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.

Mammography Rooms

A medical equipment planner is a useful resource for knowing the right questions to ask clinicians about equipment in rooms. For architects designing mammography rooms the important first question to ask is: "Will the room also be used for needle biopsy?"

If the answer is yes, you will need to delve a bit deeper to know how to properly size the room. Here is an overview of the 3 variations in mammography room equipment.

The basic diagnostic mammography x-ray unit is a "stand-up" unit, meaning the patient will stand in front of the x-ray unit for the exam. This is the common method of cancer screening for the breasts. If a lump or mass is detected, a biopsy will be taken to determine the type of mass. In the event a biopsy is required, a stereotactic biopsy unit my be used. This allows a needle biopsy to be taken so a lab can test the tissue sample. The needle biopsy is a less invasive process than a surgical biopsy.

There are 2 types of stereotactic biopsy units. The first, is an accessory to the basic mammography X-ray unit. It may be used with the patient in either an upright or prone position. If used in the prone position, it will require additional space for the stretcher to be positioned.

The second type utilizes a special procedure table with a cut-out for the breast. This device requires more space to accommodate the equipment.


For illustration here are some photos for each type:

Diagnostic Mammography X-ray Unit:

Example #1


Example #2

Diagnostic Mammography X-ray Unit with stereotactic biopsy option:

Example #1: Prone


Example #2: Upright

Dedicated Stereotactic biopsy Unit:


The women's health arena continues to evolve, with many new options for breast cancer screening. Be sure to keep open communication with your medical equipment planning consultant to stay abreast of these changes. If you have specific questions or comments, please post them to this blog.

UPDATE MAY 30, 2008: An excellent point was raised in the following comment:

***************
Another important consideration when designing Mammography rooms (or suites) is new digital machines throughput capacity. Digital units are so fast that an area previously designed for analog equipment can now handle twice the number of patients or more. Increased throughput requires re-thinking of reception, interview rooms, waiting, sub-waiting (gowned), dressing rooms and other support spaces. This is due to the fact that exam time slots can now be shorter (two patients every 15 minutes!) and volume is higher. When programming a new facility this is resolved up front. But when upgrading equipment in an existing space, careful consideration should be given to the department as a whole. In hybrid departments (where analog and digital machines are in use) the workload will shift to the digital room (s) creating areas of high and low utilization.

Carlos L. Amato, AIA, ACHA Director of Healthcare Planning, RBB Architects Inc
***************

Mr. Amato offers an excellent point about the impact of technology on departmental throughput. While technology promises "better and faster", the human component of how these faster turn rates are handled in terms of patient queuing and consultation is an important consideration. Thank you for your insight!

PACs Systems and digital imaging

For the past 10 years the evolution of PACs systems have been impacting how medical equipment planners approached the planning of hospitals. These changes started with the shift away from designated dark rooms for x-ray film processing. While that space was reclaimed into the department, additional devices have filled that footprint. Image plate readers and laser printers are able to produce hard copy x-ray films and share these images in a digital format with others without the need for dedicated darkrooms. While the overall space requirement of the equipment has not been reduced, its ability to be in an open lighted area has certainly freed-up space that would otherwise have been dedicated to the darkroom. A healthcare architect should look to a medical equipment planner for insight into trends and technologies that will impact the space requirements of each project. Even if a medical equipment planning consultant is not on-board the project yet, it is a good idea to have firm on retainer to ask questions during the initial space planning and schematic design phases.

To understand the shift from traditional x-ray film to a hospital PACs system, try thinking of a digital camera versus a traditional film camera. The benefit of having your image in a digitized format allows you to share it via the web or other computer network quickly and easily. It is important to note that the PACs system ( Picture Archival and Communication) is a system, not a specific device. There are several components, each having an impact on the cost and efficiency of the overall system.

The goal of digital imaging is to offer much faster access to the images. This speed is represented in 2 ways, first in the acquisition of the image and second, in the sharing of the image.

Step 1 is image acquisition. For this there are 3 possibilities. First, conventional film. Second, CR or computer radiography and third, DR or direct digital radiography.

The analogy of a film camera versus a digital camera is easy for most of us to imagine. In the tradition process, film had to be developed before the image could be seen. In CR, the x-ray image is acquired on a plate and then processed in a "Plate Reader". There is only a slight speed advantage between traditional film processing and CR. Here is a rather fun video that compares traditional film processing to the CR Plate reader method.




You can see from the video that the CR is slightly faster. This method of digitizing the image still requires the plate (The digital imaging version of a memory card) to be inserted into a machine (Plate Reader) to be viewed on a computer screen. By contrast DR, or direct digital radiography, offers instantaneous access to the image. As the x-ray is taken, the image is captured and displayed directly from the x-ray device. In DR, there is no additional step of running a plate though a reader.

An x-ray tech must view the image before the patient can be excused (Usually). This allows them to confirm the x-ray quality was good (Patient position & exposure). With CR, the image is delivered to a monitor after it is passed through a reader. In DR, the image display is instantaneous. This allows the technician to know immediately if the x-ray taken was of sufficient quality to allow the film to be "read" by a radiologist. The patient can be excused and the room prepared for the next patient.

After the acquisition phase, the sharing/distribution/communication of the image will benefit greatly from the digital version of both CR and DR. Rather than needing to hand deliver a developed x-ray film back to the radiologist or tech, the images are available on-screen. This is of tremendous benefit when the referring physician, radiologist, and imaging tech all need copies.

A hard copy x-ray film can be passed though a scanner to become digitized. Today this is common for retrieving old patient x-rays. Typically the x-rays are kept on file for 7 years if an adult and until the age of 21 if a minor. That means there are a lot of hard copy films in storage. Because many of these films (OK, most) are never going to be pulled, it would be a wasteful exercise to convert all of them to digital.

What typically happens is a request to retrieve an old x-ray film is made, the film is pulled and scanned into a digital file. This x-ray film is now a part of the PACs system and can be distributed accordingly. As old x-ray films are no longer required to be stored, they are destroyed and the storage space can be converted to other uses.

So to recap:

Traditional x-ray images were created in film, the film was developed, and the hard copy film was available to be hand delivered or duplicated as needed.

CR, or computed radiography, allowed the x-ray image to be stored on a "Plate" and read into a digital file on the PACs network. The CR system still required the plate to be manually loaded into the device, creating a lag time between the time of the x-ray and when the plate was transported and loaded into the reader.

DR, or direct digital radiography, allows the image to be captured into the PACs system and visible to the tech, radiologist or doctor at the moment the x-ray is taken. This greatly streamlines the process.

Both CR and DR allow the image to be sent via electronic means. The limiting factors are access to a computer and a monitor with sufficient resolution. In most cases, the monitor resolution is only a factor for the radiologist who is looking for very subtle variations, such a cancer screening in mammograms, etc. A broken bone will appear easily on the monitor you are using to view this blog.

The added benefit of PACs is the reduced need for storage of hard copy x-rays. The existing stores of x-ray film are being purged a little more each year as the required holding period for the films expires.

The cost of the technology to acquire, store and share digital x-rays is high as compared to the traditional methods. This meant that the technology was implemented only in the areas where it could be cost justified. The imaging department, ER and ICU were about the only place you might find a PACs viewing monitor or plate reader. Today, the cost of the systems have come down and the original investment in the technology has allowed for a small incremental investment to move the technology into other departments and even off-site locations.

The traditional x-ray viewbox (Illuminator) will eventually be phased out in much the same way as the darkroom has been. As a medical equipment planner, the important task is to understand the clients need at building occupancy, but also in the future. Making sure that there is a clear migration path for PACs stations to replace the x-ray viewboxes is just one example of where medical equipment planning makes a project more efficient. An architect has a tremendous volume of codes, regulations and client expectations for simply designing the 4 walls, floor and ceiling or each room. The medical equipment planners insight into how technology changes will impact the work flow and space requirements is of critical importance. When selecting your medical equipment planner, make certain they are involved early with the architectural design team.

Cath Labs, Angiography Suites, and EP Labs

A medical equipment planner usually finds the more complex areas of the hospital the most interesting to plan.

These 3 rooms are some of the most equipment intensive and expensive areas within a hospital. All 3 rooms are using similar imaging equipment, however the specifics of what these diagnostic studies are used for vary slightly.

In a catheterization laboratory (Or Cath Lab) the emphasis is on the heart and the blood vessels delivering oxygen to the heart muscle. The images generated by the study will allow doctors to visualize if there are any problems in the hearts ability to pump blood or restrictions in the ability to deliver blood to the heart muscle. Here is a brief video explaining the Catheterization procedure:




In an Angiography Suite (Also called Special Procedures or Angio Lab) the focus expands to other parts of the circulatory system. The legs, arms, neck and head are imaged to determine if there are blocked or compromised blood vessels. A corrective procedure, called an angioplasty, can be done to repair a blocked or narrowed vessel. The differences in designing a Cath Lab or an Angio lab are minimal from an architectural perspective. The Cath Lab is focused specifically on the heart, so the patient will be situated on the table with the imaging device focused on the center of the chest. In an Angio suite, the study may be on an arm, leg, or other area of the body, so the imaging table may be extended to allow the part of the body to be underneath the imaging device. It is this "travel" of the imaging table that requires an Angio Suite to have greater freedom of movement. Of critical importance is designing the room to allow full articulation of the imaging table. In an angio suite, the table may be extended and rotated on an angle to best position the patient.

Here is a video of a patients upper right-side. (Imagine the position a patient would have been be in to accommodate this image.)



Another difference between traditional Cath Labs and Angio Suites is the size of the imaging head - called an image intensifier. This is simply the diameter of the video image. Typical sizes of the image intensifier are in 1 inch increments from 7 inches to 16 inches. The smaller sizes are common for Cath Labs, while the larger sizes are common for Angio Labs. While this may seem counter-intuitive (You might think the heart would have the larger view and the arteries a smaller view) the heart has a very defined location and size, so the smaller image-intensifier is adequate. In an Angio procedure, the additional diameter of view allows for the clinicians to view other structures around the suspect vessels. Essentially, it is the ability to see the forest, not just the tree.

Finally there is the EP Lab or Electro-physiology lab. These rooms are specialized in analyzing the electrical signals controlling the heart. When a patient has issues with a fast,slow, or irregular heart rate, the cause may be with the electrical signals being sent to the heart. The EP lab uses sophisticated monitoring equipment to trace and record the path of the electrical signal and allows the clinician to recommend corrective action. These corrective actions may include invasive procedures, such as implanting a pace maker or ablation therapy. Here is a video offering an overview of how electrical signals control the heart. This particular video references using an EKG, not an EP lab, but the explanation of the physiology of the process is excellent.



Here are photos of each type of room. You will find them to be almost identical in view. A large C-arm shaped x-ray device, an imaging table, and several ceiling mounted monitors to allow the clinicians to view the live video, archived, and other reference images.

Cath Lab





Angio Lab





EP Lab




In addition, CT Scanners are being widely used for angio procedures. The broad functionality of CT scanners allows them to deliver a wide variety of images, helping facilities achieve a greater return on investment. Single-function devices, such as a Cath lab or Angio suite require a return-on-investment to justify the cost to purchase and operate. (1 million is the minimum cost to equip a room). Manufacturers will continue to try and expand the range of applications their devices can provide as healthcare providers are tasked with creating greater value for their dollar. CT, MRI and possibly other modalities will continue to be offered as alternatives. Cath/Angio Suite are also common, allowing the same room to be used for both types procedures.

Utilizing your medical equipment planner

Are you working with a medical equipment planner on your project? If so, they can be a valuable resource early in the design process. Too often the equipment planners are relied upon to furnish an equipment report and cutsheets in DD's or CD's, but little in the earlier SD phase.

If you are a "form follows function" person like me, it makes sense to understand what impact the medical equipment may have on the rooms before designing them. The medical equipment technology evolves very rapidly, so your equipment planner may offer insights to help you design a better work flow for both rooms and departments.

When working on projects in the early 1990's the shift from "wet" processing to "dry" processing of x-ray film had a huge impact on facility design. One project in particular had designed a centralized silver recovery system. The architect and engineers had all of the used developer and fixer from 8 darkrooms draining into a centralized holding tank for silver recovery and disposal. It was something that would have served their existing facility very well. However, this system was going to have no benefit to the new facility within a year or two after opening.

The cost of the waste distribution system was to be paid for by the anticipated economies of scale and recouped cost from silver recovery. Unfortunately, these economies were simply never going to be reached. The dry processing technology was well on its way to making both darkrooms and silver-based processing chemicals obsolete. While the project would open its doors with traditional wet processing, these systems were to be replaced very soon afterward.

The centralized system was value-engineered out of the design during CD"s, but a discussion with the equipment planner a few month earlier would have saved thousands of dollars in design fees.

What new trends and technologies might influence your next project?

Patients are getting larger. Bariatric beds require larger door widths, allowing them to be moved in and out of patient rooms. The rising use of ceiling mounted patient lifts is reducing back injuries to staff, but also requires structural support to accommodate both the lift unit and the patient. The heavier the patient, the greater the structural support required. Will your ceilings support 700 pounds? Does it make sense to designate rooms as "future" bariatric rooms and install the structural support in the ceilings now?

PACs is getting more prevalent. Fewer hard copy films mean less need for film archives space. PACs viewers are replacing x-ray view boxes. Requirements for shelving units, carts, and racks to accommodate 11X17 film are greatly reduced in most facilities. Don't just emulate existing space and designs for x-ray film. Develop an understanding of how the facility will digitize hard copy films that are pulled from archives or that accompany a referred patient. The design of customized casework to accommodate these over-sized x-ray film jackets is a waste of time and money in todays environment.

How might your project be affected by the next leap in technology? Ask your medical equipment planning consultant for a list of medical trends and their potential impact on each department. It's a great exercise for educating your project design team and will also help to engage your equipment planner earlier in the project.

Planning Imaging Areas (Non X-Ray)

If my experiences are representative of most medical equipment planners, the design team members who are unfamiliar with all of the imaging modalities may assume that every imaging device uses X-rays. The need to provide shielding for the imaging rooms, even the ones that do not employ x-rays, only reinforces this mistaken belief.

There are in fact several imaging modalities that do NOT use X-rays. MRI uses a combination of magnetic field and radio-frequency waves to create an image; An ultrasound unit uses sound waves; and several devices under the umbrella of "Nuclear Medicine" utilize radioisotopes to create images of the internal structures of the body.

Nuclear Medicine: These machines generate images by detecting the emittance of radioisotopes that have been given to a patient. These radioisotopes can be injected directly, via an IV, or they may be inhaled or ingested. These devices include:
Gamma Camera (Single, Dual or Triple Head)
PET Scanner (Positron Emission Tomography)
SPECT (Single Positron Emission Computed Tomography)

The rest of this blog entry will focus on nuclear medicine imaging. If you are interested in learning more about MRI or Ultrasound, follow these links:
MRI (Magnetic Resonance Imaging) See blog entry for MRI
Ultrasound See blog entry for Ultrasound


Each of these modalities are what I would call "passive" or "listening" devices. They create an image by detecting the signals or activity emitted within the patients body. (MRI and Ultrasound units are covered in greater depth within their respective posts in this blog.) The Nuclear Medicine modalities mentioned above rely upon the rapid decay of radioisotopes to emit energy, which these devices capture to generate an image.

So while an x-ray device will generate x-rays to pass through the body to create the image, these "passive" devices are highly efficient listening devices that detect and capture the activities occurring inside of the body. You could spend a week lying on the table of a gamma camera and it would have no effect on you. So if you were a fan of "The Incredible Hulk" growing up (or still are), you will be relieved to know that undergoing a nuclear medicine test in a gamma camera has zero risk of turning you green or morphing your into a Mr. Universe contestant. It can however affect your mood.

Patient anxiety is common among those undergoing tests for a variety of reasons:
1. They are having a medical test in a hospital.
2. The equipment is large, imposing, and looks similar to that thing that turned Bill Bixby into The Incredible Hulk.
3. The sign on the door has a big "Radiation" symbol on it.

These rooms require radiation shielding to prevent the clinicians, technicians, and other staff from being exposed to the cumulative effects of these low-dose radiation exposures. The patient will either ingest, inhale, or be injected with a radioactive isotope. (The individual dosage level is not dangerous) The room shielding simply addresses the need to shield others from the cumulative effect of repeated exposures. For a nuclear medicine tech, they may see 5-8 patients per day, 5 days per week. So they have the potential for exposure at levels 100 times what a patient receives in their single study. Patients carry the radioisotope in their blood stream, which then exits the patients body via breath or through the skin. As it disperses, the tech and any others in the room will be exposed to trace amounts of radiation. The room shielding simply "holds" these low levels of radiation in the room until its energy is dispersed. Each of these radioisotopes lose their radioactive properties very rapidly.

Most of the radiation exposure that a technician is exposed to is in the "Hot Lab" where the actual dosage of the radioisotope to be given to the patient it prepared. This room has lead-lined cabinets for storage of the radioisotopes, and for disposal of any left-over material in the syringe.

Here are photos of the devices mentioned above:
Positron Emission Tomograpghy (PET)


SPECT Camera


Upright SPECT (Specialized for cardiac studies)


Gamma Camera (Single Head)


Gamma Camera (triple head)


A note about the number of heads on a Gamma Camera:
The number of heads on a gamma camera influences the speed of the image acquisition process. The camera head(s) rotate around the patient, capturing data to create the image. A single head camera must make a 360 degree rotation while a 2-head camera must rotate 180 degrees and a 3-head camera only 120 degrees to capture the same amount of information.

There are also hybrid units that will be discussed in later blogs:
SPECT/CT (SPECT Camera and CT Scanner)
PET/CT (Positron Emission Tomography and CT Scanner)

For each of these imaging modalities, the actual source of the radiation is the radioisotope, not the equipment itself. There are several radioisotopes that are comonly used, each having a specific property that makes it uniquely suited for various studies. The purpose of this blog is to understand the basics of room planning criteria, not the actual science behind how radioisotopes work. If you are interested in learning more about radioisotopes and their uses, visit Wikipedia.

Of great importance to the planner should be an understanding the movement of these radioisotopes through the facility. Some hospitals and clinics have an outside service deliver them on a just-in-time delivery schedule. Others have a cyclotron to manufacturer them on-site. It is important to understand the deliver method and ensure that adequate security, storage and containment is available at every step of the process. A later blog post called "Planning for cyclotrons and radioisotopes" will be dedicated to this subject.

Planning Imaging Areas (X-Ray Units Part II)

Each x-ray device has a unique niche that it fills. Some are specific to imaging a body part, others are used for specific types of studies, and some are generic enough to be used in multiple different situations. It is helpful for anyone working with a medical equipment planner or providing medical equipment planning services to have a good understanding of each. Here is a sampling:

Mammography - Used to x-ray the breast, most often to screen for breast cancer.


Chest Unit - Used to image the chest area ideal for lungs, heart, liver, etc.


General Rad - Used to image the skeletal system (Bones & joints)


Mobile X-Ray Unit - Used for a variety of extremity and chest imaging needs at the patient bedside.


Portable C-arm - Creates a fluoroscopic image.


Flouroscopy (R&F Unit)- Creates a "Live Motion" image using a phosphor plate and an image intensifier to create a video.


CT Scanner - Used to image in 3D by creating "slices". The X-ray tube rotates around the patient and takes multiple x-rays, that are then re-created as a 3D image.


See a video of the internal workings of a CT scanner:

Podiatry - Used to image the foot


Dental - Used to image teeth and jaw


Angio/Cath/EP - These rooms are highly specialized for imaging the heart and vascular system.


Adding the term "digital" to any of these devices simply means that rather than use an x-ray film cassette, the system uses a digital imaging device. Much like traditional film has been largely replaced by digital cameras, the speed and expanded functionality of digital x-ray is changing the way departments are run. You will still find some radiologists who swear by film as a superior method, especially as it relates to mammography, where the subtlety of the image colors can be critical to detection. A quick explanation of why they feel this way may be helpful.

A traditional x-ray film is gathered as x-rays pass through body and strike the x-ray film surface on the other side of the body. It is the "actual" image created by the x-ray. In digital, a conversion process occurs. The x-rays that strike the surface of the digital receptor are converted into a signal that is transferred to a computer screen. It is essentially a series of dots that are each assigned a location in an x/y grid. The concern about digital imaging has been that very subtle variations may not be as clear in a digital image as in a traditional film. There is a a similar argument over the quality of CD's compared to the original pressed vinyl recordings of artists.

The technology has progressed greatly in the past few years, but there are still some who challenge the superiority of digital over film. There is no question that efficiency and lower costs are achieved by using digital imaging techniques to produce and share images among doctors and hospitals.

Planning Imaging Areas (X-Ray Units Part I)

In looking at how to best parse the various imaging modalities: MRI, Nuclear medicine, Ultrasound, etc. I have decided to simply lump all of the x-ray units into one long blog entry. I think doing it this way will accomplish two things: First, it will help make a clear differentiation between x-ray and non-x-ray imaging technologies, and second, it will help to show the variations in x-ray devices. While somewhat remedial for a clinician, a medical equipment planning project will often include team members who are not as well versed in these nuances. The role of a medical equipment planner is to educate the entire design team to the technologies being used. This helps to elevate the overall level of medical planning knowledge.

An x-ray is an x-ray. But there are various types of x-ray units to address different needs. These can be broken into 2 basic groups:

1) Body part(s) to be imaged
2) Portability

When the patient can come to the x-ray unit, the x-ray device and room can be specialized to the type of study or body part. Teeth, Jaw, breast, foot, chest, etc. If the unit comes to the patient, the x-ray unit is more universal: Portable X-ray unit or Mobile C-arm. There are in fact 2 sizes of C-arm, the smaller of the 2 (Mini C-arm) typically used to image limbs (hands, wrists, feet, etc).

Specialty clinics will typically have dedicated rooms and task-specific x-ray units:
Dental office > Dental x-ray unit (Teeth)
Podiatry office > Podiatry x-ray unit (Foot)
Womens Clinic > Mammography X-ray Unit (Breast)
Cardiology Department > Cath Lab (Heart)

The more generic a department patient population, the more universal the x-ray device:
Emergency Departments and Imaging Departments usually share access to multiple imaging rooms:
General Radiographic - Skeletal system
General Rad/Tomography - 3D views of skeletal system
R&F (Radiographic/Fluoroscopic) - Video images and clips of internal structures
CT (Computed Tomography) - 3D images of structures

In addition, the ER usually has access to a portable X-ray and Mobile C-arm when the patient cannot be easily moved, or time is of the essence. More on these distinctions in later blogs...

X-rays are a form of radiation and therefore require the room to be shielded. Lead is the most common form of shielding, due mostly to its density. Using concrete or other shielding substance will greatly increase the thickness of the walls and complicate the design of surrounding rooms. The greater the throughput of the the x-ray device, the greater the cumulative amount of radiation produced. When a patient is having an x-ray, the amount of radiation given at at a single sitting is not dangerous. It is the cumulative exposure over time that is dangerous. Each of us can go in for dental x-rays, a routine chest x-ray, or a visit to the ER if we sprain or break something. These infrequent exposures represent no health risk to us.

The rooms are shielded for the protection of those who work in the vicinity of the room. The offices, exam rooms, conference rooms and staff work areas.

A patient may receive a series x-rays (Usually 1 - 8, but can be more) in a single sitting. The x-ray tech may see 3 - 4 patients per hour over an 8 hour shift. So that would be over 200 exposures per day. Without the lead shielding, the clerk who sits at the desk on the adjacent wall or the family members sitting in the waiting room across the hall would be exposed to these very large cumulative doses. So we are shielding the people who are working, visiting or being cared for in the adjacent areas.

Radiation scatters, so think not only about the 4 walls, but also the floor and ceiling. A licensed physicist will calculate the amount of shielding required, but typically every x-ray room can be shielded with a simple 1/8 inch leaded sheet rock. The critical factor is the installation. Joints, corners, and punch outs need to be installed correctly to avoid any leakage.

The source of all x-rays is an x-ray tube. The tube is housed in an articulating arm, (wall, table or ceiling mounted) or within the unit itself. The other components of an X-ray unit have a specific purpose related to: patient positioning, power generation, or image acquisition.

Patient positioning. X-rays produce images because they pass through bone, tissue and fluid at different rates. Dense structures appear in white and less dense appears in black on the image. The goal of patient positioning is to make the x-rays pass through the patient in a path that will have the least interference to the structure the radiologist wants to view. If you have ever shifted, moved, or repositioned yourself to get a better view of something, you have been "positioning". So standing, laying down, sitting, or otherwise being contorted into the "ideal" position to yield the best image of a bone, organ or structure the radiologist wants to read. The table is the most basic positioning device. These can tilt up, side to side and telescope to allow the technician to move a patient into the ideal position. This articulation requires ample room.

When a design team takes a "department tour" you typically see an imaging table in its flat position. Here is a unit articulated up to a 90 degree position:



Think of a swiss army knife in your pocket. Then think of it with every blade and tool extended. The x-ray room needs to accommodate the table in all of its various extensions. So when you do a walking tour of the department and see the table in its "closed" position, you may not get a sense of the space it needs to move around within. I find that 1 in 5 departments I have visited had at least 1 room with a conflict between the range of motion of the imaging table and 1 of the walls or cabinets.

Power Generation. X-ray tubes require a lot of energy. Most will require a dedicated 480v feed into the power cabinet. From there, the vendors equipment usually steps down the power required for the various other system components - electronics, table, x-ray tube, control panel, etc. There may be floor trenches, wall ducting and cable trays to distribute the power and data lines. Every vendor is a little bit different, so a vendor site-specific drawing is critical to ensure your room is adequately sized and designed. The problem is that technology evolves so quickly and manufacturers have a tendency to leap frog one another every year or so, it is difficult for an administrator or department head to commit to the exact manufacturer and model more than just a few months in advance. This typically leaves the design team and contractor with a dilemma. How to complete the room on schedule. The best alternative I have found is to skip the room until the PO for the X-ray unit is issued. Yes, pouring the floor, working in the ceiling, and hanging leaded dry wall will add some punch list items to your project. But, it will be cheaper than tearing out walls, ceiling and cutting/breaking out new troughs.

Image acquisition. Image acquisition is simply the process of capturing an x-ray image. Traditionally, a film cassette is placed behind the patient. The X-ray tube generates a burst of x-rays that pass through the patient and into the x-ray film cassette. The x-ray film captures the image. The film cassette is placed in a "bucky" or simply leaned up against the patient. A bucky is a device that holds the x-ray film cassette. Today, there are digital x-ray units that have almost eliminated the need for film. The x-ray image is captured digitally in a receptor and processed directly into an image (DR or Direct Radiography) or the image is captured on a phosphorous plate that is read in a "Plate Reader". Think of a phosphor plate as a high-tech "Etch-a-sketch".

The plate reader converts the image into digital format, then clears the phosphor plate. These plates are re-used many times before needing to be replaced.

Here is a wall bucky:


Here is a plate reader:


Here is a laser imager:


The plate readers and laser imagers are now an integral part of the image acquisition process. Fewer and fewer "wet processing" systems are in use. "Wet processing" is the catch-all term for traditional x-ray film processing that involves the use of chemicals (developer & fixer) and film processors in a dark room.

No less important in all of this is the image viewer. The image viewer is a high definition computer monitor. It displays the x-ray image and allows the operator to zoom, edit and make adjustments to make the image much easier to view. These have taken the place of x-ray view boxes (Illuminators), which were used to view hard copy x-rays.

Here is a PACs Viewer (Top) and PACS reading station (Bottom):

Planning Ultrasound Rooms

Ultrasound is a diagnostic tool that has evolved greatly in the past 5 years. The systems have branched into 2 primary types: Abdominal and Vascular. The same units can accomplish either procedure, however different software and probes are used. The most common procedure is the fetal ultrasound, used to visualize the fetus of a pregnant mother.

Medical equipment planners can help design a space but offering the design team insight into the use and function of the technology.

I will start with a review of the abdominal ultrasound:

The ultrasound unit is roughly 3/4 the height of a domestic refrigerator and about the same width and depth. There are also very small hand-held units available, but the traditional sized machines are still the primary workhorse in both hospital and outpatient settings. The features and capabilities have grown more robust in a number of ways. The range of options now includes 2D, 3D, and 4D visualization software. There are various probes (The scanning instrument that is tethered to the unit) are also more varied, with each probe "tuned" to scan different body parts and organs.

Here is a video offering some perspective on the use and 2D, 3D and 4D ultrasound.



In addition to fetal ultrasound, the liver, kidneys, and other abdominal structures can be imaged.

With all of these technological enhancements, the requirements for the room itself have remained largely unchanged.

A room that is dedicated to abdominal ultrasound should have the following:
1. An easily darkened room. Any exterior windows should have curtains or blinds capable of being drawn. The room lighting should be on dimmers or switched to allow the lighting to be reduced by at least 70% or more. This allows the monitor to be more easily viewed by both the ultrasound technician and the others.

2. Easy access to a bathroom. For fetal ultrasounds, the patient (Pregnant mom) is asked to drink about 1 litre of water prior to the ultrasound. This fills the bladder and helps to produce a sharper image. The patient is asked to "hold it" for the ultrasound, but will want to use the bathroom almost immediately afterward.

3. Room for family members. Ultrasound is a diagnostic test that produces no x-rays and uses no contrast agents, so a family member can easily accompany the patient into the exam room. An exam table or stretcher is usually placed in the center of the room. While this allows 360 degree access around the patient, the primary reason for this configuration is it allows the ultrasound unit and operator to occupy the space to the right-side of the patient and the left side is available for a family member to stand and view the ultrasound. It also allows easy access for the patient.

4. A remote video monitor placement. The monitor on the ultrasound unit is for the ultrasound technician to use. It may be in a bad location to be viewed by the patient or the family members. A hard copy image is usually printed for the patient to take with them, but it is preferred to allow the others in the room to have easy viewing access. A ceiling or wall mounted video monitor will allow easy viewing and avoid any issues with the patient moving around to view the image or any family member leaning into the technician's "comfort space" to get a closer look.

Vascular Ultrasound:
Physically there is very little difference about an ultrasound unit used for vascular procedures. A vascular ultrasound will look at the structure and blood flow within the heart, the specific valves and chambers of the heart, as well as the veins and arteries that make up the circulatory system. Common ultrasound procedures include the neck, leg and heart. An ultrasound study of the heart is called an echo cardiogram. These are often done using what is called a "stress" test.

The stress test simply refers to elevating the patients heart rate prior of the study. There are two types of stress test: An exercise stress (The patient walks on a treadmill or up and down a small fight of stairs) or a Pharma stress (The patient is given an injection that increases their heart rate.) The pharma stress is used if the patient is physically unable to walk or exercises to increase their heart rate.

In the exercise stress test, the patient immediately moves from the treadmill to a stretcher and lay's down. The technician will conduct the echo (ultrasound) while the heart rate is still elevated to determine if the heart is pumping blood efficiently. The layout of the room is important as the room needs to accommodate the patient, the technician, the ultrasound unit, stretcher, treadmill and EKG unit. This makes for a crowded room! The patient is tethered to the EKG unit with leads that are connected to the EKG machine as they are walking on the treadmill. After reaching the desired heart rate, the patient needs a clear path to the stretcher to lay down.

The room design for a vascular study can ignore the need for bathroom access mentioned in the fetal ultrasound section. The patient is not required to drink water for these procedures. However the space requirements within the room are greater.

Here is a video of what an ultrasound unit looks like. Nothing too interesting about it, but you will see if from variety of angles and perspectives.



You may have noticed from the first video that there is gel applied to the patient. This accomplishes 2 things: Allows the probe to glide smoothly across the skin and also creates a "good connection" for the probe to transfer data across the patients skin. The room will usually have a "gel warmer" which is a small container used to warm the gel to a comfortable temperature. The elevated temperature makes the gel more fluid and offers greater comfort of the patient. (Nobody likes something cold applied to their skin.)

Finally, the introduction of very small handheld units have evolved to cater to the "bedside" ultrasound market. These units are designed to be light and easily carried from room to room. I would call them ultra-portable. They have less features and are not replacements for the full-size units.