Recommended Standards For Newborn ICU Design

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Recommended standards for newborn ICU design
Article in Journal of Perinatology · October 2006

DOI: 10.1038/sj.jp.7211587
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Journal of Perinatology (2006) 26, S2–S18
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Recommended standards for newborn ICU design

RD White, Consensus Committee Chairman
Regional Newborn Program, Memorial Hospital, South Bend, IN, USA
Wilson-Orr. We also wish to acknowledge the professional advice of

This paper presents the work of the sixth Consensus Committee on Jack Evans, Brian Kubicki and Edward Logsdon on Standard 23,
Recommended Standards for Newborn intensive care unit (NICU) design. and to thank Christa Plott for her technical support in preparing
Recommended standards for NICU structure, lighting, noise control, this document.
infection control, family support and other design considerations are offered, These standards have now been disseminated to more than 25
along with supporting interpretations, references and a glossary of terms. countries and several hundred NICUs, architectural firms, state
Journal of Perinatology (2006) 26, S2–S18. doi:10.1038/sj.jp.7211587 planning agencies and medical professionals. Because upgrading
these standards is a continuing process, we are anxious to get your
feedback regarding any changes or additions you think are
Keywords: NICU design; family-centered care; developmental care; access to important for these standards so that we can incorporate these into
nature; sustainable design our discussions. In addition, we would like to know the impact
these standards are having on neonatal unit design and care.
Preface Please contact us to let us know how you are using these standards.
The recommended standards for newborn intensive care unit
(NICU) design that follow are the result of an ongoing effort by
many people. The participants in the 6th consensus conference
who developed these standards are listed in the pages that follow, Endorsements
but we wanted to also recognize our International Advisory The following organizations have reviewed and endorsed the
Committee who provided input during the consensus process, recommendations published in this report:
including Ken Appleman, Anne Augustin, Carlo Bellieni, Michael Council of International Neonatal Nurses, Edmund, OK, USA
Dunn, Linda Franck, Maureen Gilmore, Carl Kuschel, Jerry King, Institute for Family-Centered Care, Bethesda, MD, USA
Diane Paul, Neil Roy, Kaye Spence, Jane Sweeney and Lynne American Dietetic Association, Chicago, IL, USA
Participants
Joy Browne, PhD Robert Cicco, MD Douglas Erickson

Associate Professor Pediatric Neonatal Associates Consultant
Department of Pediatrics at the Children’s Hospital 2015 Swallow Hill Road American Society for Healthcare Engineering
University of Colorado Pittsburgh, PA 15220-1626 PO Box 1074 RS
School of Medicine Tel: +1 412 578 5858 St Croix
1056 E19th Avenue Fax: +1 412 578 1529 Virgin Islands 00821
Denver, CO 80218 E-mail: tririver@comcast.net Tel: +1 847 347 0627
Tel: +1 303 861 6546 Fax: +1 340 713 1771
Fax: +1 303 764 8092 E-mail: derick@bigplanet.com
E-mail: browne.joy@tchden.org
Stanley N Graven, MD Skip Gregory, NCARB James W. Harrell, FAIA, FACHA

Professor of Pediatrics Bureau Chief Director Healthcare Planning & Design
University of South Florida Agency for Health Care Administration GBBN Architects Inc.
13201 Bruce B. Downs Blvd. 2727 Mahan Drive 332 East 8th Street
Tampa, FL 33612-3805 Building #1 Cincinnati, OH 45202
Correspondence: Dr RD White, Regional Newborn Program, Memorial Hospital, 615 N.

Michigan Street, South Bend, IN 46601, USA.
E-mail: robert_white@pediatrix.com
Recommended standards for NICU design
RD White
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Tel: +1 813 974 6694 Suite 145 Tel: +1 513 241 8700
Fax: +1 813 974 5172 Tallahassee, FL 32308 Fax: +1 513 241 8873
E-mail: sgraven@health.usf.edu Tel: +1 850 922 6469 E-mail: jharrell@gbbn.com
Fax: +1 850 922 6483
E-mail: gregorys@ahca.myflorida.com
Carol B Jaeger, MS, PNP, CNNP, RNC Beverly H Johnson, President/CEO Carole Kenner, RNC, DNS, FAAN
Vice President Institute for Family-Centered Care Dean/Professor
Clinical Services-Neonatal 7900 Wisconsin Avenue, University of Oklahoma Health Sciences
Children Hospital Suite 405 Center
700 Children’s Drive Bethesda, MD 20814 College of Nursing
Columbus, OH 43204-2696 Tel: +1 301 652 0281 1100 North Stonewall Avenue
Tel: +1 614 722 6216 Fax: +1 301 652 0186 Oklahoma City, OK 73117
Fax: +1 614 722 4768 E-mails: http://www.familycenteredcare.org/ Tel: +1 405 271 2420
E-mail: jaegerC@chi.osu.edu bhjmom@earthlink.net Fax: +1 405 271 3443
E-mail: carole-kenner@ouhsc.edu
Kathleen JS Kolberg, PhD George A Little, MD Anna Marshall-Baker, PhD

Health Sciences Office Professor of Pediatrics & OB/GYN Interior Architecture
Office of the Dean of Science Dartmouth-Hitchcock Medical Center University of North Carolina
Jordan Hall of Science Lebanon, NH 03756 259 Stone Building
University of Notre Dame Tel: +1 603 650 5828 Greensboro, NC 27402-6170
Notre Dame, IN 46556 Fax: +1 603 650 5458 Tel: +1 336 256 0307
Tel: +1 574 631 2846 E-mail: george.a.little@dartmouth.edu Fax: +1 336 334 5049
Fax: +1 574 631 8883 E-mail: anna marshallbaker@uncg.edu
E-mail: kkolberg@nd.edu
Carol A McGlone, RN, CIC Gilbert L Martin, MD M Kathleen Philbin, RN, PhD
Epidemiology Nurse Specialist Director, NICU Coordinator, Nursing Research
Department of Epidemiology Pediatrix Medical Group The Children’s Hospital of Philadelphia
Children’s Hospital Citrus Valley Medical Center 34th Street and Civic Center Blvd.
700 Children’s Drive 1135 S. Sunset, Philadelphia, PA 19104-1000
Columbus, OH 43205-2696 Suite 406 Tel: +1 856 963 6708
Tel: +1 614 722 4992 West Covina, CA 91719 Fax: +1 856 342 8007
Fax: +1 614 722 6337 Tel: +1 626-813-3716 E-mail: philbin@email.chop.edu
E-mail: mcglonec@chi.osu.edu Fax: +1 626-813-3720
E-mail: gilmartin@pol.net
Mark S Rea, PhD Mardelle McCuskey Shepley Judith A Smith, MHA

Professor and Director Director Principal
Lighting Research Center Center for Health Systems & Design Smith Hager Bajo
Rensselaer Polytechnic Institute Interim Head 19779 Spyglass Hill Court
21 Union St Department of Architecture Ashburn, VA 20147
Troy, NY 12180 Texas A&M University Tel: +1 703 726 9770
Tel: +1 518 687 7100 College Station, TX 77843-3137 Fax: +1 703 726 9771
Fax: +1 518 687 7120 Tel: +1 979 845 7877 E-mail: jsmith@shbajo.com
E-mail: ream@rpi.edu Fax: +1 979 862 1571
E-mail: mshepley@archmail.tamu.edu
Walt Vernon, PEJD Robert D White, MD, Chairman

President Director
Mazzetti & Associates Consultants & Engineers Regional Newborn Program
530 Bush Street Memorial Hospital
Suit 300 615 N. Michigan Street
San Francisco, CA 94108 South Bend, IN 46601
Tel: +1 415 362 3266 Tel: +1 574 647 7351
Fax: +1 415 362 3267 Fax: +1 574 647 7248
E-mail: walterv@mazzetti.com E-mail: robert_white@pediatrix.com
Journal of Perinatology
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Contents
Introduction
Application of these standards
Substantive changes to 6th edition
The NICU
Standards:
1 Unit configuration
2 NICU location within the hospital
3 Minimum space, clearance and privacy requirements for the infant space
4 Electrical, gas supply and mechanical needs
5 Airborne infection isolation room(s)
6 Family entry and reception area
7 Handwashing stations
8 General support space
9 Staff support space
10 Family transition room(s)
11 Family support space
12 Support space for ancillary services
13 Administrative space
14 Ambient lighting in infant-care area
15 Procedure lighting in infant-care areas
16 Illumination of support areas
17 Daylighting
18 Floor surfaces
19 Wall surfaces
20 Furnishings
21 Ceiling finishes
22 Ambient temperature and ventilation
23 Acoustic environment
24 Safety/infant security
25 Access to nature and other positive distractions
Glossary
References
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Introduction Decision makers may find these standards do not go far enough,
The creation of formal planning guidelines for newborn intensive and resources may be available to push further towards the ideal.
care units (NICUs) first occurred when Toward Improving the
Outcome of Pregnancy was published in 1976.1 This landmark
publication, written by a multidisciplinary committee and Application of these standards
published by the March of Dimes, provided a rationale for planning Unless specified otherwise, the following recommendations apply to
and policy for regionalized perinatal care, as well as details of roles the newborn intensive care built environment, although most have
and facility design. Since then, the American Academy of Pediatrics broader application for the care of ill infants and their families.
(AAP) and American College of Obstetricians and Gynecologists Where the word shall is used, it is the consensus of the
(ACOG) have published several editions of their comprehensive committee participants that the standard is appropriate for future
Guidelines for Perinatal Care,2 and The American Institute NICU constructions. We recognize that it may not be reasonable
of Architects has likewise published several editions of their to apply these standards to existing NICUs or those undergoing
Guidelines for Construction of Hospital and Healthcare limited renovation.
Facilities.3 In 1993, Toward Improving the Outcome of We also recognize the need to avoid statements requiring
Pregnancy was revised.4 The second TIOP reviewed medical mandatory compliance, unless a clear scientific basis or consensus
and societal changes since the original document and formulated exists. The standards presented in this document address only those
new recommendations in recognition of these developments, areas where we believe such data or consensus are available.
particularly the ascendance of managed care. Individuals and organizations applying these standards should
The purpose of this committee is to complement the above understand that this document is not meant to be all
documents by providing health-care professionals, architects, encompassing. It is intended to provide guidance for the planning
interior designers, state health-care facility regulators and others team to apply the functional aspects of operations with sensitivity
involved in the planning of NICUs with a comprehensive set of to the needs of infants, family and staff. The program planning
standards based on clinical experience and an evolving scientific and design process should include research, evidence-based
database. recommendations and materials, with objective input of experts
With the support of Ross Products Division/Abbott Laboratories, in the field in addition to the internal interdisciplinary team.
a multidisciplinary team of physicians, nurses, state health The design should creatively reflect the vision and spirit of the
planning officials, consultants and architects reached consensus on infants, families and staff of the unit. The program and design
the first edition of these recommendations in January 1992. The process should include:
document was then sent to all members of the AAP section on
perinatal pediatrics to solicit their comments, and we also sought Review of articles on practice, teambuilding and planning
input from participants at the 1993 Parent Care Conference and Education in the change process
at an open, multidisciplinary conference on NICU design held in Visits to new and renovated units
Orlando in 1993. Subsequent editions of these recommended Vendor fairs
standards were then developed by consensus committees in 1993, Vision and goals
1996, 1999 and 2002, under the auspices of the Physical and Program planning
Developmental Environment of the High-Risk Infant Project. Space planning, including methods to visualize 3-D space
Various portions of these recommended standards have now Operations planning, including traffic patterns, functional
been adopted by the American Institute of Architects’ Guidelines,3 locations and relationship to ancillary services
the AAP/ACOG Guidelines2 and by standards documents in several Interior planning
other countries. In the future, we will continue to update these Surface materials selection
recommendations on a regular basis, incorporating new research Review of blueprints, specifications, other documents and
findings, experiences and suggestions. mock-ups
It is our hope that this document will continue to Building and construction
provide the basis for a consistent set of standards that can be used Post-construction verification and remediation.
by all states and endorsed by appropriate national organizations,
and that it will also continue to be useful in the international
arena. Substantive changes – 6th edition
Although many of these standards are minimums, the intent is In the four short years since the last edition of these recommended
to optimize design within the constraints of available resources, standards, remarkable changes have occurred in the ‘landscape’ of
and to facilitate excellent healthcare for the infant in a setting that NICU design. Private or single-family room designs, formerly a
supports the central role of the family and the needs of the staff. rarity, are now so common as to be the primary feature of most
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new construction projects in the US, driven by a dramatic increase New standard (25): access to nature and other positive
in evidence that such designs are practical, popular with families, distractions. A new standard has been written that requires
and justified by an increasing awareness of the impact of the opportunities for access to nature (broadly defined) for both staff
sensory environment on premature and ill newborns. Much of this and families.
evidence is cited in an issue of Clinics in Perinatology to which In several standards related to materials used (flooring, ceiling
many members of the consensus committee contributed.5 Secondly, finishes, etc.), we have specified that these be free of toxic
electronic medical records and wireless communication devices substances to the greatest extent possible, as well as recycled/
have become much more prevalent. Finally, the impetus for recyclable, and obtained from regional sources whenever possible.
sustainable design has strengthened, and is now viewed as both We made several other less substantive changes in the
practical and imperative. These changes and more are reflected in recommended standards which are not summarized here as they
this new edition of the recommended standards; we summarize the are not likely to have a significant impact on the design process,
most substantive changes below. but were part of our effort to be sure that the standards are as
useful and contemporary as possible.
Standard 12: support space for ancillary services. We added

language in the interpretation section that identified a specialized The NICU
feedings preparation area as a space that should be provided in the No consensus national standard of what constitutes an NICU exists.
NICU unless this function is performed elsewhere in the hospital, Some states have defined levels of care, whereas other states have
and specified certain features that should be included. informal or no systems for classification. The AAP has defined
NICU levels of care based primarily on availability of specialized
Standard 14: ambient lighting in infant-care areas. We equipment and staff2, but such units often encompass both
further described criteria for appropriate ambient light quality; in intensive and step-down or intermediate care.
addition to a color-rendering index (CRI) of 80 or greater, we also For the purposes of this document, newborn intensive care is
specified that this lighting must have a full-spectrum color index defined as care for medically unstable or critically ill newborns
(FSCI) of 55 or greater, and a gamut area (GA) of no less than requiring constant nursing, complicated surgical procedures,
65 and no more than 100. continual respiratory support or other intensive interventions.
Intermediate care includes care of ill infants requiring less
Standard 16: illumination of support areas constant nursing, but does not exclude respiratory support. When
We added a recommendation to consider addition of an area where an intensive care nursery is available, the intermediate nursery
staff can receive exposure to high-intensity light for at least 15 min serves as a ‘step down’ unit from the intensive care area. When
to ameliorate the effects of night-shift work and seasonal affective hospitals mix infants of varying acuity, requiring different levels of
disorder. care in the same area, intensive care design standards shall be
followed to provide maximum clinical flexibility.
Standard 18: floor surfaces. High-gloss flooring is prohibited.
Flooring is required to be free of toxins, selected from regional
sources when possible, and installed early enough to allow at least Standards
2 weeks for off gassing before occupancy. Some of these Standard 1: unit configuration
requirements also appear in the standards on other finishes in the The NICU design shall be driven by systematically developed
NICU, including walls, ceilings and casework. program goals and objectives that define the purpose of the unit,
service provision, space utilization, projected bed space demand,
staffing requirements and other basic information related to the
Standard 21: ceiling finishes. The noise reduction coefficient mission of the unit. Design strategies to achieve program goals and
(NRC) requirement has been increased from 0.9 to 0.95. objectives shall address the medical, developmental, educational,
emotional and social needs of infants, families and staff. The
Standard 23: acoustical environment. The acceptable design shall allow for flexibility and creativity to achieve the stated
maximum sound levels have been reduced to an Leq of 45, L10 of objectives.
50 and Lmax of 65. To support this requirement, the noise criterion The NICU shall be configured to individualize the care giving
for heating, ventilation and air conditioning (HVAC) and other environment and services for each infant and family.
mechanical equipment has been established as no greater than 35,
and extensive supportive language in the interpretation provides Interpretation. Program goals and objectives congruent with the
assistance to planning teams so that this requirement can be met. philosophy of care and the unit’s definition of quality should be
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developed by a planning team. This team should include, among space needed for parenting and family involvement in care, and
others, health-care professionals, families (whose primary privacy for families.
experience with the hospital is as consumers of health care), Infant space for intensive care infant beds situated in a single-
administrators and design professionals. infant room should be at least 150 net square feet (14 m2) per
The program goals and objectives should include a description infant to provide adequate space for equipment and families.
of those services necessary for the complete operation of the unit The width of aisles in multiple bedrooms should allow for easy
and address the potential need to expand services to accommodate movement of all equipment that might be brought to the infant’s
increased demand. bedside, as well as easy access for a maternal bed. The width of the
The specific approaches to achieve individualized environments corridors or aisles outside single-infant rooms or infant spaces
are addressed in subsequent sections. designed with permanent cubicle partitions should allow for
simultaneous passage of two such items as mandated by state
Standard 2: NICU location within the hospital and federal architectural and fire codes.
The NICU shall be a distinct area within the health-care facility, The need for privacy for infants and families should be
with controlled access and a controlled environment. addressed not only in design of each bed space, but also in the
The NICU shall be located within space designed for that overall unit design – for example, by minimizing traffic flow past
purpose. It shall provide effective circulation of staff, family and each bed.
equipment. Traffic to other services shall not pass through the unit.
The NICU shall be in close and controlled proximity to the area Standard 4: electrical, gas supply and mechanical needs
of the hospital where births occur. When obstetric and neonatal Mechanical requirements at each infant bed, such as electrical and
services must be on separate floors of the Hospital, an elevator gas outlets, shall be organized to ensure safety, easy access and
located adjacent to the units with priority call and controlled access maintenance.
by keyed operation shall be provided for service between the There shall be a minimum of 20 simultaneously accessible
birthing unit and the NICU. electrical outlets. The minimum number of simultaneously
Units receiving infants from other facilities shall have ready accessible gas outlets is:
access to the hospital’s transport-receiving area. Air 3,
Oxygen 3 and
Vacuum 3.
Interpretation. The purpose of this standard is to provide safe There shall be a mixture of emergency and normal power for
and efficient transport of infants while respecting their privacy. all electrical outlets per current National Fire Protection Association
Accordingly, the NICU should be a distinct, controlled area recommendations.6
immediately adjacent to other perinatal services, except in those There shall be provision at each bedside to allow data
local situations (e.g., free-standing children’s hospitals) where transmission to a remote location.
exceptions can be justified. Transport of infants within the hospital
should be possible without using public corridors.
Interpretation. A system that includes easily accessible raceways
Standard 3: minimum space, clearance and privacy for electrical conduit and gas piping, workspace and equipment
requirements for the infant space placement is recommended because it permits flexibility to modify
Each infant space shall contain a minimum of 120 ft2 (11.2 m2) of or upgrade mechanical features. All outlets should be positioned to
clear floor space, excluding handwashing stations, columns and maximize access and flexibility. Standard duplex electrical outlets
aisles (see Glossary). There shall be an aisle adjacent to each may not be suitable, as each outlet may not be simultaneously
infant space with a minimum width of 4 ft (1.2 m) in multiple accessible for oversized equipment plugs. The number of electrical,
bedrooms. When single-infant rooms or fixed cubicle partitions are gas and suction outlets specified is a minimum; access to more
utilized in the design, there shall be an adjacent aisle of not less may be necessary for critically ill infants. This area should also
than 8 ft (2.4 m) in clear and unobstructed width to permit passage include communication devices, supply storage and charting space,
of equipment and personnel. resulting in an efficient, organized and self-contained workstation
In multiple bedrooms, there shall be a minimum of 8 ft (2.4 m) around the infant.
between infant beds. Each infant space shall be designed to allow
privacy for the infant and family. Standard 5: airborne infection isolation room(s)
An airborne infection isolation room shall be available for NICU
infants. A hands-free handwashing station for hand hygiene and
Interpretation. These numbers are minimums and often need to areas for gowning and storage of clean and soiled materials shall
be increased to reflect the complexity of care rendered, bedside be provided near the entrance to the room. Ventilation systems for
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isolation rooms shall be engineered to have negative air pressure Standard 7: handwashing stations
with air 100% exhausted to the outside. Airborne infection isolation Where a single-infant room concept is used, a hands-free
room perimeter walls, ceilings and floors, including penetrations, handwashing station shall be provided within each infant room. In
shall be sealed tightly so that air does not infiltrate the a multiple bedroom, every infant bed shall be within 20 ft (6 m) of
environment from the outside or from other airspaces. a hands-free handwashing station. Handwashing stations shall be
Airborne infection isolation rooms shall have self-closing devices no closer than 3 ft (0.9 m) from an infant bed or clean supply
on all room exit doors. An emergency communication system and storage.
remote patient monitoring capability shall be provided within the Handwashing sinks shall be large enough to control splashing
airborne infection isolation room. and designed to avoid standing or retained water. Minimum
Airborne infection isolation rooms shall have observation dimensions for a handwashing sink are 24 inches wide 16
windows with internal blinds or switchable privacy (opaquing) inches front to back 10 inches deep (61 cm 41 cm 25 cm)
glass for privacy. Placement of windows and other structural items from the bottom of the sink to the top of its rim. Space for pictorial
shall allow for ease of operation and cleaning. handwashing instructions shall be provided above all sinks. There
Airborne infection isolation rooms shall have a permanently shall be no aerator on the faucet. Walls adjacent to handwashing
installed visual mechanism to constantly monitor the pressure sinks shall be constructed of non-porous material. Space shall also
status of the room when occupied by a patient with an airborne be provided for soap and towel dispensers and for appropriate trash
infectious disease. The mechanism shall continuously monitor the receptacles. Towel dispensers shall operate so that only the towel
direction of the airflow. itself need be touched in the process of dispensing, and constructed
in such a manner as to be consistent with Standard 23.
Handwashing facilities located at a level where they can be used
by people in wheelchairs shall be available in the NICU.
Interpretation. An airborne infection isolation room adequately Separate receptacles for biohazardous and non-biohazardous
designed to care for ill newborns should be available in any waste shall be available.
hospital with an NICU. In most cases, this is ideally situated within
the NICU, but in some circumstances, utilization of an airborne
infection isolation room elsewhere in the hospital (e.g., in a Interpretation. Sinks for handwashing should not be built into
pediatric intensive care unit) would be suitable. counters. Sink location, construction material and related
Airborne infection isolation rooms should have a minimum hardware (paper towel and soap dispensers) should be chosen with
of 150 ft2 of clear floor space, excluding the entry work area. durability, ease of operation, ease of cleaning and noise control in
mind. Non-absorbent wall material should be used around sinks to
At least one single-occupancy isolation room should be
available for any infant with a suspected airborne infection. A space prevent the growth of mold on cellulose material.
Local, state and federal regulatory agencies dictate what
within the NICU should also be available to safely cohort a group
of infants infected with or exposed to a common airborne healthcare-generated waste is biohazardous or non-biohazardous
pathogen. and appropriate disposal methods that are dependent on the type of
When not used for isolation, these rooms may be used for care waste. Depending upon the jurisdiction, biohazard signage may
of non-infectious infants and other clinical purposes. need to be affixed.
Standard 6: family entry and reception area Standard 8: general support space
Distinct facilities shall be provided for clean and soiled utilities,
The NICU shall have a clearly identified entrance and reception
area for families. Families shall have immediate and direct contact medical equipment storage and unit management services.
with staff when they arrive at this entrance and reception area. Clean utility/holding area(s): For storage of supplies frequently
used in the care of newborns.
Soiled utility/holding room: Essential for storing used and
contaminated material before its removal from the care area.
Interpretation. The design of this area should contribute to Unless used only as a holding room, this room shall contain a
positive first impressions for families and foster the concept that counter and a hands-free handwashing station separate from any
families are important members of their infant’s health-care team, utility sinks. The handwashing station shall have hot and cold
not visitors. Facilitating contact with staff will also enhance security running water that is turned on and off by hands-free controls,
for infants in the NICU. soap and paper towel dispensers, and a covered waste receptacle
This area should have lockable storage facilities for families’ with foot control.
personal belongings (unless provided elsewhere), and may also The ventilation system in the soiled utility/holding room shall
include a handwashing and gowning area. be engineered to have negative air pressure with air 100%
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exhausted to the outside. The soiled utility/holding room shall be without impinging on infant or family privacy. Infants’ charts,
situated to allow removal of soiled materials without passing computer terminals and hospital forms may be located in this
through the infant-care area. space.
A designated area for collection of recyclable materials used in Design of the NICU must anticipate use of electronic medical
the NICU shall be established.7 This area shall measure at least record devices so that their introduction does not require major
1 ft2 per patient bed and be located outside the patient-care area. disruption of the function of the unit or impinge on space designed
Charting/staff work areas: Provision for charting space at each for other purposes. Design considerations include ease of access for
bedside shall be provided. An additional separate area or desk staff, patient confidentiality, infection control and noise control,
for tasks such as compiling more detailed records, completing both with respect to that generated by the devices and by the traffic
requisitions and telephone communication shall be provided in around them.
an area acoustically separated from the infant and family areas. Laundry room: If laundry facilities for infant materials are
Dedicated space shall be allocated as necessary for electronic provided, a separate laundry room can serve the functions of
medical record keeping within infant-care areas. laundry and toy cleaning within the NICU. Infant clothing and the
cloth covers of positioning aids should be laundered on a regular
Interpretation. Storage areas: A three-zone storage system is schedule and as needed. In addition, toys utilized by infants or
desirable. The first storage area should be the central supply siblings are required to be cleaned on a regular schedule for each
department of the hospital. infant and between infants. Space for a commercial-grade washer
The second storage zone is the clean utility area described in the and dryer should be accommodated. The dryer should be vented
standard; it should be adjacent to and acoustically separated from through an outside wall. The placement of a commercial-grade
the infant-care area. Routinely used supplies such as diapers, dishwasher could promote the efficiency and effectiveness of the
formula, linen, cover gowns, charts and information booklets may aseptic cleaning process for toys.
be stored in this space. There should be at least 8 ft3 (0.22 m3) for
each infant for secondary storage of syringes, needles, intravenous Standard 9: staff support space
infusion sets and sterile trays. Space shall be provided within the NICU to meet the professional,
There should also be at least 18 ft2 (1.7 m2) of floor space personal and administrative needs of the staff. Rooms shall be sized
allocated for equipment storage per infant in intermediate and located to provide privacy and to satisfy their intended
care, and 30 ft2 (2.8 m2) for each infant bed in intensive care. function. Locker, lounge, private toilet facilities and on-call rooms
Total storage space may vary by unit size and storage system. are required at a minimum.
Easily accessible electrical outlets are desirable in this area
for recharging equipment.
The third storage zone is for items frequently used at the
infant’s bedside. Bedside cabinet storage should be at least 16 ft3 Interpretation. Support elements can be defined as those that
(0.45 m3) for each infant in the intermediate care area and 24 ft3 facilitate the provision of infant care and the well being of the staff;
(0.67 m3) for each infant in the intensive care area. Bedside they may account for at least one-third of the floor space of the
storage should be designed for quiet operation. entire unit.
Hospitals contribute significant waste each year to incinerators Staffing areas are defined as space limited to use by staff
and landfills. This creates not only an environmental hazard, but members to meet personal, professional and administrative needs.
also conditions that are harmful to human health. Providing a These areas include lockers, lounges, counseling, education and
designated collection area enables staff to separate and store for conference space, and on-call rooms that provide privacy and
collection waste such as paper, newsprint, corrugated cardboard, satisfy their intended function.
plastics, metals, batteries, fluorescent lamps and glass to either
facilitate existing hospital procedures for recycling or initiate a Standard 10: family transition room(s)
recycling system. Space within the designated collection area may Family-infant room(s) shall be provided within or immediately
also be used for collection of medical supplies for distribution to adjacent to the NICU that allow(s) families and infants extended
hospitals or clinics in need of such materials. private time together.
Charting/staff work areas: A clerical area should be located The room(s) shall have direct, private access to sink and toilet
near the entrance to the NICU so that personnel can supervise facilities, emergency call and telephone or intercom linkage with
traffic into the unit. In addition, there should be one or more staff the NICU staff, sleeping facilities for at least one parent, and
work areas, each serving 8 to 16 beds. These areas will allow sufficient space for the infant’s bed and equipment.
groups of 3 to 6 caregivers to congregate immediately adjacent to The room(s) can be used for other family support, educational,
the infant-care area for report, collaboration and socialization counseling or demonstration purposes when unoccupied.
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Interpretation. Access to family-infant room(s) encourages Interpretation. Ancillary services such as (but not necessarily
overnight stays by parents and the infant in the NICU. The room(s) limited to) respiratory therapy, laboratory, pharmacy, radiology,
should be sufficiently equipped and sized to accommodate the developmental therapy and specialized feeding preparation are
parents, with additional space for a physician, nurse, social worker, common in the NICU. Distance, size and access are important
chaplain or other individuals who may need to meet with the considerations when designing space for each of these functions.
parents and baby in private. Satellite facilities may be required to provide these services in
For security reasons, transition room(s) should be situated a timely manner.
within an area of controlled public access. Unless performed elsewhere in the hospital, a specialized
The number of electrical, medical gas and suction outlets feedings preparation area or room should be provided in the NICU,
specified will be dependent on the function(s) intended for this away from the bedside, to permit mixing of additives to breast milk
area. or formula. This area should be equipped with a hands-free
Sufficient family-infant rooms should be provided to allow those handwashing station, counter work space and storage areas for
families who wish to room in with their infants the opportunity to supplies, formula and both refrigerated and frozen breast milk.8
do so. The appropriate number of rooms will depend on each
hospital’s practice pattern, the number of single-infant rooms with Standard 13: administrative space
parent sleeping facilities, the availability of other rooms nearby, the Administrative space shall be provided in the NICU for activities
size of the region served and other variables. directly related to infant-care, family support or other activities
routinely performed within the NICU.
Standard 11: family support space
Space shall be provided in or immediately adjacent to the NICU for Interpretation. A wide range of personnel is assigned to the
the following functions: family lounge area, lockable storage, NICU, many of whom require office or administrative space. When
telephone(s) and toilet facilities. Separate, dedicated rooms shall planning the NICU, administrative space should be considered for
also be provided for lactation support and consultation in or each discipline that provides service to the unit on a daily basis and
immediately adjacent to the NICU. A family library or education needs a distinct area for carrying out their responsibilities, even
area shall be provided within the hospital. Access to the internet if that individual has additional office space elsewhere.
and educational materials shall be provided via a computer station
in the family lounge or at the infant’s bedside. Standard 14: ambient lighting in infant-care areas
Ambient lighting levels in infant spaces shall be adjustable through
a range of at least 10 to no more than 600 lux (approximately 1 to
60 foot candles), as measured at each bedside. Both natural and
Interpretation. Family lounge area: This should include electric light sources shall have controls that allow immediate
comfortable and moveable seating, as well as a play area stocked darkening of any bed position sufficient for transillumination when
with entertainment materials for children. A nourishment area necessary.
should also be considered, as well as external windows or skylights. Electric light sources shall have a CRI9 of no less than 80, a
Lockable storage: Secure storage for personal items should be FSCI10 of no less than 55, and a GA10 of no less than 65 and no
provided at each infant space. greater than 100. The sources shall avoid unnecessary ultraviolet
Lactation support: Comfortable seating, a handwashing sink or infrared radiation by the use of appropriate lamps, lens or
and a means of communication to the NICU should be provided. filters.11
Family education area: This should include publications, No direct view of the electric light source or sun shall be
audiovisual resources and internet access so that families can learn permitted in the infant space (as described in Standard 3): this
about health conditions, child development, parenting issues and does not exclude direct procedure lighting, as described in Standard
parent-to-parent support. This area might also include space and 15. Any lighting used outside the infant-care area shall be located
supplies to learn about and practice caregiving techniques. so as to avoid any infant’s direct line of sight to the fixture.
Telephones: Telephones should be provided that offer privacy Lighting fixtures shall be easily cleaned.
and that enable an individual to sit down while talking.
Consultation room: This should include comfortable seating Interpretation. Substantial flexibility in lighting levels is
and allow complete visual and acoustic privacy. required by this standard so that the disparate needs of infants at
various stages of development and at various times of day can be
Standard 12: support space for ancillary services accommodated, as well as the needs of caregivers. In very preterm
Distinct support space shall be provided for all clinical services that infants, there has been no demonstrable benefit to exposure to
are routinely performed in the NICU. light. After 28 weeks gestation, there is some evidence that diurnally
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cycled lighting has potential benefit to the infant.12 Caregivers bright light from these locations does not reach the infants’ eyes
benefit from moderate levels of ambient light in order to perform (see Standard 14).
tasks and maintain wakefulness. Consideration should be given to providing a space easily
Control of illumination should be accessible to staff and accessible to all staff that will provide an opportunity for exposure
families, and capable of adjustment across the recommended range to higher-intensity light levels for at least 15 min a shift in order to
of lighting levels. Use of multiple light switches to allow different ameliorate the effects of working at night and seasonal affective
levels of illumination is one method helpful in this regard, but can disorder.13 This space can be illuminated with white light to
pose serious difficulties when rapid darkening of the room is produce 300 to 500 lux at the eye, which is produced by
required to permit transillumination, so a master switch should approximately 1500 to 2500 lux at the work plane. If a blue local
also be provided. lighting system is used, the illumination should be from a
Perception of skin tones is critical in the NICU; light sources spectrally narrowband source – such as a blue LED – with a peak
that meet the CRI, FSCI and GA values identified above provide wavelength at or near 470 nm, and should produce at least 30 lux
accurate skin-tone recognition. Light sources should be as free as at the eye.14
possible of glare or veiling reflections. When the light sources to be
used are linear fluorescent lamps, these color criteria can be met Standard 17: daylighting
by using lamps that carry the color designation ‘RE80’. At least one source of daylight shall be visible from infant-care
areas, either from each infant room itself or from an adjacent
Standard 15: procedure lighting in infant care areas staff work area. When provided, external windows in infant-care
Separate procedure lighting shall be available to each infant bed. rooms shall be glazed with insulating glass to minimize heat gain
The luminaire shall be capable of providing no less than 2000 lux or loss, and shall be situated at least 2 ft (61 cm) away from any
at the plane of the infant bed, and must be framed so that no more part of an infant’s bed to minimize radiant heat loss. All external
than 2% of the light output of the luminaire extends beyond its windows shall be equipped with shading devices that are neutral
illumination field. This lighting shall be adjustable so that lighting color or opaque to minimize color distortion from transmitted
at less than maximal levels can be provided whenever possible. light.
Interpretation. Temporary increases in illumination necessary to

evaluate a baby or to perform a procedure should be possible Interpretation. Windows provide an important psychological
without increasing lighting levels for other babies in the same benefit to staff and families in the NICU.9,15 Properly designed
room. daylighting is the most desirable illumination for nearly all
As intense light may be unpleasant and harmful to the caregiving tasks, including charting and evaluation of infant skin
developing retina, every effort should be made to prevent direct tone.
light from reaching the infant’s eyes. Procedure lights with However, placing infants too close to external windows can
adjustable intensity, field size and direction will help protect the cause serious problems with radiant heat loss or gain and glare,
infant’s eyes from direct exposure and provide the best visual therefore provision of windows in the NICU requires careful
support to staff. planning and design.
Shading devices should be easily controlled to allow flexibility at
Standard 16: illumination of support areas various times of day, and should either be contained within the
Illumination of support areas within the NICU, including the window or easily cleanable. These should be designed to avoid
charting areas, medication preparation area, the reception desk direct sunlight from striking the infant, IV fluids or monitor
and handwashing areas, shall conform to IESNA specifications.11 screens.
Interpretation. Illumination should be adequate in areas of the Standard 18: floor surfaces
NICU where staff perform important or critical tasks; the IESNA Floor surfaces shall be easily cleanable and shall minimize the
specifications in these areas are similar to but somewhat more growth of microorganisms.
specific than the general guidelines recommended by AAP/ACOG.2 Flooring material with a reflectance of no greater than 40%9
In locations where these functions overlap with infant-care and a gloss value of no greater than 30 gloss units shall be
areas (e.g., close proximity of the staff charting area to infant used,16,17 to minimize the possibility that glare reflected from a
beds), the design should nevertheless permit separate light sources bright procedure or work-area light will impinge on the eyes of
with independent controls so that the very different needs of infants or caregivers.
sleeping infants and working staff can be accommodated to the Floors shall be highly durable to withstand frequent cleaning
greatest possible extent. Care must be taken, however, to insure that and heavy traffic.
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Flooring materials shall be free of substances known to be Surfaces shall be free of substances known to be teratogenic,
teratogenic, mutagenic, carcinogenic or otherwise harmful to mutagenic, carcinogenic or otherwise harmful to human health.
human health.
Interpretation. As with floors, the ease of cleaning, durability
and acoustical properties of wall surfaces must be considered.
Interpretation. Although ease of cleaning and durability of NICU
Although commonly used, vinyl wall covering contains PVC and
surfaces are of primary importance, consideration should also be
will degrade indoor air quality, and thus should be avoided. VOCs
given to their glossiness (the mirror-like reflectivity of a surface),18
and PBTs such as cadmium often are found in paints, wall-
their acoustical properties and the density of the materials used.
coverings, acoustical wall panels and wood paneling systems and
Reduced glossiness will reduce the risks from bright-reflected glare;
also should be avoided. Specify low- or no-VOC paints and coatings.
acoustic and density properties will directly affect noise and
comfort. Standard 20: furnishings
Materials should permit cleaning without the use of chemicals Built-in and freestanding furnishings such as cabinets and carts,
that may be hazardous, as it may not be possible to vacate the especially those in the infant-care areas, shall be easily cleanable
space during cleaning. with the fewest possible seams in the integral construction. Exposed
Transition surfaces that do not obstruct mobility, are durable, surface seams shall be sealed. Furnishings shall be of durable
and minimize noise and jarring of equipment should be provided construction to withstand impact by movable equipment without
at the intersection of different flooring materials. significant damage.
Materials suitable to these criteria include resilient sheet Furnishings and materials shall be free of substances known to
flooring (medical grade rubber or linoleum) and carpeting with an be teratogenic, mutagenic, carcinogenic or otherwise harmful to
impermeable backing, heat- or chemically welded seams and human health.
antimicrobial and antistatic properties. Carpeting has been shown
to be an acceptable floor covering in the hospital19 and the NICU20
and has obvious aesthetic and noise reduction (NR) appeal, but it Interpretation. Countertops should have the fewest possible
is not suitable in all areas (e.g., around sinks or in isolation or seams. Edges exposed to impact should be ‘soft’ (i.e., bull-nosed).
soiling utility/holding areas). Small floor tiles (e.g., 12 inch Corners created at wall or backsplash intersections should be coved.
squares) have myriad seams and areas of non-adherence to the Intersections with sinks or other devices should be sealed or made
sub-floor. These harbor dirt and fluids are a potential source of integral with the top. Casework construction should not chip or
bacterial and fungal growth. flake when struck by objects in the normal routine of infant care,
Much is known21 regarding the effects of chemicals such as and should be of sufficient moisture resistance to prevent
mercury on human health and development. Additional efforts deterioration.
should be made to exclude persistent, bioaccumulative toxic Furnishings in the NICU are often composite pieces, made of
chemicals (PBTs) such as polyvinyl chloride (PVC) from health- various parts and layers of materials that are assembled with glue
care environments. PVC or vinyl is common in flooring materials or adhesives. Materials and substances typically used in these
including sheet goods, tiles and carpet. The production of PVC furnishings often contain VOCs such as formaldehyde, which is
generates dioxin, a potent carcinogen and fumes emitted from frequently found in pressed wood products including plywood and
vinyl degrade indoor air quality. Dioxin releases are not associated particle board. Vinyl-based laminates, which often are applied to
with materials such as polyolefin, rubber (latex) or linoleum. the surface of pressed wood products, also contain VOCs such as
Volatile organic compounds (VOCs) such as formaldehyde and PVC. Specify low- or no-VOC materials, including urea-
chlorinated compounds such as neoprene should also be avoided formaldehyde-free adhesives, for all furnishings in the NICU.
when selecting adhesives or sealants for floor coverings. Specify Specifying furnishings and materials from regional sources
low- or no-VOC and non-toxic and non-carcinogenic materials. (within a 300 to 500 mile radius) not only provides support for the
Flooring-containing natural rubber (latex) should be certified local community, but also reduces the amounts of fossil fuels
non-allergenic by the manufacturer. necessary for transport.
Infants should not be moved into an area of newly installed
flooring for a minimum of 2 weeks to permit complete off gassing Standard 21: ceiling finishes
of adhesives and flooring materials. Ceilings shall be easily cleanable and constructed in a manner to
prohibit the passage of particles from the cavity above the ceiling
Standard 19: wall surfaces plane into the clinical environment.
Wall surfaces shall be easily cleanable and provide protection at The ceiling construction shall not be friable and shall have a
points where contact with movable equipment is likely to occur. NRC22 of at least 0.95.
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Finishes shall be free of substances known to be teratogenic, 50 dB, both A-weighted, slow response. Transient sounds or Lmax
mutagenic, carcinogenic or otherwise harmful to human health. shall not exceed 65 dB, A-weighted, slow response.
To achieve these conditions, the noise criteria (NC) for the HVAC
Interpretation. As sound abatement is a high priority in the systems, other mechanical systems including plumbing, and
NICU, acoustical ceiling systems are desirable, but must be selected equipment in each of these areas shall be a maximum of NC 35.
and designed carefully to meet this standard. Ceiling surface materials in infant care, family and staff work areas
VOCs and PBTs such as cadmium are often found in paints and and the areas opening onto them shall have a NRC of at least 0.95
ceiling tiles and should be avoided. Specify low- or no-VOC paints (Standard 21). Announcing systems shall have adjustable volume
and coatings. controls for the speakers in each room and for each microphone
that sends signal through the system. Doors and operable windows
Standard 22: ambient temperature and ventilation to infant-care areas, adult rest and sleep rooms, and staff work and
The NICU shall be designed to provide an air temperature of 72 to break areas shall be designed to meet NC 35 requirements and
781F (22 to 261C) and a relative humidity of 30 to 60%,23 while shall have acoustic seals.
avoiding condensation on wall and window surfaces.
A minimum of six air changes/hour is required, with a Interpretation. The acoustic environment is a function of both
minimum of two changes being outside air. the facility (e.g., mechanical systems of the building, the intrusion
The ventilation pattern shall inhibit particulate matter from of exterior sounds, the sound containment afforded by doors and
moving freely in the space, and intake and exhaust vents shall be walls and the sound absorption afforded by surface finishes) and
situated to minimize drafts on or near the infant beds. Ventilation operations (e.g., the activities of people and function of equipment
air delivered to the NICU shall be filtered with at least the efficiency and furnishings).
specified in the AIA Guidelines.3 Filters shall be located outside the The acoustic conditions of the NICU should favor speech
infant-care area so that they can be changed easily and safely. intelligibility, normal or relaxed vocal effort, acoustic privacy for
Fresh air intake shall be located at least 25 ft (7.6 m) from staff and parents, and physiologic stability, uninterrupted sleep and
exhaust outlets of ventilating systems, combustion equipment freedom from acoustic distraction for infants and adults.24 Such
stacks, medical/surgical vacuum systems, plumbing vents, or areas favorable conditions encompass more than the absence of noise
that may collect vehicular exhausts or other noxious fumes. and require specific planning for their achievement. Speech
Prevailing winds or proximity to other structures may require intelligibility ratings in infant areas, parent areas and staff work
greater clearance. areas should be ‘good’ to ‘excellent’ as defined by the International
Organization for Standardization ISO 9921:2003. Speech
Interpretation. Heat sources near the exterior wall, if applicable, intelligibility for non-native but fluent speakers and listeners of a
should be considered to ameliorate the ‘cold wall’ condition, which second language requires a 4 to 5 dB improvement in signal-to-
in turn can be a source of convection drafts. This application of noise ratio for similar intelligibility with native speakers. The Leq,
heat may also alleviate the conditions leading to condensation on L10 and Lmax limits will safeguard this intelligibility and also
these walls. protect infant sleep.25
The airflow pattern should be at low velocity and designed to The permissible NC of an hourly Leq of 45 dB, A-weighted,
minimize drafts, noise levels and airborne particulate matter. A slow response is more likely to be met in the fully operational
HEPA filtration system may provide improved infection control for NICU if mechanical systems and equipment are rated NC 30 or
immunocompromised patients. less. NC 30 translates to approximately 40 dB of facility noise. An
Because a regular maintenance program is necessary to assure additional 5 dB of operational noise above this background will
that systems continue to function as designed after occupancy, result in an Leq of about 45 dB. Limiting operational noise to only
NICU design should attempt to maximize the ease of maintenance 5 dB above the background will require conscientious human
while minimizing its cost. effort.
Acoustically absorptive surfaces reduce reverberation and,
Standard 23: acoustic environment therefore, sound levels at a distance from the sound source. When
Infant bed areas (including airborne infection isolation areas), possible, one surface of each opposing pair of walls should be
staff work areas, family areas, and staff lounge and sleeping areas covered with sound absorptive surface materials with an NRC of at
and the spaces opening onto them shall be designed to produce least 0.65. Where this is not possible, the upper portions of all four
minimal background noise and to contain and absorb much of the walls (above areas likely to be damaged by the movement of
transient noise that arises within them. The combination of equipment) should be covered with such material. Glass should be
continuous background sound and transient sound in any of these limited to the area actually required for visualization because it is
areas shall not exceed an hourly Leq of 45 dB and an hourly L10 of highly reflective. Whereas a variety of flooring will limit impact
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noise somewhat, specialized carpeting offers the most protection. Mechanical area NR 60-65
Carpeting used in infant areas must have impermeable backing, Electrical area NR 50-55
monolithic or chemically- or heat-welded seams, and be tolerant of
(adapted from Evans JB, Philbin MK. Facility and operations
heavy cleaning including the use of bleach.
planning for quiet hospital nurseries. J Perinatol 2000; 20 (8):
Fire alarms in the infant area should be restricted to flashing
S105–12. Revised and reprinted with permission of Jack Evans, PE,
lights without an audible signal. The audible alarm level in other
The Journal of Perinatology, and Nature Publishing Company).
occupied areas must be adjustable. Telephones audible from the
Sound transmission from the exterior of the building should
infant area should have adjustable announcing signals.
meet the NC 30 criteria inside all spaces identified in the standard.
The type of water supply and faucets in infant areas should be
Acoustical engineering: It is advisable to enlist the services of an
selected so as to minimize noise, and should provide instant warm
acoustical engineer from the onset of the project through post-
water in order to minimize time ‘on’.
construction validation. This specialty service is usually not covered
Noise-generating activities and equipment (e.g., vacuum tubes,
by architectural fees and can assist in program and design
refrigerators, ice machines, printers, linen and supply carts,
development, design of mechanical systems, specification of
medication and supply dispensing machines, conference areas,
equipment and building construction, and test and balance
clerk’s areas, multiple-person work stations and travel paths not
validation.
essential to infant care) should be acoustically isolated from the
infant area. Permanent equipment such as that listed above is Standard 24: safety/infant security
included in the NC 35 limit, if it is installed within one of the areas The NICU shall be designed as part of an overall security program
specified in the standard.Post-construction validation of to protect the physical safety of infants, families and staff in the
construction specifications: Noise and vibration measurement, NICU. The NICU shall be designed to minimize the risk of infant
reporting and remediation should be included in the test and abduction.
balance specifications for construction of the building and for
mechanical systems. Interpretation. Because facility design significantly affects
Criteria for transmission loss (TL) between adjacent spaces: with security, it should be a priority in the planning for renovation of an
space at a premium, many incompatible adjacencies are possible existing unit or a new unit. Care should be taken to limit the
in NICU designs (e.g., break area, meeting room or mechanical number of exits and entrances to the unit.
room sharing a wall with a nursery or sleep room). Specialized Control station(s) should be located within close proximity and
wall and floor/ceiling treatments will help to obtain the desired direct visibility of the entrance to the infant-care area. The control
sound levels in these non-optimal conditions. point should be situated so that all visitors must walk past the
The criteria below are for sound TL or attenuation through station to enter the unit. The design should provide for maximum
horizontal barriers (e.g., walls, doors and windows) and vertical visibility of the nursery from the workroom or charting area.
barriers (e.g., between floors). The sound transmission class (STC) However, security considerations should not adversely affect the
rating spans speech frequencies and is relevant for separation of quality of spaces for families in the NICU. The need for security
spaces with conversational and other occupant-generated noise. should be balanced with the needs for comfort and privacy of
The NR rating, which covers a wider frequency span, is more families and their infants.
relevant for mechanical noise dominated by low frequencies. The Technological devices can be utilized in flexible and innovative
recommended criteria for TL below apply to barriers between manners within the design of the multiple-bed or single-infant
adjacent spaces and infant areas or adult rest or sleep rooms. room NICU schematic. Such technology, when utilized in
conjunction with the thoughtful planning of the traffic patterns
Adjacent spaces to/from and within the NICU space, support areas and family
Pedestrian-only corridor space, can facilitate a safe, yet open family friendly area.
STC 45
Equipment corridor STC 55 Standard 25: access to nature and other positive distractions
Infant area STC 40 When possible, views of nature shall be provided in at least one
Reception STC 55 space that is accessible to all families and one space that is
Meeting room with amplified sound accessible to all staff. Other forms of positive distraction shall be
STC 55 provided for families in infant and family spaces, and for staff in
Staff work area STC 55 staff spaces.
Administrative office, conference
STC 45 Interpretation. Culturally appropriate positive distractions
Non-related area STC 50 provide important psychological benefits to staff and families in the
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NICU. Looking out of a window, viewing psychologically supportive vestibules, toilet rooms, closets, lockers, wardrobes, fixed-based
art or taking a stroll in a garden may help to reduce stress or cabinets and wall-hung counters).
increase productivity.26 When possible, windows should have views
of nature environments. These environments might consist of trees, Color-rendering index27. A measure of the degree of color shift
plants, human and animal activity, gardens and landscapes. In that objects undergo when illuminated by a lamp, compared with
urban settings, appropriate nature elements might include planters those same objects when illuminated by a reference source of
or water features. When such views are not possible, artwork with comparable correlated color temperature. A CRI of 100 represents
nature images or other nature simulations (e.g., video and the maximum value. A lower CRI value indicates that some colors
artificial representations) should be provided throughout the unit. may appear unnatural when illuminated by the lamp.
Family and staff lounge spaces are ideal locations for views of Incandescent lamps have a CRI above 95. The cool white
nature and other positive distractions. fluorescent lamp has a CRI of 62; fluorescent lamps containing
Provision should be made for direct access to nature and other rare-earth phosphors are available with CRI values of 80 and
positive distractions within the hospital complex. These nature above.
environments may consist of outdoor spaces such as gardens or
walking paths or indoor spaces such as greenhouses and atria. Cubicle. Space enclosed on multiple sides with full height or
Amenities within the nature environment might include water partial partitions with at least one opening without a door.
features, plant and animal life and solitary and group seating.
Other positive distractions might include fitness centers and access
to music. External windows. Windows located on the exterior skin of a
building, looking outside the building or into courtyards.
Glossary Full-spectrum color index. A mathematical transformation of

full-spectrum index into a zero to 100 scale, where the resulting
Ambient lighting. The continuous ‘background’ illumination for values are directly comparable to CRI. An equal energy spectrum is
a specified area. defined as having an FSCI value of 100, a ‘standard warm white’
fluorescent lamp has an FSCI value of 50 and a monochromatic
Ambient temperature. Thermal measurement of the generalized light source (e.g., low pressure sodium) has an FSCI value of 0.
space around the neonate. Usually refers to room temperature.
Gamut area. A measure of color rendering based upon volume
Backsplash. A vertical, protective surface located behind a sink or in color space. It is the range of colors achievable on a given color
counter. reproduction medium (or present in an image on that medium)
under a given set of viewing conditions.
Biohazardous. Refers to human tissue, cells, body fluids or
culture materials that may contain infectious or other hazardous Hands-free washing station. An area that provides a
materials. freestanding sink, meets all handwashing station requirements
described in Standard 7, such as space for cleaning agents and
Brominated flame retardants. Bromide compounds that stop drying capability, and in addition, is operable without the use of
or diminish fire. Brominated flame retardants (BRFs) such as hands.
polybrominated diphenyl ethers are used in many products
including furniture, textiles and electronic equipment to reduce the Infant bed. Furniture or equipment used to hold an infant.
risk of fire. When heated, BRFs produce dioxins and furans (VOCs).
BRFS are PBTs and suspected endocrine disruptors. Infant room. Contains the infant space.
Cabinetry. Box-like furniture constructed for storage; could Infant space. The area surrounding the infant bed and
consist of drawers, counters or shelves. containing all support equipment and furniture.
Casework. The components that make up a cabinet. Luminaire. A complete lighting unit consisting of a lamp or
lamps and the parts designed to distribute the light, to position and
Clear floor space. The space available for functional use that protect the lamp(s), and to connect the lamp(s) to the power
excludes other defined spaces (e.g., plumbing fixtures, anterooms, supply. (Also referred to as fixture.)
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Non-public service corridors. Designated traffic pathways that Positive distractions. Sensory experiences which enable an
are restricted to staff use for staff access and patient or material individual to focus on psychologically supportive and compelling
transport. stimuli. These stimuli are intended to divert attention from
negative experiences. Positive distractions should be culturally- and
Parent–infant rooms. Separate rooms in or adjacent to the age-appropriate and could range from nature and art to video
NICU designed for parents to room-in with their infants during games and music.
some portion of the NICU stay. These rooms include infant-care
space, parent-sleeping space and facilities as described in Room. Space enclosed with full-height partitions or walls
Standard 10. equipped with a door.
Perfluorochemicals. Perfluorochemicals (PFCs) are a family of Single-family rooms. Rooms within the NICU analogous to
man-made chemicals used to make products that resist heat, oil, private patient rooms elsewhere in the hospital that are designed to
stains, grease and water. Common uses include nonstick cookware, provide for the care of one or more infants from a single family.
stain-resistant carpets and fabrics, as components of fire-fighting These rooms have the usual provisions for infant care as well as
foam, and other industrial applications. Two chemicals in the PFC space for family members to stay at the bedside or in the room for
group are perfluorooctane sulfonate (PFOS; C8F17SO3) and extended periods of time. A sleeping area for family members is
perfluorooctanoic acid (PFOA; C8F15O2H). The chemical structures often provided within these rooms, but may also be situated
of PFOS and PFOA make them extremely resistant to breakdown in immediately adjacent to them, or elsewhere in the NICU or
the environment and they are considered to be PBTs and VOCs. hospital.
Volatile organic compounds. VOCs are the primary source of

Persistent bioaccumulative toxins. PBTs are substances that indoor air pollution and are measured as organic gases. VOCs such
transfer easily among air, water and land, and are stored in fatty as formaldehyde and urethane are released from products during
tissue. As a consequence, they accumulate or magnify as you go up use and are often found in pressed wood products and household
the food chain, and, thus, also span generations. Effects to human products including paint and wood preservatives. Importantly, the
health range from eye, nose and throat irritation to organ and EPA reports that levels of VOCs average 2 to 5 times higher in
nervous system damage to cancer. indoor environments than outdoor. Health effects are directly
related to the amount of exposure, but range from allergies to
Phthalate plasticizers. Phthalates currently are not listed as nervous system disorders to cancer.
PBTs because there is some evidence that fish and mammals can Acoustic Terms (Disclaimer: The following terms are defined
break these down within 24 h of entry; however, phthalates are in conceptually although not technically accurate language.
often VOCs and are pervasive in our environments. Phthalates are a Technically precise definitions can be found in official documents
family of chemicals used to soften plastics such as children’s toys, and professional textbooks.)
adhesives and floor and wall covering. In healthcare, DEHP (di(2-
ethylhexyl) phthalate) is most often used to soften PVC medical Allowable sound level criteria, NC and room criteria. Sound
devices including IV bags and tubing, catheters and enteral levels can be measured over the entire spectrum of audible
nutrition feeding bags. Phthalates are also used as fixatives in frequencies. For some technical purposes (e.g., spaces in which
perfumes, as time-release coatings on medications, and in nail verbal communication is important), the spectrum can be divided
polish, to make them more flexible. AKA ‘plasticizers,’ they may be into smaller frequency spans, such as octaves or specific narrow
absorbed through the skin, inhaled or ingested. They are associated bandwidths. Background noise within a room is often measured in
with reproductive and developmental harm, suppression of the octave bands for comparison with a family of smooth, balanced
immune system and damage to organs and the nervous system. curves, called NC or room criteria (RC). This criteria system is used
for design and validation of building spaces because it is more
Polychlorinated biphenyls. Polychlorinated biphenyls (PCBs) descriptive than a single number such as dB or dBA, which does
are mixtures of organic chemicals that are non-flammable, not carry enough information to distinguish between a pure tone, a
chemically stable and have high-insulating qualities, making them balanced spectrum or sound dominated by lower or higher
ideal in industrial and commercial applications including paints, frequencies.
plastics and rubber products. PCBs are considered to be PBT
substances that build up in the food chain and accumulate to Background or facility noise. Background noise refers to the
levels that are harmful to environmental health and carcinogenic continuous ambient sound in a space owing to the mechanical
to humans. PCBs also can be VOCs. and electrical systems of the facility or building itself. Background
RD White
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noise is produced by sources outside the building and by the elements, superficial cracking in partitions or even structural
building’s own HVAC systems, vacuum tube systems, elevators, damage. Very small magnitudes of vibration not perceptible to
plumbing, automatic doors, etc. Because occupant-generated noise humans can disturb high magnification optical microscopes or
will add to the ‘noise floor’ or background noise of the building, very sensitive electronic equipment. Sources of vibration common
allowable background level criteria are set low enough to prevent in hospitals are helicopter flyovers and landings/take-offs, magnetic
annoyance, reduced speech intelligibility, sleep disturbance, or resonance imagers, sound systems and heavy trucks. Buildings can
other disturbance after the building is occupied. be constructed to prevent the propagation of vibration through the
building.
Facility vs operational noise. Exterior sources (e.g., street traffic
and outdoor building mechanical equipment) and interior sources
(e.g., air conditioning and exhaust systems) generate facility noise. References
It exists in the empty building as it is constructed. The people and 1 Committee on Perinatal Health. Toward Improving the Outcome
equipment that occupy the building generate operational noise. of Pregnancy. Recommendations for the Regional Development
of Maternal and Perinatal Services. The National Foundation – March
Operational noise. Operational noise is generated by people and of Dimes: White Plains, NY, 1976.
equipment that occupy the building and are separable from the 2 Guidelines for Perinatal Care. 6th edn American Academy of Pediatrics/
building. A general rule of thumb states that occupants and their American College of Obstetricians and Gynecologists: Elk Grove Village,
equipment will add about 10 dBA to background noise. However, IL/Washington DC, 2002.
this generalization does not apply to all room uses. For example, 3 Guidelines for Design and Construction of Hospital and Health Care
Facilities. The American Institute of Architects Academy of Architecture for
two or three people in an office environment with 45 to 55 dBA
Health: Washington, DC, 2006.
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4 Committee on Perinatal Health. Toward Improving the Outcome of
conference room with a 35 to 45 dBA background might add 20 dBA. Pregnancy. The 90’s and Beyond. The National Foundation – March
A large group of people might add 40 dBA. In intensive care units of Dimes: White Plains, NY, 1993.
with hard surfaces, close spacing of patient beds and large amounts 5 White RD (ed).. The sensory environment of the NICU: scientific and
of staff and equipment, the occupied room noise may be 20 dBA or design-related aspects. Clin Perinatol 2004; 31(2): 199–388.
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Association: Quincy, MA, 2005.
Occupant-produced noise. Occupant noise is not under the 7 Green Guide for Health Care. (available for download at www.gghc.org).
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a design parameter through the use of a matching architectural 8 Robbins, Sandra T, Beker, Leila T, American Dietetic Association. Pediatric
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Breastmilk in Health Care Facilities. American Dietetic Association:
of occupant-produced noise lies primarily in the realm of quality
Chicago, 2004.
assurance programs and hospital management.
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Society of North America: New York, 2000.
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space, sound levels are affected by reflections of sound waves from Color. Vol 8, Issue 1. Lighting Research Center: Troy, New York, 2004.
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pressure builds up in the space, increasing the original level with of North America: New York, 1995.
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absorptive, reflected energy is reduced and sound pressure does not Clin Perinatol 2004; 31(2): 217–228.
build up. Acoustically absorptive surface materials are rated by an 13 Glickman G, Byrne B, Pineda C, Hauck WW, Brainard GC. Light therapy
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range of the audible spectrum of sound frequencies. Although an (LEDs). Biol Psychiatry 2006; 59(6): 502–507.
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oversimplification, the NRC rating of a material can be thought of
Alzheimer’s patients – a pilot study. Light and Human Health: EPRI/LRO
as the percentage of sound energy absorbed. If the NRC of a wall
5th International Lighting Research Symposium. The Lighting Research
panel, for example, is 0.65, about 65% of the sound energy of a Office of the Electric Power Research Institute: Palo Alto, CA, 2002,
source is absorbed and about 35% reflected back into the room. pp 151–156.
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Vibration. Vibration is perceptible to humans at a certain research. J Health Care Inter Des 1991; 3: 97–109.
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magnitudes of vibration can cause rattling of lightweight building docs/Permit_Access/main.cfm(accessed 4th November 2oo6).
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Perspectives in NICU Planning, Report of the Fourth Annual Ross criteria for newly constructed or renovated hospital nurseries. J Perinatol
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21 US Environmental Protection Agency. Envirofacts master chemical 26 Parsons R, Tassinary LG, Ulrich RS, Hebl MR, Grossman-Alexander M. The
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American Society for Testing and Materials: West Conshohocken, PA, 2001. glossary.asp (accessed 15th April 2006).
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Recommended standards for newborn ICU design

Article in Journal of Perinatology · October 2006

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Recommended standards for newborn ICU design

Wilson-Orr. We also wish to acknowledge the professional advice of

Joy Browne, PhD Robert Cicco, MD Douglas Erickson

Stanley N Graven, MD Skip Gregory, NCARB James W. Harrell, FAIA, FACHA

Correspondence: Dr RD White, Regional Newborn Program, Memorial Hospital, 615 N.

Kathleen JS Kolberg, PhD George A Little, MD Anna Marshall-Baker, PhD

Mark S Rea, PhD Mardelle McCuskey Shepley Judith A Smith, MHA

Walt Vernon, PEJD Robert D White, MD, Chairman

Standard 12: support space for ancillary services. We added

Interpretation. Temporary increases in illumination necessary to

Glossary Full-spectrum color index. A mathematical transformation of

Volatile organic compounds. VOCs are the primary source of

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