HOSPITAL HYGIENE.

THE HYGIENICAL ESTIMATION OF PLACING AND PLANNING OF SEPARATE STRUCTURAL SUBDIVISIONS OF HOSPITAL ON MATERIALS OF PROJECT.

Functioning of medical-preventive institutions represents a complex of technological, scientific - practical, economic and social - psychological problems, which decision impossible without the hygienic requirements and recommendations.

Tasks of hospital hygiene:

Ø     Preference to acceleration of recovery the patient, achievement of indemnification of functions, medical and psychological rehabilitation.

Ø     Achievement for psychological and somatic comfort for the patients during stay in hospital institutions.

Ø     Prevention of nosocomial infection

Ø     Maintenance of epidemic and radiologic safety.

Ø     Maintenance of healthy occupational environment for the medical personnel.

Ø     A regulation of use of new disinfectants, detergents, polymeric materials, newest equipment and technologies in medical institutions.

Ø     Formation of bases of a healthy life style at the personnel and patients MPI.

Ø     Minimization of influence on an environment for construction and operation of medical institutions.

         The main characteristic of all medical-preventive institutions is presence so called "hospital environment ". Hospital environment is a set of all factors of physical, chemical, biological and information nature, which carries out influence on an organism of the patient during treatment. There are microclimate of hospital premises, various radiation end wave influences, medicines, antiseptics  and polymer material, special hospital strains of bacteria. These factors define dynamics of medical rehabilitation and health of patient and staff.

Before to buid any health facilities it’s recommended to arrange their planning with the authorized general plans and projects on the basis of the circuits of area development.

Fig. Situation plan of hospital

 

 

Fig. General plan of hospital

 

 When they develop the general plans of medical-preventive institutions it is necessary to take into account local climatic conditions and to provide measures on protection of building and nearby area from the adverse external factors. A choice of the ground area for an arrangement of houses of hospitals, maternity houses and others in-patient institutions should be agreed with local authorities and institutions of environmental health service. The medical institutions have to settle down in residential or suburb zones in conformity with the authorized plan and projects of detailed planning of the residential area in view of its functional application. General hospitals and maternity houses should be placed outside of the centre of cities and settlements, the hospitals of emergency care have to be under construction in view of the maximal approximation to groups of the population, which they are served. The specialized hospitals or complexes with capacity for over than on 1000 beds for  the patient stay during long time, and also special hospitals (psychiatric, tuberculosis and other) is necessary to place in a suburb zone, with 1000 m sanitary space from residential territories. In a choice of a site for health facility it is necessary to remember an environmental sanitary situation and prevailing direction of winds ("wind rose").

 

Table 7.1 Standards for area of health facility in Ukraine

The ground in hospital area must be clean, dry, without sharp differences a relief. The hospital area should be placed in aerodynamic shadow, so that the velocity of air movement did not exceed 5 m/s. They electrify the area, supply it with waterpipes and water drain, border on perimeter and protect by a strip of green plantings with width not less than 15 meters (2-3 lines of trees with low schtamb and rich crone). . It is forbidden to construct hospital institutions in places which were earlier used  for landfills, field of assenization (irrigation, filtration), cemetery, etc., and also that have polluted soil.

         Hospitals and maternity houses should be remoted from the railways, airports, high-speed highways and other powerful sources of pollution.

          At an arrangement medical and maternity institutions in residential zone it is necessary to place them not closer than 30 m from a red line of building and 30-50 m from apartment houses, depending on the number of floors in houses of medical-preventive institutions.

          The hospital area should be gardened and comfortable. The area of green plantings and lawns has to make not less than 60 % of the general area and area of garden zone - 25 sq. m. on a bed.

Bush it is necessary to place not closer than 5 m from a hospital house, trees - not closer than 10 m. Trees and the bushes with poisonous fruits, sharp hooks, allergic-dangerous (give a lot of pollen) plants are not used for gardening.

Hygienic meaning of vegetations:

Positive:

v    Protection against wind, dust and noise

v    Optimization of microclimatic conditions: they give a shadow, normalize a humidity of air and make an aerodynamic shadow

v    Bactericide influence of phytoncides on bacterial pollution of air

v    Oxygenation of air

v    Fixing of dust by a grassy lawn

v    Architectural-planning meaning

v    Aesthetic and psychohygienic meaning

Negative:

v    They can be a potential source of allergens

v    Some plants are poisonous

v    Danger of traumatisation with sharp and rigid stalks of plants, with heavy fruits etc

v    Adsorption of dust particles by plants surface

Hospital area located in territory of settlements should have a strip of green plantings with width not less than 15 m with two-line planting of high-schtamb trees and  a line of bushes. Behind perimeter of a site of polyclinics, woman wealness centers and dispensary without IPD, and also ambulance stations they use a strip of green plantings.

          The bushes should be in width not less than 5 m around of radiologic and infectious departments, and also along the X-ray studies if they are on the ground floor.

Now they use 3 basic systems of building of medical institutions. They are distinguished by a various degree of centralization and isolation of functional departments.

The centralized system of building of hospitals is characterized by the maximal concentration of medical service. Usually the hospital house represents a multi-storeyed structure the separate departmentes and services situated at various levels in general architectural space. In Ukraine the hospital could not have more than 9 floors.

The basic advantages of the centralized system is:

Ø     Economy. At the expense of the small area and absence of duplication of the basic building volumes, functional departments, and engineering networks, the charges on construction and technical equipment of hospital decrease.

Ø     The reduction of the vertical and horizontal ways of movement of the personnel and patients allows to raise efficiency of medical process.

Ø     The large concentration of scientific and technical resources allows to develop departrments on the basis of this centralized type hospitals, which give the qualified and specialized medical care.

In the same time for this system has some drawback:

Ø     The raised risk of nosocomial infections. Difficulty of isolation of departments with a various structure, presence of ascending flows of bacterial aerosols, intensification of loading on hospital environment lead to increased risk of disease.

Ø     Deterioration of conditions of hospital environment. High concentration of technical equipment makes excessing of noise level. The microclimate of the top floors could be overcooling because of power wind drafts.

Ø     The architectural flexibility of the centralized system is low usually.

The decentrilized system is characterized by organization of various functional departments in separate houses.

The essence of pavilion system is the arrangement of separate functional departments in 2-3 floor-houses. The basic advantage of this system is:

·        Good isolation of various departments, that allows to prevent occurrence of nosocomial infections,

·        Good conditions for observance medical care regimen

         However, nowadays they were compelled to refuse decentralized  system. It is connected with:

·        The large expenses on building works and technical equipment

·        Reduction of garden zone

·        Increase of the length of movement for the personnel and patients. There are some technical decisions for reduction of the routes of the personnel, in particular underground type of communication, but it does not solve a problem

          Presently most perspective is the mixed system of construction. It unites features of centralized and decentralized system. It has the most flexible architectural planning.

         The territory of hospitals, maternity houses and other in-patent institutions should have convenient access roads with a firm covering. Internal roads and foot paths should be covered by the concret or asphalt.

The optimum capacity of multiprofile hospitals is accepted in 600-800 beds (allowable - 1000 beds).

Table 7.2 Zones of sanitary space between hospital objects

         In the territory of hospitals there should be the following zones:

1.              Zone of medical departments:  for the infectious patient, medical departments for noninfectious  patient, for pediatric departments, for patrimonial houses and maternity departments, psychosomatic departments, dermato-veneralogical departments, radiologic departments

2.              OPD and administrative zone

3.              Garden zone

4.              Zone of court yard

Separate entrances to the various hospital zones should be provided. For emergencies they provide “Ambulance Road” – the entrance and exit for ambulance should create one-flow driving in and out of the hospital department area.

          The patologo-anatomic departments with a funeral zone should be isolated from ward departments and they should not be looked through windows of the departments, from the hospital garden, and also through windows of inhabited and public houses.

          Distance between houses with windows of chambers has to make 2,5 heights of opposite house, but not less than 24.

          Infectious, maternity, psychosomatic, dermatovenerologic and the children's departments of hospitals should be placed in the separate houses. If hospital has the out-patient department, the last should situate close to periphery of a site.

          Before front entrances to the hospitals, polyclinics, SES, dispensaries and the maternity houses they are provided grounds for the visitors by the account 0,2 m² per one bed or per one visit on duty, but not less than 50 m². Parking area for a vehicle of institutions, employees and visitors should be placed not closer than 100 from ward departments. The temporary parking of a vehicle of individual usage should be placed on distance not closer than 40 m from the entrance to the hospital.

          In territory of infectious hospital (department) should be allocated a "clean" and "dirty" zone isolated by one from one strip of green plantings. On departure from a "dirty" zone there should be stipulated platforms for desinfection of transport.

         Buildings of out-patient  institution as rule do not have more than 5 floors.

         The departments of children's hospitals for children till 3 years with the mothers should be placed not above than fifth floor, the chambers for infants and children's psychiatric departmentes - are not higher than the second floor.

         Cleaning of territory has to be carried out daily. For collecting of wastes and household dust they establish containers with covers. These containers should be disinfected and washed properly. Distance between a ground for dust container and ward and medical-diagnostic departments should be not less than 25 m. They should dispose waste from containers every day. Specific (postoperation, patologo-anatomic and other) medical waste should be incinerated in special furnaces.

         Planning of medical and maternity hospitals have to provide optimum sanitary - hygienic and antiepidemic modes and conditions of  patient stay, work and rest of the personnel.

          Structure of institutions and planning of its premises have to exclude an opportunity of crossing or another contact of "clean" and "dirty" flows.

Maternity houses - specialized stationary institutions, which provide health care for pregnant women in childbirth, recently delivered women, newborns, to the gynecologic patients (at presence  of gynecological department).

         They offer to place in basement of medical-diagnostic departments warehouses, sanitary - household premises for the personnel (wardrobes, shower-room), sanitary care unit, buffets and restaurants for the personnel, central laundry, premises for collecting and sorting of a dirty linen, premises for desinfecting of bad pans, oil-clothes and beds, premises of preservation, regeneration and heating of a medical muds; storehouse of radioactive dross and linen polluted with radioactive substances.

         It’s forbidden to place medical-diagnostic departments, workshops using hazardous materials and reception wards in basement of hospital.

         X-ray rooms and laboratories of radiodiagnostic should not be adjacent on a horizontal or vertical with chambers for the pregnant woman and children. It is forbidden to place x-ray studies under premises of shower, lavatories and other possible sources of water.

         Premises of hospitals, maternity houses and others should be illuminated by day light. The illumination by the second light or only artificial illumination is used in premises of barns, toilets, bathrooms, enema room, rooms of personal hygiene, shower and wardrobe rooms for the personnel, thermostate, microbiological banks, preparation and operational, apparatus, narcosis, photolaboratories and some other premises which do not require natural illumination. Operation room projected with natural illumination, it is necessary to focus on the north.

         The corridors of ward sections (departments) should have natural illumination. Distance between light pockets should not exceed 24 m, and between the first light pocket and window in the dead end of the corridor – 30 m.

          For protection from blinding actions and overheating in summer time from direct solar rays in medical stationary located in 3 and 4 climatic areas aperture wrapped up on sector of horizon 70-240º of northern latitude they have to use solar protection equipment.

Table 7.3 Window orienting in the hospitals

* — not more than 10% of all beds

          The artificial illumination should answer assignment of a premise,  be sufficient, regulated and safe, to prevent the dazzling and other adverse influence on the human organism and internal hospital environment.

          The general artificial illumination is necessary stipulated in everything, without exclusions, premises. For illumination of separate functional zones and workplaces, they use local illumination.

          The artificial illumination of hospital premises is provided with luminescent and bulb lamps.

We use combined lighting (general and local illumination) in the hospital wards. In one-bed chambers the general illumination is provided. In chambers of children's and psychiatric departments, intensive therapy, the reanimation, in postoperation chambers they provide only ceiling fixtures of general illumination. For night shifts they use lamps in niches near doors

          The emergency illumination is provided at dressing, manipulation, procedural, ATS, assistant, drugstores, reception wards, laboratories of the urgent analysis, X-ray-operation room, and on the nurse stations.

Table 7.4 Artificial lighting of hospitals

         All hospitals should be equipped by centralized water supply, ssewege system, ventilation (if it’s necessary  - by systems of air conditioning), rubbish-collector with rubbish chamber, elevators as needed, electrical and telephone networks. If necessary they use centralized vacuum rubbish collectors and other equipment.

 

Fig. Hospital

 

 

Fig. General plan of hospital

The site land project of the patient care institution includes the following zones:

-         a zone of the patient care buildings for non-infectious patients;

-         a zone of the patient care building with infectious diseases;

-         a polyclinic zone;

-         a zone of morbid anatomical department;

-         a household zone;

-         a landscape zone.

The infectious, obstetric, children’s, tuberculosis and psychiatric departments should have separate landscape zone of their own.

The hospital site housing density depending on the amount of beds should not exceed 10 – 15 %. Up to 60 – 65 % of the area should be occupied by all kinds of green area; 20 – 25 % - a household zone, passages and passageways. The size of the landscape zone should be not less than 25 m² per one bed.

The distances between the hospital buildings should be the following:

-         between the walls with wards and doctors’ rooms windows – 2.5 of the opposite building height but not less than 25 m;

-         between the radiological building and other ones – 25 m;

-         the morbid anatomical building and a household one – at the distance of 30 m from other buildings, residential including;

-         between the buildings’ flanks – not less than 30 m, from the polyclinic, women’s consulting center and health centre – not less than 15 m.

The admission department for somatic patients (in the central building) and the rooms for the patients’ discharge should be joined together and should include: the examination room, sanitary inspection room, the wards for temporary admitted patients’ stay, the resuscitation and intensive care room, sometimes – the X-ray room.

There should be separate admission and discharge departments for the children’s, obstetric, infectious, dermatovenerologic, tuberculosis and psychiatric departments.

The admission departments areas depend on the amount of patients supposed to be admitted during 24 hours.

The sanitary inspection room is planned according to the current principle and consists of: the examination room, cloakroom, bath-and-shower room, dressing room.

In the infectious, dermato-venerologic and tuberculosis departments the admitted patient’s clothing is referred to the disinfecting department which is situated in the separate building within the household zone.

The laundry, central nutrition unit, boiler-room, garages and other hospital premises are also situated within the household zone.

 

HYGIENIC REQUIREMENTS CONCERNING HOSPITAL DEPARTMENTS

 

Each hospital department is intended for patients with similar diseases. It should include: ward sections for 25–30 beds, with 6–8 wards for 2–4 beds with the area of 7 m² per bed, not less than 2 wards for 1 bed with the area of 9-12 m² for severe somatic and infectious patients, with the cubic capacity of 20-25 m³ for each patient and the ventilation volume – 40-45 m³/hour. Except the wards in the ward, sector there should be a room for patients’ day-time stay (area of 25 m²), glazed verandah (30 m²), and medical accessory premises: the doctor’s room (8-9 m²), the procedure and manipulation room (12-15 m²), the medical nurse’s station (4 m²), and in the surgical departments sections – dressing rooms (pure and purulent). Besides, there should be a bar with a canteen (for two ward sections with the area of 18 m²), a room for clean and dirty linen (each of 4 m²), a lavatory with a bathroom (10 m²), a lavatory for patients and for personnel, a sanitary room (6-8 m²), and a corridor. There can be two types of the corridor: a side one with windows facing towards the Northern points, or a central – with light gaps (halls).

The optimal ward windows orientation in the Northern hemisphere is the South-East or South. But there should be 1-2 wards with the orientation towards the Northern points for severely ill patients or patients with fever. Beds should be located parallelly to the light conductive wall for a patient to be able to turn back from the dazzling effect of the direct solar radiation. The natural lighting indices (near the internal wall) should be the following: the daylight factor – 1,3-1,5 %, the lighting coefficient – 1:4-1:6, the angle of incidence – not less than 27°, the angle of aperture – not less than 5°, the coefficient of depth of premises – not more than 2. The artificial lighting should be general, 30-60 lux, and the night light – 10-15 lux with lamps in the lower part of the walls.

The wards ventilation should be achieved by means of exhaust ventilation ducts, presence of window leaves and windows which can be opened; the modern hospitals should be equipped with air-conditioners.

In the infectious diseases units the following rooms should be equipped: box wards (with every bed isolation), semi-boxes (the isolated wards with common lavatory and bathroom), and absolute boxes (the isolated wards with lavatory and bathroom).

The operating block of a surgical department should be situated in the blind-ended projection or in the separate outhouse of the hospital. In the operating block there should be following rooms: the operating room – 30 m² (on the basis of 30-50 surgical beds in the department; for the complex operations – 40-45 m²), the pre-operating room – 10-12 m², the sterilizing room (one for two operating ones), the anesthetic room – 15 m², the instrumental room, the surgeon’s room (for protocols), the laboratory of the express tests, the plaster dressing room, the room of the mobile diagnostic, resuscitative apparatuses and the anesthetic equipment, the premises for the sterile and used operating linen, the washing and shower room for the operating brigade, the postoperative resuscitative wards, the lavatories for personnel, the operating nurse’s room and others depending on the surgical department type.

In the surgical departments there should be pure and purulent dressing rooms.

There are some peculiarities of the children’s departments and hospitals, tuberculosis, psychiatric and other specialized patient care institutions’ planning; they are explained in the normative documents and can be learned if it’s necessary.

 

A regional hospital for 510 beds with a polyclinic for 1 000 visitors per shift*

(the project is worked out by the chair)

An explanatory note

A regional hospital group of buildings for 510 beds with a polyclinic for 1 000 visitors per shift is a center of providing population with a high qualified medical assistance; it is obliged to serve the district town and the district itself with a population of up to 100 thousand people taking into account other existing district hospitals.

The group of buildings consists of central building for 450 beds (9-storey one), the infectious one for 60 beds, the polyclinic or out-patient building (2-storey one) and accessory premises (1-storey building).

The polyclinic for 1 000 visitors per shift should provide the medical assistance to the population of up to 40 thousand and to provide them with the medial consultations.

The hospital is an organization, methodical and consulting centre for the patient care institutions of the entire district.

The hospital comprises 10 departments which are listed below.

The treatment and accessory premises of the hospital comprise the central building, the intensive care unit, the rehabilitation, X-ray, admission and administrative departments; there are the operating block and the clinical diagnostic laboratory. This project can be used within the I-B, II and III climatic zones.

To build the hospital group of buildings, a site with area of 7.3 hectares is required.

The hospital territory is divided into the following zones: the in-patient, the out-patient buildings (polyclinic), the infectious diseases unit, the household and accessory premises and landscape area (see fig. 44.1).

The central building departments should occupy the next floors:

1^st floor – the obstetric department, the children’s department for 30 beds for the children till 1 year old, the admission department and the central hospital entrance;

2^nd floor – the rehabilitation, obstetric and children’s (for 30 beds for children till the age of 6) departments ;

3^rd floor – the rehabilitation, intensive care and children’s (for 30 beds for children after the age of 6) departments;

4^th floor – the therapeutic department consisting of 2 sections for 30 beds and rehabilitation (5^th floor – the neurological department for 30 beds, the therapeutic section for 30 beds and the X-ray department;

6^th floor – the functional diagnostics department, the gynecological department consisting of 2 ward sections for 30 beds;

7^th floor – the chemist’s shop, the otolaryngological department for 30 beds and the ophthalmologic one for 30 beds as well;

8^th floor – the surgical department consisting of 2 ward sections for 30 beds and the clinical diagnostic laboratory;

9^th floor – the trauma unit for 30 beds and the operating block

*The chair can prepare another variant of the study (or real) project of the hospital institution.

The treatment and diagnostic departments are situated on each floor near the in-patient departments and are interconnected with them.

The ward sections have a short main corridor, lighted on each side. At the place where the corridors are crossed there should be projected halls of the day-time stay and the nurses on duty stations .

The infectious diseases unit for 60 beds is projected in the U-shaped 1-storey building, where the boxes’ section for 30 beds (one flank) and the semi-boxes’ section for 30 beds (another flank) are situated.

The morbid anatomical department is projected in the separate isolated building.

The household block is projected as an isolated building and household yard where central heat post, boiler house, garage, workshop, laundry and nutrition unit are located.

The hospital is projected in the skeleton bearing-wall constructions of II-04 series.

The hospital buildings are provided with the central water heating system, the tidal-exhaust mechanical ventilation, hot water supply from the boiler room, the electricity supply from the transformer substation and low current from the district telephone station and internal ATS.

 The quality of water has to allow State Standard "Drink water". The system of hot water supply is projected with circulation.

         Table 7.5 Hygienic requirements for water supply (daily needs)

For waste treatment from hospital catering service in hospitals they establish fat-catching device. The treatment of waste from hospitals including infectious is carried out by municipal sewer system. At absence of municipal sewege systemthey use system of local waste treatment.

          For all health facilities should be provided reserve (emergency) hot water supply. They could use electrical boilers or second input of hot water supply. For heating it’s used water heating system with maximal water temperature in heating devices 85^oC (Using water steam heating in the hospitals is prohibited).

         The heating radiating concrete panels can be used in following premises: operation, preoperation, resuscitation wards, narcosis, delivery, premises of electrolight treatment, psychiatric departments of hospitals, therapy rooms, rooms for premature babies, injured children, little children and newborns infection wards, combustiological wards, complete and incomplete boxes, premises of blood bank, storerooms for sterile materials and medications, x-ray rooms, laboratories and experimental - biological clinics (vivaria).

          The toilets for the patient should be equipped with cabins, hangers, drying devices for hands, mirrors. In lavatories of female ward sections there should be equipped cabins of women hygiene with ascending shower (bidet).

          The quantity of sanitary devices (toilet pans) for the patient in ward departments of hospitals should be accepted at the rate of  1 device per 15 men and per 10 women, but not less than 1 device. The quantity of pissuare in male lavatories has to equate to quantity of another sanitary devises. The sizes of lavatory cabins for the patient should be not less than 1,5 (1,1) m with obligate opening of doors outside. In sanitary - household premises for the attendants it is necessary to accept:

1.     Quantity of sanitary devices for the medical staff - not less than 2 devices for the women and 1 device for the men; but not less than 1 sanitary unit on each department

2.     Quantity of shower cabins -  1 shower cabin per 10 employees in infectious and phthysiatric departments, in other departments - 1 shower cabin on 15 employees in the largest shift. If less number of the personnel it is necessary to provide 1 shower cabin on department.

         Lavatory for the patient in ward departments for hundicapped patients should have special equipment (racks, folding ), that the seriously ill patient can use of sanitary devices.

          The houses of medical and patrimonial houses should be equipped with systems of balanced ventilation, except for infectious departments. In the last should be established the exhausting ventilation. The exhausting ventilation from chambers has to be carried out through individual channels, which prevents of air movement by the vertical.

         They use exhausted from operational, narcosis, resuscitation, patrimonial and X-ray rooms, as a rule, from two zones: 40 %- from upper zone (10 cm. from a ceiling), 60 %- from the bottom zone (on 60 cm from a floor) in view of allocation in these premises of gases and steams, which can form explosive mixes, or difficult positively charged ions.

Ventilation systems in operation, narcosis, resuscitation, maternity and other wards with severe sanitary should be equipped with  bacterial filters.

Table 7.6 Hygienic demands to hospital environmnet

Notes:                   *   — summer / winter

                            *1) — 20% through neighbor premises

                            *2) — inlet with sterile air

 

Reception ward of hospital has following functional tasks:

·        Reception, registration and distribution of patients

·        Previous diagnostics

·        The decision of a question about necessity of in-patient or out-patient treatment

·        Sanitary treatment of patients

·        Prevention of communicable diseases

·        Shifting needed patients to other health facilities

·        Discharging the patient and distribution of an information.

The number of patients are receipted by the reception ward depend on the number of beds in the hospital and its specialization::

·        2 %  of beds number - in TB, mental and rehab hospitals

·        15 %- in emergency hospitals and maternity houses

·        10 %- in other hospitals.

The number of the patient flows should be accepted from the ratio:

·        1 flow per 800 beds- TB and rehab hospitals

·        1 flow on 600 beds- in mental hospitals

·        1 flow on 150 beds- in emergency care facilities

·        1 flow on 200 beds- others hospitals.

         For each flow in hospitals (excepting infectious, children and obstetric hospitals) they provide one examination room/box and one sanitary treatment unit. In infectious hospitals and infectious departments of general hospitals they provide reception wards with examination boxes, their quantity depends on quantity of beds in department:

·        up to 60 beds - 2 boxes.

·        100 -3 boxes

·        more then 100 beds-by the formula X=3*x, where x - 1 additional box for every 50 beds of department.

The similar boxes are organized in children hospitals.

          In obstetric departments the reception premises (examination room, sanitary treatment unit) should be provided as combined for physiological department and department of a pathology of pregnancy and separately for observation and gynecologic departments. The movements the patient of all departments, including stairs and elevators, should be isolated one from one.

         If it’s necessary they organize traumatological shifts, their offices should be placed on the ground floors of houses.

          For reception of the infectious patient they provide isolator room which connected to examination room of the ward.

         Ward department is the basic functional structural element of in-patient medical institutions. The basic types of ward departments is: noninfectious department (for adult and children) and infectious departments, maternity department

          If children departments has 60 or more beds they should be placed in separate buildings. Infectious and TB departments are placed only in separate buildings.

          Ward department consists of ward sections and general premises located between the sections. The general premises include the medical and diagnostic offices, catering service premises etc.

          The ward section represents the isolated complex of rooms and medical-auxiliary premises providing care for patients with homogeneous diseases. The quantity of beds in ward section, as a rule, is not less 20 and no more than 30 (except for psychiatric).

          The quantity of 1 bed rooms in observation obstetric department, department of a pregnancy pathology and also in hematological, neurosurgical and urologic departments for adult persons and children should be not less than 15 %, and in others departments - not less than 7 % of quantity of beds in department.

          The quantity of 2 beds rooms  in the specified departments has to make not less than 15 %. In all other departments project not less than two 3 bed rooms in each section.

The  best ratio is 20%of one-bed, 20% for two-bed and 80% for three and four-bedrooms.

In infectious stationary basic structural unit of ward department could be not  a ward, but complete or uncompleted box or boxed room. Boxes provide a complete isolation of the patient. There are 1-2 bed boxes using in Ukraine.

Isolator has two exits: to the department and to outdoor environment. The patient never leave  Isolator through the department door, they pass only through external exit with tambour. The access of the medical personnel to Isolator is provided from a "conditionally clean" corridor through sluices, where medical staff should change their gowns, wash and disinfect hands. The doors in the sluices should be placed on the slanting line. Isolator department have the largest maneuverability and carrying ability, it is important for small departments.

Incomplete Isolatores distinguish from boxes  because they have no an external exit. They also are provided on 1 and 2 beds. The mode  of non- Isolator department differs from boxed one by  that the patients are brought in incomplete isolatores through a general corridor department. In isolator departments it is recommended to use 25 % of all beds in isolatores per 1 bed, other - in 2 beds isolators. In everyone ward section should be provided two incomplete boxes on 1-2 beds.

In noninfectious departments for children  older one year and for adults they use rooms having not more than 4 beds. Capacity of rooms for infants, and also for newborns in observation obsteric department should be not more than on 2 beds each.

Recommended percent of boxes in section for children younger 3 years is 100 %.

          At presence of the gynecological departments in structure of health institution it should be isolated from obstetrics and other “clean” departments. Women in the childbirth and pregnant women are divided into 2 flows in the filter of reception department . One  flow is made  by women in childbirth and pregnant women, which are directed at department of a pathology of pregnancy and physiological department, other - in observation department.

The reception in observation department of the maternity house is for the pregnant women and women in the childbirth who have:

·        a fever (temperature of a body 37,6 ^oC  and more without other expressed symptoms)

·        long waterless interval (waters break in 12 and more  hours before the reception in hospital)

·        trombophlebitis of any localization (acute or chronic form in a stage of an exacerbation)

·        inflammatory diseases of kidneys and urine tracts (acute stage, an exacerbation of chronic process during pregnancy, symptomless bacteriuria- 100000 CCU/ml and more)

·        signs of any urogenital infection  (colpitis, cervicitis,  choriamnionitis etc)

·        clinical or laboratoric data about TORCH infection (TORCH - toxoplasmosis, rubeola, cytomegalovirus, herpes, listeriosis, veneral diseases (STD))

·        intrauterinal death of fetus

·        acute respiratory disease (influenza, tonsillitis), signs of inflammatory diseases (pneumonia, otitis)

·        skin diseases of infectious ethyology

·        Tuberculosis (closed forms of any localization at absence of specialized hospital). (Pregnant women and women in the childbirth with the open form of a tuberculosis are should be hospitalized in the specialized maternity houses (department); if there are not presented  - in boxes or isolators of observation department with the following transferring in tuberculosis dispensary)

And also:

·        skin diseases (noninfectious)

·        at absence of the medical documentation

·        for an abortion on medical and social indication in ІІ the period of pregnancy

·        malignant tumors

·        women have the anomalies of development of a fetus, which revealed during pregnancy (at absence of specialized hospitals)

·        women in the childbirth (in terms 24 hours after deliveries in case of childbirth outside of medical institution)

They transfer the pregnant women, women in the childbirth and women recently delivered if these women have:

·        increase of temperature of a body 38^oС and higher (at three times measuring)

·        fever with not clear genesis (temperature of a body up to 37,5^oС), that lasts more than 1 day

·        postpartum inflammatory disease (endometritis, mastitis, wound infection т. і.)

·        extragenital infectious diseases which do not require transferring in specialized in-patient department (ARVI, herpes etc.)

          The pregnant women, women in the childbirth  and women recently delivered, which suffer on infectious diseases, are subject to hospitalization and transferring in the appropriate infectious hospitals. The observation department should be placed or in the separate house, be isolated, above it there should not be an obstetric department.

          At presence of gynecological department to it the separate reception is provided. Gynecologic department is necessary completely isolated from obstetric departments.

The operational block

          The operational block is structural unit of hospital using for surgical operations.

          The operational blocks are divided into general and specialized (traumatologic, cardiologic, neurosurgical). By an attribute of presence one department (aseptic) or two (aseptic and septic) operation room are divided on aseptic and combined.

          The operational block has such functional zones:

 І. The sterile zone: an operational room

ІІ. A zone of restrictions

·        group of premises for preparation to operation: preoperation, wardrobe for overalls, narcosis room,

·        group of premises for the equipment: apparatus room (AABC, hypotemia)

·        group of premises of postoperation wards

·        group of auxiliary premises, which contain also sluice at an entrance to operational room

ІІІ. A zone of the limited access:

·        group of premises for diagnostic researches

·        group of premises for preparation tools and equipment for operation: sterilization, instrumental-material (instrumental-financially)

·        group of premises of the personnel: offices of the surgeons, office of the doctor - anaesthesiologist, room of the nurses-anaesthesiologists, room of attendants

·        auxiliary premises: sluices at an entrance in septic and aseptic of department, room to the central board, plasters і and that similar

·        warehouse premises:  blood bank etc

 

Fig. The operational block

 

          It is necessary to accept quantity operational in CR, interregional and urban regional hospitals: 1 on everyone 30 beds to a surgical structure and 1 on 25 beds in hospitals of emergency care. The ratio of septic and aseptic operational in operational blocks of general hospitals is necessary 1:3, but it is not less than one septic operational room per block.

          The quantity of beds in post-operation ward is accepted as 2 bed per operation room. At presence of departments of anaestasiology and reanimation or the reanimations and ІТ department, postoperation wards are not provided, and their quantity is taken into account of beds of department of anaestesiology and reanimation.

         Postoperation room are being placed in separate isolated section at the operational block, or in structure of branch anaestasiology and reanimation or the reanimations and ІТ department or it's isolated in structure of surgical department.

          For maintenance of free transportation the patient width of door apertures is necessary to be not less than 1,1 m. A floor in operation room should have antistatic covering. The ventilation in operation and dressing room provides conditioning of air. Than inflows of air from system of conditioning - in the top zone of a premise (is not lower 2,5 from a floor), exhaustion - from two zones: top and bottom (0,4 from a floor). Air, which is showed in operational has to be cleaned with  the bilaterial circuit (rough and thin clearing).

For control on the hospital environment they use following indicator of air pureness:

·        Oxygen: 20-21 %. Very stable size, does not decrease even at intensive consumption (restoration for the infiltration).

·        Carbonic gas:

·        · very clean air < 0,05%

·        · rather clean air < 0,07%

·        · satisfactorily clean air < 0.1%

·        Dust pollution:

·        It is no more than 500 particles in 1 cm³

·        ·clean air < 0,1 мг/м3

·        dirty air > 0,15 мг/м3

·        Oxydation of air:

·        clean air - up to 6 mg О₂/м³

·        · is moderate - polluted - up to 10 мг О2/м3

·        · dirty - up to 12 мг О2/м3

Hospitals produce about 230 kg of sold wastes per bed annually (0,63 g/day). Nowadays they use for waste treatment in the hospitals some modern schemes:

In canalized dwelling place there are:

1.     complex of local treatment units with thermal decontamination in liquid and solid phase of waste. It has high effectiveness of decontamination. Power is about 100 m³/day

2.     complex of local treatment units with septic-dehelminthizator. (25 m³/day)

3.     complex of local treatment units with a septic (25 m³/day)

4.     complex of local treatment units with the contact defenders (10-15 m³/day)

5.     complex of local treatment units with a 2-level septic (100-150 m³/day). It's used in Odessa infectious hospital, for example.

6.     complex of local waste buildings with a aerotank of continued aeration and mechanic aerator (400 (!) m³/day)

7.     complex "Rapid Lock" (to 840 (!) m³/day)

8.     complex of local treatment units with circular oxygenation channel (COC). It's used for waste treatment of tuberculosis hospitals if volume of waste is up to 700 m³/day

9.     complex of local treatment units with emsher and biofilter. They use it for waste treatment of tuberculosis hospitals if volume of waste is up to 500 m³/day

10. complex of local treatment units with septic and biofilter ( for small tuberculosis hospitals, waste to  50 m³/day)

For canalized areas they use:

11. complex of local treatment units with ground fields of filtration (irrigation). The scheme are being used if volume of wastes is 50-100 m³/day and there is sandy soil.

12. complex of local treatment units with underground fields of filtration. Waste pipes (drenas) is placed on the depth 3 m, loading is about 15-20 l/day The scheme are being used if volume of wastes is 50-100 m³/day

13. complex of local treatment units with sand-gravel filters

14. complex of local treatment units with filtering trench

For waste treatment in tuberculosis hospitals they use two-stages of biologic purification.

Fig. Ward section of teraputic department

 

Fig. Ward section of children department

 

Fig. Ward section of infection department

 

 

 

Fig. Typical ward section

 

You know that on the hospital area they provide some functional zones. The infectious departments should be isolated from non-infectious. The currents of movement for "pure" and "dirty" (suspicious for communicable diseases) patient should be also isolated from each other according to a principle of one-way flow. It’ very important how departments are distributed by the floors. Departments requiring aseptic conditions (surgical, maternity, neonatological) should be placed on the first floors of a hospital building. At the arrangement of operation - reanimation complex septic operations have to be placed above aseptic. In infectious cases of departments intended for hospitalization of the homogeneous patients they place them by the floors, thus the most contagious patients (with aerial infections) are placed in the top floors.

            Sanitary - antiepidemic measures provide health promotion activity among the patients and personnel, monitoring of an epidemic situation, including revealing vira- and bacteria carriers. With this purpose the system of the previous and periodic (current) medical surveys is introduced. So, pupils of medical schools, the students of medical high schools during  practice should pass obligatory physical examination with participation of physician, dermatovenerologist, they have to make fluorography (if this research was not taken during the previous 6 months), analysis feces on carriage of intestinal infections and helmints eggs, and the persons are more senior than 18 years - on HIV, RW and urethral (for women also vestibular and vaginal) smear on Neisseria gonorrhoeae.

          Before practice in maternity houses, newborn wards, children's hospitals (departments), surgical departments etc. it is necessary to pass inspection of stomatologist, otholaringologist with an obligatory capture smears on staphylococci tests (from a nose and fauces)

          Prior to the beginning work in maternity houses, children's hospitals and other MPI medical workers should to pass inspection including fluorography (6 months), RV and tests on gonorrhea, analysis on HIV they repeat every year, carriage of pathogenic staphylococcus and RW -too, tests on gonorrhea and analysis on HIV - 1 time per 6 months, on carriage - 1 time per 6 months will be carried out.

All hospitals should be supplied with a linen - accordingly of sheet of equipment at enough. Change of a linen by the patient should be carried out in process of its pollution, regularly, but not less once for one week. Polluted linen should be changed immediately. The change of bed-clothes for delivered women should be carried out 1 time per 3-4 days, body linen and towels - daily, under napkins - by the necessity. Change of a linen by the patient after operation should be carried out regularly to the discontinuance of exudation from wounds.

In maternity hospitals (patrimonial blocks and other premises with aseptic mode for newborn) should be used a sterile linen.

          The temporary (not more than 12 hours) preservation of dirty linen in departments could be provided in the shut container (metal, plastic boxes, dense boxes, and other capacities, which are subject of disinfecting). For work with a dirty linen the personnel should be supplied sanitary clothes (dressing gown, cap, mask, glove).

The clean linen should be stored in the special premises, deduced for it. In departments they should have a daily stock of a linen. Linen and container should be marked.

The washing of a hospital linen should be carried out by centralized way in special laundries at the hospitals. The washing of a linen in medical institutions is carried out in conformity with the instruction on technology of processing of a linen of medical establishments at factories – laundries.

The washing of hospital linen in urban municipal laundries on a condition of allocation on them of special technological lines is supposed which exclude an opportunity of contact of hospital linen with not hospital. The linen in infectious, observation and purulent - surgical departments before washing should give in disinfecting in special premises by processing of disinfecting solution in washing machines.

After recovery of the patient, his death, and also for the prevention of pollution a mattress, pillow, the blankets should be changed and a disinfected.

At the reception ward all in-patients will pass special sanitary processing in acceptance branch (acceptance soul or baths, the cutting of nails and other procedures) by the necessity. It depends on results of the examination.  They give to each patient soap and wiping  bast for personal use. After sanitary care the complete set clean body linen, pajamas, shoes (slippers) is given out to the patient. They keep the personal clothes and the footwear for safety in special container with hangers (polyethylenic bags, covers with a dense fabric etc.) or it is transferred to preservation to its relatives or familiars.

Washing of the patient is carried out not less than 1 time per week with marking in the case history. Hygiene of the seriously ill patients (washing, wiping of a skin of the person, parts of a body, rinsing oral cavity etc.) will carry out constantly after the meal and at pollution of a body. It should be organized a hair dressing and shaving for the patient. Each patient should be supplied with a personal towel and soap. 

The serving medical personnel of hospital, patrimonial houses and other medical institutions should be supplied complete sets of the replaceable worker (sanitary) clothes: dressing gowns, caps, replaceable shoes (slippers) in quantities, that provides daily change sanitary clothes. All medical personnel of medical or patrimonial institutions have to be faultlessly tidy and accurate, edge of the worker (sanitary) clothes should completely close personal (home) clothes. The hair should completely be covered with caps. Change of footwear of the personnel of operational, patrimonial blocks, resuscitation, dressing rooms and newborn departments should be with non-fabric material, suitable for desinfecting.

The doctors, nurses should wash hands before the examination of each patient or performance of procedures, and also after "dirty procedures " (cleaning of premises, change of the patient linen, visiting of a lavatory etc).

 

HOSPITAL SYSTEMS

The development of the internal market and creation of trusts has produced incentives for hospitals to plan on the basis of maximising the role and status of the individual trust. We have, however, observed over the past two years an increasing trend for groups of hospitals to work more collaboratively, and a softening, or even abandonment, of the competitive ethos, in line with the government's white paper The New NHS.⁶

The result of this is that the type and range of options that are considered to be available change when the objective is how to plan for an area where a number of hospitals form a potential network of complementary provision, rather than how to compete. Joint plans are increasingly likely to be followed by mergers, the ultimate surrender of individual aspirations to the collective will. The recent acute strategy for Scotland is an early example of what seems to be a growing trend towards planning on a system-wide basis.

This development reflects the view that some services must be organised on a scale larger than any one hospital, for some services for populations as large as one million. However, as the Calman Hine report recognised for cancer care, the amount of evidence bearing on such large scale issues is limited.⁷ Furthermore, neither the Calman Hine report nor the Scottish strategy report⁸ adequately deals with the relation between services organised in this way, as they do not allow for the impact of their proposals on the way other services are providedeven though the same staff and facilities may be involved.
The wider system

Both the demands placed on hospitals and their efficiency as providers depend on the nature and effectiveness of community based services such as rehabilitation facilities and out of hours cooperatives formed by general practitioners. They also depend on the way in which potential users, particularly of emergency services, decide whether and how to access care. Although the phrase "whole systems approach" has now found its way into official documents, virtually no research has been commissioned at the "whole system" level.
Staffing and medical specialisation

One of the most powerful factors making for change in hospitals has been increasing medical specialisation. As the recent review by the York Centre for Reviews and Dissemination⁹ and Posnett's article in this series¹⁰ have shown, high quality evidence on the benefits of this process of centralisation and specialisation is limited. Nevertheless, the recent recommendations for hospitals by the BMA and the Royal Colleges of Physicians and Surgeons envisage a continuation of this process.¹¹ Furthermore, the colleges are issuing guidance that will put managers in a position in which they will have to close or reduce the role of some hospitals.

This is in direct opposition to the high value placed on access by the public, and unless models can be developed to overcome this it is possible that the accountability of the colleges will be questioned, and they may come into direct conflict with politicians. The problem is particularly acute in more rural areas, where even the revised minimum populations suggested in the most recent document by the BMA and the royal colleges may be hard to achieve. A compromise will need to be developed between the requirements of education and training and the development of local services, and some hospitals may not be able to continue to function as educational establishments responsible for training junior doctors.

Changes in the way that hospitals provide care have implications for clinical training and the working environment of clinical staff as well as for future staffing requirements, and vice versa. Because responsibility for these different areas is divided among the professions, training organisations, the Department of Health, and the NHS Executive, the links between them have been persistently neglected.

The results of this are apparent in the current crisis in the recruitment of nursing staff. Although many other factors play a part, one element is the lack of research on the number and type of nurses that hospitals require and the contribution of nursing to patient outcomes.
The research agenda

The previous sections have focused on the areas where we believe that more research is required. Two general points need to be made.

Firstly, research relevant to hospitals has tended to concentrate on single interventions and less frequently on some models of service delivery such as hospital at home. It tends not to address issues about the planning of whole systems, and it is rare for the results of hospital reconfiguration to be evaluated. Although there is a requirement for large capital schemes to be evaluated after completion, this does not seem to happen routinely, and where such evaluations are carried out the results are often not in the public domain. Politicians and policymakers may find the critical evaluation of previous decisions uncomfortable, but unless it is carried out mistakes will be repeated and there will be no collective learning within the NHS about how to plan such schemes.

In the past, funding to support this type of research has been limited. The new research into service delivery and organisation to be commissioned by the NHS Executive offers the potential for many of these areas to be investigated.

Even though this initiative is welcome, it will not be enough. An additional problem is that the time lag in implementation means that evaluation may become history rather than research and, given the pace of change, the past may not be a reliable guide to the future. No substantial sources of funding have been available to support this type of research. Moreover, many of the questions for which planners, managers, and policymakers need answers are not easily answered with traditional methods of research into the health service.

Secondly, new research techniques are required to support planning for the hospitals of the future, including the development of scenario planning and modelling, and simulation techniques to identify uncertainties and the sensitivity of plans to forecasting errors. There should be more evaluation of completed plans and much better systems to exchange knowledge about innovations. Some nationally led experiments are also neededin the development of service modelsfor example, for rural areas where the trends referred to above are undermining existing patterns of provision.

Little research has been done that highlights the central issues of hospital planning: how many hospitals we need, what services each should offer, how they should relate to each other, and how, once these issues are resolved, they should be organised, staffed, and managed. http://www.bmj.com/cgi/content/full/319/7221/1361

Plans for the future of hospitals need to recognise our lack of knowledge, and, if there is to be central guidance, this should be that whatever is planned should be robust in as many possible futures as are conceivable. Research should be directed at understanding how flexibility can be incorporated into hospital design at low cost. In this respect there is perhaps some reason to be concerned about the impact of the private finance initiative. These schemes will have fewer beds but may not incorporate design ideas that allow flexibility since, in many cases, the costs associated with the planning will fall on the NHS.

This failure of research reflects a larger failure to take the planning of hospitals seriously, which has been particularly marked since regional health authorities were abolished. Although geographical variations rule out a "one size fits all" approach, we have identified a range of issues that require a central response. The professions have begun with the publication of a consultation document on acute hospital services to respond to this challenge.¹² We can only hope that the Department of Health will do so too

HOSPITAL AND HOSPITALISM

The medicine is one of the most abundant spheres of labor activity of society. It calculates more than 170 medical specialties. In the system of public health services of Ukraine more than 200 thousand doctors are employed, including dentists, over 500 thousand of nurses.

DUTIES AND RESPONSIBILITIES OF EACH SERVICES

FUNCTIONS OF THE HOSPITAL

Hospital administration functions can be classified into three broad categories:

1. Medical - which involves the treatment and management of patients through the staff of physicians.

2. Patient Support - which relates directly to patient care and includes nursing, dietary diagnostic, therapy, pharmacy and laboratory services.

3. Administrative - which concerns the execution of policies and directions of the

hospital governing discharge of support services in the area of finance, personnel, materials and property, housekeeping, laundry, security, transport, engineering and board and the maintenance.

MAJOR FUNCTIONS OF THE ADMINISTRATIVE SERVICE

1. Provide service related to accounting, billing, budget, cashiering, housekeeping, laundry, personnel, property and supply, security, transport, engineering, and maintenance; and

2. Render support services to hospital care providers, clients, other government, and private agencies, and professional groups.

RESPONSIBILITIES

1. To plan, direct and coordinate financial operations of the hospital;

2. To prepare work and financial plan and provide fund estimates for programs and projects;

3. To manage the receipt and disbursement of cash/ collections;

4. To administer personnel development programs, policies and standards;

 

5. To give advice on matters affecting policies, enforcement and administration of laws, rules and regulations;

6. To procure, store, manage and issue the inventory and disposal of unserviceable hospital equipment and materials; and

7. To provide general services such as repairs and maintenance, housekeeping, laundry, transport and security.

 

FUNCTIONS OF DIFFERENT DEPARTMENTS UNDER THE ADMINISTRATIVE SERVICE

ADMINISTRATIVE OFFICE – Directs and supervises the activities and functions of administrative units to effectively deliver quality support services.

1. PERSONNEL SECTION - Development and administration of a comprehensive manpower development program which includes recruitment and selection, promotion, training, employee welfare and benefits, manpower planning and research.

2. PROPERTY AND SUPPLY SECTION - Procurement, storage, inventory, distribution and disposition of hospital supplies, materials, and equipment.

3. HOUSEKEEPING SECTION - Develop and maintain clean, safe and sanitary environment for patients and hospital personnel.

4. LINEN AND LAUNDRY SECTION - Ensure adequate supply of clean linens for patients and hospital units.

5. ENGINEERING AND MAINTENANCE SECTION - Installation, operation and maintenance of electrical, mechanical and communication equipment and allied facilities including buildings and vehicles.

6. MOTOR POOL SECTION (TRANSPORT) - Convey transport patients, hospital officials and personnel to their destination.

7. SECURITY FORCE - Ensure safety of hospital patients, facilities and personnel, maintain peace and order, and enforce hospital rules and regulations.

 

8. MEDICAL SOCIAL SERVICE -The Medical Social Service function Is to see to it that patients attain emotional equilibrium as they are assisted with other needs which interfere in hospitalization and treatment.

9. MEDICAL RECORDS  - Process, maintain, analyze and safe keep all medical records created in this hospital; prepares hospital statistical reports; and formulate and develop effective policies, systems and procedures for the efficient operations of the section.

10. PHARMACY SECTION - Ensures continuous supply of drugs and medicines to patients by maintaining an adequate quantity in stocks of those approved by the Pharmacy Therapeutic Committee. Dispenses, compound drugs for in and out patients. Controls the purchasing, requisitioning, safekeeping and issuing of drugs. Maintains records and files of dangerous drugs and other pharmaceuticals as required by law. Serves as the Drug Informant Center

11. DIETARY SERVICE – Maintain or enhances the health of the patients and personnel by providing them with high quality and nutritious food through an efficient Dietary Service; Provides or serves safe, nutritious and attractive food through careful planning, wise procurement and proper preparation of balanced and satisfying meals within budgetary limits; Implements diet prescription in coordination with physician and nurse; Provides nutrition consultation and education services to patients as well as in-service training to both dietary personnel and other related fields; Promotes and maintains cooperation with other department in the hospital towards total patient care.

12. ACCOUNTING SECTION - Systematic recording of all financial transactions, preparation of financial statements and relevant reports, and maintenance and safekeeping of the hospital’s Book of Accounts.

13. BUDGET SERVICE - Prepares the Work and Financial Plan and provision of fund estimates for hospital programs and projects.

14. CASHIER SERVICE - Receipt, deposit, custody and disbursement of cash/collection of the hospital (Cash Management)

15. MEDICARE AND BILLING SECTION - Admits, classifies Pay and Medicare Patients, orients patient with regard to privileges, obligations, responsibilities during the course of confinement. Prepares statement of account on service and bills rendered to patient. File records, bills and statement of account.

16. INFORMATION AND ADMITTING SECTION

FUNCTIONS OF THE NURSING SERVICE

1. Plans, organizes, and directs the overall nursing service activities in all clinical and special areas in the health fields of maternal and child nursing, medical and surgical nursing.

2. Defines the philosophy, goals, objectives and policies of the hospital, and interprets them to the nursing staff, patients, and the community.

3. Develops the basic, functional and position organization chart that will allow for an open communication horizontally and vertically to ensure smooth operations of the service.

4. Develop program methods of the major functions of the service.

5. Formulates qualification standards, job specifications and job descriptions of various categories of nursing personnel in line with the hospital policies and Civil Service Commission rules and regulations and the Nursing Law.

6. Delegates assignments with commensurate authority to ward supervisors and follows this up.

7. Determines and makes recommendations concerning hospital wards’ facilities, equipment and surgical supplies affecting nursing care, and plans for allocation and utilization of space and equipment to ensure safe environment for patients and working personnel.

8. Formulates and implements nursing care policies and standards operating procedures as guides for the nursing personnel and initiates periodic revision of some as need arises.

9. Determines the staffing needs based on patients’ conditions ranging from the minimally-ill, moderately-ill or critically-ill to ensure smooth operations of the service.

10. Makes general nursing rounds weekly and as the need arises and look into patients nursing needs and ward conditions to ensure safe environment and safe care.

11. Cooperates in providing referral system between the hospital and community health centers and other agencies. Assigns and re-assigns nursing personnel periodically to meet the needs of nursing service. Provides opportunities for growth and development of personnel-recognizes personnel and professional abilities, maintains continuing staff development program. Develops and carries guidance and counseling program.

12. Cooperates with individual/group in other departments or services in carrying forward the work of the hospital as a whole.

13. Supervises and coordinates activities of nursing personnel engaged in specific nursing services such as Obstetrics, Pediatrics, Surgical or Medical, or from two or more clinical nursing divisions.

14. Supervises Senior Nurse in carrying out their responsibilities in the management of nursing care. Evaluates performance of Senior Nurse and nursing care as a whole. Inspects clinical nursing division to verify that patient needs are met.

15. Plans and organizes orientation for clinical nursing division staff members and participates in guidance and education programs. Interviews pre-screened applicants and makes recommendations for employing or for terminating employees.

16. Visit clinical nursing divisions to oversee nursing care and to ascertain condition of patients. Gives advice for treatments medications, and narcotics, in accordance with medical staff policies in absence of physician. Arranges for emergency operations and relocations of personnel during emergencies. Admits or delegates admissions of new patients.

17. Assigns duties to professional and ancillary nursing personnel based on patients’ needs, available staff, and service needs. Supervises and evaluates work performance in terms of patient care, staff relations and efficiency of service. Provides for nursing care and cooperates with other members of medical care team in coordinating patients’ total needs. Identifies and studies nursing service problems and assists in their solutions. Observes nursing care and visits patients to insure that nursing care is carried out as directed and treatment is administered in accordance with physician’s instructions and to ascertain needs for additional or modified services. Maintains safe environment for patients. Operates or supervises operation of specialized equipment assigned to unit and provides assistance and guidance to nursing team as required.

18. Accompanies physician on rounds to answer questions, receives instructions and notes patients’ care requirements. Reports to replacement on next tour on condition of patients or of any untoward or unusual actions taken. May render professional nursing care and instruct patients and members of their families in techniques and methods of home care after discharge.

19. Collects clinical data thru the process of interviewing observations using all senses and clinical instruments and utilization of diagnostic examination reports.

20. Implement nursing actions and legal orders of the physician.

21. Evaluates results of interventions and revise plan to cope with changing conditions of the patient.

22. Endorse patients and give attention to patients’ comfort and safety.

23. Assists the midwife in maintaining cleanliness and orderliness of the unit.

24. Delivers clean medical supplies to patient care units and collect used supplies, instrument sets, rubber goods, etc.

25. Reviews patient’s pre-operative preparation including spiritual.

26. Assists in emergency operations when other professional staff are not available.

27. Makes general assessment of patients in the recovery room and confers with head nurse nursing management of each patient.

FUNCTIONS OF THE MEDICAL SERVICE

TRAINING SERVICE:

1. Provides qualified individuals with practical and scientific knowledge in the diagnosis and treatment of diseases.

2. Installs a sense of responsibility, discipline and compassion in the management of surgical patients.

3. Develops adequate administrative ability and leader- ship qualities.

4. Trains qualified individuals to practice various clinical disciplines in areas where their expertise are needed within the context of national dispersal program.

5. Develops and implements a training strict and fair selection process the admission of resident physicians.

6. Maintains a good atmosphere for teaching and learning in the different clinical departments.

ANCILLARY  SERVICE

Laboratory:

1. Prepares the medical graduate in the specialized practice of Clinical and Anatomic Pathology.

2. Prepares future teachers of Clinical and Anatomic Pathology.

3. Gives the physician sufficient skill and experience to practice the science and art of Clinical Pathology Independently and proficiently.

4. Supports the spirit of keeping abreast with the current trends of concepts and practice by reading, experience and research.

5. Imparts to the trainee the role of Clinical Pathology in relation to other fields of medicine.

6. Inculcates the ethic practice of Clinical Pathology.

Radiology

 Develops knowledge, attitudes, and skills of professional radiologist at par with the standards of the Department of Health and Philippine College of Radiology and responsive to the country’s needs.

OUT-PATIENT SERVICE

1. Provides quality medical care services to as many out- patient as possible.

2. Provides the widest coverage of quality health care for the people not for curative only but also promotive and preventive health care to minimize the development of diseases.

3. Ensures that health services are always available to the people.

4. Provides health services that is within the financial capability of the people.

5. Provides health services based on what the people really needs and what the h

6. Provides facilities for training of health workers and initiate medical research for the improvement of the quality of health care.

EMERGENCY SERVICE

1. Provides a plan for the reception area and treatment of patients who need emergency services.

2. Provides a well organized with adequate facilities, adequate enough to assure prompt diagnosis and the institution of appropriate emergency attendance for care and management.

3. Checks the medicine cabinet in the Emergency Room if the necessary emergency medicines are available for the next 24 hrs.

IN-PATIENT SERVICE

1. Provides, develops and adopts a patient care system of its own befitting appropriately its particular needs.

Emergency Physician Rights and Responsibilities

Emergency physicians typically practice in a hospital-based setting. In nearly all cases, such practice is pursuant to a contractual arrangement on which practice at the hospital is based. The legitimate purpose of such contracts is to ensure the efficient and reliable staffing of the emergency department (ED). However, such contracts also often limit or eliminate the rights physicians otherwise have under the medical staff bylaws and contain other provisions that may compromise the professional autonomy of physicians. Consequently, such contracts may harm the public interest.

The American College of Emergency Physicians (ACEP) believes that high-quality emergency care is best provided when emergency physicians practice in a fair and equitable environment. To provide guidance to physicians and others with respect to contractual arrangements involving the practice of emergency medicine in a hospital-based setting, ACEP hereby adopts this statement of Emergency Physician Rights and Responsibilities.

This guidance should be of value to hospitals, physicians, and professional or business entities contracting with individual physicians or groups of physicians for the provision of emergency care in hospitals. It is anticipated that these guidelines will benefit the profession and the public. These guidelines are not intended to dictate individual contracting practices; rather, ACEP members must make independent determinations regarding their employment and contractual relationships with hospitals, practice groups, and other entities based on their individual circumstances.

Rights of Emergency Physicians

Emergency physician autonomy in clinical decision making shall be respected and shall not be restricted other than through reasonable rules, regulations, and bylaws of his or her medical staff or practice group.

Emergency physicians have a right to expect adequate staffing and equipment to meet the needs of the patients seen at the facility and to have the institution provide support to improve patient safety. Emergency physicians shall be provided such support and resources as necessary to render high-quality emergency care in the ED setting and shall not be subject to adverse action for bringing to the attention of responsible parties deficiencies in such support or resources when done in a reasonable and appropriate manner.

Emergency physicians shall be reasonably compensated for clinical and administrative services and such compensation should be related to the physician qualifications, level of responsibility, experience, and quality and amount of work performed.

Emergency physicians shall not be required to purchase unnecessary, unneeded, or excessively priced administrative services from a hospital, contract group of any size, or other parties in return for privileges or patient referrals.

Emergency physicians shall be provided periodic reports of billings and collections in their name and have the right to audit such billings, without retribution.

Emergency physicians shall be accorded due process before any adverse final action with respect to employment or contract status, the effect of which would be the loss or limitation of medical staff privileges. Emergency physicians' medical and/or clinical staff privileges shall not be reduced, terminated, or otherwise restricted except for grounds related to their competency or professional conduct.

Emergency physicians who practice pursuant to an exclusive contract arrangement shall not be required to waive their individual medical staff due process rights as a condition of practice opportunity or privileges.

Emergency physicians shall not be required to render anything of value in return for referral of patients by a hospital (e.g., through the awarding of an exclusive contract) other than assurances of reliability and high-quality care; nor shall emergency physicians receive anything of value in return for referrals of patients to others.

Emergency physicians, both independent contractors and physician employees, shall be represented in the contract negotiation process between hospitals and those payers providing reimbursement for emergency services. Emergency physicians are entitled to fair rights and reimbursement pursuant to such contract agreements.

Emergency physicians shall not be required to agree to any restrictive covenant that limits the right to practice medicine after the termination of employment or contract to provide services as an emergency physician. Such restrictions are not in the public interest.

Responsibilities of Emergency Physicians

Emergency physicians bear a responsibility to practice emergency medicine in an ethical manner consistent with contemporary emergency medicine principles. Emergency physicians must maintain current emergency medicine knowledge and skills through independent study and continuing medical education (CME) activities.

Emergency physicians should exhibit professionalism in the ED in regard to behavior, attire, and reliability.

Emergency physicians should participate in medical staff and/or hospital affairs with the support of the ED medical director.

Emergency physicians should gain knowledge of the basic principles of documentation, coding and reimbursement, recruiting costs, coding and billing costs, practice expense costs, and other applicable physician administration costs, to assist in accurate billing for their services and to properly interpret practice revenue and expense information which they receive.

 

Emergency physicians must maintain knowledge of and compliance with major federal and state regulations that affect the practice of emergency medicine, such as the Emergency Medical Treatment and Active Labor Act (EMTALA).

Emergency physicians who are employees, contractors, or principals of a practice group, during the course of the relationship, have certain duties and responsibilities to the group. Active efforts, during the relationship, to interfere with or acquire a contractual relationship of the practice group may expose the individual to legal liability.

On-Call Responsibilities for Hospitals and Physicians:

USA Today and the Los Angeles Times recently reported on the refusal of specialists to come to the hospital when called to care for emergency room patients. The newspapers alleged that specialized treatment sometimes isn't available because doctors won't come in when called, won't volunteer to be on call in the first place, or simply are not available.

While these cases appear to be isolated, they strike at the heart of the public's confidence in what hospitals do. They are part of a larger concern about both caring for and being accountable to our communities. That's why it's important to continue to make sure your organization is doing everything it can to provide all patients with the care they need when they need it.

Make sure you're following the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) and its regulations. Be aware that a number of jurisdictions have state-based EMTALA laws that should be followed with the same rigorous attention to detail. EMTALA is intended to ensure that all patients who come to the emergency department receive appropriate care, regardless of their insurance or ability to pay. Hospitals are required to provide patients with a medical screening examination to determine if they have an emergency medical condition and, if so, to stabilize their condition. The law prevents hospitals from transferring patients until they're stable, unless the expected benefits of transfer outweigh the risks or the patient has made a request to be transferred. Violations carry penalties of up to $50,000 per incident and possible exclusion from Medicare and Medicaid.

After reviewing this advisory, check off the following items from your to-do list:

Make sure your hospital's medical staff bylaws and emergency department policies regarding on-call physician responsibilities are consistent with EMTALA's requirements.

Review EMTALA with your medical staff (including residents and interns), governing boards, senior managers, nurses and key personnel. Share copies of hospital emergency department policies and procedures with them. Determine when medical staff had its last training session on EMTALA. Consider whether it's time for a "refresher" course.

Engage your community on this issue. Have your community and media relations' teams speak candidly to community leaders and local media about your policies...your procedures...your commitment to ensuring quality care.

Encourage your medical staff, nurses, and other health care professionals to consult your hospital's risk manager for assistance and advice on EMTALA and its on-call requirements.

Background

In the vast majority of communities, the "on-call" system works well. It's largely invisible to the public, but is one of the cornerstones of good hospital care. Physicians respond night and day - take time from family and other activities - to be there for patients who are brought to their community hospital.

"On-call" duties come with the privilege of practicing in a hospital. They are a covenant between physician and hospital as part of their mutual responsibility to all patients who come to the hospital door. Physicians who break that covenant call into question their medical staff privileges. Every hospital should have policies to ensure appropriate "on-call" coverage of the emergency department by specialists and sub-specialists.

Hospital and Physician Requirements

Hospitals and physicians, including on-call physicians, who violate EMTALA may face stiff penalties. They could include civil fines of up to $50,000 per violation or exclusion from participating in the Medicare and Medicaid programs. Specifically:

§ Hospitals must maintain a list of physicians, including specialists and sub-specialists, who are on call to evaluate and treat patients in the emergency department.

Hospitals are responsible for ensuring that on-call physicians respond within a reasonable period of time.

The medical staff bylaws or policies and procedures must define the responsibility of on-call physicians to respond, examine, and treat patients with emergency medical conditions.

Although physicians are not required to be on call at all times, hospitals must have policies and procedures that are followed when a particular specialty is not available or on-call physicians cannot respond because of situations beyond their control (for example, if the physician is performing another surgery).

In most cases, on-call physicians must come to the hospital to examine the patient when a request is made for their services. If, however, their offices are located in a hospital-owned facility on contiguous land or on the hospital campus, the patient may be seen in the physician's office.

If a hospital transfers a patient to another facility because an on-call physician fails or refuses to appear, it must give the on-call physician's name and address to the receiving hospital. Failure to provide this information would violate EMTALA.

House staff responsibilities include the following:

Provide initial medical care to assigned patients in ambulatory/outpatient or inpatient settings appropriate to the resident's experience and ability.

Patient care responsibilities assigned to residents will be commensurate with their level of training, according to ACGME Special Requirements for the training program, and the judgement of the program director and the attending physician.

Where appropriate, formulate a plan of care based on a thorough assessment of the patient's history, current condition, and needs.

Write orders for the implementation of the plan of care.

Coordinate consultations with physicians and other members of the multi disciplinary health team.

Facilitate communications regarding the plan of care with the patient, family, attending physician(s), and any other involved member(s) of the health team.

Perform and/or assist in procedures according to the level of delegation appropriate to the resident's experience and ability.

Adhere to the duty hour regulations and policies of the School and submit hours worked as mandated by the School and/or program.

Participate in education, research, and patient care experiences required by the particular program within which he/she is a trainee.

Supervise and teach other house staff and medical students as appropriate.

Adhere to the affiliated hospitals' policies and procedures for the medical staffs including the "Bylaws, Rules, and Regulations for the Medical Staff" of each hospital and the School of Medicine "Personal Information for House Staff."

Before rotating to another assignment, complete and sign all medical records, charts, and reports assigned to him/her in a timely fashion.

Participate in institutional orientations, relevant committees, projects, and other leadership assignments and activities involving the clinical staff.

Demonstrate the knowledge and skills necessary to provide care, based on physical, socioeconomic, psychosocial, educational, safety and related criteria, appropriate to the age of patients served in the assigned service area.

Reflect a fundamental concern with and respect for patients' rights.

Develop an understanding of ethical and medical/legal issues surrounding patient care, hospitals' policies governing these issues, and structures available to support ethical decision making.

Sensitive to and apply cost containment strategies while caring for patients.

Conduct him/herself professionally, ethically, and personally in a manner consistent with the standards and aims of the medical staff of the affiliated hospitals and the School of Medicine.

Develop and participate in a personal program of self study and professional growth with guidance from the teaching staff.

Participate in the evaluation of the program and its faculty.

 

                   The experience of European countries

    The European countries have a long experience of collection, analysis and distribution of occupational and environmental health data.

    The German Accident Insurance Act (from July 6, 1894), launched by the efforts of Otto von Bismarck, was the first of its kind in the world. The health insurance scheme, pension funds and so-called Berufsgenossenschaften (literally –occupational comradeships) were established in Germany by the end of XIX century.

    Later, the system was adopted with some adjustment by the Scandinavian countries. By the end of XX century the experience of the Scandinavian countries – Sweden, Finland, and Denmark – in occupational and environmental health became recognized world-wide.

    In Sweden, official statistics on occupational injuries have been available since 1906. Since 1918, the National Social Insurance Board was responsible for data collection on occupational health; since 1955, the data were officially published in the series Sveriges officiella statistic (Swedish Official Statistics). Currently, the data are collected by ISA (Work Injury Information System). The purpose of ISA is to provide supportive documentation for policies regarding a preventive work environment [28]. The statistics are generated from  the data of a special work injury report form; this report is also  filed with a public social insurance office. The ISA consists of a computerized registery and also  an archive containing microfilms of work injury reports. The Swedish Work Environment Authority (SWEA) conducts special processing of primary data. The data with personal identifiers removed are available for individual researchers. The results can be found at SWEA website (www.av.se), as well as in the form of annual printed reports.

    There was a special study performed in 1990s, which compared data from several survey studies of work-related health problems and registered work injuries. It was demonstrated that no more than about a half the cases that were presumed to be work-related illnesses were reported to ISA. It was also found that a certain percentage of so-called administrative dropouts existed (up to 21%),hen the health problems were reported to Social Insurance Office, but the data of the workers were not found in ISA later [29].

    There is also Cancer registry, which collects data on cancer cases. As the occupation of a cancer patient is also registered, the Cancer registry can also be used for occupational health statistics, and has the ability to examine associations between cancer and certain occupations.

It is very important that the National Institute for Working Life (Arbetslivsinstitutet) is not concentrated only on working health issues, but covers a much wider spectrum of problems. One can speculate that it therefore has much better connections with political circles than most of the institutes in other countries (especially if compared with similar institutes in former socialist countries).

    It can be seen that occupational health problems are well covered in the Swedish press currently, especially those dealing with issues of  occupational stress, the  health problems of office workers (e.g. due to indoor environmental quality, video display terminals, etc.). An interesting book named “Medicine in press and under press” was published by a collaborator of National Institute for Working Life in Malmö Dr. Bo Hagström [30]. The relationship between Swedish medicine and Swedish mass media are described in the book.

    In general, the Swedish system of occupational data surveillance and analysis is probably one of the best in Europe, satisfying most of needs, and providing the decision makers with reliable, accurate data.

    It should be emphasized that such a system was created because of decades of strong and productive cooperation between employers’ organizations and trade unions; such co-operation was also strongly endorsed and nurtured by governmental bodies.

Unfortunately, it seems that at present level of the political system in Russia, very few positive features of the Swedish system could be directly borrowed. Nevertheless, certain approaches might be replicated and, perhaps, the Russian trade unions could participate more actively in the planning stage of policy regarding the sphere of occupational health.

    As an example of a former socialist country, Hungary still has its economy in transition, though few remains of socialist system can be seen now.

    For example, the Hungarians have held onto the list of occupational diseases introduced in 1970s. Though there is a newer list of occupational diseases, which has been modified according to EU recommendations, workers with occupational diseases from the new list do not receive financial compensation yet.

There is a registry of occupational diseases in Hungary, led by the Institute of Occupational Health, as well as a system for biological monitoring of more than 30 hazardous chemicals. (In Russia, it is thought that it will take at least 10 years to develop a similar biological monitoring system. Sweden currently requires biological monitoring of only two chemicals – lead and cadmium). Annually, the Institute of Occupational Health publishes a special report on the state of occupational health in the country, based mainly on the registry data. Despite this timely information, there are still complaints that few necessary political decisions are based on the annual report data.

    The Hungarian mass media has also remained uninterested in covering the problems of occupational and environmental health, unless there is some sensational case.

    So, the Hungarian system seems to present the case where scientists possess all the necessary data, but have no opportunity to present them to society to focus more attention on the issue.

 

The Ukrainian experience

    Historically Ukraine had strong connections with the same Soviet system of occupational and environmental health where the roots of the current Russian system began. Nevertheless, certain changes have taken place.

    Being a smaller country than Russia, Ukraine did not need to implement the system requiring “regional centers for occupational medicine”, as did Russia in 1994. The Soviet system of the Research Institutes of Labor and Hygiene responsible for several neighboring regions has remained in the Ukraine. On one hand, it has prevented the creation of “regional centers” that lack the proper group of specialists in most fields of occupational medicine (e.g., occupational neurology, occupational surgery, occupational ophthalmology, etc.). On the other hand, presently, the Kharkhiv Institute of Labor Hygiene is responsible for e.g. Odessa region of Ukraine. This presents a problem, unfortunately, as illustrated by the 600 km distance between the occupational physicians and the workers who have to be under their care. Although there is no national occupational registry in Ukraine currently, there are registries in some regions. Work on implementation of a registry on national level has recently begun.

    The caliber of work among certain Ukrainian occupational medicine physicians is much greater than the general level of occupational medicine in the country as a whole. This progression can be seen in the surveillance work concerning occupational and environmental exposure to ionizing radiation (the result of Chernobyl disaster) and the resultant health effects (Kiev Research Institute for Labor Medicine). Also, major advances can be seen in the collection and analysis of health data of computer users (Kharkiv Research Institute for Industrial Hygiene). In both Kiev and Kharkiv Institutes there has been surveillance of data occurring for more than 10 years.

    During a recent visit to Kharkiv, there was a discussion devoted to introduction of the so-called “Health passport” in Ukraine. According the Healthcare Ministry Order, the “Health Passports” are individualized data banks kept on recordable CDs (CD-R) minidisks which catalogue patient information. These CD-R minidisks are to be kept by the citizens of Ukraine, and brought with them every time they seek medical care. The data from these visits are added to these disks after any new visit of the patient to the hospital/polyclinic.

    Despite of approval of such a system, even by President Kuchma (as it was announced), it is difficult to understand how all the data (including X-ray images, ultrasound video etc.) will fit onto 180 MB minidisks. Each new cycle of adding information onto a CD-R disk requires at least 20-30 MB of additional service data.

With regards to mass media interest, unfortunately, occupational and environmental health is not a topic driving interest in Ukraine.

 

The main possibilities for reforming information data flow in occupational and environmental health

    The following three items of reforms were suggested in the letter of the Nizhny Novgorod Research Institute for Hygiene and Occupational Pathology to the Health Care Committee of State Duma (The Lower Chamber of Parliament) of The Russian Federation. The letter described possible directions of reforms in occupational and environmental health, including the following proposals regarding medical informatics:

 

    1. Development of a system to organize and carry out investigations to evaluate the most accurate, reliable, and valid occupational morbidity rate in Russia in order to guide managerial and political decisions aimed at the promotion of workers’ health.

    Currently, the officially registered occupational morbidity in Russia is substantially less than that of industrially developed countries. The State Report “On Sanitary and Epidemiological Situation in the Russian Federation in 2000” pointed out that “incomplete documentation and surveillance of patients with occupational diseases were due to flawed labor safety legislation…, due to shortcomings in the organization and quality of preventive examinations of workers.” To reveal the true rates of occupational morbidity in Russia, special investigations should be organized and performed, using e.g., the American experience: carefully selecting representative enterprises in targeted industries and agriculture, and then carrying out investigations to better assess occupational morbidity at these enterprises. The results could then be extrapolated to the larger industrial sector.

    The results of such a study would be used as a scientific base for managerial and political decisions aimed at worker health and safety  prevention.

 

    2. Development of computer software to create and conduct a national registry of patients with occupational diseases, and the implementation of this software in Federal and regional centers of occupational medicine in Russia.

    Presently, there is no registry of patients with occupational diseases in Russia. Though the Social Insurance Fund conducts a data base of patients with occupational injury and illness who receive financial compensation, this database  does not give a complete picture of occupational morbidity in Russia and its structure. Therefore, a surveillance system should be created in Russia to provide the systematic collection, analysis, interpretation, and dissemination of morbidity data  which documents labor conditions, various occupational hazards,  and possible occupational disability. This mechanism of a a continuing surveillance system, when implemented, will be able to be used to predict the state of occupational health in the country, as well as in separate regions.

 

    3. The expansion of the scientific basis of modern telemedical technologies, enabling greater transfer of medical information through telecommunication channels which will then increase the availability of qualified medical service for inhabitants of the distant regions of Russia.

    During last several years, telemedical technologies have been actively developed in Russia. The technologies have allowed qualified medical services to be available for certain populations in a few regions of Russia, where such services had not been available otherwise.

    Nevertheless, certain problems with telecommunications exist: legal and some organizational questions remain unclear; there is no standardized scientific method or basis for telemedical consults. Establishing a standard methodology, and addressing legal concerns will help expand the use of modern telemedical technologies, hastening their implementation in the sphere of occupational and environmental health.