Setting up an neonatal intensive care unit (NICU) is a challenging job which requires a lot planning and contemplation on many fronts.
A well organized neonatal unit is the back-bone on which clinicians and nurses work to produce the desired outcome. Without a well organized unit, medical and paramedical staff may struggle to apply their skills in a timely and efficient manner, which ultimately affects over-all outcome of the unit. Setting up a good NICU is not a single-handed job, it is a team work. While designing, a lot needs to be planned before putting into practice. Experts with knowledge and skills—like architects, civil and electrical engineers, fire-personnel, interior designers, bio-medical engineers - form a core team. This team works and designs a plan based on requirements of clinicians, nurses and supporting staff.
In a developed country recommended standards of newborn ICU are already made and they are revised at regular intervals. Unfortunately we do not have such standards. National Neonatal Forum has already specified requirements to establish various levels of care in NICU but guidelines to design such units in our country are not there.
Recommended standards of materials, meant suitable for environment of developed country and usage may not be suitable/required for our NICU. One may need to spend a lot to procure such materials. In that case, we need to look at what is best available in our country. Materials that are harmless and durable should be used.
Thus before embarking upon the design of an NICU, following requirements need to be kept in mind:
- Available space for NICU (carpet area)
- Number of beds required (current and future)
- Number of staff required: clinical, personnel in each shift to handle babies and other services.
- Equipment: movable and non-movable
- Light source: emergency and regular
- Acoustic effect: internal and external
- Heating, ventilation system and air conditioning (HVAC).
Once this is decided, following can be planned:
- Space planning: visualized 3D space
- Operational planning-traffic pattern
- Functional location of beds and equipment
- Ancillary services location
- Interior planning
- Surface – floor, walls and ceiling material planning
- HVAC - designing outlets.
Based on the above, a blue-print is prepared. Inputs are required at every level before execution of the design.
NICU LOCATION WITHIN THE HOSPITAL
Ideally, NICU should be in close proximity to the birthing unit in the hospital. If that is not possible, an elevator just adjacent to birthing unit with facility for key operation is desirable. Traffic for other services/disciplines should not pass through NICU. Those NICUs where babies are received from outside, NICU should have direct access to hospital transport receiving area.
Space Requirement
Depending upon the complexity of care rendered, bed space can be planned-Keeping in mind family's involvement in care of an infant.
Traditional design of NICU is of “multiple bed NICU”, where a single big area is designed with multiple beds. Current and more popular concept in developed world is of “single family room NICU”, where mother stays with baby in NICU. Such units not only require huge space, but also more staff. Evidence supports that such designs are practical, popular and justified by increasing awareness of the impact of the sensory environment on premature and ill newborns.
In resource limited set ups such concept may not be viable. In that case, a well spaced multiple bed NICU also serves equal purpose. For level 3 multiple bed NICU, infant bed space should be 120 sqft of unobstructed space. The distance between two baby beds should be 8–12 feet, so that the area adjacent to each infant space will have a minimum width of 4 feet. Each infant space should be designed to allow privacy for infant and family.
Infant space for intensive care infant beds situated in a single infant room should be at least 150 sq.ft per infant to provide adequate space for both equipment and family. The width of aisle in multiple bedroom should be enough to allow for easy movement of all equipment which might be brought to the infant's bedside, as well as for easy access of maternal bed. Aisle width of 8 feet is good enough for this purpose.
FAMILY SUPPORT AREA
Adequate space is required immediately adjacent to the NICU for families. The family hold area should have space for gowns, hand washing, secured storage for their belongings, a small pantry and toilet. The sitting should be comfortable and play area with entertainment material for children should be provided. These rooms should have emergency call and telephone or intercom linkage with NICU staff. It is a good idea to provide internet and education material in this area.
STAFF SUPPORT AREA
Adequate space should be provided within the NICU to meet the professional, personal and administrative needs of the staff. These areas include lockers, lounges, counseling space, education and conference space. On call rooms with adequate facilities are required for relaxation.
MOTHER'S ROOM
A mother's room is an important part of any well-designed NICU. These rooms should be within or immediately adjacent to the NICU. These rooms should be sufficient equipped and sized to accommodate parents and people from various disciplines (clinicians, nurses, social workers, etc.) who may need to meet the parents in private. The aim of these rooms is to encourage over-night stay by parents of the infants in NICU when opportunities arise to do so. The number of rooms will depend on number of growing babies in the NICU, and regional practices. These rooms need to have medical gas and suction outlets. Light music and TV facilities along with educational video/ material are desirable.
SUPPORT SPACE FOR ANCILLARY SERVICES
Specialized feeding preparation area or room should be provided in the NICU, which is away from the bedside. This area will require hands-free hand washing station, counter for work space, and storage area for formula. A dedicated fridge is required for refrigerated and frozen breast milk.
Other ancillary services such as respiratory therapy, laboratory, pharmacy, radiology, developmental therapy are part of NICU. Distance, size and access are to be decided based on overall working pattern of the hospital, e.g. for multispecialty hospital, all these services can be centralized.
ADMINISTRATIVE SPACE
The disciplines that provide services to the unit, on a daily basis need distinct areas to carry out their responsibilities. Such disciplines can share a single room.
GENERAL SUPPORT SPACE
Adequate facilities should be provided for clean, soiled utilities, medical equipment storage and unit management services.
Clean utility areas are for storage of supplies frequently used in newborn care. Soiled utility room is essential for storing used and contaminated material before its removal from care area. It is desirable to have hand washing facility and covered waste receptacle with foot control. This area should have negative air pressure with 100% air exhausted to the outside. More important would be its location in the NICU. It should be located in such a way that soiled material can be removed without passing from infant care area.
Adequate charting space in form of separate area or desk for tasks like complying detailed records, completing requisitions and telephone communication should be provided.
Ideally three zone storage system is desirable. The first storage area should be control supply of the hospital. Second storage zone is the clean utility area. Third storage zone is for items frequently used at the infant's bedside (in the form of bedside cabinets). While designing third storage zone and charting area, ease of access to the staff, infection and noise control should be considered.
For laundry facility, separate laundry room with washing machine and dryer is required. Commercial grade washer, dryer should be installed.
ISOLATION ROOM
An air-borne infection isolation room is a part any good NICU. This room should have negative air pressure with 100% air exhausted to the outside. Adequate hands free hand washing station, area for gowning and a separate area for clean and soiled material is required near the entrance of the room. At least a single occupancy isolation room should be available for infant suspected with 5air-borne infection. A space within the NICU should also be available to safely isolate infants infected with common air borne pathogen. Isolation room should have self closing devices on exit doors.
HAND WASHING STATIONS
Hand washing station should be no closer than 3 feet from an infant bed or clean supply store. NICU where a single infant concept is used, a hands free hand washing station shall be provided with each infant room. In multiple bed room NICU, every infant bed shall be within 20 ft of a hands-free hand washing station.
The sink should be large enough to control splashing and should be designed to avoid standing or retained water. The minimum dimensions for hand washing sink are 24 inches wide × 16 inches front to back × 10 inches deep from bottom of the sink to the top of its rim (61 cm × 41 cm × 25 cm). Hand washing instruction in written and pictorial should be provided above the sinks. There should be no aerator on the faucet.
Sink location, construction material and related hardware should be chosen with durability, ease of operation, ease of cleaning and noise control in mind.
ELECTRICAL GAS SUPPLY AND MECHANICAL NEED
Electrical and gas outlets near each infant bed should be organized, to ensure safety, easy access and maintenance. From available resources in the market, a system should be chosen which can include race ways for electrical conduit and gas piping. There should be minimum 18 to 20 simultaneously accessible electrical outlets.
Minimum number of gas outlets is 3 for air, 3 for oxygen and 2 for vacuum. A provision should be made to allow data transmission to a remote location.
GENERAL LIGHTING
Illumination plays an important role in the healing environment and inappropriate lighting can have negative effect on the health of sick babies. On one side perception of skin tone is critical in NICU, and on the other side continuous exposure to bright light in preterm infants can cause harmful effects.
Ambient lighting levels in infant space should be adjustable through a range of at least 10 to 600 lux as measured at each bedside. Both natural and electrical light sources should have controls that allow immediate darkening of any bed position, sufficient for trans-illumination when necessary. A master switch is desirable when rapid darkening of the room is required. Control of lights should be accessible to staff and families. No direct view of electrical light or sun in infant space should be provided, So as to avoid any infant's direct line of sight to the fixture.
To perform the procedures, separate lighting capable of providing no less than 2000 lux is required. This lighting should be adjustable to the required level when required. Lighting fixtures should be easily cleanable.
In the NICU which has lot of natural light, the issue of fluctuation in ambient temperature should be addressed. The thermal effect can cause fluctuation in ambient temperature. The window glass should be double glazed units with appropriate U–factors and solar factors.
At least one source of daylight should be visible from infant care area. Such windows should also be of double glazed glass and should be situated at least 2 feet from any part of the infant bed to minimize radiant heat loss.
FLOOR SPACE
Floor surfaces should be easily cleanable and should minimize growth of microorganisms. Floors should be highly durable to withstand frequent cleaning and heavy traffic. Consideration should also be given to glossiness, their acoustical properties and density of the material used. Polyvinyl chloride or vinyl is common in flooring materials. The production of PVC generates Dioxin, a potent carcinogen. Dioxin releases are not associated with materials such as polyolefin, rubber (latex) or linoleum. Resilient sheet flooring (medical grade rubber or linoleum) is suitable flooring. While laying the flooring, seams should be heat or chemically welded. Careful carpeting should provide impermeable backing.
WALL SURFACES
As with floors, the ease of cleaning, durability and acoustic properties of wall surfaces must be considered. The outer surfaces of walls must be created with materials that have antibacterial solid mineral surface and should be bacteriostatic.
CEILING FINISHES
False ceilings should be modular type and ideally hermetically sealed. Suspended ceiling should be structured by means of nontoxic silicon application for cleaned rooms, such that an air-tight environment is created in NICU.
AMBIENT TEMPERATURE AND THE VENTILATION
The air temperature of the NICU should be 20 to 26°C (72 to 78°F) and a relative humidity of 30 to 60%.
A minimum of six air changes per hour is required with a minimum of two changes being outside air. Ventilation air delivered to the NICU should be filtered with at least 3 micron HEPA filters. Filters should be located outside the infant care area so that they can be changed easily and safely.
ACOUSTIC ENVIRONMENT
The permissible noise criteria of an hourly Leq is of 45 dB and an hourly L10 is of 50 dB. Transient sound should not cross 65 dB. To achieve these conditions, the noise criteria for surroundings should be considered.
Apart from engineering requirements, to run NICU at distinctive level, requires addressing lot many other issues like:
- Protocol based management
- Training of medical and paramedical staff
- Software specifically designed for NICU
- Follow-up clinics
- Maintenance services for medical and nonmedical gadgets.
BIBLIOGRAPHY
- Guideline for perinatal care 6th Edition AAP and ACOG.
- Guidelines for design and construction of Hospital and health care facilities. The American institute of architects. Washington DC, 2006.
- How to set up a good NICU- Proceeding of the single theme workshop at PGI, Chandigarh, September 2010.
- Lighting for healthcare facilities, RP2. Illuminating engineering society of North America, New York, 1995.
- RD White. Recommended standards for NICU designs. Journal of perinatology: 2006; 26: s2–s18.