INDIAN HEALTH CARE INDUSTRY

35 Billion dollars a 10% growth every year Employees about 4 million people An additional 2 million beds to be added to existing 1.1 million costing 82 billion dollars Tertiary care growing at Faster rate 0.91 GDP expected, to touch 2% GDP Refurbish units and Foreign investments. Banks assisting medical technologies at about 5 billion dollars with an increase another 2 billion dollars Health city concepts Bed Space : Conventional 50 Sqm Specialization 70 Sqm Futuristic 135 Sqm

HOSPITAL PLANNING
I. Viability and Feasibility: 1The type of services to be provided-secondary care / tertiary care Sophistication in building plan & equipments Investments & returns he is looking for Feasibility : The potent ional of the planned institution The medical facilities that are made available The migration pattern of the patients Competition from the existing hospitals and new entrants

Planned Reporting : 1. Required medical Departments as per above observations 2. Recommend required equipments such for required human resources as per above requirement 3. Financial performance for a period of operation short term or long term 4. To arrive at competition date to plan future expansion 5. To plan future expansions

II. Land Selection Architecture and Design Consultant, Core Team and As per Vasthu III. Finance IV. Equipment V. Time Frame VI. HR Policy in selection VII. Romance with Chaos- Disaster planning VIII. Hospital Planning : Stage 1 : Facility Planning Stage 2 : Institutional Planning Stage 3 : Strategic Planning VIII.Hospital Marketing IX. Tariff, Pricing, Packages and Insurance

HOSPITAL PLANNING AND DESIGN

1. Hospital Lay Out 2. Design soundness 3. Hospital Safety : a. Fire b. Flood c. High Wind d. Earth Quakes e. Blast

PHYSICAL ENVIRONMENT
1.Light 2.Colour 3.Sound 4. Climate:
a. Temperature b. Humidity

5. Ventilation :
a. Health Hazards b. Specialized Cleaning

Building Elements and Materials Slip Hazards-Floors Ramps, Steps and Stairs Walls and Ceiling Elevators Shielding Openings-Doors and Windows

HOSPITAL INSTALLATIONS
1. a. b. c. d. e. f. Electric Supply: Arrangements for Continuous supply Generating Sets Portable Emergency Lights UPS Voltage Stabilizers Duplicate Feeders

2.Water Supply 3. Sanitary Equipment: a.Wash basins b. Water Closet 4. Life Safety and Emergency Power 5. Communication System 6. Medical Gases, Pipe air and vacuum

General Standards for Details and Finishes

 Hospital

with an organized emergency service shall have the emergency access well marked to facilitate entry from the public roads or streets serving the site. Other vehicular or pedestrian traffic should not conflict with access to emergency station. Access to emergency services shall be located to incur minimal damage from floods and other natural disasters.

Rooms which contain both tubs, shower and or water closet for important use shall be equipped with doors and hardware permitting emergency access from the outside when such rooms have only one opening, the doors shall open outward or in a manner that will avoid pressing a patient who may collapsed within the room.  The minimum door size for in patient bedrooms shall be 110 m wide and 210m high to provide clearance for movement of beds and other equipment like mobile Xray unit. Doors to other rooms used for stretchers and or wheel chairs shall have a minimum width of 80 cm. Door width and height shall be the nominal dimension of the door leaf ignoring projections of frame and tops. For that matter 10 cm for width and 5 cm for height may be added to arrive at the door way opening.

Patient rooms or suites intended for 24 hours occupancy shall have windows that can be opened from the inside to vent noxious fumes and smoke products and to bring in fresh air in emergencies. Operation of such windows shall be restricted to inhibit possible escape or suicide.  Dumb waiters shall not open directly into a corridor or exit, but shall open into a room with a fire resistance rating of not less than one hour. Thresholds and expansion joint covers shall be flush with the floor surface to facilitate the use of wheel chairs and carts. Expansion and seismic joints shall be constructed to restrict the passage of smoke.

Mirrors shall not be installed at hand washing fixtures in food preparation areas nurseries, clean and sterile supply, scrub sinks, or either area where asepsis control would be lessened by hair combing.  Floors and walls penetrated by pipes, ducts and conduits shall be tightly sealed to minimize entry of rodents and insects. Joints of structural elements shall be similarly sealed.

 Ceilings, including exposed structure in areas normally occupied by patients or staff in food preparation and food storage areas, shall be cleanable with routine house-keeping equipment. Acoustic installation and lay in ceiling, when used, shall not interfere with infection control. In operating rooms, delivery rooms for cesarean sections, isolation rooms and sterile processing rooms, provide ceilings that contain a minimum number of fissures, open joints or crevices and minimize retention or passage of dirt particles. Wall finishes for such rooms shall also be free for fissures open joints, or crevices that may retain or permit passage of dirt particles.

In psychiatric patient rooms, toilets and seclusion rooms, ceiling construction shall be monolithic to inhibit possible escape or suicide. Ceiling mounted air and lighting devices shall be security type. Ceiling mounted fire prevention sprinkler heads shall be of the concealed type.

PREVENTIVE MAINTENANCE PROGRAMME

 Selective use of music, with adequate concern for patient comfort. Ensure patient control of light within their territorial space, access to unfiltered day light for long term patient. Select warm or cool colour appropriately to activity level intended to space. Maintain an optimal thermal condition of patient and staff.

 Ensure periodical change of filter to provide the

correct level of temperature and humidity control. Periodical cleaning of air-conditioning ducts system through a specialist contractor preferably by deploying compressed air technique. Restore frequent cleaning of floors with devices like vacuum, mopping, brushing, machine cleaning, chemicals cleaning, waxing or so on related to usefulness of flooring material related to function.

Maintain high hygienic standards for walls and ceiling. Repainting and cleaning schedule must not hamper the working efficiency of adjoining area. Shielded surfaces must be checked and repaired against any damage or leakage to ensure radio frequency interference-proof environment and elimination of Electromagnetic interference.

 Effective working of builders hard ware of doors and windows must be assured through periodical checks. Self closing device must work smoothly, emission of nasty sound in its working should be at once eliminated.  Glass pans must be kept clean through an easily accessible means for cleaning. Broken glass must be replaced. Brushing up, not picking up of broken glass pieces is recommended. Building must be frequently inspected for loose slate, bricks, stone, plaster etc, such repairs under no circumstances be delayed or kept in abeyance.

 Where there is a variation in floor level, sufficient illumination at all hours must be provided. Elevator call buttons shall not be activated by heat or smoke. Elevator doors should strike within a minimum impact and should promptly reopen.  Occurrence of rust, damp conditions, stagnation of water, leakage and seepage corrosion, scale formation in water supply system should be avoided through periodical inspection. Water course must be dechlorinised, overhead tanks cleaning and good maintenance practices must be adhered to.

 Regular cleaning of cooling towers be undertaken. Water droplets produced by fans within the cooling tower should not be allowed to result in contaminated situation. Patient toilets must be cleaned at least twice a day to safeguard against risk of cross infection. Gas connections must not be interchanged. Piped gas fault must immediately be attended.  Avoid mechanical or physical pressure on cables, which may deform insulation and may reduce its ability to withstand voltage pressure. Select properly and lay cables on trays to achieve high reliability over voltage surges and over heating of joints and terminals.

 Ensure smooth and proper working of circuit breaker mechanism. Electrical equipment must not be connected to the outlet points with loose leads or bare ends or wires.  To one out-let point and connecting wires must be matching to take the specified load of equipment to be connected. Heating appliances light and fans must be switched off when any room is to be locked or left unattended. All the electrical appliances, equipment must be properly earthed.  All electric, water supply, air-conditioning and other services involving use of plants and machinery must be maintained to remain good working conditions through periodical checks regular upkeep and proper maintenance drive.

GEOGRAPHICAL, ENVIRONMENTAL AND MISCELLANEOUS FACTORS

1. Meteorological Information
 Temperatures  Rainfall  Humidity

2. Geographical Information
Existing road and rail communications Terrain : mountains, reverine, plain Surrounding district boundaries Susceptibility to quakes /floods Ecology-atmospheric pollutants from adjoining industries and other sources, proximity of sources of noise such as air-fields or rail/tracks  Building height restrictions due to proximity of airports.     

3. Miscellaneous Availability of  Trained Manpower Water Electricity Sewage disposal

Example Data Direct population Indirect population Admission per year per 1000 Population Direct population Admission per year per 1000 Population Indirect Population Average length of stay in days Occupancy rate desired

6,00,000 8,00,000 165 55 10 -85%

Admission per year = 6,00,000 X 165 (direct population) 1000

= 99,000

Admission per year = 8,00,000 X 65 (in direct population) 100

= 44,000

Total admission per year = 1,43,000 Total Bed days per year = 1,43,000 X 10 = 1,43,000

Total beds required with = 1,43,000 100% Occupancy 365

= 3918

Total beds required with = 85% Occupancy

3918 X 100 85 = 4610

Total beds with 100% occupancy 85%

LAND REQUIREMENTS
Site Cover percentage = Total ground floor area of all buildings X 100
Total area of site available Floor area ratio (FAR) It is the ratio of the total covered area on all floors of a building to the total area of the site, ei. if a hospital building standing on a plot of land and measuring 12,000 Sq. Meter has four floors, each floor having 1,500 Sq. meter floor area (total floor area on all floors 6,000 Sq. Meter) the FAR at this site will be two.

DISTRIBUTION OF FLOOR SPACE BY WARDS AND DEPARTMENTS ________________________________

Wards OPD Diagnostic ADM Service & Therapeutic Deptts ____________________________________________ 37-45% 12-18% 18-22% 8-12% 15-20% ____________________________________________

BREAK DOWN SPACE REQURIMENTS GENERAL HOSPITAL Area Sq. ft. per bed Nursing units 250-280 Nursery 12-18 Delivery suite 15-20 Operations theatres 30-50 Physical Medicine 12-18 Radiology 25-35 Laboratory 25-35 Pharmacy 4-6 CSSD 8-25 Dietary 25-35

Area Medical Records Housing Keeping Laundry Mechanical installations Maintenance workshop Stores Public Areas Staff Facilities Administration Total Circulation Total Net area

Sq. ft. per bed 8-15 4-5 12-18 50-75 4-6 25-35 8-10 10-15 40 50 567-751 115-140 682-891

1. 2. 3. 4.

CIVIL ASSETS Land and location Hospital Buildings Internal Electrification and Lighting Internal Water supply

5. Public health services 6. Lightening Protection 7. lift and dumb waiters 8. Structured cabling 9. Intelligent Buildings 10. Hospital Roads Pathways and Drives 11. Articulture, Arboriculture and Landscaping

12. Medical gases 13. IT services 14. Compound wall 15. Ventilation Building including internal services

FINANCES 1. 2. 3. 4. 5. 6. 7. 8. 9. By a group NGO Governmental Individuals Trustees Pharmactical Companies Health Care Companies Quasi Government Organisation Medical Colleges

1. 2. 3. 4. 5. 6. 7.

COMPONENTS OF EBD (Evidence Based Design) Patient Room Sound absorbing tiles and carpeting Adequate ventilation Easy Navigation Natural light Room with a view Operating Room and ICU Neonatel Intensive care

CLINICAL SERVICES
Out Patient Services : Functions and Types
a. a. b. c. d. e. f. Ambulatory Services Specialist Diagnostic and Medical Opinion Referral Patient Medical Rehabtation Health Promotion and Health Education Training Medical Students Epidemiological Social clinic research and Periodic assessment of clinical outcome Preventive and Promotional services Eg.Immunization, Screening and antenatal

TYPES a. Centralised outpatient services Eg. Polyclinics b. Decentralised Outpatient services Eg. Speciality clinics c. Satellite clinics

PLANNING CONSIDERATIONS Physical facilities and Layouts

a. Location b. Principles of Planning layout c. Layout :
1.Double loaded single corridor with rooms on each side of the corridor 2. Double corridor for the entry from opposite sides of the room 3. Triple corridor which provides two rooms of examination treatment rooms on each side of the staff corridor Contd.

Physical Facilities : Public Areas (Entrance Zone) 1. Entrance Easily accessible with wide door 2. Reception and Information 3. Registrations and Records area 4. Waiting area 5. Public toilets and wash room 6. Snack bar

CLINICAL AREAS Sub waiting area Consultation room: 15 to 17 Sq. Meter area Special Examination Room :

ANCILLARY FACILITIES Injection Room : 062 to 0.86 Sq. Meter per patient Treatment and Dressing Room : 12 to 16 Sq. Meters Pharmacy Waiting area should be comfortable

1. 2. 3. 4. 5. 6. 7. 8.

AUXILIARY FACILITIES Laboratory 15 to 20 Sq. meters Radiology Blood Bank Health Education Facilities Medical and Service Facilities Screening Clinic Demonstration Rooms Preventive and Promotive Health Facilities

ADMINISTRATIVE AREAS Administrative Office Business Office House Keeping Storage Facilities : a. General Stores b. Drug Stores c. Linen stores

CIRCULATION AREAS

Includes corridors stairs, lifts etc. This occupies 30% of the total building

EQUIPMENTS Wheel chairs, stretchers, consultation room cum examination room should have work table physician desk wall mounted cabinets x-ray view box revolving stools and chairs besides, examination couch, washbasin instrument trolley all OPDs should have equipments for resustation of patient collapsing suddenly

STAFFING Staffing level for outpatient services should be depended on analysis of the objectives of the Departments and the volume of work load in each of its functional areas.

ORGANIZATIONAL AND MANAGERIAL CONSIDERATIONS a. Policy : To achieve continuity of high quality care with modern techniques b. Procedures : To implement appointment systems to spread out the reporting time of patient c. Managerial Consideration : It is the first point of contact between patient and the Hospital so the management has to give maximum importance in not getting overcrowding and long waiting times

ACCIDENT AND EMERGENCY SERVICES

Definition : Urgent and high quality medical care to prevent loss of life and limbs and to initiate action for restoration of normal healthy life Functions : To Provide immediate and Life saving medical care to patients  To liaison with courts and police in medico legal cases wherever required to provide ambulance services To fulfill role of information and communication center during disasters  Education Training and Research for the medical staff

PLANNING CONSIDERATIONS o Location o Space Requirements and Patient Load o Physical Facilities and Layout o Architectural Design o Communication

STAFFING CONSIDERATIONS Categories : a. Professional b. Nurses c. Paramedical Staff d. Casual Staff

POLICY AND PROCEDURES

 Ambulance Services  Registration and Records  Investigations and Management  Admissions and Referrals  Medico Legal Issues

EQUIPMENT REQUIRMENTS
Essential Equipment : 1. Centralised piped oxygen and suction supply 2. Airways outlets and resuscitation bags 3. Wall mounted / portable manometer 4. Portable defibrillator, ECGs and cardia monitors 5. Respiratory aids eg. Ambu bag venti mask and nebulizer 6. Crash Trolley 7. Slit lamp, Loop, adequate number of trolley wheel chairs

OPERATION THEATRES TYPES OF OPERATIONS : Micro Surgery: Cryo Surgery : Laproscopic Surgery: Bio Medical Laser :

NUMBER OF OPERATING ROOMS o Number and type of surgeons o Type Of Hospital o Hospital Policy and procedures o Hospital bed complement o Number and nature of elective and emergency surgery anticipated o Number of operations per day o

DESIGN CONSIDERATIONS
a. b. c. d. e. f. g. h. i. j. Location Size of the Operating Room 40-60SqMeters Number of Operating Rooms Grouping of Operation Theaters Zoning- Protective,clean,sterile&disposal Electrical Air-conditioning and Ventilation Pendent Plumbing /Sanitary Installation Fire Fighting

ELECTRICAL
a. b. c. d. Light operational luminence 2000-3000 candles/sq.M Reflectance (Glare)Clothes & instruments Colour Composition- particularly of skin Operating Light-4000-10,000 lux,shadowless,heat radiation,positioning,mirror for anesthesist,lamp not more than 2 mts above ground,camera for viewing,sterile handle accessories should be handy e. General Light-500-2000 lux to avoid shadows f. Fiber Optic Operation Lamp-cold light g. Uninterrupted Power Supply h. Standby Generator i. Stable Electrical Supply-stand by power j. Also air condition ventilation

o Expected average length of stay of surgical

patients o Expected turn over interval in operation theatre o Size of an average OT list o estimated time for cleaning between operations o Time allowed for staff breaks o Amount of time operating suites can be equipped and staffed o Amount of time reserved for emergency use o Allowance for septic patients

Number of Operating Suites and Number of Operations Per Day No. of operations per day =
No. of surgical beds x % of BOR x 365 ALS x 100 x Number of working days in that Hospital

maintanance
Minimises risk of hospital infection Minimises unproductive movement of staff, supplies and patient Increases efficiency of staff working in the operation suites Ensures smooth work flow Reduces hazards in the operating suites Ensures proper positioning of the equipment Ensures optimum utilization of the operating suits.

INTENSIVE CARE UNIT Definition :Is a specific area Hospital where sophisticated monitoring, titrated life support, specific therapy and specialized nursing, can best provided for potentially salvageable, critically ill patients with life threatening illness or injury.

TYPES OF ICU
ICTU : Intensive Care and Therapy Unit CICU : Coronary Intensive Care Unit PICU : Pulmonary Intensive Care Unit BICU : Burns Intensive Care Unit OICU : Obstetric Intensive Care Unit NICU : Neonatal Intensive Care Unit ANCU : Acute Nursing Care Unit MICU : Medical Intensive Care Unit SICU : Surgical Intensive Care Unit

STAFF REQUIREMENTS
Medical Staff : Director /Incharge of ICU Senior Resident / Registrar Two junior Staff on 12 hrs duty may be Post Graduate students Junior Residents : Day and Night Nursing Staff : Nurse Patient Ratio 1:1/1:2 during Day time 1:2 /1:3 during Night time Contd

Intensive Care Unit Staff Requirements for 8 beds:

Incharge Nurses 4 Trained Nurses 32 Nurses in Training 6 SHO / Registrar (On rotation) 4 Consultant 1 Domestic Staff 4 Ward Administrator 2 Secretary 1 Peon 1 Director of ICU 1 Physiotherapist 2 Radiographers 3 Biochemistry Technician 1 Blood Bank Technician 1 Bacteriological Technician 1

EQUIPMENT REQUIREMENTS
Monitoring Equipment Therapeutic Equipment Fiberoptic Brobnchoscope Infusion sets Wall mounted Manometer Ventilators Defibrillators Pulse Oxymeters

POLICY AND PROCEDURES Admission Procedure :

 Patient with Multiple injuries or after major surgery for observation, monitoring and support  Patients requiring support of airway and artificial ventilation of lung Patient requiring support to maintain cardiovascular integrity including those in haemorrhagic shock Patients requiring control of toxemia of metabolic or infective origin (including pneumonia)  Patients who are donor or recipient of transplant.

POLICIES
a. Patient admitted to ICU remain the clinical responsibility of consultant/unit head b. Bed is kept in the appropriate ward to await there return c. No patients are directly admitted to ICU d. Patients coming directly from casualty are transferred from other hospitals are first shown admitted under special unit in ward and then shifted to ICU in exceptional cases

e. Admission to ICU shall normally be by recommendation of ICU Consultant f. Admission will be made to ICU only bed is available g. The consultant of ICU will be responsible for maintain continuity of care and for initiating treatment decided upon at morning rounds after consulting with physicians and whom patient is admitted the senior resident may initiate such treatment as indicated in emergency however consultant must be informed about it.

DAY TO DAY CARE AND DISCHARGE PROCEDURE

 Liaison with the parent unit is essential for proper treatment of patients in ICU  Daily ICU rounds shall be held in morning at 9-11 AM along with doctors of parent unit  The treatment instituted to patients is written by the senior resident posted in ICU  Discharge of patient is taken in consultation with consultant of the parent unit  Patient who have recovered and stable can be discharged  Patients in whom immediate threat is alleviated  Patients in whom immediate threat is alleviated but expected to die shortly  Patients in whom death is imminent even if intensive care is continued

IN PATIENT SERVICES Functions :

1. To provide highest quality of medical and nursing care to the patients 2. To provide necessary equipments essential drugs and other stores required for patient care 3. To make the patient feel almost in the home by taking care of Physiological and psychological needs 4. To provide facility to meet the needs of the visitors 5. To provide highest degree of job satisfaction for nursing and medical staff which includes training and research

PHYSICAL FACILITIES
The wards constitute 35 to 50% of hospital area and should be located well inside the hospital to avoid cross infection and adjacent to laboratory blood bank, imaging CSSD etc. The area per bed is 70 to 90 Sq. ft. but in acute obstetrics and orthopedics it is 100 to 120 Sq. Ft per bed the distance between the two rows of the bed is 5 ft. distance between two beds is 4 ft. , clearance between bed head and wall should be 1 ft. the standard dimension of hospital bed is 6ft 6 inches X 3 ft. 3 inches

SHAPE AND DESIGN 1. Open Ward Houses about 35 patients 2. The length of the ward was not less than 96 ft. Advantages of Open Ward 1. Nurses have ample visibility and direct observations of the patient at all times 2. Cross ventilation is maintained 3. Natural light is available 4. It is economical to contract and maintain Contd..

Disadvantages of Open Ward :

1. Noise lack of Privacy 2. Danger of cross infections 3. Constant glare to patients

RIG WARD
1. Each cubical having 1,2,4 or 6 beds arranged parallel to longitudinal walls Advantages and Disadvantages 1. Communication between the nurses and the patients becomes more difficult 2. The patients are deprived of direct observation by the nurse the wards become longer more number of nurses required costly to built and maintain.

Ancillary Accommodation
1. Nursing Station : Nerve Center location is as per design 2. Treatment room 3. Clean utility room 100 to 200 Sq.ft 4. Ward kitchen or pantry 5. Day room 6. Stores 7. Dirty utility room 8. Bath and Toilets :
a. b. c. d. Urinal 1 for 16 beds WC 1 for 8 beds Bath 1 for 12 beds Wash basic 1 for 10 beds

9. Janitors Room

AUXILIARY ACCOMMODATION a. Duty Room for doctors b. Seminar room attendant room c. Side room laboratory d. Locker room for the staff e. Wheel chair/ Trolley bay

FACTORS INFLUENCING IMPATIENT CARE 1.General 2. Hospital Staff 3. Educational and Training 4. Physical Facilities and Equipments 5. Clinical and Service Facilities 6. Effective use of beds 7. Quantum of work 8. Administration

ROLE OF NURSING SERVICES

To assist the individuals, sick or well, in the performance of those activities contributing to its health or recovery or peaceful death he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

General Role :  Round the clock nursing services  Monitoring and coordinating nursing care  assisting other professionals in implementing their plans of care Specific Role  Access to patient care needs  Plan and provide nursing care interventions  Prevent complications and promote improvement in patient comfort and well being  Alert other care professionals to patients conditions  Documentation

FUNCTIONS OF NURSING CARE SERVICES Actual care of nursing care services all aspects and treatment  The organization and administration of nursing services  Education and Practices  Quality Control  Supervision  Looking after the stores  Establishment of Communication system for Nursing personnel  Education for the health services  Counseling for health personnel patient and public  Formulation of Policies, Standards, and goals for nursing services

JOB DESCRIPITON OF WARD INCHARGE (SISTER) Qualifications : a. Registered Nurse, Registered Midwife with seven years experience as staff nurse b. Registered Nurse, Registered Midwife with Diploma in ward administration and six years experience as staff c. B.Sc. Nursing with five years experience as staff nurse d. She must be registered with the State Nursing Council Ratio : Sister for every 25 bed medical surgical and periodical wards For each shift ICU, CCU, Labour room, Operation Theatre, overall OPD, Gynic OPD etc.

Causality and Emergency one for each shift Leave Reserve 30% Reportable to Nursing Superintendent

DUTIES AND RESPONSIBILITIES

a. b. c. d. e. f. g. h. i. Distributing ward duties to staff nurses students and class IV Making plans for recognition for ward and maintaining discipline Maintaining supplies Giving and receiving nursing reports of day and night Keeping custody of dangerous drugs and records of administration Writing confidential reports of staff nurses Reporting immediately incident of importance to higher authorities Weekly roaster for nurses General cleanliness of the ward supervising the laundry holding the meetings with ward staff to work out difficulties

j. Seeing the Doctors orders of carried out k. She must not allow any nursing personnel to give I.V. fluids, Blood transmission or take blood sample for investigations l. Seeing that medications dressing nursing procedures investigations and other treatments are carried out m. Report patients conditions to doctors when they come on rounds n. Accompany the doctors during their rounds and brain to doctors attention any point of importance o. Seeing that the preparations of transport of patients to OTs and other departments properly p. Verifying the patients coming from OPD from other departments for admissions to particular department and that papers of patients are in order without which the patient should not be admitted apart from this she is also a teacher for nursing students

Qualification : General nursing and midwifery or B.Sc. nursing from recognized university Duties : Administrative a. Help the ward in charge b. Maintain general cleanliness of the ward c. Write the diet register and supervise d. Maintain drug registers e. Supervise medicines given by students f. Maintain emergency trays and date of expiry of drugs g. Take over duty from previous nurse h. instruments supplies and drugs etc. i. Information about serious patients j. supply necessary linen

JOB DESCRIPITON OF STAFF NURSE

k. Administer injections tablets and liquid medicines as per the routes l. Prepare patients for operation with documentation m. accompany the doctors on rounds and take instructions n. see that specimens are sent to laboratory with documentation o. Insist the unit doctors prepare and sign the documentation p. Keep blood transmission tray ready to help the doctor procedure q. A staff nurse is not allowed to give I.V. infusions or blood transmissions r. observe patients condition and report to ward in charge or duty doctor s. Check every new admission and prepare documentation as per norms and particularly when the patient is transferred from one ward to another t. Maintain temperature charts or special charts this been particularing MLC u. Write day and night orders and maintain ward static's

 counseling including how to take medicines properly on discharge Apart from this teaching activities to students nurses

Ratio-Staff Nurses and Nursing Sister Department Nursing Sister Staff Nurses
1. General Medical 1 for 25 beds 1 for 3 beds and surgical ward 2. ICU, ICCU and other 1 for each shift 1 for each bed per shift special wards 3. Labour Room 1 for each shift 4 for each shift 4. O.T. 1 for each shift 3 per table for shift 5. Obs. & Gynae 1 overall 1 for each room 1 for Gynae OPD of department 6. Out patient Dept. 1 for each OPD Actual Needs 7. Pediatrics 1 each shift 1 for two beds 8. Casualty&Emergency1 each shift 1 for two beds 9. Leave Reserve 30% in all categories

Note : Norms vary from time to time

ROLE OF NURSING SERVICES

To assist the individuals, sick or well, in the performance of those activities contributing to its health or recovery or peaceful death he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible.

General Role :  Round the clock nursing services  Monitoring and coordinating nursing care  assisting other professionals in implementing their plans of care Specific Role  Access to patient care needs  Plan and provide nursing care interventions  Prevent complications and promote improvement in patient comfort and well being  Alert other care professionals to patients conditions  Documentation

FUNCTIONS OF NURSING CARE SERVICES Actual care of nursing care services all aspects and treatment  The organization and administration of nursing services  Education and Practices  Quality Control  Supervision  Looking after the stores  Establishment of Communication system for Nursing personnel  Education for the health services  Counseling for health personnel patient and public  Formulation of Policies, Standards, and goals for nursing services

JOB DESCRIPITON OF WARD INCHARGE (SISTER) Qualifications : a. Registered Nurse, Registered Midwife with seven years experience as staff nurse b. Registered Nurse, Registered Midwife with Diploma in ward administration and six years experience as staff c. B.Sc. Nursing with five years experience as staff nurse d. She must be registered with the State Nursing Council Ratio : Sister for every 25 bed medical surgical and periodical wards For each shift ICU, CCU, Labour room, Operation Theatre, overall OPD, Gynic OPD etc.

Causality and Emergency one for each shift Leave Reserve 30% Reportable to Nursing Superintendent

DUTIES AND RESPONSIBILITIES

a. b. c. d. e. f. g. h. i. Distributing ward duties to staff nurses students and class IV Making plans for recognition for ward and maintaining discipline Maintaining supplies Giving and receiving nursing reports of day and night Keeping custody of dangerous drugs and records of administration Writing confidential reports of staff nurses Reporting immediately incident of importance to higher authorities Weekly roaster for nurses General cleanliness of the ward supervising the laundry holding the meetings with ward staff to work out difficulties

j. Seeing the Doctors orders of carried out k. She must not allow any nursing personnel to give I.V. fluids, Blood transmission or take blood sample for investigations l. Seeing that medications dressing nursing procedures investigations and other treatments are carried out m. Report patients conditions to doctors when they come on rounds n. Accompany the doctors during their rounds and brain to doctors attention any point of importance o. Seeing that the preparations of transport of patients to OTs and other departments properly p. Verifying the patients coming from OPD from other departments for admissions to particular department and that papers of patients are in order without which the patient should not be admitted apart from this she is also a teacher for nursing students

Qualification : General nursing and midwifery or B.Sc. nursing from recognized university Duties : Administrative a. Help the ward in charge b. Maintain general cleanliness of the ward c. Write the diet register and supervise d. Maintain drug registers e. Supervise medicines given by students f. Maintain emergency trays and date of expiry of drugs g. Take over duty from previous nurse h. instruments supplies and drugs etc. i. Information about serious patients j. supply necessary linen

JOB DESCRIPITON OF STAFF NURSE

k. Administer injections tablets and liquid medicines as per the routes l. Prepare patients for operation with documentation m. accompany the doctors on rounds and take instructions n. see that specimens are sent to laboratory with documentation o. Insist the unit doctors prepare and sign the documentation p. Keep blood transmission tray ready to help the doctor procedure q. A staff nurse is not allowed to give I.V. infusions or blood transmissions r. observe patients condition and report to ward in charge or duty doctor s. Check every new admission and prepare documentation as per norms and particularly when the patient is transferred from one ward to another t. Maintain temperature charts or special charts this been particularing MLC u. Write day and night orders and maintain ward static's

 counseling including how to take medicines properly on discharge Apart from this teaching activities to students nurses

Ratio-Staff Nurses and Nursing Sister Department Nursing Sister Staff Nurses
1. General Medical 1 for 25 beds 1 for 3 beds and surgical ward 2. ICU, ICCU and other 1 for each shift 1 for each bed per shift special wards 3. Labour Room 1 for each shift 4 for each shift 4. O.T. 1 for each shift 3 per table for shift 5. Obs. & Gynae 1 overall 1 for each room 1 for Gynae OPD of department 6. Out patient Dept. 1 for each OPD Actual Needs 7. Pediatrics 1 each shift 1 for two beds 8. Casualty&Emergency1 each shift 1 for two beds 9. Leave Reserve 30% in all categories

Note : Norms vary from time to time

NURSING SERVICES ORGANISATION AND ADMINISTRATION

Nursing as a Profession :
Florence Nightingale Pioneer in model nursing and model hospital administration laid down standards and started school of nursing in 1860 in London. In India Organised training for nurses started around 1854 with opening of school for mid wise at Madras One school open at Calcutta for nursing in 1859 and Madras 1871 Following Bhore Committees recommendations in 1946 Indian Nursing council was found in and around 1949 with the object of standardising training for Nurses in India

Functions of Nursing Care Services

 The actual provision of nursing care services and treatment  The Organisation and Administration f Nursing services Education and Practice  Quality Control Supervision  Provision for financial resources, and procuring materials and supplies  The establishment of communication system for nursing personal other health workers, patients health authorities. Educational and Health services Counselling for patients and public Essential information Research and studies concerning all aspects of nursing

Director of Nursing Or Nursing Superintendent Dy. Asst. Director or Matron

Supervisor Supervisor Supervisor Med.Services (Surg. Services) (OT) Head Nurse Head Nurse Head Nurse Staff Nurse Staff Nurse Staff Nurse

Supervisor (Obs. Unit) Head Nurse Staff Nurse

NURSING SUPERINTENDENT Qualification :

Master in Nursing with any Speciality with 6 years experience of which 3 years in administration or Post Basic BSC Nursing with 3 years experience in any position or Basic BSC Nursing with 10 years total profession Responsible for planning and Organisation in Hospitals a. Preparing a Philosophy and Objectives for the Nursing Department in accordance with those of Hospital b. To see all the service areas are managed as per their needs Utilizing the Speciality of nurses in particular areas only eg. Psychiatry and Pediatrics

c. Planning in staff as per INC recommendations

d. Cooperating with authorities during emergencies e. Preparing an organizational chart showing channels of communications

2. General Administration :
a. Framing Personal polices, keeping within the Frame work of Government Rules and Regulations b. Interpreting and implementing the policies of Governing body the hospital and the INC c. Carrying out the correspondence with hospitals within and out

d. Attending the correspondence from outside agencies e. Proposals for special equipment conducting the rounds of ward and departments f. Preparing the job descriptions for the staff g. Investigating complaints taking disciplinary action h. Preparing annual statistics and projecting man power needs handling grievances and solving problems i. To see the ward procedure manual is maintained in all the wards j. Sanctioning the leave to nursing personal and keeping the record of the same k. Writing confidential reports reading and analyzing daily reports on hospital situation and informing the same to higher authorities

l. Taking active interest in staff programmes through orientation of new staff, in service Education programme encouraging and recommending interested nurses to get further training and higher education,performance and evolution 2. Experimenting with newer duty and staffing patterns 3. Miscleaneous 1. Giving leadership to Nursing Department 2. Encouraging Nursing personal to become members of professional association 3. Participating in meeting, workshop, seminars of local, stating or national level 4. Providing counseling services to nursing services

The Nurse patient Ratio as per the SIU(staff inspection unit ) Norms
General ward 1:6 Special Ward 1:4 Nursery 1:2 Labour Room 1:1 ICU 1:1 OT Major 1:2 OT Minor 1:1 Causality 1:35 Burn 1:2 OPD 1:40

Physical Medicine and Rehabilitation Disability and Rehabilitation

Disease Impairment Disability Handicap The programs associated with disability 1. National Leprosy Eradication Programme 2. Blindness Control Programme 3. Iodine Deficiency Disorders Control Programme 4. National Mental Health Programme 5. National AIDS control Programme 6. Universal Immunization programme including the Child Survival and Safe Motherhood (CSSM) Programme.

Ministry of Health and Family Welfare in its 5th conference of Central Council of Health and family welfare in 1997 passed following resolutions : Establishment of Centers for Rehabilitation in the district Hospitals trained manpower to tackle the problem of within the community and for transfer of Technology to grassroots level strengthen the research causation and prevalence of disability in the community

To start PMR Department in every medical college and Trained Doctors and Paramedical staff Apex institutes under ministry of Health and Family welfare
 All India Institute of Medicine and Rehabilitation Mumbai All India institute Medical Sciences New Delhi All India Institute of Speech and hearing National Institute of Medical Health and Nuro Sciences Department of Rehabilitation, Safdarjung Hospital

Apex Institutes under Ministry of Social Justice and Empowerment :

 National Institute for visually Handicap Dehradun  Ali Yavar Jang National Institute for Hearing Handicap Mumbai  National Institute for Mentally Handicap Secunderabad  Institute of Physically Handicap New Delhi  National Institute for Rehabilitation Training and Research Cuttack  National Institute for Orthopaedically Handicapped Calcutta  ALIMCO at Kanpur is the premier institute to assist ambulation There are 17 Vocational Rehabilitation Centers in the Country and 40 special employment Exchanges for disability.

Disability It is defined as an existing difficulty in performing one or more activities. Subject to age and sex Impairment Loss of abnormality of body structure of a physiological or psychological function a. Activity Limitation b. Participation Restriction

Prevention of Disability Primary Prevention Secondary Prevention Tertiary Prevention Rehabilitation defined as the combined and coordinated use of medical, social, educational and Vocational measures for training and retraining the individual to the highest level of functional ability

Medical Causes of Disabilities :

1. Congenital Disorders Genetic :  Mental Retardation, hearing impairment, speech disturbances, Visual impairment, genito urlnary malformations, CHD and Digestive Systems Disorders a. Non-genetic  Perinatal disability, low birth weight  Malnutrition, Severe anaemia , Pregnancy anaemia  Diseases during pregnancy like rubella, Syphilis, Tetanus, Drug use.  Complications during delivery birth drama brain damage, and Respiratory distrubances

2. Communicable Diseases Common poliomyelitis, TB, Leprosy, Trachoma others Meningitis, Encephalitis, Herpes, Osteomyelitis, Venereal diseases, Septic arthritis, Chronic Eye infections, Otitis media, and AIDS

3. Non communicable Somatic Diseases Back disorders, Paralysis, Arthrosis, Rh. Arthritis, Heart conditions, CVA, Palmonary Dysfunctions, Epilepsy, Vision impairments, Hearing impairments, Diabetes and cancer

4.Functional and Psychiatric Disorders : Psychotic eg. Schizophrenia Non-psychotic eg. Phobic states 5. nd Drug Abuse Alcoholism

6. Trauma And Injuries

Traffic accidents : rail, road, air, sea Work Accidents : industrial, agriculture Home Accidents Other sources Recreation and sports War and civil unrest Natural Catastrophes Earthquake Floods Cyclones

7. Mal Nutrition : Protein calorie Vitamin Xerophthalmia Nutritional anaemia 8. Other Causes:
Exposure to toxic substances in air, water, food Unsuccessful suicidal attempts Crime : inflicting bodily injury , psychological disturbance

Iatrogenic disturbance

Common cause of Disability Visual : Cataract, trachoma, Trauma, Congenital, Vit A deficiency Hearing : Congenital nerve deafness, Chronic otitits media, Noise pollution Speech : Congenital, Brain damage Loco motor : Poliomyelitis, Amputation, Cerebral palsy, Accidents. Mental : Congenital, Cerebral Palsy, Cretinism

REHABILITATION Physical / Mental Rehabilitation Physio social Rehabilitation Educational Rehabilitation Vocational Rehabilitation Rehabilitation Approaches -Community base Rehabilitation - Institution based Rehabilitation - Outreach Programme

PHYSICAL LAYOUT, STAFFING AND EQUIPMENT

Physical Layout : it differs from design to design and space available must satisfy MCI Norms in Medical Colleges Staffing : Director Professor (PMR)1. Associate Professor (PMR) 2. Assistant Professor (PMR) 2.Senior Resident (PMR)4 Junior Resident (PMR) PG Students 4 Junior Resident House Surgeons 10 Senior Physiotherapist 2 Physiotherapist 10 Senior Occupational Therapist 2 Occupational Therapist 10 Contd.

Audiologist and speech Therapist 2 Multi Rehabilitation workers 10 Sr. Medical Officer 1 Medico Social worker 1 Psychologist 1, Vocational Counselor 1 Workshop manager 1, Sr. Prostheuisist and Orthosist 2 Prosthtist and Orthotist 4 Prosthetic and Orthotic Technician 12 Teacher 2 Craft Instructor 2 Technicians in various trades 4 Administrative Officer 1 Head Clerk 1 Accounts clerk 1 Stenographer 2 Typist 2 Personal Assistant 2 UDC 2 LDC 4 Nurses 2 Nursing Orderly 10 Safaiwala 6 Driver 2 Peon 2 Contd.

Infrastructure :
Medical Section and OPD Services Physiotherapy services Occupational Therapy Services Hearing and Speech Therapy services Medico social Services Psychological and Vocational services Indoor Services Operation Theatre Services Administrative Block Public Utility Services Wheel Chair and Trolley Services Waiting Space Dharamshala for Attendants

Contd.

EQUIPMENT - Diagnostic Equipment - Therapeutically Equipment - Surgical Equipment

LABORATORY SERVICES
Functional Components Histopathalogy Clinical Pathology Micro Biology Haematology Bi-chemistry Research Laboratories Nutrition and Metabolism Infectious Diseases Immuno Histo Chemistry Serology and Endocranalogy

1. Histo Pathology : Laboratory performing organ, tissues, cell examinations for the diagnosis of various types of diseases and abnormalities Examination of tissues/ Organs from living/ Dead body in the form of either surgical specimal biopsy or autopsy 2. Clinical Pathology : All body fluids such as blood urine, sputum, stool, pleural, Peritoneal fluids are examined for physical chemical bacteriological microscopic examination of normal and abnormal contains

3. Micro Biology : Study of Microbes such as bacteria, viruses, parricides etc. The study involves identification, morphological and cultural studies, serology and sensitive organs responsible for causing the disease or commonly found as commensals 4. Hematology :Branch of laboratory science in which study of blood and blood components is done for detection of various abnormalities in normal and illhealth

5. Clinical Pathology : Science which determines and measures various chemical substances in normal and abnormal amounts produced during disease process includes examination of clinical substances, hormones, ingimes isoengymes, vitamin's and metabolites

6. Clinical Research Laboratories : Laboratories which deal with research related to patient care system development of techniques, methods and applications, therapeutic drugs, reagents, kits, equipment development and animal experimentation

BIO CHEMICAL TEST 1. Hemoglobin 2. Total Protein 3. Albumin 4. Urea 5. Glucose 6. Bilirubin 7.Alkaline Phosphates 8. Calcium 9. Phosphorus 10. Sodium 11.Potassium 12. Chlorides 13. Amylase 14. Aspertate Transaminse 15. Alkalne Transaminse 16. Cholesterol 17. Urate 18. Bicarbonate 19. Creatinin 20. Tryglisarides

RADIO DIAGNOSIS AND IMAGING SERVICES Types of Services : Radiology is linked images of human bodies and these images can be achieved either by transmission or by emission Transmission : Transmission is a technique there is a source which emits race and which are picked up after reflection from body part and taken on plate or screened.
Eg. X-rays, CT Scan and Ultrasound

Emission : Involves giving a dose of radioisotopes or Radionuclides to the patients which are picked up by target organs or cells and emit gamma race which are recorded, by camera

1. X-rays: oldest radiodianostic tool, the principle is transmission of x-rays from a source to specified part of the body and images are taken on films 2. Ultrasound and colour Doppler : No biological hazards and most used equipment because of low cost and easy accessibility

3. Computer assisted tomography / CAT Scan

has astonishing clarity of details of morphology previously seen only at necropsy or Anatomy atlas. Conventional roentgenography is valuable in evaluating tissue with large differential density, it can not clearly distinguish most soft tissue structures and display overlapping super imposed shadow of the area under investigation but CT images has over come this images and provides sensitive well demarcated and detail images. CT is most specific in brain and spin and injuries

4. Magnetic Resonance imaging: Non invasive

morality concept is magnetic field created over the body being evaluated by strong magnet which results in emission of radio frequency signal by hydrogen nuclear of the tissues after they have been RF vs in presence of strong magnetic field. The RF signal so emitted has characteristic's called relaxation time. T1 Relaxation time (longitudinal Magnetization ) T2 Relaxation time useful in CNS disorders and also cardiology and gastro enterology

5. Positron Emission Tomography (PET) Helps in studying physiology in human body by using isotopes of half life to obtain information regarding fundamental metabolic process Pet is based on three dimensional restructure of brain section using positron enmity radio nuclides it helps to measure quantitatively regional cerbel blood flow, blood volume, oxygen metabolism glucose transport and metabolism, neurotransmitter metabolism.

6. Mammography : An x-ray based morality

commonly used to detect breast diseases and an advanced version being digital mammography, commonly used for screening breast cancers.
7. Nuclear Imaging: Radio active tracers (radio nuclides ) or applied to medical situations the studies can be vivo I.e,. Studies requiring injection of Radionuclides into patient involving absorption excretion and hematology uptake and imaging studies such as renal scan lever scan bone scan thyroid scan thallium scan for myocardial perfusion and others.

Invitro do not require injection to the patient done in laboratories by using radio nuclide on tissues such as thyroid hormone assay by radio immune assay method the techniques that are used in single photon Emission Computed Tomography (SPECT) and Gamma Camera SPECT : Less expensive system can also cross blood brain barrier. For eg. Isopropyl amphetamine has been used to detect abnormalities like epilepsy, Alzheimer's and Parkinson's

PHYSICAL FACILITIES : a. Expected work load . b. Location c. Areas: 1. Patient waiting area 2. Circulation area 3. Technical area 4. X-ray rooms , 40 Sq Meters 5. Space 6. Related areas for x-ray department 7. Ultra sound unit 25 Sq Meters 8. CT area 110 to 120 Sq meters 9. MRI center 125 to 130 Sq. Meters 10. Mammography 15 to 20 Sq. Meters 11. Nuclear Imaging 110 to 120 Sq. meter

d. Supportive Areas : 1. Consultation Rooms 10 Sq. Meters 2. Conference room Adequate accommodation 3. Library 4. Store Room 5. Staff Room 6. Record Room

e. Layout and flow Activity f. Communication g. Equipment Installation h. Heating ventilation and airconditioning system (HVAC) i. Electric source and backup system j. Future Expansions

Equipment Maintenance Preventive Maintenance Concurrent maintenance Breakdown maintenance

Annual Maintenance Contract 1. Duration of Contract 2. Periodicity of visits and check points 3. spares should be available without delay details of payment schedule breakdown time and number of breaks 4. Penalty class

BIOLOGICAL EFFECTS OF RADIATION HAZARDS

Radiation injuries can arise from various sources eg. Gamma, BETA, Alfa and Neutrons the effects can be acute and chronic Acute Ration Effects : Also called radiation (ARS) few hours to one week after exposure classified under Prodromal ie. Within few hour lasting few days Laten Period ie., last in few days or weeks Manifest Phase ie., recovery occurs with in six week of exposure

a. b. c. d. e. f. g. h.

Chronic or Delayed Effects Shortening of life span Cataract formation Chronic Radio Dermatist Leukemia Cancer Decreased fertility Genetic mutation Epilation

 Radiation Protection and Safety  Radiation Protection and Monitory  Principles in layout of a Diagnostic X-ray room
a. The x-ray tube should never point towards the control room b. the X-ray tube should never point towards the dark room c. The X-ray tube should never point towards window or door d. The control should be far away from the tube

VIDEO IMAGING MODALITIES Digital Radiography Digital Subtraction angiography's also known digital vascular imaging computed raised tomography Sonography Echocardiography Thermograph Cardia Catheterization laboratory , Magnetic resonance imaging and Nuclear medicines scanning

BLOOD TRANSFUSION SERVICES Role and Functions : a. Recruitment of donors and maintenance of donor records b. Collection, storage and preservation of blood and blood components c. Laboratory procedures d. Teaching, training and research e. Clinical/therapeutic functions.

TYPES /CATEGORIES OF BLOOD

Cat 1 : Hospitals consuming 3-7 units of blood /bed/year bed strength 100-400 Space required 100 Sq M It includes district hospitals, Corporation Hospitals Cat 2 : Hospitals consuming 8 to 15 units of blood /bed/year bed strength 400-1000 space required 300 Sq. M. It includes medical college specialized Hospitals Cat 3 : Hospital consuming more than 16 units of blood /Bed/Year Bed strength > 1000 space required 895 Sq. M It includes super specialization Hospitals Metro Pollitan Medical Colleges

LOCATION AND SPACE  Donor Recruitment area Bleeding Complex  Therapeutic area  Laboratories Administrative and Clerical offices Teaching Facilities

EQUIPMENT 1. Refrigerator: For routine work With alarm system temperature display and recording also with 24 hrs power supply stainless steel inside with pull out shelves No. 3 are required one for storing untested blood one for tested blood one for cross-matched blood 2. Table Top Centrifuge : capable of taking minimum of 16-20 12X100 mm tube and micro plate carrier

3. Water bath 37C with temperature control of + 10C of fiber glass 4. Incubator 37 C with temperature control of + 10C 5. Hot Air oven for drying glass ware 6. Micro scope binocular 7. 1 Kg balance for weighing blood bags during collection 8. Tube stripper cutter and aluminum clips to seal kid bags 9. BP apparatus 10 Domestic Refrigerator for storing anti-sera kits etc.

11. PH meter 12. VDRL Agitator 13. Blood bag stand (stainless) for keeping bag upright 14. Test tube racks/test tubes and glass slides, marker pencils etc 15. Flexible table lamps with concave mirror 16. Blood bags single (350 ml. And 450 ml.) and multiple (double, triple and multiple) 17. Sera for grouping and other reagents 18. Distillation and double distillation plant

For Blood Component work 1. Blood bank refrigerated centrifuge: for 450 ml blood bags Temperature of 0-25
C

2. Freezer : 70 and 20 with alarm system

temperature display and continuous power supply

3.Dielectric Tube Sealer 4.Plasma Separation stand 5. Tube stripper, Cutter and aluminum rings

6. Platelet Agitator cum incubator for platelet storage 7. Cryoprecipitate Thawing Bath 8. Laminar air flow 9. Weighing scale of 2 KG with sensitivity of 100 mg 10. 1Kg balance in 5 mg increments of weighing plasma bags 11 Computers and printers etc

For Screening of the Blood 1. Elisa system with washer incubator and Reader 2. Kits for HIV HbsAg, HCV, VDRL

STAFFING Bleeding Complex I II 1. Jr. Doctor 1 1-2 2. Nurses 2 3 3. Social workers 1 2 4. Lab. Attendant 1 1

III 2 4 3 2

Laboratory I 1. Technical Supervisor 2. Technical Assistant 2 3. Lab Technician 4 4. Lab Assistant 1 5. Lab Attendant 2

II 1-2 4 11 2 4

III 4 8 13 4 5

Donor Organizer 1. Associated 2. Social Worker 3. Vehicle + Driver

I OS 2 Os

II 1 5 1

III 2 10 3

Service Staff 1. Clerk Typist 2. Store Keeper 3. Cleaner Sweeper

I OS OS OS

II 1 1 1

III 2 1 2

Medical Doctor MD I II Transfusion, MD (Pathology) 1. Professor 2. Asst. Professor 1 3. Lecturer 2

III 1 1 3

Selection of Donor
1. Age between 18 to 65 years 2. Body wit high : 110 ponds or more for 450 ml of blood 3. Temperature less than 37.5 C 4. Pulse between 50-100 beats per minute 5. Blood Pressure systolic between 90-180 mm 6. Hemoglobin 13.5 g/dl male 12.5g/dl female 7. Specific gravity :> 1.055male and >1.053 female

Deferral :
1. Permanent: History of viral hepatitis, , jaundice , malignant, leukemia, convulsion, abnormal bleeding tendency HbsAg test, serious cardiopulmonary disease, 2. Temporary : cold, flu, diabetes, tuberculosis, Syphilis and other infections Diseases of heart, lungs, kidneys, stomach, or liver. 3. A minimum of 72 hours deferral is made for a donor who has consumed aspirin

Blood Components : 1. Packed Cells 2. Fresh frozen Plasma 3. Platelet rich plasma 4. Platelet concentrate 5. Single donor Plasma 6. Cryo-precipitates 7. Factor VIII concentrate 8. Factor IX concentrate 9. Hemoglobin

Indications :
1. Packed Cells : Sever anaemia and edema, Chronic Leukemia, Chronic Hypoplastic and Aplastic anamias, Hemolytic anaemia 2. Fresh Frozen Plasma : deficiency of coagulation factors DIC, Thrombocytopenic purpura, Neutralization 3. Cryoprecipitate : Von willebrands disease, renal failure, Congenital platelet disorders, Haemophilia, Christmas disease

4. Specific Immunoglobulins : used for passive immunization for varicella, Tetanus Hepatitis Cytomagalovirus infections

5. Hyper immune Gammaglobulins : Primary Rh-immunization in case of Hemolytic disease of the newborns 6. Fresh Blood : massive Transfusion, Bleeding disorders

Blood Transfusion Reactions :

About 2-4 % transmissions lead to minor or major reactions. 1. Clerical Mistakes a. Upto 80 % of cases are due to incorrect labeling of samples b. Errors in wr4iting the correct particulars on requisition c. Confusion in identity of the patient 2. Technical Errors a. Wrong grouping and cross matching b. Rare blood group

PHARMACY SERVICES Functions of Pharmacy : Purchasing, Storing, Distribution of Drugs Ensuring potency and quality of drugs during the storage of Hospitals Supply of drugs to inpatients, wards of various departments including causality OT

Dispensing drugs for OP services Maintenance of formulary system and implementation of drug committees Furnishing the drug information to professionals Adhering to loss concerning to pharmacy(ethics) Maintaing records of books for purchase and sale of drugs Patient Education

Drug Committees
1.Hospital Medical Superintendent -Chairman 2. Head of the Medical Department 3. Head of Surgical Department 4. Head of OBG & Gynae Department 5. Head of Periodic Department 6. Nursing superintendent 7. Chief Pharmacist- Secretary Functions Prepare Hospital formulary of accepted drugs in Hospitals Selection of Suppliers and to keep overall check of pharmacy

ABC Analysis
Classification percent of items A 10 B C 20 70 percent of items 70 20 10

A B C

VED analysis V E D AV AE AD BV CV BE CE BD CD

ABC and VED classification matrix

Central Sterile Supply Department (CSSD) Functions of CSSD 1. To receive and process used and un sterilse supplies and sets from nursing units, OPD, operation theatres, labour rooms, etc. 2. To sterilize and dispense sterile articles to user units 3. To maintain an uninterrupted supply of bacteriological safe supplies at all times

4. To undertake studies for improvement of sterilization practices and processing methods to provide supplies economically 5. To impart training to hospital personnel in safe hospital practices 6. To participate in hospital infection control programme 7. To advice hospital administration on suitability of supplies and equipment from sterilization point of view.

SPACE REQUIRED AND ACTIVITIES

Up to 100 beds Up to 200 beds Up to 300 beds 300 and above 10Sqft per bed 9-10 sq ft per bed 8-9 sq ft per bed 7-8 sq ft per bed

These Activities comprise of the following 1. Receipt of used supplies 2. Accounting 3. Washing, Cleaning and drying 4. Sorting 5. Gauze cutting and assembling 6. Packing 7. Sterilisation 8. Sterile storage 9. Issue

Equipment
1. 2. 3. 4. 5. 6. Autoclave Mechanical and Electrical Dry oven Grass cutter Ultra sound washer ETO Storage cupboards and racks high pressure water lids 7. Needle sharpener 8. Cleaning and Decontamination devices 9. Glove processing unit Testing apparatus indicator tapes and bacter logical indicators

STERILISATION PROCESS Freezing the article from all living organisms including bacteria fungus spores and viruses , Sterilisation process in use in hospitals in India
1. Heat sterilization a. By steam b. By dry heat 2. ETO Sterilisation 3. Chemical Sterilisation 4. Radiation Sterilisation Not done in hospitals as a routine

STANDIRDISATION OF TAX FOR SURGARIES

 Cut down set  lumber puncher set  Sternal puncher set  Catheterisation set  Bladder wash set  Liver biopsy set  Fine-needle aspiration cytology (FNAC)  Paracentesis set  Suturing Set  Thoracic aspiration Set  Incision and drainage set  Tracheotomy set

Medical Records
Def: McGibony Defined medical record as clinical scientific, administrative and legal document relating to patient care in which are recorded a sufficient data written in sequence of events to justify diagnosis and warrant treatment and end results Also as simply a systematic documentation patients personal and social data history of his or her ailment, clinical findings, investigations, diagnosis, treatment given, and an account of follow up and final outcome Serves as clinical document, Scientific document, an Administrative document and a legal document It is a privilege communication the information from which cannot be released without the consent of patient but it is also an impersonal document when its contents are used for research and training without this closing to whom it belongs to.

FUNCTIONS OF MEDICAL RECORDS

Patient Needs

a. Serves as story of patients passage through hospital eg. Medical certificate, diagnosis etc. b. Serves as re-admission record and subsequent course in the hospital c. A written report of family history and personal history d. For insurance claims union benefits and Industrial compensation

Physician Needs :
a. Practise of Scientific medicine based on recorded facts b. Continuity of medical care c. Evaluation of his or her own capabilities and short comings d. Effective communication for the medical team e. Can be promptly retrieved for study and research f. As a material source to survey the result of treatment in particular disease and title g. Medical audit

Institute Needs : a. Generating hospital statistics b. Teaching and Research c. Admission Control d. Planning of services e. Improving the quality of Care f. Safeguard in MLC cases g. The testimony based on recorded facts is given greater consideration than testimony depended on memory

Health Authorities Needs : a. The records are important to the public health authorities as they contain reliable information regarding morbidity and mortality patterns b. Reports like births and deaths, infectious diseases, notifiable diseases, Statistics regarding insurance of diseases and types and number of family planning procedures

MEDICAL RECORDS PURPOSE

The medical record is indispensable from the standpoint of the patient, the doctor, and the hospital and for medical education and research. The purpose it serves in relation to these aspects is as under : The patient : you will agree that the primary reason fro record keeping is to improve the care of the patient. It is essential for immediate diagnosis, treatment and for the future welfare of the patient. Every illness, however, minor involves study and examination to the extent that it is impossible for any individual to keep all details in mind. The written report is evidence that the patients care is being handled in a scientific manner. Other points in relation to this are :

 It serves to document the clinical story of the patients illness and course of the disease. It serves to avoid omission or unnecessary repetitions of diagnostic and treatment measures. It assists in continuity of care in the event of the future illness. It serves as evidence in the event of when the legal question arises. Provides necessary information for insurance, contributory health scheme or for the employment purposes.

The doctor : From the point of view of doctor, the medical records serves as :
Assurance of quality, quantity and adequacy of diagnostic and therapeutic measures undertaken. An assurance of orderly continuity of medical care. Evaluation of medical practice. An aid in research and the continuing education of health professionals A protection in the event legal question arises.

The hospital : From the hospital point of view the medical records are necessary for following purposes to : Document the type and quantity of work undertaken and accomplished Furnish proof of the type and quantity of care rendered to the patient. Evaluate the proficiency of the individual doctor, of r administration and clinical purposes. Evaluate the services of the hospital in terms of accepted norms and standards Protect the hospital in the event of legal matters. Serve as an administrative record of personnel performance and staffing needs, for budget preparation, justification for physical facility allocation and utilization, for statistical data for administrative use and evaluation, for estimating equipment and supply utilization and needs.

Medical Education and Research : Medical records can also be used for the medical education and research in following ways :

Recorded observations are the basis for all clinical research. Group studies of records by the medical staff serve to further the education of doctors and other health personnel Medical records supply pertinent data for the use by public health authorities in control of the diseases.

STAFFING : The staffing of medical records department depends upon the size, type and services being provided by the hospital. Dr. JR. McGibony has suggested staffing pattern for a 500 bedded non-teaching hospital as under

Medical Record Officer :1 Medical Record Technician :4 Clerks :3 Peon :1 Statistician :1 For comprehensive services in addition to MRO staff as under may be considered for a teaching hospital of 500 bed and above. Each category of personnel should be computer literate.

Admission and Inquiry Office Asst. Medical Record Officer :1 Medical Record Technicians :5 Medical Record Attendant :4 Receptionist :5 Central Record Office Asst. Medical Record Officer :1 Medical Record Technicians/ Asst. Medical Record Technicians/Clerks:8 Statistical Asst. :1

CODING AND INDEXING Coding In each medical records International Code Number is assigned to the diagnosis based on International Classification of Disease issued by the World Health Organisation. This is to bring about accuracy and uniformity in the reporting of the diseases by the various hospitals.

Indexing The various forms of indexing as under of the medical records is done depending upon the purpose :
a. Alphabetic or Master Index : Indexing based on patients name sequenced in the alphabetic order. The primary purpose of a name index is to provide entry into the filing system and finding out medical record for a patient. The patient index card is usually 3x5 card giving identification data, registration number, address, date of admission, a date of discharge, diagnosis and department to which admitted.

b. Disease index : Disease index is a catalogue of cards of 3x5 or 5x8, maintained to find out groups of clinical records of patients having the same diagnosis. Besides patients identification data, age, sex, result of treatment and complication may be also mentioned.

c. Operation index : it is a catalogue containing the details of patients who have undergone the operations. Additional details such as site, procedure used, postoperative complication as a result may be documented. d. Physicians index : catalogue containing the details of all patients treated by particular physicians. Analysis of such records may be utilized for evaluating the performance of a physician. Columns can be made into the card based on the information desired.

e. Unit index : Details of all the patients treated in a particular unit are indexed. There records may ultimately be utilized to evaluate the performance of a particular unit.

REPORTS AND RETURNS

Wide ranging reports and returns can be generated in the medical records department. The basic purpose of these reports are : a. Evaluating the quality of care being rendered b. Locating the deficiencies in : i. Means : Staff, Physical facilities, equipment including plants and machine ii. Methods : Operating policies and procedures iii. End results : outcome of the benefits derived by the community from the hospital.

c. Effectiveness of hospital administration and d. Prevention of the diseases. The types of reports and their frequency will vary with the type of hospital and their administrative requirement. The reports may be generated daily, weekly, monthly quarterly and annually depending upon the requirement,. There reports generally pertains to : a. Vital Statistics b. ADT Analysis (Admission, Discharge and Transfer Analysis) c. General Health Statistics Comprehensive list of such reports and returns cannot be laid out since there will be so much variation from hospital to hospital. Some of the re reports that can be commonly generated by the hospital are :

a.       

Reports Related to Hospital Bed Daily Census Maximum patients on any one day Minimum patients on any one day Daily average Bed occupancy rate Total patient days care Bed turn over interval

b. Admission  Daily admission  Daily admission unit/Speciality wise  Total admission over a period  Patients distribution by age, sex, religion and region

c. Discharges  Daily discharges  Total patients discharged over a period  Days of care to the patients discharged  Average length of stay

d. Deaths  Daily number of deaths

 Total deaths over a period  Total deaths over 48 hours  Net death rate  Gross death rate  Foetal death rate  Maternal death rate  Infant death rate  Post operative death rate  Anesthetic death rate

e. Work load Statistics :  Total number of outpatients : - New Cases - Repeat Cases  Total number of operations  Total number of X-ray and other related investigations  Total number of lab investigations/lab wise investigations  Department wise workload statistics

f. Hospital Care Evaluation Statistics :  Post operative infection rate

 Post operative complication rate  Caesarian section rate  Autopsy rate  Consultation rate  Rate of normal tissue removed  Percentage of disagreement between final and pathological diagnosis  Gross result of treatment, I.e,, patients recovered, improved or not relieved.

Following will give you clear understanding of some of the most commonly used terms : Admission
Admission is the acceptance of a patient by the hospital for inpatient service, which may be for investigation and /or treatment. Normal babies born in the hospital are not considered as admissions. The premature or diseased newborns are considered admission. As a general rule the newborn figures are not mixed up with other hospital data. These figures should be tabulated separately.

Discharge :
Discharge is the release of an inpatient. Death of an admitted patient is also considered as discharge.

Hospital Deaths
Death of a n admitted patient is considered as a hospital death. Death of a patient in the casualty, OPD or in an ambulance, before the actual admission of the patient is not counted as the hospital death. Total deaths of hospitalized patients is known as Gross Deaths. Total deaths after 48 hours of admission is considered net deaths.

Patients Day
A patient day is the period of service rendered to an inpatient between the census taking hours of two successive days. While co0unting, the day of discharge of an inpatient is not counted, irrespective of the time of discharge. Similarly the day of the admission is counted always regardless of t he time of admission

Patient day is a valuable unit used for expressing the

various activities of a hospital such as patient days of service rendered during a given period, cost of food per patient per day etc.

Bed complement
Bed complement is the number of hospital beds normally available for use by the inpatient. It includes the following types of beds : Adult beds Cribs Bassinets for use of infants other than new borns Incubators of premature Casualty ward beds Post-operative warded beds Intensive care unit beds Isolation beds Staff sickness beds

a. b. c. d. e. f. g. h. i.

The following types of beds are not included in the bed complement of a hospital a. Recovery room beds b. Observation beds of casualty c. Examination beds

MEDICO LEGAL ASPECTS OF MEDICAL RECORDS A. COMPLETE B. Adequate C. Accurate D. Legible

Ownership of the Medical Records A. As a personal document B. As impersonal Document Indian Evidence Act of 1872as Amended A. In the court of Law B. Life Insurance Corporation of India C. Income Tax D. Patient will E. Queries regarding birth or death

HOSPITAL ACQURIED INFECTION (HAI) Also called Noscomial infections responsible for 1. Long stay hospital 2. Antibiotic Misuse 3. More no. of investigations 4. Cost of Treatment goes up To the Hospital 1. Qualitative utilisation of beds reduced 2. Productivity loss 3. Drug resistance 4. Loss of Reputation 5. Spread of Infection 6. Risk to the employee by Resistatant Pathogens 7. Cost of maintenance of services 8. More load on clinical and supportive services

 Interrelation of source of infection

Air
Other Patients

Endogenous

Patient

Apparatus Instruments

Hospital Personnel

Fomites

ENVIRONMENT

Agent
a. Viruses b. Bacteria conventional pathogens like staphylloccocci group-A, streptococci and solmonelle conditional pathogens like pseudomonas, proteus c. Fungi d. Protozoal e. 25-50% due to gram negative 10% of infection due to staphylloccocci and stephilococas aresta producing unlimited forms of diseases

Sudomonos infection in burns and urinary tract infections Ecoli in catheter associated urinary tract infections Solmenalle in fecull contamnell and other cases

Organisms responsible for human infections Organisms Percentage E coil 20 Staphylococcus aureus 11 Other Staphylococci 11 Pseudomonas 9 Klebsiella 9 Proteus 8 Other Mixed 32

Route of spread of infectious a. Droplet infection Eg. Sneezing, coughing and nose blowing b. Contact route : Patient to patient nurse to patient direct contact with each other indirect contact by way of instrument and dressing c. Environmental route : water and Food d. Intravenous route :Eg. Central venus Catheterisation 90%

Manifestation of Hospital Infection : Inform of bacterimea, RTI , Gastro entities, meningitis and skin infectious UTI and wound infections are seen after surgery Staphococco, streptocacous , E coli and Pseudomonas responsible for bacterimea Klebshelli,Ecoli and streptococcus in respiratory infectious - E-coli and solmanella GI Tract infections - Klebshelli and pnumococcus in meningities

Streptococcus,steplococus, E-coli, Pseudomonas with infected wounds E-coli and proteus with UTI. About 40% of all Noscomial infections

High Risk areas in Hospital

1. Age 2. Primary ailments 3. Diminished body resistance due to Immuno suppressive drugs 4. Indiscriminative use of antibiotic steroids 5. Areas Nurseries, Intensive Care unit, Dialysis nit, Oran transplant unit, Burn unit, Isolation ward, Cancer ward, Operation theatres, Delivery rooms, Post-operative ward

Hospital Infection control Program a. Identification and reporting of Infection b. Good hygiene and aseptic techniques c. Personal orientation and CME d. Coordination of all Departments with Medical audit committee

Infection Control Committee includes representatives from medicine, Surgery, obg and gynae, pediatrics, pathology, administration, nursing staff and microbiology Representative of House Keeping Staff : dietary department, engineering, pharmacy, OTs,CSSD are also required . The important officers are Hospital Epidemiologist, Infection control Officer and Chairman

COMMON CHEMICALS USED FOR DISINFECTION

o Phenols and Cresols Eg. Lysol and Settle o Alcohol Eg. Ethyl Alcohol o Halogen : Eg. Iodine and chlorine compounds o Aldehyde : Formoline Qlutardihyde 2% o Dye : Eg. Gentian Violet o Acid :Eg.Boric acid and carbolic acid o Gas : Eg. Ethylene oxide o Oxidizing Agent : Eg. Hydrogen Peroxide o Surface active Soap

Role and Functions of ICC 1. Determine the method surveillance and reporting of

2. Lay down criteria for reporting all types of infections,

Effective Control Measures People : Repeated studies confirm hospital personnel as significant carriers. Conscientious washing of hands between patient contacts effectively prevents spread of cross-infection. Aseptic Techniques :Insertion and removal of catheters, surgical tubing's, drainage tubes and packs need strict notouch techniques even while they are done outside of operation theatre

Segregation of Contaminated Instruments

Linen, sputum cups, bedpans, urinals and similar items Disinfection Practices: Phenolic compounds are active against gramnegative organisms ammonium compounds against staphylococci streptococci and lodophores and hypo chlorites have a broad spectrum of action.

Sterilisation Practices : Must be meticulously by a trained person. All steam and ethylene oxide sterilizers should checked at least once each week with a suitable live spore preparation by the laboratory. Isolation Facilities ; With communicable diseases and those vulnerable to infection. Such facilities must be made available in ICU nurseries burn unit and transplant unit. Wearing of mask gown and gloves must be mandatory

Antibiotic Policy : Major problem multi drug resistance due to extensive use of certain antibiotics Precautions for the Staff : Staff should immunized against cholera typhoid or hepatitis B all the food handlers working in dietary department must be periodically screened . Persons with nose and throat infections must be temporarily removed from nurseries ICU and operation theatres.

Out Patient Department : If there is acute communicable condition the patient should be segregated Dietary Services : temperatures in refrigerators and deep freezers must be checked stored food and supplies Fruit and Vegetables should be examined for infection before consumption Careful handling of soiled linen : Soiled linen should be considered as potent ional infected and treated with care. Packed in separate bags and clearly labelled should be process separately at water temperatures above 70 degrees for 25-30 minutes good.

House Keeping : Cleaning of walls, floors, window panes bed side screens and tables should be cleaned with disinfected Terminal Disinfection : Terminal Disinfection of isolation rooms must be carried out before permitting the room for reuse. Air Hygiene in Operation Theatres: Air filters should be frequently cleaned. Developing a sense of Awareness : Training and retrain in the precautionary measures for prevention and control.

AIDS AND DISINFECTION Twenty five per cent ethyl alcohol, 2 per cent glutaraldehyde and 0.2 per cent sodium hypo chlorite have shown to be adequate for Disinfection of instruments and contaminated surfaces. Disinfection of Hands : is the most important step for prevention of infection, and this applies with AIDS also. Is alcoholic rubs.

Disinfection of Instruments : Two percent alkaline glutaraldehyde can achieve complete Disinfection given sufficient contact time. Instrument parts containing rubber, plastic Fiberoptic and lenses can also be disinfected or sterilized by alkaline glutaraldehyde. Test Specimens : Dispatched only in sealed, watertight containers

Gloves : Should be worn by all personnel who come into contact with blood blood constituents, tissue, body fluids or excretions and potentially contaminated surfaces of HIVinfected patients Gowns : worn when there is possible risk of contact with secretions, excretions or blood. Face marks : coughing patients should wear a mask , transmission of pneumocystis carinii infection visitors and nursing staff should wear masks in presence of AIDS patient.

Goggles : some form of eye protection, dentists and for physicians surgeons and nurses in bronchoscope endoscopies and ENT surgery possibly also in resuscitation measures. Hands : Disinfected before and after contact with patients Surfaces :Surfaces and furnishing treated immediately with disinfectant. Syringes and Needles : discarded into a firm sharps container. Resuscitation : Mouth-to mouth resuscitation should be available at bedside of every AIDS patients

Disposables : Contaminated disposables must be disposed in accordance with procedures for infectious wastes by incineration Instruments : ethylene oxide or other suitable disinfectant Breathing tubes must be cleaned carefully and disinfected after use by every patient laryngoscopes and endotrachial tubes. Accommodation : Disordered immune system of possible communicable diseases which might be dangerous for AIDS patients should not share rooms with AIDS patients.

PHYSICAL FACILITIES AND LAYOUT

Layout : a. Receipt and Storage Area b. Day Store c. Preparation Area d. Cooking Area e. Service Area f. Dish washing and pot washing area g. Record Room h. Staff Room

Receipt and Storage Area: a. Day Store b. Preparation Area c. Cooking Area d. Service Area e. Dish Washing and Pot/Pan Washing f. Other Facilities

MANAGERIAL ISSUES
1. Regular Cleanliness of the food preparation area 2. Regular maintenance of equipment and proper day to day cleaning of utensils, crockery, cutlery etc. 3. Periodical health check up of staff working in department is essential. This should be done every year. Proper health record of each employee should be main trained 4. The employees should be given 2-3 sets of uniforms and ensure they wear it. 5. On the job training of new employees who join the department should be done.

6. Food prepared should be checked by the dieticians before serving. 7. The menu should be displayed 8. Dieticians and officer in-charge should make regular visits towards and enquire from the staff and the patients about any observations in the diets served. 9. Budgetary provisions act as a regulatory mechanism to control costs. Working out food costs regular (Weekly/monthly), helps in guiding the department. 10. Proper maintenance of records in the department regarding materials received, daily issue, number of diets served, etc.

POLICIES AND PROCEDURES

1. The Dieticians/Officer Incharge of the dietary service should be responsible for determining the quantity/quality of food items to be purchased. 2. Dieticians should form part of the team of identify the sources of purchase either spot purchase or on rate contract basis. They should determine the frequency of purchasing different items. 3. The procedures for purchase should be laid down. It will be economical and convenient to have most of the food items on rate contract basis fixed for a year. 4. Power of emergency purchases whenever required should be delegated to the officer in-charge of the service.

5. The food items received should be inspected by a team comprising of 3-4 members which should include Dietician/Officer in-charge as well. After receipt of goods the stocks should be entered in the stock registers and maintain proper consumption records under the supervision of the controlling officer. 6. The storage bins, racks, cupboards, refrigerators, coolers etc,. Should be properly maintained and kept clean. 7. Proper sanitation and cleanliness including rodent control measures should be observed. 8. A supervisory staff should be available in the patient kitchen during all the working hours.

9. Work schedule should be planned properly avoiding split shifts as far as possible,. 10. Dieticians should visit the wards everyday and have liaison with the staff nurses and the patients. 11. Requisition of different diets from the wards should be signed by the sister in-charge giving the bed number, ward number and the type of diet required by the patient. 12. Nurses should also check and supervise the distribution of meals in the wards. 13. Supplementary requisitions for those patients who are admitted late in the day, should also be entertained by the dietary department.

14. Service timings should be fixed with due regard to the traffic on floor, lifts and local food habits of the people in general. 15. Menus should be planned in advance and also displayed everyday on a notice board in the main kitchen. The meals should supply physiological needs and should be appealing and attractive to the patients. 16. Records pertaining to the diets served should maintained on daily basis and complied on weekly and monthly basis. Cost analysis of diets should be worked out every week/month. 17. Charges for meals for staff members and visitors should be fixed by a committee involving management and staff members which should be reviewed periodically.

Types of Therapeutic Diet

1. High energy well balanced: wasting disease and under nourish 2. Low energy well balanced: Obesity & Likely Diabetics 3. Very low protein, low to moderate energy: Acute GN / HE 4. Very low protein moderate energy: acute renal failure 5. Low protein sodium restricted : chronic renal failure 6. High protein sodium restricted : Nephrotic syndrome or Hypoalbuminaemia 7. Very low fat high carbohydrate: Hepatic or obstructive jaundice, malabsorption and steatorhoea.

8. Low sodium low energy : Heart Failure 9. Reduced saturated fats :to lower plasma cholesterol 10. Gluten Free: Coeliace disease 11. High fiber diet: Diverticulosis and constipation 12. Liquid/semi liquid : chewing or swallowing malignant disease of GIT 13. Bland soft diet : peptic ulcer and GI tract diseases 14. Tube Feeds : Surgery of head and neck, Esophageal obstruction gastrointestinal surgery, severe burns, comatose patients etc.

TYPES OF LAUNDRY SERVICES 1. In-plant System 2. Rental System 3. Contract System 4. Co-operative System

CATEGORIES OF LINEN IN HOSPITAL

1. Store Linen a. Patient Linen, body linen, Bed linen b. Staff Linen : c. Department Linen 2. Laundry Linen a. Soiled linen b. Infected Linen c. Foul Linen d. Radio-active Linen

PLANNING CONSIDERATION Linen Requirements

With 100% bed occupancy should have 6 sets of linen per patient 1. One set in patient bed 2. One set en-route to laundry 3. One set in process in laundry 4. One set ready for use 5. Two sets for active storage for work and use in case of emergencies 2.5 kg/bed/day can be taken as average

HOSPITAL - IV HOSPITAL PLANNING AND DESIGN

0.7 beds per 1000 population presently available required one bed per 1000 population for 2020 2.5 beds per 1000 population in metro cities like Delhi and Mumbai Reasons and absence of Realistic National Health Policy Haphazard medical care planning and inadequate funds Present cost of equipping Hospital as per norms is Rs.4 lakhs per bed

PATIENT CARE AND HIGH QUALITY

Provision of Appropriate Technical equipment and facilities necessary to support Hospital Objectives An organization structure that assigns responsibility appropriately and requires accountability for various functions within the institutions Continuous review of care provided by physicians nursing staff and paramedical staff and other Hospital Activities 2

EFFECTIVE COMMUNITY ORIENTATION 1. A Governing body of persons who have demonstrated concern for the community and leadership ability 2. Policies that assures availability of services to all the people in the Hospital service area 3. Participation of Hospitals in the community programs to provide preventive care 4. Public information programs that keeps the community identified with Hospital goals and objectives 4

1.

2.

3. 4.

5.

ECONOMIC VIABILITY A corporate organization that accepts responsibility for sound financial management in keeping with desirable quality of care Patient care objectives that are consistent with projected service demands, availability of operating finances and adequate personal and equipment Planned program of expansion based only on demonstrated community need Specific program of funding that will assure replacement, improvement and expansion of facilities and equipment without imposing too much cost burden on patient charges An annual budget that will permit the hospital to keep pace with times 5

6.

ORDERLY PLANNING 1. Acceptance by Hospital Administrator for short and long range planning supported by financial organizations and Architectural advisors 2. Establishment of short and long range objectives with a list of priorities and target dates 3. Preparation of functional programs that describes short range objectives and the facilities equipment and staffing 6

A SOUND ARCITECTURAL PLAN 1. Engaging an architect experienced in hospital design and construction 2. Selection of site large enough to provide future expansion and accessibility of population 3. Recognition of neat of uncluttered traffic patterns within and without the Hospital for movement of Physicians, Hospital staff, Patients and visitors and efficient transportation of supplies 4. An architectural design that will permit efficient use of personal, inter changeability of rooms and provides flexibility 5. Adequate attention to important concepts such as infection control and disaster planning 7

CLASSIFICATION OF HOSPITALS 1. 2. 3. 4. 5. 6. 7. Private (Personal) Partnership Private (Family) Trust Public Charitable Trust Cooperative Society Private Limited Company Public Limited Company

HOSPITAL PLANNING TEAM 1. All the people involved in delivery as well as utilization of services are concerned with Hospital Planning i.e., people, patients , nursing, medical staff and management 2. Technical Requirements of a particular professional group in isolation have led to creation of physical forms limited in their utility a. Hospital Consultant b. The core group c. Hospital Architect 9

Phases of Planning inception feasability studies Outline proposal Scheme Design Detail Design Tender Action Construction Commissioning Shake down

10

1. 2.

a. b. c. d. e.

BED CAPACITY OF THE HOSPITAL Observation of beds equipments and staff for over night dues Pediatric bassinets and incubators in pediatric departments However, beds in the following areas do not form a part of bed count : Vaccinate and incubators in the maternity suite Labour rooms Causality and emergency departments Recovery room Any which are not equipped and staffed for over night dues 11

REQUIREMENTS FOR PLANNING STRUCTURE A. Soil Structure B. Public Utilities a. Water- ISI Suggest 455 liters of water per consumer day LPCD for hospitals of 100 beds and over overall requirement of water in hospitals is estimated at 300-400 Liters per day b. Savage Disposal solid waste from Hospitals is approximated 1 kg per bed per day Liquid affluence will be same as the hospital requirement of water i.e., between 300-400 liter per bed per day 12

HOSPITAL PROJECT STAGING -Stage a

Functional Content ! Project Team Outline brief ! Assessment of functional content ! Submission to owners (Govt. Private Organisation, etc.) for approval ! Site appraisals, gross floor areas ! Building space Draft master plan ! Estimation of cost and phasing ! Appraisal of work by owners 13

Stage B Operational Policies

! Operational Policies !Departmental and interrelated activities !Departmental and hospital policies !Development control plan !Budget cost ! Continuous informal discussion with owners through stage B 14

Stage C Schedules of
Accommodation, ! Schedules of accommodation

Sketches final Cost estimate

!Sketch drawing ! Equipment schedules component estimates !Cost revenue and staffing estimates
!Final Cost approval 15

Stage D Detail design working !Working drawings Drawings- tender action !Engineering detail !Bills of Quantities !Calling Tenders 16

Stage F Commissioning ! Staff assembly and training !Equipment and supplies assembly !Testing of installations !Opening 17

Stage E Contract and construction

! Assessment of tenders !Award of contract ! Construction ! Engineering commissioning

c. Power requirement of Electric power is approximately 1 KV on per bed per day basis Besides stand by generator is also necessary

Elements requiring consideration and analysis

Morbidity Statistics Prevalence Communicable disease Degenerative Diseases of
Accidents rate Specific disease/disorders

Measurement of

Death rate Birth rate Maternal mortality rate Infant mortality rate

Demographic

Age and sex profile Population density Occupational characteristics Extent of urbanisation Extent of migratory population Economic development of the area

Socio-economics Statistics

Economic status of the community Literacy and educational standard Social habits and socio-cultural grouping Housing conditions Styles of living Industrialization

Hospital Statistics

Type of existing hospital services Admission rates Diseases-specific admission rates Hospital beds in the region Utilization of existing health and hospital services Extent and effectiveness of general practitioner services

LEVELS OF MEDICAL CARE

Level of Care 1. Primary Medical Facility Level of decision maker

Dispensary, Primary General practitioner health centre of sub- medical asst. centre multipurpose worker District hospital(Inter mediate) or equivalent Provincial or similar hospital (regional) Mostly general practi ioner partly specialists Specialists

2. Secondary

3. Tertiary

4. Quatenary Institute of research Super-specialists, and higher training researchers

Geographical, environmental and miscellaneous factors

1. 2. Meteorological Information Temperatures Rainfall Humidity Geographical information Existing road and rail communications Terrain: mountainous, riverine, plain Surrounding district boundaries Susceptibility to quakes/floods

 Ecology-atmospheric pollutants from adjoining industries and other sources, proximity of sources of noise such as air-fields or rail/tracks Building height restrictions due to proximity of airports 3. Miscellaneous availability of !Trained manpower !Water !Electricity !Sewage disposal

MASTER PLAN IN ITS TOTALITY Circulation routes a. Internal Circulation b. External Circulation Other Requirements a. Distances b. Compactness c. Parking for each inpatient bed there is likely to atleast one visitor per day

and for each inpatient there will be about three outpatients d. Landscaping : Preferably best located on relatively high ground e. Visual Impact f. Linearity

ZONAL DISTRIBUTION AND INTER RELATION OF DEPARTMENTS A. Hospital Stores B. CSSD C. Hospital Kitchen D. Hospital Workshop E. Laundry

A. Miscellaneous 1. Size of the location of the water tanks 2. Location of the Hospital incinerator 3. Boiler house for supply of steam to laundry, CSSD and Kitchen 4. Garages of ambulance and staff vehicles 5. Mortuary of storage of dead bodies and post mortem room 6. Residential campus of specialists, residents, nurses and other essential staff. 7. A Community Centre with grocery and fruit shop, barbers shop, and a community hall 8. Dharmshala or choultry for attendants and relatives of the patients to stay.

Space requirements total gross building total area (building gross) 782-1005 sq. ft. this includes stairs corridors ducks, wall thicknesses, and mechanical area Taking liberal figures of 1000 sq. ft. per bed the land requirements for 500 hospital bedded would be an area of one hectare for every 25 beds

BREAK DOWN OF PROJECT COSTS 1. Acquisition of site 2. Site survey, investigations 3. Landscaping 4. Construction contract-building with fixed equipment 5. Supervision and inspection 6. Equipment diagnostic and therapeutic 7. Movable equipment 8. Architect fees 9. Consultants Fees 10. Site engineer fees

Categorization of Services
Group I : Services required immediately telephones domestic services, Central liner services, stores and works department Group II : Requiring lengthy period of preparation CSSD for trial runs, X-ray, OT , Pharmacy. Group III : May be partially open before patient admitted paramedical services and OPD Group IV : Will not operational until all above departments are open - wards

Plants and Equipments Required in A General Hospital

Physical Plant : Lifts Refrigeration and air-conditioning Fixed sterilizers Incinerators Boilers Pumps Kitchen equipment Mechanical laundry Central Oxygen, suction Generator

Hospital furniture and appliances Beds Stretchers Trolleys Wheelchairs Bedside lockers Dressing drums Kitchen utensils Bedside lamps Movable screens Hand wash stands Operation tables Instrument trolleys Bedpans Waste bins Hospital linen

General Purpose Furniture and Appliances 1. Office machines Intercom sets Typewriters Calculators Cash registers Filling systems Electronic exchange Computer

2. Office Furniture 3. Crockery and cutlery Diagnostic and therapeutic equipment 1. Equipment for general use Surgical instruments BP Instruments Suction machines Rehabilitation department equipment Physiotherapy department equipment Sterilizers Equipment for clinical laboratory Voltage stabilizers Refrigerators Chemical analyzers-microscopes

2. Equipment interacting with patients during diagnostic and therapeutic procedures Short-way diathermy machines Electric cautery machine Defibrillators X-ray machines Monitoring equipment Respirators Incubators ECG machines USG machines