KEY POINTS
- 1.
Historically, neonatal intensive care units (NICUs) have been designed as open-bay units with multiple patient beds in a room. However, the trend has shifted toward designing units with single-patient or single-family rooms.
- 2.
Single-family rooms have facilitated a reduction in auditory and noxious stimuli and improvement in positive stimuli to support appropriate development.
- 3.
Parents and families have reported increased engagement in the care of their infants.
- 4.
In NICUs with single-family rooms compared with open-bay NICUs, maternal feeding and infant growth seem to have improved.
- 5.
Care in single-patient rooms was expected to reduce infection rates, but the evidence for such improvement is uncertain.
- 6.
Single-family rooms have improved parent involvement but may have created new challenges for caregivers. The introduction of alarms may help by alerting staff members about changes in the clinical status of the patients and facilitating timely intervention.
Introduction
Historically, neonatal intensive care units (NICUs) have been designed as open-bay units with multiple patient beds in a room, a design that was introduced in the 1940s. The trend has shifted toward the inclusion of parents with neonatal care. Thus units consisting of single-patient or single-family rooms (SFRs; many of which include a reserved space for parents inside the patient room) required new construction. This configuration for neonatal care units was introduced as the ideal design in the 1990s. The new design reflected the general trend in healthcare toward patient and family satisfaction by emphasizing privacy and a feeling of individualized care, but by design, it neglects the elements that aid staff in caring for the patients, such as visibility, ease of access to patients, and efficiency of caring for multiple patients. The movement represented a change in focus away from the needs of staff and toward families’ needs, which in many cases are contradictory.
Patient Safety
Alarms are designed to alert staff members to patient status changes and allow for intervention as necessary. Caregiver alarm fatigue, caused by sensory overload and resultant decreased or delayed responsiveness to alarms, can have adverse effects on patient safety. Exposure of nurses and patients to alarm sounds was found to be 44% higher in the open-bay style NICU ( Fig. 1.1 ) than in the SFR-style NICU ( Figs. 1.2 – 1.4 ), potentially with effects on both patients and staff. Excessive alarm exposure may also cause nurses to increase upper alarm limits to decrease the frequency of alarms, resulting in patient oxygen saturations being outside of the recommended ranges. Infants experience greater than 80% of their noxious noise exposure from alarms, which can be harmful in many ways, including affecting patient cardiopulmonary stability and sleep-wake cycles. ,
Decrease Stressful Stimuli and Increase Positive Stimuli
In the NICU environment, the needs of multiple parties must be balanced. Newborn and infant patients require minimal noxious stimuli ( Figs. 1.5 and 1.6 ) and the presence of positive stimuli to support appropriate development. Parents want to be able to assist with the care of their infants and to have privacy while living in the unit with their infants (see Fig. 1.4 ). The staff needs to have the ability to care for patients in a low-stress and amicable working environment (see Fig. 1.6 ). By the 1990s, preterm infants were increasingly found to be uniquely vulnerable to the effects of negative sensory stimuli, stress, and sleep-cycle disturbances.
One negative sensory stimulus is noise, compared with sound. The goal for the sound environment in the NICU, especially when considering preterm infants whose auditory organs and neurologic pathways are still developing and maturing, should always be a minimization of noxious noise while maintaining exposure to positive sounds as would happen within the womb (see Fig. 1.5 ). The negative effects of noise, especially high-frequency noise, on preterm infants include short-term effects on the stability of cardiovascular and respiratory systems, , disruption of sleep patterns, and potential long-term harm to the auditory and nervous systems. ,
There has long been a recommendation to reduce sound exposure in the NICU so that it does not exceed a level greater than 45 dB for preterm infants and term infants who are ill. As was intended from the design, sound exposure is decreased in SFRs compared with open-bay NICUs. , An unintended consequence of the reduced sound environment appears to be delayed language development at 2 years of age in former preterm infants from SFRs compared with their open-bay counterparts.
There is a positive correlation between preterm infants’ exposure to parental speech and their quantity and quality of vocalizations at postmenstrual ages of 32 and 36 weeks, indicating that positive sound is beneficial to their development. Evidence shows enhanced development of the auditory cortex after exposure to recordings of maternal voice and heartbeat in infants born extremely prematurely, compared with routine NICU sound exposure.
The modification of noise in the NICU environment has been shown to decrease transitory noise after the implementation of clinical mobility communication systems (CMCS) such as smartphones and the elimination of overhead pages. In one study, the percentage of sounds that exceeded the thresholds recommended by the Environmental Protection Agency and International Noise Council decreased from 31.2% to 0.2% after the implementation of CMCS.
The benefit of music as a positive stimulus has also been explored. In one study, playing Brahms’ lullaby sung by a female vocalist to late preterm infants was noted to reduce sleep interruptions and increase brain maturation patterns measured by amplitude-integrated electroencephalogram. This study suggests that singing to preterm babies may have implications for their brain development. The SFR NICU plan reduces infants’ exposure to harmful noise. Future areas of study will need to examine how to provide positive auditory stimuli, more closely mimicking the environment in the womb, to the developing infant.
Infection
Outcome studies comparing infection rates between open-bay and SFR NICUs are conflicting and controversial. No difference in hospital-acquired infections (HAI) was found in one study. In contrast, catheter-associated bloodstream infections were decreased from 10.1 per 1000 device-days to 3.3 per 1000 device-days over 9 months after the transition from an open-bay to an SFR-style layout in one US NICU. A systematic review and meta-analysis through August 2018 that included 13 separate patient populations (N = 4793) of preterm infants showed a reduction in rates of sepsis with no change in long-term neurodevelopmental outcome in the SFR design versus open bays. A retrospective review of medical records of infants admitted to open-bay versus single-family units, including 1823 infants and 55,166 patient-days, showed similar rates of methicillin-resistant Staphylococcus aureus (MRSA) colonization, late-onset sepsis, and mortality. Further analysis showed hand hygiene compliance was associated with decreased MRSA colonization, with hazard ratios of 0.83 and 0.72 per 1% higher compliance. The increased daily census was associated with increased MRSA colonization only in SFRs and not open-bay setups, with a hazard ratio of 1.31 ( P = .039).
Family-Centered Care and Improved Parent-Infant Interactions
SFRs are an improvement in many aspects of family-centered care in the NICU (see Fig. 1.4 ). One of the most important attributes of SFRs is parents’ ability to participate in decision-making and help with bedside caregiving. SFRs provide a feeling of increased privacy for families, as was shown in one NICU in the United States that conducted a survey during a 6-month period after moving from an open-bay style to an SFR style. Parents felt more involved in care and less like visitors and felt they had privacy to experience their emotions of happiness and distress with their infant. SFRs with space for families to stay have been shown in multiple studies to improve family satisfaction. , Families are more involved in care, including spending more time in the patient’s room, , maternal breastfeeding rates are higher, , and the total length of stay is shortened, likely all because families feel more comfortable with a private, dedicated space within the patient room. Parents’ ability to be present and involved from admission to discharge likely also increases their confidence in caring for their infant long before discharge, contributing to the decreased length of stay. However, contrary to the expectation that spending more time at the bedside would reduce anxiety, maternal stress related to NICU admission was slightly increased in the SFR setting. To counter this difficulty, many centers have included family lounges within the NICUs to provide some space where parents can try to relax and at least transiently lower their anxiety levels from having a premature or critically ill infant who may be at increased risk of mortality ( Fig. 1.7 ).
Patient- and family-engaged care is defined as “care planned, delivered, managed, and continuously improved in active partnership with patients and their families (or care partners as defined by the patient) to ensure integration of their health and healthcare goals, preferences, and values” and is considered the culture of care. There is a direct relationship between NICU design and the culture of care. The benefits of the SFR NICUs are owed to increased maternal and paternal involvement. The SFR setting provides the privacy and opportunity for maternal involvement; for example, increased rates of breastfeeding and human milk provision at 4 weeks was higher in SFR NICUs. Every 10 mL/kg/day increment of breast milk at 4 weeks was associated with increased cognitive, language, and motor Bayley scores (0.29, 0.34, and 0.24, respectively). The SFR provides a private space that promotes parental involvement, extensive presence, and skin-to-skin care that cannot be accomplished in a traditional and crowded open-bay unit.
Staffing Patterns, Nursing Workload, and Communication
The trend toward SFR structure in NICUs, despite solving some problems regarding parent involvement, creates a shift in challenges to caregivers, with inconsistent impressions among different groups. In a study of a group of 127 nurses conducted before and after the transition from open-bay to SFR NICUs, 70% of the nurses felt that they had an increased workload in the single-family layout owing to increased physical difficulty with more walking required and an inability to see all patients at once or from other patients’ bedsides. Nurses in single-family units found it troubling that there was not a centralized location from which all their patients could be seen, thus making it difficult to know the status of all their patients at all times. , The reduced visibility of patients to their nurses and reliance on mechanical monitoring raises concerns about patient safety in an SFR-style unit. A study of 21 staff members conducted 1 year after transitioning from an open-bay to a single-family design found that the staff felt they had less interaction with one another and thus had fewer opportunities for assistance and learning from colleagues. In contrast, a survey of interdisciplinary staff conducted as quality improvement 1 year after the transition to an SFR structure found that staff had a perception of improved patient care, an improved environment for patients, families, and caregivers, and lower workplace stress. There may be other factors that influence caregivers’ impressions of workload and patient safety between sites, potentially including strategies (e.g., video monitors, communications systems, etc.) to adapt to these challenges.
Growth and Weight Gain
Growth is improved in SFR NICUs compared with open-bay NICUs in preterm infants <30 weeks’ gestation and <1250 g at birth. Infants in SFR NICUs had higher rates of human milk provision at 1 and 4 weeks and higher human milk volume at 4 weeks. Vohr et al. reported that increments of 10 mL/kg/day in human milk at 4 weeks were associated with increases of 0.29, 0.34, and 0.24 in Bayley cognitive and language scores. Lester and colleagues compared patients in the same unit from before and after the transition to SFRs and found greater and faster weight gain among 123 preterm infants in SFRs compared with 93 patients in an open-bay unit (23.9±3.8 g/day versus 22.2±4.7 g/day, respectively; P < .003). However, other growth parameters such as head circumference were not significantly different between groups. The results may have had multiple confounders because rates of sepsis were higher in the SFR NICU group. In contrast, necrotizing enterocolitis rates were lower compared with the open-bay group (sepsis, 25.8 versus 17.9; necrotizing enterocolitis, 4.3 versus 10.6, respectively). Another published study compared two populations of infants with a gestational age of 28 to 32 weeks at birth in SFR versus open-bay NICUs that both used the same feeding protocols and found no significant differences in weight, length, or head circumference at 34 weeks’ postmenstrual age and 4 months’ chronologic age. Consistent with other studies, the SFR parents spent significantly more time with their babies and provided more skin-to-skin care than did the parents of babies in the open-bay unit, but developmental milestones achieved were not significantly different between the two.
Neurodevelopment Outcome
Neurodevelopment of preterm infants may be affected by placement in an SFR NICU. Vohr et al. reported in 2017 that Bayley III language composite scores were significantly higher and cognitive scores were marginally higher in preterm infants with a birth weight ≤1250 g at 18–24 months’ chronologic age in SFR NICUs, after adjusting for covariates. Interestingly, infants grouped by the amount of skin-to-skin care, breastfeeding, and maternal care and not by room type had greater cognitive, language, and communication scores, implying that maternal involvement had a more significant impact on outcomes than the site of care did. Lester et al. found that the number of days of maternal involvement was greater in the SFR than the open-bay NICU ( P < .002), suggesting that the effect of the SFR was actually related to increasing maternal involvement. In this study, for every 1-day increase in the number of days per week of maternal involvement, the cognitive composite score increased by 1.6 points ( P = .002), the language composite score increased by 2.9 points ( P < .000), and both the receptive and expressive communication scores increased by 0.5 points ( P < .000).
In contrast, Pineda et al. reported lower Bayley language scores, a trend for lower motor scores, and lower amplitude integrated electroencephalography cerebral maturation in 2-year outcomes of 86 infants born at <30 weeks’ gestational age and nursed in an SFR room compared with an open-bay NICU. The low developmental scores were attributed to the lower sensory exposure and stimulation in the SFR NICU. Of note, in the study by Pineda et al., the parents had less visitation during the length of stay (25.5±25.4 hours/week for SFR infants versus 16.9±13.5 hours/week for open-bay infants), leading to consequently decreased holding, cuddling, skin-to-skin care, and breastfeeding and further supporting the argument that outcomes may be owed to maternal or paternal involvement. Although the observations from the studies by Pineda et al. and Vohr et al. appear to present conflicting outcomes, they support the literature that upholds the importance of maternal presence and involvement in infants’ care.
A systematic review and metanalysis of 13 study populations comparing outcomes at 18 to 24 months of age in preterm infants cared for in an SFR NICU versus an open-bay NICU, found no difference in cognitive Bayley III scores among the two NICU designs.
Hybrid Model
Some NICU designers advocate for a hybrid model of SFRs and group-care spaces that is used selectively based on each infant’s clinical status and the developmental and social needs of infants and families. Some NICUs in Sweden and Turkey transition infants (also known as “feeders and growers”) from the traditional open-bay room to the SFR as they become more mature and require less intensive care. Also, there are differences in the use of SFRs depending on the stay and visitation policies of each setting. Some SFR NICUs require parents to “live in” and stay 24 hours a day from admission until discharge. However, most SFR NICUs in the United States do not mandate a similar requirement; instead, they have an open-door policy where rooming-in is encouraged but at the convenience of parents.
Impact of the COVID-19 Pandemic
The pandemic of SARS-COV-2 in 2020 altered the standard family visitation policies in all healthcare facilities. During the peak of the pandemic, policies for visitation of parents in the NICU varied from no visitation to the standard preoutbreak 24/7 visitation policies. , , Most NICUs across the nation had some visitation restrictions that allowed one parent or caregiver, who was the same every day, at the bedside during the daytime. A few policies were stringent and only allowed the same family-designated parent or caregiver throughout the duration of the infant’s hospitalization. The NICUs with SFR designs were privileged to provide a private and closed environment, thus making infection control measures such as physical barriers, distancing, and separate air supplies attainable. More NICUs with SFRs were able to maintain a 24-hour parental presence with babies and caregivers compared with open-bay units (64% versus 45%). The majority of NICUs across the United States used technology such as teleconferencing to keep parents involved in their baby’s care during limited visitations. The plateauing of the pandemic enabled most NICUs to relax the visitation rules, allowing two caregivers at the bedside during the day, and some allowed one parent or caregiver to stay overnight.
Summary
The transition of NICU design from open bay to SFRs has advantages that overall outweigh the disadvantages. Open-bay NICUs have improved parent satisfaction and involvement, increased breastfeeding rates, allowed for more visitation during a pandemic, decreased noxious noise stimuli, and improved short- and long-term medical outcomes for infants. SFR NICUs have caused obstacles for staff in hindering visibility and the ability to take care of multiple infants at once, decreased interaction among nursing staff, increased sensory deprivation of infants, and showed evidence of increased maternal stress and rates of MRSA colonization during times of high census. The shift in care model is considered an improvement, although more work remains to be done to correct the issues that have been brought to light, with a hybrid model as a possible solution for the future that will encompass the best of both models.
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