Our term repot is to design a 50-bed hospital

and equipment it with all the needed facilities

of fire fighting and safety needs, layout plan
for the facilities is needed.

Introduction
Hospitals are to healthcare what Gothic cathedrals are to religion. They
are constructions of fallible man to inspire and encompass healing by
reaching heavenward. And like the Gothic cathedral, the “flying
buttresses” of technology, knowledge, and process, keep the edifice
from collapse. Through the rose window the entering patient sees a
vision of health and happiness, but the window is merely a thin screen,
which distorts the reality of life. The reality of life is that human frailty,
manifest in the work within the hospital, often leads to unintended
events with harmful consequences.

A modern hospital in "caring for its' patients" must always strike a

balance between the need to specialize health care with the need for
flexibility on organization, a flexibility imposed by technological
development and the evolution.

Design in the health care field today means:

Knowing today's health care process, with an eye to the near future;
Integrating health exigencies with technological limits (structures,
plant, machines); Blending a complex organization with the "patient's"
human face.

For Hospital Consulting, hospital design and planning means, primarily,

providing health care management and operations managers with the
specialist skills to identify, by agreement, the best suited functional
solutions for that specific operation.

The preliminary plan cannot but spring from a meeting of health

organization specialists and architectural, plant and technology
experts, with those who will work daily within that structure.

Hospitals are complex. The physical environment in which that

complexity exists has a significant impact on health and safety;
however, enhancing patient safety or improving quality has not been
integrated in to aspects of the design of hospital buildings. Despite the
recent discussions in architectural literature regarding design of
“patient-centered” health care facilities and “evidence based design,”
little assessment has been conducted of the impact of the built
environment on patient outcomes. Studies have focused primarily on
the effects of light, color, views, and noise, yet there are many more
considerations in facility planning that can influence the safety and
quality of care.

The hospital industry is in the throes of the largest building boom in its
history. In the next decade, an estimated $200 billion will be spent on
new hospital construction across the United States. Analysis of more
than 400 research studies shows a direct link between quality of care,
patient health, and the way a hospital is designed. Here are a few
examples of how changes in design can improve the quality of care:

Patient falls declined by 75 percent in the Cardiac Critical Care Unit at

Methodist Hospital in Indianapolis, Indiana, which made better use of
nursing staff by dispersing their stations and placing them in closer
proximity to patients' rooms.

The rate of hospital-acquired infections decreased 11 percent in new

patient pavilions at Bronson Methodist Hospital in Kalamazoo,
Michigan, which was attributed to a design that featured private,
rooms and specially located sinks.

Medical errors fell 30 percent on two new inpatient units at The

Barbara Ann Karmanos Cancer Institute in Detroit, Michigan after they
allocated more space for their medication rooms, re-organized medical
supplies, and installed acoustical panels to decrease noise levels. The
evidence is overwhelming. The healthcare environment -- where care
is actually provided and received -- has substantial effects on patient
health and safety, care efficiency, staff effectiveness and morale. The
United States spends approximately 14 percent of its Gross National
Product on healthcare, much of which is provided in hospitals. Yet,
despite this enormous expenditure and the available technological
resources, today’s hospital care frequently runs afoul of the cardinal
rule of medicine - above all else, do no harm. Hospitals also create
stress for patients, their families, and staff. The negative effects of
stress are psychological, physiological, and behavioral.

These effects include:

 Anxiety, depression, and anger (psychological); Increased blood
pressure, elevated levels of the body’s stress hormones, and
reduced immune function (physiological); and, Sleeplessness,
aggressive outbursts, patient refusal to follow doctor's
 instructions, staff inattention to detail, and drug or alcohol abuse
(behavioral).

 Poor design of the hospital environment contributes to all these

problems. Poor air quality and ventilation, together with placing
two or more patients in the same room, are major causes of
nosocomial infection. Inadequate lighting is linked to patient
depression as well as to staff medication errors. Lack of a strong
nursing presence can result in patient falls.

Seldom does an opportunity emerge to build a new hospital; indeed

most hospitals are in a continuous cycle of remodeling and expanding
their existing facilities to adapt to changing demands.

Outline for Hospital Layout

Hospitals are the most complex of building types. Each hospital is

comprised of a wide range of services and functional units. These
include diagnostic and treatment functions, such as
clinical laboratories, imaging, emergency rooms, and surgery;
hospitality functions, such as food service and housekeeping; and the
fundamental inpatient care or bed-related function. This diversity is
reflected in the breadth and specificity of regulations, codes, and
oversight that govern hospital construction and operations.

Each of the wide-ranging and constantly evolving functions of a

hospital, including highly complicated mechanical, electrical, and
telecommunications systems, requires specialized knowledge and
expertise. No one person can reasonably have complete knowledge,
which is why specialized consultants play an important role in hospital
planning and design. The functional units within the hospital can have
competing needs and priorities. Idealized scenarios and strongly held
individual preferences must be balanced against mandatory
requirements, actual functional needs (internal traffic and relationship
to other (departments), and the financial status of the organization.

In addition to the wide range of services that must be accommodated,

hospitals must serve and support many different users and
stakeholders. Ideally, the design process incorporates direct input from
the owner and from key hospital staff early on in the process. The
designer also has to be an advocate for the patients, visitors, support
staff, volunteers, and suppliers who do not generally have direct input
into the design. Good hospital design integrates functional
requirements with the human needs of its varied users.

The basic form of a hospital is, ideally, based on its

functions:

 Bed-related inpatient functions

 Outpatient-related functions
 Diagnostic and treatment functions
 Administrative functions
 Service functions (food, supply)
 Research and teaching functions

Physical relationships between these functions determine the

configuration of the hospital. Certain relationships between the various
functions are required—as in the following flow diagrams.

We then ask ourselves several guiding questions:

 How and via what mechanisms does the physical environment

participate in patient safety?
 How does the environment of the preoperative system effect
safety?
 What exactly is the preoperative environment?
 What characteristics are used to describe an environment?
 What process creates the physical environment?
 Is it possible to change either the creation process or the result
to improve safety?
Today’s Hospital Design process

Global performance, in terms of outcome, risk management and

safety, is influenced to a great extent by local interactions and
synchronization of system components (e.g., providers, patients,
technologies, information and material resources, physical and
temporal constraints). As a result, adverse events and unintended
consequences are impossible to understand.

HOSPITAL DESIGN PROMOTING PATIENT SAFETY

Reductionism approaches, to date, towards hospital constructions,
have failed to adequately control risk or reduce the number of adverse
events in these settings. Conditions in which we work such as fatigue
from 24-hour duty rotations, double shifts, high workloads, confusing
labels, noisy environments, look alike names, poor handwriting, poorly
design equipment and health care builds can lead to errors.

These are open or ill-posed problems that best understood through

controlled observations, cases study and modeling, with insights drawn
from other complex adaptive systems such as emerging economies
and dynamic social systems. Recognizing this, we feel that complex
system theory can be the basis for a new principled approach to
optimizing hospital design, performance and outcomes, managing risk
and guiding health policy.

The traditional hospital design process requires that architects be

given program objectives, (function and program) which are then
translated in room requirements (a space program) and followed by
the creation of department adjacencies (block diagrams). Once this
preliminary information has been provided, room-by-room adjacencies
are developed and then a detailed design of each room is completed
(schematic and design development). Architects then convert room-by-
room design to construction documents that represent how individuals,
equipment, and technology in hospitals will function together.
Equipment and technology planning generally occurs in the later
stages of the design process. Typically, no discussions of patient safety
or designing around precarious events are raised at this stage.

This creates an opportunity to repeat latent conditions existing in

current hospital designs that contribute to active failures (adverse
events or sentinel events). Human factors, the interface and impact of
equipment, technology and facilities, is also not typically discussed or
explored early in the process.
Patient Safety Challenge
In the early 1990’s researchers such as Leape and Brennan started
questioning the safety of healthcare institutions.[3] The IOM report in
2000 posited that between 44,000 and 98,000Americans die in US
hospitals due to preventable errors. To put these numbers in
perspective, hospitalization is more dangerous than flying in an
airplane, operating a nuclear reactor or flying off the deck of an aircraft
carrier. Staying in the hospital is more dangerous than driving there.

There are two possible responses to this challenge – a personal or a

systems approach.

Our primary response to this epidemic has been to focus on the

personal approach in which after an error or accident we search for the
“guilty parties.” The legal system is most willing to help in this
“righteous cause” as it rids the system of “incompetent doctors” and
punishes “bad hospitals.”

The concept of “systems” is important in the discussion of health care

safety and health facility design. A system is a set of components,
sometimes called subsystems or Microsystems, which are related or a
complex whole formed from related parts, or an organization of people,
tools, resources and environment. This last term, “environment” is the
focus of our study, specifically the physical environment in which
components are housed as opposed to the cultural environment.

Fire precautions in the design, construction and use of buildings. Code

of practice for means of escape for disabled people. British Standards
Institution, 1999. Where escape lifts are considered necessary, a
minimum of two lifts should be provided, sufficiently remote from each
other to ensure that at least one is always available. Additional
guidance can be found in Health Technical memorandum 05-03: Part E
– ‘Escape bed lifts’ and BS 5588-8.

The Chartered Institute for Building Services

Engineers CIBSE
Provides further info in its Guide The Building Regulations Approved
Document M: Access and facilities for disabled people (London:
HMSO/Department of the Environment/Welsh Office)(1992)

According to some experts:

Some situations require variations from the normal strategy of direct
escape for example:

The provision of protected areas where people with disabilities can

await assistance in relative safety, i.e. protected from the effects of fire
and smoke. It is current practice to avoid the use of lifts for evacuation
purposes unless they are specifically designated and constructed for
the evacuation of people with disabilities and/or hospital patients. This
is because of the potential
dangers of smoke ingress into the lift, loss of power and the possibility
of discharging at the fire floor.

Whilst it is not permitted by current codes, in certain types of building,

particularly high rise buildings and those with deep basements, it may
be advantageous to use suitably designed and constructed lifts in the
evacuation of the less active members of the population as well as
people with disabilities.

Characteristics of Systems
A healthcare system includes several sub-components. The foremost
are the medical or clinical processes, which are undertaken. Another
component is technology, medical and nonmedical. This would include
information systems, diagnostic systems, imaging systems as well as
mundane technologies such as floor cleaning equipment, supply
ordering and distribution technologies.

Next there is organization, the administrative arrangement that

includes policies, procedures, strategies and tactics, management
tools, business plans, etc. Providers are another subsystem. They
include professional, technical, administrative, management, patient,
public, government and others. Finally, the designed, built
environment is a subcomponent. It includes a large number of
characteristics.

Charles Perrow studied major accidents and discovered that systems,

rather than individuals, were often at fault. Perrow and James Reason
re-defined how we should proceed to understand causes of accidents
and fix problems. One of Perrow’s contributions was to describe how
the components of systems relate. He defined two scales, complexity
and coupling, which explained how components of systems react.

Complexity can range from low complexity to high complexity. Making

a sandwich is a low complexity undertaking. Flying a fighter jet off an
aircraft carrier is highly complex. Coupling ranges from loose to tight. If
an activity is not highly dependent on the exactness of preceding
activities, it is loosely coupled.

The steps of making a sandwich are loosely coupled. The steps in flying
off the carrier are tightly coupled. Healthcare, for example, is a system
that is highly complex and tightly interrelated.

Designing an operation theater

Designing an operating theatre outlines the intricacies of the hospital
design process. An operating theatre suite consists of the Theatre, the
Anesthetic room, Scrub room and the Dirty Utility (or just Utility) room.
We will look at planning just the Operating Theatre itself in this hospital
design guide article. The size and room dimensions vary but as an
indication it should be about 7 meters wide by 8 meters long (56
square meters).

Any surgeon will tell you that over-riding principles while designing an
operating theatre are: Flexibility of use of the space; Ease of cleaning
the theatre – including the floor, walls, surgeons panel and any
equipment such as pendants and theatre lights; Ease of use of
surgeons panels, theatre lights and pendants.
There are different arguments for either having all equipment and
instruments on mobile trolleys to allow 100% flexibility on use of the
theatre and ease of cleaning the theatre versus mounting a great
majority of equipment on ceiling mounted theatre pendants. The
ceiling slab must be able to hold the weight of the theatre lights,
pendants and the equipment if mounted on the pendants. It is highly
recommended that you check with your structural engineer.
Ceiling Mounted Equipment:
1. Pendants

Expect a Surgical and an Anesthetic Pendant in any theatre, which

have power, data, and various gas outlets. There are several major
suppliers on the market with numerous different types. Pendants can
be rigid, rigid, retractable or fully articulated. Theatres require fully
articulated pendants for maximum flexibility.

A lot of co-ordination is required between medical gas, electrical, and

pendant trade contractors together with electrical, mechanical and
structural engineers/consultants while installing pendants to ensure all
structural steel support is in place, gas pipes are properly connected
and power and data cables run at the correct programmed dates.

Various lives saving equipment must be powered off Un-interruptible

Power Socket(s) – UPS, in case of power failure during surgery.

2. Theatre Lights

There used to be the Gas Discharge lights or Halogen lights. Aspects to

consider were bulb life, costs associated and Theatre down time while
bulbs were changed. There is a new kid on the block in the last couple
of years – LED technology. About 30% more expensive compared to
the existing technology but very long life bulbs (over 20,000 hours),
ease of maintenance (couple of minutes to replace an LED), cheap cost
of replacement (fraction of older technology) and ability to vary light
temperature hence helping to diagnose cancerous cells etc.

A battery must back up theatre Lights back up in case of power failure

during surgery. Suggested time can be 3 hours back up. Note that
general lighting and emergency escape lighting should also be on
similar battery/UPS back up time.

3. Camera

In a teaching facility, a camera (now a days High Definition Camera)

and microphone is also required for one way video (from Operating
Theatre to Lecture Theatre and/or Seminar Rooms) and two-way audio
for surgeons and students to communicate. The camera can either be
installed in the handle of the main Theatre Light of installed on a
separate ceiling mounted arm. Consider all implications for power and
data transfer (HD requires much higher bit rate transfer). Consider a
wireless Reality TV / Big Brother style microphone on the surgeon to
allow freedom of movement.

In Orthopaedic Theatres you would need to consider the largest ceiling

mounted item – The Laminar Flow or the Ultra Clean Ventilation (UCV)
Canopy. This item will need a separate article as we are planning a
general Theatre in this article.

4. Radiation Protection

Depending on the equipment, room size and location of the equipment

and adjacent areas, a qualified Radiation Protection Advisor must be
employed to advise on what materials must be used for walls and
doors (and floor and ceiling if required) to ensure the X-Ray equipment
radiation is contained an does not harm anyone. (The operator in the
room operates from behind a lead screen).

I hope that the above main points will help you think and plan ahead
when you want to add/update your next imaging room and will allow
you to quiz manufacturers, builders, architects and engineers involved
to give you the best and most effective and economical solution for
your money.

MEDICAL EMERGENCY FACILITIES IN HOSPITAL

 Emergency Department
 Emergency Department Layout
 Patient Experience
 Critical Conditions Handled
o Cardiac arrest
o Heart attack
o Trauma
o Mental Illness
o Asthma
 Hospital Emergency Equipments & Facilities

Emergency Department
The Emergency Department (ED), also termed Accident &
Emergency (A&E), Emergency Room (ER), Emergency Ward (EW), or
Casualty Department is a hospital or primary care department that
provides initial treatment to patients with a broad spectrum of illnesses
and injuries, some of which may be life-threatening and require
immediate attention. In some countries, emergency departments have
become important entry points for those without other means of
access to medical care. Staff teams treat emergency patients and
provide support to family members. The emergency departments of
most hospitals operate around the clock.

 Emergency department layout

 Patient experience
 Special facilities, training, and equipment

Emergency Department Layout

A typical emergency department has several different areas; each

specialized for patients with particular severities or types of illness.
One body of expertise that seems particularly applicable to emergency
medicine services is Operations Management. Operations management
utilizes a systems approach to the provision of a service, including the
definition of the particular characteristics of a service (such as the
service package, the service process, and the virtual value chain
embedded in that service), structured planning for service quality,
appropriate service metrics, selected management tools, and
consideration of strategies for interdisciplinary collaboration, as well as
cultural change. It is important to link clearly the service function to
the institutions mission/strategic plan, as well as the expectations and
needs of ED patients who are served there.

Some departments employ a therapist whose job is to put children at

ease to reduce the anxiety caused by visiting the emergency
department.

Many hospitals have a separate area for evaluation of psychiatric

problems. Psychiatrists and mental health nurses and social workers
often staff these. There is typically at least one room for people who
are actively a risk to themselves or others (e.g. suicidal).
  Intangibility:
Services are not manufactured according to precise standards, nor can
they be stored. How consumers perceive services is very subjective,
since they are a performance rather than a tangible good.

 Variability:
Consistent service delivery is very difficult, particularly in fields such as
medicine, due to the high labor contribution of the service along with
the variation between clinicians.

 Inseparability:
Service quality is extremely difficult to control since it is produced and
consumed at the same time. There is no opportunity to measure or
inspect the service prior to actually delivering it. Additionally, the
consumer (patient) significantly impacts the quality of the service
provided. For example, the description of a patient's symptoms can
significantly affect the outcome of the visit. The better the description,
the more likely a better outcome.

Patient Experience
If the patient's service expectation is not met, there are ways to
remedy this shortcoming. Service recovery is an effective tool to
prevent patient defection, but it is necessary to have a well-crafted
plan in place before the actual event occurs. Patient retention can
have a significant financial impact.

Patients are becoming more difficult and demanding and the health
care industry may decide that it wishes to take notice of this. Other
sectors of the economy are providing an ever-higher quality of service
and are raising consumers' expectations along with it. Patients always
will only come to expect that much and more from high-tech and high-
cost medical encounters.

Critical Conditions Handled

Some of the critical conditions are discussed in order to explore the

urgent need of facilities that have to be place in Hospital.

Cardiac Arrest:
Cardiac arrest may occur in the ED/A&E or a patient may be
transported by ambulance to the emergency department already in
this state. Treatment is basic life support and advanced life support as
taught in advanced life support and advanced cardiac life
support courses. This is an immediately life-threatening condition
which requires immediate action in salvageable cases.

Heart Attack:
Patients arriving to the emergency department with a heart attack,
they will receive oxygen and monitoring and have an early ECG; aspirin
will be given if not already administered by the ambulance team.

Trauma:
Major trauma, the term for patients with multiple injuries, often from a
road traffic accident or a major fall, is sometimes handled in the
Emergency Department.

Some emergency departments in smaller hospitals are located near a

helipad, which is used by helicopters to transport a patient to a trauma
center. This inter-hospital transfer is often done when a patient
requires advanced medical care unavailable at the local facility. In such
cases the emergency department can only stabilize the patient for
transport.

Mental Illness:
Some patients arrive at an emergency department for a complaint of
mental illness. Patients who appear to be mentally ill and to present a
danger to themselves or others may be brought against their will to an
emergency department for psychiatric examination. The emergency
department conducts medical clearance rather and treats acute
behavioral disorders. From the emergency department, patients with
significant mentally illness may be transferred to a psychiatric unit.

Asthma
Asthma are assessed as emergencies and treated with oxygen
therapy, bronchodilators, steroids or theophylline, have an
urgent chest X-ray and arterial blood gases and are referred
for intensive care if necessary.

Wall Mounted Equipment:

1. Surgeons Panel

The panels can the older style steel type or the more current
Membrane Type panels, which allow ease of cleaning/disinfections. The
membrane can be made anti-microbial by inclusion of silver nitrate. A
newer version of panels can be touch screen however its not proving
very popular as it can take several screen touches to reach a certain
function, whereas other two panel types have all the buttons available
in the panel.

For ease of cleaning and aesthetics, the panels should be flush

mounted. Note that all the pendants, theatre lights, general lights, gas
alarm panel, IPS/UPS, and warning signs for X-Ray in-use / Laser in-use
signs outside Theatre, air sampling ducts, clocks etc need considered
and carefully co-ordinated among the trade contractors and design
consultants for services and wiring.
Floor Mounted Equipment:
1. Theatre Table

Generally these are rechargeable and don’t necessarily require power

socket close by.

2. Trolleys

Trolleys are used for instruments and equipment such as video

endoscopes and anesthetic equipment. We mentioned ease of cleaning
at the start. To enable this the walls should have special plastic enamel
paint to allow chemical cleaning if required in case of disinfections. The
ceiling is generally constructed of plasterboard or special metal to
ensure it is air-tight and easily cleaned.

Airflow regime is an important part of moving the air from clean areas
towards dirty and out of the Operating Theatre suite to ensure the
Theatre is the cleanest environment for operating on the patients.

I trust the above has given you some basics to consider when planning
your next operating theatre. Of all the clinical areas in any hospital, X-
Ray, CT, and Fluoroscopy need much more planning and co-ordination
than any other thing imaginable. This is mostly due to the fact that the
equipment used and its implications on the building structure and
services is much more complex with the exception of the MRI. We will
deal with MRI in another article and will only discuss factors to be
considered while designing an X-Ray room, which, in principle will hold
for the CT & Fluoroscopy rooms as well.

Room Dimensions, Entrance and Access Route

As X-Rays are large and heavy pieces of kit, first and foremost
consideration should be: Can the largest part be brought to its
intended location from the entrance via any corridors and lifts? You
should consult the equipment manufacturer’s specific model pre-
installation guide before you make the purchase and involve an
architect to ensure the kit will pass through all doors and corners and
will not get stuck in the lift doors (if the location is not on (ground
floor)!

The manufacturers will advise of the critical room dimensions for the
equipment to work and intended clinical procedures to be carried out
successfully with regards to the prevailing local regulations.
Structure
As clinicians will know, X-Ray equipment consists of the floor mounted
table, wall mounted chest bucky and (mostly) ceiling mounted X-Ray
tube. In addition, there is the operator’s control console and the
generator cabinet with a couple of Emergency Stop buttons. The
ceilings and walls must be strong enough to not only take the weight of
these items but have proper pattresing to attach the equipment as
recommended.

All these pieces of equipment require power and interaction hence

cables run between these items. With the table being in the middle of
the room, there is a need for having a floor trunking with removable lid
between the wall and the table to house any cables. The exact
location, dimensions and details of this trunking must be established
with the equipment manufacturer. If your hospital is a new build, you
need to pass that information together with the floor loading and
ceiling slab deflection and minimum vibration requirements to your
structural engineer and the architect. If it is an existing building, you
are best advised to establish the above requirements and involve your
builder, architect and a structural engineer before purchasing the
equipment.

Most probably, the services between the floor mounted equipment and
the ceiling mounted tube will be run on surface mounted floor to
ceiling wall trunking with removable lid. Make sure that the ceiling is
strong enough to take the load of the tube and that the area above
does not have any equipment or plant that makes vibrations. In
addition, the veiling mounted tube glides along the length of the table
on two rails.

These rails are mounted on secondary steel attached to the ceiling.

This secondary steel is usually Instruct or Mars Strut which are
registered trademarks and you will normally employ specialist sub-
contractors to install these as the radiographic equipment suppliers
work once the room is complete with all services available, secondary
steel installed and floor and wall trunkings and high level cable trays in
place and room finished to builder’s clean.

Services & Environment

Will suffice to say that you will require power and data (check if
broadband) as per the manufacturer’s specification. The equipment
will generate significant heat and hence cooling will also be required.
Make sure you ask whether humidity control is also required as
generally people do not understand differences between comfort
cooling, air-conditioning and humidity control.

There will usually be an emergency stop button at the control console

and another possibly near the table. The actual location of all services
and equipment will have to be precise according to the supplied
drawings provided specifically for your project by the equipment
manufacturer.

Conclusions
The design process for health care environments needs to be radically
changed to address patient safety challenges. Creating an
environment in which a culture of patient safety can flourish is a
daunting challenge. It will never happen if participants in the process
are unwilling to think outside the constraints of convention and if they
are unwilling to challenge the rigor mortis which characterizes the
cultural and intellectual development of so many of our professional
and commercial institutions.
We suggest a patient safety driven process that has the
following characteristics:

 Process starts with a complete team including designers, users,

clinicians, contractors, equipment vendors, human factors
specialists, managers, patients, and others.
 Considers and respects the many environmental constraints that
influence patient safety.
 Includes continual training and learning.
 Works through collaboration and sharing of ideas.
 Is encouraged to experiment, simulate, test and research.
 Has patient safety as a core focus.
 Measures and tracks all processes and outcomes.