The strategic planning team will continue to develop the vision and goals that led to the decision to pursue new
construction. It should include, at a minimum, an administrator, a neonatologist, and a nursing director. This group will be responsible for reviewing utilization and demographic information (available from state and local planning and health agencies, the insurance industry, and the Census Bureau) in order to define the NICU’s service area and appropriate number of beds. Some general guidelines in this area include estimates that 5% to 12% of all newborns will need intensive care at the time of birth, and 1% to 2% will need ventilator care. Total NICU days for a defined region will approximate 1.25 patient-days per live birth—if a region has 10,000 live births per year, it will generate approximately 13,000 NICU patient days, or an average census of 35 babies, with an average length of stay of 20 to 25 days. These numbers will be influenced considerably by the level of care provided by a particular NICU, referral and back transport patterns, admission and discharge criteria, and competing NICUs serving the same region. Because of fluctuations in census, a unit should have sufficient bed positions to care for 40% to 50% more babies than the average census calculations, so a region with 10,000 deliveries per year will need 50 to 55 NICU beds. Many areas currently exceed this number by a sizable proportion because of serving a particularly high-risk population, or because of inefficiencies inherent in multiple NICUs serving a single region.

The strategic planning team also should make some basic calculations regarding staffing patterns, if this is to be a new service for the hospital. Depending on patient mix, overall staffing patterns may require 4 to 6 nurses and 2 support staff (inclusive of nursing administration, respiratory therapy, developmental therapy, social work, ward clerk, and housekeeping staff) for every 10 babies. A unit with an average census of 20 babies, for example, would require 8 to 12 nurses on each shift, or 40 to 65 full-time equivalents (FTEs), with an additional 20 to 25 FTEs for support staff. One neonatologist is needed for each 6 to 8 babies (average census); this is one area, among several, where units with an average census of less than 20 infants encounter certain inefficiencies because of their size. On the other hand, large units (more than 40 beds or so) can be difficult to design and manage efficiently because of the space requirements. Some hospitals have addressed this issue by dividing their NICU into intensive care and continuing care, or step-down areas. Some units will also need to plan staffing for transport team or nurse practitioner coverage. Six to 7 full-time positions are required for 24-hour coverage of each position for these services. A transport team with 2 nurses and a respiratory therapist, for example, would require at least 12 nurses and 6 therapists to provide full-time, in-house coverage.

Next, the strategic planning team also will need to assess the impact of the new or renovated NICU on other hospital departments, especially obstetric, maintenance, and supply services. When these issues are clear, the team will proceed to interview and engage an architect. The timing of this step is important—the architectural firm should be involved before any design decisions are made, but after the strategic planning team has articulated a clear set of goals for the process. Several architectural firms can be asked to make formal presentations of their general concepts for the project, as well as present examples of other projects that they have designed. The architectural firm chosen should have complete engineering and interior design specialists on staff, as well as an equipment representative and a neonatal nurse planner. The entire architectural team should be familiar with the latest trends in NICU design and the scientific principles behind the design process. Once chosen, the architectural group and the strategic planning team can then develop a timetable for planning and construction of the new facility.

This group is composed of the hospital’s chief financial and operational officers, nursing management, and any other individuals representing areas of the hospital whose budgets will be significantly affected by the new construction. Consultants, such as those helpful in the equipment selection process (see Equipment Selection section), also may be asked to join the team. The one-time costs for the project will include architectural fees, the physical plant, and new equipment. Ongoing costs may include increased staffing for direct patient care, housekeeping, and maintenance functions. These costs should be clearly identified early in the planning sequence, with the assistance of the care practices team (see The Care Practices Team section). This team should continue to meet intermittently throughout the planning process, because some unanticipated expenses often surface as the design takes shape.

This is the largest group, and it represents caregivers in the NICU. At a minimum, the following disciplines should participate: neonatology, nursing management and staff, respiratory therapy, social work, pharmacy, laboratory, radiology, infection control, nutrition, housekeeping, and parents. Depending on local care practices, surgery, obstetrics, and clinical research may be appropriate additions to this list. As each individual provides information on his or her own specialty to enhance care for babies, families, and staff, the team should be encouraged to look beyond existing practices and view the new construction as an opportunity to change the way things are done. In particular, most NICUs will need to reevaluate their care practices with respect to parental access and developmentally supportive care, which may have been severely restricted under their previous NICU design. They should consider environmental design features that will provide the most optimal living conditions for babies, working conditions for staff, and integration of families, and they should begin to address some of the conflicts inherent in these ideals. As a team, this group can then identify general
space, equipment, staffing, and maintenance and cleaning requirements, which can be reported to the financial and design teams for determination of feasibility.

When the strategic planning, financial planning, and care practice teams have agreed on the general scope of the project, including goals, approximate size and cost, major changes in care practices, and an architectural firm, the design team can begin its work. Members of this team should include the architectural group, the hospital’s project manager, neonatology, nursing, respiratory therapy, parents, and the equipment consultant. After creating a functional plan that addresses all the needs identified by the care practices team, this group should visit new or updated NICUs to get additional ideas, learn how to avoid pitfalls, and solicit suggestions on their functional plan. This team then will meet regularly over several months as blueprints are developed to reconcile all these concepts into a working unit. Detailed minutes should be kept and reviewed at the beginning of each meeting.

Performing the tasks below will enable the planning team to get maximum benefit from a site visit:

A questionnaire should be developed to ensure that all needed information in relation to a site visit is captured and recorded. Segments of the questionnaire could be contact information, general statistics, and specific questions.

NICUs have historically been undersized, with insufficient room for storage, parental access, and offices, even when accurate estimates are made for the number of babies to be cared for. Change has been incremental, as administrators, architects, and NICU staff gradually expand their horizons to accommodate new practices, particularly increased parental access.

Given this historical perspective and extrapolating from floor space requirements in adult and pediatric intensive care units (ICUs), it is likely that an NICU design should allow 600 gross square feet per bed to meet the needs of the babies, staff, and families. This figure includes office, storage, and support space as well as the patient care areas; gross square footage estimates also include space required for hallways, ductwork, restrooms, and the like. This figure is an average; teaching hospitals with active clinical research programs, for example, might require more than 600 gross square feet per bed, whereas a community NICU might require somewhat less. Any design that provides less than 500 gross square feet per bed will inevitably demand compromises and limit flexibility for the future, when parental access desires and lengths of stay (because of increasing survival of extremely low-birth-weight infants) may be even greater than they are today.

Previous estimates of floor space requirements often recommended square footage per bed position (e.g., 120 to 150 square feet per intensive care bed position), and most state codes still use this convention. If this method is used, an additional 30 square feet of storage space must be planned outside of the patient care area, as well as 24 cubic feet of cabinet storage at each bedside, at a minimum.

The NICU should be immediately adjacent to the high-risk delivery rooms whenever possible. There are few, if any, NICUs that are more than a few hundred feet from a high-risk delivery service that do not consider their location as the source of certain risks to optimal care. In some circumstances, especially very large hospital complexes or freestanding children’s hospitals, this ideal may be impossible to achieve. In the former situation, a resuscitation area within the delivery room complex or in each delivery suite, always valuable, becomes crucial; in the latter case, all infants are accepted as transfers, and proximity to the ambulance entrance and heliport becomes particularly significant. When the NICU is on a different floor from the delivery suites, as often occurs in larger hospitals, controlled elevator access between these two areas is essential.

Many NICUs, particularly in small or medium-sized hospitals, share staff and responsibilities with the well baby nursery or pediatric ICU. When these areas are
contiguous, much of the support space (e.g., family lounge, staff lockers, equipment storage) can be shared, and the opportunities for staff to assist one another are enhanced.

Traffic patterns for infants who leave the NICU for procedures should be identified and private hallways created wherever possible, so that ill infants and their attendants do not need to use public areas.