Circulation Is Critical To Hospital Facilities Planning

G D Kunders

Hospital Planning Starts With Circulation

Circulation is the space within the hospital administrative and support services that is not common to any specific department. This includes corridors, stairwells, toilets, courts, lobbies, elevators, etc. This space must be considered in determining the total square footage of the building concept design. The importance of circulation is apparent from the extent of space apportioned to it in the total square footage of the hospital – approximately 120 to 150 sq ft per bed in the total hospital area of 800 to 1000 sq ft per bed.

However, circulation is much more than mere allocation of common space. Its significance lies in the proper integration of the many departments of the hospital so that different types of traffic traversing the length and breadth of the hospital are separated as much as possible, traffic routes are kept short, and patients and other important functions are protected against intrusion and from the risk of hospital acquired infection. “For the architect not familiar with modern hospital planning, the principal subject for study should be circulation,” said one planning expert. Needless to say that the skill with which the architect handles circulation will determine the efficiency of the hospital for its life.

The function of hospital planning is aptly summed up by Emerson Goble, an expert in hospital planning, thus: “Separate all departments, yet keep them all close together; separate types of traffic, yet save steps to everybody: that’s all there is to hospital planning.” Imagine a nurse walking an unnecessarily long distance over a route that she traverses many times every day because the architect did not pay attention to the principle of the shortest route. She feels fatigued at the end of the day, day in, day out, and after 10 or 20 years of service may be cursing the architect for being responsible for her varicose veins.

Why is circulation so important?

Protection of Patients

The primary principle underlying the circulation theory is the protection of patients. The nursing unit corridor is a virtual traffic highway; in some cases a thoroughfare. Too much traffic disturbs patients and impedes smooth and efficient care. Of more serious consequence is the risk of contamination – hospital acquired infection. Assured protection against infection is the very heart of good patient care. For the architect it forms the basis of good hospital planning.

Shortest Traffic Routes

The second principle is the establishment of the shortest possible traffic routes. Unnecessary steps cost money, time and fatigue and increase the chances of infection. This is not a one-time cost but a continuous one because the steps taken by the nurse and others on the routes of the nursing floor are repeated endlessly day and night, every day of the year. On the other hand, short routes save steps to every one – patients as well as those who are concerned with patient care – doctors, nurses and personnel. Moreover, the hospital is a place where doctors and nurses are dealing with emergencies and life and death situations. In these situations, every minute is precious. Even otherwise, there is no room for tardiness in a hospital set-up; everything should be done fast. Shorter routes and fewer steps save lives.

Separation of Dissimilar Activities

Separation of different types of activities and different kinds of traffic is the third principle that should be followed. Such an arrangement helps to minimize chances of infection, for example, when clean and dirty operations, or clean and dirty utilities, or clean and infectious linen are separated. Similarly, seriously ill patients are separated from convalescent or ambulatory patients. Separation of dissimilar activities also helps towards better organisation, a more efficient working arrangement, saving time and steps, and reducing confusion.

Quiet and noisy activities are likewise separated. For example, there is much noisy bustle in the departments such as the kitchen and the engineering department; they are isolated so as not to disturb the critical patient care areas. And finally, different types of traffic outside as well as inside the hospital are (and should) be separated.

Control is Vitally Important

Control is the fourth principle that is of vital importance to planning. A certain amount of control comes with the separation of dissimilar activities. But that is not enough. In certain areas of the hospital, greater control is called for. For example, the nurse must exercise control and supervision over patient corridors and the coming in and going out of visitors. Infants must be physically protected. They must also be protected from the germs brought in by visitors and staff. Babies are vulnerable to epidemics especially to the dreaded infant diarrhoea. This is the primary reason why in a good system only the nurse – not even the doctor – enters the nursery, that too masked and gowned and through an anteroom.

Exterior Traffic

It is necessary to separate the different types of traffic that traverse, sometimes crisscross, the hospital in all directions. The most effective way of doing this is by separating the traffic coming from outside before it even gets within the building. In actual fact, it is essential to separate the traffic outside in order that it is regulated inside.

In principle, there should be four separate entrances to a hospital for four important exterior traffic lines. These entrances are determined by the adjacencies and traffic flow inside the facility. The four major entrances are (a) main hospital entrance for dropping and picking up inpatients and visitors (b) outpatient entrance for outpatients (c) emergency entrance for emergency patients and ambulance cases and (d) service entrance for delivery of supplies and for pick up or removal of trash and garbage from the facility. In some hospitals removal of dead bodies takes this route.

Main Entrance

In most of our hospitals there is one main entrance that is used by every one – outpatients, inpatients, visitors, medical staff and personnel. One can imagine the confusion caused by the merging of the outpatient crowd with the other traffic at the main hospital entrance. The problem is compounded by a perennial stream of suppliers, vendors and job seekers. At no time should this traffic be allowed to mingle with other hospital traffic lines or to go through the main lobby and administrative corridors. In two ways this can pose a serious problem. One is from outpatients and other exterior traffic straying into inpatient and other sensitive areas of the hospital. The other is the security risk. The author recommends that the outpatient block is kept locked after outpatient hours. For this, it should be contiguous but semi-detached from the inpatient block.

Larger hospitals provide a separate entrance for staff. Some provide reserved parking area for doctors, usually at the rear. They should not be expected to fight a traffic jam every time they come to the hospital. Where parking is so reserved, a special entrance for them may be arranged. Doctors as a rule prefer to use less crowded corridors to avoid anxious patients or garrulous relatives trying to buttonhole them when they are in a hurry to reach the operating rooms or patient floors. Reserved parking space for the doctors is necessary in front of the emergency department too.

Emergency Entrance

There should be a separate entrance to the emergency department – also called ambulance entrance – for cases brought in by ambulance or private vehicles. There should be adequate reserved parking space for ambulances and cars of patients and medical staff. The access should be large enough to admit one or more ambulances negotiating with stretchers.

In many hospitals, especially where there is no separate entrance to the main hospital, or where the main entrance remains closed, emergency entrance becomes the main entrance for the hospital during the night. In some others, it becomes an unobtrusive route for removing the dead.

Service Entrance

This should preferably be in the rear because deliveries (especially of bulky items) are a noisy and unpleasant operation that should be screened from view from the patient care areas as much as possible. More importantly, it should be near the unloading dock close to the kitchen and the storage areas that receive much of the supplies. The unloading dock should have a covered area big enough for a truck to turn around. There should be no pedestrian traffic around this area. Garbage and other solid wastes are removed from this point, so also the dead bodies in some hospitals.

Interior Traffic

As part of the written operational programme, flow charts for patients, personnel and visitors within and between departments should be developed and given to the architect. They form the basis for architectural plans. A design that has taken flow charts into account will expedite traffic, eliminate congestion and promote efficiency of operation. It will also ensure placement of departments and layout of equipment in proper relationship. The golden rule to remember is: “Separate departments, yet keep horizontal travel to the minimum.”

Conclusion

In a study involving hundreds of hospital plans, experts observed a large number of screwed-up schematics. In almost every one of them, they could trace the trouble to failure to heed the basic principles of circulation. And what is worrying is that these principles were violated not by starters alone but by experts as well.

The writer is Healthcare Facility Planner and Author. E-mail: gdk@vsnl.net