Hospital Operation Chapter 3

Medical Care System

 Learning Objectives
OPD: Location, space requirement, waiting time,
ancillary facilities
Casualty: Location, types of emergency services,
staff
Disaster preparedness
ICU: Types, staffing, essential equipment
IPD: Types, activities, staffing, ancillary services
O.T. : Layout, zones, sterilization, scheduling,
management
 Importance
Reduce morbidity, mortality-stepping stone to health
promotion and disease prevention
Reduces the no. of admissions
Ensures only those who need inpatient care are
admitted
Demand:
No. of outpatients visits/person/year from
population living in the formal catchment area of the
hospital
Re attendance rate / new outpatients registered
Proportion of pregnant women attending antenatal
clinics
 Location
Independent approach to entrance of the
hospital, on ground floor for easy access
Close to registration, casualty, laboratory,
radiology, pharmacy
OPDs of all specialties in the same building for
cross reference
Kept close when not used
Lay out of OPD
 Functions:
Provide Specialist diagnostic specialist opinion
Treat ambulatory patients
Screen patients for hospitalization
Follow up of discharged patients
Provide primary healthcare
HE
Immunization
Well baby clinics
ICTC
Training & education of medical, paramedical & nursing staff
Collection, compilation analysis of medical records
Functions as sentinel surveillance centre for disease control
Epidemiological study of diseases
 Flow chart of OPD in a hospital
Radiology, pathology, pharmacy,
Blood bank, ECG, EEG, Physiotherapy

Pharmacy, ICTC, ANC

Consultations, Injection Room,
Dressing room, Immunization clinic
Medico social worker
Plaster rm, minor surg. Proced.

Consulting Consultants
Administrative
Chamber of offices
area
doctors

Sub-waiting area OPD Sub-waiting area

Public relation Billing counter Admitting

Medical Office
Records Enquiry
Department Information Waiting area Public utility
Registration services
appointments

Outpatients
Physical facilities of OPD of a hospital

Clinical area

Patient Admin.
area OPD area

Circulati
on area
 Patients area
1. Entrance
2. Reception
3. Registration
4. Record room
5. Desks
6. Waiting area
7. Public utility service
8. Snack bar
9. PCO
10. Audiovisual material
11. Mobile charging facility
12. ATM
13. Locker room/cloak room
 Clinical area
Sub-waiting area Laboratory
Consultation room Radiology
Special examination room Blood bank
Injection room Health education
Dressing room Medical and social work
Minor OT Counseling services
Plaster room/ Cast room Physical medical rehabilitation
Pharmacy
 Administrative area
Administrative office-15 sq. meter for 100
bedded hospital
Business office
Housekeeping area
Store room for
General store
Drug store
Linen store
 Circulation area
Stairs
Corridors
Lifts
Conveyer belts
 Equipments
Wheel chairs Examination coach
Stretchers Wash basin
Work tables Instrument trolly
Physicians desks Equipments for resuscitation
Wall mounted cabins E.C.G. Machine
X ray view box Portable X ray machine
Revolving stool Ultrasonography machine
Chairs E.E.G. Machine

Staffing
Medical staff
Nursing staff
Paramedical technician, security, clinical, housekeeping
OPD in charge with his secretariat
PRO
 Control of overcrowded OPD
Automation, trained staff, new time management
techniques
Dedicated full time doctors
Displaying map of the hospital at the entrance,
signages, close location of diagnostic
departments
Better scheduling
Efficient billing and front office staff
Proper flow, I.T.
 Control of overcrowded OPD
Screening and disposal of minor illness patients
by general duty doctors
Special clinics at different timings
Individual or block appointment systems
Applying queuing theory
Synchronize functioning of ancillary facilities with
OPD workload
Increasing the hours of OPD services, even
evening OPD services
 Public relations
OPD timing
Overcrowding
Appointment system
Queue jumping
Managerial issues Citizens charter
Absenteeism
Quality management
Computerization
Grievance redressal system
 Evaluation
Volume of work performed
a. Clinic/department-wise statistics
b. New patients/follow up patients
c. Trends of patients attendance i.e.
seasonal/monthly
d. Utilization rates of clinics
e. Tests performed
f. OPD procedure
 Evaluation
Utilization statistics
a) Average no. of visits per person per year
b) Age/sex/race/geographical distribution of
population
Visit level
a) New appointment
b) Walk in appointment
c) Immunization
d) Antenatal clinics
Cost and revenue
a) Direct patient cost like salaries, cost of supplies
b) Indirect patient cost like utilities, housekeeping etc.
Casualty
 Location
Ground floor
Direct access to the main road
Adequate space for vehicles
Separate entrance, close to admissions,
medical records, cashiers booth
Close to radiology
 Types of Emergency Care
Agencies and organizations( both private and
public)
Communication and transportation network
Trauma systems
Rehabilitation facilities
Highly trained professionals
Informed public
Govt. EMS: Fire and Police
Voluntary
Private Ambulance Service, hosp. based
 Functions of emergency department
To provide immediate lifesaving medical care
To provide emotional support to patient and his relatives
To take care of medico- legal aspects of the patient-liaison
with police
Communication with media-disasters, VIP Patients
Education, training, research
To provide transport services both intramural and extramural
Types of emergencies:
First-What must be done within few minutes
Second-what must be done within 6 hours
Third emergency- what must be done within 24 hours
Types of emergency services: Major-teaching hosp.; Basic-all
hosp.; Standby-PHC; Referral-First aid given, referred
 Planning of emergency services
Easy access to people, vehicles
Separate access to ambulance, reserved ambulance parking
Resuscitation arrangements-pre hosp. and in hospital
Close watch and medical supervision of patients
Special protection for violent patients
All amenities / comforts for patients waiting area
Demarcated triage area/ well equipped emergency OT
Effective communication system-specialist, transport,
investigations
Effective disaster management program; Adequate staffing
SOPs to minimize errors; Security and safety of pts., staff
Teaching, training, evaluation system
 Patients area
1. Reception
2. Trolley bay
3. Waiting area
4. VIP ROOM
5. Space for security, staff, police, ambulance
6. Public utility service
7. Coffee and Snack bar
8. PCO, Fax, computer, broad band,
photocopiers
9. Pharmacy
 Clinical area
Trauma room Janitors closer
Examination and treatment Duty room for residents, house
room officers, interns
Triage area for screening and Lockers for staff
quick segregation of patients Seminar room, meeting room
Staff works area Room for anesthetist
Nursing station
Emergency ward with adequate
no. of beds
Storage area for drugs, linen
Toilet for patients
 Administrative area / Circulation
Accommodation for CMO, duty officer, consultants
Office for sister i/c of casualty
Office for assistant/ deputy medical superintendent
or i/c Casualty
Administration office
Accommodation for APRO/ PRO of casualty

Circulation: Ramps, corridors, conveyer belts, lifts for

easy and smooth flow of staff, patients, visitors,
supplies.
 Equipments
Centralized piped oxygen, suction Cut down set for IV Line
supply

Airways, outlets, resuscitation bag Utility table, emesis basin, kidney tray

Manometer-portable and wall Slit lamp, loupe ENT equipment

mounted

Defibrillator Equipments of OT

ECG machines and monitors Adequate no. of trolleys, wheelchairs,

stretchers

Pulse oxymeter Portable X ray, USG, CT/ MRI, Endoscopes

Nebulizer, ambubag, vent mask, Well equipped path. laboratory

spacers

IV fluids, drip stand, catheters Sufficient bandages, cotton, plaster, drugs

 Staffing/ other requirements
Medical manpower: physicians, surgeons, orthopedic,
pediatricians, anesthetist, CMO, intern, house officer,
residents
Nursing: full timenursing staff
Para medical staff: ECG technician, OT technician,
physiotherapist, lab. Technician. Radiographer
Group D and C staff: ward boys, safai wala, chawkidar, drivers,
security personnel, clerical staff
Polices/ Procedures-SOPs
Ambulances with equipments and efficient team
Record maintenance*medico legal requirements
Referral policy
Disaster preparedness
Code blue procedure- announce emergency
 Physical facilities for 200-300 bedded hospital
Name of facility No. Size in ft. Area in sq. ft.
Main entrance 1 8 * 10 80
Waiting area 1 20 * 20 400
Reception 1 -
Examination cubicle 4 80 * 4 320
Observation ward 10 84 sq. ft. 840
Emerg. X ray room 1 12 * 15 180
Emerg.lab. 1 12 * 15 180
Treatment room 1 12 * 15 180
Fracture/ plaster r 1 12 * 10 120
 Physical facilities for 200-300 bedded hospital
Name of facility No. Size in ft. Area in sq.ft.
Doctors room 1 240 240
Nurses duty room 1 12 * 10 120
ECG technicians rm 1 12 * 10 120
Room for Gr. C & D 1 12 * 10 120
Store room 1 12 * 10 120
Staff toilets & urinals 2 8 * 10 160
Water cooler 1 - -
Police post 1 12 * 15 180
Pts. Toilets & urinals 1 12 * 15 180
 Maintenance of records
Records are required for:
Court case
Compensation to injured patient
Insurance
In the event of complaint
Medical audit
Records maintained in casualty
Case register-all patients
Register for medico-legal cases
Police intimation register
Call book to ask for services for different specialty doctors
In/out register for resident doctors
 Evaluation
No. of visits
Average length of visits
Variation to peak and lean period
Seasonal trend of attendance
Medical audit:
Completeness, adequacy and accuracy of records
The correctness and substantiation of the final diagnosis
Errors in diagnosis and management of cases
Case of complication
Cases of death
Quality of record maintenance
Investigations which should be avoided/ where indicated
could not be done-reasons for not doing
Polices, procedures, ambulance, record maintenance, referral
policy, medico-legal case, disaster preparedness,
Grievance redressal system-pts., visitors ( CPA)
 Disaster Preparedness
Identified Disasters:
Floods and Drainage Management
Earthquakes
Dam failures/ Dam bursts
Biological Disasters/ Epidemics
Cattle Epidemics
Nuclear Disasters
Fires- forest, urban, rural
Serial Bomb blasts
Air, Road, rail Accidents
Food poisoning
 Health objectives of Disaster
Preparedness
Prevent morbidity and mortality
Provide care for casualty
Manage adverse climatic and environmental
conditions
Ensure restoration of normal health
Protect staff, public health and medical assets
 Disaster Mgt Approach in Hospital
Discharge less acutely ill patients
Cancel elective procedures
Add additional beds to wards/ rooms
Set up cots in open spaces
Pre established procedures to call back staff
for extra duties/ shifts
Maintain/ increase stocks of equipment/
supplies, pharmaceuticles
 Mass casualty management plan
Situation analysis
Triage
Roles and responsibilities
Triggering the plan
Operational areas
Support for operational areas
Co-ordinating with other health facilities
Community relations
preparedness
 ICU
Specialty nursing units designed,
equipped and staffed with specially
skilled personnel for treating very
critical patients or those requiring
specialized care and equipment
 Functions of ICU
Close observation and treatment of critically ill
patients
To provide specialized treatment with specialized
highly skilled manpower and equipment
To utilize skilled staff more effectively and efficiently
Surveillance of critically ill patients
Care for postsurgical operations
To provide care for medical emergencies
Care for cardiac emergencies
To provide support to critically ill patients
 Functions of ICU
Classification:
Open-Attending physicians admit case
Semi closed Director of ICU approves
admissions
Closed unit-Director and associates are
responsible for all the admissions and
discharge
 Types of ICU
NICU: Neonatal Intensive Care Unit
PICU: Paediatric Intensive Care Unit
SICU: Surgical Intensive Care Unit
CCU: Coronary Care Unit
 Staff of ICU
Administrator
Committee
Medical Staff
Nursing Staff
Staff Nurse Patient Ratio
Morning Shift 1:1
Evening Shift 1:2
Night Shift 1:3
 Physical facilities
Location-close to OT/Recovery rooms Easy
access to emergency, resp. therapy, surgery,
pathology, radiology
Bed strength-6-20
Patients space min. 15 sq. ft. of clear area
Nursing call-Two way communication system
Hand washing-pt. bed area
Patients services Pipeline oxygen, compressed
air, electrical sockets 5/15 amp.
 Physical facilities
Lighting-nonreflecting 25-30 Lux active
treatment, 150-200 Lux doctors/nurses room
Temp-60-70 degree F.; Noise-50 decibel;
Humidity 50-60 %
Electricity-round the clock with UPS, inverters,
standby generator
Medications-essential drugs, Iv fluids,
refrigerator, SOP for inventory control
Isolation room
Storage area-housekeeping and other supplies
 Equipment
Monitoring Therapeutic Equipments
Equipments
Cardiac monitor Ventilator
Pulse- oxymeter Nebulizer
ECG Laryngoscope, Bronchoscope,
Endoscope
USG, 2D Echo Defibrilator

Diagnostic Instruments
Endoscope Tracheostomy set
ECG Machine Cut-open set for IV line
X ray machine-portable Pace maker attachment set
USG Machine
 Inpatient department

To provide accommodation for patients

at the point in an illness when
dependence on others is highest
 IPD
Components:
Nursing station
The beds
Necessary services, storage work
Public areas needed to carry out the nursing care
Functions:
To provide highest quality of medical and nursing care
To provide essential equipments, drugs and other materials required for
patient care
To provide comfortable env.-eating, sleeping, toilet
To provide facilities for visitors
To provide highest degree of job satisfaction
Meticulously maintaining medical records
To provide opportunity for education, training and research in the field of
medicine, nursing and hosp. admin.
 Planning and designing of ward
Factors:
Hospital policy
Space requirement
Function
Work plan
Location-away from main roads and OPD
Work flow
Interdepartmental relationship
Traffic flow- horizontal circulation up to 300 beds. More-
vertical
Staffing of IPD
Communication
Utilization of service
 Forms of ward
Nightingale
Rigs pattern
Modified Rigs pattern
Racing track ward
T and Y shaped ward
Single straight corridor ward
L shaped plan
Cruciform plan
H shaped plan
E shaped plan
Box plan
Central corridor multiple rib pattern
 Nightingale ward
characteristics Disadvantages
Pts. Beds in two rows at right angle to No privacy of patients
the longitudinal walls
Bathroom and WC at one end Noise pollution
Nursing station, doctors room, other Risk of cross infection
facilities at other end
Length of the ward 96 feet to home Constant glare to patient
30-35 patients
Continued till 1925
Bathrooms and isolation rooms were
added to it
Then nurses table shifted to centre
In topical countriescorridors on either
sideto protectward from direct
sunlight
 Rigs ward
Advantages Disadvantages
Privacy to patient Communication between
patient and nurse is difficult

Risk of cross infection Direct observation of pt.

minimized difficult

Isolation of infection cases Nurse has to walk more due to

earlier complexity of wards

Enhancing flexibility of More nurses required, costly to

utilization build and maintain
 Components of a nursing unit
Primary; 1 bed-14 sq. meters; 2 bed 21; 3bed 28; 4 bed 42 sq.
meters
Ancillary-nursing room (20 * 20), MOs room, clean utility
room9100-120sq. Feet), Treatment room, kitchen ( 100sq.
Feet), Day care room, stores
Auxilliary
Sanitary- dirty utility room, bathroom and WC
Urinal 1 for 6 beds
WC 1 for 8 beds
Bathroom 1 for 12 beds
Washroom 1 for 10 beds
Janitor room
 Ancillary Services attached to wards
Nursing station
Treatment Room
Clean Utility Room
Ward Kitchen / Pantry
Stores
Duty Room for Doctors
Seminar Room
Attendants Room
Side Room Laboratory
Locker Room for Staff
Wheelchair / Trolley Bay
Operation Theatre
 Aims of planning
To promote high degree of asepsis
Ensure maximum safety to patients and staff
working in OT
Ensure maximum utilization of OT
Ensure maximum comfort to the surgical team,
considering long hours of work in difficult posture
To provide complete environmental control
Flexibility of uses of operation suites
Prevention of iatrogenic complications
 Clean zone
Preop. Room
Recovery room
Theater work room
X ray plaster room,
Protective zone sister room
Patients waiting Anesthetist room Sterile zone
area and reception Operating suite
Trolley bay Scrub room
Lift Anesthesia room
Stairs Zoning of OT Instruments trolley
Switch room area
Pre anesthesia room
Changing room
Store room Dirty room
Disposal corridor
Janitor corridor
Disposal zone
 Sterilization of Operation Theatre
Special air flow pattern- filtered and purified air
Standard cleaning- disinfection with appropriate
chemical agents
Fumigation
Infection Control Committee, restricted entry,
thorough washing and carbolisation, regular
training
Operation theatre discipline, surveillance,
bacterial counts
Keeping floors dry, vacuum cleaning
 Functions of OT
Perform surgery in safe, aseptic environment
Ascertain patients comfort, both physical and emotional
Maintain high standards of performance
Acquire, maintain, suitably utilize equipments
Maintain theatre discipline by following prescribed
procedures, up dating time to time
Attempt maximum utilization of theatre by proper scheduling
Prevent iatrogenic complications
Prevent health hazards-env., radiological, anesthetic and
infecting agents
Minimize postponement of surgery
 Criteria for planning
Environmental criteria: provide complete env. Control for safety
of pt./ staff
Economic criteria: optimization of interrelationship between
various financial areas and operating departments
Work flow criteria: The flow of patients, staff and supplies in
operating department to be well planned
Functional criteria: Design follows function

No. of opers./day= No. of surg. beds * % of bed occ. Rate 365

Av. length of stay *10* No.of working days
 No. of OT required
No. of Indoor OPD+ Emergency
hosp. beds Minor Major Minor Major
300 2 3 1 X

500 2 5 1 1

750 2 8 1 1

1000 2 10 1 1
 Advantages of grouping of OT
Easy expansion in future
Maximum flexibility of use
Better staffing, organization and control
Greater efficiency in resource utilization
Easy to maintain
Minimize cross infection
Increases utilization of OT
Minimization of cancellation of OT list

SIZE: General: 40 sq. meter

CVTS/Neurology/Orthopedics: 60 sq. meter
Endo-scopy suite procedure room: 20 sq. meter
 Staff
Theatre superintendent: Maintain cleanliness, asepsis;
equipments in working order; adequate stock of
consumables and instruments; finalize operation
schedules
Trained nurses: two per table; special training for
pediatric, cardiac, neuro surgery. Recovery room nurse
patient ratio-1:1
Theatre assistants: assist in preparation of trolley;
packing instruments, gloves, gowns, coordinating supply
of sterilized items from CSSD; arrange for the
transportation of the patients from ward to theatre and
back
Labour staff: cleaning, segregation, taking blood/biopsy
samples to laboratory
 Administration of OT
OT scheduling- perfect planning, patient flow
and coordination, timely patient preparation,
efficient patient reception, parallel processing
by use of induction area, flexible facilities,
continuous process improvement
Punctuality
Training of staff - asepsis, universal
precautions
Operating list- well in advance
Dirty cases- at the end
 Administration of OT
Monitoring of OT asepsis:
Once a week maintenance
Swabs for microbial growth
AC checked including filters
HEPA filter
Env. Control-temp., humidity, ventilation, air change
Adequate pressure maintenance
Disinfection of equipment, OT table, other articles
Fumigation at regular interval with std. equipment
and std. procedure
Staff with infection should not be allowed to enter
OT
Common problems with O.T. Management

Poorly designed processes

Change reluctance/ friction
Lack of motivation
Dodging responsibility/ placing blame
Lack of discipline