Experts in health care facility design suggest ways in which biomeds can be involved in planning and designing cardiac cath labs, both freestanding and in hospitals and clinics.
Following an architectural study designed to increase procedures, a radiology department director gives up her office in an effort to make room to meet the growing demand for ultrasound studies. After the remodeling, two new ultrasound machines are delivered and placed in the beautiful new ultrasound area. The new waiting area is lovely, the dressing rooms are finally big enough, and the hospital is very happy with the project. A month later, the department purchases two large fans on tall stands to put in each of the new rooms. The biomed department was not involved in the renovation planning.
Although the designers looked at the existing ultrasound machines and the patient tables to see that a 150-sq-ft room was large enough, they never considered that the machines produced 6,000 watts of heat and that the exam room doors were always shut to keep the rooms dark during exams. The equivalent of four 1,500-watt hair dryers running continuously in the closed rooms all day long made the patients and the staff very uncomfortable. With timely technical information, the remodeling project would have addressed the need for increased air-conditioning from the previous director’s office requirements.
As this story demonstrates, health care is constantly changing, and providers are continuously evolving care delivery to make it more efficient, convenient, and focused on patients’ well-being. These changes impact how the users of the facility ensure it is operational, functional, and optimally maintained; and they affect the design and process of how the facilities are created. That is why the insight of biomedical, radiology, and clinical engineers can be like a shot in the arm for health care facility designers. Ideally engaged as team members early in the process, their input adds value during programming and design and throughout the remaining phases of the project.
This technical input benefits the project’s design and construction process by helping the project meet the schedule and budget. Knowing what is needed up front reduces design revisions and construction changes. During the move-in and start-up phase, the input benefits the health care organization by helping to ensure that the equipment will fit and will work the first time it is plugged in. When the facility is being “operationalized,” the input helps ease the transition to a different facility, both by eliminating anxiety of new personnel and moving equipment into the space. It can prevent cost increases by controlling oversights that result in costly and inconvenient changes after construction is complete. Further, having input can improve the function of the facility. It eliminates costly operational inefficiencies that become extremely difficult, even cost prohibitive, to change. A facility designed for its users aids in recruitment of talented staff, which is in short supply.
The benefits are clear. The key word is early. Biomedical, radiology, and clinical engineers should be brought in early in the process to take advantage of these benefits. Obviously, knowing what types of patients that will be seen and the various uses of the facility—whether dedicated or multiuse—will affect design. Additionally, there are some areas that need to be considered when designers collaborate with biomedical, radiology, and clinical engineers.
Emergency power. Providing backup power is essential in health care facilities, where patients’ lives can be at stake. Requirements may vary between hospitals and outpatient centers, so the design team must determine which guidelines to follow. The building services to be maintained during an emergency need to be identified, as does the proper source for emergency power.
Heating, ventilating, and air-conditioning (HVAC) requirements. Determining HVAC needs for outpatient centers generally relates to patient procedures. Cath labs are becoming more like operating rooms with similar air change and filtration requirements. Linear accelerator and MRI rooms, on the other hand, have HVAC needs that are closer to those of an exam or minor procedure (noninvasive) room.
Hours of operation. For freestanding, outpatient facilities that do not operate 24/7, evening and weekend shutdowns affect system design. “Night set-backs” on the main systems are generally preferred, but some equipment or electronically intensive areas may have continuous cooling needs.
Plumbing systems. Providing domestic water and fire-protection systems is usually straightforward. Depending on specific site conditions, however, water pressure and/or flow rates may be issues. A booster pump for domestic water and/or a fire pump for fire-protection systems can resolve these issues. Specific equipment requirements should be reviewed, especially for washer/sterilizers and other high flow-rate units.
Wiring requirements. Special care is needed to provide adequate protection between power, control, and data wiring. Interference from one—generally power surges from motors—can adversely affect the others. Shielding is required to prevent the electronic interference between these systems.
Building-design standards. Unlike a hospital, freestanding outpatient facilities are not institutional buildings, so they cost less to construct. This can, however, lead to issues with vibration, floor loading, roof structure, sound insulation, and power systems. Input helps determine what equipment will be used and how these elements impact the design.
Work rooms/support space. It seems obvious, but the design team needs to know how the clinical engineers are going to use work rooms, control rooms, and support space so the areas are properly sized and adjustments do not have to be made after moving in.
Space configurations. Rooms, corridors, and door openings will have to be configured so it is easy to go out with the old and in with the new for replacements and upgrades. A large piece of equipment may require knock-out panels, removable skylights, or large doorways.
Clearances. Accurate space requirements are needed for movable and fixed equipment. For example, the design team may provide clearance for a typical piece of equipment, only to discover the actual requirements result in modifications to the new casework.
Ownership Models and Service Contracts
Design-process decisions. The design firm needs to understand the roles and responsibilities of various decision-makers so that the project is managed appropriately throughout the process. Even though biomedical, radiology, and clinical engineers are rarely able to control the ownership model, it is important for all members of the project team to understand it. One missing link can delay a project, which affects everyone involved.
Maintenance. The owner also drives who is required to maintain the building. When the project moves from design to reality, the project team will work with the maintenance team to help familiarize them with procedures in preparation for move in, since different procedures can impact equipment.
Equipment and Material Selection and Evaluation
Performance history. Biomedical, radiology, and clinical engineers know better than the designers how certain pieces of equipment work. Their input helps drive decisions on what equipment to purchase so that the design accommodates the features of the equipment used.
Standardization. When new equipment is being purchased, an informed decision needs to be made as to whether it maintains the established standard vendor in the facility. For staff training and equipment service, maintaining an established standard vendor is important. In some cases, new equipment purchases are opportunities to begin correcting problems with an obsolete standard. In cases where an additional product is purchased that does not maintain an established standard or does not begin a transition to a new and better standard, then the new purchase creates additional problems with training, maintenance, and supply requirements.
Equipment reputation. Like performance history, this aids in deciding what equipment to purchase, which relates to design. Warranties and service responses are taken into consideration to determine what equipment is the best fit for the health care facility.
Life-cycle costing. In freestanding facilities, life cycles of materials and products may be different from those in a hospital. The team will go over the different options of materials and products to make sure the life cycle is appropriate for the building and equipment use.
Regulatory Agency Requirements
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other regulatory agencies. When designing a full-service hospital, following JCAHO or similar requirements is inherent. These requirements should also be considered in the outpatient setting using a checklist of both facility and operational items.
Emergency protocols. These become increasingly important in a freestanding outpatient setting, since the buildings are often located several miles from a hospital campus. If a patient needs to go to a full-service hospital, how will they exit the building in a discreet manner, away from public spaces?
Code-blue team. Within the unit, a code-blue team should be set up, and everyone should know what to do if there is a problem with a patient. Where should defibrillators, code carts, and other emergency equipment be located?
A Case in Point
The increase of outpatient cath lab centers is one example of a changing paradigm in health care delivery. Remote, freestanding outpatient cath lab centers have different objectives in terms of design, technical, and operational issues than do cardiology facilities attached to hospitals or clinical services provided within a hospital.
For a freestanding outpatient cath lab facility in central Illinois under design, input from the clinical engineers has been vital. In fact, one of the team members from an affiliated health care planning firm specializes in equipment planning and is a certified clinical engineer, adding great value to this project.
The technical design of this facility does not rely on the function of the existing hospital-based cath labs and their equipment, but rather on the use of equipment specifically configured for routine procedures with high throughput and rapid reuse. Limiting unnecessary components reduces initial cost, service contract costs, and potential failure of unnecessary features. The patient holding, recovery, and monitoring areas are also revised to reflect the level of monitoring provided for outpatient-only procedures.
St. Francis Hospital and Health Center’s cath lab, Indianapolis.
Another project, a new cardiac and vascular care center attached to the Indianapolis campus of St. Francis Hospital and Health Centers, houses six cath labs: two EP, two coronary, and two mixed coronary/vascular labs.
Executive Director Tom Malasto emphasizes that having technical experts involved at the earliest stages of a project is a cornerstone to a successful effort.
“In today’s health care environment, technology plays a critical role in the clinical outcome and patient experience like never before. Our technical experts represent a significant component of our patient-care teams,” says Malasto.
George Gladding, CBET, St. Francis Hospital and Health Centers, has been closely involved in the planning committee for the new cardiac and vascular labs.
Gladding says that it is important for hospitals to use their team talents to plan ahead for construction projects. The hospital benefits financially. They save money by being able to make wiser decisions and avoid “overbuying” on service contracts.
“Involving technical experts in a planning committee has a high return to all involved, from the physicians, nurses, and technicians to the patients,” Gladding says.
It is also important for the mentality to change. Instead of viewing clinical engineering as the people to call only when “something is broken,” having them as part of a team can help prevent some of the problems and resolve them sooner. Having clinical engineering involved in the team helps build trust and improve communication between all involved.
Being equipped for the future means adjusting to not only the changing models of outpatient care, but also to the changing care delivery within a hospital.
For example, in south-central Indiana, a traditional 1976 operating room suite is being revised for a minimally invasive surgical practice. In this project, three 400-sq-ft general operating rooms are being converted into two specialty rooms for minimally invasive surgery. When this facility was built, minimally invasive surgery did not exist. With its introduction in 1990 for the rapid removal of the gall bladder, it has radically redefined general surgery. Today, the majority of general surgical cases involve the use of video endoscopy systems for any surgery involving internal organs. Through use of overhead equipment booms configured with the specific medical equipment needed for these surgical procedures, two 600-sq-ft rooms are going to achieve 50% higher efficiency than the three rooms that are being replaced. This will be achieved because each of the new rooms will be able to eliminate nonsurgical time to a point where each new room will schedule twice as many cases per day as the rooms they replace. This is only possible by selecting proper equipment that can be used in every case, without unnecessary room set up and takedown between patients.
Timely input is important to the success of a construction or renovation project, no matter what type of health care is delivered. Keeping these points in mind will help make sure that health care projects result in a facility that works for all who use it.
Kevin L. Downey is principal, BSA LifeStructures, Indianapolis.
Gary L. Vance is associate principal and director of planning, BSA LifeStructures.