1

Welcome

Neonatal Couplet CarePlanning for the Flexible Use of Rooms A Large Birth Service Hospital Experience

Session Description• The Fruits of Open Minded Thinking!• NICU Room Design Evolution• NICU Admissions –Flexibility• Benchmarks – Medical Rationale Supporting DesignBenchmarks Medical Rationale Supporting Design• Facility Specs

• The Experience of Winnie Palmer Hospital• Decision leading to the Concept• Operational Tools and Process for Implementation• Success Criteria

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Session Objectives

• Describe the Neonatal Couplet Care Concept• Learn the Benefits of such a design for both

the family and infant• Identify basic room specs for Neonatal

Couplet Care• Examine operational concerns for both

physicians and staff• Observe the amenities in the room designed

for family considerations

The Fruits of Open Minding Thinking….

35 years ago – No Microwave Ovens and LDR rooms

1994 “The internet has no here to go” 1994 “The internet has no where to go”

From Weapon Drones to Lily Drones to Drones for 911

NICU Room Design Evolution

Baby Barns Pin Wheels Semi-Private Rooms Single Family Rooms Single Famil Rooms ith Bathrooms Single Family Rooms with Bathrooms

Neonatal Couple Care Rooms What is this?Promoting Parenting from the Birth Day

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Births…. NICU Admissions

Births in the US- 3.98 Million in 2014 (1% Increase from 2013)- Potential for increase annually/next 20 years

Prematurity ratesDeclining- Declining

Neonatal Admissions- Increasing – but with larger babies and less

prematurity- 2007-2014 Admission rates still increasing from 64 to

78.9/1000

Goals of the Neonatal Couplet Care Model

Minimize separation of the infant and parents Support parents confidence – Feel more secure at discharge Facilitate bonding and attachment Parent Presence insures more prompt response from

professionals – tuning into the signals from the patient Positive effect on breastfeeding A new way of working for the staff – Coaching rather than “doing” Early discharge --- home care

Provide room use flexibility for both adult and pediatric patients

Data Support from Karolinska Institutet

10,000 Birth Service Facility in Sweden 14% C-Birth Rate 8.5% Admission rate to NICU

366 Infants --- Randomly allocated to “family care rooms’ and standard care rooms

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Profile of the InfantsFamily Care N=183

Standard Care N=183

Gestational Age at Birth

24-29 Weeks 28 31

30-34 Weeks 102 103

35-36 Weeks 53 48

Twins 21 24

KAROLINSKA INSTITUTET STUDY

LOS in the Hospital/Intensive CareFamily Care N=183

Standard Care N=182

Difference in Days

ALL INFANTS (Mean)

27.4 /13.3 DAYS

32.8/18 DAYS (5.3)/(4.7) DAYS

Gestational Age t Bi that Birth

24-29 WEEKS 56.6/32.4 DAYS

66.7/43.1 DAYS

(10.1)/(10.6) DAYS

30-34 WEEKS 19.2/6.0 DAYS 23.6/8.5 DAYS (4.4)/(2.5)DAYS

35-36 WEEKS 6.4/1.5 DAYS 7.9/2.5 DAYS (1.3)/(1) DAY

Infant MorbidityFAMILY CARE N=183

STANDARD CARE N=182

FAMILY CARE % OF STANDARD CARE

VERIFIED SEPSIS

7.1% 9.8% 72%

VERIFIED NEC 2.7% 3.3% 82%

DIAGNOSED 15 3% 16 9% 90%DIAGNOSEDPDA

15.3% 16.9% 90%

IVH GRADE II-III

3.3% 3.8% 86%

ROP STAGE II-V 2.7% 6.6% 41%

BPD (Moderate-Severe)

1.6% 6.0% 26%

KAROLINSKA INSTITUTET STUDY

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Additional Medical Support for the Concept

RT SUPPORT -- LOWER IN THE FAMILY CARE ROOMS MECHANICAL VENT DAYS -- LOWER IN THE FAMILY CARE

ROOMS CPAP DAYS -- LOWER IN THE FAMILY CARE ROOMS SUPPLEMENTAL OXYGEN DAYS -- LOWER IN THE FAMILY

CARE ROOMS PARENTAL PRESENCE AND SKIN TO SKIN MIGHT

CONTRIBUTE TO BETTER SLEEP ORGANIZATION

Karolinska Institutet Study

Benchmarks

Karolinska Danderyd Institutet, Sweden Catholic Medical Center, Manchester, NH Winnie Palmer Hospital, Orlando, FL T o Uni ersit Hospitals in So th US Two University Hospitals in South US

- (Planning Stages)

- How to License these rooms?

Click to edit Master title style

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Click to edit Master title style

CMC – Neonatal Couplet Care – How Does it Really Work?

Infant is born on The Mom’s Place in an LDRP room Infant is stabilized in the room Infant is placed on mom or dad’s chest and transferred to

th SCN i t N t l C l C Rthe SCN into a Neonatal Couple Care Room SCN nurse assumes care for the Couplet Couplet remains in the Neonatal Couplet Care room until

mom is discharged Infant is transferred to the SCN until discharge

CMC -- Benefits of Neonatal Couplet Care

Increases the rate of exclusive breastfeeding Increases the amount and duration of kangaroo care Parents are more prepared at discharge High job satisfaction ratings (NDNQI S r e ) High job satisfaction ratings (NDNQI Survey) Decreased staff turnover Decreased LOS for NAS Babies

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201 SF

PatientRoom

201 SF

PatientRoom

204 SF

PatientRoom

201 SF

PatientRoom

205 SF

PatientRoom

201 SF

PatientRoom

233 SF

ADAPatientRoom 59 SF

ADAPatient

Bathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

252 SFStair #2

19 SF

SubStation

19 SF

SubStation

23 SF

SubStation

191 SF

Pod BStaff

Station

167 SF

On CallRoom

71 SF

MedicationsRoom

21 SF

WorkAlcove

42 SF

ScrubAlcove

68 SF

On CallBathroom

187 SF

MonitorRoom

201 SF

PatientRoom

38 SF

PatientBathroom

291 SF

AirborneInfectionIsolation

ADARoom

56 SF

ADAPatient

Bathroom

15 SF

PPEAlcove

193 SF

SoiledWorkroom

805 SFCorridor

201 SF

PatientRoom

19 SF

SubStation

18 SF

SubStation

227 SFCorridor

85 SF

EquipmentStorage

103 SFRT Work

336 SF

Multi-purposeRoom

194 SFChase

71 SFChase

300 SFElevator

Elevator

68 SFElevator

20 SF

SeatingNiche

17 SFAlcove

ICU

RENO

VATI

ON |

ORLA

NDO,

FLO

RIDA

OVERALL PLANSProposed Level 11 Floor Plan

114 SF

NurseManager

Office

46 SFHousekeepi ng

124 SFElectrical

112 SFIT

147 SF

Formula|MilkRoom12 SF

PTS136 SF

Reception

406 SFCorridor

104 SFCorridor

62 SFCorridor

171 SF

PublicElevatorLobby

191 SF

VisitorWaiting

260 SF

StaffElevatorLobby

204 SF

PatientRoom

201 SF

PatientRoom

204 SF

PatientRoom

199 SF

PatientRoom

200 SF

PatientRoom 200 SF

PatientRoom

201 SF

PatientRoom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

40 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

246 SFStair #3

19 SF

SubStation

19 SF

SubStation

19 SF

SubStation

185 SF

Pod AStaff

Station

113 SF

AsstNurse

ManagerOffice

254 SF

SharedOffice

14 SFAlcove

44 SF

ScrubAlcove

200 SF

PatientRoom

38 SF

PatientBathroom

953 SFCorridor

200 SF

PatientRoom

19 SF

SubStation

19 SF

SubStation

321 SFCorridor

201 SF

PatientRoom

201 SF

PatientRoom

204 SF

PatientRoom

201 SF

PatientRoom

202 SF

PatientRoom

201 SF

PatientRoom

327 SF

PatientRoom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

38 SF

PatientBathroom

250 SFStair #1

19 SF

SubStation

19 SF

SubStation

19 SF

SubStation

191 SF

Pod CStaff

Station

03 S

105 SF

SocialWorkOffice

12 SFAlcove

43 SF

ScrubAlcove

204 SF

PatientRoom

38 SF

PatientBathroom

293 SF

AirborneInfectionIsolation

ADARoom

53 SF

ADAPatient

Bathroom

16 SF

PPEAlcove

179 SF

CleanHold

883 SFCorridor

201 SF

PatientRoom

23 SF

SubStation

19 SF

SubStation

213 SF

StaffLounge |Lockers

60 SF

StaffToilet

60 SF

StaffToilet

67 SF

StaffToilet

60 SF

PublicToilet

270 SF

VisitorLounge

Color Legend

Clinical Support

Inpatient

Inpatient Circulation

MEP

Public

Vertical Circulation

357 SFCorridor

71 SFChase

43 SFChase

44 SFChase

196 SFElevator

134 SFe ato

68 SFElevator

21 SF

SeatingNiche 11 SF

SeatingNiche

113 SF

EquipmentStorage

80 SF

MedicationsRoom

21 SF

WorkAlcove

59 SF

AnteRoom

126 SF

EquipmentStorage

244 SF

ProtectiveEnvironment

Room 38 SF

PatientBathroom

73 SF

MedicationsRoom

11 SF

WorkAlcove

48 SF

NourishmentRoom

11 SFAlcove

10 SF

CCAlcove

406 SFCorridor

Area Tab : 18,000 DGSF

66 SF

Scrub &Gown

WIN

NIE

PALM

ER H

OSP I

TAL

| LEV

EL II

NI

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Winnie Palmer Hospital for Women and Babies, Orlando, FL

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Orlando Health Highlights One of Florida’s most comprehensive private, not-for-profit healthcare

networks.

Seven facilities: One tertiary care center, 3 leading community hospitals, 2 nationally-recognized specialty hospitals, and one world-class cancer center.

Central Florida’s only statutory teaching hospital offering graduate medical education.

A healthcare leader for nearly two million residents and thousands of international visitors annually.

Home to the only Level One Trauma Center for Adults and Pediatrics.

Orlando Health Highlights More than 2,000 inpatient beds

– Orlando Regional Medical Center (ORMC)– Arnold Palmer Hospital for Children– Winnie Palmer Hospital for Women & Babies– Dr. P. Phillips Hospital – Health Central Hospital– South Seminole Hospital– South Lake Hospital (50% ownership)

Two large physician practices directly employing over 500 physicians– Physician Associates & Orlando Health Physician Group

Orlando Health providers are active participants in Accountable Care Organizations

Arnold Palmer Medical Center

Arnold Palmer Hospital for Children (APH) – 158 beds and Winnie Palmer Hospital for Women & Babies (WPH) – 315 beds- Comprehensive range of pediatric and OB/GYN sub-specialties- Academic Center of Excellence for Minimally Invasive Surgery by AAGL

• 85% MIS rate for GYN surgeries- Magnet designated facility

R i d US N B t Child ' H it l ki i 8 i lti- Received US News Best Children's Hospitals ranking in 8 specialties- Beacon Award recipient- Tertiary Referral Center – 20 counties- Largest Neonatal ICU and 2nd largest delivery hospital in the U.S.- OB/GYN and Pediatric Residencies- Hosted inaugural hospital facility site visit for IHI National Forum on Quality

Improvement in December

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Hospital Statistics

• 315 Beds / 11 Floors• 400,000 sq. ft.

– Includes one shelled floors and OR horizontal expansion

• 142 NICU beds• 30 LDRs and 4 dedicated C/section ORs• 102 Post Partum beds (expansion to 132 approved)• 8 ORs dedicated to Women’s Surgery; 3 GYN dedicated

robots• 31 bed Women’s Surgery Unit• 5 bed Women’s Intensive Care Unit

Operational Highlights

• 2rd largest birth facility in the U.S.• Largest NICU in the U.S. with all beds under a single roof• Pediatric and Obstetrical Residency Programs• Busiest Women’s Triage Unit in U.S.• History of Top 10% in the U.S. for patient satisfaction• CWISH partner• Comprehensive Concierge and Amenities Services• Connection to Arnold Palmer Hospital for Children and

Pediatric Subspecialty Physicians

Operational HighlightsFiscal Year 2014

• 14,230 babies born in 13,883 deliveries• 1,300 NICU admissions

3 000 Hi h i k OB ti t• 3,000+ High-risk OB patients• 5,400 Gyn surgery patients• 30,000 Triage visits• 12,000 Outpatient visits• 1,000 visitors per day

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Obstetrical Program

• Serve as community ‘safety net’ for obstetrical patients• Treat our competitors patients• Women’s Triage with dedicated physician coverage• OB/GYN Hospitalist Group providing 24/7 care

• 12 employed physicians, 4 Nurse Midwives, 3 ARNP’s• Anesthesiologists 24/7 (Dedicated to OB/Women)• Anesthesiologists 24/7 (Dedicated to OB/Women)• In-house neonatologists 24/7• 6 employed MFM Physicians• Only high-risk OB practice in Central Florida serving

uninsured/underinsured patients• 28 OB/GYN Residents• Women’s Intensive Care Unit

• Collaborative patient management between Medical Critical Care and Maternal-Fetal Medicine

Alexander Center for Neonatology

• Established in 1975 with 6 beds • Over 30,000 babies have been admitted• Named for founder Dr. Gregor Alexander

• Received national award featured in US News & World Report – Children’s Miracle Network ‘Lifetime Service Award for Dedication to Children’

• 1,500 admissions annually (12% of all births)• 90 Level II beds• 52 Level III beds• Average daily census during 2014 was 108 babies

• Ranked by US News and World Report

Alexander Center for Neonatology• Provides regional ‘safety net’ to the smallest & sickest

infants• 14 dedicated neonatologists – in house 24/7• ECMO – Extracorporeal Membrane Oxygenation Only 1 of 4

centers in the state of FloridaD l d t l f ECMO th t tl d t t id & ti ll• Developed protocols for ECMO that are currently used statewide & nationally

• ‘Center of Excellence’ designation achieved in 2010 from ELSO; redesignated in 2014

• NICU Delivery Room Teams attend 62% of all deliveries• Dedicated NICU Transport Team• Supported by every Pediatric Sub-Specialty

• 75% of all NICU babies need some type of care from a sub-specialist

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Alexander Center for Neonatology

• Quality Outcomes• Vermont Oxford Network participant 900 participants

VON WPHCLD → 24.4% 14.4%CLD, <33 wks → 26.0% 15.7%Severe IVH → 8.1% 4.1%

• Active in physician/nurse research projects & publications• Highest survival rate in the state for low birth-weight babies• Survival rate for NICU population as a whole is 90%

Severe ROP → 6.2% 0.9%NEC → 5.1% 2.3%

Weight (500-750 gms) (750-1000 gms) (1000-1500 gms) (>1500 gms)

Survival Rate 85% 91% 99.5% 99.9%

WPH NICU continued to have an increase in census since

NICU Expansion – Including Neonatal Couplet Care Rooms

2011 – OH Board approval to build-out the shelled space of the 11th floor of WPH

July 2012 - Schematic Design approved August 1 October 12 2012 Designcensus since

the opening of WPH in 2007

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August 1 – October 12, 2012 Design Development

July 2013 - Construction started March 2014 - First 10 rooms opened for

occupancy

Keys to A Successful Program = BUY-IN

• Proposal & Presentation to Executive Leadership• Promoted to Physician Leadership• Managers Involvement in Process• Team Member Education• Front Line Nurses

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• CHALLENGES• Fear of the unknown• Design of the floor needs to take into consideration both patient

populations (code requirements for both adult acute care beds and for Level II NICU)

• Interdependence on Key Departments for Success of Program• Nursing Staff ‘Buy-in’

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Floors Charge master – developed with 3 different room charges

Equipment to meet both populations

Tools and Processes for Implementation

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Maintaining stock and supply for both patient populations Skill set of nursing staff – teams caring for a dyad Parent/Patient expectations – role change of the mother

WPH -- 11th Floor Design Team

• Architecture and Interior Design: Page Sutherland Page, Dallas

• MEP Engineering: TLC Engineering, OrlandoSt t l E i i P S th l d P D ll• Structural Engineering: Page Southerland Page, Dallas

• Furniture Selection, Artwork and Accessories: TJNG, Orlando

• Medical Equipment Planning: Balfour Resource Group, Dallas, Nashville

• Construction: ROBINS & MORTON, Orlando

WPH - NICU Design Guidelines

We are a network of professionals dedicated to the care and nurturing of premature and sick infants and their families. We will use the best demonstrated care practices, current technology and environmental design to enable our patients to achieve the greatest quality of life. We will be unwavering in our commitments to our patients, each other and our

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community.• Is this best for the patients and their families?• Parents are the nucleus.• Provide a warm, inviting, comforting, and nurturing environment.• Communicate that we are a team and we care.• Focus on Trust, Quality, and Safety.• Address the progression of recovery.

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General Facts

Floor is approximately 20,000 gross square feet 3 Pods – 10 Private rooms per pod (30 rooms) Each room a minimum of 150 square feet

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Each room a minimum of 150 square feet 3 Isolation rooms on the floor – 1 in each pod 3 ADA accessible rooms - 1 in each pod 3 Rooms to care for multiples – 2 adjourning rooms

connected by a door in-between

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The Measures of Success…• 6/26/15

We moved from a room with 4 other babies, to a private room, on the 11th floor -accommodating & privacy increased/improved as we moved.

• 6/30/2015Being on the 11th Floor gave me the opportunity to care for my baby around the clock & be

well prepared to care for him after discharge.

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• 07/14/2015We were so very grateful to be able to transfer to the 11th floor where I was able to stay

and care for my baby one- on-one. Loved that place!! Love.

• 07/20/201411th floor was amazing as we were able to transfer there on the 3rd day after birth.

• 08/13/2015Pod 8 was good for her initial stay, but 11th floor was even better to help us be there 24/7

and help our baby take her feedings by bottle not feeding tube.

Key Learnings, Process Improvements and Take-Aways

1. This concept provides universal rooms for flexibility2. Has been used Internationally yet slow to evolve in the

US3 Improved neonatal outcomes and decreased LOS3. Improved neonatal outcomes and decreased LOS4. Neonatologist hesitancy is an obstacle5. Best care to keep mother and baby together

Kathleen Bajo, MHA and Stacy Jemtrud RN, MSNkathleen.bajo@gmail.com

Stacy Jemtrud@Orlandohealth comStacy.Jemtrud@Orlandohealth.com

www.smith-hager-bajo.com

www.winniepalmerhospital.com