Hospital ManagementOPD, ER, Wards

Session IV

Wednesday, February 15, 2012

Dr. Ashfaq Ahmed Bhutto MBBS, MBA, MAS, DCPS, MRCGP, (PhD)

OUTPATIENT CLINICSModule 1

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Acknowledgement

This document is intended to be used as a guide.

Adopted from Department of Veterans Affairs Ambulatory Care Service, the Department of Veterans Affairs Veterans Health Administration

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Patient flow in OPD

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ACCESSIBILITY Outside Accessibility

Walks Free of steps or abrupt changes of level. Minimum width of 5’ -0”. Maximum gradient of 1:33 (otherwise considered a ramp). Cross slopes no greater than 1:50. Walks with gradients of 1:50 to 1:33 have rest areas every 200’. Changes in level are blended to common levels by grading,

curb cuts or ramps. Firm, nonslip surfaces Free of gratings, manholes, etc. Level platforms (minimum of 6’-0” x 6’-0”) at doors. 2.

Hazards Accessible paths of travel are free of hazardous side

protrusions.5

ACCESSIBILITY

Curb Ramps Provide wherever a walk

crosses a curb. Located or protected to

prevent obstruction by parked vehicles or street

Furnishings. Maximum slope, 1:20 Minimum width, 4’-0”. Smooth transition from curb

ramp to street or grade level.

Firm, slip resistant surface.

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ACCESSIBILITY Ramps

Maximum slope, 1:20 Slope of 1:33 to 1:24: ramp no greater than 40’ in length. Slope of 1:25 to 1:20: ramp no greater than 35’ in length. Cross slope no greater than 1:50. Minimum clear width, 4’-0”. Top and bottom landings are at least 5’0” long. Intermediate landings at least 35’ or 40’ intervals are at least 5’0” long. Where doors swing onto a ramp landing, the landing is level an at least 6’-0” x 6’-0”. Where required, handrails are installed on both sides. Handrails are mounted at a height of 2’-9” and extend 1’-0” beyond beginning and

end of ramp. Firm, slip-resistant surface. Ramp curbs are at least 4” high by 4” wide.

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ACCESSIBILITY

Passenger Loading Area In a safe area and clearly

designated for passenger arrival and departure.

Close as possible to accessible entrance.

Zoned to prohibit parking. Ramped to sidewalk level. Access aisles, measuring at

least 5’-0” wide by 20’-0” long and parallel and level with the vehicle pull-up space.

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ACCESSIBILITY Parking

10% of total number of parking spaces accessible. Located conveniently to accessible entrances. Identified by accessibility symbols and routing signage. Spaces are at least 8’-0” wide with access aisles on each side. Spaces 11’-0” wide with 5’-0” access aisles for specially adapted

vans. Access aisles are at least 5’-0” wide with surface slope not

exceeding 1:50. Smooth transition from access aisle to adjacent walkway. Minimum clear width of adjacent walkways not reduced by

vehicle overhang.

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Inside Accessibility

Entrances All highly used entrances are accessible. They are connected by an accessible walk to accessible parking and public

streets. They are connected to all accessible elements (e.g. elevators and ramps) and

spaces throughout a building by paths of travel at 3’-8”. Signage at accessible entrances. Maximum opening force for interior hinged doors is 5lbs. Thresholds are flush with finished floor or beveled with a slope no greater than

1:2. Operating devices on doors are easy to operate with one hand. Knurled surfaces on operating hardware of doors leading to hazardous areas. Bottom rail (kickplate) is at least 1’-0” high. Automatic doors are used in high-use areas.

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OPD Entrance

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Inside Accessibility Floors

Firm and slip-resistant surface. Changes in level between 1/4” and 1/2” are beveled with a slope no greater than 1/2”.

(Changes in level up to 1/4” require no edge treatment). Changes in level greater than 1/2” comply with “Ramps”.

Carpet Carpet is securely attached and has a low-cut pile and tight weave.

Corridor Handrails 1 1/2” diameter. 1 1/2” space between handrail and mounting surface. Height of handrails, 2’-10”. Handrail sections are free of sharp edges. Wall surfaces behind handrails are smooth. Ends of hand rails are rounded. High and low bumper guards in equipment and W/C & Litter storage. Low bumper guards (just above base) at reception, interview counter & service windows

(agent cashier & pharmacy) to protect against W/C footrest.

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INTERIOR FINISHES

Interiors Design solution is consistent with the interior concept including

the users needs. Design solution reflects state-of-the-art health care design

including, but not limited to, color, textures, and patterns. Materials and finishes meet fire, safety, and accessible codes. Design projects a high quality of care and caring. Way finding system is developed to satisfy the orientation needs

of the first time user. Signage is a coordinated system and is appropriate, readable,

and directive. Space planning is appropriate to functions.

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EMERGENCY DEPARTMENT Module 2

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Emergency department

Emergency department (ED), OR Emergency room (ER), OR Emergency ward (EW), OR Accident & emergency (A&E) department OR Casualty department

ER in a hospital or primary care is a department that provides initial treatment to patients with a broad spectrum of illnesses and injuries, some of which may be life-threatening and requiring immediate attention.

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Signage

A hospital with an emergency department usually has prominent signage reading Emergency or Accident and Emergency (often in white text on a red background) and an arrow to indicate where patients should proceed.

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History-Emergency Medicine

During the French Revolution, after seeing the speed with which the carriages of the French flying artillery maneuvered across the battlefields, French military surgeon Dominique Jean Larrey applied the idea of ambulances, or "flying carriages", for rapid transport of wounded soldiers to a central place where medical care was more accessible and effective. Larrey manned ambulances with trained crews of drivers, corpsmen and litter-bearers and had them bring the wounded to centralized field hospitals, effectively creating a forerunner of the modern MASH units. Dominique Jean Larrey is sometimes called the father of emergency medicine for his strategies during the French wars.

Reference wikipedia

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History-ER

The first specialized trauma care center in the world was opened at the University of Louisville Hospital in 1911 and developed by surgeon Arnold Grishwold during the 1930s and '40s. University of Louisville was also the first hospital to have equipped police vehicles with medical supplies and trained officers to give emergency care while en route to the hospital. Arnold Grishwold also developed auto-transfusion.-Reference wikipedia

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1st step in ER

Millions of People visit an emergency room each year. This is a 24-hour-a-day, non-stop world of emergency medicine. A visit to the emergency room can be a stressful, scary event. Why is it so scary? First of all, there is the fear of not knowing what is wrong with you. There is the fear of having to visit an unfamiliar place filled with people you

have never met. Also, you may have to undergo tests that you do not understand at a pace

that discourages questions and comprehension.

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Emergency Room Patients

Car accidents Sports injuries Broken bones and cuts from

accidents and falls Burns Uncontrolled bleeding Heart attacks, chest pain Difficulty breathing, asthma

attacks, pneumonia Strokes, loss of function and/or

numbness in arms or legs Loss of vision, hearing

Unconsciousness

Unconsciousness Confusion, altered level of

consciousness, fainting Suicidal or homicidal thoughts Overdoses Severe abdominal pain,

persistent vomiting Food poisoning Blood when vomiting, coughing,

urinating, or in bowel movements Severe allergic reactions from insect

bites, foods or medications Complications from diseases, high

fevers

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Understanding ER

Triage Registration Examination Room Diagnostic Tests Diagnosis and Treatment

Emergency Physician Emergency Nurse Physician Assistant Emergency Department Technician Unit Secretary

Doctors in training Disposed off

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Basic requirements for emergency care

Beds in the right place Fully staffed emergency operating theatres Availability of properly trained staff and surgeons Availability of ICU beds

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Staffing requirement

There is a requirement for one consultant general surgeon for 30 000 population as per UK specifications.

A proud country should be capable of providing the surgical needs for a population of 450–500 000 as follows: General surgical units of 11 general surgeons 4 vascular surgeons Trauma and orthopaedic units comprising 15 consultants Department of 30 anaesthetic consultants.

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Functional flow in ER

A brief triage, or sorting, interview to help determine the nature and severity of their illness.

Individuals with serious illnesses are then seen by a physician more rapidly than those with less severe symptoms or injuries.

After initial assessment and treatment,ONE OF BELOW IS DONE

Admitted to the hospital Stabilized and transferred to another hospital for various

reasons Discharged

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Emergency Department Patient Flow Concept MapED to Wards

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ED Performance Reports

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Basic requirements for an emergency surgical service

Core specialties on site 24-hour clinical radiology and staffed emergency operating theatre ICU, coronary care, haemodialysis unit Consultant availability for the full 24-hours in the two main admitting

specialties of general surgery and trauma and orthopaedics in addition to acute general medicine and anaesthetics

Appropriate training arrangements.

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Critical conditions handled at ER

Cardiac arrestAdvanced Life Support Advanced Cardiac Life Support

Heart attack Trauma

Advanced Trauma Life Support (ATLS) There is critical time frame: commonly known

as the "golden hour." Asthma and COPD

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Core specialties required

Full anaesthetic service with ICU General medicine General surgery Gynaecology Paediatrics Radiology Trauma and orthopaedics Pathology and blood transfusion.

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Justification of dedicated team

Emergency surgical care, in all but the smallest hospitals, requires that the surgical team of consultant, specialist registrar and/or senior house officer, junior house officer and/or nurses should be free of all other programmed commitments for the duration of their emergency duties.

Ideally, there should be sufficient workload to: Justify the dedication of the team to emergencies Make good use of emergency daytime operating theatres both for

trauma and general surgery Enable a separate vascular surgical rota from the general surgical rota.

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Essential of ER design

High visibility Flexibility Greater efficiencies Disaster planning Security Patient care Collaboration

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Department layout

A typical emergency department has several different areas, each specialized for patients with particular severities or types of illness.

The triage area The resuscitation area The majors, or general medical area A pediatric area

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ER waiting area

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Hallway

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Triage

Triage is a system used by medical or emergency personnel to ration limited medical resources when the number of injured needing care exceeds the resources available to perform care so as to treat those patients in most need of treatment who are able to benefit first.

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History of triage

The word triage is a French word meaning "sorting", which itself is derived from the Latin tria, meaning "three".

The term has historically meant sorting into three categories, although this is no longer necessarily the case. The credit for modern day triage has been attributed to Dominique Jean Larrey, a famous French surgeon in Napoleon's army.

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START (Simple Triage and Rapid Treatment)

START is an expedient triage system that can be performed by lightly-trained lay and emergency personnel in emergencies.

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Triage

Triage separates the injured into four groups:

DECEASED: who are beyond help IMMEDIATE: the injured who can be helped by transportationDELAYED: the injured whose transport can be delayed MINOR injuries: The walking wounded who need help less urgently.

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INDOORModule 3

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Core bed requirement

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Space allowances for the single room and 4-bed room from the schedules of accommodation

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The Nightingale ward

This is an open-plan wardcontaining 25-30 beds. Services are located at either end of a long, rectangular ward; staffsupervision is in the aislebetween the two rows of beds. This is the noisiest type of ward.

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Straight, single-corridor ward

This simple layout has manyadvantages: all of the rooms canbe lit and ventilated naturallythrough windows. Service roomsand the nurses' station arecentrally placed, and distancesare minimized. Staff can seedown the full length of thecorridor, making supervisioneasier than in other forms. Theywill know where other staff areworking and can callthem quickly in an emergency.

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L-shaped ward

In this layout, the patient beds areon the two legs of the L, and thesupport services and staffsupervision are on the junction.Services and supervision areconcentrated at the entrance, withminimal penetration into the Patient areas.

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The race track

In this type of ward, the patientareas are laid out at the peripheryof a deep rectangle, and theservices and staff areas are in themiddle. Patients are given a view,but the staff has no view (andperhaps no ventilation when theWARD central air-conditioning isnot working!). Staff have longdistances to travel, andcommunication between them isdifficult.

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The cruciform plan

In this plan, the patient roomscomprise a peripheralarrangement, and the supportand supervision areas are laidout at the intersection of thearms. This form results in a lotof cross-traffic. It is used indouble wards, where there aretwo separate ward units butonly one set of supervisorystaff.

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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.

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Space to transfer a patient to and from a bed

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Thank You

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