Figure 3-70. Space plan for internal medicine, 2640 square feet. (Design: Jain Malkin Inc.)
on an angled bed and gravity flow drains different lobes of the lung. The therapist, after administering bron-chodilator medication, cups the patient's back, and the patient coughs up the mucous.
There is no generally accepted standard layout for a pulmonary function lab because it depends largely on the specific pieces of equipment the practitioner has and whether cardiovascular screening will be included. In the last instance, it is called a cardiopulmonary lab. Figure 3-70 shows a layout in which PFT and cardiopulmonary screening are performed.
Typically, in such a combined setting, one might have an ergometer exercise bicycle, a treadmill, telemetry, a physical therapy-type table, ECG, spirometer, a crash cart with defibrillator and oxygen, and a desk for the tech. One may also find a computerized metabolic testing unit (Figure 3-67) used primarily with an exercise bike, occasionally with a treadmill, previously discussed.
The majority of pulmonologists do only diagnostic testing in their offices and then refer the patient to a hospital outpatient facility for inhalation therapy, if the use of inhome nebulizers is not adequate. But this is rare; most treatment can be provided in the home.
Accommodating the equipment shown in Figure 3-69 requires considerable space as each patient needs privacy. If no partitions, screens, or curtains exist in the room, then it can only be used for one patient at a time, despite the inventory of equipment and diagnostic instrumentation.
Executive Health Centers. Sometimes a cardiopulmonary lab is part of an executive health screening facility (Figure 3-71) and, if so, a high-profile "corporate" image may be appropriate. Windows are a desirable feature in this room. A wood-look sheet vinyl floor is less institutional than vinyl composition tile and easy to maintain, but carpet is also functional.
In general, technicians are able to operate multiple types of diagnostic instruments since equipment is so automated it requires little training. Pulmonary function studies, and certainly respiratory therapy, require a trained respiratory therapist or nurse or an aide with PFT training. The volume of patients would determine staffing for ECG, Holter, echocardiography, and pulmonary testing. Techs often have workstations or desks in the room with the equipment so they can monitor the patient while doing desk work. Their work areas need to have space for supplies used in the procedures, a place to store microcassettes or tapes of patients' test results, and file cabinets for computer printouts of test results. In the future, compressed digital storage will become more common.
Physicians are always present or nearby when stress testing is done. Therefore, consultation rooms for the cardiologists and pulmonologists associated with the testing should be adjacent to the test area.
Both a general internal medicine physician who does not have a subspecialty in gastroenterology and a family practice physician would likely use a multipurpose procedure room for the occasional need to look at an unprepped colon. The patient would be given a Fleet enema prior to the procedure to empty the lower portion of the colon and this would enable the physician to check for anal fissures, bleeding or a tear in the sphincter. Patients would be referred to a colon and rectal surgeon if any repair was indicated.
Internists with a subspecialty in gastroenterology (whether in a subspecialty practice or part of a general internal medicine practice) would most likely have a dedicated room for what is called "flex sig" examinations of the lower colon with a flexible sigmoidoscope, a tube with fiber-optic light, an eyepiece at one end, and a tiny camera at the other. The patient is asked to adhere to a liquid diet the day before the procedure, then "prepare" the colon with a Fleet enema for the procedure, usually scheduled the next morning. The patient is not sedated and the procedure causes only mild and momentary discomfort. Therefore, no prep or recovery rooms are required; however, a workroom (6X8 feet) opening onto the procedure room is ideal (Figure 3-52) to provide suitable accommodation for washing and drying the scopes, which are very expensive and delicate and must be handled with care. A toilet room should open onto the flex sig room (Figure 3-52).
A procedure room 10X12 feet in size is adequate. If space is tight, although it's not ideal, the washing and drying of scopes can be handled in the procedure room (as in Figure 3-72), where flex sig is part of a multiphasic executive health screening clinic. In this instance, the scopes are soaked in trays containing glutaraldehyde (a powerful disinfectant) placed on the countertop. Glutaraldehyde has a strong odor that must be exhausted from the room (note air grille running horizontally in the sink backsplash) to the exterior of the building. With adequate ventilation,
there is no detectable chemical odor.The tall cabinet at left contains drying racks for the scopes. Details are covered in the Endoscopy section.
The examination table used for a sigmoid procedure is usually larger than a standard exam table and is often motorized to adjust the height and position of the patient. In laying out the exam table and casework in this room, it is important to note that the patient lies on his or her left side with knees bent with the physician, obviously, working from behind the patient. A nurse usually stands at the patient's head to help relax the patient and provide reassurance.
A large internal medicine suite (5000 to 7000 square feet) will have a sigmoidoscopy room, an ECG room with treadmill, and a lab with its own waiting area, blood draw, and toilet with specimen pass-through. Certain types of X-rays may be done in the office and, if so, an X-ray room with adjoining darkroom and film viewing area will be included in the suite. The business office in a suite of this size will be composed of separate rooms for transcription, business manager, insurance, medical records, bookkeeper, and receptionist. A sizable staff lounge should also be included. The reader is referred to Chapter 6 for guidance in designing suites of this size.
The development of fiber optics has made possible the examination of the colon, the lungs (bronchoscopy), and the upper gastrointestinal tract with an endoscope. This noninvasive instrument has revolutionized surgery, by reducing problems from invasive surgery and helping doctors detect, and in some cases treat, diseases at an early stage. These 4- to 5-foot-long flexible "tubes" have powerful fiber-optic lights and allow viewing through an eyepiece (fiberscope) or, most often, on a separate video monitor (videoscope). Light is transmitted down the tube to enable the internist to examine the colon, for example, in search of tumors or polyps. The procedure is viewed, in real time, on a video monitor placed on a cart or a ceiling-mounted arm, visible to both patient and physician during the procedure (Figure 3-73). At any point, the physician can print a photo to give to the patient or save an image to a computer for later use and comparison.
Endoscopies would generally not be performed in a physician's office unless it were a large clinic with a specialized suite designed to meet all life safety requirements. A medical office building may have an endoscopy center set up as an independent business
for the convenience of gastroenterologists in the building. It would most likely be owned by gastroenterologists and, if the center is properly designed and accredited, any qualified physician could have privileges there. Sometimes endoscopies are performed in ambulatory surgery centers in special rooms dedicated to this purpose.
In recent years, colon cancer has been given considerable exposure in the news media, greatly increasing the volume of procedures both for flex sig (examining the lower 6 inches of the colon) and for colonoscopy (examining the upper and lower colon with the scope penetrating as far as 6 feet). In 2000, the ongoing debate about the efficacy of colonoscopy (an expensive procedure and one that insurance companies and HMOs would rather not pay for) in terms of saving lives tilted in favor of the procedure for individuals over 45 years of age. In fact, because many precancerous polyps occur in the upper colon where they cannot be seen in a flex sig procedure, many now view that procedure with skepticism as it may give a false sense of security. Despite this, because it is an inexpensive screening tool, flex sigs are often performed as part of a comprehensive physical examination for adults.
As further evidence of this trend, in 2000, CEO David Lawrence announced that Kaiser Permanente Health Plan would offer colonoscopy to all members over a certain age, even though the enormous cost to provide this examination would impose short-range economic hardship and the benefits would not be realized unless the member (patient) stayed with Kaiser for many years. Kaiser's mission is to form lifelong partnerships with its members and, therefore, it is in Kaiser's best interest to keep members healthy. The economic benefits of early detection and treatment are well known and often offset the cost of early screening.
For all of these reasons, including the aging population demographic, the volume of endoscopy procedures will increase as will the need to design efficient suites.
Components of an Endoscopy Suite
An endoscopy suite would include:
• Procedure room
• Dressing area with lockers for male/female (M/F) staff
• Dressing area with lockers for patients
• Bathrooms (patients and staff)
• Workroom between procedure rooms
• Prep and recovery room
• Physicians' dictation/charting
• Linen storage
Figure 3-74. Layout of endoscopy suite, 2737 square feet. (Design: Jain Malkin Inc.)
Figure 3-74. Layout of endoscopy suite, 2737 square feet. (Design: Jain Malkin Inc.)
The same procedure room can be used by pulmonologists to do bronchoscopies and by gastroenterologists to examine the upper GI tract (esophagus, duodenum, and stomach) and the lower GI tract (colon). As a point of information, endoscopy procedure rooms are not considered sterile. However, there is a benefit to having dedicated rooms when a high volume of physicians use the facility and a high volume of cases exists. Many hospitals, in fact, separate rooms by function in order to do more procedures simultaneously and to facilitate scheduling with physicians.
In a large group practice or a multispecialty ambulatory clinic, one might find a layout of rooms similar to that shown in Figure 3-74. The number of procedure rooms is related to the projected volume of cases. Procedure rooms must be large enough to accommodate a Stryker cart or gurney, the endoscopy cart with video monitor, considerable storage for clean linen and supplies, and a resuscitation cart (Figure 3-75). Hampers for soiled linen and a clock with second hand are also required. The floor should be sheet vinyl with a self-coved base. The door to the room must be wide enough to accommodate gurney traffic. Rooms need central oxygen and suction, ideally coming from the ceiling. There are typically two monitors on the endo cart, one is video for the procedure and the other for patient information. The patient is given conscious sedation through a vein in his or her arm or hand.
The patient may intermittently wake up and watch the procedure, then doze off, but there is no memory of pain or discomfort afterward.
Procedure Room Lighting. Room lighting is darkened during this procedure. Indirect perimeter lighting, which could be dimmed, combined with standard 2X4 fluorescents overhead, when more light is required, would be ideal.
Fluoroscopic Examinations. Fluoroscopy may be used in a large procedure room with a C-arm X-ray to explore bile
Figure 3-76. Endoscopy recovery area provides maximum privacy for patients and gives nurses maximum visibility. Saint Francis Hospital, Hartford, CT. (Interior architecture and design: TRO/The Ritchie Organization, Newton, MA; Photographer: Hedrich Blessing.)
ducts and the pancreas during an upper GI exam. These organs are accessed through the duodenum with tools that feed through the scope tube into those small ducts where the camera on the end of the scope won't fit. Contrast media are injected into the organ. This is called ERCP (endoscopic retrograde colangio-pancreatography).
Patients are typically prepped and recovered in the same area. Figure 3-76 shows an attractively designed hospital-based prep/recovery area with private rooms, while Figure 3-77 shows a prep/recovery area in a medical office building endoscopy center. Patients often remove their clothes and change into a gown with the cubicle curtain closed, and their clothes are stored in a basket under the gurney, which follows the patient into the procedure room which negating the need for dressing rooms. The gurney is usually used as the procedure table since it can be adjusted in height and saves time in not having to transfer the patient to another table. The nurse sets up a monitor in the prep area for blood pressure and pulse oximetry and this monitor follows the patient into the procedure room. A monitor that attaches to the gurney is best so that two people (one for the gurney and one for the monitor stand) do not have to transport the patient into the procedure room and back again.
The patient is continually monitored during the procedure and given oxygen, as needed. The recovery period is generally 30 minutes during which time patients are monitored and observed by a nurse. Physicians will often dictate between patients or after several are seen in a morning. These procedures are usually performed in the morning for the convenience of patients who are required to fast and not drink water.
This is one of the most important rooms in the suite. All equipment is cleaned and readied for use in this room. Supplies are stored here, as are the cleaned scopes, which are typically hung in a long cabinet with glass doors (Figure 3-78). Scopes are very expensive and are handled with great care.
Some technicians prefer a separate sink for cleaning scopes used In upper GI and bronchoscopy procedures. In any case, a workroom requires at least two sinks set into countertops at right angles to each other or parallel. The sinks need to be deep and should be lower than the standard 34-inch-high countertop. For most people, a 30-inch height is fine. As the scopes are long and require quite a bit of handling to properly clean, the lowered sink is more comfortable.
The nurse or tech spends a few minutes precleaning and leak-testing the scope after each procedure, then manually reprocessing or putting the scope in an AER (automated endoscope reprocessor). The nurse also preps each patient. Therefore, it is unlikely the same
person can also keep an eye on recovering patients while reprocessing scopes. Somewhere in the suite, if not in the workroom, there need to be deep cabinets for storing disposables, room for the scope transport cases (these look like hard-shell briefcases), and shelves for large binders for storing the forceps used in biopsies. Each forceps is specific to each size scope, and these are often color-coded by the staff into binders for easy retrieval.
The workroom is a busy area, packed with instruments, sterilization equipment, bottles of solutions, racks, and more. It can easily become cluttered, and therefore the room size should not be underestimated (Figure 3-79). A room 8X14 feet is the minimum functional size.
Infection Control Issues. Endoscopic procedure rooms are clean, but not sterile. GI scopes are cleaned with liquid chemical germicide (LCG) using a very specific procedure, which can be facilitated or impeded by the layout of the room, the height of the sink, and the locations of air and suction. Scopes used for bronchoscopies are usually cleaned by sterile technique. With tuberculosis on the rise, strict infection-control procedures must be followed. Proper reprocessing of endoscopes cannot and should not be underestimated as it enhances and contributes to patient safety. Attention to reprocessing equipment, procedures, and facility design can have enormous economic benefits or drawbacks.
Cleaning Process — Overview. Scopes must be reprocessed with a protocol developed by the scope manufacturer, LCG manufacturer, AER manufacturer, appropriate professional organizations such as SGNA (Society of Gastroenterology Nurses and Associates, Inc.) and AORN (Association of perioperative Registered Nurses), and all appropriate regulatory bodies. Scopes are always precleaned by drawing water and detergent into them, soaking, washing, scrubbing, and inserting a cleaning brush through the channels as part of the process. They are leak-tested in the sink. At this point, they can be highlevel disinfected by manually soaking in trays containing glutaraldehyde or in an automated endoscope reproces-sor. In the manual process, scopes are rinsed off after soaking, then taken to the "clean side" to blow out with compressed air, and hung in a cabinet to dry.
Liquid chemical germicides recently introduced into the market have reduced soak times in the AER to as low as 5 minutes (from previous lows of 20 minutes). Ten air exchanges per hour or a filter device to limit vapor exposure are usually recommended when using glu-taraldehyde and other LCGs. Although neutralization is seldom required, the LCG can usually be neutralized in a 5-gallon carboy and then dumped down the drain (a
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When it comes to pieces of aerobic equipment to buy, treadmills continue to be the most popular and the most valuable. And why not? They are simple to use and naturally intuitive. They burn calories effectively and offer a wide range of exercise options, whether walking, climbing, or jogging.