An Architectural Brief For A Proposed 100-bedded Hospital

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100-BEDDED HOSPITAL

DISSERTATION WORK DONE BY

Dr. Preet Matani

AT

HOSMAC (India) Pvt. Ltd

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

ACKNOWLEDGEMENT The dissertation period gave me an opportunity to explore the field which has always intrigued me and where my interest was- that of facility planning. I am indebted to Dr. Vivek Desai – Director HOSMAC (India) Pvt. Ltd. for giving me an opportunity to work in his organization as there are but a handful of such organizations where I could have pursued such a study. I am extremely grateful to Mr. Hussain Varawalla- Sr. Architect HOSMAC (India) Pvt. Ltd., my guide who took a lot of efforts for my sake. I am also extremely grateful for the support provided by my seniors Mr. Sameer Mehta and Mr. Kapil Rawal who were a constant source of encouragement at HOSMAC. I would like to thank Brig. S.K. Puri, my guide, for having faith in me and I hope that I would be able to live up to his expectations. I am also indebted to my teachers Dr. S.G. Kabra and Dr. Hari Singh for their guidance throughout my academic career. Lastly but not the least I would like to thank my friends - Shekhar, Rupesh, Gaurav Tripathi and Benjamin for always being with me throughout my stay at IIHMR. PREET MATANI

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

TABLE OF CONTENTS

CHPT

TOPIC

NO

PAGE NO.

1

STUDY DESIGN

1.1

INTODUCTION AND BACKGROUND INFROMATION

1

1.2

RATIONALE FOR THE STUDY

3

1.3

OBJECTIVE

4

1.4

SPECIFIC OBJECTIVES

4

1.5

METHODOLOGY

4

1.6

LIMITATIONS OF THE STUDY

5

1.7

TIME PERIOD AND PLACE

5

2

ABOUT THE ORGANIZATION

6

3

LITERATURE REVIEW

15

4

SPACE PROGRAM

23

5

OPERATION THEATRE

38

6

INTENSIVE CARE UNITS

50

7

RADIOLOGY

61

8

LABORATORY

72

9

CENTRAL STERILE PROCESSING DEPARTMENT

80

10

PATIENT ROOM

87

BIBLIOGRAPHY

89

ANNEXURES 1

LIST OF LICENCES, REGISTRTIONS AND APPROVALS

90

2

AERB SPECIFICATIONS FOR MEDICAL DIAGNOSTIC

91

EQUIPMENT (X-Rays)

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

EXECUTIVE SUMMARY

This study was carried out at HOSMAC (India) Pvt. Ltd, a consultancy firm of repute. HOSMAC has experience of building several hospitals with many new projects in the pipeline. This study is about a brief for a proposed 100-bed hospital. It is both exploratory and descriptive in nature. Once a decision has to build the hospital has been taken the next step is its architectural design. A detailed architects brief has to be first prepared to enable the architect in drawing up his plans. The landscape, facility mix, bed mix, availability of utilities in the vicinity will have to be considered. Considerable inputs from other agencies like air-conditioning, electrical, plumbing, etc. will be required to finalize the working plan for the building. Inputs from the equipment vendors especially in specialty areas like Cath-labs, CT-scanners, MRI, linear accelerators, operation theatres etc. will be essential. In India a common thing is lack of emphasis given to support services like kitchen, laundry, CSSD, back-up electricity and so on. Not only are these services vital, but these also have high capital cost and recurrent expense and hence should be properly planned. Just to illustrate the standards for healthcare design in India, we are still designing facilities where total area per bed is hardly 600 sq. ft. whereas western standards are close to 1,400 – 2,000 sq.ft. per bed and WHO recommends an area of 8001200 sq. ft per bed. While it may not be prudent to follow the western concepts blindly, one needs to pick up the good things from the modern methods. Some of the issues that could be adapted from developed countries are flexibility for future expansion, larger secondary areas for better patient comfort, proper utilities for wait areas, nurse stations, storage, changing rooms, alcoves for stretchers/ wheelchairs, adequate transport facilities, parking facilities, proper light and ventilation etc. In the case of hospitals functional complexities far outweigh physical complexities and demand an addition to the planning and design team of persons who understand not only the work process of individual departments but those of the hospital operating system as a whole. The study will help in formulating a functional brief or an architects brief that will have an analysis of functional needs, interrelationship of departments, area

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

requirements, major equipment, the grouping of accommodation and the main outline of traffic flow. This document would help the architect in understanding the complex needs of hospital functioning and enable him to build a hospital that is functional, efficient and yet economical without compromising on the design aspect.

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1.1 INTRODUCTION AND BACKGROUND INFORMATION: Planning can be defined as ' The specification of the means necessary for the accomplishment of goals and objectives before action towards these goals has begun' What are the various things that must be addressed to during healthcare programming and design process? 1. Provide a functional design that ensures efficient, safe and appropriate work spaces. 2. Accommodate technical requirements for highly sophisticated equipment. 3. Create clear, segregated paths for movement of people and material within the building. 4. Create a humane environment for patients and staff. 5. Develop building systems that can accommodate rapid change. 6. Blend technical and functional requirements into a design that brings delight to those who use the building and those who pass by it. Architects and construction oriented professionals acting alone may provide a building that operates efficiently as a physical structure, however, it is equally possible that they may entirely miss the mark in terms of operational functionality. And Functionality as a prime determinant of operational efficiency is a major factor in the total life cycle cost of all hospital structures. There is also little doubt that quality of care and treatment is also affected by the degree to which design accommodates both inter and intra-departmental functions. Hence a new discipline called functional planning has emerged over the past few years, which augurs well for the future of hospital design. Individuals possessing adequate training and experience in this field have made and are making substantial contributions to the planning and design process. Usually such planners have backgrounds in hospital management. They could also be architects who have specialized in hospital architecture or trained personnel of consulting firms.

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Responsibilities of a functional planner: 1. Physical evaluation of existing facilities (along with architect) 2. Functional evaluation of existing facilities. 3. Preparation of workload projections. 4. Functional programming. 5. Space programming (along with architect). 6. Master site planning (along with architect). Although functional planning of hospitals has not reached its maturity and indeed may never do so, concepts springing from its practice are burgeoning yearly as intense study is made of alternative operational and building systems. There are even more innovative changes in operational methods and procedures on the horizon as demands for greater employee productivity are considered. All this will directly depend upon architectural design for implementation and few can be brought into being without direct input to the design process by functional planners. Determination of the services to be provided in quantitative terms requires consideration of the following:



Functions



Locations



Relationship



Utilization



Staffing pattern



Space requirements



Work flow.

Before an architect can develop a hospital design that will best serve its functions he has to be provided a written programme explaining these requirements. This is the architects brief from the interpretation of which he prepares schematic drawings and sketch plans.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

The brief would contain the permission required from various regulatory bodies, spatial needs of various departments, manpower required, special requirements of various departments, inter and intra departmental relationships. 1.2 RATIONALE FOR THE STUDY: The future will see a continued demand for the construction of healthcare facilities including completely new or replacement facilities and projects involving major additions and modernization. The annual value of healthcare construction projects will see an uptrend in the immediate years ahead owing to various factors like opening up of the insurance sector and privatization initiatives. Therefore planning and design will continue to merit prime emphasis amongst other responsibilities of healthcare officials. In the case of hospitals functional complexities far outweigh physical complexities and demand an addition to the planning and design team of persons who understand not only the work process of individual departments but those of the hospital operating as a single functional system. Functional planning is the responsibility of a trained hospital administrator who should be capable of interpreting complex relationships, internal traffic flows (personnel and supplies), Technological requirements and operational procedures to the extent a product of beauty, reasonable cost and optimal utility will result. A functional design can promote skill, economy, conveniences and comforts whereas a nonfunctional design can impede activities of all types, detract from the quality of care and raise costs. A non-functional building is the nemesis of any hospital striving to compete in the current climate of competition and emphasis on productivity. Thus this stage consisting of preparation of the architects brief is important as the design of the hospital will become crystallized during this phase. Time and trouble spent during this stage will be well repaid and will enable the whole project to proceed smoothly with a minimum of subsequent revision. In undertaking any complex activity it is well to examine the experiences of others in similar situations if such information can easily be found and properly interpreted.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

1.3 OBJECTIVE: To prepare an architectural brief that would help the architect to build a functional, economical and efficient hospital.

1.4 SPECIFIC OBJECTIVES: 1. To study/understand the issues involved in functional planning of a hospital. 2. To determine the recent trends and changes in the healthcare facility needs and to evolve a document that can incorporate these changes so as to enable the architects to build hospitals in tune with modern requirements. 3. To draw up a space plan for the proposed hospital. 4. To study certain departments in greater detail and to provide a brief that may be used as a basis for detailed programming later on. 1.5 METHODOLOGY:



Both primary and secondary research was carried out with more emphasis on the latter.



Primary research will involve in-depth interviews with hospital consultants and architects experienced in building healthcare facilities.



Secondary research will involve descriptive studies of the functional planning carried out while building hospitals in the recent past. This will also involve literature review by going through different books and journals.

Thus the study design is both exploratory and descriptive in nature.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

1.6 LIMITATIONS OF THE STUDY:



Considering the time factor all the departments of the hospital were not dealt with: only certain key departments were covered.



The study could provide only a preliminary brief for the architect. It would be the basis for the development of a more detailed brief.

1.7 TIME PERIOD AND PLACE: The study was carried out at HOSMAC (India) Pvt. Limited, Mumbai from 24th January till 17th April 2003.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Chpt. 2 ABOUT THE ORGANIZATION: HOSMAC India Private Limited is a pioneering name in the field of Hospital Planning & Management consultancy in India. Since its inception in 1996, HOSMAC has grown rapidly to become a Unique hub of skill sets which cuts across various facets of a health care facility be it architecture, engineering, management, or information technology. In a short span of 6 years, HOSMAC has notched up an impressive string of more than 80 projects in India and abroad. HOSMAC provides the entire range of services that any health care service provider, may require: undertaking market research, feasibility studies, detailed architectural design, project co-ordination, equipment procurement, commissioning assistance, conducting an operational audit for existing hospitals. To provide such wide ranging services HOSMAC has a motivated team of highly qualified and experienced professionals (doctors, MBAs, architects, engineers and project managers). On a cumulative basis these professionals have more than 245 man years of experience and have rendered more than 60,000 hours of management consulting services, designed 1.4 million sq feet of hospital space, and are coordinating hospital projects worth more than 3.34 billion INR. Unlike other industries, the health care industry is extremely complex in terms of the

wide

spectrum

of

specialties,

technologies,

and

the

skilled/unskilled

manpower. The smooth interplay of these factors only will lead to a successful health care organization. The alarming rise in cost for providing quality health care will drive hospitals to cut costs rather than only enhancing revenue.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Some of HOSMAC’s services OSPITAL PLANNING & PROJECT MANAGEMENT Market Research For Project Conceptualization A comprehensive market research is undertaken to ascertain the needs in the local health care market. HOSMAC's field workers are specifically trained to conduct surveys and gather secondary data from various governmental and nongovernmental

agencies.

The survey could include – 

households



medical professionals



diagnostic centres



nursing homes



hospitals.



relevant

data

government/media

from

census

publications,

report, and

demographic

various

other

sources

surveys, is

also

searched Such a market study is essential: 

to primarily know the deficiencies in the health care market, thereby assisting us arriving at a proper facility & bed mix.



to helps us finalizing the project size



for existing hospitals to undertake benchmarking in areas like tariff rationalization, compensation policies, utilization reviews for various services etc.

Feasibility Reports Having decided on the facility mix, the next value added service provided by HOSMAC includes a very detailed and comprehensive feasibility study of the project. This has been our major strength and we have to credit more than 30 such studies. We are proud to mention here that many of our reports have been

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

accepted by leading Financial Institutions in the country like IDBI, ICICI, IL&FS and also multilateral agencies like the World Bank, Kfw etc.

The feasibility report would essentially contain the following vital information: 

Brief description on the major findings of the market research



Proposed facilities plan



Detailed project cost inclusive of land & building, medical equipment, nonmedical equipment, furniture & fixtures, utilities, pr-operative costs, contingencies, and working capital requirement, and the means of finance



Income and expenditure projections based on the feedback from the market research and form HOSMAC's exhaustive database



Profit and Loss/ Balance sheet/Cash flow statements



Break even analysis



Sensitivity analysis

Architectural Designing It is a known fact that Hospital Architecture in India is a neglected specialty. HOSMAC's aim is to bridge this gap by providing modern yet practical costeffective solutions to the health care industry. Healthcare architecture differs from that of other building types in the complexity of the functional relationships between the various parts of the hospital. In the residential and commercial building types the design brief is relatively easy to understand and cater to. Healthcare architecture, however, requires specialized knowledge on the part of the architect and the supporting engineering team. The lack of such trained professionals results in many of the hospitals in India today being ill conceived and costing their promoters much more in construction and in inefficient operation than they need to. Eventually it is the patient who bears the brunt of this incompetence through lack of quality in the medical care provided, physical and mental discomfort and increased cost of hospitalization.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Specialized healthcare architecture is a field that is still in its infancy in India. As pioneers in the field, HOSMAC is uniquely positioned to advise its' clients. This advice is based on the combination of the skills and knowledge of our varied team of professionals, which consists of doctors, architects, engineers and hospital management graduates and the resource of an extensive database of information compiled over the years. However, this specialized field is not only about satisfying the stringent functional demands that the hospital makes on its designer. The emphasis of healthcare architecture is also on improving the quality of the environment for patient and caregivers alike. It must meet the needs of people who use such facilities in times of uncertainty, stress, and dependency on doctors and nurses. It must recognize and support patients' families and friends by providing pleasant spaces. At the same time the building should project an underlying reassurance that the patient is in the hands of competent medical staff and in a technically sound healthcare facility. In the future patients will be increasingly demanding of healthcare organizations. Those facilities that are designed to be most responsive to patients in terms of convenience, caring encounters, service orientation and the quality of care will do best in meeting these new demands. Architects are regarded as talented problem solvers. The problem here is to find a way to deliver a high quality of care and access in a setting that is also highly supportive of human relationships during times of great anxiety and fear. The particular skills of HOSMAC's design team are well suited to meeting this challenge. We invite you to proceed to learn more about how HOSMAC (India) can help you design and construct your proposed healthcare facility. Project Management Apart from providing Architectural Designing solutions, HOSMAC also provides the most vital project management services. An ardent need was felt for this as most hospital projects in India suffer from lack of co-ordination between various agencies like the promoters, architects, contractors, consulting agencies, doctors, equipment vendors etc. HOSMAC thus identified this as a vital growth area and has been rendering such services to help our clients in combating TIME/COST

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

overrun

apart

from

giving

functionally

sound

infrastructure

solutions.

This service includes important activities 

Liaison

with

all

Agencies

-

Architects/contractors/equipment

vendors/utility service consultants and suppliers 

Monitoring Project with PERT/CPM



Managing Change in Project Plans - most vital and complicated component due to the various fall outs from the change in project design



Managing equipment planning schedule including cost-feature analysis, procurement process, installation etc.

MANEMENT CONSULTANCY Management Consultancy Services Turn Around Strategies Such assignments include studying the historical trends of the hospital in terms of its income/expenditure patterns, identifying cost/profit centers, identifying the key success criteria for improving the bottomline. Having done this we provide a strategic

business

plan

with

definite

milestones

to

implement

our

recommendations and monitor the same. Operational Audits This is again a niche service provided by HOSMAC for health care institutions requiring specific departments to be studied for improvement which may be qualitative and/or efficiency related. An example of studies could include:

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

improvement of the lab services



operation theatre utilization reviews



manpower audits



medical audits



infection control programs



reorganization of profit centres

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL



support service audits etc.

Costing of Services This is a highly specialized service which we provide. It is a well known fact that hospitals in India set their tariffs in comparison to the market rates. This leads to skewed rate setting and the customer is the looser. HOSMAC has conducted several costing exercises for our clients to help them understand the real cost of providing services by virtue of which our clients have an advantage over their competitors. In many cases we found that hospitals were under pricing their services hoping that volumes will cover up the cost, whilst they were actually increasing their losses. We have developed an in-house format for costing of various services on a department wise basis which enables us to conduct our studies in a systematic manner within a short span of time. Systems Study & Re-design Though HOSMAC does not provide computerization solutions, we are thorough in system analysis and provide vital interface solution with the agency providing the computer solutions. Also such assignments are essential for hospitals which do not have computerized systems for various activities. The activities involved include 'walking through' the processes, identifying the stumbling blocks, finding solutions, implementing

redesigning the

'changed'

the

systems/processes/forms/reports/records,

processes

and

providing

online

correctional

interventions. Many of our clients have found our association to be invaluable whilst implementing the computerization modules. Manpower Audit & Training Hospitals are labour intensive institutions and salary expenditure forms the major head of expenditure. Therefore it is of paramount importance that a proper manpower plan is formed and implemented. Also notable feature is that in hospital setting the interaction between the highly skilled and unskilled workforce is of a very high magnitude leading to IR problems. Whilst conducting such study, we undertake an exhaustive manpower audit of all departments and benchmark it with the industry standards to ascertain the deficiencies. Wherever required redistribution of manpower, job enlargement, and job enrichment solutions are recommended. Customized training programs are conducted targeting specific needs like attitudinal change, team building, grooming in etiquettes, etc. Marketing Strategies

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

This has been one of our most popular services and we have devised and implemented successfully our marketing plans. We begin our assignment by benchmarking the services against the best hospitals in the client's service segment and conducting a customer satisfaction survey to understand the drawbacks in our services and products to be marketed. This followed by a proper product development for marketing, which includes improvement in the service delivery mechanisms, proper pricing, identification of target audience, preparation

of

brochures/mailers,

and

setting

milestones

for

productivity

enhancement. We help our clients in implementation of the strategy by making visits to the corporates and monitoring the overall process of marketing. L EQUIPMENT PLANNING Biomedical Equipment - Planning & Procurement Norms Advances in Engineering and Information Technology in the recent years have brought about several changes in the field of Medical Science. Medical Equipment play a very significant role in the field of medicine and healthcare delivery system. Sophisticated biomedical equipment requires a host of utilities like the air conditioning and refrigeration, stabilized power supply systems etc. The design criteria of these support systems are of paramount importance. Hospital equipment fall into an extremely wide spectrum ranging right from a hitech MRI and CT scanner to a simple patient trolley. These all account for a major part of any hospital project cost, which could go upto almost 60%. Of this, biomedical equipment could account for nearly 50% of the cost. Keeping this in view it is essential to ensure maximum utilization of the equipment with minimum downtime. The health care industry is experiencing a new era in cost containment. In the past, little attention was given to the financial impact of equipment related decisions. Today, however, times have changed. In this new environment, "stateof-the-art" is no longer sufficient as planning criteria for selecting new technology. Today, for a technology to be appropriate, it must address the needs for efficiency, cost-effectiveness, and productivity and at the same time, improve or maintain the quality of patient care. In addition, hospitals are finding themselves in an extremely competitive arena, which puts an additional emphasis on a technology's marketability. The challenge faced by hospital executives today

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

is to gain the management and control required to make effective equipment planning decisions. Whilst medical devices can be broadly categorized into diagnostic and therapeutic equipment, the selection criteria for procurement would need to take into account several factors viz. type of hospital & level of services provided; services available in the neighbourhood and technology employed; background of the staff that would operate the equipment; proposed tariff for the services employing medical devoices; etc. Having addressed these issues one would need to carry out a separate financial feasibility for the major and critical equipment and then set out to prepare the specifications and features of the medical devices that would be considered most appropriate for the hospital. After having undergone this exercise too there are multiple products that one can choose from. For this one would need to apply further criteria and do a detailed analysis of factors related to the technology and design base of the equipment; the maintenance convenience

and

available

service

support;

forthcoming

technology

and

interchangeability with the current generation; presence of the manufacturer / vendor in the existing market place; and once again the factors are several!

Product Development Assistance  Provide benchmarking data regarding market expectation from a hospital management system 

Details hospital best practices  Undertake detailed reviews of newer modules and upgrade versions and provide recommendation of any enhancements/modification  Periodic comprehensive review and study of the existing modules to update and upgrade continuously

Implementation Assistance 

Jointly prepare implementation plan with solution provider



Undertake a comprehensive system study

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL



Gap analysis



Preparing specification for customization



Site monitoring assistance 

Undertake audits of the sites where software is already installed to

identify areas of problem

Business Development Assistance  new

Provide business development assistance in terms of identifying leads,

represent

and

recommend

the

presentation to key clients as hospital consultants.

LITERATURE REVIEW:

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business

partner

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Since Henri Fayol's pioneering treatise on management in 1916, planning has involved two considerations, i) Assessing the future and ii) making provisions for it. According to Robert M. Fuller "Planning is of course decision Making because it involves selecting from among established alternatives" Certainly the adoption of a systematic planning process is imperative in any hospital facility. Failure to adopt and to adhere to a specific methodology almost invariably results in a deterioration of the quality of planning. Architectural design represents the most definitive act of planning any building project. Although representing a new discipline, functional planning already has achieved recognition through its contribution to operational functionality and has become a key factor in hospital design. Future research in this area of planning and design process may further enhance productivity in the healthcare field. In terms of broad categories of activities the process of hospital project planning can be a multistep process. The steps are as follows: 1. Perception of need for a building program. 2. Strategic Planning and feasibility assessments. 3. Organizing for planning, design and construction. 4. Determining the planning, design and construction approach. 5. Scheduling planning, design and construction. 6. Opening the completed project. The role of the Functional planner is most important in steps 3 and 4.

Selection of the professional planning team A complete team should possess capabilities in •

Financial Feasibility Consulting.

•

Functional Planning.

•

Architectural and Engineering services

•

Construction Management.

Selection Timing:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

The Functional Planner, the architect and the construction manager can all make valuable contributions in the early stages of a project and should be contracted at approximately the same time. Because the functional planner has the most intense involvement in the very first stages, he might be brought in first, but the other two must closely follow.

The possibility to influence a project and its cost is reduced during the course of its development after the client has decided to establish the requirements of the user and started to investigate the problems. The largest reduction of possibilities to influence the design occurs at point 1, which marks the clients decision concerning implementation. The figure is based on a study by Stig Nordquist.

Responsibilities of a Functional Planner: 1. Physical evaluation of existing facilities (along with architect) 2. Functional evaluation of existing facilities.

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3. Preparation of workload projections. 4. Functional Programming. 5. Space programming (along with architect) 6. Master site planning (along with architect) 1. Physical evaluation of existing facilities: This is a study to determine the degree of physical obsolescence of existing facilities and to identify major code violations and physical problems and to project future usability. 2. Functional evaluation of existing facilities: This is a study to define functional problems that detract from operational efficiency, quality of patient care, and convenience of building inhabitants to evaluate

traffic

flows

and

physical

relationships,

to

determine

space

insufficiencies in terms of current requirements to study the need for modernization, alterations and expansion, according to strategic plan findings and to note possible alternative future uses of the structure as a whole as well as of various departmental areas. 3. Preparation of workload projections: The functional planner can determine and formulate concepts of operation for the proposed project according to previous study findings. These concepts will be incorporated in the functional program. These projections form the basis for functional programming, revenue projections and staffing estimates.

4. Functional programming: Using approved recommendations and findings of the strategic plan, findings of physical and functional evaluations and workload projections, the functional

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

planner formulates recommendations for operational concepts, the detailed room composition of the project, required phasing, alterations, internal and external traffic flows, interdepartmental relationships and operating systems. 5. Space programming: Based on the functional program, as amended and approved by the hospital a room by room listing is made of all areas in the proposed project. Net square footage is assigned to each space, and totals accumulated for every department or functional entity. using the net figures, appropriate calculations are then made to set gross totals for each department or functional entity as well as the total for the entire project.

Some pointers to successful hospital planning Good planning is critical to the hospitals success: If a hospital has to be successful it must be built on the bedrock of three sound principle namely good planning, good design and construction and good management. The absence of the first two of the equally important but closely related triad, good planning and good design and construction means failure to design the facilities for the optimum utilization of staff and services. This in turn results in a mediocre hospital that fails to realize its economic goals. Efficient, Functional and economical hospital: The real test of any hospital is the quality of healthcare it provides. If the hospital has to pass this test- a truly rugged test-planning and design must result in a functional, efficient and economical hospital. It should be remembered that even minor defects in designing could make the operation of a hospital inefficient. The corollary of this is that an inefficient hospital costs significantly more to operate, staff and maintain, not to mention the fact that the patients within it get less health services for the money they pay. It should be borne in mind that economy of operation and maintenance over the life of the building as well as the quality care to patients depends in a large measure on the proper planning and designing of the hospital and is more

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

important than the economy of construction. The initial cost of building a hospital is insignificant when compared to the cost of running and maintaining it over the years- by one reckoning eighteen to twenty times over a period of say twenty years. Another study says that the running cost of a hospital over 4 to 5 years from the date of completion is about the same as the capital cost. and if the facilities are not planned and designed properly this intangible cost can be enormous. the efficiency with which the physicians and their assistants can function has been greatly handicapped by obsolete design. Patient comfort and provision for expansion have often been overlooked. Growing efficiency and innovative ideas have revolutionized hospital building construction to meet among other things, the special needs of patients. It is believed that a pleasant environment that makes for an enthusiastic and more productive staff also benefits the patients albeit indirectly.

Promoters and hospital planners often overlook to include in the facilities design what helps to preserve the patients' dignity and status as a human being or details that would make the hospital more livable. Many patients complain that hospitals as institutions reduce privacy, individuality and more importantly human dignity. Many of these details and facilities can be incorporated with little or no extra cost. While planning and designing a hospital the patients needs and expectations should be kept uppermost in mind and any design should aim at his satisfaction and comfort. Today's healthcare facility is by its very nature a complicated entity and planning and designing such a facility to serve the increasingly complex needs of its patients, staff and management team is difficult and complicated. The problem is compounded by rapid changes and advances that are taking place in the fields of technology and medicine and the constant need to modernize, renovate, replace and expand healthcare facilities. Process of planning: A common understanding should be established between the architect and the engineers on one hand and the promoters, doctors, administrators and planners

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

on the other. A wide variety of professionals need to be integrated into a planning team that is responsible for the implementation of this complex process. Initial planning encompasses the general physical facilities that are being considered, the space requirements, cost constraints, time schedules, standards that must be included. In the next step details of the operational plan for each department should be considered-

location

of

each

department,

requirement

of

floor

space,

intradepartmental and interdepartmental relationships, circulation, traffic flow and requirements in relation to equipment, personnel and patients.

Operational and Functional planning first: Before any plans can be drawn by the architect an understanding of the requirements of the hospital in terms of services it is going to provide, number of beds, departmental functions, departmental needs, major equipment, space requirements, required personnel, relationships and adjacencies must be agreed upon. All this must form a written document. This is called operational planninga written programme needed for any architectural project. Operational planning establishes a dept-by dept description of needed space by outlining for example, the no. and type of surgeries, X ray rooms, outpatient services, laboratory services etc. the exercise thus determines current and projected needs within the facility. A consultant or an administrator who is knowledgeable and has experience in the operation of the hospital is by far the best person to develop this document. Normally there is either no briefing of the architect or the brief given to him is inadequate. The promoters must clearly tell the architect the requirements of the hospital and not the other way round. The architect should not dictate to them nor should he conjecture what the requirements are or what he should design. More often than not there is no written brief or operational program and to know what is needed the architect has to fend for himself. Sometimes he is asked to prepare his building schedules with the help of doctors, at other times he is asked to observe other hospitals and take guidelines from them. Both these are unsatisfactory methods. Key to Functional planning:

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20

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

The proper sequence is the development of operational planning that defines the major requirements and needs first. The operational plan is then developed into a functional plan. Planning of the hospital on a functional basis-that lists every room and suggests net sizes for major functional rooms and the total size of the department. The key to functional planning is not just a room list but understanding that travel and adjacencies will affect operational cost for the life of the facility says David R. Porter the renowned hospital architect. Mistakes in planning may prove costly: Instances are aplenty of hospitals that were not planned with these critical factors in mind-within five to ten years they found that the cost of construction had been equalled or surpassed by operating expenses. Functional grouping of high traffic areas such as X-ray, laboratories, surgical and delivery suites, physical therapy and clinics on two floors is desirable. It permits concentration of hospital activities in a manageable unit. When future expansion or changes becomes necessary, they can be accomplished without disturbing the nursing areas. Operational Plan and Functional Plan must precede Architectural Plans: Planning and Building a hospital to serve the increasingly complex needs of modern healthcare is an intricate job. The architect though competent in his profession may not be competent in the technical aspects of hospital architecture and may lack knowledge of some of the specialized clinical and administrative areas and matters. This document called the operational plan and functional plan developed from it form the basis and are necessary prerequisites for the architect to prepare the architectural plans.

Hospitals must be planned for the future: A fundamental rule that promoters should remember is that the hospital should be planned for at least 10 to 15 years ahead or else experts say plans will be

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

obsolete when they come to the drawing board. With the rapid development and advances in technological, medical and administrative sciences and innovative techniques and therapies, space requirements of every department has increased markedly. New departments come to be needed, and more space is required to some specialties. In addition to space needs, technology is imposing a host of physical demands on our hospitals. Well planned systems must be built into them to keep pace with the changes. Said one design expert ' We have got to design `Smart` hospitals that respond to present needs while anticipating future change. Within the building all departments must be planned in such a way that they can stand individually. This can be done by freely locating each department with space around for expansion. Further care should be taken that expensive permanent fixtures and fixed equipment such as plants and elevators are not located at the free ends of the departments as they would permanently block expansion plans. Future expansion is rendered easy with free ended buildings with extendable corridors.

Space Program: The space plan is made on the basis of personal interviews with hospital administrators experienced in building hospitals and also with the help of

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

literature review and would help the architect in finalizing his plans. Hospitals are a difficult planning subject as explained earlier. The maxim ‘Design follows function’ must be kept in mind while allocating space details. The area specifications may be taken as indicative as suitable alterations would have to be made by the architect to conform to the grid matrix. The total space area including the parking space, HVAC and water is 1,05,319 sq ft which works out to be 1053.19 sq ft. This is in concurrence with modern standards of constructing hospitals which provide for an area of 800-1200 sq ft per bed. Ground Floor: Key Departments like OPD, Emergency, Radiology, Laboratory would be situated on the ground floor. The Radiology dept. would be situated near the Emergency dept.(According to a study nearly 40% of cases coming to Emergency require X rays) The administration department would be located on the 1st floor along with the Blood bank and General and Paediatric wards. The Labour room, Obstetric ward and NICU would be located on the 2nd floor along with the semi-private ward. The CSSD would also be located on the 2nd floor just below the operation theatre with provision for dumb waiters between the CSSD and the OT. The OT’s will not be located on the top floor to avoid the excess heating nor will they be located near the major traffic areas. The ICU’s and private wards will also be located on the 3rd floor. The residential area will be located on the 4th floor just above the ICU’s and the OT’s. So a doctor can easily attend to the patient when called. 30% of the area is kept for circulation.

Department wise area allocation Department

14

Area sq.ft

23

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

General ward Semiprivate + deluxe Private+deluxe Obstetric Ward Paediatric Ward NICU ICU OT OPD Physiotherapy dept Radiology Other diagnostic Facilities (ECG, EEG, Stress test, Endoscopy) Laboratory Blood Bank Pharmacy Outlet Pharmacy Store MRD CSSD Laundry Kitchen Restaurant Housekeeping Telecommunication PR Department Security Auditorium Prayer Room Mortuary Library Manifold Room Administration A/c Department Stores EDP Emergency Room Ambulance Telephone Booth Shoppe Executive health checkup Residents Total Space for 100 beds Area per bed (Current standards 800-1200 sq ft)

3978 8437 8437 3679 2847 4921 7235 5844 4940 975 5005 3380 2425 1840 260 520 1430 1957 1918 2300 2860 325 390 260 195 1950 260 975 390 390 2314 780 2405 780 1937 325 260 130 1300 15000 105319 1053.19

Parking Space Electrical+HVAC+Water

14

46875 4550

24

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Distribution of floor space by wards and departments Wards Diagnostic Facilities OPD+ Emergency+ Related Areas Administrative Area Service departments Residential Areas

45378 12650 10117 11349 10790 15000

Breakdown of Space Requirements of key departments Area Sq ft per bed Nursing Units 273.78 ICUs 121.56 Operation Theatres 58.44 Radiology 50.05 Laboratory 24.25 Pharmacy 7.8 CSSD 19.57 Dietary 23 MRD 14.3 Housekeeping Dept 3.25 Laundry 19.18 Mechanical Installations 49.4 Stores 24.05 Administration 30.94 Distribution of Beds General Semi- Private (two in one) Private Deluxe ICU NICU Obstetric Ward Paediatric Total Other Beds Pre -op Post op Emergency

16 26 13 6 10 9 10 10 100 4 6 4

Allocation of Departments floor wise G+0 OPD Emergency Radiology Laundry Kitchen Physiotherapy

14

25

4940 1937 5005 1918 2300 975

43% 12.01% 9.60% 10.78% 10.25% 14.25% 100%

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Pharmacy outlet PR Dept Manifold room Shoppe Telecommunications Prayer Hall Ambulance Telephone booth Mortuary Laboratory

260 260 390 130 390 260 325 260 975 2425

Total space

22750

G+1 Restaurant Housekeeping Administration Security Accounts Department Executive Health Check Up Blood Bank MRD General Ward Paediatric Other Diagnostic Facilities Pharmacy Stores EDP Dept

2860 250 2314 195 780 1300 1840 1430 3978 2847 3380 520 780

Total space

22474

G+2 CSSD Semiprivate ward + Deluxe beds Stores Obstetric ward NICU

1957 8437 2405 3679 4921

Total Space

21399

G+3 OT ICU Private + Deluxe

14

5844 7235 8437

Total space

21516

G+4 Residential Area Library

15000 390

26

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Auditorium

1950

Total space

17180

Department Wise Space Plan General Ward Beds Nursing Station Doctors room Nurses room Treatment room Staff toilet Store Pantry Clean utility room Dirty utility room Toilets General Waiting Area

16 1 1 1 1 1 1 1 1 1 3 1

120 200 100 100 100 50 60 60 60 60 50 200

1920 200 100 100 100 50 60 60 60 60 150 200 3060 918 3978

26 3 1 1

175 350 200 100

4550 1050 200 100

1 1 1 1 1 1 1

100 60 60 60 60 50 200

100 60 60 60 60 50 200 6490 1947 8437

13 3 1

350 350 200

4550 1050 200

Add 30% circulation space Total space

Semi private (2 in 1) Beds Beds deluxe Nursing station Dr's room Nurses rest room Store Pantry Clean utility room Dirty utility room Toilet Waiting area Add 30% circulation space Total Space Single Room\ Private Beds Beds deluxe Nursing station

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Dr's room Nurses rest room Store Pantry Clean utility room Dirty utility room Toilet Waiting area

1 1 1 1 1 1 1 1

100 100 60 60 60 60 50 200

100 100 60 60 60 60 50 200 6490 1947 8437

8 2 1 1 1 1 1 1 2 1 1 1 1 1 10 3

225 250 350 250 50 100 100 50 50 60 60 60 60 300 150 75

1800 500 350 250 50 100 100 50 100 60 60 60 60 300 1500 225

add 30% circulation space Total Space

ICU Beds Beds - Isolation room Nursing Station Equipment Room Stat Lab Doctors Room Nurses Rest room Toilet (staff) Toilets -General Store Pantry Clean Utility Room Dirty utility Room Waiting Area Beds For Relatives Toilets cum Bath

5565 1670 7235

Add 30% circulation space Total space

NICU Open Care units Nursing Station Equipment store room Doctors room Nurses rest room Toilets staff Component milk formula room Feeding room Nursing room Toilets - General Waiting Room Beds for relatives

14

9 1 1 1 1 2 1 1 1 3 1 9

28

125 200 200 100 100 50 50 60 100 50 250 150

1125 200 200 100 100 100 50 60 100 150 250 1350

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

3785 1136 4921

Add 30% circulation space Total space

Obstetric Ward Beds Nursing Station Doctors room Nurses room Clean utility Dirty utility Pantry Staff toilet General toilets Store Labour rooms Waiting Area

10 1 1 1 1 1 1 1 2 1 2 1

120 200 100 100 60 60 60 50 50 100 300 200

1200 200 100 100 60 60 60 50 100 100 600 200 2830 849 3679

10 1 1

120 200 200

1200 200 200

1 1 1 1 1 1 2 1

100 60 60 60 60 50 50 200

100 60 60 60 60 50 100 200 2190 657 2847

2 1 2 2 2 1 1 1

450 625 100 100 60 200 100 150

900 625 200 200 120 200 100 150

Add 30% circulation space Total space

Paediatric Ward Beds Nursing Station Doctors room Nurses room Clean utility Dirty utility Pantry Store Toilet- Staff Toilet- General Waiting Area Add 30% circulation Space Total space Operation Theatre OT rooms General OT Room Specialty OT Room Scrub room Instrument room Wash room/ Dirty utility Store room Chief anaesthetist room Dr's room

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

OT incharge room Nurse room Dumbwaiters Pantry Equipment room Trolley bay Toilet Change rooms Reception Waiting room Pre operation room Post operation room

1 1 2 1 1 1 2 3 1 1

60 60 20 40 200 150 40 50 60 100

60 60 40 40 200 150 80 150 60 100 350 600 4495 1349 5844

OPD May I help you desk Registration/billing Waiting area-- Reception Toilets (M&F) Reception and Records room OPD waiting area Consultants rooms (Medicine,

1 1 1 8 1 1 5

50 200 500 25 250 400 150

50 200 500 200 250 400 750

Surgery, Gyn obs, Paed & Ortho) Sub Waiting Areas Staff toilets Doctors toilets Trolley/ Wheelchair bay Collection room Minor OT OPD Store Staff room Administrators office

5 2 1 1 1 1 1 1 1

50 50 75 200 50 300 75 250 150

250 100 75 200 50 300 75 250 150 3800 1140 4940

1 1 1 1

300 350 500 750

300 350 500 750

1 1 1 1

50 200 100 350

50 200 100 350 2600

4 beds 6 beds

Add 30% circulation space Total

Add 30% circulation space Total Other Diagnostic Facilities ECG Room EEG Room 2 D echo room Stress Test Room Endoscopy Dept Reception Waiting Consultation Endoscopy room

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Add 30% circulation Space Total

780 3380

Physiotherapy Department add 30% circulation space total

Radiology MRI Ultrasound Ultrasound Room Change room Sub Waiting X ray- General Radiography room Control room Change room Sub waiting Special X ray Radiography room

1

750

750 225 975

1 1

750 350

750 350

1

650

650

1

900

900

1 1 1 1 1 2 1 1 1

100 100 300 100 100 50 150 150 100

100 100 300 100 100 100 150 150 100 3850 1155 5005

1 1 1 1 1 1 1 1

75 300 200 200 200 200 150 40

75 300 200 200 200 200 150 40

Control room Change room Toilet Barium Preparation Sub- Waiting Staff room Radiologist room Waiting room Reception Technicians room Staff toilets Records room Film Store Reporting room Add 30% circulation space

Laboratory Reception Biochemistry Haematology & clinical pathology Histopathology Microbiology Serology Sample collection Toilet

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Toilets (staff) Waiting Report dispatch area Staff room Technicians

2 1 1 1 1

50 100 100 100 100

100 100 100 100 100 1865 560 2425

Blood Bank Waiting area Examination room Recovery& refreshment room Bleeding room Staff room Blood bank in charge room Component separation room Toilet (staff/visitors)

1 1 1 1 1 1 1 2

200 75 150 150 60 100 400 40

200 75 150 150 60 100 400 80

Issue counter Store room

1 1

50 150

50 150 1415 425 1840

1 1

400 200

400 200 600 180 780

1 1 1

500 100 500

500 100 500 1100 330 1430

1 1 1 1 1 1 1 1

100 200 75 50 100 100 450 200

100 200 75 50 100 100 450 200

Add 30% circulation space Total

Add 30% circulation space Total

Pharmacy Store area Retail area Add 30% circulation space Total MRD Process room Office room Record cum store room Add 30% circulation space Total CSSD Receipt area Wash room Gloves sterilizing room Change room CSSD Supervisor room Clean area for packing Actual sterilizing room Sterile store room

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Staff toilets Trolley Park Dumb Waiters

2 1 2

40 150 20

80 150 40 1505 452 1957

Laundry Receipt area Dirty area Ironing/ wash area Laundry incharge room Toilet Store room Mending room

1 1 1 1 1 1 1

100 150 400 150 50 200 100

100 150 400 150 50 200 100

Delivery/ Distribution Trolley Park

1 1

100 100

100 100 1350 443 1918

1 1 1 1 1 1 1 1 1 1 1 1 1 1

80 100 100 100 150 100 150 350 150 150 50 40 200 50

80 100 100 100 150 100 150 350 150 150 50 40 200 50 1770 531 2301

1 1 1

1500 500 200

1500 500 200 2200 660 2860

Add 30% circulation space Total

Add 30% circulation space Total Kitchen Receipt area Dietician room Store room Utensils area for storage Dry area Cold area Preparation area Cooking Area Washing area Trolley park Change area Toilet Dining room Garbage room Add 30% circulation space Total Restaurant Sitting area Preparation Store Add 30% circulation space Total Housekeeping

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Office Store

1 1

50 200

50 200 250 75 325

1 1

50 250

50 250 300 90 390

1

200

200 60 260

1

150

150 45 195

Mortuary Add 30% circulation space Total Space

1

750

750 225 975

Auditorium Add 30% circulation space Total

1

1500

1500 450 1950

Prayer room Add 30% circulation space Total

1

200

200 60 260

Library Add 30% circulation space Total

1

300

300 90 390

Electrical HVAC +Water+Boiler Compressor air & Vacuum Add 30% circulation space Total

1

3500

3500

Add 30% circulation space Total Telecommunication Office Cable area Add 30% circulation space Total

Personnel Relation department Office Add 30% circulation space Total Security Office Add 30% circulation space Total

1050 4550

Manifold room Area Office

14

1 1

34

250 50

250 50

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

300 90 390

Add 30% circulation space Total

Administration MD/CEOs office MS office Office (secretary) Waiting room Manager administration Clerical office Nursing superintendent Staff for nursing superintendent Toilets MD/CEO/MS Clerical staff

1 1 2

250 200 50

250 200 100

1 1 1 1 1

200 150 350 200 200

200 150 350 200 200

1 2

50 40

50 80 1780 534 2314

Add 30% circulation space Total A/C department Office Process area

1 2

200 200

200 400 600 180 780

1 1 1

100 1500 250

100 1500 250 1850 555 2405

1 1

100 500

100 500 600 180 780

1 1 1

500 100 100 75

500 100 100 75

Add 30% circulation space Total Stores Receipt area Storage area Office Add 30% circulation space Total EDP Office Server room Add 30% circulation space Total Emergency room Triage Med. Officer Nursing station Dr change room

14

4 beds

35

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Nurse change room Toilet Minor OT Waiting area Reception

1 1 1 1 1

75 40 250 250 100

Add 30% circulation space Total

447 1937

Ambulance Control room Telephone Booth Shoppe

1 2 1

250 50 100

Add 30% circulation space Total Residential Area

250 100 100 450 135 585 15000

Executive Health Check Up Reception Waiting area Doctors rooms Collection room Records & Storage Toilets

1 1 3 1 1 2

Add 30% circulation space Total Parking space Area for 1 car = 275 sq.ft Area for parking 150 cars 30 staff, 120 general

100 300 150 50 100 50

100 300 450 50 100 100 1000 300 1300

41250

Area for I scooter = 75 Area for 75 scooters 25 staff, 50 general

5625

Total

14

75 40 250 250 100 1490

46875

36

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Operation Theatre Function: The function of this department is to receive patients after diagnosis, to anaesthetize them, to operate upon them and to supervise their post-operative condition before returning them to their wards. The surgical patients account for 30% to 40% of the in-patient admissions.

Location: The OTs can be grouped together in a centralized form to have an entire OT complex or they can be decentralized. However for having decentralized OTs eg like those for gynaecology, ophthalmology and ENT the quantum of work should justify the need for them. Centralized OTs are preferred normally as there is greater economy of staff and equipment, better professional supervision and greater efficiency. There will be 3 OT’s- 2 General and 1 Specialty OT. They will be located on the 3 rd floor. The location will be such that they will be away from major traffic areas and also not on the top floor. This will avoid overheating. They will be located close to the ICU’s for the easy transport of patients. They will also be located close to vertical transport and above the CSSD. There will be 2 dumbwaiters- one for clean linen and one for soiled linen. Key Factors influencing OT complex Planning: The total volume of expected operations alongwith the anticipated work period is used to calculate the no. of operating rooms needed. Around 1 operating suite is recommended for every 50 beds. The number of operating rooms has also been indicated to be 5 per cent of the total number of surgical beds. OR in larger hospitals a thumb rule 0.1 operations per bed per day has been used. For Indian theatres conducting general surgeries it is estimated that the average time taken for each surgery will be around 75 minutes per operation. Hence one OT can perform around 5 general surgeries daily. A separate emergency OT would be justified when 50 or more cases are reported in the casualty. The other factors

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

that would influence the planning are the case mix and the type of operations to be performed and also the ALOS of surgical patients. The no. of operating rooms forms the basis for determining the number of preop beds and the post-op beds. Number of operations per day = No. of surgical beds ALOS of surgical patients Number of OT rooms = Total no. of operations in hospitals Capacity of 1 OT Basic Functions: 

Reception and identification of the patient.



Pre- op supervision of the patient.



Depilation of the patient if not done in the ward.



Transfer of patient to the operating table.



Induction/ Intubation/ Positioning



Preparation of the operative area and surrounding skin.



Draping of patient



SURGERY



Sewing up/ Removing drapes/ Extubation



Transfer of patient to post- anaesthetic recovery area.



Post- operative supervision of the patient/ Step down.

Layout : The OT will be independent of the general traffic and movements of the rest of the hospital. The rooms should be arranged in a manner that allows continuous progression

from

the

entrance

through

the

increasingly clean. The various zones in the OT are

14



Protective Zone



Restricted Zone



Clean zone



Super clean Zone



Ultra clean Zone.

38

various

zones

that

become

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

The protective zone is the area where the entry is restricted to the patients, the staff and their relatives. It is till the waiting areas for the relatives. The entry to the restricted zone is limited to the patients and the staff. This area includes the patient reception area, the staff changing rooms. The clean zone, which is the next zone, consists of the pre and post op areas, the administrative areas, the stores, laboratory, space for equipment storage. The superclean zone consists of the operating theatre and its ancillary rooms like the scrub room, the instrument room and wash room. The ultraclean zone consists of an area of 1 metre on either side of the operating table. An operating room for general surgery will have an area of 450 sq ft. However operating room for specialty surgeries like orthopaedic and Neurosurgery will be around 625 sq ft. The operation suite will consist of an operating room, a scrub room, a waste disposal room and an exit room. The waste disposal room will lead into the dirty corridor so that waste can be disposed off without it being allowed to renter the clean zones. There will be a service lift to carry away the waste and also a dumb-waiter to carry the soiled linen to the CSSD. In older times it was believed that it was desirable to have a separate induction room. However while such a room reduces the operating rooms occupancy time as the patients can receive pre-operative anaesthesia while other patients are on the operating table. The disadvantages however outweigh the benefits. The main disadvantage may be the huge increase in capital as well as running costs incurred in such a room. Also there will be the cost of additional equipment and the utilization of the room will be low.



The preop holding area and post op recovery room should have piped and

medical gas outlets.



Provisions should also be made for flash sterilizers.

If the operating room has windows this will increase the heat load inside and provision should be made for it. Windows provide for visual relaxation but whether operating rooms should have them or not is a debatable question as they may cause distraction if provided.



The temperature inside the OTs will be maintained at 21 degrees. The airflow is laminar airflow i.e. positive pressure is created such that air flows from the clean zones to the dirty zones. The laminar airflow is

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

created through a plenum in the ceiling. The velocity of air flowing through this plenum is 60 ft/min. The size of the plenum will be around 6 by 6 feet. This will be enough to cover the patient on the operating table and also the entire operating team. The air moves outwards through outlets, piped gas, suction and nitrous oxide are provided through pendants in the OT.



HEPA filters which can filter air upto 0.3 microns will be used.

 

Between 20- 100% fresh air is used. The rest is recycled.

Humidity levels will be 55% plus or minus 5%



The floor of the OT will be granite with brass strips. This helps in earthing purposes for the electrostatic current. The walls can be of stainless steel or marble whereas the ceiling can be of stainless steel or Plaster of Paris. The theatre corridors will preferably be 3.2 metres and not less than 2.85 metres wide.

Circulation within the department: Patient flow: In-patient nursing units

Holding area

Operating room

Pt rooms

Post op recovery

Staff: Entrance Changing rooms room/changing

Working area

Rest room

Exit Equipment & supplies:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Clean Entrance

Supply area

Theatre area

User Area

Sterile: CSSD

Theatre

Preparation area

User Area

Dirty linen and instruments: Theatre

Disposal room

CSSD Laundry

Relationships with other departments: -

Patient areas

-

Support areas

The surgery dept will be related to patient areas like the emergency dept, the ICU, patient rooms. They should have direct horizontal or vertical access to surgery. Support areas such as pharmacy, laboratory, CSSD and housekeeping services should have access to surgery through nonpublic and non-sterile corridors. CSSD will have vertical adjacency to surgery and will be connected by dumbwaiters with the Operation Theatre. Equipment required: Movable Equipment Surgical tables C arm machines Anaesthesia machines Heart lung Machines Flash sterilizers Fixed Equipment: Medical gas Surgery lights Laminar flow Functional Areas:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Control Station: The control station is primarily a clerical area located in a position to control traffic into the surgery department. A control station differs from a nurse station in that less people work out of this area. Surgeries are scheduled; records and administrative functions are maintained. Space is provided for requisite items to be delivered or picked up by other departments. Casework and furniture required: ♦

Computer support components

♦

File drawers

♦

Form trays to organize the large volume of paper and forms.

♦

Marker board for posting daily surgery schedule.

Pre-Operative Holding: Patients arriving for surgical operations will be held in this area until the operating room is ready. Here patients may be given medications or intravenous fluids under close observation of the nursing staff. Casework and furniture required: ♦

A small workstation for filling out forms and paperwork.

♦

Locker to hold patient care supplies.

♦

Sink unit.

♦

Medicine prep/ Storage

♦

Specialty procedure carts.

Scrub Area: They are placed with access to the operating rooms. Surgical scrub sinks are generally ceramic or stainless steel with foot or knee controls. Shelves will be placed above the sink to hold scrub brushes and masks. Casework and furniture required: ♦

Overhead storage of 2 feet per sink is required.

Operating room: It is the area where surgical procedures are performed under sterile techniques.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Operating room will have positive pressure ventilation systems, with controlled temperature and humidity, to prevent corridor air from entering. The work surface for the circulating nurse will be placed near the entrance door and the movable modular casework on the wall at the foot end of the table depending on the head orientation of the patient. Modular casework applications: Procedure/supply carts used for ♦

Anaesthesia supplies and equipment

♦

Suction and cautery equipment

♦

Monitoring equipment

♦

Prep and dressing

♦

Anaesthesia carts.

Lockers used for ♦

General supply storage

♦

Backup supplies

♦

Specialty procedure carts.

Dirty utility: Used linens, instrument sets and equipment are placed in soiled utility immediately after surgery. This room may hold soiled linen and instruments until they are returned to central supply. This opens outside to the dirty corridor from where the things are removed via the dumbwaiter to the CSSD or to the laundry via the service lift. Movable modular caseworks: ♦

Process tables or work surfaces for receiving soiled items.

♦

Sink unit.

Staffs lounge: A staff lounge is used primarily for coffee breaks, snacks and as a place for staff to rest from the pressures of patient care. Space should be provided for a refrigerator, microwave oven and large coffee maker.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Staff change rooms usually adjacent to staff lounge are provided for male and female staff to change from street clothing to surgery attire. Clothing lockers, toilet facilities and showers are provided. Movable modular caseworks and furniture: ♦

Tables and seating

♦

Base cabinets for storage

♦

Overhead storage for coffee maker and supplies.

Administrative office: The following positions will require an administrative office 

Director/ Head of Anaesthesiology



OT in charge



Operating room materials manager/ Store room

Movable Modular Casework and furniture systems: ♦

Cantilevered work surfaces

♦

Work surfaces for keyboard drawers or trays to accommodate computers and printers

♦

Overhead storage and marker boards for displaying information.

♦

Task lights and personal lights.

Lighting: Intensity: At the plane of the incision it would be desirable to achieve an all round intensity of about 40,000 lux. Luminance: Normal luminance brightness for the central field during an operation should be 2,000 to 3,000 cd/sq.m The floor around the surgical table should have a luminance of 200 to 300 cd/sq m, the walls 300 to 500 cd/sq m and the ceiling lights 1,000 cd/sq m at most. Operation lamp characteristics: 

The intensity of light be variable, but generally at least 40,000 lux at the working plane, and at least 8,000 lux at the bottom of a 13 cm deep and 5 cm wide incision.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL



The operation lamp should with no part hang lower than 2.0 m above the floor.

General Lighting in operation room: General lighting in the operation room should attain a minimum of 400 lux. In the U.S. general illumination capability of 2,000 lux uniformly distributed throughout the room with provision for reducing this level has been recommended. Lighting in Operation room: A reasonable level of illumination at washbasins is 300 to 500 lux. In the U.S. for scrub rooms the illumination level of 2000 lux has been recommended as members of the surgical team will encounter in the operating room. Lighting in post anaesthetic recovery room: Patients are disoriented and aware of bright lights during the awakening period. Therefore light fittings must be placed where they will not disturb the patient. A lighting intensity of about 300 lux is recommended. A mounted wall or ceiling source of higher intensity spot illumination about 10,000 lux must be available for performing procedures if required.

Colour in surgical department: Generally in the UK pale blue, grey and green have found to be most suitable. Blues and yellows should be avoided. A light grey colour for the operating room floor has been recommended. For the scrub up room yellowish or red shades may be used. For the anaesthetic room the reflections on the patients face would not obstruct the anaesthesiologists judgement of the patients condition. The colour scheme in the anaesthetic room may be the same as that for the operating room, possibly softer and warmer. Noise levels In operating room: The noise level in operation rooms should be below 50 decibels.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

In anaesthetic rooms as well as in the labour and delivery rooms the noise levels should be below 45 decibels. In recovery room: A special sensitivity to noise and need for protection from it is found in newly operated persons whose autonomic nervous system is in disorder. One of the patients greatest irritations in the recovery area is the laughter and other noises of the staff. In recovery rooms sound absorbent ceiling materials and wall finishes with a reflection factor of about 50 per cent should be used. Temperature in the operating room: The temperature in the operating room will be maintained between 21 to 23 degrees. Humidity: The acceptable limits for relative humidity as regards static electricity and comfort are 45 to 60 per cent. Low relative humidity has been reported to be an optimal condition for Kleibsiella pneumoniae Type A while high humidity in the hospital enhances the danger of growth of Ps. Aeruginosa. Humidity in the operation room is believed to contribute to the prevention of dehydration of exposed tissues. At a relative humidity of about 50 per cent a very thin invisible film of moisture forms on operation equipment and other surfaces. The film of moisture conducts static to earth before a spark producing potential is built up. A standard of relative humidity between 40 to 65 per cent has been fixed for operating rooms. (55 % + or – 5%) Flooring in operation room and anaesthetic room: The rooms flooring in the operation rooms and the anaesthetic rooms should be Non slippery when wet. Withstand intensive application of water and disinfectants Not absorb physically foreign molecules Be elastic and recover after the removal of heavy objects. Have a high resistance to breakdown. Be fire resistant. Be colourfast.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

PVC flooring is the floor finishing that satisfies the majority of the requirement of the operating room flooring.

Walls: Suitable surface materials include laminated polyesters with an epoxy finish and hard vinyl coverings which can be heat sealed. Semi matt wall surfaces reflect less light than high gloss finishes and are less tiring to the staff. The corners in the operating room should be rounded with the wall surfaces to make cleaning routines easier. Doors: Door hardware should be designed with single lever action and should require no more than 4 kg of pressure to open the door. In the operation department, staff dressed in sterilized garments require a minimum door opening width of 90 cm. A clearance of about 10 cm on either side of the bed including special equipment is required to move it through an opening. A width of 150 cm for two leaf door openings can be recommended. A device that holds the door open must be provided to simplify equipment moving. The sound insulation properties of the doors should be good. Operating rooms and anaesthetic rooms should be provided with safety glazed openings with blinds to save unnecessary opening. In the post- operative recovery area the doorways should pass beds easily. A door width of about 145 cm is recommended. Electrical outlets and switches: Electrical outlets should not be placed so that the power cords between the wall outlets and the junction boxes and apparatus hinder the staff. In operating rooms about 20 outlets are needed for advanced operations. Electrical outlets in the vicinity of the operating table should be combined in a control panel comprising switches, fuses and plug outlets for main voltage

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

and low voltage for electronic appliances. It is preferred to have the control panel hanging from the ceiling from the pendant. In post anaesthetic units upto 8 electrical points are necessary for each bed.

Medical gases, piped air, vacuum. Oxygen, compressed air, nitrous oxide and vacuum are supplied via gas pipes identified by colours according to international standards. To maintain homeostasis the inspired gases should be warm and humidified. Heated humidifiers which supply gases at 35 degrees centigrade and at 100 per cent relative humidity. The temperature of gases should be monitored to prevent tracheobronchial burn. Gas outlet points shall be at least 20 cm from electrical components to avoid generation of sparks. For preoperative areas oxygen, suction and compressed air are required. For the operation theatre and postoperative areas oxygen, compressed air, nitrous oxide and suction are required.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

v

Intensive Care Units: Function: ICUs are specialty nursing units designed, equipped and staffed with specially skilled personnel for treating very critical patients or those requiring specialized care and equipments. Location: The ICU’s should be located in a geographically distinct area within the hospital with controlled access. No through traffic to other departments should occur. Location should be chosen so that the unit is adjacent to or within direct elevator travel to and from the Emergency Department, operating room, Intermediate care units and Radiology department. There are 2 schools of thoughtOne suggests that ICUs should be in a centralized place and be contiguous with or readily accessible to one another. Having intensive care facilities in a centralized place allows the specially trained professionals and equipment an almost instant access to patients in all clinical services when an emergency develops. Such an arrangement also eliminates the need for duplication of costly equipment and personnel. The second school of thought favors that the location should be dependent on the type of patients eq.-The surgical ICU should be close to the operating rooms. -

The Medical ICU should be in close proximity to the medical wards.

-

The NICU should be close to the obstetrics ward.

-

The Neurosurgical ICU can be located close to the emergency department

Layout: 12 to 16 beds per unit are considered best from a functional perspective. There will be 10 beds in the ICU. There will also be 2 isolation rooms within the ICU to

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

accommodate increasing incidence of contagious and immunocompromised patients. Supply corridors should be separated from public/patient corridors.

The ICU consists of the following areas 

Patient rooms.



Central/ Nursing Station



X ray viewing areas/ Storage areas



Clean and dirty utility rooms



Equipment storage



Food prep area/ Pantry



Staff areas/ Doctors Room/ Nurses rest room



Supply and service corridors.



Stat lab



Visitors waiting room.



Doctors room.

Patient rooms: Patient rooms must be designed to support all necessary healthcare functions. There will be at least 225 square feet area per bed. An emergency alarm button must be present at every bedside within the ICU. The alarm must sound automatically in the central nursing station and the origin of these alarms must be discernible. The patient bed should be located permanently away from the wall to give staff a 360 degree access to the patient. There is generally a headwall behind each patients bed for a freestanding utility column to mount monitors and equipment and to supply suction, air, oxygen and regular electrical and emergency electrical services.

Space

for

computer

terminals

and

patient

charting

should

be

incorporated in the design. Storage for computer terminals and patient charting should be incorporated in the design. Storage for patients personal belongings, patient care supplies and pharmaceuticals should be provided at the bedside. An ICU design should consider natural illumination and view. Windows are an

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

important aspect of sensory orientation and every room should have the patient facing the windows to reinforce day/ night orientation if possible. The patients must be situated so that direct visualization by healthcare providers is possible at all times. This approach permits the monitoring of patient status under both routine and emergency situations.

Movable Modular Casework: ♦

Bedside supplies placed in an L cart with drawers or in a storage unit.

♦

Locker within or adjacent to the patient room to house immediate necessary supplies and linen.

♦

Cantilevered work surface or mobile table with a keyboard tray as a station for nurse charting done on a bedside computer.

Isolation rooms: There will be 2 isolation rooms in the ICU. Isolation rooms are used by patients with highly communicable diseases or those who are unusually susceptible to infection. Cleanliness and contamination are key concerns in these rooms. Each isolation room will contain at least 250 square feet of floor space with an anteroom. Each anteroom should contain at least 20 square feet to accommodate hand washing, gowning and storage. An attached toilet must be provided in the isolation rooms. Movable Modular Casework: Same as that required for patient rooms.

Central station: A central nursing station should provide a comfortable area of sufficient size to accommodate all necessary staff functions. Within the nurses station the staff manages patient records and charts, communicates regarding the patients conditions, views patient monitors, orders tests and treatments and dispenses medications. Adequate space for computer terminals and printers is essential. Patient records should be easily accessible and adequate space must be provided for them. Adequate surface space and seating for medical charting by both

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

physicians and nurses should be provided. Shelving file cabinets and other storage for medical record forms must be located so that they are readily accessible by all personnel requiring their use. A refrigerator for pharmaceuticals and a sink with hot and cold running water must be provided. Behind the nursing station a small area may be provided as a rest room for nurses. This area can contain a bed, which can be utilized by pregnant nurses to rest in between work. Doctors Dictation: An area should be provided for physicians to review patients charts, dictate progress notes and write patients orders. It should have access to telephones. Charting: A stand up or sit down area should be provided with access to patients charts by nurses and physicians. This area is generally maintained by the unit clerk or the unit secretary. Cart Storage: An area must be provided to store and quickly access crash carts and procedure carts. This area should be accessible to supplies for restocking carts and have electrical access to maintain rechargeable equipment. Movable Modular Casework and Furniture: ♦

Cantilevered work surfaces

♦

Monitor shelves

♦

Computer tools and keyboard trays.

♦

Lateral filing components.

♦

Procedure and crash carts.

X ray viewing area A separate area at the nursing station or near each cluster of ICUs must be provided for the view of the patient radiographs.

Storage areas:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Provision should be made for storage of crash carts and portable monitors/ defibrillators near each set of ICUs. Stat Lab/Equipment storage: A separate storage area behind the nursing station for storage of large patient care items not in active use such as mobile X ray must be provided. Space should be adequate enough to provide for easy access, easy location and easy retrieval. Much of the equipment must be accessible to electrical outlets to maintain battery charges. Movable Modular Casework: They can be used to store small and large equipment and may include ♦

Modular Shelving units

♦

Bulk supply carts.

Space for Laboratory equipment: Since many patients in the ICU require Arterial blood gas analysis and electrolyte analysis space must be provided for an ABG analyzer and an electrolyte analyzer. Clean and dirty utility rooms: They must be separate rooms that are not interconnected. Clean utility room: It should be used for the storage of all clean and sterile supplies and also for the storage of clean linen. It requires space for supplies, linen, procedure trays and procedure carts. Movable Modular Casework: ♦

Cantilevered work surfaces with drawers

♦

Extra- deep modular shelving units

♦

Lockers for medical supplies and linen

♦

Bulk supply carts

♦

Procedure carts.

Dirty Utility room:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

It must be provided with a sink. Separate covered containers must be provided for soiled linen and waste materials. Special containers should be provided for the disposal of needles and other sharp objects. Air supply from the dirty utility room must be exhausted. This room typically has a sink. Movable Modular Casework: ♦

Cantilevered work surfaces with drawers

♦

Cantilevered sink unit.

If a special procedures room is desired it could be located between the clean and dirty utility rooms. A separate hatch can be provided from the clean utility room to the special procedure room and from the special procedures room to the dirty utility room. Food preparation area/Pantry: An area where food can be brought from the kitchen in food trolley and heated/prepared before it can be distributed to the patients.

Staff change rooms and toilets: Rooms must be provided for staff to change and there should be lockers to keep their belongings. Separate toilets should be provided for the staff. Patient and supply corridors: The patient and supply and service corridors should be separate from each other so as to facilitate easy movement. Reception area/Visitors lounge/Waiting room. The reception area should be located such that all visitors should pass this area before entering. This area should contain information about the patients admitted and should also be of help to the attendants of the patient. Waiting room: One to one and a half seats per critical bed is recommended here. Public telephones( preferably with privacy enclosures) must be provided. Television

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

and/ or music should be provided. Tea/coffee vending machines, public toilet facilities and a drinking fountain should be located in the lounge area. One bed per patient admitted must be provided for the patients’ attendants. This room must have adequate toilet and bathing facilities. A separate family consultation room can be provided. This will help if the treating physician wants to talk with the family/ relatives of the patient.

Interdepartmental Relationships: ICUs should be located close to or be easily accessible from 

Emergency Department



Operation Theatre



Laboratory



Radiology



General Nursing units/ Wards

Most admissions are through OT or emergency. Also they should be close to vertical transport cores. An intermediate area should have twice the number of intensive care beds in an ICU Patient/material flow. Patients will come to the unit from in-patient admitting, emergency/trauma department, other patient care units, surgical departments or cardiac cath departments. From here the patients may go to other patient care units like intermediate care/ general nursing units, surgical OT, diagnostic departments like radiology, laboratory, Endoscopy or the patient can be discharged home

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Patient/Material flow in ICU:

Support Services Dietary Materials Management CSSD Housekeeping

Admitting Services

Emergen cy room

Triage Observati on

ICU

Trauma unit

Other Patient units

Diagnostics Radiology Laboratory Cath Lab Endoscopy EEG/EMG

OT/Surgery/Recovery

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Discharge Home

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Lighting: While considering optimal lighting, attention must be given to the reflectance value of walls, ceilings, and floor. The reflectance value is dependent upon their texture and colour. Some recommended reflectance values are ceilings 80 to 95%, upper walls 40 to 60%, lower walls 15 to 20%, floors 15 to 30%, furniture 25 to 40%. General overhead illumination plus light from the surroundings should be adequate for routine nursing tasks including charting, yet create a soft light environment

for

patient

comfort.

The

intensity

of

300

lux

has

been

recommended. Total luminance should not exceed 30 foot candles (fc). It is preferable to place lighting controls on variable control dimmers located just outside the room. This approach permits changes in lighting at night outside the room, allowing a minimum disruption of sleep during patient observation. Night lighting should not exceed 6.5 fc for continuous use or 19 fc for short periods. Separate lighting for emergencies and procedures should be located in the ceiling directly above the patient and should fully illuminate the patient with at least 150 fc shadow free. A patient reading light is desirable and should be mounted so that it will not interfere with the operation of the bed or monitoring equipment. The luminance of the reading lamp should not exceed 30 fc. Colour in intensive care units: Blues and greens should be avoided in the intensive treatment rooms as about 50 % of the light reflects from the walls the green and blue colours and may appear to make the patient cyanotic. Gray colour is preferred. Blue or blue green shades should be used in waiting and holding areas where they are calming.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Noise levels: The international noise council has recommended that noise levels in hospitals acute care areas should not exceed 45 db in daytime, 40 db in evening and 20 db at night. Normally noise levels in most hospitals are between 50 to 70 dB with occasional episodes above this range. For these reasons floor coverings that absorb sound should be used. Walls and ceilings should be constructed of materials with high sound absorption capabilities. Temperature and humidity in ICUs: A temperature of 22 to 23 degree centigrade and humidity at 50 to 60 percent have been found appropriate in the intensive care and treatment units as well as in isolation rooms. Doors: In the ICU handles can be omitted from doors which can be pushed open. Also the door width should be about 145 cm. In neonatal intensive care units the door units the door widths of 90 cm are accepted. Utilities: Each ICU must have electrical power, water, oxygen. Compressed air, vacuum, lighting and environmental control systems that support the needs of patients and critical care team under normal and emergency situations. A utility column (free standing, ceiling mounted or floor mounted) is the preferred source of bedside electrical power, oxygen, compressed air and vacuum and should contain the controls for temperature and lighting. When appropriately placed, utility columns permit easy access to patients head to facilitate emergency airway management if needed. If utility columns are not feasible utility services may be supplied on the head wall. Electrical Power: Electrical service to each ICU should be provided by a separate feeder connected to the main circuit breaker panel that serves the branch circuits in the ICU. The main panel should also be connected to an emergency power source that will quickly resupply power in the event of power interruption. Each outlet or outlet cluster within an ICU should be serviced by its own circuit breaker in the main

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

panel. It is critical that the ICU staff have easy access to the main panel in case power must be interrupted for an electrical emergency. Grounded 110 volt electrical outlets with 30 amp circuit breakers should be located within a few feet of each patients bed. Outlets at the head of the bed should be placed approximately 36 inches above the floor to facilitate connection and to discourage disconnection by pulling the power cord rather than the plug. Outlets at the sides and foot of the bed should be placed close to the floor to avoid tripping over electrical cords. In intensive care and treatment units 10 electrical outlets per bed are required. In neonatal intensive care units 10 to 12 outlets per bed are required.

Water Supply: The water supply must be from a certified source, especially if haemodialysis is to be performed. Zone stop valves must be installed on pipes entering each ICU to allow service to be turned off should line breaks occur. Hand washing sinks deep and wide enough to prevent splashing, preferably equipped with elbow, knee, foot or sonar operated faucets must be available near the entrances to patient modules or between two patients in ward type units. This is a critical component of general infection control measures. When a toilet is included in a patient module, it should be equipped with bedpan cleaning equipment, including hot and cold water supplies and a spray head with foot control. In addition when toilets are present, environmental control systems must be modified. Oxygen, Compressed Air and Vacuum. Centrally supplied oxygen and compressed air must be provided at 50 to 55 psi from main and reserve tanks. At least 2 oxygen outlets per patient are required. One compressed air outlet per bed is required two are desirable. Connections for oxygen and compressed air outlets must occur by keyed plugs to prevent the accidental exchange of gases. Audible and visible low and high pressure alarms must be installed both in each ICU and in hospital engineering. Manual shut off valves must be located and identified in both areas to permit interruption of the supplies in case of fire, excessive pressure or for repair purposes. At least three vacuum outlets per bed are required. The vacuum system must maintain a vacuum of at least 290 mm hg at the outlet farthest away from the

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

vacuum pump. Audible and visual alarms must indicate a decrease in vacuum below 194 mm hg.

Environmental Control systems: Suitable and safe air quality must be maintained at all times. A minimum of six total air changes/ room/ hr are required, with two air changes/ hr composed of outside air. For rooms having toilets, the required toilet exhaust of 75 cubic ft/min must be composed of outside air. Central air-conditioning systems and recirculated air must pass through appropriate filters.

Radiology Department: Function The term radiology now incorporates: 

Radiodiagnosis—

•

X Ray

•

Sonography

•

CT Scan

•

Magnetic Resonance Imaging (MRI)

•

Digital Subtraction Angiography (DSA)



Radiotherapy



Nuclear Medicine



Interventional radiology

The functions of the radiology department are; ♦

Receiving the patient.

♦

Exposing the film using the appropriate modality

♦

Developing and checking the quality of the film image.

♦

Viewing and interpretation by a radiologist.

♦

Dictation and transcription of the interpretation and forwarding the report to the requesting physician or surgeon.

♦

Filing both the film and the written report.

Location: The department should be easily accessible to the OPD, casualty and the inpatient wards. The location of the department will be on the ground floor.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

It should have some scope for expansion at a later date. Layout: Planning for a good design for the X ray department is a complex process. Equipment for Radiodiagnosis department is expensive, requires a great deal of care and maintenance and appropriate space central to the users WHO has recommended the standard size of the X ray room at 20 sq. mts Approximate requirement of space for hospitals of different sizes is 750 beds --- 800 sq m 500 beds --- 650 sq m 300 beds --- 370 sq m 200 beds --- 175 sq m 100 beds --- 65 sq m. Generally the space distribution in an X ray department is as follows: 11% control rooms and cubicles 16.5% X ray rooms. 9.0% Film processing and interpretation. 20.5% Administrative 8.5% Teaching 5.0% Waiting and Recovery 29.5% Circulation and wall area. Patient and work flow: According to experience 3 percent of the patients are taken directly to the X Ray rooms. 17 percent are bed or stretcher cases. 80 percent are ambulant or use wheel chairs or are minors. Around 5 to 10 percent of the departments patients are children. Patients Receptionist Waiting Undressing/Enema

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

X ray Procedure Film Processing

Wet film examination

Viewing by Radiologist Interpretation

Report to the patient Functional areas: Waiting: From the main reception area the patients are directed to sub-waiting areas. A floor area of about 1.3 sq m should be allowed for each waiting patient. Parking areas for beds and trolleys should be provided. The corridors must be 2.8 m wide for bed traffic. Lavatories: Lavatories should be easily accessible to waiting patients. Some should be larger so that an attendant could assist. Handgrips on the wall for the patient are recommended. Doors to lavatory compartments should open outwards. All lavatories must have a wash basin. Changing cubicles: The patients who are to be X rayed require undressing or stripping to the waist. Each X ray room requires about 2 well lit and ventilated cubicles of about 1.3 sq mts size. Each cubicle should have a chair, clothes hook and a mirror. Contrast media preparation room/Barium Preparation: In the vicinity of the undressing cubicles and X ray rooms there should be a room where contrast media, frequently barium powder is mixed for investigations. X ray screening room:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

A standard size of 40 sq mts has been recommended. The depth of the screening room should not be less than 5.8 m. In the room a working height of about 3.3 m is recommended. In all X ray rooms a stainless steel unit with a sink and a washbasin is needed because of the microbial cross-contamination and infection potential. Door openings should be at least 1.3 m wide. Radiodiagnostic rooms should have natural lighting and ventilation whenever possible. All artificial lighting in the screening room should be wall mounted. The ceiling has to be free from air ducts, pipes etc and should be weight bearing in all directions for the installation of ceiling mounted equipment. All rooms will have a control, tube (an X ray emitting device), tube stand or support and cabling. Important design considerations: •

The space should be configured to allow a stretcher to be manoevered with minimum turns by placing the axis of the X ray table perpendicular to the wall with the door by which the patient will enter the room.

•

The control console will be opposite the door with direct access to the vertical core.

•

Minimum size of a room should not be less than 20 sq mts/ideal is 40sq. mts.

•

An overhead type tube support facilitates X raying a patient in bed or on a stretcher.

•

The X ray tube should never point towards the control unit, darkroom or window.

•

Control panel should be as far away as possible from X ray table.

•

Radiation hazard to the occupants of the X ray room is inversely proportional to the square of the distance between the tube and the individuals.

•

The passage of film cassettes from the radiography room to the darkroom takes place through the hatch window opening into the darkroom. The hatch must be adequately lead lined to prevent the entry of radiation scatter into the darkrooms.

•

Also the doors and windows of the radiography room have to be lead lined to prevent radiation scatter from the room.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

•

A door on the control booth is required to protect the technician in the booth from scattered radiation.

•

The control panel should be wired to a signal outside each X ray room to indicate when the machine is on, to prevent other personnel from inadvertently entering the room. A red light bulb will be satisfactory as a signal.

Special equipment: ♦

Table and tube.

♦

Wall bucky (a device that holds film in a position during exposure)

♦

Control console

♦

Sink and casework

♦

Transformer and power cabinet.

Fluoroscopy room: Fluoroscopy makes use of radio- opaque media that may be introduced into the body to create images of tissue that would not otherwise show up well on X ray. Because the radio- opaque material is typically barium introduced through the mouth or the rectum, it is important to have a toilet room directly accessible from the procedure room. Important design considerations: Apart from the design considerations for X ray rooms other considerations peculiar for fluoroscopy room are: •

The toilet room will be directly attached to the fluoroscopy room.

•

Barium will be prepared in a procedure room.

•

Floors should be designed keeping in mind that loads upto 2,000 kg/m will be borne by the floor.

Special equipment; ♦

Fluoroscopic X - Ray tube and table.

♦

Image intensifier.

♦

Spot film camera

♦

Video monitor.

♦

Wall bucky

♦

Control Console

♦

Sink and casework.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

♦

Transformer and Power cabinet.

X ray machines : Machines which operate at a higher milliampereage are better for taking X rays of thicker part of the body with less exposure time, but they are more expensive. For chest X rays and X ray of the extremities better films of these parts are obtained with 100 or 200 mA machines. However Examination of the skull, abdomen and special investigations are best carried out with machines working at 500 mA and above.

Image intensifiers: Special investigations and fluoroscopy together form about 14 percent of all investigations. Image intensifiers greatly enhance the brightness of the normal fluoroscopic images reducing the dose to the patient. Image intensifier systems are distinguished by a C arm suspended from an overhead support clamped between the floor and ceiling on an upright metal column. Some details on X-ray machines available and prices. Portable X ray- 60 mA

---- Rs.1,25,000

300 mA X ray

-----Rs. 7,50,000

500 mA X ray

----- Rs.9,00,000

1,000 mA X ray with IITV—Rs.32,00,000 Film processor tank

---- Rs. 3,00,000

X ray viewer (8 film panel)-- Rs. 9,000. Power requirements: 1. Mains •

220 volts AC, three phase.

•

50-60 cycles

•

25 Amps

•

Mains impedance should not be greater than 0.5 ohms.

2. For a steady current with least impedance, a separate power line exclusively for the radiology department is essential.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

3. Frequent voltage fluctuations give unsatisfactory results. Voltage stabilizer is necessary for each machine. Radiation Protection: If radiology rooms are isolated and built so that people cannot come within one metre of its outside walls then no protection to the walls is required. However as this is not always possible the walls of the rooms where radiographic machines are located have to be adequately reinforced.

AERB guidelines (also see annexure) PROTECTIVE BARRER

The protective barrier for positioning between the operator/control panel and the X-ray tube/patient must be of appropriate size and design so as to shield the operator adequately against leakage and scattered radiation. The protective barrier must have a minimum lead equivalence of 1.5 mm. A viewing window having 1.5 mm lead equivalence must be provided in the barrier. The lead equivalence must be indicated on the barrier as well as on viewing window.

FLUOROSCOPY CHAIR

The fluoroscopy chair must have a minimum of 1.5 mm lead equivalence and its design must ensure adequate protection to the radiologist against stray radiation.

PROTECTIVE APRONS

The protective aprons must have a minimum lead equivalence of 0.25 mm and their size/design must ensure adequate protection to the torso and gonads of the user against stray radiation.

PROTECTIVE GLOVES

Protective gloves must have a minimum lead equivalence of 0.25 mm and the design must ensure adequate protection against stray radiation reaching the hands and the wrists and must permit easy movements of the hand/fingers.

GONAD SHELD

The gonad shields must have a minimum lead equivalence of 0.5 mm.

PASS BOX

The cassette pass box intended for installation in the X-ray

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

room wall must have a shielding of 2.0 mm lead equivalence. The design must be such that the pass box can be opened from one side at a time. FILM STORAGE

The box intended for temporary storage of undeveloped films must not have less than 2.0 mm lead equivalence all around.

VEHICLE X-ray units installed in a mobile van or vehicle e.g. for MOUNTED Xmedical surveys/clinics in remote areas, must be provided RAY EQUIPMENT with an appropriate shielding enclosure so as to ensure adequate built in protection for persons likely to be present in and around the vehicle. SHIELDING CONTINUITY

Appropriate overlap of shielding materials must be provided at the joints or discontinuities so as to ensure minimum prescribed shielding all over the surface of all radiation protection devices. Care must be taken to ensure that lead or any other shielding material does not creep or flow, resulting in reduction of shielding in any location.

MARKINGS

The lead equivalence of shielding incorporated in radiation protection devices must be marked conspicuously and indelibly on them.

CONVENTIONAL SAFETY

Facilities for immobilization of patients, specially children, should be provided so as to minimize holding of patients during X-ray examinations.

CONVENTIONAL SAFETY

Appropriate equipment must be available to prevent/manage conventional hazards such as fire, flooding and electrical emergencies.

SAFETY ACCESSORIES

Additional radiation protection devices which would be necessary for specialized radiological investigations must have a minimum of 0.5 mm lead equivalence

SERIAL CHANGERS

Automatic serial changers should be used where the volume of work demands such specialized equipment.

•

For a 100 mA machine a wall thickness equivalent to 1 mm of lead is required.

•

1 mm of lead thickness = 12 cm of poured concrete = 10 cm of sheet glass

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

= 5 mm of steel. •

The appropriate wall thickness using different materials can be calculated using the following equation: Thickness of concrete x 2.35 gm/ cu. Cm = Thickness of other material x Density of other material.

•

As per the recommendations of the radiation protection division of the BARC, Mumbai the walls of the radiography rooms have to be 9 inches thick concrete walls or 14 inches thick brick masonry walls which are sufficient for primary as well as secondary radiation. Where they are thin, lead shielding of walls is advisable.

•

The places which need special protection are i. The wall behind the chest stand in the radiology room. ii. Wall between radiology room and the adjoining room.

•

Personal protective measures like wearing the lead-rubber apron while working and lead rubber gloves while doing fluoroscopy work provide adequate protection.

•

Use of dosimeters to measure the level of radiation.

Dark room/ Film processing room: The darkroom should preferably be air-conditioned. Where the volume of work is high, automatic film developing and fixing can be done wherein the exposed film is fed at one end and comes out automatically developed, fixed and dried at the other end. If the daily workload in the department exceeds 50 films, a small automatic film processor should be installed. The darkroom is conveniently located between two X ray rooms to facilitate handling of films, a film transfer cabinet between the two X ray rooms to facilitate handling of the films. A utility sink is provided in the darkroom for handwashing. The passage into the darkroom should be zigzag to serve as a lightlock between the darkroom and outside. The size of the darkroom depends on the number of staff working in it. For the first person about 8 sq m. is required and for every additional person 2 sq m is required. Dark colours, especially black should be avoided. Citrus fruit colour and pastel shades are suitable for the walls and the ceiling of the darkroom.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Ten air changes per hour are recommended. Radiologists office: The office has a series of viewing boxes where the radiologists examine radiologists examine radiographic plates and dictates reports. A single radiologist can report upto 50 to 60 cases in a month. Manpower required: Radiologists X ray technicians Darkroom assistants Staff Nurse Attendants Record clerk Receptionists. Temperature in Radiodiagnostic department: Some heating design temperatures for Radiodiagnostic departments. Room

Temperature in degrees centigrade

Waiting area

19

Patients changing room

22

Lavage room

21

Diagnostic X ray room

22

Processing area

19

Viewing area

19

Records

19

Office

19

Chemical and film stores

16

Flooring in Radiology Department: In radiology units loads of 2,000 kg/sq m are installed which must be kept in mind while designing the flooring of the radiology department. Walls:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Permanent wall radiation screening in the X ray department rooms where the working capacity does not exceed 150 kV and radiation is undirected should comprise of a 2 mm thick sheet of lead and equivalent material. In the X ray department shielded floors will be necessary if there are rooms below the X ray rooms, particularly if tubes pointing downwards are used. When under couch tubes are used ceiling shielding will be necessary for the rooms above. Windows: Unshielded openings, if provided in am X-ray room for ventilation or natural light etc., must be located above a height of 2 meters from the ground/floor level outside the X-ray room. Ultrasound room: Ultrasound or sonography operates on the principles of sonar and records size and shape by tracking reflected sound waves. A hand held transducer emits regular pulses of high frequency sound and translates received echoes into images. Space requirements: •

Space requirement for a sonography room is about 25 sq mts.

•

Space for staff, for storage of material and patient reception, waiting and toilets which admit a wheelchair also are needed.

•

A changing cubicle of about 2 sq mts in size should be made available for the ultrasound room. It should be equipped with hooks, mirrors and means for locking up the patients valuables.

•

A toilet attached to the room is desirable.

Special equipment: ♦

An ultrasound unit with the console placed on the right side of the patient.

♦

Examination bed

♦

Film illuminators.

MRI room: MRI is performed by placing the patient in a powerful magnetic filed that aligns the magnetic spin of the atomic nuclei. Radio frequency energy is introduced which disturbs the alignment of the nuclei. Different atoms respond at different

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

radio frequencies thus providing a distinction between tissue types. MRI does not utilize ionizing rays and can create detailed two and three dimensional images of both hard and soft tissue. Important design considerations: Since MRIs use radio frequencies to generate imaging they are susceptible to electro magnetic interference from outside sources. The room is wrapped with a copper fabric to shield it. Special equipment: ♦

MRI unit

♦

Patient couch

♦

Operators console and video monitor in the control room.

Clinical laboratories: Function: Basic lab services provide information regarding the bodies chemical make up and balance, the presence, numbers, performance and general activity of cells, inherent genetic characteristics and the presence and level of bacteria and viral organisms. In addition analyses of body tissue and cellular condition are assessed through anatomical pathology studies. Clinicians use laboratory tests to make decisions about patient care. Location: Generally

laboratories are centralized for

optimum

efficiency in

staffing,

management, quality control and equipment utilization. There may be a collection center located in the outpatient department and a frozen section component located in the surgical suite for immediate access during procedures. Blood gas analyzers may be located either in the ICUs or in the laboratory depending on the necessity. Stat labs may be located in those departments where necessary. The laboratories will be located on the ground floor. Interdepartmental relationships: The labs should be easily accessible from the emergency department, the ICUs, the OT’s, the OPD’s and the inpatient wards. Key Determinants: The majority of tests performed in labs today are automated, requiring relatively little handling by technologists (except to initiate the testing process or to calibrate and verify properly functioning equipment). Therefore the types and

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

numbers of testing machines within each lab section determine the capacity of the lab and amount of space needed.

Flow of test orders and specimens: Outpatient

Inpatient

Patient visits

Physician records

physician

request for testing on patient chart

Fills out request for testing

Specimen is collected From patient

Outpatient comes to lab for testing

Specimen is sent to

Specimen is logged and

Specimen receiving

decision is made on which dept To send the specimen based on Tests required

Specimen may be split into

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Several containers

Departments receive sample

Departments test sample

Departments log results

Results are sent to the

Outside lab

Outpatient department

Results are received at

nurses station and

Attached to patients chart Patient collects the Results

Physician reviews chart And makes decision

Inpatient

Key design considerations: 

Biochemistry and haematology are most frequently located closest to the specimen reception area due to the high volume of work. Microbiology may be located farthest from the reception area because of the lower volume of testing to be performed and to isolate these biohazardous activities from other procedures.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL



Chemical resistant and stain resistant materials should be used for laboratory worktops and casework finishes. Bacteria resistant, cleanable building finishes should be used in all areas. In areas of gross tissue handling, such as gross tissue stations and the frozen section lab, stainless steel is often used to enhance cleanability and durability.



Casework used today is modular and easily movable to facilitate quick, economical rearrangement. Casework 36 inch high is standard.

Functional areas: Rooms Specimen Control/ receiving – 75 sq. ft Phlebotomy/ Blood drawing area – 150 sq. ft Biochemistry – 300 sq ft. Haematology –200 sq ft. Blood Bank – 1840 sq ft Microbiology –200 sq ft. Histology –200 sq ft. Administrative areasPathologists office – 100 sq ft Secretarial/ Transcription area/Reception – 100 sq ft. Specimen receiving: All orders by physicians for tests and specimens to be examined are received and logged in here. Specimens are then distributed to the appropriate areas within the lab. Record keeping, generating computer reports takes place here. Specimen receiving is usually located near the entrance of the laboratory for easy access to traffic coming into the lab. Specimen receiving should be located in close proximity to chemistry, haematology, urinalysis and blood bank as most of the specimens go to these areas. Casework and furniture:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

♦

Stand up work surfaces to receive and hold specimens.

♦

Process tables for centrifuges

♦

Administrative work surfaces for seated work and computer use.

♦

Work surfaces at stand up height for specimen preparation.

♦

Locker with tray/ shelves to store blood drawing supplies used by phlebotomists.

Phlebotomy area: Area designated for drawing of blood samples from outpatients. Space is provided for phlebotomists trays containing supplies necessary for drawing blood samples from inpatients. Casework : ♦

Modular shelving or lockers used for storage of phlebotomists trays and supplies.

Biochemistry: Blood, urine and other body fluids and tissues are analyzed in the biochemistry lab for their chemical constituents. It will have the largest workload and the number of technicians. It contains a large number of expensive highly specialized testing equipment. It requires workstations with running tap water, distilled water and many electrical outlets, some with dedicated lines for specific equipment. Space must be provided for disposable supplies, reagents and instrumentation. ♦

Workstations with modules and access panels for air and vacuum outlets, running tap water, distilled water, drainage.

♦

Casework cabinets may be used for storage below work surfaces.

♦

Overhead flipper and shelf storage or below work surface drawers and shelves for disposable supplies.

♦

Shelves below work surfaces towards the bottom of lockers as storage for reagent containers.

♦

Chem- surf or resin work surfaces for staining areas.

♦

Cantilevered work surfaces, file drawers for administrative work space for supervisors.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

♦

Process tables for vibrating equipment, microscopes or large instrumentation that may need easy access from all sides for use or repair.

Haematology: It is the area of the lab in which blood samples are analyzed to determine the no. and type of RBC’s, WBC’s and platelets. Complete blood counts (CBC) are performed using large automated counters. Haematology performs approximately 50% of the procedures of the lab. Hence it should be in close proximity to specimen control, have a specimen preparation area, room for several large automated instruments, storage for reagents and many supplies and areas for microscopes. Casework and furniture: ♦

Stand-up and sit down workstations with chem-surf or resin work surfaces for receiving and preparing specimens and for staining.

♦

A large number of workstations using modules and support panels.

♦

Casework cabinets for storage below work surfaces.

♦

Process tables for vibrating equipment such as a centrifuge.

♦

Lockers on terminal panels

Microbiology: It is a study of specimens to isolate and identify disease causing organisms e.g. Bacteria, fungi, viruses and parasites. 

Ideal location of microbiology is away from the main entrance of the lab.



Separate area for media preparation and media inoculation requiring long work surfaces.



Ventilation and exhaust systems are key requirements.



Subspecialties- Bacteriology (bacteria) Mycology (Fungi) Virology (viruses) Parasitology (parasites)

They should be isolated from general lab and have negative air pressure to guard against contamination of other lab areas from the substance under examination. Movable Modular Casework:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

♦

Heavy- duty work surface with drawers.

♦

Drawers under work surfaces to hold inoculation loops, slides, cover slips, petri dishes, test tubes, pipettes etc.

♦

Casework cabinets for storage below work surfaces.

♦

Modular shelving units, C frame storage units with different sized drawers or lockers to store stains and reagents for immediate accessibility.

♦

Resin work surfaces which are stain and heat-resistant for working with stains, reagents and flames.

♦

Modules with water, electrical outlets and vacuum.

♦

Cantilevered sink unit.

Histology: Function: Histology prepares microscopic slides of tissues removed from patients during surgery or autopsy. After examination of the specimen by the naked eye in gross pathology, pathologists examine prepared slides under the microscope to determine or confirm the diagnosis. The important thing to be kept in mind is the considerable cleaning problem caused by the large amount of paraffin used – often in the melted state.

Pathologists office: The chief pathologist will be provided with an office with room for meeting people. He will have a microscope in the office. Movable Modular Casework and Furnitures: ♦

Chair for chief pathologist

♦

Chairs for visitors.

♦

Work Surface

♦

Overhead storage

Secretarial/ Waiting: There will be an administrative area for secretaries and receptionists. Waiting areas are provided for patients waiting to have testing done. These areas will be

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

located towards the front of the laboratory to discourage traffic in the clinical areas. Movable Modular Casework and Furniture systems: ♦

Work surfaces with keyboard trays or drawers to accommodate computers and printers.

♦

Flipper storage, display shelves and open shelves for storage of manuals and books.

♦

Task lights and personal lights.

Lighting in laboratories: When precision instruments are involved or colours have to be judged the illumination level should be about 1,000 lux and when regular instruments 500 to 600 lux. The reasonable level of illumination at work with microscopes is about 3,000 lux. Lighting in laboratories must not cause reflectance, glare and shadows. Temperature and humidity: In laboratories a fairly stable temperature of between 21 to 22 degrees centigrade and a relative humidity between 40 and 60 percent should be maintained. Flooring in laboratories: For laboratories special building adaptions, such as deep inserts in the floor, must be taken in planning considerations early on. All materials used should be tested with strong acids, alkalis, water, solvents, and histological stains. The floors should be of non- slip quality also when wet, easy to clean, hard wearing and fire resistant. Linoleum and tiles are widely used in laboratories. Asbestos vinyl tiles are hard wearing and not so slippery when wet. They are however attacked by some alkalis and acids. Flexible vinyl is preferred for laboratory floor covering because it is more impervious and therefore a little more resistant to chemical attack. Flexible vinyl is resistant to acids but not to all

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

solvents. Vinyl sheets should not be laid where it would be subjected to abrasive materials or to heavy point loads. Doors in laboratories: In laboratories 120 cm is considered to be the minimum acceptable door width. For easy exit door widths should swing out from the laboratory.

Central Sterile Processing Department (CSSD/CSPD): Functioning: Central Sterile Processing is a service whereby medical/surgical supplies and equipment-both sterile and non-sterile are cleaned, prepared, processed, stored and issued for patient care. Its primary function is the sterilization of instruments for surgery, labour and delivery and other departments. It is also responsible for the distribution of sterile and clean disposable items. Objective: The objective of the CSSD is to provide a centralized and standardized sterilization facility with a view to reducing the incidence of infection in a healthcare setting. Location: Since around 40% of the load on CSPD is from the surgical department the ideal location of the CSPD would be next to the surgery or either above or below surgery. Vertical transport is important if the location is either above or below the surgical department. This is usually through dumbwaiters that provide direct access for both clean as well as soiled materials. Interdepartmental relationships: The CSSD is located such that it is easily accessible from the surgical department, the wards and the ICUs. Key factors to be kept in mind while planning CSSD:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL



While designing the CSSD care should be taken that the flow of traffic is continuous from receiving where the soiled items commence their journey to issuing where sterilized items are issued, without retracting steps.



The CSSD is located on a lower floor then 2 dedicated dumbwaiters should be provided-one sterile and the other soiled-which connect the CSSD floor with the surgical suite. Dumbwaiters are small elevators that are used to deliver supplies. The sterile dumbwaiter opens into the sterile area of the surgical suite and transports all sterile items without being contaminated in transit. The second dumbwaiter which opens from the disposal zone of the surgical suite, brings down the soiled items to the soiled area of the CSSD for reprocessing.

Work Flow: IN

Soiled returns from theatres

Soiled returns from wards and departments

SORT/WASH/DISINFECT/DRY

Make up packs

SET Trays

Sterilize

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Despatch to theatres

Sterilize

80

OUT

Hold in processed goods storeDespatch to wards/departments

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

The department is divided into three zones to accomplish the functions of decontamination, assembly and sterile processing and sterile storage and distribution. These zones are a follows 1.

Decontamination zone.

2.

Sterilization zone

3.

Storage and distribution zone.

A distinct separation must be maintained between the soiled and sterile areas. The staff works on either side and cannot cross from one side to the other. 1. Decontamination zone: The reusable equipment and soiled instruments and supplies are received from departments for initial or gross cleaning. These items are cleaned and decontaminated by means of manual or mechanical processes and chemical disinfection. Equipments used are: 

Washer Decontaminator: Used to clean heat intolerant items.



Ultrasonic washer: Used to remove fine soil from surgical instruments after manual cleaning and before sterilization

2. Sterilization zone: After the instruments have been cleaned and inspected, they are assembled into sets and trays. Each set or tray is wrapped or packaged for terminal or final sterilization. Then the sets are prepared for issue, storage or further processing. Equipment most commonly used are: •

14

High/Low pressure sterile processing systems.

81

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

•

Ethylene oxide gas sterilizers.

•

Chemical sterilization systems.

•

Microwave sterilization systems.

3.Storage and distribution zone: Following sterilization instruments are stored in sterile storage or sent to the appropriate department.

Space requirements: The space requirements for CSSD are around 10 –15 sq. ft per bed. Primary areas: 1. Entrance area. 2. Soiled returns hold. 3. Washing area. 4. Gowning area. 5. Packing room. 6. Linen preparation room. 7. Sterilizer loading area. 8. Sterilizer plant room. 9. Cooling area. 10. Processed goods store. 11. Dispatch area. Offices and staff facilities: 12. Staff changing room. 13.Staff toilets. 14. Office of the manager/in charge of dept/CSSD supervisor room. Functions of each area: 1. Entrance area: There may be one or more entrance areas to the CSPD. One may be for the staff and visitors and the return of soiled goods whereas the other may be for the delivery of sterile supplies.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

2. Soiled returns hold: The primary function is receiving collection trolleys containing soiled returns from users in the hospital. Adequate parking space is required for the no. of trolleys expected to be held at any time. 3.Washing area: Its function is to offload soiled returns from trolleys, to sort, clean and dry all reprocessable items returned. Most items including trays and containers will be cleaned and dried using an automated process. Items not suitable for the automatic process will be cleaned at a hand-washing and drying systems facility. 4.Gowning area: Before entering the packing room all staff and visitors must conform to the changing procedure policy. 5.Packing room: Here all items are inspected and assembled in preset trays and procedure packs and then transferred as packaged goods to the sterilizer loading area. 6.Linen preparation room: The function is to receive clean linen from the materials store and to transfer prepared linen into the packing room. 7.Sterilizer loading area: This is located next to the packing room. Trays and packs will be received from the packing room and loaded onto carriers and pallets. The carrier or pallet will be loaded onto the appropriate sterilizer chamber using a sterilizer loading trolley. 8.Sterilizer plant room: Its primary function is accommodating steam and hot air sterilization machines if required. 9.Cooling area: The function is cooling trays and packs. To achieve a good and safe practice, loads should remain on the carrier or pallet until cooled. 10.Processed goods store: Here goods that have been processed by the department are stored.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

11.Despatch area: Its function is to receive trays and packs from the processed goods store and to load distribution trolleys with goods for dispatch. 12.Staff changing room: Full changing facilities for male and female staff are required if suitable central staff change is not available nearby. An individual locker may be allocated to each full-time and part-time, member of staff. 13.Staff toilets: Toilets should be provided for the staff with WCs and washbasins. 14.Office of the manager/incharge of the dept : The requisites for this room are computer facilities, a desk with telephone and a document storage cabinet. There should be enough space for the manager and visitors. Equipment and accessories: 1. SS work table with wastage bin. 2. Worktable with undershelf. 3. Vertical sliding door 4. Two door instrument washer-disinfector. 5. Single free standing basket rack. 6. Storage shelf. 7. Storage shelf 8. Work table with single sink 9. Work table with 2 sinks 10. Ultrasonic cleaner. 11. Glove washer 12. Glove dryer 13. Glove powderer. 14. Glove storing bin. 15. E.T.O. sterilizer. 16. Preparation & packing table. 17. Rectangular sterilizer. 18. Trolley with carriage. 19. Storage tank 20. Water still

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

21. Double free standing basket rack. Finishes: 

In the processing areas finishes should be suitable for frequent washing down and tolerant to disinfectants. Joints should be avoided as they can hold moisture, encouraging the growth of organisms. Worktops, sinks, etc should be built up to walls and any gaps sealed. Where gaps are unavoidable they should be wide enough for easy cleaning. Movable worktops adjacent to machines permit easy cleaning and maintenance.



Ledges trap dust particles and should be avoided. This is particularly important in the packing room and linen preparation room which as clean rooms require finishes which are easily cleaned and low in maintenance.



Finishes must be suitable to cope with heavily loaded trolleys which are used in many spaces. Buffering on trolleys and mobile equipment is one of the most effective ways of reducing damage.

Flooring in the CSPD: 

Throughout the processing areas, stores and circulation spaces a uniform floor level must be maintained. The finish must be suitable for heavy trolley traffic. The flooring should be turned up at walls in an integral covered skirting which should be continuous with the floor and be finished flush with the wall so that the junction between the skirting and the wall does not provide a ledge for the collection of dust.



The finish must be hardwearing and easy to clean. Appropriate finishes would be PVC sheet with welded joints or resin based flooring. A non slip surface should be considered for wet areas.

Walls in the CSPD: 

In the storage and processing areas hollow wall construction should not be used because of possible infestation risk and liability to trolley damage. Walls should be of solid construction, rendered to a hard smooth finish to withstand heavy treatment. Epoxy coating would be appropriate in

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

processing areas. Emulsion paint is appropriate in stores, circulation areas and staff areas. Ceilings: The minimum height from floor level to ceiling is 2.8 metres. Doors: Doors should be adequately sized to allow clear passage of trolleys and wheeled medical equipment.

Patient room: The patient room should be planned to provide the maximum amount of patient comfort while allowing for the greatest quality of patient care. The room should be designed to provide enough space for the patient and family or visitors as well as equipment. Spatial Requirements: It is recommended that the area for one bed room should be less than 120 sq feet in the general ward. The two bed rooms should be of 350 sq feet in size with a minimum of 175 sq ft allotted to each bed and provided with curtains for visual privacy. The private and deluxe rooms should have a area of 350 sq. ft. There should not be less than four feet of space between the beds, and sufficient space to allow the nurse to pass between the bed and the wall. Important design considerations: 

The patients beds should be placed parallel to the exterior wall so that patients can avoid facing the window and the outside glare.



The doors of the patient rooms should not open outward into the corridor.



The toilet in the patient room should be provided with a grab bar and an emergency call button within easy reach. 30 to 35 mm diameter of the grab bar will provide most people with a safe grip.



14

The door of the toilet should open outwards towards the patient room.

86

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL



Electrical outlets for a reading light, nurses call and television should be at the head of the bed and so also the telephone.



An additional electrical outlet for cleaning equipment like vacuum cleaner and portable X ray is needed on the opposite wall.



The television may be ceiling hung or wall hung and should be in direct sight from the bed.



Windows should be provided for orientation of the patient to the outside world. The height of the window sill should not exceed three feet to allow the patient the outside view.



The door width of all patient rooms should not be less than 1.2 m so that a standard hospital bed can be wheeled in without obstruction. A standard hospital bed measures 1.0 m in breadth and 2.15 m in length.



Suitable width of corridors is 2.4 m to facilitate movement of stretcher trolleys.



The floor of ceiling height of the ward unit should not be less than 3.00 m.



A comfortable working height while standing is usually 91.5 cm at the wash basin rim. Wash basins used by wheelchair patients should have a maximum height of 80 cm.

Movable Modular Casework and furniture: ♦

L carts or supply carts for general medical supplies.

♦

C frame storage units with drawers for general patient supplies.

♦

Cantilevered work surfaces for nurse charting.

♦

Patient bed

♦

Chair for the patient

♦

Visitors chair.

Lighting requirements: In the patient room the level of illumination of 100 lux is quite satisfactory for general lighting of the patient areas which will also meet the needs of the nursing staff. For examination purposes an examination light capable of providing 500 to 1000 lux will be required. Noise in ward units:

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Acceptable noise levels in wards range between 30 to 40 decibels.

BIBLIOGRAPHY: 1. Hospitals: The Planning and Design Process – Owen Hardy and Lawrence Lammers. 2. Designing for total Quality in Healthcare- Kunders G. D. 3. Principles of Hospital Planning and Administration – B.M. Sakharkar. 4. Hospital Planning and Administration –MacCaulay and Llewelyn-Davies. 5. The Frontline Hospital- by Philip Mein. An article in a WHO offset publication. 6. Planning,

building

and

operation

of

healthcare

facilities

–

B.

M.

Kleczkowski. Also an article in a WHO offset publication. 7. Modern Hospital – International Planning Practices – Ervin Putsep. 8. Hospital Planning Module – Dr. Vivek Desai. 9. Herman Miller – Graphic Standards Programming and Schematic Design. 10. Building Type Basics For Healthcare Facilities – Stephen A. Kliment. 11. Sterile Services Department – Scottish Hospital Planning Note. 12. Hospital Planning Design & Management – G.D. Kunders. 13. Hospital Architecture – Guidelines for design & renovation – David R. Porter. 14. www.aerb.gov.in - Safety code on medical, diagnostic X- ray equipment and installations.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

ANNEXURE 1 List of Licenses, Registrations and Approvals required. License Food inspector license (storage of

Agency Municipal Authority

kitchen items) Storage of spirit Storage of acids, alcohols, acetone, X

Municipal Authority Municipal Authority

ray films, oxygen cylinders LPG cylinders Drug license form 12(permission to

Central Govt. Prohibition and excise dept.

import) License for spirit License for alcohol

Prohibition and excise dept. Prohibition and excise dept.

Registration Reg. Under Shops and establishment

Agency Municipal Authority

Act FDA for blood bank FDA for Pharmacy Reg of vehicles(ambulances)

Central Govt. Central Govt. RTO

Approval list of items Imaging dept (X ray, MRI, CT scan,

Agency BARC, Central govt.

Gamma camera, RIA, Mammography) Chimney for incinerator 14

Pollution board 89

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

Electrical installations Lifts Fire Fighting Incinerator Sewage treatment plant

PWD, municipal authority Municipal Authority Chief fire Officer Pollution Board Pollution board

Annexure 2 AERB SPECIFICATIONS FOR MEDICAL DIAGNOSTIC X-RAY EQUIPMENT

PURPOSE

This Code is intended to govern radiation safety in the design, installation and operation of medical diagnostic X- ray equipment in order to:(a) ensure that workers occupationally exposed to radiation/members of the public are not exposed to radiation in excess of the operational limits specified under the Radiation Protection Rules, 1971; (b) do whatever is reasonably achievable to reduce radiation exposures below these limits; (c) ensure availability of appropriate equipment, personnel and expertise for patient protection; and (d) ensure timely detection and prompt rectification of radiation safety related defects or malfunctioning of the equipment.

SCOPE

14

Radiation safety in the use of radiation generating plants is governed by section 17 of the Atomic Energy Act, 1962. Pursuant to the provisions of the Act, the Central Government had promulgated the Radiation Protection Rules, 1971 Which stipulate basic safety standards for all types of radiation applications in medicine, industry, research etc. Appropriate radiation surveillance procedures have been issued under rule 15 for ensuring radiation protection in various types of applications. Radiation Surveillance Procedures for Medical Applications of Radiation are applicable to medical X- ray equipment and installations. This Code elaborates the safety requirements contained in the Atomic Energy Act, 1962 and the Radiation Surveillance Procedures, relevant to medical diagnostic X-ray equipment and installations and their use. Practical aspects of implementing these requirements will be further elaborated in the various guides to be issued under this Code.

90

AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

In this Code, unless the context otherwise requires:-

14

(i)

"adequate protection" means protection against radiation so provided that the levels of radiation are kept as low as reasonably achievable and in no case exceed the prescribed operational limits;

(ii)

"appropriate" means appropriate in the opinion of the competent authority to ensure adequate protection;

(iii)

"collimator" or "field limiting diaphragm" means the mechanism for defining the useful beam;

(iv)

"commissioning" means starting the use of a diagnostic X-ray equipment subsequent to performing such tests and measurement as are necessary to confirm the safety and performance of the equipment as per the design intent;

(v)

"competent authority" means any officer or authority appointed by the Central Government by notification. At present atomic Energy Regulatory Board is the competent authority;

(vi)

"cone" means a device by which the X- ray beam is confined to a specified area;

(vii)

"decommissioning" means discontinuation of the use of a diagnostic X-ray equipment on a permanent basis, with or without dismantling the equipment;

(viii)

"dose" means energy absorbed in matter from ionising radiation per unit mass of the matter. The S.I. Unit of dose is gray (Gy). The special unit of dose is the rad and 1 rad = 1 centigray (cGy);

(ix)

"dose equivalent" means the quantity obtained on multiplying the absorbed dose in tissue by appropriate weighting factors to correct and normalize for variation in the degree of biological effect produced by the same dose of different ionising radiations or under different irradiation conditions. The dose equivalent is used for radiation protection purposes only. The unit of dose equivalent is sievert (Sv) when the absorbed dose is expressed in gray. 1 sievert = 100 rem (Appendix-IV) ;

(x)

"dosimetry" means operations and measurements performed

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

in connection with (a) the determination of rediation dose;(b) dose distributions in the irradiated volume; and (c) measurements related to operational limits;

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(xi)

"employer" means any person who employs radiation workers or who is self-employed as the only radiation worker in a radiation installation;

(xii)

"filter" means a layer of radiation attenuating material incorporated in the tube housing to preferentially absorb the less penetrating components of the useful beam; "permanent filter" means the filter which is an integral part of the tube housing and which cannot be removed by the user, unlike the "added filter";

(xiii)

"fluoroscopic screen" means a card-board or plastic base upon which a layer of fluorescent salt is evenly spread which emits visible radiation on being subjected to X- rays;

(xiv)

"focus" means that area of the anode in an X-ray tube on which X- ray producing electrons are incident. The area from which the useful beam appears to originate, relative to the film is called "apparent focus".

(xv)

"grid" means a device composed of alternate strips of lead and radiolucent material encased suitably to be placed between the patient and X- ray film to absorb scatter. "potter bucky grid" or "bucky" means a device containing a grid and a mechanism to impart motion to the grid during radiography exposure;

(xvi)

"handle" means manufacture, possess,store,use, transfer by sale or otherwise, import, transport or dispose of;

(xvii)

"kerma" means the energy transferred (per unit mass) by gamma rays, X-rays, or neutrons in the form of kinetic energy of secondary charged particles at the point of interest in an irradiated medium. If the irradiated medium is air,the corresponding kerma is called air kerma. The SI unit of kerma is gray ( Appendix-IV);

(xviii)

"lead equivalence" means the thickness of lead, which, under specified conditions of irradiation, affords the same attenuation as the material under consideration;

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

14

(xix)

"leakage radiation" means radiation coming out of the tube housing out side the useful beam area.

(xx)

"light beam collimator" or "light beam diaphragm" means the mechanism to collimate and indicate the radiation field by an optical equipment;

(xxi)

"mobile equipment" or "portable equipment" means equipment intended to be moved or carried from carried from one location to another between periods of use;

(xxii)

"operational limits" means limits on levels of radiation as the competent authority may by notification specify from time to time;

(xxiii)

"person" includes(I) any individual, corporation, association of persons whether incorporated or not, partnership, estate, trust, private or public institution, group, government agency, or any state or any political sub-division thereof or any political entity; (ii) any legal successor, representative or agent of each of the foregoing;

(xxiv)

"protective barrier" or "shielding" means a barrier of radiation attenuating material used to reduce radiation levels;

(xxv)

"quality assurance tests" means tests performed to ensure the performance and reliability of the X-ray equipment as per the design specifications;

(xxvi)

"radiation" in the context of diagnostic X- ray equipment means X- rays originating from the X-ray tube or its high voltage components/accessories, It also includes the scattered radiation;

(xxvii)

"radiation protection survey" means an evaluation of radiation safety in and around a radiation installation using appropriate radiation measuring instruments;

(xxviii)

"radiation surveillance" means measure that may be specified by the competent authority to provide adequate protection either generally or in any individual case;

(xxix)

"radiation worker" means any person who is occupationally exposed to radiation and who in the opinion of the competent authority should be subject to radiation surveillance;

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

(xxx)

"radiograph" means a permanent record of a transmission image, produced by a beam of X-rays after passing through the subject;

(xxxi)

"radiological safety officer" means any person who is so designated by the employer and who in the opinion of the competent authority is qualified to discharge the functions outlined in the Radiation Protection Rules, 1971;

(xxxii)

"safety" means radiation safety and does not include electrical/mechanical and other safety considerations;

(xxxiii)

"scatter" or "scattered radiation" means radiation scattered by the medium on which the primary beams is incident;

(xxxiv)

"stationary equipment" means either fixed equipment or equipment which is not intended to be moved from one place to another,

(xxxv)

"tube housing" means a shielding enclosure provided around an X- ray tube, in order to(I) define the useful beam; and (ii) limit the radiation levels outside of the useful beam such as not to exceed the radiation leakage levels as specified in section 3 of this Code;

(xxxvi)

"useful beam" or "primary beam" means that part of the emergent radiation from an X-ray tube housing which is capable of being used for the purpose for which the X-ray equipment is intended; and

(xxxvii)

"X-ray equipment" or "x-ray unit" means the integrated assembly consisting of X-ray tube along with its housing, support structure, associated accessories necessary for proper operation and inclusive of built-in-radiation safety devices as provided in section 3 of this Code.

In this Code(i) "shall" indicates a mandatory requirement as per provisions in the Radiation Protection Rules, 1971; (ii) "must" indicates a recommendation that is essential to meet the currently accepted standards of radiation protection; and (iii) "should" indicates an advisory recommendation that is highly desirable and that is to be implemented where feasible.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

BUILT- IN SAFETY SPECIFICATIONS FOR MEDICAL DIAGNOSTIC X-RAY EQUIPMENT Specifications for Radiography Equipment TUBE HOUSING

Every tube housing for medical diagnostic X-ray equipment shall be so constructed that the leakage radiation through the protective tube housing in any direction, averaged over an area not larger than 100 cm2 shall not exceed an air kerma of 1 mGy in one hour approximately 115 mR in one hour) at a distance of 1.0 meter from the X-ray source when the tube is operating at each of the ratings specified by the manufacturer. There must be a distinctly visible mark on the tube housing to indicate the plane of the focus.

CONES &/ DIAPHRAGMS

The X-ray tube housing must be provided with light beam collimators for all general purpose stationary diagnostic X-ray machines. For mobile units, a light beam collimator should be preferred over cones wherever possible. Field limiting diaphragms or cones shall comply with the leakage radiation level requirements prescribed for the tube housing. Each cone should be indelibly marked with field size at the specified focus to film distance.

BEAM FILTER

The useful beam portal of an X-ray tube housing with maximum rated operating potential above 100 kV must have a total filter equivalent to at least 2.5 mm aluminum of which 1.5 mm should be permanent. The X-ray tube housing must have a total filter equivalent to at least 2.0 mm aluminum ( of which 1.5 mm should be permanent) for units operating upto 100 kV except mammography and dental units. Mammography units must have a permanent filter equivalent to at least 0.5 mm aluminum in the useful beam. The total permanent filtration in the useful beam for conventional dental radiography equipment with a maximum tube voltage not exceeding 70 kV must be equivalent to not less than 1.5 mm aluminum. The inherent\permanent filter incorporated must be indicated in the housing. The added filters must have their equivalent filtration clearly marked

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

on them. TUBE POSITIONING

The X-ray unit must have appropriate features and display aids for tube positioning, target to film distance selection, useful beam centering and angulation, positioning of the patient and for the Xray film exposure in the desired manner.

LOCKING DEVICES

The tube housing and the tube stand must have appropriate locking devices to immobilize` the tube in the desired location and orientation.

BUCKY ALIGNMENT

The X-ray table must have provisions for correct positioning of the grid, the bucky tray and the film cassette in proper alignment with the useful beam and for their locking in the desired position.

CABLE LENGTH

The X-ray unit must have electrical cables of sufficient length so that the control panel/operation switch can be located and operated from a minimum distance of 3 metres from the nearest position of the X-ray tube. For dental radiography units and mobile/portable X-ray equipment the cable must not be less than 2 metres.

CONTROL PANEL

The control panel must be provided with means to indicate the exposure parameters and conditions including the tube potential, tube current, time of exposure, integral exposure in milliampere seconds (mAs), technique selection and the engagement of the buck mechanism. A Clearly marked and identifiable indicator must be provided at the control panel to show whether the X-ray beam is 'ON' or 'OFF' for portable/mobile/dental units appropriate exposure parameters should be provided.

COMMON STATION

When more than one tube can be operated from a single control panel, there must be indication at or near the tube housing and on the control panel showing which of the tubes is being operated.

EXPOSURE SWITCH

The control panel must have provision to terminate the X-ray exposure automatically after a preset time or manually at any moment before this time by removing pressure from it , When mechanical timers are provided, repeated exposures must not be possible without resetting the timer. The timer must

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be so arranged that inadvertent exposure is not possible. RADIATION LEAKAGE The radiation level at 5 cm from the transformer FROM TRANSFORMER surface of the X-ray unit shall not exceed 5 mGy in one hour (approximately 0.6 mR in one hour). SPECIAL CONES

The field defining cone-cum-spacer of dental radiography and mammography units must be such that they will ensure a focus to skin distance of at least 20 cm for equipment operating at more than 60 kV and at least 10 cm for dental radiography must limit the field diameter at these distance to less than 7.5 cm at the cone end.

Specifications for Fluroscopy Equipment FLUOROSCOPY TUBE HOUSING AND FILTRATION

The tube housing shall conform to the leakage radiation levels prescribed for radiography equipment in 3.1.1 The useful beam must aluminum for general fluoroscopy and not less than 2.5 mm for cardiovascular studies.

PROTECTIVE LEAD GLASS

The protective lead glass covering of the fluorescent screen must have a lead equivalent thickness of 2.0 mm for units operating upto 100 kV. For units operating at higher kilovoltages the lead equivalence must be increased at the rate of 0.01 mm per kV.

LEAD RUBBER FLAPS

The X-ray table and the fluoroscopy stand must be provided with means of adequate protection for the radiologist and other staff against the scattered X-rays. Lead rubber flaps having lead equivalence of not less than 0.5 mm and sufficient dimensions to protect the radiologist must be so provided that they are suspended (a) from the bottom of the screen such that the flaps overlap the fluoroscopic chair in vertical fluoroscopy and (b) from the edge of the screen, nearest to the radiologist, such that the flaps extend down to the table top in case of horizontal fluoroscopy. The 'bucky-slot' must be provided with a cover of 0.5 mm lead equivalence on the radiologist's side.

TUBE SCREEN ALIGNMENT

The X-ray tube and the fluoroscopic screen must be rigidly coupled and aligned so that both move together synchronously and the axis of the X-ray beam passes through the centre of the screen in all positions of the tube and screen.

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FIELD LIMITING DIAPHRAGM

The field limiting diaphragm control mechanism must be so mechanically restricted that even when the diaphragm is fully opened and the screen is at the maximum distance from the table there is still an unilluminated margin of at least 1 cm all along the edges of the screen.

FOCUS TO TABLETTOP DISTANCE

The focus to table top distance must be so adjusted mechanically that it shall not in any case be less than 30cm for fluoroscopy units and should preferably be (a) 45 cm for general fluoroscopy units. And (b) 60 cm for units used exclusively for chest screening.

DIAPHRAGM CONTROL

The diaphragm control knobs must be located on the frame of fluorescent screen and provided with local shielding, if necessary, so as to offer adequate protection for the hands of the radiologist.

FOOT-SWITCH & VISUAL INDICATOR

foot operated pressure switch must be provided for conduction fluoroscopy examinations. There must be a visual indication on the control panel when the beam is 'ON'.

FLUOROSCORY TIMER

The unit must have a cumulative timer and its maximum range shall not exceed 5 minutes. There should also be provision for an audible signal at the end of the preset time.

TABLE-TOP DOSE

The air kerma rate measured at the table top for the minimum focus to table top distance should be as low as possible and in any case must not exceed 5 cGy per minute (approximately 5.75 R per minute).

AUTOMATIC BRIGHTNESS

When automatic brightness control is used to adjust kV or mA of the X-ray tube to maintain constant luminescence at the viewing screen, appropriated monitoring equipment must be incorporated to check the Tube potential and tube current

SPECIFICATIONS FOR RADIATION PROTECTION DEVICES PROTECTIVE BARRER

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The protective barrier for positioning between the operator/control panel and the X-ray tube/patient must be of appropriate size and design so as to shield the operator adequately against leakage and scattered radiation. The

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

protective barrier must have a minimum lead equivalence of 1.5 mm. A viewing window having 1.5 mm lead equivalence must be provided in the barrier. The lead equivalence must be indicated on the barrier as well as on viewing window. FLUOROSCOPY CHAIR

The fluoroscopy chair must have a minimum of 1.5 mm lead equivalence and its design must ensure adequate protection to the radiologist against stray radiation.

PROTECTIVE APRONS

The protective aprons must have a minimum lead equivalence of 0.25 mm and their size/design must ensure adequate protection to the torso and gonads of the user against stray radiation.

PROTECTIVE GLOVES

Protective gloves must have a minimum lead equivalence of 0.25 mm and the design must ensure adequate protection against stray radiation reaching the hands and the wrists and must permit easy movements of the hand/fingers.

GONAD SHELD

The gonad shields must have a minimum lead equivalence of 0.5 mm.

PASS BOX

The cassette pass box intended for installation in the X-ray room wall must have a shielding of 2.0 mm lead equivalence. The design must be such that the pass box can be opened from one side at a time.

FILM STORAGE

The box intended for temporary storage of undeveloped films must not have less than 2.0 mm lead equivalence all around.

VEHICLE X-ray units installed in a mobile van or vehicle e.g. for MOUNTED Xmedical surveys/clinics in remote areas, must be provided RAY EQUIPMENT with an appropriate shielding enclosure so as to ensure adequate built in protection for persons likely to be present in and around the vehicle. SHIELDING CONTINUITY

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Appropriate overlap of shielding materials must be provided at the joints or discontinuities so as to ensure minimum prescribed shielding all over the surface of all radiation protection devices. Care must be taken to ensure that lead or any other shielding material does not creep or flow, resulting in reduction of shielding in any location.

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

MARKINGS

The lead equivalence of shielding incorporated in radiation protection devices must be marked conspicuously and indelibly on them.

CONVENTIONAL SAFETY

Facilities for immobilization of patients, specially children, should be provided so as to minimize holding of patients during X-ray examinations.

CONVENTIONAL SAFETY

Appropriate equipment must be available to prevent/manage conventional hazards such as fire, flooding and electrical emergencies.

SAFETY ACCESSORIES

Additional radiation protection devices which would be necessary for specialized radiological investigations must have a minimum of 0.5 mm lead equivalence

SERIAL CHANGERS

Automatic serial changers should be used where the volume of work demands such specialized equipment.

LOCATION OF The rooms housing diagnostic X-ray units and related X-RAY equipment should be located as far away as feasible from INSTALLATION areas of high occupancy and general traffic, such as maternity and paediatric wards and other departments of the hospital that are not directly related to radiation and its use. LAYOUT

The layout of rooms in an X-ray department should aim at providing integrated facilities so that handling of X-ray equipment and related operations can be conveniently performed with adequate protection. The number of doors for entry to the X-ray room should be kept to the minimum. The doors and passages leading to the X-ray installation should permit safe and easy transport of equipment and non-ambulatory patients. The dark room should be so located that the primary X-ray beam cannot be directed on it.

ROOM SIZE

The room housing an X-ray equipment must be spacious enough to permit installation, use and servicing of the equipment with safety and convenience for the operating personnel, the servicing personnel and the patient. The room size must not be less than 25 sq.m. for a general

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AN ARCHITECTURAL BRIEF FOR A PROPOSED 100 BEDDED HOSPITAL

purpose X-ray machine. SHIELDING

Appropriate structural shielding shall be provided for the walls, the ceiling and the floor of the X-ray room so that the doses received by workers occupationally exposed to radiation and the members of the public are kept to a minimum and shall not exceed the annual effective dose equivalent limits of 50 mSv and 1 mSv respectively. The doors of an X-ray room shall provide the same shielding as that of the adjacent walls, in case persons are likely to be present in front of them when the X-ray unit is energized. Appropriate shielding must be provided for the dark room to ensure that undeveloped X-ray films stored in it will not be exposed to more than an air kerma rate of 10mGy per week (approximately 1.13 m R per week).

OPENING & VENTILATION

Unshielded openings, if provided in am X-ray room for ventilation or natural light etc., must be located above a height of 2 meters from the ground/floor level outside the X-ray room.

ILLUMINATION Rooms housing fluoroscopy equipment must be so designed CONTROL that adequate darkness can be achieved conveniently when desired in the room. For the use of radiologist after dark adaptation. EQUIPMENT LAYOUT

The X-ray equipment must be installed in such a way that in normal use the useful beam is not directed towards control panel, doors, windows or areas of high occupancy. The useful beam should preferably be directed towards unoccupied area should be left all around the X-ray table for safe and free movements of equipment-trolley, radiology staff and service personnel.

CONTROL PANEL

In the case of diagnostic X-ray equipment operating at 125 kV or above the control panel must be installed in a separate control room located outside but contiguous to the X-ray room and provided with appropriate shielding, direct viewing and oral communication facilities between the operator and the patient.

WAITING AREAS

Patient waiting areas must be provided outside the X-ray room.

WARNING LIGHT & PLACARD

A suitable warning signal such as a red light must be provided at a conspicuous place outside the X-ray room and kept 'ON' when the X-ray unit is in use, to prevent

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inadvertent entry of persons not connected with the examination. An appropriate warning placard, as indicated in Appendix-III, must also be outside the X-ray room.

OPERATIONAL SAFETY COMMISSIONING

When a diagnostic X-ray equipment is newly installed/reinstalled in a new location/the equipment is subjected to major repairs or structural modifications are carried out in the existing installation, the installation shall not be commissioned unless a radiological protection survey conducted by the R.S.O. or any other person duly authorized by the competent authority has confirmed adequate protection and operational safety in the X-ray installation. Records of all such surveys shall be maintained for inspection of the competent authority.

PERIODIC INSPECTION

Periodic inspection of the X-ray equipment, the lead rubber protective clothing and the safety/shielding features of the X-ray room must be conducted to assure replacement of defective components/items affecting radiation safety. Records of all such inspections must be maintained.

OPERATION OF X-RAY EQUIPMENT

The X-ray equipment should be so operated that the primary beam is directed towards the areas of the primary beam is directed towards the areas of minimum occupancy. Installation of more than one X-ray unit in the same room should therefore be discouraged. Only the patient whose radiological examination is to be carried out shall be allowed in the room except under conditions specified under

CONTROL PANEL

When the control panel is in the X-ray room itself, the panel must be located as far away from the X-ray unit/chest stand as possible and duly shielded by a protective barrier.

FURNISHING & FIXTURES

When the control panel is in the X-ray room itself, the panel must be located as far away form the X-ray unit/chest stand as possible and duly shielded by a protective barrier.

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BEAM RESTRICTION

Under no circumstances must the X-ray beam be directed towards the control panel and other similar areas where the shielding is adequate for secondary radiation only.

ASSISTANCE TO PATIENTS

Holding of children or infirm patients for X-ray examinations must be done only by an adult relative or escort of the patient and not by a staff member. Protective aprons and gloves must be provided to persons rendering such help. Innobiliasation devices should be used to prevent movement of children during exposure. In no case shall the film or the X-ray tube be held by hand.

SAFETY OF STAFF All efforts must be made to conduct the X-ray examination in such a way as to achieve the desired result with minimum of exposure to the patient/staff. Measures such as use of protective clothing, optimum exposure setting, minimization of retakes and optimum film processing techniques must be employed for this purpose. OPERATIONAL STAFF

No persons other than those specifically concerned with a particular X-ray examination shall stay in the X-ray room during radiological examination. The X-ray unit must not be operated by any unauthorized person.

MOBILE EQUIPMENT

A mobile X-ray unit shall be used with appropriate safety measures to protect the public in the vicinity. Minimum occupancy, maximum distance from occupied areas and temporary shields shall be employed for the purpose.

SERVICING OF UNIT

Servicing X-ray equipment must be undertaken only by such technologists who have been authorized by the competent authority on the basis of their expertise and radiation protection background to undertake this job safety. In addition to the personnel monitoring devices, the service personnel must use appropriate radiation survey meters and direct reading dosimeters for on the spot verification of their working conditions.

PATIENT PROTECTION EXAMINATION REQUIRMENT

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Any X-ray examination should be prescribed only after a critical evaluation of the patient’s condition in order to

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avoid unnecessary exposures. In the event of doubt on the advisability of an X-ray examination the matter should be resolved by the radiologist in consultation with the referring physician. Clinical indications, provisional diagnosis and information required form Xray examination should be stated by the referring physician. The practice of conducting mass radiological surveys for the detection of tuberculosis, mass mammography for occult carcinoma and chest examinations should be undertaken with caution. TRANSFER OF RECORDS

Transfer of radiographs from one institution to another should be encouraged to avoid repeat examinations.

QUALITY ASSURANCE

A new diagnosis X-ray equipment must not be used unless all the appropriate quality assurance tests have been performed satisfactorily. Quality assurance tests must be repeated periodically to ensure continued good performance. Any defects noticed must be corrected before recommisioning the unit.

FLUOROSCOPY REQUIREMENT

No fluoroscopic examination should be conducted if the required information can be obtained form radiography. Wherever possible image intensifiers of high gain, coupled with a TV monitor should be used for fluoroscopy. No fluoroscopic work shall be done on equipment not designed for fluoroscopy.

PATIENT DOSE REDUCTION

All efforts shall be made to keep the patient dose as low as technically achievable. Appropriate techniques such as use of high efficiency filmscreen combinations, minimum field size, minimum fluoroscopic time and tube current, good dark adaptation and room darkening must be employed for this purpose in day–to-day practice of radiology.

ELECTIVE RADIOLOGICAL EXAMINATIONS OF FEMALES

Elective radiological examinations of the lower abdomen and pelvis of women in the reproductive age should be carried out. Preferably within the first 10 days from the onset of menstruation. However the examination may be performed if the clinical condition of the patient needs immediate X-ray examination.

FOETAL PROTECTION

Radiological examination of the lower abdomen and pelvis of a pregnant woman must be conducted that the foetus receives minimum possible radiation dose. In all other X-ray examinations of the pregnant women the

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lower abdomen and the pelvis must be covered with a protective shield. ORGAN SHIELD

Gonad shields must be employed to shield the reproductive organs of the patient unless it would interfere with the information desired. Eye shields should be provided to protect the eyes of the patients undergoing some special examinations like carotid angiography. Thyroid shields should be used where necessary.

EXAMINATIONS OF CHEST

Photoflurography and radiography of the chest should be performed with a focus to receptor distance of at least 120 cm.

RECORDS

Records of all radiological examinations should be maintained by the radiologist for follow-up and future reference. Reports, and if possible radiographs, should be given to the patient for future reference.

RADIATION PROTECTION PROGRAMME FUNCTIONS OF R.S.O.

The radiological safety officer (RSO) shall implement all radiation surveillance measures, conduct periodical radiation protection surveys, maintain proper records of personnel doses, instruct all radiation workers on relevant safety measures, educate and train new entrants and take appropriate local measures including the issuance of clear administrative instructions in writing to deal with radiation emergencies. The RSO shall ensure that all radiation measuring and monitoring instruments in his custody are properly calibrated and maintained in good condition. Suitable records of such surveys, including the layout drawing, dose mappings, deficiencies noticed and the remedial actions taken shall be maintained for future follow-up.

PERSONNEL MONITORING

Appropriate personnel monitoring devices shall be used by all radiation workers.

PREGNANT WORKERS

Once pregnancy of a radiation worker is established, she shall not receive more than

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10 mSv (1 rem) at a uniform rate during the remaining period of her pregnancy . TRAINNES

Medical students/trainees must not operate an X-ray equipment except under the direct supervision of authorized operating personnel.

STORAGE OF RADIATION SENSITIVE MATERIALS

Storage of undeveloped X-ray films and personnel monitoring devices must be done appropriately in areas protected form X-rays and other radiation sources in the installation.

PERSONNEL REQUIREMENTS AND RESPONSIBILITIES SAFETY PERSONNEL

Every X-ray installation shall have a radiological safety officer. The radiological safety officer may be employer himself or a consultant or a full/part time employee to whom the employer will delegate the responsibility of ensuring compliance with the appropriate radiation safety/regulatory requirements applicable to his X-ray installation. The minimum qualification and experience currently prescribed for an R.S.O. are indicated in Appendix-I

RADIOLOGIST

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All diagnostic radiology installations should be manned as far as possible by qualified radiologists. However, the services of a qualified radiologist must be made available in (i) all installations having more than two Xray units or even single X-ray unit having fluoroscopy facility and (ii) all establishments performing special procedures such as cardiac catheterization, angiography procedures, genito-uro-radiological procedures such as cardiac catheterization, angiography procedures, C.T. scans and all other sophisticated imaging devices and procedures. The minimum qualifications and experience currently prescribed for a radiologist are given in Appendix-I. Other installations having a single X-ray unit without fluoroscopy may be manned by a physician without radiology qualifications but having a degree recognized by the Medical Council of India, provided a qualified/ certified X-ray technologist is available. A dental X-ray equipment may be manned by a dentist

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damentals of radiographic techniques and radiation protection. Only qualified X-ray technologists will be allowed handle X-ray equipment. The minimum qualifications and experience for X-ray technologists in Appendix-I. However, the competent authority may consider relaxation of qualifications for certification of radiography technologists in case of experienced personnel where only the X-ray unit without fluoroscopy facility installed. RESPONSIBILITES In any diagnostic X-ray installation, the ultimate OF THE EMPLOYER responsibility of ensuring radiation safety, availability of RSO and qualified personnel for handling of X-ray equipment and providing them requisite equipment and facilities to discharge their duties and functions shall rest with the employer. He shall inform the competent authority of any change in equipment or staff including the RSO. RESPONSIBILITES OF THE RADIOLOGIST

The radiologist shall undertake an X-ray examination on the basis of a medical requirement. He shall so conduct the examination as to achieve maximum reduction in radiation dose to the patient while retaining all clinically important information.

RESPONSIBILITES OF X-RAY TECHNOLOGIST

The X-ray technologist and other attending staff shall ensure appropriate patient protection, public protection and operational safety in handling the X-ray equipment and other associated facilities.

RESPONSIBILITES OF THE R.S.O.

The RSO shall assist the employer in meeting the relevant regulatory requirements applicable to his X-ray installation.

RESPONSIBILITES OF THE MANUFACTURER

The manufacturer of X-ray equipment must make available to the actual user detailed procedures for routine quality assurance tests, exposure charts, operating manuals and a copy of safety/regulatory documents as may be issued by the competent authority from time to time. The manufacturer must provide appropriate servicing and maintenance facilities during the useful life time of the X-ray equipment.

REGULATORY CONTROLS

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DESIGN CERTIFICATION

Every medical X-ray diagnostic equipment shall meet the design safety specifications stipulated in this code. The manufacturer/vendor shall obtain design certification from the competent authority prior to marketing the X-ray equipment.

REGISTRATION OF X-RAY EQUIPMENT

The sale, transfer, gift, leasing or loan of X-ray equipment must be registered with the competent authority by the seller or the person transferring such equipment.

REPORT ON UNSAFE EQUIPMENT

Persons undertaking servicing of X-ray equipment must immediately report to the competent authority any equipment no longer safe for use according to this equipment, its locations/address, the name and address of the employer/owner and nature of defects that equipment hazardous.

INSPECTION

The diagnostic X-ray installation shall be made available by the employer for inspection, at all reasonable times, by the competent authority or his representative, to assure compliance of this code.

DECOMMISIONING

Decommissioning of an X-ray equipment shall be registered with the competent authority by the employer immediately.

GUIDE & ORDERS

The employer shall ensure that persons handling medical x-ray diagnosis equipment duly addible by the previsions of this Code and their further elaboration in the various Guides issued by the competent authority. He shall also ensure that these documents are made available to them and further that any other measures of safety as the competent authority may stipulate at any time in each individual case are duly implemented without delay.

CERTIFICATION OF Any consultant undertaking contract(s) to discharge the RSO duties and functions of RSO in diagnostic X-ray installations shall do only after obtaining certification from the competent authority for the purpose. Such certification shall be granted on the basis of his qualification, experience and the testing/survey/dosimetry equipment available with him. CERTIFICATION OF Servicing of X-ray equipment shall be undertaken only SERVICE by persons holding a valid servicing safety certification

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ENGINEERS

from the competent authority. The certification shall be granted on the basis of his qualification ,training, experience, safety record and the servicing facilities of such person.

REVOCATION OF CERTIFICATION

The competent authority may revoke the license/certification of an RSO/Service Engineer in the event of persistent negligence in the discharge of his duties.

PENALTIES

Any person who contravenes the provisions of the Radiation Protection Rules, 1971 elaborated in this code or any other terms or conditions of certification granted to him by the competent authority, is punishable under section 24, section 25 and section 26 of the Atomic Energy Act, 1962. The punishment may include imprisonment or fine or both.

Source:www.areb.gov.in -Safety code on medical, diagnostic X- ray equipment and installations.

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