Every year, more newborn intensive care unit (NICUs) are transitioning from the open concept bed space to more single-family rooms in the hopes of positively affecting neurodevelopmental outcomes by reducing infections, controlling light and sound exposure, and improving the bonding and breastfeeding experience.1-3 These moves require careful planning and orchestration to ensure both the infant and families remain safe during the transition. Previously, macrosystem simulation has been studied for such events and found to identify safety threats prior to the move; however, other systematic processes have been implored with the development of a Move Planning Committee prior to the event.4
The level 4 NICU at this Midwestern, tertiary academic center experienced an expansion from an 85-bed unit to a 125-bed unit in the first quarter of 2018. In this initial expansion, a new tower was built to accommodate these additional bed spaces. This resulted in 37 physical rooms with 40 beds and 3 additional "multiple birth rooms" to allow siblings to room together. Part of this challenge was that the level 2 nursery and the labor & delivery department in the adult hospital would move from their existing location a half a mile away to within 100-ft proximity to the NICU. In addition, the level 2 nursery would be absorbed into the existing level 4 NICU and would be under the same hospital license.
The planning for this endeavor started in the spring of 2017. A NICU Expansion Move Planning Committee was created and composed of nurses, physicians, support staff, pharmacists, dieticians, management, social workers, and family partners. In addition, performance improvement specialists were brought into the committee for additional skills to facilitate and make recommendations on planning the workflow for the provider work rooms, supply rooms, and emergency equipment location and placement. Planning and design representatives were there to gain feedback from the committee regarding construction and design that would accommodate workflow.
The committee met every other week and then weekly as the expansion was near completion. Overall, every piece of the puzzle had an owner and a deadline. Each process was identified including the following: staffing, communication, medical model of care, nursing model of care, stocking and supplies, emergency equipment, admissions, training and education, and provider work rooms.
Since this was a multiphase project, there was a lead owner for each phase. Each phase consisted of a move either horizontally or vertically both within the hospital and across facilities. Not only was the NICU undergoing new construction but also the older version of the unit was being refurbished. This required additional patient movement.
With the intricacies involved in this multiday and multiphase move, it became clear that emergency preparedness was of the utmost importance. The vertical transfers occurred first, which were the least acute care patients. Lessons learned from that move identified gaps in communication, so 2-way radios were used for subsequent moves with the higher-acuity patients. Move Teams were created consisting of a registered nurse, patient care technician, respiratory therapist, and an MD or advanced practice nurse. Key staff members were placed in the new and old sections, so there would be no interruption of care. A very synchronized plan was created, and different color Move Teams were established according to patient acuity. The red, yellow, and green designations were created to reflect the highest- to lowest-level acuity. The timing of the movement was coordinated with the acuity so that adequate emergency response and coverage were available. When the level 2 nursery moved from an adjacent building, in addition to the Move Team, there was an Emergency Response Team located in between the 2 buildings. The Emergency Response Team carried intubation equipment, oxygen, and suction in order to accommodate any untoward events.
A visual map with color coding was created on a laminated poster board with Velcro adhesive for each bed space, patient, and team assignment according to colored acuity. The preceding 5 days prior to each move had certain target outcomes that needed to be completed (see Table 1). A command center was established on each day of the move. There were 4 separate move days over the course of several weeks to accommodate the completion of the construction. Because of the synchronized planning, the entire move of the patients occurred over 4 hours when it was anticipated to be completed in 8 hours. In addition, no adverse events were reported as a result of the move. Approximately 100 patients were moved in the course of the 4 patient move days.
Once the move was complete, planning for the code response was also redesigned. In the previous NICU, the entire NICU Code Team would respond to code activations. Because of the larger footprint of the space and the increased number of personnel, each zone had a Code Response Team. This resulted in expanding from 1 to 3 Code Response Teams available each day.
Integral to this coordination were the Family Partners who were involved from the beginning of the planning process. The Family Partners are a group of families whose children have undergone treatment in our hospital and partner in continuous improvement from the patient and parent points of view. The focus areas for this group during the move was support of the families whose infants were moving to the new tower so that the focus for the staff could be on safe patient movement. During the move, the Family Partners were instrumental in orienting the family to the new room so that the staff could focus on the needs of the infant. This included orientation to call lights, lounge location, elevators, and other amenities. They developed premove patient/family communication pieces and recommended to the staff what resources families might need.
The leadership team later reflected on the importance of communication between providers and the support staff; however, they also realized that engaging the Family Partners to assist with the communication to the families was an important part of the project's success. In anticipation of a subsequent move planned in August 2019 to accommodate an additional 37 private NICU rooms, an emergency preparedness drill will be conducted focused on mass evacuation in order to simulate before the move occurs. This process has become the standard work for most hospital moves within the facility.
-Christine Kilian, MSN, RN, NNP-BCN
-Lisa M. Steurer, PhD, RN, CPNP-PC
-Elizabeth Kruvand, BSc
St Louis Children's Hospital
St Louis, Missouri
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