Journal of Perinatology (2014) 34, 811–815 © 2014 Nature America, Inc. All rights reserved 0743-8346/14 www.nature.com/jp
COMMENTARY
The business case for building better neonatal intensive care units MM Shepley1, JA Smith2, BL Sadler3 and RD White4 Journal of Perinatology (2014) 34, 811–815; doi:10.1038/jp.2014.174
INTRODUCTION There is increasing evidence that the physical environment of the neonatal intensive care unit (NICU) has a tangible effect on the vulnerable infants who spend the first crucial weeks or months of their life there. While many aspects of NICU design have been evaluated, none is more tangible than the single-family room (SFR) concept because of its many potential benefits, possible hazards and its increased cost of construction. Data are now available to allow us to establish a cost-benefit analysis of SFR design in the NICU by assessing its impact on operating costs. This paper reviews the cost implications of SFR design and compares those with its quantifiable benefits. We also enumerate non-quantifiable benefits and hazards of SFR design and describe additional desirable, evidence-based design aspects for those who are considering new NICU construction or major renovation. IMPACT OF THE NICU ENVIRONMENT The design and construction of NICUs have some specialized attributes. NICUs have a unique and impactful microclimate and culture. As has been stated, ‘A case can be made that in no other part of the hospital is providing an optimal physical environment more important than the NICU because nowhere else will the adverse effects of noxious physical elements have more profound and long-lasting effects.’1 Studies conducted in NICUs now show clear correlations between incorporating evidence-based design (especially SFRs) and improved outcomes and lower operating costs. SFR require additional space that entails higher one-time construction costs and slightly increased heating, cooling and nonclinical support personnel costs. Therefore, it is important to ascertain whether the benefits of SFR design can justify these costs. THE HYPOTHETICAL NICU ADDRESSED IN THIS STUDY To illustrate the financial implications of current best practices in NICU design, we describe a hypothetical 40-bed NICU with 32 acuity adaptable private (SFR) and four semiprivate rooms, with each pair of semiprivate rooms convertible into a four-bed room. The supplies and amenities provided in each room are unspecified, as for the most part they are not unique to SFR or multiple-bed room design. We selected a medium-sized NICU; therefore, it will be suitable for comparison with a large number of units.
Why a mix of SFR and semiprivate beds? This design is intended to provide private rooms for any of the families that want them in all but the highest census conditions, including options for twins or higher-order multiples. At the same time, families that would prefer to be in a more open setting or babies whose families are not present and need a less isolated setting can be put into a shared room. UNDERSTANDING THE COST CHALLENGE Recent changes in the landscape are having an impact on healthcare systems. Physicians and hospitals are forming new alliances and payment for services is shifting from volume to value. The pressures for accountability with transparency of outcomes and reduced operating costs are increasing. Hospital administrators may react to the need to reduce costs by reducing capital expenditures, even though construction costs represent a small portion of the budget and the design of the physical environment of care has the potential to reduce operating costs. One issue that is often overlooked is the relationship between the design and construction of hospitals and their operating costs. Whereas some earlier studies demonstrated the impact of changes in the physical environment on staffing or patient outcomes, we were unable to find studies that compared the construction cost of changes in the environment of care with savings attributable to improved patient outcomes and staff costs until 2004, when a multidisciplinary team of two hospital CEOs, a professor of marketing, two architects and a health trend specialist described the Fable Hospital—an imaginary facility that included a selected series of design innovations that research had shown improved care, reduced harm and that patients, families and staff preferred.2 The results were compelling—the one-time incremental construction costs led to significant operating cost savings, and a powerful return on investment. The authors updated the analysis in 2011 with Fable Hospital 2.0 and the business case was even more compelling, noting a one-time incremental construction cost of $29 million produced annual savings of $10 million.3 Whereas some of the Fable Hospital concepts are applicable in the NICU, others are not; therefore, it is important to explore NICU-specific research in order to determine whether a similar argument can be made for cost-effectiveness of various design features. COST IMPLICATIONS OF SFR NICUs Two types of cost must be taken into consideration when analyzing the implications for our hypothetical NICU: one-time construction costs and ongoing operating costs. Regarding the one-time costs, our predominantly SFR NICU, when compared
1 Department of Design Environmental Analysis, Cornell University, Ithaca, NY, USA; 2Smith Hager Bajo Inc., Ashburn, VA, USA; 3Institute for Healthcare Improvement, La Jolla, CA, USA and 4Pediatrix Medical Group, Memorial Hospital, South Bend, IN, USA. Correspondence: Dr RD White, Pediatrix Medical Group, Memorial Hospital, 615 North Michigan Street, South Bend, IN 46601, USA. E-mail: [email protected] Received 5 May 2014; revised 14 August 2014; accepted 19 August 2014
Building better NICUs MM Shepley et al
812 with a multiple-bed room design, will require an additional 45 net square feet per bed (minimum 165 square feet clear in the SFR versus 120 square feet clear in the multiple-bed room), based on the Recommended Standards for Newborn ICU Design.4 This 45 net square feet per bed, or 67.5 gross square feet (GSF) using a 1.5 conversion factor, denotes the incremental difference between the two designs and does not imply that NICUs should be built to minimum standards for either multiple-bed or single-room design. The amount of space allocated beyond the minimum should be equivalent for both designs based on a NICU’s functional needs. Good hospital design integrates functional requirements that often add space to the minimum standard for reasons such as the NICU’s level of acuity, teaching status, family-centered and developmental care philosophies, and adaptable flexibility. Using recent actual and short-term projections of NICU construction costs, $550 per GSF is a conservative estimate for most locales. 2013 RS Means Cost Data5 estimated that construction cost for a two- to three-storey hospital including fees averaged $313 to $391 per square foot depending on the type of materials. Additional costs would be expected for building an NICU because of intensive care unit design requirements and the lack of economies of scale in comparison with a two- to threestorey building. In our hypothetical NICU, each of the 32 SFR rooms at an additional 67.5 GSF results in an increase of 2160 GSF, with a total one-time cost of approximately $1,188 000 (2160 GSF x $550 per GSF). Ongoing operating cost in the predominantly SFR NICU entails a post-occupancy cost for increased heating and cooling of approximately $11 to $12 per GSF per year; for the additional 2160 GSF, this represents a total of $25 000 per year. Whereas most NICUs converting to SFR did not report an increase in personnel needs, some (usually large units) did require up to one additional FTE in support personnel but they did not modify the nurse to patient ratio (Domanico et al.6 and personal communications to JAS and RDW). For the purposes of this exercise we used an additional 1.0 FTE as an ongoing cost for a nonclinical support person, at a cost of approximately $50 000 per year. MEASURABLE ECONOMIC BENEFITS OF SFR DESIGN Two recent studies document economic value attributable to SFR design. Ortenstrand et al.7 demonstrated a reduced length of stay (LOS) of 10.1 days per admission in infants of o30-week gestation, all of it during the intensive care stage of the stay, whereas Stevens et al.8 showed a 15.5% reduction in overall direct costs. These two studies employed strong methodologies, with a randomized controlled trial utilized by Ortenstrand et al. and extensive data gathering to control for as many variables as possible in the Stevens et al. study, which documented real-world cost savings after the move to an SFR NICU. There are several additional potential benefits to SFR design identified in other studies that do not have a direct and easily calculable financial benefit; these will be summarized later but will not be included in the cost-benefit analysis. In our hypothetical medium-sized NICU, we make the following assumptions for the purpose of the financial calculations: (1) an average daily census of 25 babies; (2) annual operating costs of at least $10 million with the cost of critical care being $2500 per day;6 and (3) 80 admissions per year of infants of o 30-week gestation. In order to calculate the cost savings of SFR using the Ortenstrand study, we must make further assumptions about the 80 infants of o 30-week gestation: (1) babies who die shortly after birth would not be expected to benefit in this cost analysis; therefore, only survival beyond 7 days of age is considered, reducing the population expected to demonstrate reduced LOS to at least 60 infants per year; (2) As only 80% of our rooms are SFR, only 80% of those 60 infants or 48 infants might benefit from this Journal of Perinatology (2014), 811 – 815
design feature. We consider all of these estimates—annual operating costs for a unit this size, the daily cost for critical care and the number of surviving infants of o 30-week gestation—to be conservative estimates for the purpose of this exercise. Using these assumptions, the savings for a reduced LOS of 10 intensive care days per infant for 48 infants in our hypothetical NICU at $2500 per day would be $1 200 000 per year. If we subtract $75 000 for increased operating costs from that number, the annual cost savings of SFR design based on the Ortenstrand study would be $1 125 000, which should be realized year after year. Although the research of Stevens et al. was conducted in a different country (United States versus Sweden) used a different metric (total direct costs for all levels of NICU patients versus reduced LOS in a subgroup of higher acuity patients) and used a different study design (historical controls versus randomized controlled trial), the analysis of cost savings for SFR design produced very similar results. In a medium-sized NICU with annual operating costs of at least $10 millions, the 15.5% reduction in total direct costs seen in the Stevens study would produce a savings of $1 550 000. If that number is adjusted to account for only 80% of the infants being cared for in SFR rooms, the annual savings would be $1 240 000 or $1 165 000 after subtracting the $75 000 annual increased operating costs. In both models, we have used conservative estimates so as not to overstate the potential economic benefit of SFR design. Even so, it is apparent that the results of the two studies are very consistent and that using either methodology the cost of constructing SFR in the NICU is recouped after the first year, with substantial annual savings thereafter. (Table 1) OTHER BENEFITS AND HAZARDS There are multiple infant-, family- and staff-related benefits demonstrated through research and experience in NICUs (Table 2). Some, such as parent/baby skin-to-skin care, must be supported by the unit’s culture to achieve maximal benefit, and probably contribute to the desirable outcomes seen with SFR designs. Whereas positive outcomes have been established, research is needed to calibrate the impact of these benefits on operational and capital costs. For example, the observed reduction in the number of infections should be examined relative to the fiscal implications. More extensive summaries of research on benefits and hazards related to NICU design are described elsewhere.9,10 Other potential benefits of private rooms drawn from adult studies that might be applicable to infants include less patient movement and increased patient safety due to fewer handovers.11,12 Table 2 also lists potential hazards associated with SFRs for infants, families and staff. The potential negative outcomes should also be validated by parallel studies. RESEARCH AGENDA FOR THE NEONATAL COMMUNITY The following design features have not been directly evaluated in the NICU setting; therefore, no cost-benefit analysis can be undertaken. They are aspects of optimal design in any area of the hospital but perhaps are especially important in the NICU because of the presence of fragile infants in crucial stages of development who will be in this setting for weeks or months at a time. The authors recommend that the neonatal research community undertake studies on the cost and benefits of these topics. ●
Green NICUs. This aspect includes operational protocols that support sustainability as well as the selection of materials, the use of daylight and energy conservation fixtures.14 © 2014 Nature America, Inc.
Building better NICUs MM Shepley et al
813 Table 1.
Calculating the economic return on investment
Design scenarios
Additional construction costs
Additional construction costs for 32 private rooms in a 40-bed NICU
1 188 000
Annual operating Calculations cost savings
Scenario 1 – assume 10 day average length of stay (ALOS) reduction for babies o30 weeks gestation (Ortenstrand et al.7)
$1 125 000
Scenario 2—assume 15.5% direct operational cost reduction with private rooms (Stevens et al8)
$1 165 000
Table 2.
$1 188 000 Additional construction costs: 165 square feet for private room − 120 square feet for multiple-bed room = 45 additional square feet per private room × 1.5 conversion factor to gross square feet = 67.5 gross square feet per private room × $550 construction cost per square foot = $3 125 additional cost per private room × 32 private rooms = $1 188 000 total additional construction costs 80 Admissions per year o30 weeks gestation − 20 babies who die in the first week of life who would not be expected to benefit in this cost analysis = 60 admissions with 47 day survival × 80% who might be cared for in a private room (SFR) = 48 admissions o30 weeks gestation who live 47 days and are cared for in a private room × 10 days reduced ALOS per baby = 480 days reduced ALOS annually attributed to SFR × $2500 direct cost per day = $1 200 000 − 75 000 increased heating ventilation and air conditioning (HVAC) and personnel costs = $1 125 000 annual savings in reduced LOS $10 000 000 Annual operating costs for 40-bed NICU ×15.5% reduction in annual operating costs = $1 550 000 × 80% of patients using private rooms = $1 240 000 annual savings attributable to private rooms − 75 000 increased HVAC and personnel costs = $1 165 000 annual savings in direct operating costs
Non-quantifiable benefits and hazards of single-family rooms
Population
Outcome
Citation
Potential benefits of single-family rooms Infant Improved sleep time Reduced moderate to severe bronchopulmonary dysplasia (BPD) Reduced apnea Reduced bloodstream infections Reduced time on total parenteral nutrition (TPN) Shorter time to full enteric feeding Increased maternal breast milk Reduced rehospitalization rate Family Increased satisfaction Improved family-caregiver communication Longer but less frequent interactions between families Longer/more parent visits Staff Improved environment of care Improved quality of care Potential hazards of single-family rooms Infant Delayed language development Staff Reduced interaction among caregivers Increased walking distance
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Daylight/access to nature. Positive outcomes have been associated with daylight and access to nature leading to stress reduction.15 Central/decentralized areas for staff/families—in a unit with private rooms, a central ‘nursing station’ can be a substantial distance from some patients; therefore, decentralized areas immediately outside patient rooms may improve patient safety
© 2014 Nature America, Inc.
Stevens et al.8 Ortenstrand et al.7 Domanico et al.6 Walsh et al.;18 Domanico et al.6 Domanico et al.6 Stevens et al.8 Domanico et al.6 Erdeve et al.21 Carter et al.;22 Kotzer et al.;23 Shepley et al.;24 Stevens et al.8 Carter et al.22 Harris et al.13 Pineda et al.25 Harris et al.;13 Shepley et al.;24 Smith et al.;26 Milford et al.;27 Kotzer et al.;23 Stevens et al.28 Walsh et al.;18 Smith et al.;26 Milford et al.;27 Stevens et al.8 Pineda et al.29 Walsh et al.;18 Smith et al.,26 Stevens et al.28 Stevens et al.8
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and nursing satisfaction. It is likely though that there is still a role for a central area where nurses can collaborate and socialize when they do not need to be at the bedside, and similar areas should be provided for families. Staff health—there is extensive data in the occupational health literature establishing the value of ergonomics, access to nature, noise control, and so on for caregivers. There is also Journal of Perinatology (2014), 811 – 815
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an evolving interest in the hazards of shift work.16 Design features to support staff health might also include a nap or quiet room and an exercise area. Family space—Designing an NICU that is welcoming and supportive to families is likely to lead to increased family presence and participation in the care of their infant, and may contribute to improved outcomes. Family space near the infant’s bedside optimally includes a comfortable chair for skin-to-skin care, a bed, storage and a workspace. Elsewhere in the NICU, there should be a family lounge with nutrition, access to nature and additional amenities, including shower and laundry facilities. Infection control—As infection is a major determinant of neonatal outcomes, good NICU design requires access to proper sinks and waterless cleaners, as well as suitable HVAC systems.4 Whereas there is not yet clear evidence that SFR design can reduce caregiver transmission of hospital-acquired pathogens in NICUs, there are several plausible ways in which this might occur. Adult studies document that increased contact with roommates is a risk factor for infection.17 Breast milk storage/milk prep—A dedicated area for this purpose may reduce the risk of contamination and errors. Communication systems—wireless devices allow patient alarms to be transmitted electronically and provide nurses with the means to communicate quickly with their colleagues and support services. These are essential in SFR settings but can also be of value in any large patient care area. Acoustical control—multiple researchers have found noise reduction to be of benefit to patients and staff in NICUs.8,10,18,19
LONG-TERM POPULATION HEALTH IMPACTS Owing to rising costs and uneven health-care outcomes, there has been growing recognition that America’s health-care system must make a fundamental shift and move beyond the single aim of providing better health care for individual patients to a broader scope. According to Berwick et al.,20 three objectives must be achieved to improve the health-care system: reductions in costs, improvements in the health-care experience and enhancement of the health of the general population. Design of a NICU that provides short-term tangible positive outcomes, saves money and enhances the health of the babies, families and caregivers who spend time is consistent with this more comprehensive goal for health care. Preliminary evidence raises the possibility that the design of NICUs, by influencing the sensory environment of high-risk newborns during a crucial period of brain development, can lead to longlasting health implications for the baby, its family and its community. If a more nurturing environment in the NICU can improve developmental outcomes and reduce chronic illness, it is likely that costs for medical care, education and therapy will be reduced as well. CONCLUSIONS The incremental cost of constructing an NICU with mostly SFRs rather than placing all beds in a multiple-bed room design may be recouped after the first year of operation, with substantial operating savings each year thereafter. If additional observed benefits were quantifiable, the savings from SFR design could be much greater. There may be valid reasons for not placing some babies in an SFR NICU room; however, financial barriers are not among them. Whereas the details of construction costs and savings will vary throughout the country, the core conclusion is clear—building well-designed NICUs will save significant dollars year after year Journal of Perinatology (2014), 811 – 815
and will improve outcomes for patients, families and staff. We hope that all hospitals will aspire to provide optimal physical environments for their tiniest and most fragile patients. In today’s challenging economic environment and in facing severe pressures to reduce operating costs, they cannot afford to do otherwise. CONFLICT OF INTEREST The authors declare no conflict of interest.
REFERENCES 1 White R. Small comforts: evidence-based design comes to the NICU. HERD 2012; 5: 3. 2 Berry LL, Parker D, Coile RC, Hamilton DK, O Neill DD, Sadler BL. The business case for better buildings. Front Health Serv Manage 2004; 21: 3–24. 3 Sadler BL, Berry LL, Guenther R, Hamilton K, Hessler FAMerritt C et al. Fable hospital 2.0: The business case for building better health care facilities. Hastings Center Report 41(no.1)2011; 13–23. 4 White RD, Smith JA, Shepley MM. The Committee to Establish Recommended Standards for Newborn ICU Design. Recommended standards for newborn ICU design, eighth edition. J Perinatol 2013; 33: S2–16. 5 RS Means. 2014 RSMeans Building Construction Cost Data, 72nd Annual Edition 2013; 861–871. 6 Domanico R, Davis DK, Coleman F, Davis BO. Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. J Perinatol 2011; 31: 281–288. 7 Örtenstrand A, Westrup B, Broström EB, Sarman I, Åkerström S, Brune T et al. The Stockholm neonatal family centered care study: effects on length of stay and infant morbidity. Pediatrics 2010; 125: e278–e285. 8 Stevens DC, Helseth CC, Thompson PA., Pottala JV, Khan MA, Munson DP. A comprehensive comparison of open-bay and single-family-room neonatal intensive care units at Sanford Children’s Hospital. HERD 2012; 5: 23–40. 9 NACHRI & the Center for Health Care Design. Evidence for Innovation: Transforming Children’s Healthcare through the Physical Environment. National Association of Children’s Hospitals and Related Institutions: Alexandria, VA, 2008. 10 Shepley M. Design for Pediatric and Neonatal Critical Care. Routledge: London, 2014. 11 Hendrich AL, Fay J, Sorrells AK. Effects of acuity-adaptable rooms on flow of patients and delivery of care. Am J Crit Care 2004; 13: 35–45. 12 Brown KK, Gallant D. Impacting patient outcomes through design: acuity adaptable care/universal room design. Crit Care Nurs Q 2006; 29: 326–341. 13 Harris DD, Shepley MM, White RD, Kolberg KJS, Harrell JW. The impact of single family room design on patients and caregivers: executive summary. J Perinatol 2006; 26: S38–S48. 14 Marshall-Baker A. Human and environmental health: sustainable design for the NICU. J Perinatol 2006; 26: S31–S33. 15 Alimoglu MK, Donmez L. Daylight exposure and the other predictors of burnout among nurses in a university hospital. Int J Nurs Stud 2005; 42: 549–555. 16 Figueiro MGWhite RD. Health consequences of shift work and implications for structural design. J Perinatol 2013; 33(Suppl 1): S17–S23. 17 Hamel M, Zoutman D, O'Callaghan C. Exposure to hospital roommates as a risk factor for health care–associated infection. Am J Infect Control 2010; 38: 173–181. 18 Walsh WF, McCullough KL, White RD. Room for improvement: nurses' perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care 2006; 6: 261–270. 19 Van Enk RA, Steinberg F. Comparison of private room with multiple-bed ward neonatal intensive care unit. HERD 2010; 5: 52–63. 20 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs 2008; 27: 759–769. 21 Erdeve O, Arsan S, Yigit S, Armangil D, Atasay B, Korkmaz A. The impact of individual room on rehospitalization and health service utilization in preterms after discharge. Acta Paediatr 2008; 97: 1351–1357. 22 Carter BS, Carter A, Bennett S. Families' views upon experiencing change in the neonatal intensive care unit environment: from the ‘baby barn’ to the private room. J Perinatol 2008; 28: 827–829. 23 Kotzer AM, Zacharakis SK, Raynolds M, Buenning F. Evaluation of the built environment: staff and family satisfaction pre-and post-occupancy of the children's hospital. HERD 2011; 4: 60–78. 24 Shepley MM, Harris DD, White R. Multiple-bed room and single-family room neonatal intensive care units: caregiver satisfaction and stress. Environ Behav 2008; 40: 249–268.
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815 25 Pineda RG, Stransky KE, Rogers C, Duncan MH, Smith GC, Neil J et al. The singlepatient room in the NICU: maternal and family effects. J Perinatol 2011; 32: 545–551. 26 Smith TJ, Schoenbeck K, Clayton S. Staff perceptions of work quality of a neonatal intensive care unit before and after transition from an open bay to a private room design. Work 2009; 33: 211–227. 27 Milford CA, Zapalo BJ, Davis G. Transition to an individual-room NICU design: process and outcome measures. Neonatal Netw 2008; 27: 299–305.
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28 Stevens DC, Helseth CC, Khan MA, Munson DP, Smith TJ. Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design. J Perinatol 2010; 30: 352–358. 29 Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M, Kidokoro H et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr 2014; 164: 52–60.
Journal of Perinatology (2014), 811 – 815
COMMENTARY
The business case for building better neonatal intensive care units MM Shepley1, JA Smith2, BL Sadler3 and RD White4 Journal of Perinatology (2014) 34, 811–815; doi:10.1038/jp.2014.174
INTRODUCTION There is increasing evidence that the physical environment of the neonatal intensive care unit (NICU) has a tangible effect on the vulnerable infants who spend the first crucial weeks or months of their life there. While many aspects of NICU design have been evaluated, none is more tangible than the single-family room (SFR) concept because of its many potential benefits, possible hazards and its increased cost of construction. Data are now available to allow us to establish a cost-benefit analysis of SFR design in the NICU by assessing its impact on operating costs. This paper reviews the cost implications of SFR design and compares those with its quantifiable benefits. We also enumerate non-quantifiable benefits and hazards of SFR design and describe additional desirable, evidence-based design aspects for those who are considering new NICU construction or major renovation. IMPACT OF THE NICU ENVIRONMENT The design and construction of NICUs have some specialized attributes. NICUs have a unique and impactful microclimate and culture. As has been stated, ‘A case can be made that in no other part of the hospital is providing an optimal physical environment more important than the NICU because nowhere else will the adverse effects of noxious physical elements have more profound and long-lasting effects.’1 Studies conducted in NICUs now show clear correlations between incorporating evidence-based design (especially SFRs) and improved outcomes and lower operating costs. SFR require additional space that entails higher one-time construction costs and slightly increased heating, cooling and nonclinical support personnel costs. Therefore, it is important to ascertain whether the benefits of SFR design can justify these costs. THE HYPOTHETICAL NICU ADDRESSED IN THIS STUDY To illustrate the financial implications of current best practices in NICU design, we describe a hypothetical 40-bed NICU with 32 acuity adaptable private (SFR) and four semiprivate rooms, with each pair of semiprivate rooms convertible into a four-bed room. The supplies and amenities provided in each room are unspecified, as for the most part they are not unique to SFR or multiple-bed room design. We selected a medium-sized NICU; therefore, it will be suitable for comparison with a large number of units.
Why a mix of SFR and semiprivate beds? This design is intended to provide private rooms for any of the families that want them in all but the highest census conditions, including options for twins or higher-order multiples. At the same time, families that would prefer to be in a more open setting or babies whose families are not present and need a less isolated setting can be put into a shared room. UNDERSTANDING THE COST CHALLENGE Recent changes in the landscape are having an impact on healthcare systems. Physicians and hospitals are forming new alliances and payment for services is shifting from volume to value. The pressures for accountability with transparency of outcomes and reduced operating costs are increasing. Hospital administrators may react to the need to reduce costs by reducing capital expenditures, even though construction costs represent a small portion of the budget and the design of the physical environment of care has the potential to reduce operating costs. One issue that is often overlooked is the relationship between the design and construction of hospitals and their operating costs. Whereas some earlier studies demonstrated the impact of changes in the physical environment on staffing or patient outcomes, we were unable to find studies that compared the construction cost of changes in the environment of care with savings attributable to improved patient outcomes and staff costs until 2004, when a multidisciplinary team of two hospital CEOs, a professor of marketing, two architects and a health trend specialist described the Fable Hospital—an imaginary facility that included a selected series of design innovations that research had shown improved care, reduced harm and that patients, families and staff preferred.2 The results were compelling—the one-time incremental construction costs led to significant operating cost savings, and a powerful return on investment. The authors updated the analysis in 2011 with Fable Hospital 2.0 and the business case was even more compelling, noting a one-time incremental construction cost of $29 million produced annual savings of $10 million.3 Whereas some of the Fable Hospital concepts are applicable in the NICU, others are not; therefore, it is important to explore NICU-specific research in order to determine whether a similar argument can be made for cost-effectiveness of various design features. COST IMPLICATIONS OF SFR NICUs Two types of cost must be taken into consideration when analyzing the implications for our hypothetical NICU: one-time construction costs and ongoing operating costs. Regarding the one-time costs, our predominantly SFR NICU, when compared
1 Department of Design Environmental Analysis, Cornell University, Ithaca, NY, USA; 2Smith Hager Bajo Inc., Ashburn, VA, USA; 3Institute for Healthcare Improvement, La Jolla, CA, USA and 4Pediatrix Medical Group, Memorial Hospital, South Bend, IN, USA. Correspondence: Dr RD White, Pediatrix Medical Group, Memorial Hospital, 615 North Michigan Street, South Bend, IN 46601, USA. E-mail: [email protected] Received 5 May 2014; revised 14 August 2014; accepted 19 August 2014
Building better NICUs MM Shepley et al
812 with a multiple-bed room design, will require an additional 45 net square feet per bed (minimum 165 square feet clear in the SFR versus 120 square feet clear in the multiple-bed room), based on the Recommended Standards for Newborn ICU Design.4 This 45 net square feet per bed, or 67.5 gross square feet (GSF) using a 1.5 conversion factor, denotes the incremental difference between the two designs and does not imply that NICUs should be built to minimum standards for either multiple-bed or single-room design. The amount of space allocated beyond the minimum should be equivalent for both designs based on a NICU’s functional needs. Good hospital design integrates functional requirements that often add space to the minimum standard for reasons such as the NICU’s level of acuity, teaching status, family-centered and developmental care philosophies, and adaptable flexibility. Using recent actual and short-term projections of NICU construction costs, $550 per GSF is a conservative estimate for most locales. 2013 RS Means Cost Data5 estimated that construction cost for a two- to three-storey hospital including fees averaged $313 to $391 per square foot depending on the type of materials. Additional costs would be expected for building an NICU because of intensive care unit design requirements and the lack of economies of scale in comparison with a two- to threestorey building. In our hypothetical NICU, each of the 32 SFR rooms at an additional 67.5 GSF results in an increase of 2160 GSF, with a total one-time cost of approximately $1,188 000 (2160 GSF x $550 per GSF). Ongoing operating cost in the predominantly SFR NICU entails a post-occupancy cost for increased heating and cooling of approximately $11 to $12 per GSF per year; for the additional 2160 GSF, this represents a total of $25 000 per year. Whereas most NICUs converting to SFR did not report an increase in personnel needs, some (usually large units) did require up to one additional FTE in support personnel but they did not modify the nurse to patient ratio (Domanico et al.6 and personal communications to JAS and RDW). For the purposes of this exercise we used an additional 1.0 FTE as an ongoing cost for a nonclinical support person, at a cost of approximately $50 000 per year. MEASURABLE ECONOMIC BENEFITS OF SFR DESIGN Two recent studies document economic value attributable to SFR design. Ortenstrand et al.7 demonstrated a reduced length of stay (LOS) of 10.1 days per admission in infants of o30-week gestation, all of it during the intensive care stage of the stay, whereas Stevens et al.8 showed a 15.5% reduction in overall direct costs. These two studies employed strong methodologies, with a randomized controlled trial utilized by Ortenstrand et al. and extensive data gathering to control for as many variables as possible in the Stevens et al. study, which documented real-world cost savings after the move to an SFR NICU. There are several additional potential benefits to SFR design identified in other studies that do not have a direct and easily calculable financial benefit; these will be summarized later but will not be included in the cost-benefit analysis. In our hypothetical medium-sized NICU, we make the following assumptions for the purpose of the financial calculations: (1) an average daily census of 25 babies; (2) annual operating costs of at least $10 million with the cost of critical care being $2500 per day;6 and (3) 80 admissions per year of infants of o 30-week gestation. In order to calculate the cost savings of SFR using the Ortenstrand study, we must make further assumptions about the 80 infants of o 30-week gestation: (1) babies who die shortly after birth would not be expected to benefit in this cost analysis; therefore, only survival beyond 7 days of age is considered, reducing the population expected to demonstrate reduced LOS to at least 60 infants per year; (2) As only 80% of our rooms are SFR, only 80% of those 60 infants or 48 infants might benefit from this Journal of Perinatology (2014), 811 – 815
design feature. We consider all of these estimates—annual operating costs for a unit this size, the daily cost for critical care and the number of surviving infants of o 30-week gestation—to be conservative estimates for the purpose of this exercise. Using these assumptions, the savings for a reduced LOS of 10 intensive care days per infant for 48 infants in our hypothetical NICU at $2500 per day would be $1 200 000 per year. If we subtract $75 000 for increased operating costs from that number, the annual cost savings of SFR design based on the Ortenstrand study would be $1 125 000, which should be realized year after year. Although the research of Stevens et al. was conducted in a different country (United States versus Sweden) used a different metric (total direct costs for all levels of NICU patients versus reduced LOS in a subgroup of higher acuity patients) and used a different study design (historical controls versus randomized controlled trial), the analysis of cost savings for SFR design produced very similar results. In a medium-sized NICU with annual operating costs of at least $10 millions, the 15.5% reduction in total direct costs seen in the Stevens study would produce a savings of $1 550 000. If that number is adjusted to account for only 80% of the infants being cared for in SFR rooms, the annual savings would be $1 240 000 or $1 165 000 after subtracting the $75 000 annual increased operating costs. In both models, we have used conservative estimates so as not to overstate the potential economic benefit of SFR design. Even so, it is apparent that the results of the two studies are very consistent and that using either methodology the cost of constructing SFR in the NICU is recouped after the first year, with substantial annual savings thereafter. (Table 1) OTHER BENEFITS AND HAZARDS There are multiple infant-, family- and staff-related benefits demonstrated through research and experience in NICUs (Table 2). Some, such as parent/baby skin-to-skin care, must be supported by the unit’s culture to achieve maximal benefit, and probably contribute to the desirable outcomes seen with SFR designs. Whereas positive outcomes have been established, research is needed to calibrate the impact of these benefits on operational and capital costs. For example, the observed reduction in the number of infections should be examined relative to the fiscal implications. More extensive summaries of research on benefits and hazards related to NICU design are described elsewhere.9,10 Other potential benefits of private rooms drawn from adult studies that might be applicable to infants include less patient movement and increased patient safety due to fewer handovers.11,12 Table 2 also lists potential hazards associated with SFRs for infants, families and staff. The potential negative outcomes should also be validated by parallel studies. RESEARCH AGENDA FOR THE NEONATAL COMMUNITY The following design features have not been directly evaluated in the NICU setting; therefore, no cost-benefit analysis can be undertaken. They are aspects of optimal design in any area of the hospital but perhaps are especially important in the NICU because of the presence of fragile infants in crucial stages of development who will be in this setting for weeks or months at a time. The authors recommend that the neonatal research community undertake studies on the cost and benefits of these topics. ●
Green NICUs. This aspect includes operational protocols that support sustainability as well as the selection of materials, the use of daylight and energy conservation fixtures.14 © 2014 Nature America, Inc.
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813 Table 1.
Calculating the economic return on investment
Design scenarios
Additional construction costs
Additional construction costs for 32 private rooms in a 40-bed NICU
1 188 000
Annual operating Calculations cost savings
Scenario 1 – assume 10 day average length of stay (ALOS) reduction for babies o30 weeks gestation (Ortenstrand et al.7)
$1 125 000
Scenario 2—assume 15.5% direct operational cost reduction with private rooms (Stevens et al8)
$1 165 000
Table 2.
$1 188 000 Additional construction costs: 165 square feet for private room − 120 square feet for multiple-bed room = 45 additional square feet per private room × 1.5 conversion factor to gross square feet = 67.5 gross square feet per private room × $550 construction cost per square foot = $3 125 additional cost per private room × 32 private rooms = $1 188 000 total additional construction costs 80 Admissions per year o30 weeks gestation − 20 babies who die in the first week of life who would not be expected to benefit in this cost analysis = 60 admissions with 47 day survival × 80% who might be cared for in a private room (SFR) = 48 admissions o30 weeks gestation who live 47 days and are cared for in a private room × 10 days reduced ALOS per baby = 480 days reduced ALOS annually attributed to SFR × $2500 direct cost per day = $1 200 000 − 75 000 increased heating ventilation and air conditioning (HVAC) and personnel costs = $1 125 000 annual savings in reduced LOS $10 000 000 Annual operating costs for 40-bed NICU ×15.5% reduction in annual operating costs = $1 550 000 × 80% of patients using private rooms = $1 240 000 annual savings attributable to private rooms − 75 000 increased HVAC and personnel costs = $1 165 000 annual savings in direct operating costs
Non-quantifiable benefits and hazards of single-family rooms
Population
Outcome
Citation
Potential benefits of single-family rooms Infant Improved sleep time Reduced moderate to severe bronchopulmonary dysplasia (BPD) Reduced apnea Reduced bloodstream infections Reduced time on total parenteral nutrition (TPN) Shorter time to full enteric feeding Increased maternal breast milk Reduced rehospitalization rate Family Increased satisfaction Improved family-caregiver communication Longer but less frequent interactions between families Longer/more parent visits Staff Improved environment of care Improved quality of care Potential hazards of single-family rooms Infant Delayed language development Staff Reduced interaction among caregivers Increased walking distance
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Daylight/access to nature. Positive outcomes have been associated with daylight and access to nature leading to stress reduction.15 Central/decentralized areas for staff/families—in a unit with private rooms, a central ‘nursing station’ can be a substantial distance from some patients; therefore, decentralized areas immediately outside patient rooms may improve patient safety
© 2014 Nature America, Inc.
Stevens et al.8 Ortenstrand et al.7 Domanico et al.6 Walsh et al.;18 Domanico et al.6 Domanico et al.6 Stevens et al.8 Domanico et al.6 Erdeve et al.21 Carter et al.;22 Kotzer et al.;23 Shepley et al.;24 Stevens et al.8 Carter et al.22 Harris et al.13 Pineda et al.25 Harris et al.;13 Shepley et al.;24 Smith et al.;26 Milford et al.;27 Kotzer et al.;23 Stevens et al.28 Walsh et al.;18 Smith et al.;26 Milford et al.;27 Stevens et al.8 Pineda et al.29 Walsh et al.;18 Smith et al.,26 Stevens et al.28 Stevens et al.8
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and nursing satisfaction. It is likely though that there is still a role for a central area where nurses can collaborate and socialize when they do not need to be at the bedside, and similar areas should be provided for families. Staff health—there is extensive data in the occupational health literature establishing the value of ergonomics, access to nature, noise control, and so on for caregivers. There is also Journal of Perinatology (2014), 811 – 815
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an evolving interest in the hazards of shift work.16 Design features to support staff health might also include a nap or quiet room and an exercise area. Family space—Designing an NICU that is welcoming and supportive to families is likely to lead to increased family presence and participation in the care of their infant, and may contribute to improved outcomes. Family space near the infant’s bedside optimally includes a comfortable chair for skin-to-skin care, a bed, storage and a workspace. Elsewhere in the NICU, there should be a family lounge with nutrition, access to nature and additional amenities, including shower and laundry facilities. Infection control—As infection is a major determinant of neonatal outcomes, good NICU design requires access to proper sinks and waterless cleaners, as well as suitable HVAC systems.4 Whereas there is not yet clear evidence that SFR design can reduce caregiver transmission of hospital-acquired pathogens in NICUs, there are several plausible ways in which this might occur. Adult studies document that increased contact with roommates is a risk factor for infection.17 Breast milk storage/milk prep—A dedicated area for this purpose may reduce the risk of contamination and errors. Communication systems—wireless devices allow patient alarms to be transmitted electronically and provide nurses with the means to communicate quickly with their colleagues and support services. These are essential in SFR settings but can also be of value in any large patient care area. Acoustical control—multiple researchers have found noise reduction to be of benefit to patients and staff in NICUs.8,10,18,19
LONG-TERM POPULATION HEALTH IMPACTS Owing to rising costs and uneven health-care outcomes, there has been growing recognition that America’s health-care system must make a fundamental shift and move beyond the single aim of providing better health care for individual patients to a broader scope. According to Berwick et al.,20 three objectives must be achieved to improve the health-care system: reductions in costs, improvements in the health-care experience and enhancement of the health of the general population. Design of a NICU that provides short-term tangible positive outcomes, saves money and enhances the health of the babies, families and caregivers who spend time is consistent with this more comprehensive goal for health care. Preliminary evidence raises the possibility that the design of NICUs, by influencing the sensory environment of high-risk newborns during a crucial period of brain development, can lead to longlasting health implications for the baby, its family and its community. If a more nurturing environment in the NICU can improve developmental outcomes and reduce chronic illness, it is likely that costs for medical care, education and therapy will be reduced as well. CONCLUSIONS The incremental cost of constructing an NICU with mostly SFRs rather than placing all beds in a multiple-bed room design may be recouped after the first year of operation, with substantial operating savings each year thereafter. If additional observed benefits were quantifiable, the savings from SFR design could be much greater. There may be valid reasons for not placing some babies in an SFR NICU room; however, financial barriers are not among them. Whereas the details of construction costs and savings will vary throughout the country, the core conclusion is clear—building well-designed NICUs will save significant dollars year after year Journal of Perinatology (2014), 811 – 815
and will improve outcomes for patients, families and staff. We hope that all hospitals will aspire to provide optimal physical environments for their tiniest and most fragile patients. In today’s challenging economic environment and in facing severe pressures to reduce operating costs, they cannot afford to do otherwise. CONFLICT OF INTEREST The authors declare no conflict of interest.
REFERENCES 1 White R. Small comforts: evidence-based design comes to the NICU. HERD 2012; 5: 3. 2 Berry LL, Parker D, Coile RC, Hamilton DK, O Neill DD, Sadler BL. The business case for better buildings. Front Health Serv Manage 2004; 21: 3–24. 3 Sadler BL, Berry LL, Guenther R, Hamilton K, Hessler FAMerritt C et al. Fable hospital 2.0: The business case for building better health care facilities. Hastings Center Report 41(no.1)2011; 13–23. 4 White RD, Smith JA, Shepley MM. The Committee to Establish Recommended Standards for Newborn ICU Design. Recommended standards for newborn ICU design, eighth edition. J Perinatol 2013; 33: S2–16. 5 RS Means. 2014 RSMeans Building Construction Cost Data, 72nd Annual Edition 2013; 861–871. 6 Domanico R, Davis DK, Coleman F, Davis BO. Documenting the NICU design dilemma: comparative patient progress in open-ward and single family room units. J Perinatol 2011; 31: 281–288. 7 Örtenstrand A, Westrup B, Broström EB, Sarman I, Åkerström S, Brune T et al. The Stockholm neonatal family centered care study: effects on length of stay and infant morbidity. Pediatrics 2010; 125: e278–e285. 8 Stevens DC, Helseth CC, Thompson PA., Pottala JV, Khan MA, Munson DP. A comprehensive comparison of open-bay and single-family-room neonatal intensive care units at Sanford Children’s Hospital. HERD 2012; 5: 23–40. 9 NACHRI & the Center for Health Care Design. Evidence for Innovation: Transforming Children’s Healthcare through the Physical Environment. National Association of Children’s Hospitals and Related Institutions: Alexandria, VA, 2008. 10 Shepley M. Design for Pediatric and Neonatal Critical Care. Routledge: London, 2014. 11 Hendrich AL, Fay J, Sorrells AK. Effects of acuity-adaptable rooms on flow of patients and delivery of care. Am J Crit Care 2004; 13: 35–45. 12 Brown KK, Gallant D. Impacting patient outcomes through design: acuity adaptable care/universal room design. Crit Care Nurs Q 2006; 29: 326–341. 13 Harris DD, Shepley MM, White RD, Kolberg KJS, Harrell JW. The impact of single family room design on patients and caregivers: executive summary. J Perinatol 2006; 26: S38–S48. 14 Marshall-Baker A. Human and environmental health: sustainable design for the NICU. J Perinatol 2006; 26: S31–S33. 15 Alimoglu MK, Donmez L. Daylight exposure and the other predictors of burnout among nurses in a university hospital. Int J Nurs Stud 2005; 42: 549–555. 16 Figueiro MGWhite RD. Health consequences of shift work and implications for structural design. J Perinatol 2013; 33(Suppl 1): S17–S23. 17 Hamel M, Zoutman D, O'Callaghan C. Exposure to hospital roommates as a risk factor for health care–associated infection. Am J Infect Control 2010; 38: 173–181. 18 Walsh WF, McCullough KL, White RD. Room for improvement: nurses' perceptions of providing care in a single room newborn intensive care setting. Adv Neonatal Care 2006; 6: 261–270. 19 Van Enk RA, Steinberg F. Comparison of private room with multiple-bed ward neonatal intensive care unit. HERD 2010; 5: 52–63. 20 Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Affairs 2008; 27: 759–769. 21 Erdeve O, Arsan S, Yigit S, Armangil D, Atasay B, Korkmaz A. The impact of individual room on rehospitalization and health service utilization in preterms after discharge. Acta Paediatr 2008; 97: 1351–1357. 22 Carter BS, Carter A, Bennett S. Families' views upon experiencing change in the neonatal intensive care unit environment: from the ‘baby barn’ to the private room. J Perinatol 2008; 28: 827–829. 23 Kotzer AM, Zacharakis SK, Raynolds M, Buenning F. Evaluation of the built environment: staff and family satisfaction pre-and post-occupancy of the children's hospital. HERD 2011; 4: 60–78. 24 Shepley MM, Harris DD, White R. Multiple-bed room and single-family room neonatal intensive care units: caregiver satisfaction and stress. Environ Behav 2008; 40: 249–268.
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28 Stevens DC, Helseth CC, Khan MA, Munson DP, Smith TJ. Neonatal intensive care nursery staff perceive enhanced workplace quality with the single-family room design. J Perinatol 2010; 30: 352–358. 29 Pineda RG, Neil J, Dierker D, Smyser CD, Wallendorf M, Kidokoro H et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr 2014; 164: 52–60.
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