Single Family Rooms for the NICU: Pros, Cons and the Way Forward

    Single Family Rooms for the NICU: Pros, Cons and the Way Forward Michael S. Dunn MD, FRCPC, Elizabeth MacMillan-York RN, Kate Robson MEd PII: DOI: Reference:

S1527-3369(16)30004-6 doi: 10.1053/j.nainr.2016.09.011 YNBIN 50687

To appear in:

Newborn and Infant Nursing Reviews

Received date: Accepted date:

11 April 2016 16 September 2016

Please cite this article as: Dunn Michael S., MacMillan-York Elizabeth, Robson Kate, Single Family Rooms for the NICU: Pros, Cons and the Way Forward, Newborn and Infant Nursing Reviews (2016), doi: 10.1053/j.nainr.2016.09.011

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ACCEPTED MANUSCRIPT Single Family Rooms for the NICU: Pros, Cons and the Way Forward

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Primary and Corresponding Author: Michael S. Dunn, MD, FRCPC [email protected] Aubrey and Marla Dan Program for High Risk Mothers and Babies Sunnybrook Health Sciences Centre 2075 Bayview Avenue Toronto, Ontario M4N 3M5 CANADA Department of Paediatrics University of Toronto Toronto, Ontario CANADA

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Elizabeth MacMillan-York, RN [email protected] Aubrey and Marla Dan Program for High Risk Mothers and Babies Sunnybrook Health Sciences Centre 2075 Bayview Avenue Toronto, Ontario M4N 3M5 CANADA

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Kate Robson, MEd [email protected] Family Support Specialist Aubrey and Marla Dan Program for High Risk Mothers and Babies Sunnybrook Health Sciences Centre Room M4-201 2075 Bayview Avenue Toronto, Ontario M4N 3M5 CANADA

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 1 Abstract Single Family Rooms (SFRs) have been embraced by many as essential to the

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design of a modern NICU. It is generally accepted that they reduce the risk of

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nosocomial infection, facilitate individualized and developmentally appropriate levels of sensory input for infants and enhance parental comfort and privacy. Most centers that

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have adopted SFRs report that staff and families view the shift positively. However,

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there are some potential concerns with exclusive use of SFRs, most important being the possible negative impact of an environment devoid of important sensory inputs on the

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developing preterm neonate. Family members and staff can also be negatively affected by feelings of isolation. In this article, we explore the advantages and disadvantages

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associated with the use of SFRs in the NICU and provide suggestions to help mitigate

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the possible negative effects on infants, families and staff.

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Keywords: NICU design, neurosensory development, parent-infant attachment, single family rooms

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 2 Introduction The neonatal intensive care unit is a setting that must provide safe, effective care

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to vulnerable newborns and their families whilst promoting appropriate neurosensory

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development and parent-infant attachment. This can be a challenging set of objectives when invasive and intensive monitoring are required along with close observation and

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frequent therapeutic or care-giving interventions. The configuration of the NICU is

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critical to enabling these functions and there has been considerable effort on the part of clinicians, scientists and architects to create standards that can provide guidance to

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those planning to build a new NICU or renovate their current unit.1

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Evolution of the NICU

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Neonatal intensive care emerged in the middle of the twentieth century in response to advances in technology and improvements in health care systems. NICUs

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were usually housed in pediatric hospitals and received patients from a large

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geographical catchment area. As infants were often extremely sick and methods of support relatively rudimentary, the main goal was simply to have the patient survive. Neonates were housed in open, brightly lit rooms with multiple headwalls. There was little regard to the effects of the environment or care practices on infants and little effort was made to welcome and provide support to families. The main focus of NICU design was to accommodate equipment, facilitate monitoring and enhance efficiency and convenience for staff.2 The 1980s and 1990s became an era in which preterm neonates were shown to be susceptible to the negative effects of noxious sensory stimuli, chronic stress and

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 3 sleep deprivation.3,4 There was an appreciation that these infants were in a period of rapid neurosensory development and yet were being raised in a setting markedly

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different from their natural habitat. Neurosensory and motor responses to stimuli

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indicated a previously underappreciated sophistication, setting the stage for new approaches to care that were geared to the baby’s state and stage of development[5].

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The importance of parental presence and physical contact in nurturing these babies was

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recognized and initiatives to engage, support and integrate families into the NICU team

Goals of Modern NICU Design

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began to emerge.6,7

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The NICU can be described simplistically as a microsystem designed to provide

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care to sick or premature neonates and their families.8 There is no doubt that the physical configuration and functional organization can either enhance the ability to

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provide excellent care or impact negatively. For those designing a new NICU, the

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following general goals should be kept in the forefront when planning: 1. Provide an environment that will support a. safe, high quality health care b. optimal infant neurosensory development c. parent-infant attachment d. well-being of families and staff 2. Address the medical, developmental, educational, emotional and social needs of infants, families and staff

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 4 The facility must accommodate the technology and equipment necessary to meet the medical needs of the sickest or most fragile infants but must also do so within an

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environment that will support optimal development. This means it should be designed in

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such a way that the baby is shielded from noxious sensory stimuli (visual, auditory, tactile and chemosensory) while developmentally supportive neurosensory inputs are

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enabled.9 It has been shown that the best way to ensure the latter is to maximize

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parental presence and engagement in care.10 Bob White, MD implored NICU providers in 2004 to embrace the concept that mothers’ arms should be considered to be the ideal

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locus for the provision of neonatal care.11 This concept has been enthusiastically endorsed by many and effectively applied in a number of health care settings.

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Family integrated care has been put forward as a model in which parents take on

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the primary roles of care providers for their infant while the nurse becomes the teacher, counsellor and coach.12,13 For this model to be effective, it is essential that the NICU be

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designed in such a way that families feel comfortable to spend prolonged periods of

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time with their infant and encouraged to engage in intimate, nurturing encounters.4,14 It is also essential that nurses are enabled to assume their roles as the families’ primary social contact, connection to other members of the interdisciplinary team, role models for understanding and interacting with the infant, and principal guides for the NICU journey from admission to home.15

Single Family Rooms It has been recognized for some time that single patient rooms are preferable to open wards or multiple patient rooms when care is provided to hospitalized adults and

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 5 children.16 However, evidence supporting the extension of this principle to NICUs was lacking until recently. For the most part, new units designed over the past ten years

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have contained a number if not a full complement of SFRs. Rationale for doing so has

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been largely based on the recognition that the sensory environment for these vulnerable neonatal patients can be better controlled in SFRs and that parental presence will be

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facilitated. A number of centers making the transition from open bay to SFR NICU have

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assessed and reported the impact by comparing the effects of the SFR model to a more traditional open bay setting. Although largely observational and of variable quality, these

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studies generally reveal a substantial benefit to babies, families and staff with SFR design (Table 1). However, several studies have highlighted potential negative effects of

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SFR care on the developing preterm infant when isolation and sensory deprivation can

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retard normal neurosensory development.28,29

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The SFR as an “Isolation Chamber”

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Investigators at the Washington University School of Medicine in St. Louis, MO recently conducted a series of comprehensive studies to assess the impact of neonatal intensive care provided within SFRs versus open bay beds.28-30 They used a quasiexperimental design in which babies were assigned to a bed space that was either within a SFR or in the open bay area of the unit based on availability. In spite of the lack of randomization and potential bias introduced with this study design, the two groups of infants were very similar and many of the outcomes objectively assessed. Important findings from this series of studies include that, although parents were more inclined to visit when their baby was in the SFR, they felt higher levels of stress. More importantly,

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 6 babies cared for in SFRs had delayed maturation on aEEG, more abnormal findings on MRI taken near term gestation and were more likely to have delayed language

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development.

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Until this series of reports emerged, designers and neonatal clinicians were working under the assumption that being able to house premature neonates in SFRs

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should translate into improved long term neurodevelopmental outcomes. Why might

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NICU babies cared for in SFRs fare less well than those cared for in the open bay? And why should their mothers be under more stress? The investigators delved deeper to see

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if they could explain these findings and highlighted the following potential contributory factors. In their unit, which is located in what they describe as an "urban setting with low

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rates of visitation", infants cared for in SFRs were often exposed to low levels of

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stimulation. Infants in the SFRs were cuddled by their parents a mean of only 2.3 times and held skin-to-skin less than once per week. Total visitation was just over 24 hours

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per week. They measured sound levels and found that infants in the SFRs were

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exposed to an average of 9 hours of silence per day. And finally, they did an ancillary study showing that among the infants studied, those who were visited and held more often in the NICU had better outcomes in terms of early neurobehavior.30 It looks like SFRs may be well suited to enable NICU patients and their families to spend long periods of time together but, if practices or psychosocial realities do not allow for long periods of parental presence and touch, outcomes may actually be worsened. Parents who are unable or not encouraged to visit may experience added stress as a result of concern about their baby being isolated and in a potentially unsafe environment.28

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 7 So how do we deal with these observations? Should we abandon SFRs and go back to open bay NICUs? The answer is clearly no as the advantages of SFRs for most

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infants, families and staff have been repeatedly demonstrated. Further insights can be

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gained by examining the findings from studies performed at the Women and Infants Hospital of Rhode Island as they were moving into a new SFR unit.14 Investigators

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carefully examined important clinical and neurobehavioral outcomes in relation to unit

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design and other changes in practice. They found that infants cared for in the SFR unit had improved outcomes in a number of medical and neurodevelopmental domains at

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discharge but discovered that many of these improvements were mediated by increases in maternal involvement and developmental support afforded by SFRs.

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So, the long and short seems to be that SFRs should still be promoted but

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practices that encourage parental presence and appropriate human contact with the baby must go along with them to avoid adverse neurodevelopmental consequences of

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isolation and deprivation. Most important are strategies to promote and facilitate the

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presence of parents. If parents cannot or do not attend, they should be encouraged to identify one or more alternative support persons who is willing to commit to spending time with and nurturing the infant. Cuddler programs have been adopted in some centers to ensure that all infants in the NICU have access to a consistent individual whose sole responsibility is to provide developmentally supportive, positive human contact on a regular basis.31 Nursing and other staff providing care in the NICU must also acknowledge that it is everyone’s responsibility to contribute to the infant’s wellbeing through the personal provision of nurturing human contact.31-32 In the SFR when the family is not in

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 8 attendance, infants are no longer surrounded by people but are isolated from them. It is imperative that, with each interaction, the nurse and other staff communicate with the

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infant through touch and voice. This serves also to teach families and other members of

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the interprofessional team to understand infants’ cues and how to interact with the infant

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in a developmentally appropriate fashion.

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Isolation for Family Members and Staff Impact on Families

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The experience of having a hospitalized baby can itself cause feelings of social isolation.33 One potential risk of a SFR model is that these feelings could be

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exacerbated.34 Some units have taken a proactive approach towards addressing this

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issue by creating social opportunities for families, both formal and informal. In units with family programming and support programs, parents did not report elevated feelings of

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isolation.35 Potentially better practices for lessening the risk of social isolation for

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families include hiring a graduate family member in a staff role, offering peer mentoring opportunities by matching current NICU families with graduate NICU families, and establishing a calendar of regular social events to which all NICU families are invited.3637

Opportunities for informal learning may also limited in a SFR unit as a result reduced observational learning and parent-to-parent interaction. It is essential, however, to support the educational needs of families to ensure they develop feelings of competence and confidence before the transition to home.38 To support educational needs of families in SFR units, educational programs should be formalized and

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 9 promoted.39 Additionally, culturally-appropriate educational materials should be created

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in a variety of formats (text, video, audio) and languages.40-41

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Impact on Staff

Surveys of NICU staff following move to a SFR unit found that many, especially

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nurses, feel some isolation from their peers. There are fewer opportunities for informal

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social interaction and gatherings. This may have the effect of decreasing staff satisfaction and perceived quality of work life. This may also result in reduced

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opportunities for informal learning.19,25,26,42

In an open bay unit, all members of the interprofessional team, especially

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novices, are presented with frequent opportunities for informal learning through

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observation and demonstration. Examples might include welcoming a family to their infant’s bedside for the first time, caring for the family experiencing bereavement or how

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to respond to various clinical events. Novice staff greatly benefit from directly observing

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how an experienced, top-performing staff person deals with complex or unusual clinical situations. This kind of learning is less accessible in a SFR NICU. Staff need to be proactive in identifying their learning needs and in seeking out experiential learning experiences.25,34,42 Additional precepting or scheduled buddying may be helpful in alleviating these concerns.

Other Concerns with SFRs Monitoring, Alarms and Communication

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 10 One purported advantage to an open bay NICU is that staff charged with monitoring patients and responding to changes in status can do so through direct

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observation and can quickly and easily access a baby who requires support. Other staff

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are close by and can be mobilized to provide additional help if needed. One of the greatest fears raised by staff preparing to move from an open bay unit to a SFR unit is

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that they will not be able to detect an important change in status and respond to it as

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readily. Another fear is that staff feel they will be alone and unable to get help when needed.42 However, with advances in the technology of monitoring and communication

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devices, nurses can be linked directly with the infants in their care as well as with other members of the care team. The presence of a code call and staff assist button is

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necessary in every SFR. As non-verbal communication will be ineffective, nurses, and

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other staff members need to be ready to ask for help when needed and to give help without question. Rapid response to infant alarms (and minimization of nuisance

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alarms) will help to decrease parental (and staff) stress and allow them to relax when

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away from their infant as they have increased confidence that the infants’ needs are being met.43,44

The Way Forward One of the key decisions that must be made by anyone designing a new NICU is whether to have it based on a full complement of SFRs. This may be desirable for many of the reasons mentioned (Table 1) as it promotes equity for families, affords greater opportunities to personalize and humanize the care space and ensures that families that can attend their infant are able do so in a private and comfortable setting. However,

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 11 isolation is an inevitable by-product of privacy. There is a real concern about the negative impacts of isolation and sensory deprivation on infants who are at a key

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developmental stage. We need to make allowances for this, either through modifying

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our approaches to clinical care or by making adjustments to the NICU design. Social isolation of family and staff is another real concern with SFR units unless deliberate

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structural, operational and practice elements are put in place to mitigate these effects.

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In socio-political settings that enable parents of preterm infants to spend a great deal of time with their infant, SFR units should be the norm. However, even in these

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settings, practices need to be adjusted to ensure that infants not frequently attended by their parents receive the necessary level of positive, nurturing sensory inputs.

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Alternatively, it may be advisable to design and build a hybrid unit in which infants who

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do not require SFRs for medical reasons and whose parents do not or cannot attend can be moved into a shared space within which they are exposed to human

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conversation and activity.45

Implications for Unit Design 1. Single family rooms should be the preferred location for most premature and sick newborns. 2. SFRs should be constructed in such a way that family members can spend long periods of time with their infant in comfort. Ideally, comfortable sleep spaces and washroom facilities should be immediately adjacent to the baby’s space. (Please refer to previous chapter, “Design Considerations for Families”.)

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 12 3. SFRs should be grouped in a way that staff responsible for the care of the infants and families can monitor and access their patients easily. Groupings of six or

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more rooms opening into a central area should be the goal to afford effective

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monitoring, response and access whilst ensuring there is a place for interprofessional discussions and informal gatherings of staff.

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4. Designers should consider having a mix of SFRs and group-care spaces to be

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selectively utilized based on the medical, developmental and psychosocial

Implications for Unit Leadership

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factors impacting each infant and family.

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1. Ensure that staffing is adequate and that monitors, alarms and communication

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systems work effectively to alert caregivers to a change in status that requires a response and that appropriate support from other staff can be quickly accessed.

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2. Understand the need for, and provide, adequate staffing for the convalescing

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infant whose family cannot be present. While acuity may be lower as measured by standard workload tools, they may actually require a considerable amount of direct care time if outcomes are to be optimized. 3. Provide opportunities for staff to gather daily to obtain updates on unit and infant status. If this cannot be done physically, have electronic documentation available to all staff that will relay the same information. This should allow each staff member to seek out informal learning opportunities as well as alleviate some of the feelings of isolation.

ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 13 4. Provide opportunities for nurses, and other members of interprofessional team to improve basic caregiving, procedural, emergent and communication skills by

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informal means through role playing, mock events, formal teaching, invitations to

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observe and participate, and thoughtful, group reflection.

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Implications for Nursing

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1. Acknowledge and prepare for an increased emphasis on the nurse’s role as communicator, role model and teacher to families and as the main connection of

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families to other members of the interprofessional team. 2. Ensure that encounters with NICU patients are done in a sensitive and nurturing

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manner. Family members should be encouraged to spend as much time as

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possible with their infant and to provide positive sensory inputs. 3. Plan for more deliberate and organized communication with families and other

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staff members as the opportunities for casual conversations and informal

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learning are decreased. 4. Be proficient in the concept of age appropriate developmentally supportive care to be able to teach families to understand cues, emotionally connect with and physically care for their infant. 5. Formalize the status of expert nurse to serve as a mentor to other members of interprofessional team.

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ACCEPTED MANUSCRIPT Dunn, MacMillan-York, Robson – Single Family Rooms 20 Appendix

Reported Benefits of Single Family Rooms for the NICU Decrease length of hospital stay12,17

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Decreased BPD12

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Decreased apnea18

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Decreased infection14,18,19

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Improved hand hygiene19,20

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Increased breastfeeding18

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Improved environmental control21-23

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Improved staff and parental satisfaction17,19,24-27

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Increased parental presence28

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Table 1