SUMMARY. This paper reports on the principles underlying the planning of the new Burns Centre at the Celio Military Polyclinic in Rome. The prevention and control of hospital infection were primary considerations. The organization of the spaces for burn patient care is described, and an analysis is made of some basic functional models. The criteria for climatization in the special wards are presented. The problem of hospital infection, which is the result of a series of interacting causes, must not be underestimated, and its reduction brings undoubted human and economic benefits.
The purpose of this paper is to consider the principles of the planning of the new Burns Centre at the Celio Military Polyclinic in Rome. The planning took into account criteria for the prevention and control of hospital infection, which in the past has always been among the main problems from the sanitary point of view. In view of their clinical condition, this a problem of vital importance in seriously burned patients. The diagram below (Fig. 1) presents a percentage breakdown of the commonest infections observed in samples from 400 hospitals.
In the last 50 years, great attention has been paid to the creation of special hospital units where the probability of infection in burned surfaces is reduced to a minimum. In many countries specific centres have been built for the care of seriously burned patients.
The centres considered in this study are characterized by the fact that they possess particular organizational and structural requisites. The organizational aspects regard above all the “human factor” in routine management of the patient.
The main objective of this planning is therefore to examine the structural aspects and to identify certain factors that to a greater or lesser degree influence the incidence of cross-infection in a hospital dedicated to the care of burn patients. This paper provides a detailed analysis of the following factors:
Both these factors concern the patient’s hospital environment, and their potential effection the containment of infection has to be managed from the very first stages of planning, and subsequently in the construction, maintenance, and management of a burns centre.
<% immagine "Fig. 1","gr0000025.jpg"," Intensive care unit: percentage distribution of infections out of a total number of 276 germs isolated",230 %>In 1972 the ISBI Action Committee on the Organization of Burns Care, in a report on the distribution of spaces in burn care facilities, proposed five different categories:
These models make up an expandable sequence of structures, each of which has the equipment to handle burns treatment in various situations and in countries that are at varying levels of development.
For brevity’s sake, we have assessed here only the hypotheses that can be applied to the model of the 5-bed unit in the new burns centre in the Celio Military Polyclinic.
While the general concepts are still valid from the point of view of the planning of the new burns department in this polyclinic, it was found necessary to emphasize certain fundamental considerations that are basic to the control of the infections that were taken into account in the distribution of the spaces.
With a view to preventing as far as possible the transport of micro-organisms by potential carriers (personnel, patients, air particles) and all contact with immunodepressed patients, priority was given to:
The organization of the internal spaces is therefore part of an interactive system of measures that counteract infection, and not something unrelated or independent. An important contribution is given by an efficient air-conditioning system, while from the sanitary point of view scrupulous respect of hygiene standards by all hospital personnel must be insisted upon.
Having established these general criteria, we studied the spaces necessary for the functioning of various sizes of burns units in relation to the possibilities of the site analysed in the Celio Military Polyclinic in Rome. With reference to the first four types specified in the above-mentioned report on the organization of burn treatment facilities (WHO) (individual care, burns service, burns unit, and burns centre), a list of general functions was therefore drawn up in order to group together spaces possessing similar uses or requisites.
The functions considered were subdivided as follows:
The specific volumes necessary for each of the four types were then established in relation to their relative functions.
1. Single room model
The single room model for burn patients (the minimum unit, for “individual care”) can be an entity that is repeated as necessary in order to satisfy a wide range of needs; it also contributes to standardization of staff activities.
The study for a standard room takes into account the needs of two different types of patients:
In the application adopted at the Celio Military Polyclinic (Fig. 2), we discarded the second solution of the two-bed room with bathroom and shower in each room. This was because with acute or septic patients a single room is essential in order to guarantee the further reduction of the spread of infection due to mobilization of the patient and the consequent dispersal of organisms.
The single room suite thus consists of:
| <% immagine "Fig. 3","gr0000027.jpg"," Single-bed room ",230 %> | <% immagine "Fig. 4a","gr0000028.jpg"," Model A",230 %> |
Figs. 4A, B, and C show three schematic models that represent a series of studies for the placing of patients in single rooms (as also in double rooms, a solution not used here for the reasons given.
Model A (Fig. 4A) is the simplest version, satisfying the need of each type of room; unfortunately, owing to the arrangement of the spaces available at the Celio Military Polyclinic in Rome, it was not possible to provide the hydrotherapy care indicated in the diagram.
Fig. 4B shows how the different arrangement creates viewing opportunities from the outward side of each single room, where visitors can sit and talk to the patients over an intercom system; also in this case - although we used the system offering viewing possibilities along the service corridor, as shown in this figure - the two-bed room system was not used.
Fig. 4C shows the visitors’ areas for the single rooms. In each room the accommodation area has a narrow front side, so that the area occupied by two single rooms, plus their therapy room, is equivalent to that of two double rooms. This arrangement could not be applied in the Celio Military Polyclinic in Rome because of the nature of the spaces available; it would however have afforded greater flexibility in the distribution of complex burn facility structures.
| <% immagine "Fig. 4b","gr0000029.jpg"," Model B",230 %> | <% immagine "Fig. 4c","gr0000030.jpg"," Model C",230 %> |
2. Burn care model
In the planning phase, the main objective - on the basis of analyses of models for individual care in burns service, burns units, and burns centres - was the elimination of all points of contact between sources of micro-organisms and immunodepressed patients. To achieve this objective, which necessarily requires strict control of the movement of internal and external personnel, the model structure was considered in terms of groups of functions. Some key features are listed below:
A study of these parameters indicated a basic conceptual arrangement for each of the four types, all of which have the following common features:
This solution is one of the simplest for burn care structures, and in the arrangement adopted at the Celio Military Polyclinic in Rome it can take up to two patients at a time. This arrangement, considering its particular application, is intended for a hospital department where all vital support services are available (operating rooms, etc.), affording the patients’ considerable autonomy from the viewpoint of sepsis and privacy. In this case access to the individual care unit can be controlled separately from the rest of the division. On the basis of these overall considerations we present the functional scheme of the distribution of spaces adopted in the planning phase for the new burns centre at the Celio Military Polyclinic in Rome The solution adopted, as can be seen, is a combination of the various possibilities described, having been studied in association with the military health authorities interested in the ultimate use of the Centre, including the Management of the Polyclinic, which insisted on certain parameters in the planning stages and provided important guidance for the management of emergency surgery cases arriving from the basement floor in pavilion 16, where the surgical care area in the new burns centre will be located.
The general arrangement is concentric in form, with a central patient support nucleus with general service areas, an intermediate ring of patient rooms, and an external corridor for visitors. The patient room has one part for septic patients, one part for acute patients, and one part for non-acute patients.
To limit contact between the various zones, there is a separating corridor with a perimeter zone serving as a staff rest area.
The service area block contains:
To simplify matters, given that the burn unit has to be part of a more complex hospital structure, it was conceived as occupying a whole floor of a building having two external walls. The third and fourth sides provide access and links to the rest of the hospital.
<% immagine "Fig. 6","gr0000032.jpg"," Plan of the Celio Miltary Polyclinic Burns Unit in Rome",230 %>The planning of the air-conditioning plant was based on two fundamental requisites - the need to guarantee certain ideal microclimatic conditions (temperature, humidity, odour minimization, etc.), with minimum noise levels, and the need to achieve and maintain different levels of asepsis in the air in relation to the varying functions of different areas.
The bacterial charge of the area can be reduced either by filtration or by sterilization. The latter is achieved using ultraviolet lights located both directly in the rooms or the aeraulic ducts and as a complement to the filters.
A conditioning plant for the septic areas of specialist areas (e.g. victims of serious burns) has both an active and a passive function:
In relation to point a), good results can be obtained:
In relation to point b), the air flow can be controlled:
In the planning phase we selected and studied three high-efficiency lavage systems:
| <% immagine "Fig. 7","gr0000033.jpg"," Laminar flow ",230 %> | <% immagine "Fig. 8","gr0000034.jpg"," Direct vertical flow",230 %> |
Laminar flow systems can be either horizontally or vertically oriented. In either case the air flow acts on the entire volume and is characterized by an elevated air-charge ratio.
The direct vertical flow concentrates its action in the area where the medical team works, in the vicinity of the patient.
The air flow originates from a ceiling-high pressure chamber and enters through two channels:
The system’s capacity (20-25 air changes per h, reducing to 15 when the rooms are not in use) is clearly lower than that of laminar flow ?PER CAMERE BIANCHE? and reduces the bacterial colony forming units per m3 to a level that is tolerable for delicate operations and appropriate for our purposes. This system, which does not use air nozzles and thus does not disturb patient comfort (high-speed nozzles create a disturbing wind-effect), was selected for use in the air-conditioning plant in the new burns centre in the Celio Military Polytechnic in Rome. Each room has its own diffuser for the input of sterile air, with a special dedicated system for local control, in each separate room, of all thermohygrometric, pressure, and air flow conditions.
There is also another system, the Joubert system, not used in Italy. In 1979, in Lyons, France, Prof. Joubert began to develop a system based on direct vertical flow for operating rooms, but with certain modifications:
On the basis of this study, the planning phase took into account vertical laminar flow with room-by-room control of pressure, temperature, and humidity levels and 15 to 30 volume exchanges per h.
<% immagine "Fig. 9","gr0000035.jpg"," Joubert system",230 %>In recent years the development by health services of more sophisticated treatment protocols and the consequently greater incidence of burn cases among immunodeficient patients have highlighted the problem of hospital infection. In economic terms alone, the extra costs of prolonged hospitalization due to infection justify investments in special structures where risks can be reduced to a minimum. To this regard a strong input in the planning and development phase of the new centre was given by the Management of the Celio Military Polyclinic.
Among the conditioning systems examined, the direct vertical flow system and the Joubert system are best suited for rooms with high-risk patients (acute, septic) and overpressure filters; both these systems offer a very high air exchange rate, with good aerodynamic features, low noise, and low energy costs.
While both systems are suitable for post-treatment units with a centralized plant, the vertical flow system uses external air only. The Joubert system recycles a portion of ambient air, which means that it can be used in countries where health regulations permit recycling (such is the USA, Germany, and France), but not where this system is banned (e.g. Italy).
The solutions proposed do not ignore the problem of hospital infections. These infections are the result of a series of interacting causes, none of which can be underestimated or ignored; they can however be neutralized using a series of interactive measures.
The efficiency of a climatization system in a hospital environment can be further improved by the use of correct pressure gradients and correct architectural layout, taking into account the concepts of modularity and separation (between the various functions, the patients, and personnel) that we have analysed.
The planning of the new burns centre at the Celio Military Polyclinic in Rome has thus allowed the realization of the above results.
<% immagine "Fig. 10","gr0000036.jpg"," Layout of the new burns centre at the Celio Miltary Polyclinic in Rome",230 %>RESUME. L’Auteur décrit les principes du projet du nouveau Centre des Brûlures auprès de la Polyclinique Militaire Celio à Rome. La prévention et le contrôle des infections hospitalières constituaient des considérations d’importance primaire. L’Auteur décrit l’organisation des espaces pour les soins des brûlés et présente une analyse de certains modèles fonctionnels de base. Il considère en outre les critères pour la climatisation des services spéciaux. Il ne faut pas sous-estimer le problème des infections hospitalières, qui sont le résultat d’une série de causes interagissantes, et toute réduction de ces infections porte des bénéfices indubitables humains et économiques.