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Figure 3-38. Standard examination room layout. (Design: Jain Malkin Inc.)

layout puts the physician on the patient's right side, which is standard, even for most left-handed practitioners. Physicians are trained to examine from the right side as this makes it easier to palpate certain organs. It should be noted that an attempt to place plumbing back to back (mirror image) will result in left- and right-handed exam rooms. This is foolish economy. Every exam room should be identical in layout to be efficient so that the practitioner has the same degree of comfort and orientation in each room. One could almost draw a vertical line through this room dividing it into two zones—the right side for the physician or provider and the left for the patient. In a "right-handed room," the entry door will be on the right side and the exam table on the left, as one would face the room upon entering.

Despite this rationale, one may find practitioners with other preferences such as in Figure 3-39 where the sink cabinet faces the wall with the door (this layout wouldn't work were there windows on this wall), although the physician still addresses the patient from the right side. The patient is exposed as the foot or stirrup end of the exam table faces the door, but a cubicle drape can be

Exam Room Interior Design
Figure 3-39. Examination room. Montefiore Medical Center in the Bronx. (Architecture and interior design: Guenther Petrarca, New York, NY; Photographer: ©Christopher Lovi.)

pulled across the width of the room. The wooden wall panel behind the wall-mounted examination instruments is an attractive feature of the room.

Size

The first functional consideration is size: 8X12 feet is the ideal size for exam rooms (gives a clear dimension of 7 feet 6 inchesX11 feet 6 inches inside the room) as it comfortably allows for a full-size exam table, a built-in sink cabinet with storage above, dressing area, small writing desk (usually wall mounted), a stool on casters for the doctor, a guest chair for the patient, a treatment stand (if required), and perhaps a small piece of portable medical equipment.

If the room is used for purposes other than routine examinations, such as stress testing, the room would contain an electrocardiogram (ECG) unit and a treadmill, as well as an exam table, and it should be 9X12 feet or 10X12 feet in size. If a dressing area is not required, the length of the room can be shortened to 10 feet.

The reader may wish to refer to Chapter 2 for a discussion of alternate sizes of exam rooms with respect to planning grids. Practitioners may prefer a wider exam room (9X12 feet) as in Figure 3-40 or even a square room 10X10 feet as in Figure 3-40 although, if these occur on exterior walls and the planning grid is 4 feet, the wall will have to jog 2 feet one way or the other (creating an awkward unusable space in front of the window) to terminate at a mullion.

Dressing Area

If space permits, it is desirable to provide a dressing area for patients. This need be no more than a 3-X3-foot, surface-mounted drapery cubicle track at the ceiling (with radius corner), with a built-in bench or a chair, clothes hooks, hangers, a mirror, and perhaps a shelf for disposable gowns. It provides patients with privacy in undressing.

The alternative is that patients must disrobe in the open exam room, with the fear that the nurse or doctor may walk in on them while they are naked or while they are squeezing into a girdle or pantyhose. Older people, and those with orthopedic girdles or braces, tend to be more sensitive about this than younger people.

There is also the possibility of creating a private dressing alcove with a 30-inch-wide door or panel hinged to the wall. It is perpendicular to the wall when in use and folds flat against the wall when not in use. The chair can be used either inside the dressing area when the hinged panel is extended or outside when the panel is folded flat against the wall. Called the Dressing Nook, such a product is currently manufactured by Midmark Corporation

Ada Bathroom Layout
Figure 3-40. Alternative layouts and sizes for examination rooms. (Design: Jain Malkin Inc.)

(Figure 3-8). As an alternate, one may place a cubicle drape around the door as in Figure 3-40.

With certain medical specialties, for example, ear, nose, and throat (ENT) or orthopedics, patients rarely undress, or if they do so, they primarily undress just to the waist, so private dressing cubicles would not be a priority in these practices.

It should be noted that cubicle drape fabric is specially fabricated for this purpose. It is 72 inches wide, has two "good" sides in terms of pattern and appearance, and can be washed at a temperature of 160 degrees Fahrenheit. Manufacturers include Maharam, Carnegie, DesignTex, and Momentum.

Position of Exam Table

The second functional consideration is the position of the examining table. The foot or stirrup end of the table should be angled away from the door (Figure 3-41) as well as the wall, so that the doctor has access to all sides of the patient, and the patient is out of view of passersby in the corridor when the door is opened. Related to the position of the exam table is the placement of the wall-mounted diagnostic instrument panel (Figures 3-6, 3-39, 3-41, and 3-42).

The door to an exam room should be hinged so that it opens away from the wall (does not stack against the wall). While this might seem awkward in most rooms, it is desirable in a medical exam room because it shields the

Exam Room Design

Figure 3-41. Standard examination room. (Design: Jain Malkin Inc.; Photographer: Robinson/Ward.)

Pediatric Exam Room Decor

Figure 3-42. Primary-care examination room with lowered desk surface for physician. (Architecture: Moon Mayoras Architects, San Diego, CA; Interior design: Jain Malkin Inc.; Photographer: Steve McClelland.)

Figure 3-41. Standard examination room. (Design: Jain Malkin Inc.; Photographer: Robinson/Ward.)

Figure 3-42. Primary-care examination room with lowered desk surface for physician. (Architecture: Moon Mayoras Architects, San Diego, CA; Interior design: Jain Malkin Inc.; Photographer: Steve McClelland.)

patient from corridor traffic, should the door be opened accidentally, and gives the patient more privacy when dressing, since one has to walk around the open door to enter the room. It should be noted that the ADA requires 18 inches of clear space on the pull side of the door, making it awkward to open the door to shield the patient in a 7-foot-6-inch-wide room as it puts the door almost in the center of the room (Figure 3-38).

Cabinets

The sink cabinet may be located either on the foot wall opposite the door or on the long wall, to the right, as one enters the room. Either location is functional in a room in which pelvic or proctologic examinations are done.

The sink cabinet need have only a small sink (a 12-x 12-inch stainless steel bar sink works well), as instruments will be washed at the nurse station or lab. In addition, the sink should have a single-lever faucet. The sink cabinet should be a minimum of 48 inches long, 24 inches deep, and 34 inches high. If space permits, it might have a built-in compartment for trash with a hinged "trash slot" cut into the face of the cabinet door (Figure 3-42). Each exam room needs a container for general waste as well as biohazardous waste.

An upper cabinet may be provided (48 inches long, 14 inches deep, 36 inches high), over the base cabinet, for storage of disposable gowns, sheets, and other paper products (Figure 3-38). Shallow drawers in the base cabinet store instruments, syringes, surgical gloves, dressings, tongue depressors, and the like. Paper towel and liquid soap dispensers should be mounted on the wall near the sink, as well as sharps containers and a rack for holding boxes of gloves (Figure 3-43). These items are often provided by the paper or supply vendors who service the units but, if the designer does not oversee the installation, they may be placed with no regard for the aesthetics of the room.

Obstetricians and gynecologists often like to warm their specula prior to examinations. For this purpose, an electrical outlet may be provided in the drawer in which the specula are stored. The more expensive pelvic examination tables have a built-in warmer.

A small wall-hung writing shelf may be provided in an exam room to enable the physician to complete most examinations in the exam room without returning to the consultation room. The prefabricated unit in Figure 3-44 can be customized to house a laptop computer. It has storage for a chart, a place for prescription pads, and a tackable surface, and it is self-closing. If the sink cabinet is located on the long wall or the foot wall, the countertop can be extended, and lowered, from 34 inches to 30 inches, to serve as a writing desk (Figures 3-36 and 3-42). A rolling stool that stores under the "desk," when not in use, should be provided for the physician.

The patient may sit on the exam table (Figure 3-42) or on a guest chair while the physician is taking a patient history or writing a diagnosis. Over time, the use of laptop computers or fully loaded PC tablets (Figures 3-29a and 3-29b) will become more common and may influence the character of the physician/patient interface.

The cabinetry should be clad with plastic laminate, rather than painted. The additional cost when fabricating cabinets is minimal, and well worth it, when one considers the abuse of the painted surfaces plus the inconvenience, and cost, of repainting.

Writing Desk Wall Mounted

Figure 3-43. Plexiglas glove box holder. Figure 3-44. Wall-mounted fold-down physician's writing desk.

(Photo courtesy: Custom Comfort, Inc., (Photo courtesy: Peter Pepper Products, Inc., Compton, CA.)

Figure 3-43. Plexiglas glove box holder. Figure 3-44. Wall-mounted fold-down physician's writing desk.

(Photo courtesy: Custom Comfort, Inc., (Photo courtesy: Peter Pepper Products, Inc., Compton, CA.)

Windows

There is controversy over the benefit of windows in exam rooms. There is no need for natural light in an exam room for most specialties (it is recommended for dermatology exam rooms, however), so the inclusion of windows would be either a matter of the physician's preference or a given of the building's architecture. However, natural light makes the room more pleasant, especially if the patient is kept waiting. If present, the glass should start at a height sufficient (generally 42 inches) to afford the patient a measure of privacy.

Gray glass is superior to bronze since the latter casts an unhealthy tint on a patient's skin. Horizontal slat wooden blinds or vertical blinds are particularly well suited to windows in exam rooms, as the slats can be tilted to provide privacy without cutting off the light or view entirely.

Too many windows in a medical building can make it difficult to lay out the rooms efficiently unless one wishes to have partitions that terminate in the middle of a window, instead of at a wall or a mullion. This is particularly common when the architect who designed the building was not familiar with medical space planning, and a window module was designed that was not compatible with the size of the rooms in a medical office—basically a 4-foot module.

Electrical Requirements

Three grounded duplex electrical outlets should be provided in an examination room—one above the cabinet countertop, one at the foot of the table, and one near the head of the table. Except for the outlet over the counter-top, which would run horizontally at a height of 42 inches, the other outlets may be a standard 15-inch height. Some physicians use a wall-mounted diagnostic instrument panel that would be positioned on the long wall, at approximately 60-inch height, near the head of the exam table (Figures 3-39, 3-41, and 3-42). It requires an electrical outlet that may be placed low on the wall, or high, depending on how much electrical cord one wants visible. Rooms used for ophthalmic or ENT examinations have special electrical requirements, to be discussed in Chapter 4.

Certain exam rooms, such as pediatric or orthopedic exam rooms, often require only two electrical outlets, one over the countertop and the other near the foot of the exam table. Outlets in a pediatric exam room must be carefully guarded and located where a child cannot reach them.

Some examinations, such as OB-GYN exams, require an additional light source, which is usually a high-intensity quartz halogen lamp on a mobile floor stand. Some practitioners like a ceiling-mounted high-intensity lamp at the foot of the exam table. This requires support in the ceiling for mounting it (Figure 3-42). A halogen light may also be bracketed to the end of the exam table (Figure 3-39).

It may be necessary to shield a specialized exam room (one used for electrocardiograph machinery, for example) against electrical interference from surrounding medical offices or equipment, although this is increasingly rare with current equipment.

Exam Table

The standard exam table is 27 inches wideX54 inches long plus stirrups and pull-out footrest (Figures 3-39 and

3-42) if it is to be used for pelvic or urologic examinations. If not used for these purposes, the table will have a pull-out foot board that extends the length of the table to about 6 feet. There are specialized tables for cystoscopic (uro-logical) examinations (Figure 4-158).

The examining room, as described above, will be suitable for most physicians, but some medical specialties require modifications, and these are discussed in future chapters. Most notably, orthopedic surgeons use an 80-inch-long exam table, which is sometimes placed against a wall. Pediatricians also often place their exam tables against the wall.

The combination consultation room and examination room popularized some years ago by the Mayo Clinic (Figure 3-37) is an alternative that has a place in some practices. The Mayo brothers were pioneers in exploring options for the design of exam rooms to enhance productivity. Whatever the design of the exam room, the formula for a productive and efficient office is in the relationship between exam rooms, consultation rooms, nurse stations, and support areas.

Treatment/Minor Surgery

Each family practice or general practice suite will have a minor surgery or procedure room (Figure 3-45). It is sometimes called a treatment room. It is a large exam room (usually 12X12 feet) that serves a variety of purposes. It may be used as a cast room, in which case a plaster trap should be provided in the sink, and cabinets should contain a bin for plaster and for the remains of casts that have been removed (see Chapter 4, Orthopedic Surgery).

It may be used as an ECG room, as an operating room for minor surgical procedures using local anesthetics, and as an emergency exam room for accident cases. In treating emergencies, the physician may need one or more aides in the room plus certain medical equipment not usually stored in other exam rooms. Add to that the relatives who accompany the patient and frequently wish to remain in the treatment room, and the need for an oversized, multipurpose exam room becomes clear.

A minor surgery room should have a 10- to 12-foot length of upper and lower cabinets—one full wall of built-ins. Usually, this room will have a ceiling-mounted surgical light over the treatment table, in addition to standard fluorescent lighting (Figure 3-45). Proper illumination is mandatory for this room.

If the suite is so situated within the layout of the medical building as to make possible a direct entrance to the minor surgery room, it is desirable. Accident cases or those with contagious diseases do not have to walk through the waiting room if they can enter the minor surgery room directly. This would be an unmarked door in the public corridor of the medical building provided with a buzzer, or the door might simply state Emergency Entrance—Ring Bell for Service.

The receptionist taking the emergency call would ask the patient to go to the door marked Emergency Entrance and ring the bell.

Consultation Room

This room functions as a private office for the most part, but some physicians do consult with patients here. Routine consultation can be handled in a well-designed exam room, saving the physician the trouble of continually returning to his or her private office with each patient.

Certain physicians (e.g., internists, oncologists) spend a good deal of time interviewing the patient on the initial visit. In such cases, physicians may feel that the consultation room provides a more conducive atmosphere for establishing the relationship or for discussing serious illnesses. Surgeons also tend to use their private offices for consultation with patients, but this remains a matter of individual preference for each physician.

The consultation room is also used by the physician for reading, returning phone calls, dictating notes, or just relaxing. The minimum size for this room is 10X12 feet, but 12X12 feet is better. The room must accommodate a desk with computer, credenza, bookshelves for the doc

Design Sketch Minor Procedure Room
Figure 3-45. Minor surgery room. (Design: Jain Malkin Inc.; Photographer: John Christian.)

Figure 3-46. Diplomas, attractively framed. (Design: Jain Malkin Inc.; Photographer: Michael Denny.)

Figure 3-46. Diplomas, attractively framed. (Design: Jain Malkin Inc.; Photographer: Michael Denny.)

Montefiore Hospital DiplomaNurse Station Storage Ideas
Figure 3-47. Shared physician office. Montefiore Medical Center in the Bronx. (Architecture and interior design: Guenther Petrarca, New York, NY; Photographer: Lynn Massimo.)

tor's library, two guest chairs, a coat closet (optional), and perhaps a private bathroom.

The room should be furnished like a living room or study with cut pile carpet, textured wallcoverings, comfortable furniture, and artwork. If the doctor has a hobby that lends itself to expression in room decor, this is the one room in the suite that can be highly personalized. Family photos, armed forces honors, and personal memorabilia humanize the doctor's image and provide a clue to him or her as a person, apart from the medical practice.

The physician's diplomas and credentials should be nicely framed and displayed in the consultation room. If grouped artistically (Figure 3-46), they can complement the room's decor.

A consultation room should have natural light if possible. In addition, table lamps or indirect lighting may add to the room's homelike ambience. It is desirable to locate the consultation room at the rear of the suite to give the physician more privacy and to ensure that patients do not pass it on their way to the examining room. Still, some assertive patients find their way to the consultation room uninvited and unannounced.

It may be possible to locate an outdoor exit in the private office. The physician may thus enter or leave without being seen by patients. If such a door is not possible, then a private rear entrance to the suite, as previously discussed, is mandatory.

In certain suites, such as pediatrics, the consultation room is used so minimally that several physicians may share one. Their combined medical library would be stored here, and each doctor would have a small desk and telephone (see Figure 3-47).

At the other extreme, a physician will occasionally request a consultation room with a sofa large enough to sleep on, a table with reading lamp, a refrigerator, and bathroom with shower, in addition to the usual components of a private office. Such an office may serve a cardiac surgeon who, due to many emergency surgeries, may have to spend the night at the office (if it is near the hospital) or just catch up on sleep during the day between surgeries.

Nurse Station Design
Figure 3-48. Nurse station. (Design: Jain Malkin Inc.; Photographer: John Christian.)

Nurse Station and Laboratory

The nurse station is an area where the doctor's nurses or assistants perform a variety of tasks such as weighing patients, sterilizing instruments, dispensing drug samples, giving injections, taking a patient's temperature, performing routine lab tests, communicating with patients by

Containerised Mobile Hiv Clinics
Figure 3-49. Nurse station, pediatric community clinic. (Interior design: Jain Malkin Inc.; Photographer: Steve McClelland.)

telephone, or handling office paperwork (Figures 3-48 and 3-49).

The nurse station may be only a 6-foot length of coun-tertop (with cabinets below and above) recessed in a niche in the corridor (Figure 3-52), or it may be an 8-x 12-foot room or area adjacent to the exam rooms (Figure 3-2). The size of the nurse station depends on the num

Gloves Nurse
Figure 3-50. Pneumatic blood draw chair. (Photo courtesy: Custom Comfort, Inc., Orlando, FL.)

ber of nurses or aides who will use it, the type of medical practice, and the functions to be performed by those individuals. The nurse station in Figure 3-35 offers physicians maximum access to nurses and numerous stand-up-height writing shelves.

The number of physician extenders can be estimated on the basis of each doctor requiring one or two assistants, depending on whether the practice is a high-volume specialty. This person, depending on training, may assist the physician in the exam room or may actually perform certain examinations. Obstetricians and gynecologists have been using nurse practitioners in this expanded role for routine pelvic and gynecologic examinations. Since OB-GYN is a very high-volume specialty, the use of nurse practitioners saves the physician time on routine examinations and permits him or her to concentrate on patients with more demanding medical problems.

Therefore, the nurse station in an OB-GYN suite must be large enough to accommodate the nurse practitioners and other aides who need a knee space for sitting down and writing notes, one or two scales (all OB-GYN patients are weighed each visit), with a writing shelf nearby. Sometimes scales are recessed into the floor, if practical, in terms of cost and construction parameters. This recess in the concrete slab can be carpeted with the adjacent floor carpet. An area of approximately 24 inches should be allowed for each scale. This is not the size of the recess but the floor space necessary to accommodate a standard medical scale with balance rod.

There is an advantage to locating the nurse station near the front of the suite in a small office (under 1500 square feet). The nurse has easy access to patients as he or she leads them from the waiting room to the exam room, and the nurse can cover for business office staff when they are momentarily away from their desks. In larger suites, each doctor may have a nurse or medical assistant working from a nurse station convenient to his or her pod of exam rooms (see Figures 3-2 and 3-52).

In some medical offices, the nurse station is combined with the laboratory. In otolaryngology (ENT), for example, this is true since few lab tests are performed in the office.

The nurse station/lab would be used for preparing throat cultures and for cleanup of instruments in the sink or for sterilizing instruments. With the widespread use of disposable syringes, gowns, sheets, and even many examination instruments, relatively few items have to be washed or sterilized.

In an OB-GYN practice, the laboratory would usually be a separate room because a good deal of lab work is generated in the suite. Each patient supplies a urine sample for analysis, which is performed in the lab, and each patient having a pelvic exam and Pap smear will have a tissue culture that will have to be prepared for sending to a cytology lab.

A number of other routine tests would be performed within the lab, plus many gynecologists do D&Cs (dilation and curettage), terminations of pregnancy, and other types of minor surgery procedures in a well-equipped minor surgery room in the office. These procedures can be messy and require an adequate area for cleanup and a good-sized nurse station, plus lab support facilities.

A lab should have a double-compartment sink, a knee space area for a microscope, and a full-size refrigerator, if necessary (otherwise an undercounter one). It may also have a blood drawing station with a specialized blood draw chair (Figures 3-50 and 5-79) as standard tablet-arm chairs are not functional for this purpose. It is advisable to shield the patient whose blood is being drawn from the sight of other patients, who often become faint upon observing the procedure. The countertop will have a centrifuge for spinning down blood before sending it out to a lab and may have (if more lab work is done within the suite) a countertop analyzer. Refer to Chapter 5 for photos of clinical analyzers.

It is desirable to have at least one toilet room adjacent to the lab so that a specimen pass-through door in the wall can give the lab technician access to urine specimens without leaving the lab (see Figure 3-21). The reader is referred to Chapter 5 for more detailed specifications of a small laboratory and to the Appendix for a diagram of a specimen pass-through.

The nurse station of an orthopedic surgery suite would be of minimal size since there are no lab tests per formed, and no blood is drawn. The supplies needed for examinations or for making or removing casts would be stored in the respective rooms, and very little would have to be carried into a room for a procedure. In fact, orthopedic offices have tech workstations rather than nurse stations.

By contrast, a family practice or G.P. suite would have a large nurse station. Since such a wide variety of medical procedures are performed and there is such a wide range of patients, it would be impractical to store in each exam room all the supplies one might need. Therefore, the nurse prepares the exam room with any special supplies, injections, dressings, and instruments that she anticipates will be required. A good many of these items will be stored in the nurse station, and each nurse station might have its own autoclave for sterilization of instruments. In addition, the nurse might give allergy or other injections at the nurse station; blood might be drawn for tests to be done in the suite's own lab or sent out for processing; patients are weighed at each visit; and many other routine tasks are carried out here.

A nurse station should always have a sink and often has an undercounter refrigerator and a knee-space work area with telephone (Figures 3-47 and 3-48). Most nurse stations have a scale space, with a nearby shelf, for recording the weight in the patient's chart. The reader is referred to Chapter 4 for nurse station requirements for each medical specialty.

Legislation Affecting In-House Labs

Regarding the laboratory, the physician decides whether to do lab tests within the office or send the work out. Some do not even like to draw blood in their office, preferring to send the patient to a lab, if one is conveniently located in the medical building.

Stark Legislation

In the past, physicians may have had a financial interest in a lab to which they referred their patients, but with the federal Stark legislation enacted a number of years ago, this is rare. Only under the "safe harbor' provision, and under certain conditions, for example, in rural areas where an independent lab may not be available, may physicians own a lab. Otherwise, financial interest in a lab, or other ancillary services, is viewed as a potential conflict of interest.

It is estimated that today fewer than 10 percent of medical practices do lab work in house as CLIA (Clinical Laboratory Improvement Act), federal legislation enacted in 1988, imposes a level of compliance that results in high overhead and—with the decrease in reimbursement—it becomes a drain, rather than an economic incentive. Also, under managed care, a patient's insurance may dictate what lab must be used.

CLIA Compliance

Lab tests physicians may commonly do in their offices— and are allowed to do without CLIA compliance (although they still need to register with CLIA)—are what are referred to as "waived tests," something equivalent to the kinds of self-tests one could purchase at a pharmacy. These include dipstick urine tests for pregnancy or diabetes.

Physicians who elect to do what are called "nonwaived" tests in the office would come under CLIA regulations. The most commonly performed tests include blood counts, glucose tolerance tests, kidney and liver function tests, and cholesterol testing or a full lipid panel. This work would require benchtop hematology and chemistry analyzers. See Chapter 5 for photos of automated analyzers and more detailed information about laboratories.

Drug Testing

Large family practice suites and clinical laboratories may wish to do testing for drugs as part of employment-required physical exams. A toilet room designed for this purpose is discussed in Chapter 5.

OSHA Issues

The Occupational Safety and Health Administration (OSHA) of the U.S. Department of Labor protects workers from occupational hazards and risks. It publishes guidelines, standards, and regulations governing a multitude of settings, products, and situations, most of which have to

Opti Klens Eyewash Station
Figure 3-51. Opti-Klens I eyewash faucet diverter. (Photo courtesy: Desert Assembly, Inc., Henderson, NV.)

do with processes and procedures, none of which come under the purview of the architect or designer. OSHA also evaluates products such as sharps disposal containers to determine if they meet OSHA standards. Periodically, worksites, including medical and dental offices, may be visited by OSHA inspectors. Designers should be aware of the following issues:

1. Personal-use or edible items cannot be stored in the same refrigerator as blood or tissue samples. However, according to OSHA, refrigerators containing medications or other substances stored for medical procedures (e.g., challenge solutions for glucose tolerance tests) are not subject to the restriction.

2. An eyewash diverter valve device mounted to a faucet is required in any workplace where the eyes of the employee may be exposed to injurious materials. In OSHA interpretations letters, it is not clear where, in a medical or dental office, they might be required. However, a large primary-care office might have one; urgent-care clinics (for walk-in patients) and ophthalmologists often have one for patients. The device must meet American National Standards Institute (ANSI) Z358.1-1990, as does the Opti-Klens® unit in Figure 3-51.

3. In offices where staff are exposed to bloodborne pathogens, staff should remove their lab coats prior to leaving the suite. The idea is to not carry home organisms on one's clothing. Although not required by OSHA in physicians' or dentists' offices, depending on the specialty, the practitioner may wish to provide a locker room and change area for staff. Disposable items with bodily fluids must be red-bagged and labeled "biohazardous waste" and collected by a service. A biohazardous storage room, usually near the staff entrance to the suite, will house the waste until it is picked up. It can also be stored in a soiled utility room. [Note: Some suite plans in this book lack this room as it was not a requirement when these suites were designed.]

4. Occupational exposure to bloodborne pathogens including hepatitis B and C viruses as well as human immunodeficiency virus (HIV) poses great risk to healthcare workers. Needle-stick injuries are a serious hazard and OSHA has researched every aspect of this problem and published numerous standards and documents relating to how injuries occur and how they can be reduced. Standards for selecting the safest sharps disposal container and suggestions for training staff are covered in the Occupational Exposure to Bloodborne Pathogens Standard.

Placement of Sharps Disposal Containers

It is of interest to note that one of the three factors most often related to sharps injuries is inappropriate placement of the sharps container. It should be visible and placed at an arm's reach and below eye level at the point of use. According to OSHA, the fixture should be below the eye level of 95 percent of adult female workers, which results in an optimal installation range of 56 to 52 inches at a standing workstation and 42 to 38 inches for a seated workstation.

A word of warning: When a physician's office staff conveys to the designer OSHA standards and regulations that must be met, it is advisable to check it out by calling OSHA. In the author's experience, much of the time, either no regulation exists or, if it does, its effect on the built environment has been misunderstood. The problem is that individual OSHA inspectors may cite a facility for a perceived infraction that cannot be found in a literal reading of the OSHA text. In addition, each state has its own OSHA interpretations. Physicians' office staffs are right to treat employee safety issues seriously and to want to address them to the letter of the law since the liability and risks are substantial for noncompliance. However, much of the compliance deals with staff training, keeping procedure manuals updated, and making certain the staff actively follow the procedures they have outlined to protect patients and employees. In that regard, an excellent resource for OSHA compliance training, consulting, and compliance products is HPTC in Plymouth, Michigan (www.hptcinc.com).

Other Support Services

X-Ray Room

This discussion will focus on the one-room X-ray unit that can be found in a family practice or internal medicine suite (Figure 3-52). Rather simple radiographic examinations are performed here—films of extremities, chests, gallbladders, appendixes, and so forth. More complicated procedures will be performed in a radiologist's office. A large internal medicine practice might have a suite of radiographic rooms within its facility with a full-time radiologist on staff. But usually a patient who requires GI (gastrointestinal) studies, thyroid scans, computed tomography (CT) scans, radiation oncology therapy, or other specialized or complicated diagnostic imaging procedures will be referred to a local hospital on an outpatient basis or to a nearby radiology clinic.

A 10X14-foot room is adequate (not taking into account the dressing area and darkroom) for most X-ray machines used in a family practice or internal medicine office, although a slightly larger room would be more comfortable. Usually, a 9-foot ceiling height is required. There should be a place inside or outside the room for a patient to dress (ideally a 3-X4-foot alcove with a drapery or door for privacy), a control area for the technician, and a place to process the film. Although the equipment breaks down into components, it is advisable to provide a minimum 3-foot-wide door in this room for ease in moving the equipment. Although new imaging equipment is digital and filmless, many physicians have existing equipment that is not and it is unlikely most will trade it in as long as it's still serviceable. Therefore, the discussion about film-less imaging will be confined to Chapter 5.

The radiography room does not need a sink or prep area unless GI studies are performed or contrast media are used, in which case a bathroom must be located close to the radiographic room (Figure 5-5).

Two or more walls of an X-ray room will have to be shielded with lead to protect office occupants as well as passersby from radiation scatter. It is necessary to obtain a radiation physicist's report, which takes into account the type of equipment and the location of the room within the suite and within the medical office building, in order to know which walls must be shielded, the thickness of the lead, and the height of the lead panels. Frequently, the door to the room must also be lead-lined. Such a door is very heavy and must have a heavy-duty door closer. The control partition, if located within the room, must also be lead-lined. It is possible to buy prefabricated, lead-lined control partitions with glass viewing panels from X-ray supply houses.

If the control area is located outside the X-ray room, there must be a lead-lined glass window to enable the operator to observe the patient at all times (Figure 4-122). The control area need not be large—3 feet square is generally adequate.

There are considerable variations in size of radiology equipment, power requirements, and other specifications from one manufacturer to another. Therefore, it is advisable to obtain planning guides for each piece of equipment before proceeding.

A valuable reference in designing radiology rooms is the catalog of radiology accessories marketed by each manufacturer. These catalogs are available online through the Internet and, in addition, some are available as printed catalogs as well. General Electric has a particularly good one, in which many items are pictured with dimensions and pertinent data. This will familiarize the designer with the numerous accessory items (cassette pass boxes, film illuminators, film dryers, automatic processors) that must be accommodated in a radiology room or suite.

A lead-lined cassette pass box should be located in the wall between the darkroom and the radiography room. The pass box is used for passing exposed and unex-posed film back and forth between the rooms.

The manufacturer's literature will specify utility requirements and critical distances between equipment. Additional support is usually needed in the ceiling to support the tube stand. The X-ray unit, if new, will often be supplied by a local distributor who will assist the designer in locating the equipment in the room. Or, if the physician is relocating existing equipment to a new office, it will usually be moved and reinstalled by a skilled techni cian who can offer assistance as to the equipment's requirements.

Darkroom

In the future, most radiographic equipment will be digital but, currently, most general practice and internal medicine clinics—if they do radiography—will have a darkroom. It should be set up with a "wet" and a "dry" side (Figure 10-78). A 6-x8-foot room is the minimum size, although, if designed to meet the ADA, and in view of the fact that a darkroom door always opens inward, the room would have to be larger. The room should have two full-width countertops either parallel to each other or at right angles. The wet side contains the sink, automatic processor, and replenisher tanks, while the dry side is used for loading cassettes. A light-proof metal film storage bin should be located under the dry side of the counter. Ideally, the cassette pass box would be positioned in the wall close to the film storage bin.

Sometimes a rack for storage of cassettes is provided. A floor drain must be located near the processor. One outlet should be provided over the counter on both the wet and the dry sides. An outlet is needed for the film storage bin as well. The processor requires only cold water if it is a recent model with an internal temperature control.

Local codes normally require a vacuum breaker on piping to darkroom tanks to prevent the chemical waste from backing up into the water supply. Also, acid-resistant pipe is recommended, since chemical waste is highly corrosive.

The room must have an exhaust fan, and some codes require that the door have a light-proof louver ventilation panel. The darkroom door must be 36 inches wide and have a light seal. It should open inward, so that if someone tries to enter while film is exposed, the technician inside the room can put a foot against the door to prevent it from opening. Some darkrooms have a red warning light that is activated when developing is in progress.

The darkroom must have two sources of light. A 75-watt incandescent fixture, surface-mounted to the ceiling, will suffice for general illumination, but a safelight must be provided for working with exposed film. The safelight may be plugged into an outlet at 60 to 72 inches off the floor, and it can work by a pull chain or be wired into a wall switch. If the latter, the switch should be located away from the incandescent light switch so that the technician does not confuse them and hit the wrong one while the film is exposed. Any recessed light fixtures and the exhaust fan must have a light-sealed housing.

Counters and cabinets in a darkroom may be at a 36-inch or 42-inch height, according to personal preference. If designed to meet the ADA, the countertop must not exceed the 34-inch height. There is no need for closed storage in the darkroom. All shelves should be open shelves.

A small viewing area is required outside the procedure room, near the darkroom (Figure 4-124).This may consist of nothing more than a double-panel view box illuminator, either surface mounted to the wall or recessed (Figure 4133). The X-ray technologist checks the films for resolution and clarity before handing them to the physician for diagnosis. If the film is not good, the patient is still at hand, with little time lost in having to take the film again. In a larger X-ray suite of rooms, the viewing area will be larger, with several banks of film illuminators and a place for two or more persons to sit down.

The film will be developed by an automatic film processor which may be a small tabletop unit such as dentists, otolaryngologists, or plastic surgeons use, or a floor model that sits outside the darkroom in the tech work area (Figures 3-52 and 4-124) with a feed tray that fits through the wall into the darkroom (see Figure 5-25). The exposed film is fed into the processor from the darkroom and "daylights" (drops out after processing) into the tech work area. See Chapter 5 for more detail. The suite in Figure 4-127 is set up for digital radiography but still accommodates storage of old film files.

Storage

Medical offices should have a storage room at least 6 feet square with two or more walls of adjustable shelves for storage of office supplies, sterile supplies, pharmaceutical items, housekeeping supplies, and cartons of toilet paper, hand towels, and facial tissue. If the office does not use a janitorial service, the vacuum cleaner and mop and pail would be stored here.

Staff Lounge

Any suite with more than two employees should have a staff lounge. The room need not be larger than 10X12 feet with a built-in sink cabinet 6 to 8 feet in length, an undercounter refrigerator, microwave oven, garbage disposal, a small table and chairs, and possibly lockers for personal effects. Do not underestimate the countertop area required considering coffee maker, appliances, dish drying rack, and space for the box of dougnuts. Remember that a refrigerator with an ice maker will require a water line. A larger staff lounge might include a sofa where an employee can lie down as well as a full-size refrigerator. This is a private room where the staff may take coffee breaks or eat their lunch. A staff lounge is an amenity that pleases employees and makes their jobs a little more pleasant. Furthermore, one does not want staff eating food in the nurse station, in the lab, or at the reception desk.

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Responses

  • LEWIS MYERS
    How to store gloves in medical office exam rooms?
    7 years ago
  • Hallie
    Are wall mounted sharps container the safest?
    7 years ago
  • annunziata
    Is it against osha to do lab testing at the nurses desk?
    7 years ago
  • oran
    Can sharps containers be stored under the sink in clinics?
    6 years ago

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