Piped Medical Systems

Understanding the piped medical delivery systems in your facility is a great opportunity to familiarize yourself with all of the various components that create these "systems". Depending upon your frame of reference, the "start" and "end" of these systems will vary from the clinician's perspective and a contractors point of view. To a nurse, the system starts at the patient location. To an engineer or contractor, the mechanical room is the "starting" location.

As a rule, I try to organize my thinking around patient care being the driver of all needs. Therefore, I will discuss these systems as starting at the patient location and ending in the associated mechanical rooms or storage locations.

Piped Medical Systems Include:
Medical Gasses: Pressurized gasses distributed from a central location.
Vacuum/Suction: Centralized suction pump(s).

Depending upon the type of care and acuity level, the gas and suction requirements will vary from department to department and room to room. Some of these needs are driven by code, while others are staff preferences.


Medical Gasses:
Oxygen - Provides oxygen to patients.
Medical Air - Used to blend with oxygen or to power some devices.
Nitrous Oxide - Used in operating rooms to anesthetize a patient.
Nitrogen - Used in some rooms to power pneumatic instruments/brakes.
Compressed Air - Used to power pneumatic instruments/brakes or to clean instruments.

Vacuum/Suction:
Medical Suction - Provides a vacuum to draw fluids away from the patient into a collection canister.
Dental Suction - Provides a vacuum to draw fluids away from the patient into a central collection point.
Waste Anesthesia Gas - Provides a vacuum to remove exhausted anesthetic agents by the patient from the room.

Most gasses and suction outlets are provided with a flowmeter or regulator to regulate the flow or strength. Others are simply turned on or off.

Post #1: Oxygen and Medical Air at the patient side

Oxygen is delivered to the patient with a flowmeter controlling the volume of oxygen delivered to the patient. This is measured in LPM or liters per minute. For adults, the most common flowmeters are adjustable from 0 - 15 LPM. For infants, they use "low-flow" flowmeters that allow the flow to be regulated in much smaller increments. These can be commonly found in 0-3 LMP or 0-8 LMP. It is important to note that the flowmeter is controlling the flow volume, so the exact same gas system can deliver the oxygen to both adult and infant areas. The mechanical engineer is responsible for sizing the system to ensure there is proper capacity to support all locations and any anticipated future growth.

The flowmeters look almost identical, except this low flow offers increments of 0 - 3 LPM. (Increments of measure vary by manufacturer and model)




The more common "adult" version offers 0-15 LMP adjustment indicators:



From both of these types of flowmeters, plastic tubing will connect to either a nasal cannula or oxygen mask to provide the oxygen to the patient. Oxygen is expensive and flammable, so for both financial and safety reasons, the delivery of oxygen must be as efficient as possible.

Nasal Cannula:



Oxygen Mask:



Medical Air:
The system for medical air is identical, except medical air is less common. Today medical air is only used to blend air with oxygen for infants or in ventilators. Therefore, most patient locations that offer oxygen do not offer air.

An air flowmeter looks identical to an Oxygen flowmeter, except the color is standardized for easy differentiation. Oxygen is green and Air is yellow.





As a recap, the air and oxygen from a piped medical system is regulated at the patient location with a flowmeter and delivered using a mask or nasal cannula. A hose connects from the patient (Using a mask or nasal cannula) to the flowmeter. THe flowmeter attaches directly to a medical gas outlet. (More on this in my next post)

The tubing, masks and cannula are disposable. Therefore another consideration when designing the room is the convenient storage of these disposable products. It is common to see additional sets of tubing and nasal cannula wedged behind the flowmeter as a storage method.




While this is convenient, it can be unattractive and lead to items falling on the floor. Using a drawer in a bedside cabinet or wall mounted baskets are a better option in my opinion.

Wall mounted Storage Basket Option:



Bedside Cabinet for storing disposable supplies:





Our next post will discuss the medical gas outlets and all of the various configurations available.

A place for everything and everything in its place.

Every now and then an equipment planner will come across someone even more anal retentive than themselves. But not very often. We can rattle off: Water, steam, drain, vent, gas, vac, data, volts, watts, amps, BTU's like some frat boy reciting the Greek alphabet during pledge week.

So after months specifying the "perfect" compliment of equipment; identifying alcoves for every stretcher, wheelchair and C-arm; and coordinating the infrastructure requirements with the electrical and mechanical engineers, we expect everything to be perfect.

So when I get a call that the lead apron racks are pulling out from the walls in two locations on a recent project, I'm not too happy.

We'll it turns our that the "perfect" location that was planned for them was changed to a new location. (This can happen when you're not on-site to supervise the installation.) So now I'm standing in the sub-sterile room looking at 4 holes in the wall, a dusting of drywall powder on the floor and about 80 pounds of lead aprons clumped together like a 5th graders laundry pile. The lead apron rack has been neatly leaned up against a wall, clearly identifying it as the culprit to this mess.

"Why didn't you put the bracket where it was shown on the plans? Where all of the backing is?" I ask. "We wanted it over here." Is the response...

I can feel the urge for sarcasm growing in me. But, instead I take a few dimensions and go order a custom wall plate. It spans two studs and allows the apron rack to be installed in the new location with ample wall support to keep it from ripping through the drywall again.

My take-away from this little exercise is a mental note to start having the contractor provide wall backing in both a primary AND a secondary location when there is the potential to have more than 1 mounting location. In addition, I'll start suggesting that wall backing span 4 studs. The additional construction cost is minimal and will allow for much greater flexibility when the staff who actually occupies the space wants to give their personal touch to the configuration.

For items such as ice makers and televisions, there are several utilities that help to identify the mounting location. (Electrical, data, plumbing, etc.) But, there are some items that will offer no clear indication of where they are to be mounted without looking at a layout drawing. (Like lead apron racks for example.)

When you are planning your project, make certain you take into account the opportunity for flexibility. An artificial sense of needing to have only 1 "correct" way to do things can come back to haunt you when other opinions enter the picture.

For Example:

A wall like this, with many utility connections, the opportunities are limited for placing wall backing.



But, if you have a large empty wall, go ahead and put backing in a large enough area to allow for some flexibility. The larger the area with backing, the more opportunity to allow alternative configurations.



Don't go crazy with it, but certainly consider the benefit of allowing the facility staff to configure to their liking. As an architect or planner, we are typically only around until the ribbon cutting ceremony. Give those that get to use the space in years 2 - 30 some options for using it the way they want to. Even if your way really is better : )

What to do when construction slows down

I read an article today that mentioned an interesting (If not a bit scary) statistic. According to the American Hospital Association, 56 percent of recently surveyed hospitals were reconsidering or postponing large construction projects. In the short-term that is bad for architects, contractors and equipment vendors. When the economy recovers, it means that there will be the need to re-confirm the planning assumptions used. What changed in terms of population, competition and technology?

The medical equipment list will need to be reviewed for the same reasons as the design of the space. Here are a few areas to focus your review:

1) Save money by not spending it. Re-examine opportunities to re-use existing items. If your new project was delayed, the Doc's likely kept on begging for that new ultrasound, laser, or OR tables. You might find that this year's annual budget was spent reducing the need for purchases on your new project.

2) Commit early for better pricing. As we all know, equipment vendors are focused on hitting their quarterly numbers. This slow down will have a very negative effect on them. When your project is back on the front burner, vendors will be looking to get revenues flowing again. If you have a high confidence level in your project completion date, you should be able to negotiate a better price if you commit in an earlier quarter than you would have otherwise. Ask for the deal. Any VP of Sales knows that locking out the competition is worth a few points. Even better, call your GPO and push them to organize a group buy for the big ticket items you need. As a side bonus, the contractor will love you because there won't be any last minute change orders. (Or at least fewer!).

3) Sit down with the architect. Go through the plans and get an understanding of what changed and why. Sometimes changes that meant little to the architect my offer an opportunity to alter the equipment list. For example, many clients will shell some spaces to allow for future expansion. You can easily eliminate the equipment from those rooms. But if you drop from ten LDR's to 4, can you still justify a dedicated ultrasound? Maybe they share with Imaging for another year.


Worried you won't be around when the project is re-started? Suggest new ways for your expertise to be used. In any downturn, the focus turns to cost-cutting. If you have enough experience to know what is broken in the system, do you have the expertise to fix it? Submit a proposal to improve the utilization of equipment, streamline the capital purchasing process, develop facility standards or move a paper process into an electronic process. If the facility is not spending capital dollars, the C-suite might be willing to spend operational dollars to effect cost-savings when the spigot opens again.

If you have other suggestions, or a comment on these first few suggestions, we'd like to hear from you.

Planning for Bariatric Patients

I received an e-mail requesting some insight into a SPECT camera capable of accepting a patient who weighs over 360 pounds (165kg). This got me thinking about the very narrow (no pun intended) focus that manufacturers offer bariatric patients in the area of medical equipment.

Beds, lifts, scales and wheelchairs represent almost all of the medical equipment designed for patients over 300 lbs. CT, MRI, Gamma Cameras and other diagnostic modalities are completely lacking in their ability to accept a patient of significant size. Most OR tables, exam tables and stretchers are rated up to 400 pounds, but they do not offer the width to support the patients size, making the stretchers side rails useless. Exam tables are difficult to "hop up onto" and few of the hi-lo tables are functional over 400 lbs. Rather than design for the size of a bariatric patient, many manufacturers have taken a literal interpretation of the request for a table that will support up to 650 pounds.

Here is an example of two different manufacturers take of bariatric exam tables:







As you can see, one offered a well thought out solution to the patient while one kept their original design and simply increased the weight capacity. If you are planning a department for patients in the 400 - 650lb. range, make sure you do more than just request a higher weight capacity. Make certain the equipment is functionally appropriate for the size and mobility limitations of your patients.

For the architects, you will need to size doors to accommodate the wider wheelchairs. A standard 3 foot door will not accommodate the larger transportation equipment. This bariatric transport chair is 41 inches wide, but even a 42 inch door is too narrow when you add the door and a push bar.



4 foot doors are needed for egress from the exam area all the way to the parking lot. Make sure you have a clear path into the department without any bottlenecks. Unless the obesity trend beings to reverse itself, the future holds even greater demand for specialized equipment to diagnose, treat and care for bariatric patients. If your project will be designed and equipped for bariatric patients, make certain you take the time to do it right.

Ambulatory Surgery Centers

The two biggest issues I run into on surgery centers are:
1) Coordination between equipment and infrastructure needs.
2) User-initiated changes during the procurement process.

There are a lot of things going on in the walls and ceiling of a surgery project. Duct work, medical gases, electrical, plumbing, cable trays, etc. Trying to install the medical equipment can be an arduous process in itself. When you discover a coordination issue such as a missing electrical outlet, missing back flow prevention device, or an item that required either dedicated or emergency power; that cramped space in the walls and ceiling can make resolution a real headache. And having user-generated changes can really throw a wrench into the works.

Here is a sequence of photos showing the ceiling of an OR being installed over the span of 5 weeks. Image how much easier it is to make a change in the ceiling during week 1 than in week 5.

Week 1


Week 2



Week 3



Week 5


While it is frustrating for the architect, engineers and contractor to have changes to the manufacturer and model of the medical equipment, it is important to understand that medical equipment technology changes rapidly. The devices that were specified in the year or two ago since design development have likely been replaced by newer and better offerings. If you’re project is in California, design development might have been 3 or 4 years ago. Change happens.

The best solution is to closely monitor these issues. Be diligent. Involve your equipment planner in the plan review process. I find that too often, the engineers are designing the electrical, plumbing and mechanical for equipment that they do not understand. It is always beneficial to have the equipment planner, or the vendor do a plan review to make sure all the requirements are shown on the plans. A purchasing agent, materials manager, or clinician is NOT going to have the expertise or comfort level to do a plan review. Be sure to use someone knowledgeable about both the equipment and reading architectural plans - especially the mechanical, electrical and plumbing.

Next, be proactive. Request that someone from the project team be on the list to review all PO’s before approval. They don’t need the authority to approve or reject anything, but they should offer input on any cost impact for making each purchase.

Here are a few examples:

OR lights
Each manufacturer has a slightly different approach to power. Some have a remote power transformer that mounts above the ceiling. Some have a remote power transformer that can be installed in the room within casework or on a shelf. A few offer units integrated into their wall mounted dimmer control. So a change from vendor A to vendor B will impact conduit runs and electrical locations.

Medical gas connections
Typically the mechanical contractor will supply the medical gas wall outlets, if a head wall system is used, the facility may purchase it. In either situation, the gas flow meters and suction regulators are almost always purchased from a different vendor. Making certain that the connection types match is a simple, yet too often they are missed as part of the coordination process.

Under counter appliances
Three letters, ADA, have made under counter dishwashers, refrigerators and ice makers a coordination headache. Because of the lower counter heights in ADA compatible areas, the space tolerances for these appliances are minimal. A waterfall edge on a counter or the thickness of carpet can be the difference between a tight fit and no fit at all.

The cost of this coordination is minuscule compared to the cost of the potential change orders that can be avoided. In this endeavor, timing is everything. When the project team knows about a change with enough time to add the outlet, move the conduit, or pull the right wire, the project saves substantial cost. If these changes are noticed on installation day, when the walls are painted and everything is trimmed out, the cost goes up significantly.

Imagine the time and effort to try and work in these spaces to make changes or add new services:

Conduit and Duct Work:



Med Gasses and duck work:



Cable tray, Duct work and Fire sprinklers:




Cryogen Vent and Duct Work


Equipment planners define budgets and equipment requirements in the design stages of a project. Make certain that you involve them all the way through to occupancy to avoid the perils of equipment–related change orders. Keeping your project on schedule and on budget is always easier when you have information in a timely manner and the opportunity to make educated decisions.

Chemotherapy

My initial 3 posts on Cancer Centers focused on radiation therapy. The linear accelerator, brachytherapy and a few of the more unique radiation treatment systems (The Gamma Knife and The Cyber Knife). These devices require rooms that are equipment intensive and require shielding to contain the radiation.

By contrast, chemotherapy allows a very open room design concept. The terms infusion therapy, chemo, and oncology are used interchangeably. They refer to an additional form of cancer treatment. Sometimes used as the primary treatment, but typically used in concert with radiation therapy. Chemotherapy or "Chemo" is normally delivered as an IV fluid. The chemicals are harsh on the patients system, but they are not radioactive. However, just as in radiation treatment, the treatment attacks healthy cells in addition to the cancer cells. Hair loss, weakness, vomiting and a host of other adverse side-effects are created for the patient.

The chemo treatment typically involves being hooked to an IV for 90 minutes. (There are also some inhaled treatments, but this delivery method is rare.) Depending upon the patient, this duration may be longer or shorter. The patient population is varied. Age, sex, weight, health, etc. cover all extremes. Improved cancer screening and detection means otherwise healthy patients are being treated along side very weak and frail patients. The very sick inpatients may receive a chemo treatment in their hospital room. Typically both inpatient and outpatients are intermingled in the chemo area.

Patients normally sit in a recliner chair.

When planning for a chemotherapy area, there are several factors the design team should keep in mind:

1) Patient comfort
Most IV therapy areas are "communal" in nature. The patients are able to see each other and interact. A warming cabinet to provide a warm blanket to patients who are cold will allow the room temperature to be kept at a more moderate temperature. With weight loss and frailty, the ability to maintain body heat is marginalized. A comfortable seat, comfortable temperature and a choice on their individual level of privacy are important.




2) Patient Sensitivities
There are many adverse side-effects to chemo therapy. Among them are sensitivities to certain smells and reduced immune function. As best as possible the space should remain free of odors and fragrances. That means no microwave for popping popcorn or coffee pots for making coffee. The environmental services crew (Housekeeping) will sometimes use different cleaning solvents in the area to minimize any lingering smell. It is a good idea to plan the room air changes beyond the code minimum. I believe the recommended room air change rate is 12 per hour. This also helps to avoid cross infection of patients who might otherwise come in contact with an airborne virus or bacteria.


3) Patient Entertainment
In this age of ipods and video games, a 90 minute chemo session can be passed more easily with a personal entertainment device. A common area TV is difficult to view when cubicle curtains are in the way. An individual TV with pillow speaker is the ideal. Patients should also have the option of bringing their own headphones and media players.



4) Materials
In a new facility, that new carpet smell can be nauseating for some patients. Take care in selecting your flooring, paint and fabrics to minimize passive emissions. With the green movement in full-swing, talking to your vendors should reveal some products to meet these requirements.


Creating an environment that is comfortable and accommodating to varying patient needs is the goal.

Samples:

Here is a chemo infusion area looking rather clinical:





Here is another one with a more pleasing aesthetic feel.





Here is a virtual walk-thru of a very nice infusion area. I doubt very many projects could afford this.

No matter your budget or patient population, if you are planning an oncology area and do not have hands-on clinical experience it is a good idea to spend some time on a site tour to get a feel for the space.

Cyber Knife, Gamma Knife and others

In addition to the more typical linear accelerator and brachytherapy unit designs, there are also radiation treatment units offering a unique design approach. Two of these are:

The Cyber Knife (Manufactured by Accuray) which uses a robotic arm and highly sophisticated 3D planning software to offer full body treatment. Here is a video overview of the system. You can see that the robot arm and patient gantry move to achieve the best access to the tumor.




Gamma Knife (Manufactured by Elekta), specializing in brain tumors. The system uses about 200 low-dose beams of energy to focus on the brain tumor. This allows the healthy brain surrounding the tumor to receive a low-dose of radiation and the tumor to receive the combined energy of all the beams.

Here is the manufacturers video about one of their 3 current models:




The design of all these systems are unique because their inventors have taken different approaches to building their mouse-trap. The ultimate goal is the same: Deliver a lethal dose of radiation to the tumor, while minimizing damage to the surrounding healthy tissue.

For each of these devices, the room shielding requirements are similar to conventional Linear accellerators. Please view the previous Linac post for details.

Brachytherapy

Brachytherapy is an umbrella term used to describe three forms of radiation delivery: High Dose Rate, Low Dose Rate and Pulsed Dose Rate. These are all delivered via a machine frequently referred to as an "afterloader". So the terms brachytherapy and afterloader therapy are interchangeable.

The three deliver methods are simply variations in the strength and frequency of the dose. HDR (High Dose), LDR (Low Dose) and PDR (Pulsed Dose).







In brachytherapy, the patient and afterloader are placed into a lead shielded room. The afterloader contains a radiation source that is safely contained within an integral lead container. Tubes are connected between the patient and the afterloader to allow wires to feed the radiation source from the afterloader to the cancerous area in the patient. Brachytherapy is common in brain, prostate, cervical and many other types of other cancers.


The planning criteria for the room includes the following:
1. The room must be shielded to prevent radiation exposure to the adjacent areas. (Walls, floor and ceiling).

2. Both audio and video communication are used to maintain surveillance and communication between the patient and the technician. A CCTV camera and an intercom are used.

3. The afterloader is typically housed in a lead lined room in the oncology department or cancer center and transported to the patient.

Brachytherapy can occur in a lead-lined patient room or within a specialized room designed specifically for brachytherapy. If available, a linac vault can also be used. The ability to contain the radiation within the room, allow the staff to maintain visual and audio communication, and allow the transport of the afterloader from its "home" to the treatment space are the key design criteria.

Cancer Center

Cancer centers, as the name implies are focused on the treatment of cancer. Once a cancer diagnoses is made, the size, type and location of the cancer will determine the treatment regimen. (Other factors, such as the patients age and health will also weigh heavily on the treatment options.)

Most treatment plans offer a combination of surgery and one or more treatment options. (For purposes of this post, I will focus on the treatments that occur outside of the OR. A future post on Operating Rooms will cover the design implications in the modern OR.)

Categories of Cancer Treatment options include:
Radiation treatment involves the use of radioactive energy beams, implantable "seeds", and other sources of direct delivery of radiation to the location of the tumor.

Chemotherapy is a pharmacological treatment method, using a "cocktail" of medications to eradicate the cancer cells or stifle its growth.

The most common radiation treatment device is a linear accelerator or "Linac". The linear accelerator generates a high energy x-ray beam. This treatment method seeks to bombard the tumor with radiation in an effort to kill the cancer cells. The room housing the linac must keep the radiation contained, preventing any exposure to surrounding areas. The room is typically called a "vault" or "maze". The term vault comes from the similarity of its construction to a bank vault. Thick walls of concrete, lead and/or boron are used to prevent the radiation from escaping. The design is maze like in an effort to keep the scatter radiation from having a direct path to the vault door.

Here are two videos of a linac, one is animated and the other shows the range of motion of an actual unit. In the second video, note that the gantry (table) would normally have the patient positioned at the axis of the rotation.








The patient is in the room alone during treatment. The massive door is shut and the technician will maintain communication with an intercom and a video feed into the room. All radiation dissipates immediately after the device is shut off and the staff can enter the room.

In contrast the the environment of the Linac, chemotherapy is typically delivered in a communal area, such are a room of recliner chairs. The patients are free to interact if they wish during their treatment. Chemotherapy is delivered intravenously. An IV bag and/or infusion pump will deliver the chemo chemicals into the bloodstream. Here is a video describing cancer and chemotherapy.



In future posts, we will explore the varieties of radiation treatment (Brachytherapy, Gamma Knife, Cyber Knife, and seed therapy).

Outpatient Focus for the Summer

My editorial calendar changes each season and Summer is time to focus on outpatient areas. This offers a broad range of topics to discuss, so I expect my volume of posts will increase. Summer break was the time of year when elective surgeries seemed to increase among my family and friends. Once school was out there was more flexibility in the schedule. It also meant that there were fewer school related activities to get in the way of rehab and follow-up appointments.

A new poll is posted, so please feel free to suggest areas of emphasis - Surgery, physical therapy, oncology, etc. This blog is a chance to share the types of information you need most, so please suggest the best areas to focus upon.