The Dangers of Being Single in the NICU

A clear trend has emerged across the country whereby there is almost universal adoption of single patient/family room design for newly built (not renovated) NICUs. I know this personally because in my travels speaking these past few years these are the only type of units I see or hear being built (more than two dozen units so far). Our new hospital here in San Diego, opening in 2016, is no different as the single patient room design our architects came up with is very much in line with what other healthcare design firms are doing.

The promise of this new design was improved outcomes, including increased privacy, increased parental involvement in patient care, assistance with infection control, noise control, improved sleep, decreased length of hospital stay, and reduced re-hospitalization.¹ The excitement of much more space per patient has recently been dampened by concerns that not all the potential pitfalls of such a move have been fully considered.² This study from Dr. Terrie Inder’s team when she was in St. Louis, MO showed early negative effects on neurodevelopment and brain structure/function with birth hospitalization in a single patient NICU room compared to open bay design. They suggest that single patient rooms may present a type of sensory deprivation for our babies. This has raised a huge concern that our new NICUs (that typically will stay in their configuration for more than 3-4 decades) were designed incorrectly.

First of all, why are we changing to this design? If I can use my own NICU as an example the footprint for individual infants has increased with larger and more equipment supporting our babies. These include the monitoring devices, incubators, ventilators, noninvasive ventilation apparatus, ECMO circuits, neuro-NICU equipment, enteral feeding devices, etc. Furthermore, interrogating infants with sophisticated testing equipment including ultrasound machines, continuous EEG devices, NIRS monitoring, etc. has concomitantly increased. We are now beyond being out of space and desperately await the opening of our new NICU. In the two decades that I have practiced pediatrics, the only thing I can think that I have seen get smaller have been phototherapy lights! So much for technology miniaturizing our world. Even the computers have bigger footprints, think WOW!

I am pretty sure too that the consumers, the parents, encouraged this to happen. The lowest scores we get in our parent satisfaction surveys always fall in the physical space category, a hard thing to change without a new building or renovation. Customer satisfaction is a basis for a hospital’s reputation and brand quality and this clearly is a driver. On the patient side however there are many good reasons besides space constraints of equipment. The move towards family centered care is more feasible with a private or semi-private concept where family members can stay as long as you want and have more opportunities to hold their infants. We all feel viscerally that having families around more is a positive thing for their babies even if we can’t quite define what these benefits are.

Surprisingly, though, I have yet to come across a single patient NICU where more than half of parents can be found spending a major portion of the day or night in their infant’s rooms. In fact, most people tell me it is closer to 25 to 30% of the parents that are present. The big question is, are we forgetting what infants need by pushing for parental satisfaction?

What is the consequence of not being held to the normal healthy newborn? If we look at primate experiments, even brief periods of mother-infant separation can have long-lasting effects on the maternal infant bonding and developmental maturation of the infant. Infants do need to be held for prolonged periods of time to establish good attachment to their parents; but how are we to achieve this given the preterm infant’s early predicament? The window for this attachment and bonding is likely very early and is important throughout hospitalization, particularly when painful or noxious stimuli are applied by the care team. That is a big reason why we see such great success with skin to skin care in the developed world and continuous kangaroo care models in the NICU in developing countries. Nothing beats the human touch! Many of us feel that the preterm infant is left alone more than they should be, even as it is with open bay units. I suspect that if other units are like ours, most preterm babies spend a majority of their day alone. Sure, the exceptional parent can afford 4-5 hours of holding time daily, but even that still leaves a large chunk of the day alone.

Does the fetus use its senses in utero? The fetus beyond 22 weeks gestation has some capacity to see, hear and feel both comforting and noxious stimuli. With eyes closed they are listening to the heartbeat of their mother. Physics will tell us that sounds travel very well through liquid. The sounds that the fetus hears may include such loud and cacophonous sounds as people yelling, subway noises, vacuum cleaners, and close up gurgling of borborygmi (aka bowel sounds). The fetus is not really sheltered from high decibel and disruptive noises that may stimulate a change in vital signs. Furthermore there is an important window here for language development as the fetus continually hears their mother’s voice. Tactile sensations are muted by being suspended and bathed in warm amniotic fluid in utero. Abrupt and noxious tactile stimuli are less likely given the maternal shielding of her abdomen. The fetus is bathed in warmth and has a placenta that provides all the circulatory and cellular metabolic clearance necessary for long-term survival. In utero, infants may not be able to see so well but they will have some light penetration. There are not likely to be very stark or noxious visual stimuli. The fetus then is accustomed to sensory stimulation on all fronts and removing much of the developmental stimuli may be a harmful thing.

Perhaps, however, the focus on raising the alarm on single patient room NICU design is not correct. At this past Hot Topics in Neonatology in Washington, D.C., contrary views were presented from Dr. Terrie Inder (data from her previous center in St. Louis, MO) and by Dr. James Padbury (Brown University in Rhode Island) on the impact of single patient room design.³ Dr. Padbury’s group found a number of positive effects of single patient rooms, including better weight gain, reduced stress, reduced sepsis, improved attention, improved feeding outcomes and reduced medical procedures. At first I thought this was going to stir a major debate in their respective data. What ensued was more of an agreement that their data was in fact congruous with each other. In the case of Dr. Inder’s data the infants in her unit comparatively had much less parental involvement than in the unit in Rhode Island. This puts the focus more on the role of human interaction and developmental support. My own experience with single patient rooms that I have visited is they are deathly quiet when no visitor or caregiver is there. There are much fewer distracting noises and much less alarms but also fewer human voices and conversation. Therefore, the presence of parents, interactive role of nurses and other staff may be much more relevant in influencing brain development and long-term neurodevelopmental status and may need to be regulated more in the quiet single patient room NICU.

The other thing to consider is that not all children are the same. My first born was a true high maintenance infant that demanded that we carry her until she was about 9 months. My second child was very different and was perfectly content on his own and just needed some sensory cue that we were in the room or could be heard. This high variability of an infant’s demands for attention and comfort prevents us from generalizing. Perhaps what we need to develop are better indicators of stress to delivery the right kind of response. As we all know, an infant will cry for attention increasingly until it reaches a despondent point of exhaustion when they realize no one is available to comfort them. The impact of repeated inattention in times of stress could very well have lifelong consequences emotionally and behaviorally to the individual. Knowing how to respond to an infant’s cues without parents continually present is going to be the new challenge.

So, are there other downsides of the single patient room? The most consistent impressions I hear from staff that have switched to this design are regarding the loss of community. The large open bay NICU provides a holistic approach to managing a large number of infants together with other staff. It supported a community approach to learning where senior staff could see out of the corner of their eyes what was going on around the room and assist if need be. This was a key aspect to the learning curve of a newly minted bedside nurse. From the physician’s perspective the whole view perspective of the NICU gave you great confidence that you could have within your view all the potential trouble patients, making your triaging of priorities to act on quite easy. I have visited new NICUs that have mirror image sections with rows upon rows of single patient rooms over an enormous stretch of space, football field size. I suspect that when doors and hallways become redundant like that, identifying which patient is where can no longer be a holistic snapshot. A corollary to this experience is the loss of the pullout patient bedside spreadsheet. In one glance on rounds I remember seeing all the information that I needed to decide on what to do with the infant in front of me. No EMR I know has been able to replace this integrative gestalt view. In an open bay NICU, one could see and hear what was going on throughout the unit, but so could all the parents in the room. In this age of increasing scrutiny for HIPAA violations we are now acutely aware of accidental leaks of information due to physical space. Developing policies that are both family centered and ensuring privacy can be challenging, almost incongruous with each other.

Reasons why we should worry about single patient rooms

• Loss of mentoring by senior nurses, i.e. learn by watching
• Reduced social environment for nursing, other staff, and parents
• Reduced awareness of priorities and activities in NICU
• Increased response time for emergencies
• Alarm fatigue
• Sensory deprivation with consequent impact on neurodevelopment outcomes of infants

I don’t see us returning to solely open bay setups, but perhaps more consideration is needed to have blended units to afford some of the benefits of the open bay design for high acuity or absent parents. The physical spaces that we create for our infants and their families have an enormous impact on the daily satisfaction and routine of infants, families and staff. More effort is needed in addressing barriers to providing contact time between parents and their infants. Fortunately, with the right understanding of what we should focus on, being single in the NICU may not be so bad after all!

References:

1. Shahheidari M., Homer C. Impact of the design of neonatal intensive care units on neonates, staff, and families: a systematic literature review. J Perinat Neonatal Nurs. 2012 Jul-Sep;26(3):260-6; quiz 267-8. doi: 10.1097/JPN.0b013e318261ca1d.

2. Pineda RG, Stransky KE, Rogers C, Duncan MH, Smith GC, Neil J, Inder T. The single-patient room in the NICU: maternal and family effects. J Perinatol. 2012 Jul;32(7):545-51. doi: 10.1038/jp.2011.144. Epub 2011 Oct 27.

3. Lester BM, Hawes K, Abar B, Sullivan M, Miller R, Bigsby R, Laptook A, Salisbury A, Taub M, Lagasse LL, Padbury JF. Single-family room care and neurobehavioral and medical outcomes in preterm infants. Pediatrics. 2014 Oct;134(4):754-60. doi: 10.1542/peds.2013-4252. Epub 2014 Sep 22.