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Cost and Design Analysis of Neonatal Intensive Care Units: Comparing Single Family Room, Double-Occupancy, Open-Bay, and...

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COST AND DESIGN ANALYSIS OF NE ONATAL INTENSIVE CARE UNITS: COMPARING SINGLE FAMILY ROOM DOUBLE-OCCUPANCY, OPEN-BAY, AND COMBINATION SETTINGS FO R BEST DESIGN PRACTICES By NATALIE PAIGE HARDY A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF INTERIOR DESIGN UNIVERSITY OF FLORIDA 2005

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Copyright 2005 by Natalie Paige Hardy

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iii ACKNOWLEDGMENTS I would like to extend a si ncere thanks to many people who supported me in the completion of this thesis. First I would like to thank my friends and family, especially my parents, Linda Murray and Dudley Har dy, for all of their love and support. I would like to thank Profe ssor Michael Cook for agreeing to be on my research committee. Professor Cooks knowledge of building construction and cost estimating was essential to this research project. His li ghthearted attitude was appreciated as well. Finally, I would like to thank Dr. Debra Ha rris for her enthusiasm, knowledge, and guidance throughout this endeavor. As my committee chairperson, Dr. Harris was essential during every phase of this projec t as well as a mentor and a friend.

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iv TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iii LIST OF TABLES............................................................................................................vii LIST OF FIGURES.........................................................................................................viii ABSTRACT....................................................................................................................... ..x CHAPTER 1 INTRODUCTION........................................................................................................1 Purpose........................................................................................................................ .2 Significance..................................................................................................................2 2 LITERATURE REVIEW.............................................................................................4 Introduction................................................................................................................... 4 NICU Design and History............................................................................................4 NICU Environment and Its Effect on Neonates...........................................................6 Light and Noise.....................................................................................................6 Infection Control...................................................................................................9 NICU Environment and Its Effect on Family...............................................................9 NICU Environment and Its Eff ect on Healthcare Staff..............................................10 Nursing Models: Family-Centered Care and Developmental Care...........................11 Family-Centered Care.........................................................................................11 Developmental Care............................................................................................11 Recommended Standards for NICU Design...............................................................12 Construction Cost.......................................................................................................13 Floor Plan Analysis.....................................................................................................15 3 METHODOLOGY.....................................................................................................16 Research Design.........................................................................................................16 Sampling Procedures..................................................................................................16 Participants.................................................................................................................17

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v Ethics......................................................................................................................... .17 Data Collection...........................................................................................................18 Data Analysis..............................................................................................................19 Floor Plans...........................................................................................................19 Construction Cost................................................................................................20 4 RESULTS OF THE STUDY......................................................................................23 Demographic Descriptive Information.......................................................................23 Single Family Room NICU Description.............................................................23 Double-occupancy NICU Description................................................................23 Open-bay NICU Description...............................................................................24 Combination NICU Description..........................................................................24 Floor Plan Analysis Results........................................................................................24 Single Family Room Floor Plan..........................................................................25 Double-occupancy Floor Plan.............................................................................26 Open-bay Floor Plan............................................................................................27 Combination Floor Plan......................................................................................28 Construction Cost Results...........................................................................................29 Single Family Room Costs..................................................................................29 Double-occupancy Costs.....................................................................................30 Open-bay Costs...................................................................................................30 Combination Costs..............................................................................................30 5 DISCUSSION AND CONCLUSSIONS....................................................................31 Findings......................................................................................................................3 1 Construction Cost................................................................................................31 Floor Plan Space Allocation................................................................................32 Implications for Research Findings............................................................................34 Single Family Room............................................................................................34 Double-occupancy...............................................................................................36 Open-bay.............................................................................................................37 Combination........................................................................................................37 Limitations of the Research........................................................................................39 Future Directions........................................................................................................40 Conclusions.................................................................................................................41 APPENDIX A LETTER TO PARTICIPATE.....................................................................................42 B AGREEMENT TO PARTICIPATE...........................................................................43 C CERTIFICATION OF COMPLETION FOR HIPAA...............................................44 D PUBLIC RELATIONS FORM...................................................................................45

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vi E PERMISSION TO PUBLISH.....................................................................................46 F FACILITIES PLANNING FORM.............................................................................47 G CONSTRUCTION COST DATA..............................................................................48 H NICU SPACE ALLOCATION DATA......................................................................49 I INFANT CARE AREA SPA CE ALLOCATION DATA..........................................51 J SINGLE FAMILY ROOM ALLO CATION OF SPACE DIAGRAM......................52 K DOUBLE-OCCUPANCY ALLOCA TION OF SPACE DIAGRAM........................53 L OPEN-BAY ALLOCATION OF SPACE DIAGRAM..............................................54 M COMBINATION UNIT ALLOCATION OF SPACE DIAGRAM...........................55 N CIRCULATION DIAGRAM FOR SI NGLE FAMILY ROOM UNIT.....................56 O CIRCULATION DIAGRAM FOR DOUBLE-OCCUPANCY UNIT.......................57 P CIRCULATION DIAGRAM FOR OPEN-BAY UNIT.............................................58 Q CIRCULATION DIAGRAM FOR CO MBINATION LAYOUT UNIT...................59 LIST OF REFERENCES...................................................................................................60 BIOGRAPHICAL SKETCH.............................................................................................63

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vii LIST OF TABLES Table page 4-1 Comparison of Construction Cost Data...................................................................30 5-1 Comparison of NICU Space Allo cations: Percentage of Unit................................33 5-2 Comparison of Infant Care Area Space Allocations................................................33 H-1 Unit Space Allocation Square Feet Amounts...........................................................50 H-2 Unit Space Allocation Percentage of Unit...............................................................50 I-1 Average Infant Care Area Space Allocation Square Feet Amounts........................51 I-2 Average Infant Care Area Percentages of Space.....................................................51

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viii LIST OF FIGURES Figure page 2-1 Example of Pin-wheel Configuratio n which is commonly used in open-bay layout NICUs..............................................................................................................5 3-1 Geographic Location of Participants........................................................................17 4-1 SFR Unit Space Allocations.....................................................................................26 4-2 SFR Infant Care Area Space Allocations.................................................................26 4-3 Double-occupancy Unit Space Allocations..............................................................27 4-4 Double-occupancy Infant Care Area Space Allocations..........................................27 4-5 Open-bay Unit Space Allocations............................................................................28 4-6 Open-bay Infant Care Area Space Allocations........................................................28 4-7 Combination Unit Space Allocations.......................................................................29 4-8 Combination Infant Care Area Space Allocations...................................................29 5-1 Cost per Square Feet an d Cost per Infant Station....................................................32 5-2 SFR Infant Care Area. This diagram s hows the typical layout of a private room in the SFR NICU case..............................................................................................34 5-3 Comparison of Family Space Bedside vs. Family Space outside Infant Care Area35 5-4 Comparison of Net to Gross Factor among Settings................................................36 5-5 Staff Space Bedside vs. Family Space Bedside.......................................................38 5-6 Open-bay Layout Circulation Diagram....................................................................38 5-7 Combination Layout Circulation Diagram...............................................................39 J-1 Single Family Room Allocation of Space Diagram.................................................52 K-1 Double-Occupancy Allocation of Space Diagram...................................................53

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ix L-1 Open-Bay Allocation of Space Diagram..................................................................54 M-1 Combination Unit Allocation of Space Diagram.....................................................55 N-1 Circulation Diagram for Single Family Room NICU..............................................56 O-1 Circulation Diagram fo r Double-occupancy NICU.................................................57 P-1 Circulation Diagram for Open-bay NICU................................................................58 Q-1 Circulation Diagram fo r Combination layout NICU................................................59

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x Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Interior Design COST AND DESIGN ANALYSIS OF NE ONATAL INTENSIVE CARE UNITS: COMPARING SINGLE FAMILY ROOM DOUBLE-OCCUPANCY, OPEN-BAY, AND COMBINATION SETTINGS FO R BEST DESIGN PRACTICES By Natalie Paige Hardy August 2005 Chair: Debra Harris Major Department: Interior Design Newborn intensive care is care for critic ally ill newborns requiring constant nursing, complicated surgical pr ocedures, regular respiratory support, or other intensive interventions. Presently, the neonatal inte nsive care unit (NICU) population is increasing attributable to recent social and demogr aphic trends such as teenage pregnancy, technological advances in neonatology, a nd fertility medicine techniques causing multiple births and low birth weight neonates. As a result of the increased use of NICUs, many hospitals are remodeling their facilitie s. Consequently, designers and hospital administrators are in need of informati on that will help generate knowledge-based guidelines. More specificall y, designers and administrators are in need of information regarding the environmental a nd cost implications between various NICU types. This study examines the construction cost and design implications among four NICUs which offer different settings 1) single family r oom (SFR); 2) double-occupancy; 3) open-bay; and 4) combination layout.

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xi The case study involved the comparison of f our NICUs located in the United States that were built or remodeled since 1995. Cons truction costs and architectural floor plans were collected from each participant NICU. The floor plans were categorized by use 1) infant; 2) family; 3) staff; 4) systems; 5) uni t circulation; 6) family space at bedside; 7) staff space at bedside; and 8) clear floor space. The NICU space allocations were compared across each facility to identify any design trends. The construction costs were adjusted to the year 2005 and normalized to the National City Average. From these results, the cost per square feet (SF) and cost per infant station were calculated and compared. The primary results showed that the ope n-bay case had the highest construction cost in both cost categories (cost/SF and cost/infant station) and the combination case had the lowest cost in both cost categories. The SFR and double-occupancy cases offered the most family space bedside and the least family space outside the infant care area. In comparison, the open-bay case offered the leas t amount of family space bedside and the most amount of family space outside the infant care area. These results pose the questions: 1) is it preferable to have more family space at bedside in the infant care area or 2) is it preferable to have more family space outside the infant care area? The study recognizes the limitations associated with case study research and that the results are not completely generalizable due to variables which cannot be controlled. Future research focusing on the environmenta l and cost implications associated with various NICU types is needed to provide the best setting for the patient, family, and healthcare staff.

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1 CHAPTER 1 INTRODUCTION Newborn intensive care is care for critic ally ill newborns requiring constant nursing, complicated surgical pr ocedures, regular respiratory support, or other intensive interventions. An infant is considered prem ature if he or she is born before 37 weeks of gestation and weighs less than 2,500 grams (g). A very low birth weight (VLBW) infant is a child born weighing under 1,500 g (F eldman Reichman, Miller, Gordon, & Hendricks-Munoz, 2000). There are three levels that define the Ne onatal Intensive Care Unit (NICU). Level I (basic) care is a hospi tal nursery that can perform neona tal resuscitation, evaluate and provide care of healthy newborn infants and near-term infants (35 to 37 weeks’ gestation), and stabilize newborn infants born before 35 weeks’ gestational age until transfer to a facility that can provide the appropriate level of ne onatal care. Level II (specialty) care is a hospital special care nurse ry that can provide ca re to infants born at more than 32 weeks’ gestation and wei ghing more that 1500 g. These neonates are moderately ill with problems th at are expected to resolve qu ickly and are not anticipated to need subspecialty services on an urgent basis. Level III (subspecialty) care is a hospital NICU that can provide cont inuous life support and comprehensive care for highrisk, critically ill newborn infants. Level III is subdivided into three levels differentiated by the capability to provide advanced medical and surgical care (Committee on Fetus and Newborn, 2004). This study focuses on Level III NICUs.

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2 Technological advances in neonatology have resulted in an incr ease in the NICU population. Recent social and demographic trends including teenage pregnancies, pregnancies with drug abuse, and neglected perinatal care have increased the number of neonates needing special care. In addition, fertility medici ne techniques have led to multiple births and low birth weight (LBW) ne onates (Mathur, 2004). As a result of the increased use of NICUs, many hospitals are remodeling their facili ties (Shepley, 2002). Consequently, designers and hospital administra tors are in need of information that will help generate knowledge-based design guidelines. Purpose This research project explor es the design and financial cost implications of single family room (SFR) NICU facilities. This work is part of a larger effort comparing SFR and multi-bed variation NICUs regarding 1) neonate outcomes; 2) family needs and preferences; 3) staff behaviors and pref erences; 4) construction costs, and 5) administrative/operational costs. For the purpos e of this study, the researcher compared the construction costs between a SFR, doubl e-occupancy, open-bay, and combination layout NICU, as well as the environmental implications of each type of NICU. Significance An efficient and nurturing physical envi ronment is critical for the support of premature infants, their families, and the healthcare staff that care for them. The advancements in neonatology, increasi ng NICU population, and need for updated facilities supports research in this area to provide designers with evidence-based guidelines to consult. In conjunction with successful environmental design, the costs of building, maintaining, and operating a NICU is equally important. Research based knowledge on the construction cost of SFR, double-occupancy, open-bay, and

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3 combination layout NICUs is currently lacking and will aid in the decision-making process when designing and building new facili ties. The findings will be represented as cost per square feet and cost per infant station, providing healthcar e administrators and design professionals key information in de termining the best practices for designing NICUs that support patients, families, and heal thcare staff. Additionally, for each setting, circulation and space allocations for infant, family, and staff are compared to better understand how space is allocated for diffe ring types of NICU facilities.

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4 CHAPTER 2 LITERATURE REVIEW Introduction The design of the NICU is multifaceted because the environment affects the premature infant as well as the healthcare sta ff which, in turn, impacts the infants. NICU design is further complicated because alongs ide environmental impact concerns, one must be concerned with the obvious costs (c onstruction and operational) and less obvious costs to family and staff such as environm ental stress, preferences, and satisfaction. This review of the literature focuses on r ecent trends and research of environmental factors in the NICU and their affect on the newborn infants, their family, and healthcare staff. Two nursing philosophies, family -centered care and developmental care are introduced. In addition, the limited res earch on construction cost, specifically construction costs for NICUs will be discu ssed. Finally, the literature on floor plan evaluations as a research instrument will be presented. NICU Design and History Traditional NICU designs have vari ed from open rooms supporting 10-50 incubators to smaller rooms with four-to-ei ght station pods, separate d either by walls or cubicle curtains (Mathur, 2004; Shepley, 2002). In the 1980s, the benefits of family participation in the care of their babies we re realized. This ch ange in care philosophy influenced the design of the pin-wheel configuration where patient privacy was addressed. With the use of the pinwheel configuration (Figure 2-1), privacy (not necessarily lighting or acoustical privacy) can be afforded by partitions and headwalls in-

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5 between the incubators, while allowing sta ff to observe several neonates at a time (Mathur, 2004). Figure 2-1: Example of Pinwheel Configuration which is commonly used in open-bay layout NICUs Recently, a trend in the design of NICUs ha s been to increase the number of private patient rooms for neonates and their families. Several factors have contributed to the recent popularity of SFRs 1) supportive da ta on infant outcomes; 2) increased understanding of the value of breastfeed ing and kangaroo-care (Ferber & Makhoul, 2004); 3) the hospital-wide trend toward pr ivate rooms (Mader, 2002; Mathur, 2004); 4) the success of family-centered and deve lopmental care (Cohen, Parsons, & Petersen, 2004; Robison, 2003); and 5) the success of innovative prototypes. Some resistance to the SFR NICU is base d on the perception that it would require more staff because all neonates can not be obs erved at all times if residing in single patient rooms. It is thought that an open floor plan reduces the need for staff to make frequent trips between unit ba ys and storage areas, thereby enabling them to spend time with infants (Shepley, 2002). In order to en able nurse’s constant supervision of neonates in the SFR setting, it is essential that SFR units use communication technology to

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6 mitigate the perceived need for more staff. Today’s advanced monitoring, surveillance, and nurse locator systems can immediately not ify staff of patient activities and allow access to patient information from remote lo cations (Mathur, 2004). Another perceived disadvantage to the SFR NICU is the notion that SFR design is more expensive than traditional designs because it requires more square footage (Moon, 2005). Unfortunately there is limited data to validate these a ssumed advantages and disadvantages of SFR, open-bay, and multi-bed variation NICUs. NICU Environment and Its Effect on Neonates Recent studies have shown that an envi ronmentally sensitive NICU can enhance growth, shorten stay, and reduce hospital co sts (Malkin, 1992; Mathur 2004). Features of the NICU physical environment taken into design consideration often focus on environmental control: lighting control, acous tic control, temperature control, infection control, privacy and security. Other variables such as co lor and comfort are important environmental factors to be considered in the research, design and development of NICUs. Light and Noise The NICU requires a range of lighting le vels to regulate neonates’ biological rhythms, perform procedures, evaluate skin tone, and ensure the ps ychological well-being of staff and families. Unfortunately, these bright lights can be painful and stressful to premature infants. Constant light may distur b body rhythm interrupti ng their sleep cycles and bright light may not permit neonates to open their eyes and look around (Malkin, 1992; Mathur, 2004; Nair, Gupta, & Jatana, 2003; White, 2002). It has been shown that cycled light, instead of conti nuous light, can improve the growth rate of premature infants (Miller, White, Whitman, O’Callaghan, & Maxwell, 1995). Although covering isolettes

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7 to minimize light exposure is practiced in many NICUs, isolette covers should not totally block an infant from view, because of the need to view the patient (Aucott, Donohue, Atkins, & Allen, 2002). It is recommended that light source s be balanced and free as possible of glare and veiling reflections (White, 2002). The noise level in a functioning NICU impinges on the infants, staff, and family. The level of noise is a result of many things 1) the operational polic ies of the unit; 2) the equipment selected for the unit; and 3) the basic acoustic qualities of the unit’s design and finishes (White, 2002). NICU sound levels can be compared to “light auto traffic” at 70 decibels; infants are often exposed to these continuous hi gh decibel levels with no escape. The constant noise; besides being stressful, may lead to hearing loss for the infant (Levy, Woolston, & Browne, 2003; Malkin, 1992; Nair et al., 2003). The effect of reducing light and noise between 7pm and 7am was examined in a randomized controlled trial. It was found that decreasing sound and light for 12 hours every night resulted in improved weight ga in and increased time sleeping for neonates (Mann, Haddow, Stokes, Goodley, & Rutter, 1986). Levy et al. (2003) compared the mean noise amounts between Level II and Le vel III NICUs. It was found that mean noise amounts are significantly higher in Leve l III NICUs than in Level II NICUs. Considering the acuity of the patient, noise control is especially important in Level III NICUs. Researchers have tried to develop systems to reduce noise in open-bay NICUs. It has been found that noise amounts can be decreased significantly by implementing regular quite hours and by modifying nursery la youts, especially placement of incubators (Strauch, Brandt, & Edwards-Beckett, 1993). Berens and Weigle (1996) proposed an

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8 innovative NICU design that dramatically reduces noise by separating physically and acoustically, all of the NICU “noisemakers” into a control room. Other inexpensive strategies for noise reduction include 1) placing blankets over incubators to muffle sound (this technique limits visibility to neonates); 2) using padded plastic garbage cans instead of metal; 3) padding incubator doors; 4) rearranging incuba tors to reduce pockets of increased or focused noise; 5) removing water from ventilator tubing frequently to reduce bubbling noises; 6) placing noisy equipment su ch as telephones, radi os, and centrifuges in a separate room adjoini ng the unit or in an isolated pod away from infants; 7) modifying heating and cooling systems to re duce noise; 8) talking quietly and closing doors and portholes gently; and 9) not dropping things on top of the incubator (Levy et al., 2003; Nair et al., 2003). The use of acous tical ceiling systems and carpet also assist in noise abatement, but must be selected and designed carefully for high performance results (White, 2002). The design of health care f acilities is governed by ma ny regulations and technical requirements; it is also affected by many less defined needs and pressures. The implementation of the Health Insurance Port ability and Accountability Act (HIPAA) has influenced hospital design, including NICU design, due to the need to provide patient privacy. These regulations put new emphasi s on acoustic and visual privacy, and may affect the location and layout of workstations that handl e medical records and other patient information, both paper and electronic, as well as patient accommodations (Carr, 2005). According to Mathur (2004), individu al private rooms are the only reasonable way to meet the acoustical privacy requirements under HIPAA.

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9 The control of light and noise is importan t and must be addressed in NICUs. The control of light levels may be more manag eable in SFRs because the light requirements are only dictated by one patient and one family. As discu ssed, there are many strategies to limit noise and provide lighting strategies in open-bay layouts. However, personal control of noise and light for each neonate and family is desirable to suit their individual needs (Mathur, 2004). Infection Control Hospital acquired infections are common in very low birth weight (VLBW) infants; occurring in approximately 20% of VLBW in fants (Gaynes, Edwards, Jarvis, Culver, Tolson, Martone, 1998; Sohn, Garrett, Sinkow itz-Cocran, Grohskopf, Levine, Stover, Siegel, Jarvis, Pediatric Prevention Networ k., 2001). Due to neonates’ immature immune system, the NICU is a high risk area for de veloping infections. In open-bay NICUs, infection control may be complicated because particulate matter tends to move freely in an open space. According to Mathur (2004), isolating neonates from each other and from outside sources of infections is the most eff ective solution for infection control in NICUs; hence, according to Mathur a SFR NICU provi des the best isolation for neonates. Many hospitals are moving towards private rooms to help with infection control (Mader, 2002). If the use of single rooms redu ces communicable infections; the results may translate into financial savings (Price Waterhouse Coope rs Web site, 2004) and less stress on the neonates. NICU Environment and Its Effect on Family The impact of family presence and visiti ng policy is commonly addressed in NICU research. For family members visiting thei r premature babies, privacy and comfort are important features to provide for them (She pley, Fournier and Mc Dougal, 1998). Parents

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10 experience a high level of stress in the NI CU due to confusing medical information, conflict with responsibilities at home, difficulty getting to distant facilities, loss of earnings, the high temperatures in a unit, and caring for a sick child (Callery, 1997; Goldson, 1992; Raeside, 1997). It has been not ed that increased visitation with the baby in the NICU results in a better chance of recovery (Zeskind & Iacino, 1984). Based on Zeskind and Iacino’s findings pertaining to the positive effects of increased family visitation; providing a NICU environment that is comfortable for visiting families is optimal. Research on family stress and needs in the NICU is important; presently research concerning family issues regarding the divers e NICU arrangements would be beneficial. Are there differences in parent-child intera ction in the four se ttings (e.g., number of visits, time spent at bedside)? Which type of unit is most prefe rred by families? These parent-child issues will be investigated in th e larger NICU research project. The family needs and preferences will be studied by data collection from medical charts relating to parent participation. Plus, a family survey will concentrate on the family-centered care philosophy and how the facility su pports the parents, siblings, and other family members. NICU Environment and Its Effect on Healthcare Staff The NICU environment can be highly stress ful for the healthcare staff, suggesting that, to reduce stress, the fac ility layout must support their activities (Shepley, 2002). It is thought that SFRs may increase the amount of time nurses spend walking in the NICU. In a longitudinal case study performed by Shep ley (2002), nurse time spent walking in an open-bay NICU was compared to the original closed bays. The hypothesis that the total amount of time spent walking from activity to activity would be reduced was not supported. Hence, an open-bay layout does not necessarily produce less walking distance

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11 for nurses compared to closed bay units, and may not minimize walking distances in single family room units. Within the context of the parent study, staff behaviors and preferences will be compared in both the private and open setti ng. This data will be extracted from anonymous hospital records (medical errors staff turnover, staffing numbers) and collected by administering a survey targeted to the healthcare staff. Nursing Models: Family-Cente red Care and Developmental Care Family-Centered Care A move toward family-centered care and a consumer-focused orientation have resulted in the widespread use of individua l private rooms for obste trical services and universal patient rooms (Mathur, 2004). Fam ily-centered care is the philosophy that the healthcare providers and family are partners, wo rking together to best meet the needs of the patient by promoting communication, respec ting diversity, and empowering families. Full parent participation in care requires unr estricted access to the neonatal intensive care unit which may increase the poten tial infection risk (Moore, Coker, DuBuisson, Swett, & Edwards, 2003). The literature suggests that the family-centered care delivery model improves satisfaction with the hospital experi ence and that parents who are informed and involved are more confident and competent car ing for their sick children (Cohen et. al, 2004). Single family room NICUs may provide the best setting for family-centered care by affording an area for each family adjacen t to the neonate; as well as providing a setting that may help wi th infection control. Developmental Care Developmental care consists of four st andards in the NICU 1) caregiving is flexible, individualized, and responsive to vulne rabilities of every infa nt; 2) parent-infant

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12 relationships are supported from birth; 3) all caregivers practice collaboratively; and 4) a developmentally appropriate environmen t is provided (Robison, 2003). Als, Buehler, Duffy, Liederman, & McAnulty (1995) assessed the effectiveness of individualized developmental care in the NI CU for low-risk pre-term infants. The control group received standard care and the experimental gr oup received individualized care at the same facility. Results sh owed that individualized care supports neurobehavioral functioning and appears to prevent frontal lobe and attentional difficulties in the newborn period, the possibl e causes of behavioral and scholastic disabilities often seen in low-risk pre-term infants in later ages The Journal of the American Medical Asso ciation (1994) reported that infants who were provided with developmentally supportiv e care through control of the environment and individualized attention were found to benefit from a reduced dependence on respiratory support, earlier oral feeding, re duced incidence of complications, improved weight gain, shorter hospital st ays, and reduced costs of care, compared with infants not provided this type of care in the contro l group (Als, Lawhon, Duffy, McAnulty, GibesGrossman, & Blickman, 1994; Robison, 2003). A NICU that provides more control over environmental features may better support developmental care since developmental ca re focuses on uninterrupted sleep, self regulation, and decreasing both light and noise in the NICU environment (Robison, 2003). Recommended Standards for NICU Design The Guidelines for Design and Construction of Hospital and Health Care Facilities (2003) serves as a standard for American hospital and medical facilities. In a multibedroom unit, every bed position shall be with in 20 feet of a hands-free hand washing

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13 station. Where an individual room concept is used, a hands-free hand washing station shall be provided within each infant care room In the interest of noise control, sound attenuation shall be a design f actor. Provisions shall be ma de for indirect lighting and high-intensity lighting in all nurseries. Controls shall be provided to enable lighting to be adjusted over individual patient care spaces. Each patient space shall contain a minimum of 120 square feet (SF) per bass inet excluding sinks and aisles. There shall be an aisle for circulation adjacent to each patient care spac e with a minimum width of three feet. Each infant care space shall be designed to allow privacy for the baby and family. The NICU shall be designed as part of an overall safety program to protect the physical security of infants, parents, and staff to minimize th e risk of infant abduction (The American Institute of Architects Academy of Architecture for Health, 2003). These recommendations are the benchmark for desi gn standards. Many municipalities adopt these standards, in effect; making the gui delines required minimum standards. Often, hospitals require the design team to follow these guidelines, even when they are not required by law. Construction Cost Controlling costs is essen tial for hospital administrato rs in today’s tough economic environment. The costs to the healthca re system are many and complex, including upfront cost associated with the construction of the facilit y. Construction costs can vary depending upon a number of factors such as 1) local, state, and na tional regulations; 2) type of contract (negotiated, hard bid, guaranteed bid max); 3) season of year; 4) contractor management; 5) weather conditions ; 6) local union rest rictions; 7) building code requirements; 8) availability of adequate energy, skilled labor, and building

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14 materials; 9) owners special requirements/rest rictions; 10) safety requirements; 11) size of project; and 12) location of project (Waier, 2005). The type of project also has great infl uence on construction cost: new construction or remodel. In the case of a remodel, the extent to which the existing building impedes 1) construction activity; 2) the extent of demoliti on required; and 3) utilities that may have to be relocated affect costs. Decisions aff ecting cost of new cons truction can include: 1) selection of the site; 2) selection of the basi c structural system, mechanical and electrical system types; and 3) exterior enve lope criteria (Bobrow & Thomas, 2000). Healthcare construction costs vary by region, with a premium for construction in seismically active areas (Bobrow & Thomas 2000). When making cost comparisons from city to city and region to region, the Means City Cost Indexe s (CCI) is a valuable tool, since hospitals in urban areas tend to have higher costs due to a higher cost of living than do hospitals in rural ar eas. The publication contains average construction cost indexes for 719 U.S. and Canadi an cities covering over 930 thre e-digit zip code locations, and is updated yearly. The publication is ai med primarily at commercial and industrial projects costing one-million dollars and up. The costs are primarily for new construction or major renovation of buildings. A city cost can be adjusted to the national average or to a specific city. The 30 City Average I ndex is the average of 30 major U.S. cities and serves as a national average (Waier, 2005). When comparing construction costs between different years, the costs should be normalized to the same year. The Means Hist orical Cost Index can be used to convert building costs at a particular time to the a pproximate building costs for some other time (Waier, 2005).

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15 Floor Plan Analysis Archival data collection and/or post-occ upancy evaluations (POE) can offer useful cost-saving knowledge. Each project, no matter how well executed, has both successes and failures; designers can learn from POEs and improve the design of future facilities (Wang, 2002). Preiser, Rabinow itz, and White (1988) divide POEs into three levels of involvedness: indicative POE, investigative POE, and diagnostic POE. An indicative POE is one that analyzes as-built drawings a nd lists them into topics; and interviews are conducted with building occupants to be tter understanding the performance of the building. An investigative POE is one th at compares an existing situation with comparable facilities and summa rizes current literature regard ing the topic. A diagnostic POE involves a multi-methodological appro ach (surveys, observations, physical measurements, etc.) conducted in comparison to other facilities. The research method of floor plan analysis for this endeavor is a combination of the three types of POEs as written by Preiser et al. (1988). The floor plan analyses involved examination of as-built drawings, comp arison with comparable facilities, and measurements categorized into topics. According to Moon (2005), providing private rooms may result in higher construction costs due to more square footag e. However, according to Mathur (2004), the increased area for a single room is offset by the elimination of parent sleep rooms within or adjacent to the unit. The floor plan evaluations will help clarify the suggestion that SFR NICUs require more space and potentia lly a higher cost than open-bay or multibed variation units.

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16 CHAPTER 3 METHODOLOGY Research Design The objectives of this study were two-fold 1) to compare the construction cost of four NICU types and 2) to analyze the fl oor plans of each case to identify any design trends within each setting. The research me thod used for this project is a multiple comparison case study. The dependent variable s are Level III NICUs built or remodeled since 1995. The independent variables are si ngle family room (SFR), double-occupancy, open-bay, and combination layout NICUs. Four cases that offer c ontrasting situations were compared and analyzed. The project inco rporated three phases 1) data collection; 2) data analysis; and 3) comparison of case study results. The research project took place at the University of Florida in Gainesville, Florida. Sampling Procedures Hospitals were selected for this study by a sample of convenience. The hospitals are located in the United States and meet the criteria for nursing model and unit design (SFR, double-occupancy, open-bay, or combinat ion). Thirty-one Level III NICUs built or remodeled since 1995 were identified as meeting the inclusion criteria and asked to participate. The hospitals were sent a letter explaining the research project and asked to voluntarily participate in the st udy and those who agreed to pa rticipate were included in the study (see Appendix A).

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17 Participants Eleven hospitals across the United States formally agreed to participate in the study. From the eleven participants, a comp arison based on plan evaluation, photographs, and printed documentation from four hos pitals was completed (Figure 3-1). Figure 3-1: Geographic Lo cation of Participants Because of design variation, four categories have been developed 1) single family room; 2) double-occupancy; 3) open-bay; and 4) combination (a mixture of SFR, openbay and double-occupancy). Inclusion criteria requires the NICU mu st be Level III, built since 1995, hold 16 beds or greater, and have an average census of twelve patients per day or greater. Participation is voluntary and based on informed consent (see Appendix B). Ethics There are limited ethical concerns to be awar e of with this resear ch project as there are no human participants or patient records to alter. Furthermore, the participating hospital’s names will remain anonymous. Ho wever, the researcher is aware of the Belmont Report on ethical principles and guide lines for the protecti on of human subjects

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18 of research. This research project does not require In stitutional Review Board (IRB) approval; nevertheless it falls under the larger project’s IRB approval. The researcher completed and received the ce rtificate of completion for HI PAA for researchers at the University of Florida on September 28, 2004 (s ee Appendix C). Hence, the researcher understands the importance of pr oviding privacy for participants and documents that may be involved in this research endeavor. Hospital participation in this study is voluntary and no monetary benefit or coercion to participate was used. Explicit au thorization was obtained before any hospital records were investigated. The incentive to participate in this study is to help add to the knowledge base of NICU design to provide the best environm ent for the patient, family, and staff. The compilation of data to compare and conclude outcomes must be an ethical process. The researcher is aware of the uneth ical practice of slanti ng or changing data to produce a significant or specific outcome. For this research project, any significant data serves a positive purpose for future NICU design. Data Collection Information specific to the NICUs particip ating in the study was collected with the approval of the healthcare fac ilities administration. Data collection involved collecting archival data associated with the reviewed plans for constr uction costs. The floor plans were requested to be sent as AutoCAD f iles, AutoCAD is a computer aided drawing program commonly used by architects and in terior designers. The construction costs gathered from the hospital’s facilities depart ment were primarily sent electronically or by mail. The construction costs are limited to th e cost of the Level III NICU, which in some cases required extraction from a larger project. Photos and marketing materials were also

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19 requested with permission to publish to help further identify various design features in each NICU (see Appendix D and Appendix E). The AutoCAD drawings requested from each participant consist of 1) floor plan with labels; 2) furniture plan and equipment pl an; 3) finish schedule; 4) reflected ceiling plan; 5) lighting power and systems plan; 6) sections; 7) elev ations; 8) headwall elevations; and 9) door schedule (see Appendix F). The plans that were most beneficial were the floor plans and the furniture, fixture, and equipment plans. Data Analysis Floor Plans Following the collection of floor plans and architectural documents from the four NICU facilities and performing an initial lite rature review, a system was developed to effectively organize and analy ze the floor plans. The purpose of the plan evaluations was to examine NICU design issues and identify trends in design layout. The main focus of the four plan evaluations was on the allocation of space for the staff, patient, and family; as well as the amount of space a llocated to unit circulation. The first step of the plan analysis ph ase involved assess ing each NICU by categorizing every room into one of twelve categories: patient, family, public shared, staff medical, staff communal, staff office, sta ff, storage, service medical, service facility, circulation vertical, and unit circulation. Next, the twelve categories were assigned to one of six general categories: patient, family, staff, public, systems, and unit circulation. This step helped to clearly identify the a llocation of space within each unit for the six main area categories. The square feet (SF) total of every space was measured and listed in a Microsoft Excel spreadsheet. The amounts of family and staff space at each baby station were

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20 identified. This was accomplished by measurin g midpoint at each isollette to divide the room or space into half, not including the ac tual baby station. The amount of family space at bedside and staff space at bedside was listed in a Microsoft Excel spreadsheet. Last of all, the amount of clear floor sp ace for each infant area was measured and calculated. This step was completed by totali ng the family and staff space in each infant area and then subtracting any permanent fi xtures such as sinks and/or counters. After the floor plans were assessed and measured, three sets of diagrams were prepared for each setting 1) circulation diagra m; 2) allocation of space diagram; and 3) infant care area diagram. The diagrams ove rlaid the AutoCAD floor plans to precisely illustrate the allotment of spaces each case provides. The diagrams helped to identify the circulation patterns and user zones for each setting (see Appendices J-M and Appendices N-Q). The plan assessment was followed by calcula ting the average square feet for 1) infant space; 2) family space; 3) staff space; 4) circulation; 5) staff space at bedside; and 6) family space at bedside. Once all of the pl ans were measured and calculated, the net to gross factor for each facility was calculated (the amount of space taken up by walls and unusable space). Construction Cost The breakdown of cost topics requested from each participant was 1) land acquisition; 2) construction cost; 3) design and engineering fees; 4) owner construction administration; 5) development and soft cos t; 6) equipment; 7) furnishings and fixtures; and 8) financing (see Appendi x F). From this informati on, only the construction costs were extracted for comparison. Once the co sts were collected a nd organized, the cost needed to be adjusted to the year 2005 and normalized to the national average cost. The

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21 Means Historical Cost Index was used to adjust the archival cost data from each participant to what the approximate construc tion cost for each facility would be in the year 2005 (see Formula 3-1). After the costs were adjusted to 2005, the Means City Cost Indexes were used to compare cost from city to city, with the end result normalized to the National City cost average (see Formula 3-2). Formula 3-1 X Year in Cost in Cost Year for Index X Year for Index 2005 2005 Using formula 3-1, the Historical Cost Index for a specific year X was divided by the Cost Index for year 2005; the decimal va lue was then divided into the particular hospital construction cost, giving the approximate cost if that facility was built in 2005. Formula 3-2 Index Cost City Cost Average National Cost City Specific 100 Using formula 3-2, to obtain the Na tional Average Cost, the particular construction cost (Specific City Cost) was multiplied by 100 (the National Average Index) and then divided by the sp ecific city cost index, giving the adjusted cost of that facility in comparison to the National Average. Once the NICU construction costs were adju sted to be comparable in year and region, the costs were divided by the total squa re feet of the unit to give the cost per square foot for each case (see Formula 3-3). Formula 3-3 Foot Square per Cost Feet Square NICU Cost on Constructi Adjusted Additionally, the construction costs were divided by the number of beds in each unit to provide the cost per infant care ar ea (see Formula 3-4). The results should serve

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22 as a general guide for the cost of bui lding SFR, double-occupancy, open-bay, and combination layout NICUs. Formula 3-4 ion InfantStat per Cost Beds of Cost on Constructi Ajusted #

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23 CHAPTER 4 RESULTS OF THE STUDY Demographic Descriptive Information Single Family Room NICU Description The SFR NICU is located in the Midwest. In a typical year, the unit cares for 350 to 400 high-risk infants. The facility was built (new-construction) in 2001, is located on the 2nd floor, and has 22 Level III licensed infant stations. Included in the 22-bed total is 1 designated isolation room with an ante room adjoining. Each infant room has a daybed, recliner, and phones that flash, not ring. The family lounge has seating, TV/VCR, a kitchenette, and washer and dryer. Adjacen t to the family lounge are three sleep rooms with double beds. The NICU patient area has 4 nurse substations as well as 4 breast milk areas equally dispersed. The facility pract ices family-centered care and kangaroo care. Double-occupancy NICU Description The double-occupancy NICU is located in the West. Approximately 1,200 newborns are cared for in the NICU each ye ar. The facility was remodeled in 1998 and has 48 Level III licensed infant stations. Include d in the 48-bed total is 1 isolation room. All of the patient rooms are semi-private w ith the majority (94%) of the rooms being double-occupancy. The infant stations are set-up one of two ways: two beds along the same wall or two beds cattyco rner to one another on opposin g walls. The family lounge has seating, lockers, laundry facility, shower room, breast feeding room, and 2 sleep over rooms. The NICU patient area has 5 nurse st ations equally disperse d. The facility has billowing clouds and fiber optic “stars ” which decorate the ceiling.

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24 Open-bay NICU Description The open-bay NICU is located in the Sout heast. The facility was expanded and remodeled in 2004 and has 20 Level III licensed in fant stations. Included in the 20-bed total are 2 isolation rooms a nd 2 ECMO rooms (cardiac bypass for babies). Additionally, the unit has 2 exam areas. The infant sta tions are set-up two wa ys: 1) the pin-wheel configuration and 2) open spaces along the perimeter walls. The family lounge has seating, TV/VCR, lockers, restrooms, more breastfeeding space, and a sky light. The NICU patient area has 2 nurse stations. Combination NICU Description The combination NICU is located in the S outh. The facility was remodeled in 2004 and has 45 licensed Level III infant stations. The unit supports a combination layout with three semi-private double-occupancy rooms, si x pods of pin-wheel configuration infant stations, open-bays along perimeter walls, and 1 isolation room. E ach infant area has a recliner bedside and a sink within close proximity. The family lounge has seating, lockers, a child play area, restroom, family office, and pump room. Eight small nurse areas are spread throughout the NICU patie nt areas. Both family-centered care and developmental care are practiced by the healthcare staff. Floor Plan Analysis Results The floor plans for each NICU were sepa rated into five categories of spaces: infants, family, staff, unit circulation, and miscellaneous. The infa nt space includes all of the patient rooms together including isolati on, ECMO, and ante rooms. The family spaces include the following areas 1) family lounge (restroom, kitchenette, and laundry); 2) sleep-over rooms; 3) breas tfeeding and pump rooms; 4) conference and consultation; 5) family scrub; 6) family transition; 7) vending and nour ishment; and 8) parent quiet

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25 rooms. Staff space consists of 1) nurse sta tions and reception; 2) pharmacy; 3) alcoves; 4) staff lounge and lockers; 5) staff restrooms; 6) clean a nd soiled utility; 7) supply; 8) offices (social service, nurse practitioner, di ctation, and physician); 8) labs; 9) procedure areas; 10) medication preparati on and formula/breast milk; 11) respiratory therapy; 12) equipment; 13) x-ray; and 14) on-call rooms. Unit circulation includes all lateral circulation throughout the unit. Vertical circ ulation such as stairs and elevators were excluded from the unit circulation category because external factors such as fire exits and building location influence ver tical circulation requirements. Lastly, a category to encapsulate universal building features was developed and designated “miscellaneous”. This category includes 1) public space; 2) sy stems; and 3) vertical circulation. The systems sub-category includes 1) housekeeping; 2) general storage; and 3) mechanical, data, and electrical rooms. Single Family Room Floor Plan The SFR unit is 18,130 square feet (SF) Of the 6 key allocations of space categories, unit circulation comprises the highe st percentage of the unit at 28% (Figure 41). The average infant station area is 171 SF. The average family space at bedside is 88 SF. The average staff space at bedside is 64 SF. The infant station is 19 SF (Figure 4-2). The average clear floor space is 137 SF, which is 80 % of the room (see Appendix H and Appendix I).

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26 Single Family Room Unit Space Allocations Infants 21% Family 7% Staff 20% Unit Circulation 28% Net to Gross Factor 13% Miscellaneous 11% Figure 4-1: SFR Unit Space Allocations Single Family Room Infant Care Area Space Allocations Family Space Bedside 51% Staff Space Bedside 38% Infant Station 11% Figure 4-2: SFR Infant Care Area Space Allocations Double-occupancy Floor Plan The double occupancy unit is 16,337 SF. Of the 6 key allo cations of space categories, infant space comprises the highest pe rcentage of the unit at 33% (Figure 4-3). The average infant station area is 111 SF. The average family space at bedside is 52 SF. The average staff space at bedside is 39 SF. Th e infant station is 20 SF (Figure 4-4). The average clear floor space is 82 SF, which is 74 % of the room (see Appendix H and Appendix I).

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27 Double-occupancy Unit Space Allocations Infants 32% Family 7% Staff 17% Unit Circulation 28% Net to Gross Factor 9% Miscellaneous 7% Figure 4-3: Double-occupancy Unit Space Allocations Double-occupancy Infant Care Area Space Allocations Family Space Bedside 47% Staff Space Bedside 35% Infant Station 18% Figure 4-4: Double-occupancy Infa nt Care Area Space Allocations Open-bay Floor Plan The open-bay unit is 10,871 SF. Of the 6 key allocations of space categories, staff space comprises the highest percentage of th e unit at 33% (Figure 4-5). The average infant station area is 115 SF. The average fa mily space at bedside is 40 SF. The average staff space at bedside is 48 SF. The infant station is 27 SF (Figure 4-6). The average clear floor space is 85 SF, which is 74 % of the room (see Appendix H and Appendix I).

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28 Open-bay Unit Space Allocations Infants 21% Family 11% Staff 33% Unit Circulation 22% Net to Gross Factor 12% Miscellaneous 1% Figure 4-5: Open-bay Unit Space Allocations Open-bay Infant Care Area Space Allocations Family Space Bedside 35% Staff Space Bedside 41% Infant Station 24% Figure 4-6: Open-bay Infant Care Area Space Allocations Combination Floor Plan The combination unit is 20,519 SF. Of th e 6 key allocations of space categories, unit circulation comprises the highest percenta ge of the unit at 30% (Figure 4-7). The average infant station area is 111 square feet The average family space at bedside is 41 SF. The average staff space at bedside is 42 SF. The infant station is 29 SF (Figure 4-8).

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29 The average clear floor space is 80 SF, which is 72% of the room (see Appendix H and Appendix I). Combination Unit Space Allocations Infants 24% Family 10% Staff 19% Unit Circulation 30% Net to Gross Factor 10% Miscellaneous 7% Figure 4-7: Combination Unit Space Allocations Combination Infant Care Area Space Allocations Family Space Bedside 37% Staff Space Bedside 37% Infant Station 26% Figure 4-8: Combination Infant Care Area Space Allocations Construction Cost Results Single Family Room Costs The adjusted construction cost for the SFR NICU is $4, 680, 707.00. The cost per square foot is $258.00 and the cost per in fant station is $212,759.00 (Table 4-1 and Appendix G).

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30 Table 4-1: Comparison of Construction Cost Data NICU Type Adjusted Construction Cost NICU Square Feet Cost per Square Feet Cost per Infant Station SFR $ 4,680,707 18,130 SF $258 $212,759 Doubleoccupancy $ 5,399,950 16,337 SF $331 $112,499 Open-bay $ 4,387,062 10,871 SF $404 $219,353 Combination $ 3,956,015 20,519 SF $193 $87,911 Double-occupancy Costs The adjusted construction cost fo r the double-occupancy NICU is $5,399,950.00. The cost per square foot is $331.00 and the cost per infant station is $112,499.00 (Table 4-1 and Appendix G). Open-bay Costs The adjusted construction cost for the open-bay NICU is $4,387,062.00. The cost per square foot is $404.00 and the cost pe r infant station is $219,353.00 (Table 4-1 and Appendix G). Combination Costs The adjusted construction cost for the combination NICU is $3,956,015.00. The cost per square foot is $193.00 and the cost per infant station is $87,911.00 (Table 4-1 and Appendix G).

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31 CHAPTER 5 DISCUSSION AND CONCLUSSIONS Findings The purpose of this research project was to compare four different NICU settings in regards to their construction costs and space a llocation features. Present literature has focused mainly on SFR and open-bay NI CU settings, though combination and doubleoccupancy settings are common as well. Each NICU type may have benefits and drawbacks; and there are various techniques to limit the weakne sses in each setting. The review of literature focusing on construction costs reflects the lack of research in this particular area, especia lly relating to NICUs. Construction Cost The NICU construction costs were compared on two levels 1) cost per SF and 2) cost per infant station. The open-bay sett ing has the highest cost per SF at $404. The combination setting has the lowest cost per SF at $193. Similarly, the open-bay has the highest cost per infant sta tion at $219,353. The combination has the lowest cost per infant station at $87,911. It should be noted that SFR setting was the second lowest for cost per square feet and doubl e-occupancy was second lowest in cost per infant station (Figure 5-1). Figure 5-1 shows the cost re sults for both cost ca tegories (cost/SF and cost/infant station) for each NICU.

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32 Cost Per Square Feet and Cost Per Infant Station $193 $404 $331 $258 $87,911 $219,353 $112,499 $212,759 Single Family Room Double-occupancy Open-bay Combination Cost Per SF Cost Per Infant Station Figure 5-1: Cost per Square Fe et and Cost per Infant Station Floor Plan Space Allocation The NICU floor plans were evaluated and compared in terms of user and systems space 1) infant; 2) family; 3) staff; 4) unit circulation; 5) net to gross factor; and 6) miscellaneous. The double occupancy setting ha s the most unit space allocated to patient area at 33%. The remaining NICUs all have similar amounts of space allocated to patient area at approximately 22%. The open-bay set ting has the most unit space allocated to family space at 11%. Note that the SFR a nd double-occupancy settings both allocate the least amount of space to family. The open ar rangement has the most unit space allocated to staff at 33%. The combination setti ng has the most unit sp ace allocated to unit circulation at 30% (Table 5-1). The infant care areas were analyzed and compared in terms of 1) average infant care area; 2) average family space at bedside; 3) average staff space at bedside; and 4) average clear floor space in infant care area. The SFR setting has the largest average infant care area at 171 SF with the highest amount of clear floor space at 80 %. Also, the

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33 SFR has the highest percentage of family space at bedside at 51% (Figure 5-2). The open-bay setting has the highest percentage of staff space at bedside (42%) (Table 5-2). Table 5-1: Comparison of NICU Space Allocations: Percentage of Unit NICU Type Infant Space Family Space Staff Space Unit Circulation Net to Gross Factor Miscellaneous SFR 21.1% 6.5% 20.3% 28.2% 13.0% 10.9% Doubleoccupancy 32.7% 6.7% 17.3% 27.5% 8.5% 7.3% Open-bay 21.2% 10.9% 32.7% 22.2% 12.0% 1.0% Combination 24.4% 9.9% 18.8% 29.9% 10.3% 6.7% Table 5-2: Comparison of Infa nt Care Area Space Allocations Percentage of Infant Care Area NICU Type Average Infant Care Area Family Space Bedside Staff Space Bedside Clear Floor Space SFR 171 SF 51% 38% 80% Doubleoccupancy 111 SF 47% 35% 74% Open-bay 115 SF 35% 42% 74% Combination 111 SF 37% 37% 72%

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34 Figure 5-2: SFR Infant Care Area. This diagram shows the typical layout of a private room in the SFR NICU case. Implications for Research Findings Single Family Room According to Mathur (2004), the incr eased area for SFRs is offset by the elimination of parent sleep rooms within the unit. In comparison to the other NICU cases, the SFR unit allocates the least amount of space to family, which is space outside of the infant care area (lounge, sleep rooms, etc). However, the SFR has the highest percentage of space for the family at bedsid e (Figure 5-2 and Figure 5-3). These results pose the questions: 1) is it preferable to have more family space at bedside in the infant care area or 2) is it preferable to have mo re family space outside the infant care area? These results also support Mat hur’s suggestion that the incr eased area for SFRs is offset by the lesser amounts of allocated family space in the SFR unit.

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35 Comparison of Family Space: Family Space Bedside Vs. Family Space Outside Infant Care Area 37% 35% 47% 51% 9.9% 10.9% 6.7% 6.5%0 20 40 60 80 100Single Family Room DoubleOccupancy Open-bayCombinationHospital Participants% of Unit % Family Space Bedside % Family Space Outside Infant Care Area Figure 5-3: Comparison of Fa mily Space Bedside vs. Family Space outside Infant Care Area According to Moon (2005), providing private rooms (in general) may result in higher costs due to more square footage. The results of this study do not support Moon’s position, since the SFR unit was second lowest in the cost per SF category and third lowest in the cost per infant station category (Figure 5-1). Furthermore, the total amount of space offset by the decreased amount of family space outside the infant care area conflicts with Moon’s suggesti on that private unit s require more total square footage (Table 5-1). The assumption that SFRs have a higher ne t to gross factor is to some extent supported by this study. The SFR unit has the highest net to gross factor at 13%, however the open-bay has the second highest net to gross factor at 12%. The 1% difference may be a result of more family space in the open-bay, which would mean more walls in the family space, increasing the ope n-bay’s net to gross factor (Figure 5-4).

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36 Comparison of Net to Gross Factor8.5% 12.0% 10.3% 13.0%Single Family RoomDouble-OccupancyOpen-bayCombinationParticipants % of Uni t Figure 5-4: Comparison of Net to Gross Factor among Settings The infant rooms in this particular SFR unit exceed the recommended guidelines for minimum square footage, which is 120 SF. Even so, with the average infant care area at 171 SF and the clear floor space at 80%, this is only approximately 5% more than the double-occupancy and open-bay average clear floor space percentages. Meaning, the extra SF in the SFR setting is not necessarily going to average clear floor space, but to fixed design features such as: sinks, counters, couches, and lockers. Double-occupancy The double-occupancy case has similarities with the SFR case. The main difference in the infant care areas between the SFR and double-occupancy is the number of beds in the room. As one might expect the double-occupancy has the second highest amount of average family space at bedsid e and second lowest amount of unit space allocated for family (Figure 5-3). Both th e SFR and double-occupancy cases have family space outside the patient area, just at a lo wer percentage. The double-occupancy’s cost per SF was in-between SFR and open-bay, but the cost per infant station was significantly lower than the SFR and open-bay (Figure 5-1).

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37 The double-occupancy case was the most e fficient from a func tionality standpoint; the net to gross factor was the lowest at 8.5% (Figure 5-4). This may be a result of fewer walls used for infant space (2 beds per room instead of 1 bed per room) and fewer walls in family space outside the infant care area. Open-bay The open-bay unit has the highest amount of family space outside of the infant care area and the least amount of fam ily space bedside (Figure 5-3). This indicates a priority for family space, though not especially at bedside. The open-bay unit has the highest amount of staff space bedside as well as th e highest amount of staff space outside the infant care area. This indicates a priority for staff space throughout the entire unit. The open-bay unit has the highe st costs in both categorie s (Figure 5-1), a surprising outcome given the assumptions from the liter ature (Moon, 2005). It should be noted that the open-bay project was a remodel as well as an expansion projec t. The expansion involved capturing part of the roof space not on the first floor. The expansion of the facility may have increased the construction cost because of additional cost associated with expansion, hence, thes e factors should be consider ed when comparing the high construction cost for the open-ba y to the other NICU settings. Combination The combination setting has the lowest co st per SF and cost per infant station (Figure 5-1). Within the infant care area, the family and staff space bedside are nearly equal to one another (Figure 5-5).

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38 Staff Space Bedside Vs. Family Space Bedside in Infant Care Area37.4% 41.5% 34.9% 37.6% 36.5% 35.0% 47.1% 51.3%0% 20% 40% 60% 80% 100%Single Family Room DoubleOccupancy Open-bayCombinationHospital Participants% of Uni t Staff Space Bedside Family Space Bedside Figure 5-5: Staff Space Bedsid e vs. Family Space Bedside The combination unit allocated the most space to unit circulation and the open-bay unit allocated the lowest amount of space to circulation (Figure 5-6 and Figure 5-7). Both of these units make use of the pinwheel configuration for some of their baby stations. The combination unit has six pin-wh eel stations; the use of pin-wheels may be a factor in the combination unit’s high amount of unit circulation. Figure 5-6: Open-bay La yout Circulation Diagram

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39 Figure 5-7: Combination Layout Circulation Diagram Limitations of the Research Several factors may have impacted the result s of this study. A sample size of four hospitals, one of each type, is a small sample size to produce generalizable results. Case studies are thought to not be generalizable due to multiple variables which may not be controlled (Yin, 2003). Due to the extraction of construction cost data from larger projects, data errors could have been made. Plus, the project relied on participants to send data (construction cost) to be analyzed, providing for possible human error. As discussed in Chapter 2, many factors can impinge on construction cost s that are specific to each case. For example, the budget for one hospital may have been substantially higher than the budget for another, in turn, having one NICU that is more high-end than another. Factors such as weather and type of projec t (new construction or remodel) can also have an effect on

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40 cost. The construction cost which were adju sted to the year 2005 and normalized to the National Average are approximations based on hi storical cost and city cost indexes. The researcher made certain assumptions during the plan analysis phase about the way certain areas are most likely used. For ex ample, when calculating space at bedside, dividing the infant area in ha lf at midpoint infant station and assigning sides to family and staff based on furniture placement (reclin er or stool placement in most cases) is purely an assumption on how the space is used. In actuality, during daily activities in the NICU, carts and multiple chairs may be move d in and out of patient areas depending on the circumstance. In the process of assigning specific rooms to family and/or staff, assumptions were made on what user group uses the room more frequently. Telephone calls were made to NICU contacts to verify room usage, but in some cases, rooms are shared by family and staff. For example, consultation rooms ar e shared areas, in most cases consultation rooms were assigned to family space if they we re adjacent to family lounges. Similarly, when calculating unit circulation in the open-bay and combina tion layout NICUs, assumptions were made in the open areas to calculate circulation ba sed on guidelines for aisle widths in NICUs. Future Directions As seen from this research study, there are a range of NICU settings: single family room, double-occupancy, open-bay, and combina tion. Further empirical research on the implications of these various settings is n eeded, in particular the costs of building, maintaining, and operating these facilities. Research on family preference and behaviors is needed, particularly to help determine wh ether more family space should be allocated

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41 bedside or outside of the infant care area. Future NICU studies should compare more than one case of each setting to produce results that are more generalizable. Conclusions Each NICU setting has its strengths and weaknesses. Depending on the NICU operations and nursing model, one type may be more supportive than another. For example, in a family-centered care environm ent, family participation is encouraged; hence the facility that provides more space for family at bedside may be preferred, rather than more family space outside the infant care area. The literature suggests that e nvironmental control is impor tant for neonates’ growth 1) acoustical control; 2) lighti ng control; 3) infection control; 4) temperature control; 5) privacy; and 6) security. Single family rooms may be the best setting to afford privacy and environmental control for the benefit to in fants. From the results of this study, the SFR setting did not have the hi ghest construction cost. Theref ore, if assuming SFR units provide the most control of the environment, the single family room unit may be the preferred layout for future NICU projects.

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42 APPENDIX A LETTER TO PARTICIPATE

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43 APPENDIX B AGREEMENT TO PARTICIPATE

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44 APPENDIX C CERTIFICATION OF COMPLETION FOR HIPAA

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45 APPENDIX D PUBLIC RELATIONS FORM

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46 APPENDIX E PERMISSION TO PUBLISH

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47 APPENDIX F FACILITIES PLANNING FORM This is a two-part form pertaining to ar chitectural drawings and NICU construction costs. The total project costs were simplifie d into seven topics; only the construction cost were analyzed and compared for this project.

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48 APPENDIX G CONSTRUCTION COST DATA This table lists the construc tion cost figures before th ey were adjusted to be comparable in year and region with the e nd result being the ad justed cost national average. Table G-1: Constr uction Cost Data NICU Geographic Region Construction Date Un-adjusted Construction Cost Adjusted Cost 2005 Adjusted Cost National Average SFR Midwest 2001 $3,644,287 $4,282,847 $4,680,707 Doubleoccupancy West 1998 $4,842,500 $6,247,742 $5,399,950 Open-bay Southeast 2004 $3,442,880 $3,557,907 $4,387,062 Combination South 2004 $3,284,524 $3,394,261 $3,956,015

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APPENDIX H NICU SPACE ALLOCATION DATA

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50Table H-1: Unit Space Allo cation Square Feet Amounts NICU Total Project Square Feet Infant Space Family Space Public Space Staff Space Systems Space Unit Circulation Vertical Circulation Net to Gross Factor SFR 18130 SF 3832 SF 1182 SF 706 SF 3680 SF 493 SF 5107 SF 779 SF 2351 SF Double Occupancy 16337 SF 5336 SF 1090 SF 208 SF 2833 SF 130 SF 4496 SF 852 SF 1391 SF Open-bay 10871 SF 2299 SF 1184 SF 0 SF 3555 SF 110 SF 2418 SF 0 SF 1305 SF Combination 20519 SF 4998 SF 2038 SF 105 SF 3864 SF 395 SF 6142 SF 855 SF 2120 SF Table H-2: Unit Space Allocation Percentage of Unit NICU Infant Space Family Space Public Space Staff Space Systems Space Unit Circulation Vertical Circulation Net to Gross Factor SFR 21.1% 6.5% 3.9% 20.3% 2.7% 28.2% 4.3% 13.0% DoubleOccupancy 32.7% 6.7% 1.3% 17.3% 0.8% 27.5% 5.2% 8.5% Open-bay 21.2% 10.9% 0.0% 32.7% 1.0% 22.2% 0.0% 12.0% Combination 24.4% 9.9% 0.5% 18.8% 1.9% 29.9% 4.3% 10.3%

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51 APPENDIX I INFANT CARE AREA SPACE ALLOCATION DATA Table I-2: Average Infant Care Area Percentages of Space NICU Clear Floor Space Family Space Bedside Staff Space Bedside Infant Station SFR 79.9% 51.3% 37.6% 11.1% Doubleoccupancy 74.1% 47.1% 34.9% 18.0% Open-bay 74.1% 35.0% 41.5% 23.5% Combination 72.0% 36.5% 37.4% 26.1% Table I-1: Average Infant Care Area Space Allocation Square Feet Amounts NICU Infant Care Area Clear Floor Space Family Space Bedside Staff Space Bedside Infant Station SFR 171 SF 137 SF 88 SF 64 SF 19 SF Doubleoccupancy 111 SF 82 SF 52 SF 39 SF 20 SF Open-bay 115 SF 85 SF 40 SF 48 SF 27 SF Combination 111 SF 80 SF 41 SF 42 SF 29 SF

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52 APPENDIX J SINGLE FAMILY ROOM ALLO CATION OF SPACE DIAGRAM The SFR unit allocated the least amount of family space outside the infant care area, which was 6.5% of the unit, while alloca tion the most amount of family space at bedside. Figure J-1: Single Family Room Allocation of Space Diagram

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53 APPENDIX K DOUBLE-OCCUPANCY ALLOCA TION OF SPACE DIAGRAM The double-occupancy unit allocated the highe st amount of space to infant space at 32.7% of the unit. Similar to the SFR unit, w ithin the infant care area, the family space at bedside was second highest and the family space outside the infant care area is second lowest at 6.7% of the unit. Figure K-1: Double-Occupancy Allocation of Space Diagram

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54 APPENDIX L OPEN-BAY ALLOCATION OF SPACE DIAGRAM The open-bay unit allocated the most amount of family space outside the infant care area at 11% and the least amount of family space bedside at 35%. The open-bay unit allocated the highest amount of staff space bedside within the infant care area at 42%. Figure L-1: Open-Bay A llocation of Space Diagram

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55 APPENDIX M COMBINATION UNIT ALLOCATION OF SPACE DIAGRAM Figure M-1: Combination Unit Allocation of Space Diagram

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56 APPENDIX N CIRCULATION DIAGRAM FOR SI NGLE FAMILY ROOM UNIT This diagram represents the unit circulat ion in the SFR NICU which was 28.2% of the unit. The SFR and double-occupancy unit’ s allocated similar amounts of unit space to circulation, with a 1% difference (see Appendix O). Figure N-1: Circulation Diagram for Single Family Room NICU

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57 APPENDIX O CIRCULATION DIAGRAM FOR DOUBLE-OCCUPANCY UNIT This diagram represents th e unit circulation in the doubl e-occupancy layout which was 27.5% of the unit. The double-occupanc y and SFR unit’s alloca ted similar amounts of unit space to circulation, with a 1% difference (see Appendix N). Figure O-1: Circulation Diag ram for Double-occupancy NICU

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58 APPENDIX P CIRCULATION DIAGRAM FOR OPEN-BAY UNIT This diagram represents th e unit circulation in the open-bay layout NICU. The circulation comprised 22% of the unit, wh ich was the lowest circulation amount in comparison to the other three NICUs. Figure P-1: Circulation Di agram for Open-bay NICU

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59 APPENDIX Q CIRCULATION DIAGRAM FOR CO MBINATION LAYOUT UNIT This diagram represents th e unit circulation in the co mbination layout NICU. The circulation comprised 30% of the unit, wh ich was the highest ci rculation amount in comparison to the other three NICUs. Figure Q-1: Circulation Diagra m for Combination layout NICU

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60 LIST OF REFERENCES Als, H., Buehler, D.M., Duffy, F.H., Liederman, J., & McAnulty, G.B. (1995). Effectiveness of individualized developmental care for low-risk pre-term infants: Behavioral and elecroph ysiologic evidence. The American Academy of Pediatrics, 96(5), 923-932. Als, H., Lawhon, G., Duffy, F., McAnulty, G., Gibes-Grossman, R., & Blickman, J. (1994). Individualized developmental care fo r the very low birth-weight preterm infant–medical and neurofunctional effects. Journal of the American Medical Association, 272, 853-858. The American Institute of Architects A cademy of Architecture for Health. (2003). Guidelines for Design and Construction of Hospital and Healthcare Facilities, Washington, D.C. The Facilities Guidelines Institute, with assistance from the U.S. Department of Health and Human Services. Aucott, S., Donohue, P.K., Atkins, E., & A llen, M.C. (2002). Neurodevelopmental care in the NICU. Mental Retardation and Developmental Disabilities Research Reviews, 8, 298-308. Berens, R.J. & Weigle, C.G.M. (1996). Cost analysis of ceiling tile replacement for noise abatement. Journal of Perinatology, 16(3), 199-201. Bobrow, M. & Thomas, J. (2000). Inpatient ca re facilities. In S.A. Kilment (Ed.), Building type basics for healthcare facilities (pp. 131-191). NY: John Wiley and Sons. Callery, P. (1997). Paying to participate: Fina ncial, social, and personal costs to parents of involvement in their ch ildren’s care in hospital. Journal of Advanced Nursing, 25, 746-752. Carr, R.F. (2005). Health Care Facilities. Retrieved from the WBDG Web site on March 2, 2005, from http://www.wbdg.org/design/health_care.php Cohen, J., Parsons, V., & Petersen, M.F. ( 2004). Family-centered care: Do we practice what we preach? JOGNN, 33, 421-427. Committee on Fetus and Newborn. ( 2004). Levels of neonatal care. Pediatrics, 114(5), 1341-1347.

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61 Feldman Reichman, S.R., Miller, A.C., Gor don, R.M., & Hendricks-Munoz, K.D. (2000). Stress appraisal and coping in mothers of NICU infants. Children's Health Care, 29 (4), 279-293 Ferber, S.G. & Makhoul, I.R. (2004). The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioral responses of the term newborn: A randomized controlled trial. Pediatrics, 113(4), 858-865. Gaynes, R.P., Edwards, J.R., Jarvis, W.R., Culver, D.H., Tolson, J.S., & Martone, W.J. (1998). Nosocomial infections among neonate s in high-risk nurseries in the United States. National nosocomial infections surveillance system. Pediatrics, (3), 357361. Goldson, E. (1992). The neonatal intensive care unit: Premature infants and parents. Infants and Young Children, 4(3), 31-42. Levy, G.D., Woolston, D.J., & Browne, J.V. (2003). Mean noise amounts in level II vs. level III neonatal intensive care units. Neonatal Network, 22(2), 33-38. Mader, B. (2002). Private hospital room s the new norm [Electronic Version]. The Business Journal of Milwaukee. Retrieved April 30, 2005, from http://www.bizjournals.com/milwaukee/st ories/2002/11/11/focus2.html?GP=OTC MJ1752087487 Malkin, J. (1992). Birth centers : Freestanding and acute care settings. In V.N. Reinhold (Ed.), Hospital interior architecture: Crea ting healing environments for special patient populations (pp. 235-266). NY: J ohn Wiley and Sons. Mann, N.P., Haddow, R., Stokes, L., Goodley, S., & Rutter, N. (1986). Effect of night and day on preterm infants in a newborn nursery: Randomized trial. British Medical Journal, 293(6557), 1265-1267. Mathur, N.S. (2004). A single-r oom NICU – The next genera tion evolution in the design of neonatal intensive care units. Retrieved from the AIA Web site on November l2, 2004, from http://www.aia.org/aah_a_jrnl_0401_article3 Miller, C.L., White, R., Whitman, T.L., O'Calla ghan, M.F., & Maxwell, S.E. (1995). The effects of cycled verses noncycled lighting on growth and development in preterm infants. Infant Behavior and Development, 18(1), 87-95. Moon, S. (2005). Construction – and costs – Going Up. Modern Healthcare, 35(10), 3042. Moore, K.A.C., Coker, K., DuBuisson, A.B., Swett, B., & Edwards, W.H. (2003). Implementing potentially better practices for improving family-centered care in neonatal intensive care units: Successes and challenges. Pediatrics, 111, 4, 450460.

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62 Nair, C., Gupta, S.C.G., & Jatana, L. (2003). NICU environment: Can we be ignorant? MJAFI, 59, 93-99. Preiser, W.F.E., Rabinowitz, H.Z., & White, E.T. (1988). Post-occupancy evaluation. New York: Van Nostrand Reinhold. Price Waterhouse Coopers LLP. (2004). The role of hospital design in the recruitment, retention, and performance of NHS nurs es in England. Retrieved May 20, 2005, from http://www.healthyhospitals.org.uk/di agnosis/HH_Full_report_Appendices.pdf Raeside, L. (1997). Perceptions of envir onmental stressors in the neonatal unit. British Journal of Nursing, 6, 914-916. Robison, L.D. (2003). An organizational guide for an effective developmental program in the NICU. JOGNN, 32, 379-386. Shepley, M.M. (2002). Predesign and postocc upancy analysis of staff behavior in a neonatal intensive care unit. Children’s Health Care, 31(3), 237-253. Shepley, M.M., Fournier, M.A., & McDougal, K. (Eds.). (1998). Healthcare environments for children & their families. Dubuque, IA: Kendall Hunt. Sohn, A.H., Garrett, D.O., Sinkowitz-Cocra n, R.L., Grohskopf, L.A., Levine, G.L., Stover, B.H., Siegel, J.D., Jarvis, W.R ., Pediatric Preventi on Network. (2001). Prevalence of nosocomial infections in neonatal intensive care unit patients: Results from the first national point-prevalence survey. Journal of Pediatrics, 139(6), 821-827. Strauch, C., Brandt, S., & Edwards-Beckett, J. (1993). Implementation of a quiet hour: Effect on noise levels an d infant sleep states. Neonatal Network, 12(2), 31–35. Waier, P.R. (Ed.). (2005) R.S. Means Building Construction Cost Data. Kingston, MA: Reed Construction Data, Inc. Wang, D. (2002). Design in relation to re search. In L. Groat & D. Wang (Eds.), Architectural Research Methods (pp. 99-132). John Wiley & Sons, Inc. White, R.D. (2002). Recommended St andards for Newborn ICU Design. Report of the Fifth Consensus Conference on Newborn ICU Design. Retrieved on May 10, 2005, from http://www.nd.edu/~kkolberg/DesignStandards.htm Yin, R.K. (2003). Case Study Research – Design and Methods, Thousand Oaks, CA.: Sage Publications. Zeskind, P.S. & Iacino, R. (1984). Effects of ma ternal visitation to pre-term infants in the neonatal intensive care unit. Child Development, 55, 1887-1893.

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63 BIOGRAPHICAL SKETCH Paige was born in Jacksonville, Florida, and has an older sister. Throughout grade school she enjoyed gymnastics, piano, and crea tive activities. Paig e went to Riverview High School in Sarasota, Florid a, and graduated in 1994. She was a cheerleader for the Riverview Rams for two years. During her undergraduate y ears at the University of Florida, Paige studied anthropology, with a focus on cultural anthr opology. She graduated in May of 1999 with a Bachelor of Arts in anthropology. After graduation, Paige worked for Delta Airlines for three years. Paige returned to the Univ ersity of Florida in Au gust of 2002 and started the Master of Interior Design program. Paige developed many interests in interior design, including universal design, sp ecifically designing for the agin g population; as a result she completed a graduate minor in gerontology. Sh e enjoys all aspects of the design process: research, space planning, 3-dimensional desi gn and furniture design, and presentation rendering. Following graduation, Paige plans to con tinue living in Florida and work at a design firm.


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Title: Cost and Design Analysis of Neonatal Intensive Care Units: Comparing Single Family Room, Double-Occupancy, Open-Bay, and Combination Settings for Best Design Practices
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Copyright Date: 2008

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COST AND DESIGN ANALYSIS OF NEONATAL INTENSIVE CARE UNITS:
COMPARING SINGLE FAMILY ROOM, DOUBLE-OCCUPANCY, OPEN-BAY,
AND COMBINATION SETTINGS FOR BEST DESIGN PRACTICES















By

NATALIE PAIGE HARDY


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF INTERIOR DESIGN

UNIVERSITY OF FLORIDA


2005

































Copyright 2005

by

Natalie Paige Hardy















ACKNOWLEDGMENTS

I would like to extend a sincere thanks to many people who supported me in the

completion of this thesis. First I would like to thank my friends and family, especially

my parents, Linda Murray and Dudley Hardy, for all of their love and support.

I would like to thank Professor Michael Cook for agreeing to be on my research

committee. Professor Cook's knowledge of building construction and cost estimating

was essential to this research project. His lighthearted attitude was appreciated as well.

Finally, I would like to thank Dr. Debra Harris for her enthusiasm, knowledge, and

guidance throughout this endeavor. As my committee chairperson, Dr. Harris was

essential during every phase of this project as well as a mentor and a friend.

















TABLE OF CONTENTS


page

A C K N O W L E D G M E N T S ................................................................................................. iii

L IST O F T A B L E S ......................... ........ ...................... .. .. .. ...... ............. .. vii

LIST OF FIGURES .......................... ....... .................. viii

A B STR A C T ................................................. ..................................... .. x

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

P u rp o se ...................................................... .......................... 2
S ig n ific a n c e .......................................................... ................ .. 2

2 LITERA TURE REVIEW .......................................................... ..............4

In tro d u ctio n .................................................................................. 4
N ICU D esign and History ..................................... ........................................4
NICU Environment and Its Effect on Neonates ........................................ ................6
L eight and N oise ...............................................................6
Infection C control ......................................................................... .............
NICU Environment and Its Effect on Family............................................................9
NICU Environment and Its Effect on Healthcare Staff ............................................10
Nursing Models: Family-Centered Care and Developmental Care...........................11
Fam ily-Centered Care .......................................... .......... .. .............. .. 11
D evelopm mental Care .................................................. ........ .............. .. 11
Recommended Standards for NICU Design............................................................12
C o n stru ctio n C o st ................................................................................................. 13
Floor Plan A analysis .................................................. ........ .. ........ .... 15

3 M E T H O D O L O G Y ........................................................................ .......................16

R research D design ....................................................... 16
Sam pling Procedures .................. ..................................... .. ........ .... 16
P a rtic ip a n ts ......................................................................... 1 7










E th ic s ................................................................1 7
D ata C collection .................................................................................................. 18
D ata A n aly sis ................................................................................ 19
F lo o r P la n s ..................................................................................................... 1 9
Construction Cost ............................................................................. 20

4 RESULTS OF THE STUDY ............................................................... .............23

Demographic Descriptive Information .........................................23
Single Fam ily Room N ICU D description ........................................ ............23
Double-occupancy NICU Description .............................. ...........23
Open-bay N ICU D description ..................................................................... 24
Com bination N ICU D description ................................................................... 24
Floor Plan Analysis Results .............................................................. ...............24
Single Fam ily R oom Floor Plan ................................................................... 25
D ouble-occupancy Floor Plan ....................................................... 26
O p en -b ay F lo or P lan ...................................................................................... 2 7
Com bination Floor Plan .............................................. ...............28
C on struction C ost R results ..................................................................................... 29
Single Fam ily R oom C osts ....................................................................... ...... 29
Double-occupancy Costs ................................. ................................ 30
O p en -b ay C o sts ............................................................................................. 3 0
C om bination C osts ...........................................................30

5 DISCUSSION AND CONCLUSSIONS ................ ................................ 31

F in d in g s ................................................................................................................ 3 1
C construction C ost ........................................................................... 31
Floor Plan Space A location ...................................................................... ..... 32
Im plications for R research Findings .................................................................... 34
S in g le F am ily R o o m ............................................................................................3 4
D ou b le-o ccu p an cy ......................................................................................... 3 6
O p en -b ay ....................................................... 3 7
C o m b in atio n ...............................................................3 7
Lim stations of the Research .............................................................. ...............39
F future D direction s ................................................................40
C o n c lu sio n s........................................................................................................... 4 1

APPENDIX

A LETTER TO PARTICIPATE............................................ ...............42

B AGREEMENT TO PARTICIPATE .................................................................... 43

C CERTIFICATION OF COMPLETION FOR HIPAA ..........................................44

D PUBLIC RELATIONS FORM .....................................................45



v









E PERM ISSION TO PUBLISH .......................................................... ............... 46

F FACILITIES PLANNING FORM ........................................ ........................ 47

G CON STRU CTION CO ST D A TA ...................................................................... ...48

H NICU SPACE ALLOCATION DATA........................................... ............... 49

I INFANT CARE AREA SPACE ALLOCATION DATA ..........................................51

J SINGLE FAMILY ROOM ALLOCATION OF SPACE DIAGRAM ...................... 52

K DOUBLE-OCCUPANCY ALLOCATION OF SPACE DIAGRAM......................53

L OPEN-BAY ALLOCATION OF SPACE DIAGRAM ............................................54

M COMBINATION UNIT ALLOCATION OF SPACE DIAGRAM..........................55

N CIRCULATION DIAGRAM FOR SINGLE FAMILY ROOM UNIT .....................56

O CIRCULATION DIAGRAM FOR DOUBLE-OCCUPANCY UNIT ...... .......57

P CIRCULATION DIAGRAM FOR OPEN-BAY UNIT .......................... .......58

Q CIRCULATION DIAGRAM FOR COMBINATION LAYOUT UNIT................. 59

L IST O F R E F E R E N C E S ...................... .. .. ............. ....................................................60

B IO G R A PH IC A L SK E TCH ..................................................................... ..................63
















LIST OF TABLES


Table pge

4-1 Comparison of Construction Cost Data ....................................... ............... 30

5-1 Comparison of NICU Space Allocations: Percentage of Unit............................. 33

5-2 Comparison of Infant Care Area Space Allocations .............. ..........................33

H-1 Unit Space Allocation Square Feet Amounts.......................................................50

H-2 Unit Space Allocation Percentage of Unit ............. .............................................. 50

I-1 Average Infant Care Area Space Allocation Square Feet Amounts ......................51

I-2 Average Infant Care Area Percentages of Space ........................................... 51
















LIST OF FIGURES


Figure page

2-1 Example of Pin-wheel Configuration which is commonly used in open-bay
layout N ICU s .............. ................................ ........... .............. 5

3-1 Geographic Location of Participants................... ...................... ............... 17

4-1 SFR Unit Space Allocations...................... ..... ............................. 26

4-2 SFR Infant Care Area Space Allocations....................... .................... 26

4-3 Double-occupancy Unit Space Allocations....................... ..................... 27

4-4 Double-occupancy Infant Care Area Space Allocations.................................27

4-5 Open-bay Unit Space Allocations .......... ... ................................ ............... 28

4-6 Open-bay Infant Care Area Space Allocations ................................ ............... 28

4-7 Combination Unit Space Allocations............... ............................... 29

4-8 Combination Infant Care Area Space Allocations ....................................... 29

5-1 Cost per Square Feet and Cost per Infant Station ......................................... 32

5-2 SFR Infant Care Area. This diagram shows the typical layout of a private room
in the SFR N IC U case. .................................................... ........ .. ...... ............34

5-3 Comparison of Family Space Bedside vs. Family Space outside Infant Care Area 35

5-4 Comparison of Net to Gross Factor among Settings.................... ................36

5-5 Staff Space Bedside vs. Family Space Bedside ....................................... .......... 38

5-6 Open-bay Layout Circulation Diagram............................ .................... 38

5-7 Combination Layout Circulation Diagram ...........................................................39

J-1 Single Family Room Allocation of Space Diagram ..............................................52

K-l Double-Occupancy Allocation of Space Diagram ........................... ...............53









L-l Open-Bay Allocation of Space Diagram........ ...................... ................54

M-l Combination Unit Allocation of Space Diagram............................................. 55

N-l Circulation Diagram for Single Family Room NICU............................................56

0-1 Circulation Diagram for Double-occupancy NICU ...........................................57

P-1 Circulation Diagram for Open-bay NICU............................................................58

Q-1 Circulation Diagram for Combination layout NICU ............................................59











Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Interior Design

COST AND DESIGN ANALYSIS OF NEONATAL INTENSIVE CARE UNITS:
COMPARING SINGLE FAMILY ROOM, DOUBLE-OCCUPANCY, OPEN-BAY,
AND COMBINATION SETTINGS FOR BEST DESIGN PRACTICES

By

Natalie Paige Hardy

August 2005

Chair: Debra Harris
Major Department: Interior Design

Newborn intensive care is care for critically ill newborns requiring constant

nursing, complicated surgical procedures, regular respiratory support, or other intensive

interventions. Presently, the neonatal intensive care unit (NICU) population is increasing

attributable to recent social and demographic trends such as teenage pregnancy,

technological advances in neonatology, and fertility medicine techniques causing

multiple births and low birth weight neonates. As a result of the increased use of NICUs,

many hospitals are remodeling their facilities. Consequently, designers and hospital

administrators are in need of information that will help generate knowledge-based

guidelines. More specifically, designers and administrators are in need of information

regarding the environmental and cost implications between various NICU types. This

study examines the construction cost and design implications among four NICUs which

offer different settings 1) single family room (SFR); 2) double-occupancy; 3) open-bay;

and 4) combination layout.









The case study involved the comparison of four NICUs located in the United States

that were built or remodeled since 1995. Construction costs and architectural floor plans

were collected from each participant NICU. The floor plans were categorized by use 1)

infant; 2) family; 3) staff; 4) systems; 5) unit circulation; 6) family space at bedside; 7)

staff space at bedside; and 8) clear floor space. The NICU space allocations were

compared across each facility to identify any design trends. The construction costs were

adjusted to the year 2005 and normalized to the National City Average. From these

results, the cost per square feet (SF) and cost per infant station were calculated and

compared.

The primary results showed that the open-bay case had the highest construction

cost in both cost categories (cost/SF and cost/infant station) and the combination case had

the lowest cost in both cost categories. The SFR and double-occupancy cases offered the

most family space bedside and the least family space outside the infant care area. In

comparison, the open-bay case offered the least amount of family space bedside and the

most amount of family space outside the infant care area. These results pose the

questions: 1) is it preferable to have more family space at bedside in the infant care area

or 2) is it preferable to have more family space outside the infant care area?

The study recognizes the limitations associated with case study research and that

the results are not completely generalizable due to variables which cannot be controlled.

Future research focusing on the environmental and cost implications associated with

various NICU types is needed to provide the best setting for the patient, family, and

healthcare staff.














CHAPTER 1
INTRODUCTION

Newborn intensive care is care for critically ill newborns requiring constant

nursing, complicated surgical procedures, regular respiratory support, or other intensive

interventions. An infant is considered premature if he or she is born before 37 weeks of

gestation and weighs less than 2,500 grams (g). A very low birth weight (VLBW) infant

is a child born weighing under 1,500 g (Feldman Reichman, Miller, Gordon, &

Hendricks-Munoz, 2000).

There are three levels that define the Neonatal Intensive Care Unit (NICU). Level I

(basic) care is a hospital nursery that can perform neonatal resuscitation, evaluate and

provide care of healthy newborn infants and near-term infants (35 to 37 weeks'

gestation), and stabilize newborn infants born before 35 weeks' gestational age until

transfer to a facility that can provide the appropriate level of neonatal care. Level II

(specialty) care is a hospital special care nursery that can provide care to infants born at

more than 32 weeks' gestation and weighing more that 1500 g. These neonates are

moderately ill with problems that are expected to resolve quickly and are not anticipated

to need subspecialty services on an urgent basis. Level III subspecialtyy) care is a

hospital NICU that can provide continuous life support and comprehensive care for high-

risk, critically ill newborn infants. Level III is subdivided into three levels differentiated

by the capability to provide advanced medical and surgical care (Committee on Fetus and

Newborn, 2004). This study focuses on Level III NICUs.









Technological advances in neonatology have resulted in an increase in the NICU

population. Recent social and demographic trends including teenage pregnancies,

pregnancies with drug abuse, and neglected perinatal care have increased the number of

neonates needing special care. In addition, fertility medicine techniques have led to

multiple births and low birth weight (LBW) neonates (Mathur, 2004). As a result of the

increased use of NICUs, many hospitals are remodeling their facilities (Shepley, 2002).

Consequently, designers and hospital administrators are in need of information that will

help generate knowledge-based design guidelines.

Purpose

This research project explores the design and financial cost implications of single

family room (SFR) NICU facilities. This work is part of a larger effort comparing SFR

and multi-bed variation NICUs regarding 1) neonate outcomes; 2) family needs and

preferences; 3) staff behaviors and preferences; 4) construction costs, and 5)

administrative/operational costs. For the purpose of this study, the researcher compared

the construction costs between a SFR, double-occupancy, open-bay, and combination

layout NICU, as well as the environmental implications of each type of NICU.

Significance

An efficient and nurturing physical environment is critical for the support of

premature infants, their families, and the healthcare staff that care for them. The

advancements in neonatology, increasing NICU population, and need for updated

facilities supports research in this area to provide designers with evidence-based

guidelines to consult. In conjunction with successful environmental design, the costs of

building, maintaining, and operating a NICU is equally important. Research based

knowledge on the construction cost of SFR, double-occupancy, open-bay, and






3


combination layout NICUs is currently lacking and will aid in the decision-making

process when designing and building new facilities. The findings will be represented as

cost per square feet and cost per infant station, providing healthcare administrators and

design professionals key information in determining the best practices for designing

NICUs that support patients, families, and healthcare staff. Additionally, for each setting,

circulation and space allocations for infant, family, and staff are compared to better

understand how space is allocated for differing types of NICU facilities.














CHAPTER 2
LITERATURE REVIEW

Introduction

The design of the NICU is multifaceted because the environment affects the

premature infant as well as the healthcare staff which, in turn, impacts the infants. NICU

design is further complicated because alongside environmental impact concerns, one

must be concerned with the obvious costs (construction and operational) and less obvious

costs to family and staff such as environmental stress, preferences, and satisfaction.

This review of the literature focuses on recent trends and research of environmental

factors in the NICU and their affect on the newborn infants, their family, and healthcare

staff. Two nursing philosophies, family-centered care and developmental care are

introduced. In addition, the limited research on construction cost, specifically

construction costs for NICUs will be discussed. Finally, the literature on floor plan

evaluations as a research instrument will be presented.

NICU Design and History

Traditional NICU designs have varied from open rooms supporting 10-50

incubators to smaller rooms with four-to-eight station pods, separated either by walls or

cubicle curtains (Mathur, 2004; Shepley, 2002). In the 1980s, the benefits of family

participation in the care of their babies were realized. This change in care philosophy

influenced the design of the pin-wheel configuration where patient privacy was

addressed. With the use of the pinwheel configuration (Figure 2-1), privacy (not

necessarily lighting or acoustical privacy) can be afforded by partitions and headwalls in-









between the incubators, while allowing staff to observe several neonates at a time

(Mathur, 2004).

















Figure 2-1: Example of Pin-wheel Configuration which is commonly used in open-bay
layout NICUs

Recently, a trend in the design of NICUs has been to increase the number of private

patient rooms for neonates and their families. Several factors have contributed to the

recent popularity of SFRs 1) supportive data on infant outcomes; 2) increased

understanding of the value of breastfeeding and kangaroo-care (Ferber & Makhoul,

2004); 3) the hospital-wide trend toward private rooms (Mader, 2002; Mathur, 2004); 4)

the success of family-centered and developmental care (Cohen, Parsons, & Petersen,

2004; Robison, 2003); and 5) the success of innovative prototypes.

Some resistance to the SFR NICU is based on the perception that it would require

more staff because all neonates can not be observed at all times if residing in single

patient rooms. It is thought that an open floor plan reduces the need for staff to make

frequent trips between unit bays and storage areas, thereby enabling them to spend time

with infants (Shepley, 2002). In order to enable nurse's constant supervision of neonates

in the SFR setting, it is essential that SFR units use communication technology to









mitigate the perceived need for more staff. Today's advanced monitoring, surveillance,

and nurse locator systems can immediately notify staff of patient activities and allow

access to patient information from remote locations (Mathur, 2004). Another perceived

disadvantage to the SFR NICU is the notion that SFR design is more expensive than

traditional designs because it requires more square footage (Moon, 2005). Unfortunately

there is limited data to validate these assumed advantages and disadvantages of SFR,

open-bay, and multi-bed variation NICUs.

NICU Environment and Its Effect on Neonates

Recent studies have shown that an environmentally sensitive NICU can enhance

growth, shorten stay, and reduce hospital costs (Malkin, 1992; Mathur, 2004). Features

of the NICU physical environment taken into design consideration often focus on

environmental control: lighting control, acoustic control, temperature control, infection

control, privacy and security. Other variables such as color and comfort are important

environmental factors to be considered in the research, design and development of

NICUs.

Light and Noise

The NICU requires a range of lighting levels to regulate neonates' biological

rhythms, perform procedures, evaluate skin tone, and ensure the psychological well-being

of staff and families. Unfortunately, these bright lights can be painful and stressful to

premature infants. Constant light may disturb body rhythm interrupting their sleep cycles

and bright light may not permit neonates to open their eyes and look around (Malkin,

1992; Mathur, 2004; Nair, Gupta, & Jatana, 2003; White, 2002). It has been shown that

cycled light, instead of continuous light, can improve the growth rate of premature infants

(Miller, White, Whitman, O'Callaghan, & Maxwell, 1995). Although covering isolettes









to minimize light exposure is practiced in many NICUs, isolette covers should not totally

block an infant from view, because of the need to view the patient (Aucott, Donohue,

Atkins, & Allen, 2002). It is recommended that light sources be balanced and free as

possible of glare and veiling reflections (White, 2002).

The noise level in a functioning NICU impinges on the infants, staff, and family.

The level of noise is a result of many things 1) the operational policies of the unit; 2) the

equipment selected for the unit; and 3) the basic acoustic qualities of the unit's design

and finishes (White, 2002). NICU sound levels can be compared to "light auto traffic" at

70 decibels; infants are often exposed to these continuous high decibel levels with no

escape. The constant noise; besides being stressful, may lead to hearing loss for the

infant (Levy, Woolston, & Browne, 2003; Malkin, 1992; Nair et al., 2003).

The effect of reducing light and noise between 7pm and 7am was examined in a

randomized controlled trial. It was found that decreasing sound and light for 12 hours

every night resulted in improved weight gain and increased time sleeping for neonates

(Mann, Haddow, Stokes, Goodley, & Rutter, 1986). Levy et al. (2003) compared the

mean noise amounts between Level II and Level III NICUs. It was found that mean

noise amounts are significantly higher in Level III NICUs than in Level II NICUs.

Considering the acuity of the patient, noise control is especially important in Level III

NICUs.

Researchers have tried to develop systems to reduce noise in open-bay NICUs. It

has been found that noise amounts can be decreased significantly by implementing

regular quite hours and by modifying nursery layouts, especially placement of incubators

(Strauch, Brandt, & Edwards-Beckett, 1993). Berens and Weigle (1996) proposed an









innovative NICU design that dramatically reduces noise by separating physically and

acoustically, all of the NICU "noisemakers" into a control room. Other inexpensive

strategies for noise reduction include 1) placing blankets over incubators to muffle sound

(this technique limits visibility to neonates); 2) using padded plastic garbage cans instead

of metal; 3) padding incubator doors; 4) rearranging incubators to reduce pockets of

increased or focused noise; 5) removing water from ventilator tubing frequently to reduce

bubbling noises; 6) placing noisy equipment such as telephones, radios, and centrifuges

in a separate room adjoining the unit or in an isolated pod away from infants; 7)

modifying heating and cooling systems to reduce noise; 8) talking quietly and closing

doors and portholes gently; and 9) not dropping things on top of the incubator (Levy et

al., 2003; Nair et al., 2003). The use of acoustical ceiling systems and carpet also assist

in noise abatement, but must be selected and designed carefully for high performance

results (White, 2002).

The design of health care facilities is governed by many regulations and technical

requirements; it is also affected by many less defined needs and pressures. The

implementation of the Health Insurance Portability and Accountability Act (HIPAA) has

influenced hospital design, including NICU design, due to the need to provide patient

privacy. These regulations put new emphasis on acoustic and visual privacy, and may

affect the location and layout of workstations that handle medical records and other

patient information, both paper and electronic, as well as patient accommodations (Carr,

2005). According to Mathur (2004), individual private rooms are the only reasonable

way to meet the acoustical privacy requirements under HIPAA.









The control of light and noise is important and must be addressed in NICUs. The

control of light levels may be more manageable in SFRs because the light requirements

are only dictated by one patient and one family. As discussed, there are many strategies

to limit noise and provide lighting strategies in open-bay layouts. However, personal

control of noise and light for each neonate and family is desirable to suit their individual

needs (Mathur, 2004).

Infection Control

Hospital acquired infections are common in very low birth weight (VLBW) infants;

occurring in approximately 20% of VLBW infants (Gaynes, Edwards, Jarvis, Culver,

Tolson, Martone, 1998; Sohn, Garrett, Sinkowitz-Cocran, Grohskopf, Levine, Stover,

Siegel, Jarvis, Pediatric Prevention Network., 2001). Due to neonates' immature immune

system, the NICU is a high risk area for developing infections. In open-bay NICUs,

infection control may be complicated because particulate matter tends to move freely in

an open space. According to Mathur (2004), isolating neonates from each other and from

outside sources of infections is the most effective solution for infection control in NICUs;

hence, according to Mathur a SFR NICU provides the best isolation for neonates. Many

hospitals are moving towards private rooms to help with infection control (Mader, 2002).

If the use of single rooms reduces communicable infections; the results may translate into

financial savings (Price Waterhouse Coopers Web site, 2004) and less stress on the

neonates.

NICU Environment and Its Effect on Family

The impact of family presence and visiting policy is commonly addressed in NICU

research. For family members visiting their premature babies, privacy and comfort are

important features to provide for them (Shepley, Fournier and McDougal, 1998). Parents









experience a high level of stress in the NICU due to confusing medical information,

conflict with responsibilities at home, difficulty getting to distant facilities, loss of

earnings, the high temperatures in a unit, and caring for a sick child (Callery, 1997;

Goldson, 1992; Raeside, 1997). It has been noted that increased visitation with the baby

in the NICU results in a better chance of recovery (Zeskind & Iacino, 1984). Based on

Zeskind and lacino's findings pertaining to the positive effects of increased family

visitation; providing a NICU environment that is comfortable for visiting families is

optimal.

Research on family stress and needs in the NICU is important; presently research

concerning family issues regarding the diverse NICU arrangements would be beneficial.

Are there differences in parent-child interaction in the four settings (e.g., number of

visits, time spent at bedside)? Which type of unit is most preferred by families? These

parent-child issues will be investigated in the larger NICU research project. The family

needs and preferences will be studied by data collection from medical charts relating to

parent participation. Plus, a family survey will concentrate on the family-centered care

philosophy and how the facility supports the parents, siblings, and other family members.

NICU Environment and Its Effect on Healthcare Staff

The NICU environment can be highly stressful for the healthcare staff, suggesting

that, to reduce stress, the facility layout must support their activities (Shepley, 2002). It

is thought that SFRs may increase the amount of time nurses spend walking in the NICU.

In a longitudinal case study performed by Shepley (2002), nurse time spent walking in an

open-bay NICU was compared to the original closed bays. The hypothesis that the total

amount of time spent walking from activity to activity would be reduced was not

supported. Hence, an open-bay layout does not necessarily produce less walking distance









for nurses compared to closed bay units, and may not minimize walking distances in

single family room units.

Within the context of the parent study, staff behaviors and preferences will be

compared in both the private and open setting. This data will be extracted from

anonymous hospital records (medical errors, staff turnover, staffing numbers) and

collected by administering a survey targeted to the healthcare staff.

Nursing Models: Family-Centered Care and Developmental Care

Family-Centered Care

A move toward family-centered care and a consumer-focused orientation have

resulted in the widespread use of individual private rooms for obstetrical services and

universal patient rooms (Mathur, 2004). Family-centered care is the philosophy that the

healthcare providers and family are partners, working together to best meet the needs of

the patient by promoting communication, respecting diversity, and empowering families.

Full parent participation in care requires unrestricted access to the neonatal intensive care

unit which may increase the potential infection risk (Moore, Coker, DuBuisson, Swett, &

Edwards, 2003). The literature suggests that the family-centered care delivery model

improves satisfaction with the hospital experience and that parents who are informed and

involved are more confident and competent caring for their sick children (Cohen et. al,

2004). Single family room NICUs may provide the best setting for family-centered care

by affording an area for each family adjacent to the neonate; as well as providing a

setting that may help with infection control.

Developmental Care

Developmental care consists of four standards in the NICU 1) caregiving is

flexible, individualized, and responsive to vulnerabilities of every infant; 2) parent-infant









relationships are supported from birth; 3) all caregivers practice collaboratively; and 4) a

developmentally appropriate environment is provided (Robison, 2003).

Als, Buehler, Duffy, Liederman, & McAnulty (1995) assessed the effectiveness of

individualized developmental care in the NICU for low-risk pre-term infants. The

control group received standard care and the experimental group received individualized

care at the same facility. Results showed that individualized care supports

neurobehavioral functioning and appears to prevent frontal lobe and attentional

difficulties in the newborn period, the possible causes of behavioral and scholastic

disabilities often seen in low-risk pre-term infants in later ages .

The Journal of the American Medical Association (1994) reported that infants who

were provided with developmentally supportive care through control of the environment

and individualized attention were found to benefit from a reduced dependence on

respiratory support, earlier oral feeding, reduced incidence of complications, improved

weight gain, shorter hospital stays, and reduced costs of care, compared with infants not

provided this type of care in the control group (Als, Lawhon, Duffy, McAnulty, Gibes-

Grossman, & Blickman, 1994; Robison, 2003).

A NICU that provides more control over environmental features may better support

developmental care since developmental care focuses on uninterrupted sleep, self

regulation, and decreasing both light and noise in the NICU environment (Robison,

2003).

Recommended Standards for NICU Design

The Guidelines for Design and Construction of Hospital and Health Care Facilities

(2003) serves as a standard for American hospital and medical facilities. In a multi-

bedroom unit, every bed position shall be within 20 feet of a hands-free hand washing









station. Where an individual room concept is used, a hands-free hand washing station

shall be provided within each infant care room. In the interest of noise control, sound

attenuation shall be a design factor. Provisions shall be made for indirect lighting and

high-intensity lighting in all nurseries. Controls shall be provided to enable lighting to be

adjusted over individual patient care spaces. Each patient space shall contain a minimum

of 120 square feet (SF) per bassinet excluding sinks and aisles. There shall be an aisle for

circulation adjacent to each patient care space with a minimum width of three feet. Each

infant care space shall be designed to allow privacy for the baby and family. The NICU

shall be designed as part of an overall safety program to protect the physical security of

infants, parents, and staff to minimize the risk of infant abduction (The American

Institute of Architects Academy of Architecture for Health, 2003). These

recommendations are the benchmark for design standards. Many municipalities adopt

these standards, in effect; making the guidelines required minimum standards. Often,

hospitals require the design team to follow these guidelines, even when they are not

required by law.

Construction Cost

Controlling costs is essential for hospital administrators in today's tough economic

environment. The costs to the healthcare system are many and complex, including

upfront cost associated with the construction of the facility. Construction costs can vary

depending upon a number of factors such as 1) local, state, and national regulations; 2)

type of contract (negotiated, hard bid, guaranteed bid max); 3) season of year; 4)

contractor management; 5) weather conditions; 6) local union restrictions; 7) building

code requirements; 8) availability of adequate energy, skilled labor, and building









materials; 9) owners special requirements/restrictions; 10) safety requirements; 11) size

of project; and 12) location of project (Waier, 2005).

The type of project also has great influence on construction cost: new construction

or remodel. In the case of a remodel, the extent to which the existing building impedes 1)

construction activity; 2) the extent of demolition required; and 3) utilities that may have

to be relocated affect costs. Decisions affecting cost of new construction can include: 1)

selection of the site; 2) selection of the basic structural system, mechanical and electrical

system types; and 3) exterior envelope criteria (Bobrow & Thomas, 2000).

Healthcare construction costs vary by region, with a premium for construction in

seismically active areas (Bobrow & Thomas, 2000). When making cost comparisons

from city to city and region to region, the Means City Cost Indexes (CCI) is a valuable

tool, since hospitals in urban areas tend to have higher costs due to a higher cost of living

than do hospitals in rural areas. The publication contains average construction cost

indexes for 719 U.S. and Canadian cities covering over 930 three-digit zip code locations,

and is updated yearly. The publication is aimed primarily at commercial and industrial

projects costing one-million dollars and up. The costs are primarily for new construction

or major renovation of buildings. A city cost can be adjusted to the national average or

to a specific city. The 30 City Average Index is the average of 30 major U.S. cities and

serves as a national average (Waier, 2005).

When comparing construction costs between different years, the costs should be

normalized to the same year. The Means Historical Cost Index can be used to convert

building costs at a particular time to the approximate building costs for some other time

(Waier, 2005).









Floor Plan Analysis

Archival data collection and/or post-occupancy evaluations (POE) can offer useful

cost-saving knowledge. Each project, no matter how well executed, has both successes

and failures; designers can learn from POEs and improve the design of future facilities

(Wang, 2002). Preiser, Rabinowitz, and White (1988) divide POEs into three levels of

involvedness: indicative POE, investigative POE, and diagnostic POE. An indicative

POE is one that analyzes as-built drawings and lists them into topics; and interviews are

conducted with building occupants to better understanding the performance of the

building. An investigative POE is one that compares an existing situation with

comparable facilities and summarizes current literature regarding the topic. A diagnostic

POE involves a multi-methodological approach (surveys, observations, physical

measurements, etc.) conducted in comparison to other facilities.

The research method of floor plan analysis for this endeavor is a combination of the

three types of POEs as written by Preiser et al. (1988). The floor plan analyses involved

examination of as-built drawings, comparison with comparable facilities, and

measurements categorized into topics.

According to Moon (2005), providing private rooms may result in higher

construction costs due to more square footage. However, according to Mathur (2004),

the increased area for a single room is offset by the elimination of parent sleep rooms

within or adjacent to the unit. The floor plan evaluations will help clarify the suggestion

that SFR NICUs require more space and potentially a higher cost than open-bay or multi-

bed variation units.














CHAPTER 3
METHODOLOGY

Research Design

The objectives of this study were two-fold 1) to compare the construction cost of

four NICU types and 2) to analyze the floor plans of each case to identify any design

trends within each setting. The research method used for this project is a multiple

comparison case study. The dependent variables are Level III NICUs built or remodeled

since 1995. The independent variables are single family room (SFR), double-occupancy,

open-bay, and combination layout NICUs. Four cases that offer contrasting situations

were compared and analyzed. The project incorporated three phases 1) data collection; 2)

data analysis; and 3) comparison of case study results. The research project took place at

the University of Florida in Gainesville, Florida.

Sampling Procedures

Hospitals were selected for this study by a sample of convenience. The hospitals

are located in the United States and meet the criteria for nursing model and unit design

(SFR, double-occupancy, open-bay, or combination). Thirty-one Level III NICUs built

or remodeled since 1995 were identified as meeting the inclusion criteria and asked to

participate. The hospitals were sent a letter explaining the research project and asked to

voluntarily participate in the study and those who agreed to participate were included in

the study (see Appendix A).









Participants

Eleven hospitals across the United States formally agreed to participate in the

study. From the eleven participants, a comparison based on plan evaluation, photographs,

and printed documentation from four hospitals was completed (Figure 3-1).
















MEXICO

Figure 3-1: Geographic Location of Participants

Because of design variation, four categories have been developed 1) single family

room; 2) double-occupancy; 3) open-bay; and 4) combination (a mixture of SFR, open-

bay and double-occupancy).

Inclusion criteria requires the NICU must be Level III, built since 1995, hold 16

beds or greater, and have an average census of twelve patients per day or greater.

Participation is voluntary and based on informed consent (see Appendix B).

Ethics

There are limited ethical concerns to be aware of with this research project as there

are no human participants or patient records to alter. Furthermore, the participating

hospital's names will remain anonymous. However, the researcher is aware of the

Belmont Report on ethical principles and guidelines for the protection of human subjects









of research. This research project does not require Institutional Review Board (IRB)

approval; nevertheless it falls under the larger project's IRB approval. The researcher

completed and received the certificate of completion for HIPAA for researchers at the

University of Florida on September 28, 2004 (see Appendix C). Hence, the researcher

understands the importance of providing privacy for participants and documents that may

be involved in this research endeavor.

Hospital participation in this study is voluntary and no monetary benefit or

coercion to participate was used. Explicit authorization was obtained before any hospital

records were investigated. The incentive to participate in this study is to help add to the

knowledge base of NICU design to provide the best environment for the patient, family,

and staff.

The compilation of data to compare and conclude outcomes must be an ethical

process. The researcher is aware of the unethical practice of slanting or changing data to

produce a significant or specific outcome. For this research project, any significant data

serves a positive purpose for future NICU design.

Data Collection

Information specific to the NICUs participating in the study was collected with the

approval of the healthcare facilities administration. Data collection involved collecting

archival data associated with the reviewed plans for construction costs. The floor plans

were requested to be sent as AutoCAD files, AutoCAD is a computer aided drawing

program commonly used by architects and interior designers. The construction costs

gathered from the hospital's facilities department were primarily sent electronically or by

mail. The construction costs are limited to the cost of the Level III NICU, which in some

cases required extraction from a larger project. Photos and marketing materials were also









requested with permission to publish to help further identify various design features in

each NICU (see Appendix D and Appendix E).

The AutoCAD drawings requested from each participant consist of 1) floor plan

with labels; 2) furniture plan and equipment plan; 3) finish schedule; 4) reflected ceiling

plan; 5) lighting power and systems plan; 6) sections; 7) elevations; 8) headwall

elevations; and 9) door schedule (see Appendix F). The plans that were most beneficial

were the floor plans and the furniture, fixture, and equipment plans.

Data Analysis

Floor Plans

Following the collection of floor plans and architectural documents from the four

NICU facilities and performing an initial literature review, a system was developed to

effectively organize and analyze the floor plans. The purpose of the plan evaluations was

to examine NICU design issues and identify trends in design layout. The main focus of

the four plan evaluations was on the allocation of space for the staff, patient, and family;

as well as the amount of space allocated to unit circulation.

The first step of the plan analysis phase involved assessing each NICU by

categorizing every room into one of twelve categories: patient, family, public shared,

staff medical, staff communal, staff office, staff, storage, service medical, service facility,

circulation vertical, and unit circulation. Next, the twelve categories were assigned to

one of six general categories: patient, family, staff, public, systems, and unit circulation.

This step helped to clearly identify the allocation of space within each unit for the six

main area categories.

The square feet (SF) total of every space was measured and listed in a Microsoft

Excel spreadsheet. The amounts of family and staff space at each baby station were









identified. This was accomplished by measuring midpoint at each isollette to divide the

room or space into half, not including the actual baby station. The amount of family

space at bedside and staff space at bedside was listed in a Microsoft Excel spreadsheet.

Last of all, the amount of clear floor space for each infant area was measured and

calculated. This step was completed by totaling the family and staff space in each infant

area and then subtracting any permanent fixtures such as sinks and/or counters.

After the floor plans were assessed and measured, three sets of diagrams were

prepared for each setting 1) circulation diagram; 2) allocation of space diagram; and 3)

infant care area diagram. The diagrams overlaid the AutoCAD floor plans to precisely

illustrate the allotment of spaces each case provides. The diagrams helped to identify the

circulation patterns and user zones for each setting (see Appendices J-M and Appendices

N-Q).

The plan assessment was followed by calculating the average square feet for 1)

infant space; 2) family space; 3) staff space; 4) circulation; 5) staff space at bedside; and

6) family space at bedside. Once all of the plans were measured and calculated, the net to

gross factor for each facility was calculated (the amount of space taken up by walls and

unusable space).

Construction Cost

The breakdown of cost topics requested from each participant was 1) land

acquisition; 2) construction cost; 3) design and engineering fees; 4) owner construction

administration; 5) development and soft cost; 6) equipment; 7) furnishings and fixtures;

and 8) financing (see Appendix F). From this information, only the construction costs

were extracted for comparison. Once the costs were collected and organized, the cost

needed to be adjusted to the year 2005 and normalized to the national average cost. The









Means Historical Cost Index was used to adjust the archival cost data from each

participant to what the approximate construction cost for each facility would be in the

year 2005 (see Formula 3-1). After the costs were adjusted to 2005, the Means City Cost

Indexes were used to compare cost from city to city, with the end result normalized to the

National City cost average (see Formula 3-2).

Formula 3-1
Index for Year X
x Cost in 2005 = Cost in Year X
Index for Year 2005

Using formula 3-1, the Historical Cost Index for a specific year Xwas divided by

the Cost Index for year 2005; the decimal value was then divided into the particular

hospital construction cost, giving the approximate cost if that facility was built in 2005.

Formula 3-2
Specific City Cost
Specific Ci x 100 = City Cost Index
National Average Cost

Using formula 3-2, to obtain the National Average Cost, the particular

construction cost (Specific City Cost) was multiplied by 100 (the National Average

Index) and then divided by the specific city cost index, giving the adjusted cost of that

facility in comparison to the National Average.

Once the NICU construction costs were adjusted to be comparable in year and

region, the costs were divided by the total square feet of the unit to give the cost per

square foot for each case (see Formula 3-3).

Formula 3-3
Adjusted Construction Cost
= Cost per Square Foot
NICU Square Feet
Additionally, the construction costs were divided by the number of beds in each

unit to provide the cost per infant care area (see Formula 3-4). The results should serve






22


as a general guide for the cost of building SFR, double-occupancy, open-bay, and

combination layout NICUs.

* Formula 3-4

Ajusted Construction Cost
#=of B Cost per I fidll.ition.
# of Beds














CHAPTER 4
RESULTS OF THE STUDY

Demographic Descriptive Information

Single Family Room NICU Description

The SFR NICU is located in the Midwest. In a typical year, the unit cares for 350

to 400 high-risk infants. The facility was built (new-construction) in 2001, is located on

the 2nd floor, and has 22 Level III licensed infant stations. Included in the 22-bed total is

1 designated isolation room with an ante room adjoining. Each infant room has a daybed,

recliner, and phones that flash, not ring. The family lounge has seating, TV/VCR, a

kitchenette, and washer and dryer. Adjacent to the family lounge are three sleep rooms

with double beds. The NICU patient area has 4 nurse substations as well as 4 breast milk

areas equally dispersed. The facility practices family-centered care and kangaroo care.

Double-occupancy NICU Description

The double-occupancy NICU is located in the West. Approximately 1,200

newborns are cared for in the NICU each year. The facility was remodeled in 1998 and

has 48 Level III licensed infant stations. Included in the 48-bed total is 1 isolation room.

All of the patient rooms are semi-private with the majority (94%) of the rooms being

double-occupancy. The infant stations are set-up one of two ways: two beds along the

same wall or two beds cattycorner to one another on opposing walls. The family lounge

has seating, lockers, laundry facility, shower room, breast feeding room, and 2 sleep over

rooms. The NICU patient area has 5 nurse stations equally dispersed. The facility has

billowing clouds and fiber optic "stars" which decorate the ceiling.









Open-bay NICU Description

The open-bay NICU is located in the Southeast. The facility was expanded and

remodeled in 2004 and has 20 Level III licensed infant stations. Included in the 20-bed

total are 2 isolation rooms and 2 ECMO rooms (cardiac bypass for babies). Additionally,

the unit has 2 exam areas. The infant stations are set-up two ways: 1) the pin-wheel

configuration and 2) open spaces along the perimeter walls. The family lounge has

seating, TV/VCR, lockers, restrooms, more breastfeeding space, and a sky light. The

NICU patient area has 2 nurse stations.

Combination NICU Description

The combination NICU is located in the South. The facility was remodeled in 2004

and has 45 licensed Level III infant stations. The unit supports a combination layout with

three semi-private double-occupancy rooms, six pods of pin-wheel configuration infant

stations, open-bays along perimeter walls, and 1 isolation room. Each infant area has a

recliner bedside and a sink within close proximity. The family lounge has seating,

lockers, a child play area, restroom, family office, and pump room. Eight small nurse

areas are spread throughout the NICU patient areas. Both family-centered care and

developmental care are practiced by the healthcare staff.

Floor Plan Analysis Results

The floor plans for each NICU were separated into five categories of spaces:

infants, family, staff, unit circulation, and miscellaneous. The infant space includes all of

the patient rooms together including isolation, ECMO, and ante rooms. The family

spaces include the following areas 1) family lounge (restroom, kitchenette, and laundry);

2) sleep-over rooms; 3) breastfeeding and pump rooms; 4) conference and consultation;

5) family scrub; 6) family transition; 7) vending and nourishment; and 8) parent quiet









rooms. Staff space consists of 1) nurse stations and reception; 2) pharmacy; 3) alcoves;

4) staff lounge and lockers; 5) staff restrooms; 6) clean and soiled utility; 7) supply; 8)

offices (social service, nurse practitioner, dictation, and physician); 8) labs; 9) procedure

areas; 10) medication preparation and formula/breast milk; 11) respiratory therapy; 12)

equipment; 13) x-ray; and 14) on-call rooms. Unit circulation includes all lateral

circulation throughout the unit. Vertical circulation such as stairs and elevators were

excluded from the unit circulation category because external factors such as fire exits and

building location influence vertical circulation requirements. Lastly, a category to

encapsulate universal building features was developed and designated "miscellaneous".

This category includes 1) public space; 2) systems; and 3) vertical circulation. The

systems sub-category includes 1) housekeeping; 2) general storage; and 3) mechanical,

data, and electrical rooms.

Single Family Room Floor Plan

The SFR unit is 18,130 square feet (SF). Of the 6 key allocations of space

categories, unit circulation comprises the highest percentage of the unit at 28% (Figure 4-

1). The average infant station area is 171 SF. The average family space at bedside is 88

SF. The average staff space at bedside is 64 SF. The infant station is 19 SF (Figure 4-2).

The average clear floor space is 137 SF, which is 80 % of the room (see Appendix H and

Appendix I).











Single Family Room Unit Space Allocations

o Unit
Circulation
28% m Net to Gross
Factor
13%
o Staff
20% Miscellaneous
m Family m Infants 11%
7% 21%



Figure 4-1: SFR Unit Space Allocations


Single Family Room
Infant Care Area Space Allocations



o Infant Station
11%


U Staff Space Family
Bedside Space
38% Bedside
51%



Figure 4-2: SFR Infant Care Area Space Allocations

Double-occupancy Floor Plan

The double occupancy unit is 16,337 SF. Of the 6 key allocations of space

categories, infant space comprises the highest percentage of the unit at 33% (Figure 4-3).

The average infant station area is 111 SF. The average family space at bedside is 52 SF.

The average staff space at bedside is 39 SF. The infant station is 20 SF (Figure 4-4). The

average clear floor space is 82 SF, which is 74 % of the room (see Appendix H and

Appendix I).











Double-occupancy
Unit Space Allocations

Net to Gross
Factor m Miscellaneous
o Unit 7%
Circulation Infants
28% 32%


o Staff
17%


* Family
7%


Figure 4-3: Double-occupancy Unit Space Allocations


Double-occupancy
Infant Care Area Space Allocations


o Infant Station
18%


* Staff Space
Bedside
35%


Family
Space
Bedside
47%


Figure 4-4: Double-occupancy Infant Care Area Space Allocations

Open-bay Floor Plan

The open-bay unit is 10,871 SF. Of the 6 key allocations of space categories, staff

space comprises the highest percentage of the unit at 33% (Figure 4-5). The average

infant station area is 115 SF. The average family space at bedside is 40 SF. The average

staff space at bedside is 48 SF. The infant station is 27 SF (Figure 4-6). The average

clear floor space is 85 SF, which is 74 % of the room (see Appendix H and Appendix I).











Open-bay
Unit Space Allocations



O Unit
O Staff U
Circulation
22%

m Net to Gross
Factor
11% m Infants 12
21% m Miscellaneous
1%


Figure 4-5: Open-bay Unit Space Allocations


Open-bay
Infant Care Area Space Allocations



o Infant Station
24% m Family
SSpace
Bedside
35%

Staff Space
Bedside
41%


Figure 4-6: Open-bay Infant Care Area Space Allocations

Combination Floor Plan

The combination unit is 20,519 SF. Of the 6 key allocations of space categories,

unit circulation comprises the highest percentage of the unit at 30% (Figure 4-7). The

average infant station area is 111 square feet. The average family space at bedside is 41

SF. The average staff space at bedside is 42 SF. The infant station is 29 SF (Figure 4-8).










The average clear floor space is 80 SF, which is 72% of the room (see Appendix H and

Appendix I).


Combination
Unit Space Allocations


Net to Gross
o Unit Circulation Factor
30% % 10%
m Miscellaneous
7%
o Staff
19%
7 Infants
Family 2
10%



Figure 4-7: Combination Unit Space Allocations


Combination
Infant Care Area Space Allocations

O Infant
Station
26%

Family
Space
Bedside
SStaff Space 37%
Bedside
37%


Figure 4-8: Combination Infant Care Area Space Allocations

Construction Cost Results

Single Family Room Costs

The adjusted construction cost for the SFR NICU is $4, 680, 707.00. The cost per

square foot is $258.00 and the cost per infant station is $212,759.00 (Table 4-1 and

Appendix G).









Table 4-1: Comparison of Construction Cost Data
Adjusted NICU Square Cost per Cost per Infant
NICU Type Construction
ST C Feet Square Feet Station
Cost

SFR $4,680,707 18,130 SF $258 $212,759

Double-
Doubl $5,399,950 16,337 SF $331 $112,499
occupancy

Open-bay $4,387,062 10,871 SF $404 $219,353

Combination $3,956,015 20,519 SF $193 $87,911



Double-occupancy Costs

The adjusted construction cost for the double-occupancy NICU is $5,399,950.00.

The cost per square foot is $331.00 and the cost per infant station is $112,499.00 (Table

4-1 and Appendix G).

Open-bay Costs

The adjusted construction cost for the open-bay NICU is $4,387,062.00. The cost

per square foot is $404.00 and the cost per infant station is $219,353.00 (Table 4-1 and

Appendix G).

Combination Costs

The adjusted construction cost for the combination NICU is $3,956,015.00. The

cost per square foot is $193.00 and the cost per infant station is $87,911.00 (Table 4-1

and Appendix G).














CHAPTER 5
DISCUSSION AND CONCLUSIONS

Findings

The purpose of this research project was to compare four different NICU settings in

regards to their construction costs and space allocation features. Present literature has

focused mainly on SFR and open-bay NICU settings, though combination and double-

occupancy settings are common as well. Each NICU type may have benefits and

drawbacks; and there are various techniques to limit the weaknesses in each setting. The

review of literature focusing on construction costs reflects the lack of research in this

particular area, especially relating to NICUs.

Construction Cost

The NICU construction costs were compared on two levels 1) cost per SF and 2)

cost per infant station. The open-bay setting has the highest cost per SF at $404. The

combination setting has the lowest cost per SF at $193. Similarly, the open-bay has the

highest cost per infant station at $219,353. The combination has the lowest cost per

infant station at $87,911. It should be noted that SFR setting was the second lowest for

cost per square feet and double-occupancy was second lowest in cost per infant station

(Figure 5-1). Figure 5-1 shows the cost results for both cost categories (cost/SF and

cost/infant station) for each NICU.











Cost Per Square Feet and Cost Per Infant Station








59 99
Single Family Room Double-occupancy Open-bay Combination


Cost Per SF U Cost Per Infant Station

Figure 5-1: Cost per Square Feet and Cost per Infant Station

Floor Plan Space Allocation

The NICU floor plans were evaluated and compared in terms of user and systems

space 1) infant; 2) family; 3) staff; 4) unit circulation; 5) net to gross factor; and 6)

miscellaneous. The double occupancy setting has the most unit space allocated to patient

area at 33%. The remaining NICUs all have similar amounts of space allocated to patient

area at approximately 22%. The open-bay setting has the most unit space allocated to

family space at 11%. Note that the SFR and double-occupancy settings both allocate the

least amount of space to family. The open arrangement has the most unit space allocated

to staff at 33%. The combination setting has the most unit space allocated to unit

circulation at 30% (Table 5-1).

The infant care areas were analyzed and compared in terms of 1) average infant

care area; 2) average family space at bedside; 3) average staff space at bedside; and 4)

average clear floor space in infant care area. The SFR setting has the largest average

infant care area at 171 SF with the highest amount of clear floor space at 80 %. Also, the









SFR has the highest percentage of family space at bedside at 51% (Figure 5-2). The

open-bay setting has the highest percentage of staff space at bedside (42%) (Table 5-2).

Table 5-1: Comparison of NICU S ace Allocations: Percentage of Unit
Net to
Infant Family Staff Unit Net to
NICU Type Gross Miscellaneous
S Space Space Space Circulation
Factor

SFR 21.1% 6.5% 20.3% 28.2% 13.0% 10.9%

Double-
Double- 32.7% 6.7% 17.3% 27.5% 8.5% 7.3%
occupancy

Open-bay 21.2% 10.9% 32.7% 22.2% 12.0% 1.0%

Combination 24.4% 9.9% 18.8% 29.9% 10.3% 6.7%


Table 5-2: Comparison of Infant Care Area Space Allocations
Percentage of Infant Care Area
Average Infant Family Space Staff Space Clear Floor
yp Care Area Bedside Bedside Space

SFR 171 SF 51% 38% 80%

Double-
Double- 111 SF 47% 35% 74%
occupancy

Open-bay 115 SF 35% 42% 74%

Combination 111 SF 37% 37% 72%

























NOT TO SCALE
Figure 5-2: SFR Infant Care Area. This diagram shows the typical layout of a private
room in the SFR NICU case.

Implications for Research Findings

Single Family Room

According to Mathur (2004), the increased area for SFRs is offset by the

elimination of parent sleep rooms within the unit. In comparison to the other NICU

cases, the SFR unit allocates the least amount of space to family, which is space outside

of the infant care area (lounge, sleep rooms, etc). However, the SFR has the highest

percentage of space for the family at bedside (Figure 5-2 and Figure 5-3). These results

pose the questions: 1) is it preferable to have more family space at bedside in the infant

care area or 2) is it preferable to have more family space outside the infant care area?

These results also support Mathur's suggestion that the increased area for SFRs is offset

by the lesser amounts of allocated family space in the SFR unit.










Comparison of Family Space:
Family Space Bedside Vs. Family Space Outside
Infant Care Area

100
S80
S60-

20-

Single Family Double- Open-bay Combination
Room Occupancy
Hospital Participants

% Family Space Bedside 0 % Family Space Outside Infant Care Area

Figure 5-3: Comparison of Family Space Bedside vs. Family Space outside Infant Care
Area

According to Moon (2005), providing private rooms (in general) may result in

higher costs due to more square footage. The results of this study do not support Moon's

position, since the SFR unit was second lowest in the cost per SF category and third

lowest in the cost per infant station category (Figure 5-1). Furthermore, the total amount

of space offset by the decreased amount of family space outside the infant care area

conflicts with Moon's suggestion that private units require more total square footage

(Table 5-1).

The assumption that SFRs have a higher net to gross factor is to some extent

supported by this study. The SFR unit has the highest net to gross factor at 13%,

however the open-bay has the second highest net to gross factor at 12%. The 1%

difference may be a result of more family space in the open-bay, which would mean more

walls in the family space, increasing the open-bay's net to gross factor (Figure 5-4).










Comparison of Net to Gross Factor


12.0':' .:.
10.3'` :





Single Family Room Double-Occupancy Open-bay Combination
Participants

Figure 5-4: Comparison of Net to Gross Factor among Settings

The infant rooms in this particular SFR unit exceed the recommended guidelines

for minimum square footage, which is 120 SF. Even so, with the average infant care area

at 171 SF and the clear floor space at 80%, this is only approximately 5% more than the

double-occupancy and open-bay average clear floor space percentages. Meaning, the

extra SF in the SFR setting is not necessarily going to average clear floor space, but to

fixed design features such as: sinks, counters, couches, and lockers.

Double-occupancy

The double-occupancy case has similarities with the SFR case. The main

difference in the infant care areas between the SFR and double-occupancy is the number

of beds in the room. As one might expect, the double-occupancy has the second highest

amount of average family space at bedside and second lowest amount of unit space

allocated for family (Figure 5-3). Both the SFR and double-occupancy cases have family

space outside the patient area, just at a lower percentage. The double-occupancy's cost

per SF was in-between SFR and open-bay, but the cost per infant station was

significantly lower than the SFR and open-bay (Figure 5-1).









The double-occupancy case was the most efficient from a functionality standpoint;

the net to gross factor was the lowest at 8.5% (Figure 5-4). This may be a result of fewer

walls used for infant space (2 beds per room instead of 1 bed per room) and fewer walls

in family space outside the infant care area.

Open-bay

The open-bay unit has the highest amount of family space outside of the infant care

area and the least amount of family space bedside (Figure 5-3). This indicates a priority

for family space, though not especially at bedside. The open-bay unit has the highest

amount of staff space bedside as well as the highest amount of staff space outside the

infant care area. This indicates a priority for staff space throughout the entire unit.

The open-bay unit has the highest costs in both categories (Figure 5-1), a surprising

outcome given the assumptions from the literature (Moon, 2005). It should be noted that

the open-bay project was a remodel as well as an expansion project. The expansion

involved capturing part of the roof space not on the first floor. The expansion of the

facility may have increased the construction cost because of additional cost associated

with expansion, hence, these factors should be considered when comparing the high

construction cost for the open-bay to the other NICU settings.

Combination

The combination setting has the lowest cost per SF and cost per infant station

(Figure 5-1). Within the infant care area, the family and staff space bedside are nearly

equal to one another (Figure 5-5).











Staff Space Bedside Vs. Family Space Bedside
in Infant Care Area

100%
80%
60% -

20%
0%
Single Family Double- Open-bay Combination
Room Occupancy
Hospital Participants

Staff Space Bedside u Family Space Bedside

Figure 5-5: Staff Space Bedside vs. Family Space Bedside

The combination unit allocated the most space to unit circulation and the open-bay

unit allocated the lowest amount of space to circulation (Figure 5-6 and Figure 5-7).

Both of these units make use of the pin-wheel configuration for some of their baby

stations. The combination unit has six pin-wheel stations; the use of pin-wheels may be a

factor in the combination unit's high amount of unit circulation.


[ CIRCULATION PATH
Figure 5-6: Open-bay Layout Circulation Diagram



































Figure 5-7: Combination Layout Circulation Diagram

Limitations of the Research

Several factors may have impacted the results of this study. A sample size of four

hospitals, one of each type, is a small sample size to produce generalizable results. Case

studies are thought to not be generalizable due to multiple variables which may not be

controlled (Yin, 2003).

Due to the extraction of construction cost data from larger projects, data errors

could have been made. Plus, the project relied on participants to send data (construction

cost) to be analyzed, providing for possible human error. As discussed in Chapter 2,

many factors can impinge on construction costs that are specific to each case. For

example, the budget for one hospital may have been substantially higher than the budget

for another, in turn, having one NICU that is more high-end than another. Factors such

as weather and type of project (new construction or remodel) can also have an effect on


CIRCULATION PATH
* VERTICAL CIRCULATION









cost. The construction cost which were adjusted to the year 2005 and normalized to the

National Average are approximations based on historical cost and city cost indexes.

The researcher made certain assumptions during the plan analysis phase about the

way certain areas are most likely used. For example, when calculating space at bedside,

dividing the infant area in half at midpoint infant station and assigning sides to family

and staff based on furniture placement (recliner or stool placement in most cases) is

purely an assumption on how the space is used. In actuality, during daily activities in the

NICU, carts and multiple chairs may be moved in and out of patient areas depending on

the circumstance.

In the process of assigning specific rooms to family and/or staff, assumptions were

made on what user group uses the room more frequently. Telephone calls were made to

NICU contacts to verify room usage, but in some cases, rooms are shared by family and

staff. For example, consultation rooms are shared areas, in most cases consultation

rooms were assigned to family space if they were adjacent to family lounges. Similarly,

when calculating unit circulation in the open-bay and combination layout NICUs,

assumptions were made in the open areas to calculate circulation based on guidelines for

aisle widths in NICUs.

Future Directions

As seen from this research study, there are a range of NICU settings: single family

room, double-occupancy, open-bay, and combination. Further empirical research on the

implications of these various settings is needed, in particular the costs of building,

maintaining, and operating these facilities. Research on family preference and behaviors

is needed, particularly to help determine whether more family space should be allocated









bedside or outside of the infant care area. Future NICU studies should compare more

than one case of each setting to produce results that are more generalizable.

Conclusions

Each NICU setting has its strengths and weaknesses. Depending on the NICU

operations and nursing model, one type may be more supportive than another. For

example, in a family-centered care environment, family participation is encouraged;

hence the facility that provides more space for family at bedside may be preferred, rather

than more family space outside the infant care area.

The literature suggests that environmental control is important for neonates' growth

1) acoustical control; 2) lighting control; 3) infection control; 4) temperature control; 5)

privacy; and 6) security. Single family rooms may be the best setting to afford privacy

and environmental control for the benefit to infants. From the results of this study, the

SFR setting did not have the highest construction cost. Therefore, if assuming SFR units

provide the most control of the environment, the single family room unit may be the

preferred layout for future NICU projects.




















APPENDIX A
LETTER TO PARTICIPATE


UNIVERSITY OF

FLORIDA


College of Design, Construction, & Planning
Department of Interior Design


PO Box 115705
Gainesville, FL. 32611-5705
(352) 392-0252x457
Fax (352) 392-7266
Email: debraharris@dcp.ufl.edu


January 7, 2005






Dear ,


We are conducting a study to identify best design pracices for Neonatal Inlensive Care Units (NICU) that
support infants, their families, and the healthcare staff. A recent trend in the design of NICU facilities has
been to increase the number of private patient rooms for neonates and their families. This study will
compare private patient room units, open bay units, and combination units in two steps. One step includes
data for health outcomes, perceptions, and quality of experience for staff and parents of neonates. The
second step is the purpose of this inquiry.

Your Level m NICU was identified to participate in the study. Participation is voluntary and involves
providing electronic documents that assist in assessing the impact of design on: 1) quality of the indoor
environment; 2) impact on direct care systems; and 3) differences in construction, operation, and
administrative costs. We are asking that you provide three types of electronic data for this study:
1. Plans of the NICU (see detailed list on permission form)
2. A limited list of hospital records data
3. Costs for construction, operation. and admrmnijralon nf the NICU
Based on the plan analysis, a limited number of facilities will be asked to allow a 2-day site visit to their
NICU.

We appreciate your participation and expect that the study will provide important information that will
inform and provide design guidelines for Neonatal Intensive Care Units. The attached Agreement Form
provides an opportunity to designate participation. Please complete the form and return by January 18,
2005 by mail using the self-addressed stamped envelope or fax to Debra D. Harris at 352/392-7266. If you
have any questions, please contact Debra D. Harris, Ph.D. at 352/392-0252 x457 (or cell at 352/262-4458).
An email with directions for sending the data will be forthcoming upon the receipt of the agreement form.

Sincerely,



Debra D. Harris, Ph.D.


An Equal Opporumity Alitruion






















APPENDIX B
AGREEMENT TO PARTICIPATE


UNIVERSITY OF

FLORIDA
College of Design, Construction, & Planning (352) 392-0252x457
Department of Interior Design Fi\ I 121 192-7266
PO Box 115705, Gainesville, FL. 32611-5705 Email: JAbrhmhtmr ,dcp ufll edi

Neonatal intensive care unit environmental design research:
A comparison between open bay and single family rooms
AGREEMENT TO PARTICIPATE

Please initial on the line for agreement to participate:

S 1. Hospital records (as available)
Ahital a. Number of infant stations e. Average number of support staff required for unit
&hm b. Average census per shift
c. Admissions per year f. Staffturnover
d. Average number of skilled NICU staff required for unit g. Patient transfers
per shift b. Medical errors reported
i. Nosocomial infection rates
2. ACAD drawings and photo documentation (as available)
rIniial a. Floor plan f Sections
r s b. Furniture plan g. Elevations
c. Finish plan b. Headwall elevations and details
d. Reflected ceiling plan i. Door and frare elevations and details
e. Lighting power and systems plan j. Photos and marketing materials

3. First costs total project costs (as available)
Inital a. Land acquisition e. Development and soft costs
"r b. Construction costs f. Equipment
c. Design and engineering g. Furnishings and fixtures
d. Owner construction administration h. Financing costs

S4. Operational costs (as available)
Initial a. Initial investment cost d. Replacement cost
re b. Operations cost e. Residual value
c. Maintenance and repair cost

5. Administrative costs (as available)
Initial a. Staffing direct care
her b. Staffing support
c, 5.jic"cV
We agree to participate in the study by providing the requested information initialed above for the NICU study comparing NICU unit
design and the impact on users, costs, and planning.

Name/Contact:
Telephone:
Email:
Hospital Name:
Address:



Signature for approval: Date

We Ippie.-ie '-he un; an.d efiln t parlcpluale in our istu:ly. Please FAX. ro Deba D Ha l i., Ph D at l ;2. 92-7266 OR use the
en. losed serirn n\elope b ) .ariu ar I1, 200'
THANK YOU!


















APPENDIX C
CERTIFICATION OF COMPLETION FOR HIPAA


CongatUatii ons!! hlip privacv.health .ill ed.i tmr-.jin rreearch .erlli.le asT,"ld-6:)


UP Health Science Center

Certificate of Completion
This is to certify that

Natalie Hardy
has successfully completed the

HIPAA for Researchers
at the University of Florida
on 9/28/2004

If you wish, you may print a copy of this certificate as a record of completion by
clicking on the print button below. It will print black and white, not in color.

This HIPAA for Researchers training Completion has been recorded.
If you have any questions, contact Everall Peele, HIPAA training Coordinator In the
Privacy Office at 352-273-5096 or epeele@ufl.edu
You may now close this browser window.
If you used get your certtflate link and the name on the certificate appears to be incorrect, please go
back using the browser back button and enter your correct name.




















APPENDIX D
PUBLIC RELATIONS FORM




NEONATAL INTENSIVE CARE UNIT ENVIRONMENTAL DESIGN RESEARCH
INSTRUCTIONS FOR DATA COLLECTION OF THE LEVEL III NEONATAL INTENSIVE CARE UNIT

PUBLIC RELATIONS
Send Electronic Submission of Data and questions to debraharris@dop.ufl.edu

Provide photographs and materials for current NICU Level Ill. If available, please provide archival records of
previous HICU Level IIL.


Please provide the following algital documents. The documents may be sent electronically to debraharris@dop.uf.edu as
attachments or attached as a zip lile. On the emall subject lrie please name the nosplda' aia 'Public Relalions Data."
The permission to publish lorms may be laxed to Debra Harris at 352.392.7266.

The following documents are Included? YES NO
1. NICU III Photographs
2. NICU Marketing Materials
3. Form Permission to Publish complete and
fax to Debra Harris at 352.392,7266 for each
image submitted to research study


Thank you for your time and participation
Thank you for your time and effort in providing the requested data. If you have any questions or concerns please call
Debra D. Harris, Ph.D. at 352.392.0252x457 or email at debraharris@dcp.ufl.edu



















APPENDIX E
PERMISSION TO PUBLISH


PERMISSION TO PUBLISH



To: Debra D. Harris
NICU III Environmental Design Research Study
College of Design. Constucl ion & Planning
PO Box 115705
Gainesville. Florida 32611-5705

From:




Date:


Piaw fHll out ihe follo;i;g tonri and mail or fax to Dcbra Harris at 352 392.7266. Thanlk ou vitr iour help.


Gives permission for the reproduction of the following


images that may appear in peer-reviewed journals


The following credit inform ion will be provided in association with this image:

Image # : (describe image)

Hospital: (please provide name)

Architect: (please provide name)

Photographer: (please provide name)


Signature of Hospital Representative


Printed Name


Title


Date























APPENDIX F

FACILITIES PLANNING FORM


This is a two-part form pertaining to architectural drawings and NICU construction



costs. The total project costs were simplified into seven topics; only the construction cost


were analyzed and compared for this project.




NEONATAL INTENSIVE CARE UNIT ENVIRONMENTAL DESIGN RESEARCH
INSTRUCTIONS FOR DATA COLLECTION OF THE LEVEL II NEONATAL INTENSIVE CARE UNIT
FacllIllla Planninl
Send Electronic Submission of Data to debrahards@dcp.uInedu
The drawig documents may be sent electronically as attachments or attached as a zip fie. On the e-mail subject line, list
the hospital and Faclities Daal."
The following drawings are Included? YES NO
Floor plans with labels
Furiture plan
Equipment plan
SFinish schedule
Reflected ceiling plan
Lighng / power plan
Systems plan
Sections & Elevalions
Headwall elevalions and details
Door schedule
Do the drawings indicate support spaces dedicated to the
NICU thai may be In close proximity to the unit?
Date of Occupallon MM/DD/YR:
First Costs (Total ProJect Costs) Indicate whether you have provided data for the esaegorles listed below. Submit
In Excel format. Do not use abbreviations or acronyms unless definitions are provided. On the e-mail subject line, list the
hospital and -Facilties First Cost Data"
The follow data Is Included? YES NO NIA
Land aquisitlon (If applicable)
Construction
Dsign and engineering
Owner construction and administration
Development and salt costs
Furnishings, futures and equipment
Financing


Thank you for your time and participation!
ltanh yu4J lor ULr I.me ind eIorl i n prOvidr, Tr'e i6quel1.ea data. If y:u rae any qluelions C c. nenms please ,all
Decra D. Harrs Ph.D at M52 392 0254525? r enI ns.1 i. brar.dair-si ::p Jul e















APPENDIX G
CONSTRUCTION COST DATA

This table lists the construction cost figures before they were adjusted to be

comparable in year and region with the end result being the adjusted cost national

average.

Table G-l: Construction Cost Data
Un-adjusted Adjusted Cost
NTU Geographic Construction Cnstrutnd Adjusted National
NICU R Construction 2 National
Region Date Cost 2005
Cost Average
SFR Midwest 2001 $3,644,287 $4,282,847 $4,680,707
Double-
Double- West 1998 $4,842,500 $6,247,742 $5,399,950
occupancy

Open-bay Southeast 2004 $3,442,880 $3,557,907 $4,387,062

Combination South 2004 $3,284,524 $3,394,261 $3,956,015















APPENDIX H
NICU SPACE ALLOCATION DATA












Table H-l: Unit Space Allocation Square Feet Amounts
Total Project Infant Family Public Staff Systems Unit Vertical Net to Gross
NICU
Square Feet Space Space Space Space Space Circulation Circulation Factor
SFR 18130 SF 3832 SF 1182 SF 706 SF 3680 SF 493 SF 5107 SF 779 SF 2351 SF
Double
Double 16337 SF 5336 SF 1090 SF 208 SF 2833 SF 130 SF 4496 SF 852 SF 1391 SF
Occupancy
Open-bay 10871 SF 2299 SF 1184 SF 0 SF 3555 SF 110 SF 2418 SF 0 SF 1305 SF
Combination 20519 SF 4998 SF 2038 SF 105 SF 3864 SF 395 SF 6142 SF 855 SF 2120 SF


Table H-2: Unit Space Allocation Percentage of Unit
U Infant Family Public Staff Systems Unit Vertical Net to Gross
NICU
Space Space Space Space Space Circulation Circulation Factor

SFR 21.1% 6.5% 3.9% 20.3% 2.7% 28.2% 4.3% 13.0%
Double-
ub32.7% 6.7% 1.3% 17.3% 0.8% 27.5% 5.2% 8.5%
Occupancy
Open-bay 21.2% 10.9% 0.0% 32.7% 1.0% 22.2% 0.0% 12.0%

Combination 24.4% 9.9% 0.5% 18.8% 1.9% 29.9% 4.3% 10.3%














APPENDIX I
INFANT CARE AREA SPACE ALLOCATION DATA


Table I-1: Average Infant Care Area Space Allocation Square Feet Amounts
Infant Clear Family Staff
Infant
NICU Care Floor Space Space Stat
Station
Area Space Bedside Bedside

SFR 171 SF 137 SF 88 SF 64 SF 19 SF

Double-
Double- 111 SF 82 SF 52 SF 39 SF 20 SF
occupancy

Open-bay 115 SF 85 SF 40 SF 48 SF 27 SF


Combination 111 SF 80 SF 41 SF 42 SF 29 SF



Table 1-2: Average Infant Care Area Percentages of Space

Clear Floor Family Space Staff Space Infant
NICU
Space Bedside Bedside Station


SFR 79.9% 51.3% 37.6% 11.1%

Double-
Double- 74.1% 47.1% 34.9% 18.0%
occupancy

Open-bay 74.1% 35.0% 41.5% 23.5%


Combination 72.0% 36.5% 37.4% 26.1%














APPENDIX J
SINGLE FAMILY ROOM ALLOCATION OF SPACE DIAGRAM

The SFR unit allocated the least amount of family space outside the infant care

area, which was 6.5% of the unit, while allocation the most amount of family space at

bedside.


M INFANT SPACE
* FAMILY SPACE
* STAFF SPACE
[ SYSTEMS SPACE
PUBLIC SPACE


Figure J-l: Single Family Room Allocation of Space Diagram












APPENDIX K
DOUBLE-OCCUPANCY ALLOCATION OF SPACE DIAGRAM

The double-occupancy unit allocated the highest amount of space to infant space at

32.7% of the unit. Similar to the SFR unit, within the infant care area, the family space at

bedside was second highest and the family space outside the infant care area is second

lowest at 6.7% of the unit.


HI


i NOT TO SCALE
Figure K-1: Double-Occupancy Allocation of Space Diagram


INFANT SPACE
FAMILY SPACE
SSTAFF SPACE
7 SYSTEMS SPACE
PUBLIC SPACE
[ NOT IN SCOPE OF PROJECT












APPENDIX L
OPEN-BAY ALLOCATION OF SPACE DIAGRAM
The open-bay unit allocated the most amount of family space outside the infant

care area at 11% and the least amount of family space bedside at 35%. The open-bay unit

allocated the highest amount of staff space bedside within the infant care area at 42%.


I
~


INFANT SPACE
FAMILY SPACE
*STAFF SPACE
SYSTEMS SPACE
Figure L-l: Open-Bay Allocation of Space Diagram














APPENDIX M
COMBINATION UNIT ALLOCATION OF SPACE DIAGRAM


r -


Figure M-: Combination Unit Allocation of Space Diagram
Figure M-1: Combination Unit Allocation of Space Diagram


INFANT SPACE
FAMILY SPACE
SSTAFF SPACE
[]SYSTEMS SPACE
0 PUBLIC SPACE














APPENDIX N
CIRCULATION DIAGRAM FOR SINGLE FAMILY ROOM UNIT

This diagram represents the unit circulation in the SFR NICU which was 28.2% of

the unit. The SFR and double-occupancy unit's allocated similar amounts of unit space

to circulation, with a 1% difference (see Appendix 0).


CIRCULATION PATH
l VERTICAL CIRCULATION


Figure N-l: Circulation Diagram for Single Family Room NICU














APPENDIX O
CIRCULATION DIAGRAM FOR DOUBLE-OCCUPANCY UNIT

This diagram represents the unit circulation in the double-occupancy layout which

was 27.5% of the unit. The double-occupancy and SFR unit's allocated similar amounts

of unit space to circulation, with a 1% difference (see Appendix N).


I ]- ;1


I CIRCULATION PATH
E VERTICAL CIRCULATION


Figure -1 Circulation Diagram for Double-occupancy NICU
Figure 0-1: Circulation Diagram for Double-occupancy NICU














APPENDIX P
CIRCULATION DIAGRAM FOR OPEN-BAY UNIT

This diagram represents the unit circulation in the open-bay layout NICU. The

circulation comprised 22% of the unit, which was the lowest circulation amount in

comparison to the other three NICUs.


U CIRCULATION PATH
Figure P-l: Circulation Diagram for Open-bay NICU











APPENDIX Q
CIRCULATION DIAGRAM FOR COMBINATION LAYOUT UNIT
This diagram represents the unit circulation in the combination layout NICU. The
circulation comprised 30% of the unit, which was the highest circulation amount in
comparison to the other three NICUs.


LI


0


fi vL-


* CIRCULATION PATH
[ VERTICAL CIRCULATION


Figure Q-1: Circulation Diagram for Combination layout NICU


___
















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BIOGRAPHICAL SKETCH

Paige was born in Jacksonville, Florida, and has an older sister. Throughout grade

school she enjoyed gymnastics, piano, and creative activities. Paige went to Riverview

High School in Sarasota, Florida, and graduated in 1994. She was a cheerleader for the

Riverview Rams for two years.

During her undergraduate years at the University of Florida, Paige studied

anthropology, with a focus on cultural anthropology. She graduated in May of 1999 with

a Bachelor of Arts in anthropology. After graduation, Paige worked for Delta Airlines

for three years.

Paige returned to the University of Florida in August of 2002 and started the

Master of Interior Design program. Paige developed many interests in interior design,

including universal design, specifically designing for the aging population; as a result she

completed a graduate minor in gerontology. She enjoys all aspects of the design process:

research, space planning, 3-dimensional design and furniture design, and presentation

rendering.

Following graduation, Paige plans to continue living in Florida and work at a

design firm.