Icrc Hospital Design Vol 1

ICRC HOSPITAL DESIGN
AND REHABILITATION
GUIDELINES
VOLUME 1: MODELS OF CARE
REFERENCE
ICRC HOSPITAL DESIGN
AND REHABILITATION
GUIDELINES
VOLUME 1: MODELS OF CARE
TABLE OF CONTENTS
ACKNOWLEDGMENTS..............................................................................................................................11
ABBREVIATIONS..................................................................................................................................... 12
FOREWORD............................................................................................................................................. 13
1. INTRODUCTION................................................................................................................................ 14
1.1 Target audience ...............................................................................................................................................................15
1.2 When to use these guidelines......................................................................................................................................15
1.3 How to use the guidelines.............................................................................................................................................16
1.4 Structure..............................................................................................................................................................................18
1.4.1 Volume 1: Models of Care............................................................................................................................ 18
1.4.2 Volume 2: Functional Space Catalogue....................................................................................................20
1.5 Updating the guidelines................................................................................................................................................ 22
1.6 Complementary resources........................................................................................................................................... 22
2. READING KEYS................................................................................................................................. 22
2.1 Text and graphics........................................................................................................................................................... 22
2.2 Bubble diagram keys...................................................................................................................................................... 23
2.2.1 Zone key........................................................................................................................................................ 23
2.2.2 Functional space keys.................................................................................................................................. 23
2.2.3 Flows and connections................................................................................................................................24
2.3 Functional space tables................................................................................................................................................ 25
EMERGENCY DEPARTMENT.................................................................................................................... 27
3. INTRODUCTION TO THE EMERGENCY DEPARTMENT......................................................................28

3.1 Definition and role.........................................................................................................................................................28
3.2 Objective of the model of care....................................................................................................................................28
3.3 Structure of the MoC.....................................................................................................................................................29
4. OUTLINE OF THE MoC......................................................................................................................29

4.1 Walk-in patients.............................................................................................................................................................29
4.2 Ambulance patients....................................................................................................................................................... 30
4.3 Patient pathway............................................................................................................................................................... 30
5. DAY-TO-DAY EXECUTION OF THE MoC........................................................................................... 33

5.1 Introduction...................................................................................................................................................................... 33
5.2 Zone 1: Security monitoring and access points................................................................................................... 35
5.2.1 Patient flow.................................................................................................................................................. 35
5.2.2 Support spaces.............................................................................................................................................. 38
5.3 Zone 2: Front door..........................................................................................................................................................40
5.3.1 Patient flow..................................................................................................................................................40
5.3.2 Support spaces..............................................................................................................................................43
5.4 Zones 3 and 4: Sub-acute side and acute side.....................................................................................................44
5.4.1 Patient flow in Zone 3 (consultation).......................................................................................................45
5.4.2 Patient flow in Zone 4 (resuscitation)......................................................................................................47
5.4.3 Support spaces in Zones 3 and 4................................................................................................................50
5.5 Zone 5: Shared area ...................................................................................................................................................... 53
5.5.1 Patient flow.................................................................................................................................................. 53
5.5.2 Support spaces.............................................................................................................................................. 55
6. EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT.................................................................. 61
6.1 Introduction.......................................................................................................................................................................61
6.2 Execution of the MoC in an MCI................................................................................................................................64
6.3 Changes to patient flow in an MCI...........................................................................................................................66
6.3.1 Mass-casualty triage space (external).....................................................................................................66
6.3.2 Decontamination scenario.........................................................................................................................68
7. ADDITIONAL DESIGN CONSIDERATIONS.......................................................................................... 72

7.1 Staff flow............................................................................................................................................................................ 72
7.1.1 During day-to-day execution of the MoC............................................................................................... 72
7.1.2 During a mass-casualty incident.............................................................................................................. 72
7.2 Relatives and carers....................................................................................................................................................... 72
7.3 Goods and services ........................................................................................................................................................ 73
7.4 Operational policy considerations............................................................................................................................ 73
7.4.1 Administration............................................................................................................................................. 73
7.4.2 Hours of operation....................................................................................................................................... 73
7.4.3 Sterile services.............................................................................................................................................. 73
7.4.4 Linen services............................................................................................................................................... 73
7.4.5 Food services................................................................................................................................................. 73
7.4.6 Cleaning services......................................................................................................................................... 73
7.4.7 Storage (within the unit)............................................................................................................................ 73
7.4.8 Separation of males and females..............................................................................................................74
7.4.9 Blood bank....................................................................................................................................................74
7.4.10 Laboratory....................................................................................................................................................74
7.4.11 Medical imaging..........................................................................................................................................74
7.4.12 Observation area..........................................................................................................................................74
7.4.13 Pharmacy (including clinical consumables)...........................................................................................74
7.4.14 Physiotherapy..............................................................................................................................................74
7.4.15 Mortuary (including disposal of body parts)........................................................................................... 75
7.4.16 Security checks............................................................................................................................................. 75
7.4.17 Health Care in Danger (HCiD)................................................................................................................... 75
7.4.18 Waste management.................................................................................................................................... 75
7.5 ED aggregation example.............................................................................................................................................. 75
8. OVERVIEW OF THE ED BY ZONE....................................................................................................... 77

8.1 General bubble diagram............................................................................................................................................... 77
8.2 Item flow to/from Zone 5............................................................................................................................................80
8.3 Zone 1 bubble diagram..................................................................................................................................................82
8.3.1 Legend........................................................................................................................................................... 83
8.3.2 Physical space list........................................................................................................................................ 83
8.3.3 Scope of Zone 1............................................................................................................................................. 83
8.4 Zone 2 bubble diagram.................................................................................................................................................84
8.4.1 Legend...........................................................................................................................................................85
8.4.3 Scope of Zone 2............................................................................................................................................. 85
8.5 Zones 3 and 4 bubble diagram...................................................................................................................................86
8.5.1 Legend...........................................................................................................................................................87
8.5.3 Scope of Zones 3 and 4................................................................................................................................ 87
8.6.1 Legend...........................................................................................................................................................89
8.6.2 Physical space list........................................................................................................................................89
8.6.3 Scope of Zone 5.............................................................................................................................................89
OPERATING DEPARTMENT..................................................................................................................... 91
9. INTRODUCTION TO THE OPERATING DEPARTMENT.......................................................................92

9.1 Definition and role.........................................................................................................................................................92
9.2 Patient mix........................................................................................................................................................................92
9.2.1 Weapon wounds...........................................................................................................................................92
9.2.2 Other urgent surgery...................................................................................................................................92
9.2.3 Other surgical programs.............................................................................................................................93
9.2.4 Operations performed in the OD...............................................................................................................93
9.2.5 Damage-control procedures......................................................................................................................93
9.2.6 Anaesthesia..................................................................................................................................................93
9.3 Objective of the model of care....................................................................................................................................93
9.4 Structure of the MoC.....................................................................................................................................................93
10. OUTLINE OF THE MoC..................................................................................................................... 94

10.1 Patient pathway...............................................................................................................................................................94
10.2 Progressive asepsis zoning..........................................................................................................................................97
11. DAY-TO-DAY EXECUTION OF THE MoC......................................................................................... 100

11.1 Introduction....................................................................................................................................................................100
11.2 Zone 1: Protective zone (way in)..............................................................................................................................101
11.2.1 Patient flow (way in)................................................................................................................................102
11.2.2 Support spaces............................................................................................................................................ 103
11.3 Zone 2: Clean zone (way in)...................................................................................................................................... 104
11.3.1 Preoperative patient flow (way in).........................................................................................................104
11.3.2 Support spaces............................................................................................................................................106
11.4 Zone 4: Sterile and ultra-sterile zone...................................................................................................................108
11.4.1 Support spaces............................................................................................................................................109
11.4.2 Support spaces shared by clean and sterile zones................................................................................ 110
11.5 Zone 2: Clean zone (way out).....................................................................................................................................111
11.5.1 Post-operative patient flow (way out)................................................................................................... 111
11.6 Zone 1: Protective zone (way out)...........................................................................................................................112
11.6.1 Patient flow (way out)...............................................................................................................................112
11.7 Staff flow........................................................................................................................................................................... 112
11.7.1 Staff who cross the first red line...............................................................................................................112
11.7.2 Staff who cross the second red line (i.e. scrub)......................................................................................113
11.7.3 Other clinical staff...................................................................................................................................... 114
11.7.4 Other staff................................................................................................................................................... 114
11.7.5 Zone 3: Staff zone.......................................................................................................................................115
11.8 Supply flows.....................................................................................................................................................................116
11.8.1 Non-sterile flow........................................................................................................................................ 116
11.8.2 Sterile flow/centralized sterile services.................................................................................................. 116
11.8.3 Zone 5: Disposal zone (dirty flow).......................................................................................................... 116
11.9 Flow for relatives, carers and visitors....................................................................................................................118
11.10 Managing flows through the OD............................................................................................................................. 120
12. ADDITIONAL DESIGN CONSIDERATIONS........................................................................................ 123

12.1 Relations between OD and other departments...................................................................................................123
12.2 Operational policy considerations.......................................................................................................................... 124
12.2.1 Blood bank.................................................................................................................................................. 124
12.2.2 Cleaning services....................................................................................................................................... 124
12.2.3 Hours of operation..................................................................................................................................... 124
12.2.4 Medical imaging........................................................................................................................................ 124
12.2.5 Mortuary (including disposal of body parts).........................................................................................124
12.2.6 Physiotherapy............................................................................................................................................ 124
12.2.7 Security........................................................................................................................................................124
12.2.8 Storage within the department...............................................................................................................124
12.2.9 Waste management.................................................................................................................................. 124
12.3 OD aggregation example............................................................................................................................................ 125
13. EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT................................................................ 126

13.1 Introduction....................................................................................................................................................................126
13.2 Execution of the MoC in an MCI..............................................................................................................................126
14. OVERVIEW OF THE OD BY ZONE..................................................................................................... 128

14.1 General bubble diagram............................................................................................................................................. 128
14.2 Zone 1 bubble diagram................................................................................................................................................ 130
14.2.1 Legend......................................................................................................................................................... 130
14.2.2 Physical space list.......................................................................................................................................131
14.2.3 Scope of Zone 1............................................................................................................................................131
14.3 Zones 2 and 3 bubble diagram..................................................................................................................................132
14.3.1 Legend......................................................................................................................................................... 133
14.3.2 Physical space list...................................................................................................................................... 133
14.3.3 Scope of Zones 2 and 3.............................................................................................................................. 133
14.4 Zones 4 and 5 bubble diagram................................................................................................................................. 134
14.4.1 Legend......................................................................................................................................................... 135
14.4.3 Scope of Zones 4 and 5.............................................................................................................................. 135
INPATIENT DEPARTMENT.....................................................................................................................137
15. INTRODUCTION TO THE INPATIENT DEPARTMENT...................................................................... 138

15.1 Definition and role....................................................................................................................................................... 138
15.2 Patient mix...................................................................................................................................................................... 138
15.2.1 Surgical – weapon wounds...................................................................................................................... 138
15.2.2 Other surgical care..................................................................................................................................... 139
15.2.3 Internal medicine...................................................................................................................................... 139
15.2.4 Infectious diseases..................................................................................................................................... 139
15.2.5 Obstetrics/gynaecology ............................................................................................................................ 139
15.2.6 Neonatal care............................................................................................................................................. 139
15.2.7 Paediatrics.................................................................................................................................................. 139
15.2.8 Mental health............................................................................................................................................. 139
15.3 Nursing models of care...............................................................................................................................................140
15.3.1 Nursing staff...............................................................................................................................................140
15.4 Objective of the model of care..................................................................................................................................140
15.5 Structure of the MoC....................................................................................................................................................141
16. OUTLINE OF THE MoC.....................................................................................................................141

16.1 Patient environment.....................................................................................................................................................141
16.2 Enabling high-quality clinical and non-clinical care..................................................................................... 142
16.3 Patient pathway............................................................................................................................................................. 142
17. DAY-TO-DAY EXECUTION OF THE MoC FOR A GENERIC IPD.......................................................... 145

17.1 Introduction.................................................................................................................................................................... 145
17.2 Zone 1: Entrance zone.................................................................................................................................................146
17.2.1 Patient flow................................................................................................................................................ 147
17.2.2 Role of relatives and carers......................................................................................................................149
17.3 Zone 2: Hospitalization zone....................................................................................................................................149
17.3.1 Inpatient bed space ...................................................................................................................................149
17.3.2 Patient flow.................................................................................................................................................151
17.3.3 Support spaces............................................................................................................................................ 152
17.4 Zone 3: Support activities zone............................................................................................................................... 155
17.5 Zone 4: Staff zone......................................................................................................................................................... 158
17.5.1 Clinical staff................................................................................................................................................ 158
17.5.2 All staff........................................................................................................................................................ 158
17.6 Zone 5: Hygiene and sanitation zone....................................................................................................................160
18. EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT................................................................ 162

18.1 Introduction....................................................................................................................................................................162
18.2 Execution of the MoC in an MCI..............................................................................................................................162
19. ADDITIONAL DESIGN CONSIDERATIONS........................................................................................ 163

19.1 Size of the department................................................................................................................................................ 163
19.2 Patient overflow............................................................................................................................................................ 163
19.3 Sample layout of inpatient bed spaces.................................................................................................................. 165
19.4 Summary of key design principles.........................................................................................................................166
19.5 Operational policy considerations..........................................................................................................................166
19.5.1 Administration...........................................................................................................................................166
19.5.2 Blood bank..................................................................................................................................................166
19.5.3 Cleaning services....................................................................................................................................... 167
19.5.4 Hours of operation .................................................................................................................................... 167
19.5.5 Infection control......................................................................................................................................... 167
19.5.6 Medical imaging........................................................................................................................................ 167
19.5.7 Mortuary (including disposal of body parts)......................................................................................... 167
19.5.8 Physiotherapy............................................................................................................................................ 167
19.5.9 Security........................................................................................................................................................ 167
19.5.10 Sterile services............................................................................................................................................ 167
19.5.11 Storage within the department............................................................................................................... 167
19.5.12 Waste management.................................................................................................................................. 167
20. VARIATIONS ON THE MoC.............................................................................................................. 168

20.1 High-dependency unit (HDU)..................................................................................................................................168
20.2 Obstetrics department................................................................................................................................................169
20.2.1 Introduction................................................................................................................................................169
20.2.2 Patient pathway........................................................................................................................................ 170
20.2.3 Patient flow through the department.................................................................................................... 173
20.2.4 Support spaces ........................................................................................................................................... 177
20.3 Neonatal unit.................................................................................................................................................................. 177
20.3.1 Introduction................................................................................................................................................ 177
20.3.2 Patient pathway........................................................................................................................................ 178
20.3.3 Patient flow through the department....................................................................................................180
20.3.4 Support spaces ........................................................................................................................................... 185
20.4 Paediatric department................................................................................................................................................. 187
20.5 Infection units within an IPD................................................................................................................................... 187
20.6 Discrete detainee unit................................................................................................................................................. 187
20.6.1 Separate IPD for detainees....................................................................................................................... 188
20.6.2 Core clinical spaces and support spaces................................................................................................. 188
20.6.3 Specific design features to consider........................................................................................................ 188
20.6.4 Detainees in the regular IPD.................................................................................................................... 188
21. OVERVIEW OF THE IPDs BY ZONE.................................................................................................. 189

21.1 Generic IPD bubble diagram..................................................................................................................................... 189
21.2.1 Legend......................................................................................................................................................... 191
21.2.3 Scope of Zone 1........................................................................................................................................... 192
21.3 Zone 2 bubble diagram............................................................................................................................................... 192
21.3.1 Legend......................................................................................................................................................... 193
21.3.3 Scope of Zone 2........................................................................................................................................... 193
21.4 Zone 3 bubble diagram................................................................................................................................................194
21.4.1 Legend......................................................................................................................................................... 195
21.4.3 Scope of Zone 3........................................................................................................................................... 195
21.5 Zone 4 bubble diagram...............................................................................................................................................196
21.5.1 Legend......................................................................................................................................................... 197
21.5.3 Scope of Zone 4..........................................................................................................................................198
21.6 Zone 5 bubble diagram...............................................................................................................................................198
21.6.1 Legend.........................................................................................................................................................199
21.6.2 Physical space list......................................................................................................................................199
21.6.3 Scope of Zone 5...........................................................................................................................................199
21.7 Obstetrics department bubble diagram............................................................................................................... 200
21.8 Neonatal unit bubble diagram.................................................................................................................................202
FIGURES AND TABLES

Figure 1.1 – ICRC infrastructure projects worldwide related to health facilities.................................................14
Figure 1.2 – Degree of influence over a construction project over time and the relevance of the ICRC
Hospital Design Guidelines......................................................................................................................................................16
Figure 1.3 – The key steps of preparing a health-infrastructure project (centre), traditional phases
of managing construction projects (far left) and the relevant guideline module(s) (far right)....................17
Figure 1.4 – Examples of the MoCs......................................................................................................................................19
Table 1 – Functional space cards available in the catalogue......................................................................................20
Figure 1.5 – Examples of space cards..................................................................................................................................21
Figure 4.1 – ED inflows and outflows.................................................................................................................................30
Figure 4.2 – Main steps of the ED walk-in patient pathway......................................................................................31
Table 2 – ED patient pathway – patient and staff perspectives and questions for the design team......... 32
Figure 5.1 – General ED circulation during day-to-day execution of the MoC.................................................. 34
Figure 5.2 – Relations of the core clinical spaces in Zone 1 of the ED...................................................................36
Figure 5.3 – Relations of the core clinical spaces and other functional spaces in Zone 2 of the ED...........41
Figure 5.5 – Relations of the core clinical spaces (only) in Zone 4 of the ED.....................................................48
Figure 5.6 – Relations of the core clinical spaces and other functional spaces in Zones 3
and 4 of the ED.............................................................................................................................................................................51
Figure 5.8 – Relations of the core clinical spaces and other functional spaces in Zone 5.............................. 57
Table 3 – Design measures to facilitate MCI management........................................................................................63
Figure 6.1 – Day-to-day execution of the MoC (left) and execution of the MoC in an MCI (right)...........65
Figure 6.2 – MCI flow, option 1 – a predesignated triage space outside the ED is used during an MCI
instead of the usual triage room, and the waiting area is used as an additional treatment area................67
Figure 6.3 – MCI flow, option 2 – if a predesignated triage space outside the ED is not available
(e.g. because outdoor space is absent or not appropriate), the waiting area is used as an MC triage
space instead of the regular triage room...........................................................................................................................70
Figure 7.1 – Example of an ED aggregation.....................................................................................................................76
Figure 8.1 – General view of the ED....................................................................................................................................79
Figure 8.2 – Item flow through the ED...............................................................................................................................81
Figure 8.3 – Zone 1 of the ED.................................................................................................................................................82
Figure 8.4 – Zone 2 of the ED................................................................................................................................................84
Figure 8.5 – Zones 3 and 4 of the ED..................................................................................................................................86
Figure 8.6 – Zone 5 of the ED................................................................................................................................................88
Figure 10.1 – OD inflows and outflows...............................................................................................................................94
Figure 10.2 – Main steps of the OD patient pathway....................................................................................................95
Table 4 – OD patient pathway – patient and staff perspectives and questions for the design team........96
Figure 10.3 – Progressive asepsis in the OD and flow control...................................................................................98
Figure 10.4 – Border crossing points in the OD..............................................................................................................99
Figure 11.1 – General OD circulation during day-to-day execution of the MoC................................................101
Figure 11.2 – Relations of the core clinical space in Zone 1 of the OD (way in).................................................101
Figure 11.3 – Patient flow in Zone 1 of the OD (way in)............................................................................................. 102
Figure 11.4 – Relations of the core clinical space in Zone 2 of the OD (way in)............................................... 104
Figure 11.5 – Patient flow in Zone 2 of the OD (way in)............................................................................................ 105
Figure 11.6 – Relations of the core clinical space in Zone 4 of the OD (way in)............................................... 108
Figure 11.7 – OR support spaces and points of entry and exit.................................................................................109
Figure 11.8 – Relations of the core clinical space in Zone 2 of the OD (way out)...............................................111
Figure 11.9 – Relations of the core clinical space in Zone 1 of the OD (way out).............................................. 112
Figure 11.10 – Flow of OD staff crossing the first red line.........................................................................................112
Figure 11.11 – Flow of OD staff crossing the second red line (scrubbing)............................................................ 113
Figure 11.12 – Zone 3 of the OD – the staff zone...........................................................................................................114
Figure 11.13 – Supply flows between centralized sterile services and the OD.................................................... 117
Figure 11.14 – Flow of visitors in the OD..........................................................................................................................118
Figure 11.15 – General flows through the OD................................................................................................................. 120
Figure 11.16 – Circulation through the corridors between Zones 2, 3, 4 and 5................................................. 122
Figure 12.1 – OD’s functional relationships with clinical support areas and operational areas..................123
Figure 12.2 – Example of an OD aggregation................................................................................................................. 125
Figure 13.1 – Changes to the OD in an MCI..................................................................................................................... 127
Figure 14.1 – General view of the OD................................................................................................................................129
Figure 14.2 – Zone 1 of the OD............................................................................................................................................. 130
Figure 14.3 – Zones 2 and 3 of the OD...............................................................................................................................132
Figure 14.4 – Zones 4 and 5 of the OD............................................................................................................................. 134
Figure 16.1 – IPD inflows and outflows............................................................................................................................ 142
Figure 16.2 – Main steps of the IPD patient pathway................................................................................................ 143
Table 5 – IPD patient pathway – patient and staff perspectives and questions for the design team..... 144
Figure 17.1 – General circulation in the IPD during day-to-day execution of the MoC ...............................146
Figure 17.2 – Relations of the core clinical space in Zone 1 of the IPD................................................................ 147
Figure 17.3 – Generic inpatient bed space – single and multiple..........................................................................149
Figure 17.4 – Relations of the core clinical space in Zone 2 of the IPD............................................................... 150
Figure 17.5 – Single straight corridor configuration with inpatient bed spaces and hand-wash bays... 150
Figure 17.6 – The nurses’ station has a direct view of all beds...............................................................................153
Figure 17.7 – Location of hand-wash bay between beds with minimum required dimensions................. 154
Figure 17.8 – Shared support spaces in Zone 3 of the IPD........................................................................................ 156
Figure 17.9 – Functional spaces and staff flow in Zone 4 of the IPD................................................................... 159
Figure 17.10 – The core clinical support space in Zone 5 of the IPD.....................................................................160
Figure 19.1 – Example of three combined clusters with support spaces serving all clusters placed
in a central position and a double corridor (racetrack model)................................................................................164
Figure 19.2 – Two clusters sharing the support activity and staff zones – each cluster includes
12 beds along a single corridor and its own nurses’ station.................................................................................... 165
Figure 20.1 – Patient pathway showing the HDU’s main relations with other departments......................168
Figure 20.2 – HDU inpatient bed space – 2 m minimum between beds.............................................................168
Figure 20.3 – HDU inpatient bed space – 2 m minimum between beds.............................................................169
Figure 20.4 – The obstetrics department’s main relations with other departments.....................................169
Table 6 – Obstetrics department patient pathway – patient and staff perspectives and questions
for the design team.................................................................................................................................................................. 172
Figure 20.5 – Circulation through the obstetrics department during day-to-day execution
of the MoC................................................................................................................................................................................... 174
Figure 20.6 – Pre-delivery patient bed space –2 m minimum between beds.................................................. 174
Figure 20.7 – Spaces and flows in the obstetrics department................................................................................ 175
Figure 20.8 – Delivery room and clearance needed around delivery table........................................................ 176
Figure 20.9 – Post-delivery bed spaces for mothers and babies........................................................................... 176
Figure 20.10 – Neonatal unit’s main relation................................................................................................................ 177
Figure 20.11 – Main steps of the neonatal unit patient pathway........................................................................... 178
Table 7 – Neonatal unit patient pathway – patient and staff perspectives and questions
for the design team..................................................................................................................................................................179
Figure 20.12 – Circulation in the neonatal unit during day-to-day execution of the MoC......................... 180
Figure 20.13 – Spaces and flows in Zones 2, 3 and 4 of the neonatal unit......................................................... 182
Figure 20.14 – Neonatal inpatient incubator/cot space............................................................................................. 183
Figure 20.15 – Neonatal cluster with 16 open-care cots...........................................................................................184
Figure 20.16 – Mother and baby bed space.................................................................................................................... 185
Figure 21.1 – Generic inpatient department...................................................................................................................190
Figure 21.2 – Zone 1 of the IPD............................................................................................................................................191
Figure 21.3 – Zone 2 of the IPD...........................................................................................................................................192
Figure 21.6 – Zone 5 of the IPD..........................................................................................................................................198
Figure 21.7 – General view of the obstetrics department......................................................................................... 201
Figure 21.8 – General view of the neonatal unit...........................................................................................................203
ACKNOWLEDGMENTS 11
ACKNOWLEDGMENTS
This work would not have been possible without the contributions of a dedicated group of people from dif-
ferent specialties over many years.
Their collective expertise has ensured that the final product is aligned with best practices and suitable for
environments often faced with the devastating effects of armed conflict and other violence.
First and foremost our thanks go to Rose Macfarlane, International Committee of the Red Cross nurse and
current advisor to the New Zealand Ministry of Health, who wrote the first draft of this entire work. Her
combination of skills and knowledge in health-facility planning and nursing truly represents the spirit of
this project.
The versions that followed were drafted by Maria Cristina Ruggeri, Federico Sittaro, Soraya Kesri and
Teddy Pauli, who also created most of the graphics together with Francesca Marafini and Diego Ignacio
González Sanz.
On the clinical side, many reviewers have commented on different versions of this work: Amanda
Baumgartner-Henley, Sanja Janjanin, Jeannette De Vries, Marie-Catherine Marquis, Yvonne Del Prado,
Christine Poulain, Zaher Osman, Tesfaye Makonnen Feleke, Joana de Barros e Sá, Teija Hannele Toivola,
Joseph Adase, Andrea Reis, Sophie Massot, Sylvie Faillétaz, Benjamin Nyakira, Sigrid Kopp, Didier Lembeye,
Sandrine Chaunu, Lucia Maddalena Bernhard, Caroline Laurence Perruchot, Harald Veen, Nelson Pita de Olim,
Mauro Dalla Torre, Daniel Lopez Villanueva, Dmytro Kuchumov, Tonje Tingberg, Lisa Thomas, Marie Julie Muller,
Lysann Kaiser, Julie Barnet, Filippo Gatti, Rodrigo Acosta Zermeño, Ana Elisa Barbar and Laurent Sabard.
A big thank you to them and anyone else who may have been inadvertently omitted here.
Federico Sittaro Esperanza Martinez

Editors
12 ICRC HOSPITAL DESIGN AND REHABILITATION GUIDELINES
ABBREVIATIONS
CSSU Centralized sterile services unit
ED Emergency department
HCiD Health Care in Danger
HDU High-dependency unit
HEPA High-efficiency particulate air
IPD Inpatient department
IV Intravenous
M/F Male/female
MCI Mass-casualty incident
MoC Model of care
OD Operating department
OPD Outpatient department
OR Operating room
PPE Personal protective equipment
WHO World Health Organization
FOREWORD 13
FOREWORD
The International Committee of the Red Cross (ICRC) is mandated by the Geneva Conventions to assist and
protect people affected by armed conflict and other violence. This often means ensuring that communities
have access to essential health services by setting up temporary hospitals or by repairing and/or expanding
existing ones.
In doing so, our humanitarian teams often encounter the dilemma of how to ensure the best possible care
in often-austere environments where undertaking infrastructure work is riddled with challenges. Moreover,
given the protracted nature of armed conflict in many places around the world, health-care professionals,
architects and health planners must also think about establishing hospitals that are sustainable and, crit
ically, culturally appropriate.
The ICRC Hospital Design Guidelines answer these questions. Because the design is centred on the needs of
people – patients, family and health staff – the expected result is better health outcomes. Because the guid-
ance is built on practical experience acquired through decades of work in hospital projects in war-torn areas,
it is suitable for low-resource, challenging settings. And, finally, because it is based on best practice in the
fields of both health and design, it will be a useful tool when engaging with health authorities in long-term
projects and planning.
From an institutional perspective, this work truly represents the ICRC’s multidisciplinary approach by com-
bining the expertise of a range of specialists in the Water and Habitat Unit and the Health Unit. The guidelines
also incorporate measures to ensure the physical safety of health-care workers and patients, a key area of
concern for the ICRC.
The objective of these guidelines is to assist professionals involved in planning and implementing hospital
projects in low-resource settings by providing clear information and explaining the reasoning behind design
choices. Moreover, it is intended to support dialogue and joint planning with authorities responsible for
ensuring the health of their communities.
I wish to acknowledge Federico Sittaro, strategic planner for the Water and Habitat Unit, and Head of Health
Esperanza Martinez, who led teams over several years to complete this first edition and whose commitment
and persistence have been integral to the endeavour.
Finally, I hope these guidelines will become a collective good for all the dedicated professionals involved in
providing health care to people affected by armed conflict around the world.
Dominik Stillhart
Director of Operations
1. INTRODUCTION
Since 2010, the ICRC has led health-infrastructure activities in more than 2,000 projects. On average, the
ICRC works on health-infrastructure projects in 26 different countries each year.
300
250
200
Projects
150
100
50
0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Year
Figure 1.1 – ICRC infrastructure projects worldwide related to health facilities (source: ICRC Water and
Habitat Project Assistant database)
This volume of activities across the globe means that ICRC teams are confronted with a multitude of different
standards, traditions and approaches in relation to planning, building, repairing or renovating health-care
facilities. Moreover, the specific circumstances of each project also determine the nature of, and challenges
associated with, the work to be carried out. For example, the operational requirements when health infra-
structure is suddenly destroyed are substantially different to what is needed to halt the progressive degrad
ation of health-service delivery amid a protracted crisis.
Because realities on the ground and operational demands vary so widely, it is impossible to set globally
applicable standards for infrastructure design. On the contrary, what is required are guidelines that imple-
ment a principles-based approach to hospital design while providing flexibility for local adaptations.1
The essential principles are:

• simplify flows of patients, staff and items to reduce movement time, and more importantly,
to reduce the risk of cross-contamination
• guarantee clinical staff’s access to each patient according to the clinical procedure to be performed
and guarantee movement of the patient according to their condition
• guarantee a space that can host all the equipment and supplies required for a given function to be performed.
The ICRC Hospital Design and Rehabilitation Guidelines implement these general principles at all levels: from the
spatial relations between departments down to the arrangement of individual spaces. The guidelines illus-
trate organizational principles and spatial organization that can be adapted to almost any locale’s needs and
resources. Moreover, they promote internationally accepted principles of hospital design and provide a common
vocabulary for framing the exchange between professionals often coming from very different backgrounds.
1 Broadly speaking there are two approaches to design: standards-based and principles-based. The standards-based
approach is prescriptive in nature and presents a fixed set of parameters or recommendations to be respected
(e.g. surface areas or ratios). National hospital design guidelines often implement this approach. The principles-based
approach, in contrast, provides design recommendations based on the functional objectives to be attained rather
than on fixed, quantitative parameters. The latter is generally regarded as more applicable and more versatile.
However, the two approaches can be complementary, and some reference standards are provided in these guidelines.
INTRODUCTION 15
1.1 TARGET AUDIENCE

Successfully planning and carrying out a hospital construction, repair or renovation project relies on close
and timely interaction between the following three key stakeholders, with these guidelines serving to foster
a common understanding and agreement between them:
• the health project planner or manager responsible for conceiving and implementing the project
• the Water and Habitat engineer responsible for delivering the associated infrastructure
• the health-facility managers who are the final recipients of the infrastructure and who are responsible
for running the facility.
1.2 WHEN TO USE THESE GUIDELINES

The ICRC Hospital Design and Rehabilitation Guidelines can be used both for building new hospitals and for
repairing or renovating existing facilities. They can also be used when setting up temporary structures (tents
or prefabricated constructions).
However, while the spatial relations (how spaces are positioned relative to each other), flows and organiza-
tion of activities are similar, there are some specific challenges related to each situation.
In a new construction, the plan starts from a blank slate, and therefore the relations between spaces are
relatively easy to respect. Nevertheless, the most common challenge in such projects is to ensure there is an
appropriate ratio of built space to the overall space of the compound being considered.2 Often, there is too
little open space. A compound that is too small severely limits how well mass-casualty incidents and infec-
tious disease outbreaks can be managed. A high density of construction also decreases natural ventilation and
lighting, limits external circulation and access to general service areas such as water and waste installations,
and restricts the access of emergency services such as fire brigades.
When repairing or renovating an existing structure, the main challenge is usually related to the amount of
built space available. In this case it is paramount to properly understand the existing model of care before
intervening: How does the department work? What doesn’t work, and why? Oftentimes building new spaces
is seen as the easiest way to resolve a dysfunctional model of care with results that are far from optimal.
Moreover, intervening in such circumstances may impede a timely operational response.3
2 The ratio between built space and open space can range widely according to several factors: slope and configuration
of the terrain, number of floors, etc. For a basic review see: World Health Organization (WHO), District Health Facilities:
Guidelines for Development and Operations, WHO, Geneva, 1998.
3 A construction project takes time. Needs and objectives need to be clearly established and shared between the parties
involved, which can take days, months or years. Once a vision is agreed on and the project’s scope is defined,
the feasibility study takes an average of three months, a detailed design six months and construction between 12 and
18 months. For more information see: ICRC, Protocol for the Management of Construction Projects, ICRC, Geneva, 2016.
1.3 HOW TO USE THE GUIDELINES

These guidelines aim to simplify the preparation of hospital infrastructure projects and make the collab
oration between health planners, engineers and health-facility managers smoother and more efficient.
THIS MANUAL
100%
0%
Concept Detailed
Brief Construction Use
Design Design
 Ability to affect design

 Cost of changes to design
Figure 1.2 – Degree of influence over a construction project over time and the relevance of the ICRC
Hospital Design Guidelines (adapted from United Nations Office for Project Services, Technical Guidance
for Prison Planning, 2015)
This chart – mapping the ability to affect the design vs the cost of implementing changes over the course of
planning and constructing a facility – shows that a well prepared construction project saves not only money
but also a considerable amount of time and energy for an extended group of stakeholders. These guidelines
target precisely that initial, highly iterative phase. That is when the stakeholders should be interacting most,
when expectations and existing constraints need to be identified and addressed collaboratively.
The figure below illustrates how the health-infrastructure design process is a succession of iterative steps.
In each step, new information is added, which triggers additional feedback from the design team. With a few
exceptions, each of these steps requires the participation of a wide range of stakeholders, both from inside
and outside the hospital facility. Patients, carers,4 staff members and hospital managers all have insights
relevant to the successful preparation of the design. The health planner and the engineer have the shared
responsibility of collecting their input and integrating it into the proposed solutions.
4 A carer, also called a “caretaker” or “caregiver”, is a relative or other person who provides for the basic needs
of the person seeking clinical care.
INTRODUCTION 17
PROJECT PROJECT PREPARATION PROCESS GUIDELINE MODULES

MANAGEMENT PHASES
Perform needs
assessment
Define services
covered
Define medical
services
Define catchment
area
Determine
admission criteria
VISION
Perform spatial/
architectonic
assessment
Determine volume
of activities
Define core
clinical functions
Define local model
of care
Establish size
of core clinical
MODEL
spaces
OF CARE
Define support
spaces
Perform
Define support
architectonic
spaces
analysis
List spaces and

functional relations
FEASIBILITY
STUDY
FUNCTIONAL
List equipment, SPACES
furniture and fittings
for each space
Develop concept Draw up finishing

design specifications
Lay out
architectonic drafts
Figure 1.3 – The key steps of preparing a health-infrastructure project (centre), traditional phases of
managing construction projects (far left) and the relevant guideline module(s) (far right) – preparatory
steps are colour-coded by who has the leading role: red for the health planner and blue for the engineer
The overall preparation for the project includes four main, iterative cycles:
• Define needs and medical service(s) required. Depending on the circumstances, this cycle might include
carrying out health needs assessments, a health systems assessment, epidemiological studies, collection
of surveillance data and stakeholder-mapping. The step is critical, as it quantifies the project’s relevance
and provides an outlook on future needs. It provides an estimate of how many patients might access
the facility and how that number might evolve over time. From a design point of view, it enables
consideration of any future need for extensions and what space would be necessary.
• Define core clinical functions. This cycle aims at determining the core clinical activities within
the service(s) that have been identified based on the relevant model of care. This enables a proper
assessment of the available plot (or existing facility, in case of repair or renovation) based on
the service-specific design requirements. The number of existing or expected patients of each service
– the volume of activities – will determine how that service is configured, for example, the number
of operating rooms or inpatient beds per department. All of the models of care, as proposed in these
guidelines, have been written with the express intent of being used during this cycle. They are templates
describing standard situations that need to be fine-tuned to the local reality. The focus should be on
the core clinical spaces and assessing not only their feasibility but also the staff’s capacity (e.g. numbers,
skills and competencies).
• Define support spaces. This cycle further develops the layout by adding the support required for
the clinical activities identified in previous cycles. Once the core clinical activities have been proposed,
evaluated and confirmed, the various levels of support must be considered. Here, the information in
the model of care must be complemented with the information available in the catalogue of functional
spaces. Input from clinical staff is essential at this point because the lists of equipment and specific
surface needs will be drawn up, and the architectonic considerations and design must match the space
available. At this stage, project preparation shifts from medical considerations to architectonic ones.
• Develop concept design. This last cycle should result in one or more conceptual designs that deliver
the infrastructural setup within the specific spatial and organizational constraints. Here, the details
of equipment, fittings and space relations are formalized with the location-specific space constraints
included in the planning process. Only at this point is it possible to produce meaningful drawings –
which are strongly recommended when formalizing the design. If required by the scope of the project,
multiple alternative layouts can be produced, rather than subjecting a single layout to multiple changes.
The process of evaluating these alternatives – together with the whole design team and the involvement
of hospital managers, department users and possibly patients – has proved extremely enriching.
In fact, comparing different layouts is a powerful way to identify better solutions through compromise,
achieving greater satisfaction for multiple stakeholders.
1.4 STRUCTURE
This publication has two modules contained in separate volumes. The first module deals with models of care,
while the second is a catalogue of functional spaces.
1.4.1 VOLUME 1: MODELS OF CARE

A model of care (MoC), also called a “hospital brief”, is a description of how the activities of a specific
department are organized and what tasks are performed at each stage of a patient’s stay. It describes both
day-to-day activities and the changes in management and set-up that need to occur to cope with mass-
casualty incidents.
An MoC provides essential information on how the built environment should be organized to enable and
support clinical activities. For health staff, the MoC provides a quick but comprehensive overview of how to
set up a given service, while from a construction perspective it provides the essential information for under-
standing the role of each space in the context of the specific services provided.
INTRODUCTION 19
The first edition of the guidelines covers three departments key to ICRC operations:
• the emergency department (including relations with medical imaging and laboratory services)
• the operating department (including relations with centralized sterile services)
• the inpatient department (including the high-dependency unit, obstetrics department, neonatal unit,
paediatric department, infection units and discrete detainee unit)
The physiotherapy and outpatient departments as well as laboratory services will be added in future editions.
The MoC for each department is structured the same way, with the following subsections:
• Outline of the MoC – description of the main design concepts relevant to the department, description
of the patient pathway and a summary of the most important questions for the design team
• Day-to-day execution – description of the main zones and how each space functions under normal
circumstances
• Execution in a mass-casualty incident – description of how activating a mass-casualty plan affects
the department’s use
• Additional design considerations – other points that must be considered when designing, repairing
or renovating the department
• Overview of the department by zone – summary of each main zone, including bubble diagrams,
lists of physical spaces and descriptions of each zone’s scope.
ENTRANCE
1
Decontamination Ambulance
shower bay
1
Staff sanitary Monitoring and (Ambulance/Car)

facility (M/F) access points parking area
2
ED entrance
& lobby
Staff dressing Decontamination Ambulance
space (decont.) shower bay
FAST TRACK (ACUTE CASES)

Medical record Registration
MASS- storage space
Staff undressing Stretcher
CASUALTY
space (decont.) parking area
SPACE
Patient sanitary
Play Area Waiting area
facility (M/F)
2
Arrival, waiting
FAST TRACK
& triage room

Triage room
3
Resuscitation
room
Treatment room Resuscitation
(sub-acute) room (acute)
5
4 5
3 4
Isolation suite
EXTERNAL
CONSULTATION
EXTERNAL
CONSULTATION
Figure 1.4 – Examples of the MoCs
The guidelines break down each department into five to six zones. Each zone is composed of functional
spaces, the specific features of which are discussed individually. The relations between spaces are illustrated
in diagrams using arrows.5
5 There is a distinction between a “space” and a “room”. Generally, a space is a portion of a room or a corridor
dedicated to a specific function, though it may also be a room. For example, storing necessary equipment is a critical
function that needs to be incorporated into any design. If some floorspace is not set aside for this, corridors might
be full of equipment, blocking the traffic of stretchers and slowing the transfer of patients. The equipment bay is
the space dedicated to this function; each individual bay may be placed in a recess of a corridor within a department
or incorporated into the design of a given room.
In each section are tables describing individual functional spaces, including their basic characteristics and
main relationships as well as the type of activities performed in them. There are three categories of spaces:
• Core clinical spaces are where the interactions between medical staff and patients occur;
they are the main focus of the design.
• Core clinical support spaces are where essential support for clinical care is provided. Core clinical
spaces cannot function without core clinical support spaces, and they are usually placed in close
proximity to each other.
• General support spaces are necessary for the entire department to function correctly. However,
sometimes they are not properly accounted for, and their omission from a design may negatively impact
patient outcomes (e.g. if there is not enough capacity to properly enforce infection-control measures).
The objective is to ensure that spaces are organized in a way that facilitates staff activities based on inter
nationally accepted principles of hospital care. For example, an emergency department needs to funnel
patients through efficiently and in a monodirectional fashion, from the entrance to the exit, and an operating
department needs to be organized around strict access-control principles in order to properly maintain the
aseptic conditions under which surgery must be performed.
1.4.2 VOLUME 2: FUNCTIONAL SPACE CATALOGUE

The second volume provides more detailed information to assist the design phase of the project; it should be
consulted after you have become acquainted with the MoCs here.
Each functional space card in the catalogue provides a more detailed description of the activities performed in
a specific space as well as essential furniture, equipment and fittings. Each space is further classified in terms
of requirements for finishes. These cards should guide the choice of materials for each space.
Currently there are 61 cards in the Functional Space Catalogue.
Core clinical Core clinical General support

Total
spaces support spaces spaces
Emergency department 9 2 2 13
Operating department 4 (+1) 1 1 6 (+1)
Inpatient department 1 (+2) 1 - 2 (+2)
Centralized sterile services - 3 (+1) 1 4 (+1)
Imaging service 2 1 3
All departments, including:
- entrance areas
- bed spaces
- nurse’s spaces
- hygiene rooms 5 12 12 29
- patient rooms
- staff spaces
- storage spaces
- sanitary spaces
Total 21 (+3) 20 (+1) 16 61
Table 1 – Functional space cards available in the catalogue (numbers in brackets represent aggregations
of spaces)
Each functional space card also provides an illustration of how items may be organized in the allotted floor
area taking into consideration ergonomic and clinical principles.6 Many also have a three-dimensional
axonometric view, a plan view and a section view.
6 When items are not fixed, they will be moved as required during clinical activity. In these cases, their location in the
illustrations is not determinative, and a note has been added to the drawings.
EMERGENCY DEPARTMENT - ZONE 5 47
Zone 1
10. RESUSCITATION ROOM (EXAMPLE 1) Suggested area No. of staff Last reviewed Core clinical space
A room used for the assessment, resuscitation and treatment of critically ill or severe 19 m2 3 2022
Core clinical support space
trauma patients, which may involve one or more potentially invasive procedures Space category No. of patients Expected revision
Clinical – wet 1 2025 General support space
INTRODUCTION
10.7 AXONOMETRY (1) 10.9 PLAN (1) C

E033
F024
Zone 2
F009
E035
C E064
F010 E013
B F009
E031
E052
E023
Elevation C
Elevation C
E078
E064
E052 F046
Figure 1.5 – Examples of space cards

F010 E031
F044 E035
E023 E026 F024 F044
Zone 3
E026
F045
5.00 m
F046 E078 E064
B D
E033
F034 E013 Space for portable
E044
E045 E056 ultrasound machine
E056 F022
& X-ray unit
S006
E071 2
F020 E064 E037 F043
19.0 m
or
E038
F045
F043
S006
Zone 4
F022
S001
F034 E071
From ambulance bay

D A
10.10 ELEVATION (1) to operating room
A
3.80 m
Note: Equipment is portable;

Zone 5
E052
positions in the diagram are given
F009 E026
for illustrative purposes only. F045
10.8 MAIN RELATIONSHIP (1) E031

2.70 m
Ambulance bay > Resuscitation room > Operating room E023

E056
E064
F046
E078
Aggregation
C
21
0.6 m x 0.6 m grid

1.5 UPDATING THE GUIDELINES

These guidelines have been conceived as an evolving body of knowledge. They exist in print and in digital
form, which is accessible to all ICRC staff. Maintaining a digital version enables the latest additions and revi-
sions to be integrated quickly.7 It also provides the opportunity to collect feedback following the guidelines’
implementation in various projects.
1.6 COMPLEMENTARY RESOURCES

The guidelines focus on issues that do not appear in pre-existing guidelines from the ICRC’s Health or
Water and Habitat units (e.g. models of care, functional spaces, flows). Areas already discussed in other
such resources are therefore not widely explored here, e.g. electrical compliance, handicap accessibility and
waste-management facilities. In most instances, updated links or references have been provided.
2. READING KEYS
2.1 TEXT AND GRAPHICS
The ICRC Guidelines for Health Facility Design and Rehabilitation currently include MoCs for three departments:
• emergency department
• operating department
• inpatient department (including generic inpatient department, high-dependency unit, obstetrics
department and neonatal unit).
Each MoC is divided into five zones (six for the obstetrics department) and is accompanied by an explanation
of the main activities carried out there, the relationships between functional spaces, and the recommended
flow of patients, staff and visitors within and between zones. (“Flows” are the movements of people and
goods between rooms and services, such as the patient’s progression from the entrance to the inpatient bed
space.)
For ease of understanding, the text is accompanied by bubble diagrams. The bubble diagrams are schematics
that illustrate activities, relationships and flows to provide visual support for both the project owner and
the construction project manager during the development and finalization of the architectural programme.
Finally, there are tables for each functional space: the tables summarize the scope and characteristics of each
essential and non-essential space to work properly. For the most important functional spaces, there are floor
plans of hypothetical rooms with the location of the most commonly used furniture and equipment for pre-
defined room sizes. Each table also cites the related database where three-dimensional models and technical
details are provided for the functional space.
The text, diagrams and tables must be considered together because they are complementary parts of a whole.
7 For example, at the time of the introduction’s writing, the MoCs for the outpatient department, the physiotherapy
department and the laboratory are being drafted. Also under development are complementary construction-related
modules – such as the selection criteria for finishes, e.g. for floors, walls, lighting and ventilation.
READING KEYS 23
2.2 BUBBLE DIAGRAM KEYS

The bubble diagrams show two functional levels with their main flows: zones and functional spaces.
2.2.1 ZONE KEY

Zones, the first level, are represented by colour-coded areas within which bubbles are grouped to represent
functional spaces. Note that the key to the right does not include Zone 6, which is only present in the obstet-
rics department.
Zone 1
Zone 2
Zone 3
Zone 4
Zone 5
2.2.2 FUNCTIONAL SPACE KEYS

Importance and access
Functional spaces, the second level, are represented by bubbles. The shape of the bubble’s outline shows
whether the functional space is essential or optional. Rectangles are used for essential spaces (e.g. the in
patient bed space or the nurses’ station). Hexagons represent optional spaces, in which non-core activities
are carried out (e.g. the waiting area). The colour of the outline represents who has access to the space: red
for spaces accessible to patients, black for spaces only accessible to staff, and grey for spaces accessible to
staff and visitors.
Space accessible to patients
Space accessible to patients (temporary structure)

T
Optional space accessible to patients
Space accessible to staff only
Optional space accessible to staff only
Optional space accessible to staff and visitors
Aggregation of single spaces

Type of space
The colour filling the bubbles shows what kind of space it is: A core clinical space is where a clinical activity
is carried out in one of the five zones (e.g. the inpatient bed space in the inpatient department). A core clinical
support space is indispensable to the good function of the related core clinical space (e.g. the nurses’ station
in the operating department), while a general support space is an independent space where other activities
take place (e.g. the staff office in the emergency department).
Core clinical spaces
Core clinical support spaces
General support spaces
2.2.3 FLOWS AND CONNECTIONS

The main flows within the department are represented by lines or arrows between the bubbles. They show
the main movements of people or items between the internal and external spaces and departments carrying
out core activities. The black arrows represent staff movements, while purple represents patient flows – the
movements of people in need of health care. There are several distinct patient flows, which result from the
sequencing of patients’ activities in relation to the various zones.
Primary flow for patients
Secondary flow for patient
Patients in egress
Primary flow for visitors
Primary flow for staff
Secondary flow for staff
Direct connection between spaces
Primary flow for supplies
Primary flow for non-sterile supplies

READING KEYS 25
2.3 FUNCTIONAL SPACE TABLES

The functional space table summarizes the main points of the text for the relevant space. The table is yel-
low for a core clinical space, pink for a core clinical support space and turquoise for a general support space
(as in bubble diagrams). The example below shows the layout of a generic functional space table without
colour-coding.
NAME OF FUNCTIONAL SPACE

Scope
Describes the main activity performed within the room.
Main characteristics
Includes information about preferred location, details on specific activities performed, additional information
for better understanding, design keys, etc.
Main relationship
FROM a functional space/zone/corridor/exit
TO a functional space/zone/corridor/exit
Functional space card Gives the number of the relevant Type ESSENTIAL or NON-ESSENTIAL
functional space card, which may contain (among others)
the layout of a hypothetical room with general dimensions,
an equipment and furniture list and indications for
finishes.
EMERGENCY
DEPARTMENT
3. INTRODUCTION
TO THE EMERGENCY
DEPARTMENT
3.1 DEFINITION AND ROLE
The emergency department (ED)8 is a medical treatment facility commonly present in large health-care facil-
ities such as hospitals. (In some cases it may be freestanding, according to local circumstances and needs.)
Depending on various criteria, such as the population density in the surrounding area or the level of devel-
opment of the country’s health-care system, the ED is often an important entry point for patients without
other means of access to medical care.
The ED usually operates 24 hours a day to provide health care for those who require urgent care (i.e. for
non-life-threatening conditions, such as a broken leg) or emergency care (i.e. for life-threatening conditions,
such as severe trauma from weapons or a car accident). Patients either arrive on their own or are brought to
the ED by ambulances, other health-care vehicles, police, firefighters, etc.
The ED provides consultation, treatment and observation as general services. It is closely linked to external,
complementary departments present in the hospital such as imaging and the laboratory, as well as the oper-
ating department for more severe cases.
The ED is also critical when implementing a mass-casualty plan in a mass-casualty incident. It is also at the
front line in the provision of health care to the wounded.
3.2 OBJECTIVE OF THE MODEL OF CARE

The aim of this section is to set out a model of care (MoC) for the ED and the space requirements best suited
to how and where the ICRC works.
Like the rest of the MoCs contained in these guidelines, this MoC is meant to be updated on a regular basis
because techniques and technologies evolve rapidly and quality standards are constantly improving. The
frequency of future updates has yet to be determined.
8 In some places the Emergency Department is called an “emergency room” or “emergency unit”.
Introduction to the emergency department 29
3.3 STRUCTURE OF THE MoC

This section contains the following subsections:
• Day-to-day execution – description of the five main zones and how each space functions under normal
circumstances
or renovating an ED
• Overview of the ED by zone – summary of each main zone, including bubble diagrams, lists of physical
spaces and descriptions of each zone’s scope.
4. OUTLINE OF THE MoC

The goal of an MoC is to reduce unnecessary steps in the patient journey and to ensure the essential com-
ponents of that journey occur as promptly as possible. Delivery of services within the ED depends the flow
of patients both into the department and out (for those patients who are referred onwards or discharged).
First, patients arrive at the entrance of the ED. There they are registered, assessed or triaged and sent to the
appropriate space within the department for diagnosis and treatment. Finally, they are discharged, admitted
to an inpatient unit, sent to the operating room (OR) or, if they die, sent to the mortuary.
Patients should travel through the department in one direction (known as a “monodirectional flow”). How-
ever, they may have to leave the ED for an X-ray and return, or move between functional spaces within the
ED – movements which are determined by their clinical condition or at the discretion of staff working within
the ED.
The ICRC model includes two entrances to the ED: one for walk-in patients and another for ambulance
patients. The ED entrances must never be used as general entrances to the hospital, nor as thoroughfares for
staff and non-ED patients moving within the hospital, as this has a detrimental effect on patient care and
privacy and potentially compromises patient and staff safety.
The MoC is set out below; in subsequent chapters you will find explanations of how to carry it out on a day-
to-day basis and in a mass-casualty scenario.
4.1 WALK-IN PATIENTS

The walk-in entrance should be different from the ambulance entrance and must be well signposted. Patients
arriving by private transport must be able to be dropped off close to the walk-in entrance. The access point for
people with physical disabilities and/or impaired mobility should be located next to the ED and, if required,
wheelchairs should be provided.
4.2 AMBULANCE PATIENTS

The ambulance entrance should be well lit and close to the ED resuscitation room to reduce the time needed
to reach the resuscitation area. The route to the resuscitation room should be direct and have a minimum
number of corners so ambulance personnel can easily push patients on trolleys. Security personnel should
monitor this area and keep the ambulance bay free of crowds and cars.
In an ICRC setting, most of the patients will be trauma or surgical emergencies (although other medical
emergencies cannot be excluded). These patients require initial assessment and stabilization in the ED.
Afterwards, some will go straight to the OR or high-dependency unit (HDU), while others will go directly to
inpatient wards to await surgery or receive other medical care.
4.3 PATIENT PATHWAY

To design appropriate health-care spaces, it is always essential to consider the needs and activities of all
users – patients, staff and others – and prioritize them according to clinical risks and outcomes. The com-
plex network of interactions between patients, staff and other users should be the cornerstone for designing,
repairing or renovating the ED.
Some needs can be approximated in advance (for example based on seasonal or other historical data), en-
abling ED services to be planned to some extent and making sure that the right people are in the right place
at the right time. Matching resources with these needs is essential, as a functional and effective emergency
service will bolster other services within the hospital.
In the ED, monodirectional patient flow is the paramount design parameter given that, regardless of the
severity of their condition, patients move through the ED from an entrance to an exit. Therefore, ensuring a
monodirectional patient flow dictates how a renovation plan is assessed or a new ED designed. This feature
is the greatest contributor to the efficient management of the department, and it becomes even more critical
during mass-casualty events.
INGRESS
Patients walking in
or arriving by ambulance
External Operating
consultations Department
Imaging, Laboratory
Emergency
Department
Inpatient
Mortuary
department
EGRESS
Patients discharged
to home
Figure 4.1 – ED inflows and outflows
Understanding what happens as a patient moves through the ED – the patient pathway – is critical to
designing the department well. The following chart resumes the major functional steps that occur as walk-in
patients make their way through the ED.
OUTLINE OF THE MoC 31
• Patient locates ED and enters from outside or another medical facility

• Patient passes through security control
ENTRY • Patient self-directs to the registration area
• Patient is registered at the registration desk

• Patient identifies triage room and waiting space
GETTING • Patient receives information on next steps
SEEN • Patient is transferred to the appropriate area
• Patient undergoes initial assessment

RECEIVING
• Patient receives treatment and undergoes investigations
CARE
• Patient self-directs to adjunctive services or waits for diagnostic results

• Patient undergoes adjunctive diagnostics and/or treatment
EXTERNAL • Patient receives disposition instructions (see next page)
CONSULTATION
• Patient is admitted to other department or unit

• Patient is discharged
EXIT • Patient is transferred to another hospital
Figure 4.2 – Main steps of the ED walk-in patient pathway
The table below breaks down the functional steps of the pathway further and adds parameters for patients
arriving through the ambulance entrance, the corresponding functional spaces and the perspectives of both
patients and staff. The column on the right summarizes the questions the design team must consider before
or during the design process.
DESIGN TEAM CHECKLIST
STEPS ED AREAS PATIENT PERSPECTIVE STAFF PERSPECTIVE DESIGN TEAM QUESTIONS

Arrival Zone 1: • Finding their way from • For driver: being able • Who – what patients?
ambulance bay, outside or other parts to take a sick patient • Accessibility?
decontamination of the hospital to the ED via the fast track • Decontamination screening?
shower room • Going through security • Having protection from • Patient arrival – how (means)
control the elements and privacy and with whom (carers, etc.)?
• Arriving at a sheltered • Having safety and security • How many patients – peak times,
drop‑off point • Decontaminating patients massive influxes?
• Self-directing to the • Routes and signs – sign positioning,
registration space language?
• Shelter from weather?
• Privacy?
• Entrance/exit unobstructed?
• Ambulance to remain at hospital?
Parking?
• Safety and security?
Getting Zone 2: • Easily identifying • Overseeing registration • Infection screening?
seen front door registration desk of patients at the desk, • Urgency protocol?
(registration • Identifying the triage room in a bay or by a relative • Waiting patients – how
space/triage room) and waiting area • Using fast track to pass and with whom?
• Receiving communication easily from ambulance bay • Communication and information?
and information on next to resuscitation room • Rapid assessment and treatment?
steps • Screening for infection • Diagnostics?
• Defining the degree • Safety and security?
of urgency
Receiving care Zones 3-4-5: • Undergoing assessment • Conducting assessment, • Urgency streaming?
treatment room, • Receiving treatment and diagnostics, treatment, • Waiting patients – how
consulting room, undergoing investigations observation and with whom?
procedure room, • Taking fast track from • Admission?
resuscitation room, resuscitation room to OR • Assessment? Diagnostics?
interview room, • Making appropriate Treatment? Observation?
isolation suite, plaster disposition decision • Communication and information?
room • Referral or transfer?
External Imaging, laboratory • Self-directing to adjunctive • Reviewing adjunctive • Diagnostics? Treatment?
consultations services or being diagnostics and disposition Observation?
transferred for diagnostic decision • Communication and information?
results • Referral or transfer?
• Receiving adjunctive • Safety and security?
diagnostics and/or
treatment
• Receiving disposition
instructions9
Discharge • Being admitted to another • Deciding to admit, step • Discharge – where to, how
department or unit down, transfer or discharge and with whom?
• Being discharged patients • Routes and signs?
• Being transferred to another • Pickup/parking?
hospital • Where next?
• Being sent to the mortuary
Table 2 – ED patient pathway – patient and staff perspectives and questions for the design team
9 “Disposition” refers to where a patient is being discharged to, e.g. home or another department.
DAY-TO-DAY EXECUTION OF THE MoC 33
5. DAY-TO-DAY EXECUTION
OF THE MoC
5.1 INTRODUCTION
In order to facilitate the understanding of how an ED is organized, the department has been divided into five
zones:
1. security monitoring and access points
2. front door (registration/triage)
3. sub-acute side (consultation)
4. acute side (resuscitation)
5. shared area.
Each zone has a specific role. They are grouped together in a way that facilitates the execution of the MoC, in
particular simplifying the patient flow.
The distinction between the zones is mostly functional and not necessarily physical – the zones may be sep-
arate portions of a building or simply parts of the same physical space. This means that even an existing ED
conceived with a different model in mind can be simply reorganized according to this MoC.
During day-to-day operation, the sub-acute side is likely to be the busiest zone.
Patient flow between the sub-acute side and acute side should be kept to a minimum, but at the same time
this flow must be physically possible in case a patient is recategorized.
Depending on the local circumstances, some patients may be redirected elsewhere for treatment (e.g. a pri-
mary health clinic). In some locations, the sub-acute side may actually be the primary health clinic.
By using this approach every day, patients, ambulance staff and health staff will learn how presentation at
the ED should work.
During the day-to-day execution of the MoC, the clinical assessment/triage person will direct patients
through Zones 1 and 2 to the most appropriate core space for treatment.
ENTRANCE
1
Security monitoring Patient arrival outside to EU
and access points
2 Registration
Waiting
Front door Triage
3 4
Sub-acute Acute
side side
5 HDU / OR /
Shared area (MORTUARY)
Resuscitation
Treatment Treatment
Consultation Procedure
Interview
Isolation
Plaster
EXIT / IPD / OPD
Figure 5.1 – General ED circulation during day-to-day execution of the MoC
Following treatment and/or stabilization, patients will be admitted directly to the operating department or
an inpatient department, or they will be discharged. Those who die will be sent to the mortuary.
A general principle for the whole department is that the flow through the five zones must be monodirectional
and lead to a well-marked exit. This is key to optimizing day-to-day functioning and avoiding blockages
that might delay transfers of critical patients. This becomes even more important during management of a
mass-casualty incident.
The first two zones are the entrance to the department and therefore are situated one after the other. Zones
3 and 4 can be situated in parallel since the patient flow is split according to clinical acuity. Nevertheless,
passage and communications between these two main clinical zones must be maintained. Zone 5 has to be
accessible from Zones 3 and 4, and vice versa.
This chapter describes how each zone is organized. Each contains physical spaces sorted into three categories,
which are colour-coded in diagrams and tables: core clinical spaces (yellow), where the major interactions
with patients happen, core clinical support spaces (pink) and finally general support spaces (turquoise).
For each of the five zones, the patient flow and relationships between spaces are illustrated with a bubble
diagram, and then the main functional spaces are described and summarized in tables.
5.2 Z ONE 1: SECURITY MONITORING

AND ACCESS POINTS
In Zone 1 the patient arrives at the facility, with or without a carer, in an ambulance or other vehicle or on
their own. They should be able to do the following:
• find their way to the ED from the outside or from other parts of the hospital
• pass through security control
• identify the infection-screening point and, if necessary, be identified by staff as requiring special
attention (decontamination or fast-tracking, if in a severe condition)
• be sheltered while being dropped off.
This zone will play a crucial role during the implementation of a mass-casualty plan, which is discussed in
section 6.
5.2.1 PATIENT FLOW

Patients will arrive at the ED either on foot (on their own or being carried), by stretcher or by vehicle (ambu-
lance, car, etc.). Ideally, the ED should have a separate entrance from the main entrance of the hospital to
protect the arrival of emergency cases. The ED gate may already be located inside the perimeter fence of the
hospital grounds.
The entrance to the ED needs to be straightforward, unimpeded and marked with wayfinding signage using
simple graphics, as those arriving are often distressed. Some will have minor injuries or illnesses while others
will be seriously ill or have sustained major trauma. There should be two entrances to an emergency depart-
ment: an entrance for those arriving using their own means of transport (referred to as walk-in patients)
and the ambulance entrance. Both entrances should have a sheltered drop-off zone. To facilitate the efficient
management of severe cases, the ambulance entrance should be close to the resuscitation area (the fast
track). Vehicular traffic should be one-way so that after dropping patients off vehicles can continue without
obstructing incoming vehicles.
ENTRANCE


MASS-
CASUALTY
SPACE
2
Arrival, waiting
FAST TRACK
& triage room
3
Resuscitation
room
5
4
EXTERNAL
CONSULTATION
Figure 5.2 – Relations of the core clinical spaces in Zone 1 of the ED

AMBULANCE BAY
Scope
This is the patient drop-off area outside the ED, near its main entrance.
The space needs to enable one-way vehicular flow to prevent returning or reversing vehicles from obstructing
subsequent vehicles’ access.
The drop-off space should have a washable concrete floor, a weather-proof canopy and, if possible, one or more
sheltered sides to provide privacy for patients.
Main relationship
FROM security monitoring and access point
TO waiting area (or decontamination shower room)
Functional space card See card 2 Type ESSENTIAL
The ambulance bay should include a stretcher parking area – storage for trolleys and stretchers for those
patients who need to lie down for transfer to registration, triage or clinical spaces.
Patients in particularly severe condition and/or with potential contamination should be identified at this
point. If their arrival was not previously announced they need to be flagged at the ambulance bay by admin-
istrative staff.
If the patient has or may have been exposed to or contaminated with toxins, chemicals, radioactive materials
or other hazardous substances, the decontamination shower room is used to decontaminate patients before
they enter the ED.
DECONTAMINATION SHOWER ROOM

Scope
The room is used to decontaminate patients. It should only be used for one patient, and up to four staff, at a time.
If there are more than two contaminated patients, the mass-casualty decontamination plan should be activated.
In this case, temporary decontamination tents will have to be set up. (This process also relies on separating walking
and non‑walking flows.)
The decontamination shower room is equipped with cold and warm water and ideally a patient conveyor. It is connected
to the staff dressing space, storage for personal protective equipment (PPE) and the staff undressing space. Wastewater
from decontamination activities should be properly treated before being released.
Main relationship
FROM security monitoring and access point/ambulance bay
TO waiting area
Functional space card See card 5 Type NON-ESSENTIAL
Ideally, there is an alert system to identify potentially contaminated patients before they enter the facility.
Once patients are decontaminated, they can rejoin the regular flow and enter the ED.
If patients require urgent care, they should be identified at this point by a rapid assessment team, if there
is one.
All other patients should go to the front door zone, where they can proceed to registration, triage and then
the right treatment areas.
5.2.2 SUPPORT SPACES

Everyone arriving at the hospital must pass through a security monitoring and access point (including during
a mass-casualty incident). Visitors and patients are checked, and if weapons are confiscated they should be
stored at security in a secure space to prevent them from being taken onto the premises. Security personnel
must have access to sanitary facilities near the monitoring point.
SECURITY MONITORING AND ACCESS POINT

Scope
This acts as a space where security personnel are sheltered and customary security control occurs.
According to the protocols in place, special measures may be taken for storing or unloading small arms.
There may be a register for patients’ and visitors’ names and time of entry. If males and females need to be separated
and searched, a double passage is required.
Main relationship
FROM outside health-care facility
TO ambulance bay/ED entrance
As previously mentioned, patients suspected of being contaminated with hazardous substances need to be
admitted to the decontamination shower room. Before attending to the patients, trained staff must don PPE,
which occurs in the staff dressing space.
STAFF DRESSING SPACE

Scope
This space is where the staff working in the decontamination shower room arrive and don PPE.
The space needs to have storage for PPE at the entrance and be big enough for staff to dress.
Main relationship
FROM outside
TO decontamination shower room
Functional space card N/A Type NON-ESSENTIAL
More importantly, after the decontamination shower room, there must be a staff undressing space. This is
where staff working in the decontamination shower room remove PPE. This should be done according to strict
procedures and with supervision. Please note that while the dressing space may be just a cabinet with PPE stock,
the undressing space is more critical. It needs to be designed to manage the risk of cross-contamination posed
by undressing operations and the waste produced (used equipment, wastewater, vapours).
STAFF UNDRESSING SPACE

Scope
This is where staff working in the decontamination shower room remove contaminated PPE.
The space needs to accommodate containers for the disposal of contaminated PPE and be large enough to allow
staff to remove PPE properly. The space must be accessible from the contaminated area and lead directly
out of the decontamination spaces. Because of the vapours released by the chlorine solutions used for disinfection,
good ventilation is required.
Main relationship
FROM decontamination shower room
TO waiting area
Functional space card N/A Type NON-ESSENTIAL (ESSENTIAL if decontamination shower room is present)
Once the patient is at the ambulance bay, an enclosed, sheltered space is needed for storing several stretchers
on wheels. They will be used as needed by incoming non-walking patients who arrive by ambulance or private
vehicle or are carried. The stretchers facilitate the patient’s transfer from outside the ED to the acute side.
STRETCHER PARKING AREA

Scope
This is storage space for wheeled stretchers used for non-walking patients.
This enclosed, sheltered space can be recessed into the ED building or be organized in a portion of the ambulance bay.
It should be arranged to ensure the stretchers’ security and the comfort of the staff in charge of using them.
Main relationship
FROM ambulance bay
TO ED entrance
It is important to consider where ambulances and private vehicles dropping off patients will park. Parking is
generally intended for these vehicles; however some places are recommended for visitors as well.10
If visitor car parking is provided, ambulance parking bays must be clearly identified with signage. The num-
ber of parking bays for ambulances and cars will depend on the facility. In hot climates, it is recommended
that an overhead canopy shelter at least the ambulance parking bays.
Visitor car parking should accommodate the special needs of people with impaired mobility and ensure they
can safely exit their vehicles and access the facility from the parking bay.
AMBULANCE/CAR PARKING AREA

Scope
This area serves as a parking area for vehicles (both ambulances and cars) dropping off patients.
It must follow the ambulance bay in the one-way flow of traffic needed for smooth patient drop-off at the entrance
of the ED. It is preferable that patients and visitors park their vehicles outside the secured perimeter of the health facility.
Main relationships:
FROM ambulance bay
TO exit (gate)
10 Parking for patients and visitors should be located outside the facility’s perimeter to facilitate access and crowd
control. If there are already parking lots inside the perimeter, they may be used as staff parking, and, as will be
covered later, the zone may also play an important role when a mass-casualty plan is initiated.
5.3 ZONE 2: FRONT DOOR

In Zone 2 patients and any carers direct themselves to the registration space, are registered and prioritized
according to clinical acuity and receive instructions to wait before being seen.
5.3.1 PATIENT FLOW

On a day-to-day basis, the arrival process inside the ED should be straightforward. Patients arrive at the
ED either by walking in or by ambulance. The ambulance entrance and walk-in entrance of the ED may
be a shared space, or they may be separate for the sake of convenience and efficiency. In either case, both
entrances should lead directly to the registration space, waiting area and triage room. Most likely a single
space will host the entrance, registration space, waiting area and triage room, but simple signage with graph-
ics should nevertheless be posted at strategic locations or lines drawn on the floor to guide the patient from
the entrance to the registration space.
Staff in the registration space or triage room may send selected patients with severe conditions directly to
the acute side (Zone 4), possibly postponing their registration. Other patients will first be registered and then
instructed to wait before being seen in the triage room (Zone 2). Patient confidentiality must be protected
during registration, and patients may need to sit when registering because of injury, illness or disability.
The registration space and triage room should be staffed with trained, dedicated personnel 24 hours a day.
Ensure there is adequate security for registration staff.
1
shower bay
2
ED entrance
& lobby

storage space
Patient sanitary
facility (M/F)
Triage room

5
3 4
Isolation suite
EXTERNAL
CONSULTATION
Figure 5.3 – Relations of the core clinical spaces and other functional spaces in Zone 2 of the ED
WAITING AREA
Scope
This space is where low-acuity patients, relatives and companions wait during visits to the ED.
It needs to be immediately adjacent to the registration space and triage room and easily accessed from clinical areas
of the ED. The area should have seating, be sheltered and ventilated, and stay warm in the winter and cool
in the summer. There should be extra space for easy circulation and handling of stretchers and wheelchairs.
For cultural reasons, it may be necessary to separate men from women and children.
Main relationship
FROM ambulance bay/registration space/triage room
TO triage room
The triage process should be led by doctors and/or nurses with appropriate expertise and experience. If the
ED is sufficiently staffed, the triage room may have a rapid assessment team in Zone 2 (by the walk-in and
ambulance entrances) able to recognize early on critical patients who need immediate treatment.
The triage room may include one designated area for ambulance patients and patients with major injuries,
and another for patients with minor injuries and illnesses. This is where patients will be clinically assessed
for prioritization of treatment.
An isolation suite in the front door zone would enable the rapid segregation of potentially infectious patients
prior to registration.
Ambulance patients preannounced as critical will be sent directly to the resuscitation room (Zone 4).
TRIAGE ROOM
Scope
This space is where the patient receives a first clinical assessment.
The patient should be able to sit or be quickly examined on a table, and medical staff should be able to examine
the patient and document the results. The triage room may be a space partitioned off from a bigger area, but privacy
must be considered. Ideally, entrances and exits are kept separate in order to facilitate movements in and out.
Main relationship
FROM waiting area
TO acute side/sub-acute side/waiting area
After triage there are two options for patients: they are directed either to the acute side for treatment or to
the sub-acute side for consultation. Since more waiting might be necessary for minor cases, those patients
may be redirected to the main waiting area; a secondary waiting area after triage might need to be considered
instead.11
11 According to the specific layout or operational policy in place, patients may wait to receive treatment in the main
waiting area in Zone 2 or a space in Zone 3 dedicated to that purpose.

As mentioned already, it is likely that a single physical space contains the ED entrance, registration space,
waiting area and triage room. According to the site’s size and location, the ED entrance and the registration
space may be independent spaces.
The staff allocated to these spaces should have a good view of the ED entrance on one side and the waiting
area on the other. Administrative staff register every patient who enters the ED according to the facility’s
policy.
ED ENTRANCE
Scope
Once the patient, ambulance staff and any relatives pass through the front door, they enter the ED entrance. Normally,
administrative staff then guide the patient/relatives to the registration space.
The arrival process should be straightforward, and the front door of the ED should be easy to locate. The ambulance
and walk-in entrances may be common or separate. The entrance is followed immediately by a buffer zone known as
the lobby. The dimensions will depend on the facility: it may be a large corridor – used as a passageway to reach the
registration space – or part of the waiting area immediately adjacent to the registration space.
Main relationship
FROM ambulance bay
TO registration space
In addition to the normal registration process for the facility, ICRC patients may be given a unique ICRC
identification code.12
A seriously injured or ill patient may receive treatment before formal registration can occur because of their
condition’s severity. If this occurs, patients still need to be registered as soon as possible according to the
facility’s and ICRC’s processes.
REGISTRATION SPACE
Scope
This is the location of the registration desk, where the patient is registered for treatment and directed to the triage room
upon arrival at the ED with ambulance staff and any relatives.
The space should be easy to spot and big enough to accommodate simultaneous arrivals. It may be integrated into
a bigger space. Often, storage space is needed to keep hard copies of records and other files for the department.
Main relationship
FROM ambulance bay
TO waiting area
12 ICRC patients include: a) all patients in an ICRC-managed facility, b) patients who require surgery in
an ICRC-managed surgical facility, c) all patients who arrive at the hospital with an ICRC comprehensive
support package during the hours ICRC mobile staff are working and d) all patients who arrive at the hospital
with an ICRC surgical support package during the hours ICRC mobile staff are working.
Separate sanitary facilities for males and females (denoted as “M/F”) should be directly accessible to the
patients, relatives and visitors waiting in the waiting area.13 A ratio commonly used is one toilet to every
20 users. The sanitary facilities may be adjacent or directly connected to the waiting area; in certain locations,
they may be outdoors but nearby. At least one wheelchair-accessible toilet should be provided.
This area should also have a point for drinking water.
For the management of children, a play area may be included near the waiting space. In this case, a sanitary
facility equipped for children should also be considered.
5.4 Z ONES 3 AND 4: SUB-ACUTE SIDE

AND ACUTE SIDE
These zones are the core of the department where treatment is provided. Patients with minor clinical condi-
tions self-direct to the sub-acute side (and secondary sub-waiting area), while patients in critical condition
are directed to the resuscitation area. They then receive treatment and investigations are carried out.
Both zones receive patients from Zone 2 and are organized in a similar way. The most relevant difference
is that patients with minor conditions are first registered and then triaged before entering Zone 3, whereas
ambulance patients in critical condition are streamed directly into Zone 4, where they are rapidly assessed
and treated by medical staff.
The route between registration/triage and the resuscitation room must be direct and unobstructed. Patients
in critical condition are likely to require others to assist in their transfer, as they may be lying on a stretcher
or a trolley with wheels.
Following treatment and/or stabilization, patients will either be admitted directly to the OR, sent to an in
patient unit or discharged. Those that die will be sent to the mortuary.
Some patients will also need secondary treatment, such as X-rays or laboratory tests. According to the facil-
ity’s operational policy, measures should be taken to simplify the flow to and from secondary diagnostic
spaces (medical imaging and the laboratory, also called “external consultation” in bubble diagrams).
13 Staff should also have access to dedicated sanitary facilities (M/F). When possible, they should be part of the staff
changing room; in either case, there should be separate sanitary facilities for staff and patients whenever possible.
2
Arrival, waiting
& triage room
4
Sub-waiting
area
5
Treatment room
Isolation suite
(sub-acute)
Consulting
Interview room
room(s)
3
Plaster room
EXIT / ZONE 4 Laboratory Medical imaging
EXTERNAL CONSULTATION
5.4.1 PATIENT FLOW IN ZONE 3 (CONSULTATION)

This area is dedicated to the management of patients with minor illnesses or injuries who do not require
resuscitation or monitoring; often such patients are non-complex, presenting with single-system conditions
and minor traumatic injuries.
On the sub-acute side the patient is assessed and treated in by a clinical staff member and directed to the
most appropriate space if further treatment is needed.
If their condition is not clinically urgent, patients may need to wait again, in which case they are directed
back to the main waiting area. Alternatively, a sub-waiting area after triage may be provided.14
After triage patients on the sub-acute side are directed to either the treatment room or the consulting room.
14 According to the specific layout or the operational policy, the area for patients to wait to receive treatment after triage
may be the main waiting area in Zone 2 or a space in Zone 3 dedicated to that purpose.
TREATMENT ROOM (SUB-ACUTE)

Scope
Located primarily on the sub-acute side, the treatment room hosts several patient bed spaces for patients with minor
illnesses who require little intervention.
This space will require support spaces, including a nurses’ station, equipment bay, linen bay, clean utility room,
dirty utility room, patient shower room and patient sanitary facilities. The number of bed spaces will depend
on the facility – the usual is two to 10. Separation by gender might be required.
Main relationship
FROM triage room
TO exit
Following treatment and/or stabilization, patients might be moved elsewhere within the ED or externally.
If the patient’s clinical condition deteriorates significantly they may be transferred to the resuscitation room
or to a patient bed space. The opposite may occur if the patient is deemed stable enough. Patients may also
need an intervention in the procedure room.15
The layout of the department should facilitate patient and staff movements within and between both sides of
the ED. Patients may also be sent outside the ED for other purposes, such as for X-rays and laboratory tests.
Specific arrangements should be made to this end in accordance with the local operational policies and the
layout of the site (e.g. to ensure that patients have somewhere to wait during diagnostics and can contact
someone when back from the lab or imaging).16
NOTE: If the ED is large enough, there should be a treatment room on both sides of the department. If it is a
very small department, both sides may share one treatment room.
After triage, some patients are directed to the consulting room. The doctor or nurse conducting the con
sultation may have to perform a variety of tasks, e.g. taking vital signs, performing auscultation of the chest,
palpating the abdomen, removing simple sutures, dressing wounds or administrating a nebulizer.
CONSULTING ROOM
Scope
This is a space for a private consultation with and physical examination of a patient.
The room is private, with an examination table for the patient to lie on and a desk and chair for the doctor/nurse.
If the room is large, the examination table should not be against the wall so the doctor/nurse can access the patient
from either side with equipment, e.g. a dressing trolley.
If the room is small, the examination table can be placed against the wall, but the doctor/nurse must still have good
access to the affected side of the patient’s body. The patient lies with that side facing the doctor/nurse.
Main relationship
FROM waiting area
TO exit (or other space in Zone 3)
15 Located primarily in Zone 4, the procedure room for more complex or invasive procedures than those that can be
undertaken in a patient bed space. The room may be shared by Zones 3 and 4 if the ED cannot accommodate
a procedure room on each side.
16 See also chapter 7, “Additional design considerations”.
Where possible, this room should be located slightly out of the way to provide a quiet and private environ-
ment. This is particularly important when dealing with victims of sexual violence.
Ideally there would be a sub-waiting area, a nurses’ station and easy access to the treatment room (sub-
acute) from the consulting room.
5.4.2 PATIENT FLOW IN ZONE 4 (RESUSCITATION)

The acute side is where patients are received, assessed and initially treated when they have life-threatening
or time-sensitive urgent conditions.
Generally, after registration and triage, the most critical patients are directed either to the resuscitation room
or to the treatment room (acute). The way in to the space will need to be accessible to patients on stretchers
or trolleys.
If the patient’s condition requires life-saving procedures, the patient is immediately transferred from the
ambulance bay to the resuscitation room (i.e. the fast-track process).17
The anaesthetist or surgeon may be summoned from the OR to assess a patient in the resuscitation room,
so the relationship between the OR and the ED is a priority; ideally they would be well connected. This is not
only to expedite patient care but also to maximize staff’s efficiency.
Some surgical cases will need to be transferred directly to the OR for urgent surgery. They will be on a trolley
or stretcher and will be accompanied by at least one clinical staff member for the transfer. The route to the
OR (called the “red axis”) needs to be direct and unobstructed, with double doors which open in the direction
of travel to expedite the journey.
RESUSCITATION ROOM
Scope
The resuscitation room is where critically ill or patients with severe trauma are assessed, resuscitated and treated,
which may involve multiple potentially invasive procedures.
In the resuscitation room, the patient lies on a resuscitation stretcher or table. This must be positioned
to allow 360° circulation around and access to the patient because staff may need to perform different interventions
simultaneously as part of the stabilization process. This may include the use of a portable X-ray machine.
Main relationship
FROM ambulance bay (via registration space)
TO OR/HDU (or other space in Zone 4)
17 Note that the resuscitation room is the only functional space within the ED that is not accessible to relatives or carers,
as patients might undergo one or more potentially invasive or time-sensitive procedures.
1
Ambulance
bay
FAST TRACK
2
Arrival, waiting
& triage room
OR
3
Resuscitation
room
Treatment room
Isolation suite
(acute)
Procedure
Interview room
room
Plaster room
5
EXIT / OPD /
IPD / HDU / OR /
Laboratory Medical imaging (MORTUARY)
Figure 5.5 – Relations of the core clinical spaces (only) in Zone 4 of the ED
Occasionally patients will die in the resuscitation room (more frequently than in other areas in the ED), so
the route to the mortuary should be discreet and, where possible, should not go through the entrance/arrival
point of the ED.
Patients who will likely require admission or must be observed for a few hours (under 24) are transferred to
the treatment room (acute). This is an aggregated space with between two to 10 patient bed spaces, depend-
ing on the area available.
In case of a mass-casualty incident, all category II (yellow) patients are managed in the treatment room,
which will have dedicated emergency medicine physicians (along with emergency medecine nursing staff)
looking after the patients directed here.
TREATMENT ROOM (ACUTE)

Scope
Located on the acute side, this treatment room hosts several patient bed spaces for patients with a high likelihood
of admission.
This space will require support spaces, including a nurses’ station, equipment bay, linen bay, clean utility room,
dirty utility room, patient shower room and patient sanitary facilities. The number of bed spaces will depend
on the facility – the usual is two to 10. Separation by gender might be required.
Main relationship
FROM triage room
TO corridor/exit
Patients who require minor surgical procedures or pregnant women about to deliver are transferred to the
procedure room on a patient trolley and are then transferred to the procedure couch. The entrance to the
room must therefore be big enough for easy transport of patients on stretchers.
Patients being discharged from the procedure room may have a short period of observation in the treatment
room, go to an inpatient unit or go home. They are less likely to go to the OR.
Good ventilation is required to optimize conditions for clean invasive procedures and reduce infection risks.
Normally procedure rooms include positive pressure (with airflow out of the room) and ventilation com
parable to that in ORs. Lighting should also be adequate for clinical interventions.
NOTE: If a plaster room is not included in the ED, plaster room functions may be performed in the procedure
room using a plaster trolley, though not ideal. If this is the case, there must be enough space for a second
patient on an examination couch or treatment trolley.
PROCEDURE ROOM
Scope
Located primarily in the Zone 4, the procedure room is for patients who require more complex or invasive procedures
than those able to be undertaken in a patient bed space.
The room has four solid walls (to ensure sights and sounds remain private), double doors for access, and a maximum
capacity of one patient, one carer and two staff members at a time.
One procedure room may be shared by Zones 3 and 4 if the ED is not big enough to accommodate a procedure room
on either side.
Main relationship
FROM triage room
TO corridor/exit
5.4.3 SUPPORT SPACES IN ZONES 3 AND 4

The resuscitation room, treatment room, consulting room and procedure room are where the main clinical
interactions take place. Equipment and clean and dirty disposables need to be at hand for the staff on shift.
The spaces described below need to be directly accessible in order for clinical activities to occur.
NOTE: In small settings these functions can be directly incorporated into the main core clinical space. In
bigger settings they need to be included individually.
The nurses’ station is the administrative base of the unit in which it is located and is the enquiry point for
patients, visitors and visiting staff. It is the coordination hub for patient care and writing up patient notes,
and it is where nursing staff gather when not with patients.
NURSES’ STATION
Scope
This is where staff can sit, prepare drugs, store medications, update records and continuously monitor the patients
in the area.
The key feature of the nurses’ station is that it is situated so the staff in it can see all patients and vice versa,
in case patients wish to attract the staff’s attention. The station is usually located in the same space as the patients.
If it is in a separate room, windows must give a direct view of the patients.
The distance between the nurses’ station and the furthest patient bed must be as short as possible.
The nurses’ station includes clean utilities. It must be furnished with a counter, chairs, a cupboard and shelf,
a hand-wash bay and space for trolleys.
Main relationship
FROM corridor
TO treatment room
Medical staff need equipment to perform medical activities. Specific equipment dedicated to a single func-
tion is stored in the corresponding space; for example resuscitation equipment is stored in the resuscitation
room. However, an open equipment bay is often needed for storing one or more pieces of mobile (wheeled)
equipment frequently used by multiple spaces. Examples include wheelchairs, trolleys, drip stands, commode
chairs and other mobile equipment.
If it is not possible to place the bay in a recess, a convenient space for storing mobile equipment should be
identified so it does not obstruct the flow of staff, patients and supplies (e.g. linen) in the room or corridor.
1
Ambulance bay
2
Arrival, waiting & triage room
FAST TRACK
OR
DAY-TO-DAY EXECUTION OF THE MoC
3 4
Equipment Sub-waiting Resuscitation Equipment
bay area room bay
Hand-wash Nurses’ station Treatment room 5 Treatment room Nurses’ station Hand-wash
bay (sub-acute) (sub-acute) (acute) (acute) bay
Isolation suite
Consulting Procedure
Linen bay Interview room Linen bay
room room
Plaster room
EXIT / OPD / IPD /

EXIT / ZONE 4 Laboratory Medical imaging HDU / OR /
(MORTUARY)
51
Figure 5.6 – Relations of the core clinical spaces and other functional spaces in Zones 3 and 4 of the ED
EQUIPMENT BAY
Scope
This is where equipment is stored that is frequently shared between one or more treatment spaces.
It must be an open space but where it will not interfere with circulation, ideally in a recess.
Main relationship
FROM corridor
TO treatment room
Medical personnel and patients must be able to wash their hands at any time. This is by far the most effective
measure for infection control. When treatment spaces are designed, the number of hand-wash bays should
be proportional to the number of patient bed spaces – the ratio is given in the Functional Space Catalogue –
and all core clinical spaces, regardless of size, must have a hand-wash bay, to ensure staff have easy access
to them at all times.
Each bay should be positioned so it does not obstruct the flow of staff, patients or supplies (e.g. linens) in
the room or corridor.
HAND-WASH BAY
Scope
This is where medical staff wash their hands after all procedures and contact with patients.
A hand-wash bay must be present in every clinical space. It should be placed in a position facilitating its use,
ideally in a recess.
The number of sinks will depend on the dimensions of the room and the number of patients and staff in it.
Main relationship
FROM corridor
TO treatment area
Linen needs to be stored next to where the relevant clinical activity is performed. This may include bed
sheets, pillowcases and blankets. A tall cupboard with doors may be built into a recess; if a recess is not feas
ible, a convenient space for linen storage (in a cupboard or on a trolley) should be identified so it does not
obstruct the flow of staff, patients or supplies in the room or corridor.
LINEN BAY
Scope
This is where clean linen is stored.
It should be an open space but where it will not interfere with circulation, ideally in a recess.
Main relationship
FROM corridor
TO treatment room
5.5 ZONE 5: SHARED AREA

This zone is shared by the sub-acute and acute sides. This is where, from the patient point of view, the patient
undergoes adjunctive diagnostics and/or receives treatment and ultimately receives disposition instructions.
From the staff point of view, this is the location of all shared support spaces for clinical activities for the
entire department as well as spaces for administrative tasks and staff needs.
5.5.1 PATIENT FLOW

The interview room in the ED is used by clinical staff for talking to distressed or disturbed patients and rela-
tives and for assessing patients who have mental health problems or are in other special circumstances (e.g.
detainees). Ideally the room is located near the front door zone.
Patients may also be directed to the interview room from the consulting or treatment rooms in Zone 3 or,
though less likely, from any space in Zone 4. Where possible, the interview room should be located slightly
out of the way to provide a quiet, private environment. This is particularly important when dealing with
victims of sexual violence.
INTERVIEW ROOM
Scope
This is a private area where clinical staff can speak with distressed patients or visitors and assess patients with mental
health problems or in special circumstances (e.g. victims of sexual violence or detainees). An acutely distressed mental
health patient may be put in this space until they calm down or are physically or chemically restrained.
The room is enclosed and ensures sights and sounds remain private. If the room is used for acutely distressed mental
health patients, staff may need the ability to remove furniture easily in order to provide a safer environment where
patients cannot injure themselves.
Main relationship
FROM Zones 2, 3 and 4
TO exit or treatment room
The plaster room where plasters and splints are applied to manage musculoskeletal injuries (e.g. fractures and
dislocations). Procedural sedation for the reduction of dislocations might take place in this space. There are
at least two patient couches so the plaster may dry on one patient while a second patient is being attended to.
The plaster room should have good access to the medical imaging department (X-ray room) and the physio-
therapy department, which may share this space if it does not have a plaster room of its own.
NOTE: If a plaster room is not included in the ED, see the note on incorporating it into the procedure room
(see section 5.4.2).
1
Ambulance
bay
FAST TRACK
2
Arrival, waiting
& triage room
OR
3
Sub-waiting Resuscitation
area room
4
Treatment room Treatment room

Isolation suite
(sub-acute) (acute)
Interview room
room room
Plaster room
5
EXIT / OPD / IPD /

(MORTUARY)
PLASTER ROOM
Scope
This space is mostly dedicated to patients with limb fractures who need to have a plaster cast or splint stabilizing
the fracture applied or removed.
The entrance and exit will need to allow for patients on stretchers, in wheelchairs or using walking aids
such as crutches.
Main relationship
FROM Zones 3 and 4
TO X-ray and physiotherapy services
If an isolation suite is present (more likely in larger EDs), it must be accessible from both sides of the ED and
located near the front door zone. The isolation suite is composed of three elements: an anteroom, a bedroom
and an en-suite bathroom. Ideally potentially contagious patients should be identified in Zones 1 or 2 and
then directed here for further diagnostics.
The anteroom, if there is one, leads directly into the bedroom and is the point from which staff and visitors
enter the bedroom. If the anteroom is not a proper room with the function of a buffer zone, it can be a space
in the corridor outside the main bedroom doors (in a recess, if possible).
The bedroom is self-contained, with direct access to its own en-suite bathroom with a shower and WC. This
space has a second door leading directly from the corridor into the bedroom, which is used for transferring
the patient and the bed or other large pieces of equipment.
If the interview room is not available, the isolation suite can also be used when assessing patients with men-
tal health problems.
ISOLATION SUITE
Scope
This is where patients are isolated when they are suspected of having an infectious disease or when they are
immunosuppressed and at greater risk of contracting an illness.
The isolation suite has three parts: an anteroom, a bedroom and an en-suite bathroom. The anteroom provides a buffer
zone between the corridor and the patient’s bedroom; staff and visitors don and remove protective clothing there
before entering and exiting the patient’s bedroom. The bedroom itself is self-contained and has direct access to its own
en‑suite bathroom with a shower and WC.
Main relationship
FROM nurses’ station
TO corridor
Functional space card See cards 37, 38, 39 and 40 Type NON-ESSENTIAL

There are 11 functional spaces that support ED activities and should be considered in the design. The six
following support spaces are directly linked to the clinical activities performed in Zones 3, 4 and 5 and are
necessary for the ED to function properly on a day-to day basis:
1. medical equipment store
2. clean utility room
3. dirty utility room
4. cleaner’s room
5. patient shower room (M/F)
6. patient/visitor sanitary facilities (M/F).
Other support spaces might also be necessary to support the needs of department staff:
1. staff office (shared)
2. staff office (single-person)
3. staff break room
4. staff changing room (M/F)
5. staff sanitary facility (M/F) directly accessible from the staff changing room.
MEDICAL EQUIPMENT STORE

Scope
This is storage for larger items not stored in equipment bays. It is an additional storage space (possibly needed only
in large departments).
It may be lockable if necessary. Consider making the space larger to accommodate items specific to mass-casualty
incidents, e.g. ventilators, intubation equipment, pumps.
Main relationship
FROM corridor
TO all ED
Usually, all supplies are delivered to the ED via the front door zone. This includes linen, consumables, house-
keeping materials, equipment and other stores. Goods are then transferred to the appropriate locations for
storage and use.
CLEAN UTILITY ROOM

Scope
This space is used for storing and preparing medications and consumables.
The space must be enclosed and lockable. In a small facility, the clean utility room may be a cupboard in a recessed
area out of the flow of traffic. It is located away from the dirty utility room.
Main relationship
FROM corridor
TO all ED
1
Ambulance
bay
EXIT / OPD / IPD /
HDU / OR /
2 (MORTUARY)
Arrival, waiting
EXIT / & triage room
ZONE 4
area room
3
4

Isolation suite
(sub-acute) (acute)
Interview room
room room
Patient shower
Plaster room
room (M/F)
5
Patient/visitor
Dirty utility Cleaner’s sanitary facilities
room room (M/F)
Staff sanitary Medical Clean utility

facility (M/F) equipment store room
Staff changing Staff break Staff office Staff office

room (M/F) room (shared) (single-person)
Laboratory Medical imaging
Figure 5.8 – Relations of the core clinical spaces and other functional spaces in Zone 5
The ED must include a dirty utility room, where reusable materials and used linen coming from clinical areas
are collected before dispatch to the relevant departments. The room is also set up to clean some equipment.
DIRTY UTILITY ROOM

Scope
This room is used for the disposal of human waste (urine, vomit, faeces, etc.) and for point-of-care urine stick testing.
Bedpans and urinals are cleaned, dried and stored here. Used rubbish and linen bags may be kept here until collection
and new rubbish and linen bags are kept here.
The room is enclosed. It is located away from the clean utility room.
Main relationship
FROM corridor
TO all ED
The ED also needs a room for storing housekeeping materials; its location should be easily accessible to
cleaning staff. It can be a single room or multiple smaller rooms.
CLEANER’S ROOM
Scope
This is a secure room for storing cleaning materials, agents and equipment, which may include a trolley, for washing
mops, buckets, brooms, etc.
It contains a slop sink for filling and emptying buckets used for cleaning. Usually there are multiple small rooms
(of about 2 m2) so cleaning staff may cover the entire department efficiently (how many rooms depends
on the ED’s size).
Main relationship
FROM corridor
TO all ED
Patient sanitary facilities and showers must always be separated by gender – one for males and one for
females – whatever the circumstances. Both the sanitary facilities and shower room have at least one space
designed for disabled users.
PATIENT SHOWER ROOM (M/F)

Scope
Patients are washed here.
There must be one room for males and one for females. Each room is large enough to wash a patient on a bed
or stretcher (prior to OR). If circumstances allow, the shower room must be provided with hot and cold water.
The showerhead must be flexible for convenient use.
Main relationship
FROM corridor
TO corridor
PATIENT/VISITOR SANITARY FACILITIES (M/F)

Scope
Patient amenities include WCs for patients and visitors. Some patients may need to provide specimens here.
The number of WCs should be determined considering the total number of patient spaces. Care must be taken to
separate male and female WCs. At least one of the patient toilets must large enough to be used by disabled people
in a wheelchair.
Main relationship
FROM corridor
TO corridor
ED staff perform administrative tasks; in addition to the nurses’ station, they need an office where privacy
can be ensured (single-person and/or shared).
STAFF OFFICE (SHARED)

Scope
Open-plan workspace for clinical staff to perform administrative tasks.
The room must be furnished with enough tables, chairs, cupboards, etc. to accommodate the staff.
Main relationship
FROM corridor
TO corridor
STAFF OFFICE (SINGLE-PERSON)

Scope
This is an individual office for clinical staff (e.g. the head of the ED, specialist doctors) to perform administrative tasks.
The room must be furnished with a table, chair, cupboard, etc.
Main relationship
FROM corridor
TO corridor
As mentioned previously, qualified nurses and nursing assistants staff the ED 24/7. They need a space to take
a break from work without having to leave the department.
STAFF BREAK ROOM

Scope
This is a room where staff can relax away from treatment areas.
A table and chairs should be provided so staff may eat and drink.
Including the room is optional and depends on size of the department and the hospital’s operational policy – it usually
only found in a larger department.
Depending on the location, segregation by gender may be required.

Main relationship
FROM corridor
TO corridor
Staff also need access to WCs, showers and a changing room. The sanitary facility may be separate but directly
connected to the changing room, or it may be within the same space as the changing room but properly
separated.
STAFF CHANGING ROOM (M/F)

Scope
The changing room is provided for staff who need to change into work clothes e.g. scrubs or uniforms.
The room has hanging spaces and/or secure lockers. It is optional for the ED; staff may use centralized changing areas
located within a reasonable distance of their workspace.
Main relationship
FROM corridor
TO corridor
STAFF SANITARY FACILITY (M/F)

Scope
This a sanitary facility for staff with WCs and showers.
It should be directly connected to the staff changing room. If there is no changing room within a reasonable distance,
there must nevertheless be at least one WC for male staff and one WC for female staff.
Main relationship
FROM corridor
TO corridor
EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT 61
6. EXECUTING THE MoC

IN A MASS-CASUALTY
INCIDENT
6.1 INTRODUCTION
The ED layout needs to be flexible enough to accommodate two different ways of working: normal activ-
ities (day-to-day execution of the MoC) and activities during a mass-casualty incident (MCI). An MCI is
‘‘a destructive event that causes so many casualties that extraordinary mobilization of medical services is
necessary.”18
The MoC illustrated below explains how the workflow can be organized to minimize the changes between
the two situations and therefore facilitate the transition from one to the other. The specific design features
illustrated help manage this transition.
During an MCI, the ED becomes the hospital unit for mass-casualty triage, stabilization and disposition. With
most EDs already functioning at or over capacity, all ED components must be optimized if an MCI is to be
managed efficiently.
The most important aspect of ED design for MCIs is the department’s external infrastructure. For the ED to
continue functioning, crowd control is key to avoiding service disruptions. Not only will the ED receive large
numbers of casualties from the MCI itself, but non-essential people can be expected to converge there, such
as members of the media, concerned family members, and volunteers and health-care workers looking to
help. As such, the set-up should enable the facility to be locked down rapidly for security purposes so that
only casualties may enter.
Access control at the gate and the ambulance bay’s structure and location play a key role in enabling efficient
vehicle flow and discharge of casualties.
It is also key to:

• strategically relocate where triage takes place, as will be explained below
• have available well-positioned, functional decontamination facilities
• ensure stores of medical supplies are adequate, well located and easily distributed
• have appropriately built, functional essential services (backup power, water supply, etc.).
Equally or even more important for managing an MCI are the following: software measures such as
patient-tracking techniques; adequate surge capacity for both patients and staff; and sufficient command,
control, communications, computers and information. However, they fall outside the scope of this document
and are not addressed here.
The features of an ED’s layout that play a crucial role during MCIs must coexist with the department’s ordin
ary functioning. The infrequency of MCIs or overwhelming day-to-day needs might push staff to repurpose
spaces initially dedicated to MCI management. This should be carefully considered, especially in urban loca-
tions, where the sudden impact of an MCI might have serious consequences.
18 W.H. Rutherford and J. de Boer, “The definition and classification of disasters”, Injury, Vol. 15, No. 1, July 1983,
pp. 10–12.
Adaptation to the location is always required. How the department is set up and functions regularly and
during an MCI should be adjusted to the circumstances. This includes preparing for specific types of MCIs
(e.g. chemical attacks are more likely in some places than others) and using the technological options that
are available (e.g. heating, ventilation and air-conditioning (HVAC) systems managing positive or negative
pressure are very seldom a viable option in low-resource settings).
The table below provides a snapshot of the situations occurring in an MCI and lists the design measures that
will facilitate management of an MCI.19
19 The text of this introduction and the table have been adapted from: P. Halpern, S.A. Goldberg, J.G. Keng, K.L. Koenig,
“Principles of Emergency Department facility design for optimal management of mass-casualty incidents”, Prehospital
and Disaster Medicine, Vol. 27, No. 2, May 2012, pp. 204–212.
MCI SCENARIO ASSUMPTIONS PHYSICAL ESSENTIAL DESIGN MEASURES ADDITIONAL MEASURES

SPACES
CONCERNED
Continuity The physical structure of the External • Facility resistant to structural collapse • Positive-pressure filtered air
of service department must remain intact infrastructure • Ambulance bay sheltered from hazardous materials system
provision throughout the duration of the (stray bullets, airborne debris, etc.) • Airtight windows and doors
MCI in order to ensure the safety • Storage building with blast-
of health-care providers and their resistant walls directly in front
ability to provide uninterrupted of ED entrance (see below
patient care. regarding PPE storage space)
Convergence Penetration of the hospital Security • Appropriate and secure perimeter fence • Strong doors (blast-resistant
of people perimeter by unauthorized people monitoring • Single vehicle entry point and/or crowd-controlling)
or vehicles is of concern, not only and access point • Ability to control all entries and exits
for the risk of overcrowding with
family members and onlookers, but
because the ED itself may become
a secondary target for attack.
Clustered By definition, MCIs result in so Ambulance bay • Ambulance bay with one-way vehicle flow (e.g. a • Multiple lanes for multiple
pattern of many casualties that local medical circular driveway) patient discharges at once
casualties on resources are overwhelmed. During • Equipment positioned in advance for offloading • Space for multiple drop-offs
arrival MCIs, casualty inflow rates can patients (mass-casualty triage store) at once
reach 30 to 50 patients within the
first half hour.
Mass-casualty • Mass-casualty triage space with single entry point • Funnel-shaped area in which
triage space (triage • Decontamination prior to triage triage is performed individually,
relocated outside • Dedicated triage area close to treatment areas and far with patients in single file
the ED) enough from care areas to avoid cross-contamination
• “Geographic” triage, i.e. sorting people into two
separate groups on the sub-acute side and acute side
• Monodirectional flow inside the ED, with one entrance
and one exit
Surge Especially in urban disasters, Equipment storage • Ease of circulation and advance positioning of • Flexible patient care areas
the ED may have only minutes Treatment areas dedicated gurneys for evacuating non-critically ill (without fixed partitions) that
to accommodate the first wave Corridors and patients from the ED and transferring them to general can be expanded rapidly to
of casualties, which may arrive circulation spaces medical floors, leaving available valuable surgical beds accommodate large numbers
without any warning and quickly • Continuous overflow areas in the layout (e.g. waiting of casualties
overwhelm department resources. area)
• Other hospital areas able to reallocate space to
patients from the ED in order to increase ED capacity
Concurrent MCIs can include or happen Decontamination • Decontamination shower room outside ED, with • PPE storage space constructed
events contemporaneously with chemical, shower room dedicated wastewater management with blast-resistant wall
biological and radiological MCIs. Isolation suite • Contiguous with isolation suite (able to accommodate between the gate and triage,
The latter may necessitate patient seated patients and patients who must lie down) which can prevent effects from
decontamination or isolation • Sufficient quantities of PPE secondary attacks
prior to definitive care. Failure to in storage • External space contiguous
decontaminate patients adequately with the ambulance bay
may result in significant hazards to that can host an additional
treating staff members. decontamination shower or
extra isolation facilities (or
ability to use parking lots for
the same purpose)
Isolation Essential services are likely to Medical supplies, • Medical equipment store with enough extra floor area • Space for mass fatalities at the
from fail during an MCI, including food, non-medical to provide extra capacity for MCIs morgue
external water, power, fuel, medical gases, supplies (water, • Prepositioning of oxygen reserves in tanks with mask • Zoned HVAC
services and heating, ventilation and air food, power, fuel, and distributors20
conditioning (HVAC). medical gases, • Uninterrupted power supply available at each bed with
Transportation of patients HVAC) monitors or other clinical equipment
or resources throughout the • Essential services with extra capacity and backup:
hospital can be unpredictable in three days’ water storage, internal water purification
the event of an MCI. Sanitation system, backup power generators and fuel located in
services and waste removal may structurally stable areas
be severely compromised. Food
and potable water may be limited, Ancillary services • Self-sufficient imaging and
contaminated or unavailable. laboratory services dedicated
to the ED
Table 3 – Design measures to facilitate MCI management
20 Oxygen tank capacity can be computed with the following formula: [(maximum expected number of ED patients) x
(10 litres/min.) x (60 min./hr) x (24 hr)] / [volume of the storage tanks to be used].
6.2 EXECUTION OF THE MoC IN AN MCI

In general terms, the registration and triage functions are the only parts of the model that change from their
day-to-day sequence during an MCI.
During an MCI, the approach to the ED will be similar, with the two sides (acute and sub-acute) still in place.
However, outside the ED a predesignated area will become the mass-casualty (MC) triage space. The MC
triage officer, who must be a clinical staff member experienced in MC triage, will process the injured using
MC triage categories.
A clinical staff member is required at this stage to reduce the chance of mistriage or other errors and thereby
expedite appropriate clinical care. Patients then will be sent by that person to the sub-acute or acute sides of
the ED or to the mortuary.
After MC triage, patients directed to either side of the ED will undergo further clinical assessment to deter-
mine clinical priority for treatment, and they will be placed in the most appropriate clinical space to receive
needed care.
All patients presenting to the ED during an MCI-related influx will be provided with a unique identification
tag in the MC triage space by the triage officer or their assistant. This process will replace the usual regis-
tration process. Individual registration of patients as per facility policy will be re-established as soon as the
situation is considered to be under control.
Compared to the day-to-day execution of the MoC, the main difference lies in the use of the external spaces
for general triage and the waiting area as overflow triage space. (See the following diagram.) Everything else
remains the same.
ENTRANCE ENTRANCE
Patient arrival
1
Security monitoring Patient arrival outside ED
and access points 1
Security monitoring Mass-casualty triage
and access points
2 Registration
Waiting
Front door Triage 2 Waiting
Front door Treatment
EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT
3 4
Sub-acute Acute 3 4
side side Sub-acute Acute
HDU / OR / side side
5 (MORTUARY) HDU / OR /
Shared area Resuscitation (MORTUARY)
5
Treatment Treatment
Consultation Procedure Shared area Resuscitation
Treatment Treatment
Consultation Procedure
Interview
Isolation
Plaster Interview
Isolation
Plaster
EXIT / IPD / OPD

EXIT / IPD / OPD
65
Figure 6.1 – Day-to-day execution of the MoC (left) and execution of the MoC in an MCI (right)
6.3 CHANGES TO PATIENT FLOW IN AN MCI

6.3.1 MASS-CASUALTY TRIAGE SPACE (EXTERNAL)
During an MCI, a predesignated triage space situated outside the ED will be put into use.
The MC triage space should be near the front door of ED, adjacent to the MC triage store. It should enable
acute and sub-acute patients to be separated and channelled easily into the ED after triage.
MASS-CASUALTY TRIAGE CATEGORIES

Category I – Red
These patients have life- or limb-threatening surgical conditions and other emergency medical condi-
tions requiring immediate intervention.
• They are sent to the acute side of the ED for initial assessment, stabilization and admission
to the OR or HDU.
Category II – Yellow
These patients require surgical or other medical interventions which can wait.
• They are directed to the acute side of the ED for initial assessment, stabilization and admission
to an inpatient ward or the HDU.
Category III – Green

These patients have superficial wounds or other non-urgent medical conditions (all sub-acute patients
not falling into categories I or II).
• They are directed to the sub-acute side of the ED. Patients will be continuously assessed, retriaged
and treated accordingly.
Category IV – Blue (secondary triage category)

These patients are initially triaged as category I (red). Upon further assessment, patients with injuries
or other medical conditions that require curative treatment beyond current capacity will be assigned
this category. If adequate resources become available (i.e. a higher-level referral facility), patients can
be reclassified as category I.
• These patients will be admitted to an inpatient unit for palliative care or possible transfer or
referral to another facility.
The dead and body parts

• These bypass the ED and go directly to the mortuary after receiving an identification tag
at the triage point.
ENTRANCE
1
Stretcher Staff sanitary Monitoring and Ambulance/Car
parking area facility (M/F) access points parking area
Staff dressing Ambulance Mass-casualty

space (decont.) bay triage store
Staff undressing Decontamination Mass-casualty

space (decont.) shower triage space
T
2
The waiting area may
become a treatment area Waiting area
if needed. In this case
the main patient flow would The original
go from the mass-casualty triage area may
triage space (in zone 1) become an extra
Triage room
directly to zones 2, 3, 4 and treatment room
Treatment room
5 and external consultation. for MCI patients
3 4
EXTERNAL
CONSULTATION
Figure 6.2 – MCI flow, option 1 – a predesignated triage space outside the ED is used during an MCI
instead of the usual triage room, and the waiting area is used as an additional treatment area
MASS-CASUALTY TRIAGE SPACE (OUTSIDE ED)

Scope
This is a space outside the ED entrance large enough to host an increased number of casualties and to enable staff
to move easily between patients in an MCI.
Most likely the percentage of acute patients will be higher than normal, which means that there should be room
for the patients to lie down as well as for the movement of trolleys and gurneys. The space should be sheltered from
the elements and from any hazardous materials (e.g. stray bullets, debris). It must have water, drainage and electricity
points as well as lighting to enable night-time work.
Main relationship
FROM ambulance bay
TO ED entrance
Refer to the ambulance bay card (2) to see different possibilities for integrating
the MC triage space, the ambulance bay and existing areas such as parking lots.
It is important to note that once the MCI management plan is triggered, the triage room in the front door
zone is not used anymore.
6.3.2 DECONTAMINATION SCENARIO

If the MCI involves a large number of people who must be decontaminated, a decontamination shower room
with only one or two showers can quickly become inefficient for even a moderate number of casualties. Fur-
ther assessment of the need for decontamination should take place outside the ED and may necessitate an
alternate triage site, such as an external structure like a parking lot or tent.
The ICRC’s weapon contamination (WEC) teams have a scale-up plan for carrying out large-scale decontam-
ination following contamination from chemical agents. The WEC mass-casualty scenario requires a minimum
set-up of:
• two 42 m2 tents for the decontamination of patients – divided either by gender or by triage category
(acute or sub-acute)
• one 20 m2 tent for staff decontamination.
MASS-CASUALTY DECONTAMINATION SPACE (OUTSIDE ED)

Scope
This space ensures that decontamination operations can be expanded with tents or other temporary structures in case
the expected number of patients surpasses a few units.21
The space outside should be pre-equipped with basic infrastructure: hot and cold water supply, wastewater drains
connected to dedicated post-treatment tanks, power outlets and smooth flooring. PPE should be continuously restocked
and available with the briefest possible delay.
Main relationship
FROM ambulance bay
TO ED entrance
21 Depending on the location and specific risks, such a space may also be important for other types of emergencies,
e.g. for infection control and/or when extra isolation spaces are needed.
In order to deal with an MCI, it is imperative that there be a buffer space available outside the ED gate where
extra structures could be put into use.
If there is no predesignated space outside the ED where mass-casualty arrivals and triage can be handled,
the waiting area in the ED will probably be used, possibly together with the existing triage room in the sub-
acute side.
For this reason, it is important that the waiting area is flexible enough in its design to cope with large vol-
umes. This means, where possible, that fixed/permanent structures and walls should be avoided so that tem-
porary spaces can be created quickly when they are needed. The use of curtains, screens or, when possible,
foldable sliding walls is a good option to enable flexible use of space. It is also recommended that furniture
(e.g. chairs and benches) is able to be quickly removed or pushed aside to gain space.
In addition, if there is no external MC triage space, it is important to plan how crowds will be controlled
around the treatment areas to avoid the uncontrolled saturation of the space (e.g. doors or a staff member
acting as a monitor).
Once the patient is sent to the most appropriate core clinical space for assessment, resuscitation, treatment,
etc. the function and set-up of Zones 3, 4 and 5 remain the same as those under normal circumstances. This
is critical, as it enables casualties to be clinically handled using the regular workflow.
NOTE: During an MCI it is possible that the relative proportions of acute and sub-acute cases will change.
More staff might be required, at least occasionally, on the acute side. It is therefore important that those
involved in the design consider minimizing the distance between the two treatment areas.
ENTRANCE
1
Staff sanitary Monitoring and Ambulance/Car
Staff dressing Decontamination Ambulance Mass-casualty

space (decont.) shower bay triage store

The original triage MC Triage space

room may become (in Waiting area)
T
part of the MC
triage space or
an extra treatment Triage room or
room for MCI treatment room
patients.
3 4
EXTERNAL
CONSULTATION
Figure 6.3 – MCI flow, option 2 – if a predesignated triage space outside the ED is not available (e.g.
because outdoor space is absent or not appropriate), the waiting area is used as an MC triage space
instead of the regular triage room
To ensure patient care during an MCI according to the flow illustrated above, the core critical spaces need
specific support.
Some support spaces are specifically for use during an MCI, such as the mass-casualty triage store. The fol-
lowing are functional spaces used under normal circumstances but which require special considerations for
use during an MCI:
1. security monitoring and access point
2. staff sanitary facilities (M/F)
3. ambulance/car parking area.
The mass-casualty triage store is positioned near the ED entrance or immediately adjacent to the place des-
ignated for MC triage.
MASS-CASUALTY TRIAGE STORE

SCOPE
This is where trolleys, gurneys and other equipment are stored for use in the MC triage space during an MCI.
The space should be secured and easily accessible.
Main relationship
FROM ambulance bay
TO MC triage space
It is important to ensure that the MC triage store not be used during day-to-day operations, while at the
same time ensuring its stock is kept updated.
During a MC scenario, the arrival point at the hospital will be crowded and chaotic. Additional security per-
sonnel will be required to manage the situation.
The large numbers of casualties in the ED from the MCI itself may converge with a number of non-essential
people such as members of the media, concerned family members and volunteers and health-care profes-
sionals wanting to help. Failure to control entry and exit points can cause disruption within the department.
To this end, a configuration with one entry and one exit point and a physical barrier completely encompass-
ing the perimeter of the facility enables optimal access monitoring with limited resources.
Since the usual day-to-day process of registering patients in the registration space of the front door zone
does not occur during an MCI until the situation is considered to be under control, the lobby of the ED will
be used only as a passageway to reach the waiting area. Patient registration in an MCI will occur outside the
ED, in the MC triage space.
As already mentioned, no change in functionality will occur in Zones 3, 4 and 5. Operations will be conducted
as usual. However, in terms of core clinical support spaces, it is important to consider the extra capacity
required to respond to an MCI. Storage spaces should be sized to accommodate extra equipment, drugs and
consumables.
7. ADDITIONAL
DESIGN CONSIDERATIONS
This section describes other points to be considered during the design, repair or renovation of an ED. They all
have a significant impact, in terms of either access and circulation or the proximity or size of physical spaces.
7.1 STAFF FLOW

All staff (medical, nursing, security, administration, porters, cleaners and other support staff) need to be
clearly identified as such, e.g. with coloured uniforms; staff working within the ED should be clearly identified
as ED staff.
They need to be able to enter and exit the department out of the sight of patients and visitors. A staff-only
entrance/exit should be provided.
7.1.1 DURING DAY-TO-DAY EXECUTION OF THE MoC

During day-to-day execution of the MoC, ED staff will need to be able to move freely between all ED zones,
especially if they must work on both sides. There are several primary routes that should never be obstructed:
• registration/triage to resuscitation
• nurses’ stations to patients
• core clinical spaces to core clinical support spaces.
The key staff members who visit the ED from other areas within the facility are surgeons and anaesthetists
from the OR, radiographers from imaging and laboratory staff.
7.1.2 DURING A MASS-CASUALTY INCIDENT

During an MCI, there will be an increase in auxiliary staff such as security (for managing crowds) and porters
(for transferring patients).
However, surgeons and anaesthetists are less likely to visit the ED during an MCI as they will be busy in the OR.
Doctors and nurses may be seconded from other areas in the facility, so the mass-casualty plan needs to have
clearly defined roles for staff who do not usually work in the ED. The plan should articulate where visiting
staff should assemble for instructions.
7.2 RELATIVES AND CARERS

Relatives must be controlled at all times during normal operations, and their access should be highly
restricted during an MCI. It is likely relatives will accompany patients in the triage room, the waiting area
and all core clinical spaces within the ED (except for the resuscitation room). Ideally this should be limited
to one person per patient.
Additional design considerations 73
7.3 GOODS AND SERVICES

There should be a “back-of-house” entrance/exit to ensure the flow of goods (consumables and other mater
ials) and services (linen, food and waste services) does not conflict with patient flows.
For the whole facility, operational policy will determine the time, frequency and (where applicable) size
of deliveries of pharmaceutical items and medical consumables, waste collection, cleaning services and
food-service delivery.
Deliveries and removals of items to and from the ED should, where possible, occur at a dedicated entrance
separate from where patients enter and exit. ED staff may use the same entrance as goods and services.
7.4 OPERATIONAL POLICY CONSIDERATIONS

7.4.1 ADMINISTRATION
While the ED may have its own management structure, e.g. a separate clinical director and nurse in charge,
it must fit into the overall administration and management structure of the facility.
7.4.2 HOURS OF OPERATION

If there are no local, trained personnel on site, the hours of ED operations are defined by when the ICRC team
is present in the facility. This will vary according to the level of support provided:
• ICRC comprehensive substitution facility – 24/7
• ICRC surgical substitution facility – 24/7
• ICRC comprehensive support – office hours only
• ICRC surgical support – office hours only.
7.4.3 STERILE SERVICES

Some reusable instruments and sets used in the ED will need to be sterilized in the facility’s centralized sterile
services unit for reuse.
7.4.4 LINEN SERVICES

Linens are required in the ED.
• Distribution and collection times as well as storage are determined based on the local circumstances.
• Storage for linens is provided in linen bays in clinical areas (preferably recessed into a partition wall).
• The use of single-use linens should be considered and planned for in the event of an MCI.
7.4.5 FOOD SERVICES

Food services may be required for patients in observation beds on the sub-acute side.
7.4.6 CLEANING SERVICES

Cleaning services for the ED will be provided according to the facility-wide operational policy.
7.4.7 STORAGE (WITHIN THE UNIT)

A range of storage is provided within the ED and includes space to store:
• mobile equipment
• linen
• clinical consumables
• mass-casualty stock
• medical records and office supplies
• equipment.
7.4.8 SEPARATION OF MALES AND FEMALES

In some settings it may be necessary to provide some physical separation for male and female patients,
including in the general waiting area in Zone 2 (only applicable on the sub-acute side; on the acute side other
means may be used to ensure privacy).
Depending on the size and caseload of the facility, there may be an area allocated for paediatric patients.
7.4.9 BLOOD BANK

When blood is required for life-saving transfusions, ED staff must request it from blood bank staff in line
with local operational policy
7.4.10 LABORATORY
Point-of-care testing within the ED may cover haemoglobin, glucose, full blood count and dry chemistry,
malaria, pregnancy testing, urine dipsticks, etc. Other tests required by ED patients can be carried out in the
main hospital laboratory.
7.4.11 MEDICAL IMAGING

In facilities supported by the ICRC, medical imaging is likely to only include analogue or digital X-ray (using
portable and/or fixed systems) and ultrasound.
A fixed X-ray unit may or may not be housed within the ED; however, if it is outside the department, it needs
to be in the immediate vicinity.22 The imaging department must be located near the ED owing to both its high
frequency of use and life-threatening situations that require prompt diagnostic answers.
A portable X-ray and ultrasound device may be housed within the ED.
7.4.12 OBSERVATION AREA

Whether the department needs an observation area where patients may stay for an extended period of time to
receive treatment will be determined by the local circumstances, case load and case mix. The area, if included,
will require its own support spaces (nurses’ station, storage, clean and dirty utility rooms, and equipment,
hand-wash and linen bays) if or shared support spaces are not nearby in the ED. In the proposed MoC, the
observation area is not its own functional space. Patients are observed if needed in the treatment room.
7.4.13 PHARMACY (INCLUDING CLINICAL CONSUMABLES)

Pharmacy supplies for the ED include:
• medications, including controlled drugs
• consumables, e.g. chest drains, catheters, syringes, needles
• IV fluids.
Dispensing for ED patients will occur at the point of care.
The pharmacy is usually located at the entrance of the hospital, near the ED and directly connected to the
pharmacy’s storage and preparation areas. It is convenient to have a counter to serve people inside the hos-
pital as well as an external window to serve people coming from outside the hospital.
7.4.14 PHYSIOTHERAPY
Physiotherapy in the ED may include assistance to stabilize fractures and to safely mobilize, transfer and
position patients.
22 Functional relationships (or proximity required between physical areas) are classified by how long it takes to walk
between them: “immediate” is under one minute; “ready” is under two minutes; and “easy” is under three minutes.
7.4.15 MORTUARY (INCLUDING DISPOSAL OF BODY PARTS)

The mortuary needs to be easily accessible from the ED. In some cases, the mortuary is external, in which
case deceased patients are transferred there by ambulance or hearse.
7.4.16 SECURITY CHECKS

A security sentry box will be located at the entrance to the hospital. There, patients, staff and visitors to the
hospital undergo security checks. The ED should not be the front door of the hospital.
7.4.17 HEALTH CARE IN DANGER (HCiD)

Safety and security measures outlined by the HCiD23 initiative need to be incorporated into the design of the
ED (and the facility as a whole). This includes, but is not limited to:
• first-line protection; perimeter fencing
• public entrance, security screening and triage
• 3M tape applied to glazed windows
• Red Cross or Red Crescent emblem displayed on the facility to identify it as a health centre
• “No weapons” signs posted
• safe room for staff.
7.4.18 WASTE MANAGEMENT

ED waste management includes the disposal of:
• human waste, including sewage
• human body parts
• medical waste, including sharps
• contaminated waste, including linen rubbish.
If waste management is centralized, there should whenever possible be direct access from outside the hos
pital to a temporary storage space or the cleaner’s room. This enables the waste operator to reach waste bags
without having to enter the department.
Keep in mind that extra waste will need to be handled in MCIs, as the use of non-reusable supplies increases
exponentially.
7.5 ED AGGREGATION EXAMPLE

The following diagram represents a complete aggregation of all the spaces needed to run a full-scale ED. It is
meant as an example illustrating the relations between the spaces and their spatial organization.
The ED may be smaller or bigger depending on the space available, and it may include more or fewer services
according to identified needs. However, relations between the spaces should always be respected.
The diagrams that follow illustrate further examples of layouts that combine two or more of the functional
spaces previously discussed.
23 For a more comprehensive assessment of preparedness for violent events against health-care facilities, refer to:
ICRC, Security Survey for Health Facilities, ICRC, Geneva, 2016; Ensuring the Preparedness and Security of Health-Care
Facilities in Armed Conflict and Other Emergencies, ICRC, Geneva, 2015.
Ambulance To external consultations

OUTSIDE ED AND entrance and operating department
FRONT DOOR ZONE
Mass
ED entrance Hand- Equip.
casualty Resuscitation wash bay bay
Decontamination shower (ambulance) Patient bed
triage room
room (+ dressing and space Linen
store Treatment bay
undressing spaces)
room
Patient bed (sub-acute Patient bed
space side) space
Acute side
Resuscitation
ED
room Patient bed Patient bed
entrance
(walk-in) space space
Walk-in entrance
Waiting area/Mass-casualty
Patient bed Patient bed
Registration Triage space (in case of MCI)
space space
space
Patient bed
Procedure space Nurses’
station
Visitor room
sanitary
facility
(M/F)
Medical Clean Dirty
Consulting Triage Interview
equipment utility utility Plaster room
room room room
Cleaner’s store room room
room
Patient Patient Patient Patient Patient

Staff bed bed bed bed bed Patient shower
Staff
office space space space space space room and sanitary
office
(single- facility (M/F)
(shared)
person)
Treatment room Isolation
(sub-acute side) suite (bedroom
Staff + anteroom
Hand-
Staff + en-suite
sanitary wash bay
break Patient Patient Patient bathroom)
facility Equip. Linen Nurses’
room bed bed bed
(M/F) bay bay station
space space space
Sub-acute side
Figure 7.1 – Example of an ED aggregation

OVERVIEW OF THE ED BY ZONE 77
8. OVERVIEW
OF THE ED BY ZONE
8.1 GENERAL BUBBLE DIAGRAM
Legend
Space accessible to patients Space accessible to staff only
Space accessible to patients Optional space accessible

T (temporary structure) to staff only
Optional space accessible Optional space accessible

to patients to staff and visitors
Primary flow for patients Secondary flow for patient
Patients in egress Primary flow for visitors
Primary flow for staff Secondary flow for staff
Primary flow for non-sterile

supplies

ENTRANCE
78
Staff sanitary Monitoring and Ambulance/Car


MASS-
CASUALTY
SPACE
2
ED entrance
& lobby
FAST TRACK

storage space
Sanitary
facility (M/F)
ICRC HOSPITAL DESIGN AND REHABILITATION GUIDELINES
Triage room
OR
3 4
bay area room bay
Hand-wash Nurses’ station Treatment room Treatment room Nurses’ station Hand-wash
bay (sub-acute) (sub-acute) Isolation suite (acute) (acute) bay
Overview of the ed by zone
room room
Patient shower
Plaster room
EXIT / ZONE 4 room (M/F) EXIT / OPD / IPD /
HDU / OR /
(MORTUARY)
5 Patient/visitor
room room (M/F)


EXIT / OPD / IPD /

HDU / OR / ZONE 4 / Laboratory Medical imaging
(MORTUARY)
79
Figure 8.1 – General view of the ED

8.2 ITEM FLOW TO/FROM ZONE 5

Legend



supplies

1
3 4
bay area room bay
Overview of the ed by zone
Hand-wash Nurses’ station Treatment room Treatment room Nurses’ station Hand-wash
Isolation suite
room room
Clinical waste Clinical waste

Human waste Plaster room Human waste
Used equipment Used equipment
Used linen Used linen
Dirty utility Medical Clean utility

Cleaner’s room
room equipment store room
Non-medical Central Sterile

Laundry Waste
store pharmacy store services
Staff break Staff office Medical Patient sanitary Patient shower

room (single-person) equipment store facility (M/F) room
Staff changing Staff sanitary

room (M/F) facility (M/F)
5
81
Figure 8.2 – Item flow through the ED
8.3 ZONE 1 BUBBLE DIAGRAM

ENTRANCE


MASS-
CASUALTY
SPACE
2
Arrival, waiting
FAST TRACK
& triage room
3
Resuscitation
room
5
4
EXTERNAL
CONSULTATION
Figure 8.3 – Zone 1 of the ED

Overview of the ed by zone 83
8.3.1 LEGEND



supplies
8.3.2 PHYSICAL SPACE LIST

CORE CLINICAL SPACES CORE CLINICAL SUPPORT SPACES GENERAL SUPPORT SPACES
Ambulance bay Staff dressing space (for decontamination) Security monitoring and access points
Decontamination shower Staff undressing space (for decontamination) Staff sanitary facility (M/F)
Mass-casualty triage space Stretcher parking area Ambulance/car parking area
-- Mass-casualty triage store --
8.3.3 SCOPE OF ZONE 1

In Zone 1 the patient and possibly a carer arrive at the facility. They should be able to:
• find their way to the ED from outside the hospital or department
• be sheltered while being dropped off
• pass through the security point
• be identified if requiring special attention (e.g. infection screening. decontamination or fast-tracking,
for patients in serious condition).
1
shower room bay
2
ED entrance
& lobby

storage space
Patient sanitary
facility (M/F)
Triage room

5
3 4
Isolation suite
EXTERNAL
CONSULTATION

8.4.1 LEGEND



supplies

Waiting area ED entrance & lobby Patient sanitary facility (M/F)
Triage room Registration space Play area

In Zone 2 the patient (and their carer) should be able to:
• direct themselves to the registration space
• be registered
• be sorted into the acute or sub-acute category
• be instructed to wait before been seen.
86
1
Ambulance bay
2
Arrival, waiting & triage room
FAST TRACK
OR
3 4
bay area room bay
Hand-wash Nurses’ station Treatment room 5 Treatment room Nurses’ station Hand-wash
Isolation suite
room room
Plaster room
8.5 ZONES 3 AND 4 BUBBLE DIAGRAM
EXIT / OPD / IPD /

(MORTUARY)
Figure 8.5 – Zones 3 and 4 of the ED

8.5.1 LEGEND



supplies

Zone 3 (Sub-Acute Side)
Sub-waiting space Nurses’ station --
Treatment room (sub-acute) Equipment bay --
Consulting room Hand-wash bay --
-- Linen bay --
Zone 4 (Acute Side)

Resuscitation room Nurses’ station --
Treatment room (acute) Equipment bay --
Procedure room Hand-wash bay --
-- Linen bay --
8.5.3 SCOPE OF ZONES 3 AND 4

These zones are where patients initially receive care. As explained, two separate patient streams are created,
acute and sub-acute. Here patients are:
• seen by health staff
• treated when first seen or directed to specific spaces for primary treatment
• directed to and from secondary treatment.

1
Ambulance
bay
EXIT / OPD / IPD /
HDU / OR /
2 (MORTUARY)
Arrival, waiting
EXIT / & triage room
ZONE 4
area room
3
4

Isolation suite
(sub-acute) (acute)
Interview room
room room
Patient shower
Plaster room
room (M/F)
5
Patient/visitor
room room (M/F)


Laboratory Medical imaging

8.6.1 LEGEND
Legend



supplies

Interview room Medical equipment store Patient sanitary facility (M/F)
Isolation suite Clean utility room Staff office (shared)
Plaster room Dirty utility room Staff office (single-person)
-- Cleaner’s room Staff break room
-- Patient shower room Staff changing room (M/F)
-- Staff sanitary facility (M/F)

In this zone patients receive care after a primary screening or primary treatment. All support spaces neces-
sary for the operation of the entire department are also located here.
Here:
• patients receive secondary treatment before disposition
• staff have all support spaces for clinical activities and administrative tasks.
OPERATING
DEPARTMENT
9. INTRODUCTION
TO THE OPERATING
DEPARTMENT
The operating department (OD) is where patients undergo surgical procedures and receive the perioperative
care needed to support the surgery (pre- and post-operative care).
An OD is composed of several operating rooms (ORs) and forms a distinct section within a health-care facil-
ity.24 Besides the ORs and their scrub bays, the OD contains a staff changing room, preparation and recovery
spaces, storage and cleaning facilities, offices, OD-specific corridors and possibly other support spaces. In
larger facilities, the OD should whenever possible be climate- and air-controlled and separated from other
departments so that only authorized personnel have access.
The places where the ICRC operates differ from one another, and therefore surgical care is provided in a wide
range of facilities and circumstances. Patient care is consistent with accepted surgical standards, but surgery
might be performed under extreme conditions and where resources may be limited.
The ICRC specializes in the surgical management of weapon wounds, a very specific surgical specialty. In
some settings, however, the criteria for admission to ICRC care may be extended to include other surgical
emergencies, including but not limited to other trauma, acute surgical abdomen, obstetric emergencies or
burn surgery.
9.2 PATIENT MIX

In the settings where the ICRC works, the case mix is varied and involves both adults and children.
9.2.1 WEAPON WOUNDS

Surgery on weapon wounds follows general surgical standards. It does however require techniques to be
adapted to deal with complex injuries not necessarily seen in civilian surgical practice.
Weapon wounds may affect patients of all ages in any part of the body. They include gunshot wounds, blast
injuries and wounds from anti-tank and anti-personnel mines.
9.2.2 OTHER URGENT SURGERY

• Road traffic accidents
• Industrial accidents
• Domestic accidents
• Acute surgical abdomen
• Obstetric emergencies
24 In some locations operating rooms are referred to as “operating theatres”.

Introduction to the operating department 93
9.2.3 OTHER SURGICAL PROGRAMS

Based on the needs that have been identified, the ICRC may provide surgical care in other fields, including,
among others, reconstructive, orthopedic or plastic surgery.
9.2.4 OPERATIONS PERFORMED IN THE OD

Surgical procedures performed in the OD may include but are not limited to:
• debridement
• delayed primary closure, including grafts and flaps
• fracture management
• abdominal, thoracic and cranial surgery
• limb amputations
• surgery for emergencies such as acute abdomen, non-weapon-related trauma and urgent
obstetric conditions.
9.2.5 DAMAGE-CONTROL PROCEDURES

• Fracture management
• Burn injury management
9.2.6 ANAESTHESIA
Anaesthesia techniques vary and depend on the surgical procedure and the patient’s condition. They include:
• local infiltration
• regional nerve block
• spinal anaesthesia
• general (balanced) anaesthesia
• general anaesthesia with intubation.

The aim of this section is to set out a model of care (MoC) for the OD and the space requirements best suited
Like the rest of the MoCs contained in these guidelines, this MoC is meant to be updated regularly because
surgical techniques and technologies evolve rapidly and quality standards are constantly improving. The
frequency of the reviews will be determined centrally.

• Day-to-day execution – description of the five main zones, how each space functions under normal
circumstances and the concept of progressive asepsis
• Overview of the OD by zone – summary of each main zone, including bubble diagrams, lists of physical
spaces and descriptions of each zone’s scope.

The OD MoC is to ensure the patient’s safety while they undergo surgery by understanding the requirements
of the care-delivery process and the patient’s pathway through the department from arrival to discharge to
another department in the facility.
The patient goes through three major steps before being discharged from the OD: pre-operative care (prep
aration), surgical procedures (surgery) and post-operative care (recovery). In parallel, the patient pathway
through the department goes from an unrestricted area (arrival) to a semi-restricted area (pre-/post-operative
care) and finally to a restricted area where the surgery takes place (the OR). In the present model, the patient
follows the same route in and out, and both pre- and post-operative care are provided in the same area.
The patient pathway is explained below, both on day-to-day basis and later on for mass-casualty incidents.
Because of the critical need for infection control in this department, all other flows (staff, visitors and sup-
plies) are also described (see section 11).
10.1 PATIENT PATHWAY

users – patients, staff and others – and prioritize them according to clinical risk and outcome. It is also crit-
ical to understand that, to ensure the safety of patients undergoing surgery, access to the OD and all flows
going through the department must be controlled.
The patient flow defines the primary reciprocal relationships between the physical spaces. Therefore, the
patient flow guides the analysis of any plan to design or renovate an OD.
You must understand the patient pathway through the OD to ensure the department is properly designed.
The OD receives scheduled and unscheduled patients:

• Scheduled patients arrive from the inpatient departments (IPDs).
• Acute unscheduled patients arrive mainly from the emergency department (ED) but occasionally
from other departments within the facility, e.g. the high-dependency unit (HDU) or from obstetrics
for emergency caesarian section or other obstetric emergencies.
Inpatient Emergency
Obstetrics
department Department
Operating
Department
Obstetrics Mortuary
Inpatient
HDU
department
Figure 10.1 – OD inflows and outflows

As a result, the OD should be located immediately next to the ED, the HDU and the obstetrics area, all critical
clinical relationships.
Ideally these services are located on the facility’s ground level. If not, a dedicated direct, unobstructed route,
called a “red axis”, must be created – at the least between the ED and the OD – to facilitate and accelerate as
much as possible the transfer of patients with life-threatening conditions from one floor to another (mainly
with a dedicated elevator or ramp).
The chart below summarizes the major functional steps that occur as the patient makes their way through
the OD, from arrival to discharge to another part of the facility.
The table below further breaks down the patient pathway. The same general functional steps are supple-
mented with lists of the corresponding physical spaces and the perspectives of patients and staff. The final
column on the right summarizes the questions the design team must always consider before and during the
design process.
• Patient is escorted to the OD lobby space by the ward nurse, possibly

accompanied by one relative
ENTRY • Patient waits alone in the patient transfer area to be registered
• Ward nurse hands over the patient to an OD nurse, anaesthetist or

recovery nurse
• Patient is registered after their identity, details, etc. are checked and
REGISTRATION their consent is confirmed
• Patient crosses the red line and is transferred to the preoperative area
PREOPERATIVE • Patient is prepared for surgery and might receive interventions such as
CARE insertion of an IV line or administration of drugs and/or oxygen
• Patient is transferred to the OR

SURGICAL • Patient undergoes surgical procedures
PROCEDURES
• Patient is directed to the post-operative area for an observation period

POST-OPERATIVE (vital signs and analgesia)
CARE
• OD staff hand patient is over to the ward nurse

• Patient is discharged from the OD and transferred to another part
EXIT of the facility
Figure 10.2 – Main steps of the OD patient pathway

STEPS OD AREAS PATIENT PERSPECTIVE STAFF PERSPECTIVE DESIGN TEAM QUESTIONS
Arrival Transition from • Patient arrives in the OD • Ward nurse/porters are able to escort the • Link to ED, HDU, obstetrics?
contaminated zone lobby space escorted patient into the OD • Entrance unobstructed?
(outside OD) to the by the ward nurse and • Non-clinical staff are able to deliver goods into • Access control? Safety and security?
protective zone possibly accompanied by the OD Intercom system?
(Zone 1) one relative • Who – what patients?
• Patient is led to the • Arrival – how (means) and with whom
patient waiting area alone (carers, etc.)?
and waits to be registered • Accessibility (stretchers, patient beds,
trolleys, wheelchairs, etc.)?
• Maintenance of the OD? Ability to update
medical equipment, including large
pieces?
• Waiting relatives (amenities and
comfort)?
Registration Zone 1: • Patient is handed over • Staff transfer patients to the waiting area and • Safety and security?
Protective zone by the ward nurse to an perhaps from their arrival trolley to an OD • Visibility and access control from
OD nurse, anaesthetist or trolley registration desk?
recovery nurse • Ward nurse hands over patients to OD clinical • Way in and through unobstructed?
• Patient is registered after staff • Flows (patients, staff, and goods)?
their identity, details, etc. • Staff identify and register patients, check their • Single or multiple entrance(s)/exit(s)?
are checked and consent details and confirm their consent • How many patients (scheduled vs
is gained • Ingress and egress in the department are unscheduled)? Massive influx?
• Fast track: patient controlled • Privacy in the patient waiting area?
passes easily through the • Clinical and non-clinical staff entering the OD Reassuring atmosphere?
protective zone are identified and go to the staff changing
• Patient can access rooms
changing room and • The surgery schedule, staff and goods are
sanitary facilities, if monitored
needed • Staff ensure the privacy and dignity of the
patient throughout the transfer process
Preoperative Transition from • Patient crosses the first • OD staff go through to the changing room • Urgency streaming?
care protective zone red line and is transferred where they remove their outside clothes, • Assessment? Treatment? Anaesthesia?
(Zone 1) to clean to the preoperative area perform personal hygiene and don OD attire • Safety and security?
zone (Zone 2) • Patient is prepared for • Patient is assessed and prepared for surgery • Nurses’ station location?
surgery and might start • Trolleys are prepared (e.g. for anaesthesia, • Unobstructed circulation in the clean
receiving interventions, equipment, linen, sterile stock) zone? Corridor width? Single/double
such as insertion of an IV • Surgical team scrubs in corridor?
line or administration of • Sufficient storage areas?
drugs and/or oxygen • Sterile storage accessible?
• Infection control (HVAC, materials, flows)?
• Flexibility?
Surgical Sterile and ultra- • Patient is transferred to • Patient is transferred from the OD trolley to the • OR – one-way/two-way flows?
procedures sterile zone (Zone the OR operating table • OR – number of doors?
4) • Once on the operating • Anaesthesia is administered to the patient • OR – dimensions? Number of staff
table, patient receives • Patient undergoes surgery allowed in the OR? Space needed for
anaesthesia • Patient is transferred from the operating table equipment and around the patient?
• Patient undergoes to the OD trolley and transferred to the clean • Infection control (HVAC, materials, clean
surgical procedures zone and dirty flows)?
• Dirty items are transferred to the disposal zone • Safety and security?
• Lighting?
• General atmosphere?
Post-operative Zone 2: • Patient is moved to the • Patient is transferred to the post-operative, • (Same general questions as for the
care Clean zone post-operative area for area monitored during their recovery and given preoperative area)
a period of observation bedside care • Patient privacy? Cross traffic with
(vital signs and analgesia) • Information on the operation is recorded patients waiting for surgery?
• Dirty and clean flows? Corridor widths?
• Flexibility?
Discharge Transition from • Patient is handed over by • All staff go to the changing rooms where they: • Number of exits?
protective zone the OD nurse and – take off and place their scrub suits into the • Where to after OD?
(Zone 1) to anaesthetic assistant to appropriate bins (reusable or non-reusable) • Visitor interview room?
contaminated zone the ward nurse – perform personal hygiene • How is OD closed? Alarm?
(outside OD) • Patient is discharged from – change their clothes and exit the changing
the OD and transferred to room
another part of the facility • If necessary, a member of the surgical team
crosses the red line to discuss the surgery with
relatives in the interview room
• Registration desk staff monitor the staff exit
• OD is locked and secured when no OD staff
remain in the department
Table 4 – OD patient pathway – patient and staff perspectives and questions for the design team
10.2 PROGRESSIVE ASEPSIS ZONING

As previously mentioned, the OD MoC is built around the need to ensure the department’s capacity to effi-
ciently perform surgical operations and facilitate infection control. The design layout must enable progressive
asepsis, where the aseptic standard increases as you go from the perimeter of the OD (the entrance) to the
operating room.25
Consequently, the layout is divided into zones, and passage from one zone to another must be controlled and
reduced to only the essential. The patients, staff and goods going through these increasingly clean zones are
subjected to specific requirements before being allowed to move forward, to ensure asepsis in the OR.
25 It is assumed here that the OR includes the operating table, three members of the team (surgeon, anaesthetist and OR
nurse) and the area around them.
INCOMING PEOPLE PATIENTS
98
STAFF VISITORS
STAFF FLOW PATIENT FLOW VISITOR FLOW MAIN ENTRANCE
Enter staff changing Enter patient transfer Enter waiting area > use Patients, staff
1
room > wash > put on area (bed trolley) interview room (optional)/ and supplies
Protective
scrub suit carer changing area
zone
(optional)
RED LINE
   1st barrier
Prepare patient Scrubbing in Controlled by
Help with patient registration desk staff 3
(optional, e.g. when child Staff Carer changing
area (optional)
needs to be helped by zone
parents)
2
Clean
Staff who zone
don't scrub
  RED LINE
Enter operating room Enter operating room 2nd barrier
> transfer patient to > get transferred to Scrubbing
operating table > give operating table > get
anaesthesia > do anaesthesia > get 4
5
surgery surgery Sterile &
Disposal
ultra-sterile Surgery
zone
zone
Figure 10.3 – Progressive asepsis in the OD and flow control

The protective zone (Zone 1) includes the main entrance to the department, a lobby, a visitor waiting area
with sanitary facilities, and a staff changing room. This zone acts as a barrier, called a “red line”, protecting
the core of the department, where the OR and in particular the operating table are located (the sterile and
ultra-sterile zone, Zone 4), and the location of all the support services (the clean zone, Zone 2).
Some spaces act like border crossing points: staff changing rooms, the patient transfer area and scrub bays.
These spaces are located between zones. The passage from one zone to another is allowed only once the
so-called “rite of passage” has occurred (changing clothes and shoes, cleaning and scrubbing in, transferring
patient from ward trolley to OD trolley, etc.).
The different zones will be further explained in the next sections.
(including ultra-sterile area)

Sterile zone
Surgery
Surgery
crossing point
Border
Operating
Scrub
room
door
bay
Pre-/post-operative care
(including staff zone and

shared support spaces)
Clean zone
crossing point
Border
changing
changing
transfer
Patient
Carer
room
Staff
area
area
Protective zone
Transfer
Transfer
Transfer
department
department
department
Operating
Operating
Operating
entrance
entrance
entrance
PATIENTS
STAFF
STAFF
Figure 10.4 – Border crossing points in the OD

11. D
AY-TO-DAY EXECUTION
OF THE MoC
11.1 INTRODUCTION
According to the principles explained previously and to facilitate understanding of how an OD is organized,
the department is divided into five zones:
1. protective zone (registration)
2. clean zone (pre-/post-operative area, including shared support spaces)
3. staff zone (shared by protective and clean zones)
4. sterile and ultra-sterile zone (operating room)
5. disposal zone (disposal room).
Each zone has a specific role. They are grouped together in order to facilitate the execution of the different
stages of the MoC, in particular to simplify the patient flow.
Occasionally, an existing operating department – conceived with a different model in mind – may simply
be reorganized according to this MoC. However, when this is not possible, consideration should be given to
alternatives adapted to specific situations.
The chapter below will describe how each zone is organized. Each one contains physical spaces arranged into
three categories: the core clinical spaces where the major interactions with the patient happen (yellow in the
bubble diagrams), the core clinical support spaces (pink) and finally the general support spaces (turquoise).
For each of the five zones, the patient flow and the room relationships are illustrated with a bubble diagram,
and then the main functional spaces are described along with functional space tables summarizing the essen-
tial points.
ENTRANCE/EXIT
1
Protective zone
Registration
Access control
Patient handover
3
Staff zone
Change
Report
Rest
2
Clean zone
Pre-/post-
operative care
4 5
Sterile & Disposal
ultra-sterile zone Surgery zone
Figure 11.1 – General OD circulation during day-to-day execution of the MoC
11.2 ZONE 1: PROTECTIVE ZONE (WAY IN)

In the protective zone, patients are escorted by the ward nurse, who helps them to do the following:
• enter the OD
• be handed over to the OD nurse, anaesthetist or recovery nurse
• be registered and have their identity, details, consent, etc. confirmed
• transfer from the arrival trolley to the OD trolley and cross the first red line escorted by OD clinical staff.
ENTRANCE
1
Patient
transfer area
RED LINE
1st barrier
2
Preoperative
area
4
Operating
room
Figure 11.2 – Relations of the core clinical space in Zone 1 of the OD (way in)
11.2.1 PATIENT FLOW (WAY IN)

Once inside the OD, patients are transferred from the arrival trolley to an OD trolley and will cross the first
red line to reach the pre-/post-operative area through a dedicated patient transfer area. There, the ward
nurse will hand over the patient to the OD nurse, anaesthetist or recovery nurse, and the patient’s details,
contacts, consent form, etc. will be checked.
PATIENT
OD main
entrance & lobby
1
Registration Patient registered by staff

space
RED LINE Patient RED LINE

1st barrier transfer area 1st barrier
3
Pre-/post-
operative care
RED LINE
2nd barrier
4 5
Figure 11.3 – Patient flow in Zone 1 of the OD (way in)
PATIENT TRANSFER AREA

Scope
On entering the OD, patients are transferred from the ward trolley to an OD trolley. Patients are held here during
the handover from the ward nurse to OD clinical staff prior to entering the clean zone (preoperative area).
On discharge from the OD, patients are transferred from the OD trolley to a ward trolley. Patients are held here during
the handover from OD clinical staff to the ward nurse prior to exiting the OD.
The space needs to accommodate a minimum of two stretchers for every OR, with space for at least two people around
each. When culturally required, there should be curtains to provide patients individual privacy.
Main relationship
FROM OD main entrance
TO preoperative area
This space needs to be large enough to enable the transfer of patients from trolley to trolley and to ensure
the patient’s privacy and dignity throughout the transfer process.
The patient transfer area may be located at the border of the protective and clean zones and may physically
prevent the staff and trolley in one zone from passing to the other.26

Before passing through the patient transfer area, the patient going to the OR needs to enter the department.
The entrance of the OD must be unimpeded and easily accessible from the ED. Patients, visitors and staff
will all enter through the same entrance. Supplies (possibly with the exception of sterile items27) will also be
transported through this entrance. Therefore, the main entrance should be wide enough for the transfer of
patients on trolleys or beds, with sufficient additional space for the accompanying ward nurse or porters and
any equipment attached to the trolley.
OD MAIN ENTRANCE
Scope
This is the main entrance and exit of the OD.
There should be a set of double doors, either swing doors for easy access or, ideally, electronic doors with a push button
or badge access. The doors should be wide enough to allow the patient to pass through while lying on a trolley or a
patient bed with sufficient additional space for an escort (a porter or ward nurse). The entrance is followed by a buffer
zone called the lobby, whose dimensions will vary depending on the facility.
The entrance should be secured to prevent unauthorized traffic into the OD.
Main relationship
FROM outside the OD
TO patient transfer area or staff changing room
According to the local operational policy, immediately after entering the OD the patient and accompanying
medical staff may go to the registration space for registration.
REGISTRATION SPACE
Scope
Upon presentation to the OD, escort staff approach the registration desk, proceed with the handover to OD clinical staff
and register the patient waiting in the patient transfer area.
The space includes a base for communication within the OD and with the greater facility. Often there will need to be
a storage space for hard copies of the department’s records and other files.
Main relationship
TO patient transfer area
26 There may be a transfer window sized to accommodate a stretcher or a low wall dividing the space in two.
27 Sterile stock in centralized sterile services may be accessed directly from the clean zone.
11.3 ZONE 2: CLEAN ZONE (WAY IN)

In the clean zone, patients are escorted by the OD nurse once the first red line has been crossed. Here, patients
will be:
• transferred to the preoperative area
• prepared for surgery – anaesthesia or recovery staff may start
• interventions such inserting an IV line or administering drugs and/or oxygen.
ENTRANCE
1
Patient
transfer area
RED LINE
1st barrier
2
Preoperative
area
RED LINE
2nd barrier
4
Operating
room
11.3.1 PREOPERATIVE PATIENT FLOW (WAY IN)

The patient arrives at the preoperative area prior to entering the OR. (The same space will be used after the
procedure.) There should be at least four patient bed spaces per OR: two preoperative and two post-operative.
It should be possible to section off each bed space with a curtain for patient privacy. This also enables patients
to be separated by gender.
Upon arrival, the anaesthetist or recovery nurse will see the patient and may start some interventions, such
as inserting an IV line or administering drugs and/or oxygen (via a concentrator).
PATIENT
OD main
1 entrance & lobby

3
Equipment Medical
bay equipment store
Pre-/post- Nurses’ Sterile

operative area station storage
Linen Cleaner’s
bay room
Dirty
utility room
2
RED LINE
2nd barrier
4 5
Operating
room
Figure 11.5 – Patient flow in Zone 2 of the OD (way in)
PRE-/POST-OPERATIVE AREA
Scope
The preoperative area (also called the holding area) and the post-operative area (also called the recovery area) are
an aggregation of patient bays. Both pre-and post-operative functions and activities occur in this space, but they are
clearly separated.
Each patient bay accommodates a patient trolley or wheeled bed. Each patient space must allow staff to access the
patient from either side, so the head of the bed should be centred. There must be a clearance of at least 1.2 m on each
side of the patient trolley. No trolley should have a side flush to a wall. The pre-/post-operative area must have a central
nurses’ station and support functions in close proximity.
Main relationship
Preop: FROM patient transfer area
Preop: TO OR
Post-op: FROM OR
Post-op: TO patient transfer area

The clean zone is organized around the pre-/post-operative area. In order to function, that core clinical space
is directly supported by a number of spaces described here below. In addition, this zone contains support
spaces serving the entire department for clinical activities and administrative tasks.28 29
The nurses’ station is placed so that staff may observe the pre-/post-operative patient bed spaces. It is the
coordination hub for patient care in the OD and writing up patient notes; it is also where nursing staff gather
when not with patients. The nurses’ station hosts the following:
• a wall-mounted whiteboard displaying the caseload for the day
• space and surfaces for all staff to write notes and for nurses to manage patient registers
and patient records
• a hand-wash bay
• stores of the drugs, IV fluids and consumables required in the pre-/post-operative area
• the crash cart, defibrillator, pulse oximeter and other resuscitation equipment.
NURSES’ STATION
Scope
in the area.
The key feature of the nurses’ station is that it is situated so the staff in it can see all patients and vice versa, in case
patients wish to attract the staff’s attention. It is usually located in the same space as the patients. If it is in a separate
room, windows must give a direct view of the patients. The distance between the nurses’ station and the furthest
patient bed must be as short as possible.
It must be furnished with a counter, chairs, a cupboard and shelf, a hand-wash bay and space for trolleys.
Main relationship
FROM preoperative area
TO post-operative area
Clinical staff need equipment to perform clinical activities. Often there needs to be an open storage bay for
one or more items of mobile equipment (on wheels) frequently use in multiple spaces. Examples include
wheelchairs, trolleys, drip stands and commode chairs. Other shared equipment include, among others, oxy-
gen concentrators, oxygen cylinders, pulse oximeters and monitors.
If it is not possible to incorporate a sufficiently large recess for storing equipment, another dedicated space
for storing mobile equipment should be identified so that it does not obstruct flows of staff, patients or sup-
plies (e.g. linen) in the room or corridor.
The equipment bay(s) must be directly accessible from the nurses’ station to minimize the time it takes staff
to retrieve the equipment and take it to its point of use.
28 See 11.4.2 for support spaces shared by the clean and sterile zones.
29 These tasks are performed at the nurses’ station or in the staff zone; they may be performed in the OR if it is properly
equipped.
EQUIPMENT BAY
Scope
This provides storage for equipment that is frequently shared between one or more treatment spaces.
It is an open space that does not interfere with circulation. Ideally, it is recessed into a partition wall.
Main relationship
TO pre-/post-operative area
Linen needs to be managed next to where the relevant clinical activity is performed. This may include bed
sheets, pillowcases and blankets. A tall cupboard with doors may be built into a recess. If is not possible to
incorporate a recess, a convenient space should be identified for storing linen on a trolley or in a cupboard so
that it does not obstruct the flow of staff, patients or supplies in the room or corridor.
LINEN BAY
Scope
This is a recessed bay where clean linen is stored on a trolley.
It is an open space that does not interfere with circulation. Ideally, it is recessed into a partition wall.
Main relationship
Hand-washing is the most effective way to control the spread of infections. Clinical staff as well as visitors
must be able to wash their hands at any given moment.
All core clinical spaces must have a hand-wash bay. Each bay should be positioned so it does not obstruct the
flow of staff, patients or supplies (e.g. linen) in the room or corridor. There should be enough bays to ensure
all staff have easy access to them at all times.
HAND-WASH BAY
Scope
This is where medical staff regularly wash their hands after any procedures or contact with patients.
A hand-wash bay must be present in every clinical space. The number of sinks will depend on the dimensions
of the room and the number of patients and staff in it. It should be placed in a position that facilitates its use,
ideally in a recess.
Main relationship
11.4 ZONE 4: STERILE AND ULTRA-STERILE ZONE

In the sterile and ultra-sterile zone, patients are escorted by OR staff once they cross the second red line.
Here, patients will:
• be transferred to the OR and from the trolley to the operating table
• undergo surgical procedures.
ENTRANCE
1
Patient
transfer area
2
Preoperative
area
RED LINE
2nd barrier
4
Operating
room
Upon arrival at the OR, the patient will be transferred from the mobile trolley to the operating table, be pre-
pared for surgery and undergo surgery. The core operating team consists of a surgeon, a surgical assistant
(doctor or scrub nurse), an anaesthetist and a circulating nurse/assistant.
The time of the procedure will vary; it may be less than 30 minutes or may take several hours.
The operating table, the scrubbed-in surgical team touching the patient and the space very near the operating
table constitute the ultra-sterile zone. The rest of the room and the non-scrubbed staff make up the sterile zone.
OPERATING ROOM
Scope
The OR provides an aseptic environment in which to carry out surgical procedures under local, regional or general
anaesthesia.
The operating table needs to be placed in the room to allow 360° circulation around and access to the patient from
the side, below and above so that multiple staff can simultaneously attend to the patient from either side (for various
interventions) and from the head of the bed (for airway management).
Equipment is placed in critical positions within the room in preparation for the patient and will be moved closer
to the patient upon arrival.
Main relationship
FROM preoperative area
TO post-operative area
Ideally there should be two adjacent, identical (mirrored) ORs with one operating table each. Although this
entails a greater capital cost up front, it improves efficiency and the effectiveness of safety measures:
• If there is only one surgical team, it allows a second patient to be set up (positioned and induced)
in the OR next door so that the team can go from one patient to the next with minimal delay.
• If there are two surgical teams, they can work simultaneously.
• Cleaning the OR between operations will not cause delays, and there is time for thorough cleaning
between procedures.
• One OR may be ready for emergency surgery.
• To expedite patient flow, regional anaesthesia may occur in the second OR while the procedure
in the first OR nears completion. When the patient from the first OR leaves, and the OR has been
adequately cleaned, the patient with regional anaesthesia in the second OR may be safely transferred
to the first OR for surgery.
After the procedure the patient will be transferred from the operating table to a patient trolley and taken to
the post-operative area for recovery. If the patient is very unwell, they will recover entirely in the OR. The
sickest patients are transferred to the HDU if there is one; otherwise they remain in the OR their condition is
satisfactory for transfer to the post-operative area or inpatient department/unit.
If the patient dies in the OD, they will be prepared (body washed, drips/drains removed, dressings applied,
etc.) prior to transfer to the mortuary through the OD main entrance. Curtains can be pulled around other
patients if privacy is required.

The OR environment should meet the required level of asepsis to provide safe conditions for the patients and
staff. Therefore, it is critical to control access and flows in and out. At all times staff must follow guidelines
on universal precautions.
In the present MoC, the OR is supported by a scrub bay for the staff entering the OR and a disposal room
(Zone 5) for the dirty flow out. The OR has three doors to allow the following flows:
1. one-way flow from Zone 2 to Zone 4 through the scrub bay30
2. two-way flow – entering patients, non-scrubbed staff and clean goods; exiting patients
and all staff (except cleaners)
3. one-way flow through the disposal room for cleaners exiting with contaminated items, including
soiled cleaning equipment, clinical waste and contaminated instruments.
CLEAN ZONE
Disposal
room
Scrub Scrub
bay bay
Operating Operating
room room
STERILE &
ULTRA-STERILE ZONE
In In In
Patient flow Staff flow Goods flow
Out Out Out
Figure 11.7 – OR support spaces and points of entry and exit
30 See section 11.7 on staff flow.

11.4.2 SUPPORT SPACES SHARED BY CLEAN AND STERILE ZONES

In addition to the scrub bay and the disposal room, the OR will share support spaces with the clean zone, such
as the sterile storage space, the medical equipment store, the cleaner’s room and the dirty utility room. These
support spaces are in the clean zone.
In this MoC, centralized sterile services is located next to the OD, and the sterile stock is directly accessible
from the clean zone. The OD take the necessary sterile instrument sets and consumables from this store to
prepare their OR trolleys according to daily needs.
STERILE STORAGE
Scope
This is where sterile packages are stored until they are distributed.
The area must protect items from the risk of recontamination and from dust, light, insects, humidity and other damage.
Staff must have good access to the items to enable stock rotation.
Main relationship
TO operating room
Functional space card See card 28 Type NON-ESSENTIAL only when centralized sterile
services is located by the OD and sterile stock is directly
accessible from the clean zone
Medical equipment frequently used in the OD’s core clinical spaces must be cleaned and stored within the
department. Equipment storage needs to be provided for parking OD trolleys, with space for at least one large
and two medium trolleys, two Mayo tables and other equipment when not in use, e.g. table attachments and
traction items.

Scope
This is used for storing medical equipment for the department or unit when not in use, e.g. mobile equipment, IV poles,
wheelchairs, trolleys, commode chairs, crutches, traction frames.
Hooks are required for hanging equipment, e.g. crutches, frames. The space may need double doors for access
depending on what is being stored.
Main relationship
TO operating room
The OD needs a room to store housekeeping materials. It must be easily accessible for the cleaning staff. It
may be a single room or multiple smaller rooms well located in the department.
CLEANER’S ROOM
Scope
This is a secure room for storing cleaning materials, agents and equipment, which may include a trolley, and for washing
mops, buckets, brooms etc.
It contains a slop sink for filling and emptying buckets used to clean floors. The floor area should be at least 2.0 m².
Main relationship
TO operating room
The OD must include a room where soiled reusable equipment, linen and other items coming from the pre-/
post-operative areas and OR are collected to be emptied/cleaned and sent to other areas of the hospital for
processing according to their type.
DIRTY UTILITY ROOM

Scope
The dirty utility room is a space in patient areas for cleaning and storing used equipment (e.g. bedpans, urinals
and bowls), disposing of human waste (e.g. urine, vomit, faeces) and point-of-care urine stick testing.
The set-up of the room should reflect a one-way flow from dirty to clean: rubbish bin; disposal of human waste
in a sluice; cleaning of bed pans and urinals (which may require a period of soaking after emptying/cleaning); storage
allowing drip-drying; and, on one side, a hand-wash basin for staff and, on the opposite, storage for clean items
and cleaning products. The room should be lockable for safety reasons.
Main relationship
TO operating room
11.5 ZONE 2: CLEAN ZONE (WAY OUT)

11.5.1 POST-OPERATIVE PATIENT FLOW (WAY OUT)
ENTRANCE
1
Patient
transfer area
RED LINE
1st barrier
2
Post-operative
area
RED LINE
2nd barrier
4
Operating
room
Figure 11.8 – Relations of the core clinical space in Zone 2 of the OD (way out)
The patient receives care during an initial recovery period following an operation in the OR.
The patient’s level of consciousness may be compromised, so they will be observed and monitored closely for
any signs of airway obstruction, bleeding or pain. Vital signs will need to be recorded; oxygen, pain relief or
other drugs may need to be administered. Suction may be required to clear the airway.
The OD will have capacity for patients to recover in the post-operative area after surgery; however, it is likely
the area will only be staffed while OD is operational (not 24/7).
11.6 ZONE 1: PROTECTIVE ZONE (WAY OUT)

11.6.1 PATIENT FLOW (WAY OUT)
ENTRANCE
1
Patient
transfer area
RED LINE
1st barrier
2
Post-operative
area
4
Operating
room
Figure 11.9 – Relations of the core clinical space in Zone 1 of the OD (way out)
After the initial recovery period, the recovery nurse, OR nurse and/or anaesthetic assistant will hand over the
patient to the ward nurse.
11.7 STAFF FLOW

11.7.1 STAFF WHO CROSS THE FIRST RED LINE
STAFF
OD main
1 entrance & lobby
Registration
space
Interview
room
RED LINE Staff changing Patient RED LINE

1st barrier room (M/F) transfer area 1st barrier
3 2
RED LINE Scrub

2nd barrier bay
4 5
Figure 11.10 – Flow of OD staff crossing the first red line

On arrival, all staff working in the OD (as well as students and official visitors) are required to change out of
their outside clothes/hospital uniforms and into scrub suits. They enter the OD via the main doors (same as
patients) to Zone 1, where the changing rooms for males and females (M/F) are located.
STAFF CHANGING ROOM (M/F)

Scope
The staff changing room is used by staff who must cross the red line and change into scrub suits.
There should be separate male and female changing rooms, including at least one shower, one WC and one hand-wash
basin per changing area. The area should include hanging space and/or secure lockers for outside clothes, hospital
uniforms and personal belongings.
In the OD, where scrub suits are provided, there must be shelves to store them in a range of sizes (small, medium, large)
and enough racks for storing clean surgical footwear (clogs) and outside footwear.
Main relationship
TO scrub bay
11.7.2 STAFF WHO CROSS THE SECOND RED LINE (I.E. SCRUB)
STAFF
OD main
1 entrance & lobby
Registration
space
Interview
room

3 2
RED LINE Scrub

2nd barrier bay
4 Operating 5
room
Figure 11.11 – Flow of OD staff crossing the second red line (scrubbing)
The route from the exit of the changing rooms to the scrub bay should be unimpeded. There should be doors
into the scrub bay in Zone 2 before the sink area; staff will pass through the space in a one-way direction,
scrub, don gowns and gloves and enter the OR.
SCRUB BAY
Scope
The scrub bay is where preoperative scrubbing occurs. It should be positioned so staff who needs to scrub enter through
doors off the corridor and move through in a one-way flow to scrub and then go directly into the OR.
Ideally three elbow-operated taps should be spread across the scrub bay so three people can scrub simultaneously.
Main relationship
FROM staff changing room
TO operating room
One scrub bay can serve two operating rooms if it is adjacent to the entrances of both ORs and has an entrance
meeting the criteria above.
11.7.3 OTHER CLINICAL STAFF

Non-scrubbed clinical staff will attend to their duties: anaesthesia staff (could also be the technician or a
nurse) will prepare their trolley and drugs, greet the patient, etc., while nursing staff will prepare the day’s
trolleys, check the whiteboard list of patients, register patients and so on.
11.7.4 OTHER STAFF

After changing, non-clinical staff, including cleaners, maintenance workers, OD porters and sterile services
staff, will move to their respective areas to perform their duties. All staff will exit the OD via the changing
rooms.
STAFF
OD main
1 entrance & lobby

3 2
Staff sanitary
facility (M/F)
Staff office Pre-/post-

(single-person) operative area
Staff break
room
RED LINE Scrub

2nd barrier bay
5
4
Figure 11.12 – Zone 3 of the OD – the staff zone

11.7.5 ZONE 3: STAFF ZONE

The OD must include some staff-only rooms where staff may perform administrative tasks, rest during their
shift and have access to amenities without leaving the clean zone, crossing the red line again.
This includes sanitary facilities. The facilities may be directly connected to the changing rooms or within the
changing rooms but properly separated.
STAFF SANITARY FACILITIES (M/F)

Scope
These are WC facilities for staff use only. Staff members need easy access to WCs once they cross the red line
in the OD.
The facility includes a hand-wash basin and either a toilet roll holder or a water point. Ideally, there is at least
one handicap toilet.
Main relationship
FROM corridor
TO corridor
OD staff also need a private space for performing administrative tasks in addition to the nurses’ station and
the registration space.

Scope
This is a staff-only, enclosed space where one staff member can perform administrative tasks.
It must have the necessary equipment (e.g. desk, chair, and computer, cabinet).
Main relationship
FROM corridor
TO corridor
As mentioned previously, procedures may take several hours. In addition, patients might need to wait after
arriving at the OD if staff are already occupied. Staff need a space to rest and perhaps have a meal without
leaving the clean zone.
STAFF BREAK ROOM

Scope
This is a staff-only room where staff can take a break, rest and relax during their shift.
The room should have appropriate seating, counter space with a sink for basic food preparation, the necessary set‑up
for boiling a kettle, and a table and chairs for dining, if required. The room may be used for small staff meetings,
tutorials, handovers, etc.

Main relationship
FROM corridor
TO corridor
11.8 SUPPLY FLOWS

OD supplies are either sterile or non-sterile. In this MoC, supplies are delivered to the OD through two differ-
ent entrances: non-sterile supplies are delivered through the main entrance of the OD, while sterile supplies,
located in the sterile storage space, are directly accessible from the clean zone.
11.8.1 NON-STERILE FLOW

All non-sterile supplies will be delivered via the main entrance of the OD (through the same doors as patients
and staff). This includes pharmaceuticals, linen, equipment, consumables and housekeeping materials. Goods
arriving on trolleys will be transferred at the first red line onto OD trolleys for storage and use. The protective
zone may include a decontamination area where supplies are unpacked.
11.8.2 STERILE FLOW/CENTRALIZED STERILE SERVICES

The OR nurses will require direct access to the sterile storage space, as this is where sterile instrument sets,
packs and consumables as well as the trolleys used in OR will be stored. (The store is in centralized sterile
services if the unit is next to the OD; if not, there must be sterile storage within the OD.) Nurses will go to
this space to gather the items required for the morning or afternoon operating lists and place them on the OR
trolleys (the number of trolleys depends on the day’s caseload). Once items have been selected and placed on
the trolleys, they will be wheeled to the pre-/post-operative area and parked as close as possible to the OR in
which they will be used. Once the trolley has been transferred to the OR, the individual packs will be opened
under sterile conditions by the scrub nurse.
11.8.3 ZONE 5: DISPOSAL ZONE (DIRTY FLOW)

The disposal zone is composed of only one functional space, the disposal room. Within the room, there is an
area set aside that acts as a collection point for soiled goods and is kept separate from the clean spaces in
the room.
The disposal room must be separated from and have no direct connection with sterile storage or clean supply
rooms.
DISPOSAL ROOM
Scope
This is where clinical waste, general waste, sharps and soiled linen are temporarily held prior to removal.
The room has a hand-wash basin, clinical service sink (optional if the room is only used for holding soiled material),
a work counter and space to separate covered containers. Cleaned and disinfected goods that are not to be used
immediately should be kept away from any soiled surfaces or goods. Cupboards or racks provide good storage.
It is considered a hazardous room.

Main relationship
FROM operating room
TO dirty utility room
Non-sterile supplies delivered
INCOMING PEOPLE from rest of hospital
INCOMING SUPPLIES MAIN ENTRANCE
Supplies received Patients, staff

1
> unpacked in and supplies
Protective
decontamination area
zone
RED LINE
 1st barrier
DAY-TO-DAY EXECUTION OF THE MoC
Sterile packages delivered

from outside
from other hospital areas
Supplies sent to Controlled by

storage areas > registration desk staff 3
Sterile supplies trolleys prepared Staff
go directly to
the clean zone zone
To storage area Sterile

To pre-/post-operative area zone
Contaminated items 2
From pre-/post-
exit directly through Clean operative area
the disposal zone zone Clean
RED LINE zone
 2nd barrier
CENTRALIZED
Sterile supplies Scrubbing

STERILE SERVICES
unpacked > delivered Dirty

> used zone
4
To/
Sterile & from
ultra-sterile OR 5
zone Disposal
To waste/
zone
laundry
Figure 11.13 – Supply flows between centralized sterile services and the OD
117
11.9 F LOW FOR RELATIVES, CARERS

AND VISITORS
Relatives of patients with scheduled procedures may accompany the patients only as far as the entrance
lobby of the OD in Zone 1. If the patient is a child, parents might be required to accompany the child, in which
case they must change their clothes before transferring into Zone 2 in order to assist surgical staff with the
preoperative procedure.
VISITOR
OD main
entrance & lobby
1
Waiting Sanitary
area facility (M/F)
Interview Carer changing

room area (M/F)

3
Pre-/post-
operative area
RED LINE
2nd barrier
4 5
Figure 11.14 – Flow of visitors in the OD
As surgery may take hours, parents who are required to wait in the OD must have their needs taken into
consideration. There should be a proper waiting area and access to sanitary facilities.
WAITING AREA
Scope
This is where parents wait when their children have been admitted to the OD.
The waiting area is under visual observation from the registration space. It must be comfortable, welcoming and calm,
with natural light whenever possible. It should have direct access to sanitary facilities and a changing area for visitors,
if present.
Main relationship
TO carer changing area
Staff not permanently allocated to the OD, occasional visitors and sometimes parents accompanying their
child into the clean zone might be allowed to cross the red line. In that case they should be asked to wear
scrub suits and hats and change their shoes to avoid bringing contamination in from the outside. If there is
no carer changing area, visitors can be brought either to the staff changing room or use the waiting area to
change.
CARER CHANGING AREA

Scope
This is where parents crossing the red line receive a scrub suit and surgical footwear or overshoes. If they remove their
outside shoes, they put them back on here when leaving.
There should be a bench for sitting, racks for holding shoes and shelves for scrubs, masks, and disposable overshoes.
There also should be bins for disposal on the way out. The space can be a recess in the corridor.
Main relationship
TO preoperative area
As part of the services offered to relatives, a quiet room may be included in this zone for confidential discus-
sions with medical staff.
INTERVIEW ROOM
Scope
This room is used for private discussion of surgical procedures among staff members or between staff and patients
and/or relatives/carers.
It is a small, private room with a desk, seating, a telephone and a small storage area.
Main relationship
TO waiting area
11.10 MANAGING FLOWS THROUGH THE OD

In order to ensure the clean flow is protected from the dirty flow, the transit areas in the clean zone must be
wide enough for two patients to pass through on trolleys with staff and/or equipment (drains, drip stands,
etc.) on both side of each trolley.
INCOMING SUPPLIES INCOMING PEOPLE
SUPPLY FLOW STAFF FLOW PATIENT FLOW VISITOR FLOW
Supplies received Enter staff Enter patient transfer Enter waiting area
> unpacked changing room area (bed trolley) > use interview
in decontamination > wash > put on room (optional)/
area scrub suit carer changing area
(optional)
  
Supplies sent Prepare patient Scrubbing in 
to storage areas > Help with patient
Sterile supplies trolleys prepared (optional, e.g. when
go directly to
the clean zone
child needs to be
helped by
parents)
Contaminated
items exit
directly through
the disposal zone
  
Sterile supplies Enter operating room Enter operating room
unpacked > delivered > transfer patient to > get transferred to
> used operating table > give operating table > get
anaesthesia > anaesthesia >
do surgery get surgery
Figure 11.15 – General flows through the OD

Non-sterile supplies delivered

from rest of hospital
PATIENTS
STAFF VISITORS
MAIN ENTRANCE
Patients, staff

from other hospital areas
1
and supplies
Protective
zone
from outside
RED LINE
1st barrier
Controlled by
registration desk staff 3
Staff Carer changing
area (optional)
zone
Staff who To storage area

Sterile
don't scrub zone
CENTRALIZED STERILE
To pre-/post-
operative area
2 From pre-/post- SERVICES Clean

operative area
RED LINE Clean zone zone
2nd barrier
Scrubbing
Dirty
4 zone
Sterile & To/
ultra-sterile from
OR 5
zone
Disposal
zone To waste/
laundry
Circulation through the corridor system must provide access to:

• the pre-/post-operative area
• each OR
• sterile services or sterile storage
• other storage and supplies
• core clinical support spaces
• support spaces for staff.
To/from staff
changing rooms
PATIENTS PATIENTS
Medical
Staff office
equipment
(single-person)
store
Pre-/post-operative area
Staff break Sterile
room storage
Nurses’
station
Staff sanitary Cleaner’s
facility (M) room
Pre-/post-operative area Sterile
services
Staff sanitary Dirty utility
facility (F) room
Laundry
Corridor wide enough

to protect the clean
CLEAN ZONE flow from dirty flow
Disposal Waste
room
Scrub Scrub
bay bay
Operating Operating
STERILE & room room
ULTRA-STERILE
ZONE
In In In
Patient flow Staff flow Goods flow
Out Out Out
Figure 11.16 – Circulation through the corridors between Zones 2, 3, 4 and 5

12. ADDITIONAL
DESIGN CONSIDERATIONS
12.1 R
ELATIONS BETWEEN OD
AND OTHER DEPARTMENTS
Operational areas
Laundry Mortuary
Clinical areas
Operating
department
Clinical support areas
Pharmacy Laboratory
Sterile services lmaging Blood bank
Priority Important Secondary
Figure 12.1 – OD’s functional relationships with clinical support areas and operational areas
The OD should be located immediately adjacent to the centralized sterile services unit and the blood bank,
which provide clinical support. Ideally all three services would be located on the ground level of the facility.

12.2.1 BLOOD BANK
Upon request, units of blood for transfusion will be delivered to the OD main entrance by laboratory staff,
who will hand them over to OD staff at the first red line.

Cleaning services will be provided by cleaning staff who work in the OD.

The OR schedule will depend on the facility, but a likely possibility is 8:00 to 16:30, Monday through Friday,
with urgent cases after hours. The recovery room and sterile services may be in use after the OR’s finish time.

A portable X-ray device may be used intraoperatively or in the post-operative space. It will most likely be
based in the medical imaging department and brought to the OD when required. In some facilities, a smaller,
digital portable X-ray machine may be available.
The use of additional technology, such as a C-Arm CT, is unlikely in the usual ICRC set-up. It may however
be used in specialist orthopedic programs.

Patients who have died or body parts that come from the OD will be taken to the mortuary according to the
hospital-wide operational policy. Dead bodies will be transferred to the mortuary from the OD main entrance.
Physiotherapy staff may be required to attend to a patient in the OR. If this is the case, they will follow the
staff pathway above.
12.2.7 SECURITY
The hospital security services will patrol the hospital grounds as per the hospital-wide operational policy.
When no OD staff are present, the OD needs to be locked and secure.
Security guards accompanying a detainee into the OD accompany them as far as Zone 2, where the patient
will meet the anaesthetist. Security guards will need to don protective clothing to pass from Zone 1 to Zone 2.
12.2.8 STORAGE WITHIN THE DEPARTMENT

Apart from the aforementioned sterile storage and equipment store, non-essential storage can be added as
supporting space depending on needs (e.g. temporary bed storage). It is critical to consider what storage is
necessary for supplies needed in a mass-casualty incident, such as extra equipment (e.g. OR table, C-arm)
and consumables (e.g. disposable linen sets).

Waste management will be carried out in accordance with the hospital-wide operational policy. Waste from
the OD should exit via a separate back door, and not from the main doors.
12.3 OD AGGREGATION EXAMPLE

The diagram below provides an example of how an operating department may be organized with two ORs and
a pre-/post-operative area with eight patient bed spaces.
Staff/patients/
visitors/goods
PROTECTIVE ZONE
OD main entrance Sanitary Carer

Registration
& lobby facility changing
spaœ
(M) area (M)
Staff Staff Patient
sanitary sanitary transfer
facility (M) facility (F) area
Waiting area
Red line Sanitary Carer
Interview
facility changing
room
(F) area (F)
Cleaner’s
room
CLEAN ZONE
Patient Patient Linen Patient Patient
bed space bed space bay bed space bed space
Staff break Hand- Preoperative Nurses’

Post- Hand- Medical
room wash area operative wash equipment store
station
bay area bay
STAFF ZONE
Linen
Patient Patient bay Patient Patient
Staff office bed space bed space bed space bed space
Sterile Sterile
(single- storage services
person) Corridor wide enough to protect clean flow from dirty flow
Staff office
(single- Laundry
person)
Operating Operating
Staff office Scrub room Disposal room Scrub Dirty utility
(shared) bay room bay room Waste
Red line Red line
ULTRA-STERILE DISPOSAL ULTRA-STERILE

ZONE ZONE ZONE
Figure 12.2 – Example of an OD aggregation


IN A MASS-CASUALTY
INCIDENT
13.1 INTRODUCTION
A mass-casualty incident (MCI) is ‘‘a destructive event that causes so many casualties that extraordinary
mobilization of medical services is necessary.”31
An MCI will have several consequences for the health facility:

• significant influx of patients
• convergence of relatives looking for information and waiting patients
• increased surge capacity when the MCI response plan is activated and more resources are made available
• increased demand for supplies
• potentially, risk to the health facility itself
Following an MCI, the OD may receive an large number of patients, followed closely by relatives and add
itional staff arriving to provide support. These inflows need to be managed, and staff must be prepared to
handle MCI scenarios.

Unlike the ED, there will be no major spatial changes to the OD model during an MCI. However, the OD will
have to efficiently absorb and manage the MCI’s consequences.
Once alerted to an MCI, the OD staff will complete ongoing surgical interventions; postpone or cancel fur-
ther non-life-saving scheduled operations; prepare the ORs; ensure that supplies are sufficient and boosted
where necessary; and assess and move patients from the pre-/post-operative area to other areas within the
hospital.
Each OR is allocated two preoperative and two post-operative spaces. At any one time, the number of patients
in these spaces cannot be exceeded, so good communication will be required to ensure the appropriate flow of
patients continues, with all spaces – especially the preoperative area – operating at capacity. Ideally, once any
operations underway are finished, the patients are moved to recovery and then to the post-operative area (if
the two spaces are separate), with no new non-urgent patients admitted to OD until the MCI is declared over.
pp. 10–12.
ENTRANCE/EXIT
POST-OPERATIVE GARE IN HDU
1
Protective zone
Access control
Support staff
3 Identification
Staff zone
Staff
Change
Shift rotation
Team set-up
Rest 2
Clean zone
Triage/preoperative care
4
5
Sterile &
Surgery Surgery Disposal
ultra-sterile
Barn zone
zone
model
Figure 13.1 – Changes to the OD in an MCI
The patients most urgently in need of surgery (i.e. with life-threatening trauma) will remain in the emer-
gency department until they can be transferred to one of the preoperative patient bed spaces. Patients who
need surgery less urgently will be transferred to the inpatient department to wait. They will be processed once
the life-threatening cases have been addressed.
Depending on the number of incoming patients and the available infrastructure, one OR could simultaneously
host two surgical cases (in a double-occupancy operating room).32
Owing to both the potentially high number of visitors and security concerns, it is important to ensure the OD
entrance can be kept closed and, ideally, guarded.
Extra supplies will be necessary to ensure operations’ continuity.
32 Also called a “barn operating room”.

14. OVERVIEW
OF THE OD BY ZONE
14.1 GENERAL BUBBLE DIAGRAM
Legend



supplies

ENTRANCE/EXIT FOR PATIENTS/STAFF/VISITORS
ENTRANCE FOR NON-STERILE SUPPLIES
OD main
entrance & lobby
1
Registration Visitor sanitary

Waiting area
space facility (M/F)
Overview of the OD by zone
Interview Carer
room changing area

3
Staff sanitary Equipment Medical

facility (M/F) bay equipment store Sterile supplies
Staff office Pre-/post- Nurses’

Sterile storage
(single-person) operative area station Sterile
zone
Staff Cleaner’s
Linen bay
break room room
Clean
Dirty zone
SERVICES
utility room
2
CENTRALIZED STERILE
RED LINE Dirty

Scrub bay
2nd barrier zone
4 5
Operating room Disposal room
129
To waste/laundry
Figure 14.1 – General view of the OD


PATIENT
OD main
entrance & lobby
1
Registration Visitor sanitary

Waiting area
space facility (M/F)
Interview Carer
room changing area

3
Pre-/post-
operative area
RED LINE
2nd barrier
4 5
Figure 14.2 – Zone 1 of the OD
14.2.1 LEGEND



supplies

Overview of the OD by zone 131

Patient transfer area OD main entrance & lobby Staff changing room (M/F)
(shared with Zone 2) (shared with zone 3)
-- Registration space Interview room (optional)
-- Waiting area Visitor sanitary facility (M/F) (optional)
-- -- Carer changing area (optional)

In this zone, patients:
• move into the OD, escorted by the ward nurse
• are handed over from the ward nurse to the OD nurse, anaesthetist or recovery nurse
• are registered after their identity, details, consent form, etc. are checked
• are transferred from the arrival trolley to an OD trolley and then escorted over the first red line
by OD clinical staff.
Once the patient returns, handover will be made from the OD nurse and anaesthetic assistant to the ward
nurse. Staff must:
• control the OD entrance
• receive and register patients and transfer them to Zone 2
• perform all the administrative tasks related to registration
• potentially, meet visitors or relatives in the interview room
• have access to the staff changing room to change their clothes.
132
OD main
entrance & lobby
1

3
Figure 14.3 – Zones 2 and 3 of the OD

Staff sanitary Equipment Medical
facility (M/F) bay equipment store Sterile supply
Staff office Pre-/post- Nurses’

Sterile storage
(single-person) operative area station Sterile
zone
Staff Cleaner’s
Linen bay
break room room
Clean
Dirty zone
SERVICES
utility room
CENTRALIZED STERILE
2
RED LINE Dirty
Scrub bay
2nd barrier
zone
4 5
Operating room Disposal room
14.3.1 LEGEND



supplies

Patient transfer area Nurses’ station Staff changing room (M/F) (shared
with zone 1)
Pre-/post-operative area Linen bay Staff sanitary facility (M/F)
-- Equipment bay Staff office (single-person)
-- Sterile storage Staff break room
-- Medical equipment store Scrub bay (shared with Zone 4)
-- Cleaner’s room --
-- Dirty utility room --

In these zones, patients receive care before and after surgery. The zones house all support spaces necessary
for the entire department’s operations.
Here patients on their way in:

• are transferred to the preoperative area
• are prepared for surgery; OD clinical staff may start interventions such as inserting an IV line
or administering drugs and/or oxygen.
On their way out, patients:

• are transferred to the post-operative area
• recover from surgery under OD clinical staff’s observation until they get a green light to be discharged
from the OD.
In these zones the staff have all support spaces for clinical activities and administrative tasks.
Sterile supply
To waste/laundry
Sterile
Clean
Dirty
zone
zone
zone
SERVICES
CENTRALIZED STERILE
1st barrier
RED LINE
5
Disposal room
equipment store,
storage, medical
cleaner’s room
spaces: sterile
Other service
utility room
Dirty
Operating room
operative area
transfer area
Pre-/post-
Patient
Staff changing
room (M/F)
Scrub bay
1
4
2
2nd barrier
1st barrier
RED LINE
RED LINE
Figure 14.4 – Zones 4 and 5 of the OD

14.4.1 LEGEND



supplies

Operating room Sterile storage (in Zone 2) Scrub bay (shared with Zone 2)
-- Medical equipment store (in Zone 2) Disposal room
-- Cleaner’s room (in Zone 2) --
-- Dirty utility room (in Zone 2) --

In these zones, the patient:
• is transferred from the preoperative area to the operating room and from the OD trolley
to the operating table
• undergoes surgical procedures.
Meanwhile, staff:
• enter the OR after scrubbing
• perform surgery
• take dirty/soiled items to the disposal room.
INPATIENT
DEPARTMENT
15. INTRODUCTION
TO THE INPATIENT
DEPARTMENT
The inpatient department (IPD) is where patients who need frequent clinical care for more than 24 hours
are accommodated. The length of their stay varies according to the type and level of care required. Patients
admitted to the department receive clinical care (diagnosis, treatment and observation until discharge) and,
for overnight stays, amenities for eating, bathing and sleeping.
IPDs are usually divided by groupings of activities or specialties:

• mother and child: obstetrics, gynaecology, neonatal care, paediatrics, etc.
• surgical: weapon wound ward, elective surgery ward, one-day surgery ward, etc.
• medical: internal medicine, infectious disease, tuberculosis ward, etc.
In some settings the department may also include a special care unit, such as a high-dependency unit, as
well as other clinical services such as physiotherapy. Separation by specialty helps to ensure safety measures
(e.g. to prevent cross infection), provide security for people and goods, improve the treatment and recovery
process, reduce stress for patients and staff, and reduce errors in activities.
Each specialty has specific needs, which are reflected in their supplies, equipment and staffing.
The ICRC specializes in the surgical management of weapon-wounded patients, a very specific surgical spe-
cialty. In some settings, however, the criteria for admission under ICRC care may be extended to include other
surgical emergencies, including trauma not related to weapon wounds, acute surgical abdomen, obstetric
emergencies and even medical and paediatric conditions and burns.
15.2 PATIENT MIX

Where the ICRC works, the case mix is varied and involves patients of all ages, both male and female.
15.2.1 SURGICAL – WEAPON WOUNDS

Surgery for weapon wounds follows classical surgical standards. It does however require adapted techniques
to deal with the complexity of injuries that are not necessarily seen in civilian surgical practice.
Weapon wounds affect children and adults in any part of the body, and they include gunshot wounds, injuries
from explosions, blast injuries and wounds from anti-tank and anti-personnel mines.
Introduction to the inpatient department 139
15.2.2 OTHER SURGICAL CARE

Other conditions that require surgical care may result from:
• other violence
• road traffic accidents
• industrial accidents
• domestic accidents
• burns
• non-traumatic acute abdomen
• obstetric emergencies.
15.2.3 INTERNAL MEDICINE

Medical conditions vary by location but may include:
• non-communicable diseases (e.g. diabetes mellitus, COPD, hypertension)
• respiratory conditions (e.g. upper respiratory tract infections, pneumonia)
• parasitic diseases – malaria, diarrhea and vomiting
• malnutrition.
15.2.4 INFECTIOUS DISEASES

Infectious diseases may include, among others:
• cholera
• dengue
• Ebola
• HIV/AIDS
• tuberculosis
• typhoid.
15.2.5 OBSTETRICS/GYNAECOLOGY
This medical specialty includes the two subspecialties of obstetrics (covering pregnancy, childbirth and the
postpartum period) and gynaecology (covering female reproductive health).
Women may be admitted to hospital with pregnancy complications. There may be a delivery suite within the
facility.
15.2.6 NEONATAL CARE

In facilities with obstetric care and labour and delivery, basic or more advanced neonatal care may be provided
for babies who are born prematurely, with a medical condition needing treatment or with low birthweight.
15.2.7 PAEDIATRICS
Most facilities with inpatients will admit children with a range of medical and surgical conditions.
15.2.8 MENTAL HEALTH

If a patient with a mental health condition is admitted to an ICRC hospital, it may be prudent to care for them
in a single bedroom, ideally with an anteroom and a private bathroom. This enable staff to provide care in a
private and controlled environment. It is important that these patients have access to an outdoor space for
fresh air and exercise.
If no single bedroom is available, there must be a private room situated in or near the inpatient unit for pri-
vate conversations with the patient (e.g. an interview room).
If there is an interview room in the department, it can also be used for other private conversations between
staff and patients, relatives or other staff.
15.3 NURSING MODELS OF CARE

There are a variety of nursing models of care, such as:
• task allocation
• patient allocation – total patient care
• team nursing.
In ICRC settings where the staff includes both expatriates (qualified nurses) and nationals (including quali
fied and assistant nurses), a team nursing model usually prevails. Staff members with solid international
experience often play supervisory and capacity-building roles; however, as they are clinically up to date, they
are also expected to do hands-on work.
The team model works well and is recommended by the ICRC. For example, a nurse with international experi-
ence and one or two national nurses or nurse assistants might be assigned eight to 12 patients each (depend-
ing on patient acuity), with the most experienced nurse as the team lead.33 A nurses’ station with three nurses
can thus care for up to 36 patients.34 The nurses work together to care for all of the patients allocated to them.
While nurses may be individually responsible for all of a given patient’s care, the team lead is ultimately
responsible for all patients. This model requires excellent communication between the team members, and
caregiving is shared by the team. Using the same model, any two nurses in the team may work as a pair.
Usually, the ICRC works In hospital settings not run or managed by the ICRC. Under such circumstances, ICRC
staff must be flexible and follow the hospital’s operational policy. A memorandum of understanding should
reflect agreements on working conditions and models.
15.3.1 NURSING STAFF

The size and type of the nursing staff depends on many factors: the type of hospital, the type of response
required, the type of programme, the phase of the programme and the local availability of nursing profes-
sionals and their technical skills and competencies.
Whatever the setting or programme, ICRC staff should implement protocols for the care of patients with
weapon wounds, gynaecologic inpatients, etc. that have been approved at institutional level. Expatriate and
national nurses should follow these protocols and be able to demonstrate their application and transfer
knowledge to newcomers (e.g. to expatriate staff on their first mission and new national recruits).

The aim of this section is to set out a model of care (MoC) for the IPD and the space requirements best suited
Like the rest of the MoCs contained in these guidelines, this MoC is meant to be updated regularly because
techniques and technologies evolve rapidly and quality standards are constantly improving. The frequency of
these reviews will be determined centrally.
33 This role is often played by expatriate personnel. However, national staff with the required qualifications, skills and
competencies can also play this role in some settings (taking into consideration other operational factors, such as the
security situation and the degree of acceptance for the ICRC’s work).
34 For a detailed description, see section 18.1, “Size of the department”.

• Day-to-day execution for a generic IPD – description of the main zones and how each space functions
under normal circumstances
• Variations on the MoC – the specific Inpatient Departments including the HDU, the Neonatal Unit
and the Obstetrics Department
• Overview of a generic IPD by zone – summary of each main zone, including bubble diagrams, lists
of physical spaces and descriptions of each zone’s scope.

Below, you will find the MoC for a generic IPD, followed by the variations on the MoC needed for specialized
care. The MoC focuses on:
• the patient environment
• what must be in place for clinical and non-clinical services to function properly in an IPD.
This section lays out the patient pathway for day-to-day operations; later on, the guidelines cover the patient
pathway in a mass-casualty incident.
16.1 PATIENT ENVIRONMENT

When a health-care facility, especially an IPD, is designed, repaired or renovated well, it helps patients to
recover faster both physically and psychologically. It also enables staff to work more efficiently. Special
attention must be given to a number of factors during the design phase:
• How much privacy patients are afforded in bedrooms depends on the space available, the number
of patients, how bed spaces are separated from each other, the distance between beds, the presence
or absence of private bathrooms and whether noise has been reduced following an appropriate
acoustic analysis.
• Natural ventilation and lighting should be present in all health-care areas when possible,
and they are required in patient bedrooms. Some spaces might require mechanical ventilation
for a better ventilation rate.
• The hospital compound should not be too dense – patients should be able to easily enter and move
around the facility and a safe space outside so that they may exercise and get fresh air.
• Finishing touches such as colours and textures within spaces also influence patients’ recovery.
• Measures such as keeping spaces clean and separating rooms and pathways are key to promoting
good hygiene practices and supporting patients in their recovery.
• Depending on the locale, gender segregation in some spaces will be required. In general, local customs
and religious beliefs play a crucial role in determining the overall design of the health-care facility.
The matter of visitors is also important: Family and carers are often the primary source of basic nursing
care and are with patients most of the time, helping them wash, eat, etc. Some will stay in the facility for
extended periods.
• There must be a family, multipurpose or play area for family, carers and accompanying children.
• In some locations, accommodations for family and carers may be provided within the hospital
compound or outside it (e.g. at a hotel nearby).
• Visitors must have access to adequate sanitation facilities to promote hygiene practices and prevent
the spread of infections.
16.2 E NABLING HIGH-QUALITY CLINICAL

AND NON-CLINICAL CARE
The quality of care in an IPD also depends on what support spaces, and services, are available (it must be
determined what spaces are essential and non-essential), whether the spaces are the right size to meet
needs (determined by local standards, ratios, medical staff, etc.) and whether their layout is conducive to an
efficient IPD.
The nurses’ station is the hub for staff in an IPD. Medical staff go to patient bed spaces from the nurses’
station, and nurses return there after their rounds. The distance between the space and the rest of the IPD’s
functional spaces must be optimized so clinical staff spend as little time as possible in transit. This has a
strong impact on quality of care.
16.3 PATIENT PATHWAY

To design appropriate health-care spaces, you must consider the needs and activities of all users (patients,
staff, etc.) and prioritize them according to clinical risk and potential outcomes.
This includes understanding the patient pathways through an IPD. As IPDs may be divided into specialized
units, or clusters, the patient pathway will vary according to what type of care is needed and how acutely.
Acute patients will arrive at the IPD from the emergency department (ED), the operating department (OD)
after an operation or the high-dependency unit. Patients may also be admitted directly from the facility’s
main entrance, in the case of referred patients or patients with specific conditions. Patients may be admitted
to the IPD before undergoing procedures in other departments.
INGRESS
Patients arrive
at main entrance
HDU HDU
Operating Inpatient Operating

department department department
Emergency
Mortuary
department EGRESS
Patients are
discharged
Figure 16.1 – IPD inflows and outflows

The chart below summarizes the major functional steps for patients moving through the IPD from admission
to discharge.
• Patient arrives at the IPD entrance from outside the health-care facility
or from the ED, OD or HDU
ADMISSION • Patient is registered and given a unique patient number
• Patient may be assessed or examined

PRE- • Patient coming from the ED, OD or HDU is escorted directly
HOSPITALIZATION to the hospitalization zone
• Once admitted, patient gets a bed space with a locker for personal
belongings
HOSPITAL • Patient gets clinical care
IZATION • Patient receives visitors, following the hospital’s operational policies
• Patient may engage in activities in the multipurpose room
• Patient receives adjunctive diagnostics and/or treatment

EXTERNAL • Patient receives treatment instructions
CONSULTATIONS
• Patient is admitted to another unit or discharged from the hospital

• Medical staff follow up with the patient for the necessary period
DISCHARGE & after discharge
FOLLOW-UP
Figure 16.2 – Main steps of the IPD patient pathway
The table on the following page further breaks down the patient pathway, listing the spaces that correspond
to the major functional steps as well as the perspectives of both the patient and staff. The last column on the
right summarizes the questions the design team should always consider before and during the design process.
STEPS IPD AREAS PATIENT PERSPECTIVE STAFF PERSPECTIVE DESIGN TEAM QUESTIONS
Arrival Admission • Patients arrive at IPD by foot, • Staff register patient or verify • Who – what patients and how many?
points outside wheelchair or bed existing registration • Accessibility?
the IPD: main • Patient receives a unique • Porter is able to escort • Arrival – how (means) and with whom
entrance, ED, patient number or has the patient to the IPD using (carers, etc.)?
HDU, OD an existing patient number a wheelchair, stretcher or bed • Routes and signs (position, language,
verified etc.)?
• Patients receive care from • Entrance/exit unobstructed?
clinical and non-clinical staff • Safety and security?
Pre- Zone 1: • Patients coming from the • Staff may assess or examine • Waiting visitors (how and where)?
hospitalization Entrance, ED, OD or HDU are escorted patients upon arrival • Safety and security? IPD access
interview room, directly to the hospitalization control?
consulting room zone
• Private discussions with
patients and relatives may be
had in an interview room
• Upon arrival at the obstetrics
department, women are
assessed in a consulting room
affording privacy
Hospitalization Zones 2, 3 • Patients are escorted to their • Staff carry out clinical • Number of patient bed spaces?
and 5: inpatient bed space, get activities in the inpatient bed • Number of nursing staff members?
hospitalization settled and store their personal space • Number of support spaces?
zone, sanitary belongings in the bedside • Staff have easy access • Distance between beds?
facilities, locker to the inpatient bed space • Line of sight between nurses’ station
shared spaces • Patients undergo clinical and sufficient room around and patient bed spaces?
(multipurpose care (diagnosis, treatment, the bed to carry out clinical • Accommodations for relatives and
room) rehabilitation and observation) and non‑clinical activities carers?
and may be prepared • Staff have easy access • Distance between nurses’ station
for procedures in other to hand‑wash bays and support spaces?
departments, e.g. the OD • Staff are able to observe • Critical relations with other clinical
or HDU the patient bed spaces from departments and services (e.g. OD, ED,
• Patients sleep, eat, wash, etc. the nurses’ station HDU, physiotherapy)?
during their stay • Staff carry out clinical support • Relations with support departments
• Patients may receive visitors in activities, preparing trolleys (imaging, laboratory, pharmacy,
accordance with the hospital’s and medications, delivering centralized sterile services)?
policy on visiting hours patients’ meals, cleaning, etc. • Relation with operational departments
• Patients may carry out • Staff have access to the staff (kitchen, laundry)?
activities in the multipurpose zone and nurses’ station for • Flexibility of the ward (e.g. ability to
room administrative tasks, meetings, divide a 24 or 36 bed cluster into two,
handovers, rest change care specialty, isolate patients)?
• Possible extension?
• Natural lighting, air quality, courtyard?
• Communication system, IT?
• Urgency protocol, patient overflow?
External Medical • Patients undergo adjunctive • Staff review adjunctive • Diagnostics? Treatment? Observation?
consultations imaging, diagnostics and/or treatment diagnostics and make • Communication and information?
physiotherapy, • Patients receive disposition disposition decisions • Referral or transfer?
laboratory instructions • Safety and security?
Discharge • Patients are admitted • Staff follow up with patients • Discharge – where to, how and with
and follow-up to another unit or discharged on any next steps whom?
from the hospital • Staff fill out discharge forms • Routes and signs?
• Patients are followed up on by • Staff hand over clinical • Where next?
medical staff summaries, test results, • How to follow up?
prescriptions as needed
Table 5 – IPD patient pathway – patient and staff perspectives and questions for the design team
DAY-TO-DAY EXECUTION OF THE MoC FOR A GENERIC IPD 145
17. D
AY-TO-DAY EXECUTION
OF THE MoC
FOR A GENERIC IPD
17.1 INTRODUCTION
For ease of understanding, the MoC divides the IPD into five zones:
1. entrance zone (patient arrival)
2. hospitalization zone (including clinical and non-clinical care)
3. support activities zone (shared support spaces)
4. staff zone (staff-only spaces)
5. hygiene and sanitation zone (patient sanitary facilities).
Each zone has a specific role. They are grouped together to facilitate the MoC’s execution, in particular to
simplify the patient flow.
Occasionally, an existing IPD – conceived with a different model in mind – may simply be reorganized to
suit this MoC. However, when this is not possible, consideration should be given to alternatives adapted to
specific situations.
Below are descriptions of how each zone is organized. Each contains functional spaces arranged into three
categories: core clinical spaces (yellow in the following bubble diagrams), where the major interactions with
the patient happen, core clinical support spaces (pink) and general support spaces (turquoise).
For each of the five zones, the patient flow and relationships between spaces are illustrated with a bubble
diagram, and then the main functional spaces are described along with a functional space table summarizing
the essential points.
This section sets out the day-to-day MoC, with explanations and illustrations of the principles of arranging
patient bed spaces and configuring layouts for specific functional spaces with hygiene and comfort in mind.
ENTRANCE/EXIT
1
Entrance zone
Patient arrival
3
Support
activities
zone
4 2
Staff clerical Hospitalization
tasks and zone
amenities Clinical treatment personal care
Accommodations
Administration
Staff amenities
5
Hygiene and
sanitation zone
Figure 17.1 – General circulation in the IPD during day-to-day execution of the MoC
17.2 ZONE 1: ENTRANCE ZONE

Ideally the IPD has only one independent entrance for patients, located on the ground floor.
The entrance zone is where patients and visitors arrive at the IPD and wait. It is the buffer space between the
outside and the hospitalization zone. Here, patients:
• are registered with a unique patient number or, if they have already been registered in another
department, have an existing patient number verified
• are admitted
• are sometimes assessed by clinical staff.
This zone is also the primary area for relatives and carers to wait and to take a break when they are not with
patients.
When a hospital is set up amid a humanitarian crisis, this zone may be omitted. However, in protracted crises
emergency responses often gradually become long-term responses, and the hospitalization zone is essential
to a well-planned health-care facility and thus to a long-term response. Planning should be forward-looking.
17.2.1 PATIENT FLOW

In Zone 1, the patient arrives from outside the IPD by foot, wheelchair or bed, most likely escorted by clinical
staff and potentially relatives. Some patients may also arrive from the ED, OD or HDU, if there is one.
IPD ENTRANCE
Scope
This is the main entrance and exit of the IPD.
There should be a set of double doors wide enough to allow the patient to pass through lying on a trolley or a patient bed
with sufficient additional space for an escort (a porter or ward nurse). The entrance is followed by a buffer zone known
as the lobby, whose dimensions will vary depending on the facility.
The entrance should be monitored to prevent unauthorized traffic into the IPD.
Main relationship
FROM outside IPD
TO waiting area
PATIENT
1
IPD entrance
& lobby
Interview Waiting
room area
Multipurpose
room
4 3
Inpatient bed spaces

& isolation suites
EXTERNAL 5
CONSULTATION
Figure 17.2 – Relations of the core clinical space in Zone 1 of the IPD
In some places, the waiting area may be divided in two, with one area for men and one for families (including
both parents and children). And in some places, an area for women is required (often used for both women
and children). While the space is optional, it is important, especially for families and carers, because they can
relax there when not with patients.
Upon arrival, clinical staff may speak with patients and/or relatives in the interview room to explain what is
to come and perhaps explain how the facility operates. This discussion is not an obligatory step in the patient
pathway, and the room may be used later for private discussions between staff and carers or relatives.
INTERVIEW ROOM
Scope
This is a private environment for discussions between staff and relatives or carers as well as some mental health
patients or victims of sexual violence.
It is a small, enclosed room that ensures sights and sounds remain private. It has a desk, seating, a telephone
and a small storage area.
Main relationship
FROM IPD entrance
TO exit
The length of patients’ stays varies depending on their condition and the type of care; a multipurpose room
is meant as a living room at the junction of the hospitalization zone and the external area. It is necessary so
that patients can receive visitors without bothering other patients, enjoy entertainment, socialize and avoid
restrictions associated with remaining only in their patient bed space. In some places, it may also be a play-
room for children accompanying visitors.
MULTIPURPOSE ROOM
Scope
This room, a living room of sorts, is used by staff, patients and potentially relatives for activities such as teaching, health
promotion or entertainment. In the IPD, patients receive visitors in this room to keep the hospitalization zone quiet.
It should include comfortable chairs, a table, a lockable cupboard and a hand-wash basin.
In some locations it may be necessary to segregate patients by gender.

Main relationship
FROM waiting area
TO hospitalization zone
17.2.2 ROLE OF RELATIVES AND CARERS

Relatives and carers may accompany some patients for the duration of their hospital stay. The hospital’s
operational policy should outline which patients may have a full-time carer reside in the hospital, e.g.
patients in the HDU or paediatric patients.
In some places, relatives and carers are expected to look after the patients’ hygiene, nutrition, etc. If this
is the case, on their arrival nursing or hygiene staff members will brief them on their responsibilities, such
as keeping the patient’s belongings organized, cleaning the ward and other tasks in cooperation with staff.
Relatives will need somewhere to retreat to when ward routines require them to do so. They should also have
somewhere to sleep, do laundry and cook. The extent of these facilities will depend on the hospital’s setting
and operational policy. Relatives and carers who visit during the day will only be to do so during specific
visiting hours.
17.3 ZONE 2: HOSPITALIZATION ZONE

This zone is organized around the main core clinical space of the department, the inpatient bed space. This
is where the patient lives and receives nursing care during their stay.
The ICRC mostly works in places where hospitals still use the traditional ward configuration for inpatients
(multiple inpatient bed spaces arranged in a row). It is essential that there a minimum distance be maintained
between beds for infection-control purposes, to allow the carers to perform their activities without interfer-
ence and, importantly, to ensure the patient’s comfort when accommodated with other patients.
17.3.1 INPATIENT BED SPACE

Most likely, the inpatient bed will have a solid wall at the bedhead. If there is a single bed in a room, there
should be at least one metre of space between the long sides of the bed and the walls on either side. Where
beds are arranged in a row, there should be at least 1.2 metres between beds to prevent the spread of infection
and provide easy access to the patient. In this case, patient beds should be separated by curtains or portable
screens for privacy and comfort. Curtains can be pulled back, and portable screens removed, when staff need
to observe several patients at once.
Figure 17.3 – Generic inpatient bed space – single and multiple (measurements in cm)
PATIENT
1 IPD entrance
& lobby
4 3
2
Linen
bay
& isolation suites
Hand-wash
bay
Nurses’ Equipment
station bay
EXTERNAL
CONSULTATION
5 Staff sanitary Patient
facility (M/F) shower room
Figure 17.4 – Relations of the core clinical space in Zone 2 of the IPD
Hand-
wash
bay
Hand-
wash
bay
Figure 17.5 – Single straight corridor configuration with inpatient bed spaces and hand-wash bays
(measurements in cm)
Staff and carers must be able to access the patient from either side of the bed. Only the bedhead should be
against a wall. No bed should have its long sides against a wall.
The arrangement of inpatient bed spaces in ICRC-supported hospitals varies, but generally beds are arranged
in the traditional straight, single corridor configuration, with a row of beds on either side of a rectangular
space or tent and a corridor down the middle. Whatever the layout, there must be good lighting, strategically
placed hand-wash bays and enough space for circulation.
INPATIENT BED SPACE

Scope
The inpatient bed space is where the patient will lie on a bed while receiving medical, nursing and physiotherapy care.
There must be at least 1.2 m of clearance between beds and 1 m between beds and side walls or other obstacles.
Curtains or portable screens must be provided to ensure patient privacy. Each space should include a chair for visitors
and a bedside locker for personal belongings.
Main relationship
TO sanitary facilities
17.3.2 PATIENT FLOW

During their stay, the patient will receive medical, nursing and/or physiotherapy care, which involves having
vital signs checked, physical examination, blood tests, drug therapy and administration of inhalers, dress-
ings, physiotherapy exercises and other simple tests.
In addition to the inpatient bed spaces, there must be isolation suites within the department to accommodate
patients with special requirements, e.g. patients who are dying, infectious, delirious or distressed, or have
mental health conditions, photosensitivity from tetanus, or need of protection.
Isolation suites must be located close to the nurses’ station but off to the side so they do not obstruct the
view of the inpatient bed spaces; the entrance to the anteroom should still be visible from the nurses’ station.
The isolation suite has three elements: the anteroom, the bedroom itself and the en-suite bathroom (with a
shower and WC).
ISOLATION SUITE
Scope
This is where patients are isolated when they are suspected of having an infectious disease or when they are
immunosuppressed and at greater risk of contracting an illness. The bedroom can also be used for patients who benefit
from being cared for in a single room, for example photophobic patients, dying patients, patients with mental health
conditions or detainees.
An anteroom provides a buffer zone between the corridor and the patient’s bedroom. The anteroom is where staff
or visitors don protective clothing on the way into and out of the patient’s bedroom. The bedroom itself is self-contained,
and has direct access to its own en-suite bathroom with a shower and WC.
Main relationship
TO support spaces
Functional space card See cards 37, 38, 39 and 40 Type NON-ESSENTIAL
The anteroom is intended to act as a buffer, with staff and visitors entering the bedroom directly from the
anteroom. If the anteroom is not present as a separate room, there should nevertheless be a buffer space in
the corridor outside the main bedroom doors (in a recess if possible).

During a patient’s stay, they may be required to pass between the inpatient department and the imaging,
operating and physiotherapy departments. Blood samples will usually be taken on the ward rather than the
patient having to go to the laboratory.
Patients will be cared for in the inpatient bed space by clinical staff. A nurses’ station must be placed centrally
so that staff and patients are within each other’s line of sight. The nurses’ station is the coordination hub for
providing patient care and writing up patient notes and is where nursing staff gather when not with patients.
NURSES’ STATION
Scope
in the area.
The key feature of the nurses’ station is that it is situated so the staff in it can see all patients and vice versa, in case
patients wish to attract staff attention. It is usually located in the same space as the patients. If it is in a separate room,
windows must give a direct view of the patients. The distance between the nurses’ station and the furthest patient bed
must be as short as possible.
The station must be furnished with a counter, chairs, a cupboard and shelves, a hand-wash bay and space for trolleys.
Main relationship
FROM inpatient bed spaces
TO shared support and staff spaces
Hand-
wash
bay
Hand-
wash
Nurses’ station bay
Figure 17.6 – The nurses’ station has a direct view of all beds
Often there should be an open storage bay for one or more items of mobile (wheeled) equipment frequently
used in multiple spaces, such as dressing trolleys, vital signs equipment, IV poles, examination lights, oxygen
concentrators.
Ideally, the equipment bay would be recessed into a partition wall. If that is not possible, mobile equipment
should be stored in a convenient space where it does not obstruct the flow of staff, patients or supplies (e.g.
linen) in the room or corridor.
Any equipment bays must be directly accessible from the nurses’ station to minimize the time it takes staff
to retrieve the equipment and take it to its point of use.
EQUIPMENT BAY
Scope
This provides storage for equipment that is frequently shared between one or more treatment spaces.
It is an open space that does not interfere with circulation. Ideally it is recessed into a partition wall.
Main relationship
TO inpatient bed spaces
Linen needs to be managed next to where the clinical activity is performed. Linen may include bed sheets,
pillowcases and blankets. A tall cupboard with doors may be built into a recess. If a recess is not possible,
linen should be stored in a convenient space (on a trolley or in a cupboard) where it will not obstruct the flow
of staff, patients or supplies in the room or corridor.
LINEN BAY
Scope
This is a space for storing clean linen on a trolley or in a cupboard.
Ideally, the bay is recessed into a partition wall. If a recess is not possible, the space should not interfere
with circulation.
Main relationship
Hand-washing is one of the most effective ways to control the spread of infection. Medical staff and any
visitors must be able to wash their hands at any given moment.
All core clinical spaces must have a hand-washing basin. Each basin should be positioned so it does not
obstruct the flow of staff, patients or supplies (e.g. linen) in the room or corridor. There should be enough
hand-wash bays to ensure staff members always have easy access to them.
HAND-WASH BAY
Scope
This is where medical staff regularly wash their hands after any procedures or contact with patients.
A hand-wash bay must be present in every clinical space. The number of sinks will depend on the dimensions
of the room and the number of patients and staff in it. It must be placed in a position facilitating its use.
Main relationship
It is important to consider the location of hand-wash bays when designing the space.
Hand-
wash
bay
Figure 17.7 – Location of hand-wash bay between beds with minimum required dimensions
(measurements in cm)
Ideally, they are roughly equidistant from any point in the room – when located at either of the shorter walls
of a room, they might be too far away for staff and patients to use them.
17.4 ZONE 3: SUPPORT ACTIVITIES ZONE

In the IPD, support activities are required by all zones of the department and must be considered in any
design. Therefore, the support activities zone is an independent zone in the inpatient department, while it is
incorporated into larger zones in other departments.
Medical equipment frequently used in the IPD’s core clinical spaces must be stored within the department
and cleaned when necessary. There must be storage space for parking trolleys, with space for at least one
large trolley, two medium trolleys, two Mayo tables and other equipment when not in use – e.g. table attach-
ments or traction items.

Scope
This is where medical equipment for the department or unit is stored when not in use, e.g. mobile equipment, IV poles,
wheelchairs, trolleys, commode chairs, crutches, traction frames.
Hooks are required for hanging equipment, e.g. crutches, frames. The space may need double doors for access
depending on what is stored.
Main relationship
TO inpatient bed spaces and isolation suites
1 Non-medical To waste/laundry/
store sterile services
4
Cleaner’s Dirty utility
room room
Clean utility Medical

room equipment store
Sterile
services/
central
2
Linen pharmacy
bay store
& isolation suites
Hand-wash Non-medical
bay store/central
pharmacy store
Nurses’ Equipment
station bay
CONSULTATION
EXTERNAL
Figure 17.8 – Shared support spaces in Zone 3 of the IPD
The IPD also needs a room for storing housekeeping materials, which must be easily accessible for the clean-
ing staff. It can be a single room or multiple smaller rooms well located in the department.
CLEANER’S ROOM
Scope
This is a secure room for storing cleaning materials, agents and equipment, which may include a trolley, and for washing
mops, buckets, brooms etc.
It contains a slop sink for filling and emptying buckets used to clean floors. The minimum floor area is 2.0 m². The room
should be lockable for safety reasons.
Main relationship
The IPD must include a room where dirty materials and linen coming from clinical areas are collected before
dispatch to other departments. The room is also set up for cleaning some items.
DIRTY UTILITY ROOM

Scope
The dirty utility room, found in patient areas, is a space for cleaning and storing used equipment (e.g. bedpans, urinals
and bowls), disposing of human waste (e.g. urine, vomit, faeces) and point-of-care urine stick testing.
The set-up of the room should reflect a one-way flow from dirty to clean: rubbish bin; disposal of human waste
in a sluice; cleaning of bed pans and urinals (which may require a period of soaking after emptying/cleaning); storage
allowing drip-drying; and, on one side, a hand-wash basin for staff and, on the opposite, storage for clean items
and cleaning products. The room should be lockable for safety reasons.
Main relationship
All stores and supplies will be delivered via the IPD entrance. This includes, among others, linen, equipment,
consumables and housekeeping materials. Goods will then be transferred to the appropriate locations for
storage and use.
CLEAN UTILITY ROOM

Scope
This room is used for storing and preparing medications and consumables.
For safety reasons, the space must be enclosed and lockable. In a small facility, the clean utility room may be
a cupboard in a recessed area out of the flow of traffic. It is located away from the dirty utility room.
Main relationship
17.5 ZONE 4: STAFF ZONE

17.5.1 CLINICAL STAFF
Clinical personnel (doctors, qualified nurses, nursing assistants, etc.) will staff the IPD 24/7.
On a surgical inpatient ward, rounds are carried out by a core team of a surgeon, anaesthetist, OR nurse,
head nurse or ward nurse, and physiotherapist. (This varies for other inpatient wards.) The schedule for
these rounds will depend on the facility’s operational policy. Outside routine ward rounds, any staff members
(including mental health staff and social workers) may be required to visit inpatients at any time.
Physiotherapists and physiotherapy assistants will need to go to patients who cannot move from their bed
space. They also provide care in dedicated spaces (e.g. the physiotherapy department) if present in the facility.
Clinical staff need a nurses’ station for writing up patient notes and doing routine record keeping (e.g. record-
ing vital signs and drugs administered).
17.5.2 ALL STAFF

Non-clinical staff also need access to the inpatient areas. They may include cleaners, food-service personnel,
porters and laboratory and pharmacy staff. All staff (clinical and non-clinical) must have access to various
staff-only spaces within the department, including sanitary facilities, changing rooms (which may be located
somewhere else in the facility), locker spaces, one or more staff break rooms and teaching spaces (the multi
purpose room may be used for the latter), and food-preparation facilities (which may be in the staff break
room(s)).
Staff should not enter the ward in their own clothes, which means that the staff changing rooms should be
located away from, or before the entry to, the inpatient bed spaces and isolation suites. Sanitary facilities can
be directly connected to or within the changing rooms but must be properly separated.
STAFF SANITARY FACILITIES (M/F)

Scope
These are WC facilities for staff use only. Staff need easy access to WCs without leaving the department.
There must be a hand-wash basin and a toilet roll holder and/or water point. There must be at least one handicap toilet.
Main relationship
FROM clinical spaces
TO IPD entrance
STAFF
Interview IPD entrance

room & lobby
Multipurpose
room
1
4 3
Staff office
(single-person)
Staff break
room
2
Staff sanitary Inpatient bed spaces

facility (M/F) & isolation suites
Staff changing
room (M/F)
Nurses’ station
EXTERNAL
CONSULTATION
5
Figure 17.9 – Functional spaces and staff flow in Zone 4 of the IPD
Clinical staff perform administrative tasks and need, in addition to the nurses’ station, a room where privacy
can be ensured.

Scope
This is a staff-only space for a single person to perform administrative tasks.
The office is enclosed and includes the necessary equipment – a desk, chair, computer and cabinet.
Main relationship
FROM IPD entrance
TO interview room
As clinical personnel will staff the IPD 24/7, they need a space to take a break from work without having to
leave the department.
STAFF BREAK ROOM

Scope
This staff-only space is where staff can take a break, eat and relax during their shift without leaving the department.
The room should have appropriate seating, counter space with a sink for basic food preparation, the necessary set-up
for boiling a kettle, and a table and chairs for dining, if required. The room may be used for small staff meetings,
tutorials, handovers, etc.

Main relationship
TO scrub bay
17.6 ZONE 5: HYGIENE AND SANITATION ZONE

During an inpatient stay, patients will require access to WCs and showers. A nurse may have to assist less
ambulant patients – e.g. transferring them from wheelchair to toilet. In the IPD, these facilities are used by
patients often each day. They therefore require specific attention during the design phase, which is why they
are set apart as their own zone.
4 3

& isolation suites
Nurses’
station
EXTERNAL
CONSULTATION 5
Staff sanitary Patient
facility (M/F) shower room (M/F)
Figure 17.10 – The core clinical support space in Zone 5 of the IPD
The patient WCs for inpatient areas are most likely to be grouped with showers and hand-wash basins and
may be located within or outside the building, depending on local circumstances. They should however be
easily accessible. In multistorey buildings, the WCs and showers should be situated immediately adjacent to
the inpatient department on the same storey, as some patients will not be able to use stairs easily.35
PATIENT SANITARY FACILITIES (M/F)

Scope
These are WC facilities for patients.
There must be separate spaces for males and females. Each facility has a block of individual toilet stalls (one for every
six to eight patients). There is one hand-wash basin for every one to two WCs.
Each WC should accommodate a patient who is either ambulant or on a commode chair. There must be at least one
handicap toilet with a grab rail on one wall to assist the patient.
Main relationship
In all locations, there must be separate spaces in patient sanitary facilities and shower rooms for males and
females. Both the sanitary facilities and shower rooms have at least one space designed for disabled users.
PATIENT SHOWER ROOM (M/F)

Scope
This is where a patient who is ambulant or on a commode chair can shower.
There must be separate spaces for males and females. The room is a block of individual shower stalls (ideally,
one for every eight patients). A seat may be provided in the shower for patients who need to sit. The room is designed
to be handicap-accessible, with a grab rail on one wall to assist the patient.
A nurse or carer may have to assist less-ambulant patients in the shower, so the space must be sized accordingly.
Main relationship
35 In some special cases (in a burn unit, for instance), a large bath specially designed for the removal of dressings and
treatment of large burns may be included in a larger patient shower room.

IN A MASS-CASUALTY
INCIDENT
18.1 INTRODUCTION
A mass-casualty incident (MCI) is ‘‘a destructive event that causes so many casualties that extraordinary
mobilization of medical services is necessary”.36
An MCI will have several consequences for the health facility:

• significant inflow of patients
• convergence of relatives looking for information and waiting patients
• increased surge capacity when the MCI response plan is activated and more resources are made available
• increased demand for supplies
• potentially, risk to the health facility itself.
Following an MCI, the OD may receive a significant number of patients, followed closely by relatives and
additional staff arriving to provide extra support. These consequences need to be managed, and staff must
be prepared for them.

When the hospital shifts into mass-casualty mode, a cascade of events will occur according to the number of
patients expected to arrive at the hospital.
In areas where an influx of patients owing to an MCI is a relatively frequent occurrence or highly likely to
occur, a predetermined space usually on standby would be activated (e.g. a tent or empty ward).
If there is no space on standby, staff will need to clear wards by discharging the least-sick patients or at least
shifting them to an alternative space to make way for those incoming. Staff may need to be kept on duty and
others brought in. Supplies will need to be checked and added to where necessary.
In an MCI, inpatient wards will receive two categories of patients: category II (those who will need surgical
interventions but can wait) and category IV (those whose injuries surpass available resources but who would
be reclassified as category I for immediate surgical intervention if and when resources become available).
pp. 10–12.
19. ADDITIONAL DESIGN

CONSIDERATIONS
19.1 SIZE OF THE DEPARTMENT
The larger the inpatient ward (within reason and based on identified needs), the more economical and effi-
cient it will be to run. There is no perfect size, but usually 24 to 36 beds work well as an operational unit. When
determining the size of an inpatient ward, you must take into consideration available nursing resources,
patient acuity and census. It is essential to be able to staff a ward during the night shift. If it can be made to
work during a night shift, it should be easy during a day shift, as more staff members are usually available.
If necessary, 24- and 36-bed wards may be broken down into clusters of eight or 12 patients each; those
numbers suit most nursing teams and enable more flexible use of the space.
In places where tents are used as inpatient areas, the ward size will be determined by the tent size. Where
possible, larger tents (accommodating 24 to 36 patients) should be used for general surgical or medical
patients. Smaller tents (accommodating fewer than 15 patients) may be used for higher-acuity, sicker
patients, e.g. HDU patients.
19.2 PATIENT OVERFLOW

In some set-ups it is difficult to manage inpatient overflow – especially when patients must be separated by
gender. Therefore, there needs to be flexibility so that wards may be reassigned by gender or acuity.
CLUSTER 1 > 12 BEDS
HYGIENE AND HYGIENE AND

SANITATION ZONE SANITATION ZONE
Inpatient bed Inpatient Inpatient Inpatient bed

space bed bed space
space space
Inpatient bed Inpatient bed

space space

space space
Hand- Nurses’ station Hand-

wash wash
bay bay
Hand-
Linen Equip.
wash
bay bay
Inpatient bed bay Ante- En-suite
space room bath-
room
SUPPORT ACTIVITY CLUSTER 3 > 12 BEDS

Inpatient bed ZONE
space Dirty utility room Patient Hand-
Cleaners’ room En-suite
Medical equipment store bedroom bathroom
wash
Inpatient Inpatient Inpatient HYGIENE
(single) Patient bedroom bay
Clean utility room bed bed bed
Inpatient bed Etc. (single) AND
space Anteroom space space space SANITATION
Patient
ZONE
and
visitor
entrance
Linen
Inpatient bed bay Inpatient bed
ENTRANCE STAFF POSSIBLE space space
ZONE ZONE EXTENSION Hand- Nurses’
wash
Multipurpose Staff break room OF STAFF ZONE bay station
room Staff office IF NEEDED Inpatient bed Inpatient bed
Interview room Staff sanitary facility space Equip. space
Etc. Staff changing room bay
Staff Etc.
and
goods
entrance HYGIENE
Inpatient bed Inpatient Inpatient Inpatient Inpatient Inpatient Inpatient AND
SUPPORT ACTIVITY
space
Patient bed bed bed bed bed bed SANITATION
ZONE Hand- ZONE
bedroom space space space wash space space space
Dirty utility room (single) bay
Inpatient bed Cleaners’ room
space Medical equipment store
Clean utility room
Etc.
Inpatient bed Ante- En-suite

space Hand- room bath-
Linen Equip. room
wash
bay bay
bay
Hand- Hand-
wash wash
bay Nurses’ station bay

space space

space space
Inpatient Inpatient
Inpatient bed bed bed Inpatient bed
space space space space
HYGIENE AND HYGIENE AND

SANITATION ZONE SANITATION ZONE
CLUSTER 2 > 12 BEDS
Figure 19.1 – Example of three combined clusters with support spaces serving all clusters placed
in a central position and a double corridor (racetrack model)
19.3 SAMPLE LAYOUT OF INPATIENT BED SPACES

CLUSTER 2 > 12 BEDS CLUSTER 1 > 12 BEDS
HYGIENE AND HYGIENE AND HYGIENE AND HYGIENE AND

SANITATION ZONE SANITATION ZONE SANITATION ZONE SANITATION ZONE
Hand- Hand-
wash Inpatient bed Inpatient bed wash
bay bay
space space
space Inpatient bed Inpatient bed space
space space
space Linen Linen space
bay bay

space space
Nurses’ station Nurses’ station
space space
Equip. Equip.
Inpatient bed bay bay Inpatient bed
space space
Inpatient bed space space Inpatient bed
space space
Hand-
Inpatient bed Inpatient bed Hand-
wash space space wash
bay bay
En-suite Ante- Inpatient bed Inpatient bed Ante- En-suite

bathroom
space space room bath-
room room
SUPPORT ACTIVITY ZONE

Patient Dirty utility room Patient
bedroom Cleaners’ room bedroom
(single) Medical equipment store (single)
Clean utility room
Etc.
Patient and Staff and

visitor entrance goods entrance
ENTRANCE ZONE STAFF ZONE
Multipurpose room Staff break room

Interview room Staff office
Etc. Staff sanitary facility
Staff changing room
Etc.
Figure 19.2 – Two clusters sharing the support activity and staff zones – each cluster includes 12 beds
along a single corridor and its own nurses’ station
The layout of inpatient areas varies depending on the architectural concept, expectations for the hospital’s
management and local standards (for instance, regarding how many rooms should get natural light from the
south). The most common models are:
• the traditional Nightingale ward model, where beds are lined up along each side of a long rectangular
space (up to 36 beds per ward). Generally, the patients accommodated in such a ward are less sick
and more mobile.
• the cluster model, where a typical cluster of patient beds is six, eight or 12 beds. Each cluster has
a nurses’ station and core clinical support spaces. Depending on the design, the nurses’ stations
and support activity zone may be shared. Using clusters enables discrete cohorts of patients
to be grouped either by acuity, clinical diagnosis or even gender – e.g. in a 24-bed space
comprised of two 12-bed clusters, one might be a cluster of 12 HDU beds.
In general, sicker patients or those requiring more intensive care will be grouped in smaller clusters to facili
tate thorough observation by clinical staff. The HDU, delivery room and post-delivery observation space are
described further on.
19.4 SUMMARY OF KEY DESIGN PRINCIPLES

To sum up, the design of an IPD should incorporate the following principles:
• maximize patient safety and minimize risk of errors and accident by using a standard layout
for inpatient bed spaces, providing good lighting, strategically locating hand-wash bays and ensuring
there is enough space around beds for staff to deliver care
• optimize work flows for clinical and non-clinical staff by creating the shortest possible travel distances
between core clinical support spaces and inpatient bed spaces, the nurses’ station, etc.
• enable closer levels of observation corresponding to increased patient acuity, for example by positioning
staff at the nurses’ station and patients within each other’s line of sight
• follow standard infection-control principles such as by providing hand-washing facilities, ensuring
beds are separated by at least the minimum distance to prevent cross infection, etc.
• ensure flexibility, as how the space is used may change over time or shift as needed (e.g. during
a mass-casualty incident)
• ensure good air quality with natural ventilation and/or heating/cooling systems appropriate
to the climate
• ensure good lighting, both natural lighting with views of external spaces for patients and staff
and supplementary lighting for staff performing their duties
• provide easy access to sheltered outdoor spaces for patients, including bedridden patients, to make
them as comfortable as possible during their stay.

19.5.1 ADMINISTRATION
Ward and clinical administrative duties usually include organizing and supervising clinical teams, organizing
ward routines, creating daily care plans for patients, managing patient files, maintaining log books and regis
ters, ordering supplies, contacting the maintenance department, etc. This is generally the responsibility of
the nurse in charge, and they need to work jointly with surgical teams, other clinical and non-clinical staff,
the hospital administrator and the hospital project manager.
19.5.2 BLOOD BANK

Upon request, units of blood for transfusion will be collected from the blood bank by a qualified nurse and
taken directly to the IPD.

Cleaning services will be performed in accordance with hospital’s operational policy. There may be a weekly
or monthly routine of emptying of the whole ward for a thorough clean.

The IPD operates 24/7.
19.5.5 INFECTION CONTROL

Standard ICRC infection-control principles and protocols will be applied at all times.

With the exception of some cases in the HDU, patients will be transferred to the medical imaging department
by bed or wheelchair or on foot.

Deceased patients will be prepared in their beds by nurses and/or carers and transferred to the mortuary by
patient trolley.
Physiotherapy will occur bedside for patients restricted to their beds (e.g. HDU and traction patients). Some
HDU patients will be required to get out of bed and sit on a chair beside their bed and even go on short walks.
Those who can will be mobilized, and many patients will leave the inpatient ward for physiotherapy in the
physiotherapy department (if there is one) or for exercise outdoors.
19.5.9 SECURITY
Security measures will be taken in accordance with hospital’s operational policy.
Consideration should be given to providing a safe room built to specification and equipped with food and
supplies for staff seeking shelter. The details of such measures should be part of the hospital or IPD’s con-
tingency plan. Local or international fire safety measures apply as well.
19.5.10 STERILE SERVICES

Instruments used in the inpatient areas will be returned to sterile services for processing, usually by ward
staff. There may be a small, secure store of specific processed instruments on the ward.
19.5.11 STORAGE WITHIN THE DEPARTMENT

All inpatient wards require storage space, either recessed in a bay, in cupboards, on shelves or in a specific
room. Items in storage should be easily accessible but still secure, to prevent theft and loss.

Waste will be managed in accordance with hospital’s operational policy. It may be stored in the dirty utility
room or disposal room within the IPD until it is collected by staff.
20. VARIATIONS ON THE MoC

The generic IPD MoC and the basic IPD zones may be adapted to the specific requirements of different inpatient
groups by adding a zone or slightly modifying existing zones, transforming a generic IPD into a specific IPD.
20.1 HIGH-DEPENDENCY UNIT (HDU)

High-dependency patients are the highest-acuity, sickest patients in the facility. They require more intensive
nursing, medical and physiotherapy care. The HDU should be located immediately adjacent to the ED and OD.
Home Inpatient
department
Medical Operating
HDU
imaging department
Emergency
Home department
Figure 20.1 – Patient pathway showing the HDU’s main relations with other departments
The HDU inpatient bed space is based on a generic inpatient bed space; however, owing to the intensity of
care delivery in an HDU, the space around the bed is larger to accommodate additional equipment and enable
more staff to tend to the patient simultaneously. Preferably the bed would be positioned away from the wall
for easy access or on wheels so that it might be pulled away from the wall if necessary.
NOTE: The minimum distance between two beds in a row is two metres.
It is unlikely that patients will be mechanically ventilated in an ICRC HDU; however, the ICRC may support
hospitals which have that capacity.
Figure 20.2 – HDU inpatient bed space – 2 m minimum between beds (measurements in cm)
VARIATIONS ON THE MoC 169
Usually the HDU will be a discrete cluster of individual bed spaces (up to 12, depending on the level of service
provision and human resources available). The cluster will have its own support spaces, separate from other
inpatient areas. The nurses’ station must be positioned so as to overlook all patients.
Hand-
min. 90
wash
bay
Nurses’ Hand-
station wash
bay
Figure 20.3 – HDU inpatient bed space – 2 m minimum between beds (measurements in cm)
The entrances to the HDU should be controlled (one general entrance and one airlock entrance for bed trans-
fers). As in the OD, the same principles of progressive asepsis are applied in this unit.
20.2 OBSTETRICS DEPARTMENT

20.2.1 INTRODUCTION
Obstetrics and gynaecology are concerned with the care of pregnant women and their unborn child and the
management of diseases specific to women. The specialties combine medicine and surgery and include mid-
wives and midwife assistants in addition to, or in instead of, nurses.
The heart of the department is the pre-labour and delivery zone, where women go from pre-labour to de
livery to post-delivery observation. In obstetrics, privacy is a crucial element if a woman is to give birth in
acceptable conditions. Patients may spend many hours in the delivery zone, and culturally appropriate inter
ior design is important for creating a comfortable and soothing atmosphere.
Accommodations are provided before and after delivery. The length of stay depends on the health of the
woman and the unborn or newborn child.
Where obstetrics care is provided as an inpatient service, the department’s relationships with the neonatal
unit and the operating department are key.
Neonatal Obstetrics Operating

unit department department
Figure 20.4 – The obstetrics department’s main relations with other departments
20.2.2 PATIENT PATHWAY

users – patients, staff and others – and prioritize them according to clinical risk and outcome. Obstetrics
beds should be on wheels so an anaesthetist can provide care at the patient’s head if needed.
In the event of newborn’s death, cultural consideration must be made. For example, the family may wish to
take the body directly from the hospital. The mother or other relatives should be offered a private room and
not be directed back to the ward right away.
The table below breaks down the patient pathway. The major functional steps are given along with the corres
ponding spaces and both the patient’s and the staff’s perspectives. The last column on the right summarizes
the questions the design team should always consider before and during the design process.
STEPS OBSTETRICS PATIENT PERSPECTIVE STAFF PERSPECTIVE DESIGN TEAM QUESTIONS

AREAS
Arrival Outside • Scheduled patient coming from home • Staff register patient • Who – what patients?
department, is admitted upon arrival and sent to • Clinical staff prepare • Accessibility?
Zone 1: pre-delivery zone for examination and the various obstetrics • Arrival – How (means) and with whom
Facility preparation or to OD for scheduled spaces prior to patient’s (carers, etc.)?
admission caesarean section (C-section) arrival • How many patients?
points • Unscheduled patient is admitted from • Routes and signs – positioning,
Main entrance facility’s main entrance or ED after language, etc.?
examination and sent to pre-delivery • Entrance and exit unobstructed?
zone, or OD for emergency C-section • Safety and security?
Pre-delivery Zone 6: • Patient is assessed in a consulting room • Staff may examine • Visitors waiting – how and where?
Pre-delivery and then led to pre-delivery space for or otherwise assess • Safety and security? Access to IPD
space observation and preparation before patient upon arrival controlled?
Sanitary delivery • Staff help patient to • Number of nursing staff members?
facilities • As labour progresses, patient may be patient bed space and • Number of obstetrics inpatient bed
Shared spaces moved to the labour/holding area (if explain the pre-delivery spaces?
present) process and next steps • Distance between beds?
• Patient will need access to sanitary • Distance between pre-delivery space
facilities and consideration must be and delivery room?
given to accommodations for relatives • Line of sight between nurses’ station
and bed spaces?
• Relatives waiting – where?
Delivery Zone 6: • Once ready, patient is taken to delivery • Obstetrician, assisted • Number of deliveries per day?
Delivery room room and positioned on delivery table by midwives, helps • Number of nursing staff members and
Sanitary • Baby is born, or mother is transferred to patient to give birth obstetricians?
facilities OD in case of complications • Staff transfer patient to • Number of support spaces?
Shared spaces • Newborns can be resuscitated on site OD by trolley or bed on • Space for walking during labour?
if needed wheels, if needed • Accessibility of labour‑support
• Staff resuscitate equipment?
newborn on site, if • Distance between delivery room and
needed post-delivery observation space?
• Staff prepare the • Clearance around delivery table?
newborn (rinse • Resuscitation area inside delivery
and perhaps dress, room or in independent room shared
depending on local by two delivery rooms?
practice) and give to the • Relatives waiting – where?
mother for the first time • Critical relations with other
departments (OD, ED)?
• Relations with clinical support services
(imaging, laboratory, pharmacy, sterile
services)?
• Extension possible?
• Natural lighting? Air quality?
• Communication system? IT?
• Emergency protocol? Patient
overflow?
Post-delivery Zone 6: • After delivery, mother and newborn • Clinical staff monitor • Diagnostics? Treatment? Observation?
Post-delivery are taken to post-delivery observation the mother and the • Distance between delivery zone and
observation space until approved for transfer to newborn for a period obstetrics hospitalization zone?
space obstetrics inpatient bed spaces for before leading them • Communication and information?
Sanitary further care or discharge to the obstetrics • Referral or transfer?
facilities • Patient will need access to sanitary hospitalization zone • Safety and security?
Shared spaces facilities and accommodations for
relatives must be considered
• If a newborn dies, the body will be taken
to the mortuary or given directly to the
family
STEPS OBSTETRICS PATIENT PERSPECTIVE STAFF PERSPECTIVE DESIGN TEAM QUESTIONS

AREAS
Hospitalization Zones 2, 3 • Mother and baby are sent to obstetrics • Staff have easy access • Number of obstetrics inpatient bed
and 5: hospitalization zone, or to neonatal to incubator space spaces?
Obstetrics unit if the newborn’s health is at risk and room to perform • Number of nursing staff members?
hospitalization (prematurity, need for mechanical clinical and non-clinical • Number of support spaces?
zone ventilation, etc.) activities • Distance between beds?
Sanitary • Staff have easy access • Line of sight between nurses’ station
facilities to hand-wash bays and bed spaces?
Shared spaces • Staff can observe • Accommodations for relatives?
patient bed spaces and • Distance between nurses’ station and
incubators from the support spaces?
nurses’ station • Ratio of total staff area to collaborative
• Staff carry out clinical staff area?
support activities, • Critical relations with other
preparing trolleys and departments (OD, ED)?
medications, delivering • Relations with clinical support services
patients’ meals, (imaging, laboratory, pharmacy, sterile
cleaning, etc. services)?
• Staff provide support • Relations with operational
and help mothers departments (kitchen, laundry)?
with baby care • Flexibility of the ward? Isolation?
(breastfeeding, hygiene, • Extension possible?
etc.) • Natural lighting? Air quality? Outdoor
• Staff have access courtyard?
to the staff zone for • Communication system? IT?
administrative tasks, • Emergency protocol? Patient
meetings, handovers, overflow?
rest • Safety and security?
Discharge – • Mother and baby are admitted to • Staff follow up on the • Discharge – where to, how and with
and follow-up another unit or discharged patient, with a home whom?)
• Mother and baby are followed up on visit if required • Routes and signs?
by medical staff in the following days • Where next?
either at the hospital or at home • How to follow up? How many days?
Table 6 – Obstetrics department patient pathway – patient and staff perspectives and questions for the design team
20.2.3 PATIENT FLOW THROUGH THE DEPARTMENT

The obstetrics department is organized using the same zoning proposed for the generic IPD. However, it has
one additional zone, which is dedicated to labour and delivery activities, including pre- and post-delivery care.
The zones in the obstetrics department are:

2. obstetrics hospitalization zone (including step-down for mothers and babies)
5. mother hygiene and sanitation zone (patient sanitary facilities)
6. pre-delivery and delivery zone (delivery and newborn observation).
In addition to the spaces described in the MoC for a generic IPD, Zone 1 of the obstetrics department includes
a consulting room, where women are assessed upon arrival. After examining the patient, clinical staff will
decide if they need to be admitted to the department and taken either to Zone 6, where the delivery will take
place, or to Zone 2 for hospitalization.
Depending on the location and the caseload, Zone 1 may need a dedicated space for relatives with sanitary
facilities to prevent overcrowding.
CONSULTING ROOM
Scope
This is a space for private consultations and physical examinations.
The room is private, with a table for the patient to lie on and a desk and chair for the doctor or nurse. The examination
table should be away from the wall so staff can access the patient from either side with equipment, e.g. a dressing
trolley. There is a workbench along one wall and an integral sink with cupboards under and over it.
The room may have an ultrasound machine and a gynaecology couch (with a drop section at the foot). There is
an articulated examination light that can be positioned so the doctor can perform vaginal examinations.
Main relationship
FROM main entrance
TO pre-delivery bed spaces
ENTRANCE/EXIT
6
1 Pre-delivery and
Entrance zone delivery zone
Patient arrival Delivery
Newborn observation
3
Support
activities
zone
4
2
Staff clerical
Hospitalization zone
tasks and
Accommodations
Administration
Staff amenities
5
Hygiene and
sanitation zone
Figure 20.5 – Circulation through the obstetrics department during day-to-day execution of the MoC
After a full assessment, if the patient is going to be admitted for labour and delivery she will be taken to a
pre-delivery bed space, which is based on the generic inpatient bed space. (However, beds throughout the
department should be spaced at least two metres apart because of higher-acuity patients and the need for
more equipment and privacy.)
The patient will remain in this space and be monitored until she is taken to the delivery room for delivery. The
number of pre-delivery bed spaces will depend on the facility, including the number of deliveries per month
(workload), but it is likely to be two to four.
Figure 20.6 – Pre-delivery patient bed space – 2 m minimum between beds (measurements in cm)
The consulting room and pre-delivery bed spaces must be in the immediate vicinity of the delivery room and
should have easy access to the OD in case a C-section is required. The delivery room should also be next to
the neonatal unit (if there is one).
Women may lie on the delivery table, and staff and carers must be able to access the patient from either long
sides and from the foot of the bed. The delivery table should not have either long side against a wall. There
should be at least 1.2 metres of clearance on either side of the delivery table and two metres’ clearance at the
foot of the bed.
Operating Pre-delivery Nurses’ Linen

department PATIENT bed space station bay
Consulting Entrance Labour/holding area Patient Hand-wash

room & lobby Delivery room shower room bay
Patient/visitor
Interview Post-delivery Equipment
sanitary facility
room observ. space bay
1 (M/F)
4 3
NEONATAL UNIT/
DISCHARGE

& isolation suites
EXTERNAL 5
CONSULTATION
Figure 20.7 – Spaces and flows in the obstetrics department

DELIVERY ROOM
Scope
The delivery room is an enclosed space set up for women to have uncomplicated and assisted (vacuum, forceps) vaginal
delivery as well as procedures that do not require more than local anaesthesia (e.g. suture of perineal tears).
There must be enough space next to the delivery table for an IV stand and for staff to be able to bring the woman in on
a stretcher and transfer her to the table.
Main relationship
FROM pre-delivery bed spaces
TO post-delivery observation space
Hand-
wash
bay
Figure 20.8 – Delivery room and clearance needed around delivery table (measurements in cm)
The delivery room should include a separate area from the location of the delivery table(s) with enough space
for resuscitating newborns if necessary. During resuscitation, staff must be able to stand at the newborn’s
head and on either side. This space should have its own equipment: a flat surface on which to perform resus-
citation, good lighting and a dressing trolley with resuscitation equipment.
After delivery, the mother and newborn will be taken to the post-delivery bed spaces, which are also based
on the generic inpatient bed space. However, more space is required between each bed to make room for a
newborn bed/cot space, the woman’s personal belongings and the necessary monitoring equipment. Some
procedures, such as blood transfusion or manual vacuum evacuation for the mother, may be undertaken here.
For further care, the newborn may be transferred to the neonatal unit if there is one.
Figure 20.9 – Post-delivery bed spaces for mothers and babies

The patient and her baby will remain in this space under observation until they are taken to the obstetrics
hospitalization zone (Zone 2) for further care, or discharged home. Ideally patients would not have to pass
back through the delivery room upon discharge.
If the health conditions of the newborn are not optimal, they might be transferred to the neonatal unit to be
closely monitored by medical staff there.
The number of post-delivery bed spaces depends on the facility, including the number of deliveries per
month (workload), but it is likely to be two to four.
As mentioned previously, the patient may require hospitalization after delivery and will be taken to Zone 2.
This zone is organized like the generic inpatient hospitalization zone. The only difference is that the patient
bed space is larger as described above (two metres between beds). Also, thought must be given to providing
overnight accommodations for partners or relatives. An isolation suite may also be included in the obstetrics
department.

The patients in Zone 6 will need to be monitored closely, so the nurses’ station needs to overlook the bed
spaces and support spaces, including patient sanitary facilities and the shower room. They need to be close
at hand to allow staff to work efficiently.
Should the unit be small, the nurses’ station and relevant support spaces may be shared by the pre-delivery
bed space(s), delivery room and post-delivery bed space(s). In some situations, there may only be one mid-
wife on duty, so the layout must enable them to go about their activities and observe patients.
In addition to the support spaces in Zone 6, Zone 3 of the obstetrics department contains the same sup-
port spaces as Zone 3 of the generic IPD MoC, which are shared by the whole department. Likewise, Zone 4
remains the staff zone, only accessible to hospital staff.
20.3 NEONATAL UNIT

20.3.1 INTRODUCTION
The neonatal unit provides specialized care 24/7 for sick newborns (babies aged 28 days and under37), irre-
spective of birthweight. Babies in the unit require constant observation and may be premature or have low
birthweight without associated disease, or they may have conditions such as neonatal asphyxia, infections
(including neonatal tetanus) and respiratory distress.
About half of the babies in a neonatal unit are not born prematurely but are ill and need care, such as surgery,
treatment for an infection or light therapy.
The neonatal unit should be located immediately next to the obstetrics department.
Obstetrics Neonatal
department unit
Figure 20.10 – Neonatal unit’s main relation
37 World Health Organization, Newborn Health in the Western Pacific, World Health Organization, Geneva: https://www.
who.int/westernpacific/health-topics/newborn-health, accessed 19 July 2021.
20.3.2 PATIENT PATHWAY

users – patients, staff and others – and prioritize them according to clinical risk and outcome.
The chart below summarizes the major functional steps of the patient pathway through the neonatal unit,
from arrival to discharge to another part of the facility.
• Newborn (with or without mother) arrives at the neonatal unit

from the obstetrics department or operating department after
ARRIVAL AFTER a strict infection control procedure
DELIVERY • Newborn is registered
• Newborn may be examined before being sent to an incubator/cot space

PRE-HOSPITAL in the nursery
IZATION
• Admitted newborn is placed in an incubator/cot at the nursery
for the necessary time
• Mother receives a bed space and locker for personal belongings
HOSPITALIZATION • Newborn gets clinical care from nurses as well as breastfeeding
AND and other care from mother
PRE-EGRESS • Newborn gets visitors, following the hospital’s operational policies
• Newborn and mother go through step-down process after intensive care
here and stay together before discharge
• Adjunctive diagnostics and/or treatment takes place

EXTERNAL • Disposition instructions are given
CONSULTATIONS
• Newborn is admitted to another unit or discharged

DISCHARGE &
• Medical staff follow up for the necessary time after discharge
FOLLOW UP
Figure 20.11 – Main steps of the neonatal unit patient pathway

STEPS NEONATAL UNIT PATIENT PERSPECTIVE STAFF PERSPECTIVE DESIGN TEAM QUESTIONS
AREAS
Arrival Outside neonatal • Newborn arrives in incubator • Staff carry out registration • Who – what patients? How many?
unit: from OD or obstetrics process • Accessibility?
Obstetrics • Mother arrives in a wheelchair or • Porter is able to escort • Arrival – how (means) and with whom
department bed from OD or obstetrics patient on wheelchair/ (carers, etc.)?
Operating • Admitted patients are registered stretcher/patient bed to • Routes and signs – positioning,
department neonatal unit language, etc.?
• Entrance and exit unobstructed?
Pre- Zone 1: Entrance • If the department is meant for • Staff may examine or • Visitors waiting – how and where?
hospitalization Gowning room vulnerable newborns, strict otherwise assess the • Safety and security? Access to
Consulting room infection control procedure is newborn upon arrival department controlled?
followed (gowning room) to • Staff help parents and
prevent nosocomial infection and visitors with the gowning
remind staff and visitors to wash procedure
their hands before contact with
infants
• Upon arrival, mother is assessed
in a consulting room and
newborn is examined
Hospitalization Zones 2, 3 and 5: • Newborn is taken to • Staff have easy access to • Number of bed spaces and cots/
Hospitalization an incubator/cot space; mother incubator/cot space and incubators?
zone is escorted to a bed space, gets enough room to perform • Number of nursing staff members?
Sanitary facilities settled in and stores personal clinical and non-clinical • Number of support spaces, including
Shared spaces belongings in the bedside locker activities those specific to neonatal care (for
• Newborn undergoes clinical care • Staff carry out clinical breastfeeding, autoclaving, laundry,
(diagnosis, treatment, intensive activities in the incubator/ etc.)?
care, rehabilitation, observation) cot space • Relationship between bed spaces for
and may be prepared for • Staff have easy access mothers and nursery?
procedures in another to hand-wash bays • Distance between beds/cots/
department, e.g. the OD • Staff can observe bed incubators
• Mother is encouraged to spaces and incubators/cots • Line of sight between nurses’ station
get involved in infant care from the nurses’ station and bed spaces?
(breastfeeding, kangaroo care, • Staff carry out clinical • Accommodations for relatives?
etc.) support activities, preparing • Distance between nurses; station and
• Newborn and mother are trolleys and medication, support spaces?
accommodated for the length of delivering patients’ meals, • Breastfeeding room – privacy?
their stay, sleeping, resting and cleaning, etc. Procedures? How many mothers?
bathing • Staff provide support and • Critical relations with other
• Patients may receive visitors in help mothers with baby care departments (OD and ED)?
accordance with the hospital’s (breastfeeding, hygiene) • Relations with clinical support services
operational policy • Staff have access to the (imaging, laboratory, pharmacy, sterile
• Prior to discharge and after staff zone for administrative services)?
intensive care, mother and tasks, meetings, handovers, • Relations with operational departments
newborn will stay in observation rest (kitchen, laundry)?
together in the step‑down area • Flexibility of the ward? Isolation?
Extension possible?
• Natural lighting? Air quality? Outdoor
courtyard?
• Communication system? IT?
• Emergency protocol? Patient overflow?
External Imaging • Adjunctive diagnostics and/or • Staff review adjunctive • Diagnostics? Treatment? Observation?
consultations Physiotherapy treatment take place diagnostics and disposition • Communication and information?
• Disposition instructions are given decisions • Referral or transfer?
Discharge • Patients are admitted to another • Staff follow up on the patient • Discharge – where to, how and with
and follow-up unit or discharged with any next steps whom?)
• Patients receive follow-up from • Routes and signs?
medical staff • Where next?
• How to follow up?
Table 7 – Neonatal unit patient pathway – patient and staff perspectives and questions for the design team
20.3.3 PATIENT FLOW THROUGH THE DEPARTMENT

Like the generic IPD, the neonatal unit is divided into five zones:
2. neonatal hospitalization zone (including a step-down area for mothers and babies)
5. mother hygiene and sanitation zone (patient sanitary facilities).
Zone 1 includes a lobby and possibly a waiting area. If the department provides care for vulnerable newborns,
a gowning area at the entrance is required to provide a high level of infection control.
GOWNING AREA
Scope
This area is where staff and visitors don protective clothing (gowns, masks, gloves, etc.) on the way in to the cots/
incubators, and remove the clothing on the way out. Gowning and gloving is necessary if the department is isolated
or meant for intensive care.
There is storage for clean protective clothing, a hand-wash basin (with soap, a hand towel, etc.), a rubbish bin
and a dirty linen skip for used gowns.
Main relationship
FROM main entrance
TO nursery
Type ESSENTIAL Functional space card See card 39
In the entrance zone, there should also be a consulting room for examining infants.
ENTRANCE/EXIT
1
Entrance zone
Patient arrival
Infection control
3
Support
activities
zone
2
4
Neonatal
Staff clerical
hospitalization zone
tasks and
Accommodations
Administration Nursery/step-down
Staff amenities
5
Mother hygiene
and sanitation zone
Figure 20.12 – Circulation in the neonatal unit during day-to-day execution of the MoC
CONSULTING ROOM
Scope
This is a space for private consultations and physical examinations.
The room is private, with a couch for the patient to lie on and a desk and chair for the doctor or nurse. For examinations
of infants, the usual equipment needs to be changed out for equipment and an exam table, etc. for infants. If the room
is large, the examination couch should not be against the wall so the doctor or nurse can access the patient from either
side with equipment, e.g. a dressing trolley.
Main relationship
FROM main entrance
To neonatal hospitalization zone
Newborns will receive care in individual incubator/cot spaces located in Zone 2. Medical, nursing and physio-
therapy care may involve vital signs monitoring, physical examination, blood tests, drug therapy, administra-
tion of inhalers, dressings, physiotherapy exercises, etc. In addition, care for newborns will include feeding,
bathing, changing and weighing them. The incubator/cot spaces will have special equipment; depending on
the services provided in the facility, this may include an incubator, a radiant warmer, equipment for oxygen
therapy and phototherapy, and a range of physiological monitoring and resuscitation equipment.
INCUBATOR/COT SPACE
Scope
The neonatal inpatient incubator/cot space is where the patient lies in an incubator or a cot to receive medical, nursing
and physiotherapy care.
It is preferable for the incubator/cot to have sides. Each incubator/cot must be positioned so that staff and carers can
access the patient from either side: the head of the incubator/cot should be centred, and the long sides should not be
flush to any wall.
Main relationship
TO breastfeeding and expressing room
PATIENT
Consulting Entrance
room & lobby
To waste/laundry/sterile services/
non-medical store/
Gowning
central pharmacy store
area
1
4
Clean utility Medical Disposal
room equipment store room
Cleaner’s Dirty utility Laundry

room room room
3
Side
laboratory
Breastfeeding
and expressing
room Boiling and
Incubator/cot
spaces autoclaving
Linen
bay Clean supply
2 store
Nurses’ Hand-wash
station bay
CONSULTATION
Equipment
EXTERNAL
bay
Step-down
area
Breastfeeding
and expressing
room
Figure 20.13 – Spaces and flows in Zones 2, 3 and 4 of the neonatal unit
Figure 20.14 – Neonatal inpatient incubator/cot space
Most likely, the incubators or cots will have their head against a solid wall and be arranged in a row, with at
least 1.2 or two metres between them to provide access to the patient and prevent the spread of infection. The
precise minimum distances are as follows:
• between isolation incubators/cots – two metres
• between neonatal incubators/cots – 1.2 metres
• between any incubator/cot and a wall – one metre.
When arranged in a row, incubators/cots may be separated for privacy by curtains, solid partitions or portable
screens. Curtains can be pulled back and portable screens removed to enable observation of several patients
at once.
The neonatal inpatient incubator/cot spaces will be arranged in a cluster of eight to 16 incubators and/or
open-care cots (depending on the level of services provided and human resources available) in an area sep-
arate from other inpatients.38
38 In a district hospital, “[a] unit with fewer [than eight] beds becomes unviable and with more than 16 beds becomes
unwieldy …. Consideration of factors such as economies of scale, management, technology and maintenance of
a minimum level clinical experience point towards a minimum capacity of 10 to 12 beds.” UNICEF, Toolkit for Setting up
Special Care Newborn Units, Stabilisation Units and Newborn Care Corners, UNICEF, New York, pp. 4–5.
Hand-
wash
min. 90
bay
Hand-
wash
bay
Nurses’ station Hand-

wash
bay
Figure 20.15 – Neonatal cluster with 16 open-care cots
In addition to the incubator/cot spaces, Zone 2 includes areas for mothers, such as a breastfeeding and
expressing room and a step-down area.
The breastfeeding and expressing room is a comfortable, private room with lockable doors where mothers
may breastfeed their babies and express breast milk using an electric pump provided by the unit. Sterilizing
facilities must be close by. The room should include facilities for hand-washing, a chair and access to a fridge
exclusively for expressed breast milk.
BREASTFEEDING AND EXPRESSING ROOM

Scope
This is a room for mothers to breastfeed under the supervision of a nurse and to express breast milk.
The room must be comfortable and private. It has chairs, a workbench, a sink, a locked cupboard and a fridge. It is
under the supervision of staff at the nurses’ station.
Main relationship
FROM incubator/cot spaces
TO nurses’ station
The step-down area is meant for the treatment and observation of newborns after intensive care, once it
becomes possible to place mother and baby together. In some places, mothers and babies can stay in the
same bed.
STEP-DOWN AREA
Scope
This is a treatment and observation area for newborns coming from intensive care, accompanied by their mothers.
Each module should have space for a patient bed as well as a cot. In rooms with multiple beds, the beds must be at
least two metres apart. There must be enough space around each bed/cot for staff and carers to access the patient
from either side. Only the bedhead should be flush to a wall; neither of the long sides should rest against a wall.
Main relationship
TO incubator/cot spaces
An isolation suite may be provided for infectious cases. As in the HDU, these patients require a higher level
of nursing, medical and physiotherapy care than other infants or children.39
Figure 20.16 – Mother and baby bed space (measurements in cm)

The unit will have its own support spaces, separate from other inpatient areas. The nurses’ station must have
a view of all patients.
In addition to the support spaces found in a generic IPD, the neonatal unit will need a side laboratory, boiling
and autoclaving room, and laundry room
Basic tests are performed in a side laboratory within the department.
39 See 17.3.2, “Patient flow”.

SIDE LABORATORY
Scope
This is a room for performing basic laboratory investigations that require immediate results, e.g. performing tests
for blood gas tensions, electrolytes, glucose, lactate, bilirubin and coagulation.
It is located close to the incubator/cot spaces and includes a specimen fridge, a hand-wash bay, a sharps bin, a bench
and space for a supply trolley.
Main relationship
Functional space card N/A Type ESSENTIAL
Care provided to newborns includes feeding. A space must be provided where parents and nurses may prepare
meals and sterilize receptacles.
BOILING AND AUTOCLAVING ROOM

Scope
This a support space for the kitchen and is where infant formula is prepared and bottles sterilized.
It includes freezer storage for milk/formula and storage for baby bottles, teats, equipment and disposable items.
Main relationship
TO breastfeeding and expressing room
In addition, newborns will need to be changed frequently, so there must be a space where parents and nurses
may wash and dry babies’ clothes.
LAUNDRY ROOM
Scope
This is where baby clothes are washed and dried.
It has a washing machine and dryer, a stainless steel sink and drainer, and a counter with cupboards.
Main relationship
A disposal room should be provided within the unit for holding waste until it is collected by the relevant staff
and transferred in accordance with the hospital operational policy. Within the room, there is an area that is
kept separate from the clean spaces in the room and acts as a collection point for soiled goods.
DISPOSAL ROOM
Scope
This is where clinical waste, general waste, sharps and soiled linen are temporarily held prior to removal.
The room has a hand-wash basin, clinical service sink (optional if the room is only used for holding soiled material),
a work counter and space to separate covered containers. Cleaned and disinfected goods that are not to be used
immediately should be kept away from any soiled surfaces or goods. Cupboards or racks provide good storage.
It is considered a hazardous room.

Main relationship
FROM clinical areas
TO exit
20.4 PAEDIATRIC DEPARTMENT

Paediatrics involves the medical care of infants, children and adolescents.
Paediatric inpatient bed spaces will be based on the generic inpatient bed space. All requirements for the
physical locations of support spaces are the same as for adult wards.
It may be necessary to separate boys and girls in both bedroom and bathroom areas, either physically or
through how the department is organized spatially.
A separate play or school space for children may need to be provided. Depending on the climate, an outdoor
space for children may be suitable, though it must be contained for safety. A multipurpose room can be used
for children’s activities.
20.5 INFECTION UNITS WITHIN AN IPD

Where high numbers of infectious cases are present, a whole ward may be set up as an isolation unit, possibly
in a tent. It must be self-contained, with its own support spaces including WCs and shower facilities. Standard
infection control principles will apply.
20.6 DISCRETE DETAINEE UNIT

All patients who enter the health facility have the right to be treated. Detainees may require full inpatient care
for several days. They will be accompanied by one or more guards from the place of detention, and in some
cases they may be handcuffed to each other.
Any patient visiting a health facility should be treated with dignity and respect. This is especially important
for a patient in custody, as the presence of a security guard or physical restraints, such as handcuffs, will
usually draw unwanted attention to the detainee.
At all times the safety of the detainee inpatient, their guard, hospital staff and other patients and carers must
be accounted for.
20.6.1 SEPARATE IPD FOR DETAINEES

If the hospital has a major place of detention in its catchment area, consideration should be given to provid-
ing a self-contained detainee inpatient space, with two to ten inpatient bed spaces in accordance with local
needs (based on hospital and prison admission data).
20.6.2 CORE CLINICAL SPACES AND SUPPORT SPACES

• Isolation suite (for medical isolation)
• Shared bedroom(s) (for four to six patients) with immediate access to shared WC and shower facilities
• Core clinical support spaces (nurses’ station, storage, medications)
• Single central corridor (for safety and simplicity)
• Arrangement for guards carrying out their duties: chairs and a small table, access to staff sanitary
facilities and shower room, access to a space for breaks, meetings, handovers and drinking water.
20.6.3 SPECIFIC DESIGN FEATURES TO CONSIDER

• There should be treatment spaces which provide acoustic privacy for patients.
• A security guard may be required to observe a patient while they receive treatment and, in some cases,
may be physically shackled to the patient (e.g. with handcuffs). If safe for the detainee inpatient,
other patients and hospital staff, the guard may be able to exit the room and guard it from the door.
There may need to be a viewing panel in the door or a small window through which the guard can keep
an eye on the detainee.
• The windows in the room should prevent escape (i.e. with bars, unbreakable glass or only
a small opening).
• There should be a central single corridor with bedrooms and core clinical support spaces opening onto it.
The ward must be easily securable (with lockable doors).
20.6.4 DETAINEES IN THE REGULAR IPD

When a separate IPD for detainees is not available, a detainee inpatient should, if possible, be accommodated
in a single bedroom in a regular inpatient ward. The bedroom should have its own sanitary facilities and
windows that cannot be broken or opened to facilitate escape (metal bars may be necessary). If the guard is
not required to be in the bedroom with the patient, they should be stationed outside the entrance to the room
with a chair, a small table and access to sanitary facilities, a shower room and drinking water. If no single
bedroom is available, it is recommended to place privacy screens around the patient’s bed.
If a single room is not available, the guard will have to remain at the patient’s bedside. In this scenario, the
patient and guard should be placed at the periphery of the ward, not in the middle.
OVERVIEW OF THE IPDs BY ZONE 189
21. OVERVIEW OF THE IPDs

BY ZONE
21.1 GENERIC IPD BUBBLE DIAGRAM
Legend



supplies

PATIENT
1
IPD entrance
& lobby
Interview Waiting
room area
Multipurpose Non-medical
room store
4
Cleaner’s Dirty utility To waste/laundry/
Staff office room room sterile services
(single-person)
3
Clean utility Medical Non-medical

Staff break
room equipment store store/central
room
pharmacy store
Sterile services/
Staff sanitary central pharmacy
facility (M/F) store
2
Linen
bay
Staff changing Inpatient bed spaces
room (M/F) & isolation suites
Hand-wash
bay
Nurses’ Equipment
station bay
Medical
imaging
5
Physiotherapy
EXTERNAL
CONSULTATION
Figure 21.1 – Generic inpatient department

Figure 21.2 – Zone 1 of the IPD
21.2.1 LEGEND



supplies


Interview room IPD entrance & lobby Multipurpose room
-- Waiting area (optional) --

Upon arrival the patient will either be escorted directly to the hospitalization zone (Zone 2) or stop in Zone 1,
where they, possibly with a relative, will have a private discussion in the interview room with clinical staff.
During the patient’s stay, the multipurpose room will be used for activities such as teaching or health pro-
motion. If the patient’s health is good enough, they may receive visitors in this room in order to keep the
hospitalization zone quiet. The multipurpose room can be considered a living room, so entertainment might
occur there as well.

PATIENT
1 IPD entrance
& lobby
4 3
2
Linen
bay
& isolation suites
Hand-wash
bay
Nurses’ Equipment
station bay
EXTERNAL
CONSULTATION
5 Patient sanitary Patient

21.3.1 LEGEND



supplies

Inpatient bed space Nurses’ station --
Isolation suite Linen bay --
-- Hand-wash bay --
-- Equipment bay --

Zone 2 includes the main core clinical spaces of the department, where the patients will receive clinical and
non-clinical care during their stay. In this zone, the patient will:
• receive clinical care in their inpatient bed space (diagnosis, treatment, observation)
until discharged home or transferred to another department
• possibly, be taken to other departments for further investigation and treatment
(imaging and physiotherapy)
• be accommodated during their stay
• receive visitors according to the hospital’s operational policies
• have access to sanitary facilities.
In Zone 2, all clinical staff not with patients will gather at the nurses’ station, which is the coordination hub
for patient care and writing up patient notes. The position of the nurses’ station is critical and should enable
staff stationed there to observe all inpatient bed spaces and those entering the hospitalization zone. Staff will
have access to the support spaces listed in the table above for clinical activities, in addition to the support
spaces in Zone 3.
1 Non-medical To waste/laundry/
store sterile services
4
Cleaner’s Dirty utility
room room

Sterile
services/
central
2
Linen pharmacy
bay store
& isolation suites
Hand-wash Non-medical
bay store/central
pharmacy store
Nurses’ Equipment
station bay
CONSULTATION
EXTERNAL

21.4.1 LEGEND



supplies

-- Clean utility room --
-- Cleaner’s room --
-- Medical equipment store --
-- Dirty utility room --

Zone 3 contains the support spaces that serve the entire department. Patients should not have access to these
spaces. They can be arranged along a corridor, centralized in a block, positioned side-by-side or spread out
within the department.
The spaces in this zone support both clinical and non-clinical staff in their duties. Nursing staff will prepare
the day’s trolleys here and monitor and replenish stored goods.
Medical equipment frequently used in the core clinical spaces of the IPD will be stored in the medical equip-
ment store. There is also a room for storing housekeeping materials, the cleaner’s room. A dirty utility room
must be provided where reusable materials and linen coming from clinical areas are collected before being
dispatch for cleaning.

STAFF
Interview IPD entrance

room & lobby
Multipurpose
room
1
4 3
Staff office
(single-person)
Staff break
room
2
Staff sanitary Inpatient bed spaces

facility (M/F) & isolation suites
Staff changing
room (M/F)
Nurses’ station
EXTERNAL
CONSULTATION
5

21.5.1 LEGEND



supplies

-- -- Staff office (single-person)
-- -- Staff sanitary facility (M/F)
-- -- Staff changing room (M/F) (optional)
-- -- Staff break room

Zone 4 is dedicated to support spaces for staff. Patients and relatives should not be allowed in staff-only
areas.
A staff office is needed for the clinical staff in charge of running the department. It should be close to the
interview room for discussions with patients and visitors.
Staff will need access to sanitary facilities close to their work place to avoid leaving the department during
their shift. A staff break room is mandatory. There, the staff can take breaks, get some rest and eat during
their shift. Staff might need to use the multipurpose room in Zone 1 for larger meetings or other assorted
activities.

1
4 3

& isolation suites
Nurses’
station
EXTERNAL
CONSULTATION 5
Patient sanitary Patient

21.6.1 LEGEND



supplies

-- Patient shower room Patient sanitary facility (M/F)

Patients in Zone 5 will need access to sanitary facilities and showers. These facilities must be designed to
accommodate people with reduced mobility. Zone 5 should be close to the inpatient bed spaces.
Patients might need partial or full assistance when using these spaces. In such cases, staff will accompany the
patient and provide the necessary support. In some locations, relatives and carers are expected to be respon-
sible for patients’ hygiene. If this is the case, nursing or hygiene staff will brief them on arrival. Additional
rooms may be designed specifically for patients who need full assistance. Finally, Zone 5 must be kept clean.
Patients and relatives will be briefed on this upon arrival; housekeepers will be in charge of general cleaning.
21.7 OBSTETRICS DEPARTMENT

BUBBLE DIAGRAM
Legend



supplies

Operating
department PATIENT
Consulting Entrance Pre-delivery Nurses’ Linen

room & lobby bed space station bay
Interview Waiting Labour/holding area Patient Hand-wash

room area Delivery room shower room bay
Patient/visitor
Multipurpose Post-delivery Equipment
sanitary facility
room observ. space bay
1 (M/F)
4 NEONATAL UNIT /
Cleaner’s Dirty utility DISCHARGE
Staff office room room
(single-person)
3

Staff break
room
Staff sanitary
facility (M/F) To waste/laundry/
2
Linen sterile services
bay non-medical store/
Staff changing Inpatient bed central pharmacy store
room (M/F) spaces & suites
Hand-wash
bay
Nurses’ Equipment
station bay
Medical
imaging
5
Patient sanitary Patient
Physiotherapy
EXTERNAL
CONSULTATION
Figure 21.7 – General view of the obstetrics department

21.8 NEONATAL UNIT BUBBLE DIAGRAM

Legend



supplies

PATIENT
Entrance
& lobby
Consulting Waiting
room area
To waste/laundry/sterile services/
non-medical store/
Gowning
central pharmacy store
area
1
4
Clean utility Medical Disposal
Staff office room equipment store room
(single-person)
Cleaner’s Dirty utility Laundry
room room room
Staff break
room 3
Side
laboratory
Staff sanitary Breastfeeding
facility (M/F) and expressing
room Boiling and
Incubator/cot
spaces autoclaving room
Staff changing
room (M/F) Linen
bay Clean supply
2 store
Nurses’ Hand-wash
station bay
Medical
imaging
Equipment
bay
Step-down
Physiotherapy area
Breastfeeding
and expressing
room
EXTERNAL
CONSULTATION
5
Figure 21.8 – General view of the neonatal unit

The ICRC helps people around the world affected by armed conflict and other violence, doing everything it
can to protect their lives and dignity and to relieve their suffering, often with its Red Cross and Red Crescent
partners. The organization also seeks to prevent hardship by promoting and strengthening humanitarian
law and championing universal humanitarian principles. As the reference on international humanitarian
law, it helps develop this body of law and works for its implementation.
People know they can rely on the ICRC to carry out a range of life-saving activities in conflict zones,
including: supplying food, safe drinking water, sanitation and shelter; providing health care; and helping
to reduce the danger of landmines and unexploded ordnance. It also reunites family members separated
by conflict, and visits people who are detained to ensure they are treated properly. The organization works
closely with communities to understand and meet their needs, using its experience and expertise to respond
quickly and effectively, without taking sides.
facebook.com/icrc
twitter.com/icrc
200
instagram.com/icrc
04.2022
International Committee of the Red Cross

19, avenue de la Paix
1202 Geneva, Switzerland
4389/002
T +41 22 734 60 01
shop.icrc.org
© ICRC, April 2022

Icrc Hospital Design Vol 1

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Icrc Hospital Design Vol 1

Uploaded by

Copyright:

Available Formats

ICRC HOSPITAL DESIGN

3. INTRODUCTION TO THE EMERGENCY DEPARTMENT......................................................................28

4. OUTLINE OF THE MoC......................................................................................................................29

5. DAY-TO-DAY EXECUTION OF THE MoC........................................................................................... 33

7. ADDITIONAL DESIGN CONSIDERATIONS.......................................................................................... 72

8. OVERVIEW OF THE ED BY ZONE....................................................................................................... 77

9. INTRODUCTION TO THE OPERATING DEPARTMENT.......................................................................92

10. OUTLINE OF THE MoC..................................................................................................................... 94

11. DAY-TO-DAY EXECUTION OF THE MoC......................................................................................... 100

12. ADDITIONAL DESIGN CONSIDERATIONS........................................................................................ 123

13. EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT................................................................ 126

14. OVERVIEW OF THE OD BY ZONE..................................................................................................... 128

15. INTRODUCTION TO THE INPATIENT DEPARTMENT...................................................................... 138

16. OUTLINE OF THE MoC.....................................................................................................................141

17. DAY-TO-DAY EXECUTION OF THE MoC FOR A GENERIC IPD.......................................................... 145

18. EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT................................................................ 162

19. ADDITIONAL DESIGN CONSIDERATIONS........................................................................................ 163

20. VARIATIONS ON THE MoC.............................................................................................................. 168

21. OVERVIEW OF THE IPDs BY ZONE.................................................................................................. 189

FIGURES AND TABLES

Federico Sittaro Esperanza Martinez

The essential principles are:

1.1 TARGET AUDIENCE

1.2 WHEN TO USE THESE GUIDELINES

1.3 HOW TO USE THE GUIDELINES

 Ability to affect design

PROJECT PROJECT PREPARATION PROCESS GUIDELINE MODULES

List spaces and

Develop concept Draw up finishing

1.4.1 VOLUME 1: MODELS OF CARE

Staff sanitary Monitoring and (Ambulance/Car)

FAST TRACK (ACUTE CASES)

& triage room

Figure 1.4 – Examples of the MoCs

1.4.2 VOLUME 2: FUNCTIONAL SPACE CATALOGUE

Currently there are 61 cards in the Functional Space Catalogue.

Core clinical Core clinical General support

10.7 AXONOMETRY (1) 10.9 PLAN (1) C

Figure 1.5 – Examples of space cards

From ambulance bay

Note: Equipment is portable;

10.8 MAIN RELATIONSHIP (1) E031

Ambulance bay > Resuscitation room > Operating room E023

0.6 m x 0.6 m grid

1.5 UPDATING THE GUIDELINES

1.6 COMPLEMENTARY RESOURCES

2.2 BUBBLE DIAGRAM KEYS

2.2.1 ZONE KEY

2.2.2 FUNCTIONAL SPACE KEYS

Space accessible to patients

Space accessible to patients (temporary structure)

Optional space accessible to patients

Space accessible to staff only

Optional space accessible to staff only

Optional space accessible to staff and visitors

Aggregation of single spaces

Core clinical spaces

Core clinical support spaces

General support spaces

2.2.3 FLOWS AND CONNECTIONS

Primary flow for patients

Secondary flow for patient

Primary flow for visitors

3. INTRODUCTION TO THE EMERGENCY DEPARTMENT......................................................................28

5. DAY-TO-DAY EXECUTION OF THE MoC........................................................................................... 33

7. ADDITIONAL DESIGN CONSIDERATIONS.......................................................................................... 72

8. OVERVIEW OF THE ED BY ZONE....................................................................................................... 77

9. INTRODUCTION TO THE OPERATING DEPARTMENT.......................................................................92

11. DAY-TO-DAY EXECUTION OF THE MoC......................................................................................... 100

12. ADDITIONAL DESIGN CONSIDERATIONS........................................................................................ 123

13. EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT................................................................ 126

14. OVERVIEW OF THE OD BY ZONE..................................................................................................... 128

15. INTRODUCTION TO THE INPATIENT DEPARTMENT...................................................................... 138

17. DAY-TO-DAY EXECUTION OF THE MoC FOR A GENERIC IPD.......................................................... 145

18. EXECUTING THE MoC IN A MASS-CASUALTY INCIDENT................................................................ 162

19. ADDITIONAL DESIGN CONSIDERATIONS........................................................................................ 163

21. OVERVIEW OF THE IPDs BY ZONE.................................................................................................. 189

5.2 Z ONE 1: SECURITY MONITORING

5.4 Z ONES 3 AND 4: SUB-ACUTE SIDE