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Planning an Imaging Department - E press Healthcare

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A good rule of thumb for basic imaging planning: Architecture (and architects) ma be forgiving, but technolog never is, opines Dr Rashi Agarwal, Director, PRAXIS - A New Dimension to Healthcare The imaging department within a hospital or as a stand-alone centre can be treated as a separate business as it is a big profit centre. Apart from providing routine and specialised diagnostic services with imaging technique for indoor, out-patients and walk-in patients it also provides therapeutic services like radio therapy, nuclear medicine as well as interventional radiography. This acts as a big source of revenue generation for a hospital or a stand-alone centre with high profitability. Launching a new diagnostic and therapeutic imaging centre involves very specific requirements and roadmaps that have a direct impact on planning. Firstly, planning must focus on the strategic level of any organisation, whether it is a multi-national corporation running a hospital or a sixperson radiology group. Think of all organisations as a triangle with three horizontal levels: strategic, managerial and operational. Certain common steps in the planning process are necessary to ensure the success of any construction project in a diagnostic imaging department. Determining the need for the project, analysing requirements for equipment, space and personnel, and budgeting for the project are necessary steps. They are followed by scheduling and designing various aspects of the project. PROJECT ANALYSIS: The essential first step is to determine whether a proposed project is necessary . Doing a costbenefit analysis and determining if the return on the investment will be positive are important for a project's success. Good planning and communication with key staff members of the healthcare institution and the members of the design and construction team will help ensure successful implementation of any project. Ca eg ie f he Radi g De a e

Radiology department can have diagnostic as well as therapeutic functions. Given below are the various functions that fall under each category: (I) DIAGNOSTICS (1) Routine X-Ray studies (a) Plain - e.g. chest, spine, etc (b) Routine fluoroscopic procedures e.g. Barium studies, IVP (c) Special fluoroscopic procedures e.g. Angiography, Myelography (2) Routine ultrasound studies (a) Ultrasonography - e.g. Abdomen, Pelvis (b) Doppler studies peripheral (B/W & colour) e.g. 2 D echo, vascular studies, etc (3) Special imaging techniques (a) CT Scan (Computerized Axial Tomography) (b) MRI (Magnetic Resonance Imaging) (c) DSA (Digital Substraction Angiography)
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Planning an Imaging Department - E press Healthcare

(II) THERAPEUTIC (1) Radio Therapy e.g. contact, cobalt (2) Nuclear Medicine (3) Interventional Radiography:- X-Ray Record Rooms, Films & Chemicals storage, etc WHO (1988) ha h ee ca eg ie :

general radiography, general ultrasound, general fluoroscopy, conventional tomography as Level 1, plus doppler ultrasound, mammography, angiography (incl. DSA), C T as Level 2, with more sophisticated techniques, plus MRI

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The location of the department and the relative positions of the examination rooms have a considerable bearing upon the protection requirements. Aspects for planning are accessibility, convenience, privacy, traffic flow, etc. i.e. that should be well connected. Accessibility to wards, OPD and emergency is a major point of consideration for this department. Central location with space for expansion is an added advantage. The site is generally chosen by considerations other than those for protection; however the following points are worth bearing in mind: Mai B i di g A i ia

Since irradiation to surrounding areas is a concern, the location of the department in a separate building preferably a single storey may reduce such problems. But this could be a merely incidental advantage to the otherwise disadvantageous position. i) G d U e F

Ground floor location can often avoid the problem of providing protection for the floor but, may introduce difficulties to the irradiation of buildings outside the area. For ground floor installations, the positions of the windows may to a considerable extent dictate the layout of the department. Location of the department on the upper floor will require to take the position of the adjacent buildings into consideration. When the department is on the upper floor, it is important to attend to the shielding of the floor. R e f Pa i g a d De ig

Although much of today's imaging equipment and healthcare construction is new, many of the rules for planning and design remain the same. The environment stresses the transparency of medical imaging technology and installation. Unfortunately, that thinking allows a lack of attention to details, fundamental requirements and even safety concerns. A good rule of thumb for basic imaging planning: Architecture (and architects) may be forgiving, but technology never is. For instance, while MRI installation has been accomplished in smaller rooms, the basic understanding of magnetic field placement or restrictions has not changed. Current-generation CT or R/F equipment still requires adequate radiation shielding and clean power, if not more so. The role of the facility engineer is often critical in the early planning stages of a project to determine what utilities may be needed, any need for plumbing or electric work, power sources, building code requirements, the need for medical gasses and suction and so forth. Analysis of a potential project's equipment, space and personnel needs is also critical. Gathering the necessary information from various sources within the healthcare institution is essential. The design of the modern medical imaging department must meet several seemingly divergent needs:
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Planning an Imaging Department - E press Healthcare

Accommodate large, heavy, noisy technical medical equipment with extensive infrastructure and shielding requirements. Create a safe, pleasant and efficient staff work environment. For a safe radiation environment, there are certain principles and considerations like "separation" of different functional areas helps control access : Public areas (waiting room, changing rooms etc.) Staff areas (offices, meeting rooms etc.) Work areas (radiation rooms, dark rooms, labs etc.) Restriction/control of public access to work areas The work areas will normally be controlled areas, therefore public can only access it when being examined or treated Flow of staff to/from and within work areas - separate from public areas Consideration of spaces adjacent to radiation areas, including above and below Film processing/storage location relative to radiation areas chemical storage and disposal ventilation (glutaraldehyde fumes) silver recovery bulk film storage Natural light in imaging rooms of all types - MRI, CT, even R/F - will have the most significant impact on patient comfort and anxiety. Evidence-based medicine and, evidence-based design has spurred important research into the measurable impact of design on patient outcomes, staff performance and overall efficiency. Based on research, design includes increased natural light, appropriate materials and measurable design impacts on work performance are being incorporated into new hospitals and outpatient imaging centres. This will directly impact to comfort patients who are likely to be anxious or uncomfortable, or a combination of both. Radi g R Fea e :

Administration Area- Reception General Facilities e.g. Dressing Rooms, Drinking Water, Toilets, Waiting Room etc. Storage facilities X-Ray Record Rooms, Films & C hemicals Storage, etc Diagnostic X-Ray Room- X-Ray units 200 MA / 400 MA C entral Panel Area X-Ray Table etc Film Processing Area Dark Room automatic Processor, etc Specialised Procedures Rooms e.g. Barium Studies Sonography Room (Routine USG) Electrical Installation Radiologists office Rooms for storage of Mobile and portable units Electrical Installation Radiation Protection - BARC recommendation (9 ) - Specified wall thickness, Lead C oating (depending on capacity of unit) - Protective Barrier Screens - Use of lead Aprons of Gloves - Badges to detect amount of radiation received by staff Air C onditioning, Intercom, etc Fire safety precautions Resuscitation facilities

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Planning an Imaging Department - E press Healthcare

Imaging technology is focused toward MRI, CT and PET, more often being combined with CT in PET/CT. It is timely to consider current design determinants: S ace: The dimensions and weight of the equipment need to be considered and support appropriate clinical patient care and staff support. Ve d h d a i g : These critical planning tools provide baseline information for guiding templates and establishing critical utilities or services, but do not provide the level of design detail as architectural drawings. E ab i hi g i e: Minimal room size does not adequately support patient care needs, appropriate line of sight to observe the patient or critical staff support. Mag e e i e e : As MRI equipment has increased in power, magnetic fields have increased, too. Changes mean the increases are not directly proportional. CT eed: Influences the room and shielding design. The greater throughput of high-speed scanners can result in a more patients undergoing scans daily and planning must be done accordingly. H i a e i e e : Inpatients require more care than ambulatory care patients. This may limit the number of patients hospital radiology departments can assess daily. PET a d PET/CT: High radiation doses have a major impact on planning and shielding. Due to large exposure used for imaging, areas that do not require shielding with other imaging modalities require protection. S d fi g: An essential and often overlooked component of MRI suites is soundproofing. Vib a i : This is a crucial issue for MRI and CT. This can be controlled by isolated slab design and special anchorage details. Digi a eadi g : Incorporating image interpretation, PACS and radiology information systems are carefully designed for physical space demands, lighting and ergonomics. Lighting must be placed to avoid glare on the monitor. Individual work spaces must be designed to allow privacy and collaboration at the same time. Work surfaces and seating must consider flexibility for height and physical comfort which supports work performance. LA OUT T ica R De ig

Shielding and X-ra room design The lay out of rooms in a radiology installation shall be such that the number of doors for entry should be kept minimum. The unit should be so located that it is not possible to direct radiation towards doors, windows, control panel or areas of high occupancy. Room Si e The room housing an X-ray unit shall not be less than 18m2 for general purpose radiography and conventional fluoroscopy equipment. The size of the room housing the gantry of the unit shall not be less than 25m 2. Also not more that one unit of any type shall be installed in the same room and no single dimension of any room shall be less than fourm. Shielding Appropriate structural shielding shall be provided for walls, doors, ceiling and floor of the room housing the X-ray unit so that doses received by workers and the members of public are kept to the minimum and shall not exceed the respective annual effective doses as prescribed by the competent authority. Appropriate shielding shall also be provided for the dark room to ensure that
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Planning an Imaging Department - E press Healthcare

the undeveloped X-ray films are not exposed to more than 10 ?Gy per week. Mag e ic Fie d e g h affec hie di g

Openings and Ventilation Unshielded openings in an X-ray room for ventilation or natural light shall be located above a height of two m from the finished floor level outside the X-ray room. Illumination Control Rooms housing fluoroscopy equipment shall be so designed that adequate darkness can be achieved conveniently, when desired, in the room. Control Panel The control panel of diagnostic X-ray equipment operating at 125 kVp or above shall be installed in a separate room located outside but, contiguous to the X-ray room and provided with appropriate shielding, direct viewing and oral communication facilities between the operator and the patient. In case of X-ray equipment operating up to 125 kVp, the control panel can be located in the X-ray room. The distance between control panel and X-ray unit/chest stand shall be not less than three m for general purpose fixed X-ray equipment. Wai i g A ea Patient waiting areas shall be provided outside the X-ray room. Wa i g Ligh a d P aca d

A suitable warning signal such as red light shall be provided at a conspicuous place outside the X-ray room and kept "ON" when the unit 21 is in use to warn persons not connected with the particular examination from entering the room. An appropriate warning placard should be ideally placed. Da R

The dark room shall be located adjacent to the X-ray room. Medica E i e Pa i g

Advancement in healthcare technology has resulted in a quantum change in the desirable requirements of healthcare equipment. As technology continues to evolve, it has a direct impact on the overall space, it occupies as well as on clinical operations. Advanced digital equipment requires integration with Information and other systems as well as different technologies. Equipment grading system must take into consideration the following factors for selection: Need assessment which decides on the necessity by deliberating on the user's coefficient, patient load, and break even point. Prompt after-sales service, easy availability of spares and comprehensive warranty is ensured in any procurement. Provision for software upgradation is also ensured as part of the service contract. Indigenous equipment is preferred over imported ones. Correct contract formulation is the most important part so as to control and utilize the equipment to its optimal capacity. At the same time, bank guarantee and penalty clauses are carefully planned before any purchase. Sound purchasing policies, procedures, scientific management of stores and system approach to meticulous planning, demand estimation, appropriate staffing, adequate control, and accounting of stores is a prerequisite for modern material management in any hospital. Pe e Re i e e
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Planning an Imaging Department - E press Healthcare

Safet Personnel Every X-ray department shall have a Radiological Safety Officer (RSO) having qualified and approved by the competent authority. The RSO may either be the employer himself/herself or a consultant or a full/part-time employee to whom the employer shall delegate the responsibility of ensuring compliance with appropriate radiation safety/regulatory requirements applicable to his/her X-ray installation. Radiologist All installations having more than two X-ray units, or even a single X-ray unit with fluoroscopy facility, and all establishments performing special procedures, shall have the services of a qualified radiologist. X-Technologist All X-ray installations shall have either a radiologist or a qualified X-ray technologist to operate the X-ray unit. Service Engineer The service engineer undertakes servicing of X-ray equipment shall immediately report to the competent authority any equipment no longer safe for use, and the nature of defects that make the equipment hazardous. Receptionist The receptionist registers patients for OPD imaging procedures. Provides customer service and works collaboratively with all the radiology areas to ensure timely procedures and reporting. File Clerk The file clerk performs duties including performing daily clerical duties as necessary. He maintains the inventory department, monthly office supplies and/or as needed. He processes patient examination charges to data processing department daily and checks off the patient log for completeness. Attendant An independent attendant or a receptionist who serves as an attendant for female patients during changing and the procedure as per medical ethics with a male doctor or technician. Safe S a da d a d G ide i e

Patient safety in radiology is a growing concern. Safety standards and guidelines are significant for architects and owners. Carelessness in planning and design is often the result of taking basic criteria for granted. Adopted safety guidelines should be referenced in planning standards or regulations.For ionizing radiation, shielding characteristics are based on the National Council on Radiation Protection and Measurements (NCRP) Report 147: Structural Shielding Design for Medical X-Ray Imaging Facilities. The information has been updated, including new modalities not previously discussed. F N c O e a A ea

e: Lead glass, clear view, good lighting

POLICIES AND PROCEDURES (I) Ge e a Prohibit entry of pregnant woman in radiation areas Staff uniform policy HR functions
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Recovery of silver from fixer and developer solution (II) R i e ced e

Reception and waiting Regi a i Technique of various procedures set out in a manner- processes are standardised to minimise patient exposure and reduce costs by addressing higher than normal repeat rates. Reporting by radiologist Preparation and dispatch of reports Billing and cash collection (III) Radia i ec i :

Walls one ceilings as per BARC requirement Use of standard equipment Personnel Monitoring - Blood tests, Badges Lead Glass Screens Lead Glass Screens, Aprons, gloves (IV) Rec da d e i g

Proper identification, reporting and storage- film and chemical storage are normally checked on a quarterly basis. This helps assure that the film and chemistry quality are maintained and inventory is rotated on a first in, first out basis. (V) Mai e a ce fe i e

Preventive maintenance- A visual check list is maintained to assure that all components of the radiographic system are working properly and that the mechanical rigidity and stability of the equipment in optimal. Breakdown repairs- replacement of equipment, change or updating current equipment (VI) Q a i C Mea e

Use of proper technique of exposure- time, intensity etc. Various tests are routinely carried out to evaluate frequency of each test, acceptable test limits, test procedures, maintenance and service records. Use of Good Equipment Films Proper identification, reporting and storage Hea i g E i e f I agi g

While imaging equipment and technology planning concerns are important, these considerations should not override those of employees and patients. Patients and staff are in a stressful situation, no matter the quality of technology. The requirements of the technology should be dealt with transparently, so that individuals can focus on the environment. Patients are concerned about privacy. Imaging can be a sterile, restricted environment. Thus it makes good sense to utilise design to stress communication flow, involvement and empowerment whenever and wherever possible. Let's face it; imaging for the patients involves waiting and abandonment, two difficult factors to overcome without some help in the design.Staff is concerned about technical performance and patient accommodation, while performing highly repetitive tasks. The design of staff spaces that focuses on work flow and improved job performance will result in patient and staff satisfaction, less errors, and likely improved work.In both cases, the result will be a tangible step to deal with increased work demand and ever faster technology. Shorter imaging exams due to less patient anxiety and improved staff performance can be expected. An evidence-based consensus emerges that the design of care environments helps patients feel
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Planning an Imaging Department - E press Healthcare

safe, comfortable and facilitates the healing process, the trend toward healthy design and its compelling benefits is too powerful to ignore for imaging spaces. Evidence suggests design can improve patient, family, and staff satisfaction, provide a positive return on investment and even directly impact image quality.
Email: rashi@praxishc.com

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