concept of critical care

CONCEPT OF CRITICAL CARE

INTRODUCTION

The intensive care unit is not merely a room or series of room filled with patients attached to interventional technology; it is the home of an organization: the intensive care team.

THE INTENSIVE CARE TEAM.

This team – • Doctor• Nurses• Therapists• Nutritionists• Chaplains and other

support staff, builds an environment for healing or dying.

CRITICAL CARE NURSING

Critical care nursing is that specialty within nursing that deals specifically with human responses to life-threatening problems.

SEVEN Cs OF CRITICAL CARE

• Compassion • Communication (with patient and family). • Consideration (to patients, relatives and

colleagues) and avoidance of Conflict. • Comfort: prevention of suffering • Carefulness (avoidance of injury) • Consistency • Closure (ethics and withdrawal of care).

CRITICAL CARE NURSE

A critical care nurse is a licensed professional nurse who is responsible for ensuring that acutely and critically ill patients and their families receive optimal care .

CRITICAL CARE UNIT

• Critical care unit is a specially designed and equipped facility staffed by skilled personnel to provide effective and safe care for dependent patients with a life threatening problem.

THE AIM OF THE CRITICAL CARE:-

is to see that one provides a care such that patient improves and survives the acute illness or tides over the acute exacerbation of the chronic illness.

THE EVOLUTION OF CRITICAL CARE

•Forty years of development in critical care and critical care nursing has given rise to a recognized speciality in nursing practice .•Critical care units have evolved over the last four decades in response to medical advances .

HISTORICAL PRESPECTIVES• Florence nightingale recognized the need to

consider the severity of illness in bed allocation of patients and placed the seriously ill patients near the nurses’ station.

• 1923, John Hopkins University Hospital developed a special care unit for neurosurgical patients .

• Modern medicines boomed to its higher ladder after world war 2

Bennett, D. et al. BMJ 1999;318:1468-1470

HISTORICAL PRESPECTIVES• As surgical techniques advanced it became

necessary that post operative patient required careful monitoring and this came about the recovery room.

• In 1950, the epidemic of poliomyelitis necessitated thousands of patients requiring respiratory assist devices and intensive nursing care.

• At the same time came about newer horizons in cardiothoracic surgery, with refinements in intraoperative membrane oxygen techniques.

HISTORICAL PRESPECTIVES

• In 1953, Manchester Memorial Hospital opened a four bedded unit at Philadelphia was started.

• By 1957, there were 20 units in USA and

• In 1958,the number increased to 150.

CONTEXTUAL FORCES• The expansion of American hospital system and

hospital insurance.• Architectural, hospital changes towards private

and semi private accommodations.• Reallocations for direct patient care responsibility

and creations of new forms of care.• During 1970’s,the term critical care unit came

into existence which covered all types of special care

TYPES OF ICUs

There are two types of ICUs,• An open :-. In this type, physicians admit, treat

and discharge and • A closed: in this type, the admission, discharge

and referral policies are under the control of intensivists.

ICUS CAN BE CLASSIFIED AS:

• Level I: This can be referred as high dependency is where close monitoring, resuscitation, and short term ventilation <24hrs has to be performed.

• Level II: Can be located in general hospital, undertake more prolonged ventilation. Must have resident doctors, nurses, access to pathology, radiology, etc.

• Level III: Located in a major tertiary hospital, which is a referral hospital. It should provide all aspects of intensive care required.

STAFFING

• Large hospital requires bigger team.

Medical staff

• Carrier intensivists are the best senior medical

Staff to be appointed to the ICU.• He/she will be the director.• Less preferred are other specialists viz. From

Anaesthesia, medicine and chest who have clinical Commitment elsewhere.

• Junior staff are intensive care trainees and trainees on deputation from other disciplines.

NURSING STAFF

• The major teaching tertiary care ICU will require trained nurses in critical care.

• It may be ideal to have an in house training programme for critical Care nursing.

• The number of nurses ideally required for such units is 1:1 ratio.

• In complex situations they may require two nurses per patient.

• The number of trained nurses should be also worked out by the type of ICU, the workload and work statistics and type of patient load.

UNIT DIRECTOR:-

Specific requirements for the unit director include the following:

• Training, interest, and time availability to give clinical, administrative, and educational direction to the ICU.

• Board certification in critical care medicine. • Time and commitment to maintain active and regular

involvement in the care of patients in the unit.

• Availability (either the director or a similarly qualified surrogate) to the unit 24 hrs a day, 7 days a week for both clinical and administrative matters.

• Active involvement in local and/or national critical care societies.

• Participation in continuing education programs in the field of critical care medicine.

• Hospital privileges to perform relevant invasive procedures.

• Active involvement as an advisor and participant in organizing care of the critically ill patient in the community as a whole.

• Active participation in the education of unit staff. • Active participation in the review of the appropriate use

of ICU resources in the hospital.

NURSE MANAGER• An RN (registered nurse) with a BSN (bachelor of

science in nursing) or preferably an MSN (master of science in nursing) degree

• Certification in critical care or equivalent graduate education

• At least 2 yrs experience working in a critical care unit• Experience with health information systems, quality

improvement/risk management activities, and healthcare economics

• Ability to ensure that critical care nursing practice meets appropriate standards .

• Preparation to participate in the on-site education of critical care unit nursing staff

NURSE MANAGER• Ability to foster a cooperative atmosphere with regard to

the training of nurses, physicians, pharmacists, respiratory therapists, and other personnel involved in the care of critical care unit patients

• Regular participation in ongoing continuing nursing education

• Knowledge about current advances in the field of critical care nursing

• Participation in strategic planning and redesign efforts

Critical Care Unit nursing requirements:-

• All patient care is carried out directly by or under supervision of a trained critical care nurse.

• All nurses working in critical care should complete a clinical/didactic critical care course before assuming full responsibility for patient care.

• Unit orientation is required before assuming responsibility for patient care.

• Nurse-to-patient ratios should be based on patient acuity according to written hospital policies.

Critical Care Unit nursing requirements :-

• All critical care nurses must participate in continuing education.

• An appropriate number of nurses should be trained in highly specialized techniques such as renal replacement therapy, intra-aortic balloon pump monitoring, and intracranial pressure monitoring.

• All nurses should be familiar with the indications for and complications of renal replacement therapy.

RESPIRATORY CARE PERSONNEL REQUIREMENTS

• Respiratory care services should be available 24 hrs a day, 7 days a week.

• An appropriate number of respiratory therapists with specialized training must be available to the unit at all times. Ideal levels of staffing should be based on acuity, using objective measures whenever possible.

• Therapists must undergo orientation to the unit before providing care to ICU patients.

RESPIRATORY CARE PERSONNEL REQUIREMENTS

• The therapist must have expertise in the use of mechanical ventilators, including the various ventilatory modes.

• Proficiency in the transport of critically ill patients is required.

• Respiratory therapists should participate in continuing education and quality improvement related to their unit activities.

• Ideally, 24-hr in-house coverage should be provided by intensivists who are dedicated to the care of ICU patients and do not have conflicting responsibilities.

• Ideal intensivist-to-patient ratios vary from ICU to ICU depending on the hospital’s unique patient population. Hospitals should have guidelines for these ratios based on acuity, complexity, and safety considerations.

• The following physician subspecialists should be available and be able to provide bedside patient care within 30 mins:

PHYSICIAN SUBSPECIALISTS

• General surgeon or trauma surgeon • Neurosurgeon • Cardiovascular surgeon • Obstetric-gynecologic surgeon • Urologist • Thoracic surgeon • Vascular surgeon • Anesthesiologist • Cardiologist with interventional capabilities • Pulmonologist

PHYSICIAN SUBSPECIALISTS

• Gastroenterologist • Hematologist • Infectious disease specialist • Nephrologist • Neuroradiologist (with interventional capability) • Pathologist • Radiologist (with interventional capability) • Neurologist • Orthopedic surgeon

S.NO.

THERAPIST FUNCTION

1. Physiotherapists prevents and treat chest problems, assist mobilization, and prevent contractures in immobilized patients

2. Pharmacists A advise on potential drug interactions and side effects, and drug dosing in patients with liver or renal dysfunction

3. Dietitians Advise on nutritional requirements and feeds

4. Microbiologists Advise on treatment and infection control

5. Medical physics technicians

Maintain equipment, including patient monitors, ventilators, haemofiltration machines, and blood gas analysers

OTHER PERSONNEL:

A variety of other personnel may contribute significantly to the efficient operation of the ICU. These include:-

• Unit clerks• physical therapists• occupational therapists• Advanced practice nurses• Physician assistants• Dietary specialists, and • Biomedical engineers.

LABORATORY SERVICES

• A clinical laboratory should be available on a 24-hr basis to provide basic hematologic, chemistry, blood gas, and toxicology analysis.

• Laboratory tests must be obtained in a timely manner, immediately in some instances. "STAT" or "bedside" laboratories adjacent to the ICU or rapid transport systems.

Radiology and imaging services:

• The diagnostic and therapeutic radiologic procedures should be immediately available to ICU patients, 24 hrs per day.

• Portable chest radiographs affect decision making in critically ill patients.

ORGANIZATION OF ICU

• It requires intelligent planning.• One must keep the need of the hospital and

its location.• One ICU may not cater to all needs.• An institute may plan beds into multiple

units under separate management by single discipline specialist viz. medical ICU, surgical ICU, CCU, burns ICU, trauma ICU, etc.

ORGANIZATION OF ICU

• The number of ICU beds in a hospital ranges from 1 to 10 per 100 total hospital beds.

• Multidisciplinary requires more beds than single speciality. ICUs with fewer than 4 beds are not cost effective and over 20 beds are unmanageable.

• ICU should be sited in close proximity to relevant areas viz. operating rooms, image logy, acute wards, emergency department.

• There should be sufficient number of lifts available to carry these critically ill patients to different areas.

ORGANIZATIONAL MODELS FOR ICUs:

• the open model allows many different members of the medical staff to manage patients in the ICU.

• the closed model is limited to ICU-certified physicians managing the care of all patients; and

• the hybrid model, which combines aspects of open and closed models by staffing the ICU with an attending physician and/or team to work in tandem with primary physicians.

DEFINITION OF INTENSIVE CARE UNIT EQUIPMENTS:-

• Intensive care unit (ICU) equipment includes patient monitoring, respiratory and cardiac support, pain management, emergency resuscitation devices, and other life support equipment designed to care for patients who are seriously injured, have a critical or life-threatening illness, or have undergone a major surgical procedure, thereby requiring 24-hour care and monitoring.

PURPOSE

• An ICU may be designed and equipped to provide care to patients with a range of conditions, or it may be designed and equipped to provide specialized care to patients with specific conditions

DESCRIPTION

• Intensive care unit equipment includes:-

• patient monitoring

• life support and emergency resuscitation devices

• diagnostic devices

PATIENT MONITORING EQUIPMENTS

• Acute care physiologic monitoring system

• Pulse oximeter

• Intracranial pressure monitor

• Apnea monitor

LIFE SUPPORT & RESUSCITATIVE EQUIPMENTS

• VENTILATOR

• INFUSION PUMP

• CRASH CART

• INTRAAORTIC BALOON PUMP

DIAGNOSTIC EQUIPMENTS

• MOBILE X-RAYS

• PORTABLE CLINICAL LAB. DEVICES

• BLOOD ANALYZER

THERAPEUTIC ELEMENTS IN ICU ENVIORNMENT

•Window and art that provides natural views; views of nature can reduce stress, hasten recovery, lower blood pressure and lower pain medication needs.

•Family participation ,including facilities for overnight stay and comfortable waiting rooms.

THERAPEUTIC ELEMENTS IN ICU ENVIORNMENT

• Providng a measure of privacy and personal control through adjustable curtains and blinds ,accessible bed controls ,and TV ,VCR and CD players.

• Noise reduction through computerized pagers and silent alarms.

• Medical team continuity that allows one team to follow the patient through his or her entire stay.

ICU TEAMICU TEAMICU deign should be approached

by multidisciplinary team consisting of :-

• ICU MEDICAL DIRECTORS• ICU NURSE MANAGER• THE CHIEF ARCHITECT• THE OPERATING ENGINEERING

STAFF

OTHER ADDITIONAL MEMBERS• ENVIORNMENTAL ENGINEER• INTERIOR DESIGNERS• STAFF NURSES• PHYSICIANS • PATIENTS• FAMILIES

• THE CHIEF ARCHITECT -He must be experienced in hospital space programming and hospital functional planning.

• ENGINEER – He should be experienced in the design of mechanical and electrical systems For hopitals,especially critical care unit.

FLOOR PLAN AND DESIGNIT SHOULD BE BASED ON:-• Patient admission pattern• Staff & visitor traffic patterns• Need for support facilities such a

nursing station ,Storage, clerical space,

• Administrative & educational requirements.

• Services that are unique to the individual institution.

FLOOR PLAN AND DESIGN• Eight to twelve beds per unit is

considered best from a functional perspective .

• Each healthcare facility should consider the need for positive- and negative pressure isolation rooms within the ICU.

• This need will depend mainly upon patient population and State Department of Public Health requirements.

FLOOR PLAN AND DESIGN• Each intensive care unit should be a

geographically distinct area within the hospital, when possible, with controlled access.

• No through traffic to other departments should occur. Supply and professional traffic should be separated from public/visitor traffic.

• Location should be chosen so that the unit is adjacent to, or within direct elevator travel to and from, the Emergency Department, Operating Room, intermediate care units, and Radiology Department

PATIENT AREAS.:-

Patients must be situated so that direct or indirect (e.g. by video monitor) visualization by healthcare providers is possible at all times. This permits the monitoring of patient status under both routine .and emergency circumstances. The preferred design is to allow a direct line of vision between the patient and the central nursing station.

In ICUs with a modular design, patients should be visible from their respective nursing substations.

Sliding glass doors and partitions facilitate this arrangement, and increase access to the room in emergency situations.

RECOMMENDED NOISE RANGES

Signals from patient call systems, alarms from monitoring equipment, and telephones add to the sensory overload in critical care units.

The International Noise Council has recommended that noise levels in hospital acute care areas

• not exceed 45 dB(A) in the daytime, • 40 dB(A) in the evening,• 20 dB(A) at night. ☻Notably, noise levels in most hospitals are

between 50-70 dB(A) with occasional episodes above this range

CENTRAL STATION• A central nursing station should provide a

comfortable area of sufficient size to accommodate all necessary staff functions.

• When an ICU is of a modular design, each nursing substation should be capable of providing most if not all functions of a central station.

• There must be adequate overhead and task lighting, and a wall mounted clock should be present.

• Adequate space for computer terminals and printers is essential when automated systems are in use.

• Patient records should be readily accessible .

CENTRAL STATION• Adequate surface space and seating for

medical record charting by both physicians and nurses should be provided.

• Shelving, file cabinets and other storage for medical record forms must be located so that they are readily accessible by all personnel requiring their use.

• Although a secretarial area may be located separately from the central station, it should be easily accessible as well

X-RAY VIEWING AREA.

A separate room or distinct area near each ICU or ICU cluster should be designated for the viewing and storage of patient radiographs.

An illuminated viewing box or carousel of appropriate size should be present to allow for the simultaneous viewing of serial radiographs.

A "bright light" should also be available.

WORK AREAS AND STORAGE

Work areas and storage for critical supplies should be located within or immediately adjacent to each ICU.

There should be a separate medication area of at least 50 square feet containing a refrigerator for pharmaceuticals, a double locking safe for controlled substances, and a sink with hot and cold running water.

Countertops must be provided for medication preparation, and cabinets should be available for the storage of medications and supplies.

RECEPTION AREA

RECEPTIONIST AREA• Each ICU or ICU cluster should have a

receptionist area to control visitor access. • Ideally, it should be located so that all

visitors must pass by this area before entering.

• The receptionist should be linked with the ICU(s) by telephone and/or other intercommunication system.

• It is desirable to have a visitors' entrance separate from that used by healthcare professionals.

• The visitors' entrance should be securable if the need arises.

Special Procedures Room.• If a special procedures room is desired, it

should be located within, or immediately adjacent to, the ICU.

• One special procedures room may serve several ICUs in close proximity.

• Consideration should be given to ease of access for patients transported from areas outside the ICU.

• Room size should be sufficient to accommodate necessary equipment and personnel.

Special Procedures Room.• Monitoring capabilities, equipment,

support services, and safety considerations must be consistent with those provided in the ICU proper.

• Work surfaces and storage areas must be adequate enough to maintain all necessary supplies and permit the performance of all desired procedures without the need for healthcare personnel to leave the room

Clean and Dirty Utility Rooms.

• Clean and dirty utility rooms must be separate rooms that lack interconnection.

• They must be adequately temperature controlled, and the air supply from the dirty utility room must be exhausted.

• Floors should be covered with materials without seams to facilitate cleaning.

• The clean utility room should be used for the storage of all clean and sterile supplies, and may also be used for the storage of clean linen.

Clean and Dirty Utility Rooms.

• Shelving and cabinets for storage must be located high enough off the floor to allow easy access to the floor underneath for cleaning.

• The dirty utility room must contain a clinical sink and a hopper both with hot and cold mixing faucets.

• Separate covered containers must be provided for soiled linen and waste materials.

• There should be designated mechanisms for the disposal of items contaminated by body substances and fluids.

• Special containers should be provided for the disposal of needles and other sharp objects.

Equipment Storage• An area must be provided for the

storage and securing of large patient care equipment items not in active use.

• Space should be adequate enough to provide easy access, easy location of desired equipment, and easy retrieval.

• Grounded electrical outlets should be provided within the storage area in sufficient numbers to permit recharging of battery operated items.

Nourishment Preparation Area

• A patient nourishment preparation area should be identified and equipped with food preparation surfaces, an ice-making machine, a sink with hot and cold running water, a countertop stove and/or microwave oven, and a refrigerator.

• The refrigerator should not be used for the storage of laboratory specimens.

• A hand washing facility should be located in or near the area.

Staff Lounge.• A staff lounge must be available on or near

each ICU or ICU cluster to provide a private, comfortable, and relaxing environment.

• Secured locker facilities, showers and toilets should be present.

• The area should include comfortable seating and adequate nourishment storage and preparation facilities, including a refrigerator, a countertop stove and/or microwave oven.

• The lounge must be linked to the ICU by telephone or intercommunication system, and emergency cardiac arrest alarms should be audible within.

Conference Room.• A conference room should be conveniently located for ICU

physician and staff use.• This room must be linked to each relevant ICU by telephone or

other intercommunication system, and emergency cardiac arrest alarms should be audible in the room.

• The conference room may have multiple purposes including continuing education, house staff education, or multidisciplinary patient care conferences.

• A conference room is ideal for the storage of medical and nursing reference materials and resources, VCRs, and computerized interactive and self-paced learning equipment.

• If the conference room is not large enough for educational activities, a classroom should also be provided nearby.

Visitors' Lounge/Waiting Room.

• A visitors' lounge or waiting area should be provided near each ICU or ICU cluster.

• Visitor access should be controlled from the receptionist area. One and one-half to two seats per critical care bed are recommended.

• Public telephones (preferably with privacy enclosures) and dining facilities must be available to visitors.

• Television and/or music should be provided.• Public toilet facilities and a drinking fountain should

be located within the lounge area or immediately adjacent.

Visitors' Lounge/Waiting Room.• Warm colours, carpeting, indirect soft

lighting, and windows are desirable .• A variety of seating, including upright,

lounge, and reclining chairs, is also desirable.

• Educational materials and lists of hospital and community-based support and resource services should be displayed.

• A separate family consultation room is strongly recommended.

Patient Transportation Routes

• Patients transported to and from an ICU should be transported through corridors separate from those used by the visiting public.

• Patient privacy should be preserved and patient transportation should be rapid and unobstructed.

• When elevator transport is required, an oversized keyed elevator, separate from public access, should be provided.

Supply and Service Corridors

• A perimeter corridor with easy entrance and exit should be provided for supplying and servicing each ICU.

• Removal of soiled items and waste should also be accomplished through this corridor.

• This helps to minimize any disruption of patient care activities and minimizes unnecessary noise.

Supply and Service Corridors

• The corridor should be at least 8 feet in width.

• Doorways, openings, and passages into each ICU must be a minimum of 36 inches in width to allow easy and unobstructed movement of equipment and supplies.

• Floor coverings should be chosen to withstand heavy use and allow heavy wheeled equipment to be moved without difficulty .

Patient Modules• Ward-type icus should allow at least 225

square feet of clear floor area per bed.• Icus with individual patient modules

should allow at least 250 square feet per room (assuming one patient per room),

• Provide a minimum width of 15 feet, excluding ancillary spaces (anteroom, toilet, storage).

Patient Modules

• Isolation rooms should each contain at least 250 square feet of floor space plus an anteroom.

• Each anteroom should contain at least 20 square feet to accommodate hand-washing, gowning, and storage.

• If a toilet is provided, it must be private.

Patient Modules

• A cardiac arrest/emergency alarm button must be present at every bedside within the ICU. The alarm should automatically sound in the hospital telecommunications center, central nursing station, ICU conference room, staff lounge, and any on-call rooms. The origin of these alarms must be discernable.

• Space and surfaces for computer terminals and patient charting should be incorporated into the design of each patient module as indicated.

Patient Modules• Storage must be provided for each

patient's personal belongings, patient care supplies, linen and toiletries. Locking drawers and cabinets must be used if syringes and pharmaceuticals are stored at the bedside.

• Personal valuables should not be kept in the ICU. Rather, these should be held by Hospital Security until patient discharge.

• Every effort should be made to provide an environment that minimizes stress to patients and staff. Therefore, design should consider natural illumination and view.

Patient Modules• Windows are an important aspect of

sensory orientation, and as many rooms as possible should have windows to reinforce day/night orientation .

• Drapes or shades of fireproof fabric can make attractive window coverings and serve to absorb sound.

• Window treatments should be durable and easy to clean, and a schedule for their cleaning must be established

IMPROVING SENSORY ORIENTATION

Additional approaches to improving sensory orientation for patients may include :-

• the provision of a clock, calendar, bulletin board,

• pillow speaker connected to radio and television.

• Televisions must be out of reach of patients and operated by remote control.

• If possible, telephone service should be provided in each room.

• Comfort considerations should include methods for establishing privacy for the patient. Shades, blinds, curtains, and doors should control the patient's contact with his/her surroundings.

• A supply of portable or folding chairs should be available to allow for family visits at the bedside. An additional comfort consideration is the choice of color scheme for the room, which should promote rest and have a calming effect.

•

•To provide for visual interest, one or more walls within patient view may be selected for an accent color, texture, graphic design or picture .

•Advice from environmental engineers and designers should be sought to deinstitutionalize patient care areas as much as possible.

Utilities

• Each intensive care unit must have :-• Electrical power, • Water, oxygen,• Compressed air,• Vacuum, lighting,• And environmental control systems that support the needs of the patients

and critical care team under normal and emergency situations, and these must meet or exceed regulatory and accreditation agency codes and standards .

ELECTRIC SUPPLY

• Grounded 110 volt electrical outlets with 30 amp circuit breakers should be located within a few feet of each patient's bed .

• Sixteen outlets per bed are desirable.• Outlets at the head of the bed should be placed

approximately 36 inches above the floor to facilitate connection,

• To discourage disconnection by pulling the power cord rather than the plug.

• Outlets at the sides and foot of the bed should be placed close to the floor to avoid tripping over electrical cords.

Water Supply. • The water supply must be from a certified source,

especially if hemodialysis is to be performed.

• Zone stop valves must be installed on pipes entering each ICU to allow service to be turned off should line breaks occur.

• Hand-washing sinks deep and wide enough to prevent splashing, preferably equipped with elbow-, knee-, foot-, or sonar-operated faucets, must be available near the entrances to patient modules, or between every two patients in ward-type units.

Lightning

• Total luminance should not exceed 30 foot-candles .• It is preferable to place lighting controls on variable-

control dimmers located just outside of the room.• Night lighting should not exceed 6.5 fc for

continuous use or 19 fc for short periods.• Separate lighting for emergencies and procedures

should be located in the ceiling directly above the patient and should fully illuminate the patient with at least 150 fc shadow-free

• A patient reading light is desirable, and should be mounted

Environmental Control Systems.

• A minimum of six total air changes per room per hour are required, with two air changes per hour composed of outside air.

• For rooms having toilets, the required toilet exhaust of 75 cubic feet per minute should be composed of outside air.

• Central air-conditioning systems and recirculated air must pass through appropriate filters.

• Air-conditioning and heating should be provided with an emphasis on patient comfort.

• For critical care units having enclosed patient modules, the temperature should be adjustable within each module.

Computerized Charting

• These systems provide for "paperless" data management, order entry, and nurse and physician charting. If and when a decision is made to utilize this technology, it is important to integrate such a system fully with all ICU activities.

• Bedside terminals facilitate patient management by permitting nurses and physicians to remain at the bedside during the charting process.

OTHER FACILITIES

•Voice Intercommunication Systems

•Satellite Laboratory•Physician On-Call Rooms•Administrative Offices