Hospital Operation Chapter 3

Medical Care System

 Learning Objectives
• OPD: Location, space requirement, waiting time,
ancillary facilities
• Casualty: Location, types of emergency services,
staff
• Disaster preparedness
• ICU: Types, staffing, essential equipment
• IPD: Types, activities, staffing, ancillary services
• O.T. : Layout, zones, sterilization, scheduling,
management
 Importance
• Reduce morbidity, mortality-stepping stone to health
promotion and disease prevention
• Reduces the no. of admissions
• Ensures only those who need inpatient care are
admitted
Demand:
• No. of outpatients visits/person/year from
population living in the formal catchment area of the
hospital
• Re attendance rate / new outpatients registered
• Proportion of pregnant women attending antenatal
clinics
 Location
• Independent approach to entrance of the
hospital, on ground floor for easy access
• Close to registration, casualty, laboratory,
radiology, pharmacy
• OPDs of all specialties in the same building for
cross reference
• Kept close when not used
Lay out of OPD
 Functions:
 Provide Specialist diagnostic specialist opinion
 Treat ambulatory patients
 Screen patients for hospitalization
 Follow up of discharged patients
 Provide primary healthcare
 HE
 Immunization
 Well baby clinics
 ICTC
 Training & education of medical, paramedical & nursing staff
 Collection, compilation analysis of medical records
 Functions as sentinel surveillance centre for disease control
 Epidemiological study of diseases
 Flow chart of OPD in a hospital
Radiology, pathology, pharmacy,
Blood bank, ECG, EEG, Physiotherapy

Pharmacy, ICTC, ANC

Consultations, Injection Room,
Dressing room, Immunization clinic
Medico social worker
Plaster rm, minor surg. Proced.

Consulting Consultants
Administrative
Chamber of offices
area
doctors

Sub-waiting area OPD Sub-waiting area

Public relation Billing counter Admitting

Medical Office
Records Enquiry
Department Information Waiting area Public utility
Registration services
appointments

Outpatients
Physical facilities of OPD of a hospital

Clinical area

Patient Admin.
area OPD area

Circulati
on area
 Patient’s area
1. Entrance
2. Reception
3. Registration
4. Record room
5. Desks
6. Waiting area
7. Public utility service
8. Snack bar
9. PCO
10. Audiovisual material
11. Mobile charging facility
12. ATM
13. Locker room/cloak room
 Clinical area
Sub-waiting area Laboratory
Consultation room Radiology
Special examination room Blood bank
Injection room Health education
Dressing room Medical and social work
Minor OT Counseling services
Plaster room/ Cast room Physical medical rehabilitation
Pharmacy
 Administrative area
• Administrative office-15 sq. meter for 100
bedded hospital
• Business office
• Housekeeping area
• Store room for
General store
Drug store
Linen store
 Circulation area
• Stairs
• Corridors
• Lifts
• Conveyer belts
 Equipments
Wheel chairs Examination coach
Stretchers Wash basin
Work tables Instrument trolly
Physicians desks Equipments for resuscitation
Wall mounted cabins E.C.G. Machine
X ray view box Portable X ray machine
Revolving stool Ultrasonography machine
Chairs E.E.G. Machine

Staffing
• Medical staff
• Nursing staff
• Paramedical technician, security, clinical, housekeeping
• OPD in charge with his secretariat
• PRO
 Control of overcrowded OPD
• Automation, trained staff, new time management
techniques
• Dedicated full time doctors
• Displaying map of the hospital at the entrance,
signages, close location of diagnostic
departments
• Better scheduling
• Efficient billing and front office staff
• Proper flow, I.T.
 Control of overcrowded OPD
• Screening and disposal of minor illness patients
by general duty doctors
• Special clinics at different timings
• Individual or block appointment systems
• Applying queuing theory
• Synchronize functioning of ancillary facilities with
OPD workload
• Increasing the hours of OPD services, even
evening OPD services
 Public relations
OPD timing
Overcrowding
Appointment system
Queue jumping
Managerial issues Citizen’s charter
Absenteeism
Quality management
Computerization
Grievance redressal system
 Evaluation
• Volume of work performed
a. Clinic/department-wise statistics
b. New patients/follow up patients
c. Trends of patients attendance i.e.
seasonal/monthly
d. Utilization rates of clinics
e. Tests performed
f. OPD procedure
 Evaluation
• Utilization statistics
a) Average no. of visits per person per year
b) Age/sex/race/geographical distribution of
population
• Visit level
a) New appointment
b) Walk in appointment
c) Immunization
d) Antenatal clinics
• Cost and revenue
a) Direct patient cost like salaries, cost of supplies
b) Indirect patient cost like utilities, housekeeping etc.
Casualty
 Location
• Ground floor
• Direct access to the main road
• Adequate space for vehicles
• Separate entrance, close to admissions,
medical records, cashier’s booth
• Close to radiology
 Types of Emergency Care
• Agencies and organizations( both private and
public)
• Communication and transportation network
• Trauma systems
• Rehabilitation facilities
• Highly trained professionals
• Informed public
• Govt. EMS: Fire and Police
• Voluntary
• Private Ambulance Service, hosp. based
 Functions of emergency department
• To provide immediate lifesaving medical care
• To provide emotional support to patient and his relatives
• To take care of medico- legal aspects of the patient-liaison
with police
• Communication with media-disasters, VIP Patients
• Education, training, research
• To provide transport services both intramural and extramural
Types of emergencies:
 First-What must be done within few minutes
 Second-what must be done within 6 hours
 Third emergency- what must be done within 24 hours
Types of emergency services: Major-teaching hosp.; Basic-all
hosp.; Standby-PHC; Referral-First aid given, referred
 Planning of emergency services
• Easy access to people, vehicles
• Separate access to ambulance, reserved ambulance parking
• Resuscitation arrangements-pre hosp. and in hospital
• Close watch and medical supervision of patients
• Special protection for violent patients
• All amenities / comforts for patients waiting area
• Demarcated triage area/ well equipped emergency OT
• Effective communication system-specialist, transport,
investigations
• Effective disaster management program; Adequate staffing
• SOPs to minimize errors; Security and safety of pts., staff
• Teaching, training, evaluation system
 Patient’s area
1. Reception
2. Trolley bay
3. Waiting area
4. VIP ROOM
5. Space for security, staff, police, ambulance
6. Public utility service
7. Coffee and Snack bar
8. PCO, Fax, computer, broad band,
photocopiers
9. Pharmacy
 Clinical area
Trauma room Janitor’s closer
Examination and treatment Duty room for residents, house
room officers, interns
Triage area for screening and Lockers for staff
quick segregation of patients Seminar room, meeting room
Staff works area Room for anesthetist
Nursing station
Emergency ward with adequate
no. of beds
Storage area for drugs, linen
Toilet for patients
 Administrative area / Circulation
• Accommodation for CMO, duty officer, consultants
• Office for sister i/c of casualty
• Office for assistant/ deputy medical superintendent
or i/c Casualty
• Administration office
• Accommodation for APRO/ PRO of casualty

Circulation: Ramps, corridors, conveyer belts, lifts for

easy and smooth flow of staff, patients, visitors,
supplies.
 Equipments
Centralized piped oxygen, suction Cut down set for IV Line
supply

Airways, outlets, resuscitation bag Utility table, emesis basin, kidney tray

Manometer-portable and wall Slit lamp, loupe ENT equipment

mounted

Defibrillator Equipments of OT

ECG machines and monitors Adequate no. of trolleys, wheelchairs,

stretchers

Pulse oxymeter Portable X ray, USG, CT/ MRI, Endoscopes

Nebulizer, ambubag, vent mask, Well equipped path. laboratory

spacers

IV fluids, drip stand, catheters Sufficient bandages, cotton, plaster, drugs

 Staffing/ other requirements
• Medical manpower: physicians, surgeons, orthopedic,
pediatricians, anesthetist, CMO, intern, house officer,
residents
• Nursing: full timenursing staff
• Para medical staff: ECG technician, OT technician,
physiotherapist, lab. Technician. Radiographer
• Group D and C staff: ward boys, safai wala, chawkidar, drivers,
security personnel, clerical staff
• Polices/ Procedures-SOPs
• Ambulances with equipments and efficient team
• Record maintenance*medico legal requirements
• Referral policy
• Disaster preparedness
• Code blue procedure- announce emergency
 Physical facilities for 200-300 bedded hospital
Name of facility No. Size in ft. Area in sq. ft.
Main entrance 1 8 * 10 80
Waiting area 1 20 * 20 400
Reception 1 -
Examination cubicle 4 80 * 4 320
Observation ward 10 84 sq. ft. 840
Emerg. X ray room 1 12 * 15 180
Emerg.lab. 1 12 * 15 180
Treatment room 1 12 * 15 180
Fracture/ plaster r 1 12 * 10 120
 Physical facilities for 200-300 bedded hospital
Name of facility No. Size in ft. Area in sq.ft.
Doctor’s room 1 240 240
Nurses duty room 1 12 * 10 120
ECG technician’s rm 1 12 * 10 120
Room for Gr. C & D 1 12 * 10 120
Store room 1 12 * 10 120
Staff toilets & urinals 2 8 * 10 160
Water cooler 1 - -
Police post 1 12 * 15 180
Pts. Toilets & urinals 1 12 * 15 180
 Maintenance of records
Records are required for:
 Court case
 Compensation to injured patient
 Insurance
 In the event of complaint
 Medical audit
Records maintained in casualty
• Case register-all patients
• Register for medico-legal cases
• Police intimation register
• Call book –to ask for services for different specialty doctors
• In/out register for resident doctors
 Evaluation
 No. of visits
 Average length of visits
 Variation to peak and lean period
 Seasonal trend of attendance
Medical audit:
 Completeness, adequacy and accuracy of records
 The correctness and substantiation of the final diagnosis
 Errors in diagnosis and management of cases
 Case of complication
 Cases of death
 Quality of record maintenance
 Investigations which should be avoided/ where indicated
could not be done-reasons for not doing
 Polices, procedures, ambulance, record maintenance, referral
policy, medico-legal case, disaster preparedness,
 Grievance redressal system-pts., visitors ( CPA)
 Disaster Preparedness
• Identified Disasters:
 Floods and Drainage Management
 Earthquakes
 Dam failures/ Dam bursts
 Biological Disasters/ Epidemics
 Cattle Epidemics
 Nuclear Disasters
 Fires- forest, urban, rural
 Serial Bomb blasts
 Air, Road, rail Accidents
 Food poisoning
 Health objectives of Disaster
Preparedness
• Prevent morbidity and mortality
• Provide care for casualty
• Manage adverse climatic and environmental
conditions
• Ensure restoration of normal health
• Protect staff, public health and medical assets
 Disaster Mgt Approach in Hospital
• Discharge less acutely ill patients
• Cancel elective procedures
• Add additional beds to wards/ rooms
• Set up cots in open spaces
• Pre established procedures to call back staff
for extra duties/ shifts
• Maintain/ increase stocks of equipment/
supplies, pharmaceuticles
 Mass casualty management plan
• Situation analysis
• Triage
• Roles and responsibilities
• Triggering the plan
• Operational areas
• Support for operational areas
• Co-ordinating with other health facilities
• Community relations
• preparedness
 ICU
Specialty nursing units designed,
equipped and staffed with specially
skilled personnel for treating very
critical patients or those requiring
specialized care and equipment
 Functions of ICU
• Close observation and treatment of critically ill
patients
• To provide specialized treatment with specialized
highly skilled manpower and equipment
• To utilize skilled staff more effectively and efficiently
• Surveillance of critically ill patients
• Care for postsurgical operations
• To provide care for medical emergencies
• Care for cardiac emergencies
• To provide support to critically ill patients
 Functions of ICU
Classification:
Open-Attending physicians admit case
Semi closed –Director of ICU approves
admissions
Closed unit-Director and associates are
responsible for all the admissions and
discharge
 Types of ICU
• NICU: Neonatal Intensive Care Unit
• PICU: Paediatric Intensive Care Unit
• SICU: Surgical Intensive Care Unit
• CCU: Coronary Care Unit
 Staff of ICU
• Administrator
• Committee
• Medical Staff
• Nursing Staff
Staff Nurse Patient Ratio
Morning Shift 1:1
Evening Shift 1:2
Night Shift 1:3
 Physical facilities
• Location-close to OT/Recovery rooms Easy
access to emergency, resp. therapy, surgery,
pathology, radiology
• Bed strength-6-20
• Patients space min. 15 sq. ft. of clear area
• Nursing call-Two way communication system
• Hand washing-pt. bed area
• Patient’s services Pipeline oxygen, compressed
air, electrical sockets 5/15 amp.
 Physical facilities
• Lighting-nonreflecting 25-30 Lux active
treatment, 150-200 Lux doctor’s/nurse’s room
• Temp-60-70 degree F.; Noise-50 decibel;
Humidity 50-60 %
• Electricity-round the clock with UPS, inverters,
standby generator
• Medications-essential drugs, Iv fluids,
refrigerator, SOP for inventory control
• Isolation room
• Storage area-housekeeping and other supplies
 Equipment
Monitoring Therapeutic Equipments
Equipments
Cardiac monitor Ventilator
Pulse- oxymeter Nebulizer
ECG Laryngoscope, Bronchoscope,
Endoscope
USG, 2D Echo Defibrilator

Diagnostic Instruments
Endoscope Tracheostomy set
ECG Machine Cut-open set for IV line
X ray machine-portable Pace maker attachment set
USG Machine
 Inpatient department

To provide accommodation for patients

at the point in an illness when
dependence on others is highest
 IPD
Components:
• Nursing station
• The beds
• Necessary services, storage work
• Public areas needed to carry out the nursing care
Functions:
 To provide highest quality of medical and nursing care
 To provide essential equipments, drugs and other materials required for
patient care
 To provide comfortable env.-eating, sleeping, toilet
 To provide facilities for visitors
 To provide highest degree of job satisfaction
 Meticulously maintaining medical records
 To provide opportunity for education, training and research in the field of
medicine, nursing and hosp. admin.
 Planning and designing of ward
Factors:
• Hospital policy
• Space requirement
• Function
• Work plan
• Location-away from main roads and OPD
• Work flow
• Interdepartmental relationship
• Traffic flow- horizontal circulation up to 300 beds. More-
vertical
• Staffing of IPD
• Communication
• Utilization of service
 Forms of ward
• Nightingale
• Rig’s pattern
• Modified Rig’s pattern
• Racing track ward
• ‘T’ and ‘Y’ shaped ward
• Single straight corridor ward
• ‘L’ shaped plan
• Cruciform plan
• ‘H’ shaped plan
• ‘E’ shaped plan
• Box plan
• Central corridor multiple rib pattern
 Nightingale ward
characteristics Disadvantages
Pts. Beds in two rows at right angle to No privacy of patients
the longitudinal walls
Bathroom and WC at one end Noise pollution
Nursing station, doctor’s room, other Risk of cross infection
facilities at other end
Length of the ward 96 feet to home Constant glare to patient
30-35 patients
Continued till 1925
Bathrooms and isolation rooms were
added to it
Then nurses table shifted to centre
In topical countriescorridors on either
sideto protectward from direct
sunlight
 Rig’s ward
Advantages Disadvantages
Privacy to patient Communication between
patient and nurse is difficult

Risk of cross infection Direct observation of pt.

minimized difficult

Isolation of infection cases Nurse has to walk more due to

earlier complexity of wards

Enhancing flexibility of More nurses required, costly to

utilization build and maintain
 Components of a nursing unit
• Primary; 1 bed-14 sq. meters; 2 bed 21; 3bed 28; 4 bed 42 sq.
meters
• Ancillary-nursing room (20’ * 20’), MOs room, clean utility
room9100-120sq. Feet), Treatment room, kitchen ( 100sq.
Feet), Day care room, stores
• Auxilliary
• Sanitary- dirty utility room, bathroom and WC
 Urinal 1 for 6 beds
 WC 1 for 8 beds
 Bathroom 1 for 12 beds
 Washroom 1 for 10 beds
• Janitor room
 Ancillary Services attached to wards
• Nursing station
• Treatment Room
• Clean Utility Room
• Ward Kitchen / Pantry
• Stores
• Duty Room for Doctors
• Seminar Room
• Attendant’s Room
• Side Room Laboratory
• Locker Room for Staff
• Wheelchair / Trolley Bay
Operation Theatre
 Aims of planning
• To promote high degree of asepsis
• Ensure maximum safety to patients and staff
working in OT
• Ensure maximum utilization of OT
• Ensure maximum comfort to the surgical team,
considering long hours of work in difficult posture
• To provide complete environmental control
• Flexibility of uses of operation suites
• Prevention of iatrogenic complications
 Clean zone
•Preop. Room
•Recovery room
•Theater work room
•X ray plaster room,
Protective zone •sister room
•Patients waiting •Anesthetist room Sterile zone
area and reception •Operating suite
Trolley bay •Scrub room
•Lift •Anesthesia room
•Stairs Zoning of OT •Instruments trolley
•Switch room area
•Pre anesthesia room
•Changing room
•Store room •Dirty room
•Disposal corridor
•Janitor corridor
Disposal zone
 Sterilization of Operation Theatre
• Special air flow pattern- filtered and purified air
• Standard cleaning- disinfection with appropriate
chemical agents
• Fumigation
• Infection Control Committee, restricted entry,
thorough washing and carbolisation, regular
training
• Operation theatre discipline, surveillance,
bacterial counts
• Keeping floors dry, vacuum cleaning
 Functions of OT
• Perform surgery in safe, aseptic environment
• Ascertain patients comfort, both physical and emotional
• Maintain high standards of performance
• Acquire, maintain, suitably utilize equipments
• Maintain theatre discipline by following prescribed
procedures, up dating time to time
• Attempt maximum utilization of theatre by proper scheduling
• Prevent iatrogenic complications
• Prevent health hazards-env., radiological, anesthetic and
infecting agents
• Minimize postponement of surgery
 Criteria for planning
• Environmental criteria: provide complete env. Control for safety
of pt./ staff
• Economic criteria: optimization of interrelationship between
various financial areas and operating departments
• Work flow criteria: The flow of patients, staff and supplies in
operating department to be well planned
• Functional criteria: Design follows function

No. of opers./day= No. of surg. beds * % of bed occ. Rate 365

Av. length of stay *10* No.of working days
 No. of OT required
No. of Indoor OPD+ Emergency
hosp. beds Minor Major Minor Major
300 2 3 1 X

500 2 5 1 1

750 2 8 1 1

1000 2 10 1 1
 Advantages of grouping of OT
• Easy expansion in future
• Maximum flexibility of use
• Better staffing, organization and control
• Greater efficiency in resource utilization
• Easy to maintain
• Minimize cross infection
• Increases utilization of OT
• Minimization of cancellation of OT list

SIZE: General: 40 sq. meter

CVTS/Neurology/Orthopedics: 60 sq. meter
Endo-scopy suite procedure room: 20 sq. meter
 Staff
• Theatre superintendent: Maintain cleanliness, asepsis;
equipments in working order; adequate stock of
consumables and instruments; finalize operation
schedules
• Trained nurses: two per table; special training for
pediatric, cardiac, neuro surgery. Recovery room nurse
patient ratio-1:1
• Theatre assistants: assist in preparation of trolley;
packing instruments, gloves, gowns, coordinating supply
of sterilized items from CSSD; arrange for the
transportation of the patients from ward to theatre and
back
• Labour staff: cleaning, segregation, taking blood/biopsy
samples to laboratory
 Administration of OT
• OT scheduling- perfect planning, patient flow
and coordination, timely patient preparation,
efficient patient reception, parallel processing
by use of induction area, flexible facilities,
continuous process improvement
• Punctuality
• Training of staff - asepsis, universal
precautions
• Operating list- well in advance
• Dirty cases- at the end
 Administration of OT
Monitoring of OT asepsis:
 Once a week maintenance
 Swabs for microbial growth
 AC checked including filters
 HEPA filter
 Env. Control-temp., humidity, ventilation, air change
 Adequate pressure maintenance
 Disinfection of equipment, OT table, other articles
 Fumigation at regular interval with std. equipment
and std. procedure
 Staff with infection should not be allowed to enter
OT
Common problems with O.T. Management

• Poorly designed processes

• Change reluctance/ friction
• Lack of motivation
• Dodging responsibility/ placing blame
• Lack of discipline