We have just moved to a brand new NICU, with 80 beds, in 60 single family rooms, and 10 twin rooms. It is enormous, and beautiful, each room has a parent space with a smallish pull out bed (not enough room for a couple to sleep, maybe that was the idea!), at the same time as moving we had to renew all our monitors, and we added some ventilators and got rid of others, so that we now have only 2 kinds of ventilator, the VN500 and a few creaky Sensormedics, with the others that we occasionally used no longer in service. We also, around the same time, changed the way we constitute the teams doing service, so we now have 5 teams instead of 4 and divide up the babies differently.
All of which is a preamble to saying that if we compare differences between our previous outcomes, in our mostly double-room setup before the move, and our future outcomes, in the mostly single rooms with much more space for families; even though we have the same group of neonatologists, and we haven’t made any huge change in clinical protocols, so many things have changed that to ascribe them to just the NICU environment would be questionable.
This means of course that observational studies are very limited, any study comparing outcomes with historical controls needs to be viewed with a touch, or more, of scepticism, even though we might ascribe any improvement in BPD incidence (for example) to the move to single rooms, it might well be a combination of other unrelated factors which are responsible.
It is also important, I think, to distinguish between single patient rooms, and single family rooms, some single room NICUs have very limited space for families, and the impacts maybe very different to the NICUs with family-room concepts.
I really like our new unit, even though I say that having been involved in much of the planning (not right at the beginning with the choice of a single family room design, nor right at the end with some of the final details being settled): but is an NICU like that good for babies? and for families?
How to answer a question like that scientifically? Clearly we can’t randomly admit babies to an NICU with single family rooms, single patient rooms, or an NICU with larger rooms having several babies in them. We can either do historical control studies (with limitations such as those I have already discussed) or we can study contemporary groups in different NICUs and try to correct for all the potential differences between the groups. We might be able to look at a single group or region where they have both types of NICU, and where patient admission was pseudo-random (i.e. not based on patient characteristics, but based on other factors such as bed availability).
There are two publications that demonstrate the problems with these approaches,
Pineda RG, et al. Alterations in brain structure and neurodevelopmental outcome in preterm infants hospitalized in different neonatal intensive care unit environments. J Pediatr. 2014;164(1):52-60 e2.
The first study, from Terrie Inder’s time in St Louis, compared outcomes between babies admitted to the single room wing of a new NICU and those admitted during the same period, but to the traditional “airplane hangar” NICU. Admission was based on bed availability, and the outcomes the group studied were brain imaging, short term functional outcomes (aEEG and neurological exams), and neurodevelopmental progress, including language, at 2 years of corrected age. 136 infants less than 31 weeks gestation were included, with 127 having most of the measures, and then 107 being eligible for follow-up (after deaths and dropouts) of whom 86 were seen. At 2 years the language scores were 5 points lower among the babies in the single rooms (1/2 a standard deviation). Why would this be? An important new study from the same group has analyzed the type of noise that preterm babies are exposed to, in the two types of environment, they used an automated analyzer which divided periods of noise into those with speech, distant voices, electronic sounds, other noise and silence (Pineda R, et al. Auditory Exposure in the Neonatal Intensive Care Unit: Room Type and Other Predictors. The Journal of pediatrics. 2017). Each recording episode lasted 16 hours, starting before 10am in the morning. There were more periods of silence in the single rooms, and less distant words, the duration of exposure to meaningful words was very short in both types of environment, and increased towards discharge, only around 8 minutes per 16 hour period at birth, up to about 30 minutes per 16 hour period at term.
This certainly all suggests to me that there is a great opportunity in single rooms, to increase exposure to parental, and other positive human voice sounds. Encouraging parents to talk to, sing to, and read to, their babies, and even to record their voices doing those things so the baby can hear sounds that might encourage speech development should be studied more. Is there a saturation effect? Should voice exposures be limited to when the baby is awake?
The study by Betty Vohr, compares human milk intake and developmental outcomes before and after their group moved to a single patient room, about 300 babies under 1250 g birth weight are compared.
Human milk provision increased after the move, particularly after the first 3 weeks, and Bayley III language and cognitive scores improved, with a correlation between those 2 outcomes.
A previous study from this group showed that language outcomes were critically dependent on parental involvement (Lester BM, et al. 18-Month Follow-Up of Infants Cared for in a Single-Family Room Neonatal Intensive Care Unit. The Journal of pediatrics. 2016). When they analyzed hours spent in kangaroo care, breast-feeding and involvement with other care procedures, they found that there was more parental involvement in the single rooms, and the babies with higher parental involvement had better cognitive and language scores at 2 years.
I guess what we need is a systematic review, et voila! (Servel AC, Rideau Batista Novais A. Les chambres familiales en néonatologie : effets sur le nouveau-né prématuré, ses parents et l’équipe soignante. Revue systématique de la littérature. Archives de Pédiatrie. 2016;23(9):921-6). This group searched pubmed for studies in the last 15 years that have evaluated impacts of a single family room design on babies, families and staff. They eliminated studies of single patient rooms without extra family space. They found 12 publications with varying designs and sample sizes, including one randomized trial, despite my comments at the top.
That randomized trial was in two level 2 nurseries in Sweden, who had built new spaces for families, patients were randomized if there was a bed available in both the new and the older 4 bedded spaces, and if a parent could stay for 24 hours a day for the hospitalisation. Babies were admitted either after birth or from the local level 3 NICU. That study showed shorter hospitalisation in the single room, by about 5 days on average (mostly among the babies under 30 weeks on subgroup analysis).
All the other studies were observational with differing designs; the authors of the review note that there seems to be improved weight gain in two studies, and increase in exclusive breast-feeding at discharge in one study, another study showed decreased nosocomial sepsis. From the parents point of view there was an increase in satisfaction in one study, had a greater sense of intimacy with their baby in another study. In contrast parents in one study had a greater sense of isolation, having fewer interactions with other parents, and fewer with the care team.
The nursing and medical staff felt that they worked in a better environment (3 studies) they had higher satisfaction scores (1 study) and had higher quality of work life (1 study).
These results are possibly subject to all sorts of biases: it isn’t clear often which were the primary outcome variables, and which were chosen after the data were collected; there are response biases, staff who have no choice about the NICU design (it is impossible to go back to a large multi-patient room once you have built a new single family unit) might well score their new circumstances better, because they have no choice really but to make the best of their new situation; and so on.
Nevertheless this review suggests mostly improved outcomes in single family rooms, with concerns about family isolation, and decreased aural stimulation.
Finding ways to overcome the downsides of these rooms, while maintaining those advantages might well help to improve many different outcomes of our premature infants.