Simulating The NICU Experience
The Institute for Patient-Centered Design, a nonprofit organization established to give patients and families a voice in healthcare facility design, presented its second annual Patient Experience Simulation Lab (PESL) at the 2013 Healthcare Design Conference. The neonatal intensive care unit (NICU) was selected as the subject of the 2013 PESL, in order to explore benefits and challenges of single-family patient rooms, a design choice many new facilities are making to promote privacy, safety, and family-centered care.
In both physical and virtual models, workshop participants took on the role of end users in simulated activities that offered them an understanding of the varying scenarios patients, families, and providers face. The PESL enabled participants to experience the effects of design on functions that take place inside these spaces, guided with input from actual clinicians, patients, and families.
The Institute partnered with Nexxspan Healthcare, Turner Construction, WorldViz, Georgia Tech’s SimTigrate Design Lab, and more than 20 sponsors to deliver this project. It also worked with Hand to Hold, a NICU parent support network, to better understand the family perspective.
The research was led by SimTigrate, an interdisciplinary team dedicated to driving healthcare innovation through the integration of evidence-based design and simulation. The SimTigrate approach includes evaluating existing evidence, testing solutions in simulated environments, and validating solutions in a living lab, with the goal of translating results for broader applications.
In spring 2013, the Institute released a call for design submissions in search of NICU spaces that would enable families to remain with their infants and participate in the care plan. Design teams around the world submitted both built and conceptual design projects. A jury composed of NICU mothers, clinicians, architects, and researchers conducted a blind review of the submissions, with the top-scoring projects inspiring the design of the PESL model.
Many jurors also served on a content development committee, a team created to submit evidence on NICU design and select the most relevant subject matter for the simulation lab. Mardelle Shepley and Robert White of the Consensus Committee on Recommended Standards for Newborn ICU Design led this charge, providing guidance from its recent publication.
SimTigrate’s team reviewed the literature and documented input from the team of parents, clinicians, designers, and researchers. Every product in the room was reviewed for its compliance with the recommended standards, and design decisions were made based on research.
Because neonates have underdeveloped eyes, indirect lighting was incorporated into the PESL model to limit exposure to excessive light. To prevent disturbing occupants who are trying to sleep at night, fixtures were made to be adjustable and feature soft amber light as well as a brighter white light for daytime use. A procedure light was attached to the incubator to limit its output beyond the field a user wishes to illuminate.
Lighting controls were made accessible to both staff and parents at the headwall and by remote control. In accordance with the recommended standards, the headwall columns included a master switch for immediate lighting adjustment for procedures. The headwall also provided the necessary infrastructure on each side of the incubator for medical procedures, while an angled design concealed utility outlets from the family zone, a dedicated space with amenities to support parent involvement.
The team introduced innovative products to facilitate kangaroo care (holding the infant skin-to-skin) and breastfeeding. They included an incubator that can monitor temperature even when the patient is being held and a bedside recliner with numerous comfort settings that supports new moms in practicing kangaroo care even while sleeping.
A foldable table connected to the headwall provided a surface for parents’ items, and a disposable 18-inch panel screen was created for skin-to-skin and breastfeeding privacy without obstructing the parent’s visibility of the room. A breast milk refrigerator was selected for its drawer design, which retains cold air when opened to support temperature control. A warmer was chosen for features such as its ability to warm breast milk only as high as the body temperature of a mother, which could not only protect the enzymes and proteins in milk but could also prevent the overheating of plastic containers and resulting leaching concerns.
Infection prevention is a critical concern in the NICU, so sinks are an essential design feature to mitigate infection risk. A solid-surface sink was chosen to meet recommendations for nonporous surface material and was placed in a conspicuous location in the PESL model to encourage hand hygiene. The integral sink was sized to comply with the standard, and a full-height splash guard separated it from the counter to prevent the spread of water particles onto adjacent work surfaces.
Solid-surface casework was also installed, with the material forming coved connections and eliminating crevices that can be difficult to clean. “Soft-close” cabinet door hardware helped reduce noise created by closing doors and drawers, and copper-based hardware demonstrated the use of antimicrobial material for high-touch surfaces for infection prevention.
In addition to the major building elements, more subtle features were selected to align with design goals. Rubber flooring was chosen to reduce fatigue and noise, as well as for its cleanability and sustainable nature. Privacy curtains in the family zone are disposable and 100 percent recyclable, which reduces both infection and waste. A patient information board was customized with handwashing instructions and mounted above the sink, per the recommended standards.
A prefabricated wall system facilitated a quick and clean installation because it was constructed in a controlled environment off-site to meet the project’s specifications, eliminating the need for cutting and discarding excess material on-site. Its insulated modular panels controlled sound transmission and could be sealed to become seamless while curved extrusions eliminated corners. This system addressed multiple concerns for healthcare application, including provisions for maintenance because its vinyl-wrapped modular panels never require painting and they’re removable for easy access to wall cavities.
A sleeper sofa integrated a solid-surface tabletop to accommodate parents rooming-in (sitting, working, storage, and sleeping) into one footprint. Computer monitors were mounted to maximize flexibility and conserve space, and blackout shades were installed to comply with the recommended standards of achieving darkness sufficient for transillumination. A newly designed wheelchair was also introduced and featured automated height and positioning controls, which can enable postpartum moms to lean closer to the incubator while seated.
The NICU model also included a communal space off the corridor, which could be shared by several families in pods of six to 12 rooms. A prominent goal of single-family rooms is to promote privacy, not isolation. This shared space, equipped with sound-masking technology to minimize noise disruptions, was designed to promote interaction between families. It can also provide a space for larger families to visit and gather, while enabling parents to remain close to their baby.
While design d
ecisions were made in accordance with the evidence, the materials used also allowed for a playful nursery theme using silhouettes from nature, which also responds to research suggesting views of nature reduce stress and anxiety. The team used the solid surface casework, flooring, and custom window shades as a canvas to convey the theme, which showcases a butterfly garden pattern.
The PESL team has big plans for the lab in 2014. In addition to the educational sessions on tap, members are working with a graduate industrial design studio from Georgia Tech to inspire more innovative products and continue collecting feedback from NICU parents and clinicians. Technology displayed in the lab will be explored further, such as the usefulness of a webcam system for multiple functions and custom sound masking as a design intervention strategy in the NICU environment.
Tammy Smith Thompson, NCARB, EDAC, is president of the Institute for Patient-Centered Design. She can be reached at firstname.lastname@example.org. Megan Denham, MAEd, is a research faculty member at SimTigrate Design Lab at Georgia Institute of Technology. She can be reached at email@example.com.