Description

Advances in diagnostic imaging have constituted one of the most dramatic developments in hospital care since 1895 when Wilhelm Conrad Röntgen discovered X-rays. Diagnostic imaging has now become one of the most technologically advanced fields in medicine. In 1971, the first CT scan (which uses high doses of radiation) was performed, based on an invention by Godfrey N. Hounsfield, and in the 1970s Paul C. Lauterbur invented magnetic resonance imaging (MRI), which works on the basis of strong magnetic fields. The principles of the PET scan were first explored in the late 1950s and culminated in the PET-CT scan around 2000, an innovation often attributed to David Townsend and Ronald Nutt. This was followed by the PET-MRI around 2008. Another very effective diagnostic tool in many instances is ultrasound (echography or ultrasonography), involving a relatively simple procedure which does not require large-scale equipment.

All these techniques are constantly being improved. One important trend is the development of mobile imaging equipment which can be brought to the patient’s bedside (already common practice with ultrasound machines, as they have gotten cheaper, smaller and more robust). Equipment which employs electromagnetic (predominantly high-energy X-rays) and nuclear radiation, however, will continue to be housed in radiation-safe spaces, requiring patients to be transported to it. The same is true for equipment which can only be installed if specific alterations in the building are made (Faraday cages for MRIs, for instance), or which is too large or too heavy to transport. The trend toward diagnostic imaging close to the patients is nevertheless apparent here as well. Whereas only a decade ago many experts favored concentrating all heavy-duty imaging machinery at one central location in the hospital, now those hospitals that are organized around clusters of specific categories of patients or diseases often equip individual clusters with all the medical facilities they need — even if this means decentralizing the imaging facilities. Another trend that promises to change the concept of imaging departments is the merger of imaging and surgery in, for instance, (hybrid) angiography and operating rooms, cardiac catheterization and intervention rooms and hybrid operating rooms equipped with advanced medical imaging devices such as fixed C-Arms or MRI scanners, predominantly for minimally invasive surgery.

Most types of patients, inpatients as well as outpatients, need diagnostic imaging at some point during their journey through the care pathway. Specialists in radiology and its various subdisciplines, the nursing staff and imaging/radiology technicians run the imaging department, which comprises a range of devices. Since these digital images — which need interpretation by highly trained specialists — can be made available anywhere, anytime, radiologists can provide assessments from other locations or from home; some hospitals have even contracted radiologists in distant countries, due to considerations of cost- effectiveness or shortages of skilled labor in the local market.

Spaces

As in the outpatient departments, waiting areas for imaging do not need to be decentralized. Given the ubiquitous use of mobile devices, centralized waiting areas could also work well, with notifications sent to patients when it is time to report to the imaging department. In all cases, an atmosphere should be created which helps put patients at ease. The other spaces in the department are usually highly specialized, custom-built to the specifications provided by the equipment manufacturer.

Perspective of the Patient

From the patients’ perspective, a visit to the diagnostic imaging department can be part of any care pathway, since it serves various, quite different patient groups — ranging from trauma assessment to oncological monitoring. Patients may arrive in very different conditions: they may have been brought in after an accident, or be sedated or unconscious, or be fully conscious and feeling healthy. Some come as outpatients, while others are hospitalized and bedridden. For this reason, it is desirable to separate inpatient from outpatient flows.[120] Specifically patients undergoing joint imaging-intervention therapies (endoscopic, laparoscopic, surgical) should be managed in separate therapy-based clusters. Different imaging technologies require different preparation processes — patients who are getting a CT, MRI or PET scan, for instance, might be administered contrast agents (iodine-based agents or isotopes) intravenously prior to the scan.

Safe handling procedures are especially crucial for patients arriving with polytraumatic injuries in the emergency department. In the past, accident patients had a high risk for hospital-acquired post-accident spinal injury from being transferred to diagnostic imaging departments and lifted and turned several times on the diagnostic table in order to have X-rays taken in different positions, for instance. With today’s high resolution scanners (mainly C-arms and CT scans) in the emergency department being able to rotate at almost all angles around the emergency table, both standard localized imaging as well as full-body scans can be performed without the need to lift or turn the patient.

Position Relative to Other Departments

Hardly any department is as enmeshed with other hospital functions as diagnostic imaging. The location of the department is always a compromise. However, splitting up the department is not always an option, due to the relative scarcity of specialized staff needed to operate the sophisticated machines (especially radiology technicians) and the inefficiencies associated with decentralization. Should the department, or parts of it, be located close to, or integrated with, the emergency department? Should it be close to the outpatient departments, which deliver the largest workload? Should it be located close to high-tech intervention functions such as those performed in cardiology and radiology departments? Or should it be adjacent to operating facilities on the hot floor, creating, in turn, undesirable cross-traffic flows with outpatients? The likelihood of future expansion, as well as the demands placed by heavy equipment on the building structure, suggest that a location on the ground floor facing a street façade is the best option, while the wish to transfer as many of the medical procedures as possible to the immediate vicinity of the patients calls for decentralization. In order to facilitate rapid diagnostics and intervention, emergency departments always need at least a basic level of imaging equipment while maternity wards usually have integrated ultrasound facilities.

Challenges for Future Design

The emergence of hybrid operating rooms allowing imaging procedures during a surgical intervention is yet another step toward the integration of diagnostic imaging with other medical procedures. Ever-increasing miniaturization is not just making the current devices more mobile, but also facilitating the creation of imaging devices that can be swallowed, possibly making the entire diagnostic imaging department obsolete in the long run.

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Originally published in: Cor Wagenaar, Noor Mens, Guru Manja, Colette Niemeijer, Tom Guthknecht, Hospitals: A Design Manual, Birkhäuser, 2018.