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District hospitals : guidelines for development. 2nd ed.

December 31, 1996 World Health Organization

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WHO Regional Publications. Western Pacific Series No.4

DISTRICT HOSPITALS: GUIDELINES FOR DEVELOPMENT Second Edition

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WORLD HEALTH ORGANIZATION Regional Office for the Western Pacific

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WHO Library Cataloguing in Publication Data District hospitals: guidelines for development, second edition 1. 2. 3. Hospitals, District. Hospital planning. Hospital design and construction.

ISBN 92 9061 117 0

The World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. Applications and enquiries should be addressed to the Office of Publications, World Health Organization, Geneva, Switzerland or the Publications Units, World Health Organization, Regional Office for the Western Pacific, Manila, which will be glad to provide the latest information on any changes made to the text, plans for new editions, and reprints and translations already available. © World Health Organization 1996 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. All rights reserved. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturer's products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

iii

CONTENTS Page

Foreword Contributors INTRODUCTION 1. 2. 3. Rationale The district health system The district hospital 3.1 Roles 3.2 Functions 3.3 Services 3.4 Physical scale PART I. DISTRICT HOSPITALS: PLANNING AND DESIGN 1. Methods of planning and design 1.1 The planning teams and the process 1.2 Roles of members of the team 1.3 Preparation of the design brief I .4 Designing from the brief Location 2. I Inventory and distribution of health facilities (the mapping exercise) 2.2 Service catchment area 2.3 Factors to be considered in locating a district hospital 2.4 Site selection Master physical development 3.1 Basic documents and information 3.2 Operational policy 3.3 Site utilization 3.4 Circulation 3.5 Growth and change 3.6 Disaster preparedness and safety 3.7 Energy conservation 3.8 Financial aspects 3.9 Master planning 3.1 0 Building shape 3.1 I Appropriate construction technology Department planning and design 4.1 Primary health care support areas 4.2 Out-patient department 4.3 Emergency department 4.4 Administration 4.5 Radiology department

lX X

1 2 4 4

5 5 6

11 11

13 14 16 17 17 17 18 18 24 24

26 29 33 36 39 45

47 47 49 52

53 53

55 56 57 57

Page 4.6 4.7 4.8 4.9 4.10 4.11 4.12 4.13 4.14 5. Laboratory services Pharmacy Operating theatre Intensive care unit Delivery department Nursery In-patient nursing wards General services department Mortuary 59 61 62 66 67 67 68 70 73 74 74 77 81 86 86 87 91 93 93 96 96 99 106 109 115

Engineering services 5.1 Water supply and sewerage 5.2 Mechanical engineering 5.3 Electric and electronic engineering Planning and programming construction 6.1 Tendering 6.2 Project management Evaluation of district hospital facilities Experiences in district hospital planning and design 8.1 Country A 8.2 Country B 8.3 Country C 8.4 Country D 8.5 Country E Aspects of hospital utilization design intentions versus use Selected bibliography PART II. MEDICAL EQUIPMENT

7. 8.

9. 10.

Objectives List 2.1 2.2 2.3 of essential equipment Generic specifications Essential medical equipment for a 50-bed district hospital Essential medical equipment for a 100-bed district hospital

119 120 120 121 134 135 135 135 137 138 139 141 141 141 143 145

Management of medical equipment 3.1 Problems of management 3.2 Cycle of management of medical equipment 3.3 Team approach 3.4 Sample checklists Human resources development Planned preventive maintenance 5.1 Scope 5.2 Setting up a planned preventive maintenance system 5.3 Patient safety Selected bibliography

4. 5.

Page

ANNEXES Sample checklist of maintenance requirements for a 50-bed district hospital Sample checklist of maintenance requirements for a 100-bed district hospital Outline syllabus for a course for polyvalent technicians Sample equipment record Schedules of procedure for planned preventive maintenance Guidelines for the installation of WHO Basic Radiological System (BRS) Use and detailed specifications of BRS units How is the power of an x-ray generator specified? Minimum specifications for the general-purpose ultrasound scanner 149 151 153 154 155 172

3 4 5 6 7

8 9

179 183 185 187

INDEX

TABLES No. 1 2 3 4 5 6 7 Clinical and other services available at a district hospital Stages in planning and designing a hospital Temperatures to be provided in a district hospital Conditions for ventilation in different areas of a district hospital Guidelines for lighting in a district hospital Family participation in patient care in a surgical ward Main groups of x-ray intensifying screens 6 13 79 80 83 114

127

FIGURES 1 2 3a 3b 3c 3d 3e 3f 4 5 6 7 8 9 10 Ila 11 b 11 c 12 District health system involving primary health care and a hospital at the first referral level Model of a health system based on primary health care Needs assessment team Briefing team Design team Construction team Commissioning team Planning team Mapping exercise Natural physical barrier as a determinant of catchment area Time boundaries as determinants of catchment area Minimal size of site Topography Means of draining low-lying sites Boreholes to confirm bearing capacity of well Building straddling waterway Building designed around a pond Building designed around a large tree Access to site 3 4 11

12 12 12 12 12 17 17 18 18 19 19 21 21 21 22 22

Page

13 14 15 16 17 18 19(a-d) 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50a 50b 51 52 53 54 55 56 57 58

Proper ownership titles Structures on site with ownership problems Slope section Land-use map Dimensional limits Organization of zones and spaces Plot ratios Orientation of sun and wind Slope map Use of plants and trees to direct air-flow Distribution of access routes Manoevrability of wheeled equipment Accommodation of stationary equipment Stairs Ramps Lifts Outward growth Independent expansion of separate components Upward growth Downward growth Inward growth Growth by fragmentation Increments of growth Fire avoidance Fire growth restriction Fire containment Fire detection Fire control Smoke control Escape provisions A simple solar heating system Zoning of elements on a site Village form Modular village form Train corridor plan Open-ended finger plan Block form Tower and podium design Alternative tower and podium design Court plan Compact plan Spaces for education and training in primary health care Technical support for primary health care Mobile services Primary health care (PHC) officer at hospital Out-patient department plans Plan for emergency department

22 23 24 25 25 29 30 31 31 32 33 34 34 35 35 35 36 37 37 38 38 38 39 43 43 43 43 44 44 44 46 48 49 50 50 50 50 51 51 51 51 54 54 55 55 56 57

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Page

59 60 61 62 63 64 65 66 67 68 69 70 71 72a 72b 72c 72d 72e 72f 73 74 75 76a 76b 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95a 95b 96

Simple compact plan Cluster plan Linear plan Plan for laboratory Examples of laboratories of different sizes Laboratory work-benches Essential physical requirements Location of operating department Progressive sterility Removal of airborn contamination Traffic flow in operating department Location of intensive care unit Rooming-in Nightingale ward Straight, single-corridor ward L-shaped ward T-shaped ward Racetrack ward Cruciform ward Flowchart showing movements of staff and supplies in service areas Air pressure relationships in a laboratory Modified selective system of electrical distribution, including generator Project implementation scheme for a typical district hospital Critical path analysis Process of developing a district hospital Floor plan (1), Country A Floor plan (2), Country A Site development plan, Country B Floor plan, Country B Master site plan, Country C Floor plan, Country C Master site plan (I), Country D Floor plans (l), Country D Master site plan (2), Country D Floor plans (2), Country D Site development plan, Country E First-floor plan, Country E Second-floor plan, Country E Male surgical ward, Case No. I Out-patient department, Case No.2 General surgery nursing unit, Case No.3 Model district for a 50-bed hospital BRS unit with horizontal x-ray beam BRS unit with vertical x-ray beam and patient trolley Column x-ray tube support mounted on floor rails with a ceiling rail

58 58 58 59 60 61 62 63 63 63 64

67 67 68 68 69 69 69 69 72 80 85 89 89 91 94 95 97 98 100 101 102 103 104 105 106 107 108 110 112 113 121 125 125 125

viii

Page 97 98 99 100 101 102 103 104 105a I05b 106a 106b 106c 107 108 109 110a 110b Column x-ray tube support mounted on floor rails Scattering of radiation Processing tank Lightproof darkroom ventilator Model district for a 100-bed hospital Cycle of management of hospital equipment Typical layout for the workshop of a 50-bed hospital Typical layout for the workshop of a 100-bed hospital BRS examination room Working range of BRS stand Minimum BRS department 1 Minimum BRS department 2 Small BRS department Small x-ray department showing working area for BRS stand Floor plan for primary care radiography with 4000 or more examinations per year Control protective screen and protective panel Indirect filtered light Direct filtered light 126 126 129 129 134 136 150 152 172 172 174 174 174 175 176 177 177 177

FOREWORD District hospitals have a great responsibility, not only for providing care at the first referral level but also for supporting primary health care activities at the health centre level. The importance of improving the performance of district hospitals needs no emphasis. Adequate planning, design, management and maintenance of the facilities and equipment of the district hospitals are essential to ensure the high quality of hospital services at a reasonable cost. The developing countries are passing through a transitional period in which technology transfer plays a significant part. This is especially true with regard to the planning and design of health facilities. The WHO Regional Office for the Western Pacific has therefore developed these guidelines for the planning and design of district hospitals, including instructions for the management and maintenance of essential biomedical equipment. This book is thus intended as a guide to the functioning of hospitals. It does not provide a standard model, because what may be pitifully inadequate in one place may be luxuriously redundant in another or quite adequate but unaffordable in a third. It is relevant to a wide variety of situations, and as such it is timely and should go a long way to furthering WHO's cooperation with Member States in this important field.

S.T. Han, MD, Ph.D. Regional Director

CONTRIBUTORS AND REVIEWERS Part I. District Hospitals: Planning and Design Contributors Mrs P.C. Luis Associate Professor College of Architecture University of the Philippines Diliman, Quezon City Philippines Dr Y.S. Shin Director Institute of Hospital Services Seoul National University 28 Yunkeun-Dong Chongno-ku, Seoul 110 Republic of Korea Dr Y. Nagasawa Associate Professor Faculty of Engineering Department of Architecture University of Tokyo 7-3-1 Hongo, Bunkyo-ku Tokyo 113, Japan

Reviewers Professor P.E.S. Palmer University of California Davis, California, United States of America Mr D.A. Sayers Health Services Planning and Management Consultant 18a Casey Avenue, Hamilton New Zealand Mr G.K. Majumdar Chairman and Managing Director Hospital Services Consultancy Corporation (India) Ltd 1 Copernicus Marg New Delhi 110001, India Mr G. Entwistle Consultant in Health Care Facilities 16 Queen Street, Mornington Victoria 3931, Australia

Part II. Medical equipment Main Contributors Mr M. Reeves Biomedical Engineer Apt. 2N, 76-36 113th Street Forest Hills New York, NY 11375 United States of America Dr A. Malloupas University of Cyprus P.O. Box 537 Nicosia Cyprus

Other Contributors Dr Chen-Jie Training Centre for Health Management Shanghai Medical University 138 Y Zue Yuan Road Shanghai 200032 China Mr H. Dionco Hospital Maintenance Services Department of Health San Lazaro Compound Santa Cruz, Manila Philippines Professor P.E.S. Palmer University of California Davis, California United States of America

Reviewers Dr M. Cheng Biomedical Engineering Consultant 145 Carleton Avenue Ottawa, Canada KIY OJ2 Mr J.-P. Gailly Building 5-2E, Pak Lok Garden Taipa Macao Dr J.R. Roberts Department of Medical Electronics, Medical College of St Bartholomew'S Hospital London ECI M 6BQ United Kingdom Dr N. Mishra Professor, Electrical and Computer Engineering California State University Northridge, CA 91330 United States of America

INTRODUCTION

1. RATIONALE The Declaration of Alma Ata in 1978 strongly influenced the health policies of many nations, which set out to achieve the goal of health for all by the year 2000 through primary health care. Primary health care was defmed in the Declaration as: Essential health care based on practical, scientifically sound and socially acceptable methods and technologies made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. The Declaration focused attention on the gross inequalities in health status both between developed and developing countries and among groups of people within countries. It emphasized the idea that these inequalities could be removed, with the cooperation and assistance of a number of sectors, but especially ofthe health services. Primary health care would be provided by health workers operating in facilities that were simple and located close to their clients. In the wake of the Declaration of Alma Ata, WHO emphasized the need to reorientate health systems, especially at the district level. The role of district hospitals in primary health care and that of hospitals for first referral were reviewed by WHO at various forums. The role of the hospital, which until that time had been restricted to cure and rehabilitation, was revolutionized to include promotional, preventive and educative functions in addition to its other ones. These changes required reorientation of the thinking of policy makers and health planners, who had also to keep in view fast-changing technological developments and their transfer between and within countries. The WHO Regional Office for the Western Pacific organized its fIrst regional workshop on health facility planning and development in Tokyo in October 1986; this was followed in July 1987 by a WHO bi-regional conference on technology transfer in the health field, again held in Tokyo. A regional workshop on the planning and design of district hospitals in support of primary health care held in Seoul in 1988 and a regional training course on the planning and development of health care facilities in Tokyo in December of that year also reflected the concern of the WHO Regional Office for the Western Pacific and its plans to cooperate with Member States in improving national capability and expertise in this domain. These meetings resulted in a new, multidisciplinary team approach. Such teams must be capable of drawing up plans that will ensure maximum utilization of space, provide for easy movement of people and materials and allow for possible future expansion; the plans should also involve economical methods of construction using local manpower and materials, while at the same time maximizing the benefits of the latest technological developments. In order to help achieve this goal, the WHO Regional Office for the Western Pacific has developed these guidelines; their main objectives are: (1) to present an overview of the complex plarming and design process, to guide the hospital

planning team; (2) to present in a concise form basic data and information that are important in the planning process, to serve as check] ists; (3) to provide guidelines for the selection of equipment relevant to district hospitals and for their maintenance; and (4) to help develop national capabilities and expertise in planning and designing district hospitals, and in selecting and maintaining medical and associated equipment.

Introduction

2. THE DISTRICT HEALTH SYSTEM The district health system is not a new idea: decentralization of control has long been an important political and organizational strategy. Management of health services for defined geographical areas from regional, provincial or district centres has been a common feature of most health systems in both developed and developing countries. What we are advocating is a renewed effort to implement primary health care, and the intermediate level of control must be strengthened to support and invigorate this effort. In order to succeed, primary health care must have unwavering support from the top in the form of a clear, firm national policy-but its full realization depends critically on the people at the district level who are charged with the management and implementation of primary health care strategies. It is in the district that top and bottom meet, if they are to meet at all. The district provides an excellent organizational framework within which to introduce changes in the health system. At this level, policies, plans and practical reality can meet, and feasible solutions can be developed, provided that human and material resources are made available and sufficient authority is delegated. The following definition of the district health system was adopted by the WHO Global Programme Committee in 1986: A district health system based on primary health care is a more or less selfcontained segment of the national health system. It comprises first and foremost a well-defined population, living within a clearly delineated administrative and geographic area, whether urban or rural. It includes all institutions and individuals providing health care in the district, whether governmental, private or traditional. A district health system, therefore, consists of a large variety of interrelated elements that contribute to health in homes, schools, work places and communities, through the health and other sectors. It includes self-care and all health workers and facilities, up to and including the hospital at first referral level and appropriate laboratory, other diagnostic and logistic support services. Its component elements need to be well coordinated by an officer assigned to this function in order to draw together all these elements and institutions into a fully comprehensive range of promotive, preventive, curative and rehabilitative health activities. Some key features of a district health system (Fig. I) are: -it is people-orientated; -it is clearly defined; -it incorporates the principles of primary health care in all its activities; and -it has substantial autonomy, so that it can manage and implement solutions as effectively as possible in accordance with local conditions. The term "district" is used in a generic sense to denote a clearly defined administrative area, which commonly has a population of between 50 000 and 500 000, where some form of local government or administration takes over many of the responsibilities from central government sectors or departments and where there is a general hospital for referral. The actual organization of district health systems obviously depends on the specific situation in each country and each district, including the administrative structure and personnel involved. Nevertheless, the general principles for developing such systems are based on the Declaration of Alma Ata and the Global Strategy for Health for All and incorporate the following: -equity -accessibility

The district health system

---emphasis on promotion and prevention -intersectoral action ---community development ---decentralization -integration of health programmes ---coordination of separate health services Before the role of the district hospital in the district and in the regional health system can be defined, however, plans for developing health services must be outlined and planning objectives understood.

FAMILY HOME COMMUNITY HEALTH WORKERS BASIC HEALTH UNITS

ENVIRONMENTAL CONTROL SYSTEM

c:J SCHOOL SYSTEM

I 00 00 I-

~[OTHER PHC SYSTEMS

PHC

DISTRICT HOSPITAL

INDUSTRIAL SAFETY SYSTEM

,-HFRL----

DISTRICT HEALTH SYSTEM

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DISTRICT HEALTH SYSTEM Fig. 1. District health system involving primary health care (PHC) and a hospital at the first referral level (HFRL)

A health services development plan establishes the strategy for achieving the objectives of the health services. Each service is examined with regard to the need it fulfils, its characteristics, the setting in which it is provided, its functions and the objectives and priorities for change set by the overall health system plan. The plan is based on a detailed study of the implications arising from those objectives and policies, consideration ofthe various components of the system, and examination of the constraints of existing facilities and resources, including their influence on the timing and phasing of any proposed development of the services. A decision to proceed with the design and construction of a district hospital cannot be taken until the health services development plan has been agreed. This plan determines the priorities for developing the various components to be provided in each region and district and the provisions for funding each facility. Development of health services must be planned within the financial constraints of the overall health system plan. Any additional expenditure required must be agreed before planning for a district hospital begins.

Introduction

3. THE DISTRICT HOSPITAL

3.1 Roles The WHO Expert Committee on the Role of the Hospital at the First Referral Level, which met in 1985, clarified the importance of the full involvement of hospitals in primary health care; it also crystallized the concept of the district health system as a central strategy in this approach. The report of the Committee includes a conceptual model of a comprehensive health system based on the principles of primary health care, as shown in Figure 2.

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NATIONAL CENTRAL LEVEL PROVINCIAL REGIONAL LEVEL

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DISTRICT LEVEL

Figure 2. Model of a health system based on primary health care

This model clarifies the place of hospitals at the first referral level as the component of district health systems that immediately supports the health activities of the district or community, and especially primary health care activities. Such hospitals can provide wide-ranging support for patient referral and support for various technical, administrative and educational/training activities in the district. The term "district hospital" is used here, therefore, to mean a hospital at the first referral level that is responsible for a district of a defined geographical area containing a defined population and governed by a politico-administrative organization such as a district health management team.

The district hospital

3.2

Functions The district hospital has the following functions: (1) it is an important support for other health services and for health care in general in the district; (2) it provides wide-ranging technical and administrative support and education and training for primary health care; (3) it provides an effective, affordable health care service for a defined population, with their full participation, in cooperation with agencies in the district that have similar concerns.

3.3

Services

The range of medical services offered by the district hospital differs from one country to another owing to differences in the: ---epidemiology of cases that require complex treatment, including accidents; -size and density of the popUlation; -geographic and climatic conditions; -level of economic development; -socio-cultural infrastructure; -quality and quantity of health resources; -national policy for health care; and -availability of medical and paramedical personnel. The Western Pacific Region is one of the six regions of WHO. It covers 26 Member States and one associate member (as of August 1991) and is the most populous of the six regions, the popUlations ranging from more than one billion in China to 7000 in Nauru. The socio-economic, political, geographical and climatic conditions in the Region are highly diverse: the geography varies from mountains to plains and small islands, the climatic conditions from very cold to tropical and socioeconomic conditions from highly developed to some of the least developed in the world. As shown in Figure 2, the district health system is part of the national health system. The range of services offered by a district hospital is limited by its managerial efficiency and effectiveness. When the diseases prevalent in a district vary widely in type and complexity, it may be impossible to treat all of them: some may require the intervention of highly specialized physicians and the use of sophisticated, expensive medical equipment. Patients with such diseases can be transferred to secondor third-level hospitals located in a nearby province or region. A district hospital should, however, be able to serve 85-95% of the medical needs in the district. Table I lists the services that a district hospital can provide. The extent to which the last two groups of services can be provided is flexible, depending on local financial, social and cultural conditions. The list can also be extended or modified according to local needs.

Introduction

Table 1. Clinical and other services available in a district hospital Department Clinical Medicine Surgery Paediatrics ObstetricsiGynaecology Dentistry Orthopaedic surgery Otorhinolaryngology Neurology Psychiatry Clinical support Anaesthesia Radiology Clinical laboratory Pathology Rehabilitation Service Department Non-clinical support Kitchen (catering) Laundry Warehousing (central store) Domestic hygiene Waste disposal Maintenance and repair Transport Communications Staff residential housing Administrative Finance Medical records Procurement Personnel Security Service

Essential Essential Essential Essential Essential Optional Optional Optional Optional

Essential Essential Essential Essential Essential Essential Essential Essential Essential

Essential Essential Essential Optional Optional

Essential Essential Essential Essential Essential

3.4

Physical scale

The size of a district hospital is a function of the hospital bed requirement, which in turn is a function of the size of the population served. The groupings of populations around health facilities vary. A survey of the Member States of the Western Pacific Region revealed that primary health care facilities generally serve communities of 5000-10 000 people, and first-level referral hospitals generally serve communities to 50 000500 000. In some countries, an intermediate level of primary health care facility exists, serving populations of 10 000-50 000. The physical scale of the hospital is established on the basis of a determination of the number of beds required and a suggestion for the minimal hospital area per bed. One method that can be used to determine the number of beds is based on the expected patient load, as shown in the following example: Data collected: Population of district Average length of stay in hospital Annual rate of admissions Computations: (I) Total number of admissions per year: '" district population X rate of admission per year '" 150 000 X 1120 '" 7500 (2) Bed-days per year: '" total number of admissions per year x average length of stay in hospital '" 7500 X 5 '" 37 500 150 000 5 days I per 20 population

The district hospital

(3) Total number of beds required when occupancy is 100%: bed-days per year + 365 days = 37 500 + 365 = 102.74 (4) Total number of beds required when occupancy is 80%: bed-days per year + (365 X 80%) = 128.42, say 130 beds Using this approach, the number of "justified" admissions must be estimated on the basis of the existing level of admissions, corrected according to a population survey to determine the number of people who needed hospitalization but could not be admitted and to a hospital audit that showed how many patients had been hospitalized. The "appropriate" average length of stay can be estimated from the prevailing one, corrected for both delayed and premature discharges when this information is available in hospital records. The "acceptable" rate of occupancy is established by approximation. It should be high, but not so high that incoming patients must be rejected or placed two in one bed space. Special, separate consideration should be given, however, to the needs of chronic (long-term) patients and to referrals for tertiary care. In many cases, hospital bed requirements should not be based on "international" or even national standards. Rather, an attempt should be made to approximate bed needs by district or region, taking into consideration: -the prevalence of morbidity that must be treated in a hospital, on the basis of severity and frequency, which will differ in rural, urban, peri-urban, agricultural and industrial environments; -the ability of the health services outside the hospital to reduce the need for beds; -the age structure and concentration of the population; -communications and transport facilities; -other socio-economic determinants, such as the capacity of the local area to support hospital services, including the availability and distribution of human resources and the capacity of available utilities (e.g., water and electricity supplies). The decision to build a new district hospital to augment existing facilities depends on how adequate the existing facilities are to meet the health needs of the population.

PART 1 DISTRICT HOSPITALS: PLANNING AND DESIGN

1. METHODS OF PLANNING AND DESIGN The complex process of planning and designing a hospital requires that it be a multidisciplinary endeavour. This being so, the process must be organized and systematized so that the stages, roles, activities, contributions and expected results, and their levels, standards and quality, are clear to everyone involved in the process. This section has the following objectives: (1) to present an overview of the planning and design process, to guide its participants, and

especially those working in units and agencies for health planning and designing in different countries; (2) to present concisely the basic information that is important in the process of planning and designing; (3) to organize the overview and basic information in such a way that it can serve as checklists for planning units, planning teams and professional designers, so that they can derive and organize their own planning and design; and (4) to help strengthen and develop planning and design capabilities at the local level.

1.1

The planning teams and the process

The planning and design of a hospital is a systematic process which involves stages moving progressively from the macro-level of epidemiological surveys of the needs and demands of populations in catchment areas to the micro-level of a specific space in a building designed for a particular function or human activity. It is a multi-disciplinary activity that requires the active participation of professionals in various roles; it also requires continual interaction between the users and the professionals who are to translate functional requirements into physical forms. END-USERS

The planning and design process can be envisaged as a round table, at which people in various roles sit in different combinations, depending on the objective (Figs. 3a-3f). At the earliest stage, what can be called a needs assessment team sits around the table and establishes an overall plan of the needs, the range of services to be provided, the target population or catchment area, the financial feasibility of the project and the scale of the hospital (Fig. 3a).

PLANNERS

Fig. 3a. Needs assessment team

~e tab.le chan~es composition as the briefing team moves in to prepare the key documentthe deSIgn bnef-whlch translates the requirements into functions, activities, space distribution programmes and relationships and all the other information necessary for design (Fig. 3b).

District hospitals: planning and design

The design team, consisting of all the people involved in designing the physical facilities, pools the expertise of its members to produce the instruments for implementing construction, starting from preliminary and development designs and ending in the production of technical specifications, tendering documents and detailed working drawings (Fig.3c). END-USER

END-USERS

PLANNERS

ARCHITECTS! ENGINEERS

Fig. 3b. Briefing team

Fig. 3c. Design team

The construction team implements the design from the approved drawings and technical specifications within the prescribed time and cost, and produces the physical facility (Fig. 3d).

The commissioning team staffs the hospital, commissions and procures the equipment, furniture and supplies and prepares it for operation (Fig. 3c).

END-USER STAFF

BUILDER

Fig. 3d. Construction team

Fig. 3e. Commissioning team

By the end of the project, a multitude of people will have sat around the table and made their contributions to the project as part of the planning team (Fig. 3f).

Fig. 3f. Planning team

Methods of planning and design

1.2

Roles of members of the team

In each of the stages that comprise the planning and design process, each member of the team has a role to play: -The health planner establishes the need for the hospital, its role in the community and the services it will offer. -The functional planner establishes the functioning of the different departments and of the hospital as a whole. -The financial planner establishes the financial feasibility of the project. -The physical planner establishes the relation of the hospital to the town and the community that it serves. - The architect and the engineering consultants provide professional planning, design and supervision of construction. -The builderlcontractor produces the hospital in its physical fonn using materials, labour and construction equipment. -The procurement staff and the personnel staff fonn part of the commissioning team which prepares the hospital for operation by procuring material and recruiting staff. -The client/user is the owner and final user of the hospital. These people assume either active or consultative roles at the planning table, depending on the task at hand. Table 2 gives a simplified version of the stages and their corresponding inputs and outputs and the role of working professionals at each stage. It is important to note that the engineering services should be planned jointly with the layout, so that the final result is the logical outcome that meets the needs of the actual users of the hospital, offering the best available health care service to the population commensurate with the cost. Table 2. Stages in planning and designing a hospital Stage Task Input Output Active One Establish demand for new hospital or for hospital expansion Prepare design brief Infonnation Indicators Projections Decision to construct, renovate, expand User/ Client Planners User/ Client Architect! Engineers Working team Consultative

Two

Services to be delivered Design brief Functional scale of hospital Functional requirements Design brief Additional data from consultants Design of hospital Working drawings Design of hospital Working documents

Three

Design

Architect! Engineers

User/ Client

Four

Construction

Hospital in physical fonn

Architect Builder Engineers User/Client Procurement staff Personnel staff

User/ Client

Five

Commissioning

List of staff List of furniture List of equipment List of supplies

Appointment and training of staff Procurement of furniture. equipment, supplies

District hospitals: planning and design

1.3

Preparation of the design brief

The design brief is a key document: it is the written expression of the client's needs, as expressed in consultation with various professionals, including the architect and engineers. It is important because "a good design is based on a good brief' and "a good brief is rich soil in which to grow a good design". The brief should provide the following information about the hospital and its parts or units: (I) Functional content: size and content of departments, such as number of operating theatres, number of beds in wards (2) Philosophy of service: what the departments will and will not do (3) Workload: what hours the hospital departments will work, the shifts, maintenance time,

overtime (4) Planning principles: policies and procedures of the hospital with regard to: -patient movement -staff movement -supply delivery --disposal of used goods -laundry service -food service -domestic services (5) Staffing: number and types of staff, peak periods of work (6) Functional relationships: between departments, between rooms within a department (7) Environmental factors and engineering: hospital policies with regard to: -fire protection -electrical supply (mains and stand-by) -sterilizing and sterile supply -security -hot- and cold-water supplies -heating and ventilation -lighting -medical gases and vacuum -emergency alarm system --other engineering services -landscaping and pollution control (8) Schedule of accommodations: list of all rooms and spaces in each department, type and number of occupants, sizes and activities performed in them (9) Financial aspects (a) Costs: budget, or programmed amounts, to include: -construction (a major budget item) -professional services (architects, engineers) -construction/project management services -fixed equipment -furniture and movable equipment -extra utilities, if necessary -professional procurement and installation of equipment -site investigation and development, including purchase of land

Methods of planning and design

-insurance, for fire and other liabilities required during construction -legal counsel -taxes, customs duty and other statutory charges --contingencies, for unforeseen situations (b) Possible sources of funds -central government -gifts, donations or grants -money generated by hospital activities prior to construction -money to be repaid from future hospital activities The following is a sample format and checklist of the contents of a typical design brief for a district hospital: (J) Introduction (a) Background, project initiative (b) Project funding, source (c) Philosophy of service service development plans (d) Organization (e) Other

(2) Site information (a) Physical description: bearings, boundaries, topography, surface area (b) Land use in adjoining areas (c) Any limitations of the site that would affect planning (d) Maps of vicinity and landmarks or centres (e) Existing utilities (f) Nearest city, port, airport (g) Rainfall and data on weather and temperatures (3) Policies for hospital operation: concepts on a general level, with implications at specific levels, such as: -patient movement -staff movement -delivery of supplies -disposal of used goods -laundry services -food services -domestic services -security -engineering services -fire protection -emergency alarm systems (4) Zoning: grouping of departments according to zoning principles (5) Departmental requirements: separate consideration for each department should include: (a) Description of functions and facilities -procedures, operational policies -schedule of accommodation -list of rooms -suggested area; critical dimensions, if any (b) Qualitative parameters. (i)

location, relationship to other rooms, services and departments

District hospitals: planning and design

(ii) use -function of or activities carried out in room -space requirements for activities, when critical -numbers of staff andlor patients using room at one time -wheeled traffic -goods or materials -special uses and work flow -occupancy or time in use (iii) constraints -privacy -supervision -security -separation -fire protection (iv) environment -wind direction -lighting, natural and artificial -heat, humidity, sterility --cold, room heating -sound (acceptable noise levels) -ventilation (v) fittings, fixtures and equipment (fixed and movable) (vi) loads on services -electrical -heating -ventilation and air-conditioning -hot water (c) Functional relationships and physical proximities (i) closeness matrices' (ii) bubble diagrams2 (iii) activity analyses, traffic movements. (d) Flexibility and future expansion: possibility of future growth, with schedule (6) Cost of project, other financial aspects (in terms of capital and recurring costs) (a) financing scheme (b) cost limitations for each aspect of the project (working budget) (c) priorities for phasing, if necessary (d) expected flow of funding with time

1.4

Designing from the brief

It is at this important stage that abstract ideas are translated into concrete physical facilities. In essence, the designer gains an understanding of the activities and their sequence and pictures people performing the activities; with these in mind, the designer creates the working environment, translating invisible ideas to visible spaces formed by the process of design. This process is discussed in detail below. 'Closeness matrices: graphical analyses that qualify the levels of proximity between departments, rooms or spaces, using descriptions in levels of progression, such as "physically adjacent", "easy access", "closeness not necessary", "closeness undesirable" . 'Bubble diagrams: graphical analyses that show depanments, rooms or spaces and the types and intensity of traffic between them, generated by people (patients, staff, visitors) and things (supplies, food).

2. LOCATION

2.1

Inventory and distribution of health facilities (the mapping exercise) One of the most effective ways of determining the location of a new facility is to use a base map of the district and vicinity, on which one can enter, translate and compare data, facts and information (Fig. 4). A basic mapping exercise is the first step in locating the positions of existing facilities; a graphical analysis of data on where patients come from can be used to determine the areas of influence and service of those facilities. This kind of analysis shows the overlapping of influence and any voids that need filling and therefore warrant the provision of a new facility.

VOID

I I

Fig. 4. Mapping exercise

2.2

Service catchment area The catchment area for a health facility is determined by several factors: (1) Politico-administrative boundaries are usually the strongest determinant, as they set a defined area and imply an established organization which directs, manages and operates the affairs of the population within its jurisdiction. In most countries, the hierarchy of physical facilities parallels that of the politico-administrative organization, so that a particular level of facility is under the jurisdiction of an equivalent level of the politicoadministrative unit throughout the country.

(2) Geographical boundaries are natural physical barriers to population movement and can therefore also be strong determinants of catchment areas (Fig. 5). Mountain ranges and bodies of water, for instance, deter crossmovement. People may cross politicoadministrative boundaries to reach a facility, however, if they are deterred by a natural barrier within their own district. Geographic boundaries are often formalized into politicoadministrative boundaries as a natural consequence of the development of ethnic, cohesive or homogeneous cultures on either side. Fig. S. Natural physical barrier as a determinant of catchment area

District hospitals: planning and design

(3) Time boundaries, although invisible, determine catchment areas in regions without roads and

easy means of transport (Fig. 6). Populations gravitate towards the facilities that are most easily accessible, that is, the facility they can get to in the shortest time. The factor of geography also contributes to this situation, as difficult terrain takes longer to negotiate.

Fig. 6. Time boundaries as determinants of catchment area

2.3

Factors to be considered in locating a district hospital (1) It should be within 15-30 min travelling time. In a district with good roads and adequate means of transport, this would mean a service zone with a radius of about 25 km.

(2) It should be grouped with other institutional facilities, such as religious (church), educational (school), tribal (cultural) and commercial (market) centres. (3) It should be free from dangers of flooding; it must therefore not be sited at the lowest point of the district. (4) It should be in an area free of pollution of any kind, including air, water and land pollution. (5) It must be serviced by public utilities: water, sewage and storm-water disposal, electricity, gas and telephone. In areas where such utilities are not available, substitutes must be found, such as a deep well for water, generators for electricity and radio communication for telephone.

2.4

Site selection

A rational, step-by-step process of site selection occurs only in ideal circumstances. In some cases, the availability of a site outweighs other rational reasons for its selection, and planners and architects are confronted with the job of assessing whether a parcel of land is suitable for siting a hospital. In the case of either site selection or evaluation of adaptability, the following items must be considered: size, topography, drainage, soil conditions, utilities available, natural features and limitations.

2.4.1 Size The site must be large enough for all the planned functional requirements to be met and for any expansion envisioned within the coming 10 years (Fig. 7). Recommended standards vary from 1.25 to 4 ha per 100 beds; the following minimum requirements have been proposed: 25-bed capacity - 2 ha (800 m2 per bed) 100-bed capacity - 4 ha (400 m2 per bed) 200-bed capacity - 7 ha (350 m2 per bed) 300-bed capacity -10 ha (333 m2 per bed)

Fig. 7. Minimal size of site

Location

These areas are for the hospital buildings only, excluding the area needed for staff housing. For smaller hospitals, single-storey construction generally results in lower building cost, less reliance on expensive mechanical services and lower running and maintenance costs. Thus, hospitals up to 150 beds should be single-storey constructions unless other parameters dictate that they be multistoried.

2.4.2 Topography Topography is a determinant ofthe distribution ofform and space. A flat terrain is the easiest and least expensive to build on. A roIling or sloping terrain is more difficult and more expensive to build on, but the solutions can be interesting and innovative; by using the natural slope of the ground, the drainage and sewage disposal systems can be designed so as to result in lower construction and maintenance costs (Fig. 8).

FLAT TERRAIN SLOPING TERRAIN Fig. 8. Topography

2.4.3 Drainage The terrain must allow for easy movement of water away from the site. A high point in the community is ideal. Ifthis is not available and the site is at a low point or in a depression, the following must be checked: -how the surrounding natural terrain and waterways can be used to move water away from the site; -whether the type of soil allows rapid absorption and disposal of water; -the use of other technical means of ensuring drainage, such as placing the building on a podium or on stilts, or digging temporary reservoirs (Fig. 9).

FIRST

FLOOR LEVEL ...

PODIUM

.-J--,--,-----I...,I FLOOR • LEVEL ... \ STILTS

FIRST

-.~

~"!:~0,!''/,':'" ,.' I

TEMPORARY RESERVOIRS

Fig. 9. Means of draining low-lying sites

District hospitals: planning and design

It should be noted that the placing on a site of hospital buildings and paved areas greatly increases run-off of stonn-water. A site with no apparent drainage problems when bare may be subject to serious flooding when developed, if adequate provision is not made for disposal of rainwater. Wherever possible, a site should be provided with surface openings to storm-water drains, drainage channels or waterways. Storm-water run-off from roads and buildings should be piped to such openings. It is also important to check that the waterways themselves are not subject to flooding and that, in flood conditions, water wilI not back up on the hospital site. When deciding the ground floor level of the buildings, care should be taken to safeguard against temporary flooding of the building in a heavy downpour. In areas prone to regular flooding, a raised ground floor, which alIows for expected peak floods, is essential. Local engineering advice on the possibilities of drainage from a site should be obtained before proceeding with its purchase, when such advice is available (e.g., from records of the local authority or relevant government department). It may also be necessary to perfonn percolation tests to determine the capacity of the soil to absorb liquids; this is particularly important when sewage must be treated and effluents disposed of on the site.

2.4.4 Soil conditions The soil conditions are a detenninant of foundation schemes. Ideally, the subsoil should be such that conventional, economical structural design and foundation schemes can be used. Waterlogged areas, swamps and former ricefields should be avoided. If no other site is available, however, the following steps must be taken:

(I) Check the bearing capacity of the soil. As foundation requirements vary greatly with the form of construction and the building materials used, the subsurface soil and water conditions must be detennined. A sufficient number of test borings or pits must be made so that the engineer can best judge the true subsurface conditions. The results of this investigation must be submitted in a report that contains detailed recommendations for designing the foundation. If necessary, appropriate laboratory tests should be perfonned to detennine the safe bearing capacity and the compressibility of the various strata of soil, including alkali content, which might affect concrete foundations in the long run. The bearing capacity of the soil must be confinned at key points, preferably where major foundation elements or footings would be located. In Figure 10, the starred points show the locations of boreholes or test points with respect to the locations of bUildings. Some boreholes should be dug closest to the location of the basement, if any, and to the tallest structure of the building complex, including water reservoirs and the sewage treatment plant. (2) Scrap unstable top layers, if necessary, and fill with well compacted, suitable materials, like clean coarse sand. (3) Seek engineering advice before finalizing the depth and size of the foundations, which should be designed to suit the site conditions.

2.4.5 Utilities available Electrical, water and communication lines should be available. If not, generators, deep welIs, water pumps and radio communication lines must be established. Health care facilities are quite ineffective if alI-weather roads, water supplies and a reliable electrical supply are not available at the site.

Location

'<>'

C~ 10>. '<>"

BORE HOLE LOCATION PLAN Fig. 10. Boreholes to confirm hearing capacity of soil

2.4.6 Natural features Features such as natural lakes and ponds and lush vegetation are not necessarily a disadvantage and can have great potential for enhancing the building design. Building design should respond as much as possible to the site, so that the structure is in context with the environment: a waterway that bisects a site also generally bisects the building form; this might call for an innovative design solution in which the building straddles the waterway (Fig. 11 a).

Fig. 11a. Building straddling waterway

The presence of a large pond on a site diminishes its area and coverage and might call for a multi-storey solution on a site that could otherwise adequately accommodate a sprawling building (Fig. \1 b).

Fig. lIb. Building designed around a pond

District hospitals: planning and design

A large, old tree might necessitate a design that skirts around it (Fig. llc). All attempts should be made to maintain the existing trees on the site in accordance with the profile of the building.

Fig. Hc. Building designed around a large tree

Solutions can be numerous, involving creativity and innovation, but they should be based on two overriding considerations: (i) that the design respects and follows the laws of nature; and (ii) that the limitations imposed by the natural features do not detract from the functional performance or cost-effectiveness of the facility. If the constraints of a site result in a building form that is too expensive, an alternative site should be found or the restrictive feature removed. For example, a waterway that crosses a site might be diverted around the edge of the site.

2.4.7 Limitations The site may be adequate in all respects, but it must be checked for possible constraints to its use: (1) Does it have direct access from the road (Fig. 12)?

ROAD

WITH DIRECT ACCESS Fig. 12. Access to site

PROPERTY-LOCKED SITE

SITE WITH NEGOTIATED RIGHT -OF-WAY

(2) Is it a contiguous parcel with proper ownership titles (Fig. 13)? Unsolved problems of ownership can constrain full utilization of a site. Sites with ownership problems should not be used (Figure 14).

Fig. 13. Proper ownership titles

Location

(3) Does the site have existing structures? If so: -Can they be incorporated into the design of the new structure and the existing parts converted into functional spaces in the new hospital? -If the existing structures are too old to become part of the new hospital, could they be converted to a motor pool, laundry, store or workshop? Are these building suitably located on the site? -Are they so old and dilapidated that they must be demolished? If so, are any of the parts, or elements mem bers retrievable for possible re-use? Fig. 14. Structures on site with ownership problems

I I

District hospitals: planning and design

3. MASTER PHYSICAL DEVELOPMENT 3.1 Basic documents and information

3.1.1 Documents These consist of a written and graphic description of the site and its features, including: -the title, which describes the property, the bearings and lengths of the enclosing property lines, surrounding, adjacent properties and roads, the area of the property and its encumbrances, if any; -the survey plan, which translates into graphic and scaled form the data contained in the title; -the topographic survey, which describes graphically the configuration of the site in terms of topographic lines and shows all the physical features, including trees, fences, buildings and drains; -the slope map, for sites in which there is great variation in grade. This is seldom required since sites on steep slopes would not usually have been selected or evaluated as adaptable. When it is required, this map identifies H areas on the site with a low percentage of slope, which is the ratio of the rise, or height (h) to the run, or length (x) (Fig. 15).

3.1.2 Site survey

Fig. 15. Slope section

Before the physical planning and design of a hospital is started, the proposed site must be surveyed and a plan made. The site plan indicates the following: -the courses and distances of the property lines, including details of party walls and foundations adjacent to the plot lines; ---dimensions and locations of any buildings, structures, easements, rights-of-way or encroachments on the site; ~stablished curb and building lines and curb grades of streets, alleys and sidewalks at or adjacent to the site; -all existing utility services, including their size and characteristics; the location of all piping, mains, sewers, poles, wires, hydrants, manholes, etc., upon or under the site and adjacent to the site; --official data on which elevations are based and permanent values established on or adjacent to the site; -information regarding the disposal of sanitary wastes and storm-water and suitability of subsoil for disposal of rainwater and sewage; -contemplated date and description of any proposed improvements to approaches or utilities adjacent to the site; -all trees and types of vegetation within the plot; and ~Ievations on a horizontal grid system of not more than 6-m interval, indicating changes of slope, to form a basis for a contour map of 50-cm intervals. All discrepancies between the survey and the recorded legal description should be reconciled before the physical planning for the hospital is begun.

Master physical development

3.1.3 Legal documents The legal aspect is one of the most significant considerations in planning and designing a project. Architects, engineers, planners and those in allied professions must have at least working knowledge of the applicable laws, rules and regulations, ordinances and codes of a country before they can practise their profession. Laws are generalized acts that provide parameters, guidance, supervision, direction and control over all planning and design activities. Rules and regulations implement the provisions of the law; ordinances are local laws refined and elaborated for specific areas of application; building codes embody general policies and standards for building design and construction and the requirements of modem technology to ensure the safety and optimal use, occupancy and maintenance of buildings and other structures. Some legal documents relevant to planning and design are: (a) Zoning regulations

.--

,... ( RESIDENTIAL

) )

,..-.

""'"

With the land-use map, this document ensures that the site selected is in the proper area for the intended use (Fig. 16). A planner who establishes a site in the overall context of the zoning restrictions of the locality paves the way to establishing the following aspects of the project: -access and accessibility of the area, -catchment area to be served, -distance of other facilities and utilities required, --easements and rights of way, if any, and -sources of materials and of local skilled and unskilled labour.

II!

0 '" in

F '--. z

... c

BUFFER GREEN PARK

COM "S ~ CIAL TI~ ~

(

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RESIDENTIAL

AGRICULTURAL

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kwDDDD~DDDDDDI~ HOSPITAL

BUILDING

Fig. 16. Land-use map

----~ CONTAINING BOX THAT

LIMITS BUILDING DESIGN

The volumetric dimensional limits of the building in terms of site coverage and building height are also dependent on zoning regulations (Fig. 17). Although such regulations constrain design, they also establish the criteria that help evolve a design that is in context with the overall plan for the community, without disturbing the local ethos and environment.

Fig. 17. Dimeosionallimits

(b) Building code

The building code of a country is designed to achieve the maximum safety in building construction, to establish standard requirements for the construction of buildings that can withstand powerful earthquakes and other calamities or survive them without undue damage.

District hospitals: planning and design

It contains provisions for:

-general building requirements, -site requirements, -permits and inspection requirements, -types of construction, -fire zoning, -fire-resistance requirements, -classification and general requirements for all buildings by use or occupancy, -light and ventilation, -labour safety and welfare during construction, -sanitation, -general design and construction requirements, -electrical and mechanical regulations, -use of specific or special materials, such as plastics and glass, -design and computation for earthquakes and cyclones, and -protection from ionizing radiation from x-ray equipment. (c) Fire code

A fire code is intended to minimize death, injury, loss and damage to property resulting from fire through national guidelines for the prevention and management of fire, by adopting safety standards, incorporating fire safety in design and construction and making provision for protective devices in buildings and structures. A fire code contains provisions for: -general precautions against fire; -fire safety in buildings, structures and facilities; -maintenance of fire exits; -design of high-risk buildings, such as theatres and auditoriums; -fire protection appliances; -suppression control in hazardous areas; -smoking; ~rganization of fire brigades and community volunteers; and -management and use of combustible materials. (d) Other codes

Other relevant bylaws, regulations and codes include sanitation codes, environmental protection laws and water codes; these vary in form and content from one country to another. They provide detailed provisions for design and construction. By complying with them, the planner and designer ensure that: -the permits and licences necessary for operating the hospital will be obtained, -the work is within the national standards for public health and safety, and -the designer is protected from litigation arising from interpretation of responsibility in respect of matters covered by the codes.

3.2

Operational policy

No other reference can give the planner and designer a clearer picture of the functions of a hospital than the operational policy and procedures. An operational policy is a document in which answers can be found to the basic questions: "What?", "How?", "When?" and "Where?". It spells out the operational intention of the hospital at various levels; it serves as a means of communication between members of the planning team; as it is a record of all the information on which planning and design were based, it can even serve to evaluate the performance of the finished building when

Master physical development

it is in use. The operational policy of a hospital may be developed at both the level of the whole hospital and at the departmental level. Policies at the level of the entire hospital affect all aspects and detennine the disposition of the parts of the hospital on the site. They identify groupings of activities that must therefore be zoned together. Departmental level policies affect the internal organization of particular departments within the context of the whole hospital. Development of an operational policy can be time-consuming, but organizing the process in steps using a prepared checklist can hasten the process. The major aspects that comprise the framework of an operational policy are: (1) (2) (3) (4) Function-both the major and minor functions of the health service system Scale-the workload and the number of staff required to meet the workload Organization-the procedure by which functions are to be carried out Administration-the management structure that oversees the whole operation

A sample checklist for an operational policy is as follows (each aspect is discussed in detail in the subsequent text): (1) Function

(a)

Major junctions

(i) (ii) (iii) (iv)

Aims and objectives of the services to be provided Patients and types Types of illnesses to be treated Activities involved (e.g., reception and documentation, diagnosis and treatment, disposal) Other functions contemplated (e.g., teaching, research) People involved (e.g., patients, staff, researchers, students, outside faculty members)

(b)

Minor junctions

i) ii) (2) Scale

(a) (b)

Workload (e.g., daily number of in-patients treated, of in-patient meals served, of x-rays taken) Manpower and staffing needed to meet the workload

(3) Organization policy in regard to:

(a) Patient movement. The manner in which patients are moved--on stretchers, their own beds or wheelchairs-affects decisions on circulation routes and spaces, corridor widths and door widths. It also affects decisions on types of vertical routes to be used, whether stairs, lifts or ramps. (b) Staff and staff movement. The routes taken by the staff from the outside to their places of work, how they arrive and their distribution within the hospital bears on the size and siting of staff areas and amenities, including areas for parking, changing, resting, conference and study. (c) Supply delivery. A hospital may adopt a centralized system for storage and delivery of supplies. In this case, corridor routes by which supplies are brought from the central store to departments must be of adequate dimensions to accommodate the delivery equipment used such as trolleys and mechanical pullers. In hospitals that opt for decentralized systems, traffic routes are simpler but a number of sub-supply posts must be provided in different departments or units.

District hospitals: planning and design

(d) Disposal of used goods. Used goods, especially contaminated ones, very often require design solutions that involve segregation of clean and dirty streams of traffic. Segregation may also involve use of plastic bags or sealed containers, so that clean and dirty streams can use the same corridor. (e) Laundry services. When laundry is to be undertaken within the hospital, a complete facility must be provided; if it is to be contracted outside the hospital, laundry areas may be limited to a receiving counter for clean supplies and a temporary station for soiled linen to be collected by the outside agency. Provision for washing "foul" linen may still be necessary. (t)

Food services. A centralized kitchen from which food is brought directly to patients will be large, and centralized food management will mean that the movement of large food trolleys must be considered in the design of the corridor system. A kitchen that is decentralized to the departments and wards will be smaller at the central point but will involve satellite kitchens for tray and plate preparation and washing and storage of utensils and equipment.

(g) Domestic service. A centralized domestic service will require large storage areas for fresh linen and cleaning equipment. In a decentralized system, these areas will be smaller units in different parts of the hospital. (h) Security. The number of entrances and exits is often the concern of the security unit of the administrative office of the hospital. The decision taken on the maximum number affects circulation and circulation routes both inside and outside the hospital building. (i) Engineering services. The checklist for this aspect will include questions like:

-Should hot-water lines be provided in addition to cold-water lines? If so, in what departments? -Should the hospital be air-conditioned? Should the air-conditioning be centralized for the whole hospital, or should it serve only selected areas? If selected areas, which departments or units? -What medical gas lines should be provided? Should the lines be centralized or decentralized? At what points should the lines have outlets? Or should the provisions for gas be in the form of portable tanks on carriers with rollers? U)

Fire safety. Fire safety is not limited to the provision of fire exits and fire control; fire safety should start with the design of the building. It can be improved by good planning and recognition of the specific problems of hospitals. A minimum of two compartments should be provided per floor, with proper facilities to stop fife and smoke and fire doors of appropriate standard. The larger the continuous floor area on any storey, the more fire compartments are required; this also ensures greater opportunity for progressive evacuation. Maximum amounts of fire-resistant materials should be used in constructing the buildings, in false ceilings and in partition walls, so that they have the requisite fire-resistance and flame-spread ratings as outlined in the code. Communication and call systems

(k)

The types of wired communication should be decided on, and whether all or only some of the following are required: -internal telephones -external telephones -public (coin-operated) telephones -intercoms -patient-nurse call buttons

Master physical development

--emergency alarms -public address system -radio and television -others (4) Administration (a) (b) Administrative arrangements Office accommodation

I I

3.3

Site utilization

The hospital is a rational organization of spaces in hierarchical levels: the whole hospital consists of zones, which in tum consist of spaces (Fig. 18). The space is the smallest architectural unit in this hierarchy: here, people (patients, staff, the public, students) and goods (supplies, equipment and records) interact. Thus, the design of the hospital must proceed in the same way-from the macro to the micro level, from the general to the specific, from the whole hospital to the space. The designer must envisage the whole hospital as the sum of all the parts. Some ofthe items that must be analysed at the level of the whole hospital are described below.

/: ISPAC~

EpAce; /SPAce/ ISPAcel ROOM ROOM

\SPAC~ ROOM

DEPARTMENT.) ~PAC~ ~PACij ROOM

~EPARTMEN')

~ ROOM

"'"

ISPAC~ ROOM

~PACS jSPAcij ROOM ROOM

~PACEl

RECORDS

DEPARTMENT..!

"pEPARTMEN,[

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ZONE

\...

ZONE

../

HOSPITAL Fig. 18. Organization of zones and spaces

3.3.1 Plot ratio The area of the site covered by buildings can be expressed in terms of the plot ratio, using the formula total hospital floor area Plot ratio =

total area of site The total hospital floor area can be obtained from the schedule of accommodations in the architect's brief, making due allowance for additional areas required for circulation.

District hospitals: planning and design

Examples of plot ratios and subsequent possible schemes for distributing the required areas in the hospital are as follows (Fig. 19):

A plot ratio of I means that a one-storey building will cover the entire area of the site (Fig. 19a).

Fig. 19a

Since it is recommended that 50% of a site area be left open for roads, other circulation routes, parking and landscaping, a plot ratio of I would require a solution in which the area requirements are distributed in a two-storey building (Fig. 19b). Fig. 19b.

Similarly, a plot ratio of 2 would lead to a four-storey solution (Fig. 19c)

Fig. 19c.

and a plot ratio of 0.5 would lead to a one-storey solution (Fig. 19d).

F' Ig. 19d•

In the suburbs, where population densities are low and land can be obtained easily, a plot ratio of no more than 0.5 should be sought. In the centre of a town, no more than 2 should be provided. Plot ratio, however, is a measure of desirability and is not an absolute requirement. Plot ratios of more than 2 may be justified where land is expensive and use of available properties must be maximized. In these cases, building coverage is regulated by building codes with regard to: -the distance of the building from the property boundary, and -the maximum allowable height, which in tum is limited by structural and soil conditions and by regulations with regard to, e.g., airplane and helicopter routes.

Master physical development

3.3.2 Orientation The orientation with regard to the sun and prevailing winds must be checked (Fig. 20). It has been found that orientating buildings along an east-west axis, giving the longer sides of the building northern and southern exposures, is the most desirable. In areas where the major climatic problem is humidity rather than heat, buildings should be sited at a slight angle, either towards the east or the west, depending on the direction of the prevailing wind.

.;'~/WIND E

WINTER

COLD IlfERY NORTH WIND E DESIRABLE ORIENTATION

I I

w BUILDING

DESIRABLE ORIENTATION S OF

BUILDING IN TROPICAL COUNTRIES

Q ~NTRleS BUILDING IN

Fig. 20. Orientation of sun and wind (conditions in northern hemisphere)

In order to overcome severe aspects of the climate at the building site, a favourable microclimate should be provided through landscaping, lawns, paving and planting trees and shrubs as well as constructing ornamental bodies of water and creating sunny and shady areas. Illumination and ventilation are major problems in hospitals, and these are further aggravated by modern trends to construct "deep" buildings using steel and reinforced concrete. Good ventilation in tropical climates ideally requires long, narrow buildings; but this is not always feasible, and a compromise must be found by separating activities and orientating bui/dings or wings of buildings. Incorrect orientation of buildings strongly affects the consumption of energy in the finished hospital. In areas where there are heavy rains accompanied by wind, all openings should be protected against wind-driven rain. In hot, humid areas, the external surface should reflect as much solar radiation as possible, and the walls and roof should, as far as possible, be made of lightweight material with low thermal capacity.

3.3.3 Slope study On sites with steep slopes, the best areas for building must be found. As a rule, slopes of 0-10% are desirable and easy to build on (Fig. 21); slopes greater than these require either massive cuts or massive fill or a combination of the two. Fig. 21. Slope map

District hospitals: planning and design

3.3.4 Landscaping and horticulture Advances in technology often entail a risk of lowering the quality of the environment. The setting up of a modem hospital on a new site is no exception. Even a functionally well-designed building sometimes does not fit in with the environment and does not provide the level of comfort and friendly surroundings necessary for patients. The solution may lie to a large extent in proper landscaping and horticulture arrangements, which should form part of the master plan. The physical features of the land surrounding a building---shape, contours, whether open or dotted with large trees, location of other buildings-affect the prevailing wind. Wind lanes are thus formed, or useful breezes might be blocked. The most severe aspects of the climate and the handicaps of the building site should be observed in detail, so that they can be corrected to provide, as far as possible, a favourable microclimate by landscaping, grassing, paving, planting trees and shrubs, constructing ornamental bodies of water and creating many sunny and shady areas. Dense vegetation in arid areas controls hot, dusty winds, while transpiration from leaves increases humidity and lowers the temperature. In humid areas, bushes and trees can be planted to deflect or divert winds into the building (Fig. 22; Manahan, 1983). Similarly, waterways and water channels help to reduce temperatures, and the grassing over of large areas of ground reduces glare.

C.l

~ :::::::::~n HEDGE CLOSE TO WINDOW DIRECT FlOW INTO WINDOW TREES WITH BRANCH BOTTOM AT LEVEL WITH WINDOW HEAD

DIRECTING FLOW

HEDGE AWAY FROM WINDOW DEFLECTS WIND

FOR PROTECTION Fig. 22. Use of plants and trees to direct air Row

Master physical development

3.4

Circulation Circulation routes in a hospital consist of external and internal routes.

3.4.1 External routes These consist of traffic lines within the site, from the access point to the entrance of the building (Fig. 23). They are generated by various kinds of exterior traffic, including: -patients on foot, -patients in cars or on motorcycles, -patients in ambulances, -visitors on foot, -visitors in cars or on motorcycles, -staff on foot, -staff in cars or on motorcycles, -supplies delivery, -rubbish collection, -removal of the dead, -special route for fire trucks.

I ~ ~////. VA

Whw///# l..I..-..-

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Fig. 23. Distribution of access routes

These various types of traffic should be grouped for entry into the hospital premises according to their nature. An important consideration is that traffic moving at extremely different paces (e.g., a patient on foot and an ambulance) should be separated. Some hospital guidelines recommend four access points to the site, in order to segregate traffic: --emergency: for patients in ambulances and other vehicles for the emergency department; -service: for delivering supplies and collecting rubbish; -service: for removal of dead; and -main: for all others. This kind of decentralized distribution of access, however, poses security and control problems, and hospital administrators prefer fewer points of entry and exit. A design solution that takes this into consideration is to have one or a maximum of two entrances and to break the main access road into several branches in a hierarchy of roads within the site.

District hospitals: planning and design

3.4.2 Internal routes Internal traffic streams link departments; some important guidelines are as follows: (a) Corridor size in relation to traffic intensity

Studies have shown that traffic problems are caused by: -inadequate pace of circulation, e.g., when there are more users than were provided for; -different paces of circulation, e.g., when a slow-moving trolley bed with a sedated patient and equipment obstructs the normal flow of traffic in a busy corridor; and -two-way traffic, e.g., when a food trolley and a bed trolley cross at a corridor intersection. A study of traffic in hospital corridors showed however, that a corridor 2-3 m wide can accommodate daily traffic. A corridor 3 m wide in a major hospital can accommodate a walking traffic load of 4000 people per direction per hour, or 8000 people in both directions per hour, assuming a free-flowing walking speed in hospitals of 4 kmlh. The same corridor can accommodate 2~0 journeys per hour of wheeled traffic, including supplies, bed and food trolleys.

PATIENT TROLLEY BED

HOSPITAL AIDE TURNING FROM CORRIDOR TO WARD ROOM

(b) Corridor size in relation to manoeuvrability

The intensity of the traffic in a hospital is not the critical factor in deciding the dimensions of its corridors; rather, the overriding factors are: -manoeuvrability of wheeled equipment at doors, junctions and routes of vertical movement, such as ramps, stairs and lifts (Fig. 24); and

"GO

I t;======--MANOEUVRING 2 TROLLEY-BEDS AT CORRIDOR JUNCTION

STOP

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Fig. 24. Manoeuvrability of wheeled equipment

-accommodation of stationary wheeled equipment in corridors as other users pass by (Fig. 25). (Storage of equipment in corridors should be discouraged.)

Fig. 25. Accomodation of stationary equipment

Corridors in outpatient departments and ward blocks should not be less than 2.8 m wide. A corridor must be wide enough to accommodate two passing trolleys, one of which may have a drip attached to the patient.

Master physical develop1lU!nt

If site limitations and functional interrelationships lead to a multi-storey design, the following guidelines should be considered: -The stair is the traditional and most economical route of vertical circulation (Fig. 26); however, its use as the only means of vertical circulation is limited to four storeys for walking public and staff, beyond which it must be supplemented by mechanical equipment. The stair must also be evaluated in terms of manoeuvrability; movement of trolleys and beds requires ramps and lifts. -The ramp is very convenient for wheeled traffic (Fig. 27), especially when there is no electricity supply. Since its slope must be 1:15 to 1:18, however, for safety, comfort and ease of movement, it requires a great deal of space. It must also be checked for manoeuvrability of beds and trolleys at any turning point. Fig. 27. Ramps -The lift is versatile for transporting all kinds of traffic vertically (Fig. 28). Owing to their cost, however, lifts cannot always be located at points where specific departments need them. A lift system must be designed with a clear picture of departmental distribution and must be coherent with the hierarchy of circulation routes in the hospital. The key point must be determined, at which the lifts will be grouped and from which traffic will circulate on each floor. It is recommended that the distance of a lift from the furthest point on a floor should be no more than 30 m. The number of cars of specific passenger load and car speed is difficult to determine using empirical formulae. Studies must be made of type of traffic, floor of origin, floor of destination, time of trip, programmes and schedules of departments, plan of supply rounds and other data. Such studies are tedious to undertake. In the absence of standards, some experience in existing multi-storey hospitals confmns the adequacy of: two lift cars large enough to accommodate Fig. 28. Lifts one trolley bed and eight passengers or 16 passengers and travelling at 105 m/min for a 100-bed hospital; and three lift cars of the same specifications for a 200-bed hospital. (These figures have not been adopted as a standard in any official document or by any formal study and they require confirmation.) Adequacy is also affected, of course, by public use. It is desirable to encourage the public to use the stairs, unless they are elderly, frail or incapacitated. -The escalator is a luxury provision: it is expensive to install and it devours much space. Its use is limited to ambulant people, and it cannot be used for wheeled, large hospital equipment. Its use is not recommended for any district hospital in the foreseeable future.

Fig. 26. Stairs

District hospitals: planning and design

3.5

Growth and change

Provision for growth is often ignored or treated as an afterthought, but it should form part of the initial planning and design process. If it is left to the time when an urgency is recognized for more beds, laboratory services or x-ray services, it may be difficult to accommodate these needs. It is therefore of utmost importance that, when preparing the master plan for the hospital, imaginative foresight be used to identify the areas in which there will probably be fast growth. Growth is inevitable and is generated mainly by: -Growth of the community. A community may urbanize or may change drastically as the result of an event or a catalysing situation that requires the equivalent growth of health care services. -Accumulated needs and requirements. Necessary expansion may not be undertaken immediately because of lack of resources; needs are deferred and accumulate to the bursting point. -Physical effects on the building with time. Buildings deteriorate and become obsolete and even irrelevant over the years. -Changing standards and codes. Regulations for health and safety change to meet advances in construction techniques and materials. A building may be declared unsafe and unfit for human use if it is not updated, upgraded and properly maintained. -Changing methods in medicine. Development of new equipment, miniaturization, computerization and other new technologies in the medical field translate into new requirements for architectural design to provide better and more modem clinical services.

When difficulties become apparent, the first step is to see whether there are alternative ways of overcoming the problem. Sometimes, management solutions can alleviate difficulties and make it possible to avoid or defer the need for expansion or replacement of existing facilities. When a new building with new service facilities appears to be needed for a particular department, it is sometimes possible to adopt more cost-effective procedures within the old building; the planned new service facilities may simply be the same as the old ones but in a larger space.

3.5.1 Physical growth of hospitals (a) Outward growth

This is the recommended form of expansion (Fig. 29). Thus, those areas in which growth is most probable should adjoin an outside wall; areas that are non- or slowgrowing should be in the central part of the building complex. Outward growth requires that departments be placed where they can expand into open space without disturbing the operation of other parts of the hospital and infrastructure, including the road network and sewer lines. Obviously, the greatest scope for independent expansion of separate components is available in singlestorey complexes with separate buildings, Fig. 29. Outward growth each of which is ~tendable independently of the others (Fig. "30).

Master physical development

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(b) Upward (vertical) growth

This direction of growth is the option for block forms on very limited sites (Fig. 31). It disrupts operations, particularly on the top floor of the hospital; construction materials are difficult to transport, requiring an elaborate system of scaffoldings and hoists. Excess material, although MATERIALS initially expensive, must be installed DIFFICULT ahead of time, in: TO BRING UP -foundations that will accommodate the future load of additional floors; EXCESS DESIGN OF -sanitary, electrical and mechanical FOUNDATION TO ACCOMMODATE FUTURE LOAD systems that will accommodate future require-ments; -a strong roof slab on the top floor Fig. 31. Upward growth that can be converted to a future floor slab that will support the projected load of patients and equipment; and -special and sometimes costly provisions to ensure that the building remains waterproof throughout the period of extension.

EXCESS DESIGN OF SANITARY, ELECI MECHANICAL SYST.

District hospitals: planning and design

This direction of growth utilizes the basement volumes, when they are not part of the original design (Fig. 32). This can cause enormous problems of adequate headroom and in clearing the existing system of foundations and columns. Furthermore, there are problems of waterproofing and damp-proofing the new retaining walls. As windows will be limited or impossible to install, there will be problems in providing natural ventilation and light. It is always desirable to avoid this type of growth, due to technical and cost considerations. (d) Inward growth

PROBLEM: HEADROOM ADEQUACY WATERPROOFINGI DAMP PROOFING VENTILATION, UGHT CLEARING EXISTING FOOTINGS

Fig. 32. Downward growtb

This direction of growth pushes adjoining departments out of their location to make way for a growing department (Fig. 33). It usually occurs in concentrated types of development. This type of growth disrupts the operation of both the growing and the adjoining department. It requires that adjoining departments: -be easy to relocate and -have convertible spaces. Therefore, it is not economical to relocate rooms, units or departments that have complicated engineering services, such as operating rooms, x-ray equipment, kitchens, toilets and laboratories. (e) Growth by fragmentation

D GROWING EXPANDING D~PARTMENT

DISPLACED' DISRUPTED DEPARTMENT

Fig. 33. Inward growtb

This is the division of a single department into several subunits in different locations (Fig. 34). Departments and other units that can be fragmented are: administration, dining, laboratories, storage, lockers and records. Fragmentation should be avoided, however, as it poses problems of management and control and the hospital ultimately becomes less efficient and productive owing to duplication of necessary support services.

o GROWTH BY FRAGMENTATION MANAGEMENT OF FRAGMENTS DIFFICULT

Fig. 34. Growtb by fragmentation

Master physical development

ii 3.5.2 Increments of growth It is most advisable to expand not in spurts with needs but by deliberate increments, thus:

-by number of beds, but in terms of ward units with their complementary manpower and supporting services (Fig. 35a); -by functional units, in the case of a new hospital department (Fig. 35b); -by specialist rooms and their supporting units and services (Fig. 35c).

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Disaster preparedness and safety

3.6.1 Disaster preparedness Disasters brought about by man, such as oil spills, release of radiation, leakage from atomic or chemical plants, atmospheric contamination, transport accidents, wars, civil strife and others, or by nature, such as earthquakes, storms, tsunamis, volcanic eruptions and floods can seldom be predicted accurately, if at all. No one can be prepared for all possible contingencies. Experience has shown, however, that much destruction, suffering, turmoil and subsequent loss of lives could have been avoided, lessened and even controlled if organizations and structures designed to coordinate and provide assistance during such events had been in place. Disaster preparedness, prevention and control, therefore, consists of a wide range of short- and long-term measures designed to save lives and Iimit"damage to property by a potentially disastrous event. These measures include: -legislation and operational planning, -education and training of the population, -stockpiling of supplies and materials, -technical training of personnel for relief and rescue operations, -development and maintenance of adequate communication systems, and -emergency funding. The state of preparedness of a country can be measured by the willingness of its people and its technical and financial capabilities to take the necessary precautions to safeguard life and property. Hospitals and other health facilities are essential elements in the network. Collectively, they are the key to preserving lives in the event of a calamity. Pre-disaster planning begins with the identification, understanding and analysis of the natural and other hazards in the area. The analysis will make it possible to establish priorities and to decide on the steps to be taken to reduce the risk. While there is no established standard, all-purpose emergency plan that can cover all contingencies, the following is a sample format of a disaster plan:

District hospitals: planning and design

Introduction

Legislative authority Related documents (1) To reduce vulnerability of people and communities in a territory to damage, injury and loss of life and property resulting from natural or man-made catastrophes, riots or hostile military or paramilitary action To prepare for prompt and efficient rescue, care and treatment of people victimized or threatened by disaster To authorize and provide cooperation in disaster prevention, response and recovery To provide a disaster management system that embodies all aspects of pre-disaster preparedness and post-disaster response

Aim

(2) (3)

(4)

Country (region. state)

Topography Climate Demography Industry Government organization History Natural events (by type) Industrial accidents (by type) Other types (e.g., man-made) Powers and responsibilities at each level Command authorities and posts Description and role of emergency services Arrangements for sectoral planning (medical, transport, communications, etc.) Arrangements and authority for requesting assistance from outside planning area Location Intersectoral communication and liaison Warning systems Receipt and dissemination of warnings

Threat

Command and coordination

Planning groups

External assistance

Emergency operation centres

Activation of organization

Operational information Counter disaster organizations Government departments Department of defence Local government Voluntary organizations International organizations Foreign governments Arrangements for liaison

Master physical development

Administration Supply

Financial procedures Emergency purchasing procedures Powers for requisitioning Organizational structure System for disaster warning System for survey, assessment and reporting Effective communication Trained and experienced people Announcements (requiring action) Information releases Emergency broadcasting Multi-language broadcasts Communications Police Fire service Defence Medical Rescue Evaluation Public works Post and telegraph Civil aviation Power Registration and tracing service

Organizational needs

Public information

Sub-plans

It can be seen from this sample format that the medical group is an important part of the planning group during and after a calamity. In any disaster, saving lives is always the first priority. If the planning and design of a hospital can be related to an existing plan for disaster preparedness, it will add an important dimension to the plan. The steps that can be taken by the planners and designers to this end can include:

(1) collection, collation and analysis of local data based on standard requirements; (2) collection, collation, coordination and cooperation in the preparation of: -analyses and calculations of vulnerability, elements at risk and specific risk; -listing of available resources in the area, such as manpower, transport, supplies, equipment and emergency funding; -review of laws, rules, regulations and ordinances; (3) establishing linkage with the national disaster control structure: -office of civil defence -health relief centres -hospitals and other health facilities -health legislative committees or councils; (4) preparing an operational plan and the foreseeable role and extent of involvement on the basis of the local situation and financial capability: -plan for probable events, including hospital patients and staff -plan for administrative response (staff alert, recall and deployment, operational control and deployment, management of mass casualties) -subdivision of plans into self-sufficient units

District hospitals: planning and design

-dissemination of infonnation to pertinent groups --exerc ises to test plans; (5) detennination, ordering of priorities and limitation of involvement on the basis of financial capability; and (6) assessment of public awareness programmes. Such exercises would lead to adoption of nonns, criteria and standards that merge acceptable international practice and the dictates of local disaster preparedness. Most developing countries cannot divert their limited resources to provide for an event that may or may not take place in the near future. The dimensions, strength and durability of the structure and the number and sophistication of the equipment and facilities are dictated by the economic status of the country, which may also be the primary consideration with regard to the adequacy and extent of the safety features to be incorporated. As a result, designers and planners can expect a down-grading or de-sophistication of their design or plan at the working stage. Only in extreme, special situations would additional features or higher standards be imposed. The type of calamity or disaster and the potential damage it can create is the second major factor to consider. As situations differ from country to country, historical experiences should be reviewed, and previous calculations and analyses can serve as a solid basis for making a decision. National records and advice from specialist departments like the meteorological service, geophysical observations, the mining department and flood control can be helpful in this regard. A first plan should be based on the country's experience with regard to the type, frequency and extent of death and destruction brought about by the calamity. For example, a country prone to earthquakes will highlight the seismic consideration in the design of buildings. Countries on or in the Pacific Ocean, visited often by typhoons, will give due emphasis to safety measures against typhoons and monsoons. A second plan may be area-specific. In countries that have become virtual battlegrounds as a result of political unrest, special attention should be given to the strength, size and location of a hospital and its support facilities. In areas where there are frequent battles, the designer will have to consider large spaces to accommodate the injured and large mortuary buildings. Adaptability of spaces for easy conversion into temporary havens for disaster victims and provisions for food may be considered in a third plan. Experience has shown that, during the initial impact of a disaster and for at least the next three days, the population tends to gravitate and seek shelter in hospitals. Subsidy by the government may be possible through emergency calamity funds. A hospital can be designed to accommodate 50, 75 or 100% of the estimated victims of a calamity. Decisions can also be made on what types of disaster to design for. In the final analysis, however, economics is the overriding factor. The process of planning for disasters can "payoff'. Disasters often call for overall management of a group of resources, of which the district hospital is but one. In an emergency, the control of all facilities must come under one command, each unit becoming part of a larger team. Inter-hospital and health facility cooperation in disaster planning and practice can lead to improved rationalization of the use of resources in everyday operation.

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3.6.2 Fire safety (a) The nature of fire

Fire is the perceptible phase of burning or combustion, which is the chemical combination of oxygen in air with the carbon contained in matter. The process of combustion is affected by:

Master physical development

---Oxygen: Natural air contains 21 % of this element; if it is absent or insufficient, combustion will not continue unless the material itself has oxygen in it. -Heat: Burning starts at the necessary degree of heat. Wood requires 398°C, but if it is exposed to 204°C for 30 minute, it will ignite. When the ignition point of any material is reached, it will start to flame if sufficient oxygen is present. -Nature of substance: Thinner materials ignite more easily than thicker ones; gases and vapours are more inflammable than solids. Smoke is a by-product of fire that contains carbon monoxide, which is harmful to human beings. It also conveys heat and may raise the temperature of substances it touches to ignition point. (b) Principles offire safety

-Fire avoidance (Fig. 36) is reduction of the possibility of accidental ignition of materials, or separation of heat sources from inflammable materials. Kitchens should not be located near rooms where combustible materials, such as x-ray films and oxygen tanks, are stored.

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II HIGH FIRE RI~K AREAS ·Susceptible to fire due to function

COMPARTMENT WITH WALLS OF FlRE·RESISTING MATERIAL OF 1· HOUR

DIRECTION OF EVACUATION

-Fire growth restriction (Fig. 37) is slowing the rate of development of a fire to gain time to take measures for control and evacuation of people. Compartmentalizing the hospital and constructing dividing walls made of fire-resistant materials will slow the spread of fire.

Fig. 37. Fire growth restriction

-Fire containment (Fig. 38) is restriction of the fITe at its site, using fire-resistant materials and by plugging all gaps tlrrough which it could pass, to allow effective fITe-fighting. -Fire detection (Fig. 39) is based on early knowledge of the occurrence of fire, which ensures early action to fight it. Smoke detectors can be installed in the ceiling at various points. Interiors of rooms that contain combustible material should be visible from outside. Fig. 39. Fire detection

FIRE ONLY WITHIN COMPARTMENT Fig. 38. Fire containment

District hospitals: planning and design

-Fire control (Fig. 40) is extinguishing fire. Fire-fighting equipment such as fire-hoses and fire-extinguishers must be easily visible and accessible for immediate use. Fire-fighting hosereels (for use by staff to "extinguish minor fires) should be of manageable length and should be located in corridors and exit routes at intervals that will allow the entire building to be covered. A fire-extinguisher (of a type suitable for fires in electrical appliances) should be available with each hose-reel and at the entrances to high-risk rooms, such as laboratories. Manual fire-alarms should be located at exits and be easily visible.

FIRE CABINET FIRE EXTINGUISHER

Fig. 40. Fire control

__-III- SUSPENDED CEILING

Fig. 41. Smoke control

) FIRE ESCAPE ~-===~____~____.. LADDER

Fig. 42. Escape provisions

-Smoke control (Fig. 41) is the management of the action and effects of smoke. Smoke spreads very quickly and is the greatest hazard to life in case of fire. Instead of designing ceilings with voids in suspension and vertical shafts through which fire and smoke can move, such spaces must be sealed. -Escape provisions (Fig. 42) are made for movement away from fire to a place of safety. Alternative escape routes must always be provided. Escape routes must be protected by sealing them from fire and smoke or by creating positive pressure in them. On the ground floor (escape level), an escape stair should have only one set of doors between the stairway and the outside. When the stair is within the building (as in a tower block above a podium), the escape route through the podium should be a fireprotected corridor with no doors between the bottom of the stairs and the exit doors to the outside. Thus, if fire develops in the escape route, smoke will rise in the stairwell, and people on the floors above will be warned that they must use alternative escape routes.

Norms for fire-resistance in buildings of a district hospital are as follows: (1) The structural framework and building elements of all buildings more than one storey high should be made of appropriately fire-resistant combinations of materials, such as steel, concrete and masonry. Load-bearing walls should be limited to exterior walls, fire-walls and vertical shafts.

Master physical development

(2) Bearing walls, lift shafts, chutes and other vertical shafts, walls enclosing stairways, boiler rooms, storage rooms of 10m2 or more should be of 2-hour fire-resistant construction. (3) Beams and girders supporting masonry should be individually protected with not less than 2-hour fire-resistant construction. (4) Columns, girders, trusses, floor and roof constructions, including beams, should be of not less than 1.5-hour fire-resistant construction. (5) Non-load-bearing partitions, other than corridor partitions, should be of I-hour fire-resistant construction. (6) The following flame-spreading ratings should be maintained (ASTM Standard E-119): -interior finish of walls, ceilings of all exits, storage rooms and areas of unusual fire hazard -all other areas in the building (except that up to 10% of the aggregate wall and ceiling area may have a finish with a rating of up to 200) -all floor finish materials not more than 25 not more than 75

not more than 75

All lift cars and platforms should be constructed of noncumbustible materials, except that fireretardant-treated materials may be used if all the exterior surfaces of the car are covered with metal. Cars of hospital lifts should have inside dimensions that will accommodate a patient bed and attendants.

3.7

Energy conservation

3.7.1 Choice of level of technology Energy conservation can be addressed on two levels: practical low-level technology and sophisticated high-level technology. The choice ofthe level of technology depends on a number of factors: low-technology solutions are less financially demanding and easy to maintain; high-technology equipment ensures the precise control of environmental conditions necessary for some hospital procedures but demands a high level of maintenance and spare parts inventory. The designer also has the option of combining high- and low-level technology. High- and low- technology responses are also found with regard to power sources. High technology plants (hydroelectric, thermal, nuclear and others) produce energy for the large-scale requirements of cities and countries, both domestic and industrial. By converting waste from human beings and animals into bio-gas, a useful source of energy is harnessed for minimal light requirements.

3.7.2 Utilization of solar energy Some departments in a hospital, such as the laundry, kitchen and wards, need a constant supply of hot water. The hot-water supply in a hospital not only requires the consumption of large amounts of conventional energy but also frequently fails, owing to lack of proper, timely maintenance and lack of availability of spare parts. Use of simple, solar heating devices can avoid most such problems and ensure a reliable supply of hot water, particularly in tropical climates, where supplementary energy is needed only during the cold season. Aided by the orientation of the building, this almost maintenance-free system can provide hospitals with hot water (up to 60°C) at very low cost.

District hospitals: planning and design

A number of solar water heating systems of varying capacities are now available on the market. A simple system is shown in Figure 43.

r~--

EXPANSION

INSULATION (FIBRE GLASS)

ELEMENT

COLDWATER

Fig. 43. A simple solar heating system

Solar energy can, of course, also be made use of for natural lighting. Windows should be as tall as possible in order to provide maximal lighting against the inner wall; the angle of incidence of light from the window to the inner working areas should be not less than 27°. Special inlets with translucent covers can be placed at various places in the roofto supply glare-free light during the day in various areas of the hospital, such as corridors, waiting halls and atria.

3.7.3 Building design The implications of building design on the capital and operating costs offacilities must be fully understood at the outset. Adoption of the more expensive, high energy consuming forms of building involves inherent on-going costs, and unnecessary consumption of fossil fuels should be avoided whenever possible. Factors to be considered are: (1) Unless the external environment is severely polluted, by smog, industrial gases or noise, windows that open are the best means of ventilating most parts of a hospital. Airconditioning is necessary in operating theatres and in a few other areas, such as intensive care units and x-ray facilities, but not in normal nursing wards, clinics or most service departments. The deep plan form of building necessitates more widespread use of expensive air-conditioning and artificial lighting. (2) Buildings that require high energy result in increased capital and operating costs, and the latter usually increases with time as energy and fuel cost rise. Energy thus consumes an ever-increasing percentage of the hospital budget. (3) High-energy buildings require more sophisticated equipment and more maintenance. The life expectancy of air-conditioning equipment is much shorter than that of the building, so further capital must be spent on the repair and replacement of mechanical components. (4) Mechanical and electrical building service equipment requires regular preventive maintenance, and trained personnel must form part of the hospital staff or be on call to keep it operational. The funding of the building may be severely impaired when such equipment is out of action.

Master physical development

(5) Since hospitals must remain fully operational in the event of a disaster or civil emergency, reliance on high-energy mechanical services may necessitate duplication of some items of equipment and the provision of emergency (stand-by) power. This also results in an increase in the cost of the project.

3.8

Financial aspects

The construction of a district hospital is part of the national health programme and, as such, is subject to long-established bureaucratic procedures. Knowledge of these procedures-of requirements, flow of approval of documents and required submissions at each stage--is very useful. Sources of funds for health facilities include the following: (1) national sources: -national appropriations; -special funds, established and set aside for the project; -share of locally generated, community funds; -private funds, from individuals or nongovernmental and voluntary organizations; and

(2) international and foreign sources: -loan from an international funding agency; -loan from a foreign country; -grant from a foreign investor; -grant from a private foreign institution or foundation. The mechanisms for obtaining, releasing, repaying, monitoring and other procedures greatly affect the work of planners and designers. The extent and schedule of release of funds affects the scope of the project, and the schedule of release of increments of funds affects phasing of the construction and planning of components of a total project. Details of the arrangements should be known before the master planning of the project is begun. Whatever the form of funding, reliable cost estimates should be prepared and updated at every stage of the project. A cost plan should be prepared at the earliest stage; but, as initial estimates are based on limited information, they should be reviewed at each stage of the project.

3.9

Master planning

The master plan of a hospital is the basis for present and future decisions on the layout of buildings and services, changes in needs and phasing. It indicates the phasing and grouping of individual buildings and the means of communication between them, the scale and location of utilities necessary at various stages, and directions and limits of probable future expansion or remodelling of the hospital. Any mistake in placing buildings, access roads, sewer systems, entry points and parking facilities 'on the site can restrict possibilities of growth. The architectural and engineering aspects of the project are evolved within the master plan on the basis of: -grouping main functions, like wards, medical services, admissions and central supplies; -establishing appropriate access routes for easy orientation of patients and visitors, with special emphasis on disabled people; and -providing scope for future expansion (see section 3.5, above), to cope with an increased number of beds, supplementary functions and medical specialization, by ensuring maximum interaction between hospital units and support services.

District hospitals: planning and design

The master plan consists of two elements: (i) determination of circulation routes and corridor systems; and (ii) location of elements on the site in relation to one another. Circulation routes and corridor systems (discussed above in section 3.4) must be designed so that all users can find their way around with least difficulty. The main circulation loop must be discernible as such, and the hierarchy of secondary routes that in tum break into more minor traffic paths must correspond to the hierarchy of the hospital units they serve. Simplicity should be the target of design; this reduces the requirements for signs and improves the quality of service. The placing of elements and departments on a site should result in an optimal interrelationship among departments and provide room for expansion (Fig. 44). Some principles and guidelines for the disposition of the units of a hospital are as follows:

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(I) Departments that are most closely linked to the community should be closest to the main entrance: out-patient department, emergency, administration (especially business sections), family planning clinic and other primary health care support. (2) Departments that receive their workload from those described above should be next closest to the entrance: x-ray, laboratories, dispensary. (3) In-patient departments should be in the interior zones, or wards. (4) Operating theatres, the delivery department and the nursery should have (I) and (2) on one side and (3) on the other, e.g., to provide easy access from the emergency and accident departments to x-ray and operating theatres. The delivery department and nursery must be separated from the operating theatre.

Master physical development

(5) Housekeeping and domestic service areas should be grouped around a service yard: laundry, kitchen, housekeeping, maintenance, storage and motor pool. (6) Staff facilities should be located on the periphery near roads and public transport: staff dormitories, quarters or housing. (7) Teaching facilities, if any, should be close to both staff facilities and teaching areas and to roads and public transport: student areas, educational and training components of primary health care. (8) The mortuary should be in a special service yard, with a discreet entrance; it should be away from the out-patient department, ward block and nursery.

I I i i

I I I I

3.10 Building sbape The district hospital should reflect the local architecture. Every country and every community has its own concept of form and of space and of their interrelationship, as well as having its own feeling for scale and proportion. The district hospital should reflect the rhythm of the local culture, civilization and historical heritage but at the same time be flexible enough to accommodate modern methods of health care and facilities. The hospital should not be alien to its surroundings or stand out as an exception but should fit in with local life, expressing its spirit and character. The hospital building should not be a huge, unfriendly structure but should be a human, welcoming part of the community. Layouts suitable for tropical climatic conditions include: an open-plan layout for "hot-humid" areas; a compact layout for "hot-dry" areas; and a compact layout for "upland" regions. But, as stated in a publication of the American Institute of Architects: There are no stock or standard plans for health care facilities. Each facility will be unique to the extent that site constraints, local zoning, vehicular access and neighbourhood requirements are taken into consideration in the initial project. This also applies to the varying conditions of project sites in the countries of the Western Pacific Region. Some of the basic shapes of hospitals, and the reasons for using them, are as follows: The village form (Fig. 45) is organized like a small town, in which corridors correspond to streets and departments correspond to the different land uses of a village. This design is easy to phase, which is useful when the budget is limited. It is also easy to expand, since the design is open-ended, and a wall can simply be broken down for expansion into an open space. This form requires, however, a large site; and if sufficient room is to be provided for ultimate growth, the distances between departments will be great.

Fig. 45. Village form

District hospitals: planning and design

The modular village fonn (Fig. 46) is similar to the village concept except that the departments must fit into a predetennined fonn. This fonn is useful when repeated modules are used. It results, however, in forced planning of departments to fit within the same shape: some will fit just right, others will be "bursting at the seems" and others will have wasted space. The finger plan consists of central corridor and side corridors, which link various departments branching out in "fingers". It is a development of the train corridor fonn (Fig. 47), in which one must

~AIN CORRIDO~ Fig. 47. Train corridor plan

Fig. 46. Modular village form

pass through one compartment to reach the next. Since the corridors in the finger plan have single functions, this fonn lends itself to the provision of abundant natural ventilation and lighting.

An open-endedfinger development plan (Fig. 48) can allow for the expansion of individual blocks at different times. It also allows for staged development, by progressive extension of the main corridor as further components are required. ACCIDENT .. EMERGENCY

I -......~

OUT-PATIENTS

ADMINISTRATION

Fig. 48. Open-ended finger plan

The block (Fig. 49) is a fonn for sites where the ground area is limited. As the hospital is developed vertically, optimal relationships between departments may be difficult to achieve and one department may be disposed on two levels. It is also a fonn that is difficult to expand later. It is appropriate for designing wards, since wards have generally similar floor plans; however, structural costs are likely to be higher than those for similar number of wards in a single-storey construction.

Fig. 49. Block form

Master physical development

In the tower and podium design (Fig. 50a), the fastest growing departments are located in the ground-floor podium and those that are slow-growing and departments that are typical and replicable are located in the tower. This form was developed with expansion and growth as the overriding criteria. The tower, however, relies heavily on mechanical engineering services, and the structure of the tower and the location of lifts and service ducts may severely limit the central area of the podium. The roof of the podium must be constructed of fire-resistant materials so that fire will not spread from the podium via external walls and windows to the tower block.

Fig. 50a. Tower and podium design

If the site permits it, there are definite advantages to placing the tower block next to rather than on the podium (Fig. SOb).

Fig. 50b. Alternative tower and podium design

The court plan (Fig. 51) closes on itself. It has the same advantages of natural lighting and ventilation as the village and finger plans but is easier to secure and more comfortable in humid tropical areas. This plan does, however, impose certain limitations; rooms at the comers of the court have no external light or ventilation; facilities that face the court cannot be extended without displacing other rooms. Increased demand for space may also mean that the area occupied by the courtyard must be filled in; this will require air-conditioning, and underground services (e.g., sewer and stormwater drains) that pass through the area may have to be relocated.

Fig. 51. Court plan

Fig. 52. Compact plan

The compact plant (Fig. 52) is a "deep" form and its proper functioning relies heavily on engineering services. Artificial ventilation and lighting must be provided for inner areas; heat generated by people and equipment must be removed by artificial cooling. This type of plan is therefore expensive to construct, operate and maintain. Compactness can be of advantage in terms of proximity of departments and of conservation of space, as in densely populated metropolitan areas. In such cases, however, the building usually has several floors, and the proximity of departments may be reduced by vertical separation.

District hospitals: planning and design

3.11 Appropriate construction technology The choice of building materials affects the cost and length of construction and also the long.. range operation and maintenance costs. Locally available materials and traditional building techniques should be given priority, as they are usually cheaper and better adapted to local conditions. Although walls can be made of local materials, however, roofing sometimes poses a problem. In many countries ofthe Western Pacific Region, reinforced concrete, hollow concrete tiles and precast concrete elements are not available locally and must be brought in. In general, building materials should be economical, durable, easy to clean and to maintain, sanitary and attractive. They should also be easy to handle on the site and to replace in case of breakage or damage. At the inception of the project, the designer must choose: (I) the type of construction method: -indigenous technology, -on-site methods, -prefabricated modules and components assembled on site, or -a combination of prefabricated components and on-site construction (2) the level of technology: low, medium or high Types and levels of construction technology should suit the conditions of site, geography, slope, time constraints, availability of labour and raw materials, construction equipment and other, related factors. Whenever possible, the methods adopted should be within the capability of local manpower and resources. Sometimes, it may be necessary and practicable to introduce new methods. Whenever imported techniques are used, the necessary skills should be taught so that the facility can be constructed and maintained using a high percentage of local skilled and unskilled manpower. Similarly, when outside design professionals are hired, they should work in association with local architects and engineers so that there is a transfer of knowledge and enhancement of local ability to design hospitals. This is essential for proper maintenance of the hospital and its expansion when the need arises.

4. DEPARTMENTAL PLANNING AND DESIGN This section deals only with general principles of planning and design. The detailed design brief should contain a comprehensive schedule of accommodation for each department and should state the functional planning requirements for each activity to be carried out in each space. The different departments of the hospital can be grouped according to zone, as follows: (l) Outermost zone, which is the most community orientated - primary health care support areas - out-patient department - eme)'gency department - administration - admitting office, reception (2) Second zone, which receives workload from (\) - diagnostic x-ray - laboratories -pharmacy (3) Middle zone between outer and inner zones - operating department - intensive care unit -delivery -nursery (4) Inner zone, in the interior but with direct access for the public - wards and nursing units (5) Service zone, disposed around a service yard - dietary services - laundry and housekeeping -storage - maintenance and engineering -mortuary -motor pool

4.1

Primary health care support areas

The three ways in which a hospital supports primary health care are: education and training, technical support and administrative support. Specific areas should be designed so that the hospital can fulfil its role in primary health care in the community.

4.1.1 Education and training support areas About 85-90% of out-patients seek solutions to medical problems that could be dealt with at home; only 10-15% have been referred from general practitioners and peripheral health units. Of the latter, 30-35% have major medical conditions. It is clear, therefore, that the number of unnecessary trips to hospital could be diminished if people were educated about the nature of various diseases, their causes, their treatment and how to stay healthy. As long as people run to the hospital whenever they feel ill, however, the medical staff of the out-patient department can serve as agents to teach better health rather than merely dispensing medical treatment.

District hospitals: planning and design

First-referral hospitals must therefore integrate spaces for education and training in their plans. Such spaces are convertible, flexible, multi-use spaces (such as classrooms) or comers found elsewhere (such as shelves for books and magazines). They may include (Fig. 53): --classrooms where primary health care personnel can lecture and show films and other audio-visual materials on the promotion of health, prevention of disease, sanitation, hygiene and family planning; --classrooms for training paramedical personnel and volunteers; -a library or reading room, containing materials on health written and illustrated for the layman; -a "primary health care court", "garden" or "gallery", the name being designed to create awareness of primary health care; this area can be accessible to out-patients, so that those who are waiting their turn can absorb educational material from exhibits (Fig. 53a); -a "primary health care comer" in the consultation or examination room, with educational materials for the use of medical staff (Fig. 53b); -use of dayrooms on wards for regular showing of films on health to patients, visitors and staff (Fig. 53c); -a comer in the dispensary containing information on the use of drugs and of equivalent herbal medicines (Fig. 53d).

a. DIAGNOSTIC

PHC

4.1.2

Technical support areas

The hospital can provide a laboratory service for the primary health care complex, in clinical haematology, biochemistry, histopathology and analysis of body fluids, either by expanding its laboratory facilities or by providing mobile services, or both (Fig. 54). Similarly, a central blood bank can be established at the hospital for use by the primary health care complex.

Fig. 53. Spaces for education and training in primary health care (PHC; OPD; out-patient department)

Fig. 54. Technical support for primary health care (PHC; HFRL, hospital at first referral level)

Departmental planning and design

Mobile services that might be provided include (Fig. 55): -laboratory -x-ray -medical shop, carrying common drugs, vaccines, serum and surgical items -out-patients department -intensive care unit -emergency unit All of these might be needed for hospitals that serve a widespread population, whereas only the fIrst few types of mobile unit might be needed in a small geographic area. Each unit can involve educational activities, however, including lectures and material for dissemination.

lID lID lID

4.1.3 Administrative support areas HOIPlTAL MOTORPOOL

ao ao HOB

IlD

5!1~ ALII [ TO PHC

~;rT~OlR~l8 PHC OFFICER

Fig. 55. Mobile services

The hospital should ensure documentation of referrals by a responsible medical officer (Fig. 56), so that reports on treatment and results on investigations are sent back to the peripheral unit. An ambulance service should be available to transport patients from outlying areas of the primary health care region to the hospital.

STAFF

Fig. 56. Primary health care (PH C) officer at hospital

The central sterile supply department of the hospital, especially large ones, can also be used for primary health care, with exchange and transport of soiled and sterile items. Centralization of equipment in this way can result in savings in time and money. Other services, such as laundry, can also be shared.

4.2

Out-patient department

The design of the out-patient department of the hospital depends on the scheduling of consultations, the availability of medical staff for consultations, the number of referrals from general practitioners and peripheral health units and the propensity of people in the area to go to hospitaL

District hospitals: planning and design

It may also be affected by the availability of visiting specialists from a regional base hospital, who may conduct specialist clinics intennittentiy before patients are referred for specialist'treatment.

The basic requirements of an out-patient department are simple and few: -reception and waiting areas, ---consultation rooms, -examination rooms, -treatment rooms and -staff and supply areas. Depending on the factors described above, the planner and designer can choose from a variety of schemes for grouping the basic requirements (Fig. 57): (1) Combined consultation-examination rooms give maximum privacy to the patient and maximum flexibility to the medical staff (Fig. 57a). (2) With a shared examination room, two consultants share one examination room. This requires synchronous consultation between the doctors. It is an economical arrangement, but it can slow the pace of consultations (Fig. 57b). (3) In a common pool of shared rooms, each consultant shares a centrally located pool of examination and treatment rooms. This is the most economical scheme from the point of view of space, but it results in criss-crossing of users and gives the patient the least privacy (Fig. 57c). The required ratio of examination to consulting rooms varies with the type of clinic. Allowance must be made for patients to dress and undress, so, in general, medical consultations and examinations take longer than surgical examinations; but medical clinics require only one examination space per consultant, while surgical clinics may need two or three examination rooms per consultant. In practice, the most flexible arrangement is a mixture of the two types, scheduling clinics for optimal use. Requirements vary, however, depending on local conditions and whether out-patient arrivals can be limited to working hours.

COMBINED CONSULTATIONEXAMINATION ROOMS

SHARED EXAMINATION ROOM

COMMON POOL OF SHARED ROOMS

Fig. 57. Out-patient department plans

4.3

Emergency department

This fast-paced department requires a large area that is flexible and can be converted into private areas when necessary, usually by the use of curtains on tracks around delineated spaces.

Departmental planning and design

It is vital that the provisions for movement within the emergency department allow for fluidity, with rapid access to the operating, x-ray and other departments (Fig. 58).

Fig. 58. PIan for emergency department (OR, operating room)

PATIEN AREA

PAnBlT ANA '011 IllACTUIIEI OIlTHOMIDIC CASEI

EMERGENCY CUBICLES

4.4

Administration

The administrative department is orientated to the public but is at the same time private. Areas for business, accounting, auditing, cashiers and records, which have a functional relationship with the public, must be located near the entrance of the hospital. Offices for hospital management, however, can be located in more private areas. Well-kept medical records form an integral and vital part of an efficient hospital system. Each country has its own legal requirement regarding how long such records must be maintained at the hospital. If possible, a full-scale computerized data bank should be created in which all data relating to hospital patients are retained. This allows rapid access to the previous hospital records of every patient. In addition, standardization of records in a data base makes the information available for statistical use in research into, e.g., community health, hospital planning and design, drug use and planning of ambulance services. If medical records are handled manually, adequate space must be available so that they can be kept for the required time. This space should be in an area that ensures that the records remain confidential.

4.5

Radiology department

The term "radiology department" usually refers to the department in which diagnostic imaging is provided. It is distinct from that in which radiotherapy and radiation oncology are carried out. The latter services are not provided in district hospitals of 50-100 beds, as the radiation treatment of malignant disease requires highly trained physicists and physicians who are specialized in radiotherapy and very complex, costly equipment. This service should be available only in regional hospitals. Diagnostic imaging (or diagnostic radiology) is provided by x-ray units, ultrasound and radionuclide (radioisotope) scanners. A radionuclide service will probably not be available in a 50100 bed hospital, as the supply of radioactive materials and the handling and administration of radioisotopes are beyond the training of general physicians. There are major differences between imaging with x-rays and with ultrasound. X-rays are ionizing radiation, with potential risk to personnel and patients. The images (radiographs) are recorded on x-ray film, and most examinations can be done by a non-physician technician, responding to a doctor's requests. Ultrasound carries, as far as is now known, no risk to patients or personnel, but most ultrasound examinations (scans) require the participation of a physician and may take 15-20 minutes. Ultrasound images are not easy to record, so accurate patients' records must be kept. Training a technician to undertake ultrasound scanning requires 8-12 months' experience in a busy ultrasound department. Less training can result in serious errors. X-rays can image the lungs, skeleton, kidneys, gall-bladder and bowel. It should be the first choice of imaging equipment. Ultrasound cannot image the lungs or skeleton. It is of greatest importance in obstetrics and for imaging the liver, kidneys, pancreas, gall-bladder and pelvic contents.

District hospitals: planning and design

It can be very helpful in the diagnosis of early osteomyelitis of the long bones, because of the changes to soft tissues, but cannot otherwise be used to detect bone disease. Ultrasound should be the second choice of imaging equipment, except in a busy maternity hospital, where it should take priority.

(1) Diagnostic imaging, both x-rays and ultrasound, should be available to in-patients and outpatients. The equipment needs electrical power. There are many advantages to locating x-ray and ultrasound equipment in the same department. In small hospitals with a daily workload of 5-10 patients, the two can be in the same room. As the workload increases, separate rooms should be made available. (2) Ultrasound does not require any special building construction. The room should contain a patient couch, firm but comfortable, a chair and at least 1 m2 for the equipment. The lighting must be dim-bright light makes it difficult to examine a patient properly-but the room must not be very dark. Hand-washing facilities should be located either in the room or close by. There must be a toilet close to the ultrasound room. (3) The x-ray department should consist of three rooms: - the x-ray room; - the dark-room; and - office and storage space. These must be grouped, and the x-ray room and the dark-room must be adjoining. If accommodation is limited and if only 5-8 patients are to be imaged per day, the office work can be done in the x-ray room. The dark-room, however, must be separate, and no other work should be carried out there. Figures 59, 60 and 61 show three alternative layouts for an x-ray department.

X-RAY

DARK

X-RAY

ROOM X-RAY STORAGE X-RAY VIEWING STORAGE JlIt.",OfrI

X-RAY

DRE~SING DRo~;SING

".GlmON DRESSING

WAIT

DRESSING

DRESSING DRESSING

WAIT

DRESSING DRESSING

Fig. 59. Simple compact plan

Fig. 60. Cluster plan

VIEWING RECEPTION

MI"'NO Oft'RING

Fig. 61. Linear plan

Departmental planning and design

Detailed recommendations for the location and space requirements of an x-ray department are given in Annex 6 (Guidelines for the installation of WHO Basic Radiological Systems (BRS)). Various plans are attached. If ultrasound is available, the room housing it can be located anywhere close to the x-ray section, as convenient. (4) The diagnostic imaging area should be on the ground floor of the hospital, with easy, covered access for wheel-chairs, patient trolleys and beds. Its location close to the emergency section of the out-patient department is helpful, but easy access for all patients should be the first consideration. A separate building is not necessary. One x-ray room and one dark-room can handle up to 40-50 patients per day. Because of the high cost of the equipment, it is better to increase the number of staff and to lengthen the working day rather than add additional rooms and more equipment. Even a ISO-bed hospital is very unlikely to need more than one x-ray room. If the hospital increases in size, it is preferable to place any additional x-ray room in the same area. One dark-room is sufficient for two x-ray rooms. Further information on equipment for x-ray, ultrasound and dark-rooms is given in Part II of these guidelines, paragraph 2.2.2(a).

4.6

Laboratory services

Modem medicine is increasingly dependent on laboratory services for the prevention, diagnosis and control of diseases. Pathology laboratories playa central role in the hospital and in community health services, and each hospital must have an adequate laboratory service under the direction of a medically qualified pathologist. A comprehensive laboratory should have the following sections: - morbid anatomy - haematology - clinical pathology - microbiology with sub-sections, according to the functions of the hospital in the community. The laboratory must be located and designed so as to: - provide suitable, direct access for patients - allow reception of deliveries of chemicals - allow for disposal of laboratory materials and specimens.

It should be noted that laboratory services come under great pressure to expand, as the workload tends to double every 5-8 years. Their growth will be even faster as the out-patient department is strengthened to integrate provisions for primary health care. The plan for laboratory work benches must therefore be flexible, perhaps comprising modules (Fig. 62). The information that the planner and designer need to plan a laboratory space includes: Fig. 62. Plan for laboratory

(1) deciding the range of se: ·'ices to be offered and thus the number of different areas; (2) determination of the technical units and subunits, procedures to be adopted and any special requirements; (3) estimation of the volume of work in each area, unit and subunit;

District hospitals: planning and design

(4) (5) (6) (7)

indication of style of work-manual, mechanized, automated-in each unit and subunit; detennination of number and category of personnel working in each unit and subunit; indication of principal equipment and furniture, including support services; detennination of linear metres of bench space and its arrangement, including space for auxiliary areas for washing and sterilizing, preparation of reagents and culture media, storage and locker facilities; (8) indication of preferable locations of various units and subunits; e.g., the bacteriology unit should be located at the farthest end of the laboratory, next to the washing and sterilizing unit, to diminish the hazard of contamination; (9) listing of environmental requirements and safety measures.

In order to estimate space requirements, a rule of thumb is that each member of the laboratory staff, technical or administrative, needs 6 m2 of net floor space. This does not include corridors, stairs, toilets, stores or wall space, for which an additional 30-50% of space should be provided, depending on the size and type of equipment. As mentioned above, laboratories should be planned on a modular system; i.e., the basic building unit is a laboratory module of a particular width, depth and height. This contains all of the standard features needed to support the laboratory activities, including wet and dry services, lighting, electricity and ventilation. It can be repeated as many times as necessary to make up a laboratory of the required size. Figure 63 (a, b and c) shows examples of a single-module space, a two-module suite and a threeand-a-half module suite.

A. liNGLE MODULAR IPACE

B. TWO MODULE SUITE r--h h

II l]~ I , I , , , I I ~.

I _________ 1

MOVABLE EQUIPMENTI ~URNITURE~

IDEAL MODULAR WIDTH

Fig. 63. Examples of laboratories of different sizes

The external walls of the laboratory should be of permanent, durable construction, but the partition walls should be considered to be temporary so that they can be taken out or replaced easily as the activities expand. The ceilings should be made of materials that are easily cleaned and disinfected so as to reduce airborne contamination. They should be 2.55-2.80 m in height to allow for wall-mounted distillation racks and other equipment. The floors should be made of materials that are resistant to acids, alkali and salts and can be easily cleaned and disinfected. An installation with a minimal number of joints is desirable. Doors should be located in places where entry and exit is easy and does not interfere with the laboratory benches or equipment. Laboratory doors should be no less than I m wide to allow easy access of equipment. In some areas, double doors, 1.2 m wide, should be provided for passage of large equipment, such as deep-freezes. All doors should open towards the corridor.

Departmental planning and design

The basic utilities that are to be provided in the laboratory are a water supply, sanitary drains and drain vents, electricity, compressed air, distilled water, carbon dioxide, steam and gas. Others may be necessary depending on the types of tests to be performed. A method must be designed for identifying the different pipes in the laboratory; the following colour code may be used: hot water cold water drain steam compressed air vacuum gas sprinkler orange blue brown gray white black yellow red

A typical section through the work-benches of a laboratory is given in Figure 64, showing the locations of some of the utilities. The laboratory should have external access to a small, remotely located store for dangerous goods. The quantities of such goods (particularly inflammable ones) that are held in the department should be limited and strictly controlled. SERVICE OUTLETS AS BENCH TOP UTIUTIES AS REQUIRED IN CHASE

LOCATION OF UTIUTY ACCESS IN TYPICAL KNEE SPACE

A Fig. 64. Laboratory work-benches

4.7

Pharmacy

A hospital pharmacy department essentially provides a dispensing service to in-patient wards, departments and the out-patient department. The ph~acist is responsible for the purchase, storage and dispensing of all drugs and of bulk pharmaceutical preparations, disinfectants and sterile solutions. In designing the pharmacy, the following considerations should be kept in mind: (1) The pharmacy must be located so that it is:

(2) (3) (4) (5)

(6) (7)

- accessible to the out-patient department, - convenient for dispensing and - accessible to the central delivery yard. Traffic within the department must be economical and flexible. Its size is determined by its organization and operational policies. Provision for security of dangerous drugs must be ensured. Provision for control of fire must be ensured, as many inflammable substances are stored there. Bulk quantities should not be held in the pharmacy but should be drawn from a remotely located store for dangerous goods. Finishes must be impervious to acid and alkali and easy to clean. The corridors must allow easy turning of wheeled vehicles.

The pharmacy will sometimes keep controlled drugs, poisons and other drugs liable to misuse. These are subject to statutory regulations, which the designer should be aware of in planning the rooms, and provision should be made for an alarm system to guard against intrusion and theft.

District hospitals: planning and design

The planning of the pharmacy should also include space for preparing sterile water, unless this is to be done in the central sterile supply department or elsewhere.

4.8

Operating theatre

The design of operating theatres has become more and more complex. In developed countries, the latest technology has made possible bacteria-free environments in which surgery can be undertaken under almost completely aseptic conditions. As the operating department is thus now viewed as a high-technology, sophisticated provision, it is often dismissed as a luxury when financial resources are scarce. But this is the very reason why planning and design of this department are important: to ensure a facility with a high standard of patient safety with the most economical use of manpower and other resources. Sober, down-to earth planning and design can yield an effective facility. A surgical operation is successful if the following conditions are met: -The wound heals (aseptic technique) -Blood loss is replaced (intravenous infusion). -It is painless (anaesthesia). The essential physical requirements for meeting these conditions (Fig. 65) are: -a place in which to work that is comfortable and unobstructed by the movement of other staff, with a table that is strong enough to hold the patient and easy to clean; Fig. 65. Essential physical requirements -basic services of water, light and medical gases; and -two sets of basic instruments, comprising about 50 pieces each. The number of operating theatres required is obviously related to the number of hospital beds. As a general rule, one operating theatre is required for every 50 general in-patient beds and for every 25 surgical beds. Computations can also be made on the basis of the number of surgical beds, the average length of time in the operating theatre and the expected output of the department: Number of surgical beds X 300 days (usual number of operating days with no weekends) = number of surgical bed-days available per year Number of surgical bed-days per year average + average length of stay in surgical ward

= number of surgical patients admitted per year (expected) Number of surgical admissions expected per year + actual number of working days = number of surgical operations per day (expected) Number of surgical operations expected per day X average number of hours per operation = number of operating theatre hours per day Number of operating theatre hours per day + actual number of working hours in operating theatre = number of operating theatres needed

Departmental planning and design

The average duration of operations must be determined from experience and established statistics and includes: the actual length of the operation plus about 1 hour for preparation and cleaning. Provision should also be made for pre-operative space, containing 0.75 bed per operating theatre, and post-operative space, with 1.5 beds per operating theatre.

4.8.1 Location of operating department The preferred location is on the same floor as the surgical wards, which may be the ground floor. It should be connected to the surgical ward by the simplest possible route. It should also: -adjoin the central sterile supply department; -be easily accessible from the accident and emergency department; -be easily accessible for the delivery suite; -adjoin the intensive care unit; -be located in a cul-de-sac, so that entry and exit can be controlled; there should be no through-traffic (Fig. 66).

CUL-DE·SAC

THRU-TRAFFIC

Fig. 66. Location of operating department

4.8.2 General design principles The overriding principle is that the centre of the theatre suite should be the cleanest area, the requirement for cleanliness decreasing towards the perimeter of the department (Fig. 67). Thus, any space for handling sterile supplies should be in the central area, and any space for transporting patients, Fig. 67. Progressive sterility (OR. operating room) general staff movement and removal of used material should be on the perimeter. To achieve maximal economy of shared support facilities, an operating department should be planned in pairs of operating theatres, with one main clean-up room serving all the operating theatres. In departments with more than four operating rooms, however, this might involve too great a distance to travel, and sub-clean-up spaces should be provided. To avoid airborne contamination, operating theatres and the main clean supply area should be slightly pressurised, with most of the exhaust air removed through the outer areas (Fig. 68). The air-conditioning system should provide air that has been filtered to the stringent requirements of operating theatres, and the temperature and humidity should be controlled (see section 5.2.2). Instruments and equipment may be sterilized either in a theatre sterile supply unit established within the operating department or in an adjoining central sterile supply department. In either case, dressings and gowns should be sterilized in the central unit, to minimize the requirements for large, expensive autoclaves. A small "dropped instrument" sterilizer should be located within each theatre. Fig. 68. Removal of airborne contamination

District hospitals: planning and design

4.8.3

Management

Two management systems on which policy must be decided and which affect the planning of the operating department are instrument trolley preparation and patient transport. (a) Instrument trolley preparation system

The area provided at the centre of the theatre suite for storing sterile supplies and instruments can also be used as a set-up room, for laying out the sterile instruments and supplies required for an operation on the theatre trolley (central trolley preparation). Alternatively, the sterile instruments and supplies can be transported still wrapped to the operating theatre, where they are opened and laid out on the theatre trolley (local trolley preparation). Both systems are used, although central trolley preparation is generally preferred. This system requires that the central working area be large enough to park several theatre trolleys. (b) Patient transport system

The entrance to the operating department must have a reception and transfer point. Control of unauthorized, unsupervised entry into the area ensures the principles of aseptic conditions. The transfer area is the point at which the patient is physically removed from the bad trolley to the theatre trolley. Three systems can be used, each of which involves different requirements for staff, space and equipment. - the two-trolley system, involving six patient transfers; - the theatre trolley system, involving four patient transfers; and - the trolley-bed system, involving two patient transfers.

4.8.4

General planning principles (1)

The internal layout should be based on the traffic flow within the department (Fig. 69).

PATIENTS DUDg~ ST FF W

0 0 0 0

co 0

CLEAN SUPPUES

000)0000

(---

- OUTERtCORRiDOR--:---"\ TRANSFER RECOVERY CLEAN STERILE SUPPLY UNIT

'STAFF 'CHANGEI I LOUNGE

<. ,... : I.

I '

I I 1 \

CORRIDOR

o ~

, . • I

O.R:'. II SUPPORT AREAS DISPOSAL CORRIDOR:

, ~ I • ): DIRTY ITEMS

- - - - - - - - - - - - - - - - - : . . . .: • • : • • •)

Fig.69. Traffic flow in operating department (ORs, operating rooms)

Departmental planning and design

A single corridor may be used to carry patients, staff and clean and used equipment (suitably bagged) .to and from t~e operating theatres. This corridor should lead to each operating theatre vIa ~ anaesthetIc room, a scrub-up facility and a separate theatre exit. Alternatively, clean and dIrty streams of traffic can be segregated. An enclosed, traffic-restricted room close to the operating theatres must be provided for sterile theatre supplies; it should lead directly into the operating theatres. (2)

Rooms should be arranged in continuous progression from the entrance through zones of increasing sterility, following the concept of progressive asepticism (see Fig. 67). Staff within the department should be able to move from one clean area to another without passing through unprotected or unclean areas. Patients, staff and services should enter thmugh the same control point. Air for air-conditioning should move from cleanest to less clean areas. The operating theatre should be at positive pressure in relation to adjacent rooms. Air movement in the operating theatre should be reduced so that airborne infections do not reach the patient.

(3) (4) (5) (6) (7)

4_8.5 Room planning requirements The following areas should be provided: (a) Reception and office

In a two- or three-theatre suite, the reception and the theatre sister's office can be merged. (b) Transfer area

This area should be large enough to allow for the transfer of a patient from a bed to a trolley. A line should be clearly marked in red on the floor, beyond which no person from outside the operating departInent should be permitted to set foot without obtaining authority and putting on protective clothing. (c) Holding bay

This space is required when the corridor system is used and should be located to allow supervision of patients waiting to go into the theatre. One bed per two theatres should be foreseen. (d) Staff changing rooms Access to staff changing rooms should be made from the entry side of the transfer area. At both the transfer area and the theatre side of the changing rooms, space must be provided for the storage, putting on and removal of theatre shoes. (e) Operating theatres

Each theatre should be no less than 6 X 6 m (36 m2) in area and should have access from the anaesthetic room, scrub-up room and supply room. Separate exit doors should be provided. (f) Scrub-up room

Scrub-up facilities may be shared by two theatres. A minimum of three scrub-up places is required for one theatre, but five places are adequate for two theatres. A clear area within the scrub-up room, at least 2.1 X 2.1 m, must be provided for gowning and for trolley or shelf space for gowns and masks.

District hospitals: planning and design

(g) Sub-clean-up

In suites of four or more operating theatres, a small utility area is required for each pair of operating theatres, for the disposal of liquid wastes, for rinsing dropped ins~ments and to hold rubbish, linen and tissue temporarily until they are removed to the mam clean-up room. (h) Sub-sterilizing

An area for sterilizing dropped instruments should be provided to serve two theatres. (i) Trolley parking

Parking space outside the theatre and clear of all doorways is required for patient trolleys and beds. (j) Recovery room

The recovery room should be located on the hospital corridor near the entrance to the operating department. The number of patients to be held, until they come out of anaesthesia, depends on the theatre throughput; two beds per theatre is usually satisfactory. In hospitals where there is an intensive care unit, additional room and facilities will be needed.

4.8.6 Other important conditions in the operating theatre (I) Windows are neither needed nor desirable. Some surgeons, however, advocate the

psychological benefit of having a glass panel for an occasional glance beyond the operating theatre. This can be provided internally, above the door height, with no ledges. (2) All surfaces in the operating theatre should be smooth and washable. (3) Static electricity and related hazards should be avoided. Special anti-static floors, which are quite expensive, should be provided, since floors in which the electrical resistance is below the intended limits can result in electric shocks. When inflammable anaesthetics are used regularly, the anti-static requirements should extend to the walls, or at least 2 m from any possible location of the patient and the anaesthetizing apparatus. Appropriate national standards should be adopted and enforced. (4) FuIl outside air, filtered to a high quality, must be provided. The integrity of the air-handling system must be preserved by careful siting of the main air intake and exhaust. The main air intake must be located to avoid uptake of any obvious airborne contamination, such as dust and road fumes, and well clear of the main exhaust duct, and the siting should take into account the direction of the prevailing wind. Temperature and relative humidity should be controllable. (5) Unit room air-conditioners (window type, with I tonne capacity per 18 m2 , at least one per theatre) can be provided as a stand-by.

4.9

Intensive care unit

The intensive care unit is for critically ill patients who need constant medical attention and highly specialized equipment, to control bleeding, to support breathing, to control toxaemia and to prevent shock. They come either from the recovery room of the operating theatre, from wards or from the admitting section of the hospital. This unit requires many engineering services, in the form of controlled environment, medical gases, compressed air and power sources. As these requirements are very similar to those in the operating department, it is advisable to locate the intensive care unit adjacent to the recovery room of the operating department (Fig. 70a). If engineering provisions are to be centralized for economy, the recovery room and the intensive care unit should be on either side of the support area (Fig. 70b).

Departmental planning and design

a. P E E P

b. RA A R

R~COVERY ATO.R. SHARED SUPPORT

DOD c:J

~~~~~__~~~M

AR!AS ~

1M N E ON

• EMERGENCY • WARDS

'COMMUNnv

DOD FROM • WAIIDS

c:::J

• EMi!RGENCY

Fig. 70. Location of intensive care nnit (leU; OR, operating room)

• COMMUNITY

The number of beds in this unit should correspond to approximately 1-2% of the total beds in the hospital. In the Western Pacific Region, where district hospitals provide on average 50-100 beds, this would mean only one or two beds. This number would not warrant the provision of an intensive care unit. Such a unit should contain no fewer than six beds in order to justify the highly sophisticated equipment and highly specialized manpower involved. In the district hospital, therefore, the following alternatives may be considered: -A patient who requires long-term intensive care should be referred to a higher-level hospital. -Intensive care beds can be provided within the recovery room of the operating department. -Patients who are highly dependent on nursing can be given beds or rooms very close to the nurses' station in the ward, sustained with a portable oxygen tank and monitoring equipment.

4.10 Delivery department The delivery department is very similar to the operating department in its functional requirements and layout. In many hospitals, the two departments are fused into one, with shared staff and support areas, due to a dearth of doctors, especially in rural areas, where the chief of the hospital is also the public health officer, the surgeon and the obstetrician-gynaecologist. The integration of these two departments, however, violates the basic requirements for aseptic conditions in the operating department, as these are not always required in the delivery department. The two departments should thus at least be segregated. Proximity to the operating department is desirable, however, as transfer of delivery patients may be necessary. The delivery department is a useful one for primary health care activities. Education and training materials on maternal and child health and on family planning can be effectively transmitted to receptive fathers in the waiting room. An area should be provided for this purpose.

4.11 Nursery The nursery should be located adjacent to the delivery department to ensure protected transport of newborns. Areas must be provided for cribs for both well and ill babies and for support services that include formula and preparation rooms. The number of cribs varies depending on the maternal and child health trends in the country. "Rooming-in" (Fig. 71) is virtually replacing the well-baby area in space requirements for the nursery; instead, the dimensions of maternity wards are changing to accommodate babies' cribs and other material. A small night nursery for well babies may still be required.

o ~MOTHrRS'~ BABIES' CRIBS

E=J~ o 0 Fig. 71. Rooming-in

District hospitals: planning and design

4.12 In-patient nursing wards The ward provides accommodation for patients who are dependent on others because of their illness. It has the following functions: -to substitute for the home for regular eating, bathing, sleeping, etc; -to allow examination, treatment and cure of patients; and -to prepare patients to return to domestic life. The wards in a hospital are usually classified according to specialties: medicine, paediatrics, obstetrics-gynaecology and surgery, which are the basic services offered by a district hospital. There are no radical differences between the requirements of medical and surgical wards and only minor differences between those of the other specialties.

4.12.1 Ward forms Wards are the most easily replicated areas of a hospital, whether on one storey spread over a large site or stacked one on top of the other in a multi-storey structure. The following are commonly used forms of ward (Fig. 72). (a) The Nightingale ward (Fig. 72a)

This is an open-plan ward containing 25-30 beds. Services are located at either end of a long, rectangular ward; staff supervision is in the aisle between the two rows of beds. This is the noisiest type of ward. (b) Straight, single-corridor ward (Fig. 72b)

This simple layout has many advantages: all of the rooms can be lit and ventilated naturally through windows. Fig. 72a. Nightingale ward Service rooms and the nurses' station are centrally placed, and distances are minimized. Staff can see down the full length of the corridor, making supervision easier than in other forms. They will know where other staff are working and can call them quickly in an emergency.

Fig. 72b. Straight, single-corridor ward

I I

Departmental planning and design

I I

In this layout, the patient beds are on the two legs of the L, and the support services and staff supervision are on the junction. Services and supervision are concentrated at the entrance, with minimal penetration into the patient areas. SERVICES SUPPORT

Fig. 72c. L-sbaped ward

(d) T-shaped ward (Fig. 72d) Fig. 72d. T-shaped ward

The advantages of this form are similar to those of the L-shaped ward. Support and supervision are concentrated on the vertical arm, and the patient areas are located on the horizontal arm. (e) The race track (Fig. 72e)

Fig. 72e. Racetrack ward

In this type of ward, the patient areas are laid out at the periphery of a deep rectangle, and the services and staff areas are in the middle. Patients are given a view, but the staff has no view (and perhaps no ventilation when the central airconditioning is not working!). Staff have long distances to travel, and communication between them is difficult.

(f) The cruciform plan (Fig. 72j)

In this plan, the patient rooms comprise a peripheral arrangement, and the support and supervision areas are laid out at the intersection of the arms. This form results in a lot of cross-traffic. It is used in double wards, where there are two separate ward units but only one set of supervisory staff.

Fig. 72f. Cruciform ward

4.12.2 Other factors The main characteristic of the ward in comparison to the departments of a hospital is that it provides the range of facilities necessary for meeting the basic human needs but in a controlled way. It furnishes the environmental factors of shelter, temperature, ventilation, cleanliness, noise control, privacy and, as far as possible, general comfort. It also provides services such as a supply of food, linen and other items, and the removal of waste products and used materials of all kinds. Consideration must also be given to the relatives of patients and other visitors. If provision is to be made for relatives to stay overnight, this must be incorporated into the planning. (See also section 9, Case no. 3).

District hospitals: planning and design

4.13 General services department

4.13.1 Dietary facilities (a) Location

The dietary department should be located on the ground floor, directly accessible from the service court to receive daily deliveries of meat, vegetables and dairy products. Direct deliveries to the refrigerated section eliminates traffic through corridors and cooking areas. The direction of the prevailing wind must also be considered: kitchens must be located such that heat and odours are not directed towards areas of high population. They should also not be located under wards, especially those for non-ambulant patients, as a fire safety precaution.

(b) Food distribution The central tray service (centralized food distribution) and bulk service (decentralized) both have advantages and disadvantages. In the central tray service, patients' trays are prepared in the main kitchen, loaded onto conveyors or carts, open or insulated, and transported to the various wards. Soiled dishes lire collected and returned to a central dishwashing area. This system requires fewer staff and initial equipment costs are lower than with a decentralized system; however, the food usually cools during transport and loses some of its quality. In the bulk service, food is brought to the wards in heated c arts. Trays are prepared in a sub-kitchen in each ward and loaded onto a cart, which is rolled alongside the bulk cart; each tray is served from the bulk cart at the patient's room. Dishes are washed in the sub-kitchen. This system is the most suitable in hospitals where the corridor systems are long, to ensure that the food that reaches the patients is still hot and fresh; however, it requires additional space in the wards for washing and storing trays, plates and cutlery.

(c) Components The dietary department has the following main components: -food refrigeration and storage, -cooking, -serving, -special diets, ~ishwashing and ~ining.

The department should contain the following facilities, unless commercially prepared diets and service, meals and/or disposable items are used: -food preparation centre -food serving facilities, for both patients and staff ~ishwashing facilities (or room) -pot-washing facilities -refrigerated storage-3-day supply -day storage-3-day supply -cart-cleaning facilities -cart storage area -waste disposal facilities ~ining facilities (1.5 m 2 per seated person)

Departmental planning and design

-dietician's office -j~itor's cupboard storage for housekeeping supplies and equipment, with a service SInk.

Some of these activities can be combined, so as to save space, without compromising the norms of cleanliness.

4.13.2 Housekeeping facilities (a) The housekeeper's office should be on the lowest floor, adjacent to the central linen room. (b) The central linen room supplies linen for the whole hospital. It must have shelves and spaces for sewing, mending and marking new linen. If laundry is to be handled in the hospital, the central linen room must be adjacent to the "clean" end of the laundry room. (c) The soiled linen area is for sorting and checking all soiled laundry from the hospital. It must be next to the "dirty" end of the laundry area and provided with sorting bins. (d) Laundry can either be done in-house or contracted to an outside enterprise. If it is to be done in-house, proper washing and drying equipment must be installed. If it is to be contracted out, areas must be provided for receiving clean and dispatching dirty linen and for sorting. The facilities must thus include: -a soiled linen room; -a clean linen and mending room; -a laundry-cart storage room; -a laundry processing room, with equipment sufficient to take care of 7 days' linen; -janitor's closet, with storage space for housekeeping supplies and equipment and a service sink; -storage space for laundry supplies. The last three are not needed if laundry is to be contracted out.

4.13.3 Storage facilities As hospitals are regular consumers of a large variety of goods, adequate space must be provided for their storage, inventory and distribution. Many different types of storage facilities will be required, e.g., for some live virus vaccines at -20 °C, for large equipment and furniture, for crude disinfectants, for medical gases, for dangerous drugs, for radioactive agents, which need different space provisions. Designers must obtain all the relevant information to meet the requirements. The standard for central storage space is 2 m2 per bed; in smaller hospitals, this value is usually increased. The following compartments must be provided in the hospital storage area: pharmacy storeroom, furniture room, anaesthesia storeroom, records storage and central storeroom.

The risks of fire and explosion in a medical supplies storeroom and storage of dangerous substances such as nitric and picric acids and inflammable materials such as alcohol, oxygen and other gas cylinders merit special attention.

District hospitals: planning and design

For smooth, rapid flow of materials both to and from the central store, sufficient space and ramps should be provided for handling, unpacking, loading, unloading and inspection. In a hospital planned with a functional central supply and delivery system, many of the traditional ancillary rooms could be eliminated from some departments and be replaced by systems of lifts, with sufficient parking space in the wards for trolleys. A typical flow chart of the movement of staff and supplies in service areas is shown in Figure 73.

I I I

---------.,- I

I I I I

NURSES' LOCKERS

HOUSEKEEPING HElP'S LOCKERS

STAFF DINING

CJ£I CENTRAL STORAGE

RE~Ii~G ClERK

KITCHEN

SPECIAL DIETS

O 4.13.4 Maintenance and engineering area (a) Boiler room

SERVICE ENTRANCE AND H8.P

Fig. 73. Flowchart showing movement of staff and supplies in service areas

This must be located in accordance with local fire ordinances. The boiler plant must be designed by a qualified engineer to ensure the safety of patients and staff.

Departmental planning and design

(b) Fuel storage

The space will vary according to the fuel used. The designer must know for how many days stock must be kept. (c) Groundkeeper's toolroom

Space must be provided for working and for the storage of equipment and tools for the staff in charge of landscaping and general upkeep of the garden and grounds. (d) Garage

The garage is best located in a shed or building separated from the hospital itself. If the hospital is to maintain 24-hour ambulance service, additional facilities must be provided for drivers' sleeping quarters. (e) Maintenance workshop

A carefully planned, organized maintenance programme for general repair of medical and nonmedical equipment is necessary for ensuring reliable hospital service. A mechanical workshop with an electric shop, well equipped with tools, equipment and supplies, is conducive to preventive maintenance and is most important in emergencies. Failure of lights or essential equipment in an operating theatre, such as respirators, can have serious consequences. Adequate space for equipment like lathes, welding materials and wood- and metal-working machines should be provided, and there should be storage space for damaged material, such as stretchers, beds, wheelchairs, portable machines and food trolleys. A list of the specialized tools and equipment needed for a preventive maintenance system in a district hospital is given in Part II of these guidelines. As most repair work is done outside of normal working hours, space should be provided for workers, maintenance staff, supervisory personnel and biomedical engineers.

4.14 Mortuary The mortuary has the following functions: - to hold dead bodies until burial can be arranged; - to provide a place where a pathologist can investigate causes of death and make scientific investigations; - to allow viewing and identification of bodies by relatives and other people. The mortuary should, if possible, be located near the pathology department or laboratory. It should be easily accessible from wards and the emergency and operating departments. A separate access should be available for staff, relatives and undertakers. The following areas are needed: - covered access -body store - staff changing room with lockers and toilets - soiled garments holding area - post-mortem facilities - viewing room - visitors' waiting room - cleaning materials storage room - cleaner's room - prayer and religious rites room.

District hospitals: planning and design

5. ENGINEERING SERVICES 5.1 Water supply and sewerage

Provision of a potable water supply and an adequate sewage disposal system are of primary importance in a hospital for the obvious reasons, both to contribute to the weIl-being of patients and to reduce the risks of infections and propagation of diseases, like dysentery, gastroenteritis and other water-borne diseases. In some developing countries, where modern amenities like an efficient water works and distribution system and a centralized sewerage system are not available, hospital planners and designers must use flexibility and ingenuity to find other solutions.

5.1.1 Water supply Water for use in hospital must be: -free of pathogenic organisms and irritating and poisonous substances; -clear, colourless, odour less and tasteless; -not too hard for domestic and industrial use; -free from iron and other corrosive substances"; and -at a low, agreeable temperature. Ideally, all these requirements would be met; however, there is no such water source. Even in developed countries, water must be treated by adding chlorine to the distributing reservoir or water mams. A complete waterworks consists of:

-Collecting system. This consists of the intake, where the water is drawn from the source of supply; the receiving reservoirs; the conduit through which it flows; and the pumping machinery to raise the water from one level to another until it reaches the purifying system. -Purifying system. This consists of the settling basin, where it is clarified, and the filters, in which it is purified. -Distribution system. This consists of the distributing reservoirs, in which the filtered water is received, and the network of pipes that convey the water to the point of consumption. Facilities to store a 36-hour supply should be provided for a hospital. In a simple gravity system, the force of gravity moves the water from the source to the point of consumption. The pressure required in the system for ordinary use is 3.5 kg/cm'; for fire protection without the aid of fire engines, however, the pressure required is 7.0 kg/cm'. When there is no existing waterworks in the area, planners and designers must look for the nearest body of water, such as a spring or flowing river. Using such sources, an improvised system of filtration through gravel and sand can be established, and a naturally aerated collecting and storage pond can be dug. In the absence of a spring or river, a deep well powered by a rotary submersible pump may be dug. Experience indicates that water extracted at a depth of 25 m is generaIly potable. Deeper weIls yield water of better quality, but more powerful pumps and more piping are needed. An elevated water tank can be used to store the coIlected water. Whether the water source is a spring, a river or a well, a pipe conveyance and distribution system supported by a force pump can be used.

Engineering services

The minimum water requirement, where water supply is a problem, is 50 Iitres per person per day. Normally, however, the value is 115 Iitres per person per day. A district hospital with about 100 patients and 200 personnel, or a total ofJOO people, will need at least 34500 litres of water per day. An additional volume of about 30 Iitres per person per day should be added to this basic volume in the computations for sprinkling lawns and as a stand-by for fire protection.

5.1.2 Sewerage and sewage disposal Sewage is the liquid and soft solid waste of a community, and sewerage is the system by which it is removed. The sewerage system is thus the totality of the conduits, pumping stations, treatment plants and other works necessary to collect, purify and dispose of the sewage. The laws governing the disposal of sewage vary from country to country, both in existence and observance. These may be amplified by national sanitation codes, rules and regulations and local ordinances. Normally, sewage is subjected to some preliminary treatment, such as screening, to separate the solid from the liquid waste, which is then passed through a sedimentation tank to remove minute suspended matter. The effluent from the process is then discharged into a body of water, on natural land, on prepared land, or on specially constructed filter beds of sand and gravel. (a) Choice of disposal system

Raw sewage contains both organic and inorganic matter. In order to determine the most effective and least expensive method of sewage disposal, the raw sewage must be analysed for its chemical, biological and physical properties. In planning and designing a hospital, the following information must be available: -a complete analysis of sewage at a similar institution, -an estimate of the volume of sewage that will be produced daily, -how it will be disposed of and -what type of system will be used. It should be noted that provision of on-site laundry facilities substantially increases

the daily volume of sewage. The primary aim of a disposal system is to eliminate or neutralize pathogenic bacteria and viruses that may be present in the sewage which cause cholera, diarrhoea, dysentery, typhoid fever and other diseases. It should also prevent the creation of nuisance resulting from the process of putrefaction. Bacteria can be divided into three classes, on the basis of how they break down organic matter: -aerobic bacteria, which can live and work only in a medium that is well supplied with oxygen -anaerobic bacteria, which live and work in a medium that is deficient in or devoid of oxygen -facultative bacteria, which live and work in a medium where oxygen is present in a small ratio to other elements. Each class works under conditions favourable to itself and destroys itself in the process of putrefaction.

District hospitals: planning and design

At a project site where there is no existing centralized sewerage system, one of two methods of treatment of raw sewage can be used: -In septic tanks, in which raw sewage flowing in is detained for a period of time to allow anaerobic bacteria to act on it, help in its decomposition and render it relatively inoffensive. The treated sewage is disposed of by percolation in the ground, using either a cesspool or a trench field. The suitability of the ground for this purpose must first be established by percolation tests. -Lagooning, in which the sewage is exposed to the sun in lagoons, which could be simple ponds or ponds equipped with mechanical aerators, depending on the condition and quantity of the sewage to be treated. More technologically advanced solutions are available, which include mechanical screening followed by sedimentation, aeration and fermentation. Such facilities require electrical energy and trained and skilled manpower to operate them; they are not recommended for small hospitals located in rural areas of developing countries. Factors to be considered in determining the method of disposal to be adopted are cost, available area and the availability of coagulants. Strong fermenting agents (microbes and enzymes) are also available that can be used to neutralize or control pathogenic bacteria. (b) Effluent disposal and utilization

The effluents from sewage treatment units can be discharged into lakes, streams, rivers, oceans or on the land. Sewage effluent constitutes a valuable source for recharging groundwater; however, the points of discharge must be well arranged and the quantities limited, so that there is no threat to the quality of the groundwater. Partially purified sewage effluent can be used for fish culture and farming without further dilution, depending on local solid and hydrographic conditions. When it is used to irrigate fields, much less sewage effluent needs to be used than with fresh water, because the effluents have a higher concentration of suspended matter.

5.1.3 Health care waste management1 A hospital produces not only liquid wastes but also a lot of solid waste from food preparation, as well as contaminated materials from the wards, operating department and laboratory. The waste generated in hospitals and other health care establishments may be hazardous or offensive and pose a health risk to patients, personnel in health care establishments, workers of support service organizations under contract with such establishments and the general public, if not handled and disposed of in a satisfactory manner. Treatment and disposal methods commonly used for health care waste include: -incineration -landfill -discharge to sewers -sterilization!disinfection The first three of these methods can be carried out either on-site or off-site; the sterilization! disinfection of waste should be carried out as a pre-treatment before disposal, near the source of the waste within the health care establishment.

I See "Regional Guidelines for Health Care Waste Management in Developing Countries", now being prepared by Ihe Environmental Health Centre of the WHO Regional Office for the Western Pacific.

Engineering services

5.2

Mechanical engineering

The significance of the combined mechanical--electrical components of a hospital can be deduced from the fact that the cost of installing the equipment is normally about one-third of the total cost of the building. The operation and maintenance costs are also more than the combined expenses for all other parts of the building. Furthermore, their expected life may be only one-half or even onethird that of the buildings. The primary objective of the designer of the system, therefore, is to bring down the initial cost and evolve a design that has a reasonable maintenance cost. This can be done by providing the simplest mechanical devices possible while using high-quality materials; thus, the number of repairs will be reduced as will costs for labour, fuel and power. It will also ensure that the maintenance is within the capability of local resources. The design should also include adequate protection of the health and safety of staff, public and patients. The folIowing is a checklist of the components to be considered in the mechanical design of a hospital. Engineering consultants should be brought in at a very early stage of the designing process; consultation should also take place with the necessary government authorities. General provisions General description of instalIations Fuel Proposed fuel, with justification Estimated monthly and maximum daily fuel consumption Storage of fuel, when applicable Primary source of energy Type of heating, temperatures and pressures Preliminary load and breakdown of main components Provision for future expansion Number and capacity of boilers or heat exchangers Description of boiler and auxiliaries, control and stand-by Schematic diagram Sketch of major operational features and maintenance access Primary distribution system General description Domestic heating Internal design criteria External design criteria, frequency of use Infiltration rate assumed Heating media, temperature, pressures Preliminary heat load, allowance for future expansion Scheme of circuitry Types of heat emitters in different areas Type of control operation Piping materials, types of pump Area to be heated for each type of heating (m 2) Means of absorbing thermal expansion of pipes Feed and expansion provisions Domestic hot water Means of heating Design criteria, storage, maximum demand with time Preliminary storage and heat-up capacity

District hospitals: planning and design

Size of generators, allowance for future expansion Type of piping Type and capacity of cold feed system Steam services (other than for heat or hot water) Locations (e.g., kitchen, laundry, central sterile supply department) Required pressure Criteria for load calculations Preliminary heat load Allowance for extension Ventilation and air-conditioning systems Description of systems (central or split type) Types of fan Areas served by each system Typical circuitry schemes Internal design criteria External design conditions Design criteria for assessing air volumes: -supply air temperatures; -ventilation to remove heat, moisture, odours, fumes; -minimum rates of air change per hour; -fresh air and recirculation requirements Number and capacity of fans and air-handling plants Sound levels Control operation and energy conservation Filter types and efficiencies Type of cooling and heat rejection system Type of humidification Design criteria for cooling equipment: -ambient conditions for cooling towers, etc. (including frequency if these are exceeded) ~hilled water temperature ~ondenser water temperatures Preliminary cooling load Allowance for expansion Numbers and capacity of cooling and heat rejection plants Air-conditioned area (m2) Ratio of design cooling load:air-conditioned area (W/m2) Medical gas services (when piped) Gases used (e.g., vacuum, compressed air, oxygen) General description of system Allowance for extension Types and capacities of compressors and vacuum pumps Proportion of stand-by plant used Fire protection system Type of system, coverage and classification Location of control and indicator panels Manual call points, general locations of alerting devices, type and sequence of operation Details of water supply for fire-fighting Dry/wet riser system

Engineering services

Special service systems Description and justification of any other service Instrumentation, alarms, monitors and controls General description of scope and philosophy Type of equipment proposed

5.2.1 Heating, air-conditioning and ventilation Maintaining a pleasant temperature, about 22°C, is the design target for heating and airconditioning systems in cold and warm countries. Higher or lower temperatures may be attained in specific areas through independent units to suit individual requirements. Heating and air-conditioning and ventilation systems are related both in physical installation and in their function in the hospital departments. Air-conditioning differs from ventilation in that the temperature and humidity of the air are controlled in the former. It is expensive to provide, operate and maintain, however, and it should be installed only in areas where it is essential, such as in operating theatres. Wherever possible, therefore, hospital design should minimize or eliminate the need for airconditioning and mechanical ventilation by providing occupied spaces with adequate windows, crossventilated where possible, and by using internal areas for specific purposes, such as operating theatres, darkrooms and storerooms. Careful attention to siting and design to take advantage of any cooling breezes and the use of trees to shade the building can help in optimizing natural conditions. The ventilation of a hospital is dictated by health, comfort and safety standards. In areas where excessive heat or moisture is generated, or where objectionable odours, dust or toxic gases are present in the atmosphere, a fresh air supply and exhaust system must be provided. Electric fans can be used to augment the system as and where necessary. Ventilation associated with kitchen, laundry and refrigeration equipment must be designed by qualified engineers in coordination with the users. Special care must be taken in designing extraction systell.1s over cooking installations to avoid any fire hazard due to build-up of fat in exhaust ducts. Filters to trap fat carried in the exhaust fumes should be accessible and should be cleaned regularly.

5.2.2 Technical requirements Heating, ventilating and air-conditioning systems should meet the following guidelines: (a) They should provide the temperatures shown in Table 3 and a relative humidity of 50--60%. Table 3. Temperatures to be provided in a district hospital

Area Operating theatre Delivery room Recovery room Nursery Intensive care

Temperature eC)

21-25 21-25 24

24--26 24--26

(b) All air supply and air exhaust systems must be operated mechanically. Fans serving exhaust systems should be located at the discharge end of the system. Minimal acceptable ventilation rates in the major areas should be as shown in Table 4. (c) The ventilation system should be designed and balanced to provide the pressure relationships shown in Table 4. (See also Fig. 74.)

District hospiUJls: planning and design

(d) The ventilation systems serving' sensitive areas, like operating theatres, delivery rooms, nurseries and sterile rooms, must be equipped with at least two filter beds. The exhaust from all laboratory hoods in which infections or radioactive materials are handled must have filters with 99% efficiency. Table 4. Conditions for ventilation in different areas of a district hospital Area Pressure in relation to other areas' Minimum total no. of air changes Recirculated within room

Operating theatre Emergency operating room Delivery room Nursery Recovery room Intensive care Ward room Patient area corridor Isolation room Treatment room X-ray (fluoroscopy) room X-ray (treatment) room Physical therapy room Sterilizing room Laboratory, general Laboratory, media transfer Anaesthesia storage room

+ + + + 0

+ 0 0 0 0 0

+ 0

12 12 12 12 6 6 2 4 6 6 6 6 6 10 6 4 8

No No No No No No Optional Optional No No No Optional Optional No Optional No No

DIRTY ROOM ()

GENERAL LAB

1-) I'IOOM

Q.EAN

(-/ )

CORRIDOR (+)

Fig. 74. Air pressure relationships in a laboratory

(e) All filter frames must be durable and provide an airtight fit with the enclosing ducts. All joints between segments and the enclosing ducts should be gasketed or sealed to provide a positive seal against air leakage. (f) Ducts that penetrate structures to protect against x-ray radiation should not impair its effectiveness. Ducts that pass through fire walls must be provided with automatic fIre doors on both sides of the wall. (g) Duct linings, coverings, vapour barriers and the adhesives used for applying them must have a flamespread classification of not more than 25 and a smoke-developed rating of not more than 50. Acoustic lining materials should not be used inside duct systems serving sensitive areas, such as operating theatres, nurseries and isolation rooms.

Engineering services

(h) Cold-air ducts should be insulated wherever necessary to maintain the efficiency of the system and to minimize condensation. (i) Duct systems serving hoods should be made of corrosion-resistant materials.

5.3

Electric and electronic engineering

Power is supplied to hospitals in most countries by public or private utility companies. In either case, the hospital must have a back-up gasoline- or diesel-driven generator for use in the case of breakdown, at least for emergency, delivery and operating rooms, selected corridors and exits, and stairs (see 5.3.3). In addition, battery or automatic generators may be used.

II , ,

5.3.1 Components in the electrical design The following is a checklist of those electrical components that should be considered in designing a district hospital. Engineering consultants should be brought in at a very early stage of the designing process. Consultation should also take place with the local electricity supply company and with any necessary government authorities regarding the mode and system of supplying high- and low-tension electricity to the hospital. Electricity supply Point of mains supply Maximum capacity Supply and incoming voltage Tariffs and metering Agreements with supplying authority Alterations to existing supply General description General description of any existing system (mains and essential services) Technical data on existing installation (maximum capacity, assessed connected loads and measured maximum site demand, cable types, protection methods and discrimination) General description of new system (with load estimates for both essential and non-essential supplies) Local distribution General description of sub-main and sub-circuit system (routes, board locations and area of coverage) Cable types and sub-main load estimates Installation and wiring methods Protection methods and discrimination Earthing Method adopted for each continuity and electrode system Sub-stations Type and accessibility Transformer and switch-gear ratings and type Capacity for increased load, provision for expansion Stand-by plant Type and ratings Capacity for increase load Controls and alarms Sensory circuits and starting Fuel type and stored quantity Provisions for maintenance, including access I I

District hospitals: planning and design

Distribution boards General description Sub-main or sub-circuit protection Fault rating Capacity for increased load Services supplied (assessed loads and area covered) Special safety and earthing Area, location and classifications Medical procedures carried out and equipment used Type of protection chosen, with justification General power Known major equipment, with assessed loads (e.g., kitchen and laundry equipment, autoclaves, mechanical services plant, medical equipment) Typical location and numbers of plug sockets, including number per circuit Connections to essential supply, with load estimate Hazardous areas and provisions proposed Interior lighting Area classifications Illumination levels Anti-glare design Types of fittings (surface, suspended, concealed) Lamp type and colour System data: mounting height, hours in use, reflectance Estimated connected load and load per circuit Connections to essential services with estimated loads Exterior lighting Areas served and purpose Type of fitting Control and wiring method, including routes Lightning protection Need Design criteria Description of proposed design Communications Justification for each type of area Type of system Areas served Wiring method Other features and safety considerations, like call systems, intercommunication systems, fire alarm systems and other special installations may be included as required in the design and computations for the total electric power requirements.

5.3.2 Lighting Guidelines for hospital illumination are shown in Table S.

Engineering services

Table S. Guidelines for lighting in a district hospital' Area

Recommended minimum lux

Autoclave room Bathroom Blood bank Body store (mortuary) Clean utility room Conference room Consultation. room Corridor, general Cubicle, general Cubicle, treatment Darkroom Delivery room Diagnostic x·ray, couch Diagnostic x-ray, work place Dining room, general Dining room, tables Dirty utility room Dispensary, out-patient Doctor's office Enquiry desk, reception Entrance canopy Entrance hall Gymnasium (physiotherapy) Nurse's station, day Nurse's station, night Interview room Kitchen Laboratory, pathology, benches Laboratory, pathology, local Laundry, general Laundry, mending, local Library Lift hall Maternity department Mortuary, post-mortem room Mortuary, viewing room Night-lighting, maternity, paediatric (nurses) Operating theatre, general Operating theatre, operation Operating theatre, cavity (local) Pantry Pharmacy Plaster room, operating theatre Reading lights Reception area Records, medical Recovery room Scrub-up, operating theatre Shower Sluice sink Special baby care unit (local) Staff room Stores, general Toilets Workshop X-ray room, couch X-ray room, work place 'From Chartered Institution of Building Services (1979)

150-300 100-150 200 100

II I I

ISO 300 300 150-300 100-150 300

II I I I I

SO 400 20-100 300 I I

SO 200

ISO 300 300 500 300 200 300 300 30-100 300 300 300 500 300 500 300 200 400 300

ISO 100 400

10 000 SO 000 100 300 400

ISO 300 150-300 300-400 300 100-150 200 1000 100-200

100 100-150 300-500 20-100

300

District hospitals: planning and design

5.3.3 Emergency electrical services As mentioned above, the district hospital should have a reliable alternative source of power, in addition the normal electrical service, for emergency lighting, for operation of essential equipment and for the safety of its occupants. The alternative source should be from: -a generator, when the normal service is supplied from one or more central transmission lines, or -an emergency generating set or a central transmission line, when the normal supply is generated on the premises. The emergency generating set, including the prime mover, should be located on the premises, away from the operating department and the ward block. It should be reserved exclusively for supplying electricity in an emergency. The recommended circuits to which power should be provided are: Lighting: -aU exits, including exit signs, stairways and corridors -surgical, obstetrical and emergency room operating lights -nursery, laboratory, recovery room, intensive care unit, nursing station, labour room and pharmacy -generator set location, electrical switch-gear location and boiler room -one or two lifts, if needed for emergency -telephone operator's room -computer room, when available Equipment -nurses' call system -alarm system, including fire alarm -fire pump and pump for central suction system -blood bank refrigerator -sewerage or sump lift pump, if installed -equipment necessary for maintaining telephone service -equipment in operating, recovery, intensive care and delivery rooms -one electrical sterilizer, if installed Heating, cooling and ventilation system -operating, delivery, labour, recovery, intensive care unit, nurseries and patient rooms The capacity of the emergency generating set should be of the hospital, to maintain the minimum level of services. 5~0%

of the normal electrical load

The emergency electrical system should be so controlled that, after interruption of the normal electric power supply, the generator has brought full voltage and frequency within 10 seconds to all the emergency lighting and equipment listed above. Lights powered by storage batteries can be provided to augment the emergency lighting during the period of transfer switching, immediately following the interruption of normal service; however, these should not be used to substitute for the generator set. A typical diagram of an incoming electricity supply and of how the generator is relayed is given in Figure 75.

Engineering services

INCOMING PRIMARY FEEDER

PRIMARY DISCONNECT

SWITCH

T TRANSFORMER BREAKER ~

TRANSFORMER,..-S--G-E-NE-RA-T-O-R----.

I I I I

I I

BUS

AUTOMATIC TRANSFER SWITCH

LOW-VOLTAGE BREAKERS

LOW-VOLTAGE FEEDERS

Fig. 75. Modified selective system of electrical distribution, ineluding generator

...

District hospitals: planning and design

6. PLANNING AND PROGRAMMING CONSTRUCTION Once the basic planning and preparation of the master plan are finished, a plan should be made for the construction of the hospital. It should proceed as follows: -plans, specifications and cost estimates; -tender documents; -selection of contractor and award of work; -construction activities; -project management and control; and -handing over for commissioning.

6.1

Tendering

Documents for the preparation of bids by contractors for the civil, structural, architectural, electrical and other work for the hospital buildings and services should be drawn up. These documents must contain the following information: -general conditions of contract; -technical specifications -tender drawings; and -bill of quantities.

6.1.1 General conditions of contract This should consist of: -cover or title sheet -index -instructions to bidders -bidding form -form of agreement -perfonnance bond and bidding bond fonns -description of the site -standard labour regulations and other statutory provisions applicable in the country -right of access to the work by the owner -details of liability insurance for bodily injury and property damage -special conditions of contract, if any -other relevant details, including taxes and duty

6.1.2 Technical specifications These should supplement the drawings to describe fully the types, sizes, capacities, workmanship, finishes and other characteristics of all materials and equipment, including the codes of practices and standards, both national and international, to be followed with regard to materials, workmanship and tolerance.

6.1.3 Tender drawings These should include (i) a survey drawing and the soil investigation report; and (ii) preliminary sketches of plans, as follows:

Planning and programming construction

(a) Architectural and structural

-plan.s of found~tions and basement, floors and roof, showing space assignment, sizes and outhnes of major fixed and movable equipment; -all elevations and typical sections showing various finished floor levels; -plot plan, showing roads, paving and sidewalks; and -indicative details of reinforcement of foundations, beams and columns, floor slabs and special structures, if any. (b) Mechanical and sanitary

-single-line diagram of all external and internal sewer lines and water lines, indicating diameter of pipes and location and invert levels of manholes, etc; -location and size of all soil, waste and vent stacKs with connections to house drains and equipment; single-line layout of all ducts and piping systems, including fixture connections; -diagram of riser and wet drains in the case of multi-storey constructions; -layout of boilers and major associated equipment, including central heating, cooling and the air-conditioning and ventilation system; -air-conditioning and ventilation system, with equipment, water and refrigerant piping, ducts and exhaust ventilating duct openings; -details of pumps and layout of lifts, including other handling systems; -location and layout of various services in the laboratories and elsewhere, including gas tanks (c) Electrical and associated services

-plans showing space assignments, sizes and outline of fixed equipment, like transformers, main switch and switchboards; -electricity entry, with switches and feeders to the public service feeders; -emergency electrical system, with details of supply, feeders and circuits; -fire alarm system, telephone layout and all other electrically operated systems and equipment, showing service entry, switchboards, annunciators and wiring diagrams.

6.1.4 Bill of quantities The reliability of the cost estimate of any building depends upon the accuracy of the information available at the time the estimate is made. "Preliminary" and "approximate" cost estimates are prepared at the briefing and planning stages, on the basis of approximate floor areas, the cost indices of previous projects and the prevailing market rates for similar projects. When bidding for a multidisciplinary project like a hospital, contractors should know not only the technical specifications but also the approximate quantities of each item of work (such as excavation, blockwork and shuttering), so that they can price them by considering the labour, raw materials, equipment, taxes and their margin for overhead expenses and profit. Quantity surveyors estimate the quantity of each type of work, with a variation of about ± 10%, in the form of bills of quantities. If this document is prepared carefully, both the client and the bidder obtain a reasonably accurate idea of the cost of construction.

6.2

Project management

Like any other complex process, the planning and construction of a district hospital must be coordinated and monitored if they are to be carried out effectively and delays are to be avoided. A high level of discipline and good record-keeping are essential, because of the numbers of people involved at various stages, the lengthy duration and their intermittent involvement. It is therefore desirable that someone-preferably a member of the planning team with previous experience in managing planning and construction-act as a project manager.

District hospitals: planning and design

The project manager is responsible for coordinating and expediting the whole process, organiz~ng and motivating all groups, forecasting and programming their activities and monitoring and controllmg their perfonnance. The project manager is involved continuously in the project and is committed to its successful completion. It is the job of the project manager to ensure that all team members perfonn their tasks both on time and within the budget. He or she must obtain from them regularly updated infonnation on all activities, both at the site and on the shop floor, so that corrective action can be taken, either to the budget and financial approvals or to the project. Above all, the project manager must see that everything is properly recorded and must keep everyone infonned of all major decisions that are important to them in order to attain completion on schedule. The job of the project manager does not finish when the building is completed; he or she must ensure that all relevant infonnation for operating and maintaining the facility is handed over to the client. Drawings of all structures and services as they have actually been constructed must be prepared and handed over to the client for future reference. As staff changes, the client who works in the building may not be the same person who assisted at the original briefing and planning of the hospital. Decisions that were made about the intended methods of operation and use at those stages may be questioned at a later stage. Understanding of those intentions and proper communication in recorded fonn are essential. The tasks of management and control of the complex, interdependent activities of a construction project become impossible without systematic planning and organization. The most important element in project management is a realistic time schedule. A basic schedule should be worked out at the early stages of the planning process, and this should serve as a framework for all activities. As the lapse of time between the decision to build and the actual taking over of a completed district hospital is very seldom less than 3-4 years, a time schedule should be prepared during the briefing stage, which should indicate the major stages and also provides for such activities as tendering, major construction activities, planning and procurement of medical equipment and furniture. Once the client has approved the start of the project, the project manager must prepare a time schedule for each of the major aspects of construction and must set a target date for completion of the project. This schedule should indicate how construction of different elements will proceed; at what stages the working drawings and detailed technical specifications will be made available to the contractor by the architects and engineering consultants; when materials will be procured; and when plant and medical equipment will be commissioned and installed. As the choice of construction method and building materials significantly affects the schedule, it should be considered in detail at this time. Figure 76a shows a typical time schedule for the major steps in setting up a district hospital, from the time the project is approved to when it is commissioned. This simple bar chart shows the start and finish of specific activities. It shows how they are linked, how long each will take, where they overlap, where they parallel one another, or whether there is a lag between them. It does not, however, show the interdependence of some activities, i.e. in some cases, unless one activity is complete within a predetennined time another cannot be begun, which will result in delay. Such delays are almost always followed by an increase in the cost of the project. This aspect can be monitored and controlled by critical path analysis or project evaluation and review.

6.2.1 Critical path analysis The nature of a multidisciplinary project like the building of a hospital means that complex, time-consuming, interdependent sequences of events are encountered. These can be organized by critical path analysis, which involves a diagrammatic representation of the project as a network of activities. The major consecutive activities are defined as "the critical path". Any delay in one of the activities on the critical path will delay the overall schedule for completion of the project. Although there is usually only one critical path on a network, there may be more than one sub-critical paths. Too much delay in any sub-critical path would tum it into a critical path, and this will require careful monitoring and control so that further delay is avoided. Figure 76b illustrates this approach.

Planning and programming construction

MAJOR PROJECT ACTIVITIES

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Fig.76a. Project implementation scheme for a typical district hospital

Fig.76b. Critical path analysis

District hospitals: planning and design

The process of network planning thus involves four steps: -breakdown of project activities -listing of activities -constraints and sequential relationships of activities -network diagramming It is a logical representation of all the activities, with definite points of start and finish. Once the network diagram has been completed, the duration of each activity is determined on the basis of site location, climatic conditions, availability of raw materials, quality of available labour, method of construction, height of construction, safety regulation and all other relevant factors. Although the contractor has the prime responsibility for progress on site and for completing the project by the scheduled date, the project manager must monitor the contractor's progress in order to ensure compliance. The latest situation can be ascertained by regular comparisons of actual progress with the time schedule. If delays occur, corrective action must be taken immediately to catch up with the schedule.

6.2.2 Cost control The project manager should also actively control the final cost and not merely passively register payments. The client's acceptance of the budget provides the basis for economic control over the final cost (cost control), payment of contracts and variation orders (payment control) and availability and use of funds (control of cash flow). Payments to the contractor for work done and services rendered are usually made on a fixedprice basis, either: -as a schedule of prices, giving unit prices for the .items listed in the bill of quantities (item rate contract), or as a -lump sum for the complete work, as defined by the drawings and technical specifications (lump sum contract). The first arrangement is the most common, in which the total price is determined by the actual quantities, measured on the site and multiplied by the unit price quoted in the contract. This is a reasonably fair and straightforward method, which works quite well for present-day construction systems. In times of high inflation, it is the usual practice in the case of projects with a construction time exceeding one year to pay the contractor some form of compensation for rising prices, if agreed in the contract. In current international practice, the construction agency usually gets 90% of the payment for work completed each month, and the client holds the remainder as "retention money" until the end of the "defects liability period", usually one year after handing over, during which time the contractor is responsible for remedying any defects in materials or workmanship in the buildings. Suitable variations to this procedure may be made, depending on practices prevalent in the country, as long as the quality of the work and the construction schedule are not compromised. The final payment to the contractor is based on the final certificates of the project manager, including a final account. This account should contain a summary of all variations, changes in quantities, price fluctuations and escalations, for which adjustments to the contract sum are to be stipulated.

7. EVALUATION OF DISTRICT HOSPITAL FACILITIES A district hospital is a centre for organizing and dispensing medical services to the community it serves. This is not a fixed, unchanging function, as the size of the population may change, as may its age structure, social pressures and prevalent diseases. If the facility cannot adapt within its planned life to meet these changing needs, it is not successful. The whole process of developing a district hospital thus comprises the following main stages: -briefing -designing -producing technical documents and drawings --constructing --commissioning (bringing the hospital into use) -evaluating These are shown diagrammatically in Figure 77. The intentions of the design must be validated in terms of the actual utilization of the designed structures: the feedback loop must be followed to where the briefing and design process started, in order to build up a body of knowledge about design that is relevant to the time and as dynamic as reality. I I

Fig. 77. Process of developing a district bospital

For the following reasons, therefore, it is important to monitor and evaluate the performance of a new facility after it has been operational for about a year and to continue to do so at regular intervals: -Evaluation may reveal defects in operation of the hospital that can be corrected quickly and easily. For instance, the facilities may not be being used as intended; or defects in building design might be overcome by changing methods of use. -Evaluation may reveal defects in the design that can be overcome by changing equipment, relocating activities or redirecting traffic. It will reveal where the design is giving trouble in practice and where it is working well. This will indicate where changes are needed and avoid change for the sake of change. Evaluation comprises five steps: (I) (2) (3) (4) (5) deciding the objectives of the study, setting up the necessary organization, gathering the required information, analysing the information and communicating the findings.

District hospitals: planning and design

The factors that should be evaluated are: (a) Performance in use, as perceived by the users, both staff and patients. This factor is, of course, subjective, but it provides a basis on which more objective data can be evaluated. It may also reveal the contribution that good management is making to the efficient, happy functioning of a poor design or, conversely, the deficiencies in management in a building of good design that is functioning poorly.

(b) Basic records that indicate the known advantages and drawbacks of the buildings with regard to the activities of the users. (c) Objective observations of performance on site, including: -the activities in relation to the physical layout, physical conditions, equipment, services and infrastructure; -the effect of the layout and siting on the activities in relation to the community (e.g., ease of access, communications); and -the activities and work needed to keep the facility functioning (e.g., maintenance, cleaning) (d) Objective observation of the performance of the hospital as a building, in terms of: -layout and siting of buildings, -structure, -finishes, -equipment, -engineering services, -roads, car-parks and site development and -maintenance needs (e) Information on maintenance and running costs for comparison with the planned cost and previous annual recurring costs (from similar hospitals, if any) (t) Examination of the extent to which the building fulfils the brief given to the designers and

whether it is being used in the way intended at the time the brief was prepared. If the building is not being used as intended, this may be because: -the users were not told how it was intended to be used; -the needs of the users have changed, or the brief was wrong; -the users have found a better way of carrying out their activities, or the brief was wrong; -the designer did not fulfil the brief, or the brief was inadequate; -the designer found a better way to fulfil the needs; -the building and services are not durable and well-constructed. (g) Review of the planning decisions that led to the preparation of the brief; examination of the relationship between the objectives and the physical conditions observed in the facilities, to give answers to the following questions: -Are capital, running and maintenance costs as anticipated? -Were the predictions of the planners accurate? (If not, why not?) -Are the deficiencies in operation due to inadequacies in the original planning principles? -Should experience with this district hospital influence future guidelines or policy? What general conclusions can be drawn for future reference? (h) Consideration of the adaptability of the facility to meet future demands and to cope with changing needs.

8. EXPERIENCES IN DISTRICT HOSPITAL PLANNING AND DESIGN " The Western P~cific Region of WHO comprises countries that diverge widely socioeconomically, politically, geographically and climatically. Divergences are found in populations, ranging from a few thousands of people in one country to one billion in another, climate, from very cold to tropical; and economic level, from highly developed to the least developed in the world. This variety of conditions has resulted in a variety of responses with regard to the provision of health facilities, each country responding uniquely. This section gives the experiences of five countries in the planning and design of district hospitals, highlighting special conditions in the country and some creative innovations that were adopted to respond to those conditions.

8.1

Country A

County A is a small archipelago of hundreds of islands, with two main, exceptionally rugged islands. As it lies in the warm-humid, tropical belt, it experiences air temperatures as high as 30°C in the hot months of May-October and diurnal temperatures as low as 18°C in the cool months of November-April. During those cool months, storms of hurricane strength occur. The popUlation of about 700 000, living on 18 000 km2 of scattered islands, is served by nursing stations and health centres, which are focal points of primary health care, comprising preventive c'md limited curative services. Construction on small-islands using heavy, standard construction materials by skilled building teams brought from the main islands was problematical. The workers required living allowances and regular trips home. The response to this situation was to employ prefabricated units, so that only a skeletal skilled team is required which is supported by community labour. A "kit" was developed, with a detailed explanation of the erection of interchangeable component parts, which are transported and assembled on site. The assembled basic module can serve initially as a nursing station, but it can later grow into a larger health facility. The modules can also be adapted to nurses' quarters, schools, workshops or even large dwellings. These modules are therefore known as an "open system", with many possible uses, as opposed to a "closed system", in which the modules are designed for one use. The structural frame and other large parts are made of timber, designed to resist hurricanes. The floor of the building is raised for flood protection. The materials are light and easy to transport. The floor plans given in Figures 78 and 79 show the standard designs and the increments by which the facility can grow from a basic nursing station, to a health centre and ultimately to a hospital. Country A therefore solved the problems of construction in the field and evolved a scheme that can be easily phased and is suitable for conditions of limited finance.

District hospitals: planning and design

"'-" ENTRY I " " ' EXIT

DN ENTRY! EXIT

7400 HEALTH CENTRE RURAL HOSPITAL

7500 NURSING STATION

FLOOR PLAN SCALE PROJECTS 1,130 M KEY PLANS

NURSING STATION HEALTH CENTRE (EXPANDED NURSING STATION)

o I .

RURAL HOSPITAL (EXPANDED NURSINGr """ E ! STATION) HEALTH CENTRE

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Fig. 78. Floor plan (I), Country A

Experiences in district hospital planning and design

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Fig. 79. Floor plan (2). Country A

District hospitals: planning and design

8.2

Country B

Country B is a small Pacific nation, with a population of only 160 000 distributed over two main islands and seven others, with a total area of about 2800 kIn2 • It is a relatively young nation and has a subsistence economy, based mainly on agriculture. Its national health programme, however, is aligned with the global aim for health for all by the year 2000 through primary health care. As it is a small country, the provisions for health facilities are also small. The hierarchy of facilities is as follows: -the -the -the -the sub-centre, in which a nurse or midwife provides service; health centre with two holding beds; district hospital, typically with 20 beds; and national hospital, which is the referral hospital for all specialities.

Population health coverage is almost 100%. The district hospital provides no clinical or support services, except for minor emergency operations. The hospital shown in the plans in Figures 80 and 81, however, has facilities for delivery, maternity wards and spaces for a laboratory and future X-ray equipment. The design shown lends itself to phased building construction, the wards occupying one building, the operating, delivery and diagnostic areas occupying another, and the rest of the facilities occupying a building each, interconnected by a covered walk. The open plan is ideal for a tropical climate. In the two main buildings, housing the wards and the operating, delivery and diagnostic areas, functional rooms occupy the peripheral areas and are naturally lit and ventilated. The interior, public spaces are lit and ventilated through skylights, designed to allow for dissipation of hot air. This design solution reflects the circumstances of the country with regard to the provision of health care.

8.3

Country C

Country C is an archipelago of over 7000 islands, with a total combined area of 300 000 km 2 • Its popUlation of 55 million is served by a health network with three levels of health care: -primary care, the basic community unit giving service on an out-patient basis and delivering such services in minimal health facilities; -secondary care, at district hospitals which provide out-patient and in-patient services in the basic specialities; and -tertiary care, at provincial, regional and national levels, in which out-patient and in-patient services are provided for complicated cases referred from the lower levels in equivalent higherlevel physical facilities. The floor plan shown in Figure 83 reflects this situation. The hospital had been expanded and altered through the years, some parts being demolished and others added here and there, constructed whenever funds were available. The original design has been blurred by the large number of piecemeal additions, which were neither controlled nor regulated by a master plan for growth and expansion.

Experiences in district hospital planning and design

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District hospitals: planning and design

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Fig. 81. Floor plan, Country B

Experiences in district hospital planning and design

~s a result, some of the rooms that have been added have locked in existing spaces, which now have neither natural nor artificial ventilation; the corridor system is incoherent; and departments have lost their functional interrelationships.

Since this is a common situation in hospitals in the country, measures had to be instituted to stop unguided, uncontrolled expansions, additions and alterations. An approved "master site development plan" (Figure 82) was made a prerequisite before any demolition, addition or alteration could be made. Furthermore, approval from the health infrastructure management office formed at the national level is now required for projects that exceed a specified scope.

8.4

Country D

The scale of health provisions for Country D is very demanding. Unlike the three countries described above, its population is huge-1.03 billion-and its total area 9.6 million km 2 • Innovative ways had to be found to deliver health service to many ethnically diverse people living under various geographic conditions with marked variations in climate. A comprehensive network of primary health care had to be made available to both the urban population, comprising 20% of the total, and the rural popUlation, comprising the remaining 80%. Structures for organizing services to populations in defined geographical areas had to be well formulated. Health provision was thus stratified as follows: -health workers and midwives, not necessarily based in a health facility, would care for groups of 20<Hi00 people; -a cooperative station staffed by both locally recruited and trained medical workers would serve a population of 200<Hi000 people; -a rural hospital, with 65-100 beds, would serve populations of 20 00<Hi0 000; -city and county general hospitals would serve populations of 200 00<Hi00 000. Over the past four decades, great strides have been taken in the development of health services; and a programme for the development of health facilities, which has intensified over the last decade, has increased the number of health facilities enormously. The choice of only two forms of hospital architecture, shown in Figures 84-87, is intentional. The picture of the rural health worker delivering service at the grassroots level from a minimal physical base has caught the attention of other countries and inspired them to adopt and adapt the programme to their local circumstances. The picture shown here is at the other end of the spectrum-<>f the facilities from which the technical guidance, logistic support and training of health personnel emanates for implementation of the village-level facilities and programmes. The scale of provision in these two sample hospitals is large-140 beds in model no.! and 740 beds in model no. 2. The services range from general to specialized, to include even plastic surgery and bum treatment, and the design solutions have endeavoured to match this high level oftechnology. The deviation from the usual right-angle intersection of walls should be noted partiCUlarly. In model no. I, the use of the circle is explored in the out-patient department, emergency department and conference hall. Although circles are more expensive to construct, this fonn allows distribution of rooms around the nucleus: in the out-patient and emergency departments, functional areas surround the staff base; in the conference hall, the seating arrangement focuses attention on the central speaking area. Corridors and other movement routes are shortened.

District hospitals: planning and design

100

OFFICES. OTHERS

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Experiences in district hospital planning and design

101

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District hospitals: planning and design

102

In model no. 2, hexagons are clustered to produce a progressively larger hexagonal form. Although the perimeter walls enclose spaces in longer lengths, in fact circulation is shortened and focused. The concept of space distribution is similar to that in model no. I, except that the perimeter is broken into several straight lines instead of a continuous curved line.

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Experiences in district hospital planning and design

103

GROUND FLOOR PLAN SCALE ;:-_ _ _..:..:1 :400 MTS. 0 5 10

SECOND FLOOR PLAN SCALE

1:400 MTS. 10

Fig. 85. Floor plans (1), Country D

DlslTicI hospitals: planning and design

104

CJ CJ

WARDS

SITE PLAN SCALE 0

1:1250 MTRS.

50 METERS

Fig. 86. Master site plan (2), Countr y D

Experiences in district hospital planning and design

105

10 meters

Fig. 87. Floor plans (2)

GROUND FLOOR PLAN

SCALE 1:333 MTRS. (USED AS 2nd ZONE· DIAGNOSTIC/ANCILLARy)

MODEL 1/ 2

District hospitals: pllJnning and design

106

8.5

Country E

Country E has a population of 121 million people, 76% of whom live in urban areas; the remainder live in rural areas in a geographic setting in which 75% of the land is mountainous. The country experience is one of massive reconstruction, with a basic policy of reducing provisions and their costs to a minimum in order to distribute resources equitably; expansion and upgrading were done on a small scale, only when necessary. This resulted in chaotic hospital facilities, which could not function efficiently. Four decades of growth and development brought the country to a high economic level. It became easier to upgrade health facilities, either by constructing new hospitals on new sites or by altering existing hospitals. Urban needs are now provided by hospitals of 100 beds and more, and rural needs by hospitals of fewer than 100 beds. The plans shown in Figures 88-90 are those of a 200-bed hospital that was constructed in the 1950s, before the period of rapid economic growth. The hospital has a readily legible circulation system, with a major spine corridor running north to south and various minor corridors branching out from it into the departments located on either side of the spine. The master site development plan shows a very generous site, which allows the hospital to expand easily, merely by breaking walls and occupying immediately adjacent open spaces. This design shows, however, long corridors, which may increase the distance and time for travel for staff.

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Experiences in district hospital planning and design

107

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District hospitals: planning and design

108

NURSING UNIT 150 BEDSI

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Fig. 90. Second-floor plan, Country E

109

9. ASPECTS OF HOSPITAL UTILIZATION: DESIGN INTENTIONS VERSUS USE 9.1 Case No.1 (Fig. 91)

The ward was originally designed for 52-bed occupancy. Patient areas line the exterior spaces, where the windows are, and receive natural lighting and ventilation; they also have the amenity of the view from the windows. The staff spaces and supporting service areas are on the other side of the ward corridor, along the walls adjacent to the corridor that leads to the lifts on one side and to the stairs on the other. This arrangement allows for access to the clean and dirty utility areas, the kitchen and other service areas without penetrating the inner patient areas and is a good example of the segregation of functional uses to prevent cross-traffic. The ward design thus follows the well-developed British concept of "peripheral banding", in which patient spaces line the periphery of the building and staff spaces adjoin the corridor, from which services arrive. This must have been the design intent. In actual use, when observed, the ward was teeming with people. Apart from the ward staff on duty, 69 patients had been admitted into the 52-bed ward-17 more than it could efficiently and comfortably serve. Additional beds had been brought in, which filled the available space for movement; and the beds had been spaced closer than the standard distance so that it was hard for the nurses to get round them. The presence of many family members compounded the crowded situation; however, they performed many of the nursing functions of the staff, and especially observation of the patients.

9.2

Case No.2 (Fig. 92)

This out-patient department was originally designed as a centrally air-conditioned unit. Thus, the-design was for a compact plan, in which interior rooms abound and in which artificial ventilation specifically designed for the area is used to ensure comfort and a healthy environment. Specialties were given specific areas for their permanent use, as opposed to a flexible, open arrangement in which specialties can use a pool of consultation-examination rooms interchangeably. Thus, the design had to be based on a clear specification of the expected number of patients per specialization, in order that there be no waste in providing for them. For the first several years, the department functioned efficiently. The area provisions were adequate, and the air-conditioning system was working. After some years of operation, however, the system broke down for lack of adequate maintenance; difficulties in procuring spare parts compounded the situation. The system had ultimately to be removed, and the equipment parts occupied a large storage space on the hospital premises. In the meantime, the number of out-patients has multiplied, and the department has become very congested. The centralized air-conditioning units were replaced by portable electric fans to provide comfort, but the closed atmosphere deteriorates throughout the day. Those in interior rooms suffer the most. The times have therefore overtaken the validity of the design. The circumstances under which it was assumed the department would operate are no longer valid. The time is ripe for reassessment of growth and of the necessary changes.

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Aspects of hospital utilization: design intentions versus use

111

9.3

Case No.3 (Fig. 93) This general surgery ward was designed for an occupancy of 34 patient beds, as follows: -four wards with one bed, -nine wards with two beds and -two wards with six beds.

The design, makes use of the single-corridor form, in which the deeper, larger rooms (the sixbed and two-bed wards) are on one side of the corridor and the smaller ones (staff areas and onebed wards) on the other. The nurses' station is located centrally, to maximize patient care. Theoretically, progressive nursing care requires that patients be positioned in the wards according to their level of dependence and nursing needs, the highly dependent patients being closest to the staff base. This concept is not, however, evident in actual use. In the countries of the Western Pacific Region, the family is a very strong institution. This cultural fact is both a bane and boon to hospital designers, planners and users in the Regiori. While fa i1y add to the crowding, confusion and population inside the hospital, they can, if properly guided, be ideal helpers when there is a dearth of manpower. The ward illustrated here is a good example, as there are only three nurses to fulfil the requirements of 34 surgical patients. The closeness of the family ties ensures loving care, which the staff can supplement with technical guidance and supervision. Table 6 shows the level of family participation in patient care in this ward, where 80% of the patients are attended by their families on a 24-hour basis and an additional 12% are attended overnight. With this arrangement, patients requiring intensive care can be assigned to rooms distant from the staff base-in this case, rooms 5202, 5214, 5215 and 5216. With this cultural background. the wards become virtual living rooms for family and guests, and the patient becomes the central focus of socializing. Patients who have almost recovered entertain people in their wards as if they were in their own living room. This situation must be considered in design.

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AspecJs of hospital utilization: design intentions versus use

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5201 2 BED

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GENERAL SURGERY NURSING UNIT

District hospitals: planning and design

114

Table 6. Family participation in patient care in a surgical ward with three nurses for 34 patients (case no. 3) Length of stay (days) 5 6 7 0 6

Room no. 5201 5201 5202 5202 5203 5210 5211 5214 5214 5215 5215 5216 5216 5217 5217 5218 5218 5219 5219 5220 5220 5220 5220 5220 5220 5221 5221 5221 5221 5221 5221 5222 5222 5212

Sex

Age (years) 37 38 62 64 64 71 53 65 61 63 47 36 51 57 42 71

Degree of nursing needed Intermediate Intermediate Self Intensive Self Intermediate Self Intensive Intensive Intensive Self Intensive Self Intermediate Self Intensive Self Intermediate Intermediate Self Intensive Self Intensive Intensive Intensive Self Intermediate Intermediate Discharged Self Self Intermediate Intermediate Intermediate

Attendance

F F F F

M M F F F

28 4 8 10 1 9 8 7 I 5 0 I3 3 23 I 8 6 8 8 4 5 6 0 5 4 2

M M F F

M M M F F F F F F F F

41 60 60 31 59 52 60 53 55 43

M M M M M M M M

61 57 27

24 h by family 24 h by family 24 h by family 24 h by family 24 h by family and 24-h professional aid Overnight by family and 24-professional aid Overnight by family and 24-h professional aid 24 h by family 24 h by family 24 h by family 24 h by family Overnight by family and 24-h professional aid None 24 h by family Overnight by family 24 h by family 24 h by family 24-h professional aid 24 h by family None 24 h by family 24h by family 24 h by family and 24-h professional aid 24 h by family 24 h by family 24 h by family 24 h by family 24 h by family 24 h by family 24 h by family None 24 h by family 24 h by family 24 h by family

Aspects 0/ hospital utilization: design intentions versus use

115

10. SELECTED BffiLIOGRAPHY American Hospital Association (1974) Hospital Engineering Handbook, Chicago. Bridgman, R.F. (1955) The Rural Hospital, Structure and Organization, Geneva, World Health Organization. Bridgman, R.F. and Roemer, M.l. (1973) Hospital Legislation and Hospital Systems (Public Health Paper No. 50), Geneva, World Health Organization Carter W. (1985) Procedures for Disaster Preparedness Planning (Pacific Islands Development Program Disaster Preparedness Project), Honolulu, East-West Center. Chartered Institution of Building Services (1979) CIBS Lighting Guide-Hospitals and Health Care Buildings (Publication No. 12), London. Department of Health (1977) Fire Safety in Health Buildings (Hospital Technical Memorandum No. I), London, Her Majesty's Stationery Office Department of Health (1968-1989) Hospital Building Notes Nos. 1-51 (1964-1991) and Technical Memoranda Nos. 1-88, London, Her Majesty's Stationery Office. Hardy, O.B. and Lammers, L.P. (1977) Hospitals: The Planning and Design Process, Baltimore, Aspen Systems Corporation Hudenburg, R. (1907) Planning the Community Hospital, New York, McGraw-Hili Kleczkowski, B.M. and Pibouleau, R. (1976) Approaches to Planning and Design of Health Care Facilities in Developing Areas, Vol. I (WHO Offset Publication, No. 29), Geneva, World Health Organization. KleCzkowski, B.M. and Pibouleau, R. (1977) Approaches to Planning and Design of Health Care Facilities in Developing Areas, Vol. 2 (WHO Offset Publication, No. 37), Geneva, World Health Organization. Kleczkowski, B.M. and Pibouleau, R. (1979) Approaches to Planning and Design of Health Care Facilities in Developing Areas, Vol. 3 (WHO Offset Publication, No. 45) Geneva, World Health Organization Kleczkowski, B.M. and Pibouleau, R. (1983) Approaches to Planning and Design of Health Care Facilities in Developing Areas, Vol. 4 (WHO Offset Publication, No. 72) Geneva, World Health Organization. Kleczkowski, B.M., Montoya-Aguilar, C. and Nilsson, N.O. (1985) Approaches to Planning and Design of Health Care Facilities in Developing Areas, Vol 5 (WHO Offset Publication, No. 91), Geneva, World Health Organization. Llewelyn-Davies, R. and Macaulay, H.M.C. (1966) Hospital Planning and Administration, Geneva, World Health Organization. Macagba, R. (1984) Hospitals and Primary Health Care. A Report on a Worldwide Survey in the Role ofHospitals in Primary Health Care, Sponsored by the International Hospital Federation Funded by the w.K. Kellogg Foundation of USA, London, International Hospital Federation. Manahan, G.Y. (1983) Passive Cooling Technology for Buildings in Hot-Humid Localities, Manila, United Architects of the Philippines Professional Development Center Publication. Paine, L.H.W. and Siem Tjam, F. (1988) Hospitals and the Health Care Revolution, Geneva, World Health Organization.

District hospitals: planning and design

116

Rea, J., Frommelt, J.J. and Maccoun, M.D. (1978) Building a Hospital. A Primer for Administrators, Chicago, American Hospital Association. Scottish Home and Health Department, Edinburg (1963) Hospital Planning Notes, London, Her Majesty's Stationery Office. US Department of Health, Education, and Welfare (1969) General Standards of Construction and Equipment for Hospital and Medical Facilities, Washington DC. Wheeler, E.T. (1971) Hospital Modernization and Expansion, New York, McGraw-Hill. World Health Organization (1987) Hospitals and Healthfor All. Report of a WHO Expert Committee on the Role of Hospitals at the First Referral Level (Technical Report Series, No. 744), Geneva. World Health Organization (1989) Coping with Natural Disasters: The Role of Local Health Personnel and the Community, Geneva. World Health Organization Regionlll Office for the Western Pacific (1986) Report on the Regional Workshop on Health Facility Planning and Development. Tokyo. Japan. 13-17 October, Manila. World Health Organization Regional Office for the Western Pacific (1988) Report on the Regional Workshop on Planning and Design of District Hospitals in Support of Primary Health Care. Seoul. Kyungju. Republic of Korea. 24 August-1 September, Manila. World Health Organization Regional Office for the Western Pacific (1988) Report on the Regional Training Course on Health Facility Planning and Development. Tokyo. Japan. 5-15 December, Manila.

PART II:

MEDICAL EQUIPMENT

119

1. OBJECTIVES This second part of the guidelines for development of district hospitals has two objectives: (1) to help hospital authorities in the Western Pacific Region, particularly in developing

countries and others assisting them, to strengthen and develop their skills in managing equipment; and (2) to assist technical personnel in carrying out routine planned preventive maintenance on medical equipment commonly used in district hospitals, in order to: -reduce breakdowns and prolong the life of equipment -improve the quality of health delivery and --ensure the safety of users and patients. Since defining the hospital and the health service it provides is a prerequisite for planning equipment, and although district hospitals vary widely in their bed capacity, these guidelines focus on equipment for 50- and IOO-bed hospitals. Planning for smaller or larger facilities can be done by extrapolating from these examples. These guidelines should be used with the following in mind: -Rapid changes in modern technology very often overtake the slow, tedious process of planning, selecting and procuring equipment. Guidelines must be updated regularly. The lists and specifications given here should be valid for a number of years, however, as they adhere to current standards. -The efficiency of a hospital must be evaluated continuously to ensure that the assumptions underlying these guidelines are still valid and relevant. Assessments should be undertaken and published from time to time in this regard. -These guidelines apply to generalized situations and must be translated by users to suit the specific needs of their country. They should be used as a starting point for hospital administrators to assess their needs. -Local demographic, climatic and other conditions must be taken into consideration when using these guidelines. Before obtaining equipment that is recommended here, the user should consult the manufacturer's technical and service manuals to determine whether the equipment is suitable for local conditions. Medical equipment is discussed under the following headings: -list of essential equipment -management of equipment -development of human resources -planned preventive maintenance

Medical equipnrent

120

2. LIST OF ESSENTIAL EQUIPMENT 2.1 Generic specifications

Ideally, generic specifications should be formulated for each item included in a list of essential equipment. Usually, however, reference is simply made to technical documents describing brands available on the market; as a result, the specifications may not correspond precisely to health needs. A further result is that one or only a few manufacturers supply a particular piece of equipment; and this lack of competition means that the equipment costs more than it should. There is as yet no handbook of generic specifications for common hospital and medical equipment. One should be prepared and made available to national selection and procurement committees in different countries. It could be based on the experience of WHO programmes such as the Expanded Programme on Immunization, the Radiation Medicine Unit and the Action Programme on Essential Drugs which have developed such documents as the Cold Chain Product Information Sheets and the Annotated Cold Chain Bibliography (Expanded Programme on Immunization), Future Use of New Imaging Technologies in Developing Countries (Technical Report Series, No. 723) and the Manual of Darkroom Technique, the Manual of Radiographic Interpretation for General Practitioners and the Manual of Radiographic Technique, which describe use of the WHO Basic Radiological System, comprising an x-ray unit and imaging equipment. The Manuals of General Surgery and Anaesthesia at the District Hospital, listed in the bibliography, also include annexes giving essential surgical supplies and equipment. Equipment for which generic specifications may be written comprises: -operating theatre lamps -operating theatre trolleys -operating theatre stand-by batteries -surgical diathermy -sterilizers -suction pumps -medical gases -ventilators -dialysis machines -infant incubators -electrocardiographs -monitoring equipment -short-wave diathermy -defibrillators -dental chair unit -amalgam stirrers -dental x-ray film processor -x-ray film processor -x-ray equipment (not already covered) -pH meters -spectrophotometer -centrifuges -hot-air ovens -balances -microscopes -flame photometers -water softeners -water distillers

List 0/ essential equipment

121

Generic specifications can also be written for hospital plant material, such as: -stand-by diesel generators -ventilation units -boiler units -public address system -internal telephone system -incinerators Until such a handbook is available, staff responsible for selecting and procuring equipment must try to specifY equipment that is in as close accordance as possible with the health service requirements, avoiding the inclusion of features that are specific to particular brands.

2.2

Essential medical equipment for a 50-bed district hospital

2.2.1 Scope of services The equipment listed in this section is for a district of 80 000 people with 10 urban or rural health centres and 20 rural health units. This model district is 100 km 2 in area and has a district capital of 30 000 people; there is a uniformly distributed rural population of 44 000 and three area townships of 2000 people each (Fig. 94). The SO-bed hospital, the first-referral level hospital for the district, would provide the following health services (as listed in Table 1): essential clinical services: medicine, surgery, paediatrics, obstetrics-gynaecology and acute psychiatry (when necessary); optional clinical services: stomatology and oral surgery, orthopaedic surgery, otorhinolaryngology, neurology and psychiatry; essential clinical support services: anaesthesia, radiology and clinical laboratory; and optional clinical support services: pathology and rehabilitation, including physiotherapy .

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The hospital provides first-referral coverage to the population that comes directly to the hospital and to people sent on from rural health centres and units. Patients who require complicated treatment beyond the scope of the hospital are referred to larger provincial general hospitals.

2.2.2 Essential medical equipment Choice of the equipment for each department should take into consideration the workload of that department from the whole district. (a) Diagnostic imaging equipment

Diagnostic imaging in small hospitals requires x-ray and ultrasound equipment. In a general "community" hospital, x-ray equipment is the first and essential item. Ultrasound can be added if money is available, but x-ray examinations are needed much more often.

Medical equipment

122

(1)

Diagnostic x-ray equipment X-ray equipment can be stationary, in one room, or mobile. Stationary equipment is essential. Most small hospitals do not require a mobile unit; however, if funding is available, a mobile unit is a useful albeit relatively infrequently used piece of equipment. It may be necessary for orthopaedic procedures during surgery.

(2)

Specifications for a stationary x-ray unit Detailed specifications for the Basic Radiological System (WHO-BRS) are given in Annex 7. They are summarized at the end of this section. The major requirements for any stationary x-ray unit are as follows: (i) Medium or high frequency converter generator with a tube generating potential (voltage) range of 45-120 kV

Note: Some type of power storage may be required, e.g., a capacitor or battery (see below). A generator with falling tube current (rnA) during exposure is preferable to one with constant tube current. (ii)

Minimum power, 11 kW (at 0.1 s); minimum available energy, 25 kWs

Note: If the relative speed of the screen-film system is 400, the energy requirement may be reduced to 12 kWs. The power requirement remains the same. (iii) Focal spot size, 1 mm or less (iv) (v) Accurate, variable collimator, which cannot be removed Minimum focus-film distance, 110 cm for vertical-beam radiography; 140 cm for chest radiography with horizontal beam

It should be noted that single-phase two-pulse generators (not involving multipulse converter technology) and capacitor discharge units without constant voltage (kV) during exposure are not recommended. Lastly, WHO does not recommend the use of fluoroscopy in hospitals at this level (see section 13 for details).

Summary of specifications for the WHO-BRS x-ray machine -Output of the x-ray generator high enough to produce a minimum exposure of 0.5 mR (uGy) at a source-detector distance of 140 cm and a tube potential of 120dV: (a) behind a 12-cm water phantom in 50 ms or less, and (b) behind a 30-cm water phantom in 1 s or less. The exposure conditions include the employment of a grid as specified below. The x-ray generator must also be capable of delivering a maximum local output of 25 kWs (at 90 and/or 120 kV). -Rotating anode x-ray tube with a focal spot no larger than 1 mm, with a load capacity of at least 20 kW during 0.1 s (nominal rating) and 10 kW during 1 s. -The total permanent filtration of the x-ray tube must be at least 2.5 mm of aluminium. -The control panel should indicate the state of the electricity supply and the chosen values of kV and mAs or object thickness. Only four kV values are required: 55, 70, 90 and 120 kV. Comment: Practical experience has shown that the addition of 45 and 80 kV may be of value.

List of essential equipment

123

The minimum range of mAs values is 0.8-200 in 25 equal steps (26% increments). -A fixed focus-film distance of 140 cm must be used. The design must ensure that the tube is always connected to the cassette holder in a rigid and stable way, providing precise centering of the x-ray beam. It must therefore be possible to angulate the cassette holder in relation to the x-ray beam. -A stationary, focused lead/aluminium grid with 40-50 lines/cm and a ratio of 10: I must be provided. The grid must be incorporated in the cassette holder close to the fiI~, so that the distance between the front wall of the cassette holder and the film plane IS not more than 2.5 cm. -The tube must be provided with an adequate collimator that allows restriction of the xray beam to the size of the films used. -A movable pointer or other reliable system of centering the x-ray beam must be provided. -The film sizes should be standardized, and not more than four format s should be used (the actual film sizes will depend on what is available locally). The following are recommended: 35.5 x 43 cm (large format), 18 x 43 cm (long format ), 24 x 30 cm (medium format) and 18 x 24 cm (small format). -The support for supine patients must be rigid, with an x ray-permeable top, and able to support a weight of II 0 kg without appreciable distortion. -The horizontal x-ray beam must be such that it can be used at a distanc e of 50-170 cm from the floor for examining patients who are either standing up or lying on a trolley or stretcher. -The back wall of the cassette holder must incorporate a lead shield of a minimum thickness of 0.5 mm. -Stric t control of time and temperature (without intermediate film viewin g) must be used in film processing. Darkroom equipment must be provided with the x-ray equipment. -At least two protective aprons and two pairs of protective gloves with minimum thickness equivalent to 0.25 mm of lead must be provided. -Unle ss there is an adequate protective cubicle at the installation, a protect ive screen, large enough to protect a standing operator, must be an integral part of the contro l panel. Its lead equivalence must be at least 0.5 mm Pb, provided that the x-ray beam is never directed at the screen. A lead-glass window, no smaller than 30 x 30 cm must be incorporated in the screen. Note: It is very important to bear in mind, when statements are made about power requirements (see section 3 below), that all WHO-BRS specifications publish ed refer to: -medi um-fre quenc y converter x-ray generators, -a fixed (constant) focus-film distance of 140 cm, -a screen-film speed of 200, and -a patient weight not exceeding 110 kg. The use of old, single-phase generators will more than double the power requirements. Use of modem screen-film systems utilizing green light will reduce the power requirements by 50%. If the average weight of an adult middle-aged man in the popUla tion is less than 60 kg (instead of 80 kg, which is used in the BRS calculations), the power requirements may also be reduced, by a factor of 2.

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(3)

Choice of power supply

is unreliable, In m~y rur~l ~eas and some towns and cities, the main electrical supply can severely voltage line in n variatio d both In contmUl~ and voltage control. Marke line voltage nal additio an occur, damage x-ray eqUIpment. Where variation is known to tor. regulator should be installed to protect the x-ray genera If the P?wer line is weak or unreliable, it can be replaced by a power storage s (96-12 0 V, system. Th~ .slmplest and most reliable is a set of lead-acid batterie of the high25-60 Ah); It IS also possible to use a large capacitor on the primary side kWs) given voltage transformer, provided it meets the energy requirements (12-25 above under 2 (ii). ls: Battery-powered generators have several advantages for small hospita output of 30 kWs -It is very easy to reach a power output of about 15 kW and an energy within 2-3 s. (depending on their -Wor k can continue for 1-3 weeks without recharging the batteries size). -Batte ries are not affected by variations in voltage or frequency. source such as -Batte ries can be recharged by solar power or by an intermittent power or kerosenepetrolndent a weak or otherwise unreliable power line or a small indepe powered electricity generator. with an x-ray Sealed and maintenance-free lead-acid batteries are the best to use an x-ray during occurs generator. They tolerate well the near-short-circuiting which no maintenance. exposure. They may last for more than five years and require practically nance and The alternative, nickel-cadmium batteries, require sophisticated mainte Nickel-cadmium recycling once or twice a year. This cannot be done at the hospital. batteries are not recommended. attractive X-ray generators with a large capacitor for power storage are a very alternative, if the following conditions are fulfilled: transformer. -The capacitor is connected on the primary side of the high-voltage is falling during the -The x-ray tube voltage is maintained constant and the tube current exposure. -A reliable low-power source (0.8-1.2 kW) is available. -The x-ray exposure does not require more energy than 10-12 kWs. may be A capacitor discharge x-ray generator that fulfils the above requirements a chest for choice best connected to any household wall-outlet of 220-250 V. It is the x-ray unit. ed is given in Detailed information on how the power of an x-ray generator is specifi Annex 8.

I I i J

(4)

Choice of x-ray tube support and patient support BRS design The x-ray is supported on a column with a tube-a rm. The WHOts the x-ray (Fig. 95) stipulates a single floor-column with a rotating arm that suppor to the wall ent attachm al minim s tube and the cassette holder. This model require support patient The . and is easy and quick to install. No separate chest stand is needed or ward the is a mobile trolley, which can also be used to fetch patients from emergency area. There is no weight on the ceiling.

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Fig. 95a. BRS unit witb borizontal I-ray beam

Fig. 95b. DRS unit witb vertical I-ray beam and patient trolley

The alternative is a tube--column which runs on floor rails (Fig. 96) and also has a ceiling track. The two sets of rails must be exactly parallel, and the intervening distance must not vary. This requires a level floor and a strong ceiling. The x-ray table is fixed, and an additional, separate chest-cassette holder is required. Tubecolumns are available that run on two floor rails, without ceiling support (Fig. 97); these are unstable and are not recommended.

-------~------

Y1itt--Fig. 96. Column x-ray tube support mounted on floor rails with a ceiling rail: three possible types of rail

The WHO--BRS tube and patient supports are strongly recommended. This design has been well tested in rural hospitals, is very easy to use and, with the WHO-BRS Manual of Radiographic Technique, can be used to provide all the x-ray examinations required in hospitals where there is no specialist radiologist (and will even be satisfactory when there are fully trained radiological staff).

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Fig. 97. Column x-ray tube support mounted on floor rails

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(5)

Secondary radiation grids When x-rays pass through a part of the body, some are scattered within the tissues. This reduces the contrast in the radiographic image. A so-called "grid", interposed between the patient and the film cassette, will greatly reduce the amount of scattered rays that reaches the film (Fig. 98). A grid appears as a 2-3 mm thick, flat plate and contains very thin strips of lead (about 0.05 mm wide and 2 mm high), supported by interleafing strips of an x-ray-translucent material (about 0.2 mm wide and 2 mm high), arranged as a venetian blind.

II I'

A \-----K-RAyS

----a.j

G; )~---PATI * I. puccicc tile ,..id i. nat.

ENT---....

f~; ~ \ \ -.

t=:=:;#:~==:J---TABLE-t::::===;tt:l:~~==::J

l \\ GRID 1:::::======::1_. ---FILM

Fig. 98. Scattering of radiation: A, without a grid; B, with a grid

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The grid lines will be visible on the film if it is viewed at a very short distance «30 cm) or if the grid is not correctly focused. The lead strips of focused grids are arranged in such a way that each line is imaged practically without magnification, permitting nearly 80% of the direct radiation to pass through. A focused grid must be used, however, at only one distance from the x-ray tube. If this cannot be done, or if the grid lines are wider than 0.05 mm. the grid can be moved (oscillated) during the exposure to blur the image of the lead strips. Such a moving grid is called a "bucky". Bucky mechanisms are complex mechanical devices and are also expensive. If different focu-film distances are used in radiography, different grids must be used in different imaging geometries. Grids are expensive items. WHO recommends the use of a singly standard focus-film distance, which permits the use of a single focused, high-quality grid for all examinations. (6) X-ray films and screens

X-ray films, which have photographic emulsion on both sides, are placed between two fluorescent "screens" inside a light-proof cassette. When x-rays pass through the patient and the cassette, the screens give· off light, which exposes the film emulsions, recording an image. Screens vary in their response to x-rays and their capacity to reproduce details of the image. X-ray intensifying screens are currently rated in four main groups by the manufacturers (Table 7). Unfortunately, there is no clearly defined nomenclature, and the "fast" screens from one manufacturer may be similar to the "medium" screens from another. Table 7. Main groups of x-ray intensifying screens

Group

Resolution (Iines/mm) 8-12 6-8 4--6

Relative speed Blue/UV systems 80-125 100-200 160-250 200-500

Green systems 80-125 200-250 320-400 500-800

Fine/detail Medium/universal Regular Fast

3-4

Intensifying screens emit ultra-violetlblue or green light. They must be used in combination with film that has the appropriate colour sensitivity. Use of a bluesensitive film with green-emitting screens, or the reverse, results in a loss of speed of about 50% and must be avoided. Green-emitting screens are considerably more expensive than most blue/ultraviolet-emitting screens, but they in general reduce the patient dose by a factor of 2 or more, for the same quality of image. Green systems are also much less likely to show "film graininess". This effect almost always depends on quantum noise and frequently appears in blue systems when the speed exceeds 250 and in green systems when the speed is over 500. Green-sensitive (orthochromatic) film has a longer shelflife (is less sensitive to ageing); however, it is not yet generally available and may be more expensive in some markets. Note: Never mix cassettes or film for blue and green systems.

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Provided the x-ray generator meets WHO requirements for a BRS generator (converter generator with minimum 11 kW, 25 kWs), a "medium" speed of about 200 is the safest choice because such screens and films are universally available. Note: The traditionally used amber-coloured filters for blue-sensitive x-ray film cannot be used with green-sensitive film. Green-sensitive film require a filter of a rather dark ruby-red colour. To ensure a constant supply of x-ray processing chemicals, it is advisable, but not essential, to buy film and chemicals from the same supplier. Most chemicals can be used to process any make of film. Note that three essentially different types of developer are available. One is used for large automatic processors at high temperature and needs special "starter" and "replenisher" solutions. Another is used for automatic processors with low capacity and small tanks at high temperature and does not require "starter" and "replenisher". The third type is used for manual processing at 20-25°C and is less aggressive; no "starter" or "replenisher" is used. (7) Processing x-ray films After exposure, x-ray films are taken in the cassette to the darkroom, where they are removed for processing, which can be done manually or automatically.

0) All automatic processors require a constant electrical supply and can be used only with good-quality x-ray film. Small, "table-top" processors are reliable, easy to install and provide well-processed, dry x-ray films within 3-4 min. If more than 15-20 patients are x-rayed every day, an automatic processor is desirable; if the electrical supply is unreliable, however, back-up manual processing is essential. (ii) Manual processing tanks should be made of high-quality, chemical-resistant

stainless-steel. Plastic tanks are cheaper but will warp, crack and leak (although manufacturers claim otherwise). Specifications are given in Annex 6. Most metals, including regular stainless-steel, are rapidly destroyed by x-ray chemicals. Both manual and automatic film processors must be connected to running water, preferably both hot and cold. There must also be adequate drainage: plastic, porcelain or other chemical-resistant pipes are essential, as the water running off contains chemicals (Fig. 99). (8) Safe lights and other darkroom accessories Details are given in Annex 6. The following information is also important: (i)

X-ray chemicals cannot be mixed in the darkroom, as good ventilation (e.g., open air) is required during mixing. Designated buckets for developers and fixer are essential equipment. processing. Provide a carrying tray to catch the wet drips if films are processed manually, and carry the films to a viewing box in the he office (not in the x-ray room).

(ii) Do not install a film-viewing box in the darkroom, as it will interrupt and delay

(iii) The switch that controls the filtered safe light should be located immediately inside the entrance door at the regular height for light switches used in other rooms. The switch for the white ceiling light should be placed above the safelight switch but at a somewhat "inconvenient" height above the floor: 180 cm is recommended. This arrangement averts the possibility that the white light will be turned on by mistake, which would fog or completely destroy the x-ray films.

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Hot

Cold

~ ,, , , , , I

Water Inl.t

,~ I , ,, , I ,, .. - - t ,: \.'

, .. .' '

~-.---

Malt.r Tank: 50eml wid. BOems high 150emslong 13 ems fram floor to bottom

Insert Tank: 3B ems wid. 61 ems high 11.5 em. long

Fig. 99. Processing tank

(iv) The nonnal entrance to the darkroom, through a maze, a light trap or a narrow, light-tight door, cannot be used for bringing in processing tanks and other large pieces of furniture. A door wide enough for this purpose must be available. This door must be closed or boarded over to be made light proof when the darkroom is used. (v) Adequate light proof ventilation is essential in the darkroom (Fig. 100), and the floor must be chemical-proof. Ordinary wooden floors are not satisfactory; concrete or tiles are preferable.

Fig. 100. Lightproof darkroom ventilator

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(9)

Radiation protection and safety Ionizing radiation, such as x-rays, is hannful to human (and animal) tissues. All people who work with x-ray equipment must constantly be aware of the danger. A regular radiation monitoring service for personnel should be established. Lead protective clothing must be provided and worn when appropriate. xray personnel should never hold or support patients during examination. All protective clothing must be checked regularly and the results documented. Detailed information regarding radiation protection and personnel monitoring is given in the WHO Manual on Radiation Protection in Hospitals and General Practice (Volume 1, Basic Protection Requirements; Volume 3, X-ray Diagnosis; and Volume 5, Personnel Monitoring Services). Building specifications are described in Annex 6.

(10) Mobile x-ray units If a mobile x-ray unit is purchased, the power source can be batteries (preferred) or mains. A battery-powered unit needs a mains connection only when the batteries are being charged. Most battery-powered mobile units can deliver 10-12 kW for at least 2.5 s, resulting in a total energy output of 25-30 kWs. A mains-connected mobile unit must contain a built-in capacitor to reach the output needed. Capacitor discharge (also known as condenser discharge) x-ray units store enough energy for a single x-ray exposure. They must be connected to a power source during operation for recharging, but this source can be a standard grounded wall outlet. The capacitor may be connected on the primary (low-voltage) side or on the secondary (high-voltage) side of the high-voltage transformer. Connection on the secondary side is usually combined with constant x-ray tube current (rnA), resulting in falling kV during the exposure. Such a unit can be used to x-ray the chest and the extremities only and should not be purchased for general purpose radiography. Connection of the capacitor on the primary side of the transformer is usually combined with a muItipulse converter circuit with falling rnA but constant kV during the exposure. This is a very good technical solution, often resulting in high initial power output (20-30 kW) and a satisfactory total energy output of about 10 kWs. Do not purchase a mobile unit that requires special high-power wall outlets to function. This rules out use of all two-purse single-phase units. As already noted [para (a) (1»), a mobile unit is not essential in many small hospitals but may be needed for orthopaedic surgery. Almost all other immobilized patients are better taken to the x-ray department for examination on their beds. (11) Ultrasound equipment Many varieties of ultrasound equipment are available, with varying capabilities. The minimum specifications for a general-purpose ultrasound unit are provided by WHO in a technical report from a scientific group, The Future Use of New Imaging Technologies in Developing Countries (Technical Report Series No. 723). The essential requirements are given in Annex 9. These minimum specifications must be met or exceeded, and particularly the technical requirements for resolution, as poor-quality images lead to inaccurate diagnoses. The WHO publication Manual of Diagnostic Ultrasound contains information for testing ultrasound units when first delivered, continuous quality

II II

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11 11

II 11

I 11

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assurance and essential maintenance. The purchase of sub-standard equipment is a poor investment. Comprehensive information on clinical diagnosis is also provided. (12) Recording the ultrasound image If the physicians are conscientious, the results of an ultrasound examination, including measurements, can simply be written in the patient's records, without an accompanying image. If affordable, however, a permanent image is preferable. A permanent record of the image can be obtained in several ways, which vary in expense and efficiency; all require additional attachments: (i) The least expensive is to record on special paper. At present, the resulting image is not of very good quality.

(ii) Recording on Polaroid® film requires a special camera which photographs the video image. This method is quick and efficient, but the film is expensive and not always available. (iii) Recording on x-ray film requires a separate recorder, which produces an excellent image after the film has bee processed in the x-ray darkroom. The recorder is expensive. Careful discussions should be held with the medical staff and the company that will supply the equipment in order to clarify the needs, the initial cost and the recurring costs. (\3) Fluoroscopic equipment WHO does not recommend the purchase of fluoroscopic equipment, even with image intensification, unless a specialist radiologist is present to use it. As stated in WHO Technical Report Series No. 689, A Rational Approach to Radiodiagnostic Investigations (section 4.2), "A general and important recommendation is that all barium studies should be carried out only by qualified radiologists using appropriate fluoroscopic equipment." There are several reasons for this recommendation: (i) Over 90%, often 95%, of all the imaging required in 50-100-bed first-referral hospitals is of the chest and skeleton. Radiography of the abdomen, gall-bladder and urinary tract accounts for most of the other neeps. None of these examinations requires fluoroscopy. In particular, WHO strongly recommends that chest fluoroscopy be replaced by radiography (a chest film) (WHO Technical Report Series No. 689, section 2.3.8).

(ii) The initial cost of fluoroscopy equipment and the recurring costs are considerable and not cost-effective. (iii) The radiation dose delivered during fluoroscopy is high. (iv) The diagnostic accuracy of fluoroscopy is very low. In particular, "routine" chest fluoroscopy is never indicated as part of a medical examination (WHO Technical Report Series No. 689, sections 2.1.5 and 2.3.8). (v) Ultrasound adds considerably to the diagnosis of abdominal problems and involves no exposure to radiation. (vi) Gastrointestinal examinations should be performed only by specialist radiologists.

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(b) Laboratory equipment (1)

Microscope An all-purpose microscope for general laboratory use should have a 1.2Sx binocular body tube and paired lOx wide-field-eye-pieces combined with four objectives to provide magnifications of SOx, 12Sx, SOOx and 12S0x, with co-axial coarse and fine focusing controls. The fme focus control should be graduated in 0.002-mm increments.

(2)

Blood counter The mechanical differential counter is still popular, especially in developing countries, although electronic counters are becoming common. A wide range of types is available, from which the laboratory technician can select which is needed.

(3)

Analytical balance The balance should have a digital read-out. The housing should be enamelled steel, and the pan of stainless-steel. The weighting range should be from 0 to 190 g; quantities of 0.1 mg should be readable. It should operate on 220 V, SO Hz, AC (or 110 V, 60 Hz).

(4)

Colorimeter/spectrophotometer This photoelectric device provides a photometric reading in direct proportion to concentration. The unit should have dual photoelectric cells to maintain accuracy even with line voltage fluctuation. It should also have zero adjustment before readings are taken of standard and sample and a range of filters to cover the visible spectrum.

(S)

Centrifuge A small centrifuge that can accommodate six IS-ml tubes should be available, with a speed control from 0 to S300 rev/min and an electronic sensor that controls rotation within a tolerance of approximately I %. The rotational speed should be unaffected by power fluctuations.

(6)

Water bath A water bath is used in the clinical laboratory for stabilizing temperature at 2S, 37, 42 or S6°C, depending on the method of investigation. The temperature of the bath must be maintained constant within a narrow range (+ O.IOC).

(7)

Incubator/oven A small, hot-air oven to carry out standard cultivations and sterilizations should be available, with a two-tray capacity and temperature setting and time controls. The possibility of checking temperature using an ordinary mercury thermometer is an advantage.

(8)

Refrigerator An ordinary household refrigerator with a freezer unit, for storing preparations, vaccines, blood, etc., should be purchased. It should be stood on a simply constructed wooden plinth to keep it clear of the floor to avoid rusting when there is risk of damp or condensation.

(9)

Distillation and purification apparatus This apparatus should be housed in a cabinet, made of metal that resists acids and alkali, and should be free standing. It should have an output of I litre or more per hour and a distilled water storage cap with a capacity of 6 litres or more.

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133

Portable electrocardiograph

A single-channel electrocardiograph unit with paper chart output should be obtained. It should require a common mode rejection ratio of at least 60 dB, a high input impedance of at least 5 Mil, with lead selection and a two-speed chart motor drive. (2) DC defibrillator (external)

This instrument should have an adjustable, synchronised output of 400 J maximum, with the output indicated by analog or digital metering. A suitable electrocardiograph monitor is required for use with synchronization, if it is not built in; however, portable units containing a small monitor and a defibrillator are readily available from most manufacturers. A rechargeable battery power source should also be available, usually as an internal option. Battery-powered defibrillators should have a trickle-charge option; replacement batteries should be readily available, since batteries invariably have a limited life. Paediatric paddles should also be available. (3) Portable anaesthetic unit

Two small anaesthetic units should be obtained, complete with a range of masks, incubators and hoses for use on infants and adults. Also required are oxygen and nitrous oxide attachments, soda lime rebreathing canisters and a cycloropane vaporizer. (4) Respirator

This should be of the pneumatic type, applicable for prolonged administration during post-operative care. It should have a high-pressure alarm for malfunctioning and power failure and should be portable, if possible. (5) Dental chair unit

A complete unit should be available to carry out standard dental operations, including fillings, extraction's and cleaning. Water should be supplied through a water softener or filter; a cold light source should be attached. (6) (7) Suction pump

One portable and one heavy-duty suction pump are required. Operating theatre lamp

The unit should consist of a main lamp with at least eight shadow less lamps and an auxiliary of four lamp units. (8) (9) Operating theatre table

This should be standard and manually operated. Delivery table

This should be standard and manually operated. (10) Diathermy unit

A standard cut/coagulating unit should be obtained, operated by hand or foot switch, with variable power control. (d) Other equipment (1)

Autoclave-for general sterilization Small sterilizer-for specific service~

(2) (3)

(e.g., dentistry)

Cold chain and other preventive medical equipment

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(4)

Ambulance-four--cylinder diesel, four-wheel drive vehicle equipped with medical equipment for emergencies; complete accessories, spare tyres and tools.

(e) Small, inexpensive equipment and instruments

Equipment and instruments, such as blood pressure measuring apparatus, oxygen manifolds, stethoscopes, diagnostic sets and spotlights, although essential are not included in these lists. The decision on which and how many of these items are needed is left to the discretion of individual hospital authorities.

2.3

Essential medical equipment for a tOO-bed district hospital

The model is still a hospital at first-referral level, but one serving a population of 150 000, with 20 urban or rural health centres and 40 primary health care units or more. The model district (or province), of2000 km 2, has a large district (provincial) capital of60 000 people; it has a uniformly distributed rural population of 60 000 and three townships of 10 000 people each (Fig. 101). The scope of the service in this hospital is similar to that of the 50-bed hospital, with more equipment to support the additional workload brought on by the larger area of service. This 100-bed model will have the following additional services, facilities and equipment: -blood bank; -otorhinolaryngology service is provided; -a 300 rnA, 125 kVp diagnostic x-ray machine instead of a 100 rnA, 100 kVp unit; ----equipment for an additional operating theatre; and -a four-wheel drive vehicle for maintenance staff to travel to outlying hospitals and primary health care clinics. This should be independent of other hospital transport and should have an allocation of diesel or gasoline.

Fig. 101. Model district for a 100-bed hospital

135

3. MANAGEMENT OF MEDICAL EQUIPMENT 3.1 Problems of management

The worldwide sales of medical equipment represent an extremely large figure: in 1985, the world market was estimated at US$ 30 billion (Advisory Council for Applied Research and Development, 1986). The capital cost of medical equipment is rising, in parallel with advances in technology. In spite of its cost, medical equipment is one of the most widely mismanaged resources used in health care. In many countries, there is a severe shortage of adequately trained, experienced technical personnel in the health care technical service. Such staff are essential if medical equipment is to be used properly. Without the correct level of technical staff, hospitals cannot receive the true benefit from their investment in medical equipment. Frequently, this lack of technical staff and the practical inexperience of the remaining medical and technical staff, together with their lack of knowledge, contribute directly to the breakdown and reduction in the operating life of this expensive resource. Such hospital training programmes as there are cannot cope with the demand for these specialist staff, much less with upgrading their skills and the knowledge required by the rapid development of modem medical equipment. Ministries of health often have no clear policy on the provision of a health care technical service. This is often because the staff of the ministry operates with an inadequate number of poorly trained staff. In developing countries, the health care technical service consists of people who are underpaid in comparison with technical staff in industries in the private sector, such as television and computer servicing. There is thus considerable pressure on the more highly trained maintenance staff to leave employment in the ministry and work for industries in which their technical skills will be better rewarded. This rapid turnover and/or shortage of staff makes training programmes at all levels ineffective or impossible to undertake. Technology exchange between countries at different economic levels can also create problems in this regard. Donor agencies, mostly in industrialized and developed countries, produce and donate sophisticated equipment that is frequently unsuitable for the health problems of the recipient developing countries. With the lack of trained personnel to handle this new equipment, there is a mismatch between the donor and the needs of the local health service. Consequently, expensive equipment is unused, misused and mismanaged, resulting in rapid breakdown. There is thus a gross waste of national and international resources, and, more seriously, failure to provide the health care needed by the local population.

3.2

Cycle of management of medical equipment

A system must be developed for managing medical equipment in order to use health resources effectively and efficiently. A suggested cycle of systematic management is shown in Figure 102.

3.2.1 Planning Planning for the provision of medical equipment must involve the following considerations: -the population targeted by the health service, -their health needs, -the health service functions required to meet those needs, -the health care equipment required to perform those functions and -the available resources.

Medical equipment

136

PCl.JCY NAllONALPRIORmES AS DETERMINED BY A NATIONAL PlANNING EO)y

SRECTION

BUDGET

PROCUREMENT

STAFFlRAt.lING

DISlRIBUTlON

LOGISTIC SUPPORT

OPERAllON

CALIBRATION

P.P.M. REPAIR

TESTING

Fig. 102. Cycle of management of hospital equipment

A national planning body, with an effective information service, should be organized to formulate national policies, determine priorities and allocate budget and resources. A planning group should also be organized at the hospital level to make decisions on selection and procurement of medical equipment, on the basis of the following considerations: (I) The equipment must be carefully selected to ensure that it:

-gives the best value for money, weighing lifetime cost against purchase price; ~an be maintained continuously during its expected lifetime, in terms of its upkeep, repair and spare parts (a budget for maintenance contracts, spare stocks and information transfer must be provided); and ~omes from reliable, reputable and experienced manufacturers. (2) All commercial transactions should preserve the interest of the purchaser and user as well as that of the supplier and manufacturer. Writing of specifications must involve the direct user of the equipment and qualified technical staff in the hospital; (3) The financial resources available must be allocated equitably for: -initial purchase and installation, including foreign exchange, and -running costs.

Management of medical equipment

137

(4) Arrangements for maintenance should be considered at the time of procurement and should be applied systematically throughout the lifetime of the equipment. These are discussed in detail in Chapter 5 of this Part. Maintenance arrangements can be made either under contract with the manufacturer or in-house by the health care technical service. (5) Staff should be adequately and properly trained before being allowed to use equipment. A national training centre should be established for this purpose.

3.2.2 Utilization The important aspects of equipment use are as follows: (I) The utilization rate of equipment in current use must be increased through adequate

manpower and logistic support. (2) The period of delivery, installation and assembly of equipment must be shortened. (3) Documentation about the use and maintenance of the equipment must be obtained for management purposes. (4) Inventory and storage methods must be improved and the operational procedures regulated.

3.2.3 Evaluation Indices can be used to evaluate the utilization of medical equipment. These include: Annual rate of operation of utility Annual rate of effective time of utility Positive rate Demand for equipment No. of annual visits X average operational time per visit!annual actual operational time X 100 No. of annual visits X average operational time per visit! annual possible operational time X 100 Positive visits/ total visits X 100 Use rate per person per year x population / rate of effective use time of equipment X possible operational quantity

Cost-effectiveness and cost-benefit analysis may likewise be used in evaluating the effectiveness and efficiency of the use of medical equipment. The potential years of life saved, survival rate and quality of life are some of the indicators in cost-effectiveness analysis. Cost-benefit analysis evaluates all outcomes in economic terms.

3.3

Team approach

The use and servicing of equipment involve a multi-disciplinary group comprising doctors, nurses and paramedical and technical personnel. Thus, an approach involving teamwork or collective decisions must be used in ordering new equipment. In addition, regular liaison must be maintained between the members of the group in order to solve daily operational problems. A technical committee should exist in each hospital, chaired by the hospital administrator, which reviews the equipment situation and plans for future needs. The considerations of this committee should include: -policy for health needs, -planning development, -inventory, -specification and procurement -budgeting, -training of users and servicing staff, -spare parts and -logistics support.

Medical equipment

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When selecting equipment, the members of the technical committee should ascertain the specific health needs that must be served. The members can then proceed, taking the following factors into consideration: (I) Type (not model or make) of equipment required should be identified, and general

specifications should be drawn up to meet the requirements of the medical use to which it is to be put. (2) All equipment needs should be identified and costed, including any training of users and servicing staff, physical facilities and auxiliary supplies, such as water, electricity, airconditioning, protection and safety precautions. (3) Technical support from the local agent must be sought and availability of spare parts ascertained. (4) All technical information on operation, service, installation and spare parts must be secured before payment is made. (5) Funds must be available for purchase and use of the equipment. (6) In evaluating tenders, quotations must be compared and evaluated, not only in terms of price and delivery time, but also in terms of availability and quality of back-up support, spare parts and technical staff. Because district hospitals act as referral centres for lower-level health facilities, the technical staff based in the hospital should also provide technical support to smaller health facilities. Their number, capabilities and means should therefore enable them to carry out this added task.

3.4

Sample checklists

Sample checklists for the maintenance of a 50-bed and of a IOO-bed district hospital are given in Annexes 1 and 2.

139

4. HUMAN RESOURCES DEVELOPMENT Both service personnel and users must be trained on the equipment in their charge if it is to be used and serviced properly, so that its useful lifespan will be prolonged and the quality of the output of the equipment will be maintained. At the district level, training should be in the form of courses; these are augmented by training courses offered at the national level. Training for the use and maintenance of more complicated equipment, such as x-ray machines, however, must be given at international courses or at courses and information seminars given by the manufacturer. Training must supersede the arrival of the equipment in the hospital, so that qualified staff are available when the equipment is installed. As training should be carried out in the locality or country, the availability of training staff should be assessed for the level of training required. The content of the training programme must be both practical and theoretical, with a 70% bias for the practical over the theoretical. The training centre should therefore be located near both an academic institution (for the theory) and the hospital (for the practice). Owing to lack of highly skilled, experienced staff to provide higher training, initial training should be for the artisan/craftsman or polyvalent (general) technician. A simple course, which can be offered at local technical colleges, should be worked out. A sample syllabus for such a course is given in Annex 3. At the beginning, expatriate staff may be needed to train local trainers in specialized aspects of the use and maintenance of hospital equipment. Staffing and facilities will depend on the extent of the training programme. A typical staff for a class of IS students for an academic year of 10 months is as follows: Head of training engineer, preferably electronic, although an electrical or mechanical engineer with electronics background will also be suitable; will be responsible for coordinating and supervising activities; will collaborate with technical heads of hospital departments in planning courses one electrical engineer, one electronics engineer and one mechanical engineer; in charge of giving theoretical and practical training and of writing material will assist in training; will be. in charge of preparing practical work, such as experiments, workshop training, maintenance of equipment and inventory will type and print training materials, operate computer, be in charge of registry files and information storage and retrieval I

Lecturers

Technician engineer

Secretary

Facilities are assumed to be established within an existing host institution. The space provisions required are: -two equipment laboratories of 100 m2 each; -office for the technician engineer; -storeroom for mechanical and medical equipment; -office for head of training, 10-12 m2, with conference table, bookcase and telephone; -office for lecturers, 10-12 m2 , with bookcase and telephone extension; ; -office space for secretary, filing system, library, 15m2 -space for computer data bank, 10m2 , with personal computer terminal, printer, heavyduty photocopier, filing system.

Medical equipment

140

It is assumed that the laboratories needed, such as electrical and electronics, and workshops will be made available by the most institution to which the national training centre is linked. -The equipment requirements are as follows: -Training equipment: low-level, standard, second-hand medical and hospital plant obtained from hospitals -Test equipment: DC stabilized power supplies (5), multimeters (10), standard oscilloscopes (3), signal generator (1), some of which may be available at the host institute -Spare parts: full set, at different power ratings (preferred values), of resistors and capacitors, general-purpose transistors and integrated circuits with catalogues of equivalent components; general set of multi-purpose screws, bolts and washers; common rubber O-rings -Basic tools; general sets of screwdrivers, pliers, cutters, round-nose pliers for both heavyduty and electronics work; selection of hammers, steel and rubber; sets of metric and imperial spanners, including pocket-size types; adjustable spanners and wrenches; taps and dies, metric and imperial; steel saws, small hacksaws, files (large and pocket-size); sets of Allen keys, metric and imperial -Overhead projector, slide projector -Electronic typewriter -Heavy-duty photocopier with automatic document feeder and sorter -Personal computer, lBM-compatible with a 60 megabyte hard disc, 1.2 or 1.44 megabyte floppy disc and lette-quality printer, with fast-draft quality for printing inventories, etc; standard data base and word-processing package; inventory package; equipment code package These should be standardized, when possible, within the country, or preferably within the region, so that support can be obtained from other users. Maintenance of both the software and hardware of the computer should be available, otherwise its effectiveness will be impaired. Spare floppy discs, listing paper, printer ribbons and other supplies should be available and of good quality. The software should be updated regularly by a commercial organization.

141

5. PLANNED PREVENTIVE MAINTENANCE 5.1 Scope

Planned preventive maintenance is regular, repetitive work done to keep equipment in good working order and to optimize its efficiency and accuracy. This activity involves regular, routine cleaning, lubricating, testing, calibrating and adjusting, checking for wear and tear and eventually replacing components to avoid breakdown. Productive preventive maintenance refers to the proper selection of equipment to be included in planned preventive maintenance. Decisions must be made on what to include, to reduce costs; inexpensive units that are not necessarily included in the planned preventive maintenance programme can be replaced or repaired when they break down. The overriding consideration is cost-effectiveness.

An important aspect of planned preventive maintenance is the participation and commitment of the user. Preventive maintenance should start with users, and the bulk of the work should be their responsibility. The task must be performed daily, with joint activities involving the user and a technician engineer at the end of the week. Highly technical repairs, which are the engineer's responsibility, may be scheduled every six months.

5.2

Setting up a planned preventive maintenance system

In order to establish an effective, efficient planned preventive maintenance system, a registry filing system is needed. The manufacturer's manual for preventive maintenance of the equipment can be supplemented by computer packages in setting up such a system; if a computer is not available, a manual file can be set up. The planned preventive maintenance administrative system requires the following:

5.2.1 Equipment inventory All equipment in the hospital that is in the care of the service workshop should be recorded on cards, as shown in the sample equipment record in Annex 4. All relevant information about the equipment must be entered, including its location, records of repair and maintenance and the manufacturer. A reference number is given and written on a printed paper label which is attached to each item. This number is recorded in a ledger of equipment with full identifying details.

5.2.2 Definition of maintenance task The work that must be done to maintain each item of equipment in safe and reliable operating condition must be defined; this is known as the maintenance task. These tasks can be established by consulting the manufacturers' literature and product information.

5.2.3 Establishing intervals After determining what is to be done, the frequency of the task must be decided. A heavily used item must be cleaned and checked more frequently than one which is used less often; however, minimum standards must be set. The frequency suggested in the manufacturer's manual can be used as a guide, but the actual usage should determine the maintenance procedure required. Annex 5 provides a sample schedule for planned preventive maintenance, which can be used as a guide.

Medical equipnunt

142

5.2.4 Personnel Individuals who are qualified and available to do preventive maintenance must be identified. A list should be drawn up of personnel who are readily available. Once the personnel have been listed, specific responsibilities should be assigned, perhaps in the form of a works order, giving clear instructions for the task. Each person should have a clear knowledge of his or her responsibilities. Job assignments must correspond to the training, experience and aptitude of the individual. Training is discussed in the previous chapter. If the hospital staff includes a large number of well trained, experienced individuals who are familiar with medical equipment, in-service training can easily be undertaken.

5.2.5 Reminder system Maintenance of instruments and equipment is a continuous process: once the equipment has been inventoried, the programme must continue. It may be necessary to develop a reminder system, so that appropriate personnel are notified when certain tasks are to be performed. Whether a card index system or a computer programme is used, the date that each item of equipment is scheduled for its next preventive maintenance should be recorded. The administrator should look up in advance the jobs that need to be done and draw up a monthly or weekly schedule for the staff.

5.2.6 Special test equipment People responsible for equipment management and maintenance should have at their disposal a range of test equipment to check the correct functioning of medical equipment as weB as its compliance with the basic electrical safety standards. The brand and specifications of such test equipment wiJI vary from country to country; for example, however, a range of general-purpose electrical and safety test equipment for medical use is available in the United Kingdom from Rigel (Graseby Medical Ltd, Colonia Way, Watford, Herts WD2 4LG; Telex 929263 GRAMED G; Fax 92331595) and Ultramedic Ltd (4C Newton Court, Wavertree Technology Park, Liverpool L13 lEJ; Fax 51 228 0354). Similar test equipment can be obtained in the USA from Bio-Tek Instruments Inc (Highland Park, Box 998, Winooski, VT 05404-0998; Telex 94 0136 BIO TEK SHVT; Fax 802 655 7941) and internationally through a variety of distributors. Such equipment allows the technician to perform basic electrical medical safety tests under controlled conditions. Furthermore, these safety tests indicate whether the equipment complies with the standards laid down by the International Electrotechnical Commission. Since this equipment can be contained in a briefcase, it can be carried by the technician. A wide range oftests can be undertaken, to measure different values for insulation resistance, each continuity and leakage current in different situations, under both normal and singlefault conditions. For the practical assessment of whether different types of medical equipment are working effectively, a number of specific analysers, calibrators and simulators are available from, for example, Bio-Tek in the USA and Ultramedic in the United Kingdom. These aBow technicians to check the function of ventilators and to calibrate blood pressure monitors, pressure transducers, electrocardiographs and the full range of monitoring equipment used in the intensive care unit. Analysers are available for checking the effectiveness of defibrillators, electro-surgical instruments and ultrasonic phototherapy equipment. A special-purpose analyser has been developed to assess infusion devices; this had hitherto been difficult because of their very low flow rates. It may not be appropriate for every maintenance department to be fully equipped with a complete range of such instruments, and some may be located in the major maintenance workshops, provincially or nationally.

Planned prt!llentive medicine

143

Most common items of test equipment are listed below. Others may be specified by manufacturers: -multimeters: simple, robust, digital multimeter with clamp-on attachmentto measure high current in x-ray equipment; -milliampere meter: to measure milliamperes in X-ray equipment; -line resistance meter: low-value meter for the power requirements of X-ray equipment (mainly for generator and control units); -electrocardiograph simulator: lead II output simulator to check the performance of the elctrocardiograph; -spectrophotometer standards: to check wavelength calibrations; preferably filter standard instead of solutions, for ease of use and transportation; -pH meter standards: buffer solutions to check the accuracy of readings; -oscilloscope: standard 50-Mhz model, dual trace, for testing, fault rmding and calibration; -DC power supplies: electronic power supplies, approximately 25 V DC variable and 5V and 10-V outputs for testing equipment; -signal generators: 0-10 Mhz, sine, square and sawtooth waveform generators for calibration and testing; -x-ray phantoms: various phantoms, such as hand, step wedge and grating, to test for picture quality; --defibrillator tester: to measure output (in joules).

II I I I I

5.2.7 Technical library A full technical library should be available. Installation and recommended spare parts manuals, annotated with the number of the corresponding equipment, should be kept together with electronic and component data books and appropriate technical books.

5.2.S Surveillance After the programme has been set up, periodic surveillance must be carried out to ensure that records are legible and that all entries are being made.

5.3

Patient safety

It is the responsibility of those involved in equipment management to see that both staff and patients are protected from the potential hazards that exist in the hospital environment. These hazards arise from the use and presence of: -radiation, -electricity and -biological materials. Each of these is covered by a set of national standards and working practices; these may be encompassed by legislation, such as the "Health and Safety at Work Act (1974)" used in the United Kingdom.

Medical equipment

144

The use of increasingly complex electrically powered medical equipment in hospitals has brought about the need for a clearly defined policy to avoid the occurrence of accidental injuries to both staff and patients. In the past, only a massive fault in an electronic device could result in the electrocution of a patient, as the high resistance of the body often protected the heart. With the advent of sophisticated electromedical instrumentation, this high natural resistance was deliberately minimized to allow more efficient monitoring of the patient, and the danger of electrocution is thus greater. The problem is magnified by the common practice of connecting to the patient several pieces of electrical equipment, each of which is powered independently from the mains supply. Since even a very low current, measured in milli- or even microamperes, could be hazardous, precautions must be taken to ensure proper grounding of equipment and of conductive objects that are within the reach of the patient and attending medical staff. The electrical grounding should be maintained, and periodic checks must be made to ensure that power cords are not frayed, plugs are not damaged and there is no leakage of current within the ratings specified by the manufacturers or the national standards. Medical staff should be trained to understand the need for electrical safety and some of the problems that can arise, so that they can take an active role in minimizing the potential hazards and report those that occur. As standards of electrical safety are constantly being revised, it is beyond the scope of these guidelines to furnish current details on this subject. Hospital authorities should obtain standards from reliable references developed by such entities as the US Department of Health, Education, and Welfare and the International Electrotechnical Commission. The sophisticated testing equipment listed in section 5.2.6, while an essential part of the planned preventive maintenance programme should not, however, substitute for basic common sense in the use and installation of electromedical equipment that is to be connected to patients. Mains-powered units must have a good earth. A three-pin plug must be used on the appliance lead, which must be directly compatible with the socket outlets in the hospital. Adaptors, extension blocks and extension leads should not be used, since these provide· an opportunity for the earth wire to be disconnected, which seriously compromises basic electrical safety.

145

6. SELECTED BffiLIOGRAPHY Advisory Council for Applied Research and Development (1986) Medical Equipment. An ACARD Report, London, Her Majesty's Stationery Office. Cook, J., Sankaran, B. & Wasunna, A., eds (1988) General Surgery at the District Hospital, Geneva, World Health Organization. Cook, J., Sankaran, B. & Wasunna, A., eds (1991) Surgery at the District Hospital: Obstetrics, Gynaecology, Orthopaedics and Traumatology, Geneva, World Health Organization. Department of Health (1985) The Ionizing Radiation Regulations 1985, London, Her Majesty's Stationery Office. Department of Health (1985) The Protection of Persons Against Radiation Arising from Any Work Activity. Department of Health (1988) The Ionizing Radiation (Protection of Persons Undergoing Medical Examination or Treatment) Regulations 1988 (No. 778), London, Her Majesty's Stationery Office. Department of Health (1988) Guidance Notes for the Protection ofPersons Against Ionizing Radiations Arising from Medical and Dental Use, London, Her Majesty's Stationery Office. Dobson, M.B. (1988) Anaesthesia at the District Hospital, Geneva, World Health Organization Hospital Physicists' Association (1983) Safe Design and Construction of Electromedical Equipment (Topic Group Report 37), York. Kurjak, A & Breyer, B. (1986) The use of ultrasound in developing countries. Ultrasound Med. BioI., 12,611-621. World Health Organization (1982) Quality Assurance in Diagnostic Radiology, Geneva. World Health Organization (1985) Future Use ofNew Imaging Technologies in Developing Countries, Report of a WHO Scientific Group (Technical Report Series, No. 723), Geneva. World Health Organization (1985) Manual of Darkroom Technique, WHO Basic Radiological System, Geneva. World Health Organization (1986) WHOIBRS Information Booklet, Division of Public Information and Education for Health and Radiation Medicine, Geneva. World Health Organization (1987) Interregional Meeting on the Maintenance and Repair of Health Care Equipment, Nicosia, Cyprus, 23-24 November 1986 (WHO/SHS/NHP/87.5), Geneva. World Health Organization (1990) Publications Catalogue. New Books 1986-1990, Geneva. Wolrd Health Organization (1991) Publications Catalogue. New Books 1991, Geneva.

ANNEXES

149

ANNEX 1.

SAMPLE CHECKLIST OF MAINTENANCE REQUIREMENTS FOR A 50-BED DISTRICT HOSPITAL 1. Staff Head of workshop (supervisor) a specialized technician, preferably in electronics (an electrical background with some knowledge in electronics would also be suitable); will be in charge of workshop and maintenance operations and repair of satellite units will be responsible for maintenance of plant and electrical equipment as well as routine maintenance and basic repairs to standard medical equipment and other equipment used in health clinics and centres will be responsible for maintenance of buildings

Polyvalent (general) technician

Craftsmen (plumber, boilerrnan, mason)

2. Facilities Workshop 30 m2, fitted with work-benches, storage cabinets for tool kits and equipment, one electronics work-bench, welding module, grinder, drill on stand 12 m2, fitted with storage shelves for spare parts, supplies and small equipment awaiting repair or delivery 6 m2 , fitted with lockers, benches, shower and toilet cubicles Land Rover or Jeep type, fitted with mobile tool kit, extra diesel container, mobile cabinet for spares and supplies

Storeroom Changing room Vehicle

3. Equipment Electronics test instruments Mechanical equipment Basic tools multimeters (3), DC power supply (1), soldering irons (heavy and light-duty) (3), electrocardiograph simulator vices, grinder and drill on stand, hand drills (2), welding set (electric and air compressor oxyacetylene) general sets of screwdrivers, pliers, cutters, round-nose pliers for both heavy-duty and electronics work; selection of hammers, steel and rubber; sets of metric and imperial spanners, including pocket size; adjustable spanners and wrenches; taps and dies, metric and imperial; steel saws, small hacksaws, files (large and pocket-size); sets of Allen keys, metric and imperial set of preferred values for resistors, capacitors, transistors, very common integrated circuits, general-purpose O-rings, washers, screws, bolts, nuts; consumable items for electromedical equipment

Spare parts

District hospitals: Annexes

150

4. Typical layout A typical layout for such a workshop is shown in Figure 103. 7.00 4.00

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Fig. 103. Typical layout for the workshop of a 50-bed hospital

151

ANNEX 2. SAMPLE CHECKLIST OF MAINTENANCE REQUIREMENTS FOR A IOO-BED DISTRICT HOSPITAL 1. Staff Head of workshop (supervisor) a technician/engineer, preferably in electronics (an electrical or mechanical background with some knowledge in electronics would be adequate); will be in charge of workshop and will supervise maintenance and repair of satellite units. will be responsible for plant and electrical equipment as well as routine maintenance and repairs to standard medical equipment used in health clinics and centres will be responsible for maintenance of buildings

Polyvalent (general) technician

Craftsmen (plumber, boilerrnan, mason)

2. Facilities Electronics workshop Mechanical workshop Storeroom 21 m2 , fitted with work-benches, storage cabinets for tool

kits and equipment 28 m2, fitted with drill, grinder, welding module, workbench, carpenter's bench, compressed air 12 m2 , fitted with storage shelves for spare parts,

components, supplies and equipment awaiting repair or delivery Changing room Vehicle 9 m2, fitted with lockers, benches, shower and toilet cubicles Land Rover or Jeep type, fitted with mobile tool kit, extra diesel container, mobile cabinet for spares and supplies

3. Equipment Electronics test instruments multimeters (5), DC-stabilized power supplies (2), soldering irons (heavy- and light-duty) (6), simple oscilloscope (I) vices, grinder and drill on stand, hand drills (3), welding set and air compressor general sets of screwdrivers, pliers, cutters, round-nose pliers for both heavy-duty and electronics work; selection of hammers, steel and rubber; sets of metric and imperial spanners, including pocket size; adjustable spanners and wrenches; taps and dies, metric and imperial; steel saws, small hacksaws, files (large and pocket-size); sets of Allen keys, metric and imperial set of preferred values for resistors, capacitors, transistors, very common integrated circuits, general-purpose O-rings, washers, screws, bolts, nuts; consumable items for electromedical equipment

Mechanical equipment Basic tools

Spare parts

District hospitals: annexes

152

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153

ANNEX 3. OUTLINE SYLLABUS FOR A COURSE FOR POLYVALENT TECHNICIANS English: includes oral and reading skills, grammar, vocabulary, technical English, letter and report writing Mathematics: includes computation, logarithms, trigonometry, basic algebraic equations, graphical representation Technical drawing: includes use of technical drawing instruments, elementary construction, pictorial projection, sections, electrical drawing, visualization Workshop: includes electrical installations, theory and practice of domestic and industrial wiring, selection of cables, lighting circuits, earthing systems, types of lamps, principles and practice of arc welding, gas welding, sheet-metal welding, plumbing, bench fitting, use of files, hacksaws, chisels, drills and drilling, threads, piping systems, workshop maintenance Electronics and electrotechnics: includes electrical instruments, DC and AC circuitry, electrical components, transformers, AC and DC motors, semi-conductors, power supplies, amplifiers, application of thyristors, DIACs and TRIACs Mechanical services (hospital plant): includes heating and hot-water services, refrigeration, ventilation and air-conditioning, lubricants, stand-by generators, test vehicle repair and servicing Medical equipment: includes principles, operation and simple repairs and maintenance of: blood pressure meters, stethoscopes, water baths, microscopes, autoclaves, sterilizers, trolleys, basic mechanical equipment, suction machines, centrifuges, theatre lights and lamps Hospital field work: work in hospital workshops under supervision, involving simple repair and maintenance

154

ANNEX 4. SAMPLE EQUIPMENT RECORD EQUIPMENT RECORD MOVABLE/IMMOVABLE ITEM Department: Description of item Inventory No. _ _ __ CLASSIFICATION: Location:

No. 99999

Manufacturer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Model Type SPECIFICATIONS Mfr. Serial No. _ _ _ _ __ Voltage _ _ _ _ __ Freq. _ _ __ Phase P.O. Date _ _ _ __ P.O. No. _ _ _ __ Comm. Date _ _ _ __

-------

Additional Specifications _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Available Manuals: Operating/Service/lnstaliationlRecommended/Spare Parts Accessories: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Remarks: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Repairs Record Date Description Initials

SPARE PARTS STOCK LIST Class & Item No. Description Mfr. Part No:

ISS

ANNEX 5. SCHEDULES OF PROCEDURE FOR PLANNED PREVENTIVE MAINTENANCE The schedules presented here are meant to serve only as guidelines; modifications may be introduced to conform to manufacturers' specifications. Each schedule should be amended to indicate to the maintenance engineer carrying out the work that each test should be checked against a checklist and all measurements should be recorded on a card. An outline record card could be included with each schedule for this purpose. The engineer should also note on the he record card any item that needs to be replaced, if work is to be carried out later, and whether or not the same engineer is to carry out the work.

I. X-Ray equipment Apparatus: General-purpose radiographic and fluoroscopic unit Procedure Total time

Every 6 months I. Check controller assembly

7.0 h

-Thoroughly clean interior and exterior or unit using vacuum cleaner. -Check mechanical integrity of control knobs, switches, etc. --Check mechanical integrity of connectors, relay contacts, etc. -Inspect physical condition of high-tension cables. --Check function of back-up safety timer. 2. Check high-tension transformer -Clean exterior units. --Check all connections to high-tension transformer. --Check oil level in transformer. -Inspect high-tension cable terminals; clean as necessary. -Inspect physical condition of high-tension cables. -Check main power input connections. 3. Check x-ray tube (under-table and over-table) --Check physical condition of tube(s); i.e., cracks in anode, oil leaks on housing, etc. -Inspect high-tension terminals; clean as necessary. -Inspect collimator alignment. --Check tube focal spots. --Check serial changer or spot film device (fluoroscopic). -Check resolution of image intensifier and television system. -Check under-table collimator or smooth operation of shutters. 4. Check over-table tube assembly (floor-to-ceiling or ceiling-mounted) -Check function of locking machine. -Check physical condition of counterweight cables and clamps. --Check bearing for wear; lubricate as required.

District hospitals: annexes

156

5. Check x-ray tables ---Clean thoroughly and remove debris. -Clean spot film device. ---Check bearing and bearing surfaces; lubricate as necessary. -Check physical condition of counterweight cables and clamps. ---Check function of safety devices and electromagnetic locks. ---Check condition of Bucky grid and cassette tray; check Bucky locks. 6. Check vertical Bucky stand or chest/erect x-ray stand ---Check condition of x-ray grid. ---Check cassette stand. ---Check bearing and counterweight cables; lubricate and tighten as necessary. 7. Check tomographic attachment ---Clean bearing surfaces. -Lubricate bearing as necessary. ---Check motor bearing. ---Check for excessive movement. 8. Check radiator output i.e., rnA, kVp and time. 9. Check fluoroscopic output, i.e., kVp, rnA. 10. Check radiographic and fluoroscopic timers and radiographic back-up timer. 11. Verify correct meter indications and appropriate audiovisual signals. Annual total-12-16h

II. Laboratory equipmeut Apparatus: Microscope Procedure Every 6 months 1. Check integrity of electrical grounding. 2. Check physical condition of transformer power cord and plug. 3. Clean and inspect microscope for signs of damage. 4. Clean eyepieces, condenser, objective and illuminator assembly. 5. Check adjustment of aperture diaphragm and condenser assembly. 6. Check stage assembly for smooth movement. 7. Check fine and coarse focus for smooth movement. 8. Thoroughly clean interior and exterior of unit using vacuum cleaner. Annual total-2.0 h Total time 1.0 h

Annex 5

157

Apparatus:

Colorimeter Procedure Every 6 months

Total time 1.0 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical condition of all knobs and switches. 4. Clean interior and exterior unit. S. Clean cleanliness of cuvette assembly. 6. Check alignment of galvanometer lamp and projector. 7. Clean lenses and optical filters. 8. Check transformer voltage. 9. Check operation of unit and adjust mechanical zero.

Annual total-2.0 h

Apparatus:

Centrifuges Procedure Every 6 months

Total time 0.5-2.0 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls, meter, cover latch, gasket, etc. 4. Inspect unit for signs of physical or electrical damage. S. Clean commutator, check brushes; replace if necessary. 6. Check head balance. 7. Lubricate motor and bearing, if applicable. 8. Clean interior and exterior of unit. 9. Check operating unit for vibrations and excessive noise. 10. Check speed, and calibrate tachometer if necessary. 11. Check accuracy of timer. 12. Check braking system. 13. Check safety interlocks. 14. If unit is refrigerated, check temperature, clean coils and check for leaks.

District hospitals: annexes

158

Apparatus:

Flame photometer (analog and digital) Procedure Every 6 months

Total time 1.5 h (analog) 2.0 h (digital)

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, control, etc. 4. Inspect air filter assembly, if applicable; examine filter cartridge and replace if necessary. 5. Check air and gas filters, if applicable; replace micron filters. 6. Clean burner assembly; replace G-ring seals. 7. Clean optical filters. 8. Clean and inspect electronic circuitry for signs of damage; check power supply voltage. 9. Check operating unit. 10. Check aspiration rate; adjust as necessary to manufacturer's specifications. II. Check fuel and air pressures, if applicable; adjust fuel: air ratio. 12. Verify proper operation of read-out; check electronic alignment, if applicable. 13. Calibrate unit using standard.

Annual total-3-4 h

Apparatus:

Haemoglobinometer Procedure Every 6 months

Total time 1.0 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls, etc. 4. Clean interior and exterior of unit. 5. Inspect interior for signs of damage. 6. Clean cuvette assembly thoroughly. 7. Check tubing; replace if necessary. 8. Check condition of lamp and phototube housing; clean as necessary. 9. Check lamp voltage and blank voltage; adjust if necessary. 10. Check operating unit. II. Calibrate, using standard solutions and blood control.

Annual total-2.0 h

Annex 5

159

Apparatus:

pH meter Procedure Every 6 months

Total time 0.5 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls, connection and meter/display. 4. Clean and check interior for signs of damage. 5. Check condition of electrodes and electrode holder. 6. Calibrate meter or digital display with millivolt/pH calibrator. 7. Adjust slope as required. 8. Check batteries, is applicable, and replace as necessary. 9. Check overall operation of unit by measuring pH of known solution.

Annual total-1.0 h

Apparatus:

Bilirubinometer Procedure Every 6 months

Total time 1.0 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Thoroughly clean interior and exterior of unit. 4. Check mechanical integrity of switches, controls and knobs. 5. Check condition of reference standard and sample chambers; clean as necessary. 6. Clean slide mechanism. 7. Check condition of source lamp; replace if darkened. 8. Check operation of unit.

Annual total-2.0 h

District hospitals: annexes

160

Apparatus:

Blood-cell counter Procedure Every 6 months

Total time I.5h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls, meter, etc. 4. Examine and thoroughly clean interior and exterior. 5. Check condition of vacuum regulator; lubricate pump if necessary. 6. Check integrity of manometer and clean; change mercury if necessary. 7. Inspect tubing; replace as necessary. 8. Check regulated power supply voltage. 9. Check operating units. 10. Check linearity and reproducibility.

Annual total-3.0 h

Apparatus:

Chloridometer/Chloride analyser Procedure Every 6 months

Total time 1.0 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls and knobs. 4. Check meter movements for sensitivity and zeroing. 5. Inspect generator electrodes; check electrode voltages 6. Examine indicator electrodes; clean with silver polish; examine insulators. 7. Inspect stirrer motor to ensure free rotation. 8. Check and replace battery, if applicable. 9. Inspect electrical and electronic components for damage. 10. Check operation and calibration of unit; recalibrate, if necessary, using manufacturer's specifications. Every 12 months 0.5 h

1. Inspect drive belt and stirrer shaft bearing; replace belt if necessary.

Annex 5

161

Apparatus:

Blood-gas analyser (analog and digital) Procedure Total time

Every 3 months

2.0 h (analog) 4.0 h(digital)

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Clean accumulations of salt from interior and exterior. 4. Inspect water baths for leaks, deteriorated tubing and cracks; clean interior water bath thoroughly. 5. Check water pump motor and lubricate; check vacuum system. 6. Check electronic component for signs of damage. 7. Check mechanical integrity of all controls, switches, connectors, etc; check condition of analog/digital display. 8. Inspect electrodes and electrode cables for signs of deterioration or cracks; clean electrodes and install new membranes. 9. Reassemble unit; check water circulation, water bath temperature control, vacuum and aspiration. 10. Check and calibrate pH, paz, PCOz electrodes. Every 12 months I h

I. Replace water-bath seals, tubing, O-rings and grommets. Annual total-9-17 h

Apparatus:

Electronic balance (table-top) Procedure Total time

Every 6 months I. Check integrity of electrical grounding.

0.5 h

2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls and display. 4. Check calibration of display, using manufacturer's service and standard weight. S. Clean exterior and ensure balance on a firm stand. 6. Check operating units.

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162

Apparatus:

Spectrophotometer (visible and ultra-violet spectra) Procedure Every 6 months

Total time 0.5 h (analog) 2.0 h (digital)

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches and knobs. 4. Clean exterior, particularly cuvette well. 5. Check integrity of photosensing device on cuvette wall. 6. Check mechanical zero of wavelength calibration, following manufacturer's instructions. 7. Check wavelength calibration using buffer solutions or, preferably, calibrating filter standard, following manufacturer's instructions. 8. Clean optical filters in front of cuvette well. 9. Check operation of unit.

Annua/ tota/-1-4 h

Apparatus:

Hot-plate magnetic stirrer Procedure Every 6 months

Total time 1.0 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches and knobs. 4. Clean exterior. 5. Check magnetic properties of stirrers. 6. Check transformer voltage. 7. Check operation of unit and speed of rotation.

Annual tota/-2.0 h

Annex 5

163

Apparatus:

Hot-air incubator/oven Procedure Every 6 months Total time 1.0 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches and knobs. 4. Clean interior and exterior. 5. Check transformer voltage. 6. Check accuracy of temperature calibration of thermostat, using external thermometer. 7. Check accuracy of calibration of timer, using a stop-watch. 8. Check operation of unit and adjust as indicated in manufacturer's service manual. Annual total-20 h

Apparatus:

Water bath Procedure Every 6 months Total time 1.5 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Clean and inspect for corrosion. 4. Check and clean heating element from corrosion due to hard water. Annual total-3.0 h

Apparatus:

Water distiller/softener Procedure Every 6 months Total time 1.5 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls and connectors. 4. Check water circuit for leakages and calcification. 5. Check for presence of chemicals and condition of filter. Annua/ tota/-3.0 h

District hospitllls: annexes

164

III. Electro-medical equipment Apparatus: Electrocardiograph Procedure

Total time 1.0 h

Every 6 months

1. Check integrity of electrical grounding from instrument chassis. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches and controls. 4. Inspect condition of patient cables and switches. 5. Clean interior of unit using a vacuum cleaner. 6. Inspect internal components for signs of wear or damage. 7. Clean lead selector and other exposed switch contacts. 8. Check chart recorder speed. 9. Test maker stylus. 1.0. Check condition of writing stylus; adjust heat and pressure as necessary.

11. Test and adjust gain of amplifier according to manufacturer's specifications; check amplifier balance, frequency response and common mode rejection. 12. Check integrity of electrical grounding from each electrode in all modes. l3. Check operation of unit: run a strip of all lead configurations using a cardiac simulator. Every 12 months 0.5 h

1. Sparingly lubricate recorder motor and gears as required. 2. Check and adjust test pulse reference voltage.

Annual total-2.5 h

Annex 5

165

Apparatus:

Defibrillator/Cardioverter Procedure Every 4 months

Total time 1.0 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls, connections, meters, etc. 4. Check physical condition of electrodes, defibrillator paddles and cables. 5. Check interior for signs of damage; clean as necessary. 6. Check operation of unit; measure energy output at all watt-second settings. Take care. 7. Check operation of synchronizer, if used. 8. Check voltage gain calibration of monitor, recorder, etc, if used. 9. Check trace on oscilloscope, if applicable. 10. Check chart recorder, stylus condition, stylus heat and pressure and recorder speed, if applicable. 11. Check electrical current leakage from each electrode, if applicable. Every 12 months 1.0 h

1. Sparingly lubricate recorder motor and gears as required. 2. Check batteries and replace with correct spares as required.

Annual total-4.0 h Important: Add warning about the hazards of maintaining or testing a defibrillator without having had training on the unit to appreciate the high voltage (about 5 kV) and high currents (about 50 A) that can be generated. This unit is potentially hazardous to all staff.

District hospitals: annexes

166

Apparatus:

Electrosurgical unit Procedure Every 4 months

Total time 1.0 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls, connectors, etc. 4. Check physical condition of footswitch and cable. S. Inspect accessories for signs of deterioration or defective cables. 6. Clean and inspect interior for damage. 7. Check condition of spark gaps and vacuum tubes, if applicable. 8. Measure radio frequency output in all operating modes; refer to manufacturer's specifications. 9. Verify patient plate and footswitch for correct grounding; test function of patient ground guard circuit. 10. Check radio frequency of interference with other surgical devices, e.g., patient monitor.

Annual total-3.0 h

Apparatus:

Anaesthetic machine Procedure Every 6 months

Total time 2.0 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check all rubber fittings (O-rings, diaphragms, gaskets, valve seals, etc) and replace if necessary with manufacturer's approved replacement parts. 4. Check for gas leakages. S. Clean and check calibration of flow meter.

Annual total-4.0 h

Annex 5

167

Apparatus:

Fetal monitor Procedure Every 6 months Total time 1.0 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, controls, connectors, meters, etc. 4. Check physical condition of cables and transducers. 5. Check interior of unit for signs of damage. 6. Sparingly clean and lubricate recorder as necessary. 7. Check operation and calibration of unit in accordance with manufacturer's specifications. Every 12 months 1.0. h

I. Check amplifier gain, frequency response and common mode rejection. Annual total-3.0 h

Apparatus: Procedure Every 6 months

Cardiac monitor Total time 1.0 h

I. Check integrity of electrical grounding and current leakage. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches, knobs, connectors and cables. 4. Clean interior with damp cloth. 5. Check voltage gain calibration for all lead positions. 6. Test rate meter and rate meter alarm functions, if applicable. 7. Clean and inspect electrodes, straps and patient cables. 8. Check trace on oscilloscope. Every 12 months 1. Test input circuitry. 2. Replace reference cell if necessary. 3. Check battery, if applicable. Annual total-3.0 h 1.0 h

District hospitals: annexes

168

Apparatus:

Respirator Procedure Every 6 months

Total time 2.0 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check mechanical integrity of switches and knobs. 4. Inspect high-pressure hose assembly for wear and leaks. S. Check high-pressure inlet filter and associated O-rings; clean all parts. 6. Check control pressure regulator; replace if necessary. 7. Inspect operation of all gauges; calibrate if necessary. 8. Check operation of cycling mechanism and related controls; comply with manufacturer's test procedures. 9. Inspect and clean all tube and manifold assemblies. 10. Clean and check nebulizer assembly; replace O-ring if necessary. 11. Complete fmal check of system as recommended by manufacturer.

Annual total-4.0 h

Apparatus:

Short-wavelMicro-wave diathermy Procedure Every 6 months

Total time 1.0 h

1. Check integrity of electrical grounding. 2. Check physical condition of power cord and plug. 3. Check condition of radio frequency cables and applicators for cracks, overheating or deterioration; replace if required. 4. Check mechanical condition of all accessories, front-panel controls, switches and output. S. Clean and inspect interior for signs of damage; vacuum if necessary. 6. Clean ventilation screen and oil blower motor sparingly. 7. Check operation and functioning; refer to manufacturer's specifications for tuning. S. Check for corona and arcing at high-power setting. 9. Check timer and safety shut-off. 10. Check power output with radio frequency wattmeter; compare readings with previous measurements.

Annual total-2.a h

Annex 5

169

Apparatus:

Infant incubator Procedure Every 6 months

Total time l.Sh

I. Check integrity of electrical grounding. 2. Check physical condition of power cord, connectors and plugs. 3. Check mechanical integrity of switches and controls. 4. Inspect condition of oxygen and air inputs. 5. Check water-level gauge and inspect distilled-water compartment. 6. Clean or replace water and air filters. 7. Check temperature indicator and thermometers according to manufacturer's specifications. 8. Check temperature cut-off alarm. 9. Check power failure alarm. 10. Check operation of unit; warm to temperature setting on temperature control and check with external thermometer. II. Check canopy for breakage; clean interior and exterior or unit.

Annual total-3.0 h

Apparatus:

Dental chair unit Procedure Every 6 months

Total time 1.5 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord, connectors and plugs. 3. Check mechanical integrity of switches and controls. 4. Check for leakages in water circuit; replace rubber rings and other consumable materials according to manufacturer's recommendations. 5. Check all water pipes for calcification; check integrity of filters; clean or replace as necessary. 6. Check for leakages in air circuit; replace elements accordingly. 7. Check movement of chair, tray, light and other parts. 8. Check for correct movement of all hand-pieces. 9. Check X-ray unit for correct exposure by exposing dummy dental film. 10. Check operation of unit.

Annual tota/-3.0 h

District hospitals: annexes

170

Apparatus:

Suction pump Procedure

Total time 0.5 h

Every 6 months 1. Check integrity of electrical grounding.

2. Check physical condition of power cord, connectors and plugs. 3. Check mechanical integrity of switches and controls. 4. Check two-way air valve. 5. Check for damage to bottles and clean. 6. Check air circuit for leakage and absorption. 7. Check operation of unit.

Annual total-1.0 h

Apparatus:

Operating table and lamps Procedure

Total time 1.0 h

Every 6 months

1. Check mechanical movement of moving parts and oil accordingly. 2. Check hydraulic up-down movement of table. 3. Check hydraulic circuit for leaks and replace rubber parts according to need and manufacturer's specifications. 4. Check stand-by theatre-light battery for switch-over operation; correct water level of cells, battery acidity and voltage. 5. Check mechanical integrity and operation of footswitches, if used. 6. Check operation of lights and table. Every 6 months 1. Check battery water level, voltage and acidity. 1.0 h

Annual tOlal-4.0 h

Annex 5

171

Apparatus:

Intensive care monitoring system Procedure Every 6 months Total time 2.0 h

I. Check integrity of electrical grounding. 2. Check physical condition of power cord, connectors and plugs. 3. Check mechanical integrity of switches, connectors, cables and controls. 4. Check signal connection between central panel and monitors by giving known signals and monitoring centrally. 5. Clean exterior of unit with damp cloth. 6. For bedside monitors, follow procedure given under "Cardiac monitor." Annual total-4.0 h for system connected to 4-bed unit

172

ANNEX 6. GUIDELINES FOR THE INSTALLATION OF WHO BASIC RADIOLOGICAL SYSTEMS (BRS) Location of the x-ray unit The location of the x-ray unit must be chosen primarily for ease of access for all patients. With the BRS, radiation protection is not a critical factor in the choice of location. The majority of patients will be ambulatory outpatients but some patients will arrive on trolleys or in wheelchairs. The x-ray unit should be located close to the hospital entrance, preferably on the first floor. There must be no steps, thresholds or other obstacles which would impede trolleys and wheelchairs.

i"' 125cm

Space required for the x-ray department A minimum of three rooms are required: examination room (xray room), darkroom and office! viewing room. Some additional storage space must also be available and a special film file is required if the processed x-ray films are to be filed within the x-ray department.

r---.d. 230cm 'i....

---1 )c: )( )l.

185cm ..h _ _ ...J

_--12mz

x..

290cm

165cm ~

< < ____

415cm

)

Fig. 10Sa. BRS examination room

The x-ray room must be at least 12 m2, not including the control area, where the operator is standing during the exposures. The minimum work area for a BRS stand is 2.9 x 4.2 m. See Fig. 105a.

~2~10~-~2~2~~__________

7 190 - 18Dem

Towne POSition

Axil.skuli

Fig. 10Sb. Working range of BRS stand

The control of the x-ray generator may be located behind a lead screen inside the x-ray room. A better solution is to have the control in a small separate space outside the examination room. The total area of the examination room including the control should be at least 18 m2 •

Annex 6

173

The amount of radiation absorption needed in the room walls depends upon the size of the room and the number of examinations per year. If the walls are made of concrete or clay-bricks with an effective thickness of 5 cm, the following conditions are valid for a maximum of 5 mSv (0.5 rem) per year outside the room:

Room size

Distance to nearest wall from vertical central beam 1.5 m 1.8 m 2.1 m

Ceiling height*

Max. number of exams/year

3x4m 4 x5 m

2.5 m

2000 3000 4000

2.8 m 3.0 m

4.6 x 5 m *if floor above is occupied

The darkroom should be at least 5 m2 for manual processing. No dimension of the room should be smaller than 2 m. If an automatic processor is used and the room is not continuously manned, the room may be as small as 1.5 x 2m. The office/viewing room should at least be 8 m2 • If a film file is maintained in the office, the room must be considerably larger with dimensions depending upon the anticipated size of the film archive. Also if the room is to be used for film-viewing in groups, the room must be larger. Storage space is required for chemicals unexposed x-ray film, linen, film envelopes, etc. Unused chemicals may be stored in the darkroom. Unused x-ray film must be stored standing in the original light-tight boxes away from heat, humidity and radiation. Relationship between the rooms Several complete floor plans for small BRS departments are shown in figures 106-108. The larger ones contain storage and utility rooms and a small area for waiting. It is important that the darkroom is close to the control area of the examination room. It is also vital that the darkroom is not too close to the radiation source. Design of the x-ray room Unless the x-ray room is very small or the number of examinations is very large, it is unlikely that special arrangements will be necessary for radiation protection. Walls made of wood or fibreboard are not suitable, however. Brick, concrete or gypsum plate are usually satisfactory. The walls should have a protection capability equivalent to that of 0.25 mm of lead or more and the distances mentioned in the table above should be observed. A shorter distance may be compensated for by an increase in the lead equivalence but more than 0.5 mm of lead is never needed with the BRS unit. If the x-ray room has windows, no part of the window may be less than 2 m from the outside ground. The x-ray room floor must be strong to support the weight of the stand column and the x-ray generator. The weight of the stand column will be in the range of 250-500 kg and the support area may be very small (about 400 cm 2). The x-ray generator has a wider base and may weigh as much as 350 kg if it contains lead/acid batteries. It is essential that the floor is completely level because patient trolleys will have to move over it. It should be waterproof, washable, and free of dust. The best construction material is concrete covered with vinyl.

The ceiling height should be at least 2.5 m. The ceiling will not be required to support any weight.

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174

OFFICE VIEWING

X·RAY ROOM

DARK· ROOM

0 X·RAY ROOM

Radiography Darkroom Office/viewing total net

1&m2

5m2 8.5m2

area gross area

29.5m2 35m2

o 1 2 3 4 5 6 7. ~1-41--~I--~I~I--~I--~I~1 Fig. 106a. Minimum BRS department 1

OFFICE VIEWING

DARK ROOM

~1-4--+I--~'-4I--+I--I~~1 Fig. 106b. Minimum BRS department 2

'" 2

~'o

E 4 5

0 6 7.

Radiography Control Darkroom Office/viewing total net area gross area

13m2 2.5m2 5m 2 9m 2 29.5m 2 35m2

WAITING X·RAY ROOM

Radiography Control Darkroom Office/viewing Storage Utility Waiting total net area gross area

19m2 4.5m2 7m2 13m2 4.5m 2 10m2 62m2 70m2

4m2

OFFICE VIEWING

DARK ROOM STORAGE UTILITY

supponing walls • double lines screen walls - single lines 5 6 7.

~I~I--+I--~I~I--+I--I~~I Fig. 106c. Small BRS department

Annex 6

175

8.4m

"processing

r X·RAY ROOM

- .,I I I I I I

DARKROOM

/L OFFICE light trap

dry benc:h

BRS nand leed1llass window

I I I

generator c:ontrol

:0 I I

4.Bm

I I L ____ .J

rL.,

"this wall should be of bric:k or c:onc:rete or wood c:overed with 0.25-0.5 . . l ••d

Fig. 107. Small x-ray department showing working area for BRS stand

The walls should be painted with washable semi-gloss paint in a very light (pastel) colour or be al~ost white (cream). The ceiling should be white. It is preferable to use subdued indirect light when supine patients are examined. Separate fluorescent light sources should be available in the ceiling for cleaning and service needs. The door between patient corridor and examination room must be wide enough to admit a bedusually 110-120 cm. There should be no step or threshold. It is preferable to use a steel door but if the distance to the radiation source is long (more than 3 m) or the patient load is small (less than 10 examinations per day), a wooden door may suffice. It must be possible to lock the door from the inside. If the x-ray room is large enough (18 m2 or more), the x-ray generator may be located behind a panel inside the room. The panel must permit full protection of the operator and·of cassettes with unexposed film and should contain at least 0.5 mm lead or the equivalent thickness of bricks (Fig. 109). It is often more convenient to have a separate small room for the generator control. The design of this room must prevent primary or secondary radiation from reaching the BRS operator or the x-ray cassettes even if the opening between the examination room and the control room does not have a door. Design of darkroom

The important factors in the design of the darkroom are the size of processing equipment and the need to work in almost total darkness with only safe-light illumination. There must be separation of a wet area and a dry area. The darkroom must be entirely lightproof, however bright the outside sunlight. Light-tightness of door, window and ventilation ducts must be tested carefully. No light leak from outside may be visible to someone who has spent 10 min inside the room in total darkness.

District hospitals: annexes

176

uti I.

film file 5.7m 2

2.2m2 store 2.2m2

we 2.2m2

waiting room 12.5m2

we 2.2m2

office 10.8m2

film viewing 10.8m2

examination room 16m2

dark· room 5m2

control Z 3 4 5111

1-1-11---11--+1-.... ' --II Waiting room Dressing cubicles Space for trolley Patient toilet

net area range (m2 ) 10·20 2·4 2·4 2·3 16·20 6·8 8·12 8·12 5·10 2·4 2·4 2·3 65·104

this dept (m2 )

Patient area

12.5 7.8 2.2 18.5 6.0 10.8 10.8

Examination room (incl. control) Personnel area Darkroom Viewing room Office Film file Storage and supply Utility Personnel toilet Total net area

5.7 3.3 2.2 2.2 82.0ml

Fig. 108. Floor plan for primary care radiography 4000 or more examinations per year

Annex 6

177

Fig. 109. Control protective screen and control panel

The entrance to the darkroom should be close to the x-ray generator control but it need not be directly from the x-ray room. If the workload is small (one examination per hour or less), and floor space is a problem, it may be sufficient to use a simple light-tight door. The darkroom floor should be waterproof, level and washable. A floor drain is very useful. Ceiling and walls should be painted with a semi-gloss chrome-yellow colour with no white pigment added. A pure chrome-yellow paint does not reflect any blue light which might expose the x-ray film. Also the walls should be washable. Three separate light sources are needed in the darkroom. (1) General whilte light: a 4-watt incandescent bulb in the ceiling (a fluorescent tube gives afterglow and is not acceptable) (2) Indirect filtered light: a 25-40 watt incandescent filtered light in a reflector directed upwards towards the ceiling (Fig. 110a) (3) Direct filtered light: a IS-watt incandescent

1 Fig. 11 Oa. Indirect filtered light

filtered light in reflector directed downwards towards surface of the dry-bench. Distance between bulb and table surface, 120 cm. The reflector must have the words "MAX 15 WAIT' written in large letters on the outside (Fig. I lOb). All light sources must have separate switches located so that confusion is impossible. 2

Fig. 11 Ob. Direct filtered light

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178

The darkroom must have a dry side with a dry-bench for unloading and loading of cassettes and a wet side with processing tanks. Separation of wet side and dry side becomes ufl!lecessary if an automatic processor is used. The darkroom must also have a regular sink, preferably of stainlesssteel. The minimum equipment for film processing is a 26-litre developing tank, a fixing tank of the same size or 50% larger and a rinsing tank which can handle at least the expected film production from one hour of work: usuaIly 15 cm or more in length. Design of office/viewing room

Several different activities will go on in the office and will affect the design of the room: l.

reception and dismissal of patients; keeping of records; drying of x-ray films; viewing of x-ray film, sometimes by several people; filing of x-ray films and reports in envelopes.

2. 3. 4. 5.

The room must have viewing boxes with fluorescent light for viewing of several films at the same time. A minimum is one viewing box with a light area of 43 x 72 cm for wet films (with a drip tray) and one with a minimum light area of 43 x 100 cm for dry films. The room should also contain a drying rack or drying cabinet for film, a regular office desk with room for typewriter, telephone, etc., and shelves for film and records. Storage

Storage space should be provided for unexposed x-ray film, processing chemicals, envelopes, office supply, linen, etc. Electrical supply

If the generator is dependent on a mains connection, the manufacturer of the x-ray generator will specify the power requirements. Some generators may require as much as 150 A for up to 3 seconds from a 220 V source with a smaIl impedance (0.5 ohm or less). In this case a 50 slow fuse usually will suffice, however. Generators using batteries or large capacitors may operate from standard grounded 220 V outlet and do not require more than 3 A during operation. If an automatic processor is used, its power consumption may be as much as 5 kW for short periods. The electrical supply fro room lighting and viewing boxes can be standard grounded waIl outlets for 220 V, 10 A. For further information, specific questions may be sent to: Dr Thure Holm St. Lars Roentgen Lund University Clinics S-220 06 Lund, Sweden

(Tel: 046-16 45 09)

179

ANNEX 7. USE AND DETAILED SPECIFICATIONS OF BASIC RADIOLOGICAL SYSTEM (BRS) UNITS 1. Introduction

The World Health Organization has developed a concept of diagnostic radiology that has been named the Basic Radiological System (BRS). The BRS is primarily intended to be used in communities currently deprived of radiodiagnostic services. Long practical experience has shown, however, that the BRS is equally applicable in industrialized countries. The BRS concept comprises x-ray equipment, as well as equipment for film processing and viewing of x-ray films, and manuals for radiographic technique, darkroom technique and film interpretation. The BRS is aimed at providing: (I) (2) (3) (4) better radiodiagnostic coverage of the population in the entire world; an adequate radiographic system capable of performing at least 80% of all radiographic examinations required at university level; radiographic equipment which can be operated by personnel who have had shorter training than fully qualified medical radiology technicians (MRT); better radiodiagnostic facilities to physicians working in less accessible places of the health care system.

The attainment of these objectives will result in: -better diagnosis and prognostication of disease; -improved therapeutic decisions and consequent management of patient care; -reducted cost to patient, community and government due to the shortened period of disability and bed occupancy, and the reduced need for patient transportation; -lowered radiation dosage per examination. The development of such a BRS requires an x-ray apparatus with the following major characteristics: (i) (ii) Utilization restricted to general x-ray examinations not requiring fluoroscopy, tomography or serial film changers. Simplified design and increased reliability permitting: -operation by persons with less training than that of an MRT; -operation under adverse climatic conditions; -operation in places where no electrical power line is provided or where it is undependable due to frequent power cuts, wide fluctuations in voltage and frequency, etc; -simplified procedures for fault finding and repair in case of breakdowns, thus increasing the viability of the equipment as much as possible; -operation at a reasonably low level of radiation exposure to patients and operating personnel, in compliance with international standards. (iii) The cost of the x-ray equipment has to be reasonably low, so that large numbers of complete installations can be made available to national health authorities even in developing countries with limited resources.

District hospitals: annexes

180

Place of use The BRS equipment with the characteristics described above is intended for use in: (a) (b) (c) small rural hospitals covering the needs of rural populations; large health centres and polyclinics with many outpatients; larger hospitals (rural or urban), as additional equipment in the casualty department, thus sparing the more sophisticated and expensive x-ray equipment for special x-ray diagnostic procedures, fluoroscopy, etc. Another utilization will be in private medical practice, where such equipment will bring acceptable radiodiagnostic quality within reach of privately financed practices.

Examinations to be performed

This list of examinations to be performed by the BRS equipment should serve only as a guide. The more common indications and examinations include: Skeleton Head Chest Abdomen fractures, bone and joint diseases trauma and infections tuberculosis, pneumonia and other respiratory infections, heart enlargement, tumours, trauma intestinal obstruction, calcifications, trauma and possibly intravenous urography, cholecystography, and problems in pregnancy Foreign bodies, calcifications

Soft issue

Contrast media examinations are only recommended when an experienced person is available, able to carry out and interpret such examinations and treat possible complications of contrast injections. Several of the above-mentioned examinations require special consideration of horizontal beam utilization on the recumbent patient. 4. 4.1 Technical characteristics of the BRS apparatus X-ray generator The power output of the x-ray generator is critical for two of the examinations specified above: (a) (b) the chest, which requires a very short «50 ms) radiographic exposure, and therefore a high power output for a very short time; lateral view of the lower lumbar spine, which requires a very large amount of radiation to penetrate a considerable thickness of tissue and thus high power for a longer time.

The output of the x-ray generator should be high enough to produce a minimum exposure of the 0.5 mR (within 10%) at a focus-film distance of 140 cm and a tube tension of 120 kV: (a) (b) behind a 12 em water phantom in 50 ms or less, and behind a 30 cm water phantom in I second or less. The exposure conditions include the employment of a focussed lead/aluminium grid with 40-50 lines per centimeter and a ratio of 10: I and an irradiated field at the position of the cassette collimated to 400 square centimeters. The x-ray generator must also be capable of delivering a maximum total output of 25 kWs. (This may be produced by a converter generator with an output at the x-ray tube of 10-12 kW at 120 kV).

Annex 7

181

Recent developments indicate that in the future most x-ray generators will be using the converter principle. These generators use a DC source and convert the DC to AC with higher frequency than regular mains frequency (50/60 Hz). The higher frequency AC utilizes very small and often inexpensive components. The power source may consist of batteries or rectified low impedance AC mains. Generators using batteries are to be preferred because the mains supply will often be unreliable in the working locations to be expected. Preference is given to lead-acid batteries because of the experience from practical tests conducted by WHO working groups. For the same reason preference is given to x-ray generators using AC frequencies above 2 kHz and automatic control of x-ray tube voltage (kV) at a present value, preventing voltage drop during exposure. Generators directly connected to the mains have different requirements on the mains impedance for good performance. A mains operated generator should be considered only when it can be shown that the mains impedance is consistently lower than 0.5 ohm.

4.2

Choice of exposure factors

The choice of exposure factors needs to be restricted to simplify the operation. If the "twocomponent" system (kV and mAs) is used, the number of available kV-values should be restricted to 4 fixed values: 55-70-90-120 kV + 2%. The minimum range of mAs-values, usable in the entire kV -range, is 0.8-200 mAs in 25 steps for a converter generator. The increments between the steps should be 26%. If a single-dial technique is used, changing kV and mAs at the same time and approximately following an iso-watt curve, the number of steps must be increased to more than 30.

4.3

Control panel

This should indicate the state of the electricity supply (mains or battery) before exposure and the chosen values of kV and mAs or object thickness in centimeters of water. The exposure switch should be mounted on the control panel, so that the operator must stand behind the protective screen during exposures. The protective screen, large enough to protect a standing operator, should be available as an integral part of the control panel. The lead equivalent needed is 0.5 mm if the x-ray beam is never directed towards this screen. The screen must have a lead glass window not smaller than 30 x 30 cm, placed in a convenient position to give a good view of the patient.

4.4

X-ray and collimator

The x-ray tube should be able to handle at least 20 kW during 0.1 second and 10 kW during 1 second. The focal spot should be smaller than I mm. This requires a tube with rotating anode. The anode angle may be as small as 100. The total permanent filtration in the useful beam shall be equivalent to not less than 2.5 mm A I and not more than 3 mm A I. The tube must be provided with an adequate collimator enabling restriction of the size of the beam to that of each of the film formats. A movable pointer or other reliable system for centering of the beam must be provided. The collimator design should enable its easy replacement by an adjustable light-beam collimator in countries whose regulations make these mandatory. The smallest format of the collimator may not be larger than 18 x 24 cm. The collimator design must also prevent any part of a patient from being closer to the radiation source than 30 cm.

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4.5

Support for x-ray tube and cassette holder

It is necessary to have a design which will ensure that the x-ray tube is always connected to the cassette holder in a rigid and stable way, providing precise and simple centering of the x-ray beam. The focus-film distance should be fixed at 140 cm. A stationary, focussed lead/aluminium grid having 40-50 lines per centimeter and a ratio of 10: 1 must be incorporated in the cassette holder and must cover the full area of the largest film. The cassette holder must include a lead screen in the back wall with a minimum thickness of 0.5 m Pb. This requirement may obviate the need of further radiation protection of the walls of the examination room if the floor dimensions are 3 x 4.5 m or larger and no more than 2000 x-ray examinations are made per year.

The design of the examination stand must permit: (a) (b) the use of horizontal beam for examinations of recumbent patients; the use of the patient trolley as a "floating" table top in such a way that the longitudinal midline of the trolley can be offset at least + 12 cm from the midline of the cassette holder; the use of angulated beam + 300 from the vertical and horizontal beam directions; the use of horizontal beam in the range of 50-170 cm above the floor; the use of the cassette holder as a small horizontal examination table at a distance from the floor not less than 90 cm. The cassette holder, when used as a table top must permit a load of at least 15 kg without disalignment of the focussed grid or slipping of the brake for the vertical movement of the arm carriage; the design of the stand should also permit the use of horizontal boom in two opposite directions unless a "mirror image" version of the stand is available.

(f)

The film sizes to be used should be standardized and not more than 4 film sizes are recommended. The cassette holder must accept at least the following formats: 35.5 x 43 cm, 18 x 43 cm and 24 x 30 cm.

4.6

Patient support

The patient support should be rigid, with an x-ray permeable top, approximately 2.0 x 0.65 m in size and approximately 0.7 m from the ground. It must be able to support a weight of 110 kg without appreciable distortion, should be easy to keep clean, impervious to fluids and resistant to scratching. The design of the trolley must permit positioning of the cassette holder in such a way that when the vertical beam is used the distance between table to and film plane must not exceed 8 cm. The distance between the front wall of the cassette holder and the film plane should be not more than 2.5 cm. When the beam is angulated + 300 from the vertical direction, the distance between the table top and the film plane should not exceed 25 cm in the central beam. The wheels must be a size to permit easy movement of the trolley with a 110 kg patient, and the locking mechanism should preferably be central and immobilize at least one wheel at either end.

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ANNEX 8. HOW IS THE POWER OF AN X-RAY GENERATOR SPECIFIED? I.

Power (the rate of energy transfer) is measured in watt (W). Power refers to an instantaneous condition and is unrelated to the total amount of energy used. Energy is measured in joule (J), which is the same as watt-seconds (Ws), and refers to power for a certain amount of time. The unit Ws is used to emphasize the relation with power (W) and time(s) at an x-ray exposure. Comment: It is energy that is provided throughout the world by electrical power companies. Since power is energy transferred during a specified period of time, energy is power multiplied by time. The usual unit of accounting for the energy provided by an electrical power company is the kilowatt-hour (kWh), which is not very costly. Thus, contrary to popular belief in some regions, the actual cost of the energy needed for an x-ray exposure, which is in the range of 0.25-25 kWs, is very low.

The units most commonly used in radiography are s, ms, kV, mAs, kW and kWs. Exposure times are measured in ms osr in s. Generating potential (voltage) multiplied by current (amperage) gives power (wattage). Thus, the values for kV and rnA can be multiplied to give the value for W. (Note that "kilo" and "milli" neutralize each other, meaning lOOO and 0.001, respectively.) Example: lOO kV x 200 rnA =

20 000 W

20 kW

The power of an x-ray generator is usually specified in kW. This, however, is acceptable only if the power source has a constant or near-constant output for a long time (mains or battery). The essential information requiared about a generator is the amount of energy available for an x-ray exposure. If the power source of the generator is a capacitor, the output (in kW) will fall continuously during exposure. The output of a capacitor discharge generator must be specified in kWs, and information must be given on whether the tube potential (kV) or the tube current (rnA) is falling during the exposure. (Constant kV and falling rnA are the only acceptable alternative for a general-purpose x-ray generator).

For many years, generator output has been specified by companies manufacturing x-ray machines and by their salesmen in various ways. The oldest method was devised to show only the highest possible figures; the highest attainable x-ray tube voltage and the highest attainable x-ray tube current were usually given as kV or kVp and rnA, respectively. The problem is that such values are practically never reached at the same time. Thus, it is not possible to multiply these values of kV and rnA to get the generator power. The commonest method used currently to specify the output of an x-ray generator is to give the power (kW) available at 100 kV. If the generator is connected to a constant energy source, such as the mains or a large battery, the output mainly depends on what the x-ray tube can handle. The same method has been applied to capacitor discharge x-ray generators, but power quoted in this way is valid only for an exposure time of 0.1 s. (This is the same exposure time that is used in specifications for x-ray tube load.) This type of information is highly misleading. A 30-kW capacitor discharge unit may have a total available energy of only 10 kWs, while a lO-kW battery-operated converter generator may deliver 32 kWs (in 3.2 s). For general radiography in most parts of the world where screen-film systems at a relative speed level of 200 (for example, blue-light-emitting screens and blue-sensitive film) are in use, the

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battery-operated generator is best, since certain examinations, such as those of the abdomen or lumbosacral junction of a thick patient, may require 20-30 kWs. This energy cannot be provided by a capacitor discharge unit with only 10-20 kWs of total energy available. In the future, when green-light emitting screens and green-sensitive film (whih are also recommended for improved radiation protection) become available in all parts of the world, less energy will be needed for an x-ray exposure, and a capacitor discharge frequency-converter generator, capable of delivering a minimum of 12 kWs, will be adequate. 5. Final conclusion. The power of an x-ray generator operated directly from the mains or from a battery is satisfactorily described by information about the output at 100 kY, expressed in kW, supplemented by information about the longest exposure time available with this power. It is also useful to know the peak kW values at the extreme ends of the kY range. For a capacitor discharge x-ray generator, it is also necessary to know the total amount of energy available at the same kY values mentioned above, expressed in kWs. 6. As an example, the following requirements are used by the WHO Collaborating Centre for BRS in Lund, Sweden.

Type of installation WHO-BRS (BRS operator) Screen-film system Blue-emitting screens blue-sensitive film Standard speed, 200-500

WHO-BRS (R) (Qualified radiographer) Green-emitting screens, green-sensitive film Standard speed, 400-500 chest, 200-250 non-grid, 80-125 10-15 kW 12-25 kWs 20-30 kW at 0.1 s Minimum, 12 kWs

Green-emitting screens green-sensitive film Standard speed, 400-500 chest, 200-250 non-grid, 200-250 10-15 kW Minimum, 12 kWs

Battery-operated x-ray generator.' Capacitor discharge x-ray generator" X-ray tubeb

10-15 kW Minimum, 25 kWs

Not recommended

Minimum, 15 kW (0.1 s) Minimum, 12 kWs

Same x-ray tube in all WHO-BRS installations: 20-30 kW (at 0.1 s); focus, 0.8-1.0 mm; anode angle, 12-14°

• Only medium- or high-frequency converter generators are acceptable, and voltage drop may not exceed 10% during exposure. b Double-focus tubes are not recommended: the choice between two focal spots is an added complication for a BRS operator and offers no advantage.

185

ANNEX 9. MINIMUM SPECIFICATIONS FOR THE GENERAL-PURPOSE

ULTRASOUND SCANNER (I)

Transducer Standard unit: 3.5 Mhz centre frequency. Optional unit: 5.0 Mhz centre frequency. Fixed in-slice focusing on both units desirable but not essential. Sector angle 400 (sector scanner) or better. Array length: 58 cm (linear array scanner). Controls To be simple and clearly arranged. Gain control is required. Time gain compensation to be by choice of present and variable conditions. Frame rate 5-10 Hz (sector scanner), 15-30 Hz (linear array scanner). Frame freeze and display 512 x 512 x 4 bits (to provide 16 "grey" levels). Omnidirectional calipers One pair to be provided, with facility for quantitative read-out and recording. Patient identification Facilities to be provided for manually entering and recording data-patient identification, date, etc.-on the image screen. Permanent recording Provision must be made for the economical preparation of good-quality permanent image records. Construction The unit should be portable (not more than 8 kg), drip-proof, and dust-proof. Proper and continuous operation should be possible under the following conditions: O°C to + 40°C. Temperature: Humidity: up to 95%. Prolonged storage should be possible under the following conditions: -30°C to +50°C. Temperature: up to 100%. Humidity: The unit should be rugged and capable of withstanding the vibration likely to occur during rough, cross-country transport. Special care should be taken to avoid failure of the transducer, its cable, and its connector under the above conditions. The mechanical design of the transducer should include: (a) (b) Maximum protection against damage by dropping; Tolerance of the use of a variety of coupling media, particularly local vegetable oils.

(2)

(3)

(4)

(5)

(6)

(7)

(8)

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(9)

Electrical and mechanical safety This equipment should conform to the standards set out by the International Electrotechnical Commission (Medical Electrical Equipment).' Where interventional use is intended, particular care must be taken to ensure that the relevant standards of equipment earthing (grounding) and leakage of current are met.

(10) Power supply The equipment must be capable of working from any of the following types of supply: Direct current: standard batteries, preferable rechargeable. Alternating current: -50 and 60 Hz -100, 110, 117, 125 and 200, 220, 240 V. -line voltage variation + 15%. Surge protection to be provided. (11) Servicing and quality control Although modern equipment should be reliable and stable in performance, both failures and degradation should be anticipated; the following quality control procedures are highly recommended: (a)

At regular intervals (at least every 3 months and preferably every week) the resolution and sensitivity performance of the unit should be checked using a suitable phantom. Corrections should be made if there is any appreciable change in performance over a period of time. (b) Arrangements should be made (with the manufacturer or otherwise) for a centralized repair and maintenance service to be provided, to cover a number of units in a country or region. (c) Provision must be made for a supply of spare parts to be rapidly available. These parts must include spares for the transducer, the display monitors, and the principal electronic assemblies. (12) Space Ultrasound examinations may be made at the bedside, but it is preferable to set aside a room that will provide both privacy (if necessary by curtains) and a suitable horizontal support for the patient. It is helpful if the room illumination can be reduced. A toilet should be provided close to this room. In busy departments the provision of several changing cubicles will increase the number of patient examinations that can be carried out. No added structural protection is required.

General requirements. Geneva, International Electrotechnical Commission, 1977 (Publication No. 601-1). Particular requirements/or specific types o/equipment (including ultrasound and computed tomography). Geneva, International Electrotechnical Commission (in preparation) Publication No. 601-2).

187

INDEX access, 22, 25, 33 administration, 6, 29, 48, 57 administrative support areas, 55 admission, 7 air changes, 66 conditioning, 14, 46, 65, 66, 78, 79-80 pressure relationships, 80 alarm system, 14, 29, 61, 78 Alma Ata Declaration, 1, 2 ambulance, 33, 55 anaesthesia, 6, 166 architecture, building shape, 49-51 bacteria, 75 beds, number of, 6-7, 14, 39, 67 bidding, 86 bill of quantities, 87 boiler room, 72 building code, 25-6 cast-<Jn-site construction, 52 circulation (see also corridor), 29, 33-5, 48,57 climate tropical, 31, 49 variations of within the Region, 5 clinical pathology, 6, 59 commissioning, 12 communications, 20, 28, 82 consultation room, 56 contractor, selection of, 86 construction planning and programming of, I, 11-7, 86-90 team, 12 technology, 52 contract, 86, 90 corridor, 34-5,48, 50, 61, 64, 68 cost control, 14-5, 90 critical path method, 88-90 cruciform plan, 69 culture media, 60 darkroom, 58, 128-9, 175, 177-8 data base, 57 defects, liability period for, 90 delivery department, 48, 67 design brief, 11, 13-16 drawings, 12 intentions versus use, 109-114 methods of, 11-17 of operating department, 63 diagnostic radiology, 57-58 diagnostic x-ray, equipment, 122-130 dietary department, 70-71 disaster preparedness, 39--42 dishwashing, 70 dispensary (see also pharmacy), 48 district health system, 2-3 development plan for, 3 district hospital definition of, 4-7 evaluation of, 91-92 experiences in, 93-108 location of, 17-23 master physical development, 24-52 role of in primary health care, 1 domestic services, 14, 28, 49, 71 drainage, 19-20 drawing (see design) education, 1, 49, 53-56, 67, 139-140, 153 electricity distribution, 81-82 emergency service, 84-85 supply, 7, 14, 20, 61, 81 elevators (see lifts) emergency department, 48, 56-57 energy conservation, 45--47 primary source of, 46--47, 77 solar, 45--46 engineering electric and electronic, 81-85 mechanical, 77-81 services, 28, 74-85 equipment essential, 119-134 inventory, 141 maintenance of, 1, 119-186 management of, 135-138 medical, 119-186 procurement of, 13, 137-138 record, 154 selection of, 1, 13, 137-138 testing of, 142-143 evaluation of facilities, 91-92 of use of equipment, 137

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examples, 93-108 expansion, 13, 36--39 family planning clinic, 48 finish, 61, 175, 177 fire alarm system, 44 code, 26 protection, 14, 61, 78 resistance, 43--45 safety, 28, 42--45, 71 food, distribution of, 70 fuel, 77 garage, 73 gas, medical, 14, 61 service, 78 generator, 81, 84-85, 183-84 groundkeeper, 73 growth (see also expansion), 36--39 haematology laboratory, 59 health for all, I, 2 heating domestic, 14, 77, 79-80 so lar, 45--46 hospital at first referral level, 1, 2, 3, 4 human resources, 139-140 incinerator, 76 in-patient ward, 48, 68-{)9 intensive care unit, 66-{i7, 171 kitchen, 6, 43, 49 laboratory, 2, 59-{) 1, 132 equipment, 156--171 lagoon, 75-76 landscaping, 14, 31-32 laundry, 6, 14,28, 49, 55, 71 lead shielding, 175, 181 lift, 35, 45, 72 lighting, 14, 46, 82, 83, 177 lightning protection, 82 linen, 71 L-shaped ward, 69 maintenance, 6, 49 area, 72-73 requirements, 149-152 workshop, 73, 149, 151 microbiology laboratory, 59 mobile services, 55, 130 morbid anatomy laboratory, 59 mortuary, 49, 73 motor pool, 49

Nightingale plan, 68 nursery, 49, 67-{)8 obstetrics, 6 operating department, 63, 170 operating theatre, 62-66 location of, 48--49 number of, 14, 62-{)3 orientation, 31 out-patient department, 48, 55-56 paediatrics, 6 patient movement, 27, 33-35, 64 percolation, 20, 75-76 performance bond, 92 pharmacy, 61-{)2 planned preventive maintenance, 141-144, 155-171 planning methods of, 11-17 team, 11-13 plot ratio, 30 primary health care definition of, 1 implementation of, 2 in district health system, 3, 4 support, 48, 53-55 project manager, 87-88 management, 87-90 putrefaction, 75 radiology department (see also x-ray department), 6, 57-58 race-track plan, 69 reception office, 65 records, medical, storage of, 57 recovery room, 66, 67-68 relatives, 69, 109, 111-114 retention money, 90 room planning requirement, 65-{)6 safety, 143-144 scrub-up, 65 security, 14, 28, 33, 61 sewage, disposal, 20, 24, 75-76 sewerage system, 75-76 solid waste disposal, 76 staff changing room, 65 facilities, 49 movement, 27, 33-35 number of, 14

Index

189

stairs, 35, 44 sterile supply department, central 55, 62, 63 sterilization, 14 sterility, 63, 64 storage facilities, 49, 71-72 anaesthesia, 71 central, 6, 72 fuel, 73 furn iture, 71 pharmacy, 71 records, 71 sub-clean-up, 66 supply, delivery of, 14, 27 surgery, provision of, 6 T-shaped ward, 69 tendering, 86-7 tertiary care, 7 traffic flow, 33-35, 61, 64 transport, 6

tray service, central, 70 trolley instrument, 64 manoeuvring, 34 parking, 34, 66, 72 ultrasound, 57-58,130-131,185-186 ventilation, 14, 78, 79-80 ward, forms, 68-69 waste, disposal of, 6, 14, 28 water supply, 7, 14, 20, 61, 74-77 x-ray department, 48, 57-59 equipment, 58, 122-134, 155-156, 172-84 room, 58, 173-175 zoning, 25, 53

Key facts

Organisation World Health Organization (WHO)

Document type Publications

Adoption date December 31, 1996

Source World Health Organization