THE REBUILDING OF AND MEDICAL SCHOOL

PETER F. PHILIP M.S., F.R.C.S.

Consultant Surgeon, Charing Cross Hospital; Chairman of the New Hospital Planning Committee IN 1817 DR. BENJAMIN GOLDING founded Charing Cross Hospital, in- itially known as the West Infirmary, in Suffolk Street, London, W.C.2, with the expressed intention of providing both medical care for the local population and teaching for medical students. The success of this venture was such that larger premises soon became essential. The move into these new buildings, Charing Cross Hospital, designed by Decimus Burton and sited just off the Strand, occurred in 1834. This was the first time a medical school was constructed for a hospital, as Golding stated, 'to provide the want of a University so far as medical education is concerned'. The idea was to be followed immediately afterwards by University College Hospital and King's College Hospital. During its first 150 years Charing Cross has followed the original con- cepts of Dr. Golding; but in this century, despite local expansion, it became too small and the buildings outdated. In 1957 a new grouping with the West London Hospital and Hospital was arranged. Discussions within the new Group and with the University of London and the Department of Health produced agreement to the building of a new district and teaching hospital on the expanded site of Fulham Hospital. The first phase of this, the New Charing Cross Hospital and Medical School, now by strange chance relocated in West London, accepted its first patients in January 1973. From the outset of planning it was the wish of the Board of Gover- nors of Charing Cross Hospital and the Council of the Medical School that the new hospital should provide a full district service to the people of Fulham and , as well as up to date departments for teaching of preclinical and clinical students, with professorial units in the main specialties. Teaching of all types of medical and technical staff would also be undertaken. In addition to these main aims the brief laid down that: The building should be adaptable-able to change as needs altered -but built to a standard plan where possible. It should provide the patient with a sense of friendly security and privacy. It should encourage integration of the teaching and treatment aspects at all levels. (Ann. Roy. Coll. Surg. Engi. 1973, vol. 52) 335 It t4R.@ . ! V.t g X

336 CHARING CROSS HOSPITAL AND MEDICAL SCHOOL It should provide first-class arrangements for research, which mnust be a prime aim of any teaching school. It must provide, for all who work within it, proper and congenial surroundings to enable all to play a full and rewarding part towards the care of the patients. It should help to foster a close association with the local medical practitioners and the social services of the local authority.

Fig. 2. Six-bed ward.

Inter-relationships and communications During planning very careful consideration was given to the relative positions of departments, and particularly to communications, both horizontal and vertical, to telephones, and to staff location systems. Desires to provide both increased privacy and increased care for patients are not easy to reconcile. The ward plan after much thought was fixed at 26 beds: two 4-bedded, two 6-bedded, and six single rooms. Consideration of function in design resulted in the acceptance of a race-track plan-service and treatment rooms centrally placed with bed rooms around the periphery-in order to shorten the walking distances for staff. This aim has been further helped by a very extensive inter- communication system. This system, pioneered by Mr. Cass, consists 337 PETER F. PHILIP of an 'intercom' system from each bed and all other ward areas, ac- tuated by a button and connected to a central station adjacent to the telephone exchange. This is manned throughout 24 hours. Immediate contact can be established with the patients in bed, by name, and their needs ascertained. Associated with this is a nursing staff location sys- tem: a light outside each room in the ward, again actuated by a simple button, shows the situation of nurses and sister within the ward and at the central station. The controller at the central station sorts the needs of the patients. 'Housekeeping' requests can be transmitted to the appropriate staff in the ward kitchen, while the nearest available nurse can be informed of a patient's nursing requirements in a much shorter space of time than it takes to read this. In this way a patient's 'call' will always be answered within a very short space of time, helping to give contact and reassurance while retaining privacy. A bleep system will be widely used by all medical and many other staff. They will be able to answer the call from any bedside via the patient call system, thus saving many journeys to a telephone. Within the theatres, loudspeaker phones will enable staff to deal with problems without leaving the theatre if they wish, but these will be operational only at the request of the surgeon using the theatre, and during normal working hours all telephone calls come through a receptionist at the local switchboard. A telephone in the exit room of each theatre is connected to the central dictation system so that, if required, operation notes can be dictated immediately and typed for inclusion in the patient's notes.

The tower block plan The basic plan of the main tower block, which houses the wards and the laboratories, is in the form of a cross. Three ward wings of 26 beds lie north, west, and south of the cen- tral core of 13 lifts (Fig. 3). Two of these lifts are within the core, providing quite separate disposal lifts with a good area for collection of waste from the three ward wings. There is thus no reason for dirty material of any sort to remain for any length of time in the ward area. The fourth (east) limb of the cross, or 'link' to the laboratory block, has office accommodation for medical staff, four consultant and two registrar offices, an office for secretaries, an office for a Nursing No. 7 (Salmon staffing structure), a students' laboratory, a teaching room of approximately 350 sq. ft., and research laboratories of about 1,000 sq. ft. Thus, in design, an attempt has been made to assist medical staff to conduct research close to the point of their main work, to provide a unit base with secretarial assistance, and to co-ordinate the patient- service, teaching, and research activities. 338 CHARING CROSS HOSPITAL AND MEDICAL SCHOOL The laboratory block houses the preclinical departments, three tiered lecture theatres with 120 seats, all the service and medical school de- partments, and one floor for clinical research. The professorial units of medicine and surgery each occupies one complete floor of the ward block with beds in two wings. The third ward wing on each floor is specially designed as laboratories for re- search. The 'link' area in the east wing is also adapted for teaching medical and nursing students and for working areas for the academic staff. Thus on one floor the Surgical Professorial Unit has all the clinical, teaching, research, and administration facilities together and, in addition bed lifts

supplies disposal lifts room

& lifts______'I '1 f passenger lifts Fig. 3. Plan of central core.

to spacious biochemical laboratories, there is a well-designed clinical investigation suite including a theatre, equipment with X-ray image intensifier with television display, and videotape recording facilities. Constant-environment and special sampling rooms staffed by part-time experienced nursing staff will enable any clinical investigation to be conducted in maximum comfort for the patients. The operation theatres are ten in number and are located on the 14th floor of the tower block above the wards, thus retaining the use of the central core of lifts for transportation. The actual wheeling dis- tance for patients is reduced to a minimum. Placing the theatres above the wards allowed a completely different floor plan as regards ducts and drainage, although of course restricting the perimeter to that of the ward block. 339 PETER F. PHILIP General theatre plan The theatres are all self-contained-twin theatres were considered unsatisfactory from a cross-infection viewpoint. Every surgeon has in- dividual requirements and therefore it was felt that instruments should not leave the theatre complex, but all drapes, dressings, and re- ceivers are provided from the Central Sterile Supply Department. Flow patterns to prevent cross-traffic between patients, instruments. and surgeons resulted in a basic plan for the theatre (Fig. 4). All theatres have natural light and views of the surroundings of the hospital I theatre 7 ~~~~~~~~2sluice 6 0 2 3 layup 4 anaesthetic room 7] 5 exit room 8 6 scrub up 5 W 4 3 ,8 7 teaching room 8 equipment room 'L,XJlW 0 -t L S99 disposal chute corridor

Fig. 4. Plan of a standard theatre.

for most surgeons who spend all day in theatre prefer to be able to see out at times, and it was felt essential also to provide the theatre stafT with a view outwards. Entry to theatre. Stafj arrive by lift to the 13th floor, put over- shoes on at a barrier, and then walk into their respective changing rooms. When changed into theatre clothes they pass out on to a clean corridor and up a flight of stairs to the theatre floor. This flight oc- cupies the area which on ward floors is the disposal collection room. The disposal lift shafts do not open on the 13th and 14th floors; on the 14th floor only the bed lifts open on the reception side-the east side of the lift core opposite the 'link', which in this case forms the re- covery ward. Patients arrive by lift to the 14th floor in their beds. They are theni lifted at the transfer zone to a trolley; fresh coverings replace the bed clothes. The patient's trolley then passes through electrically operated doors into the clean corridor running round the other three sides of 340 CHARING CROSS HOSPITAL AND MEDICAL SCHOOL the lift core and thence into one of the three theatre wing corridors. 'T'he bed goes to the recovery ward to await the patient's return CSSD packs and stores arrive by the bed lifts outside normal hours of theatre use in closed trolleys and are transferred to a theatre trolley at the changeover point before entering the clean zone. Circulation within each theatre. *The nursing and surgical staff enter the theatre via the scrub-up room-six places in view of the presence of students, both medical and nursing. The sinks are fed by single elbow-operated taps at each place with individual temperature ad- justment. There is a large viewing window from scrub-up into theatre. Beyond the scrub-up, a gowning area leads directly into the theatre, without a door. The clean lay-up room is supplied, by pass-through cupboards from the clean corridor, with packs from CSSD containing bowls, towels, and swabs and dressings. Instruments join these from a pass-through auto- clave between it and the dirty utility/sluice/preparation room, and knife blades, lotions, etc., are added in the lay-up room. Again there is no door between lay-up room and theatre. After the operation all instruments, swabs, etc., go to the sluice, which has a stable door-to discourage any mixing of theatre staff. lInstruments are washed and dried in a washer, stored, or relaid up. I'repacking and sterilizing of instruments is possible as the autoclaves are high-vacuum, downward-displacement in type. Disposal of swabs, bowls, and dishes for return to CSSD and of (lirty laundry, each in different coloured plastic sacks, takes place via a chute enclosed within a small room beyond two adjacent sink rooms. Thus no dirty material ever goes down the clean theatre corridors. Full air-conditioning is available in all theatres, but by virtue of thc fact that the three wings are at different points of the compass it is possible to limit the cooling needed; it is directed to those theatres needing it as the sun moves round on those few hot summer days. Other services are brought in by a main panel on the wall opposite the scrub-up observation window, This contains three X-ray panels, a bright spot, temperature and alarm controls for the ventilation, tele- phone, central communications, porters' call button, and 13-amp switch sockets. Two vertical pendants supply nitrous oxide, oxygen, and suction and compressed air to the regions of the head and foot of the table to avoid trailing cables on the floor. These pendants also carry three 13-amp sockets and a low-voltage socket. Between the anaesthetic and exit rooms is a pass-through cupboard for pillows and theatre table parts, and a door to enable the operation table to pass between one and the other room as the unit was designed 341 PETER F. PHILIP to be used with two tables, patients being positioned in the anaesthetic room and wheeled into and out of the theatre on the table. The exit room is furnished with writing desk, telephone, and sink unit for examination of pathological material before 'potting' for dispatch to the Morbid Anatomy Department. For frozen sections there is a Lamson pneumatic tube to the Morbid Anatomy Department. This leaves from a small room close to the main

Fig. 5. Standard operating theatre. exit point, which is also set up for examination of pathological speci- mens. Adjacent to this is the porter's room and blood bank refrigerator, which can be approached by the staff of the Haematology Department without entering the clean areas of the theatre. Of the ten theatres, seven are standard suites; an orthopaedic theatre with adjacent plaster theatre, a small endoscopy theatre, and a large neurosurgical and cardiological theatre opening into a fully equipped X-ray room with image intensifiers complete the ten. The X-ray room can also be entered from the main clean corridor and is fully serviced for anaesthetics. The plaster theatre also has a direct entry to a develop- ing and viewing X-ray suite. A black-and-white television link joins the X-ray rooms to the X-ray Department on the 1st floor. Each wing of the theatre floor has a sister's office at the end and also an area for special purposes-for example, one is used for the 342 CHARING CROSS HOSPITAL AND MEDICAL SCHOOL cleaning and preparation of cardiopulmonary bypass machines and an- other for special research apparatus for use during surgery. A small blood gas analysis laboratory is also included close to the cardiac/ neurosurgical theatre. A students' teaching room opens off one theatre in each wing. Each wing also has a large equipment storage room and a pack storage area. Recovery ward. Of remarkably spacious dimensions (60 ft. X 60 ft.) this has bays for 15 trolleys or beds for rapidly recovering patients and five bays in which patients can be held for longer periods of ob- servation or further special investigations. This ward is on the 'less clean' side of the theatre floor, opens off the reception area and bed lifts, and is in the 'link' area. Removal of linen and material for dis- posal is via the laboratory service lifts, so here again no contaminated material goes back into the centre core at this level. An anaesthetists' room with overnight facilities is adjacent to the recovery area. Further developments In the subsequent phase of building two operation theatres will be provided in the Accident and Emergency Department; two will be pro- vided for outpatient minor surgery and investigative procedures and there will be theatres in the radiotherapy and maternity blocks. Soon after the first phase was opened the building of the medical school block, to include a very large lecture theatre, library, students' facilities, and administration, was due to start and will be complete in 1975. Temporary library facilities are being provided in the clinical research area of the laboratory block and administration and other facil- ities in the old Brandenburg House nurses' home opposite the hospital. From December 1972 the whole staff and students have been able to enjoy the amenity of a very large assembly hall-the Wolfson Hall -the Hayward swimming pool, squash courts, and a bar in a building to be known as the Charing Cross Club situated on part of the site kindly given by the Department of Health and close to the three resi- dential towers, two of which are complete, while the third should be finished in two years' time. The complex should be complete in 1977. Conclusion This present phase is an enormous building, with most complex en- gineering services, and its completion on time is a triumph due to the efforts of the architect, Mr. Ralph Tubbs, O.B.E., F.R.I.B.A., and his professional colleagues and the contractors, Higgs and Hill Ltd. The hospital planning team are also very conscious of the kindness and co-operation received over the years from many officers in the Depart- ment of Health too numerous to name individually. 343