This discussion applies to in-plant occupational medical facilities. Although many of the concepts apply equally well to general or group clinics, the needs of the in-plant facilities are more highly specialized.
The siting and design of the clinical facility itself should be undertaken with care and preferably designed by reference to a successful model. It is impossible to describe a design that meets the needs of all organizations. This section, therefore, will concentrate on general principles of space allocation, access, configuration, interior fixtures, and equipment.
A rule of thumb perpetuated in several references suggests that a minimum of 200 square feet should be available with roughly one square foot per employee over 200 up to about 1000 square feet. This space formula is too small for efficiency of operation and does not take into account the needs of any proactive health services such as health promotion or wellness programs. About 50% above this rule of thumb one and one-half square feet, or 0.25 square meter per employee above 200 added to a minimum 1500 square feet or 30 square meters, would be preferred.
Access is critically important, to the point that it is better to accept more cramped quarters in a central location than to build a new and spacious facility on the periphery of a worksite. The occupational health clinic should be easily reached by motor vehicles, barrier-free for the handicapped, and close to where employees work. In industries where the job site is large or where the work force is spread out or remote, the clinic should be near the traffic flow in and out of the area. In office buildings or in satellite dispensaries, it is acceptable to be on an upper floor if access to an elevator on the way to an exit can be assured through key-controlled override systems and a parking place for an ambulance in emergencies can be provided. Otherwise, the clinic is best positioned on the ground floor for easy access.
The configuration of the clinic is an important determinant of its efficiency. In general, there should be a central receiving and triage area where injured or well employees can be comfortably seated. The entrance from this waiting area into the clinic area should be barrier-free and wide enough to accommodate three people standing abreast, whether supporting a fainting person or handling a stretcher. Two examination rooms should be provided, at a minimum, each with separate entrances opening onto a corridor screened from view of the waiting area. At least one examination room should be equipped for minor surgery and stabilization of trauma cases in heavy manufacturing or other industries with a high injury rate. This room should have easy access to an ambulance parking area and should be large enough to allow several persons to surround the examining table. The other can be equipped less elaborately as a consultation room. Each examination room should have a curtain and stool for use by patients to undress. A toilet and shower must be provided in the clinic area and a separate toilet for staff. If radiation decontamination is anticipated, a separate shower with its own entrance and anteroom equipped for the purpose may be needed. A rear exit is desirable, to avoid the problem of staff coming and going through a crowded waiting room and it is optimal for this exit to be adequate for the transfer of an injured worker to an ambulance without the necessity of carrying the worker through the waiting room. Administrative areas, offices of professional staff, and areas used for interviews and individualized or small group health education programs should be easily reached but soundproof for confidentiality. Record-keeping areas and files must be secure and inaccessible to casual visitors. These basic areas should be within steps of one another.
Two examples of flow plans for occupational health services are provided in Figures 10.1 and 10.2. Figure 10.1 represents a plan for a busy clinic with two health providers practicing. Figure 10.2 is a plan for a center emphasing prevention, worker's evaluation, and counselling of injured or disabled workers. Both are compromises to accommodate the space available. The best floor plan for a particular facility will depend on the space available, anticipated patient volume, staffing, and services to be provided. Traffic flow is particularly critical; paths to be taken by different types of patients should be traced and areas where paths cross and where patients are likely to stand waiting should be identified and separated. Privacy is essential; the interior of examination rooms should never be visible from the waiting area.
******************************************* * * * Figure 10.1 NOT READY YET * * * *******************************************Figure 10.1. This occupational health facility is set up for two physicians or a physician and an occupational health nurse. Examination rooms are clustered for efficiency in a busy clinical practice. The design is short on filing and conference space and lacks a combined library and conference room, a desirable feature.
******************************************* * * * Figure 10.2 NOT READY YET * * * *******************************************Figure 10.2. This facility sacrifices examining room space for educational and training functions. It works well for preventive and consultation purposes but would be inadequate for a busy clinical practice.
Above this basic configuration, there should be sufficient space for additional needs appropriate to the needs of the industry and the programs offered by the employer. Additional surgeries, a small clinical laboratory, a conference room (which can double as a medical library), and a classroom (which can double as a fitness centre for aerobics if equipped with folding chairs) may be required depending on the size and type of operation. Space for industrial hygiene, safety, radiation health, and physiotherapy may be needed; these functions can be located away from the main clinic area but it is preferable to centralize these functions in one building whenever possible in order to facilitate communication and interaction. Special rooms for audiometric testing (including a sound-proof booth), ophthalmalogic examination (if eye injuries are likely and the physician is qualified to use a slit-lamp), instrument sterilization, or a small pharmacy may be considered within the clinic area. A small, quiet room for ill employees to lie down is very desirable. These special clinic rooms need not be as centrally clustered as the basic units described in the preceding paragraph but should be on the same floor. Custodial closets should not be forgotten.
Interior fixtures should be those appropriate to a modern clinic. The waiting area should be bright, comfortable, and relaxing. The examining rooms should be equipped with examining tables, wall-mounted oto- and ophthalmoscopes, vision charts, wall-mounted sphygmomanometers, overhead lighting, sinks, and scales. The surgery room should be outfitted more completely with overhead adjustable lamps, an adjustable table, resuscitation equipment, and stools. Both should have chairs, floor lamps, adequate counter space, and both open shelves and cupboards labelled for their contents. All surfaces should be easily cleaned and light-colored, with a minimum of nooks and crannies. Each room in which a patient is likely to be interviewed should have a small writing desk and a prominent wall clock. Locks should be on all rooms or cabinets containing instruments, syringes, and drugs, even if constantly attended, and should be used after hours, even if the main clinic door is secured. Water fountains are a courtesy much appreciated. Whenever possible, built-in fixtures and indirect lighting are to be preferred for convenience, appearance, and functionality since they can be mounted above cabinets to conserve space and reduce clutter.
Interior fixtures serve many functions other than supporting the care given. One of the functions is communication. A clinic that look like a modern medical facility will inspire confidence and transmit the (presumably accurate) impression that the occupational health staff is serious and dedicated. A clinic that looks like a storage cubicle or a hospital room circa 1943 will convey the impression that the health of employees is a low priority in the organization. A related function is orientation. Even well employees are often anxious entering a medical facility; this level of anxiety is greater among new employees and among the injured or ill. Nonverbal cues help to orient a person; tersely worded signs alone are often misread or confused. Color coded rooms and lines on the wall (not on the floor, because the employee then must look down and misses other cues) as well as snappy graphics help to orient the visitor and thereby reduce anxiety, as well as increasing efficiency. A bright decor, preferably with some natural lighting, will lend a more cheerful aspect to the clinic but the color combinations used should be soft and warm. Bold primary colors are fine for accent but are visually disconcerting when overused (reds and yellows may even be alarming). Pastels, on the other hand, are not to be preferred in a predominantly masculine workforce. Clinics should not experiment with their decor, but should be familiar and reassuring, neither overly trendy nor bland.
Equipment needed in an occupational medical clinic differs little from that needed in any physician's office or clinic. Table 10.1 lists commonly used instruments and devices likely to be needed. Medications listed in Table 10.2 are the minimum needed for the symptomatic relief of common occupational disorders or personal illnesses affecting employees on the job. It is usually not cost-effective for occupational health clinics to maintain clinical laboratory apparatus beyond a bench centrifuge, microscope, and simple office supplies unless they are remote and must function as a self-contained infirmary. Likewise, it is usually not practical to acquire radiologic apparatus unless the industry is one at high risk for serious injuries and the site is a large one. The proper use of such equipment, in both instances, depends on the constant availability of trained and licensed professionals who keep abreast of technical developments and standards of practice and who service a sufficiently high volume to maintain their skills. If no fully-equipped clinics are readily accessible in the area such equipment may be necessary but the expense and the risk of slowly deteriorating into substandard practice is too great in most situations. Another reason for avoiding expensive laboratory and radiologic equipment is that in-house testing tends to be overutilized because the cost of the initial investment and maintenance has to be justified to management. This may lead to excessive ordering of tests that are seldom useful in occupational health situations (such as serum electrolytes) or to the continuation by inertia of routine studies that are no longer indicated (such as annual or preplacement chest films). Usually, a local clinic or hospital can provide such services as needed and indicated at a lower unit cost, with some guarantee of quality assurance and without an incentive to overorder tests.
Table 10.1. Equipment for an Occupational Medical Clinic 1 Furnishings 1.1 Office 1.1.1 Desks 1.1.2 Chairs 1.1.3 Bookcases 1.1.4 Filing cabinets, with locks 1.1.5 Storage cabinets, with locks 1.1.6 Clocks, wall 1.1.7 Word processor, typewriters 1.1.8 Personal business computer 1.1.9 Tables 1.1.10 Writing boards 1.1.11 Wastebaskets 1.1.12 In/Out baskets 1.1.13 Lamps, desk 1.1.14 Bulletin boards 1.1.15 Camera, 35 mm, and accessories 1.1.16 Calculators 1.2 Clinic 1.2.1 Stools, height appropriate to counter, adjustable with backs 1.2.2 Chart-holders, with priority and occupancy indicators 1.2.3 X-ray view boxes 1.2.4 Sinks with surgical handles on faucets, towel racks 1.2.5 Examination tables (see text) 1.2.6 Chairs (do not leave faint or dizzy patients sitting on stools in rooms) 1.2.7 Medication cabinet, with locks 1.2.8 Pedal-operated wastebaskets with lid and liners 1.2.9 Overhead adjustable lamps (in surgery) 1.2.10 Medical records filing cabinets (for color coded, side viewing) 1.2.11 Opaque movable screens or curtains 1.2.12 Instrument trays 1.2.13 Portable toilet 1.2.14 Autoclave 1.1.15 Cold sterilizer (note: use appropriate venting and control procedures for ethylene oxide!) 1.2.16 Refrigerator 2. Equipment 2.1 Instruments, major 2.1.1 Wall-mounted oto-/ophthalmoscope 2.1.2 Wall-mounted sphygmomanometer (blood pressure cuff) 2.1.3 Crash cart (cardiopulmonary resuscitation), fully equipped 2.1.4 Scales 2.1.5 Electrocardiograph 2.1.6 Audiometer 2.1.7 Vision screening apparatus 2.1.8 Spirometer, recording 2.1.9 Suction apparatus 2.2 Instruments, hand-held 2.2.1 Anoscope 2.2.2 Canes, crutches, walkers 2.2.3 Casettes, ear 2.2.4 Clamps, assorted (Halsted, Kelly, vascular, mosquito) 2.2.5 Crash cart (portable pre-packed unit containing all equipment and supplies needed for cardiopulmonary resuscitation and stablization for transport to hospital) 2.2.6 Dental mirror 2.2.7 Dynamometer (grip strength meter) 2.2.8 Flashlights 2.2.9 Laryngoscope (in crash cart) 2.2.10 Magnifying lens 2.2.11 Percussion hammer 2.2.12 Proctosigmoidoscope 2.2.13 Scalpels 2.2.14 Scissors, surgical 2.2.15 Specula, ear 2.2.16 Specula, nasal 2.2.17 Specula, vaginal 2.2.18 Stethoscope 2.2.19 Tape measures 2.2.20 Thermometers 2.2.21 Tuning forks 2.2.22 Vision chart, color (Ishihara plates) 2.3 Supplies, disposable 2.3.1 Syringes 2.3.2 Needles 2.3.3 Gloves 2.3.4 Vacutainers and blood-draining apparatus, assorted 2.3.5 Tongue depressors 2.3.6 Swabs, cotton 2.3.7 Gauze pads 2.3.8 Dressings, assorted 2.3.9 Suture material and needles 2.3.10 Specimen containers 2.3.11 Elastic bandages, assorted sizes 2.3.12 Cold packs 2.3.13 Cervical collars 2.3.14 Masks and hoods,surgical 2.3.15 Eye patches, pads 2.3.16 Cotton 2.3.17 Inflatable splints 2.3.18 Finger splints 2.3.19 Splints, various, inc. wrist 3. Special needs (depending on which services provided in-home and which referred) 3.1 Special medications for use only under direct order of or by physician, and kept outside of crash-cart 3.1.1 Xylocaine (esp. for minor surgical procedures) 3.1.2 Analgesics, major (morphine should only be in crash cart) 3.1.3 Intravenous fluids (to stablize for transport) 3.1.4 Specific medications for common disorders 18.104.22.168 Asthma 22.214.171.124 Epilepsy 126.96.36.199 Diabetes 3.1.5 Oxygen 3.1.6 Antibiotics (select a few appropriate to occupational injuries, e.g.dicloxacillin) 3.1.7 Vaccines 188.8.131.52 Tetanus toxoid 184.108.40.206 Hepatitis B vaccine (if hepatitis B a hazard) 220.127.116.11 Other for special needs (e.g. rubella in hospitals, selected vaccines for foreign travellers if required) 3.2 Physiotherapy equipment (consult with a registered physical therapist) 3.3 Patients and staff education aids 3.3.1 Videocasette players, monitor 3.2.2 Movie projector 3.3.3 Slide projector 3.3.4 Tape recorder and players, portable 3.3.5 Library of patients education materials (topics to include back pain,smoking cessation, alcohol abuse others as appropriate) Table 10.2. Medications Commonly Used in an Occupational Health Service Mefenamic acid caps 250 mg for menstrual cramps (Ponstel) Acetylsalicylic acid 325 mg Tables (Aspirin) Acetaminophen 325 mg tablets (Tylenol) Actifed tablets Chlorpheniramine maleate tablets (Chlor-Trimeton) Dimenhydrinate tablets and suppositories (Dramamine) Acetaminophen 300 mg + codeine 30 mg tablets (Tylenol 3) (Note: This is a controlled drug.) Diazepam tablets 5 mg (Valium) (Record all dispensed doses) Diphenhydramine hydrochloride 25 mg (Benadryl Caps) Cream and injections 50 mg/ml Epinephrine (Adrenalin) Magnesia & alumina suspension (Maalox) (Kaopectate) Imodium caps 2 mg (Loperamide) (under doctor's instruction.) Guaifenesin syrup 100 mg/5 ml (Robitussin) (Dequadin Lozenges) Phenylephrine hydrochloride, nasal drop 1/4% (Neo-Synephrine) Betamethasone valerate CR (Valisone V) Cream 0.1% Bacitracin 500 unit/g ointment (Baciguent) Dibucaine 1% Ointment (Nupercainal) Lindane - gamma benzene hexachloride 1% (Kwell Shampoo) Clove oil (for toothaches) Methylcellulose ophthalmologic 0.5% used as a lubricant (Isopto Tears) Jelonet Sterile (parafin gauze) dressing Disposable enema
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