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What’s New in the NICU?
The baby is not much bigger than the stuffed animals that line her windowsill. Born at just 33 weeks gestation she has already had surgery to correct a problem in her abdomen. Today she nestles snugly against soft blankets in an incubator in the new 13,000 square feet neonatal intensive care unit (NICU) at Massachusetts General Hospital (MGH) in Boston. The machines that monitor her breathing, heart rate, and oxygen saturation make little noise. It is hard to believe this quiet, spacious room with its sweeping view of the Charles River is part of the same busy urban medical center that surrounds it.
The design of the 18-bed, all-private-room NICU is a departure from the open-plan architecture of the hospital’s previous Level 3 nursery and the majority of NICUs nationwide. It also serves as a striking illustration of how the field of neonatology has evolved in recent years to include more family involvement and less sensory stimulation.
The change is based largely on research by Dr. Heidelise Als, a developmental psychologist at Harvard Medical School and Children’s Hospital who has shown that premature infants fare best when their care is organized around their individual needs and the needs of their families. The work of Als and her colleagues suggests that a style of specialized care called the Newborn Individualized Developmental Care and Assessment Program (NIDCAP), which combines a dark, quiet, “womb-like” environment with an individually tailored schedule and ample family involvement, helps a baby’s brain to develop closer to the way it would if she were still inside her mother’s protective uterus. Several Harvard Medical School-affiliated hospitals are taking this research into account as they begin to design and re-design NICUs that mimic the womb in every way currently possible.
“In the NICU, sound and light are especially important because infants begin to respond to these stimuli near the beginning of the third trimester,” explains Dr. Anne Hansen, Medical Director of the NICU at Children’s Hospital in Boston, which cares for almost 700 newborns each year. “In the womb, sound is muffled, but in the NICU, loud noises are common and contribute to decreased oxygen saturation, poor weight gain, and potentially hearing loss in premature infants.”
Peggy Settle, Nursing Director of the NICU at MGH, adds, “We are using technology to facilitate this very important and natural human experience. It may sound bohemian, but the goal is to help the baby sleep deeply and conserve energy so she can do what she needs to do to grow, develop, and be social with her parents.”
Beyond Survival
This current focus on patient- and family-centered care in the NICU is part of a larger trend that will likely extend beyond the NICU, observes Dr. Steven Ringer, Chief of the Division of Newborn Medicine at Brigham and Women's Hospital, which has a large Level 3 NICU that cares for over 3,600 infants each year.
“In the past, hospital environments were focused around the needs of architecture, geography, and the caregivers. Little thought went into the environmental impact on the patients,” says Ringer. But he adds a reminder that the NICU has only been around since the early 1960s and the field of neonatology since the 1970s. During the early years, most efforts were devoted to keeping patients alive.
In that regard, the field’s accomplishments are remarkable. Today, thanks in part to the advent of mechanical ventilation and pulmonary surfactant replacement therapy, which helps prevent chronic lung disease, over 90 percent of infants born before 37 weeks gestation survive. It is even possible to save the tiniest newborns weighing just one-and-a-half pounds.
And many of these pre-term infants flourish. However, sometimes their developing brains are taxed by their early arrival into an over-stimulating world, and they develop neurological complications. Studies on school-age kids born prematurely show a higher occurrence of learning disabilities and psychiatric and disciplinary problems, and up to 25 percent of those born under three pounds, five ounces develop problems with behavior, visual and motor integration, or language.
As a result, much of today’s focus in neonatology and NICU design has moved away from keeping babies alive at all costs to improving long-term outcomes.
While no one knows the precise mechanisms through which the NICU environment affects an infant’s development, it is clear that the trend toward minimizing extraneous sensory stimulation and maximizing the role of the family is making a difference. At MGH, for example, it is becoming apparent that babies settle more easily in a dim, calm space, and they seem to require fewer medical interventions, according to Settle.
Growing Pains
To be sure, not everyone is in a position to build a new NICU from the ground up. Brigham and Women’s Hospital was an innovator 15 years ago when it built its huge 46-bed open-plan NICU. Today the hospital is looking at ways to modify its design, adding features like dimmable lights, sound-absorbent wall panels, visual alarms, and new flooring to reduce unnecessary environmental stimulation. Hospitals that are able to redesign their NICUs face other challenges. At Children’s Hospital, the plan for its proposed “NICU of the Future” must be designed to accommodate the Massachusetts Department of Public Health’s requirement of 120 square feet per bed.
Even MGH has encountered growing pains. It took almost a year for nurses to accept the radical change in the way they do their jobs. Now, instead of being able to turn 360 degrees and see every infant in the unit, they look at monitors and LEDs for signs of a baby’s distress. “That was very disturbing and challenging for some people, and it took a long time to acclimate,” says Settle.
Communication presented another challenge. In an open-plan NICU, parents can see when a nurse has her hands full. In contrast, in a private room, the nurse appears to be a “captive audience” at each person’s disposal. “Parents don’t have the same understanding of the demands on the nurse’s time,” says Settle. Not only have nurses had to learn to change the way they communicate with parents, but they have also had to change the way they connect with one another. Before, they were clustered together and could chat easily; now they contact one another via cell phones set to vibrate and save face-to-face conversation for regularly scheduled meetings and breaks.
But as difficult as the transition has been, nobody left the hospital as a result, according to Settle. And after eight months, all agreed that the environmental benefits to babies and their parents were clear. So they spent the next 18 months devising ways to structure the environment so that it would work for them as well. Besides developing new styles of communication, they introduced new processes for doing everything from conducting rounds to taking breaks. One benefit for the nurses: fewer end-of-day headaches brought on by constantly tuning out background noise and other distractions while providing care.
How does the environment serve the babies? For one thing, it improves their ability to sleep deeply, heal, and socialize with their families. Further, the new NICU has increased the rate of breastfeeding to 75 percent. Moreover, parents whose babies are thriving are not exposed to parents who are grieving because their babies are not, and vice versa, which can add another layer of emotional strain. And, most importantly, there are many more opportunities for families to be with their babies--even those that cannot be saved. “A mother whose baby is acutely ill and might not survive the week or even the night can be with that baby in a way that’s not possible in an open unit,” says Settle.
In hindsight, Settle says there are a few things she would have done differently. One, she would have asked the architects to include a bathroom in each unit for new mothers. She would also have run a computer simulation of traffic through the unit before it was constructed and possibly changed the location of a room or two. She would also have provided opportunities for the staff to experience simulations of emergency procedures before moving into the new space.
But these are relatively small issues compared with the enormous improvements she has witnessed in patient care. She envisions one day combining the current technologies with closed-circuit television, to allow nurses to see not just the infants’ vital signs but how the babies look, how they are moving, and whether they are resting comfortably after a feeding. “I think there will be a lot of opportunities in the future to use technology to observe these babies in ways we are not able to do now,” she says. “And it won’t influence the conditions of their environment.”
--Written by Natalie Engler for Partners Harvard Medical International
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