Planning, Designing, Work flow of IPD of a Hospital

1. By Vidya

2. Inpatient wards are for those patient who need treatment under healthcare
personal supervision. Patients are admitted in Inpatient ward for short or long
term depending on severity of their disease.

3. • Nursing station
• ICU, CCU, HDU, OT, Post-operative care & Burns unit
• Pharmacy
• Radiology, Laboratory service
• Beds
• Sanitary Area
• Sluice Room
• Pantry
• Unit store
• Treatment room
• Dinning & Daycare/Recreation
INPATIENT DEPARTMENT CONSIST

4. • To provide highest possible quality of medical & nursing care
• To make a provision for essential equipment, drugs and other materials required for
patient care.
• To provide comfortable and desirable environment to patient as substitution of home.
• To provide facilities for visitors
• To provide opportunity for education, training and research
• To provide highest possible satisfaction to patient.
FUNCTIONS OF INPATIENT DEPARTMENT

5. FEATURES OF IPD
The IPD forms 33%-50% of the structure of hospital construction and most of the
equipment and staff are in this department with maximum amount of patient care,
training, medical teaching and research concentrated in the department.

6. FORMS OF INPATIENT WARDS
 Nightingale
 Rig’s pattern
 Modified Rig’s 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

7. NIGHTINGALE WARD
 Beds in two rows at right angle to the longitudinal walls
 Nursing station, doctor’s room, other facilities at other end
 Bathroom and WC at one end
 Length of the ward 96 feet to home 30-35 patients
 It may have side room if isolation room required for privacy and improve condition
 It provides good visibility, economical and plenty of fresh air ventilation

8. Disadvantages of Nightingale ward(open ward)
 Noise pollution
 No privacy for patient
 Risk of cross infection
 Fatigue of nurses
 Less space between bed
 Constant glare of patient

9. Modified Nightingale ward
 Nursing station is in center of the ward
 Ancillary and Auxiliary services are at one end of the ward
 Utility and bathroom are at other end of the ward
 Nurses travel is reduced
 Supervision over patient condition is easy

10. RIG’ S PATTERN WARD
 Ward is divided into small compartments separated from each other.
 Each compartment has 4-6 beds
 Beds may be on one side or parallel to each other
 1-2 Isolation room can be kept

11. ADVANTAGE OF RIGG’S PATTERN
 Privacy to the patient
 Risk of cross infection minimizes
 Less noisy
 Isolation of infectious case can be easier
 Enhancing flexibility of utilization

12. DISADVANTAGE OF RIG’S PATTERN WARD
 Communication between patient & nurse is more difficult
 Direct observation of patient is difficult
 More staffing required
 More nurses required, Costly and difficult to maintain than open ward

13. COMPONENTS OF WARD UNIT
 PRIMARY ACCOMMODATION: It consist of single bedroom or multiple bedroom for
patient and nursing station
 ANCILLARY ACCOMMODATION: Service for direct support of treatment. Example.
Portable X-ray, side lab, Pantry, Dietary, Mobile Pharmacy
 AUXILIARY ACCOMMODATION: Service in indirect support of treatment. Example.
Store, Housekeeping, Doctor’s room, Nurse’s room, Seminar- Teaching room.
 SANITARY ACCOMMODATION: Consist of WC, Bathroom, Janitor’s room, Sluice
room

14. COMPONENTS OF 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
 Auxiliary
 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

15. ANCILLARY SERVICES
 Nursing station
 Ward kitchen/ pantry
 Treatment room
 Clean and utility area
 Doctors duty room
 Seminar room
 Attendant’s room
 Side room laboratory
 Locker room
 Wheelchair room/ Trolley bay

16.  Physical Facilities related requirement
 Sufficient space for carrying out patient care activities with adequate circulation space
 Facility should be non-slippery floor, safe electrical fittings, no accidental spot etc to avoid injury
chances
 Inter bed distance should be around 6feet
 Hand washing area easily accessible to healthcare staff
 Accessibility of fire fighting equipment
 Crash cart should be kept from where it is easily accessible to healthcare staff.
 Patient washroom should have anti skid mats, emergency call button, grab bars, door opening from
outside
 Adequate privacy arrangement especially in multi-bed ward
 Availability of all necessary patient care equipment
 Biomedical waste bins as per BMW rules
 Segregated storage area for clean and dirty supplies
 Emergency exit route should be displayed

17.  Staffing related requirement
 Categories of nurses required to be identified (depending upon the type of ward)
 Nurse: Patient ratio to be defined for the ward in each shift
 Duty roster to serve as an evidence of nurse patient ratio
 Doctor should be available round the clock
 Other support staff as required

18.  Ward management related requirement
 Linen on patient bed to be changed daily
 Periodic cleaning of mattresses pillow and other bed items
 Temperature of the refrigerator in which medicine should be checked at-least once in each shift
 Crash cart should have life- saving drug and equipment it should be replenished if used
 All emergency medicine should be available as per defined quantity
 Mechanism for replenishing emergency medicine to be followed
 High risk medicine to be identified and stored separately
 If the narcotic drugs and psychotropic substance act are temporarily stored it should be under lock and
key. NDPS regulation should be followed.
 Reporting adverse patient
 List of hazardous material in the ward to be identified material safety data sheet(MSDS).
 Bio- medical waste should be segregated as per regulation
 Area of ward washroom should be kept neat and clean
 Clean supplies and dirty used items should be stored separately
 Medical records should be stored as per hospital policy
 Security and confidentiality of medical records to be maintained as per hospital’s policy
 Maintenance of admission discharge, stock, laundry, adverse incident register is necessary.

19.  Staff awareness related requirements.
 Components and time- frame for initial assessment of admitted patients.
 Uniform care policy and patient care processes that fall under it
 Patient’s rights
 Dealing with HIV+ve patients and manufacturing confidentiality
 Provision of basic cardiac support
 Code blue policy and procedure
 Other emergency code(pink code, yellow code, red code etc.)
 Identification and care of vulnerable patients
 Care of surgical patient/ paediatric patients/ obstetric patient
 Proper identification of patient
 Safe medication practices(things to check before administration monitoring, verbal orders
administering high risk medicine etc.)
 Safe blood transfusion practices
 Policy and procedure of patient’s restraint
 Pain management policy and protocol
 Standard precaution for infection control (hand hygiene, use PPE etc.)

20.  Safe injection practices
 Patient safety incidents, its types and reporting(such as near miss, sentinel, adverse drug reaction
etc.)
 Emergency evacuation plan
 Their role during any disastrous situation
 Basic fire safety measures

21.  Quality indicators of wards
 Average time for initial assessment of admitted patient and percentage outliner
 Incidence of medical errors
 Percentage of admission with adverse drug reaction
 Percentage of patients receiving high risk medicine and developing adverse drug reaction
 Percentage of transfusion reaction
 Incidence of bed sore after admissions
 Incidence of patient right violation
 Incidence of needle stick injuries
 Incidence of missing medical records
 Percentage of non-compliance observed related to infection control practice
 Patient satisfaction rate of the ward
 Time taken for discharge
 Average Patient : Nurse ratio in each shift
 Percentage of current medical record that are incomplete as per hospital policy.

22. OPERATION THEATRE

23. Operation theatre is a facility within the hospital in which surgical procedures are carried out in aseptic
environment.
Operating rooms are spacious, easy to clean, and well-lit, typically with overhead surgical lights, and may
have viewing screens and monitors. Operating rooms are generally windowless and feature controlled
temperature and humidity. Special air handlers filter the air and maintain a slightly elevated pressure.
Electricity support has backup systems in case of a black-out. Rooms are supplied with wall suction,
oxygen, and possibly other anesthetic gases. Key equipment consists of the operating table and
the anesthesia cart. In addition, there are tables to set up instruments. There is storage space for common
surgical supplies. There are containers for disposables. Outside the operating room is a dedicated
scrubbing area that is used by surgeons, anesthetists, operating department practitioners, and nurses prior
to surgery. An operating room has a map to enable the terminal cleaning staff to realign the operating table
and equipment to the desired layout during cleaning.

24. 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 equipment
 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-environmental, radiological, anesthetic and infecting
agents
 Minimize postponement of surgery

25. OBJECTIVE OF PLANNING
 To promote highest standards of asepsis
 To ensure maximum safety for patient and staff from installation hazards
 Optimum use of OT staffing time
 Smooth and effective functioning of OT
 Good working environment for Doctors and staff
 Allow flexibility by use of multiple operating suits

26. Functional consideration of OT
 Location:
 Maximum six suits in one OT complex, preferably ground floor
 Easy access to CSSD, sterilization unit emergency and surgical ward
 Maximum protection from sun, sounds, heat and wind
 Independent of general traffic flow
 Easy access to other area of OT
 Size:
 General OT unit 18’x18’ or 40sq meter
 Super specialty OT unit 60sq meter
 Additional room for heart lung machine, C-arm etc.
 Paired OTs help in proper utilization of instruments and equipment.

27. Factors Influencing Number of OT
Factors
Type of Hospital
Staff & strength
& capacity of
sterile supply
Hospital policy
No of Hospital
bed
Type of surgery
Average length
of stay
Turn over rate in
OT
Time for OT
maintenance
Projected
emergency
surgical case
Average No. of
operations

28. PLANNING CRITERIA FOR
FUNCTIONS ERGOMETRIC or
WORK FLOW
 LOCATION
 SIZE
 NO. OF OTS
 GROUPING OF OTS
 ZONING
 EQUIPMENT
 INSTALLATION
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PLANNING
CRITEREA
TECHNICHAL ENVIRONMENT
Space free movement of staff,
patients, supplies
• OT Staff
• Functional Area
• Preparation of
Patient
• Sterilization unit
• Scrub station
• Designing &
finishing
• Lighting
• Air conditioning
• Ventilation
• Water supply
• Fire safety
• Plumbing
• Clothing

29. NUMBER OF OTS
 No. of OTs= One OT unit for 50 surgical beds
 No. of Operation/day= No. of Surgical bed
 Average length of stay surgical patient
 No. of operations/day= No. of surgical beds x % bed occupancy x 365
ALS x 100 x No. of working OT day
 The number of operation per suit should not exceed 06 per day or 8 to 10hr
per day

30. Zoning of OTs
Protective
zone Clean zone
Disposal
zone
Aseptic
zone
Zoning

31. ZONING OF OPERATION THEATRE
CLEAN ZONE
• Preparation of patient
• Recovery room
• Theatre work room
• X-ray plaster room
• Sister room
• Anesthetist roomPROTECTIVE ZONE
• Patient waiting area &
reception
• Trolley bay
• Lift
• Stairs
• Switch
• Pre anesthesia room
• Changing room
• Store room
STERILE ZONE
• Operating suit
• Scrub room
• Anesthesia room
• Instrument trolley
area
DISPOSAL ZONE
• Dirty room
• Disposal room
• Janitor corridor
ZONING of OT

32. PROTECTIVE ZONE
 Reception, patient identification & case sheet check
 Waiting area for relatives
 Changing room for OT staff & surgeon
 Pre-anesthesia room
 Store room, trolley boy
 Autoclaves
 Record & controller room
 OT in charge, electricity control
 Seminar & meeting room
 Entrance to observation gallery

33. CLEAN ZONE
 Patient preparation room
 Recovery room
 Plaster room, blood storage, frozen section
 Work room for doctors, sisters
 Nurses duty room
 Anesthesia room
 Equipment room, drugs, linins, X-ray board
 Clean closet, telephone & fire fighting equipment

34. STERILIZATION OF OPERATION THEATRE
 Special air flow pattern-filtered & purified air
 Standard cleaning- disinfection with appropriate chemical agents
 Fumigation with Formaldehyde, Phosphine, Methyl Bromide etc.
 Infection control committee, restricted entry, through washing & carbonization,
regular training
 Operation theatre discipline surveillance bacterial counts
 Keeping floor dry, vacuum cleaning

35. ADVANTAGE OF GROUPING
 Easy expansion in future
 Maximum flexibility of use
 Better staffing, organization & control
 Great efficiency in resource utilization
 Easy to maintain
 Minimize cross infection
 Increases utilization of OT
 Minimization of cancellation of OT list
 Size : General: 40 sq. m
 CVTS/Neurology/ Orthopedics: 60sq. m
 Endoscopy suite procedure room: 20sq.m

36. CRITERIA OF PLANNING
 Environmental criteria: provide complete environment control for safely of Patient/staff
 Economic criteria: Optimization of interrelationship between various financial areas and Operating
department.
 Workflow: the flow of staff, patient & supplies in OT to be well planned
 Function criteria: design follows function: No. of surgical bed x % of bed occupancy rate X365
Average length of stay x 10 x No. of working day

37. Environmental factors
 Electricity
 ensure round the clock electric supply
 Standby generation system
 UPS for all equipment and gazettes
 Central field illumination
 Floor round table illumination
 Minimum glares, four power outlet on each wall at height of 1.5m
 Separate copper earthing
 Avoid extension cord
 Operating light
 Shadow less, mobile, hanging pendent easily maintainable OT light
 Intensity should be 4000lux at incision & 8000lux at 9 cm deep
 Air-conditioning
 Control asepsis, controlled air flow, positive pressure
 Maintenance of temperature 220c
 Humidity 55% + 5 percent
 100% fresh air
 Ventilation
 There should be +ve pressure ventilation with lower pressure
 All anesthesia gases should be vented out to exhaust
 Flow of air 2 to 3 cu m/min
 Air removal from floor level through weight lever
 Plumbing
 Sewerage shaft should not pass through operating room
 Toilet should be provide in the changing area
 gas pipeline system should be ensured
 All fire safety measure to be taken

38.  Water supply
 Adequate & running fresh water supply to be ensured
 Ensure self water flow after de salination
 Autoclave Room
 Provision of steam supply
 Proper maintenance of autoclave
 Linen supply should be regular & adequate
 Attached to theatres
 Equipment to be kept in cupboards
 Diagnostic and operating instrument should be disinfected in Lysol

39. Equipment's for OT
Operation Table Surgical Ceiling Lights Pulse Oximetry
Blood Sugar Meter ECG Monitor Anaesthesia
Machine

40. OT FACILITIES AND EQUIPMENT
 Regulated entry to clean zone and beyond
 Facility should be safe, for eg. Non- slippery, safe electrical fillings, no accidental
spot
 Separate storage area for clean and dirty items
 Accessibility of fire- fighting equipment, in all area of OT
 Arrangement for quick availability of sterilized items
 Space for changing shower and personal storage of staff and doctors
 All equipment in OT should be calibrate having label of calibration date and status
 OT should have an emergency evacuating route to be used in case of any
emergency.

41. Pre- Operative and Post- Operative area
 Easy accessibility of crash cart to these area.
 Use of a define criteria to decide shifting of patient from post-operative ward
 Immediate pre- operative checkup before wheeling in patient in operation room from pre-
operative ward.
 Availability of anaesthesiologist whenever required
 All staff to be trained in Basic Cardiac Life Support(BCLS)

42. Process for Patient Safety
 Use of OT attire by all staff.
 Having pre-operative assessment and provisional diagnosis before surgery
 Use of WHO surgical safety checklist for each patient
 Compliance of blood and blood product transfusion practices
 Monitoring of patient during surgical procedure:
 Heart rate
 Cardiac rhythm
 Respiratory rate
 Blood pressure
 Oxygen saturation
 Level sedation
 Documentation of types anaesthesia and anaesthetic medication in patient medical record.
 All staff must be aware standard precaution and OT specific infection control practice:
 Scrubbing
 Sterility maintenance
 Use PPE(Personal Protective Equipment)

43. Medicines/ consumable supplies
 Narcotic to be stored as per regulation (under lock and key, record maintenance etc.)
 Look alike, sound alike medicine to be stored separately as per hospital policy
 Multi- use open vials to have a label of date of opening and expiry
 High risk medicine must be stored separately
 Spirit should be stored under lock
 All high risk materials should be identified listed and material safety data sheet(MSDS) for
each of them should be kept easily available for the staff.

44. Physical Facilities
Reception of
patient
Supportive
services
Administrative
PHYSICAL FACILITIES
House keeping Store keeping
Repair &
maintenance
Clerical
Activities

45.  Patient relating activity
 Reception & preoperative preparation
 Identification of patient & part to be operated
 Shifting patient of OT table
 Administration of anesthesia
 Intubation of positioning
 Preparation of surgical area & draping
 Intubation after operation, recovery from anesthesia
 Supporting Activity
 OT dressing
 Scrubbing & hand washing
 Gowning, putting gloves
 Checking of equipment & instruments
 Administrative Activities
 Preparation of operation schedule
 Preparation of OT list
 Requisition of patient
 Identification of patient, parts and records
 Shifting patient to OT
 Preparation for doctors and assistant staff
 Clerical activities
 Operation note
 Transfusion record
 Consent to patient for operation
 Post of operative advise

46.  House keeping
 Collection of soiled linen
 Counting and collection of soiled instrument disposables
 Counting of abdominal sponges
 Cleaning of OT table & area
 Preparation of receive next patient
 Store keeping
 Ensure required medicine & instruments are ready
 Indent & stocking of essential drugs & injections
 Different king of fluid & blood
 Internal design
 Wall
• Melanin facing wall for easy cleaning
• Height should be 3 - 3 1/2m
• Pale colour to be used
• Resistant to minor damage or impact
• Free crevices and flaking
• All corners to be smoothly carved
• Door should be 1.5m wide swinging & 7feet height

47.  Roof
o Same as well, but can take load of OT lights, X-ray unit, TV camera, gas & electric panel
 Floor
o Easily washable no staining impressive
o Moderately electro conductive
o Vinyl conductive flooring is best
 Fixtures & installation
o Minimum equipment in OT suite
o Adequate free area around the table for free movement
o Table connected to gas pipeline
o No loose over head beams or pipes

48. Environmental Process
 Each operation room should be monitored for humidity and temperature on daily basis
 Each OT should monitor for pressure different at least once a month
 Each OT should be monitored for filter integrity, at least month
 All area in OT should be kept clean from dust all the time
 Regular environmental surveillance for microbes to be done in each OT and other area to
identify forming of any colonies of bacteria.
 Regular cleaning with antiseptic solution of all surface in OT fumigation, if followed by
the hospital can be done.
 Segregation of route of biomedical waste movement if this is not possible time of BMW
should be different from time of staff and clean supplied movement.

49. Awareness of OT Staff
 Prevent needle injuries
 Patient rights
 Dealing with HIV+ve patient
 Isolation requirement of patient
 Various emergency coloures codes followed in hospital
 Safe injection practices
 Patient safety incidents its types and reporting (such as near miss, sentinel, adverse drug
reaction)
 Emergency evacuation plan
 Their role during any disastrous situation
 Quality indicators of OT

50. Quality Indicators for OT and Surgeries
 Compliance percentage to environmental norms( temperature, humidity)
 Percentage compliance to WHO surgical safety checklist
 Percentage of unplanned returns to OT
 Percentage of re-scheduling of surgeries
 Percentage of re- exploration of surgical site
 Percentage of unplanned ventilation following anaesthesia
 Percentage of modification of anaesthesia plan
 Percentage of adverse anaesthesia events
 Anaesthesia related mortality rate

51. OT ADMINISTRATION
 Operation theatre committee
 Each unit must have from 4-7 OT staff
i. Chief Surgeon
ii. OT. Assistant
iii. Chief Anesthetist
iv. Anesthesia assistant
v. Scrub nurse
vi. Anesthesia nurse
vii. Circulating nurse
viii. OT Nurse for assisting
ix. Attendant, House keeping, OT technicians

52. STAFF
 Theatre superintendent
 Maintain cleanliness
 Asepsis
 Equipment in working order
 Adequate stock of consumables & instruments
 Finalize operation schedules
 Trained nurses
 Two nurses per table
 Special training for pediatric, cardiac, neuro surgery
 Recovery room nurse patient ratio 1:1
 Theatre assistant
 Preparation of trolley
 Packing instruments, gloves, gowns
 Coordinating supply of sterilized item from CSSD
 Arrange for transportation of patient from ward to theatre & back
 Labour staff
 Cleaning segregation
 Taking blood/biopsy sample to laboratory

53. ADMINISTRATION OF OT
 Monitoring of OT asepsis
 Once a week maintenance
 Swab for microbiological growth
 AC checked including filter
 HEPA filter(high efficiency particulate air)
 Environment control temperature, humidity, ventilation, air change
 Adequate pressure maintenance
 Dis infection of equipment, OT table, other articles
 Fumigation at regular intervals with standard equipment & standard procedure
 Staff with infection, should not be allowed to enter OT

54. COMMON PROBLEMS WITH OT MANAGEMENT
 Poorly designed process
 Lack of motivation
 Dodging responsibilities/ placing blame
 Lack of discipline

55. Thank You