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Room to grow: the NICU at Cook Children's Medical Center not only brings improved care to infants in central Texas, it provides insight into the benefits of private-room settings, family-centric amenities, and designing with staff needs in mind.

WITH A SERVICE AREA THAT COVERS 47 percent of the expansive state of Texas, Cook Children's Medical Center in Fort Worth draws patients from as far west as El Paso and as far south as Austin. That often meant its 55-bed neonatal intensive care unit, one of the highest level NICU programs in the country, didn't have enough space to meet population demand. In 2009, the hospital received state approval to add beds inside the open-bay care unit. But the fix wasn't big enough.

"We were saying those words you never want to say: No room in the inn," says Nancy Cychol, president, Cook Children's Medical Center. "The community deserves better than that."

In addition, Cook's brand image and reputation in the community were also on the line. "If they didn't do something, they were going to have to give up a big chunk of the market because somebody was going to step in," says Samuel Alan Black, senior vice president and senior project designer at FKP Architects (Dallas).

The hospital decided to undertake its largest-ever expansion, adding the new Dodson Specialty Clinics facility and a six-level, 270,000-square-foot North Tower with 158 new patient rooms, a food court-style cafeteria, and expanded family amenities. The tower project also included an expansion and conversion of the NICU into a two-level, 106-bed, all-private-room environment. Working with lead architect FKP, design architect David M. Schwarz Architectural Services (Washington, D.C.), and interior designer Keller Studio (Cincinnati), Cook studied best practices at private NICUs throughout the country before deciding to make the transition and investment. "Many facilities had a number of private beds and then ward-type settings," Cychol says. "We decided it was really worth the cost to do the private ICU rooms for the families and for the babies."

Driving that decision was the ability to keep patients in one room from admission to discharge and to create a more comfortable, homelike setting. Stan Davis, vice president of support services at Cook Children's, says the all-private room setting also created a standard of accommodation that could be provided to all families.

Making the transition

While the staff was on board with the decision to move to all-private rooms for improved infection control and noise control, designers decided to create a mock-up room where everyone from housekeeping to nurses to doctors could review the concept design. "There's so much at the front door that has to happen--the soap dispenser, the paper towels, light switches--so it takes time to get that right," Black says.

During the nine-month test period, the staff was able to address a range of features, such as furniture, lighting levels, and a new soiled linen and trash collection system that uses small doors along the corridor as opposed to in-room collection. The effort helped lead to a measurable reduction in noise levels in the NICU, thanks in part to such design features as poured rubber terrazzo flooring and family bathrooms located down the hallway rather than in patient rooms. Davis says that baseline testing was done in the old environment, and that sound levels at the bedside measured 13 percent quieter in the new unit under normal conditions. In fact, one of the best indicators of the improved noise control came from the nursing staff just a few weeks after moving into the space. "They said they noticed that babies were crying less," Davis notes. "Babies being disrupted in their sleep patterns cry, and babies need to sleep in the ICU to heal."

Another positive side effect of the new design, according to the staff, is the higher number of breastfeeding moms. "Don't underestimate what will happen with increased milk production when you switch from the open to the private-room unit," says Diane Osan, chairman of the board and chief visionary officer at FKP Architects. She adds that while designers had made accommodations for a larger milk bank in the new facility, the reality is they've had to add two more freezers to accommodate increased production.

Out with the old, in with new concerns

While the new design enabled Cook Children's to address some hot-button issues like infection and sound control, the transformation to a private-room setting presented a new set of concerns and challenges for staff, who were worried about maintaining contact with their patients and having a sense of camaraderie with coworkers. "They were worried about the patients being isolated and also being isolated themselves," Cychol says.

The two-level NICU is laid out in pods, or neighborhoods, each with its own name (such as Sweetheart Street for heart patients) and distinctive color palette to help with wayfinding. The sections house 18 to 24 beds and a glass-enclosed main nurses' station with an ancillary workstation located at the back of the unit. To address fears about isolation, Cychol says the first step was finding a split-screen monitoring system that would allow nurses to see vitals on more than one baby at a time. Observation stations were also placed between each room. The design features not only led to improved staff satisfaction, Davis says, but parent surveys revealed that families were 17 percent more satisfied with nurse attention in the new setting.

"The aesthetics are so much more calming and pleasing," he says. "It calms you down from a family and caregiver perspective, and the staff seems like they're more adept to function in this environment compared to the old one where so much was crammed in."

Another staff concern was the increase in travel distance inside the expanded facility. The hospital took measures to lessen travel distances with the decentralization and strategic placement of staff locker rooms and the storage of most supplies inside locked carts in patient rooms. However, a pedometer study performed before and after the move revealed increased walking distances, including 40 percent more walking by nurses. One effort made to bring staff closer to one another was the creation of a two-story staff lounge with an open staircase connecting the floors, enabling socialization and visits during break times. "That's important for them to feel like a team," Cychol says.

In fact, designers say in hindsight that they wish they'd applied the same design solution to the family lounges, where parents can take a break and use laundry facilities, microwaves, coffee makers, a library, and business center. "One of the things that's important for the families is sharing their experience, worries, and anxieties with other families," Osan says. "We could've had that same kind of synergy, but we didn't think about applying that stairwell to the family areas."

Still, there are a number of family-centric amenities in the North Tower, including a food court-style cafeteria, dining room, Starbucks coffee shop, yogurt shop, and the first hospital location for Build-a-Bear Workshop, all located one floor below the NICU.

While the project houses several advances in NICU care and facility design, one of the greatest success stories is the overall reduction in length of stay for infants. Cook reports that for the smallest of NICU babies (those born prematurely at gestational age of 23 to 27 weeks), the average length of stay has dropped approximately 40 percent after moving into the private-room environment. The new design also allowed the hospital staff to transition to a feeding-on-demand system, further benefitting patients' healing. These two interventions have a combined result in a 50 percent overall reduction in length of stay.

Completion date: North Tower, June 2011; Dodson Clinic, March 2012

Total building area: 533,000 sq. ft. (North Tower: 283,000 sq. ft.; Dodson Clinic: 250,000 sq. ft.)

Total project budget: $249 million

Construction cost: North Tower: $78.5 million; Dodson Clinic: S70 million

Owner: Cook Children's Health Care System

Lead architect: FKP Architects

Design architect: David M. Schwarz Architectural Services

Interior design: Keller Studio

Engineering: CJG Engineers (structural), Dunaway Associates (civil), Smith Seckman Reid (MEP)

Project manager/contractor: Linbeck

Carpet/flooring: Milliken, Interface, Stonhard, Armstrong, Nora, Centiva

Ceiling/wall systems: Armstrong, Certainteed

Doors/locks/hardware: ASSA Abloy, Eggers Industries (doors)

Fabric/textiles: Haworth, Carnegie, Momentum, DesignTex

Seating/casegoods: North Tower: Nemschoff, Haworth, Izzy, National Office Furniture; Dodson Clinic: Haworth, National Office Furniture, Arcadia, Agati, Spec Furniture, Izzy, Keilhauer, Nemschoff

Handrails/wall guards: Acrovyn, InPro, Construction Specialties

Lighting: Cooper, Metalux, Portfolio

Signage/wayfinding: ASI

Surfaces--solid/other: Formica, Corian

Wallcoverings: Eykon Wallcovering

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While Cook Children's Medical Center conducted capture and compare data on its open bay versus private care models at its neonatal intensive care unit, the project also provided an opportunity to look at integrated project delivery (IPD) principles.

For the 2011 North Tower project, the design team used IPD and BIM technology, enabling the six-level, 160-bed tower to be completed in 37 months. By comparison, the North Pavilion--a similar sized project also completed by FKP Architects for Cook Children's in 2003--took 49 months for the design and construction phase.

FKP estimates that the value added from the integrated team approach, the BIM utilization, and the improved speed to market had a potential increased revenue of roughly $212 million, compared to traditional design-bid-build delivery.

Anne DiNardo is senior editor of Healthcare Design and can be reached at adinardo@vendomegrp.com.
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Author:DiNardo, Anne
Publication:Healthcare Design
Geographic Code:1U7TX
Date:Apr 1, 2013
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