David P. Munson

A Comprehensive Comparison of Open-Bay and Single-Family-Room Neonatal Intensive Care Units at Sanford Children's Hospital.

Objective: This paper summarizes the results of a comprehensive comparison of open-bay (OPBY) and single-family-room (SFR) neonatal intensive care unit (NICU) designs. Background: The NICU expanded from 7000 ft2 in two large rooms to 27,000 ft2 with 45 individual family spaces. Results: Sound measurements indicated a significant reduction in the unoccupied SFR to less than half of the levels in the OPBY NICU. However, respiratory support equipment generated levels well above those of the ambient environment. Illumination was significantly reduced in the SFR. Ambient illumination in nursing work areas was less than recommended. In other comparisons with the OPBY NICU the SFR NICU was shown to have: a shorter interval until full enteric feedings were established; improved parent satisfaction; improved staff perceptions of the environment and care; a decrease in nurses State-Trait Anxiety scores; an increased need for total numbers of staff and nursing staff per shift; increased walking per shift by nurses and nurse practitioners; and improved sleep time in a very small sample of patients. Analysis of the cost of construction showed comparable cost per ft2; however, the cost per bed in the SFR NICU was much greater because of the increased area of this facility. Highly notable findings of this investigation included the same incidence of adverse outcomes of care and a reduction in the adjusted direct cost of care in the SFR NICU. Conclusion: These data overwhelmingly support the SFR NICU in preference to the traditional OPBY facility. They substantiate that the SFR NICU should be the new standard for NICU care.

A Comparison of Parent Satisfaction in an Open-Bay and Single-Family Room Neonatal Intensive Care Unit

Objective: The purpose of this research was to test the hypothesis that parental satisfaction with neonatal intensive care is greater in a single-family room facility as compared with a conventional open-bay neonatal intensive care unit (NICU). Methods: This investigation was a prospective cohort study comparing satisfaction survey results for parents who responded to a commercially available parent NICU satisfaction survey following the provision of NICU care in open-bay and single-family room facilities. A subset of 16 items indicative of family-centered care was also computed and compared for these two NICU facilities. Results: Parents whose babies received care in the single-family room facility expressed significantly improved survey responses in regard to the NICU environment, overall assessment of care, and total survey score than did parents of neonates in the open-bay facility. With the exception of the section on nursing in which scores in both facilities were high, nonsignificant improvement in median scores for the sections on delivery, physicians, discharge planning, and personal issues were noted. The total median item score for family-centered care was significantly greater in the single-family room than the open-bay facility. Conclusions: Parental satisfaction with care in the single-family room NICU was improved in comparison with the traditional open-bay NICU. The single-family room environment appears more conducive to the provision of family-centered care. Improved parental satisfaction with care and the potential for enhanced family-centered care need to be considered in decisions made regarding the configuration of NICU facilities in the future.

467 MARSHALL-SMITH SYNDROME: ANDROGEN ABNORMALITIES

In 1971 Marshall et al described a syndrome consisting of markedly accelerated skeletal maturation, relative failure to thrive and dysmorphism. Since then 11 cases have been reported. With the exception of an elevated testosterone in a neonatal female, hormonal evaluations have been normal. We present a male with Marshall-Smith Syndrome with abnormal adrenal androgen production. A.S. was noted at birth to have a bone age of 2 yrs. At age 8 mos. the bone age was 6 yrs. Noted were generalized hirsutism, prominent forehead, low set ears, shallow orbits with prominent eyes, small triangular upturned nose, hypoplasia of facial bones, long, tapered fingers, inguinal testes, small scrotum and a penile length of 5¼ cm. The following were normal for age: T4, FSH, LH, somatomedin-C, testosterone, testicular response to HCG, and androgen receptors in cultured skin fibroblasts. Seventeen hydroxyprogesterone (17-OHP) was elevated (840 ng/dl; nl 30-100) as was androstenedione (67 ng/dl; nl<50). An ACTH stimulation test was done. A 30 min. increase in 17-OHP of 23.4 ng/dl/min. suggested an adrenal enzymatic defect and hydrocortisone 20 mg/m2/day was begun. The androstenedione decreased to 13/ng/dl and on therapy has remained normal. ACTH stimulation tests were performed on both parents. The 30 min. increase in 17-OHP was elevated in both (father-13.8 ng/dl/min; mother-8.9 ng/dl/min; nl<6.5 ng/dl/min) suggesting a heterozygous state for congenital adrenal hyperplasia. It is speculated that an inherited abnormality in androgen production may be contributory to the osseous maturation seen in the Marshall-Smith Syndrome.

The Effect of Neonatal Intensive Care Unit Design on the Distance Walked by Nurses

Background: The intent of this paper is to compare the impact of neonatal intensive care unit (NICU) design upon nursing staff by investigating the number of footsteps walked per shift and complaints of physical distress following the relocation of a NICU from a traditional open-bay design, where many babies receive care in one large room, and a new single-family room NICU in which each baby receives care in a private room. Methods and findings: Staff nurse and expanded role neonatal nurse practitioner volunteers wore a pedometer for twelve-hour shifts in the open bay and single-family room NICUs. Data were analyzed by the severity of the nursing caseload and by shift for nurses, and by shift for neonatal nurse practitioners. For staff nurses, there was a significant increase from 5689 steps/shift (4.50 km) in the open bay NICU to 6523 (5.16 km) steps in the single-room unit. No differences were found in comparisons by shift. Nurse practitioners had a significant increase from 4025 (3.19 km) to 5157 (4.09 km) steps per shift. The number of steps at night increased from 2385 to 5982 steps; however, this difference was not significant due to the small sample size. Comparisons of nursing surveys for items specifically related to work-related musculoskeletal disorders demonstrated no significant differences. Conclusions: A statistically significant increase in footsteps per shift was found among neonatal nurses and neonatal nurse practitioners in the single-family room NICU as compared with the open bay facility. Although the results were statistically significant, the physical impact for distances walked were minimal. The number of steps in the single-family room NICU were ½ of the number reported for nurses on medical-surgical units. It should be emphasized that nursing administration anticipated the potential for the need for increased walking in the single-room NICU and additional support personnel were added to assist in supporting the nursing staff.

1334 THE EFFECT OF ANTENATAL ADMINISTRATION OF BETAMETHASONE ON THE HOSPITAL COSTS AND SURVIVAL OF PREMATURE INFANTS

Prenatal administration of glucocorticoids (betamethasone) has been shown to decrease the incidence and severity of respiratory distress syndrome in premature infants, but little is known regarding the immediate economic impact of this reduction in respiratory morbidity. This study examined 336 infants born during 1978 and 1979 and hospitalized in the University of Minnesota Hospitals. Comparison of survival and the hospital costs between infants whose mothers had received or not received prenatal glucocorticoid therapy showed that glucocorticoids had a significant effect in lowering mortality in infants with birth weights between 750 and 1249 grams (27-29 weeks gestation) (P<.05). Glucocorticoids were also effective in decreasing morbidity as reflected by hospital costs of surviving infants with birth weights between 1250 and 1749 grams (30-32 weeks gestation)(P<.05). In both steroid treated (r=-.994) and non-treated (r=-.919) pregnancies, prolongation of gestation decreased hospital cost in a linear fashion. The noted decrease in hospital costs should not be a justification for prenatal glucocorticoid administration but a stimulus to further examine the long term positive and negative effects of the drug on surviving infants.

571 CONSERVATIVE MANAGEMENT OF ESOPHAGEAL AND PHARYNGEAL PERFORATIONS IN THE NEWBORN

Perforation of the pharynx or esophagus is a well-described condition in the neonatal period. Controversy exists, however, whether medical or surgical therapy is the most appropriate management of such perforations. Eight cases of neonatal pharyngeal/esophageal perforation in premature infants were treated medically with antibiotics, nutritional support and closed chest-tube drainage of pneumothoraces. The times of perforation varied from 1-10 days of life and were usually associated with passage of oro-gastric feeding tubes. All perforations healed without surgical repair. No mortality or morbidity occurred in any of our patients secondary to these perforations. A review of these eight cases, and an additional seventy-four cases from the literature, revealed no difference in outcome between early surgical intervention and medical management. While certain complications such as mediastinal mass formation are definite indications for surgical drainage, most neonatal perforations of the pharynx or esophagus can be initially managed medically. Medical therapy with close observation for signs of sepsis and/or mediastinal changes will enable most newborn infants to avoid the stress of surgery and identify those infants where surgery is definitely indicated.