In hospitals across the country, neonatal intensive care units (NICUs) are evolving from compact, multipatient-room environments to expansive, all-private-room settings. “The consensus among neonatologists is that the move to a private-room NICU provides better outcomes: decreased length of stay, improved breastfeeding, and increased parent satisfaction and mother-baby bonding,” says Dr. Satyan Lakshminrusimha, chief of neonatology at John R. Oishei Children’s Hospital in Buffalo, N.Y. This fundamental shift in care has implications for NICU design, size, staffing, and operational efficiency. However, there’s an increased concern that despite the benefits noted, this new approach brings its own challenges, including new parents feeling physically and emotionally isolated while caring for their babies, requiring healthcare designers to identify solutions that balance competing needs.

Evolution of NICU care
In the 1970s, NICUs were typically designed in pods, with four to six beds per pod and four pods per 32- to 36-bed floor. These departments maintained a staffing ratio of one nurse to two to four patients and one physician to eight to 20 patients. The closed pod setup was inefficient for patient care, though—especially from a staffing perspective—because the addition of one infant beyond the capacity of the pod meant another pod had to be opened with additional staff. Twenty years later, the next generation of the NICU used a pinwheel configuration with individual patient spaces in each segment of the pinwheel, a spatial organization that provided more privacy but resulted in a noisy, crowded environment. However, mothers in need of companionship and support during a stressful time found the closeness to other mothers reassuring, and the sound of the open NICU was thought to provide a level of stimulation that’s helpful to the neonates.

More recently, healthcare organizations’ emphasis on reducing infection rates and readmissions and improving quality and safety scores has pushed the adoption of private-room NICUs, similar to other pediatric ICU layouts. Research studies, such as “18-Month Follow-up of Infants Cared for in a Single-Family Room Neonatal Intensive Care Unit” published in Journal of Pediatrics in 2016, supports Lakshminrusimha’s observation that the model improves babies’ length of stay and growth, breastfeeding, and parent satisfaction. Single patient rooms also greatly enhance patient privacy and allow nurses to spend more time with parents. Dr. Seetha Shankaran, neonatologist at Children’s Hospital of Michigan in Detroit, says her staff appreciates the private room setup because it allows them to educate and prepare parents for the care of their child.

Concepts for efficiency
As hospitals reconfigure their NICUs to support private rooms, it’s important to identify the ideal size and design of the unit for optimal patient care and staff efficiency. This can be a difficult task, as physician coverage, staffing, and patient acuity are the key determining factors and change from facility to facility. Additionally, the number of neonates cared for is a direct result of the function of the NICU in the system and the type of prenatal step-up in place. For example, the John R. Oishei Children’s Hospital, which is expected to open in November, will support all high-risk births from its own hospital as well as transfers from other regional facilities, resulting in a larger department.

The recommended optimum ratio in neonatology is 12-20 patients to one physician, eight patients to one mid-level provider, and one nurse to four patients, depending on patient acuity, Lakshminrusimha says. Size does have an impact on staff, however, and NICUs with private patient rooms are larger in square footage than those with pod or group settings. With an expanded footprint, walking distances increase substantially from patient rooms to supply closets, medication rooms, and formula prep areas. For nurses, patient assignments are often contingent on acuity and bed availability, so nurses could be caring for patients on opposite ends of a unit. For this reason, care provider stations and supplies are often decentralized in large NICUs to bring nurses closer to the point of care along with medications and patient-specific supplies, such as milk and formula, via supply servers.

Many facilities are also trying different layouts to address optimal care and staff satisfaction. For example, Boston Children’s Hospital’s new NICU, to be completed in 2022, will use an onstage/offstage concept that reduces walking distances thanks to offstage cross-corridor paths and provides areas for staff consults and communication away from patients. Others are relying on a neighborhood concept to provide clinical teams with the necessary support services to deliver efficient and effective care. At the John R. Oishei Children’s Hospital, the 45,000-square-foot NICU will house 64 beds in five neighborhoods of private rooms (with a couple of double rooms). Each neighborhood will be led by a charge nurse and provide some degree of local control, while improving communication and accessibility of resources.

Family at the center
The presence of family can contribute significantly to the growth of NICU patients and prepare parents for baby care following discharge, meaning designers should consider including spaces that support sleeping, eating, and working as well as participation in caregiving. Common family amenities in NICUs include lounge and support areas, kitchenettes and dining spaces, laundry and shower facilities, sibling play rooms, and outdoor gardens. Shankaran says she’s seeing more mothers spending time in the NICU at Children’s Hospital of Michigan and using the spacious lounge, where parents can access a computer or find a place to talk with others. “This has helped parents get to know each other and form helpful relationships that last beyond the NICU,” she says.

Within the patient rooms, family-focused design features include furniture that converts to beds, individual refrigerators for storing food, and technology. Some NICU designs also incorporate sub-waiting areas and prayer rooms to accommodate international cultures, large family sizes, and specific religious needs. To promote bonding time with parents and other family members, especially siblings who are traditionally prohibited from visiting NICUs due to space limitations and potential health concerns, many facilities are adding family suites with kitchen facilities, resource centers, and outdoor gardens.

Future thinking
As the industry continues to reimagine the NICU setting, it’s important to remember that building bigger spaces isn’t always the answer and that size is relative to the ideal operational model identified.

Maintaining a focus on patient experience and staff efficiency should be key drivers in the design of new or renovated spaces to improve baby care and family satisfaction.

Uma Ramanathan, AIA, LEED AP, is a principal at Shepley Bulfinch (Boston). She can be reached at