HOSPITAL DESIGN AND PATIENT SAFETY

By Dr. Bidhan Das

I am convinced that designing a building around safety will create a culture of safety.
-JOHN REILING, PRESIDENT AND CEO ST. JOSEPHS
COMMUNITY HOSPITAL AND Synergy Health

WE SHAPE OUR BUILDINGS AND AFTERWARDS OUR BUILDINGS SHAPE US.

-WINSTON CHURCHILL, MAY 10, 1941

How Infrastructure Is Related to Safety?

 Infrastructure usually forms the starting point in the journey to ensure safety. It is more important in a hospital setting because of incapacitated patients Safety. Changing role of hospitals is likely to be a major factor in future. Proper planning of the expected role/ functions of the hospital is essential.

ROLE OF INFRASTRUCTURE IN SAFETY..

Hospitals: very complex organization
Deals with LIFES Need to control the flow of customers Need to Control Infections Need proper planning as sterilization has to maintained in some Departments like in CSSD , OT , ICU Need to avoid crisscrossing and unidirectional flow of traffic. (staff, Patients, Sterile items, nonsterile items, kitchen and food flow, store items, Biomedical waste)

 Generally have high levels of occupancy Usually patients are temporarily incapacitated, need help in moving about Extra work load & specific role in disasters Imperative need for flexibility & expandability Environmental issues are must to be considered.

PLANNING AND BUILDING A NEW HOSPITAL

HOSPITAL SAFETY = PATIENT SAFETY ??

Hospital Safety
The degree to which the risk of an intervention/ procedure, in the care environment are reduced for a patient, visitor and health care providers

POOR HOSPITAL DESIGN EFFECTS

The negative effects of Poor hospital design:  Psychological  Physiological  and behavioral Poor air quality and ventilation are major causes of Nosocomial infection. Inadequate lighting is linked to patient depression as well as to staff medication error

We then ask ourselves several Questions?

How and via what mechanisms does the physical environment participate in patient safety? How does the environment of the peri-operative system effect safety? What exactly is the peri-operative environment? What characteristics are used to describe an environment? What process creates the physical environment? Is it possible to change either the creation process or the result to improve safety

MICRO PLANNING CONSIDERATIONS

A. PHYSICAL FACILITY 1. Scales Of Accommodation 2. Electrical System 3. Ventilation 4. Water Supply 5. Plumbing 6. Refrigeration 7. Landscaping 8. Gas Supply 9. Elevators / Lifts / Dumbwaiter 10.Telephone / Epabx 11.Fire Fighting

12. Waste Disposal 13. Hospital Space Module 14. Engineering Grid 15. Ward Area oPrimary--- Ward Unit oAncillary--- Nursing Station, Duty Doctor,Treatment Room. 16. Sanitary---- Toilets, Dirty Utility. 17. Auxiliary--- Pantry, Store, Clean Utility. 18. Corridor 19. Floor Height 20. Head Room

19. Windows 20. Floor 21. Walls 22.Doors 23.Light, Power Sockets 24.Stand-by Generator 25.Ventilation Built-up Area : Plot Area FSI = 1:1.73

MICROPLANNING Contd...
Air- Conditioning Requirements in Specialized OT

Air Changes Per Hour: Minimum total air changes should be 30 The fresh air component of the air change is required to be minimum 5 air changes out of total minimum 30 air changes. If HCO chooses to have 100% fresh air system than appropriate energy saving devices like Heat Recovery Wheel, Run Around Pipes etc should be installed.

MICROPLANNING Contd...
Air- Conditioning Requirements in Specialized OT

Air Velocity: The vertical down flow of air coming out of the diffusers should be able to carry bacteria carrying particle load away from the operating table. The airflow needs to be unidirectional and downwards on the OT table. The air velocity recommended as per the international and national guidelines is 90-120 FPM at the Grille/ Diffuser level.

MICROPLANNING Contd...
Air- Conditioning Requirements in Specialized OT

Positive Pressure There is a requirement to maintain positive pressure differential between OT and adjoining areas to prevent outside air entry into OT. The minimum positive pressure recommended is 15 Pascal (0.05 inches of water) as per ISO 14644 Clean Room Standard.

MICROPLANNING Contd...
Air- Conditioning Requirements in Specialized OT

Air Handling in the OT including air Quality:

Air is supplied through Terminal HEPA filters in the ceiling. The minimum size of the filtration area should be 8 x 6 to cover the entire OT table and surgical team. The air quality at the supply i.e at grille level should be Class 100/ ISO Class 5 (at rest condition). Class 100 means a cubic foot of air must have no more than 100 particles measuring 0.5 microns or larger.

MICROPLANNING Contd...
Air- Conditioning Requirements in Specialized OT

Temperature and Humidity The temperature should be maintained at 21 +/- 3 Deg C inside the OT all the time with corresponding relative humidity between 40 to 60% though the ideal Rh is considered to be 55%. Appropriate devices to monitor and display these conditions inside the OT may be installed.

MICROPLANNING Contd...
Air- Conditioning Requirements in Specialized OT Air Filtration: The AHU must be an air purification unit and air filtration unit. There must be two sets of washable flange type pre filters of capacity 10 microns and 5 microns with Aluminum frame within the AHU. The necessary service panels to be provided for servicing the filters, motors & blowers. HEPA filters of efficiency 99.97% down to o.3 microns or higher efficiency are to be provided in the OT and not in the AHU.

MICROPLANNING Contd...
Air-conditioning
ICU Air-conditioning
 50-60% humidity  20-25C temp

Ventilation
 10-15 air changes / hr- Fresh air  Positive air pressure maintained

MICROPLANNING Contd...
B . LEGAL & REGULATORY COMPLIANCES Hospital should have all the Licenses as per the Countries Law C . HUMAN POWER As per the workload /norms the Hospital should have its Human Power so that it is able to meet the Customers Expectations .

MICROPLANNING Contd...
D . EQUIPMENTS I. AMC/CMC II. Technology commensurations to services III. Calibration and traceability to international standard. IV.Statutory Obligations

DESIGN CONSIDERATIONS
Noise reduction Scalability, adaptability, flexibility Visibility of patients to staff Patients involved with care Standardization Automate where possible Minimize fatigue Immediate accessibility of information, close to the point of service.

ELECTRICAL SAFETY
Electrical devices shall be protected from wet floors. Frame of all electrically operated machinery shall be grounded. If a "shock is felt" , immediately remove from service, and report to the facility Department Switch to "off" position before connecting or disconnecting. Do not disconnect the plug from the wall by grasping the power cord. Remove from service device that has been dropped, abused, had liquid spilled on it or has evidence of overheating. Discontinue use if any wire or power cord shows fraying, extreme wear, cut in insulation or evidence of burning. Preventing overload

ELECTRICAL SAFETY

Areas around electrical switchboards kept clear for a distance of at least 1 meter. Fire extinguisher adjacent to electrical switchboards.

CHEMICAL SAFETY
Safe storage Safe Transportation Disposal Accidental exposure

FIRE SAFETY
Preventive measures:
Use of non combustible materials in load bearing elements, stairways & corridors Electrical wirings in separate ducts, sealed on alternate floors with NC materials All heating appliances used with proper amperage Proper storage & segregation of combustible & explosive materials Regular formal periodic inspection of exits, detectors & extinguishing systems.
National Building Code,2005

FIRE SAFETY..
Detection & Alarm systems:
Fire, Smoke, Heat, Flame detectors are available for installation Newer generation systems are wiser Addressable systems allow precise location of fire, hence better control Intelligent systems (2nd level) have automatic alteration of sensitivity threshold level between alarm & non alarm

FIRE SAFETY..
Restriction of Spread of fire:
Unit based construction, rooms with 2hrs FR* Structural frame: fire resistance of 2hrs Smoke stop doors between galleries, wards with FR of min 30 minutes, swing type opening in direction of escape A/c ducts should have dampers at inlet in plant, fire wall, entry to vertical shaft, outlet duct on all floors/compartments At least 2 areas of refuge in each horizontal plane Floor assembly (RCC) should have FR of 2hrs * FR- Fire Resistance

FIRE SAFETY..
At least 2 fire exits(2m x2m) in an area 500 meter square Corridors min 2.4mts wide, clear of obstruction, sign posted Life risk areas should be separated from hazardous service areas High fire hazard areas in separate structures with 2 hrs FR construction materials For buildings more than 24mts high, more refuge area(@0.3sq m/person )

FIRE SAFETY
Fire extinguishing systems:
Different for all types of fires Entire complex surrounded by network of hydrants 30-60 mts apart Wet riser system kept charged, 1 riser for floor area of 1000 sq mts Exclusive UG tank having:
50,000 - for up to G + 2 floors 100,000 - for 15-24mts high buildings 150,000 - for buildings 24-30 mts high
National Building Code, 2005

SEISMIC FACTORS
Structural & non structural components DBE: EQ which can reasonably be expected to occur at least once in life MCE: refers to EQs most severe effects Zone factor(Z) to obtain the design spectrum on max seismic risk by MCE in the zone where hospital is located India is divided into 4 seismic zones (II,III,IV,V) depending on probability of occurrence of EQ

SEISMIC FACTORS
General principles & design criteria:
Horizontal seismic forces are more important for consideration Design should be such that it has minimum strength to withstand all minor(<DBE) earthquakes, resist mod EQs (DBE) without structural damage, aims at withstanding MCE without collapse Simple designs are better than complex/irregular designs In longer buildings, seismic expansion joints at 30mts intervals is desirable.

SEISMIC FACTORS
General principles & design criteria
Avoid concentration of mass at higher floors Avoid soft storey- more vulnerable to damage Measures to reduce structural vulnerability:
Retrofitting by adding diagonal bracings Adding buttresses, moment resisting frames Base isolation techniques

CONCLUSION
World-wide patient safety issues are presently in the limelight. If this is overlooked/neglected, one may have to pay a very heavy price for consequences.

Thank You !