INTRODUCTION
The high proportion of burns cases, among all causes of injuries, underlines the need for specialized treatment facilities of a burns center. As burns patients require intensive life support, expert medical and nursing care and complex treatment protocols, the burns centers are accordingly designed, equipped and staffed. The recovery from burns injury among other factors also depends upon the level of healthcare facility where the victim is being treated and expertise of the medical team. The clinical outcomes in burns cases are intimately linked with the design of the facility. The facility may be standalone or integrated burns center (Box 1).
FUNCTIONS
The primary function of the burns and reconstructive surgery unit is to provide specialized care to the burns patients and those requiring reconstructive surgical interventions in order to ensure fast recovery, subsequent rehabilitation and return to vocation/society.
KEY PLANNING AND DESIGN PARAMETERS
The key planning and design parameters for emergency care unit, ICU, OT, wards, OPD and physical and rehabilitation unit for burns center are same as for any such generic unit. Special requirements have been detailed below.
COMPONENTS OF BURNS CENTER
- Emergency care unit
- Intensive care unit (Fig. 1)
- Operation theater
- Ward unit
- Outpatient department
- Physical medicine and rehabilitation unit
- Special facilities: Saline bath unit and skin/amnion banking facility.
The description of these components is limited to the extent that pertains to the specific requirements for burns and reconstructive surgery unit.
BURNS CENTER—SPECIFIC REQUIREMENTS
The stack diagram and functional relationships of the burns unit is depicted in Figures 2A and 2B. The saline bath features are enume-rated in Box 2 and Figure 3.
Weight Measurement Facility
This should be provided in the emergency unit and allow accurate weighing of the patient along with trolley.
Skin/Amnion Banking Facility
This facility is required for storage of skin and amniotic membranes used as dressing for the burnt surfaces. It is a tissue bank with facilities for storage of amnion at very low/ultra-low temperatures in large-refrigeration equipment. It must have adequate circulation space. The space required for the equipment would be equivalent to the cumulative footprint of all equipment to be installed. An area of 16 sqm is considered adequate. The room must have adequate lighting, ergonomic workstations, and separate air handling unit (AHU).
Infection Control
Hand Washing
- Dedicated hand-basins for each treatment area
- These should be available at a ratio of one per every four beds/one for every procedure/resuscitation/consulting room. Type of units could be surgical scrub station or hand wash basins in all clinical areas
- Number of units required are—for ICUs—one per enclosed room, one per bed; emergency care unit—one per four open bays; OPD—one per consultant and for other areas. A person requiring to use a hand wash unit should be within 10–12 meters away from a wash unit
- Bedside antiseptic lotion dispensers may be provided.
Isolation Rooms
These are required on a scale up to 20% of total beds. Class ‘P’ Isolation rooms ensure that burns patients are protected from infection. These rooms must have its own independent AHU for meaningful isolation in terms of heating, ventilating, and air conditioning (HVAC). Positive pressure ensures unidirectional movement of air so that all airborne contaminants are carried away. The requirements of Class ‘P’ room are shown in Box 3 and the layout of isolation room in Figure 4.
Ultraviolet Germicidal Irradiation
Ultraviolet germicidal irradiation (UVGI) is a sterilization method that uses ultraviolet (UV) light at short wavelength that is harmful to life at the microorganism level. The characteristics are given in Box 4.
Photohydroionization
Photohydroionization (PHI) is a combination of safe, low levels of ozone, UV light and metal ions that produce safe oxidizers that neutralize odors and destroy airborne bacteria and mold. These oxidizers travel through a room by natural air movement. An advantage of PHI is there are no harmful byproducts, as the oxidizers revert back to oxygen and water vapor. Commonly used oxidizer is hydrogen peroxide.1
Air Pressure Gradients
Isolation rooms provided with pressurized air ensure unidirectional movement of air and thereby airborne contaminants are carried away.
Surfaces and Finishes
Floors
Flooring should be impervious, smooth, nonstainable and should allow easy movement. These should be jointless and antistatic in operation theaters.
Walls and Skirting
Walls in clinical areas should be water resistant, smooth and joint free. The color should be nonreflecting type and of soothing shades. Skirting should have same finish as floors, be integral with floors, be tightly sealed against the wall and constructed without any voids or cracks. The characteristics of walls and floors are given in Box 5.
Ceilings
All exposed ceilings and ceiling structures in areas occupied by patients or staff, and in food preparation or food storage areas, should have finishings so as to be readily cleanable with equipment routinely used in daily housekeeping activities. In areas where dust fallout would present a potential problem, such as clinical areas, supply and storage areas and sterile stock storage, there should be a finished ceiling that covers all conduits, piping, ductwork and open construction systems.2,3
Ceilings in operating, isolation rooms should be monolithic from wall to wall without fissures, open joints, or crevices that may retain or permit passage of dirt particles. Light fittings should also be recessed and flush fitting and sealed to prevent dust ingress. Lay-in ceilings should not be used where particulate matter may interfere with infection control; however, acoustical parameters must be kept in mind.2,3
Space Standards and Dimensions
Corridors
All corridors should be at least 2.7 meters wide. Where doors have been provided in the corridors, the effective usable width is reduced by at least 25 cm. Where storage bays have been provided to store trolleys/wheel chairs, etc., these should be outside the corridor width, i.e. should be recessed. Corridor dimensions and usage are given in Table 1.
Ceiling Heights
| : 3.0 meters clear height |
| : 2.7 meters height |
| : Up to 2.25 meters |
Schedule of Accommodation and Floor Plans
The schedule of accommodation is given in Table 2. The floor plans for ground and 1st floor plan for the center are given in Figures 5 and 6.
|
Ergonomics and Human Engineering Aspects
At all places principles of ergonomics should be considered. For ensuring the facility disabled friendly and barrier free it is important to consider this issue at the time of planning. For this, ramps and rails, etc. should thus be provided. Adequate number of lifts should also be provided. The height of each step on a staircase should be such that enables easy climbing and descend. Recommended measurements are staircase width 1500 mm, tread 300 mm and riser of 150 mm.4
Signages: Signages required are—External signages—for indicating the layout of the facility and various blocks, wards, etc.; Internal signages—to indicate fire exits, specific patient care areas, offices, etc. and safety/escape signages.
These should be prominently displayed and lighted at night or should be self glow type.4
Acoustics
Without reducing their importance or sense of urgency, such signals should be modulated to a level that will alert staff members, yet be rendered less intrusive. The variables for control of noise is given in Box 6.
Security
The building plan should facilitate secured housing of the patients, staff and equipment. It must cater the requirements of access control and should have provisions for preventing thefts and other such incidents. Intruder/duress alarms should be provided in suitable places. In critical areas online camera based monitoring can be considered. Adequate guard posts should be built-in in the plan.
Communication System
The requirement of a robust communication system is essential. It should consist of multiple means of communications to have redundancy in the system.
Building Codes/Regulations
Building codes and regulations to be complied with are local and National Building Code and norms for safety.
Air Conditioning
Air-treatment plants are required to fulfill two unrelated set of requirements: firstly guaranteeing ideal microclimatic conditions (temperature, humidity, dilution of smells, etc.) while keeping noise to a minimum, and second that of reaching and maintaining required levels of asepsis in the air, as required in the burns center. The recommended system for the airflow is directed vertical flow (Fig. 7 and Box 7). This ensures adequate air changes and sterility.1,2,5
In the wards and other direct patient care areas, there should be a separate exhaust system for quick evacuation of foul air in case of requirement. This system should have its activation switch-cum-damper in the nurses’ duty station. The damper ensures that there is no need to deactivate the switch (i.e. auto-switch-off of the quick exhaust system). This system should be capable of evacuation of foul air as quickly as possible.1,2,5
Lighting
Adequate lighting is an essential requirement. In the management of burns patients for various bedside procedures both emergency and non-emergency require adequate lighting. Therefore glare free lighting should be provided as follows:
| : 100 lux |
| : 300 lux |
| : 500 lux |
CONCLUSION
The burns and reconstructive surgery center is a specialized facility which is essential to be established for management of burns. The special considerations must be taken into consideration for ensuring its appropriate utilization and effectiveness.
REFERENCES
- Gupta SK, Kant S, Chandrashekhar R, Satpathy S. Modern Trends in Planning and Designing of Hospitals—Principle and Practice. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 2006.
- Inzani F, Azienda Ospedaliera A.S.O., Restructuring and realization of the new burns centre at the Celio Military Polyclinic in Rome, in the light of new criteria in the control of infection, Annals of Burns and Fire Disasters—Vol XV–No. 4-December 2002.