hospital planning and project management 1

Study MaterialOn

PGDHHM Correspondence Course

HOSPITAL PLANNING ANDPROJECT MANAGEMENT

COMPILED BYDr. Vivek Desai

POST GRADUATE DIPLOMA INHOSPITAL AND HEALTCARE MANAGEMENT (PGDHHM)

M.B.B.S, DHA, DBM, M.Phil

Symbiosis Centre of Health Care (SCHC)

AUTHOR

Printed and Published on behalf of the Symbiosis Centre of Health Care byDr. Rajiv Yeravdekar, Hon. Director, SCHC.

Printed at Gayatri Graphics, Pune - 411 037.

2 SCHC HOSPITAL PLANNING AND PROJECT MANAGEMENT

DrVivek DesaiM.B.B.S, DHA, DBM, M.PhilVisiting Faculty SIMS

All rights reserved. No part of this work may be reproduced in any form, bymimeograph or any other means, without permission in writing from theSymbiosis Centre of Health Care.

PREFACE

The future of healthcare industry in India will see a continued strong demand forconstruction of health care facilities, including completely new or replacementfacilities and projects involving major additions and modernization. The annual valueof healthcare construction projects will see a upward trend in the immediate yearsahead owing to various factors like opening up of the insurance sector, privatizationinitiatives etc. Therefore planning and design will continue to merit prime emphasisamong several responsibilities of hospital officials. Because of the changing characterof facilities and continuing increase in their complexity, planning and design willassume greater importance than ever before. Thus planners, architects, builders,hospital executives, board members, medical staff representatives, and others whopossess responsibility for undertaking hospital construction projects should havebasic understanding of planning process and of appropriate concepts of hospital andrelated healthcare facility design objectives.

There are very few areas where human factors and human requirements play such acritical role as they do in hospital design. The need for collaboration between thosewho care for the sick and those who plan healthcare facilities is of the most criticalimportance. A close look at almost any hospital department today demonstrates howfar short we fall in meeting the human factor goals of well being and general efficiencyin hospital facility planning. It was Florence Nightingale who so succinctly pointed out“the very first requirement of a hospital is that it should do no harm to the sick.” Shewas referring not only to the clinical care of the sick, but also to the generalpsychological well being of the patient. There have been numerous instances inmodern day hospital care whereby hospital acquired infections owing to faulty air-conditioning, inadequate water supply/drainage etc. have resulted in patientmorbidity and even mortality.

One should define planning as the specification of the means necessary foraccomplishment of goals and objectives before action toward those goals has begun.Planning involves a particular kind of decision making in which one has to specifyalternatives and choose among them. Once the goals are set, alternative plans can beexamined in the context of the opportunities and constraints facing the promoters. Inundertaking any complex project, it is advisable to examine the experience of others insimilar situations and hence such information should be elicited and properlyinterpreted. The basic design of a hospital usually is carried out by one or twoindividuals, who reflect the labor of the entire planning team in a series of drawings.The quality of the facility planning effort is ultimately dependent upon designers,who, it is to be hoped, are capable of interpreting complex relationships, internal trafficflows, technological requirements, and operational procedures to the extent that afacility of beauty, reasonable cost, and optimal utility will result. No other activity is in

HOSPITAL PLANNING AND PROJECT MANAGEMENT SCHC 3

the planning continuum is more important than that occurring in the design phase.

Like any other industrial venture, proper planning of hospitals is vital for success ofthe venture. It is beyond doubt that if hospitals are properly planned andprofessionally, there can be substantial surplus/profit that could be made. The firststep is proper project conceptualization with the right mix of beds and facilities togenerate sufficient income and to attract maximum clientele. For this acomprehensive market research may be required to assess the need, demand, andsupply for health care services apart from evaluating competition. A detailed financialfeasibility report would then show the promoters the viability of the project subject tovarious scenarios like effect on profitability with change in the debt/equity ratios,project cost escalation, etc. Such studies if conducted, will go a long way in avoidingfinancial mishaps, which have taken heavy toll in many a project.

Once the decision is taken to build a hospital, the next step is its architectural design. Adetailed architect's brief has to be first prepared to enable the architect in drawing uphis plans. The landscape, facility mix, bed mix, availability of utilities in the vicinitywill have to be considered. Considerable inputs from the other agencies like air-conditioning, electrical, plumbing, etc. will be required to finalize the working planfor the building. Inputs from the equipment vendors especially in specialty areas likecardiac catheterization laboratories, CT-scanners, MRI's, linear accelerators,operation theatres etc will be essential. One thing very common in India is the lack ofemphasis given to support services like kitchen, laundry, CSSD, back up electricityand so forth. Not only are these services vital, but these also have high capital cost andrecurrent expense and hence should be properly planned.

This module is divided into three parts in order to stress the concept of an integrated

and coordinated hospital planning.

(1) The first section is devoted to conceptualizing a hospital project in terms of the

facilities to be planned in the center. This will deal with understanding the

regional demographics and requirements of health care delivery systems in the

defined geographic service area. It entails undertaking secondary data collection

and conducting market research surveys. This will enable the student to

understand the nuances of technical and financial feasibility of a hospital project.

(2) The second section deals with the planning and design aspects of hospital

buildings and will also trace historical and future development in the field of

hospital infrastructure. There will be descriptive narration to assist the student in

understanding the important planning criteria for hospital departments.

HOSPITAL PLANNING AND PROJECT MANAGEMENT4 SCHC

HOSPITAL PLANNING AND PROJECT MANAGEMENT

CONTENTS

No. Chapter Page No.

1. Planning Process and Market Research ...............................................7

2. Feasibility Study...................................................................................11

3. Hospital Planning Historical Growth ..............................................15

4. Essentials of Hospital Design .............................................................22

5. Steps Involved in Hospital Design ....................................................35

6. The Design Process...............................................................................54

7. Planning of Inpatient Wards ...............................................................62

8. Planning of Clinical Departments ......................................................68

9. Planning Support Services in a Hospital..........................................126

10. Disaster Management .......................................................................144

11. The Hospital Project Team ...............................................................165


About the Author :

M.B.B.S, DHA, DBM, M.Phil

Dr Vivek Desai


CHAPTER 1

Healthcare in India

Stakeholders

PLANNING PROCESS AND MARKET

RESEARCH

Healthcare in India is in a developing stage and it needs a radical policy shift at

government level to propel in the future to face the challenges of the future. Under the

umbrella of health care providers are outpatient set-ups, nursing homes, hospitals,

medical colleges, health spas, diagnostic centers, ayurvedic and naturopathy centers,

hospices, old age homes etc. Most of theses institutions will have varied needs, which

will differ vastly in terms of their planning needs. Health care provision in India is

different in rural and semi urban settings where it is more unorganized to modern day

super specialty centers where it more institutionalized. The sector suffers form long

years of neglect by the government in terms of priority funding despite being a basic

need of the community. The mechanisms for funding are fast changing to the private

sector involvement thereby pushing up the cost of both setting up hospitals as well as

availing health care in these hospitals. The lowering of interest rates over the years

have no doubt helped the cause of the private sector wherein more entrepreneurs are

coming forward to set up hospitals as it has become affordable to take loans and repay

them. The burgeoning growth of the insurance sector is equally helping the

community to face the problem pf spiraling health care costs.

There are innumerable stakeholders in the health care delivery domain including the

government, philanthropic trusts, educational institutions, corporate sector, insurance

companies, bio-medical vendors, architects, construction companies, patients,

relatives, the pharmaceutical industry, professionals like doctors and other para-

medical staff, and the funding agencies. Given the wide spectrum of stakeholders, the

industry growth will benefit many in the population.

The hospital ownership pattern can be basically three types:


i) Government owned - central / state / district / autonomous like army, railways etc

ii) Not For Profit Managed by Trusts / Societies

iii) For Profit Corporate Sector

The opening up of the economy has definitely helped the cause by brining in the

accountability on various stakeholders. Even the government funding is now aided by

multi-lateral agencies like the World Bank, UNICEF, European Commission, WHO etc

wherein sustainability of the initial capital expenditure is the main concern. This is no

doubt helping us to improve the delivery mechanisms. The private sector too is

developing, aided by growth in health insurance and the industry per se is moving

towards a market economy concept throwing up cafeteria choice for the consumer.

Adding fuel to growth is the concept of medical tourism wherein Indian hospitals are

gearing up for the challenge of treating foreign patients. This needs a definite focus on

hospital planning as we have to meet the global standards, which by far exceed the

ones followed until the recent past.

Project Conceptualization

The first step in hospital planning is to freeze the project concept in terms of :

Identification of the market needs

Finalization of the facility mix

Deriving the appropriate size of the project

Determining the possibility of getting skilled manpower

All the above factors have a bearing on the project cost and its viability in future. This

process understands the need of the community that will be served by the hospital in

the given geographic location. For doing this, one needs to undertake a detailed

Market Survey by collecting secondary data from various sources like the internet,

libraries, media publications, news paper archives, ministry of health and district

health departments records etc. Unfortunately India does not have a reliable

mechanism for capturing health related data especially in the private sector. Hence,

one needs to undertake primary data search by conducting interviews with house

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holds, practicing doctors and visiting existing institutions. There can be three types of

surveys required:

a) House Hold Survey : This is essentially done to understand the health care seeking

behavior pattern of the community as a whole. Sampling techniques are used to

map the statistically significant number of households. The basic information

which should be collected and analyzed is as follows:

- Demographic details of the family- Education & Income details- Disease profile in last three years- Choice of health care provider for minor & major ailments with reasons- Method of payment for availing healthcare- Their feel on deficiency in health care market- Critical success factor for the proposed project

b) Doctor's Survey : Medical professionals are normally the best judge of the

deficiency in the health care market and need to be interviewed carefully to

identify the project concept that would succeed in the geographic service area. The

sample of doctors to be interviewed should include professionals from all

possible faculties in medicine and surgery including those from diagnostic

divisions like laboratories, imaging, physiotherapy etc. The basic

information to be collected and analyzed from them would be :

- Personal details on specialty, qualification, experience etc- Area of practice and hospital attachments- Patients seen and their drainage area- Referrals to other hospitals/diagnostic centers with reasons for referring- Views on deficiency in health care market and solutions for same- Patient's capability to pay- Critical success factors for a hospital project in the service area

c) Institutional Survey : Getting a basic feedback on the competitors in the primary

service area of say 5-10 km radius would be important to assess the strengths and

weakness of major players. One would also need to know the productivity, tariffs,

salary structure etc which would help us in preparation of the feasibility report.

The important information to be collected would be as under:

- Ownership with historical growth pattern


- Service Mix (diagnostic, therapeutic, medical, surgical, support services)- Bed mix- Productivity of major services- Tariffs of major services- Bed to manpower ratio- Technology level- Annual revenue/expense in last 2-3 years to understand growth pattern

Data Analysis :

The data collected through secondary and primary sources is then analyzed to identify

a proper facility mix for the proposed project. It will also determine the scale pf the

project in terms of its bed size. In case it identifies some atypical need like cancer

treatment, it would perhaps need more research to understand the profitability of such

capital intensive specialty. The end result should give definitive information on the

following:

i) Specialties to be practiced in the proposed projectii) Number of OPD rooms

iii) Bed mix with break up

iv) No of operation theatres

v) Diagnostic services

vi) Blood bank

vii) Support services

In case the project is to be developed in phases the facilities to be phased should be

clearly identified as the engineering services and areas for the phased development

will have to be carefully planned.



CHAPTER 2

FEASIBILITY STUDY

After finalizing the Project Concept in terms of its facilities and size, the next important

step is to analyze its financial viability. This will also help the promoter in planning the

means of financing the project based on its profitability and capability of servicing the

debt proportion.

The first step of the feasibility process is to identify the cost of the project in a realistic

manner. Many projects have failed midway through construction process wherein it

was identified that the cost overrun would be in more than 50% of the estimated

budget. Hospital buildings are very complex in terms of its engineering needs and

hence specialized agencies are required to plan these and identify the cost. The cost of

the project should be broken down under the following heads:

I) Civil Works including RCC, masonry, doors, windows, interior, and

façade treatment

ii) Electrical Works

iii) Plumbing and fire fighting

iv) Air Conditioning

v) Landscape and site development

vi) Elevators

vii) Medical equipment broken down under departmental heads

viii) Non medical equipment like kitchen, laundry, computer hardware & software etc

ix) Hospital furniture and fixtures

x) Professional fees

xi) Pre Operative Expenses

xii) Municipal Taxes & deposits

xiii) Interest during construction

xiv) Contingency

The estimates for all the above should be compiled meticulously after detailed

discussions with experts and undertaking adequate research. Financial institutions

also required sufficient back up data to accept the costs before accepting the project for

funding.

After compiling the project cost, the next important step is to ascertain the income from

the project from various heads. Whilst doing this, one would rely heavily on the

institutional market research to understand the industry benchmarks for making

assumptions. Income assumptions will need to be made for the following income

heads:

i) Room rents for all categories of beds like general ward, twin/single rooms,

ICU, NICU etc.

ii) Departmental income for diagnostic services (lab, radiology, EEG, EMG,

non-invasive cardiology, audiology, cath lab, refraction etc)

iii) Income from OPD & IPD consultations

iv) Income from surgical operations (major and day care surgeries)

v) Health check schemes

vi) Pharmacy

vii) Emergency

viii) Dialysis

ix) Deliveries

x) Blood Bank

xi) Emergency

xii) Any specialty service like LINAEC, IVF, Angioplasty, Minimal Invasive surgery,

organ transplant etc. will need to be separately assessed

For calculating the income some important assumptions will need to be made with

regards to the number of OPD/IPD days in a year, bed days available depending on

the bed capacity, average length of stay (ALOS), number of admissions, number of

operation theatres, number of OPD rooms etc. These assumptions form the important

basis for assuming a realistic productivity for various departments which when

multiplied with an average tariff rate will give the income on an annual basis. An

example for assumption is given below:

Income Assumptions:



Number of beds - 100

Number OPD days - 300

Number of IPD days - 365

Bed Days available - 100 x 365 = 36,500

ALOS - 5 days therefore no of admissions

= 36500/5 = 7300/annum

Number of theatres - 4 , No of surgeries / OT / day

= 4, therefore surgeries/annum = 4 x 4 x 300

Number of OPD - 10, no of patients / OPD / hr = 4,

No of OPD/annum = 10 x 4 x 10 hrs = 400

Number of X-ray - 1 per admission for IPD and 10% of all OPD cases

One has to assume such productivity for all departments by using sound logic and

keep cross checking it with some industry benchmark. All income is calculated on

100% capacity utilization and then adjusted for year wise utilization as % in year 1, year

2, year 3, till year 10. It is important to include all heads of income as may be possible.

The next important step is to compute all the important expenditure heads for the

project operations. These heads would include the following:

I) Salaries and wages these should be computed on a cost to company basis and

should take into a staffing pattern inclusive of those for leaves, contract labors etc.

ii) Departmental expenses in terms of consumables. This could be arrived as

percentage expense to the departmental income by taking industry benchmarks

iii) Professional fee payable to doctors for rendering clinical services. This would

differ from assuming a flat salary to incentive based remuneration. Again

industry benchmarks will have to be followed for same. Some hospitals have a

mix of both the options

iv) Energy costs in terms of electricity, water, medical gases, generator

v) Food expenses for patients and staff

vi) Laundry & linen expenses for patients and staff

Expense Assumptions:

vii) Housekeeping expenses can be calculated on a per sq ft basis for the building

viii) Stationery expenses

ix) Telecommunication

x) Conveyance and car maintenance

xi) Marketing expenses

xii) Repairs and maintenance

xiii) Insurance, Legal and Audit charges

xiv) Miscellaneous expenses

xv) Depreciation

xvi) Interest cost for loans taken

xvii)Taxes for corporate hospital

After computing the income and expense statements as mentioned above, one arrives

at the various financials such as Profit & Loss statement, Balance Sheet, Cash Flow,

break even analysis. After computing these statements once can undertake sensitivity

analysis by subjecting the project assumptions certain changes and evaluating the

impact on profitability like:

- Change in debt to equity ratio

- Change in interest rates on the loan taken

- Change in capacity utilization over the five year period

- Effect of cost escalation

Such meticulous financial analysis will give the promoter confidence to decide on

whether to undertake the project or not. This also helps them to arrive at a proper debt

to equity ratio for the project.

Financial Statements:



CHAPTER 3

HOSPITAL PLANNING - HISTORICALGROWTH

The hospital as an institution offering care to those who need it is of great antiquity.

The modern word is derived from the Latin hospes (“host”), which is also the root for

the words 'hotel', 'hospice', and 'hospitality'. The earliest examples approximating the

institutions we call hospitals, however, were the Egyptian temples of 4000 years ago.

The association of religion and medicine was a natural one in many ancient cultures.

Originating in the time of the matriarchal goddess religions, when the cyclical process

of nature and women's ability to give birth were revered, the relationship between the

midwife and the woman giving birth was the first healer-patient relationship. In

primitive societies those seen as holding mystical powers came to acquire more formal

ones. Thus healing and believing brought forth the faith healer.

Early knowledge was gained both from intuition, as well as from watching animals

and then passing on the accumulated knowledge down through the generations.

Apart from primitive tools there was no technology and medicine was based upon

touch, comfort and belief.

The early Egyptians identified over 250 diseases and combined medicine with magic

and religion. As they developed the science of medicine, treatment and drugs, there

was parallel development in improvements to public hygiene and sanitation. The

Babylonians further developed medicine and records show that fees were charged for

a healer's service. Yet it was the Greeks who gave us Hippocrates and the famous oath.

Greek buildings used for medical care were still similar to temples. The Greeks

however viewed healthcare in a natural and totally holistic framework. The Greeks

assumed, as only natural, that healthcare treatment should include music, poetry, arts

and good cuisine. Temples dedicated to Asclepius were noted for their cures.

The idea of an institution created specifically to care for the sick appeared in Hindustan

in the third century B.C., and in first century Rome. In Hindustan, the king Ashoka is

credited with establishing some 18 centers for treating the ill. There were physicians

and a nursing staff, and the expense was borne by the royal treasury. Hospital style

institutions appeared in China in the first millennium A.D., as part of a state supported

care system, while in Rome there were special institutions for slaves, gladiators, and

soldiers.

From about 500 BC to 475 AD the Romans assimilated medical cultures from the

territories that they inhabited. Generally, the Romans, as the Greeks, provided

healthcare in the community. The Roman hospital was built upon a military regime

within a rigid institutional setting. Thus the early example of what has become known

as the medical model was indeed based upon the military model, that is, the provision

of care within an ordered and military setting.

The early Christian era, between 1 and 500 AD brought the return of women in the role

of healers through the Church and convents. It was the Christian commitment to care

for the sick, to comfort the lonely, and to feed the hungry which motivated the

prodigious growth of hospices, orphanages, old age retreats and hospitals proper

throughout the medieval world. The first Christian Hospital was completed between

368 and 372 AD. During the chaos that followed the collapse of the Roman Empire

between 500 and 1000 AD, monasteries retained the teachings of the early Greek texts.

Monks used their knowledge of medicine and herbs to care for the sick and the term

hospital was synonymous with offering hospitality, i.e., refuge from the ravages of the

outside world. Clarity of form was lost during the medieval Christian period, and

hospitals once again became indistinguishable from medieval architectural forms.

In the medieval west, as in the east, the church bore primary responsibility for

developing institutions of care. Among the hospitals built by it was the Hotel Dieu,

founded by the Bishop of Paris in the seventh century, which today is the oldest

working hospital in existence. Hospital facilities expanded radically from the eleventh

through the fourteenth centuries. The Crusades were in part responsible. The

crusading orders built hospitals in Germany and throughout the Mediterranean

world. Royal and noble families also contributed to the growth. England's first hospital

was built at York in 937 by Athelstan, a grandson of King Alfred the Great. In the

twelfth and thirteenth centuries, when Europe was in the grip of a vast leprosy

epidemic, hundreds of leper asylums or leprosaria were built. It has been estimated

that in 1225 there were 19,000 leprosaria in Europe. As leprosy declined, some of these

leprosaria became hospitals. Thus the Hospital des Petits Maisons outside Paris which

began as a leprosaria was alter used for indigent syphilitics and mentally disordered

pilgrims. When the bubonic plague struck Europe in the fourteenth century, the

leprosaria were the first plague hospitals.HOSPITAL PLANNING AND PROJECT MANAGEMENT16 SCHC


During the seventh century, the rise of Islam led to the Muslim conquest of many

countries. Islam inherited a rich medical tradition, and by the ninth century it had

established a sophisticated medical system. Hospital complexes were constructed at

Baghdad in the ninth and tenth centuries which employed up to 25 staff physicians,

which maintained separate wards for different conditions, and which gave medical

instruction. Thirty-four such hospitals have been identified in Muslim cities from

Mughal India to Spain. Islam, like Christianity, emphasized the community's

responsibility for those who needed help.

Byzantium's political resurgence under the powerful Macedonian dynasty in the ninth

and tenth centuries brought further hospital construction. The famous Pantocrator,

which was begun by John II Comnenus in 1136 was built as part of a complex of

buildings which included a sumptuous church, tombs for the ruling dynasty, and a

monastery. This hospital was the greatest achievement of the long Byzantium

tradition. The hospital comprised 50 rooms which were divided into 5 departments.

There were 5 rooms for surgical cases, 8 for acute illnesses, 10 each for men and women

with various complaints, and 12 for gynecological cases. The remaining 5 were

available for miscellaneous use, including emergencies. Each department had a staff of

two physicians, five surgeons and two nurses or attendants. There were also an out-

patient department for ambulatory cases, a pharmacy, baths, a mill and a bakery.

Later, in classical antiquity, the rational processes of thought were reflected in the plan

form, which gradually evolved a character of its own. Order and clarity became

evident and clear patterns of circulation were delineated and attention was paid to

functional groupings. More scientific methods of healing appeared throughout the

Renaissance period, 1400 - 1700 Ad. This was also the time of Michelangelo and

Leonardo da Vinci who saw the integration of art, invention and medicine.

In England the traditional role of the Catholic Church in healing and medicine

declined as Henry VIII broke away from Rome. The closure of monasteries by him and

the resulting loss of there medical expertise was a spur to the development of the

medical profession, which then developed outside it's religious origins. He

encouraged and gave authority to physicians, granting the College of Physicians a

charter in 1518. The years 1550 to 1850 were the dark period of nursing. Women were

assigned nursing duty in lieu of a jail sentence. Many hospitals fell into decay, and

unsanitary conditions, epidemics and diseases were common. The hospital was seen

as a place to warehouse the sick and dying and not necessarily a place for care and

treatment.

By the end of the sixteenth century, monarchs and municipalities had become the

prime movers in hospital development. In France, as in most continental European

states, the central government took responsibility. In 1656 the Cardinal Mazarin

created the Hospital General in Paris. These hospitals showed the evolution of the

medieval concept of care into the secularized one of the sixteenth and seventeenth

centuries. Though much larger and administratively complex than their medieval

predecessors, these institutions were similar in that social functions were

fundamental, while treatment was of minor importance. A further change, however,

was coming. Vesalian anatomy, William Harvey's circulation theory, and a growing

interest in clinical medicine were giving hospitals a new significance. It was there that

the actual sick could be observed, that medical applications of scientific discoveries

could be made most conveniently, and that students could be taught. Bedside

observation and teaching began in 1626 at Leyden and Utrecht, won support from

leading English scientists including Sir Francis Bacon, and through the work of

Hermann Boerhaave, the Leyden clinician and one of Europe's greatest teachers,

gained a European following. Even so, the transformation of the hospital into a

medical institution was not complete for another century and a half.Between 1700 and 1850 the foundations of the modern hospital system were

established. The number of hospitals increased, the quality of medical practice

improved, specialization advanced, and the emphasis shifted from care towards

treatment and cure. The process was most rapid in England, whose 18th century

development was phenomenal, but by the middle of the 19th century most European

societies as well as the United States had established a basic hospital system. In the

American colonies the first hospital was founded in Pennsylvania in 1751, with

Benjamin Franklin as a Trustee. Throughout the entire period of development, two

contrasting systems for planning and financing hospitals appeared. In England and

America, private funds and independent boards were the norm. On the Continent,

central governments and public funds led the way. The American hospitals served a

social need, but their staffing with trained physicians as both house physicians and

consultants showed an orientation from the beginning towards treatment and cure.

The brilliance of French medical scientists both before and after the revolution was

unconnected with the state of hospitals or other institutions. At this time, hospital

reformers, activated by a humanitarian concern over the real suffering of those

unfortunate enough to be hospitalized and convinced that an enlightened age had the

means to relieve it, began to agitate for changes. John Howard, an English prison

reformer who became interested in hospitals, was probably the person who did the



most to popularize reform ideas on the Continent. He was particularly emphatic about

the need for cleanliness and fresh air to combat the deadly miasmic vapors which were

thought to be responsible for illness, infection, and high mortalities.Probably the most important 18th century Continental hospital was Vienna's

Allgemeine Krankenhaus (general hospital) built by the order of the emperor Joseph II

in 1784. This hospital epitomized the Enlightenment absolutist's approach to medical

care and public health through administrative centralization and rationalization of

function. It also showed the growing conviction that hospitals were primarily

institutions for treating sick people, while its provision to accommodate both the poor

and paying patients struck a modern note. Vienna's influence was also significant

throughout other parts of Europe, appearing in a series of 100- to 200-bed hospitals

built between 1784 and 1850.The combination of further scientific study and epidemics such as cholera in the

United States from 1830 to 1850 created a demand for more hospitals. As hospitals

grew larger, so the incidence of cross-infection became greater. A big turning point for

health-care was the Crimean War. In Crimea, Florence Nightingale gained fame for her

nursing skills. At the end of the war Nightingale became committed to designing

hospitals. She devised a series of concepts that had to do with light, air and cleanliness.

She understood the need to plan care buildings to avoid cross-infection. The

dramatically low mortalities in her temporary barracks at Scutari made her a nearly

irresistible influence on questions of hospital organization and architecture. She

introduced a regime of greater cleanliness and order and the now famous Nightingale

ward, born out of the need for a stricter regime of care and discipline, left an indelible

mark on the subsequent planning of healthcare buildings.Both in the Crimean War and in the American Civil War, a need was recognized to

improve medical care through cleanliness, discipline and scientific rationality. Both

sides built large temporary military hospitals which were considered models of

organization and further proof for the 'fresh air' thesis. Treatment on the battlefield

became the generator for new models of care planning. Surgery until then was always

seen as a last resort. The outcome was invariably poor due to cross-infection and pain

must have been horrendous without proper anesthetic. Yet towards the end of the 19th

century, with Louis Pasteur's and Joseph Lister's understanding of living organisms

and methods of antiseptic, the surgeon came to the fore. As it became understood that

surgery was best undertaken in antiseptic conditions, the importance of the hospital as

the focus of healthcare treatment became further established. X-ray technology, which

developed first as a diagnostic tool, became a form of therapy requiring special

instrumentation and facilities; while advances in biochemistry opened a wide variety

of treatments and diagnostic tests which only a fully equipped laboratory could

perform. In much the same way that manufacturing technology shaped the factories

and shops necessary to its efficient use, medical technology influenced the

development of the modern hospital. The key dates may said to be :y 184The discovery

of anesthetics, which spread throughout the Western world within a few years.

1866-9-Lister's use of carbolic sprays for antiseptic surgery, which by

combating infection enormously reduced the number of post-operative fatalities.

1886 - Von Bergman's introduction of aseptic techniques, the sterilizing of

instruments and the use of autoclaves.

1895 - Roentgen used X-rays as an aid to diagnosis. Instead of relying on their

five senses, doctors now had the possibility of confirmation in black and

white. Laboratories similarly added a new dimension to medicine and

enormously extended the use of pharmaceuticals.

Not until the late 18th and early 19th centuries was hospital planning treated on a

functional and scientific basis. Then the 'pavilion' type plan evolved, segregating

patients into small groups and ensuring natural light and ventilation. Two other

factors led to this kind of planning. Fear of contagion led to segmentation into

increasingly isolated pavilions, and differentiation of the medical profession led to the

organization of many pavilions into specialty departments. The period from the turn of

the century to the present day has seen the architectural forms of hospitals change from

low horizontal pavilions to a vertical mono-block.

With the discoveries of X-rays and radium, the diagnostic approach to healthcare

became bound to a building rather than being brought to the people. Technological

advances accelerated throughout the 20th century. Each bore the need for new

equipment, with technology further centralizing and emphasizing the place of the

hospital as the main focus of medical skills.

After World War II, major factors influencing the evolution of hospitals in the US were

primarily internal in nature. Major design influences related to changes occurring

within a particular hospitals medical staff or those produced by new treatment

modalities and equipment. External forces played a relatively minor role in

influencing design, and the evolution of one hospitals facility was little influenced by

any other institution, except during periods of competitive action.

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During the 1960's, architectural firms in the US specializing in hospital design directed

their efforts to developing new programming techniques, applying systems theory to

planning, and updating departmental planning through functional analysis. The space

age that flowered in the 1960s was another turning point for hospital design. Electronic

devices developed for NASA included CRTs (cathode ray tubes) for monitors and

imaging devices. With the 1970's came several changes in the health care system which

shifted emphasis in hospital design. The most important factors influencing the

physical organization of the hospital were no longer internal changes but external

constraints. Important forces of change were :

Federal government's participation in the health field.

Changing patterns of illness and new modalities of treatment.

A new emphasis on the treatment of chronic diseases

Extension of health care benefits to employees through OSHA.

The principal areas in which these changes made their impact on the physical plan

of the hospital were :

Size, type and distribution of inpatient care units.

Growth of outpatient services and increased emphasis on ambulatory care.

Role and design of emergency departments.

Inter-relationships of the various departments within a hospital.

Overall relation of the hospital to the community it serves.

Regionalization of the health care system.Scientific medicine administered through hospitals has proved to be very costly.

Publicly funded insurance and compensation plans and state-funded free medical care

have helped to ease this problem in Europe. In the United States private health

insurance has been the favored method. In the course of the 1970's, it became clear that

private insurance protection against high hospital costs was inadequate, and the

creation of a further national health insurance program has become a political issue. It

is also widely believed, however, that insurance programs have underwritten the

rising costs of hospital medicine while promoting unnecessary use of hospital facilities.

At the same time, rising costs have produced cutbacks in hospital services as well as

hospital closures, raising again the problem of accessibility to care for the poorest

groups in society.Today, the weight of economics, social values, and futurist ideas necessitates a

reassessment of this series of “gifts” of history. Some of these gifts have become

liabilities. The reasons for original design are important; if they are understood, it will

be easier to decide whether the reasons apply today. If not, new designs should be

created.

ESSENTIALS OF HOSPITAL PLANNING

CHAPTER 4

Choosing a Site

(1) The first consideration in choosing the site of a hospital is convenience for the

patients. In view of the increasing importance of the outpatient service given by the

hospital, convenience of access to patients is absolutely essential, and should take

priority over other factors in the selection of the site.

(2) The next most important consideration is that the site should be large enough to

enable the hospital to expand and develop in the future. Central positions, in urban

areas, are in great demand; it is often difficult, to find a site big enough for a hospital in

a central area. Sometimes there is a fairly well developed main residential area, and

the hospital can be sited in a central position in relation to this. Sometimes it is known

that the town is going to expand in a particular direction; and it may be possible to find

a large site fairly near the periphery of the present town that will, in due course,

become central to the major residential area.

(3) Close collaboration with town-planning authorities is necessary in choosing the

hospital site. In determining the area for the hospital, preliminary calculations are

necessary. These will show the approximate total volume of the building, and the site

area must be related to this. The degree of crowding on a site can be considered in

terms of “plot ratio”. This is the ratio of the total area of the building on all floors to the

area of the site. A “plot ratio” of one represents a building whose total floor area is

equal to the area of these site that is to say, if the hospital is to be a two-storey structure,

half of the site will be covered with buildings and the other half will be available for

open space, access roads, car parking, and so forth. For purpose of reference, it may

be assumed that a plot ratio of two to one is the greatest that should be considered for

hospital development, and that this ratio is acceptable only in the centers of cities,

where a high density of building is the rule. Generally speaking, it will be found that

hospitals developed at a plot ratio of two to one will give a crowded site, high

buildings close to one another, very little open space, and a certain amount of

overshadowing and overlooking between the buildings. In suburban and rural areas,

a site should be sought and given plot ratios of 0.5 to one or less. The degree to which a

site may be built up will depend, to some extent, on whether the hospital is in an



urban or rural area, on the climate, and on the general character of buildings in the

neighborhood.

(4) In most cases a site should be accepted only if it provides room for substantial

future growth.

(5) In principle, the site should be at least double the area required for the hospital as

it is originally planned.

(6) As soon as one or more possible sites satisfying the requirements as set out above

have been found, they should be surveyed by the architect, assisted by an

engineer.

(7) The site will need to have available, from public services, supplies of water,

electricity, and, perhaps, gas.

(8) It should also have main sewerage that is capable of carrying the hospital effluent.

If main sewerage is not available, the suitability of the soil for the installation of an

effective sewage plant will have to be investigated.

(9) It should also be established that the site is free from air pollution from adjoining

industries or other sources and free from insect vectors of disease.

(10) The proximity of sources of noise should be avoided.

(11) In hot climates, it is important that the site be exposed to breezes, and in harsh

climates, it should be reasonably sheltered.

(12) The bearing qualities of the soil will also require investigation; the risk of earth

movements, geological faults, or underground mine workings has to be

considered.

The first task of the architect is to prepare a master plan for the site as a whole. This

plan should take into account foreseeable future developments of the hospital as well

as the buildings erected in the first project. An architect who has specialized in hospital

construction will be able to prepare a hospital plan once the results of the early studies,

previously discussed, are available. At this stage there will be no schedules of

accommodation or detailed plans of the individual buildings, but an architect with

sufficient experience will be able to calculate the approximate volume of each building

from the general data that are available.

The Master Plan

The master plan is the equivalent of an exercise in town planning. It is mainly

concerned with establishing the circulation routes on the site and the relative

disposition of the various departments and buildings that make up the hospital. The

circulation routes on the site are of prime importance, and the success of the hospital

plan depends very largely on getting them right. A hospital has two independent sets

of circulation routes external and internal.

All the major departments need to be linked by internal traffic routes for the use of

patients and staff and for the delivery of supplies from the supply areas to their points

of use. A great deal of the interior traffic in a hospital involves the use of trolleys.

Bedfast patients are moved on beds or trolleys; food and supplies are generally also

moved on trolleys. Trolleys cannot be pushed up stairs, and all vertical circulation

points within the hospital therefore have to be provided with lifts. Much of hospital

planning stems from the problems of internal circulation and, in particular, the need to

localize vertical circulation, so far as possible, at certain key points. It is very much

more economical and efficient to concentrate lifts than to distribute them among

different parts of the building. Four lifts banked together will give the same service as

eight individual lifts distributed at separate points.

The external traffic within the site is considerable. Ambulances and delivery vehicles

need access to the buildings at various points. Staff and visitors to patients need car-

parking facilities. There is likely to be a point, or points, where the majority of

deliveries are made for the hospital as a whole, it is also desirable to have road access to

all major sections of the hospital, and certainly to any independent buildings that there

may be. This access will facilitate the bringing of heavy items of equipment close to the

point where they are to be installed. It is also necessary for the use of fire engines in the

event of fire in the hospital, and will facilitate the maintenance of the fabric of the

buildings.

In developing the master plan, areas have to be allotted within the site for each major

department of the hospital. These areas should always be large enough to allow for

each department to expand by additional building while remaining properly

connected to the circulation networks. Only if this is done will it be possible for the

hospital to grow in an orderly manner.

Certain broad principles for establishing the departmental zones may be set forth. The

parts of the hospital that are most closely linked to the community should be allotted

positions closest to the main entrance to the site.



These include the outpatient, casualty services and such offices or other facilities as are

needed to provide a base for domiciliary services. Next in order of distance from the

entrance should be a zone allotted to the medical service departments, such as radio

diagnosis and the laboratories. These departments receive a great deal of work

directly from the outpatient department and need to be close to it. Beyond this is the

area allotted for inpatient care. Apart from the areas of the hospital used by the

patients, there is a substantial area required for the housekeeping and domestic

services stores, laundry, kitchens, and boiler house. These departments are best

grouped together around a service yard, to which most of the delivery vehicles will go.

This service area should be independent of, the main hospital entrance. Staff housing,

which will take up a substantial proportion of the site, can best be placed around the

perimeter, to give the staff easy access to roads and public transport.The considerations set out above will need to be related to the nature of the site. In

many climates the orientation of buildings in relation to sunlight or to the prevailing

breeze will determine many aspects of the master plan. Many sites are sloping, and

this may provide both difficulties and opportunities in planning

The first requirement in providing for growth and change is room for expansion in the

master plan, but there are other factors that need consideration. The master plan can

develop in the form of (1) A very concentrated building, making use, where necessary,

of multi-storey blocks; (2) Or it can be comparatively loose, occupying more area on

the ground and employing lower buildings.The former approach will lead to a hospital, which is compact and in which the

distance from point to point within the hospital is minimized. There are many

advantages in a compact hospital,

(1) It saves the time of the staff,

(2) It helps to promote collaboration by making it easy for members of the staff to

meet one another.

(3) But the more the hospital is planned as a single, massive block, the more difficult

will it be to make effective provision for growth and change

(4) The concentration of all departments close to one another means that only a very

little space is available for each to expand

(5) Further concentration makes it inevitable that the buildings go up to a fair

Planning for Growth and Change

number of storeys; and to add to a department on the fourth or fifth floor of a block is

always difficult, and sometimes impossible. If such a department needs to be

extended, it means taking over space from some adjoining department above or

below it. This will involve massive redistribution and reorganization of many

departments. It is therefore necessary to weigh very carefully the advantages and

disadvantages of concentrated versus diffuse types of structure.

The principal factor in the decision will be the prediction of the amount of change and

growth likely to occur. It may be that some sacrifice in concentration during the early

years of the hospital's life will be justified in the interests of allowing for future growth

and change. The preparation of a master plan at an early stage will being this

consideration forward and enable the advantages to be weighed and a rational

decision to be reached.

It is essential to consider which parts of the hospital are most likely to require room for

growth and which are relatively static.

The increase in cases coming into the hospital results directly from the increase in

motor traffic, and sometimes from mechanization in industry; and there seems no

reason to suppose that further development in these directions will not cause

continued increase in casualty rates.

The medical service departments, particularly the radio-diagnostic service and the

laboratories, will generally need to be extended. The demand for these services by the

clinical staff is continually increasing as new methods of diagnosis and treatment

become available. Therefore, these departments should be planned to allow for

substantial growth and should, if possible be at ground level, or in two-storey

buildings.

The accommodation for in-patients may, as the services required on each in-patient

floor can be conveniently and economically designed to run up and down in a vertical

building, e.g., lifts can be planned to deliver food trolleys to the ward pantries of every

floor. The lavatories, bathrooms and sanitary rooms can be replaced one above the

other, making use of vertical ducts for plumbing services.

It may not be necessary to increase the total amount of in-patient accommodation

within a hospital. It will almost certainly be necessary to redistribute the

accommodation among the different clinical departments, whose relative

requirements for beds are likely to change within the life of the building. This can best

be provided for by having on each floor a single, general- purpose arrangement,



capable of taking any category or patient; then, shifting a user from, say, medicine to

surgery on a particular floor will not involve any structural change. Certain in-patient

accommodation - for children, maternity, infectious diseases, and psychiatry will

require special planning, As a result, the in-patient accommodation for these services

may best be planned as separate wings apart from the main block.

This is important criteria in country like India wherein there is diverse climate as we

move from North to South and East to West. In certain climates, building have to be

heated in winter or cooled in summer; and, in some areas, buildings may need both

heating and cooling, at different times of the year. Wherever this is the case,

concentrating the buildings as much as possible can reduce running costs. The more

spread out the hospital, the larger is the surface available for heat loss or heat gain and

the more expensive is the maintenance by artificial means of the desired internal

conditions.

The expense of cooling by air- conditioning is very great, far exceeding that of heating

in most climates. Therefore, wherever air- conditioning is deemed to be necessary, the

building should be designed in as compact a manner as possible. The cooling costs will

be directly proportional to the volume of the building, so the volume should be kept

down by the use of low ceiling and by restricting the size of rooms to the absolute

minimum. It is of vital importance that the decision should be taken at an early stage as

to whether cooling by air- conditioning is required, as the whole design of the building

will be affected by this decision. When in a hot climate it is concluded that air-

conditioning is unnecessary or impracticable, the design of the building must be

carefully considered in order to get the maximum natural cooling. In hot climates, air-

conditioning will always be needed for operating theatres and, very often, for recovery

wards, labor rooms, X- ray rooms, and other special areas.

There has been considerable research on the design of buildings for various tropical

conditions, and the results are available in the form of recommendations. It is worth

noting that the design of a building for comfort in a hot, humid climate is totally

different from that in a hot, dry climate. Broadly speaking, in the former air movement

past the body is the main objective. The buildings should be light and open and

planned so that even the slightest breeze can pass right through the buildings at low

level to cool the occupants. It is impossible to plan highly concentrated hospitals for

use in hot, humid climates without recourse to air- conditioning. In hot, dry climates,

the nights are cool, and the object of the building design is to protect the occupants

Considerations Based on Climate

from the fierce heat during the day. Buildings in these climates are therefore massive,

with heavy walls and small windows. The heavy walls absorb the daytime heat and

dissipate it at night. The small windows keep the amount of radiation entering the

building to a minimum.

In developing the master plan, attention must be given to the relation of building to

each other with regard to sunlight and shade. In cool climates, where sunlight is

desirable, buildings should not be planned so as to cut off one another's light. In hot

climates, the buildings can be planned to shade each other to some extent. The shadows

cast by the sun can be studied by means of models on a device known as the heliodon,

which simulates the movement of the sun. Architects concerned with the building of

hospitals in tropical climates should take care to familiarize themselves with the great

mass of valuable information now available on design for comfort.

In temperate climates, where the winters are not very long or very severe, it will not be

necessary to give great weight to the problem of heating in relation to the general plan

of the hospital, which can be designed primarily with other considerations in mind. But

in climates of extreme cold and long winters, where the cost of heating is heavy, some

thought should be given to making sure that the general plan results in a reasonably

compact building.

The methods used for heating and ventilation of the hospital are important, as bad

design can increase the risks of cross-infection.Massive ventilation is very

advantageous in reducing this risk. In warm climates, massive natural ventilation is

easily obtained and is desirable, for comfort. It will therefore be wise to rely, in hot

climates, on natural ventilation as much as possible and to have recourse to air-

conditioning only under extreme conditions.

In cold climates, the ventilation of hospitals during the winter presents difficulties, as

sufficient ventilation is apt to cause undue cooling by the introduction of cold air from

the outside. Any proposal for artificial ventilation or air-conditioning in hospital

buildings must, therefore, be submitted to expert bacteriological criticism before

adoption.

Certain areas of the hospital must always be provided with artificial ventilation or air-

conditioning. These include the operating theatres and any other areas where open

wounds are exposed to the air. These areas must be ventilated by special means to give

a high degree of air hygiene. The design of a ventilating plant for these purposes is

highly specialized, and must be entrusted to an expert.



Light and Color

Visual Impact of the Hospital

Windows light most hospitals. It is important that patients lying in bed should not be

exposed to too large an area of sky in direct view through the windows. Control of

glare from windows requires great care in design, and various special arrangements

have been proposed for this purpose. It is therefore important for the architect to

consider the design of the windows in the light of criteria that are now known to be

good for hospital purposes.

Criteria for the artificial lighting of hospitals by night have also now been established.

A note of caution is in order with regard to fluorescent lights: these may give rise to

difficulty for doctors and nurses who have to assess a patient's condition partly by

reference to his skin color.

Emergency arrangements for providing artificial lighting by a stand-by plant, in the

event of a failure of electric power from the main source, are always essential.

The color used internally on the walls, ceiling, and floors of a hospital is an integral part

of the design of the building and should be determined by the architect. The general

lighting of a room is greatly affected by the color scheme, and it is necessary for the

colors to be considered simultaneously with the design of the windows if the best effect

is to be achieved. Color can make all the difference between a depressing or

disquieting atmosphere and a restful or a pleasantly stimulating one. There now exists

an international color notation, and colors can be specified in relation to this.

Hospital buildings are very large. As the hospital is very often set in a residential area

among buildings of a domestic scale and character, the contrast between its size and

the small, scattered houses around it may be very violent.

Consideration of planning for growth and change tends to soften the visual impact of

the hospital. The parts of it that form its front door or shop windows are the buildings

for outpatient care, reception, and emergency care. These will almost certainly be

located nearest to the entrance to the site, and may very well be planned as

comparatively low buildings, in the interests of future growth and flexibility.

The architectural handling of the design will also affect the visual impact of the

hospital. The architect has the opportunity, in planning the hospital, to give visual

expression to the human units of which the hospital is composed, or to suppress these

divisions in the interests of uniformity. For instance, in designing a ward building, he

could allow each nursing unit individual expression on the façade of the building; or by

giving each unit an identical series of windows, he could carry uniform architectural

treatment over the whole.

More than a third of the cost of hospital building goes into the mechanical engineering

services heating and ventilating, electricity, lifts, and communications. These services

form the circulation and nervous systems without which the hospital cannot function.

Therefore, the contribution of engineers to the design is of capital importance. Their

help will be needed at an early stage, when the approximate demand for water, electric

power, fuel, gas, and sewerage is being estimated. Their advice will be needed on the

choice of site and on the master plan for the hospital. Later, they will have to design

systems of heating and ventilation, lifts and telephonic and other communications.

Engineers will have to concern themselves with the installation of all the mechanical

equipment also with its subsequent maintenance. They should advise the hospital

authority on maintenance problems at a very early stage in the design. They should

advise against the installation of any machinery or equipment for which maintenance

arrangements cannot be guaranteed. Decisions on these matters may affect the master

plan of the hospital, and they should be considered at an early stage.

The engineers must also collaborate with and advise the architect on the space that will

be needed in the building to house the mechanical services. This space must be of

sufficient size to allow not just for present services, but also for any future services that

may be required. The mechanical services must be planned so that easy access can be

obtained to all equipment for repairs and maintenance without disruption of the daily

function of the hospital. Provision must be made for stand-by power in the event of a

general power failure at the main source.

All these considerations point to the fact that a modern hospital can be built and

operated only if the town in which it is located is sufficiently well equipped with

electric power, potable water, sewers, and other technical infrastructures. In addition,

competent personnel must be available to maintain the mechanical and electrical

equipment; and spare parts and other essentials for repair must be obtainable. All

these resources must be fully developed and at the disposal of other institutions as well

as the hospital; it would be unrealistic to think that an isolated and self-supporting

hospital could bear the cost of such technical services only for itself.

Hospital Engineering



Hospital Hygiene

Another important factor is hospital design is the special attention that must be given

to conditions of hygiene. Hospitals exist to treat illness, and often act as reservoirs of

infections. Surveys have found that a substantial proportion of patients acquire

infections during their stay in hospital. The cost of extra patient-days in hospitals as a

result of cross-infection, bears heavily on the patients, sickness insurance and on the

national health budget. It is therefore essential to take reasonable precaution in the

design and organization of hospitals to minimize the risk of infection.

In addition to the risk to patients and staff, hospitals can also prove a danger to the

community if the arrangements for waste disposal are inadequate. The hospital's

sewage may contain dangerous organisms. Outbreaks of typhoid have been traced

back to pollution of the water supply by hospital effluents. The approval of health

authorities should be sought with regard to hospital sewerage and disposal

installations.

Introduction of antibiotic drugs substantially reduced the dangers of infection within

the hospital. As a result, many precautions in the design of the buildings and in the

methods of work by the hospital staff were abandoned or neglected. Strains,

particularly of Staphylococcus, have developed resistance to nearly all antibiotics

known at the present time. These resistant organisms tend to establish themselves in

hospitals, hospitals, whose staff often become carriers. It is therefore, more necessary

than ever to pay the strictest attention to all available methods of control of infections.

The first line of defense must be appropriate training of all staff in correct methods of

work. Staff must be trained in aseptic techniques for use in all surgical procedures and

in “barrier” nursing of infectious patients. It may be extremely useful to secure the

permanent advice of a technician with an engineering background in order to control

and periodically survey all the vulnerable points of the hospital, such as sewers,

drains, faucets, lavatories, sinks, and so forth. The design of the buildings can also do a

great deal to facilitate safe working by the staff.

One of the most important matters in planning a hospital is to consider the disposal

routes of all waste and infected material. In every part of the hospital where patients

are treated, there will be infected material to be disposed of. In wards there will be the

patients' bedding and infected utensils, and other waste material of various kinds.

Operating rooms and surgical treatment areas will have infected dressings, dirty

instruments, and soiled linen to dispose of. In principle, it should be possible to take

infected material away from its point of use without contact with any clean supplies

coming into the unit and with minimum handling by hospital personnel. In the

nursing units, soiled linen should preferably be taken immediately from the patient's

room to a disposal room, from which a lift or other special route is available to a

reception point where the linen can be sterilized or otherwise dealt with to make it safe.

Dirty materials should, in general, go into a bin, bag, or other disposal container at its

point of origin and remain in that container until it reaches a point at which it is

sterilized or incinerated.

It has been demonstrated that chutes are to be avoided at any cost, because they cannot

be cleaned and disinfected.Moreover, because of the possible difference in

atmospheric pressure between the upper floors and the basement, clouds of dust can

circulate through the chutes. Small lifts or vertical conveyors of the “dumb-waiter”

type should replace chutes.

It should noted that under no circumstances should nurses or other persons concerned

with the care of patients be required to sort or count soiled linen. The disposal route

from the wash-up room serving the operating theatre should be direct to the central

sterilizing department, and should not pass through the operating room or any other

room in the operating suite.

Blankets used on patients' beds are a special problem, as the wool blankets

traditionally used cannot be sterilized or laundered without becoming felted and

rapidly destroyed. Therefore, it is preferable to use blankets of cotton or other material

that can be boiled.

Cleaning methods can help or hinder hygiene. Sweeping and dusting as traditionally

performed are dangerous. They spread dust in the air and raise the bacterial count.

Wet cleaning by approved methods and vacuum cleaning by approved types of

machine with special filters must be the methods adopted.

Surgical instruments and bowls have, until fairly recently, been sterilized in boiling-

water sterilizers at various points in the hospital; and dressings have traditionally been

sterilized in drums in autoclaves. These methods have not proved adequate however,

and in recent years this type of sterilization has given place to sterilization in a central

department serving the whole hospital. It is recommended that new hospitals should

be planned, from the start, with facilities for central sterilization. Under this system,

all objects that require sterilization are supplied in sealed packages from the central

department to the point of use. After use, non-disposable items are returned to the



central sterilizing department for re-sterilization. In recent years many newdisposable

articles of equipment (e.g. syringes and needles, surgical bowls, and sputum mugs)

have come on the market. It may be found more economical to use these items than to

incur the cost of cleaning and re-sterilizing the conventional equipment after each use.

The planning and operation of the central sterile supply service require exper technical

advice. However, several authoritative reports that give guidance on the subject are

available. It should be noted that the adoption of a central sterile supply service, which

has gained favor on grounds of improved safety may have economic advantages as

well. It affects the planning of the hospital radically, inasmuch as it eliminates the need

to provide sterilization facilities in the nursing units, outpatient and casualty

departments, and many other points within the hospital. In addition, this type of

sterilization avoids the damage to paint that sterilization with boiling water causes.

Many surgeons like to have their own individual sets of instruments. It is more

convenient to arrange for these to be sterilized in a room adjoining the operating room.

All other requirements for operations, including dressings, bowls, syringes, and so

forth, can be supplied to the operating room from the central sterilizing department.

In planning operating rooms and treatment areas generally, it is of vital importance to

separate clean and dirty areas and to ensure that clean material goes directly to its point

of use without coming into contact with any used material or with personnel

concerned with the handling of used material.

Proper techniques by staff and effective sterilization of instruments, bowls, and

dressings will combat infection arising from contact. Many infections are air borne,

and air hygiene is a vital part of hospital design. Air-borne organisms through the

mouth and nose may infect patients and staff. Open wounds are particularly subject to

infection from air-borne organisms. Hence, air hygiene must be considered as affecting

the atmosphere in the hospital as a whole, and particular regard must be paid to it in

operating rooms and treatment areas in which open wounds are exposed to the air.

So far as the general areas of the hospital are concerned, it is important to ensure a good

general rate of ventilation, and standards have been established for this purpose. It

should be noted, in addition, that isolation rooms should be provided with special

ventilation arrangements to ensure that contaminated air from them does not reach

other parts of the hospital. The ventilation of operating rooms is a highly technical

matter on which important research has recently been conducted; it is now possible to

specify with considerable exactitude the requirements for the special ventilating

system needed in operating rooms. Such systems need very careful design by

engineers, and should be subjected to bacteriological control.

When hospital sewage is not passed into the public sewage disposal system, it requires

treatment by an effective disposal plant kept under continuous bacteriological control.

All hospital drains, including those from washbasins and baths, must be fully enclosed.

A central incinerator should be provided in which all infected material is destroyed.

Opportunities should be taken whenever possible to use disposable materials, which

can be destroyed.

The next stage in an actual project would be the preparation of the architect's brief. At

this point it is necessary to go into the needs of every service and department

individually and in great detail, always bearing in mind the general principles

governing the plan as a whole.

It is necessary to consider, first, the function and organization of each section, whether it

is the surgical service or the catering department. It is essential to decide on controlling

principles and to reach decisions on methods of working before attempting to draw up

schedules of rooms. At this stage advice should be sought from people with practical

experience in the running of the various services. It is important, however, to pose

problems in a general form to these advisers and to press them to think afresh to

consider not only how they have organized their work in the past, but also how they

would organize it for better service to patients, or for greater efficiency, if free to think

things out from first principles. Unless care is taken at this point, there is a risk that the

architect's brief will reflect, with minor improvements.

It is of the utmost importance in planning a hospital that a large measure of imaginative

foresight should be brought to bear in an endeavor to identify the probable growing

points and to plan the greatest degree of adaptability in those services that seem most

likely to expand.

The Architect's Brief



STEPS INVOLVED INHOSPITAL DESIGN

CHAPTER 5

Planning the Grid

'Grid' is defined by Merriam-Webster's Collegiate Dictionary as: “a network of

uniformly spaced horizontal and perpendicular lines (as for locating points on a map);

also: something resembling such a network.”

A planning grid is an architectural design tool which is “something resembling such a

network.”

Healthcare designers can derive their planning grids in one of the two following ways:

1. In urban situations, where the hospital takes the form of a vertical building

comprising of a podium containing diagnostic / therapeutic and interventional

services and a tower housing the inpatient facilities, the planning grid is determined by

the layout of the inpatient tower. The module(s) used to determine the shape and size

of this grid is the module(s) used to house the various kinds of inpatient facilities

(rooms + toilets) conceptualized by the designer. In the example given below you can

see how the planning grid modules (in red) of 3.90 M x 8.50 M is determined by the

accommodation desired for a single bed patient room, a double bed patient room and

their toilets.

Expanding on this with the addition of the access corridor and stringing the rooms out

in a line, as in the plan below, we see how the planning grid starts taking the form of the

“network of uniformly spaced…lines” we started with. Looking more closely at this

plan we can see something important has been added, namely, the positions of the

columns that will support the building. We can thus see how the structural grid, the

network of lines defining the location of columns, has been derived from the planning

grid. The structural grid need not necessarily be the same as the planning grid, but is

always derived from it.



The positions of the structural columns determined by this planning grid, twisted or

otherwise, will continue downwards through the rest of the hospital, through the

lower floors (the podium mentioned above) till their respective foundations, where

they will transfer their load to the ground below. Hence the lower floors (the podium),

which will contain the Operation Theater Suite, the Radiology and Imaging Sciences

Department, the Main Kitchen and the Mechanical Areas in the basement, to name just

a few, will all need to be designed within the constraints of these column positions.

Extrapolating from here, we can see how the façade of the hospital will need to be

designed in harmony with the windows of the inpatient rooms above, which will be

designed with the use of the planning grid. Even if the podium extends beyond the

footprint of the tower above, it is almost certain that the positions of the additional

columns required would be derived from the structural grid used for the tower, which

has been derived from the planning grid determined by inpatient facility design.

2. In semi-urban or rural situations, where the land available is very likely to be larger

with respect to the built-up area desired, determining the planning grid is another

ballgame, one with much greater flexibility in the rules.

In this situation, the planning grid will be determined by what designers call as their

'concept' for the hospital. This 'concept' is also an ordering tool, and will have been

used to determine the form of the hospital in even the previous example of the urban

site, but with less freedom. When there is a lot of land available, it gives the architect

more elbowroom, and his hand is likely to move with more (hopefully graceful)

abandon. This freedom enables many different types of building layout and form.

The thought process behind design can be described as a process of analysis and

synthesis or divergent and convergent thinking. That is, a 'parting' followed by a

'meeting' of thought within their minds. At the point of separation, the designer throws

up a whole lot of different ways in which he could define an ordering principle that he

would use to design the hospital. Suffice it to say for now that based on his / her chosen

criteria the architect will (converge) select one or a combination of concepts to provide

the ordering principle.The focus of our discussion here, the 'planning grid', in this situation gets relegated to

an almost incidental design tool, subject to great local variation if the structure is single

storied, and might vary substantially even if the hospital is partially high rise and

In vertically organized healthcare facilities, we design from the top down.

partially low rise, as the two forms of building could have planning grids independent

of each other. Façade design might also vary greatly, there being less discipline to be

followed.

Another important design issue in the planning of a hospital is the layout of the major

circulation paths.

Hospitals, like the small cities they are likened to, contain main circulation routes often

described as hospital streets. The way in which the different parts of the hospital are

assembled, as a coherent whole but with the parts differentiated, make for analogies

with urban design; the way in which traffic moves, and the routes that are taken by

mechanical and electrical services are fundamental generators of the plan.

In a vertically stacked hospital, which could also be called a functionally stratified

hospital, almost always the inpatient areas are placed on the upper floors, to allow for a

more pleasant, naturally lit environment. As we read in an earlier lecture (entitled

“The Planning Grid”), the planning grid is determined by the layout of these inpatient

floors. Another important planning feature, the vertical circulation core, is also to some

extent located within the building by the layout of the inpatient floors. We somewhat

simplistically claimed in that earlier lecture that in vertically organized hospitals we

design “from the top down.” What we actually do is during the layout of the inpatient

floors, we provisionally decide on a position for the vertical circulation core and other

staircases that may be required, many times by the local building codes. This location,

however, is to be checked for it's design impact on the lower floors containing the

diagnostic / therapeutic / interventional departments. This 'checking' process is

described by the diagram of the design process presented in the self-same earlier

lecture.

The pattern of circulation conceptualized for the hospital under design will be

considerably impacted by the location(s) of the vertical circulation core(s).

The vertical circulation core is the center, the focus of all the major circulation paths of

the hospital. An attempt can be made through design to minimize vertical

Different parts of the hospital may have different planning grids derived from the

functional planning requirements of the hospital departments they house.

Circulation :



transportation by siting (for example) all surgical beds, operating theatres and the

intensive care unit on the same floor. This design approach may be used as a

justification to reduce the number of elevators, or the width of the staircases, but in no

way does this mean that the core can be located more casually by the designer.

Avoidance of dependence on lifts is particularly important in places where

maintenance and availability of spare parts is unreliable; long waits for lifts are a major

cause of inefficiency and frustration to hospital users more of a problem the taller the

building is.

It is important that patients, visitors and staff be able to orient themselves while

moving through the hospital by providing windows in corridors to enable them to

look out and to allow natural light in, important in alleviating the tedium of long

corridors. If the site enables them, courtyards are also an excellent means to this end.

As such there is no easily available prescription for the way the circulation pattern for a

healthcare facility should be. The qualities it should possess, however, I will try to

enumerate:

1. It should have conceptual clarity. By this I mean it should be designed with

purpose, and should not be leftover space or squeezed into the gaps between

other areas. Geometry can be a recourse, but it should work with

other planning imperatives, and junctions should be uniquely treated to avoid

confusion over which corner of the hexagon (for example) you have reached.

2. It should not be boring. Try to make walking from one place to another interesting,

modulate those corridors, color them differently, hang artwork along the way.

Niches, outside views, courtyards, all these will help.

3. It should enable way finding. In combination with well-designed signage and

maybe super-graphics, people should be able to find their way to their destination

with ease. Color-coding for floors or departments is sometimes used.

4. They should be wide enough to handle anticipated traffic. Stretcher traffic needs

8'- 0” width of corridor for easy movement (turning). 7'-0” will work, but use 8'-0”

if you can. Corridors between Operation Theaters make sense even with 10'-0”

width. There may be a lot of stuff parked along the sides, despite instructions to

OT staff to the contrary.

5. They should be indirectly lit. Patients on stretchers get to look at the ceilings. The

sign put up by the traffic police at the end of Marine Drive in Mumbai says, “Drive

carefully. Hospital ceilings are boring.” While not advocating rash driving, we

would advocate making the ceilings interesting.

Some of the hospitals currently existing in India have been provided with ramps in

addition to the usual elevators and stairs. Power cuts are realities that have to be

considered. But consider putting some (two) of the elevators on a generator, if this

helps in avoiding the ramp, which is wasteful of space and difficult to use, as the

gradient is often excessive. (With an acceptable gradient, the length becomes excessive,

considering that the lower floors of hospitals are considerably higher than those of the

usual non-hospital building.)When planning for the area occupied by this circulation space (corridors) in the

architectural space plan, it can be provided for as a percentage of the department area

(usable, built-up area). This percentage will vary depending on the department and

may also vary if the architect has any special feature in mind for that department which

is not explicitly provided for in the room-by-room area statement (such as semi-

covered, landscaped waiting). The percentage can vary from 35% for an Operation

Theater Suite (with 8'-0” corridors) to 20 25% for the Administration Department.

On the Inpatient floors or even in the Outpatient Department, these corridors can be

modulated by recessing pairs of doors that occur at regular intervals, and using an

accent color in the niche so created. This helps relieve the boredom of walking through

long, uninteresting corridors.

Very frequently the major circulation paths through the hospital are laid out even

before the tentative space allocation for the hospital departments is done. Thus, the

importance of conceptualizing these paths in a way that they contribute to the concept

and functional layout of the hospital is not to be underestimated, the exercise should

not be done casually.

Frequently the manner in which the healthcare architect conceptualizes the working

(and therefore layout) of certain hospital departments, notably the Operation Theater

Suite and the Radiology & Imaging Sciences Department (as described in a later lecture

titled “The Architecture of Imaging”) will determine the circulation pattern through

that department, and hence affect the layout of circulation paths in contiguous areas of

the hospital.Defining major circulation paths through the proposed and future buildings is a



design decision that will considerably impact the form, layout and thus the eventual

functioning of the healthcare facility being designed.

Identifying and understanding the conditions which constitute barriers to those with a

disability (this category includes, besides the wheelchair bound, those who for any

reason have difficulty in walking, and also those with a sensory that is, visual or

hearing impairment) is a fundamental requirement for the effective provision of

accommodation and facilities to be used by disabled people.

If the needs of people who have temporary or permanent disabilities are taken into

consideration, the resulting design can make the design easier and safer to use for

those with children, those using wheeled equipment and those carrying other items.

The principle of applying critical criteria should be used for example, where space is a

consideration, wheelchairs or other larger wheeled items need to be considered; for

vertical fixtures or fittings, the shorter person and wheelchair user must be considered;

and for wayfinding those with visual and hearing impairments must be considered.

The resulting design will help not only people who are ill or disabled but also those

who are suffering from shock or stress, as many users of health buildings are. Building

design that gives consideration to all users will also be easier and safer during an

emergency evacuation.

The best design philosophy is to consider the journey through the healthcare facility

from start to finish, analyzing all the related components of the task (negotiating

entrances, corridors, lifts, reception areas, toilets, etc) to ensure that the features,

equipment and fittings encountered in completing the journey are suitably designed

so that the overall task can be completed easily and conveniently, bearing in mind the

different requirements of staff, patients and visitors with varying degrees of functional

mobility. In this way building users will be more independent (less reliant upon staff)

and consequently less stressed, anxious and frustrated.

People with disabilities can be defined as those who, as a consequence of an

impairment, may be restricted or inconvenienced in their access to, and use of,

buildings because of the physical barriers such as doors that are too narrow, flights of

steps, or unsuitable facilities (for example inadequate lighting, or lack of handrails on

staircases or grab-rails in toilets.) Some people will be temporarily disabled as a result

of their need for hospital treatment.

Special Considerations for Designing for the Disabled

The following categories of building user are generally recognized :

1. : persons who are fully physically capable of carrying out all

activities necessary to their role or function.

2. : persons who walk with difficulty or are otherwise insecure, as a

result of a temporary or permanent impairment of the lower limbs. They may walk

with or without a walking stick (sticks, crutches, walking-frames, etc) and/or

require the assistance of another ambulant person. Some people in this category

will, in addition, have reduced strength and dexterity in the upper body and/or a

sensory impairment. Semi-ambulant people find it difficult to cover long distances

(even 50 M may be too far). Specific design requirements include: short distances;

provision of handrails and suitable spaces for taking a rest; and even non-slippery

surfaces without any changes in level;

3. Non-ambulant : persons who temporarily or permanently require to use a

wheelchair for mobility. They may propel themselves, or be pushed and

maneuvered by an assistant who may or may not be needed to assist with other

tasks. Some people will be using a wheelchair for the first time due to being in

hospital and will be unfamiliar with maneuvering it. Some people who use

wheelchairs will, in addition, have reduced strength and dexterity in the upper

body and/or may also have sensory impairment. Some will be able to stand on

their feet whilst transferring to and from a wheelchair or to and from other facilities

(such as a toilet, chair, or bed); others will require assistance to do so (in some cases

the use of a hoist). Specific design requirements include the provision of sufficient

space for passing and turning; even surfaces without changes in level; and

ensuring that any counters, signs, handles, etc are within the user's range of vision

and grasp.

4. Manually-impaired : persons who have a temporary or permanent lack of strength

and/or dexterity in the shoulders, arms and/or hands. They may also be semi-

ambulant and/or have a sensory impairment. Specific design requirements

include doors which are not too heavy, suitably designed handrails and control,etc.

5. Visually-impaired : persons who are totally blind or partially sighted. Blind people

find their way by noticing changes in the textures of floor or wall surfaces and

ambient sounds and smells; some also need the help of a cane for orientation and

detecting obstacles. Partially-sighted people need plenty of light and the colors of

Fully-ambulant

Semi-ambulant



any fixtures or fittings they are trying to locate (or are on their guard against) must

stand out plainly in contrast to the background. It must be remembered that vision

deteriorates considerably with age. 40-year-olds need twice as much light and 60-

year-olds three times as much light to see the same object as clearly as a 20-year old.

The more strongly an object contrasts with its surroundings, the easier it is to see.

However, colors do not have to be garish; subtle changes in color can be

aesthetically pleasing, and can fit in with the general décor as well as providing

contrast. Different colors in the same tone can appear very similar to people who

are color-blind for example, a strong red and green together can look much the

same and so, contrasting tones, or a combination of tone and color, are very helpful

for people with poor sight. Any type of cluttered design should be avoided, for this

makes it more difficult for a visually-impaired person to “read” the shape of a

space, and consequently impedes their ability to navigate. Good design therefore

should not only contribute towards the legibility of a building, but also facilitate

easy navigation through it. Specific design requirements include: a simple, well-

planned layout even surfaces with tactile indications of direction; no obstructions

in walking areas; well-lit areas; signs placed at a convenient height, with space to

stand in front to read them.6. Hearing-impaired: persons who are deaf and hard of hearing have the additional

problem that their disability cannot be seen and is therefore not noticed by other

people. For effective lip-reading, building areas must be well lit in order that the

face of the person speaking is illuminated. Specific design requirements include: a

simple, well-planned layout with well-lit areas; surfaces which dampen ambient

noise, signs placed at a convenient height, with space to stand in front; provision of

induction loops at reception areas and in auditoria.

A check-list giving a suggested sequence of activities to be followed in the planning

and design of access and facilities for disabled people is given below:

1. Are there parking spaces adjacent to the buildings to minimize the distances to be

traveled?

Healthcare Premises:Checklist of Access and Facilities for Disabled People

Parking :

2. Is the parking spaces wide enough to allow a car door to open fully to allow

unobstructed transfer into a wheelchair, either unassisted or assisted?

3. Is the location of the disabled parking spaces such that the approach route to the

building / facility is not obstructed by other parked cars and away from moving

traffic?

4. Are kerbs and other changes of level ramped?

5. Is the parking space and access route under cover?

6. Are there adequate signs to identify the reserved parking spaces and the best

routes into the premises?

7. Is the approach route smooth, slip resistant (whether wet or dry), free fromincidental obstructions or hazards?

8. Are handrails provided on all slopes and resting places provided at intervals

where a ramp or approach is long?

9. Are all public entrances to the building / facility accessible?

10. Are access doors wide enough to facilitate wheelchair movement?

11. Are thresholds eliminated or kept to a minimum?

12. Do door characteristics and dimensions of related spaces allow it to be opened(and closed) easily by independent wheelchair users, moving in either direction?

13. What doors can be eliminated?

14. Are lobby sized adequate and safe for both independent and assisted wheelchair

use?

15. Are corridor and approach routes satisfactory? Do they allow passing and

turning and take adequate account of corridor traffic conditions?

Approach to Building :

Internal Circulation :



16. Have all obstructions and projections from walls (or ceiling) or similar hazards atfloor level such as changes of level been avoided? If unavoidable are they clearlydiscernible?

17. Are internal door widths adequate to allow turning through 90 from the corridoror lobby? Should either of both be increased?

18. Have safety handrails been provided on corridors, ramps, and steps or at other

points where they are required by persons with impaired mobility? Have theybeen produced where they used as location aids by visually impaired people?

19. Are any large areas of glass close to circulation areas marked or framed so as to be

clearly discernible to partially sighted people?

20. Are seats available at intervals to permit an ambulant disabled and elderly

person to take a short rest when faced with long corridors to negotiate?

21. Are staircases safe and optimally comfortable for elderly and disabled people?

Are handrail and landing characteristics satisfactory?

22. Are lifts available, conveniently placed, accessible and clearly signed?

23. Are lift controls accessible to the independent wheelchair user? Are the visual

and audible signals, alarms and floor designations satisfactory? Are digits

embossed and satisfactory for blind or partially sighted persons? Is there a

24. Are there correctly designed unisex toilets, that are where a husband and wife

may enter the cubicle together, available in the public areas of the premises?

25. Are there suitable cubicles for wheelchair users in other male and female toilets

in the building?

26. Do cubicles for wheelchair users provide adequate maneuvering space within,

are turning space provided outside? Is the level of privacy afforded satisfactory?

27. Are there cubicles available with appropriate grab rails for the use of ambulant

disabled people?

0

Vertical Circulation :

Toilets :

28. Are the WC and washbasin arrangements accessible to independent wheelchair

users? Are the grab rails, mirrors, towels, door closing bars and other aids placed

satisfactorily?

29. Can ambulance discharge patients under cover within close proximity to the

entrance? Are waiting areas protected from draughts as patients move in and out

through the entrance doors? Can patients using wheelchairs (their own or

hospital chairs) whilst waiting for treatment, sit with other patients without

obstructing the corridors or circulation area?

30. Can patients in wheelchairs use the reception desk conveniently and privately?

31. Are all consulting and treatment areas fully accessible?

32. Are there changing cubicles suitable of wheelchair users, with room for

assistance to be given if required?

33. Are refreshment areas accessible to disabled people?

34. Are clear, well lit, signs posted to ensure easy circulation within the building?

35. Are telephones and other public mechanisms accessible to wheelchairs users?

Are knobs, dials, switches, handles and other controls operable and within

convenient reach?

36. Do sanitary facilities offer maximum independence and privacy to disabled

patients, both those who will be using wheelchairs and those who have walking

difficulties?

37. Is the day room accessible, with a variety of seating heights to help ambulant

disabled people? Are all notices easy to see and understand?

38. Are window controls, radio and television and call bells easily reached by

disabled patients?

Outpatient And Treatment Areas :

Ward Facilities :



39. Can disabled visitors conduct private conversations with their friends in bed or

in the ward?

40. Could disabled employees work in the building with particular reference to

offices, laboratories, canteen, rest rooms and toilet facilities?

41. Are emergency evacuation routes and emergency exits satisfactory?

42. Are fire alarms readily accessible to the semi-ambulant and wheelchair disabled?Are emergency call facilities installed to summon assistance to removelocations?

43. Are audiovisual alarm signals provided?

Hospitals should take the lead in providing disabled-friendly access to themselves as

well as wayfinding. Use the above checklist to make any facility you are planning easy

to enter and use by the disabled.

Another important design issue in hospital planning is the need to design for

flexibility.

'Flexible' is defined by Merriam-Webster's Collegiate Dictionary as: “Characterized by

a ready capacity to adapt to new, different or changing requirements.”

Flexibility, as an architectural principle applied to the design of a hospital, would be

the inbuilt capacity of that hospital to adapt itself to “new, different or changing

requirements.”

John Weeks, the first architect in Britain to fully grasp the need for this flexibility in the

design of hospitals, made the then revolutionary point that ' user studies of function

are by themselves not a sound basis for hospital design. Functions change so rapidly

that designers should no longer aim for an optimum fit between building and function.

The real requirement is to design a building that will inhibit change of function least,

and not one that will fit specific function best.'

At Northwick park hospital, London, he designed a 'hospital street' along which were

placed blocks of buildings that could expand at right angles. Both the blocks and the

Other features :

Designing for Flexibility

street were open ended. The plans of the hospital below illustrate this.

Shown above are three plans showing the development method at Northwick park

hospital and clinical research center. A linear hospital street forms the backbone to

which ribs can be attached with relative freedom. It is the earliest example of deliberate

indeterminacy in post-war hospital planning. The hospital and research departments

can be constructed and later altered or expanded, independently of one another.

Construction was carried out in phases over a period of nine years and during this time

extensions and alterations to the original brief were made without disturbing the basic

design.

This design concept proved very influential. However, the hospital sprawled over

deal of land. Then what done on urban sites where land was at a premium?

An answer to this was the concept of 'universal space': that is, a series of structurally

uninterrupted floors, to which any services such as electricity, gas, water, could be

brought from above, and from which all wastes could be taken from below.

The Greenwich Hospital, UK was the first hospital to have 'interstitial' spaces or

services sub-floors between each hospital floor. This solution is most strongly justified

in hospitals where the climate makes air-conditioning or mechanical ventilation

necessary throughout. The dedicated space for air-conditioning ducts, pipes and

great



wiring means a greater overall building volume, but the ability to service them without

entering the hospital areas they are sandwiched between is an advantage; full benefits

are only reaped if three-dimensional zoning is maintained, by “reserved rights of

ways” for the various services. Shown below is a section showing 'interstitial' spaces or

services sub-floors.

This approach makes an important point. Making a building that is adaptable to

changing requirements is largely an issue of providing the necessary building services

required by the changing requirements at the desired point in the existing building. In

India, with our RCC column and beam method of construction, this need impacts the

structural system design for the building in that punctures in the slabs may be

necessary during this change of function and thus the structural system chosen

initially has to cater to that requirement.

In order to provide for planned expansion it is necessary to develop a master plan that

provides for both short - and long - term expansion and change within the hospital and

throughout the campus. The master plan should establish major paths of circulation

projected through foreseeable phases of new and renovated buildings. The design

concept should contain within it an overall ordering principle for the entire campus,

integrating into the design a building systems framework (See: Illustration below).

Source: Hospitals and Healthcare Facilities by Redstone

With hospital accreditation by health insurance companies in India being just around

the corner, old hospitals that are too tightly tailored to the needs of initial users will

become obsolete due to the changing standards demanded by these companies, who

are likely to emerge as the new drivers of the healthcare industry.

Changing market demands, new technology replacing the old at an ever-increasing

rate of change, advances in the science of medicine and changing patterns of disease all



underline the need to design healthcare buildings for flexibility. The functional,

technical and hence financial success of hospitals thus depends on the ease with which

they can grow and change, and this dependence increases with time. The aesthetic

implications in designing buildings that will expand and change over time also

become an issue. An urban design approach is necessary; an initial building whose

form is symmetrical will tend to look skewed when expansion takes place. The higher

the buildings are, the greater the aesthetic, technical and functional difficulties in

making a workable addition.

The fact that many hospitals are built in a number of phases further complicates the

problem. There may be a series of replacements of older buildings on an existing site or

limits to the amount of investment possible at any one time. A comprehensive and

firmly established Development Control Plan is essential for a hospital built in phases

to specify the strategic direction of following phases, but not their detailed design.

The issue is complex; it involves a multiplicity of design factors that may be making

contradictory demands on the designer. We suggest you consider the various options

keeping in mind the needs of future generations to whom you will bequeath your

design solution in its built form.

What does this requirement for flexibility augur for the hospitals to be built in the 21

century?1. Buildings will be designed to facilitate the docking of mobile and plug-in

modules. It is likely that specialized major diagnostic and diagnostic-surgical

equipment will be manufactured in self-contained pre-constructed modules

intended for docking at strategic points “ports” in the building. Such mountable

and demountable \components could be readily downloaded to other facilities

for example, an ex-urban satellite of the main hospital.

2. HVAC systems will be modularized and zoned, with vertical circulation,

mechanical shafts and transport systems moved from the core of the building to

the perimeter in order to create free fields within the core floor plate that are easily

adaptable to different layouts.

3. Interstitial concepts, which seemed promising in the early 1980's, but were mostly

found to be expensive in terms of capital investment, may well return as flexibility

becomes such a vital consideration that these initial capital costs will become

justifiable.

st

4. Other structural strategies that maximize flexibility and adaptability will be

used. Floor systems will have to allow for multiple penetrations for plumbing

and electrical lines, column spacing will need to be optimized so that

departmental redesign is not cramped by existing structural constraints.

5. Other strategies for maximizing flexibility will include the deliberate specification

of “swing” space to allow temporary relocation of departments during

renovation,and to allow greater flexibility in adapting to changes in patient

population. Low- tech departments can be zoned in 'soft” spaces adjacent to

“high-tech” spaces.

6. Finally, some facilities may require the development of “universal floor plans”,

which can be adapted and readapted to accommodate virtually any need.

The concept of flexibility will extend beyond what the architect designs to the architect

him- or herself. The architect will provide a range of services beyond the traditional

architecture and engineering (A & E) tasks, including strategic business planning,

evaluation of lease-versus-build options, financial planning, mechanical and electrical

systems evaluation, space planning inventories, furniture inventories, long-range

planning and master planning. Once the building has been completed the architect

will remain in contact with the owners for the life of the facility, providing a full range

of services on a contractual basis. These services will include ongoing evaluation and

planning for expansion, contraction and adaptation to changing needs.

It is a mistake to think of the hospital architect only as a technician whose role is

primarily organizing detail. He has an aesthetic as well as an organizational and

conceptual

contribution to make. He is often the major - if not the only - participant in the

development of a hospital in a position to see it as a whole. This is seen in the attention

paid by him to the aesthetics of the exteriors and the interiors of the building. The

typical, somewhat forbidding, hospital facade of the past has given way to more

interesting configurations of building shapes which are based on the functional aspect

of interior communication and traffic requirements. There is also an increasing

awareness by hospital administrators and designers of the value of good graphic

design and art as part of the hospital environment. In good hospital architecture, the

Aesthetic in hospital design



aesthetic and functional unite to contribute to the well-being of both patient and staff.

It has a beneficial effect on both. A pleasant environment increases efficiency and

quality of work. It helps the tolerance level in meeting the pressures of very

demanding duties.

At the same time it should be kept in mind that primarily the hospital is a place for the

care of the sick where conditions may at times seem unattractive to the active and

healthy. To be aesthetically convincing the hospital must be itself and not an imitation

of something else. The patient needs most of all to feel that he is in the presence of

scientific competence as well as sympathetic attitudes.

A critical look at modern hospitals shows that they are designed for ease of

maintenance rather than human comfort. They seem to be resistant to human imprint -

a definition of an institutional environment. The architecture, instead of embracing

and welcoming inhabitants, seems to alienate and intimidate them. They resemble a

Kafkaesque labyrinth of corridors - endless in their dimly lit pallor and multiple layers

of chipped paint. If we stop thinking of patients as inmates and view them as guests,

hospitals could function more on the order of hotels and restaurants. If the individual

can relate the medical environment to something else that he or she has experienced

with a positive association, much has been achieved towards reducing anxiety.

Psychology-implications for health care design

THE DESIGN PROCESS

CHAPTER 6

Taste, unlike function, is indefinable.

We have Florence Nightingale saying:

“The very first consideration to be sought in planning a building is that it shall be fit for

its purpose. And the very first architectural law is that fitness is the foundation of

beauty. The hospital architect may feel reassured that, only when he has planned a

building that will afford the best chance of speedy recovery to sick and maimed people,

will his architecture and the economy he seeks be realized.”

Of course her heart is the right place. She was responsible for naturally well-lit and

ventilated wards, the well-known “Nightingale” ward. Do you see the convergence

with I.M. Pei and his proposal for the UCLA Medical Center, so many years later?

Then we have that connoisseur of architecture, HRH the Prince of Wales saying:

“Mammoth hospitals, built like dreary office blocks on a devastatingly functional

basis, depress the spirits, however good the care is.”

We agree. Taste may be indefinable, but let us hear Sir Norman Foster (RIBA Gold

Medal Winner) on the subject:

“Architecture is also about the spiritual needs of people as well as their material needs;

it has as much to do with optimism, joy and reassurance; of order in a disordered

world; of privacy in the midst of many; of space in a crowded site; of light on a dull day;

it is about quality.”

Quality need not be defined to be apparent. A building that is functional and pleasing

to those that use it, a building that sits easily in its surroundings, a building that is a

pleasure to behold, such a building is not a building at all! It is architecture.

The production of architecture starts with a concept. Here suffice it to be said that

concepts are usually presented in the form of drawings, with a written or verbal

commentary.



Some explanation of terminology common to drawings developed during

architectural design work may be helpful at this point.1. PLAN : The plan is the top view.

2. ELEVATION : The elevation is the side view.

3. SECTION : The section is similar to an elevation, but it shows what

remains after an imaginary slice (section) has been cut

through the object.

4. PERSPECTIVE : Perspective is a three-dimensional drawing of an object.

5. RENDERING : A rendering is a finished architectural perspective

drawing indicating materials and the effects of light,

shade and shadow to help explain form or shape. Plans,

elevations and sections are also referred to as

when materials, light, shade and shadow are shown.

6. PLAN SECTION : The term “plan” is used interchangeably to refer to a top

view and to what is actually a plan section. A plan

section is a horizontal (rather than vertical) section of a

building. It shows the top view of what remains after

everything above the slice has been removed.

After conceptual layouts have been approved (“signed off”) by the client, the architect

incorporates more detailed planning criteria into the drawings, the end product of

which is a schematic drawing. It is not done in isolation. All the various members of the

design team participate in giving inputs, comments, critical assessments and the

schematic drawings are the product of what may be a time-consuming and difficult

process, it may involve heated discussions, hopefully followed by “working”

compromises between all kinds of design factors and cost constraints.

These schematic drawings would include exterior elevations (quite likely rendered),

and fairly detailed sections, showing vertical stacking of functions. It may include

perspective views (nowadays increasing prepared and rendered on a personal

computer) and may also include a “walk-through”, a series of computer generated

images giving the illusion of a video clip starting maybe with the approach to the

building and going all the through the main entrance into the lobby and possibly

beyond, depending on the time and money spent making it.

“rendered”

Usually such rendered perspectives, scale models of the building and the walkthrough

are commissioned and paid for by the client at actual cost, falling outside the normal

scope of services of the architects.

After the schematic drawings have been approved, the architectural design

development stage begins, which is more technical and detailed.

By this time the survey, soil investigation and utility information should be

done. If not, it needs to be done ASAP. This information will support

development of initial studies in foundation and structural framing, sanitary

and storm sewer systems, site development and grading, and electric power

and energy services. Access of traffic to the building entrance, separation of

emergency and service traffic elements and provision for parking are further

studied at this time. The site survey and soil investigation are usually paid for

by the client along with whatever legal services may be necessary in securing

required easements, change in land use, etc.

Architectural development includes further study and decisions regarding

materials, windows, exterior finishes, architectural treatment and detail;

refinement of space layout within the facility, selection of finishes and

materials in keeping with maintenance and durability requirements; and

comparative cost studies of methods and materials for partition systems and

exterior walls, ceiling and windows.

Further development is also required on concepts of air handling, air

conditioning, electrical distribution-lighting-communication-data systems

and medical gas, plumbing and piping systems. During design development

these systems are worked out sufficiently to allow cost studies and basic

interfacing decisions to be made. Drawings are normally single-line indications

of piping or ductwork. Total services requirements for electrical power, natural

gas or fuel oil, sanitary and storm sewers, water, and solid waste disposal are

now established.

Hospital planning requires careful attention to the fixed and movable

equipment that will be needed to implement the operational program. Early in

design development, equipment and room detail interviews are held with

medical and staff personnel. In these sessions, equipment requirements are

documented. The information is used in coordinating room sizes, utility

Site :

Building:

Engineering:

Equipment:



services, lighting and workflow. Documentation usually takes the form of

room-by-room equipment lists, or room data sheets, and are submitted for

administrative, medical staff and departmental review after compilation.

: Complex systems of various types are often incorporated, in concept form, in

schematic design. Functionally, these include communications, data

transmission, storage and retrieval, materials handling, security, food

preparation and others. Each system that is to be incorporated must be studied

in detail and interfaced with equipment common to other building systems;

space and structural requirements are often extensive. Justification of systems

is critical, since initial and maintenance costs are usually high.

Design development drawings normally show considerably greater detail

than do schematic drawings. Major equipment and furniture are shown in the

plans in order to facilitate engineering coordination of utilities and lighting.

Plans show wall thickness, door and window function and more detail

regarding vertical circulation and materials. Sections and elevations at a larger

scale depict relationships between materials. Outline specifications, to

supplement the drawings, are compiled for each material, system and element

of work. A room-by-room equipment list, or room data book, is included to

record equipment requirements.A design development is desirable to provide summary discussion of

operational concepts, materials, special equipment, and environmental

systems. When design development documents are completed, a cost estimate

is prepared and presented with the drawings, outline specifications and

equipment information for hospital review. The estimate provides a current

check on project scope related to budget.

After approval, design development documents provide the basis for the

working drawing or contract document phase of the project. The design

development phase sets the detailed operation of each room and leads to

approval of all systems, fixed equipment, material types and building

construction.

This is the most important part of the administrator's role on the team, as it sets all of

the ideas, programs, needs and designs into the final building plan. All anticipation of

future needs are now fixed, as the following phases only detail and construct what is

now the final design product.

Systems

The Production Phase:

1. The Owner-Contractor Agreement

2. The General Conditions of Contract

The “production phase” of a health care facility is much more than just the construction

of the physical plant; in fact, it begins and ends with the execution of legal activities.

From the production and execution of the owner-contractor agreement, to the final

inspections and acceptance of the completed structure, the hospital administrator and

board will find themselves involved with complex and critical legal documents and

activities. In addition to these clearly legal activities, a new kind of architectural

drawing must now be produced: the working drawings. The working drawings, along

with the written specifications, are in themselves a form of legal document as they

describe in pictures and in words what the contractors have legally agreed to build and

the purchaser has legally agreed to pay for.

Given these considerations, it is as important that the hospital administrator and the

board members understand these documents and activities, as it was that they

understood the earlier design documents and activities.

The contract documents consist of the owner-contractor agreement, general

conditions, specifications, bill of quantities (BOQ) and drawings. At the time of signing

the agreement, a work order is issued, containing all addenda issued before execution

of the agreement, which is also signed by the client and contractor. The owner-

contractor agreement and the work order are considered the basic contract documents

because they are the only ones that require the signature of both the owner (client) and

the contractor and they incorporate all other documents referred to in them. The

agreement provides a statement of the contract sum, identifies the nature of the project,

establishes the time of commencement and completion, and describes the manner

wherein the contractor will be reimbursed for work performed.

The set of documents are as follows:

This is a legal document on stamp paper that sets forth the terms of agreement between

the owner and the contractor.

The general conditions set forth the legal and regulatory requirements of the contract.



3. The Specifications

4. The Bill Of Quantities (BOQ)

5. Drawings

6. The Work Order

Reading the Working Drawings:

These contain general specifications under various heads, such as RCC, Masonry etc.

These contain additional specifications for various items with their rates.

The drawings are graphic representations of the work to be performed and contain

information about design, location and dimensions of the elements of the project.

The working drawings, together with the BOQ and Specifications, are called the

contraction documents.

The work order contains all the addenda issued before execution of the agreement.

In smaller projects, if mutually agreed by the client and contractor, no agreement may

be signed, the only document that is signed by both being the work order. In this case,

if a dispute occurs, the recourse is only to arbitration, and not a court of law.

At first glance, working drawings are formidable, especially those of a typical hospital

project. Yet, if it is remembered that these documents tell the contractor exactly how

the building is to be built, they become like a foreign language; the more one learns

about them, the less mysterious they become. Taking part in the development of these

drawings, from schematics to working drawings, for a single hospital project would

provide a complete education, but it would take from two to four years on the average.

Essentially, each consultants drawing is meant to complement the others. The

architect is responsible for coordinating the different consultants drawings, while the

general contractor is charged with coordinating the work of subcontractors. In

addition, the specifications require that all contractors study the work of other

contractors as defined by the working drawings and specifications. The better

architectural firms require composite drawings that lay out the major elements of the

plumbing, mechanical and electrical systems. Such drawings not only force the

engineers to coordinate their work in the field, but dictate the order in which system

components are to be installed. Following completion, these drawings serve as as-

built drawings, and are turned over to the client to become a valuable record of

construction. This enables the in-house engineering personnel to more easily repair

and control the systems. Should future alterations or additions be needed, these as-

built records will be extremely useful.

Competitive bidding is the most widely used method of obtaining construction prices.

When using competitive bidding, it is wise to pre-qualify the contractors who will be

involved. That is, the architect designs a form that asks each interested contractor to

submit references and data on experience, financial conditions and ability to be

bonded.

An invitation to bid, as described above, outlines the time, place, scope and location of

the final plans and the actual bid. The sets of plans and specifications are distributed to

the general contractor. The bidding contractors should be allowed 10 days to 3 weeks

to come up with their final price, depending on the size of project. When so may people

are looking at a set of plans and specifications there are bound to be questions. The

architect should issue clarifications to each bidder, as well as any item changes. The

architect analyzes the final price submittals, and advises the client as to technical

accuracy. The contract can then be awarded.

Once the bids are received and the contracts signed, the client has very little control

over the selection of subcontractors. The client can however require that a list of

subcontractors be submitted. Whatever prices the general contractor used to

formulate his total, he can now negotiate each item: any savings that result will not be

available to the client. The contractor must, however, meet the quality and quantity as

described in the drawings and specifications.

The general conditions defined the liabilities and role of all general contractors and

subcontractors. The contractor must also understand hospital operations in order to

disrupt hospital routine as little as possible. Construction touches special nerves of the

administrator and hospital staff. The administrator will be blamed for the noise, site

confusion and distractions. These things are part of normal construction, but they

Bidding Requirements and Procedures:



place an unfamiliar burden on the hospital's normal operation. Day-by-day

construction seems like endless delay and problems to the layman; it is a way of life for

the architect and the contractor. I think they have to both understand each other's

problems and focus on building an excellent facility.

One way to save the client some of the headaches mentioned above is to employ a clerk-

of-works. This person represents the client; he is experience in construction and is

hired by the client to check daily progress. Although the architect acts as the client's

representative during construction, he only performs inspection as it is required; he

will not be on site every day. The architect's duty here is to check shop drawings (detail

of each item specified and submitted by the manufacturer for approval), verify the

contractor's invoices to the owner, and see that quality and design are met. The

architect does not tell the contractor how to build the building: he defines the size,

shape and quality of the building.

PLANNING OF INPATIENT WARDS

CHAPTER 7

Patient Housing Systems:

Classification of Wards

Patient housing systems, typically known as wards are a key element of the hospitalbuilding and may occupy thirty-five to fifty percent of the hospital built up area. Thecurrent trend of corporate hospitals is making it necessary for promoters to thinktowards improving the traditional way of laying out these wards. These areas arebecoming more comfort oriented from the customer's point of view. The importantcriteria for planning the patient hosing systems would be as under:

a) Ownership and Bed Mix of the hospital – corporate hospitals may have more singleand double rooms than general wards. The bed mix of the hospital will decide thenumbers in each category of beds. As per current practice approximately 20-25%beds may be planned in the critical beds and another 20-25% beds in generalwards.

b) Age and Gender distribution – hospitals may need to have separate floors or earmarked areas for pediatrics, male, and female categories of patients

c) Specialty based distribution – this classification may be required more in largehospitals imparting medical education wherein one would need to plan forseparate departments for surgery, medicine, orthopedics, obstetrics & gynecology,pediatrics, ENT, ophthalmology etc

d) Socioeconomic class based distribution – commonly practiced in all privatehospitals in India wherein the patient wards are segregated on basis of thesocioeconomic class of the patient

In-patient wards are classified by their specialty. In a General Hospital the usual onesare:

the adult general acute

the adult surgical

the children's or pediatric

the old peoples or geriatric

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the maternity

the orthopedic

the psychiatric

Sometimes there are isolation wards for patients carrying an infection or who for somereason have suppressed immunity and need to be nursed in a bacteria freeenvironment. There are also Intensive Care wards for patients needing special nursingand medical care. Adult wards are likely to be differentiated by sex, depending on theway they are planned and the customs of the country.

The efficient and economic running of hospital in-patient services is probably one ofthe most difficult problems of all continuously operating services. The organization ofnursing care constitutes a subsystem that very directly aims at achieving the hospitalsoverall objectives.

Over a hundred years ago Florence Nightingale held that thirty-two was the maximumdesirable number of patients in a ward unit. Although there have been revolutionarydevelopments in medicine and surgery since then, and many changes in the way theward has been planned, the number of patients that can be cared for by the ward sisterand her team has remained remarkably similar.

Today the preferred number of patients in the general acute and surgical wards may besome four beds less than Florence nightingales thirty-two but it seems to be universallyrecognized that one team should not deal with more. The number of beds under onesister is likely to vary from about 28 to 30 in general wards, or about 20 to 24 forchildren. These numbers may be affected by nursing team arrangements, but in theinterests of flexibility and possible future changes and also for structural and servicingreasons (particularly in multi-storey buildings) ward units are usually about the sameoverall size, varying only in their internal planning. Wards with fewer beds tend to bethose needing additional ancillary accommodation particular to their specialty and thesizes even out reasonably.

Inpatient nursing units

Number of Beds

Location

Accommodation

The location of wards in relation to other departments of the hospital is rarely critical,except that surgical wards and those for intensive care are best in close proximity to theoperating theaters. It is an advantage if this connection does not depend on the use oflifts, although this cannot always be achieved.

However, all wards need to be easily accessible from the hospitals main supply anddisposal routes and to have convenient communication with the diagnostic andtreatment departments, particularly such departments as physiotherapy which arevisited by ambulant in-patients. In addition all wards should be capable of beingreached by visitors along simple coherent routes from which they are unlikely to strayinto other parts of the building from which they should be excluded, or pass sensitiveareas where there are high risks of cross-infection. No ward should be used as theprincipal means of access to another. Even though it may not be entirely on a cul-de-sac, the entrance to every ward should be capable of strict control.

The ward combines clinical and housekeeping facilities with the psychologicallyimportant function of providing the patient with a reassuring home in which he can beencouraged and supported towards an early recovery. The housekeeping elementused to represent a much larger part of the work of the ward staff than it does today.This is now much reduced by centralization of the supply of food, linen, drugs andsterilized articles, so that the ward no longer carries large local stocks of linen, crockeryand medicines.

Apart from bathing, washing, toilet facilities and day spaces for ambulant patients, theancillaries in the general ward normally consist of:

a treatment room where surgical dressings can be attended to and minor operativeprocedures carried out with the minimum risk of cross-infection and withoutdistressing other patientsa clean utility room principally for the preparation of equipment used in thetreatment rooma dirty utility room for emptying and cleaning bedpans and urine bottles, cleaningother soiled items and disposing of materials such as dressingsa pantry for the preparation of beverages and for washing and drying crockerya small equipment store (mostly in critical care units)one or more nurse stationsan office (optional)provision for the storage of patients clothes

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a staff cloakrooma janitor closet

The treatment room is sometimes placed between the clean and dirty utility rooms sothat sterilized equipment from the Central Sterile Supply Department (CSSD) can bereceived and prepared in the clean utility, and after use is passed through anotherhatch into the dirty utility, where it is washed before return to the CSSD.

Intensive Care Units (ICUs) are specialty nursing units designed, equipped and staffedwith specially skilled personnel for treating very critical patients or those requiringspecialized care and equipment. Centralizing the acutely ill patients, as is often done, incontiguous units in an intensive care complex consisting of surgical-medical intensivecare unit, coronary care unit and specialty units such as renal and burn units, results inmultidisciplinary care and economical use of the space and equipment.

There is no unanimity among the medical and nursing experts as to where the ICUshould be located. There are two schools of thought. One suggests that the ICUs shouldbe in a centralized place and be contiguous with, or readily accessible to, one another.The argument is that patients admitted to the medical-surgical intensive care unit mayhave, or suddenly develop, cardiac complications. Having intensive care facilities in acentralized place allows the specially trained professionals and equipment an almostinstant access to patients in all clinical services when an emergency develops. Such anarrangement also eliminates the need for duplication of costly equipment andpersonnel.

The second school of thought favors that the location should be dependent on the typeof patients. For example, the surgical ICU should be close to the operating rooms whilethe medical ICU should be in close proximity to the medical ward to facilitate followingthe concept of progressive care, i.e. the patient is moved from the intensive care unit tointermediate care or step-down unit, and then to the general patient care area.

Intensive care units should be close to emergency, O.T. Suite, Respiratory Therapy,Laboratory and Radiology. Most admissions to ICUs are either through the emergencydepartment or from the operating rooms following major surgery. They should not betoo far away from general nursing units, as patients may need to be transferred in anemergency. They should be close to vertical transportation cores. They should be awayfrom heavy traffic and noise. The electrical influence of equipment like elevator motorsand X-ray equipment on the displays of monitors should be kept in mind. Accessibilityand direct visual contact between patient and nurse is important. The patient should be

Intensive Care Units

close enough to permit observation of respiration, facial color and other revealingsymptoms.It is generally recognized that for effective operation, there should be no more thantwelve to sixteen beds per intensive care unit. An intensive care unit of less than sixbeds is clearly uneconomical. The beds should be located permanently away from thewall, to give staff a 360 degree access to the patient.

An Intensive Coronary Care Unit is used to identify the units restricted to patients whoare suffering from cardiac emergency conditions. Patients are transferred from here toan intermediate care section, which ought to have twice the number of intensive areabeds. A Pulmonary Intensive Care Unit (PICU) is a major key in a comprehensivepulmonary care program for chronic obstructive lung disease. A laboratory foraround-the-clock determination of arterial blood gases immediately adjacent to thePICU is required, since these patients are very unstable. Logistic delays due tolaboratory remoteness or unavailable technical assistance is not acceptable.Neurovascular or stroke cases are admitted predominantly from the emergencydepartment. In a Burns Care Unit two phases of the burns illness - the shock period andthe healing period - have to be accommodated. Complete reverse isolation can be asignificant factor in the prevention of bacterial contamination of individuals incurringmajor burns injuries. For maternity patients with complications and particularly forthose in premature labor a special ante and intra partum unit also referred to as anobstetric or labor or maternity intensive care unit can be provided. In conjunction withthis, a Neonatal Intensive Care Unit (NICU) can be provided, which is an intensive carenursery which provides the best chance of saving life and of improving physical anddevelopmental status for survivors of serious perinatal illness.

The Pediatric nursing unit is concerned with the care of children. It calls for anunderstanding of the unique needs, fears and behavior of children. It is generallyaccepted that children adjust to hospitalization better when they have thecompanionship of other children in the same room. The unit is generally noisy, andshould be located away from the mainstream of hospital traffic. If possible, it should belocated adjacent to a terrace to be used as a play area.

The responsibilities of the Obstetrical nursing unit include prenatal care, observationand comforting of patients in labor, providing assistance in the delivery room, care ofthe mother after delivery and care of the newborn. Ideally the unit should be located onthe same floor as the labor-delivery suites and in close proximity to them. It should alsobe adjacent to the nursery

The Psychiatric nursing unit - many general hospitals recognize a responsibility for the

Special Nursing Units



mentally ill and provide facilities to treat them. The unit should be designed with anon-institutional atmosphere, with sensitive interior design to provide a desirabletherapeutic effect.All hospitals knowingly or unknowingly admit patients with communicable diseases.It is the responsibility of the hospital to protect other patients and hospital staff fromthese diseases. Barrier nursing and other techniques are not enough. Physical barriersare necessary. Isolation rooms are therefore provided, and are located within theindividual nursing units. They may also be grouped as a separate isolation unit.Rooms for specialized procedures such as organ transplants, bone marrowtransplants and burn cases call for special design provisions to meet the needs offunctional programs.

Newborn nurseries - they are one of the areas of the hospital where patients are mostvulnerable to infections. They should be located in the obstetrical nursing unit as closeto the mothers as possible. They should also be close to the premature baby or neonatalintensive care unit. The need for a close, natural adaptation of mother and thenewborn infant to each other right from birth is ingrained in the Indian culture. It istherefore hardly necessary to have a large nursery for full-term infants as is thepractice in the West. The basic physical and emotional needs of both the infant and themother are best satisfied by 'rooming-in', that is, placing them together soon afterbirth.

PLANNING OF CLINICALDEPARTMENTS

CHAPTER 8

General Planning Considerations

Early in the planning process, each department must be sized to accommodate the

functions necessary to accomplish its objectives. Early functional planning must

establish general concepts of operation, space needs, and required room relationships.

As a result, a functional space program can be developed by evaluating activities,

projecting work loads and assigning individual room requirements. In establishing

various work loads, a variety of utilization factors must be considered in light of the

operational procedures within each department. Such procedures vary from one

department to another. Work loads are established by considering such factors as

diagnostic tests and treatment procedures performed, patient visits, prescriptions

dispensed, meals served, and pounds laundered.

After space needs are established and preliminary plans begin, care should be taken in

the development of orderly circulation patterns, focusing on the separation of public

traffic, service traffic, and the movement of goods. It is desirable to have clear patterns

of circulation between departments as well as within each department.

A constant in the functioning of healthcare facilities is the continuing requirement for

change. Departments should be planned in a manner that supports independent,

open-ended growth and the location of "soft" space adjacent to high-tech functions

likely to grow. In addition, the proper use of modularity, multiuse space, and

changeable walls and systems can enhance a facility's ability to adapt to new

technological and care requirements.

Health facilities operate within a variety of settings, ranging from small community

hospitals to large academic medical centers, storefront clinics to multi-group practice

ambulatory care centers, and children's hospitals to specialty rehabilitation centers.

The quantity and types of ancillary departments are particular to each setting The rest

of this chapter identifies those departments most common in full-service healthcare



Example of a relationship matrix

THE SURGICAL SUITE

Introduction

Departmental Functions

Criteria for department sizing

Planning for the surgical suite, one of the most important areas of the hospital involves

various disciplines. The emotional needs of patients must be catered for and also those

of their families. There is no other aspect of hospital care that creates the level of fear

and anxiety than surgery. Therefore, any planning process must involve

administrators, surgeons, anesthesiologists, surgical nurses, representatives of

support areas (housekeeping, pharmacy, central sterile supply, and laboratory) and

individuals who consider the needs of the patient and family.

The function of the department is to receive patients after diagnosis, to anaesthetize

them either before or after transfer to the operating table, to operate, and to supervise

their post-operative condition before returning them to the wards. The pre-eminent

position of the surgical department in the hospital can be appreciated when one

realizes that in a typical general hospital, surgical patients represent 50% to 60% of the

admissions, and account for an appreciable quantum of the work of and revenue from

ancillary departments. The surgical suite of a modern general hospital and everything

that goes with it make a very complex workshop. The surgical procedures of the

present day, involving more people and highly sophisticated equipment, have

rendered ideas of planning of operating rooms of the past somewhat obsolete. The

major decision centers on the number and type of operating rooms.

The basic criteria for determining the number of operating rooms are the total number

of procedures and number of minutes expected annually for the target year.

Calculations are made to determine the total volume of expected surgical operations.

The total number of procedures performed in a given period of time is measured

against operating room capacity, including procedure and clean-up time. Surgery

generally takes place in a seven-to-eight hour, six-day-a-week period beginning at 7.00

a.m. with emergency and some elective surgery occurring during the weekend. When a

shortage of operating rooms occurs, it is not uncommon for surgery to take place in the

evenings and on weekends. As a thumb rule you can calculate one OT for every fifty

beds.



Composition of the Department

Flow of Various Individuals

The department consists of one or more operating suites that share ancillary

accommodation such as staff changing and rest rooms, arrangements for the reception

of patients, and facilities for the disposal of soiled material. The general OT's should

have a desirable clear area of 400 sq. ft. (minimum 360 sq. ft.) with 20 ft. clear dimension

(minimum 18 ft.) between fixed cabinets and built -in shelves. Rooms for cardio-

vascular, orthopedic, neurological, and other special procedures shall have a desirable

minimum clear area of 600 sq. ft. (minimum for orthopedic is 360 sq. ft. and for

cardiovascular and neurological is 400 sq. ft.), with a desirable clear dimension of 20 ft.

(18 ft. for orthopedic). A room for surgical cystoscopic and other endo-urologic

procedure should have a desirable area of 350 sq. ft. (minimum 250 sq. ft.) with a clear

dimension of 15 ft. The suites may also share a unit for the supply of sterile material and

instruments. Each operating suite normally consists of a theater, an anesthesia room, a

sterile store and a scrub-up. The orthopedic OT shall have enclosed storage space for

splints and traction equipment, which may be outside the OT, but must be

conveniently located. The space occupied by the operating rooms is only about one

fourth of the surgical suite - the supportive services and functions account for the rest

of the space.

Although the requirements of theaters can be met by an entirely internal placement,

from the point of view of staff that spends long periods in the department, some

natural light can be a valuable asset. This should be provided for some of the ancillary

staff rooms. The department should be on a cul-de-sac so that access to it can be strictly

controlled (there should be no non-related traffic through the suite). The Intensive

Care Unit should be preferably adjacent. X-rays are normally taken with the help of

mobile machines. The cleansing and the supply of sterile goods is done in a separate

Central Sterile Supply Department (CSSD) that can serve the whole hospital, or a

Theater Sterile Supply Unit (TSSU) which can serve a larger number of theaters via a

small sterile store attached to each of them.

Workflow in the surgical suite must be considered in relation to several different

groups: patients, visitors, medical staff, nursing staff, and logistical support. Patients

enter the suite from inpatient nursing units, the same day surgery area, or emergency.

Inpatients generally go to a holding area for surgical preparation, then to their

assigned operating rooms. Outpatients are transported to their assigned operating

room. After surgery, patients are transported to the PACU for recovery. Next, they go

to their assigned patient rooms, or to phase 2 recovery. Visitors wait during surgery in

the family waiting area. In some facilities, inpatient family members or visitors wait in

the patients' private room. Outpatient and same day surgery visitors wait in the

preoperative waiting area until after the surgery, when a limited number of visitors

may be allowed to attend to the patient while he or she is in the phase 2 recovery area.

All surgical staff members change into sterile clothing in dressing areas and enter the

surgical suite through a lounge. They can consult the surgery schedule for room

assignments. All those participating in the surgery scrub and gown prior to entering

the operating room. After each surgery, the surgeon speaks with the patient's family in

a consultation room. Between surgical cases, physicians can take a break in the surgery

lounge. There they can utilize the physician dictation areas to record the

proceedings/outcome of the surgery.

A surgical suite flow diagram



Reducing Risk of Infection

Of prime importance in the design of the department is the need to reduce to a

minimum the risk of infection at the operating table. Ensuring the sterility of

instruments and other apparatus is relatively simple, but no less important is the

reduction of the risks of airborne infection. This depends upon management

procedures and the physical arrangement of the department and of its ventilation

system. The physical arrangement should ensure that not only are these procedures

facilitated but that as far as possible they are inescapable.

A surgical department could be divided into zones, where the quality of the

environment would conform to the cleanliness policy adopted by the individual

hospital.

The general zone - in this zone the requirements for cleanliness correspond to the

usual hospital cleanliness standard. This zone includes waiting areas for relatives,

catastrophe and triage areas, plaster rooms, offices, record rooms, laboratories,

stores for non-sterile material, staff lounge-refreshments, toilets changing rooms.

The clean zone - this provides for the surgical department reception and holding

area, anesthesia rooms, delivery rooms, Endoscopy rooms, stores for blood,

medicine, parenteral solutions etc., stores for tubed medical gases, the sterile service

area, the general post-anesthesia area, X-ray apparatus stores, and clean bed stores.

The super clean zone - this accommodates scrub-up and gowning areas, operation

theaters, sterile stores, sterile linen stores, and thoracic post-anesthesia rooms.

The ultra clean zone - is determined by a circle with a one meter diameter from the

wound.

The aseptic zone - is limited to the area of the incision.

To minimize the risk of infection the method of artificial ventilation should ensure

that within each suite there is a supply of pure air sufficient to reduce the bacterial

count below a critical level. There should be a positive pressure in the theater and

sterile store to provide a flow of air from the clean to the less clean areas. Each theater in

the department should have its own self-contained ventilation system in order to

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reduce the risk of cross infection. There should be no movement of air from one suite to

another.

Schematic Diagram of OT Suite Airflow

Other Area Requirements

A holding area is needed at the entrance of the department where patients are

transferred to a theater stretcher. Whether a separate anesthesia room is provided or

not, the anesthetist needs a wide variety of equipment, instruments and drugs which

calls for considerable storage space. In addition, equipment used in the department,

some of them bulky items such as the C-arm and portable X-rays need to be stored in

alcoves. After the operation the patient is transferred to a recovery area for recovery

from the anesthesia, and then either to his own ward or the ICU. The Post-Anesthetic

Care Unit (PACU) (Recovery) area needs to be easily supervised and readily accessible

from all the theaters. it should contain a medication station; hand-washing facilities;

nurse station with charting facilities; clinical sink; provisions for bedpan cleaning; and

storage space for stretchers, supplies and equipment. It would be desirable to have 80

sq. ft. for each bed in addition to the above spaces and a clearance of at least 4 feet

between beds and between beds and adjacent walls. The thumb rule for sizing is one

and a half to two beds per operating room.

The procedures carried out in the surgical suite are probably the most precise and

critical of all the functions performed in a hospital. The suite itself makes the most

exacting demands upon detailed design and is frequently the most remote form the



average designers direct experience. Ventilation and lighting are probably open to

more refined improvement than in any other part of the hospital building. For these

reasons there may be much to be said for a design approach that anticipates future

flexibility and change instead of attempting precise original design with materials and

equipment that may be difficult to alter later.

The following service areas shall be provided:A control station located to permit visual observation of all traffic into the suiteA supervisor's office or stationA sterilizing facility for immediate or emergency useA medication station for distribution of drugs and routine medicineAn enclosed soiled workroom for the exclusive use of the surgical suite, for the

collection and disposal of soiled materialA clean workroom or clean supply room, where clean materials are assembled

prior to use or following the decontamination cycleMedical gas storage facilities, in addition to the main storage, separate storage

of reserve gas cylinders necessary to complete at least one day's proceduresAn anesthesia workroom for cleaning, testing and storing anesthesia

equipment, with space for anesthesia cartsAn equipment storage roomStaff clothing change areas, containing lockers, showers and lavatories, space for

donning surgical attire, with a one-way traffic pattern, from 'dirty' to 'clean'.Staff lounge and toilet facilitiesDictation and report preparation areasOutpatient recoveryChange areas for out-patients and same-day admissionsA space for patient examination, interviews, preparation, testing and obtaining

vital signs of patients for out-patient surgeryStorage areas for portable X-ray equipment, stretchers, fracture tables, warming

devices, auxiliary lamps, etc. These areas shall be out of corridors and traffic.Housekeeping facilitiesAn area for the preparation and examination of frozen sectionsProvisions for refrigerated blood storageWhere applicable, appropriate provisions for refrigeration facilities for

harvested organsProvisions for pathological specimens storage prior to transfer to pathology

section

Services, except for the soiled workroom and housekeeping room may be shared with

the obstetrical facilities if the functional program reflects this concept. Service areas,

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when shared with delivery rooms, shall be designed to avoid the passing of patients or

staff between the operating room and the delivery room areas.

There are several operational issues that affect surgical suite design for example,

integrated versus independent outpatient facilities, perimeter work corridor versus

interior work core, and integrated versus separate central sterile supply.

The consideration of an integrated versus independent outpatient facility addresses

the question of the outpatient service location. Outpatient surgery can be an integrated

part of the inpatient surgery suite or separated in an independent outpatient suite that

includes both preoperative areas and operating rooms. These areas may be located on

or off campus. The appropriate location of this service will involve the medical staff

and hospital administration.

A perimeter work corridor layout circles the operating rooms. The layout provides a

single corridor system that is used to transport patients, physicians, nursing staff and

clean and soiled supplies. Closed clean and soiled case carts and double bagging of

waste products are used to maintain sterile conditions. An interior work core separates

clean distribution from the soiled distribution system. Placed between two rows of

operating rooms, the interior work core is used for sterile supplies and instruments.

The issue of an integrated versus separate central sterile supply (CSS) is whether

central sterile supply is placed adjacent to surgery or on another floor: if it is placed

directly above or below the surgical suite, it is linked by elevator or dumbwaiter.

Although the surgical and CSS staff normally prefer an adjacent relationship, physical

building constraints often have a bearing on the location of central sterile supply.

Operational Relationship



A diagram of a surgical suite's perimeter corridor concept

A diagram of a surgical suite's interior work core concept

Trends

Intensive Care Units

Introduction

Location

Surgical facilities will continue to separate outpatient cases from inpatient cases. Thetrend is, however, toward integrating outpatient with inpatient surgery for greaterefficiency in the use of staff and instruments and cost reduction. This trend putsadditional pressure on the surgery staff to maintain outpatient standards of carewithin the inpatient hospital setting. Outpatients will continue to require direct andconvenient means of entering the outpatient area.

Pain management services will expand as new and better means of reducing pain aredeveloped. The preoperative patient areas will continue to be key locations for painmanagement services. The integration of invasive imaging (cath lab) within thesurgical suite will increase as a means of delivering invasive imaging in a surgicalenvironment. A developing trend is to combine surgery with magnetic resonanceimaging. Each of these trends carries with it the promise of improved surgical servicesand better care for the patient.

Many people – caregivers, architectural and design professionals, and patients, regardintensive care (critical care) units as the heart of the hospital. Here a seriously ill patientcan expect the maximum of care: the very best the hospital has to offer in terms ofpersonnel and technology.

Intensive Care Units (ICUs) are specialty nursing units designed, equipped and staffedwith specially skilled personnel for treating very critical patients or those requiringspecialized care and equipment. Centralizing the acutely ill patients, as is often done,in contiguous units in an intensive care complex consisting of surgical-medicalintensive care unit, coronary care unit and specialty units such as renal and burn units,results in multidisciplinary care and economical use of the space and equipment.

There is no unanimity among the medical and nursing experts as to where the ICUshould be located. There are two schools of thought. One suggests that the ICUs shouldbe in a centralized place and be contiguous with, or readily accessible to, one another.The argument is that patients admitted to the medical-surgical intensive care unit mayhave, or suddenly develop, cardiac complications. Having intensive care facilities in acentralized place allows the specially trained professionals and equipment an almostinstant access to patients in all clinical services when an emergency develops. Such anarrangement also eliminates the need for duplication of costly equipment andpersonnel.



The second school of thought favors that the location should be dependent on the typeof patients. For example, the surgical ICU should be close to the operating rooms whilethe medical ICU should be in close proximity to the medical ward to facilitatefollowing the concept of progressive care. That is, the patient is moved from theintensive care unit to intermediate care or step-down unit, and then to the generalpatient care area.

Whatever its location and adjacencies, the intensive care unit must exclude through-traffic.

Intensive care units should be close to emergency, Operation Theater Suite,Respiratory Therapy, Laboratory and Radiology. Most admissions to ICUs are eitherthrough the emergency department or from the operating rooms following majorsurgery. They should not be too far away from general nursing units, as patients mayneed to be transferred in an emergency. They should be close to vertical transportationcores. They should be away from heavy traffic and noise. The electrical influence ofequipment like elevator motors and X-ray equipment on the displays of monitorsshould be kept in mind. Accessibility and direct visual contact between patient andnurse is important. The patient should be close enough to permit observation ofrespiration, facial color and other revealing symptoms.

It is generally recognized that for effective operation, there should be no more thantwelve beds per intensive care unit. Twelve beds is seen as the upper limit of what anICU nursing staff and station can adequately monitor. An intensive care unit of lessthan six beds is clearly uneconomical.

This guideline of twelve beds maximum will become decreasingly significant as ICU'sincorporate bedside computers that enable “paperless charting” and direct recordingof vital signs through monitoring devices. Such technology will encourage“decentralized nursing” which will allow nursing staff to spend less time at a centralnursing station and more time in patient rooms and at mini-work stations directlyadjacent to these rooms.

As to the rooms themselves, the American Hospital Association (AHA) minimum is150 square feet per room. This may be adequate for non-critical patients, but it is toosmall for patients on life-support and monitoring equipment. The task force onGuidelines of the Society of Critical Care medicine recommends 150 to 200 square feetin open units, while private patient rooms should contain 225 to 250 square feet. TheICU patient room should be planned to facilitate operations in the event of a crisis.

Relationships with other Departments

Sizing Considerations

The beds should be located permanently away from the wall, to give staff a 360-degreeaccess to the patient.

It is alarming to review the substantial literature that now exists on intensive care unitsof the recent past devoted to how the environment of the intensive care unit canadversely affect patient health while simultaneously increasing stress and fatigueamong the physicians, nurses, and nurses, and others who work in these areas. The factis that many ICU's and ICCU's – are literally – sickening.

In most ICU's, the focus is not so much on the patient as it upon a disease or disorder, asif the procedures necessary for sustaining life in the physical sense were somehowincompatible with simultaneously sustaining emotional well-being. The assumptionseems to be that the ICU patient is either unconscious and unaware of his surroundingsor too sick to care about them. The issue is that emotional health cannot be neatlyisolated from physical health. The machinery makes many patients feel invaded andhelpless. The sense of claustrophobia created by packing monitoring equipment,respirators, and IV delivery equipment into a small space can dramatically increaseanxiety levels.

Windows are all too often absent from intensive care unit design. Not only does thisheighten the sense of claustrophobia inherent in these technology-packed areas, but anumber of studies have demonstrated that patients in windowless rooms are subject totemporal dislocation and even subject to “ICU psychosis”, which is characterized bydelirium, hallucination and delusions.

Harsh lighting, especially from fluorescent fixtures often aggravates the disorientingeffects of having no windows, and by lighting that is not dimmed to correspond to thebody's circadian rhythms. Sleeplessness is a common problem in intensive care units,and it is not only due to lighting, but also to the remarkably high level of noise thatprevails in many of the older units.

Excessive noise is particularly stressful for cardiac patients, who exhibit increasedcardiac workloads and arrhythmias in noisy environments. In addition, painperception is heightened by the presence of excessive noise. There are more diffusenegative responses reported by patients, including a sense that they could not “escape”their environment; a general and anxiety-provoking sense of unrelenting urgency inthe environment; sensory deprivation; crowding; and loss of privacy. Many relatedfeelings also affect those who work in the critical care unit, leading them todepersonalize patients.

All of these responses can at least be mitigated by design solutions.

Technology and Humanity: Design Priorities



Technology and Design: Achieving a Balance

Specialized Intensive Care Units

While emphasizing the human aspects of ICU design, the intention is not to denigratetechnology. Not only does medical machinery save lives, it has the potential of actuallyhumanizing the relation of caregiver to patient by saving staff time, for example in theautomatic recording of data, enabling the time freed to be used to be in contact with andtreating patients. The development of “bedside laboratory” technology can beemployed to assess blood gases, electrolytes, glucose, and hemacrit using a very smallblood sample – 0.5 ml – in less than ninety seconds.

Good design can do much to accommodate the machinery while keeping it out of theway. Particular attention should be devoted to the headwall, which, especially in theintensive care environment, bristles with connections for medical gases, suction,electrical power, and terminal hook-ups. Consideration must be given as to whetherthe hook-ups should fan out from the patient to the headwall, whether they willconverge at a power column, or run to an overhead rail system. In general medical-surgical patient rooms – and even in some critical care facilities – attractive caseworkcan be used to hide all or some of the hook-ups in the headwall.

The choice of headwall, power column or rail system is in large part determined by thelayout of the room (especially the orientation of the bed), which, in turn, is a function ofoverall unit design and the need to balance the demands of technology, accessibilityand privacy. The starting point for the layout of the room is the orientation of the bed.From the point of view of the nurse, the bed should be situated to allow readyobservation of the entire body, especially the head. Tradition dictates that the head of abed be against a wall, and certainly, headwalls accommodate readily to this approach.However, in a crisis, it is often essential to have access to the patient from all four sides.Certainly, the bed can be pulled quickly out from the wall, but tubes and monitor leadsmay continue to inhibit access or may even present a trip hazard. Some architects haveproposed a partial solution to this in non-square rooms or rooms with one angled wall,meant to increase clearance around the bed (and to give the room greater sensoryinterest to the patient). However, a similar approach is to treat the bed as an island.

An Intensive Coronary Care Unit is used to identify the units restricted to patients whoare suffering from cardiac emergency conditions. Patients are transferred from here toan intermediate care section, which ought to have twice the number of intensive areabeds. A Pulmonary Intensive Care Unit (PICU) is a major key in a comprehensivepulmonary care program for chronic obstructive lung disease. A laboratory foraround-the-clock determination of arterial blood gases immediately adjacent to thePICU is required, since these patients are very unstable. A logistic delay due to

laboratory remoteness or unavailable technical assistance is not acceptable.Neurovascular or stroke cases are admitted predominantly from the emergencydepartment. In a Burns Care Unit two phases of the burns illness - the shock period andthe healing period - have to be accommodated. Complete reverse isolation can be asignificant factor in the prevention of bacterial contamination of individuals incurringmajor burns injuries. For maternity patients with complications and particularly forthose in premature labor a special ante and intra-partum unit also referred to as anobstetric or labor or maternity intensive care unit can be provided. In conjunction withthis, a Neonatal Intensive Care Unit (NICU) can be provided, which is an intensive carenursery which provides the best chance of saving life and of improving physical anddevelopmental status for survivors of serious perinatal illness.

These and other specialized units are discussed in greater detail below:

After the surgical-medical ICU, the intensive coronary care unit (ICCU) is the mostcommonly found critical care unit in the hospital. The central design issue in the ICCUis finding a strategy to promote tranquility and even relieve visual and acousticalisolation. So-called “ICU psychosis” is a shocking enough symptom of poor criticalcare design. In the case of an ICCU, noise and visual clutter have a readilydemonstrable adverse effect on heart rates, arrhythmias, and blood pressure.

The respiratory care unit has developed as an alternative to the traditional ICU inresponse to the constraints of managed care and cost containment. Studies show that35% of surgical and medical intensive care patients were admitted to these costly unitsstrictly for the purposes of monitoring and did not require any active intervention. Thepatients were not suffering from any immediately life-threatening processes. Thestudies suggested a rationale for providing more cost-effective intermediate care unitsfor those patients in need chiefly of close monitoring rather than aggressiveintervention.

Cost savings are achieved in part through reduction in the amount and nature ofrequired equipment and, in even larger part, through reduced staffing needs. Whereasthe nurse to patient ratio in the ICU may be 1:2 or even 1:1, in the respiratory or step-down unit the ratio can safely be set at 1:3 or 1:4.

Until some time back, most buildings were standardized on the model of a thirty-year

Intensive Coronary Care Unit

Respiratory Care and Step-Down Units

Critical Care of the Elderly



old healthy male user or occupant. Increasingly, however, architects and planners aredesigning for a seventy-year-old woman who is in less then optimum health. While noradical steps need to be taken to design special critical care facilities to accommodateolder patients, certain design features can be incorporated into general ICU's to makethem friendlier to the aged.

Gerontologists speak of an “environmental docility hypothesis”, which holds that ascompetence decreases, the probability that behavior will be influenced byenvironmental factors increases. We know that critically ill patients often feel at themercy of their environment. This seems to be even more compelling among thecritically ill elderly.

Some of the design areas discussed earlier, especially noise control, light and color, areparticularly important in designing with the elderly in mind. Noise reduction shouldbe a high design priority. Because of diminished visual acuity in the elderly, lightingshould be planned to avoid glare. This also means keeping highly reflective surfaces toa minimum. Color discrimination also deteriorates with age. Differentiating amongdark shades and among pastels is a particular problem. Thoughtful use of contrast toemphasize planes and corners aids orientation. However, the elderly person shouldnot feel dominated by the colors in his environment.

An array of neurological conditions may require intensive care. Many of theseconditions can be treated appropriately in the general surgical or medical ICU, but themonitoring and treatment of intracranial pressure (ICP) in particular has been cited bymany authorities as ample rationale for creating specialized neurological intensivecare units.

Probably the best model for the neurological ICU is the Intensive Coronary Care Unit(ICCU), which focuses on continuous and sophisticated monitoring in order to achieveearly detection of developing problems. Increasingly sophisticated monitoringdevices will have to be accommodated in neurological critical care, and these must beadded to a full array of respiratory and ventilation equipment.

Perhaps the single greatest design impact of the neurological ICU is the issue ofadjacency. It is desirable to locate this unit near diagnostic facilities as MRI and CT.

Burns Unit

Another specialized intensive care facility found in larger, often regional hospitals, isthe burns unit. Some hospitals, most notably the network run by the shrine of North

Neurological Intensive Care

America (Shriners), are devoted entirely to the treatment and rehabilitation of burnvictims.

For design, the single most important clinical factor in treating burns is creatingstructures that minimize the risk of infection. Burns unit critical care patient roomsshould be private, rather than an open ward, to minimize the risk of cross-infection.

The ICU at Shriner's Hospital Galveston Burns Institute (HDR Inc. were the architects)features patient rooms that are fully enclosed with glass to allow maximum visibilitywhile providing for isolation. The HVAC system was designed to surgical operatingroom standards, and positive air pressure as well as HEPA filtering promotes surgicalsuite air quality.

The Galveston ICU patient rooms also include radiant heat systems above each bed.These are linked to thermal sensors mounted on patients who lack an insulatingepidermal layer, and, in this way, heat loss is perfectly compensated for by the radiantpanels. Environmental control extends to the maintenance of high relative humidity asneeded to help prevent damaged skin from drying out.

In addition to meeting the demanding clinical conditions required by the advancedtreatment of severe burns, the burns unit ICU should project as much of a non-institutional sense of well-being as possible. Severe burn injury is not only physicallypainful, but is especially depressing and anxiety provoking. Patients suffering fromdisfiguring injury benefit from maintenance of contact with the outside world.Tragically, it is also the case that a great proportion of burn victims are children. Thefocus of the Shrine-sponsored institutions is pediatric. But all advanced burns unitsshould be designed with the younger patient in mind.

In discussing the burns ICU we have touched upon the issue of isolation to preventinfection. Patients admitted to an intensive care unit have a higher risk of nosocomialinfection than other hospitalized patients.

Most authorities believe that design for isolation is primarily a matter of ventilation,filtering, and maintaining positive air pressure in the patient room, for patients whoare immuno-compromised. For patients who themselves are a source of infection,negative air pressure is maintained, other safeguards remaining the same. It isassumed that nursing the patient in a one-patient room with the door (or pair of doorswith an air-lock lobby) closed is the best safeguard against infection in intensive care.

The Issue of Isolation in Intensive Care Units



The Neonatal Intensive Care Unit

THE NEONATAL INTENSIVE CARE UNIT (NICU)

1. Design Issues for Neonatal Intensive Care Units

2. Design Guidelines for Neonatal Intensive Care Units

Design Issues for Neonatal Intensive Care Units

This is discussed separately as a department.

The design and planning issues with respect to a neonatal intensive care unit(NICU)are sufficiently unique to warrant a separate discussion, apart from that ofintensive care units in general, which are separately discussed above.

The discussion will be under two broad heads, These two heads are:

The modern neonatal intensive care unit is the product of two factors:

1. The development of an understanding that the pathophysiologic phenomenaassociated with the newborn are so distinctive that they require an appropriatesetting where the critically ill infant can be effectively managed, and

2. Convergent advances in electronics and biochemistry, which made such a settingfeasible.

These advances include:

1. Methods for continuous evaluation of numerous parameters of neonatal (and fetal)illness.

2. Methods of continuous monitoring of cardio-respiratory function.3. Micro-techniques for the rapid biochemical determinations from minute blood

samples.4. Servo-controlled radiant-heat incubators.

These advances, coupled with improved methods for controlling infection, promptedthe development of the NICU: a common area where all medically and surgically illinfants are treated, premature and full term, infected and non-infected.NICU's perform the following functions

1. Observe critical infants

2. Monitor critical infants electronically and bio-medically

3. Carry out advanced therapeutic procedures

4. Promote maternal-child contact to the fullest extent possible

The last functions is because it is realized by now that maternal handling as well assensory stimulation (but not over-stimulation or inappropriate stimulation) are crucialin the neonate's earliest hours and days – even if the infant is critically ill. Thusdesigners of NICU facilities are faced with a set of requirements that are, in manypoints, contradictory. One the one hand, there is a call for a common technicallysophisticated space, while, on the other, there is a call for a humane environment thatfacilitates maternal contact.

A number of studies have suggested that humanizing the NICU may be more of aclinically urgent matter than merely a desirable goal. Some authorities have suggestedthat continual exposure to bright lights may contribute to retinopathy of pre-maturity(ROP), a leading cause of blindness in premature infants. Another effect of continualhigh-level illumination is disruption of diurnal patterns at this earliest stage ofdevelopment. Monitoring of cardio-respiratory function demonstrates that these vitalsigns tend to be more stable when infants are exposed to cycled lighting that mimicsdiurnal patterns.Also, when light levels are high, noise levels are commensurately high. When lightlevels are dimmed, noise levels also decline. Indeed, noise in traditional NICU's isoften at a distressingly high level. Alarms and incubators are the biggest mechanicalnoise producers. These not only elevate levels of arousal, there is evidence thatprotracted exposure to incubator noise levels in excess of 70 decibels may contribute toactual cochlear damage and subsequent hearing loss. As in the adult ICU, sensoryoverload is also a threat to professional staff. In a more recent development,undertaken in part to minimize the ill effects of the traditional NICU unit, architectshave moved away from the warehouse style NICU, designing instead smaller units offour to six bassinets.

The only humanizing architectural element that most authorities argue againstincluding in the design of the NICU is windows, primarily due to their thermal effects,which can cause potentially harmful dips or spikes in ambient temperature. In settingswhere fully enclosed incubators are used, it is even possible that too much sunlight cancause excessive warming due to a greenhouse effect.

NICU's should incorporate muted colors, since babies especially under stress, do not



respond well to bright colors. Lighting suggested is true-color fluorescent and indirectcove lighting. To maximize efficiency, place the nurse workroom immediatelyadjacent to the NICU, to enable nurses to monitor the unit more closely. A parent roomshould be provided close by to accommodate well parents who wish to be close to theirbaby. Lighting levels can be automatically cycled to promote the babies regular sleepschedule, and finishes throughout the facility should be more traditional thaninstitutional. As far as possible, the NICU should maintain the homelike setting thatpredominates throughout the family birth unit.

The creation of formal planning guidelines for newborn intensive care units (NICU's)occurred in 1976 in the USA, and since then, the American Academy of Pediatrics(AAP) and American College of Obstetricians and Gynecologists (ACOG) havepublished a number of their comprehensive Guidelines for Perinatal Care, amongother documents.

The purpose of this document is to provide health care professionals, architects,interior designers, health care facility regulators, and others involved in the planningof NICU's with a comprehensive set of standards based on many years of clinicalexperience.

These recommendations are planned to be upgraded on a regular basis, incorporatingnew research findings, experiences and suggestions.

While many of these standards are minimal, the intent is to optimize design within theconstraints of available resources, and to facilitate excellent medical care for the infantin a setting that supports the central role of the family and the needs of the staff.

The latest revision of these standards can be found on the website:

These are the:Recommended Standards for Newborn ICU DesignReport of the Fifth Consensus Conference on Newborn ICU DesignJanuary 2002Clearwater Beach, Florida

Design Guidelines for Neonatal Intensive Care Units

www.nd.edu/~kkolberg/DesignStandards.htm

MATERNITY / OBSTETRICS DEPARTMENTIntroduction

The Maternity Department

The maternity department, also referred to as the obstetrics department, is usually thesetting for a natural process as opposed to a pathological one. This department differsfrom most other departments in a hospital because it is designed to house a happyevent, also called a “wellness' event. It is dealing with a continuous process, maybefrom insemination (if clubbed together with IVF) to pregnancy through delivery topost-natal care of both mother and child. It is not so much concerned with curing anillness but with the fulfillment of a natural act. It is important, therefore, that the designof the department should not be in any way be suggestive of ill health.

It is a good design response to keep this department separated from the rest of thehospital, it need not necessarily be on another site, but can certainly have it's ownentrance and image distinct from the facility it is a part of, to foster the concept of a“wellness” place. If connected to a multi-specialty hospital, it could share supportservices such as food and laundry, as well as diagnostic and other services the“patients” may need.

The department is divided largely into two parts:

The outpatient clinics.

The inpatient accommodations concerned with delivery and post-natal care.

The outpatient clinics can be a part of the hospital's outpatient department or may beprovided separately. These same rooms could also accommodate post-natalexaminations, family counseling and gynecological outpatients.

The delivery suites have a lot in common with the operating theaters. There aresimilarities in the ways they are located and controlled. In laying out the labor anddelivery suite, the designer should consider the functional areas comprising thedepartment such as the preparation room, labor room, delivery room, recovery roomand support services area. We recommend that there be a provision of an operationtheater in the department where major obstetrical surgery can be performed. If thisdoes not work within the area or budget constraints one of the delivery rooms shouldbe designed and equipped to serve this purpose.

Antenatal patients are usually seen at the time of booking, at about the thirty-sixthweek of pregnancy, and then weekly until admission for delivery. This clinic should

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preferably be accessed separately from the center's main entrance, and will comprise ofa waiting space, rooms for history taking and examination, urine testing room andlavatory, and office and record space. Easy access to the clinical laboratory andimaging sciences is advantageous.

The layout of the department is dependent on the type of delivery envisaged by thatparticular facility and the number of projected deliveries. There are three maindelivery models in obstetrics:

This is a process in which the patient moves through different rooms and areas duringthe various stages of giving birth. The patient is admitted to a triage area andtransferred to a labor room. The patient is then transferred to a delivery room for thebirthing process. The patient is transferred again to recovery post-delivery. Thepostpartum unit is the final stop for the new mother. The infant is placed in a nurseryadjacent to or within this unit. Of the three models, this one involves the mostmovement of the patient.

These are oversized single-occupancy patient rooms that are used for all the threeprocesses of labor, delivery and recovery. These are an established feature of thehealthcare industry in the West but have been introduced in India only in the early2000's. They consist of a well-designed room that offers the expectant mother theadvantages of a family-oriented birthing process in one room, other than when the caseis a high-risk one. They are designed like a residential bedroom, with obstetricalequipment tucked away, out of sight. These rooms can be quickly converted to high-tech procedure rooms as the delivery progresses, with the necessary equipmentbrought in. This provision offers would-be mothers the best of both worlds - thecomforts of their house in the setting of a hospital setting with competent medical care.

Although the trend in the West was to use these rooms as postpartum beds as well, thispractice has changed there because of several issues: inefficiency in room utilization,difficulties with nurse cross-training, and patient preferences to continue recovery in aquieter setting. Consequently, many postpartum beds are located adjacent to LDRareas, in their own quiet rooms, frequently with newborns rooming-in with theirmothers and with double beds provided for the fathers.

This facility consists of a single room used for the entire stay of the patient in the

1. Traditional.

2. Labor/Delivery/Recovery (LDR).

3. Labor/Delivery/Recovery/Postpartum (LDRP).

hospital. The newborn may stay in the room or in the nursery for full or partial care. Inthese three models of birthing, this one occasions the least movement of the patient.

Specialty care units like a maternity department or a comprehensive woman's carefacility can provide valuable marketing opportunities for the hospital they are attachedto not only through the services they provide but through their design as well.

Maternity units can constitute an effective marketing “niche” in today's times. Theycan be designed with a focus on “high touch”, and given a residential, non-institutionalimage. The unit can be designed to have a non-clinical atmosphere and can be a settingin which expectant mothers can meet, which can be desirable especially in newcommunities.

It could be a good marketing strategy for a healthcare facility based in a largecommunity to reach out to it's primary market area by combining a birthing center withother diagnostic and treatment functions. This configuration can create a satelliteambulatory care center with integrated physician office practices with both affiliatedand non-affiliated physicians.

The intention should be to create in the patient's mind a positive associative image ofthe hospital. This can be achieved by providing amenities not usually found inhospitals. These may range from attractive façade design and entrance areas, loungeslocated on the floor (for patients and families) to small reading areas, Internet access,and access to an electronic library, which can be educational. The ambiance in theseunits should be one that aids healing and produces tranquility, the very anti-thesis ofinstitutional environments in hospitals of the past.

An easy and clearly indicated entrance for patients is an important design requirementbecause of the urgency of the labor and delivery process and the stress and anxiety thatmay accompany it. Patients come to the maternity department from a number ofplaces, such as the women's center main entrance, the emergency department(especially after hours), and the doctor's office.

Today most healthcare facilities in the West direct patients through a central triagearea. At this point, physicians decide whether to observe or advance a patient to anLDR/LDRP room or patient room or to a cesarean section room for immediatedelivery. The area may be adjacent to or shared with a cesarean section recovery areafor staffing efficiency and flexibility in assigning patient beds. Immediate proximity ofthis area to the cesarean section suite is essential for efficient transport time.

Marketing opportunities for the main facility

Patient and Work Flow



Patients in active labor are transferred to a labor room, an LDR room or a LDRP room,where family members may join them. The LDR/ LDRP design concept incorporateslocating rooms around the perimeter of the facility for day-lighting and should allowdirect access from triage, the cesarean section area, resuscitation, and the neonatalintensive care unit (NICU). Adequate patient and family amenities ensure a successfullabor and delivery area.

In the LDRP model, staff flow begins with patient contact at the reception area, thencontinues to the triage area, labor and delivery/recovery areas, and postpartum ordischarge area. In an LDR/LDRP concept, the patient will experience the same nursingstaff throughout the labor/delivery process. Staff will move clean equipment into theroom for delivery and remove post-delivery equipment for cleanup.

After post-delivery assessment, the infant often remains with the mother duringrecovery before being transported to the nursery for further assessment, cleaning andgowning. Infants in stress are transported directly to a transition nursery or an NICU ifdirected by the neonatologist. After a delivery occurs in the cesarean section room, themother is transferred to the recovery area. At that point, the baby is observed in aresuscitation area or a transition nursery adjacent to the delivery suite.

Physician and staff gowning facilities should provide a one-way flow into the cesareansection suite, as in the surgery department. Physician and nurse work areas should bedecentralized and located closer to the patient areas to improve patient care and staffefficiency.

The obstetrics area is the focal point of a comprehensive women's center. There aresome departments and services that have strong ties with the women's center. Theneonatal intensive care unit (NICU) should be contiguous because of the frequencyand priority of the newborn being transferred to this facility.

The postpartum/ obstetrical inpatient unit and well-baby nursery require easyaccessibility, separated from public traffic and with horizontal or vertical access toobstetrics. Emergency and surgery departments require easy access; cases might comein from emergency or go to surgery.

In recently designed facilities in the West, the trend is to combine all services necessaryfor comprehensive women's care, including perinatal services, pediatrics, breasthealth services, and education centers, in addition to labor, delivery, recovery andpostpartum facilities.

Relationships with other Departments

Special Planning and Design Considerations

CLINICAL PATHOLOGY

INTRODUCTION

There are a number of special planning and design considerations for obstetrics, asenumerated below:

1. Make the unit easily accessible to visitors, but separate patient and support trafficfrom visitor traffic. This is necessary to protect the patient's privacy and dignity.

2. The design of the unit should be sensitive to the needs of the families of the patients;the colors, materials, furnishings and the overall ambience should be appropriateto the activities and mood. The use of artwork in harmony with the overall interiordesign scheme can help create positive distractions and peaceful imagery desirablein the context.

3. The focus should be on creating an ambience of “wellness”, offering views ofnature, landscape scenery, and water is very desirable.

4. In the inpatient areas (Rooms, LDR's, LDRP's), the design objective should be togive patients and their families control over their environment through permittingthem to set lighting levels and the temperature to their comfort, providingadequate storage space, and TV/VCR/music with the controls at the bedside.

The essential function of the department is to carry out diagnostic tests on specimensfrom in-patients and outpatients. It may also be concerned with work for clinics, healthcenters, local practitioners and the public health services. Within the department themain divisions are those for histology and morbid anatomy, which involve themicroscopic examination of tissues and cells; hematology, the study of blood;biochemistry, the study of living tissues and fluids, cytology, the study of body cells formalignancy etc. and microbiology, the study of micro-organisms. Each of thesedivisions may require sub-departments, their extent depending on the context andpolicy of the laboratory. Larger hospitals may have a separate unit for bloodtransfusion services (a blood bank).

In addition to those originating from outside the hospital specimens will be deliveredfrom the wards, the operating theaters, the mortuary, the outpatient department andfrom the accident and emergency department. Some specimens, particularly bloodand urine, will be obtained from outpatients on the spot, and for this a sample



collection center is needed. Nearly all specimens will pass through a central receptionand sorting office before distribution to the appropriate laboratory divisions. Smallancillary units are often sited in the ICU (for speedy blood gas analysis) or in theemergency unit. Planning for future expansion is important, as space requirements forlaboratories tend to double every 10 years.

Laboratory requirements are inevitably complex, variable and confusing, and it isessential that the brief should be comprehensive and precise if the resulting design is tobe successful. A bad brief is more likely to result in an unsatisfactory design than isusual. The brief can usually be obtained in two stages, which correspond to the stagesin which the design team requires information to progress the scheme. The first is thatneeded to produce the initial sketch designs; the second is that needed to produce thedetailed designs, from which the production information can be prepared.

The first stage brief consists of accommodation requirements. This should include:accommodation schedule-aroom-by-room list giving name, area andoccupancy of each;room relationship statement - guidance on rooms that need to be grouped in closeproximity or en suite;operational policy statement - a general explanation of how it is proposed tooperate the facility, e.g. how the facility will be supplied, how waste will bedisposed of, hours of operation;general environmental conditions - whether mechanical ventilation or airconditioning is required in specific areas or throughout;non standard requirements - identification of any rooms or areas in which out-of-the-ordinary space, servicing or other demands will affect the building form.

The second stage brief consists of detailed requirements. This should include room-by-room details of:

engineering services requirements - e.g. power supplies, water supplies, specialgases;environmental requirements - ventilation, temperature, humidity, lighting;fittings and equipment - e.g. benching, cupboards, fume cupboards, equipment;finishing's - floor, wall and ceiling finishes.

Information on the second stage is best gathered by means of room data sheets, onwhich the detailed requirements and content of each room are recorded on astandardized pro forma for the project.

LOCATION

The following factors should be borne in mind when considering the location of a

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pathology department:· It should be easily accessible from the OPD, accident and emergency and

maternity departments; surgical wards; operating theaters and intensive careunit. Medical wards and other clinical departments should also be within easyreach of these diagnostic facilities.

· There should be a close link with the main hospital routes for ease of distribution oflaboratory specimen containers, reports and blood to the wards and other hospitaldepartments; ease of transport of specimens from these to the pathologydepartment and ease of access for medical and other hospital staff.

· The function of the hospital mortuary is closely linked with that of the pathologydepartment, in particular the histopathology departments activities andpersonnel. The mortuary should be easily accessible to pathology staff.

· The whole department should be planned as an integral secure area. In particular,the total number of entrances from the exterior should be minimal, to deterunauthorized access. In addition, there should be no corridor traversing thedepartment which could be used as a link between other departments or constitutea fire escape route except for users of the department.

· The receipt of bulk deliveries of laboratory supplies and large items of equipmentmay influence planning decisions on the size and number of stores, positions oflifts, hoists, corridors and doors.

· Laboratory areas are considered to be potential sources of infection and high fire-risk areas. For these and for aesthetic reasons, proximity to staff accommodationand to those areas frequented by the public is inadvisable.

· Good access must be available for fire brigade vehicles.

· Exhausts from ventilation systems servicing the pathology department must bedischarged safely to avoid ingestion by neighboring supply ventilation systems orentry into adjacent windows of naturally ventilated spaces.

· Convenient access will be required to an incinerator for the safe disposal oflaboratory waste.

· Easy access to external stores of gases and flammable materials is desirable.



Specifications

Chemical Pathology Department

Automated testing:

Semi-automated or non-automated techniques:

· Lighting- Laboratory work requires a higher level of illumination at theworkbench, generally 500 lux, and to conserve energy it is best to have lightcolored walls, ceiling, floor and furniture surfaces. High efficiency luminaireswith mirror louvers and electronic ballasts are recommended.

· Walls and Ceilings-They should be impermeable, non-porous and smooth foreasy cleaning.

· Floors- Laboratory floors should be level. If there is a particular requirement towash down the floor as in, for example, an autopsy laboratory, floor waste gullytraps will have to be installed. Floor coverings should be pre-finished sheet vinylor equivalent material manufactured specially for the laboratory use with weldedjoints, taken 0'-6” up the walls. Abrasive-surfaced materials should not be used asthey are difficult to clean. However, some laboratories such as for autopsy arewashed down and need non-slip floors.

· Workbench Surfacing- When selecting bench surface materials, the design teamshould obtain samples of materials from the suppliers. The client can then applythe chemicals and test the stain removal procedure recommended by thesuppliers. Other tests by the client may include heat, impact, cold (liquid nitrogen)and abrasion.

Chemical pathology involves the detection and measurement of chemical andbiological substances in body fluids, mainly blood, serum and urine. Quantitativechanges give an indication of the progress of disease or response to treatment.

In general there are three types of activity that take place:

· high proportions of the most commonly requested tests areautomated, with some equipment having a high capacity. Instruments may belinked to both data input at reception and download results to a laboratorycomputer. In general instruments are freestanding.

· these cover a wide range oftechniques such as flame atomic absorption, chromatography, electrophoresis andimmunoassays, some of which utilize radioisotopes. The latter require a separateroom conforming to statutory regulations regarding radioactive substances.Chromatographical techniques may require inflammable solvents and

electrophoresis, high voltage.

· A separate emergency laboratory must be located in aposition that allows inputs of urgent specimens at all times. It is advisable to havethe emergency laboratory next to, or part of, the automated laboratory.

Hematology

Hematology is concerned with diseases of the blood and blood forming tissues. Ahematology department should provide a comprehensive laboratory and clinicalservice for patients with blood disorders and provide hematology and bloodtransfusion support for clinicians caring for patients with other diseases.

The Hematology department will normally include the following sections:

· General Hematology: Core investigations such as full blood count, differentialwhite cell count, erythrocyte sedimentation rate etc., are carried out in this area.Most routine estimations are performed using complex automatic analyzers, someof which utilize robotic sample handling and closed blood sampling. In many casesmicroscopic examination of a blood film or bone marrow smear is part of the

diagnostic process.

· Special Hematology: The more specialized hematological investigations, such asclotting tests, test for the control of anticoagulant therapy and Vitamin B12, Folateand Ferritin assays amongst others, are carried out here.

· Blood bank: This section handles the receipt, storage and issue of blood and bloodproducts for therapeutic use. Blood grouping and antibody screening andidentification tests are performed and where necessary blood matching is done fordonor and recipient.

Provision for antenatal and postnatal serology will be required if the hospital has amaternity unit.

Histopathology department

Histopathology is the study of tissues removed from the human body. This

department will normally include the following sections:· Histopathology: The majority of specimens are received in formalin from

operating theaters, out-patient clinics, post-mortem rooms and general

Emergency laboratory:



practitioners, but items may also arrive in a fresh state. Some of the latter mayrequire examination as frozen sections. Specimens are examined and selectedportions of large, or the whole of small specimens, are passed through automatictissue processing machines, before embedding in paraffin wax or resin blocks.These blocks are cut into sections that are transferred on to slides, stained,

protected by a cover slip and labeled. Medical staff will then examine the sectionmicroscopically and make a report. Tissues remaining after the

specimen has been cut up are stored for at least 4 weeks after the section has beenreported.

· Cytopathology: Cytopathology is the study of individual cells collected byscraping from the surface of an organ, from a secretion or excretion, or by needleaspiration from an organ or body cavity. A proportion of the specimens received

may already be fixed on slides. Others will be in suspension in fluid andwill need either to be spread directly or first centrifuged before they are mountedand processed for staining. Some specimens may require handling in asafety cabinet. Subsequently cytopathology staff examines the stained slides and areport is made. All slides are usually stored for many years.

Provision should be made for the following:

1. The reception of specimens; their examination and dissection; dictation offindings; and photographing of specimens. The tissue is processed using

automated systems and embedded in paraffin wax. Some tissue requires resinprocessing and embedding. Space is required for storage of gross specimens fora variable time during and after processing and for mounting ofprepared tissue for demonstration purposes.

2. The cutting of tissue sections from cold wax blocks. These are mounted onmicroscope slides, de-waxed and stained by automated or manual systems usingroutine or special techniques. Frozen section investigations, involving freezing ofselected portions of unfixed tissue and cutting sections are required for someexaminations of specimens from operating theaters and for someimmunohistochemical techniques. These are then dried or fixed and stained. All

stained slides are placed in trays for dispatch to the pathologist formicroscope examination.

3. Special histopathology procedures, which include resin work comprising sectioncutting, staining and mounting; histochemistry techniques or immunochemistry;immuno-fluorescence; and crystallography where slides prepared in the generallaboratory are treated with antisera and dyes prior to microscopic examination. Inmost, but not all cases, these techniques would be performed in teaching hospitals

rather than general hospitals.

4. Cytopathology work which includes a processing area where slides are preparedand a screening area where they are examined microscopically.

Microbiology Department

Medical microbiology is the study of microorganisms that cause human infections,and is dependent on the provision of suitable laboratory facilities for the isolation andidentification of bacteria, viruses, fungi and parasites from clinical specimens. Samplessuch as blood, urine feces and swabs are examined by a combination of techniques,including microscopic examination and culture of organisms. Detection of antibodiesin serum samples may be undertaken. Both manual and automated methods are in use.

RADIOLOGY & IMAGING SCIENCES

Diagnostic Imaging

In the last two decades, the pace of advancement in imaging technology has drasticallyaccelerated. This is due to the development of digitized information technology—therecording of images via electronic rather than film media. The first development withwidespread clinical applications was computerized axial tomography, or the CT scan.Developments in digital technology will continue, making imaging more accessibleand cost-effective. There are various ways in which a signal is created; for example,images are created with the use of isotopes generated by a cyclotron in positronemission transmission. Magnetic resonance imaging (MRI) also uses digital imagingtechnology. Not only does this afford a better way of imaging soft tissue, which doesnot have to be made radio-opaque, it portends the development of spectroscopytechniques allowing chemical diagnosis of the body without taking specimens.

ContextImaging Facilities can be located in many places: the traditional hospital radiologydepartment, the ambulatory care center, freestanding imaging centers. In smallerfacilities, one department typically contains all modalities. In larger facilities,inpatient and outpatient modalities may be separated. For example, there may be aseparate nuclear medicine department or MRI facility. In some instances, imagingmodalities can be collocated with other diagnostic/treatment facilities to createhealthcare centers of excellence (various technologies to focus on a specific organ orpatient type), such as mammography and ultra-sonography in a women's center.Many modalities can also be provided through portable devices. This allowsprocedures to be performed at the point of care in a patient's bedroom, in anexamination room, or in other treatment areas, such as the operating room.



Patient and work flowPatients may receive more than one procedure per visit, so it is important to quantifythe number and the average duration of procedures a patient undergoes.Patients can arrive at an imaging facility from a number of sources. Wheelchair orstretcher-borne patients may come from inpatient units or other treatment areas, suchas emergency. Ambulatory patients may arrive—scheduled or withoutappointments—at a reception desk. Typically, departments are configured to separatethe flow of these two types of patients.

Another key consideration in patient flow is the requirement for changing— that is,donning a hospital gown in preparation for a procedure. Historically, patients wereseparated by gender and waited, gowned, in waiting areas. More recent departmentaldesigns provide individual dressing rooms adjacent to the procedure room, wherepatients can change and wait with greater privacy.The flow of patients through the department intersects with the process of imagegeneration, interpretation, and results reporting. Historically, this was a sequentialprocess that involved.

1. Exposing the film, using the appropriate modality,

2. Developing and checking the quality of the film image,

3. Repeating the exposure if necessary,

4. Viewing and interpretation by a radiologist,

5. Dictation and transcription of the interpretation and forwarding the reportto the requesting physician or surgeon,

6. Filing both the film and the written report.

This process required the radiologist's location to be central to the patient and workflow in order to expedite the interpretation of the film. With the development ofdigitized image storage systems, this need has dwindled.

Relationships with other departments

The imaging department interacts with a large number of other departments. Bothoutpatients and inpatients can be referred to Imaging for diagnostic studies; however,certain departments have stronger relationships with imaging. The emergencydepartment, for example, is frequently positioned adjacent to imaging because of thelarge proportion of emergency patients requiring prompt radiological studies.Other special situations include casting facilities, women's diagnostic centers, andnuclear cardiology. Casting facilities, for resetting broken bones, may be placed inemergency departments or in specialty clinics. These facilities require radiography toensure that broken bones have been set properly. This is usually achieved by providingradiographic capabilities in or adjacent to cast rooms. Otherwise, the casting areashould be next to imaging for confirming the appropriateness of bone reduction.

Women's diagnostic centers require mammography, ultra-sonography, and boned nsitometry to test for osteoporosis. Satellite imaging facilities are often incorporatedwithin these centers. Alternatively, women's imaging may be incorporated as a "sub-department" of imaging, with a separate entrance and waiting area.

Nuclear cardiology is a unique crossover of services providing cardiologic diagnosisvia imaging technology. The process involves introducing a radioactive medium intothe vascular system. The effectiveness of the patient's cardiovascular system is thenobserved by monitoring the movement of the medium through the body while thepatient is "stressed" through exercise. Because this service treats cardiology patients,the usual preference is to perform such studies in cardio-diagnostic areas (e.g., in anoninvasive cardiac laboratory).

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An Imaging Departments Interrelationship Diagram



Space summary

General fluoroscopy room

Radiography room Radiography is the simplest form of radiology, relying on directexposure of film (or a digital image processor) with an X-ray-emitting device called atube. This is most useful for creating images of X-ray absorbing tissues such as bones.Avariation of radiography is tomography, which uses a rotating tube source and filmcarrier to create a two-dimensional image of a "slice" of the body. Although theequipment is slightly different, the room requirements and considerations are essentiallythe same for both techniques.All types of radiography rooms require lead-lined walls.

Recommended dimensions: 17 ft x 15 ft; making the room 20 ft x 16 ft renders it capableof conversion to a radiography/fluoroscopy room, should that later be comedesirable.

Ceiling height: 9 ft 6 in.

Key design considerations:

C o n f i g u r e t h e s p a c e t o a l l o w as tretcher to be maneuveredinto the room wit minimum turns, typicallyby placing the axis of the X-ray table perpendicular to the wall with the door bywhich the patient will enter the room.

Place the control console opposite the door with direct access to the vertical workcore.

Special equipment: Table and tube, wall bucky (a device that holds film in a positionduring exposure), control console, sink and casework, and transformer and powercabinet (the latter may be placed outside the room).

Individual supporting spaces: None.

Fluoroscopy makes use of radio-opaque media that may be introduced int! the body tocreate images of tissue that would not otherwise show up well on an X-ray. Because theradio-opaque material is typically barium introduced through the mouth or the rectum, itis important to have a toilet room directly accessible from the procedure room.Recommended dimensions: 20 ft x 16 ftCeiling height: 9 ft 6 in.Key design considerations:

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Configure the space to allow a stretcher to be maneuvered into the room withminimum turns, typically by placing the axis of the X-ray table perpendicular to the wallwith the door by which the patient will enter the room.

Place the control console opposite the door with direct access to the work core.

These rooms often serve as radiograhy rooms as well.

Attac the toilet room directly to the fluoroscopy room.

Barium may be prepared in the procedure room or a nearby "kitchen.''

Special equipment: Fluoroscopic X-ray tube and table, image intensifier, cine or "spot"film camera, video monitor, wall bucky, control console, sink and casework, andtransformer and power cabinet (the latter may be placed outside the room).

Individual supporting s aces: Patient toilet, bariumpreparation area.

Chest X-rays typically constitute the largest single category of diagnostic procedures.They are often performed as a screening tool in conjunction with hospital admission orinvasive procedures that will require general anesthesia and suppression of respiration.Many radiography or radiography/fluoroscopy rooms are equipped with wall buckiesfor chest imaging. However, because chest imaging can constitute a high proportion ofthis department's activity, a large department can justify dedicating a room or roomssolely to chest imaging. Because such rooms are designed specifically for this purpose,they are typically more operationally efficient than multipurpose rooms. Even greatereffic̴enci es can be achieved by incorporating film processing withequipment that automatically feeds dir̻ctly into the film processor.

Recommended dimensions: 12 ft x 11 ft (widiout in-room processing), 16 ft x 14 ft(with in-room processing)

Ceiling height: 9ft 6in.

Key design considerations;

To maximize efficiency, the equipment control console is typically incorporateddirectly into the room.

The focal length of the tube assembly is fixed and must be maintained.

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Chest room

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? If in-room processing is utilized, chemicals and equipment must beaccommodated outside the patient area.

In larger rooms, it is possible that a stretcher-borne patient will be X-rayed. Thus, theroom should have a door large enough to accommodate a stretcher and be configured toallow maneuvering of the stretcher.

Special equipment: Tube assembly, changer and stand, console control and transformerin room without processing; the same equipment, plus auto film transport, auto filmprocessor, silver recovery, and chemical manifold in room with processing.


Mammography is a specific type of radiography that employs low-level radiation toidentify tumoral calcifications and to characterize palpable lumps and unpalpable cystsor lumps in breast tissue. The mammography room is single-purpose room with a X-rayunit. Using a specialized type of mammography, the stereotactic room provides theradiologist with a three-dimensional view of the breast for localizing neoplasms forbiopsy.

Recommended dimensions: 10 ft x 12 ft for an upright 18 ftstereotactic

Ceiling height: 8 ft


As this is a smaller room and the patient will be disrobed, reverse swinging doors and/orcuũtains are used to prevent exposure of the patient.

Special equipment: Mammography unit, film illuminators, and sink in a mammographyroom; stereo-tactic biopsy table, operators console and digitizer in a stereo-tactic room.


Ultrasound or sonography operates on the principles of sonar and records size and shapeby tracking reflected sound waves. Typically, a hand-held transducer emits regularpulses of high-frequency sound and translates the received "echoes" into images.Because tissue density affects sound reflectivity, the returned sound wave's amplitudeallows graphic depiction of different tissues. This procedure is especially beneficialwhen the use of ionizing rays could be harmful to tissue, such as when a fetus is present.

Mammography room

unit, ft X 12 for a prone orunit

Ultrasound room

Recommended dimensions: 11 ft X 14 ft


Key design considerations: Because this is a smaller room and the patient may bedisrobed, reverse swinging doors and/or curtains are used to prevent exposure of thepatient.

Special equipment: Ultrasound unit (console typically placed to the patient's right side),stretcher, film illuminators.Individual supporting spaces: None

A computed tomography (CT) room provides an X-ray source that rotates rapidlyaround a patient, generating digital data.

Recommended dimensions: 16 ft x 19 ft for a procedure room, 10 ft x 12 ft for a controlroom, and 7 ft X 10 ft for an equipment room.

Ceiling height: 9 ft 6 in.

Key desigȀ considerations: The patient access door should be positioned to minimizestretcher turning because of the length of the equipment.At the same time, the view fromthe control room of the patient on the table while positioned in the opening of the unitmust be at least partially preserved. At times, a video camera is used to supplement thiscapability.

Special equipment: CT gantry and table in the procedure room. The control roomincludes operator's console, video monitor, injector control, laser imager, andphysician's viewing or diagnostic station. (The last two items may be placed remotely ina multiunit suite.)An equipment room houses the power and computer equipment.

Individual supporting spaces: Control and equipment rooms. These may serve morethan one procedure room.

Magnetic resonance imaging (MRI) is performed by placing the patient in a powerfulmagnetic field that aligns the magnetic spin of atomic nuclei. Radio frequency energy is

CT scanning room

MRI scanning room



introduced, which disturbs the alignment of the nuclei. Different atoms respond atdifferent radio frequencies, thus providing a distinction between tissue types. Thispowerful tool does not utilize ionizing rays and can create detailed two-and three-dimensional images of both hard and soft tissue.

Recommended dimensions: Varies with strength of magnet; generally, about 20 ft x 26 ftfor procedure room with a mid-strength magnet; along with a 10 ft X 12 ft control roomand an 8 ft x 18 ft adjacent equipment/computer room. With lower-strength magnets,the room can be as small as 12ftx 16 ft with a 9 ft x 12ft equipment room and the controlstation in the open. (Refer to manufacturer's specifications for specific model.)

Ceiling height: Varies.


The MRI magnet creates a field whose strength diminishes with distance. Magneticfield strength is expressed in units of measure called gauss. More recentgenerations of MRI units contain the 5-gauss line within the procedure room itself.

As MRI's use radio frequencies to generate images, they are susceptible toelectromagnetic interference from outside sources. To shield the room it is oftenwrapped with a copper fabric.

Because the patient is placed into a unit approximately 8 ft in length and 2'/2 ft indiameter, claustrophobia can be a problem. New-generation magnets havemitigated this problem with ultra-low field strength magnets designed with openarchitecture. Still, procedure room interior design should take into considerationexterior lighting (or the implication of it) and other devices to address this issue.

Special equipment: MRI unit, patient couch, and coil storage in procedure room.Control room includes operators console and video monitor. Equipment room housesthe power and computer equipment.

Individual supporting spaces: Control and equipment rooms. These may serve morethan one procedure room.

Unlike radiography, which transmits radiation in the form of X-rays, nuclear medicineintroduces a low-strength, short-lived, radiation-emitting isotope into the body. Theemissions are captured by a camera and translated into Images. By introducing theisotope or radio-pharmaceutical into specific tissues and organs, radiologists can

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Nuclear medicine room

capture images that would otherwise be unattainable. A recently developed type ofnuclear medicine camera—single photon emission computed tomography, orSPECT—has gained wide acceptance and application. It combines a nuclear medicineor gamma camera with digital image acquisition and interpretation capabilities togenerate tomographic portrayals of blood flow to the brain and heart.

Recommended dimensions: 18 ft X 16 ft for a single camera room. Because nuclearmedicine does not involve the use of X-rays, multiple cameras may be placed in a singleroom with adequate space.



Because nuclear medicine involves the use of radioactive materials, specialprovisions must be made for their containment and disposal. Most of these areinjectable substances. However, some are gaseous pharmaceuticals, such as xenongas for ventilation studies, which must be specially contained and exhausted.

Special equipment: Control console, computer workstation, collimator, collimatorstand, whole body scintillation camera and table, and xenon delivery system.

Individual supporting spaces:

A hot lab where radiopharmaceuticals are prepared, equipped with cabinets andwork counter, lead-lined containers for storing and working with radioactivesubstances, lead-lined refrigerator, 100 percent exhaust radioisotope hood, andapproved system for radioactive waste collection and disposal.

Dose room, where patients are injected with radio pharmaceuticals. The inclusion ofthis room enhances procedure room productivity.

In the positron emission tomography (PET) scanning room, physicians introduceradioisotopes by injection or inhalation. The isotope attaches to the body's own

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Positron emission tomography scanning room



molecules, becoming a tracer as it moves throughout the body. Typically, the isotope isvery short-lived and must be generated on-site with a cyclotron. This makes PET anexpensive, but effective, diagnostic tool.Recommended dimensions: 15 ft x 20 ft for scanner room alone



Ideally, the scanning room is placed adjacent to the radiochemistry lab, which itselfmust be adjacent the cyclotron. When this is not possible, a pneumatic tube systemcan be used to deliver the radiopharmaceutical to the clinical lab.

Special equipment: Scanner and patient couch, computer. Individual supporting spaces:

Cyclotron room of 500 sq ft with 10 ft ceiling. Because of the weight of these units(approximately 120,000 lb), a grade level location should be sought.

Radiochemistry lab of 600 sq ft where the actual pharmaceuticals are prepared.Ideally, it is located adjacent to the cyclotron room.

A control room, where computer equipment for data acquisition and processing ishoused.

Patient preparation rooms with stretchers or chairs.

Special radiography/fluoroscopy procedure rooms Special radiography/fluoroscopyprocedures include techniques that employ radiographic or fluoroscopic imagingequipment for guidance during complex exploratory and interventional procedures.Although the procedures performed in these rooms may vary, they have in common theintroduction of a catheter and the use of large and complex equipment, including one ortwo fluoroscopic C-arms. Because the introduction of a catheter invades the body, someminimally sterile techniques must be observed.

Recommended dimensions: 28 ft x 22 ft for the procedure room alone

Ceiling height: 10 ft Key design considerations:

The equipment should be arranged to allow visibility of the patient's head from thecontrol monitor.

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Many procedures occur while the patient is awake and acutely aware of his or hersurroundings. Therefore, measures should be taken to create a soothing

environment.

Because the procedures require a semi-sterile environment, extraneous traffic shouldbe limited.

Radiographic/fluoroscopic arm(s), one or two, depending on whether the unit hasbiplane capabilities; video monitors, patient table, injector, surgical lights and backtables, and catheter storage.

Individual supporting spaces:

Control room 22 ft X 12 ft, containing control console, multi-format camera or laserimager, scrub sink, and storage cabinets.

Equipment room 10 ft X 22 ft, housing electronics cabinets.

Patient preparation and recovery area.

Staff gowning and changing facilities.

The following list summarizes supporting spaces typically included in diagnosticimaging departments:

Waiting/reception area

Gowned waiting areas for departments

Dressing areas for gowned waiting or individual procedure rooms

Toilet rooms for patients

Special equipment:

Supporting spaces



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Darkroom for processing conventional films

Daylight processing area

Digital image processing area« Light room/quality assurance area

Image reading or interpretation area

Viewing/consultation areas " Film files area

Clean supply room

Soiled utility room

Staff locker/lounge/toilets " Storage alcoves

Historically, films have moved from the procedure rooms to a processing, checking, andassembly area that serves several rooms. Although conventional film processing is lessprevalent, this "work core" design is still one of the most staff-efficient configurationsfor a department. Typically, procedure rooms encircle a work core, with staff accessfrom within the core and patient access from the perimeter.

In larger departments, like modalities are grouped around these cores to create pods orclusters. For example, radiography and radiography/fluoroscopy rooms are typicallygrouped.

Mammography and ultrasound may be grouped to serve women patients. Mostdepartments are made up of groups of clusters aggregated around common orcomplementary modalities.

The pods or clusters organized around work cores are the clinical heart of thedepartment. Typically, they are interposed between the public access areas— receptionand waiting—and the staff areas—personnel facilities, storage and utility rooms,radiologist offices, and reading areas. It is important to organize the department to allowfuture expansion in key corridors. If any spaces are placed in the path of this expansion,they should be "soft" or easily relocated areas.

Work core design

Department organization

Departmental organization must recognize the potential use of mobile technology. Thisusually requires providing a sub-waiting area with access to the trailer in which themobile device is contained. Depending on the climate, access may be via a covered,open-air, or pneumatically enclosed structure.

Interior design considerations An imaging department requires high-technologyequipment for diagnosing and treating individuals who may already be in a heightenedstate of anxiety. Thus, it is most important to create environments that are friendly andnon-threatening. In addition to the appropriate furniture, fabrics, and colors, positivedistractions may be included, such as artwork, views to the outdoors, and aquariums, torelieve stress and anxiety.

Lighting is also used to create a more soothing environment. Particularly important isthe use of reflected lighting in areas where patients will be lying on their backs onstretchers or procedure tables.

Imaging is clearly one of the areas most affected by developing technology, particularlydigitally based equipment.

Special diagnostics services typically include noninvasive testing of the human body'scardiovascular or neurological performance. The tests principally use electronic,sonographic, or scintillation counter technology to monitor the body's anatomy orphysiological activity. These procedures produce measurements that are recorded overtime in hard copy or digital storage media for physician review and reference. Mostmeasurements occur over periods of 5 to 45 minutes, although durations of 24 hours areuseful in some studies.

Noninvasive diagnostic testing of the cardiovascular systems includes the following:

Electrocardiograph)/ (ECG).

Observation of cardiac performance through electronic physiological monitoring.

Echocardiography (Echo ECG)-Observation of cardiac performance through Dopplerultra-sonography monitoring coupled with physiological monitoring. Transthoracicechocardiography is the basic study, and transesophageal echocardiography (TEE) is a

Trends

Special Diagnostic Departments

Functional overview



common procedure using the same technology.

Exercise stress testing. Observation of cardiac performance through physiologicalmonitoring while the patient is subjected to varying levels of exercise demand bytreadmill or exercycle. Tilt tables may also be provided in this area for identifyingreflex-induced problems.

Nuclear scans. Observation of cardiovascular performance through physiologicalmonitoring and gamma camera or SPECT (single photon emission computerizedtomography) camera imaging of absorbed substances tagged with radioactive isotopes.Patients are typically subjected to varying levels of exercise demand via treadmill orexercycle during these studies. Nuclear scans combined with computerizedtomography, known as PET scanning (positron emission tomography), are also usefulbut remain cost-prohibitive in most cases. Thus, this technology is generally found onlyin teaching institutions to date.

Holter monitoring. An ambulatory ECG recorded continuously over a 24-hour periodvia portable magnetic tape media to monitor electro-physiological data related tocardiac behavior and performance.

Pacemaker verification. Periodic and routine testing of pacemaker devices inserted toassist in regularizing the behavior of the heart.

Peripheral vascular studies (PV). Noninvasive testing of the arteries, veins, andlymphatic system in the body extremities, using Doppler ultra-sonography.

Noninvasive diagnostic testing of the neurological system utilizes the following studies:

Electroencephalography (EEC).

Observation of brain activity through electronic physiological monitoring.

Sleep studies. Extended observation via camera and microphone, along with electronicphysiological monitoring via EEG and EKG, through normal (8-hour) or short-termperiods of sleep.

Special diagnostic services are typically found in hospital settings within departments

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Service locations

including cardiology, cardiovascular, cardiopulmonary, neuro-diagnostic, or electro-diagnostic services. These services are often centralized for inpatients and outpatients,although most inpatient ECG and EEG studies are conducted at the patient's bedside.Stress testing, echo ECG, peripheral vascular (PV) studies, and isotope scans areusually centralized owing to equipment requirements. Outpatient ECGs are completedmainly in physicians' offices, except when required for hospital preadmission testingrecords. Holter monitoring, pacemaker verification, and sleep studies are entirelyoutpatient services.

Planning for special diagnostics is based on projected work load volumes for inpatientsand outpatients. The work loads are categorized by average procedure time anddistribution between inpatient and outpatient volumes (see table above). Thepercentage of inpatient services is important, because many procedures are performedin the inpatient's room, thus reducing demand for diagnostic space within the centralarea of the service.

Key capacity determinants The variety of special diagnostic services requires manydistinct procedure rooms to separate functionally incompatible activities, facilitateefficient work flow, and avoid excessive waiting time for patients. Some procedures,such as exercise stress testing, require strenuous physical activity by the patient.Doppler equipment used in echocardiography studies may generate noise. Risk ofexposure to radioactive materials used in nuclear scans must be carefully controlled.Sleep and EEG studies require quiet areas without significant audio stimuli. Thenumber of these rooms required is based on an 8 hours per day, 5 or 6 days per week(excluding holidays) schedule. The service is available on a 24-hour basis in the acutecare setting, but principally for emergency needs after regular hours.

Patient and work flow Easy patient access to special diagnostic procedure rooms isparamount. These rooms are designed for outpatient convenience. Scheduledappointments dictate that adequate parking, clear ambulatory care entrance points, andsimple way finding to the reception and waiting areas be available.Ambulatory patientsshould have direct access between the waiting area and procedure rooms withoutpassing through staff or physician work areas. Easy transfer of inpatients, as required, toprocedure rooms is also a factor in design. Clear access to inpatient areas that keepspatients or staff from passing through public spaces is preferable.

The technician staff requires workroom space close to the procedure areas, to Inpatientaccess to testing areas must be available without transport through public areas.

Centralized staff work areas, where charting is performed outside testing rooms,

Key activity factors

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provide for quick room turnaround. These work areas must be close to the procedurespace to minimize travel distance.

Physician reading areas must be nearby, but separated for EGG (hard-copy review),echo EKG and peripheral vascular (video monitor review), and EEG (hard copyreview) functions.

A central location is required for observation of multiple EEG, sleep lab, andmultiple stress testing stations.

The healthcare technology industry will continue to explore alternative imaging andphysiological testing modalities that are faster, less intrusive, and more reliable thancurrently used tools. Efforts to simplify the patient care process and to minimize thespecialized expertise required of staff will stimulate the development of smaller, moreportable, and more rapid measurement devices capable of use at the point of care.Where such devices still require centralized use because of cost or lack of portability,the establishment of quick diagnostic centers will absorb many of these services intoconvenient areas of care where common testing required for outpatients andpreadmission testing of inpatients are co-located.

Oncology therapy is treatment for cancer patients. Two common forms of cancertreatment are chemotherapy and radiation therapy. Chemotherapy is the intravenousadmission of chemicals that attack cancer cells. Radiation therapy is the exposure ofcancer cells to radiation. This radiation can be introduced to the body either throughdirect implantation—called brachytherapy—or by means of a beam of radiation from alinear accelerator or a screened radioactive source. Because radiation is not selectiveregarding the type of cells it kills, treatment planning for radiation therapy is quitecomplex. Both chemotherapy and radiation therapy require patient preparation andrecovery. Most chemotherapy and radiation therapies are provided in an ambulatorycare setting. Because of the difference in treatment modalities, the two therapies can beseparated from each other. However, 30 percent of cancer treatment regimens involveboth chemotherapy and radiation therapy.

Patient examination and treatment, as well as treatment planning, are key activityfactors. The number of patients being treated and the type of healing environmentneeded determine space requirements. In radiation therapy, equipment requirementsare extensive, as are requirements for shielding. In both chemotherapy and radiationtherapy, proper staff supervision is critical to the efficient utilization of space.

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Trends

Oncology

Chemoterapy is administered in a non-technical area designed as patient-friendly space.The process is traumatic, stressful, and lengthy. The amount of space required dependson the total patient volume and type of desired treatment. Separate patient rooms andindividual cubicles provide privacy, while open treatment bays encourage interactionwith other patients. Creating a healing environment is the design goal for thechemotherapy facility.

Radiation therapy is performed in an area housing highly technical equipment, operatedby highly specialized staff. The therapy is usually administered by linear accelerators.Ashield must confine the dangerous beam of radiation created by the linear accelerators.

The flow of oncology patients is very predictable, because patients undergoing eitherchemotherapy or radiation therapy are usually ambulatory and regularly scheduled.Facilities are needed for those patients who are weak and nauseous followingtreatments. Radiation therapy involves initial examination and consultation with thepatient, treatment planning by the staff, treatment simulation using diagnostic x-rays toconfirm the treatment and then the radiation treatment. Both therapies usually consist ofmore than one treatment.

Oncology therapy has few relationships with other departments because most cancerpatients are ambulatory. A key factor is direct exterior access to chemotherapy andradiation therapy, respecting patient privacy. Oncology does need access to emergencyfacilities, but not directly to the emergency department. Chemotherapy requires aconnection to the pharmacy for preparations of administered chemicals.

The equipment and shielding requirements for radiation therapy are the most significantfor any area in oncology. Linear accelerators aim and focus a beam of high-levelradiation. To confine the effects of the beam to the treatment vault itself, substantialradiation shielding is required. Although lead and steel are highly effective shields,concrete is more commonly used because of its lower cost. Eighteen to 20 megavoltlinear accelerators produce a beam that can be shielded by approximately 8 ft solidconcrete.

To aim the beam, the linear accelerator must be capable of 360 degree rotation. In turn, aroom with a 10 ft overhead clearance and a 360 degree shield along the sides requires asignificant amount of floor area and building height. Because of the permanency of thiskind of construction, careful planning for placement is imperative.

Flow of patients

Key spaces



Typical room sizes for radiation therapy are as follows:Therapy vaults—high energy 600 sq ftTherapy vaults—low energy 500 sq ft

Control areas 130 sq ft

Equipment 100 sq ft

Entry maze 140 sq ft

Simulator 300 sq ft

Treatment planning 200 sq ft

Dosimetrist's office 120 sq ft

Mold room 250 sq ft

Patient toilets 60 sq ft

Sub-waiting areas 20 sq ft each

Family waiting areas 18 sq ft each

Brachytherapy is the implantation of a radioactive source in or near the site of acancerous mass. Implantation can be implemented surgically or by catheter. A patientmust be monitored during therapy, usually in a patient room that is specifically shieldedto prevent exposure to other patients.

Typical room areas for chemotherapy are as follows:

Open treatment bays 60 sq ftTreatment cubicles 60—80 sq ftTreatment groups 100-150 sq ftNurses' station 150+ sq ftPatient toilets 50-60 sq ft

(ADAcompliant)Family waiting areas 15 sq ft per personExamination rooms 120 sq ft

The stress and anxiety felt by many cancer patients can be eased somewhat if there is anopportunity for camaraderie with other patients in mutual support.

The design of the facilities for oncology therapy should provide opportunities for suchinteraction. Because of the effects of therapy on the physical appearance of patients,privacy and discretion are key design considerations.

The need for staff to supervise patients during and after their treatment influences alldesign solutions. Treatment planning is a staff function that is screened from patientsphysically and audibly. A hot lab houses radioactive substances that are prepared for

Key design considerations

brachytherapy implantation. The room must be shielded and located adjacent to theroom where implantation takes place. Preparation in the pharmacy for chemotherapyrequires laminar flow mixing hoods to ensure the sterility of the administered agents.

Physical medicine and rehabilitation (PM&R) offers services to individuals who arephysically disadvantaged, with the purpose of returning them to their maximumphysical capabilities. These services may include physical therapy, occupationaltherapy, speech pathology, audiology, and specialized programs; they may be supportedwith the development of orthotics and prosthetics to assist in their functioning. Physicalmedicine and rehabilitation are provided on an inpatient, outpatient, or in-home basis.

Physical therapy concentrates on gross neuromuscular and skeletal activity, withemphasis on regaining movement, circulation, and coordination of body and limbs.Typical components of the physical therapy service are treatment areas, a gymnasium,and a hydrotherapy area. Treatment areas may be individual cubicles or rooms. Anumber of therapies can be administered in these areas, including thermal therapy,electrical stimulation, massage, and manipulation. A gymnasium is generallyconfigured with equipment for several functions located in a common space, such asmats, platforms, gait training stairs, parallel bars, and weights, as well as other resistiveequipment and orthotic and prosthetic training services. The gym can also serve as amultipurpose space, supporting other uses such as sports events (e.g., wheelchairbasketball) and community activities. In long-term rehabilitation facilities, the physicaltherapy program may be expanded into recreational therapy for patients.

Hydrotherapy is a treatment with warm to hot circulating water in tanks. The tanks areused either for the extremities, such as the legs and arms, or for full-body submersion.Hubbard tanks, which are configured to allow each limb to be fully extended, are alsoused. The warm to hot water circulating around the body or parts of the body stimulatesblood circulation, promoting healing and reduction of pain. Larger therapy pools allowpatients to exercise while suspended in water, thus reducing the impact of body weightduring therapy. The humidity of these areas should be carefully controlled through themechanical ventilation system.

Occupational therapy focuses on optimizing a patients independence whileconcentrating on finer physical movements. Activities of daily living (ADL),vocational training, and, in some cases, a work-hardening program are used torehabilitate the patient.

Physical Medicine and Rehabilitation

Physical therapy

Occupational therapy



The activities of daily living are routine tasks that individuals are required to perform.The area provided for this therapy includes a mock bedroom, kitchen, and bathroom.These areas provide the patient with an opportunity to learn the basic essentials ofcooking, hygiene, and dressing with the benefit of an attending therapist.

The vocational training area houses a variety of equipment, including word processors,computers, cash registers, and telephone switchboards, simulating a workenvironment. The area may also include wood and metal workshops. Someoccupational therapy services include work-hardening programs, which simulate anindustrial environment, providing both education and therapy for a more rigorous worksetting. Patients learn to perform work tasks and to protect themselves from furtherinjury. Because of the noise made by equipment, it is important to address acoustics inthe vocational training area.

A patient's injuries or disease may result in communication disabilities. These are mostcommonly related to cerebrovascular (stroke) and head trauma. The purpose of therapyis to assist a patient in regaining control or adapting to a specific communicationdisability, which may include cognitive retraining. Communication disabilities includeproblems with speech and/or hearing. Audiology is most effectively supporteddiagnostically by two-compartment sound-isolated booths. In the booths patients areaccurately tested for hearing loss, as well as the effectiveness of prescribed hearingdevices.

Specialized programs Many providers have specialized programs in physical medicineand rehabilitation. These may include a pain clinic, cardiac rehabilitation, sportsmedicine, and hand therapy. Specialized areas may be required for these programs.However, many are similar in configuration to the areas for the services alreadydescribed.

Physical medicine and rehabilitation services may be housed in a variety of settings,including hospitals, ambulatory care centers, and comprehensive specialtyrehabilitation facilities. Care is provided under several physician specialties such asphysiatry, orthopedics, neurology, cardiology, and others. The specialty centers mayinclude rehabilitation treatment for cerebrovascular/stroke, spinal cord injury, headtrauma, amputation, developmental disabilities, neurological degeneration,complicated fractures, cardiac conditions, or genetic disorders.

Operational considerations The size, internal relationships, configuration, and location

Speech pathology and audiology

Settings

of physical medicine and rehabilitation services are dependent on their work loads.Work load is determined by the number of inpatient or outpatient visits and treatmentsreceived within the operating hours of the services. Capacity is determined by suchfactors as the number of treatment cubicles, mats, therapy positions or stations,cognitive retaining rooms, and hydrotherapy tanks.

Patient and work flows shape the design of the PM&R area. Because of their variousdisabilities, patients require convenient access to the services. In hospitals, the PM&Rservices are often located near the elevators at grade. This location is easily reached byinpatients and outpatients. Patients must be visible and accessible to staff. Satellitetherapy areas may be located on nursing units for the convenience of less mobilepatients. Many initial therapies occur in the patient's room.

PM&R services are related to other departments and services within a hospital. Themost common relationships are with nursing units, such as orthopedic, cardiac,neurological, and other units. These services should also be accessible to outpatiententrances, with a dedicated entrance near convenient parking.

The following are suggested support areas for PM&R:

Lounge, personal lockers, toilet, and, possibly, a place to shower

Meeting space for continued education and training

Clean workroom, soiled utility, housekeeping, equipment storage, wheelchair andstretcher storage Larger facilities may also have an orthotics and prostheticsdepartment. The department supplies, manufactures, and fits devices to assistpatients' mobility and dexterity. These devices may include artificial limbs, assistiveappliances, braces, crutches, and wheelchairs.

According to the AIA 1996-1997 Guidelines for Design and Construction of Hospitaland Health Care Facilities, typical physical medicine and rehabilitation servicesinclude five major areas:

Administrative/workPhysical therapyOccupational therapySpeech pathology/audiology

Support areas

Space needs

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Support/staff

The following are areas typically required in the department:

Reception and waiting (outpatient or staging of inpatients)

Administrative office and clerical space

Patient toilet

Wheelchair and stretcher storage

Housekeeping closet

Access to conference room

Physical therapy

Individual therapy treatment areas with a minimum of 70 sq ft

Hand washing area

Exercise area (gym)

Clean linen storage

Equipment and supply storage

Soiled utility

Patient dressing areas, showers, and lockers (if required)

Hydrotherapy (when required)

Occupational therapy

Patient work areasHand washing area

Equipment and supply storage

Activities of daily living areas

Speech pathology and audiology

Evaluation and treatment area

Space for equipment and storage

Orthotics and prosthetics

Work space

Space for fitting and evaluating

Space for equipment, supplies, and storage

These areas should be planned in a manner that encourages quality patient care,appropriate space for the proposed work load, and staff efficiency.

An overriding issue in PM&R is accessibility for patients with restricted mobility. Intreatment areas, space must accommodate not only the patient and therapist but also thetransportation modalities used to get the patient to therapy— such as a stretcher,wheelchair, or walker. Slip-resistant floor surfaces should have no tripping hazards andmust accept wheelchairs and walking accessories.

Heating, ventilation, and air-conditioning systems should address several demands inthe PM&R department. Humidity control is required in hydro-therapy and therapy poolareas. Orthotics and prosthetic manufacturing areas require special consideration ofacoustical needs and control of fumes and dust.

Physical medicine and rehabilitation

services will be performed more often in outpatient and home care settings. Theseservices will also be more and more decentralized within the community forconvenience and ease of access. There is a trend toward the development of specialtycenters of excellence for certain rehabilitation services such as those provided for spinalcord injuries, head trauma, stroke, and development rehabilitation. However, physical

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Special planning and design considerations

Trends



medicine and rehabilitation will continue to play an important role in the continuity ofcare—from inpatient to home care—in both medical and surgical specialties.

Renal dialysis is the simulation of kidney functions for patients in chronic end-stagerenal failure or temporary acute kidney failure. The simulation may be performed bytwo primary methods— hemodialysis or peritoneal dialysis. Hemodialysis is thefiltering of an individual's blood to remove the uremic toxins and water typicallyremoved by the kidneys. The process is implemented by a machine connected to thebody's veins through large-bore needles and plastic tubes. These needles may be placedin surgically created fistulas or artificial implants. These are more commonly located inthe arm, but the needles may also be placed in the neck or leg regions. The blood iscirculated through a membrane filter whereby toxins and water are removed.Alarms onthe machine monitor biophysical parameters such as the patients body temperature,relative blood volume, and hematocrit and electrolyte balances. This procedure may berequired three days a week and varies in duration from two to four hours. Home dialysiswith this method is possible, but limited by cost and caregiver availability.

Peritoneal dialysis is the removal of uremic toxins and water from the body through theperitoneal cavity around the abdominal organs. This is performed by perfusing specificwarm, sterile chemical solutions through the cavity. An artificial opening is surgicallycreated in the abdominal wall for this procedure. Dialysis by this method is typicallyperformed several times daily, depending on the size and weight of the patient— whichmay also limit its practicality. Peritoneal dialysis is considered a less efficient methodthan hemodialysis; however, it is the most common home dialysis treatment.

Renal dialysis may occur in a variety of settings, including hospitals, physician'soffices, and freestanding dialysis centers, as well as in the home. These settings vary insize and configuration, depending on types of inpatients and outpatients served.

A renal dialysis unit or center is designed around several operational considerations.The number of patients treated, the hours and frequency of treatment required forpatients, and the hours of operation are all items for discussion. Capacity is determinedby the number of dialysis positions.

Patient and work flow through a dialysis unit includes several components. The patientis weighed upon arrival. Following this evaluation, the hemodialysis patient isconnected to the dialysis machine. The machine is set to operate for a set amount oftime. The patient is disconnected from the machine and reweighed, and fluid loss is

Renal Dialysis

Settings

Operational considerations

recorded.An inpatient may return to his or her room and an outpatient may return home.Portable machines are becoming more popular in hospitals, allowing patients to remainin their rooms for treatment.

The treatment area can be open or partially enclosed, yet permitting visibility fornursing and technical staff. The nurses station is centrally located, allowing visualobservation of all patient treatment stations. Treatment positions are at least 80 sq ft(7.43 sq m) and at least 4 ft from other positions. Privacy should be addressed in thelayout and design of the treatment position. Isolation positions may also be required forinfectious cases. Tables may be placed beside recliners and stretchers as a conveniencefor the patients.

When a facility for renal dialysis is combined with the physician's office, thenephrologist may schedule an office visit at the same time a renal dialysis procedure isscheduled. The appointment may include not only a visit with the physician, but also avisit with a dietitian or social worker to address specific issues regarding nutrition orpersonal resources.

Inpatient renal dialysis services should be closely related to inpatient units forconvenience and ease of access. After undergoing a renal dialysis procedure, a patientmay be weak and faint. Therefore, outpatient services should have immediate access tothe parking lot.

Anumber of support areas are provided for the dialysis patient during treatment:

Nurses' station

Medication preparation and dispensing station

Examination room of at least 100 sq ft (9.29 sq m) If home training is provided, aseparate room of 120 sq ft

(11.15 sq m) should be available.

Clean workroom

Soiled workroom

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Support areas

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Separate reprocessing area

Nourishment stations

Housekeeping closet

General storage and storage alcoves

Water treatment and dialysis preparation

Patient toilet and personal storage

Appropriate staff facilities

In an outpatient setting, a waiting area and supporting offices

needs

According to the AIA 1996-1997 Guidelines for Design and Construction of Hospitaland Health Care Facilities, a typical renal dialysis service should include the following:

Waiting and reception (in outpatient facilities)

Treatment positions

Isolation treatment position (if required by the program)

Nurses' station

Medication station (if required)

Home training room (if required)

Examination room

Clean workroom and linen storage

Soiled workroom

Reprocessing room (if required)

Space

Nourishment station

Housekeeping closet

Equipment repair (if required)

Storage

Central batch delivery system and water treatment

Patient toilet

Patients' personal storage space

Supporting offices and staff facilities (if required)

It is important for the designer of a renal dialysis service to be sensitive to the patient'ssituation during treatment. Typically, a patient is in a recliner or on a stretcher, whichmakes lighting and ceiling treatments important. During the actual connection to themachine, adequate lighting is required. After the connection, a more indirect light isdesirable. Many centers provide shared television sets for patients' entertainment.However, it is difficult to find television programs that interest everyone. Thus,individual television sets are preferable. Acoustical considerations are also important,especially for patients who prefer to sleep during treatment.

End-stage renal failure is affecting a larger percentage of patients because of thecontinued aging of our population. As a result, the growth of renal dialysis centers willcontinue. Outpatient centers are being developed by major providers nationally. Thetrend toward consolidation of major national and international dialysis providers isexpected to continue. Currently, close to 50 percent of patients in the United Statesreceive treatments from ten major national providers. Home dialysis is also expected togrow as the procedures continue to be simplified by new machines.

Respiratory care is the care of the respiratory system—primarily the lungs. There aretwo distinct areas of activity. The first is inhalation therapy, involving a variety oftechniques ranging from simple oxygen supplementation to assisted breathing with theuse of respirators or ventilators. Diagnosis, by calculating the respiratory system's


Trends

Respiratory Care



effectiveness through pulmonary function studies and arterial blood gas analyses, is thesecond activity.

Although the two activities have traditionally been grouped together, they are verydifferent. Inhalation therapy is typically rendered at the patient's location—on nursingunits, in outpatient treatment areas and physicians' offices, and even in the home.Increasingly, inhalation therapy is being decentralized to the hospital nursing areas suchas critical care, pulmonary units, and neonatal units, which require its support. In manycases, inhalation therapists are integrated into nursing teams or nurses are cross-trainedas inhalation therapists. The study of pulmonary function has remained a discreteactivity, requiring specific equipment for diagnosis of pulmonary capacity and status, Itmay constitute a single department or be combined with other diagnostic activities in amultifunction diagnostic center within a hospital or ambulatory care facility.

Activities and capacities The key activity factor or work load measure for inhalationtherapy is number of procedures or hours of therapy. However, because theseprocedures occur outside the department—rather than in a procedure room—the keycapacity determinants are the number of therapists and pieces of equipment. The keyactivity factor or work load measure for pulmonary function is the procedure. The keycapacity factor is the number of procedure rooms.

Patient and work flow For pulmonary function testing, patient and work flow is similarto that of other diagnostic departments. The patient arrives, checks in, waits briefly,undergoes the procedure, and departs. The results of the testing are recorded,interpreted, and filed.

For inhalation therapy, the process is more complicated. As noted earlier, the therapy istypically rendered at the patient's location, with staff and equipment coming to thepatient. However, following the procedure or treatment, the therapist must recordobservations on the patient. Traditionally, this was done within the department atcharting positions. With the development of computerized records and specializedhand-held devices for recording inhalation therapy activity, this occurs on the nursingunit or at the point of care.

Another necessary process is the returning of equipment to a ready-to-use this trend canbe expected to continue, separating this activity from pulmonary function testing.

Biohazard waste disposal Because inhalation therapy equipment may acquire infectiousmaterials during the treatment process, care must be taken in disposing of thesecomponents. Containment and disposal of such waste is coordinated with the

Context


SUPPORT SERVICES IN A HOSPITAL

CHAPTER

FOOD SERVICE DEPARTMENT

Suitable food well cooked and presented is an important part of the patients' treatment.Hospitals have long recognized the public relations value of the food servicedepartment. Unfortunately, criticism of the food is one of the most frequently heardcomplaints in any hospital. The food service department is responsible for all activitiesinvolving food, nutr ition and beverages. The department's primary function is toprovide nutrition and dietetic care to both inpatients and outpatients. Ancillary servicesinclude the operation of dining facilities for employees, visitors and physicians, cateringand vending services, meal service for childcare centers and satellite facilities, andproviding education in nutrition for all campus facilities, clinics, and long term careunits.

Economics and convenience dictate the setting for the food services department.Ambulatory care centers, long- and short-term facilities, hospitals and surgical dayclinics may all include an in-house food service department. The size and complexity ofthe operations are contingent on cost. A food service may also be operated as a satellitefrom a remote or centralized facility, although such operations have unique equipmentand procedural requirements.

The departments work load hinges upon the number of meals served; operational factorssuch as food production methods, menu selection, staffing, and hours of operation play akey role. Capacity determinants may include food production methods, the size ofproduction equipment, dry/refrigerated storage space, and the number of dining rooms,floor pantries, and warming kitchens.



Work flow also affects an operations work load and capacity. Cross-traffic, doublehandling of good, and poor controls impact costs, efficiencies and food quality.Generally, products should flow as follows:

1. Receiving area

2. Prep area

3. Cooking line

4. Finished product assembly

5. Tray assembly

6. Dish washing

To ensure an optimal work flow and efficient service, the food service department andsupporting spaces must adhere to particular adjacency requirements, as follows:

Locate near the loading and unloading dock for quick, safe foodreceiving.

Locate near the servery, conference/meeting rooms, service elevator topatients rooms, and auxiliary services, such as vending and catering.

Locate near the service elevator core.

Locate next to the employee/visitor's dining facility, to accommodate lateservice, and at other strategic points throughout the facility.

Locate next to the servery and dining room.

Locate adjacent to the kitchen and food production area.The seating area should be placed next to the servery, providing easy access to foottraffic. Guest's need quick access to the visitor's parking lot.

Locate offices for management and supervisors near the appropriateproduction areas to foster communication with line workers.

Several methods are in use for delivery of meals from kitchen to wards. They differ inthe method of processing, the palatability, the means of transport and the amount oflabor that is necessary. Food may be transported to each ward in a bulk container by

Receiving area.

Kitchen.

Floor pantries.

Vending.

Physician's dining.

Employee/visitor's dining.

Offices.

heated trolley and served on to plate by the ward staff. This method has for a long timebeen the normal method and is simple and effective; it allows for immediate adjustmentsin the quantity given to individual patients but is relatively labor intensive in the wards.More recent methods are for individual meals to be portioned and plated up in thekitchen or served there on to insulated and compartmented trays, and deliveredcomplete by trolley or conveyor. Alternatively and more rarely food may be cookedcentrally, then frozen, and finally reheated in the ward kitchen, or even preparedcentrally and cooked in the ward kitchen.

There is an increasing use of bulk frozen foods, with consequent implications on thestorage requirements, and also of the bulk purchase of ready-made frozen meals fromcommercial sources. The catering may be run by the hospital or contracted out toexternal organizations. The different methods are reflected in the size, equipment andplanning of both central and ward kitchens. The washing up of crockery and utensils hasin the past done in ward kitchens. This is now usually centralized in the main kitchens,with the advantages of more efficient steam sterilization, less work for the ward staff andless noise in the ward itself.

Akitchen in the basement is certain to have a deleterious effect on the quality of food andefficiency of the department. It is likely to be dingy, dark and poorly ventilated.Agroundfloor location is preferable, and is also convenient for delivery of supplies. The storagearea should be in close proximity to the unloading dock. Easy access to the verticaltransportation system serving in-patient units is important to facilitate delivery ofpatient meals and return of used trays and utensils.

Delivering safe, high-quality food is paramount to the dietary services department.Efficient, cost-effective, and safe food production is based on a continuous system, withspecific methods for raw product flow, preparation, cooking, assembly and dispensing.To prevent cross-contamination, clean and soiled areas and products must besegregated. These functions require adequate space and a designated flow pattern.

Cross-contamination must also be addressed in the receiving area. Boxes and containersmay contain living organisms and so must not be directly loaded into the productionkitchen holding coolers. Sufficient space is needed for receiving, weighing, and storingproducts to ensure product safety, strict inventory controls, and the proper rotation ofgoods.

The design and physical facilities of the food service department have an importantbearing on the standard of food service, labor costs and the morale of the employees. Forexample, storage rooms far removed from the work area, poor arrangement of thepreparation and production area for work flow, and long traveling distance for preparedfood lower the level of efficiency and increase unnecessary steps for employeesresulting in increased costs. In the general layout, the most important factor to be borne



in mind is the logical workflow that is, receiving supplies, storing and refrigeratingthem, preparing and serving food, returning trays and washing dishes. The space andfacilities should be adequate.

For decades, a simple concept dominated cafeteria service: recreate an army mess hall,with a long line of serving stations supported by an oversized kitchen or commissary.The demands of younger patients, staff, and visitors accustomed to a variety of diningoptions and the increasing need to find new revenue streams have spurred more flexible,innovative designs.

One of the latest developments is the food court and market designs, similar to thosefound in high-end food outlets and shopping malls. Employees, visitors and outpatientsare able to move freely through food displays or boutiques, which are either self-serviceor staffed. The atmosphere promotes social activity and helps relieve stress. The varietyof food offerings also satisfies more discriminating customers.

On the production side, new technologies and equipment have allowed kitchens toconsolidate functions. These advances have enabled healthcare facilities to prepareproducts for inventory, rather than for immediate consumption, capitalizing oneconomies of scale.

Ahospital consumes a large quantity of new material that needs sterilization before use.It also processes other material that has to be cleaned and sterilized before it can be usedagain. Central Sterile Supply Department (CSSD) is a service whereby medical/surgicalsupplies and equipment – both sterile and non-sterile – are cleaned, prepared, processed,stored and issued for patient care. Hospital acquired infection remains a serious problemin health care today. The purpose of a sterile services department is to concentrate theskill and the responsibility for the supply of sterile material and to reduce the risk oferror.

The primary activities to be undertaken within the CSSD are:1. Cleaning and disinfecting processes for instruments, trays, utensils, containers and

other reprocessable items.

2. Preparing and packaging contents of trays and packs and where appropriate, single-use items and other materials as supplementary packs.

3. Sterilizing trays and packs and disinfecting those items acceptable for patient use inthis condition.

CENTRALSTERILE PROCESSING

4. Storing non-sterile materials components.

5. Storing goods processed in the department and purchased sterile goods.

6. Distributing processed and purchased goods to users.

Sterilization of instruments, operating packs, trays etc., is performed is performed byheating them with pressurized steam or by gas sterilization. Steam sterilization is calledautoclaving. However, certain items such as rubber, plastic and delicate instrumentscannot be autoclaved and so have to be sterilized by using ethylene oxide or similargases. Gas sterilization requires certain safety precautions such as aeration prior to useand special exhaust ventilation. Under both systems, sterilization is performed oncleaned instruments wrapped in special linen.

The department receives clean material from a laundry and new material frommanufacturers and suppliers. It also receives for re-use, dirty articles from within thehospital. Clean and dirty materials require separate delivery points, the clean oneserving a bulk store for new materials such as towels and masks, and the dirty oneserving a clean-up room where all re-usable goods including instruments and syringesare washed, cleaned and dried. Rubber gloves may require a separate glove room fortreatment.

The department is divided into three zones to accomplish the functions ofdecontamination, assembly and sterile processing, and sterile storage and distribution.These zones include the following:

1. Decontamination zone

2. Assembly/sterilization zone

3. Storage and distribution zone

The work flow for central sterile processing is centered on the processing of soiledinstruments through the four zones. A distinct separation must be maintained betweenthe soiled and sterile areas. The technical staff works on either the soiled side or thesterile side and cannot cross from one side to the other.

Reusable equipment and soiled instruments and supplies arereceived from surgery, labor/delivery and other departmental areas for initial or grosscleaning. These items are cleaned and decontaminated by means of manual ormechanical processes and chemical disinfection. The exchange cart is cleaned in a pass-through cart washer and readied in the assembly zone to carry items back to thedepartments. Items of equipment used in this area include the following:

Decontamination zone:



Biohazardous waste management systems

Washer/Decontaminator – used to clean heat-tolerant items

Ultrasonic Washer – used to remove fine soil from surgical instruments after manualcleaning and before sterilization

Healthcare decontamination systems (pass-through washer sterilizers or tunnelwashers) – used to sterilize instruments in perforated or mesh-bottom trays

Cart washers – used to clean carts and other transport vehicles

After the instruments have been cleaned and inspected,they are typically assembled into sets or trays, according to detailed instructions. Eachset or tray is wrapped or packed in a non-woven textile pouch or a rigidpackage/container system for terminal, or final, sterilization. At that point, the sets areprepared for issue, storage or further processing.After assembly, the instruments receivefinal sterilization. The cleaned instruments are issued to the sterile storage area untilissued. Equipment used most commonly in this zone includes the following:

High-pressure sterile processing systems (steam or electric)

Low-pressure sterile processing systems

ETO (Ethylene Oxide) gas sterilizer and aerators

ETO gas aerators

Chemical sterilization systems

Microwave sterilization systems

Following the sterilization process the instruments arestored in sterile storage or sent to the appropriate department. Other functions of thiszone include case cart preparation and delivery; telephone or requisition order filling,and delivery of patient care equipment.

It is advisable to have one high-speed autoclave, preferably in the surgical suite, as astandby in the event of a CSSD breakdown. Flash sterilization is performed in the userdepartments, particularly the operating rooms, to re-sterilize the instruments needed

Assembly/sterilization zone:

Storage and distribution zone:

immediately or those that have been dropped accidentally. Flash sterilization isautoclaving an instrument when it is unwrapped.

The department should be in the hospital service zone to simplify the reception of goods.Proximity to the boiler room is an advantage if steam is raised there. Goodcommunication routes to most of the other departments of the hospital are essential.However, it has a relationship primarily with the Surgical Suite, and can be placed nextto it. It can also be located above or below the Surgical Suite. This requires elevators ordumbwaiters to provide direct access for both clean and soiled materials to and fromsurgery. In some facilities, central sterile processing is collocated with materialsmanagement.

The size of the central sterile processing area depends on the number of surgical andobstetrics cases treated in a given period and the amount (cubic volume) of sterilestorage required. In addition the number of open heart and/or orthopedic cases treated ina given period must be considered. Key capacity determinants include the number andtype of sterilization instruments, the exchange case cart distribution system, andinstrument holding and equipment cleaning in the CSSD department.

The trend is for central sterile processing to move into total integration with surgery.This move is in response to physicians' continued concern regarding the handling ofsurgical instruments and the need for nurses to prepare the case trays for sterilization.



THE PHARMACY

The pharmacy serves the whole hospital. It stores pharmaceutical productsmanufactured elsewhere and may also store dressings. It usually manufactures somesterile and non-sterile products in bulk and dispenses prescriptions, sometimes direct tooutpatients. It supplies all wards and other departments, often on the basis of dailydeliveries. For smaller hospitals, the function of the department may be restricted tostorage and distribution. It is one of the few areas where large amounts of money arespent on purchases on a recurring basis. It is also one of the highest revenue generatingcenters.

As a department, it provides prescription medications, intravenous (IV) solutions, andinvestigational drugs for clinical research, as well as other related products for patients.There are three primary services of the hospital pharmacy:

1. Receipt and preparation of prescriptions

2. Dispensing

3. Clinical consulting

Pharmacists receive orders or prescriptions from physicians. These prescriptions areprepared and dispensed to the patient by the pharmacist. In a hospital setting,medications may be dispensed in a variety of ways. They may be prepared in a central orsatellite pharmacy and delivered to the patient care unit for administration by aphysician, nurse or other caregiver. Moreover, automated vending systems may bepositioned as satellites in high-use areas such as critical care, emergency and similarlocations. A vending system allows the caregiver to administer physician directedmedication and drugs using pharmacy-pre-stocked products in a high-use area.Pharmacists are commonly encouraged to consult clinically with the patient on theadministration of a medication. This assists the patient in learning the risks and possibleeffects of the medicine.

Because supervision of drugs is essential and security is of first importance,manufactured goods are sometimes received direct by the pharmacy rather than via thehospitals main stores. The basic workflow in the department is reception of goods,unpacking and checking, then storage either in a dressings store or a drug store, andfinally dispensing and distribution. Some of the products (poisons and dangerousdrugs) require special security measures. Others need refrigeration, and someflammable liquids may demand particular precautions against fire or explosioninvolving storage outside the building.

From the drugs store, goods pass to the dispensing section either direct or via a bulkpreparation room. In the dispensary they are broken down into correct quantities andfrom there distributed to the hospital or collected direct at a counter on prescription byoutpatients. In many of our Indian hospitals, inpatients too are required to buy theirmedicine directly from the pharmacy on a cash 'n' carry basis. In this case a separate in-patient pharmacy may be needed. Ancillary accommodation includes staff offices, alaboratory, and a suite for the manufacture of sterile products, comprising preparationroom, wash-up, autoclaves and a room for inspection, labeling and storage.

An inpatient pharmacy (in the Western model) is typically located near materialmanagement functions for convenience in receiving bulk items. It can also be locatednear inpatient care units for dispensing medications or at a central location, such as nearelevator banks. Outpatient dispensing is provided in the hospital for outpatientsrequiring discharge medications and prescriptions. Outpatient dispensing should beconveniently located for serving departing patients.

The pharmacy department should have secure access control. Entry points should belimited, if possible, to receiving and dispensing. Ideally, both entry points are under thepharmacist's visual control. Space should be available to allow separate workflows forthe preparation of prescriptions and IV solutions. Dispensing and storage areas must belocated near these two flow areas. The IV preparation area and the fume hood should benear the bulk storage area and IV dispensing. Satellite pharmacies are integral to criticalcare, surgery and other areas. Automated materials movement systems, such aspneumatic tube stations, are desirable and efficient; A 6 inch pneumatic tube system isideal for moving larger items such as IV bags.

Space determinants include the kind of drug distribution system – either centralized ordecentralized – as well as the workload generated by the patients. The patient work loadmay include both inpatient and outpatient demands.

Flexibility within the pharmacy is paramount, especially during a facility's growth andchange. Modular casework provides the flexibility of configuration and layout that isdesirable in any pharmacy. Lighting should be adequate for reading small labels andfinding medications in banks of shelves. Fume hood, to provide a sterile workenvironment for the admixtures and IV preparations, should be provided. A pass-through window, required for walk-up medication dispensing, must be secured.Security locks at all entrances is necessary.

Pharmacists are becoming active in the clinical administration of prescriptionmedications in the inpatient and outpatient settings. With this responsibility,pharmacists are more likely to support a decentralized service encouraging theiravailability to the patients. Staffing remains a critical issue in cost control; thus manyfacilities still prefer a single centralized pharmacy, augmented with automated



pharmaceutical vending machines that are decentralized throughout the hospital.

The environmental services department is responsible for maintaining a clean andsanitary environment in die hospital, including floors, carpeting, tile, drapery, windows,lights, vents, and upholstered items. This department is also responsible for furnituremoves, conference and classroom setups, replacement of patient room furniture, andtrash collection. Environmental services typically contracts with outside vendors orarranges with the maintenance department for pest control, waste removal, exteriorwindow washing, furniture repairs, window coverings, and the purchasing of trashreceptacles and mattresses.

The number of housekeeping rooms or closets is determined by the needs of the facility.A service sink or floor well with a drain is provided for mops and other cleaningequipment. Shelves or carts for the storage of cleaning chemicals and supplies are alsorequired.

Linen services are typically included within environmental services for the collectionand distribution of linens and scrubs throughout the hospital. Linen services aretypically contracted with vendors. However, some hospitals still operate full laundryservices. Linen is stored on shelves or carts. Clean linen storage may be located in cleanworkrooms or linen storage alcoves. Soiled linen can be collected in carts in corridoralcoves or transferred to soiled utility rooms for pickup.

Hospital environmental and linen services serve the hospital and satellite facilities,including medical office buildings, ambulatory care facilities, and other relatedcampuses.

The environmental and linen services department is staff-intensive and should be nearloading dock, materials management, and engineering/maintenance services, as well asclose to elevators. Larger carts may be circulated throughout the hospital for restockinghousekeeping carts located throughout the facility. Carts can also be delivered to thecentral department for restocking. Housekeeping carts are usually kept in the varioushousekeeping closets throughout the hospital. Linen carts are located in appropriateareas and are restocked on a "par" level or exchanged for a newly stocked cart.

Environmental and Linen Services

Settings

Operational considerations:

Space needs

According to the AIA 1996-1997 Guidelines far Design and Construction of Hospitaland Health Care Facilities, the following areas are generally accepted as appropriatefor environmental and linen services:

Environmental services

Linen services

Housekeeping closets

Housekeeping storage and supplies

Bed and equipment storage

Administrative offices

Vendor meeting

Linen storage

Receiving, sorting, and holding area for soiled linen

Centralized clean linen storage

Soiled and clean linen cart storage

Hand washing in soiled linen storage areas

Service entrance protected from inclement weather

Laundry or minimum laundry processing room for emergencies

Storage for laundry supplies

Staff facilities

Hospital finishes, furniture, and accessories are designed to withstand the rigorsof constant cleaning and sanitizing. Such measures help to maintain standards ofcleanliness that support a healing environment.

Outsourcing environmental and linen services is a growing trend in hospitals.

room


Trends



Engineering and Maintenance

The engineering and maintenance department is typically responsible for the entirephysical plant and grounds of the hospital. Services include preventive maintenance,corrective maintenance, casualty prevention, minor construction, and constructionadministration. Work load and departmental needs are directly related to the scope ofthe facilities and the campus for which the department is responsible.

These services should be convenient and accessible to all areas of the facilities and thecampus. Access to the dock area is necessary for building materials, supplies, andequipment. Enclosed access to all hospital departments and areas is also desirable. Thedepartment may be responsible for off-site facilities, such as ambulatory care centersand medical office buildings, as well as for the hospital and grounds.

Engineering and maintenance services are integral to the day-to-day operation of thehospital. These services are responsible for keeping the facilities in proper workingcondition and helping them function effectively. Engineering is responsible formonitoring the mechanical, plumbing, heat, ventilation, air-conditioning {HVAC), andelectrical systems, as well as preventive maintenance and repair. Supporting shop workareas, such as carpentry, electrical, plumbing, paint, welding, and HVAC, may beprovided in appropriate areas of the hospital. They may also be located in a separateoutbuilding for better acoustical and dust control. If such shops are located in anoutbuilding, covered access or transportation to the dock area should be provided.

According to the AIAcomponents of engineering and maintenance services

include the following:

Central Energy Plant

Medical Gas Park

Dock area

Administrative offices (plan room, computer-aided drafting and design [CADD] room,environmental controls room, etc.)

Settings


Space needs

1996-1997 Guidelines for Design and Construction of Hospitaland Health Care Facilities,

Appropriate shops (carpentry, electrical, plumbing, paint, welding, HVAC, etc.)Supply storage

Flammable storage

Biomedical workshop

External grounds maintenance equipment storage

Staff facilities

Engineering and maintenance services require appropriate electrical and mechanicalsystems for shop operations meeting all requirements of the Occupational Safety andHealthAdministration (OSHA). Specifically, dust control and the storage of flammablefluids must be addressed.

Safety and security services within a hospital setting provide general security, guardpatrols, preliminary investigations, fire prevention, control policies and training,disaster planning and training, and other measures for the general safety of staff,patients, and visitors. Other services include lost-and-found and patient assistance, andtransportation by vehicle. The department operates 24 hours per day, seven days a week.

Safety and security has high visibility near entrances and parking areas. It is common toplace this function close to the emergency entrance, inasmuch as this is a 24-hourentrance to the hospital. The service has relationships to employee health, infectioncontrol, engineering, and risk management.

This service typically includes a suite arrangement, one component of which is acommand post.At the post, security guards monitor closed-circuit television cameras.Adirector's office is usually adjacent to the command post. Storage is required for lost-and-found and disaster planning equipment. More healthcare facilities are establishingcar patrols on their campuses.


Safety and Security

Settings

Operational Considerations



Space needs

Trends

Functional overview

Typical safety and security services include the following:

Command post

Director's office

Security supervisor's cubicle

Storage (lost-and-found, disaster planning equipment)

Greater emphasis is being placed on safety and security at healthcare campuses becauseof a rising perception of more violence and criminal activity. This activity, experts say,is attracted by the 24-hour operation of a hospital.

Materials management is responsible for the acquisition, general storage, dailyinventory, and restocking of most, if not all, of the consumable materials used within afacility. This service may be provided for several facilities within a healthcare system toincrease efficiency of operations, reduce total space requirements, and maximizepurchasing power. The following services are provided:

Management of consumable goods such as medical-surgical supplies andadministrative paper goods

Receiving, breakdown, and stowage of supplies, in bulk cases and in units of issue

Storage of special supplies (chemical reagents, X-ray film; stock intravenous [IV]solutions, flammable or other hazardous materials)

Receiving and temporary holding of new equipment or furnishings

Distribution and restocking of supplies to consumer units on a scheduled and on-call basis using pre-established (PAR) levels

Inventory management to maintain supply and to secure optimal purchasingagreements for operational economy

Materials Management

·

·

·

·

·

·

· Administration and management of the facility's supply system in cooperationwith the managers of consumer units

Responsibilities of the materials management director may include managing thecentral sterile processing service (reprocessing/sterilizing reusable Stems) andoverseeing the linen service. Materials management service excludes food products,which are managed by the food service department. Also, this department usually relieson the clinical lab for storage of radioactive materials or special products, such asreagents, which require refrigerated storage.

A general storage area is required in facilities of all types. If serving a network offacilities, material management is often centralized at a "hub' facility, withmanagement and distribution services provided to satellites. Demand for storage spaceand staff will be driven by the mix of services and volume of activity at each site. Eachconsuming unit in smaller facilities may itself manage material acquisition and storage.However, this service is typically centralized to achieve economies of scale and tominimize staffing requirements.

Planning for this service is driven by the array of clinical services to be supported andthe operational concept for the materials management program. The projected volumesof patient care services, types of general and specialty supplies required, relativeproportion of inpatient versus outpatient care, and the administrative needs of theclinical services are components to be addressed in determining demand for materialsmanagement services. More important to space planning, however, is the frequency ofdeliveries and the type of supply system—external and internal—as well as thefunctional work flow intended for the service. These components make up theoperational concept.

Service locations

Key activity factors

1

A materials management flow diagram



Key capacity determinants

Work flow

The extent of centralized versus decentralized storage affects capacity. Inherently,decentralized storage requires more space. Some decentralization is necessary in allhealthcare facilities for enhanced productivity. Capacity is determined by the on-sitesupply reserve and delivery frequency to bulk stores and local storage rooms. Capacityis driven by the storage system: fixed shelving or high-density movable shelving, thestorage system volume—height in particular— and the extent of compartmentalization(separate areas for specialty storage, or bulk carton storage versus broken lot "unit ofissue" storage).

In materials management, work flow begins at the receiving service dock. Bills of ladingand product condition are checked in the receiving area. This area must contain space forweather-protected products and temporary holding. Weighing scales are located in thisarea, as is a clerical work space. The dock area must be raised, often with dock levelers"for receiving materials from tractor-trailer and bobtail trucks, and must have an apronat grade for smaller delivery vehicles.

Cartons of received supplies are moved directly into bulk storage areas on pallets orplaced on heavy-duty shelving. Equipment and furniture are moved to a temporaryholding space until they can be installed by engineering or environmental service staff.Hazardous or flammable supplies are stored in dedicated rooms. These rooms are oftenaccessible directly from the dock to facilitate exterior access for vendors and to provideventilated, safe storage outside the building.

From the cartons, daily-replenished supplies are moved onto more accessible shelvesfor ease of restocking by unit of issue. The "distribution room" or "clean/sterile supplyarea" is the principal storage room from which carts are loaded to restock each consumerdepartment in the facility. Depending on the inventory management system, beforedistribution each item is usually marked with a bar code label to facilitate tracking andbilling.

Bulk stores also hold cartons of prepackaged consumable sterile goods used in surgery,labor/delivery, or other special procedures areas. These items are distributed daily to thecentral sterile processing (CSP) area. The supplies delivered to the clinical areas mayinclude both consumable and reprocessed goods. For this reason, CSP is often adjacentto the distribution room of materials management to optimize material flow overminimum distances. A "break-out" room between the distribution room and CSPtypically serves as a vestibule, where supplies are removed from cartons to shelves.

The replenishment system for consuming units is an important determinant of necessaryspace. There are two basic approaches—replenishment or use of exchange carts. Ahybrid of the two is often employed. Pure replenishment requires a periodic inventory,by the materials management staff, of items consumed in each consumer area; thecollection of those items from the centralized supply distribution room onto a cart; and

j

the delivery and restocking of those items in the cabinets or on carts in the consumer unit.These storage areas are typically identified as the clean supply or clean utility rooms ofthe consumer units.

The pure exchange cart system requires the periodic replacement of the supply cart inthe consumer unit with a cart fully stocked to PAR level, and then the return of thepartially used supply cart to the distribution room for inventory and restocking. A keydifference between these systems is the redundant cart holding space needed in thedistribution room in the exchange cart system. Today's computerized inventory systemsfacilitate instant information to support the replenishment approach.

Because of their value or special storage requirements, specialty goods, such as imagingfilm supplies, lab reagents, and cath lab catheters, may be stored entirely within theconsumer department. These goods are received by materials management and movedin bulk directly to the consumer departments.

Relationships with other departments Materials management must be directlyaccessible from the exterior via a receiving dock area. In planning this department, itsactivities should be kept away from circulation routes for the public, ambulatorypatients, and most staff traffic. However, easy access to all consumer departments fordistribution is desirable. The routes of such access should be separate from publicthoroughfares. Central sterile processing should be located nearby for expedience indaily restocking. For operational reasons—often driven by preferences of surgerymanagers and physicians—CSPmay be separate from or integrated with surgery.

The design of the materials management scales, 36 to 42 in. deep pallet or deep areashould address the followingconsiderations:

Direct dock access for receiving, with staging space for checking deliveries prior tostorage or distribution

Breakdown area for unit of issue stock, with convenient waste managementpathways (box bailer or access to trash compactors)

Capability to segregate flow of clean and dirty activities at the dock (completeseparation is not necessary); ability to move trash, hazardous waste, and soiled linento holding areas or transport vehicles without conflicting with clean incoming goods

Clear and adequate circulation pathways for materials movement equipment such asforklifts

Key spaces

Key design considerations

?

?

?

?



?

?

?

?

?

?

?

?

Exterior access for selected materials storage in dedicated, code-compliant rooms,

such as for flammable or hazardous substances and portable medical gas cylindersof various sizes.

Special equipment requirements may include dock levelers, in-floor industrial cartonstorage, forklifts or pallet lifts, 24 in. deep shelving for unit of issue supply holding (infixed or movable high-density storage systems), and replenishment or exchange carts{typically 24 by 60 in.).

Supporting spaces In addition to basic storage and distribution areas, materialsmanagement should include support areas:

Staff lounge, lockers with showers and changing areas, and toilets

Administrative offices

Special design considerations include the following:

Service traffic must be separated from patient vehicle traffic.

Weather protection and environmental control should be available at the portal to thereceiving dock.

Life safety codes require rated enclosures for certain types of storage, as well asminimum ceiling or sprinkler head clearance vertically above the top levels ofstored materials

Apneumatic tube station within the or distribution room should be provided.

Various other types of automated conveyance systems may be considered, but mostare typically too costly to justify. Often, 6 in pneumatic tube transport systems areeffectively used for immediately needed items not in stock on the user unit, and astation for this system should be provided in the distribution area (unless provided inadjacent CSP).

The centralization of materials management services will continue or increase, in orderto serve greater numbers of facilities within a system. Various approaches andapplications of "just in time" delivery of supplies will continue to minimize inventoryand requirements for storage space in healthcare facilities. Automation of processes forinventory, ordering, and restocking will be increased in an effort to minimize staffingrequirements for materials handling. Distribution of supplies to the points of care willcontinue to be an expedient way to maximize use of clinical human resources. Inaddition, new ideas on achieving care goals without increasing material managementstaff requirements will be explored.

Special equipment and furniture requirements


Trends

THE DISASTER MANAGEMENT

CHAPTER 10


Introduction:Hospitals would be among the first institutions to be affected after a

disaster, be it natural or man-made. Because of the heavy demandplaced on their services at the time of a disaster, hospitals need to beprepared to handle such an unusual workload. This necessitates a welldocumented and tested disaster management plan (DMP) to be in placein every hospital. To increase their preparedness for mass casualties,hospitals have to expand their focus to include both internal andcommunity-level planning. The disaster management plan of a hospitalshould incorporate various issues that address natural disasters;biological, chemical, nuclear-radiological and explosive-incendiaryterrorism incidents; collaboration with outside organizations forplanning; establishment of alternate care sites; clinician training in themanagement of exposures to different diseases, chemicals and nuclearmaterials; drills on aspects of the response plans; and equipment andbed capacity available at the hospital.Importance of External Agencies in Disaster Management Plan:The most important external agencies for collaboration would be stateand local public health departments, emergency medical services, firedepartments and law enforcing agencies like police etc. The key hospitalpersonnel should be trained to implement a formal incident commandsystem, which is an organized procedure for managing resources andpersonnel during an emergency.The hospitals should also have adequate availability of personalprotective hazardous materials suits, negative pressure isolation roomsand decontamination showers.A hospital's emergency response plan has to be evaluated whether thatplan addresses these issues. The hospitals in abroad are required tohave disaster response plans to be accredited by the Joint Commissionon Accreditation of Healthcare Organizations (JCAHO).In India and probably in many other countries, there is no statutorybody to regulate and accredit this requirement.


OBJECTIVES OF DISASTER MANAGEMENT PLAN:

ESSENTIALS OF DISATER MANAGEMENT PLAN:

1. While responding to a mass casualty event, the goal of the healthand medical response is to save as many lives as possible.

2. Rather than doing everything possible to save every life, it will benecessary to allocate limited resources in a modified manner tosave as many lives as possible.

3. When a hospital responds to a large number of victims presentingover a short time, often without a prior warning, delivering care tothe level of usual hospital standards or benchmarks may not bepossible and "altered standards" may have to be acceptable.

4. The term "altered standards" has not been defined, but generallyis assumed to mean a shift to providing care and allocating scarceequipment, supplies and personnel in a way that saves the largestnumber of lives in contrast to the traditional focus on savingindividuals. For example, it could mean applying principles offield triage to determine who gets what kind of care. It could meanchanging infection control standards to permit group isolationrather than single person isolation units. It could mean limitingthe use of ventilators to surgical situations. It could meancreating alternate care sites in the waiting area, lobby or corridorswhich are not designed to provide medical care; minor surgicalprocedures in victims in these areas could mean altered level ofasepsis. It could also mean changing who provides various kindsof care like enhancing the scope of nurses, physician assistantsand hospital paramedics.

5. Secondary triage also may be necessary within hospital, asdemands on the system grow.

6. Hospital DMP should consider the possibility that a hospitalmight need to evacuate partially or wholly, quarantine, or divertincoming patients. For example in the event of flooding, theground floor services may need shifting to higher floors or a makeshift operation theatre may be needed. Spare capacities for suchcontingencies should be included in the DMP.

1. One of the key components of an effective health and medical careresponse is ensuring adequate supplies of a broad array ofqualified health care providers who are available and willing toserve in a Hospital. This could mean re-allocating non emergencyand non-clinical doctors to emergency area of the hospital and

recruiting retired or unemployed providers for temporary service.2. The traditional separation between the medical care community

(e.g., hospitals, physicians and nursing homes) and the publichealth community needs to be bridged in preparation for masscasualty incidents. Mass casualties will provide more work thanany organization itself can address.

3. Coordination is the key and the historic separation is a genuinedisadvantage. Several strategies help ensure protection of staffhandling disasters e.g. safety measures including personalprotective equipment, prophylaxis, training specific for differentevents, adequate back-up staff for rotation to prevent burnoutand fatigue related errors and care of families of staff.

A wide range of training of hospital staff is needed to ensure an effectivehealth and medical response to a mass casualty event. Training shouldinclude, but not limited to a general disaster response, including anintroduction to altered standards of care, but can also be extended to:-

a) Legal and ethical basis for allocating scarce resources in a MCI.b) Orientation to how an incident commands system would work in

a mass casualty event.c) How to recognize the signs and symptoms of specific hazards and

treat specific conditions.d) Basic and advanced life support; hazardous materials life

support; decontamination and isolation protocols, triageprotocols; personal protection gears.

e) And use and maintenance of emergency equipment.

Preparedness for disasters is a dynamic process. In addition to having awell documented DMP in place, it is prudent to have regular drills to testthe hospital's DMP. The drills may be hospital disaster drills, computersimulations and tabletop or other exercises.Why to have drills at regular intervals?In India, hospitals rarely have a documented DMP and even rarelyconduct disaster drills or publish the reports of such drills. The JCAHOactually requires hospitals to test their emergency plan twice a year,including at least one community-wide drill. The purpose of the hospitaldisaster drills is to train hospital staff to respond to an MCI, to validatethe readiness and effectiveness of the hospital's DMP, to make newhospital staff to become aware of procedures in disaster response, to

TRAINING REQUIREMENTS:

HOSPITAL PREPAREDNESS-ITS PURPOSE:


incorporate advancements in knowledge and technology into the DMPand to use the reports from the drill to reinforce the DMP. Hospitaldisaster drills should test various components viz incident command,communications, triage, patient flow, drugs and consumables stock,reporting, security and other issues. Survey of some published articleson disaster drills have highlighted that internal and externalcommunications were the key to effective disaster response; a well-defined incident command center reduced confusion; conference callswere an inefficient way to manage disaster response; accurate phonenumbers for key players were vital and regular updating was necessary;disaster drills appeared to be an effective way to improve clinicians'knowledge of hospital disaster procedures; computer simulation may bean economical method to educate key hospital decision makers andimprove hospital disaster preparedness before implementation of a full-scale drill; a tabletop exercise can help to motivate hospital staff to learnmore about disaster preparedness and can help to teach staff aboutaspects of disaster-related patient care in a way that simulates thepractice setting; a regional exercise involving top government officialscan help to increase awareness of the need for better disaster responseplanning; and video demonstrations may be an inexpensive, convenientway to educate a large number of staff about disaster procedures andequipment use in a short time.

The hospital's patient care role begins with and follows the disaster. Thehospital's community service role begins long before the disaster as thehospital develops tests and implements its disaster plan. The objectiveis to prepare the hospital through the development of emergencyresponse systems, staff training and purchase of equipment andmaterials so that it can continue caring for its present patients, protectits own staff and respond to the needs presented by the disaster. Finally,hospital preparedness can be enhanced more rapidly if standardizedstate and national guidelines for model hospital DMP, staff training,disaster drills and accreditation of hospitals based on DMP aredeveloped and widely disseminated.

ROLE OF HOSPITAL IN PATIENT CARE DURING DISASTER:


INTRODUCTION TO DISASTERS

1.0 Objectives1.1 Introduction1.2 Disaster impacts in some states of India1.3 Major natural disasters in India1.4 Definition

1.6 Causes of Disasters1.7 Effects of disasters

After going through this unit, you should be able to1.0 Define the terms of disaster1.1 Explain the classification of Disasters1.2 Describe the causes of disaster1.3 Identify the most important hazards and how they affect

society1.4 Distinguish between natural and human made hazards

Disasters are affecting mankind form ages. The disaster event concernsevery community and no community is immune from it. According to theGreek Philosopher Empedocles, the universe consist of five elements theEarth, Fire, Air, Sun and Water from which come the manifestation ofviolence such as Earthquake, Volcanoes, Cyclones, Droughts andFloods.

India with wide range of climatic and topographical condition is subject

to various types of natural disasters. Flood is common natural disaster

during monsoon period. Floods are estimated to affect 6.7 million

hectares of land annually. The statistics of 10 yrs indicates that on an

average in India about 30 million people are affected every year. As

already we are losing land areas to the rising sea, if trend is not checked

15% hospitable land will be under sea by 2020 displacing 30,000

families. It is estimated that if sea level rises by one meter it would

displace more than 7.1 million people in India and suck 5764 sq km of

Structure

1.0 OBJECTIVES

1.1 INTRODUCTION

1.5 Classification of Disasters


land under water. The eastern coastal region are prone to severe floods

and cyclones (Andhra pradesh, West Bengal Orissa etc) Northern region

of India namely Assam, Meghlaya, Mizoram, Manipur Nagaland Tripura

These regions are hazard prone in Asian countries. The average rainfall

in this region is 1750 mm to 6400 mm causes flood and erosion.

The shocking memories of Bhopal Gas Tragedy of 1984, Latur

Earthquake of 1993, Gujrat earthquake of 2001 and tsunami calamity

of 2004 have killed and incapacitated millions of people and destroyed

the properties in corers. Approximately 20 major disasters strike the

world yearly most common being floods, cyclones, and earthquake.

Global Statistics reveal over three decades the impact of disaster has

significantly increased.

Each year natural disaster takes a heavy toll on human life and

property.

From 1900-1988, 47 million people worldwide become homeless due to

natural disasters.

1.3 SOME MAJOR NATURAL DISASTERS IN INDIA

1.2 DISASTER IMPACTS IN SOME STATES OF INDIA

Yr Type Place Death

2004 Tsunami A.P./ T. N. / A&N

island Kerala

10749, 5460 missing

2004 Flood Assam, Bihar, Gujarat NA

2001 Earthquake Bhuj, Gujarat 16480 killed

1,44,927 injured

1999 Super Cyclone Orissa 20,000

1993 Earthquake Latur (M.S.) 8000 death

14,000 injured

1991 Earthquake Garwal (Uttaranchal) 1000

1984 MIC Gas Bhopal (M P) 3800


1.4 DEFINITION

The term 'disaster' originated from a French word, which is a

combination of two terms 'des' meaning bad or evil and 'astre' meaning

star. The expression of term disaster is bad or evil star. Disaster Means

Sudden or Great Misfortune

A disaster is any human-made or natural event that causes

destruction and devastation that cannot be relieved without assistance.

Disaster has been defined in variety of ways

1. Anything that befalls of ruinous or distressing nature: a

sudden or great misfortune mishap, or misadventure, a calamity. (OED)

2. “Any occurrence that causes damage, ecological disruption,

loss of human life, deterioration of health and health services, on a scale

sufficient to warrant an extraordinary response from outside the

affected community or area.” The present century has added a new

ecological dimension to the definition of disaster: Chemical and nuclear

catastrophes, oil spills, air, water and soil pollution, desertification, the

greenhouse effect and environmental refuses. (WHO)

3. “An occurrence, either natural or man made that causes

human suffering and creates human needs that victims cannot

alleviate without assistance” (AMERICAN RED CROSS (ARC) )

4. “An occurrence of a severity and magnitude that normally

results in death, injuries and property damage that cannot be managed

through the routine procedure and resources of government” BY FEMA

(FEDERAL EMERGENCY MANAGEMENT AGENCY)

5. “A disaster is any event that causes destructions and distress

resulting in demands that exceeds the response capacity of the affected

community. Disaster usually have an unforeseen serious and

immediate effect on health”. (Operational definition)


1.5 CLASSIFICATION OF DISASTERS

Natural Disasters Man-made Disasters

Earthquake Conventional warfare

Volcanic eruptions N u c l e a r , B i o l o g i c a l a n d

Chemical Warfare

Landslides Vehicular Accident

Avalanches Drowning

Windstorms Collapse of building

Tornadoes Explosions

Hailstorms and snowstorms Fires

Sea surges, Chemical Poisoning

Floods Droughts

Risk:

Hazards:

Risk is a measure of the expected losses due to a hazardous eventof a particular magnitude occurring in a given area over a specific timeperiod. Risk is a function of the probability of particular occurrencesand the losses each would cause. The level of risk depends on:

v Nature of the Hazardv Vulnerability of the elements which are affectedv Economic value of those elementsVulnerability:

It is defined as “the extent to which a community, structure, service,and/or geographic area is likely to be damaged or disrupted by theimpact of particular hazard, on account of their nature, constructionand proximity to hazardous terrain or a disaster prone area”

Hazards are defined as “Phenomena that pose a threat to people,structures, or economic assets and which may cause a disaster. Theycould be either manmade or naturally occurring in our environment.”

The extent of damage in a disaster depends on:1) The impact, intensity and characteristics of the phenomenon and2) How people, environment and infrastructures are affected by thatphenomenon


This relationship can be written as an equation:

Disasters of three types depending upon its nature of occurring

I. Natural Disasters

II. Anthropogenic Disasters

III. Hybrid Disasters

I. Natural Disasters - It is result of natural phenomena. E.g.

earthquake, volcanic eruptions hurricane, tornado, avalanche or flood.

In this loss of life can range from few individuals to thousands of people,

there are plenty of warning signals and man has to regard them and

encourage people to take action.

II. Anthropogenic Disasters: - It is result of man's interaction

with artificial environment e.g. Air borne hazards, nuclear accidents,

Titanic sank in north Atlantic (No life boat available union carbide plant

disaster at Bhopal. All these disasters are caused by human failure)

III. Hybrid disasters: It arise from a linkage of man – made events

and natural events e.g. Air pollution, water pollution, drought, floods

hurricanes, landslide and wildfires.

Depending on time of continuity disasters are divided into-

(I) Rapid onset disasters (II) Slows onset disaster (I) Rapid

Onset Disasters:e.g. earthquake, tsunamis, floods tropical storms,

volcanic eruptions landslides There is sequence of events following

occurrence of rapid onset disaster.

1. The relief phase – is the period immediately following the

occurrence of sudden disaster outstanding measures have to be taken to

search and find the survivors as well as meet their basic needs for

shelter, water, food and medical care.

2. Rehabilitation – actions, decisions to be taken to restore the

normal living condition of the community encouraging the people to

adjust with situation causes by the disaster.

3. Reconstruction – it includes construction of permanent houses, full

restoration of all services as equal to pre disaster state.


Mitigation – measures includes preparedness and long-term risk

reduction measures preparedness includes minimizing life losses,

damage and effective rescue, relief and rehabilitation.

(II) Slow onset disasters: e.g. drought, famine, environmental

degradation, desertification, pest infection.

– It is process of monitoring situations in

communities e.g. early warning signal is drought, livestock sales,

changes in economic condition. Detection of early warning signal is to

provide quick and effective measure and to be prepared with new action

plan for prevention. Extraordinary measures have to

be taken to support human needs, sustain human needs, sustain

livelihoods and protect property emergency phase is prolong in slow

onset disaster such as famine it is short in earthquake.Rehabilitation –

is action taken after slow onset of disasters, for resettlement of

displaced person arising out of conflict or economic collapse.Other

disaster occurring in international community includes – avalanches,

fog, frost, lighting, snow storms and tornadoes.

1.6 CAUSES OF DISASTERS

1. –Poverty generally makes people vulnerable to the impact

of hazards because they settle on hills that are prone to land slide, along

the riverside where chances of flood are on higher side.

2. – population has a major impact on man made

disaster. This is because more people will be forced to live and work in

unsafe areas. Increased numbers of people will be compete for limited

amount of resources such as employment opportunities, and land

which can lead to conflict; this conflict may result in crisis – induced

migration. Such growth occurs in developing countries, resulting in

disasters.

3. – Rapid population growth & migration are

related to rapid urbanization. It is characterized by rural poor

population moving to metropolitan areas in search of economic

Early warning

Emergency phases:

Poverty

Population growth

Rapid urbanization


opportunities & security. They may not find safe and desirable

places to build their houses which can lead to human made disasters.

4. : - all societies are constantly

changing and in continual state of transition. These include – nomadic

population becoming sedentary. Rural people move to urban areas

these examples of shifting non industrialized to industrialized societies.

Introduction of new construction material – these new materials being

used incorrectly – these technique may lead to house that cannot

withstand earthquake.

5. – Deforestation leads to rapid rain

that leads to flood – creation of drought – poor cropping pattern over

grazing, stripping of topsoil, and depletion of water supply.

6. – protective measures, safe

locations, safe evacuation routes and procedures, where to turn for

assistance in case of acute disaster . This understanding should be

incorporated into any efforts to provide external assistance.

7. War & Civil strife – The changing economy and emergence of

developed countries as supreme powers, terrorism etc have led to

various situations of wars which have led to man made disaster.

The complete disaster management cycle includes the shaping ofpublic policies and plans that either modify the causes of disasters ormitigate their effects on people, property, and infrastructure.

The mitigation and preparedness phases occur as disaster managementimprovements are made in anticipation of a disaster event.Developmental considerations play a key role in contributing to themitigation and preparation of a community to effectively confront adisaster. As a disaster occurs, disaster management actors, inparticular humanitarian organizations become involved in theimmediate response and long-term recovery phases. The four disastermanagement phases illustrated here do not always, or even generally,occur in isolation or in this precise order. Often phases of the cycleoverlap and the length of each phase greatly depends on the severity ofthe disaster.

Transitions in cultural practices

Environmental degradation

Lack of awareness & information

EFFECTS OF DISASTERS AND REHABILITATION:


o - Minimizing the effects of disaster.Examples: buildingcodes and zoning; vulnerability analyses; public education.

o - Planning how to respond.Examples: preparednessplans; emergency exercises/training; warning systems.

o - Efforts to minimize the hazards created by a disaster.Examples: search and rescue; emergency relief.

o - Returning the community to normal.Examples: temporaryhousing; grants; medical care.

Developmental considerations contribute to all aspects of thedisaster management cycle. One of the main goals of disastermanagement, and one of its strongest links with development, is thepromotion of sustainable livelihoods and their protection and recoveryduring disasters and emergencies. Where this goal is achieved, peoplehave a greater capacity to deal with disasters and their recovery is morerapid and long lasting. In a development oriented disaster managementapproach, the objectives are to reduce hazards, prevent disasters, andprepare for emergencies. Therefore, developmental considerations arestrongly represented in the mitigation and preparedness phases of thedisaster management cycle. Inappropriate development processes canlead to increased vulnerability to disasters and loss of preparedness foremergency situations.

Mitigation activities actually eliminate or reduce the probability ofdisaster occurrence, or reduce the effects of unavoidable disasters.Mitigation measures include building codes; vulnerability analysesupdates; zoning and land use management; building use regulationsand safety codes; preventive health care; and public education.

·Mitigation will depend on the incorporation of appropriate measures innational and regional development planning. Its effectiveness will alsodepend on the availability of information on hazards, emergency risks,and the countermeasures to be taken. The mitigation phase, andindeed the whole disaster management cycle, includes the shaping ofpublic policies and plans that either modify the causes of disasters ormitigate their effects on people, property, and infrastructure.

Preparedness

The goal of emergency preparedness programs is to achieve a

Mitigation

Preparedness

Response

Recovery

Sustainable Development

Mitigation


satisfactory level of readiness to respond to any emergency situationthrough programs that strengthen the technical and managerialcapacity of governments, organizations, and communities. Thesemeasures can be described as logistical readiness to deal with disastersand can be enhanced by having response mechanisms and procedures,rehearsals, developing long-term and short-term strategies, publiceducation and building early warning systems. Preparedness can alsotake the form of ensuring that strategic reserves of food, equipment,water, medicines and other essentials are maintained in cases ofnational or local catastrophes.

·During the preparedness phase, governments, organizations, andindividuals develop plans to save lives, minimize disaster damage, andenhance disaster response operations. Preparedness measures includepreparedness plans; emergency exercises/training; warning systems;emergency communications systems; evacuations plans and training;resource inventories; emergency personnel/contact lists; mutual aidagreements; and public information/education. As with mitigationsefforts, preparedness actions depend on the incorporation ofappropriate measures in national and regional development plans. Inaddition, their effectiveness depends on the availability of informationon hazards, emergency risks and the countermeasures to be taken, andon the degree to which government agencies, non-governmentalorganizations and the general public are able to make use of thisinformation.

Humanitarian Action

· During a disaster, humanitarian agencies are oftencalled upon to deal with immediate response and recovery. To beable to respond effectively, these agencies must have experiencedleaders, trained personnel, adequate transport and logistic support,appropriate communications, and guidelines for working inemergencies. If the necessary preparations have not been made, thehumanitarian agencies will not be able to meet the immediate needsof the people.

Response

· The aim of emergency response is to provide immediateassistance to maintain life, improve health and support the morale ofthe affected population. Such assistance may range from providingspecific but limited aid, such as assisting refugees with transport,temporary shelter, and food, to establishing semi-permanent


PREPAREDNESS

RESPONSE

RECOVERYRECONST

RUCTION

REHABILI

TATION

DISASTER

IMPACT


Chapter 3

Essentials of Hospital Disaster Plan

1.0 Objectives1.1 Introduction1.2 Aim of Disaster plan1.3 Objective s of disaster plan1.4 Principles of disaster plan1.5 Organization of Health services for Disasters1.6 Facilities and special equipment needed during disaster1.7 Incident Command System

1.0 Objectives

After going through this unit, you should be able to

1. Understand hospital emergency plan

2. Know aim of disaster plan and its objectives

3. Understand principles of disaster plan

4. Discuss organization of health services

5. List the facilities and equipments needed during disaster management

response

6. Explain the level of incident command system operations

1.1 IntroductionDisaster causes great loss of life and property and creates severe disruption tohuman activities, it is essential that disaster management is planned in acomprehensive and scientific manner. Hospital preparedness is crucial to anydisaster response system. EachHospital need to have an emergency preparedness plan to deal with masscasualty incidents. Hospitals that are ready can meet the unpredictablechallenge of disasters. The capacity building of health managers through in-service training for emergencies or mass causality incident management isessential.

1.2 Aim of Disaster planThe aim of disaster plan is to provide prompt and effective medical care tomaximum possible in order to minimize morbidity and mortality.

1.3 Objective s of disaster plan1. To prepare the staff & institutional resources for effective performance


2. To make the community aware of the sequential steps that should betaken at individual and organizational level.

3. To make great benefits to greater numbers4. To reduce after shock

1.4 Principles of disaster plan1. Plan should be simple and operationally functional.2. Plan should be flexible.3. It should specify various roles and responsibilities, work relationships

of disaster management team.4. It should be comprehensive and should consider all the dimensions.5. It should be multi factorial and multi dimensional and should include

fire brigade, police and administrative machineries.6. Plan based on realistic assessment of potential problems.7. Estimates of types of injuries resulting from disasters most likely to

occur in area included.8. Plan should be brief, concise, and inclusive of all who will be providing

disaster aid.9. Plan should be in accordance with timeline.10.Plan should be approved by all agencies that provide authority

endorsement.11. Plan should be sanctioned by those with power to see that the plan is

updated and implemented.12.Plan should be regularly tested and revised13.Progress of the plan should be considered on regular basis.

1.5 Organization of Health services for DisastersThe health services during disasters are critical elements. It requires carefulplanning. Following factors are to be considered while planning healthservices during disasters

1. Country's overall health care delivery system at central, state anddistrict level

2. Role of disaster management authority in existing health care system3. Region wise delegation of responsibilities and organization of

resources within the defined area.4. Formulation of comprehensive emergency medical care plan.5. Establishment of focal point of coordination to ensure the optimal

healthcare resources.6. Organization of pre hospital medical care and hospital medical care7. Provision of first level care at disaster site including rescue, relief, first

aid and basic life support measures to preserve life8. Mass casualty management9. Provision of therapeutic procedures and supply of drugs and medical

supplies.


10. Medical command and control, triage team, first aid team, casualtyevacuation team should be in place

1.6 Facilities and special equipment needed during disaster management response

1.7 Incident Command System

Incident Command System

LEVELS OF OPERATIONS DURING DISASTER MANAGEMENT:

1. Earth moving equipments2. Ambulance3. Drilling rigs4. Mobile craves5. Mobile X-ray units6. mobile trauma care centers7. Water tankers8. Wireless sets, Mobile wireless sets etc.9. Blood bank10. Labs11. Fire brigade services12. Hospital with surgery facility

:

In order toprofessionalize emergency response management, it is proposed to introduce theIncident Command System in the country. This system provides for specialist incidentcommand teams with an Incident Commander and officers trained in different aspectsof incident management – logistics, operations, planning, safety, media managementetc. Disaster is unexpected, unforeseen event causing damage on large scale. Becauseof its sudden nature leading into mass causalities, the health care providers have toresearch on site-for rescue operation. Therefore the nurses have greater role in themanagement of disaster on site and in the emergency department or in the hospital.

LEVEL OF OPERATIONS

is assigned to help hospitals and communities

for improving emergency management planning, response, and

recovery activities for unplanned and planned events.


OPERATIONS

EMS OPERATIONS FIRE OPERATIONS PUBLIC HEALTH

MEDICAL DIRECTION COMMUNICATION SURVEILLANCE IMMUNIZATION

TRIAGE TREATME TRANSPORTATION RESCUE TAGGING

Chapter 4HOSPITAL PREPAREDNESS

PREPARATION OF EMERGENCY DEPARTMENT FOR MASS CASUIALTYINCIDENTS:Mass casualty management committee:

The hospital should have a mass casualty management committee. Itsresponsibility would be preparation of the hospital contingency plan,dissemination and its follow up. It would undertake training of staff. Thecommittee member should comprise of following authorities:

· Medical administration· Hospital administration· Maintenance· Emergency Department· Surgical department· Nursing service

Department-wise preparedness

Incoming patient area:This is usually the casualty / Emergency department of hospital.

Depending on the size of casualty, this area might be extended to anotherarea of hospital if patients exceed a certain number.

Areas in the emergency department:· Triage area in the casualty· Resuscitation area for unstable patients.· Area for the beyond salvages patients.· Area for brought in dead.· Area for the walking wounded.· Alternate area / ward where sick patient can be shifted when the

casualty is over crowded.· Area where post operative patient can be received.

Patient care in casualty: (Triage)Instead of treating the most sick or most injured first, triage would focus onidentifying and receiving immediate treatment for individuals who have acritical need for treatment and are likely to survive. The goal would be toallocate resources to maximize the number of lives saved.


spectrum of care from the scene to hospitals and to alternate care sites.Emergency department access may be reserved for patients requiringimmediate care; ambulatory patients may be diverted to alternative care sites.

Needs of current patients such as those recovering form surgery or criticalor intensive care unit should be evaluated; the resources they use willbecome part of overall resource allocation.

Elective procedures may have to be cancelled and current in patient mayhave to be discharged early or transfer to another settings. Depending uponthe situation.Nurses may function as physician and physician may function outside theirspecialty credentialing of providers may be granted on emergency ortemporary basis.

In patient services by medical staff:

Medical director will coordinate the preparation, notification of inpatientservices.

Will ensure to provide adequate patient care.Facilitating pending admissions.Preparation to receive patientWill ensure care of patient

Nursing services:

Conduct accurate bed count for available medical-surgical beds.Conduct accurate count of available ICU, Isolation beds.Contact the director of pre-operative services to assess readiness of

operation theatre and recovery room.Coordinate with inpatient services for evaluation of patients who can be

discharged on priority basis to make room available.Ensure the availability of required staff and supplies.

Support services:The emergency department should have a reserve of essential drugsincluding whole blood, medical supplies and materials that can be used inlarge scale emergency. It should be stored separately in the one casualty. Itshould be easily accessible in an emergency.

Material management:Four emergency department disaster carts should be brought from central


supply to the casualty. Assign personnel to the emergency department tobring the required supplies and equipments.

Blood bankThe blood bank is alerted to the disaster activation and will co-ordinate thedistribution of blood and contact outside blood banks if needed.

PharmacyDispatches required personnel and medication to the emergencydepartment.

Lab services:Is prepared to receive a large number of samples and prepared for downtime procedures

Internal and external communicationThe internal system of communication between the various wards anddepartments must be established. Following could be done:

1. Portable loud speaker.2. Internal telephone lines3. Two way radios are the possible alternatives; this may also help in

establishing communication with staff outside hospital.There should be updated list of names of doctors and others support staff,department wise with their database.

Transportation:Emergency department clearly indicates the priorities regarding the

use of hospital ambulance and other services vehicles. It should makeprovision for fuel, designate staff to be in charge, it should have the basicand essential equipments and the medication.

For transportation of causalities within the hospital .it is important to havemobilization of adequate number of stretchers and wheal chairs.

Manuals and operational guidelines:

The administrator, departmental heads should have specific manuals foreach departments / ward as well as instruction on how to establish personalworking groups, and plan of action to be implemented in case of anemergency.


At no time the media should be allowed unescorted through any patientscare of treatment area. The office of communication and businessdevelopment will handle all news releases, press conference and theinterviews.

Family reception area:In mass casualty incidents, no visitors will be allowed in to the emergencydepartment and the hospital visiting hours should be suspended.

Family reception area will be set up in separate lobby; the patient relationshipdepartment will be responsible for notifying families.

Hospital network with other agencies:-The major emergency requires involvement of all relevant agencies and it isalso necessary to establish network with public and private agencies. Theemergency department must know the operating capacity of other hospitalsin the neighborhood. It should also network with agencies like defense,police, fire etc.

Patient referral system:

Some cases may require specialized care for which, the emergencydepartment should make alternate arrangements with other hospitals forreferring patients and provide necessary transport for the same.

Critical incident stress management programs:The emergency department has to provide short and long term stressmanagement measures for the health care providers and their families.

References1. Coping with major emergencies- Who strategy and approaches to

humanitarian action, Geneva, World Health Organization, 1995.2. WHO (1999). Community Emergency Preparedness: a manual for

managers and policy – makers, WHO3. PAHO (2000). Natural Disasters, Protecting the Public's Health,

Scientific Publication No. 5754. Emerton, M.D., Principles and practice of Nursing, 2 ed. , Chapter

18, Prentice Hall of India Pvt. Ltd., New Delhi.5. Mahoney, R.F., Emergency and Disaster Nursing, 1 ed., Mac Millan

Company, New York, 1965.

nd

st


THE HOSPITAL PROJECT TEAM

CHAPTER 11

In the conceptualization, design, construction and commissioning of any successfullyrun healthcare facility project, the services of some or all of the following types ofconsultants will be required:

In addition to these consultants, the design team would also include:

We thus have eleven individuals / consulting firms or groups of people who wouldconstitute the

Starting with the consultants, their fields of expertise and thus scope of services wouldbe as follows:

1. Hospital Consultant

2. ConsultingArchitect /Architect

3. MunicipalArchitect / LocalArchitect

4. Structural Consultant / MEP (Mechanical, Electrical, Plumbing)Consultants

5. Construction Manager

6. LandscapeArchitect

7. Interior Design Consultant / Graphic Designer

8. Bio-Medical Engineer / Medical Equipment Consultant

9. The Client / Client's Representative

10. HospitalAdministrator / CEO of Proposed Facility

11. User Groups / Representatives of Users of the Proposed Facility

Design Team.



1) The Hospital Consultant

2) The ConsultingArchitect /Architect

At the start of the project, the hospital consultant's role is to do a market survey andfinancial feasibility report to establish what should be the role of the proposedhealthcare facility in the region it is to serve. The consultant's recommendations focuson the total operational future of the facility, including the service area market financialfuture, proposed medical specialties and bed strength. His most important function is toprovide an independent professional opinion and plan based on an unbiased look at thetotal operation. This consultant is usually retained to develop a long-range plan (alsoknown as strategic plan.)

The hospital consultant's role in design and construction is thus that of a programmer.The consulting architect will help him in this. Once the facility's role in the communityhas been established, the operational and functional plans must be established. Theyshould be based on department utilization projections.

This consultant has a role to play towards the end of construction too. He can offerservices relating to recruitment of staff, setting of tariffs, formulating operatingprocedures for the different medical departments, may offer consulting services on theevaluation of medical equipment to be purchased and may facilitate computerization ofhospital functions. He may formulate marketing strategies and offer TQM / ISO 9000solutions.

In an existing facility he may advise on turn around strategies, do operational audits,costing of services and systems study and redesign. He may advise on hospital wastemanagement practice.

Fees are not regulated, and will vary depending on the scope of services.

Consulting Architects offer specialized healthcare programming and design services.They may offer these services on a national or international basis. The national firm mayhave either many offices throughout the country or a home base and a few regionaloffices. It's design expertise includes master planning, layout, and equipment fromprojects ranging from medical colleges to rural primary health care centers.

The Consulting Architect may also extend his scope of services to do conceptualplanning and schematic layouts for individual hospital projects. This will then be thenthe input to the next consultant, theArchitect.

If theArchitect has the necessary expertise to design and produce construction drawingsand documents for the hospital project himself, and if the scale of the project is within

his design and production capabilities, the consulting architect's services are not neededfor that project.

Selecting the consulting architect / architect can be a difficult and tiring process. Theselection committee may sit through four presentations a day, hearing equally gooddemonstrations of expertise. The following tips may help narrow the choice:

a) Find out which member of the firm will handle the job and evaluate his or herresponses. You will be working closely with this person for a long time, and this isthe key to a firm's selection.

b) Study the proposed team and it's organizations appearance. Ask about the teamsmembers' experience and request a reference of complete work.

c) Check the firm's references.

d) Explain your needs and the goals of your project, such as design excellence,mechanical systems and functional concerns, and ask questions as to how these canbe met for your facility.

e) Relate the fee quoted to the larger costs, those of construction and efficientoperation. Do not pick the lowest fee just because it is low. Once a fee is verbalized,it greatly influences a committee. However this fee amounts to only a small fractionof the total amount you will spend for construction, and an even smaller amount ofthe total project cost, including land and medical equipment. Money is not saved ifthe building does not operate efficiently. Every 3 to 5 years of operations will cost asmuch as the initial construction. The building will in all probability operate foraround 50 years. It is important to in your selection.

The Municipal Architect is the consultant who will be responsible for obtaining all the

requisite permissions / No Objection Certificates (NOC's) from the concerned

regulatory authorities. This would include approval of the land use, the proposed built-

up area, the open spaces around the building, the provision for parking, any recreational

space / gardens that may need to be provided and the plans showing the individual rooms

with sizes. He would also be responsible for obtaining clearance as to fire-fighting

provisions and means of exit such as staircases.

trust

3) MunicipalArchitect / LocalArchitect



If the hospital is being designed by an architectural firm that does not haverepresentation in the city / town / rural area where it is proposed, a Local Architect maybe appointed, who, as his designation suggests is based in the locality of the project. Hemay be the same as the Municipal Architect. He would then, in addition to the above-mentioned functions, supervise the day-to-day activities on site, reporting to the mainarchitect. He could also provide information on locally available materials and localmethods of construction. He could advise on the traditional architecture of the region, ifthe main architects desire to respond to it in their proposed aesthetic for the facility.

Both these architects are better selected by the Main Architect than the client, as theworking relationship between all these architects needs to be based on mutual respectand hence cooperation. Many a project has come to grief over disputes or differences inoutlook between different firms of architects working on the same project. Creativeprofessionals can often be prima donnas, or behave like them.

Structural and MEP Consultants are engineers. Structural engineers are

moregenerically called civil engineers.

Historically, engineers who worked on non-military projects became known as civilengineers. Three main divisions of civil engineering exist today:

a) Transportation Engineers

b) Structural Engineers

c) Sanitation Engineers

Civil Engineers contribute their talents to hospital construction in three areas:

a) Site Planning

b) Structural Design

c) Construction

Site planning is the art and science of arranging the uses of land. Siteplanning is done professionally by architects, landscape architects and civil engineers.The civil engineer plays a role in readjusting the existing landform through designedgrading and providing for proper drainage.

4) Structural Consultants / MEP(Mechanical, Electrical, Plumbing) Consultants

Site planning:

Structural Design:

Construction:

Mechanical Engineers

Electrical Engineers

Plumbing Engineers

The structural engineer's role is that of providing the optimumsupport for the building. Structural work needs to be coordinated with the architect andthe other engineering consultants; this coordination is absolutely essential in hospitalprojects. He will decide in consultation with the architect the structural system to be used.

It is in the preliminary stages of design that the structural engineer can effect the most

savings. He must be appointed at the beginning of the project, and work with the architect

even during conceptual design.

The civil engineer is responsible for inspection and testing of the

materials used in construction, to make certain the owner gets the quality and quantity

specified. His role is that of Construction Manager, dealt with in detail later on.

study the conservation of energy and apply it in the most

efficient and economical way. They design the heating / air-conditioning loads for the

hospital, design the system and specify the necessary equipment. He will design the

incorporation of the necessary filters into the air-conditioning system to produce the

desired sterility conditions in that space.

design the electrical systems of the hospital and calculate the

electrical loads based on lighting and equipment loads. He should be aware of the public

utility supply and rates to ensure economical power distribution and the required

emergency supply. He will specify the equipment needed. He will design control and

monitoring systems (Building Management Systems) and cater to communications and

data processing requirements.

are responsible for the processed water supply and liquid waste

disposal throughout the building. They design the capacity of the water tanks (overhead

and underground) required based on occupancy and applicable regulations. They design

the fire-fighting systems required, the sewage treatment plant (if required) and water

purification plants for the hospital.

In it's engineering requirements, each hospital presents a unique problem. There is no

universal solution to the selection of a system even after the problem is defined. There are



many technical considerations depending on the medical equipment to be housed and

the medical procedures to be performed within the proposed facility.

It is important that the MEP design team is hired as early on in the proceedings as

possible, ideally at the start of the project, as they can advise on many decisions that are

often taken without their involvement, presenting them later on with a de facto situation

resulting in inefficient design and / or construction.

Very often, at the end of the project, few among the consultants and sometimes the client

too are not satisfied with the outcome. Too often the client is heard to say, “ Well, it is not

what I expected or what I wanted.”

This condition of dissatisfaction can be avoided with value management. This performs

the following functions:

a) Understanding the client's expectations

b) Understanding the constraints on the clients

c) Understanding the expectations and limitations of the architect, engineer and

construction manager

d) Helping the design team communicate their expectations and needs to one another

e) Helping the architect and engineer make changes and stay with schedule and

budget

Coordination of the work of the engineering design team and the architectural

design team is of crucial importance. A lot can go wrong if this is not rigorously

done, especially in hospital design.

f) Monitoring and reporting issues that seem likely to delay design or cause

dissatisfaction among members of the design team.

g) Preparing and conducting special problem solving sessions to clarify values and

objectives, improve design, maintain or lower total cost, maintain or shorten

schedule, improve life cycle costs and improve energy design and costs.

h) Employing the methods and procedures of all problem-solving systems, including

value engineering, value clarification, design-to-cost and Delphi.

is a set of concepts and methods used to adjust designs to acquire the

best total value. Using definition and analysis of function, value engineering is aimed at

achieving the lowest total cost commensurate with design excellence. Specific methods

include function analysis, brainstorming sessions, matrix comparisons and analysis of

life-cycle costs.

Construction Management of hospital projects in the West began in the 1960's. By now,

almost all projects include a construction manager to save time. The advantages of

including a construction manager early in the design phase can be great. For example,

the construction manager is familiar with:

Current building systems that are available on the regional market at a competitive

price.

Current labor and industrial prices, enabling him to establish a proper estimate in the

specific area.

Sub-contracting trades that can advise on detail.

Specification review.

Value engineering

5) Construction Manager

i)

j)

k)

l)



m)

n)

o)

p)

q)

r)

Cost consulting and scheduling.

Management.

Inspections.

Insurance programming.

Samples and Testing.

Shop drawing and Coordination.

This knowledge, if applied in the design phase, can lead to cost improvements, time-

savings and fewer change orders. The expected contingencies now budgeted and used

should be reducible. Many architect-engineer firms offer construction management

services.

The construction manager performs a variety of functions, such as managing general

conditions on site, including start-up and overall supervision. Towards the end of

construction, the construction manager is responsible for drawing up a certificate of

substantial completion.

The landscape architect is responsible for the design of outdoor areas, around the

hospital or the spaces in-between buildings on a campus. While the architect usually

does the layouts of motorable roads, the landscape designer suggests the layout of

pedestrian pathways, paved outdoor areas and plantation. He may also suggest water

bodies, fountains, street furniture and lighting and provide detailed construction

drawings for all these elements. He will work in close coordination with the main

architect.

6) LandscapeArchitect

7) Interior Design Consultant / Graphic Designer

GraphicDesigner.

We are in an era in which interior architecture design has become an integral part of the

architectural process; it begins with the earliest architectural concepts and ends with the

client occupying the completed space. In the case of a hospital, it is best that the interior

designer is able to work as a direct extension of the architect and is often hired directly

by the architect to perform work included in the basic architectural contract. The

architects firm may itself contain an interior design division. Such designers are best

qualified to perform the total range of services needed to complete any medical facility

including basic design and functional considerations, durability and maintenance of

product, and control of costs.

Fees vary, based on scope of work. The earlier the consultant is retained, the better.Listed below in chronological order are some of the interior design services available:

a) Preliminary consultation, analysis of scope and architectural review.

b) Interior design materials and color coordination.

c) Environmental programming based on social and behavioral factors.

d) Operational programming for efficient use of space and furniture.

e) Inventory analysis and evaluation for existing furniture reuse.

f) Preliminary budget.

g) Space planning of detailed layouts.

h) Lighting design, coordination and review.

i) Furniture selection or design, budget and specifications.

“Corporate image” does not sound like a term that should be applied to the design andconstruction of hospitals, but it is an area of design that is of great importance. Theoverall concept of a hospital's image includes graphic art and design. The interior of ahospital should be tied to a graphics program and that requires the services of a



Two types of programs are of interest to the hospital designer. One is that of directionalgraphics, a signage program. A mass of information must be transmitted visually to thepatients, visitors and staff so that time and motion are not wasted. The program developsa consistent lettering font and style and a directional program. The second is that of thecorporate image of the hospital, the hospital logo and master program for all printeddata. Graphic design should be thought through early in the design stage, allowingincorporation of the graphic design into the total design concept.

The responsibilities of the medical equipment consultant can be limited or quite broad.

Basic equipment planning services might include:

a) Assisting the client in making equipment selections.

b) Establishing and tracking the equipment budget

c) Compiling an “equipment book” including manufacturer's installation data and“cut sheets” (equipment specifications) and obtaining other relevant data fromequipment vendors.

d) Developing room-by-room equipment lists and indicating the general location ofequipment.

e) Obtaining from the vendor and forwarding to the architect (via the owner)installation data necessary to develop architectural and engineering components ofthe building.

f) Organizing and directing equipment user group meetings in which the specificequipment needs of facility users are identified.

Additional services, which may go beyond the scope of basic equipment planningservices, may include

a) Assisting the owner in procuring and installing equipment and negotiating apurchase agreement with the vendor.

Although the equipment planner can be quite helpful in this area, many health careproviders may be affiliated with some type of bulk purchasing service and can negotiatecompetitive prices themselves. The difference between an aggressively negotiated priceand list price is considerable. Negotiated pricing also should include extended servicecontracts, which in themselves can eventually add up to a considerable sum.

8) Bio-Medical Engineer / Medical Equipment Consultant

b) Additional user group meetings.

Departmental user group meetings consist of a series of long, intense, interactive worksessions. In order for these meetings to be conducted in a time-efficient manner, eachdepartment user group should have a general idea about the equipment it is consideringto purchase or reuse. The equipment planner can be an additional resource in describingsome of the specific attributes and requirements of each unit, instead of having to beginwith more basic issues. The equipment planner will bring a more objective viewpointthan the equipment vendor.

c) Coordinating tours to visit facilities where similar equipment is in operation andpresentations by equipment vendors.

One good way to learn more about the equipment that currently is in use is to visitsimilar facilities that have recently opened. When conducting such a tour, it is best toselect a facility that is similar in scope to the one being designed. It should also havebeen operational long enough for the staff to develop more than just first impressions,but not one that is so old that the equipment does not compare with what is currently onthe market. Equipment vendors may also organize tours of their showrooms and currentfacilities showcasing their equipment. Such tours can be both educational andeconomical. However vendor organized tours tend to be less objective than thoseorganized by the architect or equipment planner.

Trade shows are another good source for learning about current equipment as well asstaffing, management and business issues relating to the operations of health carefacilities. Many equipment vendors unveil their latest technology at such shows.

As a client or his representative who intends building a new healthcare facility or addingto or renovating an existing facility, you will be working with the above-mentioneddesign team. Long before the first shovel hits dirt or hammer is swung, you will findyourself committed to many hours of planning meetings with professionals such as theabove.You will be an integral part of the design team.

This is what Vincent Wang, Design Director, Stanhope Properties plc, has to say on thesubject:

“Quality is a state of mind, not an optional extra. It cannot be bolted on. The lead mustcome from a strong and committed client and the pursuit of quality must form everystrand of the process”

An essential function you will perform right at the beginning of the project will be to

9) The Client / Client's Representative



state the project goal/s, or 'statement of intention”. This will form a reference point forpolicy decisions taken by the design team, which will need to be consistent with thisformulation of project goals or intention. Keep it short and state it with clarity. Weigheach word that forms part of this statement.

The whole team will look to you to provide direction and purpose to the whole effort. Ifyou falter or show signs of indecision this will communicate itself to the entire team, andif this goes on for an extended period of time, the whole group will come apart at theseams.You have to project, as Mr. Wang says above, strength and commitment, and leadfrom the front. If you are perceived as losing interest in the project, maybe you show theteam that you are more concerned about your other business then it is bad for morale.You must always communicate keen interest in the project. Make an effort to establish arapport with the key members of the design team. Consultants work harder for clientsthey like as people; you can't always buy that kind of extra effort with money. (Ofcourse, you can try it won't do any harm!)

Maintain project momentum. If you drag out the process, all concerned will loseinterest.

It is a good move to appoint the CEO of the proposed hospital or the HOD of theadditional department/s being added / renovated right from the design stage. If they arealready working in the existing facility they need to get themselves a hardhat and takeon a part-time job. They will be liaison and interpreter between their staff and the designteam.

My advice to this CEO is:

A) You need to be an active member of the planning and design team as early on aspossible.

B) Try to keep a copy of the most up-to-date plans. This way you can keep up withprogress and revisions.

C) Keep a current plan located in a strategic location so staff and physicians canbecome familiar with the project.

D) Take your own project meeting notes. You can double check them with thearchitectural minutes to make sure you don't forget anything. You should be on themailing list for project meeting notes.

10) HospitalAdministrator / CEO of Proposed Facility

E) Involve your staff. Invite key members of your department to architectural planningsessions.

F) Form a staff planning committee and meet regularly for feedback and plan reviews.Involve a cross section of staff from different shifts, those that embrace change andyes, those that are most resistant.

G) Create flow charts of critical work processes. Determine what your problems andissues are with your current plan. How will these processes be supported in the newplan? Examples of processes to consider include chart flow within a department,supply flow and storage, soiled / clean linen flow and clean / soiled instrument /procedure tray pathways.

A little advice on reading architectural drawings: drawings or plans are produced in areduced scale. The most common scale is 1:100 where 1 drawing unit is equal to 100units in reality. This scale is by-and-large the same as 1/ 8 of an inch equals 1 foot. Theother common scale is 1:50 or 1 / 4 of an inch equals 1 foot. Once you have your first planto review, get a scale or architectural ruler to help read the drawings and determine theplanned size of spaces.

On relating plans to space: once you can read the blueprints, relating them to your frameof reference of space is critical in planning. Here are a few quick tricks:

A) Find a room in your current department such as a patient room or supply room.Measure the size of the room. A room that is close to 8 feet by 10 feet is a goodmanageable frame of reference. You can then relate the size of your room to acomparable size room on the plans.

B) Measure doorways both on the plan and in your department. Doors through whichpatients on stretchers are to be moved are usually 60 inches wide, with two equalshutters. Patient room doorways and doorways for handicapped people are usually48 inches wide. What is planned to go through the doorway in question willdetermine it's width.

C) Acute care hallways and hallways in public spaces should be 8 feet wide (7 feet at apinch goes in India).



D) Compare the new space with what you have. For example if the supply andequipment rooms are changing sizes, compare the new space with what you have.

E) The amount of square footage doesn't always provide a guide for actual usable space.The two rooms shown here give examples of different shaped rooms that are thesame square footage.

Room A would make for a good equipment room becauseof the amount of space in the middle of the room forequipment needing floor space.

not to scale10'-0” x 12'-0”

120 sq. Ft.

Room B would make a better supply room as the wall spacecan be used for shelving.

not to scale8'-0” x 15'-0”

120 sq. Ft.

On being a proactive participant: don't let anyone tell you it's too early to startdetermining your departments needs. The earlier you have information, the moreappropriate input you can give early on in the planning process.

Internal resources:

A) An essential place to start with is your information services department. Whenplanning workspaces such as nurse stations and patient rooms, many of the issueswill relate to technology. Discuss technology for your department and facility for thenext 2 to 5 years so your department plans can be designed with enough flexibility tosupport change.

B) Meet with key support department heads. Their future plans may impact yourdepartment. Or, you may be considering changing a work process that impactsanother department. In either case, inputs from these departments can provide youwith valuable decision making information and ideas.

C) Visit other departments that have undergone recent construction, renovation and /or have purchased new equipment. Get their feedback on how the process wasmanaged and the quality of decisions made. Check with the purchasing departmentand facilities department to see what current information they may have fromvendors about new equipment. The internet is also an excellent source of productinformation!

D) Depending on the scope of the project it may be practical to build a mock-up room,for example a patient room, trauma room or an or somewhere on your campus. Thisis a great place not only to actually see the proposed size of the rooms but also tohave mock-up products and equipment brought in for staff to see and touch.

External resources:

A) Your peers in other facilities. If you haven't already done so, talk to managers whohave been or are going through their own construction project. Visit theirdepartments and have them share their experiences with you.

B) Sales reps. Word gets around the sales community pretty quickly so sales reps maybe contacting you before you think you are ready for them. They are a greatresource for up-to-date information and future trends in their industries and forreferences regarding other new facilities. They should have a list of installed orbuilt sites for you to see or key contacts for you to talk to. Trial and mock-upproducts are frequently available to assist you and your staff in making purchasingdecisions.

C) Site and / or factory visits. Many people feel that a site visit to another health carefacility is as good or better use than the traditional factory visit. Some of theadvantages of a factory visit include being able to see the full range of products andservices available to you from a manufacturer and obtaining customer references.

D) Professional meetings. Professional meetings that have large exhibit areas providethe opportunity to see many different kinds of technology and to touch, move andlearn product features and benefits in a short condensed period of time. Registeringat each booth may not only get you a free gift, but also put you in touch with a localrepresentative.

E) The internet. More and more manufacturers and professional organizations haveweb sites that will let you research information and / or shop right from your office.Professional organizations such as the American Institute of Architects have websites with articles on architectural trends and current projects.

Many construction projects, especially renovations, are phased construction unless you



can relocate to another hospital space or temporary building during construction.Disruption in operations, patient care delivery and compromises of work areas are to beexpected. Working closely with project team members including infection control staffwill ensure a smooth process.

A) Identify your priorities for the order of phasing and match them with the reality ofconstruction constraints.

B) Get as realistic a schedule as possible, accepting the fact that time lines are bound tochange.

C) Keep your staff up to date so there are a minimal number of surprises for them.

D) Visit the construction site frequently. As the building is being completed it will beeasier for you to visualize what was on the plans. You will also be able to recognizesituations that do not match the plans. It may be something as simple as a missingelectrical outlet or a thermostat placed where furniture or equipment will obstruct it.

E) When construction is far enough along, usually after the walls are put up, bring yourstaff through and start orienting them to the new space.A three-dimensional space isvery different from the flat blueprints you have been reviewing for a long time.

F) Keep your sense of humor! Generally, even if you had to make some compromises,the new department will be better then what you are currently working in.

All in all, the process of renovation or new construction can be challenging and fun ifyou are well prepared. You are the key to creating a more effective, functional andefficient clinical department or facility that supports both staff and patient care. This isyour opportunity to make a difference in this important work and acre environment.

As we have mentioned above, in an existing hospital addition or renovation, staffmembers of the concerned departments are invited to attend what are called “user groupmeetings” in which they, as the eventual users of the proposed facility comment on theplans prepared by the design team. Their comments can offer insights into the efficientoperations of the proposed facility, helping the design team get in touch with reality.These could be meetings with physicians, nurses, support staff, anyone who would beusing the proposed facility.

For the design of Inpatient units, patients can be interviewed through questionnairesrelating to their experience in the hospital, and asked for suggestions as to how their staycould have been made more comfortable. Designing for the patient costs no more

11) User Groups / Representatives of Users of the Proposed Facility

initially, and it will boost public relations for many years. This information can beobtained by “patient profiles”.

Patient profiles represent patient's needs, tastes, and opinions on their hospital staydirectly to the architects and design people. Profiles will not only directly affect theadministrator, as a buyer of hospital products, but will establish the patient and hospitalstaff as a partnership that works together to achieve a good professional environmentthat ministers to the physical and emotional needs of the patient.

With a patient profile system, reported patient needs can be analyzed in order to improvedesign standards. Whether a hospital has hired a consulting architect for a completelynew facility or a phased renovation, the patient profile information is a valuable tool indesign. It is time the design profession reflects on the needs of patients themselves, noton what we perceive to be their needs, for “their” needs are truly our own.

Community outreach programs are increasingly becoming important for hospitals toeducate the community which they serve about the services they offer, and to getfeedback from the same community as to what additional services they need to provideor change in the way they provide their current services. When designing a new facility itis well worth the designers while to present the proposed scheme to representatives ofthe community it is located in, to inform and to get feedback. In the United States it canbe mandatory to this in particular cases. For a corporate hospital, it generates importantfeedback on the needs of the community, and would help determine which medicalspecialties should be their thrust area. Meetings with local physicians who wouldpossibly refer patients to the proposed facility and asking their opinions on what medicalfacilities the proposed facility should offer would be at least a good marketing move,and might be of help too.


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