enables staff to separate and store for collection waste such as paper, newsprint, corrugated cardboard, plastics, metals, batteries, fluorescent lamps, and glass to either facilitate existing hospital procedures for recycling or initiate a recycling system.  Space within the designated collection area also may be used for collection of medical supplies for distribution to hospitals or clinics in need of such materials.

Charting/Staff Work Areas:  A clerical area should be located near the entrance to the NICU so personnel can supervise traffic into the unit.  In addition, there should be one or more staff work areas, each serving 8 to 16 beds.  These areas will allow groups of 3-6 caregivers to congregate immediately adjacent to the infant care area for report, collaboration, and socialization without impinging on infant or family privacy. Infants’ charts, computer terminals, and hospital forms may be located in this space.

Design of the NICU must anticipate use of electronic medical record devices so that their introduction does not require major disruption of the function of the unit or impinge on space designed for other purposes.  Design considerations include ease of access for staff, patient confidentiality, infection control and noise control, both with respect to that generated by the devices and by the traffic around them.

Laundry Room:  If laundry facilities for infant materials are provided, a separate laundry room can serve the functions of laundry and toy cleaning within the NICU.  Infant clothing and the cloth covers of positioning aids should be laundered on a regular schedule and as needed.  In addition, toys utilized by infants or siblings are required to be cleaned on a regular schedule for each infant and between infants.  Space for a commercial-grade washer and dryer should be accommodated.  The dryer should be vented through an outside wall.  The placement of a commercial-grade dishwasher could promote the efficiency and effectiveness of the aseptic cleaning process for toys.

Space shall be provided within the NICU to meet the professional, personal, and administrative needs of the staff. Rooms shall be sized and located to provide privacy and to satisfy their intended function. Locker, lounge, private toilet facilities and on-call rooms are required at a minimum.

Interpretation:  Support elements can be defined as those that facilitate the provision of infant care and the well being of the staff; they may account for at least one third of the floor space of the entire unit.

Staffing areas are defined as space limited to use by staff members to meet personal, professional, and administrative needs. These areas include lockers, lounges, counseling, education and conference space, and on-call rooms that provide privacy and satisfy their intended function.

Distinct support space shall be provided for all clinical services that are routinely performed in the NICU.

Space for preparation and storage of formula and additives to human milk and formula shall be provided within the unit or other location that is away from the bedside⁷. When a separate room for infant feeding preparation is not merited due to infrequency of need, commercial preparation off premises or other reasons, a separate area in the food services area or in the patient unit shall be designated for infant feeding preparation.  Hospital food preparation design guidelines shall be followed.

When the functional program requires a separate room, the room shall include the following areas that can be separated in individual rooms or combined:

(a) Ante area

(b) Preparation area

(c) Storage space  for supplies, formula, and both refrigerated and frozen breast milk.

(d) Clean-up area

To minimize contamination, the ventilation system should have a minimum filtration of 90% based on the American Society of Heating, Ventilation and Air Conditioning Engineers standards or have a HEPA forced air filtration system. 

Provisions shall be included for human milk storage. Human milk may be stored in a designated space in the infant feeding preparation room, and in designated spaces on the patient unit.

Interpretation:  Ancillary services such as (but not necessarily limited to) respiratory therapy, laboratory, pharmacy, radiology, developmental therapy, and specialized feeding preparation are common in the NICU. Distance, size, and access are important considerations when designing space for each of these functions. Satellite facilities may be required to provide these services in a timely manner.

Unless performed elsewhere in the hospital, a specialized feedings preparation area or room should be provided in the NICU, away from the bedside, to permit mixing of additives to breast milk or formula.  The cleanliness of the floor surface, walls and ceilings should be easily maintained. Floor drains are not recommended unless required by local code. Adequate sinks, electrical outlets and storage should be provided based on the individual hospital facility needs. The use of a laminar flow hood is a decision that each hospital should make. Pharmacies are not required to use laminar flow hoods to prepare oral medications. Powdered formulas are not sterile, and preparing them under a laminar flow hood does not improve the sterility of the product. All water supplied for feeding preparation should meet Federal Standards for drinking water and be commercially sterile.  Commercially sterile water is preferred because it has eliminated pathogenic and other organisms, that if present, could grow in the product and produce spoilage under normal conditions of handling and storage.