A neonatal intensive care unit (NICU) is more than a clinical unit in a hospital; it’s a first “home” to newborns and a home away from home for parents. To that end, specific care requirements related to the fragility of these patients and needs of their families present design challenges on any project.

Bringing an aging—and fully operational—NICU into the 21st century adds another degree of complexity, something encountered on the renovation of the Allison Family NICU at Yale New Haven Children’s Hospital’s Bridgeport campus in Bridgeport, Conn. The existing 5,400-square-foot NICU, consisting of three horseshoe-shaped open pods of six bays each, was designed with all patient rooms on one side of the unit and staff/support spaces on the other, making it impossible to renovate one complete side at a time.

With nowhere to temporarily relocate the entire NICU and a projected census of 14-18 babies expected during the 10-month construction schedule, a multiphase project approach was adopted for the project that began in March 2017. This allowed the design team to give deserved attention to each renovated space, including providing privacy for patients and their families, elevating outdated and deteriorated finishes, and creating functional and compliant support spaces, while also maintaining the level of care and comfort that the unit’s users expect.

Renovation stages
The project was divided into four phases. From the beginning, the design team, including architecture firm Shepley Bulfinch (Boston), worked extensively with NICU staff, contractor Turner Construction (Shelton, Conn.), and hospital administrators to develop a phasing and logistics plan that addressed everyone’s goals and expectations. This process was imperative to ensure no clinical, security, or code needs were overlooked. The plans were continuously reviewed with the hospital’s infection prevention specialists, security team, and the state’s Department of Public Health.

Phase 1: Enabling—The design team began by setting up the infrastructure required to allow the NICU to be divided into two parts. The existing NICU was supplemented with four additional patient rooms in the pediatric unit across the hall to create temporary NICU pods for seven isolettes. This allowed the hospital to take half of the existing NICU offline while still maintaining an overall bed count of 15-18 throughout the project. The project team also focused on “connecting” the two spaces so they could operate as a single unit, including modifying patient monitoring systems, security and communication devices, and shared staff and supplies. Concurrently, new NICU on-call rooms and electrical closets were built adjacent to the unit in preparation to support future phases of the project.

Phase 2: Construction Part 1—The first phase of construction focused on renovating a portion of the existing staff workroom, storage room, the reception area, pneumatic tube station, and 12 NICU bays, turning them into seven new NICU beds. The spaces that were taken offline were relocated to the temporary unit and an infection control risk assessment wall was built to separate the construction zones from operational portions of the existing NICU and temporary spaces.

The design team worked with NICU staff to understand and help develop solutions to all operational and clinical needs, identifying provisional locations for the supply storage system, pneumatic tube system, supplies, and medications. For example, the pneumatic tube station needed to remain operational throughout the project. It was first moved from the existing nurses’ station (demolished in Phase 2) to a temporary location in an adjacent corridor until its new permanent location was built at the end of Phase 3. The 6-inch pneumatic tubing was extended to the temporary station while construction activities occurred around it. Once the new station was complete, the system could then be reconnected, and normal operations could resume.

A thorough review process engaging multiple departments was developed to get consensus and buy-in on the proposed operational changes, and the project team met with staff every week during construction to provide updates and work through unforeseen obstacles. At the completion of this phase, several newly renovated spaces, including four private NICU rooms and three private NICU bays, a reception and nurses’ station, a team workroom, pneumatic tube station, clean and soiled utility rooms, staff lounge, and equipment storage, became available.

Phase 3: Construction Part 2—With Phase 2 operational, construction began on renovating the remaining eight NICU beds and support spaces to create 11 new NICU beds. This process involved displacing most of the unit’s support spaces, including the medication and formula prep alcove, staff lounge, lactation room, offices, clean and soiled utility, and the unit’s mechanical room. These spaces were strategically selected to be renovated last to provide continual support to the active unit while new support areas were built out during the earlier phase.

At this stage, the new staff lounge, soiled and clean utility, and storage rooms were moved into their new spaces. However, to accommodate the displaced medication room, formula prep, and clean supplies, the team relied on the newly constructed staff workroom as a temporary “home” for only essential, frequently used supplies and materials.

Phase 4: Integration—During the final phase of the Allison Family NICU renovation, the temporary infection control partition was removed and the two halves of the new NICU were reconnected. Work was strategically broken into segments, including connecting above-ceiling mechanical systems, tying ceilings together, completing flooring patterns, and finishing wall and paint touch-ups. This work was dictated by census numbers and took place in smaller containment set-ups to minimize disruption to the unit—approximately five sections, lasting two to three days each.

The new NICU opened in February 2018 with a host of new features, including two large quad rooms that give parents of multiples the ability to be with all their babies in one space; centralized monitoring so all nurses within the unit can view patients’ vital signs at any point and respond accordingly; and designated medication prep and formula and breast pump prep rooms, which allow nurses to perform important tasks in a private setting and support efforts to decrease errors and increase efficiencies. The new private patient rooms, which reduce stimulation to both sound and light, can be adjusted to individual patient needs, while further promoting family-centric care for babies.

Lessons learned
While every phase of the Allison Family NICU renovation included an area of focus that came with its own hurdles, there were also many overarching challenges to solve.

For example, a critically important aspect of any NICU is security. This became increasingly more challenging with a multiphase project and two physically separate spaces across the hall from each other operating as a single functioning NICU. For instance, the existing infant protection system had to be reworked and rewired several times to accommodate the changing entrances to the unit, temporary construction access, and egress doors. The project team worked closely with the users and hospital’s security and IT departments to ensure there wasn’t a lapse in service.

Additionally, attention to noise, vibration, and infection prevention and control was extremely important because of the fragile patient population, which is extremely susceptible to noise, light, and infection risks. To mitigate the potential sensory impacts due to construction, the temporary infection control wall was built using 6-inch metal studs with two layers of drywall on each side and 6 inches of acoustical insulation. Furthermore, excessively loud activities were first reviewed by hospital staff to determine the best time to perform the work, and construction teams were always responsive to unforeseen patient needs and heightened sensitivities.

Logistics were a moving target throughout the project, as well, and flexibility was key to success. The project team had to be strategic and nimble to balance project goals with patient and family well-being. One of the more complicated logistical tasks was the installation of the new air handling unit and associated ductwork. The unit that served the existing NICU needed to remain operational for Phases 1 and 2 while the new one was being built. Then, the existing unit was removed, and all the new duct-work was connected so that there were no interruptions to the end user.

And while the temporary NICU was contained in largely pre-existing spaces, consideration for potential impact on other areas of the hospital also had to be considered. For example, construction activities like plumbing relocations involved the cesarean section suite on the floor below. To meet hospital requirements and keep two C-section rooms operational during construction, the OR on the third floor dedicated a room specifically to C-sections for two weeks while above-ceiling construction work was completed.

Finally, in addition to phasing construction, the team prepped the hospital for “creative staffing”—a mix of overstaffing and borrowed staff—to assure operations were running smoothly, unforeseen challenges were tended to, and family needs were being met. The design team, contractor, client, and staff also took on a team mentality of 24/7 transparency and flexibility to offer seamless care during construction that focused on putting patient well-being ahead of the project schedule and stopping construction as required. For example, there were times throughout the project when work was stopped for the day so that hospital staff could relocate the more critical babies farther away from loud construction activities.

In the end, the resourcefulness of the project team and staff allowed for continual care with, as one family put it, “night-and-day improvements” between the old and new facility.

Ben Smuckler is an associate at Shepley Bulfinch (Boston). He can be reached at bsmuckler@shepleybulfinch.com.

Project details:
Project name: Allison Family NICU, Yale New Haven Children’s Hospital Bridgeport
Architect: Shepley Bulfinch
Contractor: Turner Construction
Engineers: BR+A (MEP), Spiegel Zamecnik & Shah Inc. (structural)
Acoustics: Cavanaugh Tocci
Lighting design: LAM