Baby Steps

Today’s opioid epidemic is the deadliest drug crisis in American history—one that’s made even more complex when considering the growing number of women who become pregnant while using opioids, both illegally and when prescribed for medical reasons. Women in this situation are often directed to and/or continue to use opiates throughout their pregnancies due to the risk of prenatal withdrawal and miscarriage if use is suddenly discontinued. As a result, their babies are born into an opiate-dependent state, experiencing Neonatal Abstinence Syndrome (NAS), which requires a complex and painful detoxification process in the days following birth.

Infants with NAS are typically cared for in a neonatal intensive care unit (NICU). But while NICUs specialize in the care of ill or premature newborns, they’re not well equipped to care for NAS babies, who require a quiet, dark environment with a dedicated caregiver who provides one-on-one care and immediately meets any need presented. Typically, NICU staff are not trained in the demanding therapeutic handling techniques needed to appropriately care for NAS infants. Additionally, there are a limited number of beds for critically ill infants and because substance-exposed infants can require several weeks to months of specialized care, NICUs can quickly become unable to care for the non-NAS infants for whom they’re originally designed.

A better solution for these NAS babies is a NAS specialty recovery center that’s designed with the right environment and that offers the appropriate type of care for substance-exposed babies. Opened in March 2020, the new Hushabye Nursery in Phoenix is the first such NAS recovery center in the state and only the third in the country. And while such facilities are specifically designed and staffed to care for NAS infants and their families, there are several obstacles to overcome in developing these projects, from securing the right occupancy and building permits to choosing the right design features to support babies’ recovery.

Right diagnosis
Simply put, the function of facilities like Hushabye Nursery can be defined as a residential facility for the detoxification of infants born to mothers who have an opioid dependency. This functional description and the appropriate facility type to care for such babies falls outside the typical healthcare facility “categories” used by local and state regulatory officials for construction approvals and permitting. This means that one of the first challenges for project teams is working with code enforcement representatives to change their perception of who the “patient” truly is and how that differs from what their codes and regulations were written to accommodate.

For example, there can be challenges related to occupancy levels and codes. The Hushabye Nursery facility has 12 patient rooms, which is greater than the five-room limit set by the City of Phoenix for similar care facilities where patients are incapable of self-rescue in the event of a fire or other emergency. To counter the city’s concerns, the designers and clinicians explained how the staffing model at Hushabye of one-to-one care with the parents or other assigned care providers would provide for 24/7 coverage, so that in the event of an emergency such providers can carry the babies out of the building directly. After considering the unique operational model, the city allowed the greater occupancy level within the new facility.

The Arizona Department of Health Services (AZDHS) also presented similar code challenges to the development of the facility. By AZDHS’ definition, the nursery falls under the category of a behavioral health facility, which has the added design and construction cost burden of installing anti-ligature devices and fixtures to prevent patients from self-harm or harming healthcare staff. To address this issue, the project team described that the NAS babies acquired their dependency as fetuses and as newborns they’re not capable of harming themselves or others, making such devices and fixtures unnecessary at this facility. After several rounds of discussion and explanations, AZDHS agreed that the facility would not be required to meet the ligature-resistant requirements due to the age of the residents and granted Hushabye Nursery approval to proceed with construction and occupancy.

While states and local municipalities have differing codes and regulations, projects like Hushabye Nursery provide examples of how to work closely with officials to educate them regarding the care of NAS babies and how these facilities can be supportive to their unique needs without disregarding the codes and regulations designed to protect the safety and welfare of the public these agencies represent.

Right “design” prescription
As a nonprofit organization, Hushabye Nursery had limited funds for facility development and sought an existing commercial property that could be economically renovated to meet the facility’s unique needs. The 8,000-square-foot facility is organized into public and private zones. Reception, family service spaces, counseling, and staff education areas comprise the public zone in the front of the facility, while the baby and caregiver spaces are located toward the rear of the facility in a private area.

NAS babies are in a state of agitation from the opioid withdrawal and need an environment with reduced stimuli, low noise levels, and low lighting levels including avoidance of daylight. To address this, the facility’s patient rooms have minimal windows for daylight, offering instead controllable lighting based on tolerance needs of each individual baby. The 12 private rooms for babies are located along isolated corridors, segregated from other nursery activities and the more public functions. Each private room has furnishings, such as an adult-sized bed, wardrobe storage, and rocking chair, to allow primary caretakers to room in with the babies, promoting social bonding critical for recovery and improved health outcomes.

With the one-on-one care, staff and volunteers work in shifts with the biological parents and are present in the room 24/7 with the babies, acting as caregivers and support. Spaces for daily needs of the care providers such as communal meal areas, showers, and separate toileting facilities are present for caregiver use in the baby zone, while remaining staff areas are centralized outside of the patient-care zone to further reduce unnecessary and undesired noise.

Growing need
More NAS recovery centers are needed not only in more regions of the country, but in every state and most major population centers that are under attack by the growing opioid crisis. In 2017, nearly 80 newborns were diagnosed with NAS every day in the U.S., which equates to almost 30,000 babies per year. This reality drives a national bed need for more facilities to serve this specialized patient population, as there are less than 100 beds currently in operation through Hushabye Nursery and two other facilities in the U.S. The right type of care environment for NAS babies can make a big difference by reducing drug dependency of these babies, lengths of stay for care, medical costs, and the impact the opioid crisis is having on the American healthcare system.

Matthew Kennedy, ACHA, is a senior healthcare planner at Orcutt/Winslow (Phoenix). He can be reached at kennedy.m@owp.com.

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