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.