Policy and Service Context

Policy context

Adult inpatient units provide suitable accommodation for the patient where diagnosis, medical and nursing care, and treatment can be provided effectively and economically.

The adult inpatient unit is the clinical unit in a hospital where patient bed space and clinical treatment space is combined. This combination allows the unit to provide patients with an effective, economical therapeutic unit for clinical diagnosis, medical treatment, and nursing care.

The inpatient unit environment needs to meet the requirements for safe nursing and clinical practice, adhere to health and safety standards, and meet recognised infection control principles, while maintaining the principle of patient privacy and dignity.

This document provides guidance on inpatient unit spaces and it should be read in conjunction with the full IUSS set of standards pertaining to an inpatient unit. Variations to the set standard for inpatient units will be noted where indicated.

Specialised guidelines for inpatient units for paediatrics, infectious diseases, i.e. tuberculosis, intensive care, obstetrics, rehabilitation, burns care, oncology and mental health care will be addressed in separate IUSS documents.

Service context

The business case and the health brief define the correct package of services and the required bed distribution per facility based on the Provincial Strategic Transformation Plan and the government policy document:Government Notice R. 185, 2 March 2012, National Health Act 61/2003Regulations: Categories of hospitals: No.35101

Table 1: Inpatient unit allocation per category of hospitalL

District hospital	Regional hospital	Tertiary hospital	Central hospital	Specialist hospitals
General medical	Medical-Internal Medicine	Subspecialty Medical	Super specialties in the disciplines listed for tertiary care, including oncology	Tuberculosis(TB) Mental Health Rehabilitation Infectious Diseases
General surgical	General surgical	Subspecialty Surgical
	Specialty Surgical: Gynaecology Orthopaedics Ophthalmology	Subspecialty Surgical: Gynaecology Orthopaedics Ophthalmology
Paediatric	Paediatric	Subspecialty Paediatric
Maternity	Maternity	Subspecialty Obstetrics
High care^ӿ	High care^ӿ
	Intensive Care Unit^ӿ	Intensive care under^ӿ supervision of a specialist intensivist	Specialist intensive care^ӿ
Mental Health Observation Room and 72 hours beds	Psychiatric Inpatient Unit	Specialist psychiatric

*To be dealt with in separate documents

Determining inpatient unit size

Operationally successful inpatient units range from 28 to 32 beds per unit. The unit is subdivided into bed units that will provide for efficient management of patient acuity and flexibility. This guideline recommends 28 to 32 beds per inpatient unit.

All inpatient units should function as stand-alone units. These units contain one, two or four bed-, with six-bed configurations only being permissible in certain instances.

The inpatient unit should be planned to operate at an optimal occupancy level considering the model of care to be provided, staffing strategies, staff availability and operational aspects.-

Hours of operation

All inpatient units and emergency admissions will operate 24 hours a day, seven days a week. Day patients will be treated for 8 or 12 hours a day or as stipulated in the health brief.

Patient visitors

The hospital determines the visiting policy. Patient visitors may be limited by age, number and allocated visiting times.

Personnel

Each unit will be assigned nursing and housekeeping staff for a 24-hour operational cycle. Nursing staff work in shifts and provide day and night nursing support. Medical and clinical support staff members provide clinical interventions according to the clinical profile of the inpatient unit and the need of the individual patient.

Facility management, such as food services, linen services, cleaning services and maintenance support, is performed on a daily, weekly or intermittent basis.

Visiting, teaching and volunteering activities may also take place within the inpatient unit space.

Operational policies

Operational policies influence the planning, design and functioning of an adult inpatient facility and must be considered early in the design process. The national and provincial departments of health prescribe operational and clinical policies in the interest of quality of care and infection control. All individual facilities will also have their own policies and procedures to be accommodated in the planning of a new facility or upgrading of an existing facility.

The following policies are relevant to inpatient units:

• Admissions	• Infection control
• Amenities for patients and visitors	• Linen management
• Amenities for staff	• Maintenance and engineering
• Cleaning	• Medication management
• Clinical information	• Operating hours
• Communication systems	• Pastoral care
• Complaints	• Risk management
• Recording of patients data	• Safety and security
• Disaster planning	• Sterilising services
• Discharge of patients	• Stores and supplies
• Equipment storage	• Waste management
• Food services	• Others to be determined

Planning and Design

Overview

Adult inpatient units provide suitable accommodation for the patient where diagnosis, medical and nursing care, and treatment can be provided effectively and economically

This document attempts to illustrate the desired planning principles and design considerations for adult inpatient units.

Part B contains planning and design guidance, design considerations, functional relationships between hospital departments with respect to adult inpatient accommodation (inpatient units), and relationships within the inpatient unit itself.

Workflow diagrams are provided to explain the flow of patients, clinical staff, support goods and services, maintenance staff, as well as the public. Workflow diagrams within departments are provided to assist in understanding the intradepartmental relationships that support the functional flow in the inpatient unit to ensure productive service delivery.

The detailed room diagrams with accompanied norms and standards are provided to clarify understanding of the different space requirements and room specific specifications for an adult inpatient unit.

Design and planning principles

Hospital design principles are dealt with in a separate IUSS document and must be read in conjunction with this document when planning adult inpatient units.

General design and planning principles

The following planning principles need to be emphasised:

Inpatient accommodation forms the core of a hospital and has functional relationships with most departments
Patients enter the facility as inpatients, day patients or outpatients.
The planning of the inpatient units should support planning principles that promote a holistic healing environment with, where possible, clear external views, consideration of noise levels, natural ventilation, as much morning sun or light as possible, and spaces that would create a pleasant healing environment.
The design should reduce noise in the facility
The design should make maximum use of natural light and views for patients and staff.
The healthcare patient environment should be clinically safe and effective.
The design should maximise patient safety and reduce the risk of errors and accidents.
The work environment should be ergonomically safe and risk free.
The design should avoid large sprawling layouts that are both resource and cost intensive.
Workflow should be efficient and support effective resource utilisation.
Appropriate space norms and room design should be implemented.
The unit should comply with quality assurance principles.
The unit should have communication and information systems that will support patient management and administration.
Layouts should reflect the service needs of the patients in the inpatient unit.
Beds should be clustered to facilitate staff efficiency, meal relief and optimal patient supervision, particularly at night when staffing levels are lower.
The design should facilitate the delivery of care at the patient’s bedside or be proximal to the bedside whenever possible. This includes suitable services and supplies at the bedside.
The environment should be aesthetically pleasing for patients and should assist staff in performing the required activities in the most efficient and supportive environment.
Staff should not have to walk far to obtain supplies and equipment.
The design should balance requirements for clinical need, and capital and recurrent budget considerations.
The orientation of the inpatient units and aspect of inpatient accommodation should be prioritised in the development of the master plan. The orientation of the inpatient units should preferably face north or northeast, but a southern orientation is acceptable.
If the prevailing wind direction is south, east and west orientations of inpatient units are discouraged.
The placement of inpatient units must ensure patient privacy. Visitors, staff and service traffic through the inpatient units should be avoided.
Inpatient units can be organised on the same level over a large floor area or they may be stacked into a multistorey block separate from diagnostic and treatment facilities, but closely linked. This allows more consistent planning of inpatient accommodation, increases flexibility in the way that beds can be organised, and enables maintenance and refurbishment to be carried out more easily.
All pipes for sanitary requirements should be placed on external walls. Service support facilities and top-up of stores or pharmaceuticals and food delivery should be accessible to the inpatient units without compromising privacy or noise levels.
The design should enable greater levels of observation in response to increased patient acuity.
There should be enough space for activity at the bedside and other activities in the inpatient unit.
There should be adequate storage space for bulky equipment.
The area should be accessible to physically and sensory impaired people.
The design should that make it possible to communicate administrative or clinical information from the bedside.
The design should consider staff members’ and patients’ privacy for clinical treatment, bodily functions, personal care, and personal discussions and telephone calls

The planners of the required space should ask the following questions:

Personnel – How many people are there at any given time in a specific place to perform a specific task or procedure?
Activities – What procedures should be performed?
Equipment – What equipment is required that will occupy the space?
Security – What access control measures does the hospital management determine?

Human resources

The need for effective human resource utilisation is an important consideration. The nursing and cleaning staff will be working shifts. Staff working in the inpatient unit will depend on the number of beds or the size of the inpatient unit. This is especially true for the nursing staff, as their numbers are calculated per patient (or bed). The staff establishment (organogram) must be included when planning staffrooms, administration spaces, and ablutions

Nursing models of care

The models of care may vary from department to department and have an impact on design. Clinically complex patients who require higher staff levels may benefit from smaller bed units to assist with the management of noise levels, supplies and equipment handling, as well as the facilitation of communication and emergency support.

Nursing care is the main activity that allows the effective and efficient functioning of the inpatient unit. The inpatient unit design should therefore ensure maximum patient observation and contact, with short travel distances for the staff.

Inpatient units should have no less than two single-bed units or more than four single-bed units per 32-bed inpatient unit.

Unit management and administration

The unit manager’s office and clinical administration space should be positioned near the entrance to the inpatient unit for the purposes of management, client liaison and supervision.

If there is a ward clerk, he or she needs to be placed at the entrance to the ward and preferably at a small reception counter or at the nurses’ station. If the ward clerk is placed at the nurses’ station, additional space must be provided to accommodate the activities of the ward clerk.

The province’s policy with regard to staff facilities should indicate whether an inpatient unit staffroom or a shared restroom between inpatient units would be preferred. Staff toilets should be provided in each inpatient unit.

Teaching and training

Hospitals are associated with the teaching of health professionals, especially in regional and tertiary facilities. The operational narrative for the project should consider the specific teaching requirements. Where teaching space is required in an inpatient unit in regional and district hospitals, the staffroom should be made larger to accommodate the lecturer and the students. Time management can ensure that the staffroom is utilised fully by scheduling the meetings or lectures to occur at times other than staff handover, tea or meal times. In tertiary hospitals where there will be larger groups for teaching, seminar rooms should be provided adjacent to the inpatient units. These can be shared on each floor or between two inpatient units.

Access and circulation

The workplace design should minimise public access. Ideally, visitors should have access through one main entrance. Security should be placed at this entrance if necessary. However, support services such as emergency response teams should have maximum access to all areas of the workplace to facilitate their intervention in emergencies.

Service staff may access the ward through a second entrance, but it should be monitored for both safety and security. Waste should exit separately.

Infection control

(Refer to the IUSS Infection Prevention and Control document.)The primary objective of hospital design is to place the patient at no risk of infection while he or she is hospitalised or in the hospital environment. Particular attention should be paid to patients with infectious diseases (TB in particular), immunocompromised patients, and paediatric patients.

Infection control considerations must include all healthcare workers. All areas of the facility shall be designed, constructed, furnished and equipped in keeping with the principles of infection control

The following aspects contribute to effective infection prevention and control and are relevant within the context of an inpatient unit:

Hand hygiene facilities should be provided in all patient care areas, clinical areas and nurses’ stations.
Hand hygiene facilities should be provided in areas where careful attention to hygiene is essential, such as kitchens, sluice rooms, utilities, medicine areas, bathrooms, toilets and change rooms.
Hand basins must be visible to staff on entering and leaving the room. In addition, antibacterial hand rub dispensers should be provided at the entrance to each inpatient unit. Hand-wash facilities should also be placed in the main passage of the inpatient unit and next to the nurses’ station.
Facilities should be provided to isolate infectious patients.
The following facilities should also be provided:
- Linen handling
- Separation of clean and dirty work flows
- Storage
- Waste management
- Ventilation
- Surface finishes

Careful aseptic technique and the observance of ‘standard precautions’
The administrative infection control measures and protocols of the hospital should be followed and implemented in the design

Airborne infection isolation and protective environments

In adult inpatient accommodation, special environments need to be created for patients who are immunocompromised and at high risk of contracting airborne infection and for infectious patients posing a risk of transmitting airborne infections. These two groups of patients require protective environment rooms and isolation rooms respectively. Where patients are both at high risk of contracting an infection and are themselves highly infectious, positive pressure protective isolation rooms may be required. For the isolation of highly pathogenic and infectious or contagious diseases, such as viral haemorrhagic fevers, ward-level isolation may not provide sufficient protection, and high-security isolation with access to laboratories that comply with the requirements for Advisory Committee on Dangerous Pathogens (ACDP) Hazard Group 4 pathogens would be required.

Protecting staff and visitors from infectious diseases is an important aspect of airborne infection isolation (AII). It should not be assumed that a well-designed and functional ventilation system provides sufficient protection for these persons. Personal protective equipment such as N95 or FFP2 respirators should be provided to all staff and visitors entering AII rooms. Where these persons are expected to enter such environments regularly, these persons should have themselves fit tested for respirator use.

Ceilings in AII and protective environment (PE) rooms shall be impervious monolithic structures to ensure excellent sealing and airtightness. Ceiling voids above these rooms, especially PE rooms, can be particularly hazardous spaces.

All swing doors shall be equipped with door closers to ensure that they remain shut when not in use. Hold-open devices are not recommended for these doors. Sliding doors are also not recommended as these pose difficulties in maintaining an adequate seal.

It is recommended that isolation rooms be provided with outside views where possible, without presenting a biosecurity risk. Privacy blinds should be installed, but these should not present a hygiene risk or hinder the nursing staff view of the patient.

Figure 1: Negative pressure isolation

Negative pressure isolation is only required for patients presenting with airborne infections, for example, measles, Severe Acute Respiratory Syndrome (SARS), and TB. These infections spread primarily through the respiratory route where the infectious particles have a diameter of less than 5 µm. The unit for measuring ventilation is air changes per hour (ACH). In accordance with the national building regulations, isolation rooms shall be single occupancy with ventilation rates in excess of 12 ACH (including en suite bathrooms and anterooms). Where airborne contamination control in these rooms is achieved through dilution, these rooms shall have near perfect mixing with air change efficiencies approaching 50%. This implies that the ventilation efficiency in the isolation room shall be 50% as efficient as plug flow. Contamination removal effectiveness around the patient can be improved by placing an extraction point near the head of the bed. Airflow patterns within the room shall be developed so that the air shall flow from the passage door and air inlet terminal, across the patient and towards the bathroom and extraction points. Convergent fluctuations of only 5 Pa in each of two adjacent rooms can potentially reduce the pressure differential between the rooms by 10 Pa. For this reason, pressure differentials of 15 Pa between rooms are recommended. Lower pressure differentials are easier to achieve, but offer less safety under normal operational fluctuations condition.

The use of visual air pressure monitors between the passage and the isolation room is required. This enables a constant visual indication of the airflow direction between the isolation room and adjacent areas. These monitors should indicate the pressure magnitude, direction and out-of-specification failure limits. All major ventilation system components serving these areas should be clearly marked with the room identification, system identification and a biohazard sign.

Supply and extraction systems should be interlocked so that a failure of the exhaust air system shuts the air supply off, preventing the isolation room from going into an overpressure status. It is acceptable to install a balanced-blade pressure stabiliser to ensure that the room does not experience extremes of pressure under supply fan failure, control system failure, or severe transient environmental conditions. However, the inclusion of these devices can increase the design capacity of the system under normal operation.

Additional information regarding engineering services design and planning for airborne precaution rooms can be found in the IUSS Building Engineering Services Guideline .[1]

Figure 2:Protective environment – positive pressure

A PE room is required for patients who are immunocompromised, but do not initially present with an airborne infectious disease. These rooms require an anteroom to ensure a clean environment in the PE room. Where these are located within open wards, such as high-care units (HCUs) or intensive-care units(ICU), and are held at pressure positive to adjacent rooms, they should include negative pressure anteroom to prevent the potential spread of infection out of the PE room. For burns ward; however, negative pressure isolation with a sink anteroom, which is more negative in pressure, could be prescribed where sufficient separation from susceptible patients in adjacent ICUs cannot be ensured. Where airborne infection risk is suspected in these rooms, staff and visitors entering the PE room should wear respirators prior to entering the anteroom. Additional ventilation measures, such as using at least HEPA (H13) filtered supply air may be required when treating burns or allogeneic patients.

Figure 3: Airborne infection protective isolation

Where patients are immunocompromised and initially suspected of presenting with an infectious airborne disease, they should be located in an airborne infection protective isolation room. These rooms shall be designed to maintain a negative pressure relative to the anteroom and adjacent rooms, with the exception of the en suite bathroom. These rooms demand very low air permeability with high-quality sealing. The Centres for Disease Control (CDC) Guidelines for Environmental Infection Control in Health Care Facilities (2003) recommend an effective leakage area of less than 0.045 m² for the entire room. Placing this in context, the equivalent gap for a single half-leaf door that has been hung relatively well is calculated in the order of 0.04 m².

Respiratory protection needs not be worn in the anteroom in this scenario, as the anteroom is held at a relative pressure positive to the patient room.

While it may be tempting to develop positive pressure protective isolation rooms that can be adjusted to operate as negative pressure protective isolation rooms for airborne infection control, this practice is strongly discouraged, since it presents the inevitable scenario where the room is operated in an inappropriate mode for the wrong case, which places many people at risk of infection. The operation of neutral pressure rooms as a compromise is also not recommended as the negligible room permeability required for these rooms is not easily achieved or maintained.

Ergonomics in design

All facilities shall be designed and built in such a way that patients, staff, visitors and maintenance personnel are not exposed to avoidable risks.

Designers should consider the optimum comfort of all situations for staff, patients and visitors.

Refer to:

Alder, D. and Tutt, P. eds., 1992. New metric handbook : Planning and design data. Oxford: Reed Educational and Professional Publishing Ltd.
Neufert, E. and Neufert, P., 2012. Neufert architects’ data. 4th ed. New York: John Wiley & Sons.

Universal access

(Refer to the IUSS Inclusive Environments document.)Consideration must be given to the wide range of clients, as well as those who are disabled, including the following

Mobility impaired
Visually impaired
Hearing impaired

Telecommunication and IT systems support

The design of the inpatient unit should include the following:

Telecommunication system
Nurse call to all patient areas with central control system
Paging and personal telephones replacing some aspects of call systems
Bar coding for supplies, X-rays and records
Computer network connections in all management and patient administration and information systems:
- Hospital information system (HIS) and electronic patient records
- Patient administration system (PAS)
- Radiology information system (RIS) (digital X-rays)
- Picture archiving communication system (PACS)
- Laboratory with a link to the National Health Laboratory Service (NHLS)
- Pharmacy system

Wayfinding and signage

Wayfinding and signage must be considered from the inception of the design process. As hospital buildings become more complex, the more difficult it is for patients, visitors, suppliers and staff to navigate their way through the building to and from their intended destination. The layout of signage throughout the hospital must be logical and it must be simple and easy to follow.

It is important to plot the various routes patients, visitors, suppliers and staff may have to travel to get to the inpatient facility from the car park, drop-off points and other departments in the hospital. Once these routes are established, principles can be applied to the design to assist successful wayfinding.

Ways to enhance wayfinding include the following:

Printed information (pamphlets
Architectural features and design elements that provide clues as to what the function of the building is and can include landscaping, sculptural features and architectural interior design
Floor covering, lighting, wall, door and window graphics
Permanent signage
Digital devices (e.g. kiosks or information screens)
Human interaction (e.g. human interaction at help desks)

The following core principles should be adhered to:

Design that includes everyone, especially those who are more vulnerable, such as the following:
- The first-time visitor
- The physically challenged
- Those with some form of impairment
- Children
Utilisation of standardised information systems
Utilising ‘key hub’ destinations along a complex journey (a person is directed to a primary hub destination then directed on to a secondary hub destination from that point)
Toponomy, giving names and numbers to places and functions
A clear, simple wayfinding system

Signage is a critical ‘wayshowing’ component of wayfinding. Information displayed in the signage needs to comply with the following:

Be organised and presented in a logical, sequential layout
Contain a maximum of five destinations in the case of directional signs
Be listed at the top of the hierarchy or highlighted as primary information in the case of key hospital hub destinations
Be presented lower in the information hierarchy in the case of secondary destinations
Be grouped and ordered with logic relevant to the destinations listed in the case of destinations on signs, either in alphabetical order according to the direction to the destination in clockwise order or according to the order of the distance to the destination (closer destinations first)
Connect labels (destinations) to arrows
Arrow designs should be based on the ISO arrow (ISO 7001)
Colour coding of floors or as a method of differentiating space may be used, however, people do not always perceive that the colour use has significance. This is worse for people who are colour blind. It is, however, a useful component of the wayfinding system
Signage should use the following:
- Accessible terminology – common references that everybody understands
- Avoid the use of acronyms and use universally understood symbols
- Provide clear contrast between the information content and its surrounding environment
- A finish that does not detract or obscure the signs intention

Figure 4: Directional signage

Mapping is an important part of wayfinding system. Maps should be located at strategic points throughout the site and allow visitors to orlantate themselves. The maps should be consistent with the signage and the typology needs to be clear.

Photograph 1: Mitchells Plain Hospital, Cape Town: Maps strategically placed per floor

In the inpatient facility

Each department and inpatient unit should be marked individually and clearly. Wayfinding should help patients, visitors and the community to understand the hospital and inpatient unit spaces. The requirement for strict access control in the hospital makes it very important for patients and visitors to be directed along routes accessible to them.

Appropriate signage for all the internal rooms and the external buildings should make use of universal signage and should, take the provincial policy on signage and wayfinding into account as far as possible. Comprehensive signposting shall be provided for all hospitals. Signposting will clearly identify staff, patient and visitor areas. It will also draw attention to restricted areas.

General

Bed numbers shall be shown outside the patient bedroom. These shall be one number per bed. In bedrooms with more than one bed, all bed numbers or the range of numbers shall be shown on the sign outside each room. In bedrooms with more than one bed, each bed number shall also be displayed at the bed head.

The lettering style Helvetica Medium upper and lower case is generally recommended. Upper case only is recommended for the building’s main entrance sign.

Room signs

Non-illuminated, internal and external room function identification signs that are located on doors require the following considerations:

The format should allow easy replacement of the sign or sign inset when the room function changes.
Numbering on the inpatient units should be uniform, starting at the entrance with the first room on the left-hand side.
Each bed in each unit must be numbered.

Patient information board

A whiteboard, which lists the patients that are currently occupying the beds, should be mounted on the wall behind the nurses’ station. The whiteboard should be a ‘wipe’ board with a suitable surface for nurses to add and erase the information. The information should be indicated as follows with lines drawn to separate each row and column:

Table 2: Example of the patient information board

Bed no	Patient name	Doctor	Date in	Date out	Notes

The patient information board should be supplied and fitted by the contractor

Ventilation and air management

Methods of ventilation are discussed in the IUSS Building Engineering Services guidance document.

Adequate ventilation throughout the health facility is important as poor ventilation affects patients and staff, and puts them at risk of being infected with nosocomial diseases. It is therefore necessary to ensure that spaces are ventilated so that the quality of the air breathed is improved by diluting the air and removing pollutants that are harmful. The main aim is to provide ventilation that maintains thermal comfort and indoor air quality that reduces the risk of cross-infection. This can be achieved through natural, mechanical or hybrid methods of ventilation.

The chosen method will have a significant effect on the design of the inpatient unit.

Day- and night-time illumination

All rooms should be provided with the required electrical illumination
All patient beds should be provided with a reading light
Night lights should be provided in passages so that they do not disturb patients
Emergency lighting is critical in inpatient units such as paediatrics, theatres and ICU

Fire detection and alarms

Refer to Fire Regulations and SANS 10400 Regulations

All inpatient units should have escape doors in case of fire
The inpatient units should be provided with smoke detection systems
Sprinkler systems are not recommended
Fire extinguishers should be provided and slightly recessed so as not to cause obstruction
All inpatient units should have an evacuation plan that is aligned with escape routes

Security

(Refer to the IUSS Security Guideline.)

Access to and from the inpatient unit
Spaces that must be secured (medication store)
Security in individual spaces of the unit

Supply and disposal

Stores, provisions, food, linen and surgical disposables, equipment and waste management will be required as part of the inpatient unit functions. The following list provides an indication of the requirements.

Laboratory – collection of specimens
Mobile X-rays
Central stores – disposables, stationery, cleaning materials and new equipment
Pharmacy – medicines and drugs, delivery of prescriptions and return of empty recyclable containers
Central Sterile Services Department (CSSD) – sterile packs, return of opened unused packs and used recyclable equipment
Linen store – clean linen, return of dirty linen
Kitchen – patient meals (the size of the kitchen depends on the meal production and delivery processes involved)
Central Cleaning Depot (CCD) – cleaning equipment
Refuse – general waste (domestic), pathological waste for incineration, recyclable waste, sharps.

Material handling of inpatient unit supplies includes the following:

To and from the laboratory – the collection of specimens
Mobile X-ray equipment – space around patient beds and parking space for the equipment (a bay off the passage)
From the central stores – delivery of disposables, stationery, cleaning materials and new equipment
To and from the pharmacy – delivery of medicines and drugs, delivery of prescriptions and return of empty recyclable containers, sending of prescriptions to the pharmacy
To and from the CSSD – delivery of sterile packs, return of opened unused packs and used recyclable equipment
To and from the linen store – delivery of clean linen, sluicing of linen and return of dirty linen to the laundry
To and from the kitchen – delivery of patient meals in a trolley, trolley parking in the inpatient unit and return of the utensils and cutlery in the trolley back to the main kitchen
CCD – delivery and storage of cleaning equipment
Refuse – removal of general waste (domestic), pathological waste for incineration, recyclable waste, sharps
General hospital policies relevant to the various departments, such as linen supply and waste management, should be applied

Medication management

Pharmacy staff should be consulted with regard to medication and intravenous fluids storage requirements for each inpatient unit.
The inpatient unit depends on the pharmacy for pharmaceutical support. This includes inpatient unit medication, scheduled drugs, patient prescriptions and discharge medication. • Security and access control to medication rooms should comply with local legislative Government Gazette No 25872, Pharmacy Act, 2 January 2004 – jurisdiction requirements and the hospital policy.
The location and design of the medication room should minimise travel distances, noise and disruption to staff undertaking medication-related activities in order to reduce error. All medication should be stored in a temperature-controlled, locked environment. The medicine trolley, inpatient unit stock and patient prescriptions should be stored in a medicine room that should be close to and directly visible from the nurses’ station.
The management of intravenous fluids should be clarified for the specific facility as to the quantity to be stored within the clean utility room (inpatient unit bulk stock is kept in the surgical and medical storeroom with small quantities kept in the clean utility).
If additives are introduced to intravenous fluids in the inpatient unit, it should occur in the clean utility room.

Figure 5: Interactive management and control of pharmaceutical substances

The equipment store is intended for storage of equipment that has to be floor parked or stored on shelves and for equipment that may require the recharging of batteries. The requirements will vary and need to be defined so that appropriate storage space is allocated according to the requirements of the inpatient unit and the needs of the patients and staff.

Options for dispensing within the inpatient unit

Lockable medication trolleys should be stored in the medicine storeroom behind or directly opposite the nurses' station so that the store is in full view of nurses at all times.

Figure 6: Relationship of medicine store

Equipment cleaning

Medical equipment: The operational narrative should guide whether reusable items will be processed in the inpatient unit or whether they will be sent to the CSSD

Beds: These are cleaned in the inpatient unit

Storage - equipment

The equipment store is intended for storage of equipment that has to be floor parked or stored on shelves and for equipment that may require the recharging batteries. The requirements will vary and need to be defined so that appropriate storage space is allocated according to the requirements of the inpatient unit and the needs of the patients and staff.

The equipment store should be located close to the sluice room, as equipment requires cleaning and disinfecting before storage.

Equipment should be organised so that it is easily accessible by staff when required. Items used regularly, such as an emergency trolley with oxygen cylinders, scales and mobile blood pressure (BP) units may be stored locally in equipment bays. Rarely used items may be stored in a central equipment store. A long rectangular room allows the optimum use of space.

Power outlets (4 to 16) should be provided for the recharging of equipment, depending on the equipment list compiled per level of care.

Equipment, particularly larger equipment that has to be floor parked, needs to be defined so that appropriate storage space may be allocated according to the needs of the patients and staff.

Storage – sterile supplies and consumables (sterile and surgical stores)

Sterile supplies should be handled and stored in a manner that maintains the integrity of packs and prevents contamination from any source, e.g. dust, vermin, sunlight, water and condensation. Sterile or surgical stores should be temperature- and light-controlled and easily cleaned. Sterile supplies (packs) are stored in the clean utility room. Surgical and medical consumables are stored in a stockroom. Supplies should be stored off the floor, with the lowest shelf at least 300 mm above floor level to avoid mechanical damage during cleaning, and the top shelf no higher than 1 850 mm.

Figure 7: Interactive relationship for the management and control of supplies and consumables

Storage of patients' belongings

The method of storing patients' belongings depends on hospital policy. However, the following considerations must be taken into account:

Method of storing patients' belongings separately
System where contaminated clothing can be washed and decontaminated prior to storing in a patient's kitroom
Labelling method
Security
Type of storage, i.e. cupboards per bed unit, store per ward or central store for the whole hospital managed by a dedicated staff member who registers all items handed in
Size of the facility: many patients coming from rural areas will carry numerous items (e.g.blankets) with them that need to be stored until they are discharged

Waste management

Management of clinical and related waste must follow infection control policies and regulations with regard to the disposal processes, as well as hospital policy. Household and paper waste should be managed in accordance with the recycling policies of the facility. The inpatient unit should be provided with a dirty utility room for storage of paper, household waste and dirty linen to reduce contamination and to separate clinical and household functions.

Operational policies for waste management and waste minimisation should be supported, particularly with regard to the following:

Provision and location of dirty utility rooms so that staff do not have to traverse public and administration areas while transporting contaminated waste items
Provision and location of recycling bins
Location of sharps container

Inpatient unit activities

Inpatient admissions to an inpatient unit need to provide for the following patient activities:

Clinical diagnostic activities (medical, diagnostic imaging, laboratory, inpatient unit rounds, doctors' visits, going for operations, investigations or rehabilitation)
Activities of daily living (dressing and undressing, eating, drinking, personal toilet and ablution activities)
Social activities such as receiving visitors
Patients might be disabled or might be semi-mobile due to weakness, age, or the disease profile

Table 3: Inpatient unit activities


	Category	Activity
A	Patient	Patient Patient may be disabled and wheelchair bound Patient to dress and undress in vicinity of the bed Patient to take meals in bed or at the bedside Patient to read, watch TV or use a computer Patient to receive treatment and medical care from therapeutic and clinical staff, either lying down or sitting up in bed or in a chair Patient to wash hands
B	Nursing care	Teaching Stripping and making beds Transfer patient from wheelchair or patient trolley manually or by means of a patient-lifting device Patient observation and clinical (doctor’s) rounds Transporting patient to theatre on his or her hospital bed Treatment procedures such as intravenous fluids, traction, etc. Emergency procedures, e.g. patient resuscitation Coordination of patient care, observation, writing up of clinical notes, entering data into computers, making and receiving phone calls and washing hands
C	Medical intervention	Diagnostic procedures, such as mobile X-rays and ultrasounds, electrocardiograns (ECGs) Teaching Treatment procedures such as intravenous fluids, traction, etc. Emergency procedures, e.g. patient resuscitation Examination of patients and washing hands Writing reports and instructions, writing up of clinical notes, entering data into computers Washing hands
E	Rehabilitative intervention: physiotherapists, social workers, occupational and speech therapists, paharmacist and radiographers	Occupationally specific therapeutic interventions Patient consulting Diagnostic procedures, such as mobile X-rays and ultrasounds, ECGs, etc Washing hands
F	Clerical or administrative	Answering telephones, receiving patients and visitors to the patient unit Writing reports and collecting and entering data and statistics, ordering food and other consumables Washing hands
G	Ancillarystaff (aide, patient assistant)	Assisting patients in wheelchair Entertaining patients Washing hands
H	General staff	Serving food to patients General tidying work Daily cleaning - sweeping, dusting, washing up Routine cleaning - floors, windows, walls Washing hands
I	Maintenance staff	Maintenance- replace globes, fix fittings, reseal floors and repair work to maintain the inpatient unit Washing hands
J	Visitors	Visit patients and socialise in the inpatient unit or day room Washing hands

Client expectations

Patient expectations

Patient privacy and dignity both in the design of the facility and in the treatment of the patient
Personal safety and security of the patient’s own possessions
The provision of patient comfort in the facility, e.g. a clean and uncluttered environment, an outside view, low noise levels in the facility, the availability of technical services (staff call system, reading light)
Adequate availability and visibility of nursing staff

Staff expectations

A work environment with reduced walking distances, but increased patient observation with minimum staff (optimal care)
Improved patient risk management, e.g. availability of technical bed-head services, availability of clinical hand basins in patient and staff areas, the availability of automatic bedpan washers, improved environmental control (with reduced infection risk)
A safe work environment, e.g. suitable height of shelves and service outlets, non-slip floors, view of unit entrance and exit, access control
Personal safety and security of possessions, e.g. staff lockers, staffroom.

Location and inter-departmental relationships

Inpatient accommodation (inpatient units) accounts for a large percentage of the surface area in a hospital and, as such, the orientation and placement of the inpatient units should be given priority in the design of a hospital master plan. Figure 8 and Figure 9 illustrate the models of care and significant relationships in a typical hospital.

The design of smaller hospitals may allow the inpatient units to be arranged over the same level. However, inpatient units of larger hospitals may be arranged into multistorey blocks separate from the diagnostic and treatment facilities. This makes it easier to place the inpatient unit block away from noisy areas, ensures patient privacy and safety, and avoids visitors, staff and service traffic through the inpatient units.

Stacking of the inpatient units in multilevel blocks also allows more consistent planning of inpatient accommodation.

The following inter-departmental relationships with the inpatient units are recommended:

Patient administration and primary circulation should be central to the entrance with the access route to the inpatient facilities off the primary circulation route.
The obstetric inpatient units should be close to the delivery suite and close to the operating theatre, preferably on the ground floor or with a direct lift access to theatres.
In district hospitals, operating theatres, HCUs, orthopaedic inpatient units and surgical inpatient units should have a close relationship and preferably be on the same floor.
Rehabilitation, physiotherapy and occupational therapy should be close to rehabilitation inpatient units and accessible to the outpatients department and the inpatient units.
Hotel services (cleaning, linen and food services), mortuary services and maintenance units should have a reasonable relationship to the inpatient units. The mortuary, kitchen and laundry should have better access than all other services, especially at night (particularly mortuary services).
Visitors to the inpatient units should not cross functional access with the services to and from the inpatient units.

Staff overnight facilities

District hospitals only have overnight facilities in the maternity wards and EU sections. Regional hospitals have overnight facilities for ICUs, EUs, maternity wards, diagnostic radiology and paediatrics with facilities for medical and surgical inpatient units not necessarily in the inpatient unit. Tertiary hospitals may have a separate overnight facility for students and qualified staff in one location or separate locations.

Figure 8: Hospital model of care

Figure 8 illustrates the position of the inpatient units in relation to the hospital support services and the outpatient services. Inpatient units should be located separately, away from the mainstream, in the hospital complex to enable better privacy and separate the flow path of inpatients from outpatients after entering the main entrance to the hospital. This reduces the volume of traffic in the main passage to the inpatient units and avoids visitors, staff and service traffic through the inpatient units.

District hospital
- Surgical inpatients are the inpatients most closely associated with the theatres.
Regional hospital
- Orthopaedic inpatients are the inpatients most closely associated with the theatres.
Tertiary hospital
- Subspecialist inpatients, such as neurosurgery and cardiology, are the inpatients most closely associated with the theatres.

Figure 9: Departmental relationships

Flow patterns

Point of entry

Patients or visitors will access the facility through a secure entrance to a parking area or drop-off point from where there should be a clear direction (signage) to the required point of entry.
Alternatively, a patient will arrive via emergency services to the emergency unit or the maternity services entrance
Staff members access the facility through a secure staff entrance from a staff parking area or drop-off point.

Figure 10: Three main flow paths

Figure 11: Inpatient flow patterns

The diagram above illustrates three main inpatient streams that will accommodate acute admissions, maternity admissions and planned admissions. To ensure resource efficiency, the workflow and zoning should support these inpatient streams. The following flow paths relate to community, inpatients, clinical, visitors and support services to the inpatient units.

Figure 12: Patient-flow diagram

The workflow between departments has an impact on patient ans staff movement, as well as goods and service deliveries to the wards. Minimum walking distances between departments should be planned in the interest of resource management and traffic reduction through the facility

Figure 13: Clinical flow diagram

The diagram above indicates the clinical workflow dependencies between the clinical service and departments.

Figure 14: Visitors flow diagram

Figure 14 indicates the routes that visitors to the inpatient units would follow and Figure 15 shows the access routes for the service departments that would ensure access to the inpatient unit without affecting traffic through patient or clinical areas.

Figure 15: Support services workflow diagram

Separation of clean and dirty flow paths in the inpatient unit

Upon arrival arrival at an inpatient unit, a single entry point is preferred in order to control traffic in and out of the inpatient unit. However, infection control principles dictate that clean services should enter at a separate point to where waste and contaminated goods are taken out of the inpatient unit.

Figure 16: Entrance to and from the inpatient unit

Patients, visitors and clinical staff, along with clean goods and services (including food deliveries), should enter and exit through the main entrance. Soiled and contaminated goods should exit from the inpatient unit through a separate entrance, preferably positioned at the most distant point from the main entrance. It must be noted that an exit separate to the main entrance is required in terms of fire regulations. This exit may be utilised to take out the contaminated goods.

It is important that deliveries to and from the inpatient unit are managed in such a way that they do not clash with visitors arriving and leaving. Goods and services should be delivered at times other than visiting hours.

Functional zones

The inpatient unit functions as a stand-alone unit consisting of six separate functions

Table 4: Inpatient unit functional zones

Zone	Accommodation spaces
Administration spaces	Inpatient unit management, nurses' station and other office spaces as required
Public spaces	Entrances, circulation and waiting areas
Patient spaces	Patient accommodation and ablution facilities, patient day rooms, disabled showers, treatment room.
Service and support areas	Inpatient unit kitchen and storage, clean utility, sluice, stores, cleaners' room, linen, cleaning, medicine store, dirty utility and waste management
Staff spaces	Staffroom, locker area, ablutions, overnight accommodation*
Teaching spaces	Training or meeting room( in district hospital staffrooms could be used)

These zones create the therapeutic environment required for successful healthcare delivery at inpatient unit level.

Figure 17: Adult inpatient accommodation: Internal zoning and relationships

Functional relationships within the inpatient unit

Inpatient unit layouts will vary depending on individual needs per project as outlined in the health and design briefs. However, general principles of design apply and the location of facilities within the inpatient unit should be a logical process optimising the workflow and travel distances for staff from service and storage areas to the patient’s bedside.

The following general principles apply to functional relationships within the inpatient unit:

The visitors’ waiting room and visitors’ toilet should be outside the entrance to the inpatient unit and may be shared by two inpatient units on the same floor.
One central entrance to the inpatient unit with access control is preferred.
The kitchen should be close to the main entrance of the inpatient unit.
Deliveries and removal of kitchen trolleys should be managed so as not to clash with visiting hours and inpatient unit rounds.
Nurses’ stations should be positioned centrally with direct visual access to the inpatient unit entrance and in close proximity to the single-bed inpatient units, where the most critical patients would be accommodated.
The larger bed units for less critical patients could be positioned further away from direct nursing supervision.
The single-bed units, clean utility, medicine store and treatment room should be positioned near the nurses’ station.
Areas such as the inpatient unit kitchen and staff areas could be positioned off the main centre of the inpatient unit.
The clean linen store (or trolley) and sluice room should be close to the bed units to reduce walking distances for the nursing staff.
Dirty utility rooms should be positioned close to the separate exit door to facilitate collection of the contaminated items and waste, avoiding cross-contamination with clean goods by separating the workflow of clean and dirty paths in the inpatient units.
Design should minimise the distance between patient bed units, staff workstations and support rooms to facilitate the efficient delivery of patient care and optimal staff utilisation.
Each bed unit will be serviced by staff and support facilities, therefore access to supplies and means of disposal is essential. One of the primary goals is to minimise the distance between patient units and workstations and support rooms. The inpatient unit should be planned to provide a public/clinical and a utility/service division.
The unit manager’s office should be positioned for maximum supervision of both clinical and household functions (close to the entrance).
The clinical administration area and doctor’s office should be near the nurses’ station with access to the clinical spaces.
The sluice, linen, and storerooms should be positioned central to the patient bed units to reduce walking distances for the nursing and cleaning staff.

No one particular inpatient unit layout has been found to be universally superior. In all cases, the final decision must be a response to the physical constraints of the site, local service needs, and operational policies.

Ablution facilities

For infection control purposes, inpatients, clinical staff and visitors should be provided with separate ablution facilities. Ablution facilities for visitors should be located external to the inpatient unit.

Patient ablution facilities should be en suite directly accessible from the adjacent bed unit. Ablution facilities for clinical staff may be provided in association, but not combined with staffroom areas. Designated toilets for clinical staff should be provided.

Key room relationships

It is important that key room relationships are maintained such as illustrated in figure 18.

Figure 18: Room relationships that promote the principal of ‘clean to dirty’ flow

Figure 19: Room relationships with the inpatient unit (Example 1)

Figure 20: Room relationships with the inpatient unit (Example 2)

List of rooms

The majority of rooms in ward are standard rooms that may be found in other departments in the health facility. These rooms have been detailed separately in the IUSS: GNS generic room requirement sheets. These sheets must be referred to when planning the rooms.

Table 5 lists the rooms found in the inpatient unit and indicates the rooms that are standard and those that are non-standard. The non-standard rooms that are described in more detail under 'room requirements'. The standard rooms are described in less detail as they are detailed in the IUSS: GNS generic room requirement sheets.

Table 5: Loss of rooms: Standard and non-standard


Room	Standard	Non-standard
Patient areas
Bed unit - Standard patient area:
Single-bed unit	x
Two-bed unit	x
Four-bed unit	x
Patient day room(provided in a district hospital) may be shared between wards	x
Patient ablutions:
En suite facility with shower, toilet and hand basin (all should be disability friendly)	x
Assisted bath where required	x
Assisted shower	x
Staff areas
Office - manager	x
Office - Counselling or doctor (optional)	x
Nurses' station	x
Clinical admin area		x
Office - administration	x
Staffroom	x
Staff lockers can be provided in a passage off the main passage leading to the restroom	x
Toilet - staff (male and female)	x
Service support areas
Bay - mobile equipment	x
Bay - Resuscitation trolley	x
Clean utility ( setting out the sterile packs and treatments)	x
Cleaners ' station	x
Dirty utility (refuse and dirty linen)	x
IT room - consult with information and communication technology (ICT) planners depending on the hospital		x
Sluice room	x
Store - Clean linen	x
Store - Equipment	x
Store - Kit (patients' clothes and belongings could be in a central area or per inpatient unit - refer to brief)	x
Store - Medicine	x
Store - Consumables (surgical and medical)	x
Treatment room	x
Inpatient kitchen	x
Body-holding room	x
Public areas
Inpatient unit corridor	x
Entrance	x
Visitors' waiting area	x

Room requirements

Bed unit – standard patient area

The bed units are to accommodate patients for the delivery of medical care and treatment.

These guidelines allow space in all bed units for equipment and the activities around each bed and between beds.

Location and relationship

Bed units should be positioned to provide appropriate supervision from the nurses’ stations and be visible between beds. En suite bathrooms shall be dedicated to each room and will be directly accessible from the bed unit.

Figure 21: Left-right orientation of a patient bed

Important: The reference to the left and right side of the bed should describe the patient's left and right when lying down in the bed facing the ceiling. The bedside locker is placed according to the patient's preference.

Staff capacity

Space is required to adequately accommodate the activities taking place at the patient's bedside and the movement by staff around the bed, which can involve several staff at any one time and may also include the use of equipment at the patient's bedside.

These activities can involve the following:

Doing clinical observations taking blood, blood pressure and the patient’s temperature
Assisting with activities of daily living: dressing, feeding and washing
Treatment procedures, such as intravenous fluids, traction, etc.
Examining the patient
Stripping and making beds
Transferring the patient from a wheelchair or patient trolley manually or by means of a patient-lifting device (patient may arrive in a wheelchair or on a patient trolley)
Patient observation and clinical (doctor’s) rounds
Diagnostic procedures, such as X-rays, ultrasounds, ECGs, etc.
Transporting the patient to the theatre on his or her hospital bed
Emergency procedures, e.g. patient resuscitation
Recording of notes at the bedside either manually or on the computer (clinical staff)
Cleaning and dusting around the bed (clinical staff)
Maintenance work (maintenance staff)

Patient activity

May sit next to the bed
Receives treatment from therapeutic and clinical staff while lying down or sitting in bed
Receives visitors

General requirements

The following is required in the bed unit space:

Space should be provided for a bed and bedside locker next to each bed, preferably on the right.
Temperature in bed units should be between 20 ˚C to 23 ˚C.
Positive air pressure should be maintained in bed units.
Bed curtain rails and curtains should be provided for privacy around each bed.
Each bed unit should have a disability-friendly en suite shower, toilet and hand basin with a call button for the nurse.
A clinical hand basin with elbow taps, goose neck and an outlet must be provided in the bed unit. The basin and backsplash should be a moulded unit. A wall-mounted mirror, soap dispenser and paper towel dispenser should be provided with each hand basin.
Waste bins should be next to but lower than the hand basin. There should be one for medical waste, one for sharps (refer to brief document) and one for general waste.
There should be adequate lighting provision (natural and artificial light) – daylight is important in the bed unit.
The patient should have visual privacy without compromising staff control and observation of the patient.
A standard equipment list per level of care (district, regional or tertiary) should be made available. The list will distinguish between loose equipment to be provided by the client and fixed (mounted) equipment to be provided and installed by the contractor.

Space requirements

Ergonomic studies have established that most activities carried out at the bedside can be accommodated within the dimensions 3 450 mm (width) × 4 100 mm (depth). This represents the clear bed space and does not include space for fixed storage.

One bed unit equals a minimum of two and maximum of four beds per 32-bed inpatient unit in a district or regional hospital. The clinical brief will outline the tertiary hospital requirements.

It is preferable for beds on opposite sides of the room to be offset to provide greater privacy.

Single-bed unit approximately 15 m² minimum

Two-bed unit approximately 27 m² minimum

Four-bed unit approximately 44 m² (majority of rooms) minimum

Six-bed unit approximately 65 m² minimum

Drawing 1: Single-bed unit (minimum space dimension requirement)

Drawing 2: Two-bed unit (a) (minimum space dimension requirement)

Drawing 3: Two-bed unit (b) (recommended space dimension requirement)

Drawing 4: Four-bed unit (a) (minimum space dimension requirement)

Drawing 5: Four-bed unit (b) (recommended space dimension requirement)

Bed services

Services should be provided in wall bed-head units behind and above the bed.

Photograph 2: Example of services in bed-head trunking

Photograph 2 shows an in-wall bed-head unit with power outlets, oxygen and vacuum outlets(shared between two beds), equipment rail for the mounting of, among other things, suction units, oxygen flow meters, nurse call button and a reading light

Drawing 6: Services to district hospital bed

Table 6: Bed-head services per level of care


BED HEAD SERVICE
Service	District hospital	Regional hospital	Tertiary hospital
Oxygen	One shared between two beds	One per head	One per head
Medical air* (low pressure)	One shared between two beds	One per head	One per head
Vacuum	One shared between two beds	One per head	One per head
Power outlets (15Amp)	Four per bed: One to patient's right side for patient use Three to patient's left side for medical equipment purposes	Six per bed: Two to patient's right side for patient's use Four to patient's left side for medical equipment purposes	Six per bed: Four to patient's left side for medical equipment purposes
Equipment rail	One per head	One per head	One per head
Nurse call	One per head	One per head	One per head
Reading light	One per head	One per head	One per head

(Refer to IUSS: GNS Building Engineering Services)

En suite sanitary facilities

Description and function

An en suite bathroom provides facilities for patients to wash, shave, groom, shower and use the toilet, either independently or with assistance. The layout and area must accommodate an assisting nurse, patient lifter or wheelchair. The minimum area for this room is 6 m².

Location and relationships

The en suite bathroom must be adjacent to the bed unit or directly accessible from each unit with the following services, preferably on an external wall:

Clinical hand basin with a mirror above it, soap dispenser and paper towel dispenser
Toilet
Nurse call button connected to the nurses’ station
An adjustable overhead hand shower head with flexible hose