Appendix 3A: Clinical Specifications

Emergency Department and Appendix 3A: Clinical Specifications

CONTENTS Page Section 1 Section 2 Section 3 INTRODUCTION Organization of the Report...1-1 Space Summary...1-1 PROJECT PARAMETERS Project Parameters...2-1 Functional Parameters...2-1 Operational Parameters...2-3 Physical Parameters...2-6 OVERVIEW Overview...3-1 General Planning Criteria...3-1 Component Planning Criteria...3-2 1.0 Medical/Surgical Inpatient Care Hemodialysis Capable Unit...3-5 2.0 Medical/Surgical Inpatient Care Neurology Unit...3-19 3.0 Intensive Care Unit...3-33 4.0 Neonatal Intensive Care Unit...3-51 5.0 High Dependency Care Unit/ Medical Surgical Unit...3-69 6.0 Emergency (excluding garage)...3-85 7.0 Laboratory Services...3-117 8.0 Respiratory Therapy Services...3-143 9.0 Pediatric Pharmacy...3-153 10.0 UBC Clinical Academic Campus...3-165 11.0 Main Entrance Services...3-187 12.0 General Administration & Support Offices...3-197 13.0 Ronald McDonald Family Room...3-211 APPENDICES Appendix A Definition of Terms...A1 Appendix B Acronyms...B1 Appendix C Consolidated Space Tables...C1

SECTION 1 INTRODUCTION

SECTION 1: INTRODUCTION ORGANIZATION OF THE REPORT The Surrey Memorial Hospital Emergency Department and Clinical Specifications report is organized into the following sections: Section 1: Introduction; Section 2: Project Parameters - this section describes factors expected to influence the development of the Facility. Parameters are organized as follows: - Functional Parameters, - Operational Parameters, and - Physical Parameters; Section 3: Clinical Specifications - this section includes general and functional component planning criteria and a description of the functional component. The functional component description includes a functional and operational description, design criteria and space requirements; and Appendices as follows: - Appendix A: Definitions and Terms; - Appendix B: Acronyms; and - Appendix C: Consolidated Space Tables. SPACE SUMMARY The following summary table illustrates space requirements by component for the 2020 planning horizon. Also included in the summary table, are additional required spaces, which have not been included in the space program. Table 1: Space Summary by Component - 2020 Component Program (nsm) 1.0 Medical/Surgical Inpatient Care Hemodialysis Capable Unit 1773.5 2.0 Medical/Surgical Inpatient Care Neurology Unit 1773.5 3.0 Intensive Care Unit 1614.8 4.0 Neonatal Intensive Care Unit 1950.1 5.0 High Dependency Care Unit/Medical Surgical Unit 1834.3 6.0 Emergency 3771.5 7.0 Laboratory Services 1567.3 8.0 Respiratory Therapy Services 139.0 9.0 Pediatric Pharmacy 238.6 10.0 UBC Clinical Academic Campus 1478.5 11.0 Main Entrance Services 455.9 12.0 General Administration & Support Offices 880.3 13.0 Ronald McDonald Family Room 204.3 Total 17681.6 Additional Space Level 0 Link to South Tower Level 1 Link to South Tower Level 1 Link to Main Diagnostic Imaging Level 2 Link to South Tower Roof top Helipad 1-1

SECTION 2 PROJECT PARAMETERS

SECTION 2: PROJECT PARAMETERS PROJECT PARAMETERS Section 2 is organized into three parts as follows: (a) Functional Parameters this part defines what programs and services are to be included in the project, and at what scope or capacities; (b) Operational Parameters this part describes the operational systems that will support the programs and services in the project; and (c) Physical Parameters this part sets out requirements related to the location of the functional components to be included in the Facility, and provides information concerning the locations of related SMH components. FUNCTIONAL PARAMETERS Planning Horizon & Component Scope/Capacity The Facility is to be programmed to accommodate estimated needs for the year 2020, with scope and workload capacities 1 as shown below: Components Estimated Needs 2020 1.0 Medical/Surgical Inpatient Care Hemodialysis Capable Unit 36 beds 11,169 patient-days 2.0 Medical/Surgical Inpatient Care Neurology Unit 36 beds 11,169 patient-days 3.0 Intensive Care Unit 25 beds 8,541 patient-days 4.0 Neonatal Intensive Care Unit Level II Level III 48 total positions 28 positions 7,665 patient-days 20 positions 5,475 patient-days 5.0 High Dependency Care Unit/Medical Surgical Unit 25 beds 8,669 patient-days 6.0 Emergency Adult Pediatric Total, Emergency 2 7.0 Laboratory Services (excl. Anatomical) Biochemistry 86,335 visits 14,839 visits 101,174 visits 4,167,108 units 2,986,632 units 1 Surrey Memorial Hospital Redevelopment Project Phase 1A, Service Strategy and Design, February 15, 2009. 2 Note: Laboratory units projected to 2015. 2-1

SECTION 2: PROJECT PARAMETERS Components Estimated Needs 2020 Hematology Transfusion Medicine Microbiology Accessioning Total Lab (excl. Anatomical) 930,223 units 3,818,922 units 4,029,703 units 19,092,946 units 8.0 Respiratory Services 13,065 ventilator-days 19,081 O2 treatments 3,345 BIPAP-days 3,640 blood gas analyses 1,000 bronchoscopies 1,293 spirometry tests 9.0 Pediatric Pharmacy 33,580 new prescriptions 6,716 prescription refills 10.0 UBC Clinical Academic Campus 29 staff + students 11.0 Main Entrance Services Includes Cashier services, Patient & Family Resource Centre, Security Kiosk, Coffee and Gift shop 12.0 General Administration & Support Offices Includes Administrative offices for Programs 13.0 Ronald McDonald Family Room Includes a place of refuge and support facilities for families of infants and children who are patients in critical care areas of the hospital. Teaching Role & Scope SMH will host both undergraduate and graduate students enrolled in a broad spectrum of health programs (medical, nursing, pharmacy, health social work, lab and imaging technologies, etc). Both centralized and decentralized facility resources will be required at SMH. The project will provide decentralized resources in the clinical areas and the centralized academic base for the UBC School of Medicine. The UBC Clinical Academic Campus will include increased 3rd and 4th year undergraduate practicums at SMH as well as post-graduate trainees. Research Role & Scope SMH will actively promote on-site clinical and health services research. Clinical research activities will encompass health evaluation and epidemiological type studies, as well as clinical trials; the latter may be coordinated through established clinical programs or may be conducted as independent protocols. It is expected that the location of cross-appointed faculty clinicians at SMH, with the UBC Clinical Academic Campus, would result in an expanded research role and required related clinical research resources. 2-2

SECTION 2: PROJECT PARAMETERS In general, research planning will allow for some on-going clinical dry bench research activity in coordination with research programs organized provincially, nationally, or internationally. No wet bench laboratory research activity is anticipated at SMH. OPERATIONAL PARAMETERS Operational Systems For the purposes of Facility planning for, the following SMH clinical and non-clinical support systems will be assumed to be operational at the time of commissioning and continuing without change in the ensuing years. Clinical Support Systems Diagnostic Imaging Services will provide the special skill-sets and resources required by all inpatient units including the critical care units, and Emergency Department. Diagnostic Imaging, in the main department, will be available for ultrasound, general radiography, CT, MRI, and selective sub-specialty imaging. The route between inpatient units in the Facility and main Diagnostic Imaging in the North Building will have minimal cross-over with the Emergency Department. Mobile radiographic and ultrasound imaging will occur within the inpatient units. A satellite diagnostic imaging component will be included in the Emergency department component providing general radiography, ultrasound and CT scans. Inpatients requiring other imaging services not provided on the units will be transported, and in the case of critically ill adult or neonate patients with monitors and a critical care team, to the satellite diagnostic imaging component. Emergency patients in the satellite diagnostic imaging component will have priority over other patients in which case those other patients would be transported to the Main Diagnostic Imaging component. All diagnostic images will be digitally produced and, as such, will be accessible wherever a high-resolution computer terminal exists and the user has the authority to access. Within the Inpatient units and the Emergency department there will be several high-resolution Picture Archiving and Communication System (PACS) viewing stations, including at care stations and in physicians workrooms. All charting computers will also be used for viewing digital medical images. Mobile radiographic and ultrasound imaging equipment will be stored on the inpatient units and in the emergency department. Respiratory Therapy Services will provide support in the treatment of patients requiring respiratory support. Typical activities will include: - attendance at all cardiac arrests; - active airway management and stabilization including mechanical ventilation, BIPAP; - assistance with conscious sedation; - assessments of respiratory patients including COPD, pneumonia, asthma, congestive heart failure, shortness of breath; - assist with rhinoscopes and bronchoscopies; - arterial blood sampling; - intubations; - administration of oxygen and aerosol agents; - routine respiratory assessments; 2-3

SECTION 2: PROJECT PARAMETERS - patient education regarding respiratory illness and medications, and self-management of chronic conditions such as asthma; and - playing a leading role in newborn resuscitation; - newborn intubation and support to various ventilation technologies; - arterial and cord blood gases; - oxygen assessment, titration, and trending, as required; - shared responsibility with nursing for inhalation therapies; and - playing an integral role in intra-hospital and inter-hospital transport. Respiratory therapists will also manage and maintain the equipment essential to the respiratory support of patients. Respiratory therapists will disassemble, clean and reassemble all used respiratory equipment on the inpatient units and in the emergency department. Items to be sterilized will be sent to the sterile processing department. Laboratory Diagnostic Services will be provided on-site in coordination with both the new Outpatient Facility (OPF) laboratory and the Fraser Health Authority regional laboratory service, which one of two regional laboratory services. The laboratory critical care tower will offer routine high volume and rapid response diagnostic testing and reporting, and will increase its role in specialized analysis. It is assumed that approximately 40% of the OPF lab work will be processed in the SMH laboratory. The laboratory component in the Critical Care Tower component will be physically separated from, operationally integrated with, the Anatomical Pathology section which is to remain in existing facilities. Orders and test results will be part of the fully electronic health record system and will also be integrated with the Provincial Laboratory Information System (PLIS). Clinical pathologist will function as members of the interdisciplinary care teams. Rehabilitation Services will occur centrally within the existing central SMH facilities, and decentrally within the SMH inpatient care units wherever operationally feasible. Rehabilitation staff will provide services to patients designed to promote optimal health. The services will include assessment, diagnostic input, treatment, and education related to the following disciplines: physiotherapy, occupational therapy, and speech language pathology. Social Work Services will provide psychosocial assessments with patients families, develop and implement a psychosocial care plan, and provide counseling, education, and support to patients and their families. Nutritional Services will provide nutritional assessment, intervention and follow-up to patients. Dietitians will recommend appropriate oral, enteral, and parenteral nutrition therapy to optimize clinical outcomes in patients. Dietitians participate as members of the interdisciplinary teams, in the overall programs in developing and revising nutritional protocols to ensure practice is current and evidence based. Pharmacy Services will be provided from both an off-site regional Pharmacy Drug Distribution Centre (PDDC) and from an on-site pharmacy. The on-site main pharmacy will fill first orders and urgent or interim doses, while the PDDC will provide routine refill doses and supplies to the on-site pharmacy locations. Point-of-Use (POU) drug distribution system will be used to distribute narcotics and ward stock to the clinical areas of all inpatient units and the emergency department. This will include automated drug dispensing cabinets on the units and in the emergency department for all medication requirements. Pre-mixed intravenous medications will be provided through Centralized Intravenous Admixture (CIVA) services, as appropriate, with urgent and interim doses being prepared or 2-4

SECTION 2: PROJECT PARAMETERS being readily available on-site, and replenishment doses being prepared through the regional Pharmacy Drug Distribution Centre (PDDC). The Pediatric Pharmacy will serve the NICU, Pediatric Emergency, and other Pediatric Inpatient and limited Outpatient populations on the SMH site. In addition to solid-form medications, this facility will have the capability to produce TPN and IV admixtures. Fax machines will be used to transmit orders to Pharmacy. Clinical pharmacists, as members of the interdisciplinary care teams, will: - review all patient charts to assess appropriateness of ordered medications and determine the need for medications not yet ordered; - monitor the patient for effectiveness and adverse effects from medications; - monitor TPN; - consult to staff and physicians; - attend rounds; - provide teaching to patients regarding medications; - provide drug information upon request; - participate in and conduct research; - trouble-shoot on both clinical and distribution issues; - establish evidence-based protocols/guidelines development; and - act as a liaison with the community for discharges involving complicated medication regimens. Other Clinical Support Services such as spiritual care will be provided from existing central SMH facilities and where such personnel are routinely active members of the interdisciplinary care teams decentralized accommodations will be provided. Non-Clinical Support Systems Health Records will be fully electronic and accessible by authorized personnel at all clinical service locations in the critical care tower. Physician reporting will utilize a voice recognition dictation system. Note: During the initial years of operation it shall be necessary to accommodate current paper-based information systems until the evolution to a fully electronic system is achieved. Telehealth audio-visual linkages to off-site resources will be available. Materiels Management will supply all consumables to various departments across the site. Supplies including medical/surgical supplies will routinely come directly from an off-site regional distribution centre, Support Services Facility (SSF), using a point of use par level top-up system, with computer-based inventory control. Area supply staff will provide 2-7 days a week top-up services of supplies to the components. Local component supplies storage will utilize a modular fixed rack/shelf system. Central SMH on-site stores will be accessible to designated personnel (Shift Coordinators) 24-hours for non-routine or urgent replenishments. Biomedical Engineering Services staff will provide full equipment support/maintenance services that include: - incoming inspections of patient-related electro-medical devices to assure proper performance and compliance with approved safety standards before use in the facility; - installation and/or management of installation of patient-related electro-medical systems and devices; - repair and maintenance of above-noted systems and devices; - preventative maintenance of incubators and other equipment in situ; 2-5

SECTION 2: PROJECT PARAMETERS - technology assessment and evaluation of medical devices during the purchasing process; - creation and maintenance of an inventory database of medical devices and service/maintenance repair history of those devices; - coordination and tracking of vendor services and contracts related to electro-medical equipment; - consultation to clinicians considering new equipment; - provision of in-service education to staff on the use of equipment; - risk management activities related to medical devices including manufacturer recalls and hazard alert follow-up and tracking; and - incident reporting, investigation, and follow-up. Conveyance System(s) for small items will include a pneumatic tube system linking all patient care components to the laboratory (accessioning area), pharmacy components, and logistics component. Pneumatic tube stations will be located in each patient care zone at the central care team station and other locations identified in the relevant schedule of accommodations. Sterile Processing will utilize a closed case cart system to service the main surgical suite, maternity operating theatres, and endoscopy procedure rooms. Other sterile supplies will form part of the medical/surgical supply system. Food Service will come from a central on-site kitchen within which food portions will be prepared, cooked, chilled, trayed, and rethermalized prior to delivery on food carts to the patient care units. Food will be ordered electronically. Special needs of patients such as special diets/restrictions, meal support (e.g., with eating disorder patients), and nutritional supplements, etc, will be accommodated. An off-site production centre will provide bulk food reception, storage and preparation. Nourishment stations will be strategically located on inpatient units and in the emergency department for staff to provide nourishment to patients. Vending machines will be available in public areas for visitors use. Linen Supply Service will deliver clean linens to the units or departments on a daily basis to meet the specific needs of the programs; linen will be delivered to the designated clean holding areas within the units or departments. Housekeeping Service 3 will be provided to critical care tower. Housekeeping staff will provide daily cleaning services to meet the specific needs of the programs. All waste and soiled linens will be collected and stored in the soiled holding rooms located within the units or departments. Designated staff will remove waste and soiled linens and transport to the final collection/disposal areas. PHYSICAL PARAMETERS The Neonatal Intensive Care Unit will be located on level 2 of the Facility so that it is adjacent to the Family Birthing Unit in the South Building. As described in Schedule 3 [Design and Construction Specifications], the General Administration and UBC Clinical Academic Campus level will be designed and constructed to allow conversion to a 3 Room requirements have been identified to support Housekeeping and Waste Management Functions; however, these are just an estimation and final space requirements need to be determined by Project Co. 2-6

SECTION 2: PROJECT PARAMETERS surgical suite in the future. The main SMH surgical suite will remain on level 1 of the South Building until it is relocated in the future. Other SMH physical parameters: Diagnostic Imaging is located on level 1 of the North Building. A satellite Diagnostic Imaging component will be located in the Facility Emergency Department to provide services to patients in the Emergency Department and if required to patients from other parts of the Facility; SMH loading docks and logistical stores will remain in the F Building; the Central Sterile Processing component of SMH will be redeveloped by the Authority in its current location (in the South Building); The Food Services component will remain in its current location on level 2 of the North Building; and Program Directors and some other administrative offices will be centralized in the Facility. 2-7

SECTION 3 OVERVIEW

OVERVIEW OVERVIEW Introduction This section is intended to provide an understanding of some of the planning criteria related to the needs of patients, staff, and visitors which impact on the Surrey Memorial Hospital Emergency Department and Project. The intent of this section is not to suggest physical planning solutions, but rather to identify the functional requirements for planning that will assist in development of the most appropriate environment for people and systems as design work proceeds. Highlighted general planning criteria are organized as follows: Internal Connection System; Public and Non-Public Areas; Elevators; and Helipad. GENERAL PLANNING CRITERIA Internal Connection System A direct and easily understood internal connection system between the Facility and existing SMH buildings is essential to the effective movement of patients, visitors, staff, equipment and materials. To achieve this end two connections are required: the South Building Spine and North Building Link. Refer to Section 4.3 (Connections to Existing Hospital and Site Services) of Schedule 3 [Design and Construction Specifications]. Public And Non-Public Areas (On-Stage And Off-Stage) There will be separation of public and non-public areas within the Facility. There will be public elevators for accessing other levels in the Facility. If patients or visitors wish to access the rest of the Hospital from the Facility, they will use the South Building Spine at level 2 of the Facility, which can be accessed from the escalator connecting the level 1 lobby and the level 2. Refer to Section 6.14.2 (Escalators) of Schedule 3 [Design and Construction Specifications. 3-1

OVERVIEW Staff, materials and patients will use the non-public circulation corridors and elevators in the Facility for movement between and around floors. The non-public connection at level 2 of the South Building Spine will provide direct access from the Family Birthing Unit in the South Building to the Neonatal Intensive Care Unit. This corridor may cross a public corridor/vestibule if access to the public corridor/vestibule is electronically controlled (including with a warning and monitoring system) and capable of being shut down to the public during the transport of an infant. The following is a diagram illustrating the concept of separation of public and non-public spaces and circulation: OFF STAGE ON STAGE PATENT, STAFF FAMILY Public DECISION POINT Elevators Refer to Section 6.14.1 (Elevators) of Schedule 3 [Design and Construction Specifications] for elevator requirements. The use of non-public elevators is particularly important for transporting critical ill patients to and from diagnostic imaging, the surgical suite, the emergency department or the helipad and the critical care units. A sufficient number of public and service elevators will be provided to support the functions of each type of elevator. Helipad A helipad will be provided on the roof of the Facility. COMPONENT PLANNING CRITERIA Introduction The Component Planning Criteria section of the Clinical Specifications document provides detailed descriptions of parts making up the Surrey Memorial Emergency Department and project. The following pages contain detailed descriptions of each clinical specification. The descriptions follow a standard format. 3-2

OVERVIEW SPECIFICATION STRUCTURE Information for each specification section is typically presented under the following headings: Functional Description provides an overview of the clinical, education and research scopes of service; Operational Description provides the minimum hours of operation, a review of patient management processes, staff work processes, and specific clinical or logistical support services; Activity Capacity provides a tabulation of the minimum expected level of activity that Project Co must accommodate; Occupancy provides a tabulation of the assumed maximum number of people to be accommodated within each functional area as outlined in the schedule of accommodation section of Design Criteria; and Design Criteria provides graphic and narrative descriptions of key external relationships, key internal relationships/environmental considerations and suggested schedules of accommodation. External Relationship Diagrams The key external relationship diagrams and text in each clinical specification section indicate the priorities of the components for its location relative to other components. There are three definitions of terms used in the external relationship description are as follows: 1. Direct Access by Internal Circulation Direct access by internal circulation refers to components, which are located together and linked internally. This form of access avoids movement through the general circulation system of the Facility. An acceptable alternative to horizontal contiguity would be vertical contiguity by means of a dedicated elevator or internal stairs. Component 1 Component 2 3-3

OVERVIEW 2. Direct Access by General or Non-Public Circulation Direct access by general or non-public circulation refers to components located near to each other and linked by minimal or moderate amount of horizontal and/or vertical general circulation. Component 1 Component 2 Component 3 3. Convenient by General Circulation Convenient access by general circulation refers to components, which are located at a distance from each other and are linked by extended horizontal and/or vertical general circulation. Component 1 Component 2 Internal Design Criteria The internal relationships/concepts section indicates basic criteria and concepts for the organization or environmental design of space (e.g., zoning, flexibility, segregation, environmental ambiance, privacy, sound attenuation, safety features, etc.). Component Functional Diagrams The component functional diagrams in this Appendix illustrate the major functional relationships within the relevant component. Please note that these diagrams are generally indicative of major functional relationships but are not intended as floor plans, are not drawn to scale and do not illustrate all rooms. Schedules of Accommodation The schedules of accommodation are tabulated with a reference number (Ref) used for cross referencing within this document and which may be used in any future supplementary document. Also illustrated is the number of existing and projected rooms or spaces (units), the net square metres per unit (nsm/unit), and the total net square metres for each room or space (nsm). Indented line items indicate a close adjacency with the preceding line item. Proposed net square metres (nsm) is stated to the nearest 0.1 m 2 and is considered the desired minimum. At the end of each space list the total net space is summarized. 3-4

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT FUNCTIONAL DESCRIPTION Scope of Services Content This specification outlines the requirements for the Medical/Surgical Inpatient Care Hemodialysis Capable Unit component. This component will provide 36-patient beds in the Facility for the delivery of secondary and selected tertiary acute care to medical and surgical adult inpatients. The specification assumes a typical general-purpose inpatient unit and although unique needs of sub-specialties promote physical differences between units, the intent remains to provide highly flexible units capable of adapting to changes in inpatient care use and methods over the facility s life. Promotion of flexibility does not preclude the designation of beds for special purposes or for design modifications around these designated beds to enhance functionality. Treatment and care services typically provided in the Inpatient Units (IPUs) will include, among others: Receiving, assessing and monitoring patients holistic needs; Consulting with physicians and members of the interdisciplinary team; Conducting shift reports and participating in interdisciplinary patient conferences; Coordinating, implementing, communicating, administering, scheduling, and evaluating the overall operations of the unit; Documenting patients' progress and maintaining patient electronic charts/records; Educating patients and their families; Providing clinical academic training for staff, students and residents; Facilitating patient comfort and relaxation, recreation and activation; Facilitating family-centred care; Meeting daily physical patient needs; Providing family/visitor support, consultation and counselling; Providing routine and emergency patient care including examinations and treatments; Admitting patients directly or via the emergency areas; Providing for and ordering medical diagnostic and treatment procedures; Participating in the overall program development for their respective populations; Providing emergency medical examination and treatment; and Providing symptom management (e.g., specialized interventions for acute pain management with support from anesthetists. Maximized Use of Staff Resources Staff resource utilization will be maximized in that the most appropriate staff persons will perform tasks. For example, nurses will not spend time in non-nursing duties such as searching for supplies, thereby allowing them to focus on care of the patients in their charge. The Clinical professional service team members (e.g., physiotherapy, occupational therapy, speech language therapy, respiratory care, laboratory, pharmacy, education, spiritual care, etc.) will travel to the inpatient units from their central components as required. 3-5

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Associated Trends The following trends will influence the future functioning of this component, and should be taken into account in the component design: Predictions of significant nursing staff shortages during the next 20 years; The medical inpatient units will to provide decentralized capability for managing infectious diseases; Increased acuity levels will be seen in patients admitted to medical/surgical units. Medical/ Surgical specialties are now becoming increasingly specialized and more complex surgery will continue to develop; The number of bariatric patients admitted is expected to increase; The parallel development of day and short stay care for a greater range of procedures, both invasive and non-invasive, will accentuate the trend in changes in acuity levels in inpatient care. It is anticipated that for medical/surgical specialties there will be a trend to increasing numbers of tertiary referrals; Increasingly, interdisciplinary teams will provide services; Number of patients going through inpatient beds is increasing, but lengths of stays are decreasing; Telehealth will increasingly provide outreach opportunities to and from health care facilities province-wide; The trend to adopt evidence-based clinical pathways will continue, with standards becoming available in many more types of cases; The nature of the geriatric population requiring inpatient care will become increasingly more complex and dependent. The patient population will have greater co-morbidities and will tend to be difficult to manage given unpredictable behaviour patterns; The volume of complex geriatric cases will increase as will the length of stay for geriatric inpatients. Interdisciplinary teams, involving physicians, specialist nurses and specialized allied staff, will provide geriatric medicine inpatient services; and The number of patients with mental illness and/or substance abuse problems is expected to increase. Scope of Education Activity The 36-bed IPU will generally provide clinical resources in support of teaching programs for the following types and anticipated maximum number of students at any given time: 3 medical/surgical residents; 3 medical undergraduates; 8 nursing (RN, LPN, RPN) undergraduate and graduate students; 1 pharmacy undergraduate/resident; 1 social work student; 2 physiotherapy students; 1 occupational therapy student; 2 speech language pathology students; 1 laboratory technology student; 3-6

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT 1 laboratory assistant student; 1 respiratory therapy student; and 1 dietetic intern. A wide range of individual and small group clinical teaching activities will be accommodated directly in the inpatient care areas. Large formal lectures or large continuing education programs will not be accommodated in the inpatient units. Inservice education and patient teaching programs will be conducted on a regular basis throughout the unit s patient/clinical care spaces as well as in staff conference room and a patient/family education room equipped with audio/video links. In total, there could be up to 12 non-staff people involved with education programs in the component at any one time. Scope of Research Activity Clinical research activities may be conducted within the component, but without the need for supplement space. OPERATIONAL DESCRIPTION Hours of Operation The IPU will be staffed 24-hours a day, 7-days a week. Patient Management Processes Reception/Admission Patients will be admitted to an inpatient unit by pre-arrangement, through Access and Bed Control, as unscheduled patients through the Emergency Department, and through inter hospital transfers. Immediately upon entry onto the inpatient unit floor, ambulant patients will report to the unit clerk at the central care team station. For families visiting a patient on the unit a separate and secure visitor entrance will be provided. The unit clerk also will greet all family members and visitors to the unit. Family members and visitors will have access to a lounge with children s play area, vending machines, washrooms, and public telephones close to the entrance to the unit. Care Patients will be admitted to a specific bed based on their dependence level. All patients will be monitored from one of the care stations. There will be direct and clear sightlines between the direct care providers and patients. Clear sight lines to patient room doors from the care stations are required. Patients will have ready access to staff at all times (lines of sight, communication systems and call systems). 3-7

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Interdisciplinary care teams made up of multiple caregivers will be supported within the care unit. An increased emphasis will be placed on family-involved/centred approach to care rather than a provider-focussed model in support of holistic care of the patient. Staff Work Processes Communications The 36-bed inpatient unit s central care team station will also act as a reception/control point for access to the unit. This care team station will include the patient care coordinator s and unit clerk s workstations, and an interdisciplinary charting workroom. Care stations will be provided ensuite with each pod of patient beds. The units will support nurse manager/leader engagement with staff, as well as, promoting staff communication and mentoring. Care Delivery Entrance Referral Source Reception/ Admissions Care Delivery Care Planning/ Charting/ Discharge Planning Immediately upon entry into the floor the family members and visitors will come upon the public area with a lounge/waiting room with play area, washrooms and telephones. Provision for hand sanitizing will be made. There will be clear directions to the central care team station where a unit clerk will greet family members and visitors. Discharge Process Flow Diagram Patient Room Patient care will occur mainly at the patient s bedside. All patient rooms will be capable of cardiac monitoring of patients with telemetry. Patients in these units will not require mechanical ventilation. Charting will occur at the patient s bedside, the workstation alcove or the care station. There will be one workstation alcove for every two patient beds. Pod-like Design Within the 36 bed unit, the patient beds will be arranged in pods with all frequently used support rooms (including medication rooms, dirty utility rooms and clean supply rooms) easily accessible by each individual pod. The pods need to be laid out in such a way to allow the 36 bed to still function as one unit. Assigned RNs and LPNs will generally be assigned for all of the patient care provided in one pod, but may be assigned to patients in the adjacent pod. In some cases, a nurse may be assigned a particular patient with higher acuity. A care station will be located en-suite within each pod for interdisciplinary team members use. As much as possible beds are to be visible to the care stations, while allowing a degree of patient privacy to be maintained. 3-8

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Inpatient pod layout should be compact as possible to minimize nurse in-flight time and maximize nurse-patient visibility by locating frequently utilized staff work areas and support spaces close to the patient bed spaces. Interdisciplinary conversations will be private and not overheard by patients. Activities in the care team stations should not disturb sleeping patients; therefore, the care team stations will be designed with as many sound control measures as possible. The medications room will be discreetly located and will include an automatic medication dispensing system and computer. Access to it will be visually supervised from the care station. At least one wall will be glazed. Six patient beds will be provided within three semi-private rooms. Each semi-private room will have two patient washrooms, one for each patient for infection control purposes. Also, there will be one workstation alcove, used for charting, for each semi-private room. These semi-private rooms will be distributed throughout the 36 bed unit. 36-Bed Unit Only essential patient care support areas will be maintained within the unit proper. Spaces will be located close to patient rooms in the following order of priority: care station(s), medications rooms, utility rooms, storage, staff conference interdisciplinary area, charting/dictation area, and office areas. Nurses, physicians, therapists, etc. will require an area where they can discuss or document a patient s condition/information in private. Since the care station desk area will likely be highly accessible to patients and their family/visitors, an acoustically private staff interdisciplinary charting room will be provided where staff will enter information to clinical records by electronic or manual means, discuss clinical issues, make confidential telephone calls, review x-rays and other diagnostic results. The space will accommodate several persons with associated workstations, printer, telephones and may be glass-fronted so that staff can observe patients from within. This room could have sliding glass doors to the nurse station to facilitate frequent access and observation between the two spaces. A conference room for up to 12 persons is required for the nursing teams to undertake handover meetings during shift changes. Counselling and interview meetings will also be undertaken and could be located in this informal space. Medical students and residents also may utilize this space for educational purposes. Staff s outer clothing will be stored in lockable coat closets. Students and volunteers will also have space for coat storage in the coat closets. Purse lockers will be provided for personal valuables and will be shared across shifts. A staff break room will be provided for beverage making, staff debriefing, grieving and rest. Pneumatic Tube System The main care team station in each pod will be provided with a pneumatic tube station. 3-9

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT OPERATIONAL DESCRIPTION The table below summarizes the projected annual activity per 36-bed Medical/Surgical Inpatient Unit. Table 1 Unit Minimum Projected Yearly Activity Medical/Surgical Inpatient # Cases (Separations) 1,269 # Patient Days 11,169 ALOS (Days) 8.80 % Occupancy 85% # Beds Set-Up 36 OCCUPANCY The maximum estimated occupancy per 36-bed Medical/Surgical Inpatient Unit will be as shown in table below: Table 2 Maximum Estimated Headcount Occupancy Person Category Day Evening Night Physicians 6 3 2 Unit Manager 1 0 0 Clinician 2 0 0 Patient Care Coordinator 2 2 0 Clinical Nurse Educator 1 1 0 Nurse Practitioner 1 0 0 Unit Nurse Clinician 2 2 0 Registered Nurse 8 8 7 Licensed Practical Nurse 3 3 3 Care Aide 3 3 3 Clinical Pharmacist 2 0 0 Social Worker 2 0 0 Physiotherapist 4 1 0 Occupational Therapist 2 1 0 Rehabilitation Assistant 4 1 0 Speech Language Pathologist 2 1 0 Respiratory Therapist 1 1 1 Dietician 1 0 0 Unit Clerk 3 3 1 Program Clerk 1 0 0 Porter 3 1 0 Housekeeper 3 3 3 Subtotal, Staff 57 34 20 Patients 36 36 36 Visitors 24 24 12 Residents 4 2 2 Students 15 15 2 Other 0 0 0 Subtotal, Other 79 77 52 Total 126 101 64 3-10

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT DESIGN CRITERIA External Relationships Locate this component to provide access to the component in accordance with the following external relationships which are listed from highest to lowest priority: Medical/Surgical Inpatient Care Hemodialysis Unit 1 Emergency Department 1 Provide direct access by non-public circulation to the Emergency Department for the movement of patients and staff. 2 ICU/HDCU 2 Provide direct access by non-public circulation from ICU/HDCU for the movement of patients and staff. 3 Surgery Suite 3 Provide convenient access by non-public circulation to the Surgery Suite for the movement of patients and staff. 4 Diagnostic Imaging 4 Provide convenient access by non-public circulation to Diagnostic Imaging for the movement of patients and staff. 5 5 Provide convenient access by non-public circulation to Laboratory for the movement of staff. Laboratory Internal Design Criteria (a) General Physical Organization On the unit there will be 36 beds, of which 30 will be private rooms and 6 will be semi-private rooms. Each pod will have its own dedicated support space and family space. Common rooms will be easily accessible from all pods. Provide attractive options to encourage patient activation and promote patient independence wherever possible. (b) Universal Patient Room Limitations may not allow for a true universal room but every attempt will be made with the space available to provide the features of a universal room. Patient rooms will be capable of accommodating changes over the life of the building in patient care delivery models and advances in technology and equipment. Patient rooms will be at least 80% private. Each private patient room will have an en-suite washroom with toilet, sink and shower. Each room will have a ceiling lift system that extends from the patient bed into the washroom. Patient rooms will have three zones: patient zone, caregiver zone and family zone; the patient zone is the area surrounding the patient bed; the caregiver zone is closest to the door and 3-11

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT includes supplies, handwashing sink and charting area, and the family zone is located farthest from the door and includes seating and sleeping accommodation for a family member. Patient rooms will be comfortable, accommodating to both families and culturally diverse patient populations. Provide all patients with exterior views from their beds. Consideration must be given to windowsill heights to enable visibility of ground level activity. Provide shelf space/storage for patient s personal items, flowers, etc., visible from the bed. (c) Lighting Requirements Lighting systems will be designed to provide for adequate patient care yet maintain optimum patient comfort. Patients can be quite sensitive to intense levels of lighting and multi-level lighting will be provided. Nighttime lighting will facilitate patient sleeping while maintaining nurse-patient observation. (d) Patient/Staff Environment For patients, consideration will be given to physical layouts and design features which minimize the typically institutional aspects of inpatient accommodation and maximize non-institutional aspects (i.e., hotel/residential) in order to provide a more therapeutic healing environment that will promote quicker recovery, ambulation, etc. And for staff, the use of natural light, noise reduction layout and materials and a sense of privacy will promote retention and reduce staff stress levels. (e) Patient Privacy Optional visual privacy will be provided from the corridor. Louver blinds built into double-glazed windows in doors and walls should be considered for this purpose. Curtains in front of the doors are also required. (f) Hemodialysis All 36 beds will be able to accommodate patients with renal deficiency, with the ability to deliver hemodialysis at the bedside. All hemodialysis capable rooms will be provided with infrastructure including central RO system and a central bicarbonate system for hemodialysis. Storage on unit is required for dialysis supplies and equipment. (g) Rehabilitation Space A rehabilitation/therapy room will be required on each unit. The therapy room will be used for rehabilitation or special therapies that cannot be accommodated in the patient s room. 3-12

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT (h) Room Isolation Capability/Infection Control There will be six designated airborne isolation rooms with attached anterooms per 36-bed unit. Each of these patient rooms will have an entrance through the adjoining anteroom (for staff) and a separate entrance directly from the corridor (for the patient). The unit will be mechanically separated/divided to create an isolation zone out of each of the pods in the event of an infectious disease outbreak. (i) Bariatric Patient Accommodation Two patient rooms per 36-bed inpatient unit will be designated to accommodate bariatric patients. All patient room doors will accommodate the movement of a bariatric bed in and out of all of the patient rooms. 3-13

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Component Functional Diagram Medical/Surgical Unit Entrance Central Care Team Station Patient Care Area Patient Care Area Patient Care Support Area Patient Care Area 3-14

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Schedule of Accommodation Provide the following spaces, numbers of spaces, net areas, and space contents as minimum requirements. Ref Space Area Requirements Remarks units nsm/unit nsm Unit Entrance 01 Waiting Room, Patient/Family/Visitor 1 25.0 Incl. seating for 20, children s play area, vending machines 02 Family Respite Room 1 14.4 Incl. seating for 6 03 Washroom, Public, Male 1 6.0 04 Washroom, Public, Female 1 6.0 05 Telephone, Public 1 2.5 Incl. 3 telephones Subtotal, Unit Entrance 53.9 Central Care Team Station 06 Central Care Team Station 1 10.8 Incl. 2 workstations, printer(s), pneumatic tube station, chart storage, PACs 07 Workroom, Office Equipment 08 Charting Area, Interdisciplinary Team Subtotal, Central Care Team Station 1 10.0 Incl multifunction printer 1 22.9 Incl. 12 workstations 43.7 Patient Care Support Area 09 Care Team Station, Large 2 23.1 46.2 Incl. 12 workstations, printers(s), PACs, pneumatic tube station, chart storage 10 Care Team Station, Small 1 17.8 Incl. 6 workstations, PACs, printer(s), pneumatic tube station, chart storage 11 Medications Room 3 16.5 49.5 Incl. eye wash station, workstation 12 Nourishment Station 3 4.5 13.5 3-15

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 13 Clean Supply Holding 3 15.0 45.0 Incl. 1 workstation 14 Alcove, Equipment Storage 29 1.5 43.5 Incl. electrical outlets at 48 15 Family Respite Room 2 17.0 34.0 Incl. seating for 8 16 Washroom, Public 2 4.5 9.0 17 Care Team Station, Small 2 5.3 10.6 Incl. 2 workstation, printer(s), PACs, chart storage 18 Soiled Utility Room 3 8.0 24.0 Incl. closed waste system 19 Washroom, Staff 4 2.5 10.0 20 Housekeeping Closet 3 6.0 18.0 Subtotal, Patient Care Support Area 321.1 Patient Care Area 21 Patient Room, Private 22 22.0 484.0 22 Washroom, Patient, Wheelchair Type 22 4.5 99.0 Incl. closed waste system 23 Workstation Alcove 11 2.0 22.0 Incl. 1 workstation 24 Patient Room, Private (Bariatric) 2 26.0 52.0 25 Washroom, Patient, Wheelchair Type 2 5.6 11.2 Incl. closed waste system 26 Workstation Alcove 2 1.0 2.0 Incl. 1 workstation 27 Patient Room, Private (Isolation) 28 Washroom, Patient, Wheelchair Type 6 22.0 132.0 6 4.5 27.0 Incl. closed waste system 29 Anteroom 6 4.0 24.0 30 Workstation Alcove 3 2.0 6.0 Incl. 1 workstation 31 Patient Room, Semi-Private 3 35.4 106.2 3-16

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 32 Washroom, Patient, Wheelchair Type 6 4.5 27.0 Incl. closed waste system 33 Workstation Alcove 3 2.0 6.0 Incl. 1 workstation Subtotal, Patient Care Area 998.4 Inpatient Support Area 34 Storage, Dialysis 1 24.0 35 Patient Therapy Room 1 21.4 Incl. 2 workstations 36 PT/OT Equipment Storage 1 6.3 37 Soiled Holding Room 1 35.0 Incl. soiled linen carts, recycling bins, cardboard recycling bin, large waste bin, biomedical wastes bin, sharps container. Locate adjacent to service elevator 38 Alcove, Stretchers/Wheelchairs 1 10.0 Locate as close as possible to service elevator 39 Storage, Equipment, Medium 2 13.0 26.0 Incl. electrical outlets at 48 40 Conference Room, Staff 1 24.0 Incl. seating for 12, 1 workstation, small video-conference room 41 Education Room, Patient/Family/Staff 1 20.0 Incl. seating for 8, 1 workstation, video-conferencing infrastructure 42 Team Conference Room, UBC 1 22.8 Part of Clinical Academic Campus, seating for 12 at conference table, see text description page 3-176, video-conferencing infrastructure 43 Workstation, Residents/Medical Students (UBC) 1 2.5 Part of Clinical Academic Campus, see text description page 3-176 44 Office, Unit Manager 1 10.0 Incl. 1 workstation 45 Shared Office, Clinical Nurse Educator/Nurse Clinician 1 18.0 Incl. 3 workstations 46 Shared Office, Social Worker 1 18.0 Incl. 3 workstations 47 Office, Clinical Pharmacist 1 10.0 Incl. 2 workstations 48 Office, Patient Care Coordinator 1 10.0 Incl. 2 workstations 3-17

1.0 MEDICAL/SURGICAL INPATIENT CARE HEMODIALYSIS CAPABLE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 49 Workstation, Program Clerk 1 10.0 Incl. 1 workstation. Located adjacent to unit manager 50 Office, Interdisciplinary Team 2 10.0 20.0 Incl. 2 workstations 51 Charting/Dictation Area, Physician 1 14.4 Incl. 4 workstations, PACS 52 Break Room, Staff 1 40.0 Incl. seating for 25, 2 workstations 53 Washroom, Staff 1 4.5 Located adjacent to Break Room 54 Locker, Staff 1 6.0 Located adjacent to Break Room 55 Shower, Staff 1 3.5 Located adjacent to Break Room Subtotal, Inpatient Support Area 356.4 Total 1 773.5 3-18

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT FUNCTIONAL DESCRIPTION Scope of Services Content This specification outlines the requirements for the Medical/Surgical Inpatient Neurology Unit component. This component will provide 36-patient beds in the Facility for the delivery of secondary and selected tertiary acute care to medical and surgical adult inpatients. The specification assumes a typical general-purpose inpatient unit and although unique needs of sub-specialties promote physical differences between units, the intent remains to provide highly flexible units capable of adapting to changes in inpatient care use and methods over the facility s life. Promotion of flexibility does not preclude the designation of beds for special purposes or for design modifications around these designated beds to enhance functionality. Treatment and care services typically provided in the Inpatient Units (IPUs) will include, among others: Receiving, assessing and monitoring patients holistic needs; Consulting with physicians and members of the interdisciplinary team; Conducting shift reports and participating in interdisciplinary patient conferences; Coordinating, implementing, communicating, administering, scheduling, and evaluating the overall operations of the unit; Documenting patients' progress and maintaining patient electronic charts/records; Educating patients and their families; Providing clinical academic training for staff, students and residents; Facilitating patient comfort and relaxation, recreation and activation; Facilitating family-centred care; Meeting daily physical patient needs; Providing family/visitor support, consultation and counselling; Providing routine and emergency patient care including examinations and treatments; Admitting patients directly or via the emergency areas; Providing for and ordering medical diagnostic and treatment procedures; Participating in the overall program development for their respective populations; Providing emergency medical examination and treatment; and Providing symptom management (e.g., specialized interventions for acute pain management with support from anesthetists. Maximized Use of Staff Resources Staff resource utilization will be maximized in that the most appropriate staff persons will perform tasks. For example, nurses will not spend time in non-nursing duties such as searching for supplies, thereby allowing them to focus on care of the patients in their charge. The Clinical professional service team members (e.g., physiotherapy, occupational therapy, speech language therapy, respiratory care, laboratory, pharmacy, education, spiritual care, etc.) will travel to the inpatient units from their central components as required. 3-19

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Associated Trends The following trends will influence the future functioning of this component, and should be taken into account in the component design: Predictions of significant nursing staff shortages during the next 20 years; The medical inpatient units will to provide decentralized capability for managing infectious diseases; Increased acuity levels will be seen in patients admitted to medical/surgical units. Medical/ surgical specialties are now becoming increasingly specialized and more complex surgery will continue to develop; The number of bariatric patients admitted is expected to increase; The parallel development of day and short stay care for a greater range of procedures, both invasive and non-invasive, will accentuate the trend in changes in acuity levels in inpatient care. It is anticipated that for medical/surgical specialties there will be a trend to increasing numbers of tertiary referrals; Services will be provided increasingly by interdisciplinary teams; Number of patients going through inpatient beds is increasing, but lengths of stays are decreasing; Telehealth will increasingly provide outreach opportunities to and from health care facilities province-wide; The trend to adopt evidence-based clinical pathways will continue, with standards becoming available in many more types of cases; The nature of the geriatric population requiring inpatient care will become increasingly more complex and dependent. The patient population will have greater co-morbidities and will tend to be difficult to manage given unpredictable behaviour patterns; The volume of complex geriatric cases will increase as will the length of stay for geriatric inpatients. Interdisciplinary teams, involving physicians, specialist nurses and specialized allied staff, will provide geriatric medicine inpatient services; and The number of patients with mental illness and/or substance abuse problems is expected to increase. Scope of Education Activity The 36-bed IPU will generally provide clinical resources in support of teaching programs for the following types and anticipated maximum number of students at any given time: 3 medical/surgical residents; 3 medical undergraduates; 8 nursing (RN, LPN, RPN) undergraduate and graduate students; 1 pharmacy undergraduates/resident; 1 social work student; 2 physiotherapy students; 1 occupational therapy student; 2 speech language pathology students; 1 laboratory technology student; 3-20

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT 1 laboratory assistant student; 1 respiratory therapy student; and 1 dietetic intern. A wide range of individual and small group clinical teaching activities will be accommodated directly in the inpatient care areas. Large formal lectures or large continuing education programs will not be accommodated in the inpatient units. Inservice education and patient teaching programs will be conducted on a regular basis throughout the unit s patient/clinical care spaces as well as in staff conference room and a patient/family education room equipped with audio/video links. In total, there could be up to 12 non-staff people involved with education programs in the component at any one time. Scope of Research Activity Clinical research activities may be conducted within the component, but without the need for supplement space. OPERATIONAL DESCRIPTION Hours of Operation The IPU will be staffed 24-hours a day, 7-days a week. Patient Management Processes Reception/Admission Patients will be admitted to an inpatient unit by pre-arrangement, through Access and Bed Control, as unscheduled patients through the Emergency Department, and through inter hospital transfers. Immediately upon entry onto the inpatient unit floor, ambulant patients will report to the unit clerk at central care team station. For families visiting a patient on the unit, a separate and secure visitor entrance will be provided. The unit clerk also will greet all family members and visitors to the unit. Family members and visitors will have access to a lounge with children s play area, vending machines, washrooms, and public telephones close to the entrance to the unit. Care Patients will be admitted to a specific bed based on their dependence level. All patients will be monitored from one of the care stations. There will be direct and clear sightlines between the direct care providers and patients. Clear sight lines to patient room doors from the care stations are required. Patients will have ready access to staff at all times (lines of sight, communication systems and call systems). 3-21

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Interdisciplinary care teams made up of multiple caregivers will be supported within the care unit. An increased emphasis will be placed on family-involved/centred approach to care rather than a provider-focussed model in support of holistic care of the patient. Staff Work Processes Communications The 36-bed inpatient unit s central care team station will also act as a reception/control point for access to the unit. This care team station will include the patient care coordinator s and unit clerk s workstations, and an interdisciplinary charting workroom. Care stations will be provided ensuite with each pod of patient beds. The units will support nurse manager/leader engagement with staff, as well as, promoting staff communication and mentoring. Care Delivery Entrance Referral Source Reception/ Admissions Care Delivery Care Planning/ Charting/ Discharge Planning Immediately upon entry into the floor the family members and visitors will come upon the public area with a lounge/waiting room with play area, washrooms and telephones. Provision for hand sanitizing will be made. There will be clear directions to the central care team station where a unit clerk will greet family members and visitors. Discharge Process Flow Diagram Patient Room Patient care will occur mainly at the patient s bedside. All patient rooms will be capable of cardiac monitoring of patients with telemetry. Patients in these units will not require mechanical ventilation. Charting will occur at the patient s bedside, the workstation alcove or the care station. There will be one workstation alcove for every two patient beds. Pod-like Environment Within the 36 bed unit, the patient beds will be arranged in pods with all frequently used support rooms (including medication rooms, dirty utility rooms and clean supply rooms) easily accessible by each individual pod. The pods need to be laid out in such a way to allow the 36 bed to still function as one unit. Assigned RNs and LPNs will generally be assigned for all of the patient care provided in one pod, but may be assigned to patients in the adjacent pod. In some cases, a nurse may be assigned a particular patient with higher acuity. A care station will be located en-suite within each pod for interdisciplinary team members use. As much as possible beds are to be visible to the care stations, while allowing a degree of patient privacy to be maintained. 3-22

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Inpatient pod layout should be compact as possible to minimize nurse in-flight time and maximize nurse-patient visibility by locating frequently utilized staff work areas and support spaces close to the patient bed spaces. Interdisciplinary conversations will be private and not overheard by patients. Activities in the care team stations should not disturb sleeping patients; therefore, the care team stations will be designed with as many sound control measures as possible. The medications room will be discreetly located and will include an automatic medication dispensing system and computer. Access to it will be visually supervised from the care station. At least one wall will be fully glazed. Six patient beds will be provided within three semi-private rooms. Each semi-private room will have two patient washrooms, one for each patient for infection control purposes. Also, there will be one workstation alcove, used for charting, for each semi-private room. These semi-private rooms will be distributed throughout the 36 bed unit. 36-Bed Unit Only essential patient care support areas will be maintained within the unit proper. Spaces will be located close to patient rooms in the following order of priority: care station(s), medications rooms, utility rooms, storage, staff conference interdisciplinary area, charting/dictation area, and office areas. Nurses, physicians, therapists, etc. will require an area where they can discuss or document a patient s condition/information in private. Since the care station desk area will likely be highly accessible to patients and their family/visitors, an acoustically private staff interdisciplinary charting room will be provided where staff will enter information to clinical records by electronic or manual means, discuss clinical issues, make confidential telephone calls, review x-rays and other diagnostic result. The space may accommodate twelve persons with associated workstations, printer, telephones and will be glass-fronted so that staff can observe patients from within. This room could have sliding glass doors to the nurse station to facilitate frequent access and observation between the two spaces. A conference room for up to 12 persons is required for the nursing teams to undertake handover meetings during shift changes. Counselling and interview meetings will also be undertaken and could be located in this informal space. Medical students and residents also may utilize this space for educational purposes. Staff s outer clothing will be stored in lockable coat closets. Students and volunteers will also have space for coat storage in the coat closets. Purse lockers will be provided for personal valuables and will be shared across shifts. A staff break room will be provided for beverage making, staff debriefing, grieving and rest. Pneumatic Tube System The main care team station in each pod will be provided with a pneumatic tube station. OPERATIONAL DESCRIPTION The table below summarizes the projected annual activity per 36-bed Medical/Surgical Inpatient Unit. Table 1 3-23

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Unit Minimum Projected Yearly Activity Medical/Surgical Inpatient # Cases (Separations) 1,269 # Patient Days 11,169 ALOS (Days) 8.80 % Occupancy 85% # Beds Set-Up 36 OCCUPANCY The maximum estimated occupancy of per 36-bed Medical/Surgical Inpatient Unit will be as shown in table below: Table 2 Maximum Estimated Headcount Occupancy Person Category Day Evening Night Physicians 6 3 2 Unit Manager 1 0 0 Clinician 2 0 0 Patient Care Coordinator 2 2 0 Clinical Nurse Educator 1 1 0 Nurse Practitioner 1 0 0 Unit Nurse Clinician 2 2 0 Registered Nurse 8 8 7 Licensed Practical Nurse 3 3 3 Care Aide 3 3 3 Clinical Pharmacist 2 0 0 Social Worker 2 0 0 Physiotherapist 4 1 0 Occupational Therapist 2 1 0 Rehabilitation Assistant 4 1 0 Speech Language Pathologist 2 1 0 Respiratory Therapist 1 1 1 Dietician 1 0 0 Unit Clerk 3 3 1 Program Clerk 1 0 0 Porter 3 1 0 Housekeeper 3 3 3 Subtotal, Staff 57 34 20 Patients 36 36 36 Visitors 24 24 12 Residents 4 2 2 Students 15 15 2 Other 0 0 0 Subtotal, Other 79 77 52 Total 126 101 64 3-24

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT DESIGN CRITERIA External Relationships Locate this component to provide access to the component in accordance with the following external relationships which are listed from highest to lowest priority: Medical/Surgical Inpatient Care Neurology Unit 1 Emergency Department 1 Provide direct access by non-public circulation to the Emergency Department for the movement of patients and staff. 2 ICU/HDCU 2 Provide direct access by non-public circulation from ICU/HDCU for the movement of patients and staff. 3 Surgery Suite 3 Provide convenient access by non-public circulation to the Surgery Suite for the movement of patients and staff. 4 Diagnostic Imaging 4 Provide convenient access by non-public circulation to Diagnostic Imaging for the movement of patients and staff. 5 5 Provide convenient access by non-public circulation to Laboratory for the movement of staff. Laboratory Internal Design Criteria (a) General Physical Organization On the unit there will be 36 beds, of which there are 30 private rooms and 6 semi-private rooms. Each pod will have its own dedicated support space and family space. Common rooms will be easily accessible from all pods. Provide attractive options to encourage patient activation and promote patient independence wherever possible. (b) Universal Patient Room Limitations may not allow for a true universal room but every attempt will be made with the space available to provide the features of a universal room. Patient rooms will be capable of accommodating changes over the life of the building in patient care delivery models and advances in technology and equipment. Patient rooms will be at least 80% private. Each private patient room will have an en-suite washroom with toilet, sink and shower. Each room will have a ceiling lift system that extends from the patient bed into the washroom. Patient rooms will have three zones: patient zone, caregiver zone and family zone; the patient zone is the area surrounding the patient bed; the caregiver zone is closest to the door and 3-25

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT includes supplies, handwashing sink and charting area, and the family zone is located farthest from the door and includes seating and sleeping accommodation for a family member. Patient rooms will be comfortable, accommodating to both families and culturally diverse patient populations. Provide all patients with exterior views from their beds. Consideration must be given to windowsill heights to enable visibility of ground level activity. Provide shelf space/storage for patient s personal items, flowers, etc., visible from the bed. (c) Lighting Requirements Lighting systems will be designed to provide for adequate patient care yet maintain optimum patient comfort. Patients can be quite sensitive to intense levels of lighting and multi-level lighting will be provided. Nighttime lighting will facilitate patient sleeping while maintaining nurse-patient observation. (d) Patient/Staff Environment For patients, consideration will be given to physical layouts and design features which minimize the typically institutional aspects of inpatient accommodation and maximize non-institutional aspects (i.e., hotel/residential) in order to provide a more therapeutic healing environment that will promote quicker recovery, ambulation, etc. And for staff, the use of natural light, noise reduction layout and materials and a sense of privacy will promote retention and reduce staff stress levels. (e) Patient Privacy Optional visual privacy will be provided from the corridor. Louver blinds built into double-glazed windows in doors and walls should be considered for this purpose. Curtains around the beds are also required. (f) EEG Monitoring Two patient rooms in the neurology unit should have clinical video monitoring for observing patients who are undergoing EEG monitoring over a 24-hour period. (g) Rehabilitation Space A rehabilitation/therapy room will be required on each unit. The therapy room will be used for rehabilitation or special therapies that cannot be accommodated in the patient s room. (h) Room Isolation Capability/Infection Control There will be six designated negative pressure isolation rooms with attached anterooms per 36- bed unit. Each of these patient rooms will have an entrance through the adjoining anteroom (for staff) and a separate entrance directly from the corridor (for the patient). The unit will be mechanically separated/divided to create an isolation zone out of each of the pods in the event of an infectious disease outbreak. 3-26

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT (i) Bariatric Patient Accommodation Two patient rooms per 36-bed inpatient unit will be designated to accommodate bariatric patients. All patient room doors will accommodate the movement of a bariatric bed in and out of all of the patient rooms. 3-27

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Component Functional Diagram Medical/Surgical Unit Entrance Central Care Team Station Patient Care Area Patient Care Area Patient Care Support Area Patient Care Area 3-28

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Schedule of Accommodation Provide the following spaces, numbers of spaces, net areas, and space contents as minimum requirements. Ref Space Area Requirements Remarks units nsm/unit nsm Unit Entrance 01 Waiting Room, Patient/Family/Visitor 1 25.0 Incl. seating for 20, children s play area, vending machines 02 Family Respite Room 1 14.4 Incl. seating for 6 03 Washroom, Public, Male 1 6.0 04 Washroom, Public, Female 1 6.0 05 Telephone, Public 1 2.5 Incl. 3 telephones Subtotal, Unit Entrance 53.9 Central Care Team Station 06 Central Team Station 1 10.8 Incl. 2 workstations, printer(s), pneumatic tube station, chart storage, PACs 07 Workroom, Office Equipment 08 Charting Area, Interdisciplinary Team Subtotal, Central Care Team Station 1 10.0 Incl multifunction printer 1 22.9 Incl. 12 workstations 43.7 Patient Care Support Area 09 Care Station, Large 2 23.1 46.2 Incl. 12 workstations, printer(s), PACS, pneumatic tube station, chart storage 10 Care Station, Small 1 17.8 Incl. 6 workstations, printer(s), PACs, pneumatic tube station, chart storage 11 Medications Room 3 16.5 49.5 Incl. eye wash station, workstation 12 Nourishment Station 3 4.5 13.5 13 Clean Supply Holding 3 15.0 45.0 Incl. 1 workstation 3-29

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 14 Alcove, Equipment Storage 29 1.5 43.5 Incl. electrical outlets at 48 15 Family Respite Room 2 17.0 34.0 Incl seating for 8 16 Washroom, Public 2 4.5 9.0 17 Care Station, Small 2 5.3 10.6 Incl. 2 workstation, printer(s), PACs, chart storage 18 Soiled Utility Room 3 8.0 24.0 Incl. closed waste system 19 Washroom, Staff 4 2.5 10.0 20 Housekeeping Closet 3 6.0 18.0 Subtotal, Patient Care Support Area 321.1 Patient Care Area 21 Patient Room, Private 22 22.0 484.0 22 Washroom, Patient, Wheelchair Type 22 4.5 99.0 Incl. closed waste system 23 Workstation Alcove 11 2.0 22.0 Incl. 1 workstation 24 Patient Room, Private (Bariatric) 2 26.0 52.0 25 Washroom, Patient, Wheelchair Type 2 5.6 11.2 Incl. closed waste system 26 Workstation Alcove 2 1.0 2.0 Incl. 1 workstation 27 Patient Room, Private (Isolation) 28 Washroom, Patient, Wheelchair Type 6 22.0 132.0 6 4.5 27.0 Incl. closed waste system 29 Anteroom 6 4.0 24.0 30 Workstation Alcove 3 2.0 6.0 Incl. 1 workstation 31 Patient Room, Semi-Private 3 35.4 106.2 32 Washroom, Patient, Wheelchair Type 6 4.5 27.0 Incl. closed waste system 3-30

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 33 Workstation Alcove 3 2.0 6.0 Incl. 1 workstation Subtotal, Patient Care Area 998.4 Inpatient Support Area 34 Procedure Room 1 24.0 Incl. 1 workstation; control room with viewing window 35 Patient Therapy Room 1 21.4 Incl. 2 workstations 36 PT/OT Equipment Storage 1 6.3 37 Soiled Holding Room 1 35.0 Incl. soiled linen carts, recycling bins, cardboard recycling bin, large waste bin, biomedical wastes bin, sharps container. Locate adjacent to service elevator 38 Alcove, Stretchers/Wheelchairs 1 10.0 Locate as close as possible to bed areas 39 Storage, Equipment, Medium 2 13.0 26.0 Incl. electrical outlets at 48 40 Conference Room, Staff 1 24.0 Incl. eating for 12, 1 workstation, small video-conference room 41 Education Room, Patient/ Family/Staff 1 20.0 Incl. seating for 10, 1 workstation, video-conferescing infrastructure 42 Team Conference Room, UBC 1 22.8 Part of Clinical Academic Campus, seating for 12 at conference table, see text description page 3-176, video-conferencing infrastructure 43 Workstation, Residents/Medical Students, UBC 1 2.5 Part of Clinical Academic Campus, see text description page 3-176 44 Office, Unit Manager 1 10.0 Incl. 1 workstation 45 Shared Office, Clinical Nurse Educator/Nurse Clinician 1 18.0 Incl. 3 workstations 46 Shared Office, Social Worker 1 18.0 Incl. 3 workstations 47 Office, Clinical Pharmacist 1 10.0 Incl. 2 workstations 48 Office, Patient Care Coordinator 1 10.0 Incl. 2 workstations 49 Workstation, Program Clerk 1 10.0 Incl. 1 workstation. Located adjacent to Unit Manager 3-31

2.0 MEDICAL/SURGICAL INPATIENT CARE NEUROLOGY UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 50 Office, Interdisciplinary Team 2 10.0 20.0 Incl. 2 workstations 51 Charting/Dictation Area, Physician 1 14.4 Incl. 4 workstations, PACS 52 Break Room, Staff 1 40.0 Incl. seating for 25, 2 workstations 53 Washroom, Staff 1 4.5 Located adjacent to Break Room 54 Locker, Staff 1 6.0 Located adjacent to Break Room 55 Shower, Staff 1 3.5 Located adjacent to Break Room Subtotal, Inpatient Support Area 356.4 Total 1 773.5 3-32

3.0 INTENSIVE CARE UNIT FUNCTIONAL DESCRIPTION Scope of Services This specification outlines the requirements for the adult Intensive Care Unit (ICU) component. The ICU component will have 25 patient beds and one procedure room that will be designed exactly the same as an ICU patient room. The 25-bed intensive care unit will provide the specialized space, equipment, resources to accommodate patient care, education, research, interdisciplinary teams, and administrative staff needs as part of an integrated critical care complex. This unit will provide a tertiary level of service to meet the needs of patients who require advanced respiratory support alone (e.g., Acute Respiratory Distress Syndrome) or basic respiratory support together with support of at least two organ systems. A Level III Intensive Care Unit is defined by the following characteristics: Care and treatment of patients with complex and severe multisystem failure; Advanced (pressure control) and specialized (oscillatory) ventilator management; Advanced hemodynamic monitoring (e.g., pulmonary artery catheter); Cardiorespiratory arrest management; Hemodialysis (continuous and intermittent); and Intensivist s services. Intensivists will determine admission and discharge to ensure resources are provided to the most acutely ill. Patients admitted to the ICU will be adults. Children (17 years old less a day) who require intensive care will be transferred to the BC Children s Hospital in Vancouver. Patients are admitted to the SMH ICU most commonly from the Emergency Department. The following list indicates the areas that ICU patients are admitted from in order of frequency: Direct from emergency (49%); Direct from outside facility (17%); Direct from other general wards in SMH (16%); Direct from the operating room (13%); and Direct from high acuity units (5%). Patients admitted to the SMH ICU most commonly have the primary diagnosis listed below. In brackets is the percent of total SMH ICU admissions for 07/08: Cardiovascular (19%); Pneumonia (17%); Metabolic or other hematology (15%); Gastro-intestinal (13%); Sepsis/septic shock (12%); and Respirology-other (11%). Once admitted to the ICU, patients typically require the following specialized care and treatments: Advanced hemodynamic monitoring; Complex modes of mechanical ventilation; Individualized sedation and analgesia protocols; 3-33

3.0 INTENSIVE CARE UNIT Continuous and intermittent hemodialysis; Enteral and parenteral nutrition; Complex post-operative surgical care; Complex pharmalogical therapies; and Protocol driven care for hypothermia, sepsis and glucose management. The SMH ICU has a mortality rate of 25%, which is consistent with other Level III ICUs. A separate cardiology unit will provide care for patients with cardio-pulmonary failure or risk of failure. Patients requiring less intensive patient care but who may require mechanical ventilation support will be accommodated in the High Dependency Care Unit (HDCU). The 25-bed ICU will require two separate and complete interdisciplinary teams to manage the care of the patients admitted to the ICU. Each team will be lead by an intensivist physician. Members of each team require specialty training in critical care. The teams will participate in daily patient rounds and develop a collaborative interdisciplinary daily plan of care for each patient. The care provided will be patient and family centred. Provision for family members will be made within the patient s room as well as within the unit. Procedures and treatments, to the extent possible, will be provided within the patient s room to minimize patient transfers. Care activity in the unit will include: Collecting and documenting patient historical medical information; Providing routine and emergency medical examination and treatment; Planning and implementing care, including examinations and treatments; Facilitating patient comfort, mobilization and reactivation; Responding to code blue (cardiac arrests) within the unit and in the rest of the hospital; Ordering medical diagnostic and treatment procedures; Preparing patients for diagnostic and treatment services; Prescribing and administering medications, in consultation with pharmacists; Providing family and/or visitor support and consultation; Maintaining patient records; Participating in daily interdisciplinary patient conferences and rounds; Providing clinical academic training for staff, students and residents, including classroom education; Communicating within the unit and with external units and facilities; Liaising with community agencies and services; and Coordinating, implementing, communicating, administering, scheduling, and evaluating the overall operations of the unit. Sterile procedures, including invasive procedures, performed in all patients rooms will include, but are not limited to: Thoracoscopy; Central line insertion; PA Catheter; Pacemaker insertion; Tracheotomy; and Lung biopsies. 3-34

3.0 INTENSIVE CARE UNIT Bronchoscopy procedures will be performed in isolation rooms. Maximized Use of Staff Resources Staff resource utilization will be maximized in that the most appropriate staff persons will perform tasks. For example, nurses will not spend time in non-nursing duties such as searching for supplies, thereby allowing them to focus on care of the patients in their charge. Associated Trends The following trends will influence the future functioning of this component, and should be taken into account in the component design: The aging population will put increasing pressure on the ICU due to the prevalence of comorbidities and longer lengths of stay; Increasing numbers of trauma and cancer, as well as, chronic ventilation patients who will require critical care; The trend will continue toward increasing need for higher levels of monitoring and care of critically ill patients, especially for patients who have undergone complex surgery, who have developed cancer, or respiratory illnesses or who have contracted an infectious disease; Increasing demands on critical care beds will necessitate the need to expand ICU outreach services outside of the unit; The number of bariatric patients admitted is expected to increase; High levels of mortality will continue as limits of technology and care are tested by the acuity levels of patients; Increased need to respond to medical emergencies at the site e.g., codes; The trend for earlier ambulation for ICU patients has been found to improve outcomes; Increasing requirements for isolation of patients due in prevalence of infectious transmittable and drug-resistant organisms; The trend towards patient and family-centred care within critical care environments will continue resulting in larger patient rooms and family support areas; Nurturing environments will be created to support healing processes and psycho-social needs; The need to create environments that foster and maintain patient privacy and confidentiality; There will continue to be the challenge of a shortage of critical care physicians and health care professionals, requiring available staff to assume broader responsibilities and requiring efforts in staff retention, such as providing on unit education, safe work environments and staff amenities (lounges, kitchenettes, lockers); Research shows healthy and efficient work environments improve patient outcomes and improves staff retention rates; Advances in technology will bring more equipment into critical care units and directly to the patient s bedside; Computers will increasingly perform a vital role in patient-related data assembly/ analysis; almost any data will be accessible by staff at any terminal device with the proper passwords; 3-35

3.0 INTENSIVE CARE UNIT Use of bedside and portable diagnostics will increase; Point-of-care testing modules will become integrated into typical monitoring systems directly linking physiological monitoring to real time patient record keeping will increase in the future; Telehealth including from the patient s bedside will increasingly provide outreach opportunities among health care facilities province-wide; The trend will continue toward working in interdisciplinary teams under the leadership of intensivists; The trend to adopt evidence-based clinical pathways will continue, with standards becoming available in many more types of cases; and The trend is to promote education and research activities right at the unit level, as well as across the hospital. Scope of Education Activity The ICU will generally provide clinical resources in support of teaching programs for the following types and anticipated maximum number of students at any given time: 5 medical/surgical residents; 5 undergraduate medical students; 12 nursing (RN, LPN, RPN) undergraduate and graduate students; 1 social work student; 2 pharmacy undergraduates/residents; 2 physiotherapy students; 1 spiritual care student; 3 respiratory therapy students; 1 dietetic intern; 1 laboratory technologist student; 1 laboratory assistant student; 1 occupational therapist student; and 1 speech language pathologist student. Inservice education and patient teaching programs will be conducted on a regular basis throughout the ICU s patient/clinical care spaces as well as in staff conference/meeting room(s) equipped with computer/tv/video links. In total, there could be up to 35 non-staff people involved with education programs in the component at any one time. Scope of Research Activity Clinical research activities may be conducted within the component, without the need for supplemental space. 3-36

3.0 INTENSIVE CARE UNIT OPERATIONAL DESCRIPTION Hours of Operation The ICU will be staffed 24-hours a day, 7-days a week. Patient Management Processes Reception/Admission/Discharge Admissions and discharges from the unit will be based on specific criteria as directed by the intensivist. Patients admitted to the ICU will be either unscheduled patients from the Emergency Department, or patients requiring a higher level of care via an inter-hospital transfers from general medical/surgical units or the HDCU. Patients will also come from the surgical suite to the ICU. Patients who arrive through Emergency will be initially resuscitated and/or stabilized before transfer to the ICU. Line insertion, airway insertion, and initiation of mechanical ventilation may occur in Emergency or in the patient s room in ICU. Patients will be transported to the ICU through non-public corridors and a non-public elevator from the emergency, the helipad and other areas of the hospital. Access routes will be quick, safe and efficient to facilitate the transfer of patients. A non-public entrance and corridors will also be used to transport deceased patients to the morgue. Upon the patient s arrival in the ICU, as many as five members of the interdisciplinary team may be involved in the initial stabilization of the patient. A quiet family waiting room (respite room) near the visitor entrance to the ICU will be provided for family members of patients admitted to the ICU. Family members will be directed to this waiting room during the patient s initial admission process. There will be other respite rooms embedded in the unit. For families visiting a patient in the unit, a separate and secured visitor entrance will be provided. Staff in the reception centre, adjacent to the visitor entrance, will monitor and control visitor access to the unit. Volunteers may also be available at the reception desk. The reception centre will include a staffed reception desk, waiting area, public washrooms, pay phones, and quiet family respite room. Care Patient care will be provided in the ICU at a 1:1 ratio of nurse to patient. All patients will be directly observed and monitored by nursing staff from patient observation alcoves (POAs) or at the care stations. In addition to professional care, an increased emphasis will be placed on family-involved/centred approach to care in support of holistic care of the patient. To facilitate this approach, families will be provided space in the patients rooms and in designated family areas on the unit. 3-37

3.0 INTENSIVE CARE UNIT Staff Work Processes Care Delivery Patient Room All care will occur at the patient s bedside with the exception of some diagnostic imaging procedures, such as CT scans. Patient rooms will be able to support extensive invasive monitoring, hemodialysis, and full respiratory support functions. The patient rooms will be large enough to accommodate a family zone, patient zone and a caregiver zone. 12-13-Bed Pods The care team station will house the unit clerk and the patient care coordinator (PCC) for each team. The station will need to accommodate docking stations for mobile Picture Archiving and Communication System (PACS), and Workstations on Wheels (WOWs), multifunctional printer, and central monitoring and communication systems. In addition, a medications room, clean supply room, soiled utility room, nutrition station, washroom, and cart storage alcoves including the crash cart, will be located with the large care team stations. An office area adjacent to the large team station will accommodate the intensivist, social worker and consultants/residents. There will be two smaller care team stations to ensure staff are close and visible to patient rooms. Interdisciplinary conversations will be private and not overheard by patients. Activities in the team care stations should not disturb sleeping patients; therefore, the care stations will be designed with as many sound control measures as possible. The medications rooms will be discretely located and will include an automatic medication dispensing system and computer. Access to it will be visually supervised from the larger care team station. One wall will be fully glazed. Interdisciplinary clinical staff will enter information to clinical records by electronic or manual means, discuss clinical issues, make confidential telephone calls, review x-rays and other diagnostic results at the large care team station. The space will accommodate at least ten persons with associated workstations, printer, and telephones. There will be a quiet family respite room for up to ten people located within each 12-13-bed pod for family members to have a private and quiet place to gather and rest. 25-Bed Unit A central reception area will act as the reception and central control area for the unit. Staff and/or volunteers will work out of the central reception area. A meeting space for up to 15 persons is required for the staff/family education purposes. Counselling and interview meetings will also be undertaken and could be located in this informal space. Students and resident also may utilize this space for educational purposes. Staff s outer clothing will be stored in lockable coat closets. Students and volunteers will also have space for coat storage in the coat closets. A staff break room will be provided for beverage making, staff debriefing, grieving and rest. 3-38

3.0 INTENSIVE CARE UNIT Pneumatic Tube System The main care team station in each pod will be provided with a pneumatic tube station. Clinical and Logistical Support Services The following subjects have been identified as critical to the effective operations of this component: (a) Diagnostic Imaging Services In addition to mobile diagnostic imaging services, ICU patients will have access to the satellite diagnostic imaging component in the Emergency Department or the Main Diagnostic Imaging Department. Dedicated alcoves or rooms for parking and storage of mobile imaging equipment and recharging batteries will be required and these areas/rooms will require adequate ventilation; (b) Laboratory Services Nursing staff mainly will be responsible for the collection of routine and STAT laboratory tests as most patients will have lines that can be used for obtaining blood samples. Laboratory tests may be analyzed in the ICU Laboratory workroom using near patient testing devices. Specimens that cannot be analyzed in ICU will be transported to the Main Laboratory via the pneumatic tube system. STAT orders will be given the highest priority to ensure shortest possible turnaround times for results; (c) Food Services In addition to TPN and liquid diets, a few patients in the ICU will require full meal (tray) service provided centrally by Food Services. Food carts will be parked in alcoves on the unit; (d) Biomedical Engineering Services Equipment storage on the unit will have outlets at 48 height for recharging equipment batteries. Biomedical engineering will conduct a maximum amount of maintenance and repair work within the ICU to avoid excessive equipment movement; (e) Respiratory Therapy Services There will be a full time presence of respiratory therapists in the ICU with dedicated space in the critical care support area; and (f) Rehabilitation Services Rehabilitation staff will provide assessments and therapy at the patient s bedsides. 3-39

3.0 INTENSIVE CARE UNIT ACTIVITY CAPACITY The facilities will accommodate the minimum workloads as shown in Table 1. These are the projected workloads for the year 2020. These numbers are based on SMH Critical Care Services data gathered in the provincial critical care database. The projections for 2020 are based on this data. Table 1 Minimum Capacity Activity Category (Projection Year 2020) Admissions 1109 ALOS (days) 7.7 Patient-days 8541 % Occupancy 90 % Beds 25 Table 2 represents the severity of illness indicators for the 2007/2008 and the 2008/2009 reporting periods. These numbers indicate that there is a continued rise in the severity of illness. SMH ICU s Apache score demonstrates a population with complex severe illness requiring increased levels of care and support as well as increased resources required for the provision of this care. Patients with higher Apache scores can be predicted to have longer LOS. Table 2 Primary (Admit) Diagnosis Projected 2020 Average APACHE II Score 1 23 Average APACHE IV Score 2 82 Vasoactive Drugs (within first 24-hours) 705 65% Ventilated Patients 901 83% Ventilator Days (Occupancy) 804 74% Acute Dialysis Rate 217 20% ICU Mortality Rate (all deaths) 326 30% OCCUPANCY The maximum estimated occupancy of this component will be as shown in Table 3. Table 3 Maximum Estimated Headcount Occupancy Person Category Day Evening Night TEAM 1 STAFF Intensivist Physician 1 1 1 Patient Care Coordinator 1 1 1 Unit Clerk 1 1 1 Critical Care Nurse 13 13 13 Respiratory Therapist 3 3 3 Clinical Pharmacy Specialist 1 0 0 Physiotherapist 1 0 0 Occupational Therapist 1 0 0 Speech Language Pathologist 1 0 0 1 Total Maximum = 41 points if all Chronic Health Points included. 2 Total Maximum = 41 points if all Chronic Health Points included. 3-40

3.0 INTENSIVE CARE UNIT Maximum Estimated Headcount Occupancy Person Category Day Evening Night Rehab Aide 1 0 0 Diagnostic Imaging Tech 1 0 0 Social Worker 1 0 0 Dietician 1 0 0 Housekeeper 1 1 1 Acute Care Aide 1 1 1 Subtotal, Team 1 Staff 29 21 21 TEAM 2 STAFF Intensivist Physician 1 1 1 Patient Care Coordinator 1 1 1 Unit Clerk 1 1 1 Critical Care Nurse 13 13 13 Respiratory Therapist 3 3 3 Clinical Pharmacy Specialist 1 0 0 Physiotherapist 1 0 0 Occupational Therapist 1 0 0 Speech Language Pathologist 1 0 0 Rehab Aide 1 0 0 Diagnostic Imaging Tech 1 0 0 Social Worker 1 0 0 Dietician 1 0 0 Housekeeper 1 1 1 Acute Care Aide 1 1 1 Subtotal, Team 2 Staff 29 21 21 SHARED STAFF Medical Director Intensivist 1 0 0 Program Director 1 0 0 Administration Assistant 1 0 0 Physician Consultants 4 0 0 Nurse Educator 2 0 0 Nurse Clinician 2 2 0 Unit Manager 1 0 0 Data Analyst 1 0 0 Research Coordinator 2 0 0 Nurse Practitioner 1 0 0 ICU Outreach Nurse 1 1 1 Quality Assurance 1 0 0 Program Clerk 1 0 0 Pharmacy Technician 1 0 0 Equipment Coordinator 1 0 0 Porter 1 1 0 Stores Attendant 1 0 0 Subtotal, Shared Staff 23 4 1 Patients 25 25 25 Visitors 50 50 12 Residents 4 2 2 Students 30 20 0 Other 0 0 0 Subtotal, Other 109 97 39 Total 190 143 82 3-41

3.0 INTENSIVE CARE UNIT DESIGN CRITERIA External Relationships Locate this component to provide access to the component in accordance with the following external relationships which are listed from highest to lowest priority: Intensive Care Unit 1 2 High Dependency Care Unit 1 Provide direct access by non-public circulation to the High Dependency Care Unit for the movement of staff and seriously ill patients, and for flexibility in the use of facilities. 3 Diagnostic Imaging Emergency 2 Provide direct access by non-public circulation to the Diagnostic Imaging component for the movement of critically ill patients, as well as imaging staff and equipment. 4 Surgical Suite 3 Provide direct access by non-public circulation to/ from the Emergency component (including CT imaging) for the movement of critically ill patients. 5 Cardiology Unit 4 Provide direct access by non-public circulation to the Surgical Suite for the movement of critically ill patients. 6 Respiratory Therapy Services 5 Provide convenient access by non-public circulation to the Cardiology Unit for the movement of critically ill patients. 6 Provide direct access by internal circulation from the Respiratory Therapy Services component for the movement of equipment and staff. Internal Design Criteria (a) Nurse/Patient Accessibility The physical environment, supplies and material resources will be planned and developed to maximize nursing time at the bedside. Distance from the patient beds to support areas should be as short as possible to minimize travel time to/from the bedside. All patient bed areas will be provided with generous space at the sides, head and end of the bed to accommodate life support and monitoring equipment, a large number of staff, and to allow access around the patient s head to manage critical airway, breathing, and circulation pathways. In addition, mobile imaging equipment is required at the patient bedside on both left and right sides, without having to move the bed. (b) Patient/Nurse Visibility All patients will be directly visible from adjacent staff work areas. It is important that visual contact be maintained at all times between nursing staff and patients. Nursing staff will have direct views 3-42

3.0 INTENSIVE CARE UNIT of a patient s head and face. There will be maximum visibility of staff work areas from the individual patient beds in order to reassure patients that care is close at hand. Staff at the patient observation alcove directly adjacent to each pair of beds will have direct observation, through a window with non-glare glass, of each of the patients and the patients monitor screens. The patient observation alcove should be large enough to accommodate two nurses plus two others and incorporate, communications, lockable cabinets, chart storage and monitors. (c) Room Isolation Capability/Infection Control There will be ten patient rooms designated as airborne isolation rooms with attached anterooms in the ICU. Each of these patient rooms will have an entrance through the adjoining anteroom (for staff) and a separate entrance directly from the corridor (for the patient). The ICU will be mechanically separated/ divided to create an isolation zone out of each of the pods in the event of an infectious disease outbreak. (d) Hemodialysis Patient Room 1 Patient Room 2 All patient rooms and the procedure room in the ICU will be provided with special plumbing, mechanical and electrical systems for hemodialysis. (e) Patient Environment The ICU will, of necessity, contain an increasing variety and complexity of technical equipment and can be quite noisy and active, especially in emergency situations. As patients are very sensitive to noise disturbance, the design will include means to contain/absorb noise wherever possible and to ensure noisier activities are carried out farthest from patient care areas. There will be windows between neighbouring ICU rooms to allow for observation of multiple patients. Each patient room will be provided with visual and acoustical privacy from activities in adjacent spaces. Room finishes as well as furnishings should be selected so as to create a healing, therapeutic and positive environment for patients undergoing a high degree of stress. (f) Lighting Requirements Lighting systems will be designed to provide for adequate patient care yet maintain optimum patient comfort. Patients can be quite sensitive to intense levels of lighting and multi-level lighting will be provided. Nighttime lighting will facilitate patient sleeping while maintaining nurse-patient observation. An examination/special procedures light will be provided in each patient room. Complete darkening of each patient room must be accomplished to allow for special procedures such as echocardiograms to occur. 3-43

3.0 INTENSIVE CARE UNIT (g) Natural Lighting Patients should at least be aware of time of day (day/night orientation) and weather conditions. Natural lighting will help maintain circadian cycles and decrease problems of ICU psychosis. All patient beds should be oriented to allow exterior views to provide patients with an alternative to a very technical environment and to provide relief to staff working in the units. The ability to see outdoor vegetation and activity is very desirable. (h) Patient Rooms Every attempt will be made with the space available to provide the features of a universal room, such fully accessible, and maximum observation of the patient from the corridor. Also flexibility will be considered in order to respond to the requirements of a constantly changing field. Versatile or convertible space will ensure that the space is fully utilized as intensive care requirements change over the life of the facility. Patient rooms will have three zones: family zone, patient zone and a caregiver zone. The family zone will be located in a manner that will foster face-to-face dialogue between the patient and their family member, while the patient is lying in their bed. All patient rooms will be the same size and will be closed, with sliding (floor trackless) glass breakaway doors at the corridor to allow for maximum accessibility and observation. Infrastructure will be designed to support the resources required to care for critically ill patients, including uninterrupted power, medical gases and vacuum systems, and ceiling lifts. Ceiling mounted articulating arms for all power (including emergency), medical air/gases vacuum, nurse call/code alarms, fluids and video equipment will be used to lift equipment, cables and cords off the floor, freeing up space for staff, mobile equipment, patient, and visitor movement. Such ceiling mounted supports will not interfere with the provision and utility of ceiling mounted patient lift devices. A clothes closet, plus shelves for personal effects, etc. will be provided. Space will also be provided for a supply cart in each room. (i) Bariatric Patient Accommodation Two patient rooms will be designated to accommodate bariatric patients. The patient rooms will be capable of accommodating special equipment such as bariatric beds/stretchers, seating for family members, required by bariatric patients. (j) Patients Sanitary Facilities Critical care patients in this unit will be relatively immobile and unable to move any distance to use a washroom. Each room will have a closed waste system for disposing of waste in an enclosed ventilated room. 3-44

3.0 INTENSIVE CARE UNIT (k) Patient Privacy Optional visual privacy will be provided between each adjacent patient bed and from the corridor. Louver blinds built into double-glazed windows in doors and walls should be considered for this purpose. Curtains around the bed are also required. (l) Doors to Unit Entry to the ICU will be through controlled access doors. Staff will be able to access the unit using a swipe card; other visitors will have to be buzzed in the unit using an intercom system. To exit the unit, the doors will be motion-sensored and automatic. (m) Access Control The ICU requires the ability to lock down during times of elevated risk. During times of elevated risk, staff can enter with proper credentials (access card), with visitors being screened by staff and door temporarily electronically released (buzzed in). (n) Storage Respiratory Therapy Equipment A storage room will be provided for respiratory therapy equipment, located adjacent to the RT workroom. The storage room will be equipped with numerous electrical outlets for charging the batteries on the various pieces of equipment held. The storage room will be located for easy and speedy access from any patient room. 3-45

3.0 INTENSIVE CARE UNIT Component Functional Diagram Intensive Care Unit Patient/Family/Visitors Reception Centre Family Support Area Patient Care Area 12 Beds + 1 Procedure Room Patient Care Support Area ICU Support Area Patient Care Support Area Patient Care Area 13 Beds Respiratory Services 3-46

3.0 INTENSIVE CARE UNIT Schedule of Accommodation Provide the following spaces, numbers of spaces, net areas, and space contents as minimum requirements. Ref Space Area Requirements Remarks units nsm/unit nsm Patient/Family/Visitor Support Area 01 Reception Centre 1 10.0 Incl. 1 workstation 02 Waiting Room, Patient/Family/Visitor 1 40.0 Incl. seating for 30, children s play area, vending machines 03 Family Respite Room 1 21.0 Incl. seating for 10 04 Washroom, Public, Male 1 6.0 05 Washroom, Public, Female 1 6.0 06 Telephone, Public 1 2.5 Incl. 3 telephones Subtotal, Patient/Family/Visitor Support Area 85.5 Patient Care Support Area 07 Care Station, Large 1 43.0 Incl. 10 workstations, printer(s), PACs, central monitors, pneumatic tube station, chart storage 08 Medications Room 1 18.0 Incl. eye wash station, workstation 09 Workroom, Office Equipment 1 8.0 Incl. multifunction printer 10 Clean Supply Holding 1 18.0 11 Nourishment Station 1 4.5 12 Alcove, Equipment Storage 8 1.5 12.0 Incl. electrical outlets at 48 13 Family Respite Room 1 17.0 Incl. seating for 10 14 Washroom, Public 1 4.5 15 Care Station, Small 1 12.0 Incl. 3 workstations, printer(s), PACs, central monitors, chart storage 16 Consult/Interview Room 1 10.0 Incl. seating for 4-6 people, calming environment 3-47

3.0 INTENSIVE CARE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 17 Office, Intensivist 1 10.0 Incl. 1 workstation 18 Workstation, Consultant/ Resident 1 4.5 Incl. 1 workstation 19 Soiled Utility Room 1 8.0 Incl. closed waste system 20 Washroom, Staff 2 2.5 5.0 21 Housekeeping Closet 1 6.0 Subtotal, One Patient Care Support Area Subtotal, Two Patient Care Support Areas 180.5 2 180.5 361.0 Patient Care Area 22 Patient Room, Private 15 25.0 375.0 Incl. closed waste system 23 Procedure Room 1 25.0 Incl. closed waste system Note: co-locate with patient rooms to share Patient Observation Alcove, designed the same as a patient room 24 Patient Room, Private (Bariatric, Isolation) 2 25.0 50.0 Incl. closed waste system 25 Anteroom 2 4.0 8.0 26 Patient Room, Private (Isolation) 8 25.0 200.0 Incl. closed waste system 27 Anteroom 8 4.0 32.0 28 Patient Observation Alcove 13 6.0 78.0 Incl. 2 workstations, monitors, seating for 4 Subtotal, Patient Care Area 768.0 Intensive Care Support Area 29 Soiled Holding Room 1 35.0 Incl. soiled linen carts, recycling bins, cardboard recycling bin, large waste bin, biomedical wastes bin, sharps container 3-48

3.0 INTENSIVE CARE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 30 Laboratory Workroom 1 7.0 Incl. 1 workstation 31 Workroom, RT/Biomedical 1 24.0 Incl. 2 workstations 32 Alcove, Stretchers/Wheelchairs 1 8.0 Locate as close as possible to service elevators 33 Storage, Equipment, Large 1 32.0 Incl. electrical outlets at 48 34 Storage, Equipment, Small 1 12.0 Incl. electrical outlets at 48 35 Storage, Supplies 1 10.0 36 Team Conference Room, UBC 1 22.8 Part of Clinical Academic Campus, seating for 12 at conference table, see text description p 3-176, videoconferencing infrastructure 37 Workstation, Residents/Medical Students, UBC 38 Education Room/Patient Therapy Room 2 2.5 5.0 Part of Clinical Academic Campus, see text description p 3-176 1 35.0 Incl. seating for 20, 1 workstation; moveable acoustically rated partition, large video-conference room 39 Office, Unit Manager 1 10.0 Incl. 1 workstation 40 Office, Clinical Nurse Educator 1 10.0 Incl. 2 workstations 41 Office, Social Worker 1 10.0 Incl. 2 workstations 42 Office, Clinical Pharmacist 1 10.0 Incl. 2 workstations 43 Workstation, Program Clerk 1 10.0 Incl. 1 workstation, adjacent to Unit Manager 44 Workstation, Interdisciplinary Team Member 5 4.5 22.5 Incl. 1 workstation 45 Meeting Room 1 22.0 Incl. seating for 15, 1 workstation, video-conferencing infrastructure 46 On-Call Room 2 7.0 14.0 Incl. 1 workstation 47 Washroom, On-Call 2 3.5 7.0 48 Support Area for Office Area 1 10.0 Incl. multifunction printer 49 Break Room, Staff 1 42.0 Incl. seating for 25, 2 workstations 3-49

3.0 INTENSIVE CARE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 50 Change Room, Male Staff 1 6.0 Located adjacent to Break Room 51 Washroom/Shower, Male Staff 1 6.0 Located adjacent to Break Room 52 Change Room, Female Staff 1 16.0 Located adjacent to Break Room 53 Washroom/Shower, Female Staff 1 8.0 Located adjacent to Break Room 54 Housekeeping Closet 1 6.0 Subtotal, Critical Care Support Area 400.3 Total 1 614.8 3-50

4.0 NEONATAL INTENSIVE CARE UNIT FUNCTIONAL DESCRIPTION Scope of Services Content This specification outlines the requirements for the Neonatal Intensive Care Unit (NICU) component. This component will act as a regional referral centre accommodating both Level II and Level IIIA Newborn Care. As part of the Provincial Neonatal Care Network, the SMH NICU may receive admissions from any part of the province. The overall system of neonatal care in British Columbia involves the following levels: Level I: for normal care; Level II: - IIA offering intensive observation/care for pre-mature infants, possibly having low-risk complications, and possibly in need of specialist consultation (on-call 24/7), and - IIB offering intensive care for pre-mature infants having moderate-risk complications, and possibly in need of specialist consultation (on-call 24/7); Level III: - IIIA offering investigations and intensive care for infants with any gestation age (> 23 weeks) and any weight, having moderate-to high-risk neonatal complications, in need of in-house 24/7 medical coverage, possibly in need of specialist obstetrical and/or pediatric neonatal consultation (on-call 24/7), and daytime access to other sub-specialists on a planned basis, - IIIB offering investigations and intensive care for infants with any gestation age and any weight, having high-risk fetal and/or neonatal complications, in need of in-house 24/7 medical coverage, access to a fetal medicine specialist and specific other sub-specialists (on-call 24/7), and access to other sub-specialists on a planned basis, and - IIIC offering investigations and intensive care for infants with any gestation age and any weight, having very high-risk fetal and/or neonatal complications, in need of in-house 24/7 medical coverage, access to a full range of sub-specialists (on-call 24/7). Levels IIB through IIIC may incorporate the use of mechanical ventilation. Level I Neonatal Care will be provided within the Family Birthing Unit component (in the South Building). Levels IIIB and IIIC Neonatal Care will be available at the Children s and Women s Health Centre (C&WHC) in Vancouver. The NICU will be comprised of 48 infant beds. All infant beds will be able to accommodate Levels IIA and B, and Level IIIA neonates. The NICU will be a closed unit with admission at the discretion of the neonatologist or his/ her designate. 3-51

4.0 NEONATAL INTENSIVE CARE UNIT Treatment and care activities typically provided in the NICU will include, among others: Supporting infant growth and development including assessing nutritional capability and providing developmentally appropriate care; Providing assessments and conducting appropriate interventions; Delivering treatments; Communicating with and providing emotional support to families; Providing parental and family education; and Liaising with the community and discharge planning. Sterile procedures, including invasive procedures, performed in infants rooms will include, but are not limited to: IV line insertions; Central line insertion; Catheter insertions; Lumbar punctures; Exchange transfusions; High frequency ventilation; Chest tube insertions; Head ultrasound; Chest x-rays; Echocardiograms; Hearing tests; Eye examinations; EEGs; Nitric; Intubation; and Laser eye surgery (in procedure room only). Five basic principles have been adopted that will impact the operational and physical characteristics of the NICU: Commitment to the model of family-centred care; A focus on developmental care; Use of an interdisciplinary clinical care team; Maximizing the use of staff resources in the most appropriate fashion; and Maximizing the use of technological advances. Family-Centred Care The NICU will be designed and operated based upon the model of family-centred care. This means: Involving the family in clinical decision-making; Readily providing the family with access to information; and Providing a physical environment that is inviting for families and supportive to their involvement. Parents will not be visitors to the NICU, but rather will be considered integral members of the interdisciplinary care team and will feel free to approach staff and physicians to discuss the care of their infant. Parent involvement is considered essential to the health and well-being of the newborn. 3-52

4.0 NEONATAL INTENSIVE CARE UNIT Parents will be invited to participate in decision-making for their infant to the level that they choose and encouraged to ask questions if there is anything they want to know or do not understand. Focus on Developmental Care The NICU will focus on integrating the developmental needs of the infant within the framework of medical care. Key concepts for delivery of developmental care include promoting organized infant neuro-behavioral and physiological function and tailoring the physical environment, such as light and sound, to protect vulnerable developing sensory systems, all within a context of family-centred care. Developmental care for infants recognizes that each infant is unique, that each can display a wide variety of behaviours, and that the physiological condition of infants differs widely. Therefore, the assessment of infant cues remains central in the provision of developmental care. Interdisciplinary Clinical Team The NICU will operate using an interdisciplinary clinical team model of care including, but not limited to the following types of individuals (alphabetical order): Clinical associates; Clinical dietitians; Clinical nurse educators; Clinical nurse specialists; Clinical pharmacists; Laboratory staff; Lactation consultants; Neonatologists; Nurse practitioners; Parents; Pediatricians; Pharmacists; Rehabilitation services staff (OT, PT, SLP, and Audiology); Registered nurses; Respiratory therapists; and Social workers. Maximized Use of Staff Resources Staff resource utilization will be maximized in that the most appropriate staff persons will perform tasks. For example, nurses will not spend time in non-nursing duties such as searching for supplies, thereby allowing them to focus on care of the infants in their charge. Maximized Use of Technological Advances The NICU will maximize the use of technological advances. In addition to the functional linkages to on-site SMH clinical and clinical support services, the NICU will have significant program linkages to many provincial, regional, and local programs and services off-site. 3-53

4.0 NEONATAL INTENSIVE CARE UNIT A specialized infant transport team will be based at the Children s & Women s Health Centre (C&WHC) in Vancouver. The team will not require any dedicated facilities at SMH. Scope of Education Activity The NICU will generally provide clinical resources in support of teaching programs for the following types and anticipated maximum number of students at any given time: 4 medical/surgical residents; 4 undergraduate medical students; 10-15 nursing (RN) undergraduate and graduate students; 1 social work student; 1 pharmacy undergraduate/resident; 2 physiotherapy students; 1 pastoral care student; 2 respiratory therapy students; 1 dietetic intern; and 1 laboratory assistant or technologist student. Inservice education and parent teaching programs will be conducted on a regular basis. All teaching activity will occur throughout the NICU s clinical care spaces as well as in staff conference/meeting room(s). The education room will be equipped for video conferencing. In total, there could be up to 30 non-staff people involved with education programs in the component at any one time. Scope of Research Activity NICU team members may actively participate in clinical research activities with the SMH NICU being a partner in the Canadian Neonatal Network and working with others as opportunities arise. Research activities in the NICU will be in the nature of data collection and analysis at a desk area, and will not require special research facilities. OPERATIONAL DESCRIPTION Hours of Operation The NICU will function 24-hours a day, 7-days a week. Patient Management Processes If the infant is to be delivered at SMH and birth is known to be high-risk with the newborn likely requiring the services provided in the NICU, the neonatologist or designate will be conferred with prior to delivery and will attend the birth. If the infant has been delivered at SMH and appears to meet the NICU admission criteria, the family physician, obstetrician, pediatrician, or midwife will consult the neonatologist or designate to determine admission. 3-54

4.0 NEONATAL INTENSIVE CARE UNIT In both situations identified above, initial resuscitation and stabilization immediately following birth will continue to occur in the FBU and can include lines insertion, airway insertion, and initiation of mechanical ventilation. Once stabilized, the newborn will be transported to the NICU by the neonatal resuscitation team (comprised of the neonatologist or designate, RN, nurse practitioner, and respiratory therapist). Travel distance from the resuscitation room in the FBU to the entrance of the NICU will be as short as possible and will be through a non-public corridor. This corridor may cross a public corridor/vestibule if access to the public corridor/vestibule is electronically controlled (including with a warning and monitoring system) and capable of being shut down to the public during the transport of an infant. At the entrance to NICU, there will be a procedure room that can be used for resuscitation if the infant has become unstable during transport. If the neonatologist or designate decides that the newborn requires a higher level of care than can be provided at SMH (provided at C&WHC in Vancouver), he/she will contact BC Bedline to arrange the transfer. The newborn will be transported to the NICU and held until the infant transport team can be assembled. The transport team is staffed by BC Ambulance Service personnel and a physician from C&WHC. If the infant has been born outside SMH, the referring facility will contact BC Bedline to determine admission to the SMH NICU. The infant transport team will bring the infant to the ambulance drop-off area near the new Emergency component or to the heliport and bring the infant directly to the NICU using non-public corridors and an appropriately-sized non-public elevator. Staff Work Processes Nurses will be assigned to infants at ratios of one nurse per 2-3 patients for Level IIB infants and one nurse per 2-patients in the Level III infants. There will be some infants who will require 1:1 or 2:1 care. Nurses will have ready access to support services located within close proximity to infant rooms. Clinical and Logistical Support Services The following subjects have been identified as critical to the effective operations of this component: (a) Diagnostic Imaging Services Chart Chart 12 Bedroom Pod Chart Chart Medications Communications Pneumatic Tube Pharmacist Chart Chart Radiographic and ultrasound imaging will occur within the NICU, while neonates requiring other imaging procedures will need to be transported to the Diagnostic Imaging component using a special transport care team. Dedicated alcoves or rooms for parking and storage of mobile imaging equipment and recharging batteries will be required and these areas/rooms will require adequate ventilation; 3-55

4.0 NEONATAL INTENSIVE CARE UNIT (b) Laboratory Services Laboratory personnel will be responsible for routine collection and testing of blood specimens. Nursing staff will collect other specimens, such as urines, swabs, and arterial blood. Near patient testing (e.g., blood gas analysis, glucose analysis, etc.) will be accommodated in the laboratory workroom where laboratory staff will perform the analysis. Specimens that require testing in the Laboratory will be transported via a pneumatic tube system; (c) Diagnostic Cardiology Services Electrocardiograms and echocardiographic testing will occur within the NICU. Diagnostic cardiology technicians will be called to the NICU and will bring the necessary diagnostic equipment with them. A dedicated link to a management system will be provided for the sending and retrieval of data and to enable viewing and reporting of ECGs on-line. If invasive cardiac procedures are required the infant will be transported to C&WHC; (d) Respiratory Therapy Services Respiratory therapy staff will be dedicated to the NICU 24-hours a day, 7-days a week. Respiratory Therapy Services will have a dedicated workroom and shared storage rooms with Biomedical Engineering; (e) Neuro-Diagnostic Services As needed, neuro-diagnostics staff will provide various services in the NICU including EEG and EMG tests; (f) Ophthalmology Services Ophthalmologists will be an important clinical resource to the NICU. Infants weighing 1,250 grams or less will be examined for Retinopathy of Pre-Maturity (ROP) every week or two; and, if necessary, will undergo laser treatment in the procedure room; (g) Social Work Social workers will conduct interviews at the bedside or in consult/interview rooms. Discharge and other necessary resource information will be discussed in an office setting, as will most interdisciplinary and community partner interactions; (h) Volunteer Services Volunteers will augment the clinical services provided in the NICU. In the event that a baby does not have adequate family support, a cuddler volunteer program will help to fill the gap. Another volunteer role will be that of unit support volunteer. This volunteer will fulfill a variety of roles including greeter, ambassador, child-minder, and resource person; (i) Rehabilitation Services Rehabilitation staff will provide assessments and therapy at the patients bedsides. 3-56

4.0 NEONATAL INTENSIVE CARE UNIT In addition to standard therapeutic services, Rehabilitation Services will also provide some specific programs in the NICU: The Feeding team will provide assessment, intervention, and education; The Neuro-Developmental Evaluation & Treatment Service will encompass assessment, intervention, and education; and Newborn Hearing Screening will involve the screening of all infants in the NICU for potential congenital and early onset hearing loss. (j) Nutrition Services A full-time clinical dietitian will be an active member of the interdisciplinary NICU team; (k) Pharmacy Services Point-of-Use (POU) drug distribution system will be used to distribute narcotics and ward stock to the clinical areas of the component; (l) Food Services Specialty formula preparations for the neonates will be made in an aseptic area of the main kitchen of Food Services and delivered to the NICU by Food Services staff. Ready-to-use nursettes of infant formula will be stored within the NICU in the clean supply rooms. In addition, each infant bed position will have a small monitored frost-free fridge for holding babyspecific breastmilk and/or formula; (m) Isolette Cleaning Services Isolettes will be cleaned by the aides in Isolette cleaning room then returned to the infant positions. There will also be limited storage of isolettes in a large equipment storage room; (n) Medical/Surgical Supply Services Designated supply rooms utilizing fixed shelving will hold inventories of medical/surgical supplies. Sterile processing department will provide sterile specialty trays. NICU supply attendants will maintain inventories and restock infant positions and specialty areas; (o) Biomedical Engineering Services Equipment storage on the unit will have outlets at 48 height for recharging equipment batteries. Biomedical engineering will conduct a maximum amount of maintenance and repair work within the NICU to avoid excessive equipment movement; (p) Pneumatic Tube System The care team station of each 12-bed pod will be provided with a pneumatic tube station; and 3-57

4.0 NEONATAL INTENSIVE CARE UNIT (q) Codes Support The NICU will be responsible for management of emergency codes called on neonates anywhere in the hospital. ACTIVITY CAPACITY The facilities will accommodate the minimum workloads as shown in Table 1. These are the projected workloads for the year 2011. Table 1 Minimum Capacity Activity Category (Projection Year 2011) Level II Separations 723 ALOS (days) 9.8 Patient-days 7665 % Occupancy 75% Beds 28 Level IIIA Separations 1077 ALOS (days) 5.1 Patient-days 5475 % Occupancy 75% Beds 20 OCCUPANCY The maximum estimated occupancy of this component will be as shown in Table 2. Table 2 Maximum Estimated Headcount Occupancy Person Category Day Evening Night Director 1 0 0 Neonatologist 4 4 2 Patient Care Manager 1 0 0 Administrative Assistant 1 0 0 Program Clerk 1 0 0 Patient Care Coordinator 1 1 1 Lactation Consultant 1 0 0 Admitting Nurse 1 1 1 Discharge Nurse 1 0 0 Procedure Nurse 1 1 1 RNs 24 20 20 Unit Clerk 3 1 1 Nursing Aide 3 1 1 Clinical Nurse Specialist 1 0 0 Clinical Nurse Educator 2 0 0 Clinical Pharmacist 1 0 0 Respiratory Therapist 3 2 2 Social Worker 3 0 0 Laboratory Technologist 2 1 0 3-58

4.0 NEONATAL INTENSIVE CARE UNIT Maximum Estimated Headcount Occupancy Person Category Day Evening Night Laboratory Assistant 1 1 1 Speech Language Pathologist 1 0 0 Occupational Therapist 1 0 0 Physiotherapist 2 0 0 Audiologist/S&HA 1 0 0 Medical Imaging Technologists 1 1 1 Biomedical Technologist 1 0 0 Health Records 1 0 0 Area Supply Staff 2 0 0 Clinical Dietitian 1 0 0 Subtotal, Staff 66 34 31 Patient/Neonate 48 48 48 Visitor/Family Member 35 30 10 Volunteer 8 4 0 Resident 4 2 2 Student 26 10 0 Subtotal, Other 121 94 60 Total 187 128 91 DESIGN CRITERIA External Relationships Locate this component to provide access to the component in accordance with the following external relationships which are listed from highest to lowest priority: Neonatal Intensive Care Unit 1 Family Birthing Unit 1 Provide direct access by non-public circulation from the Family Birthing Unit for the movement of infants at high risk. 2 Emergency Ambulance Area and Helipad 2 Provide direct access by non-public circulation from the Emergency Ambulance Area and Helipad for the movement of infants at high risk. 3 Diagnostic Imaging 3 Provide direct access by non-public circulation to the Diagnostic Imaging component for the movement of critically ill infants, as well as imaging staff and equipment. 4 Pediatric Pharmacy 4 Provide direct access by internal circulation from the Pediatric Pharmacy for the movement of staff and STAT medications on an urgent basis. 5 Laboratory 5 Provide convenient access by non-public circulation from the Laboratory for the movement of staff. 3-59

4.0 NEONATAL INTENSIVE CARE UNIT Internal Design Criteria (a) Direct Connection between NICU and Family Birthing Unit A dedicated, direct, and non-public route between the Family Birthing Unit s surgical suite and NICU for transport of neonates is required. This corridor may cross a public corridor/vestibule if access to the public corridor/vestibule is electronically controlled (including with a warning and monitoring system) and capable of being shut down to the public during the transport of an infant. Corridors must be wide enough to accommodate the neonate in an incubator and the neonatal resuscitation team. (b) Sub-Division & Configuration of Patient Care Zone The NICU will be configured symmetrical with 24 infant beds on each side of the unit and further will be sub-divided into four groupings or pods of 12 beds each. Each grouping should be configured such that two patient rooms share a charting alcove with views into each of the two rooms. Two pairs of patient rooms in each pod will have an interconnecting large doorway or sliding panels to accommodate twins (total 16 infants). For each grouping of infant beds, a care team station, medications room and PACS viewing room should be positioned centrally and be readily accessible from the patient rooms in the pod. (c) Infant Rooms The NICU will be designed utilizing 100% private infant patient rooms. The wall of each room into the corridor will be fully glazed (clear) with large sliding panels for unencumbered access. Integral blinds will provide for privacy. There will be double sets of medical gases and power in order to accommodate two neonates, if required. The specially designed headwall will be configured so as to eliminate crossover of cords, cables, hoses, etc. In the room, the infant space will be separated from the parent space by ceiling-hung sliding curtains that can be moved completely out of the way of the caregivers working around the infant. The parent space will accommodate a parent sleeping in the room and storage for personal belongings. (d) Provisions Supporting Family-Centred Care Infant patient rooms will have three zones: infant zone, caregiver zone and family zone. The infant zone is the area surrounding the isolette; the caregiver zone is closest to the door and includes supplies, handwashing sink and charting area, and the family zone is located farthest from the door and includes seating and sleeping accommodation for a family member. Space design will focus on humanizing the environment wherever possible. Access to natural light and the use of relaxing colours are two means of creating a comfortable family-centred place. Opportunity will be provided for emotionally distressed or grieving family members to find private areas away from the patients and other family members. 3-60

4.0 NEONATAL INTENSIVE CARE UNIT A Ronald McDonald Family Room will be provided (refer to Section 13.0 (Ronald McDonald Family Room) of the Clinical Specification). This room will be close to the NICU and will consist of several spaces accommodating rest and relaxation, cooking, eating, entertainment, selfeducation, parent rooms, and hygienic activities. Clothes storage lockers will also be provided in conjunction with these facilities. (e) Flexibility All patient bed spaces in the NICU will be physically as identical as possible in order to maximize flexibility of use and to reduce risks by promoting staff familiarity with the placement of supplies and equipment. (f) Access to the NICU All NICU access/egress points shall be strictly electronically access controlled by the integrated facility card access control system. The Main NICU entry which shall be electronically locked 24/7 with momentary remote release at reception by way of video intercom station. There may be times when it is necessary to prevent exit from the NICU. Video cameras will be strategically located for surveillance and evidence purposes. It should not be possible for any unauthorized person to use it as a route to or from any other area of the hospital. Immediately upon entry into the unit via the controlled front door, family members will come upon the reception desk where a clerk will greet the family member or visitor, check identification, and set-up the means for future identification (for example, RFID bracelet and photograph). A volunteer may assist. Provision for hand-sanitizing will be made. A waiting area will be located adjacent to the reception area. (g) Lighting Infant development can be seriously hampered by high light levels. Consequently, all patient spaces will be designed with sophisticated lighting systems that can be readily altered according to need. Control of illumination should be accessible to staff and families, and capable of adjustment across the recommended range of lighting levels. Use of multiple light switches to allow different levels of light is one method but a master switch should also be provided so rapid darkening of the room is possible when required. Lighting should not shine directly on infant. Note: The design team will refer to Standard 14, Recommended Standards for NICU Design, Report of the Seventh Consensus Conference, Clearwater Florida, February 2007. (h) Daylight At a minimum, 50 percent of infant rooms should be located to have access to natural light and views to the outside. Properly designed day-lighting is the most desirable illumination for nearly all care giving tasks, including charting and evaluation of infant skin tone; however, placing infants too close to external windows can cause serious problems with radiant heat loss or gain and glare. The provision of windows in the NICU will require careful planning and design in order to avoid direct sunlight upon the neonates. 3-61

4.0 NEONATAL INTENSIVE CARE UNIT Note: The design team will refer to Standard 14, Recommended Standards for NICU Design, Report of the Seventh Consensus Conference, Clearwater Florida, February 2007. (i) Acoustic Privacy & Noise Control Infant development can be seriously hampered by a noisy environment. Consequently, all patient spaces will be designed to ensure quiet environments for neonatal care. All the offices will provide for acoustic privacy during normal-level conversation, as many conversations will be confidential. Note: The design team will refer to Standard 14, Recommended Standards for NICU Design, Report of the Seventh Consensus Conference, Clearwater Florida, February 2007. (j) Caregiver Environment Staff and family members should have access to exterior views as a relief from a very technical environment. The ability to see vegetation and activity will be very desirable. (k) Room Isolation Capability/Infection Control There will be eight designated airborne isolation rooms with attached anterooms in the NICU. Each of these patient rooms will have an entrance through the adjoining anteroom (for staff) and a separate entrance directly from the corridor (for the patient). (l) Special Ophthalmology Requirement Ophthalmological laser treatments may be occasionally performed in the procedure room. (m) Biomedical Engineering Workroom Biomedical engineering staff will perform preventative maintenance and some minor repairs on the incubators within the NICU in order to minimize transport of these with the associated risks of damage. The workroom will accommodate three isolettes running concurrently (using medical gases) along with a work-bench with space for a computer workstation and handwashing sink, as well as parts bins for tools, nursery-specific calibration equipment, and spare parts, etc. This room will be adequately ventilated to ensure heat dissipation. Because the alarms on the isolettes will be active (and noisy), the BE workroom will be sound isolated from neighbouring spaces. (n) Respiratory Therapy Workroom The RT staff dedicated to the NICU will be provided with an area for storage/checking of equipment as well as two workstations for charting, etc., (for use by the RTs and the anesthesia assistants). Fixed shelving will be provided for storage. The equipment work area will be designed with medical gases and numerous electrical outlets. There will also be a handwashing sink here. (o) Storage for Biomedical/Respiratory Therapy Equipment Two storage rooms will be provided for biomedical/respiratory therapy equipment, both located adjacent to the BE workroom and to the RT workroom. Both storage rooms will be equipped with numerous electrical outlets for charging the batteries on the various pieces of equipment held. The smaller storage room will be designed to accommodate smaller items such as extra infusion pumps (up to 10), breast pumps, six SiPAPs, etc., some of which will be stored on shelves. 3-62

4.0 NEONATAL INTENSIVE CARE UNIT The larger storage room will be designed to accommodate items such as spare isolettes/ warmers (up to 12); three transport isolettes (full stretcher size), 12 ventilators, two oscillators, bili-lights, etc. Both of these rooms will be located for easy and speedy access from any patient room. 3-63

4.0 NEONATAL INTENSIVE CARE UNIT Component Functional Diagram The Support Services zone will have specified secured access for the delivery and removal of materiel without the necessity of non-nicu staff having to pass through the Patient Care zone. Patient Care Zone Non-Public Service Entry Pod Patient Care Support/ Support Services Pod Pod Pediatric Pharmacy Pod Entrance Zone Public Entry 3-64

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4.0 NEONATAL INTENSIVE CARE UNIT Schedule of Accommodation Provide the following spaces, numbers of spaces, net areas, and space contents as minimum requirements. Ref Space Area Requirements Remarks units nsm/unit nsm Entrance Zone 01 Entrance Vestibule 1 6.0 02 Reception Area 1 12.0 Incl. 2 workstations 03 Waiting Area 1 35.0 Incl seating for 6, alcove for 2 strollers, small nourishments station, small children s play area, public washroom 04 Family Respite Room 1 21.5 Incl lounge seating for 6 Subtotal, Entrance Zone 74.5 Patient Care Zone 05 Care Team Station 4 20.0 80.0 Incl. 6 workstations, pneumatic tube station, printer(s), chart storage 06 Medications Room 4 16.5 66.0 Incl. eye wash station, workstation 07 Alcove, Staff Lockers 4 2.5 10.0 08 Workstation 4 4.5 18.0 Incl. 1 workstation 09 PACS Viewing Station 4 3.0 12.0 Incl. PACS, seating for 2 persons 010 Patient Room, Infant 40 16.0 640.0 Incl. workstation, see text description page 3-60 011 Patient Room, Infant Isolation 8 16.0 128.0 Incl. workstation, see text description page 3-60 012 Anteroom, Isolation 8 4.0 32.0 013 Patient Observation Alcove 24 3.5 84.0 Incl 2 workstations 014 Washroom, Staff 4 2.5 10.0 015 Washroom, Family 4 4.5 18.0 016 Housekeeping Closet 4 6.0 24.0 3-66

4.0 NEONATAL INTENSIVE CARE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm Subtotal, Patient Care Zone 1 122.0 Patient Care Support Zone 017 Workroom, Physicians 1 55.0 Incl. 20 workstations, PACS, multifunction printer 018 Team Conference Room, UBC 2 22.8 45.6 Part of Clinical Academic Campus, see page 3-176, (one for use by FBU), video-conferencing infrastructure. Adjacent to each other, divided by moveable acoustically rated partition 019 Workstation, Residents/ Medical Students 020 Education Room, Staff & Family, Large 2 2.5 5.0 Part of Clinical Academic Campus, see page 3-176 1 35.0 Incl. seating for 20, 1 workstation, large video-conference room 021 Workstation, Other Students 6 3.5 21.0 Incl. 1 workstation 022 Office, Patient Care Coordinator 023 Shared Office, Admitting/Discharge RN 1 10.0 Incl. 1 workstation 1 18.0 Incl. 3 workstations 024 Education Room, Staff, Small 2 20.0 40.0 Set-up as per typical patient room, use of sophisticated computer-based mannequins, projection system room 025 Consultation Room, Family 2 12.0 24.0 Incl. seating for 4, calm/spiritual environment, 1 workstation 026 Laundry, Baby Clothes 1 8.0 027 Breastmilk Freezer Room 1 8.0 Subtotal, Patient Care Support Zone 269.6 Support Services Zone 028 Procedure Room/Resuscitation Room 1 20.0 Incl 1 workstation, video-conferencing infrastructure, locate adjacent to NICU patient entrance 029 Laboratory Workroom 1 10.0 Incl 1 workstation 030 Alcove, Mobile Imaging Equipment 1 6.0 Incl. electrical outlets at 48 3-67

4.0 NEONATAL INTENSIVE CARE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm 031 Image Digitizing Room 1 10.0 Incl. 2 workstations 032 Cardiology Reading Room 1 10.0 Incl. 1 Echo reading workstation with 2 monitors, 1 workstation 033 Storage, Rehab. Services 1 12.0 Incl. 2 audiology carts 034 Workroom, Biomedical Engineering 035 Storage, Small BE/RT Equipment 036 Storage, Large BE/RT Equipment 037 Workroom, Respiratory Therapy 1 25.0 1 16.0 1 25.0 1 31.5 038 Break Room, Staff 1 45.0 Incl. seating for 25, 2 workstations 039 Locker Room, Female Staff 1 30.0 Located adjacent to Break Room 040 Washroom/Shower, Female Staff 2 6.0 12.0 Located adjacent to Break Room 041 Locker Room, Male Staff 1 15.0 Located adjacent to Break Room 042 Washroom/Shower, Male Staff 1 8.0 Located adjacent to Break Room 043 On-Call Room 5 7.0 35.0 Incl. workstation 044 Washroom, On-Call 5 3.5 17.5 045 Clean Supply Holding Room 1 40.0 Incl. 1 workstation 046 Clean Linen Rooms 2 8.0 16.0 047 Storage, Equipment 1 30.0 Incl. electrical outlets at 48 048 Isolette Cleaning Room 1 20.0 Incl. holding area for 10 isolettes, disassembly and cleaning space w/ workcounter, shelving for materials/cleaning supplies 049 Soiled Utility Room 1 15.0 Incl. closed waste system 050 Soiled Holding Room 1 35.0 Incl. soiled linen cart, 2 recycle bins, 1 cardboard recycle bin, 1 large waste bin, 1 biomedical wastes bin, 1 sharps container 3-68

4.0 NEONATAL INTENSIVE CARE UNIT Ref Space Area Requirements Remarks units nsm/unit nsm Subtotal, Support Services Zone 484.0 Total 1 950.1 3-69

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT FUNCTIONAL DESCRIPTION Scope of Services Content This specification outlines the requirements for the High Dependency Care Unit/Medical Surgical Unit (HDCU) component of the new facility. The HDCU component will have 25 patient beds and one procedure room that will be designed exactly the same as an HDCU patient room. Twenty beds will be high dependency beds which will provide the specialized staff, space and equipment resources to accommodate the care of patients in serious condition but not requiring the intensity of care provided by the ICU and having care demands that exceed the capability of the general medical/surgical inpatient care units. The remaining five beds will be designated as medical/surgical beds. Most admissions to this unit will come from the ICU, General Inpatient Units, Surgical Suite and Emergency components. Patients admitted to this unit will require the unique resources of the unit and will benefit from at least one of the following examples of specialized care/treatment: Higher level of care than on a general medical/surgical unit; Constant patient observation; Numerous and complex therapeutic interventions including administration of vasoactive and cardioactive drugs; Higher patient nurse ratio up to 1:2, 1:1 nursing for short periods of time; Complete cardiac monitoring with bedside monitoring and telemetry, including blood pressure, heart rate, pulse, O 2 saturation, 12 lead ECG; Capability of invasive hemodynamic monitoring such as, arterial lines, central lines, CVP monitoring (monitoring will not include Swan Ganz catheterization); Respiratory support such as, tracheotomy care, non-invasive and invasive ventilation; Capability of hemodialysis in the patient rooms; and Capability of neurological monitoring with ICP. Treatment and care services typically provided in the HDCU will include, among others: Collecting and documenting patient historical medical information; Providing routine and emergency medical examination and treatment; Planning and implementing care, including examinations and treatments; Facilitating patient comfort, mobilization and reactivation; Ordering medical diagnostic and treatment procedures; Preparing patients for diagnostic and treatment services; Prescribing and administering medications, in consultation with pharmacists; Providing family/visitor support, consultation, conferences and counselling; Maintaining patient records; Participating in daily interdisciplinary patient conferences; 3-69

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT Providing clinical academic training for staff, students and residents, including classroom education; Exchanging information on critical care services or patients via telehealth conferencing; Liaising with community agencies and services; and Coordinating, implementing, communicating, administering, scheduling, and evaluating the overall operations of the unit. Maximized Use of Staff Resources Staff resource utilization will be maximized in that the most appropriate staff persons will perform tasks. For example, nurses will not spend time in non-nursing duties such as searching for supplies, thereby allowing them to focus on care of the patients in their charge. Associated Trends The following trends will influence the future functioning of this component, and should be taken into account in the component design: The trend towards patient and family-centred care within care environments will continue. Nurturing environments will be created to support healing processes and psycho-social needs; Research shows healthy work environments improves patient outcomes and improves staff retention rates; Hospitals will need to create environments that foster and maintain patient privacy and confidentiality; The trend will continue towards higher levels of monitoring and care of critically ill patients in the future, especially for major surgical and respiratory patients; The number of bariatric patients admitted is expected to increase; The trend to provide appropriate responses to airborne infectious disease outbreaks including isolation of large numbers of patients and to provide isolation for more types of diseases will increase; Computers will increasingly perform a vital role in patient-related data assembly/ analysis; almost any data will be available at any terminal device with the proper passwords; Point-of-Care testing modules will become integrated into typical monitoring systems directly linking physiological monitoring to real time patient record keeping; Advances in technology bringing more equipment into critical care units will continue; Telehealth will increasingly provide outreach opportunities among health care facilities province-wide; There will be a continued shortage of health care workers, requiring available workers to assume broader responsibilities and requiring efforts in staff retention; and The trend to adopt evidence-based clinical pathways will continue, with standards becoming available in many more types of cases. 3-70

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT Scope of Education Activity The HDCU will generally provide clinical resources in support of teaching programs for the following types and anticipated maximum number of students at any given time: 8 medical/surgical residents; 8 undergraduate medical students; 20 nursing (RN, LPN, RPN, ESN) undergraduate and graduate students; 2 social work students; 2 pharmacy undergraduates/residents; 3 physiotherapy students; 2 occupational therapy students; 1 pastoral care students; 2 respiratory therapy students; 1 laboratory technologist student; 1 laboratory assistant student; 2 unit clerk students; 1 dietetic intern; and 4 others. Inservice education and patient teaching programs will be conducted on a regular basis throughout the HDCU s patient/clinical care spaces as well as in staff education/meeting room(s) equipped with audio/video conferencing capability. In total, there could be up to 50 non-staff people involved with education programs in the component at any one time. Scope of Research Activity Clinical research activities may be conducted within the component, but without the need for supplemental space. OPERATIONAL DESCRIPTION Hours of Operation The HDCU will be staffed 24-hours a day, 7-days a week. Patient Management Processes Reception/Admission Patient will be admitted to HDCU by pre-arrangement, through Access and Bed Control as unscheduled patients through the Emergency Department, through intra-hospital transfers as stepdown patients from ICU or step-up patients from general medical/surgical units and from the surgical suite. Patients most likely will be transferred to and from HDCU on beds, stretchers or wheelchairs. For families visiting a patient in the unit, a separate and secured visitor entrance will be provided. Staff in the reception centre, adjacent to the visitor entrance, will monitor and control visitor access to 3-71

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT the unit. Volunteers may also be available at the reception desk. The reception centre will include a staffed reception desk, waiting area, public washrooms, pay phones, and quiet family respite room. Care All patients will be monitored from one of the Patient Observation Alcoves (POAs). Transfers out of the unit will occur as a result of changes in acuity level. Patients will have ready access to staff at all times (lines of sight, two-way communication systems and call systems). There will be direct and clear sightlines between the direct care providers and patients. Staff will be responsible for up to 4 patients at a time during break relief. Interdisciplinary care teams made up of multiple caregivers will provide support from within the care unit. An increased emphasis will be placed on family-involved/centred approach to care rather than a provider-focussed model in support of holistic care of the patient. Staff Work Processes Communications The 25-bed HDCU will be administered from a centralized HDCU reception desk, which will also act as a reception/control point for access to the unit. Two large care team stations will include the patient care coordinators and unit clerks workstations, and a charting area. Patient observation alcoves will be provided ensuite between every two patient rooms. The unit will support nurse manager/leader engagement with staff, as well as, promoting staff communication and mentoring. Care Delivery Patient Room Care delivery will be based on a patient-centred, family-involved service supported by an interdisciplinary team. To facilitate this approach, families will be provided space in the patients rooms and on the unit. The care will occur mainly at the patient s bedside. The rooms will be able to support extensive invasive monitoring, hemodialysis, and provide full respiratory support functions. Referral Source Reception/ Admissions Care Delivery Discharge Process Flow Diagram Care Planning/ Charting/ Discharge Planning Charting will occur at the patient s bedside, the POA or Care Station. There will be one POA per two patient rooms. Most procedures will be done at the patient s bedside but in some cases the patient may need to be transported to another location in the hospital, such as, Diagnostic Imaging. 3-72

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT 12-13-Bed Pod Primary patient centred care generally will be one RN assigned to one or two patients. In some cases, a nurse may be assigned a particular patient with higher acuity. A care station will be located en-suite within each grouping of beds for nursing staff and interdisciplinary team members use. All beds are to be visible to the care stations, while allowing a degree of patient privacy to be maintained. HDCU pod layout should be compact as possible to enable visual supervision of and direct access to patient rooms from the staff work areas. And provide maximum visibility of staff work areas from the individual patient beds in order to reassure patients that nursing care is close at hand. Minimize nurse in-flight time and maximize nurse-patient visibility by locating frequently utilized staff work areas and support spaces close to the patient bed spaces. Interdisciplinary conversations will be private and not overheard by patients; therefore the meeting space will be acoustically private. Activities in the team care stations should not disturb sleeping patients; therefore, the care stations will be designed with as many sound control measures as possible. The medications room will be discreetly located and will include an automatic medication dispensing system. Access to it will be visually supervised from the team care station. One wall will be fully glazed. Nurses, physicians, therapists, etc. will require an area where they can discuss or document a patient s condition/information in private. Since the team care station desk area will likely be highly accessible to patients and their family/visitors, an acoustically private staff charting room will also be provided. This area will be glass-fronted so that staff can observe patients from within. This room could have sliding glass doors to the team care station to facilitate frequent access and observation between the two spaces. 25-Bed Unit A central reception area will act as the reception and central control area for the unit. Staff and/or volunteers will work out of the central reception area. A meeting space for up to 20 persons is required for the staff/family education purposes. Counselling and interview meetings will also be undertaken and could be located in this informal space. Students and resident also may utilize this space for educational purposes. Staff s outer clothing will be stored in lockable coat closets. Students and volunteers will also have space for coat storage in the coat closets. A staff break room will be provided for beverage making, staff debriefing, grieving and rest. Pneumatic Tube System The main care team station in each pod will be provided with a pneumatic tube station. 3-73

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT Clinical and Logistical Support Services The following subjects have been identified as critical to the effective operations of this component: (a) Diagnostic Imaging Services In addition to mobile diagnostic imaging services, HDCU patients will have access to the satellite diagnostic imaging component in Emergency Department or the Main Diagnostic Imaging Department. Dedicated alcoves or rooms for parking and storage of mobile imaging equipment and recharging batteries will be required and these areas/rooms require adequate ventilation; (b) Laboratory Services Nursing staff mainly will be responsible for the collection of routine and STAT laboratory tests as most patients will have lines that can be used for obtaining blood samples. Laboratory tests may be analyzed in the HDCU Laboratory workroom using near patient testing devices. Specimens that cannot be analyzed in HDCU will be transported to the main Laboratory via the pneumatic tube system. STAT orders will be given the highest priority to ensure shortest possible turnaround times for results; (c) Food Services In addition to TPN and liquid diets, a few patients in the HDCU will require full meal (tray) service provided centrally by Food Services. Food carts will be parked in alcoves on the unit; (d) Biomedical Engineering Services Equipment storage on the unit will have outlets at 48 height for recharging equipment batteries. Biomedical Engineering will conduct a maximum amount of maintenance and repair work within the HDCU to avoid excessive equipment movement; (e) Respiratory Therapy Services There will be a full time presence of respiratory therapists in the HDCU; and (f) Rehabilitation Services Rehabilitation staff will provide assessments and therapy at the patients bedsides or in the Patient Therapy Room. 3-74

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT ACTIVITY CAPACITY The facilities will accommodate the minimum workloads as shown in Table 1. These are the projected workloads for the year 2020. Table 1 Minimum Capacity Activity Category (Projection Year 2020) Admissions 1,445 ALOS (days) 6.0 Patient-days 8,669 % Occupancy 95% Beds 25 OCCUPANCY The maximum estimated occupancy of this component will be as shown in Table 2. Table 2 Maximum Estimated Headcount Occupancy Person Category Day Evening Night Unit Director 1 0 0 Physician 6 6 2 Nurse Clinician 1 1 0 Patient Care Coordinator 2 2 1 Unit Manager 1 0 0 Unit Clerk 2 2 1 Registered Nurse 25 25 25 Clinical Nurse Educator 1 0 0 Program Clerk 1 0 0 Respiratory Therapist 2 2 2 Clinical Pharmacist 1 1 0 Physiotherapist 2 0 0 Occupational Therapist 2 0 0 Speech Language Pathologist 1 0 0 Social Worker 2 0 0 Dietician 1 0 0 Care Aide 2 0 0 Porter 1 1 0 Housekeeper 1 1 1 Other 0 0 0 Subtotal, Staff 54 41 32 Patients 25 25 25 Visitors 10 10 2 Residents 8 6 4 Students 40 20 5 Other 0 0 0 Subtotal, Other 83 61 36 Total 137 102 68 3-75

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT DESIGN CRITERIA External Relationships Locate this component to provide access to the component in accordance with the following external relationships which are listed from highest to lowest priority: High Dependency Care Unit 1 Intensive Care Unit 1 Provide direct access by non-public circulation from the Intensive Care Unit for the movement of seriously ill patients, equipment and staff. 2 3 Respiratory Therapy 2 Provide direct access by non-public circulation from the Respiratory Therapy component for the movement of staff and equipment on an urgent basis. 4 5 Emergency Diagnostic Imaging (Satellite & Main) Surgical Suite 3 Provide direct access by non-public circulation from the Emergency component for the movement of seriously ill patients. 4 Provide convenient access by non-public circulation to the Diagnostic Imaging (Satellite & Main) component for the movement of critically ill patients, as well as imaging staff and equipment. 6 General Inpatient Units 5 Provide convenient access by non-public circulation to the Surgical Suite for the movement of seriously ill patients. 6 Provide convenient access by non-public circulation to the General Inpatient Units for the movement of patients. Internal Design Criteria (a) Nurse/Patient Accessibility The physical environment, supplies and material resources will be planned and developed to maximize nursing time at the bedside. Distance from the patient beds to support areas should be as short as possible to minimize travel time to/from the bedside. All patient bed areas will be provided with generous space at the sides, head and end of the bed to accommodate life support and monitoring equipment, a large number of staff, and to allow access around the patient s head to manage critical airway, breathing, and circulation pathways. In addition, mobile imaging equipment is required at the patient bedside on both left and right sides, without having to move the bed. 3-76

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT (b) Flexibility and Future Use of Space The HDCU should be planned and designed to accommodate a future conversion to an ICU, and these two units (HDCU and ICU) should be designed so they resemble each other as much as possible, given each units unique patient needs. (c) Patient/Nurse Visibility All patients will be directly visible from adjacent staff work areas. It is important that visual contact be maintained at all times between nursing staff and patients. Nursing staff will have direct views of a patient s head and face. There will be maximum visibility of staff work areas from the individual patient beds in order to reassure patients that care is close at hand. Staff at the patient observation alcove directly adjacent to each pair of beds will have direct observation, through a window with non-glare glass, of each of the patients and the patients monitor screens. The patient observation alcove should be large enough to accommodate two nurses plus two others and incorporate, communications, lockable cabinets, chart storage and monitors. (d) Room Isolation Capability/Infection Control There will be ten patient rooms designated as airborne isolation rooms with attached anterooms in the HDCU. Each of these patient rooms will have an entrance through the adjoining anteroom (for staff) and a separate entrance directly from the corridor (for the patient). The HDCU will be mechanically separated/divided to create an isolation zone out of each of the pods in the event of an infectious disease outbreak. (e) Hemodialysis Patient Room 1 Patient Room 2 All patient rooms in the HDCU will be provided with special plumbing, mechanical and electrical systems for hemodialysis. (f) Patient Environment The HDCU will, of necessity, contain an increasing variety and complexity of technical equipment and can be quite noisy and active, especially in emergency situations. As patients are very sensitive to noise disturbance, the design will include means to contain/absorb noise wherever possible and to ensure noisier activities are carried out farthest from patient care areas. There will be windows between neighbouring HDCU rooms to allow for observation of multiple patients. Each patient room will be provided with visual and acoustical privacy from activities in adjacent spaces. 3-77

5.0 HIGH DEPENDENCY CARE UNIT/ MEDICAL SURGICAL UNIT Room finishes as well as furnishings should be selected so as to create a healing, therapeutic and positive environment for patients undergoing a high degree of stress. (g) Lighting Requirements Lighting systems will be designed to provide for adequate patient care yet maintain optimum patient comfort. Patients can be quite sensitive to intense levels of lighting and multi-level lighting will be provided. Nighttime lighting will facilitate patient sleeping while maintaining nurse-patient observation. An examination/special procedures light will be provided in each patient room. Complete darkening of each patient room must be accomplished to allow for special procedures such as echocardiograms to occur. (h) Natural Lighting Patients should at least be aware of time of day (day/night orientation) and weather conditions. Natural lighting will help maintain circadian cycles and decrease problems of ICU psychosis. All patient beds should be oriented to allow exterior views to provide patients with an alternative to a very technical environment and to provide relief to staff working in the units. The ability to see outdoor vegetation and activity is very desirable. (i) Patient Rooms Every attempt will be made with the space available to provide the features of a universal room, such fully accessible, and maximum observation of the patient from the corridor. Also flexibility will be considered in order to respond to the requirements of a constantly changing field. Versatile or convertible space will ensure that the space is fully utilized as intensive care requirements change over the life of the facility. Patient rooms will have three zones: family zone, patient zone and a caregiver zone. The family zone will be located in a manner that will foster face-to-face dialogue between the patient and their family member, while the patient is lying in their bed. All patient rooms will be the same size and will be closed, with sliding (floor trackless) glass breakaway doors at the corridor to allow for maximum accessibility and observation. Infrastructure will be designed to support the resources required to care for critically ill patients, including uninterrupted power, medical gases and vacuum systems, and ceiling lifts. Ceiling mounted articulating arms for all power (including emergency), medical air/gases vacuum, nurse call/code alarms, fluids and video equipment will be used to lift equipment, cables and cords off the floor, freeing up space for staff, mobile equipment, patient, and visitor movement. Such ceiling mounted supports will not interfere with the provision and utility of ceiling mounted patient lift devices. A clothes closet, plus shelves for personal effects, etc. will be provided. Space will also be provided for a supply cart in each cubicle. 3-78