STATUS IN WALES

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Status Note amended March 2013

HEALTH BUILDING NOTE 54

Facilities for cancer care centres

Design and briefing guide

2001

STATUS IN WALES

ARCHIVED

This document was superseded by Health Building Note 54 Facilities for cancer care

2006


DESIGN AND BRIEFING GUIDANCE

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London: The Stationery Office



London: The Stationery Office

© Crown copyright 2001

Published with the permission of NHS Estates, an Executive Agency of the Department of Health, on behalf of the Controller of Her Majesty’s StationeryOffice.

Applications for reproduction should be made in writing to:

The Copyright Unit,Her Majesty’s Stationery Office,St Clements House,2–16 Colegate,Norwich NR3 1BQ.

ISBN 0-11-322000-0

First published 2001

Cover photograph: Paulley Architects

AIMS AND OBJECTIVES

The purpose of this document is to provide guidance onhow the built environment can be designed to supportthe holistic approach to cancer care outlined in theCalman–Hine report.

The ultimate aim is to ensure that the physical facilitiesin which care is delivered enable the people whoprovide that care to adopt the latest techniques andbest practices – many of which are identified in the NHSCancer Plan – thereby promoting efficiency and raisingservice quality.

The patient’s cancer journey has been used as thefocus in preparing this guidance. The planning anddesign of the constituent parts of a cancer care centreand the way in which those parts relate to each otherhave been considered primarily with the patient in mind.In addition, the rapid development in technology – notonly in patient diagnosis and treatment but also in manyother aspects of care and organisation – is reflected inthis document, though the Agency has further plans forresearch in this key area.

Finding solutions that not only advance themodernisation of cancer care but also produceenvironments that are genuinely sympathetic to theneeds of all users has required an innovative approach.It has been necessary to examine all aspects of cancercare: from social, clinical and scientific considerations tothe detailed design and equipping of the buildings.Given such a broad approach, it is hoped that thisguidance will be of interest to a wide audience.

STRUCTURE

In order to avoid excessive complexity, NHS Estates isproducing guidance on cancer facilities in three parts:

Part 1 ‘Facilities for cancer care centres’ (this part); Part 2 ‘Facilities for cancer care units and breast carecentres’ (scheduled for publication end July 2001); Part 3 ‘Primary care and screening facilities in cancer’(scheduled for publication end October 2001).

All parts will be subject to routine revision as needed.Each part builds from introductory sections describingpolicy, clinical and scientific background through thepatient journey and associated care protocols, and usesthese to inform the design process for the builtenvironment. Schedules of accommodation and costinformation will be published in a separate documentcovering cancer, cardiac and diagnostic imagingfacilities (scheduled for end July 2001).

KEY NHS ESTATES DOCUMENTS RELEVANT TOFACILITIES FOR CANCER CARE

This work is constructed against a sliding scale ofenvironment specialisation. Those rooms or areasdevoted entirely to cancer services are described indetail. However, those used incidentally for such care,together with common areas, are simply listed and thereader is directed to other publications as appropriate.Notable among these are HBN 15 – ‘Accommodationfor pathology services’; HBN 40 vol. 2 ‘Common activityspaces: treatment areas’; ‘Facilities for diagnosticimaging and interventional radiology’ (new); and HBN 26– ‘Operating department’.

Executive summary

The built environment today should be such asto liberate professional and volunteer careproviders to move forward to best techniques…

FACILITIES FOR CANCER CARE CENTRES

ABOVE: AN HDR CONTROL AREA SHOWING THE AFTERLOADING MACHINE CONTROL AND MONITORS

LEFT: CONTROL AREA AND RECEPTION COUNTER AT THE MAZE ENTRANCE TO

LINEAR ACCELERATOR TREATMENT ROOM

BELOW: RADIOPHARMACY QUALITY CONTROL AREA

NHS Estates wishes to express thanks to the followingand other contributors:

Edwin Aird, Medical Physics, Mount Vernon Hospital

Charlotte Beardmore, Royal Berkshire Hospital, RoyalBerkshire and Battle Hospitals NHS Trust, Reading

British Institute of Radiology, London

Dr Ruth Brown, Consultant, Accident & Emergency,Kings College Hospital, Kings Healthcare NHS Trust,London

Cancerlink

Cancer Unit, Karolinska Institute, Stockholm, Sweden

Cervical and Breast Screening Units, Basildon Hospital

Dr Robert Coleman, Consultant Oncologist, WestonPark Oncology Centre, Central Sheffield UniversityHospitals NHS Trust, Sheffield

Dr Richard Dunn, West Kingsdown Medical Centre

Megan Edwards, Psychological Counselling Officer,Cookridge Hospital, The Leeds Teaching Hospitals NHSTrust, Leeds

Ian Finterman – Academic Oncology, Guys Hospital

Dr Rosemary Glanville, South Bank University

Sophie Glew, Cytology Unit, Darent Valley Hospital,Dartford & Gravesham NHS Trust, Dartford

R.W. Gregorys Engineering

Cathy Hall and other members of the RadiotherapySpecial Interest Group of IPEM

Hinchinbrooke MacMillan Hospital

Martine Jackson, Oncology Services Manager, ChristieHospital, Manchester

Dr Elizabeth Jones and Ian Spencer, NHS Estates

Jowett, Buckley & Curry – Architects

Lancaster Royal Infirmary

Chrissie Lane, Cookridge Hospital, The Leeds TeachingHospitals NHS Trust, Leeds

Leeds Oncology Centre

Richard Masuch, RKPT Architects

Mid Kent Oncology Centre, Maidstone General Hospital,Maidstone & Tunbridge Wells NHS Trust, Kent

Niall Monaghan, Radiation Consultancy Services

Newcastle Northern Cancer Centre

North Wales Cancer Centre, Glan Clwyd Hospital

Christopher Paulley, Paulley Architects

Plymouth Oncology Centre, Derriford Hospital, PlymouthHospitals NHS Trust, Plymouth

Radiopharmacy Unit, Guys Hospital

D. Rao, Paediatric Oncologist, Christie Hospital, ChristieHospital NHS Trust, Manchester

Jonathan Roberts, Marie Fisher and Terri Baxter, KingsBreastcare Centre. (Part 2 of this guidance)

John Saunders, Head of Medical Physics, Guys & StThomas' Trust

Siemens Medical Engineering

South Derbyshire RHS Team

Pier Thomas, Management Consultant, London

Maryla Twin and Andrew Sinclair, Activity Database,NHS Estates

Varian Medical Systems

Authors

Nigel Tomlinson, Chief Scientific Advisor, Engineeringand Science, NHS Estates

John Lyden, Architectural Advisor, Paulley Architects

Gerald Stone, Consultant Project Manager

Jason Britton, Assistant Scientific Advisor, Engineeringand Science, NHS Estates

Photographs and drawings

Gerald Stone, Paulley Architects

Acknowledgements

1

Contents

Executive summaryAcknowledgements

1 INTRODUCTION

Purpose and scope of document page 5

Intended audience page 5

Policy background and the Calman–HineReport page 5

Principles of the Calman–Hine ReportImplications of the NHS Plan for the built environment incancer services

2 CANCER CARE CENTRE ORGANISATION AND

STRUCTURE

Research facilities page 9

A guide to approximate sizing of cancer carecentres page 10

3 PLANNING CONSIDERATIONS

Functional relationships page 12

Integrated services page 12

Siting considerations page 13

4 THE PATIENT JOURNEY

Outline page 15

Journey steps page 15

Initial GP consultationHospital-based investigationsInvestigations

Diagnostic consultationTreatment and diagnostic reviewPain and symptom controlFollow-up and monitoringCare in the homeDignity in death

Summary of clinical procedures page 17

Initial cancer care centre diagnostic consultationDiagnostic work-upTumour stagingSurgical planning and interventionTreatment prescriptionDefinition of treatment volumeRadiotherapy support scanning by CT and MRIRadiotherapy treatment simulationImage-based treatment validation and portal imagingTreatment verification records and management (VRM)Review processPalliative care measuresHospice servicesBrachytherapyScheduling requirements

5 SPECIAL CONSIDERATIONS IN PAEDIATRIC

CARE

Basic specialisations and workingdefinitions page 20

The paediatric patient journey page 20

Clinical background page 20

Special accommodation requirements page 21

6 DIAGNOSTIC SERVICES INCLUDING

PATHOLOGY AND SPECIALIST RADIOLOGY

Facilities for diagnostic techniques page 22

IntroductionPathology servicesImaging services


2

General pathology page 22

Histopathology page 22

General radiology page 23

X-ray mammography page 23

7 SPECIALIST CROSS-SECTIONAL IMAGING

AND POSITRON EMISSION TOMOGRAPHY

Computed tomography (CT) suite page 24

Components of a CT suite

Magnetic resonanace imaging (MRI) suite page 24

Components of an MRI suite

Positron emission tomography(PET) suite page 25

Practicalities and the built environmentSafety and special design considerationsComponents of a PET diagnostic suite

8 THERAPEUTIC SERVICES INCLUDING

RADIOTHERAPY AND CHEMOTHERAPY

Radiotherapy page 27

IntroductionRadiotherapy equipment and outline treatment room

requirements – teletherapyRadiotherapy equipment and outline treatment room

requirements – brachytherapyComponents of a radiotherapy suite

Chemotherapy page 30

Chemotherapy treatment techniques and facilitiesComponents of a chemotherapy suite

9 MEDICAL PHYSICS SERVICES

The role of medical physics page 33

Facilities required page 33

10 FACILITIES FOR THE USE OF THE UNSEALED

RADIOACTIVE SOURCES

Unsealed source therapy page 34

The patient journey page 34

Components of unsealed source rooms – therapy suite

Care of the disabled page 35

11 CANCER SURGERY REQUIREMENTS

Characteristics and applications ofcancer surgery page 36

Outline classification of requirements page 37

Built environment requirements page 37

Facilities for relatively minor proceduresFacilities for intermediate level proceduresFacilities for high level procedures

12 OFFICES AND SUPPORT FACILITIES

Offices page 40

Educational facilities page 40

13 INFORMATION SYSTEM REQUIREMENTS –

IMAGE, PATHOLOGY AND RADIOTHERAPY

DATA; COMPUTERISED MANAGEMENT OF

CANCER CARE PROCESSES

page 41

14 DESCRIPTION OF ACCOMMODATION

Introduction page 42

The planning process page 43

Description of accommodation page 43

Common spaces

CONTENTS

3

Diagnostic facilitiesTherapeutic facilitiesPaediatric facilitiesClinical support spacesPatient support spaces

General design considerations page 62

Internal routes of accessBuilding access considerationsThe Disability Discrimination Act (DDA)Special facilities for individual or small group catering

15 RADIATION PROTECTION IN CANCERSERVICES

Use of radiation in cancer services page 64

Containment of radioactive materials and theprevention of contamination page 64

Constraint of radiation dose and the use ofshielding page 65

UK legislation page 66

16 BASIS OF ENVIRONMENTAL PROTECTION

Concept of radioactive discharge page 67

Minimisation of discharge and environmentalimpact page 67

Population radiation dose and effectivecontrol page 67

Decommissioning of facilities

Economic considerations page 69

17 CONTROL OF INFECTION IN CANCER

PATIENTS

Vulnerability of cancer patients – general andspecific page 70

Sources of risk page 70

Sources of potentially pathogenic organismsSusceptible hostsMeans of transmission

Preventative measures page 71

Built environment and facilities managementSpecific infection control issues during

renovation/refurbishment or constructionFacilities for immuno-compromised patients

Appendix 1 – Specialist engineering requirementspage 74

Appendix 2 – Room layouts page 84

Appendix 3 – Fire safety in radiotherapy treatmentrooms page 98

Glossary of terms and abbreviations page 102

References page 103

PURPOSE AND SCOPE OF DOCUMENT

1.1 This guidance summarises the framework for the provision of cancer services and identifies theimplications for the built environment in which differentelements of services are delivered. It notes that thecritical issue for people with cancer is that servicesthemselves should be integrated and seamless –although these may be delivered by different healthcareinstitutions in various locations. The guidance describesfacilities that are unique to cancer services and makesreference to features in facilities that are not usedexclusively on people with cancer but have a particularrelevance.

1.2 The guidance is based primarily on currentgovernment policy but is also influenced by the adviceand recommendations of a number of professional andacademic bodies. The intention is to present planningteams with a range of options for designing newaccommodation or for adapting existing buildings.

1.3 This document is part one of three to be publishedby NHS Estates. This first part of the series dealsprimarily with the facilities and design of cancer carecentres as defined by the Calman–Hine Report. Theparts are as listed below:

• Part 1 – ‘Facilities for cancer care centres’

• Part 2 – ‘Facilities for cancer care units and breastcare centres’

• Part 3 – ‘Primary care and screening facilities incancer’.

INTENDED AUDIENCE

1.4 This document aims to support the procurementand design of cancer care centres. The multi-disciplinarynature of modern planning teams is acknowledged andin consequence the target audience of this guidance isbroader than that of some earlier counterparts.

1.5 Estates professionals will find planning and designadvice. Background policy and basic clinical informationis also given to help planning teams keep pace withrapidly developing techniques in this area.

POLICY BACKGROUND AND THE CALMAN–HINEREPORT

1.6 Government policy on cancer care has beendominated in recent years by the recommendations of the Calman–Hine Report, which called for a newapproach to the provision and organisation of cancerservices in the UK.

1.7 The need for a new approach arose partly fromconcerns about the nature of cancer. First, the incidenceand prevalence of cancer for particular age groups andbody sites was and is rising. Second, cancer places amajor economic burden on both the community and theNational Health Service (NHS). In addition, it wasrecognised that cancer deaths could be reduced byearly diagnosis through prevention and screeningprogrammes. More recently a growing emphasis onwell-considered treatment policies and protocols hasalso emerged.

1.8 As well as the nature of cancer, there are alsoconcerns about the way cancer services are beingprovided:

• Treatment outcomes for patients are varied, duepartly to variations in the organisation of local cancerservices;

• Patient access to services was or is unequal due tothe disaggregated nature of cancer service provision;

• Cancer care expertise is spread too thinly across toomany geographical settings;

• The number of new patients being seen generally andin particular locations was and perhaps is too low tofacilitate the development of body-site-specificcancer care expertise;

• Co-ordination between primary/community andsecondary/tertiary cancer services was inadequate;

• Palliative care services for patients in the early as well as terminal stages of care need to be furtherdeveloped.

INTRODUCTION

1 Introduction

5

Principles of the Calman–Hine Report

1.9 In response to the above challenges, the Calman–Hine Report proposed that future cancerservices should be governed by the following principles:

• Wherever they may live, all patients should haveaccess to a uniformly high quality of care in thecommunity or hospital to ensure the maximumpossible cure rates and best quality of life. Careshould be provided as close to the patient's home asis compatible with high quality, safe and effectivetreatment.

• Public and professional education to help earlyrecognition of symptoms of cancer and the availabilityof national screening programmes are vital parts ofany comprehensive programme for cancer care.

• Patients, families and carers should be given clearinformation and assistance, in a form they canunderstand, about treatment options and outcomesavailable to them at all stages of treatment fromdiagnosis onwards.

• The development of cancer care services should bepatient-centred and should take account of patients',families' and carers' views and preferences as well asthose of professionals involved in cancer care.Individuals' perceptions of their needs may differ fromthose of the professional. Good communicationbetween professionals and patients is especiallyimportant.

• The primary care team is a central and continuingelement in cancer care for both the patient and his orher family from primary prevention, pre-symptomaticscreening, initial diagnosis, through to care andfollow-up or, in some cases, death and bereavement.Effective communication between sectors isimperative in achieving the best possible care.

• In recognition of the impact that screening, diagnosisand treatment of cancer have on patients, familiesand their carers, psychosocial aspects of cancer careshould be considered at all stages.

• Cancer registration and careful monitoring oftreatment and outcomes are essential.

Implications of the NHS Plan for the builtenvironment in cancer services

1.10 The NHS Plan was published on 27 July 2000 andhas subsequently been supplemented by a specificfurther plan for cancer. Where possible, the implicationsof the plans have been incorporated in this document, insofar as they have an effect on cancer services.However, some of the developments listed aredependent upon the outcome of further research (calledfor by government), and in consequence, the built

environment implications cannot be fully assessed at thetime of writing.

1.11 Essentially the new NHS Plan prioritises cancercare as one of a number of key clinical areas to receivespecial attention and development. Implicit in this andexplained within the Plan are expanded or new areas ofexpenditure covering the provision of staff, training andthe enhancement of cancer care facilities in terms ofbuildings and the equipment which they contain. Thekey aim of the Government is to improve both standardsof cancer prevention and quality of care for cancerpatients over a five- to ten-year period. The leadingelements likely to affect both the magnitude and natureof the built environment are summarised below:

a. The National Institute for Clinical Excellence (NICE) is charged with a new duty in respect of costeffective drug use for patients with cancer. This hasimplications for outpatient facilities and for theprovision of services by pharmacies. TheModernisation Agency has a duty to spread bestpractice in this and other related respects.

b. A programme for the provision of new equipment is contained within the NHS Plan. This involves theinvestment of some £300 million primarily for the careof those with cancer, renal and heart diseases by2004. Within this is the provision of 50 new magneticresonance imaging (MRI) systems, which theGovernment is linking directly to cancer careservices. An increase of some 190,000 proceduresinvolving the use of MRI is expected over the definedperiod. Two hundred new spiral-type computedtomography (CT) scanners, also related to cancercare services, are to be provided, giving an increasein procedures of 240,000. Of these CT machines,150 will be replacements for existing devices and 50will be entirely new. Eighty new liquid cytology unitsfor use in cervical cancer screening with a capacity of about 4 million patient examinations per annum are to be included and will accordingly requireaccommodation in purpose-designed cytology units,potentially within existing pathology facilities. Forty-five new linear accelerators, of which 20 arereplacement and 25 additional, are included. This document focuses heavily, in the appropriatesections, on the provision of facilities toaccommodate such accelerators with reduced orzero constraint upon their effective use. Governmentexpects to treat a further 12,000 cancer patientsusing these additional facilities.

c. An NHS Cancer Plan was generated in the Autumn of2000. Where possible, information has been includedto deal with the implications of this additionalpublication; a revision to NHS Estates’ advice in thisarea is scheduled for mid-2001. In particular, theimplications of the NHS Cancer Plan in terms of


6

extension of screening and further development ofcancer care services for older people will be included.

d. NHS Estates is aware of developments at WestMiddlesex University Hospital in terms of greatlyrevised facilities for dealing with those with suspectedprostate cancer. As policy develops in this area andthe possibility of national services becomes apparent,NHS Estates will modify its advice to furtherincorporate prostate cancer screening and treatment facilities.

e. The expanding and increasingly successful CancerCollaborative Initiative is taken into account in thispublication and has extensive implications for co-operation in screening, diagnosis and treatment of a range of cancers by both Calman–Hine cancercare units and centres over the coming years. Thefirst report from this group has now been published.

f. A number of national taskforces are in the process offormulation for the implementation of the NHS Plan.At the time of writing, it is expected that this willcontain a taskforce specific to cancer and related to the present National Cancer Director, ProfessorMike Richards.

g. The implications of the NHS Plan in terms of furthersupport for research and development and anenhanced involvement in clinical trials, coupled withincreasingly close working with the pharmaceuticalindustry were anticipated during the drafting of thisdocument. In consequence, model facilities for theconduct of clinical trials, including the option to treatpatients participating in trials separately from otherpatients, have been incorporated into the workpresented here.

h. The initiatives within the NHS Plan related to theimprovement of diet and nutrition have importantimplications for the provision of information to thepublic as a whole and cancer patients specifically.There is also a close relationship to reduced smoking and other lifestyle changes. The provision of information on cancer risks, public healthmeasures and broader cancer disease has beenincorporated into this document. Advice centres,information centres and the use of informationtechnology are all represented.

i. Approximately 100,000 people a year in the UK die ofcancer. Our Healthier Nation, a White Paper, set out acommitment to reduce mortality rates from cancer inpeople under 75 by at least one fifth before 2010.Particular attention is focused on the health of thosein the lower socio-economic groups (unskilledworkers are thought to be twice as likely asprofessional persons to die from cancer). This impliesadditional investment in resources related to breastdisease, colorectal, lung and gynaecological cancers.

In consequence of this, particular attention is paid tothese disease areas within this NHS Estates’guidance.

j. Changes to the breast screening programme havebeen made. Until recently, only women aged from 50to 64 have been screened for breast cancer (notincluding those in high-risk groups). Screening is nowto be extended to women aged from 65 to 70,implying a considerable increase in staff and facilities.An additional 400,000 women will need to bescreened each year as and when this programme ofexpansion is fully implemented. This will beaddressed in the third part of this NHS Estatesguidance, as is the cervical programme mentionedbelow.

k. The cervical cancer screening programme is also tobe upgraded by the introduction of new technologiesand an expansion of built facilities. New programmesin colorectal cancer screening are seen asappropriate and will be expanded under governmentschemes in coming years. (This NHS Estates’guidance does not specifically cover colorectalscreening. New advice will be generated over comingmonths as and when the programme is clarified.)

l. The possible development of a prostate cancerscreening programme at regional and national level isproposed within the Plan. A prostate cancer actionplan, encompassing research, diagnosis, earlydetection, treatment and general care, is expectedshortly. (The built environment implications of thisplan cannot be anticipated by NHS Estates at thetime of writing but will be included in a reviseddocument as soon as is possible.)

m. A screening programme for ovarian cancer is also inprospect and, again, will be covered in revisions tothis document.

1.12 In summary, the expansion of cancer diagnosisand treatment facilities is a major feature of the NHSPlan and implies both higher quality and more extensivebuilt environment and equipment portfolios. Wherepossible, the drive toward these improvements has beenincorporated in this guidance but there are a number ofspecific exceptions, which are detailed above.

INTRODUCTION

7

2.1 The multi-tier and multi-disciplinary approach to the care of cancer patients requires the provision of asophisticated centre with genuinely comprehensiveservices. This may be devoted to either adults orchildren with only a few centres providing services toboth groups. The cancer care centre is therefore theprimary repository of both expertise and specialistfacilities needed for care of patients with cancer. Therelationship between cancer care facilities and thepatient is demonstrated in Figure 1.

2.2 Cancer care centres operate in support of cancerunits: units may refer patients to the cancer care centrefor specialist diagnosis and treatment techniques.However, cancer care centres must also function ascancer units for the local catchment population. Cancerpatients living locally will attend the cancer care centre

rather than the cancer unit simply because it is closer totheir home. Cancer care centres must therefore be fullyindependent offering a comprehensive range of services.The Calman–Hine model for cancer referrals is illustratedin Figure 2.

2.3 Calman–Hine envisages that cancer care centres willbe sufficiently comprehensive and multi-disciplinary asto be able to provide support to units, not only for thebusiness of dealing with surgery and medicine/therapiesconcerned directly with tumours, but also in the broadercare of patients and any consequential disorders whichmay flow from their condition. Thus, cancer care centreswill support units broadly in the following ways:

• the provision of consultants for clinical sessions insurgery, medical cancer and radiation cancer;


8

2 Cancer care centre organisation andstructure

Figure 1 Relationship between cancer care facilities and patient

patient support groups

primary care

cancer care unit cancer care centre

hospice movement

patient

• special pathology services closely related to cancercare such as specialist haematology andhistopathology;

• the facility to transfer the patient by referral from thecancer care unit to a centre;

• provision of radiotherapy or patients otherwise caredfor in a cancer unit;

• support in the process of chemotherapy regimeprovision;

• academic, training and research co-operationagreements;

• shared liaison with Social Services;

• development and implementation of appropriatesurgical techniques.

2.4 Particular importance is attached to the surgicalissues mentioned above. Calman–Hine envisages amove from the use of general surgery in the treatment ofcancer toward a position where cancer surgery is seeneither as a specialty in its own right or as an area oftrained expertise within a discipline related to particularanatomy (for example, a renal surgeon may haveexpertise in surgery related to cancer). There has been

particular emphasis on moving breast surgery awayfrom the general surgical domain and into specialistcentres with appropriately trained surgical staff.

RESEARCH FACILITIES

2.5 Calman–Hine draws attention to the essential natureof research and development within the cancercommunity not only as a means of generating newknowledge but also for the beneficial effects on staffmorale and overall service quality. For these reasonsdesigners are asked to consider the provision of at leastmodest research accommodation as a basic part ofeach new or revised development.

2.6 Some major centres will have extensive researchportfolios and facilities. These are, for the moment,beyond the scope of this guidance. However, theminimum facilities, listed below, will be essential tosupport pharmaceutical evaluations or drug trials as wellas other key routine research support.

2.7 Drug trials require extensive and detailed recordkeeping. Accordingly a clerical office to accommodatetwo to three staff will be required. This may need accessto both local and wide area (LAN/WAN) computernetworks. Archive space may also be a requirement,particularly in centres where clinical records are still

CANCER CARE CENTRE ORGANISATION AND STRUCTURE

9

Figure 2 Relationships between cancer care facilities: Calman–Hine referral model

primary care

cancer care unit cancer care centre

care in thehome

referral

referral

direct referral

partly paper based. These areas must be reasonablysecure in order to protect the records and confidentialinformation, which much research involves.

2.8 Nurses are a key staff group for research in thisarea. Many centres will employ small teams of speciallytrained nurses to undertake or assist with research.Common (often open plan) office accommodation will bea key requirement.

2.9 Patients will often be asked to submit to additionalinterviews and clinical examinations when they take partin voluntary clinical trials. Many centres prefer dedicatedsuites to support this activity. These may be locatedaway from other patient care areas. The minimumaccommodation will consist of a number of consultationrooms with incorporated or separate examinationfacilities.

2.10 The majority of small research facilities will requirea small laboratory for the receipt and some processingof biological materials. These rooms will be similar tothose described in NHS Estates’ guidance HBN 15 –‘Accommodation for pathology services’, however,specifications will need to reflect local requirements and

research interests. Local consultation will be essential.There are also likely to be implications for the design offacilities in associated cancer care units as described inthe second part of this guidance, ‘Facilities for cancercare units and breast care centres’.

A GUIDE TO APPROXIMATE SIZING OF CANCERCARE CENTRES

2.11 This is a complex issue owing to the range ofdiseases covered by the blanket term cancer and thesimilarly extensive portfolio of diagnostic, surgical andtreatment regimes, which may be applied. Accordinglycareful local evaluation will always be necessary. TheNHS Cancer Plan will be helpful in assisting withindividual evaluations in so far as service patterns andcare standards are defined.

2.12 Tables 1–5 give an outline indication ofrequirements for cancer care centres against thecatchment area population and the numbers of newpatients expected for treatment each year. The standingrate of new cancer cases per year is about 3,400 permillion of population. Accordingly simple categories ofcancer care centre are derived.


10

TABLE 1 CATCHMENT POPULATIONS

Category Catchment population Special features

A 450,000 very smallB 550,000 – 750,000 minimum full centreC 800,000 – 1.5m regional centreD 1.5m – 3mE 3m – 5m

TABLE 2 NEW PATIENT TREATMENTS

Category Number of new patients per annum Special facilities

A <1,500 noneB 1,500 – 2,500C 2,700 – 5,050D 5,050 – 10,000E 10,000 – 15,000

TABLE 3 RADIOTHERAPY FACILITIES

Facility Category A Category B Category C Category D Category E

Linear accelerator (ME) 1 2 2 – 5 5 – 9 9 – 15Linear accelerator (HE) 1 2 3 3 3-5Simulator/CT simulator 1 – 2 2 – 3 3 – 5 5 – 8 8 – 12Planning systems 1 – 2 2 3 – 4 4 – 6 6 – 10

TABLE 4 BRACHYTHERAPY FACILITIES


Manual afterloading optional 1 1 1 1LDR/MDR optional 1 1 2 – 3 3HDR — 1 1 1 1PDR optional optional optional optional optional

CANCER CARE CENTRE ORGANISATION AND STRUCTURE

11

Notes to Tables 1–5

ME – medium-energyHE – high-energyLDR – low dose rateMDR – medium dose rateHDR – high dose rateCT – computed tomographyMRI – magnetic resonance imagingPDR – pulsed dose rate

TABLE 5 OTHER MAJOR FACILITIES


Chemotherapy preparation 1 1 – 2 2 – 3 3 – 6 6 – 9Full chemotherapy pharmacy optional 1 1 1 1Chemotherapy treatment places

– couches 12 18 25 – 45 45 – 85 85 – 135Available operating theatres 1 1 – 2 2 – 3 3 – 6 6 – 9Specialist operating theatres optional 1 1 1 2Unsealed source treatment — 1 1 2 2MRI /CT 1/1 (access) 1/1 (dedicated) 1/2 2/3 3/5

FUNCTIONAL RELATIONSHIPS

3.1 The constituent parts of a comprehensive cancercare centre are identified in Figure 3. Figure 4 thenillustrates how these elements can be grouped intodiagnostic, therapeutic, patient support and clinicalsupport areas.

INTEGRATED SERVICES

3.2 Calman–Hine recommends that cancer care centresbe integrated with more general clinical serviceproviders. Figure 5 illustrates which elements of theservice are likely to be dedicated to the cancer carecentre and which will be shared with the tertiaryhospital.


12

3 Planning considerations

Figure 3. Cancer care centre departments

consultation

information

chemotherapy

palliativecare

surgery

radiotherapy

MRI

PET scanning

CT scanning

specialistradiotherapy

pathology

postgraduatecentre

pharmacy

diagnosistreatment

patient support

complementarytherapy

rehabilitation

out-patients

in-patients

PLANNING CONSIDERATIONS

13

SITING CONSIDERATIONS

3.3 As cancer units and centres are being unified withmore general hospital provision, they are sharingservices accordingly. Such integration requires a freeflow of information and the broad availability of specialistexpertise.

The following factors are influential when making sitingdecisions:

a. Geographical considerations related to journey timesand distances anticipated for patients visiting thefacility.

Figure 4. Cancer centre departmental relationships

CONSULTATION

information

chemotherapy

palliativecare

surgery

radiotherapy

MRI PET scanning

CT scanning


pathology

research andeducation

pharmacy

DIAGNOSIS

TREATMENT

out-patients

in-patients

patient support


rehabilitation


14

b. Access by public and private transport (use of publictransport should be encouraged for the sake of theenvironment).

c. The substantial nature of the architecture and engineeringrequired by some cancer facilities is such that sites whichfavour future expansion and flexibility are preferred.

d. Suitability for receipt, storage, use and disposal ofenvironmentally-sensitive materials.

e. Relationship to academic institutions and researchfacilities.

f. Requirement for local access to non-specific butcancer-related services including surgery, pharmacyand pathology.

g. The social-medical nature of cancer favours patientcare on sites that are suitable for the creation ofgardens and water features.

Figure 5 Integrated general hospital cancer care centre

Tertiary hospital

palliative

chemotherapy

diagnosis consultation

information

patient support


radiotherapy

treatment

PETscanning

pathology

CTscanning

MRI pharmacy

cancer care centre

shared facilities

surgery

researcheducation

centre


rehabilitation

OUT-PATIENTS IN-PATIENTScare

OUTLINE

4.1 For the majority of patients encountering thepossibility of cancer the initial query or suspicion of acancer diagnosis will be made at primary care level by ageneral practitioner (GP). Attendance at Accident andEmergency (A&E) as an initial part of the journey is notcommonly observed.

4.2 The patient will pass through the care systemgenerally as illustrated in Figure 6, though significantvariations will be observed. (An outline description isprovided below.)

4.3 The feelings of both patients and relatives,particularly following news of a positive diagnosis, mustbe sensitively handled and this will reflect in the designof the built environment. So far as is possible, thefacilities available should combine the need for practical efficiency with an appropriately sensitive and patient-focused quality.

JOURNEY STEPS

Initial GP consultation

4.4 This may establish the suspicion of cancer or simplygenerate a referral arising from consideration of thepatient’s condition, family history and a physicalexamination. Some limited pathology tests using urine orblood samples may be provided. The GP surgery willtypically require a quiet room, away from the remainderof the clinical area, for use in sensitive discussions withthe patient and their family in support of ensuring overallas well as strictly medical care of the patient.

Hospital-based investigations

4.5 A proportion of patients will be referred direct to apurpose-built major cancer care centre offering strategiccancer services. Others will encounter a journey thatinvolves passing through other specialist units or a localCalman–Hine cancer unit.

Investigations

4.6 Investigations may be conducted at cancer care unitor centre level, but the centre, with its strategic role, will beable to offer a broader and more sophisticated service.

4.7 On arrival the patient will go to a central receptionarea where the identity and attendance details arerecorded and information on the next part of thepatient’s care will be outlined. Some written explanatoryinformation is also likely to be given. Particular careshould be taken to ensure that this step is wellfacilitated for all patient groups including the disabled sothat the patient’s initial experience of the centre reflectsthe focus on patient care.

4.8 For the majority of patients the journey will proceedto a central or specific procedure waiting area. In amodern cancer care centre the use of schedule controlsystems and advanced patient management techniqueswill be geared to minimising waiting times. This mayreflect in a smaller waiting area designed to create areassuring environment.

Diagnostic consultation

4.9 A meeting with a cancer specialist will outline, forthe patient, the steps to be taken in moving towardachieving a reliable diagnosis and from this a plan fortreatment. A consulting room will be used for thispurpose and a physical examination may also beoffered.

4.10 As directed the patient will proceed to theappropriate specialist diagnostic department and reportat the local reception.

4.11 The specialised tests may involve imaging,measurements, and the taking of samples of tissueand/or body fluids and are targeted on benefiting thepatient by refining the diagnosis. Although thesediagnostic facilities may be dominated, in design terms,by technical considerations, every effort must be madeto ensure the environment is not adverse from thepatient standpoint. This step may be a part of a seriesof differing tests involving a number of specialist facilitiesand journeys between these. Focus on building layoutso as to simplify the journey is always necessary for thepreservation of acceptable standards of care.

Treatment and diagnostic review

4.12 Where possible the cancer specialist will meetagain with the patient to review progress and conveyinformation as this becomes available. At this point key

THE PATIENT JOURNEY

15

4 The patient journey

diagnostic decisions may have been made and thesewill in turn give rise to discussions on treatment,prognosis or outcome for the individual patient. Thisnews, good or bad, is likely to generate an emotionalimpact on those involved and this will reflect in the builtenvironment in terms of the need to provide discreteexits and other features.

4.13 The diagnostic cycle described above is likely to berepeated several times for any given patient as thedisease and treatments proceed.

4.14 As Figure 6 illustrates, the patient journey nowcontains a complex series of options, which aredependent in terms of choice upon the patients’ wishes

and the availability of suitable treatments. For manypatients treatment may involve radical steps includingsurgery, radiotherapy and chemotherapy, though thesetechniques are also used in palliative care, which mayhave no curative intent. Psychological and social careare an essential component of the journey for almost allpatients.

Pain and symptom control

4.15 A large proportion of cancer patients will requirepain relief. Specific departments will be provided incancer care centres with many patients makingrepeated visits. Both consultation and treatment roomsare required. The patient may remain within the


16

Figure 6 Cancer care centre patient journey

Can

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unit/

canc

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entr

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rimar

y ca

reP

rimar

yca

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CANCER JOURNEY

initial consultation

investigations

diagnosis

pain and symptom control

initial treatment

follow-up

further treatment

SERVICE ORGANISATION

palliative care/terminal care

social care

home

long-term survival/follow-up

THE PATIENT JOURNEY

17

department for several hours allowing the supervisionand monitoring of treatment. The use of pain relief drugsmay be supplemented by other treatments, includingpalliative radiotherapy.

Follow-up and monitoring

4.16 The patient will make regular visits both to his/herGP and to the cancer care centre to be appraised ofprogress and advised as to treatment options. Theseconsultations will take place in general consultationrooms but again the need for careful design to ensurerespect for the patient’s privacy and sensitivities isneeded.

Care in the home

4.17 The cancer care centre may support care for thepatient in the home by the provision of information, loanof equipment, etc. Primary care and social services willfeature heavily in this part of the overall care package,as required by Calman–Hine.

Dignity in death

4.18 For some patients the journey will regrettably endin death. In terminal illness some patients may be takento A&E departments. Increasingly these have facilities forboth patient and friends/relatives, designed to achievesome measure of comfort and dignity in death. If apatient is admitted, a single bedded room should beprovided. Others will be allowed to return home to die inthe care of their GP team.

SUMMARY OF CLINICAL PROCEDURES

Initial cancer care centre diagnostic consultation

4.19 As for all clinical episodes, the initial consultationwith appropriately qualified specialists is vital. It is at thisconsultation that the early definitions of diagnosis will beput forward and an initial care plan devised.

Diagnostic work-up

4.20 This is a process by which the initial diagnosis iseither confirmed or modified and the identity of thetumour, together with its histology or nature, fullydetermined. The process is vital as the ultimatediagnosis will determine the most appropriate carepathway.

4.21 Modern diagnostic workups in cancer care aremulti-disciplinary and, therefore, contributions frompathology, radiology and general clinical sources needto be incorporated with a very high degree of reliability.

Tumour staging

4.22 The aim of chemotherapy, surgery or radiotherapyis to remove or at least reduce tumours. However, thesuccess of any treatment will depend in large part onhow advanced the cancer is. Accurately assessing thespread of the disease in a patient is therefore vital. Inthe UK there is a rigorous system for assessing thestage that disease has reached.

Surgical planning and intervention

4.23 Much modern cancer treatment begins with asurgical intervention. The surgery requires extensiveimaging work-up before it is carried out. In commonwith radiotherapy, the surgeon will tend to define atarget and will also wish to examine structures that mustbe avoided in making the surgical approach.

4.24 As an extension of the above, the use ofstereotactic localisation to precisely reach tumours inthe breast and cranial anatomy is well developed atsome cancer care centres.

4.25 The use of image-guided minimal invasiveintervention as a form of cancer treatment both invascular and non-vascular sites is advancing rapidly andrequires the provision of specialised facilities. This mayreplace alternative full-surgical techniques.

Treatment prescription

4.26 Whether the treatment is to be chemotherapyand/or radiotherapy, a strict prescription system is inuse throughout the UK in all sectors of healthcare. Forchemotherapy, the prescription will consist of a dose ofselected drugs administered in a defined pattern over anagreed period of time.

4.27 In radiotherapy the prescription will consist of anagreed dose, to be delivered over a number of fractionsor episodes of treatment, typically between four and 30.

Definition of treatment volume

4.28 The treatment volumes – that is the size, shapeand site of the disease – will normally be defined eitherby the use of radiographs or by cross-sectional imaginginvolving CT or MRI.

4.29 Film-based imaging is increasingly being replacedby new digital techniques. The role of telemedicine incancer care is discussed below.

Radiotherapy support scanning by CT and MRI

4.30 In addition to the routine diagnostic use of cross-sectional imaging, some additional imaging, directlyrelated to the business of planning treatments ratherthan diagnosis will also be required. Much of this will be


18

by CT, though some use of MRI may also beappropriate.

4.31 The data generated by these scans is transferredto a specialised computer or workstation that is devotedto radiotherapy treatment planning (RTP). All of this datais then used in the construction of a radiotherapytreatment plan, the purpose of which is to generatetreatment parameters for use on a linear accelerator,brachytherapy or Cobalt 60 treatment machine, etc.

4.32 This package of data is checked by a clinicaloncologist and then logged for use by the department inthe treatment of the individual patient.

4.33 In recent times, European legislation and Codes ofPractice in the UK have required that for each patienttwo treatment plans are created, each by a differentmethod. In practical terms this requires twotechnologists using at least two standalone ornetworked workstations.

Radiotherapy treatment simulation

4.34 This process is conducted in the simulator roomand involves the use of an X-ray machine that emulatesthe geometry of radiation beams to be used for thepatient on the linear accelerator.

4.35 The majority of radiotherapy patients receivesimulation unless their treatment regime is very simple.Some patients may, occasionally, be simulated morethan once.

4.36 Modern practice and design of simulatorsincorporates the use of image intensifiers (similar tothose used in diagnostic imaging departments) toacquire the relevant images and in some casesreconstruct the data from different views to form low-resolution CT cross-sectional images. This latter featureusually requires additional equipment.

4.37 Alternatively, for film-based solutions either thedata acquired using the image intensifier is sent directlyto a laser imager located within the department, orimages are collected directly onto film using cassetteholders integrated within the simulator’s configuration.

4.38 A typical room layout incorporating facilities fordigital imaging and treatment planning (‘Simulator withtreatment planning and conference suite’) is shown inAppendix 2: room layouts.

Image-based treatment validation and portalimaging

4.39 Portal imaging systemspermit linear acceleratorsystems themselves to create images of the patient'sanatomy. This gives a final check that the correctvolume is being irradiated.

4.40 If hard copy film-based portal images are acquiredthen a separate unit – a digitiser – may be required. Thedigitiser will convert the images into a digital data formatin order that they can be compared with simulation andplanning images.

4.41 In the future as treatment technologies becomemore sophisticated, image based validation to checkthat treatments are being delivered correctly will be animportant element.

Treatment verification records and management (VRM)

4.42 The overall approach to radiotherapy treatmentmanagement should involve the use of a VRM or similarcomputer to bring together many of the data treatmentelements referred to elsewhere in this section. Inessence, the verification, record and managementcomputer is responsible for maintenance of all the dataconcerned with treating the patient. Alternatively somecancer care centres may continue with paper-basedrecords, which will require physical storage.

4.43 While the VRM concept is described here in thecontext of radiotherapy, verification and managementelements can also be applied to a similar process inchemotherapy (and, indeed other forms of cancertreatment).

Review process

4.44 For some patients the cancer or tumour willregress under treatment and this regression is fairlyconstant and readily understood so that the treatmentregimes need not be varied sharply. However, for othersinitial treatments may not be successful or complicationsmay develop. In these latter cases, which are notuncommon, patients should be reviewed regularly sothat their condition can be assessed and alterationsmade to their treatment as necessary.

Palliative care measures

4.45 The purpose of palliative care is to controlsymptoms and alleviate suffering in patients who cannotbe cured of their disease. It is important to understandthat while palliative treatment regimes may be somewhatsimpler than their radical alternatives, this does notimply any reduction in the quality of the care delivered.

4.46 Over and above the physically defined parameters,the palliative patient, sometimes in common with radicallytreated persons, may require periods of care in a hospiceor psychological care/counselling. Under Calman–Hine,the quality of this treatment is just as important as thatused to regress tumours or control pain.

Hospice services

4.47 The last 15 years have seen a marked rise in theprovision of hospice services, mainly through the NHS

and the charitable sector. The aim of hospice services isto provide a supportive and caring environment awayfrom the hospital setting often, though not always, inpursuit of palliative care.

4.48 The hospice movement supports respite careservices. These are often helpful to people caring forfriends or relatives at home. For example, a cancerpatient may attend a hospice on either a day orresidential basis, thus relieving the carers at home, orthe carers themselves may attend support sessions atthe hospice, leaving others at home to care for thepatient.

4.49 A trained specialist in palliative care will lead thepalliative care team. The team may be based in ahospice unit, in a hospital support team or as a homesupport team within a community primary care trust.Palliative care units and teams may be funded by theNHS or in the charitable sector. In recent times, jointhealth authority and charity funding has emerged. Manyspecialist posts and initiatives in palliative care arepump-primed by the Cancer Relief Macmillan Fund.

4.50 The detailed information on operationalrequirements and facility design will be available in Part3 of this guidance.

Brachytherapy

4.51 This is a special form of radiotherapy. A patient willinitially undergo surgery involving the insertion orimplantation of applicators for use with radioactivematerials. This may be carried out in operating theatres,or, in some cases, in the simulator room

4.52 Radioactive sources may then be inserted bymechanical means through the applicators undercomputer control with all persons, other than thepatient, excluded from the treatment suite. Somemanual insertion is still used but this is a decliningpractice largely because of safety difficulties.

Scheduling requirements

4.53 Recent reports from the Royal College ofRadiologists and other learned bodies have stressed theimportance of accurate scheduling in the entire processof patient care in cancer care services. This implies abuilt environment and equipment portfolio designed toencourage reliability and prevent delays.

THE PATIENT JOURNEY

19


20

BASIC SPECIALISATIONS AND WORKINGDEFINITIONS

5.1 Cancer in children and young persons occurs at alow rate compared to that in the general adultpopulation. The nature and characteristics of disease inthese groups differs in many cases from that observedin adult cancer care centres and may include disorderswhich are diagnosed at or even before birth.

5.2 Children are for this purpose defined as being agedbirth to 14 years while the paediatric group also includesyoung persons aged from 15 to 21 years.

5.3 Paediatric care will be given in dedicated cancer carecentres or in specialist departments within a more generalCalman–Hine facility. Special facilities are needed for onlya limited range of clinical services but the long-termnature of much of the care, including prolonged in-patientstays, requires the provision of family and schoolingaccommodation. Delicate social factors are also influentialon design and department character.

THE PAEDIATRIC PATIENT JOURNEY

5.4 The paediatric patient’s journey will be determinedby the child’s age and disease. The rapid onset of manychildhood cancers is also a significant factor in the careapproach, and speed and intensity of treatment applied.

5.5 The journey will begin with a paediatric assessmentrequested either by a family GP or directly from neonatalcare. This process may be urgent and will be backed bypathology and imaging tests as needed. An in-patientstay may commence at once or shortly thereafter.

5.6 For many children the prolonged nature of thetreatments may mean that the cancer journey must alsoincorporate other aspects of normal life and personaldevelopment for the child, family and others. Thisincludes the need to provide facilities that will support a hospital-based community within which the child oryoung adult lives.

5.7 Further special journey elements will occur in thecase of certain patients, including those with the blooddisorder leukaemia, which will potentially requiretreatment by total body irradiation. The effects oftreatment include a great reduction in the body’simmune response and protection against infection isaccordingly required. The patient journey will therefore

involve remaining in an aseptic environment for longperiods of time.

5.8 Although the child will spend much time within theconfines of the paediatric cancer facility, economic andpractical considerations mean that the journey willembrace visits to adult facilities, particularly for somediagnostic procedures and radiotherapy.

5.9 Although used only when essential, theadministration of anaesthesia and/or sedation iscommon for children and accordingly modifies thejourney when compared to an adult. The giving ofanaesthetics may occur local to the treatment facility orin procedure rooms on the ward.

5.10 The nature of paediatric cancer and its sensitivetreatment is such as to require high levels of mutualcommitment and continuity, possibly extending overmany years. The patient journey reflects this and mayinclude continued visits to the same care provider evenif the family moves elsewhere. Such visits may be foradditional treatment but social needs and counsellingare equally important.

CLINICAL BACKGROUND

5.11 Diagnostic procedures for paediatric cancer differlittle from their adult counterparts but the need foranaesthetics will, in many cases, extend the time takento investigate, and also influences facility design.

5.12 Discrete children-only facilities are not generallyjustified on clinical grounds but workload may mean thatdedicated CT scanning and ultrasound rooms areappropriate. Access to positron emission tomography(PET) scanning is of particular importance. This mayinvolve increased provision or efficient transport andcommunication with established service providers.

5.13 Treatment involving chemotherapy and/orradiotherapy is commonly applied. Paediatric cancersurgery is a highly developed specialty. Generally adultfacilities can be effectively shared. However, theprovision of dedicated chemotherapy is relatively easy toachieve and generates significant benefit in terms ofpatient care standards and social sensitivity.

5.14 Both unsealed or liquid radioactive sourcetreatments as well as sealed/solid source brachytherapycan be useful (though the frequency of use is low).

5 Special considerations in paediatric care

5.15 Cancer treatments are often quite harsh and maythemselves cause a controlled level of damage or injury.Accordingly, long-term follow-up of these patients isespecially important and may result in visits by patientsfrom older age groups.

5.16 Much of the above may be used in connection with’play therapy’, which has been found to usefully reducethe extent to which sedation, particularly forimmobilisation, is needed. Play therapy would typicallyinvolve toys and games that, safely and in a friendlyfashion, reflect the treatments which the child may laterencounter.

5.17 In the modern era much is done to maximise theextent to which the child may be cared for in his or herown home. The use of outreach nursing, which must befacilitated by the cancer care centre, is particularly helpful.

SPECIAL ACCOMMODATION REQUIREMENTS

5.18 Some of the accommodation does not differ incharacter or design from that used for adults and mayindeed be shared facilities. However, a number ofspecial issues do arise and some of these are observedto be key to successful patient care.

5.19 In radiotherapy the linear accelerator bunkers willrequire special design elements to give the long sourceto target distances required for total or whole bodyirradiation. Special facilities to soften the environment ina child-friendly way should also be considered.

5.20 As treatment interruptions in some radiotherapyregimes may be especially harmful to children, the needto provide sufficient facility as to give effective back-upor redundancy is particularly important.

5.21 Linear accelerator and other teletherapy rooms forpaediatric use will always require anaesthetic andmonitoring facilities. In dedicated units considerationshould be given to the use of permanently installedmonitoring. Closed-circuit TV (CCTV) observation isalways essential. Colour equipment must be used. Voicecommunication with the patient, accessible to theparents/nurses, etc., is a very useful enhancement inreducing fear and gaining patient co-operation.

5.22 The provision of brachytherapy rooms for low- ormedium-dose rate sealed source treatments is a difficultissue. Paediatric patients may be expected to benefitfrom these rooms being specially adapted and adjacentto other children’s facilities. However, the frequency ofuse may be low so that for smaller centres acompromise with adult facilities may be essential forcost reasons. No special challenge arises for high-doserate facilities and the adult facility will always be used.

5.23 Unsealed source treatments present a particularchallenge, given the need for a child-friendly yet

specialised side ward environment, which cannot beused for other purposes for much of the time due toradioactive contamination. The use of adult facilities isfeasible but difficult in both nursing and social terms.The giving of such treatments on the open ward isunlikely to be lawful under the Ionising RadiationsRegulations 1999. See Appendix 2: Room layouts for anillustration of a modern treatment room, ‘Iodinetreatment room with en-suite shower/wc’.

5.24 Ward accommodation must necessarily feature ahigh density of single bedrooms. Accommodation forparents local to or within side rooms is needed. Thedesigns must be such as to allow for personalisation ofthe rooms by children who may remain for long periodsof time. In view of practical considerations of traveltimes, etc., full family units will be required. Theseshould have adequate accommodation even for anextended family on a stay of considerable duration. Theuse of anaesthetics will increase the number oftreatment rooms needed on each ward or unit.

5.25 Well developed procedure rooms (or a minorprocedures theatre) will be needed in or adjacent towards. This will be used for bone marrow transplant(BMT) and a range of other procedures including lumbarpuncture. This shall incorporate filtered air ventilationand anaesthetic facilities with scavenging. A recoveryroom will be needed.

5.26 Special isolation facilities for those withcompromised immunological status or infectionvulnerability will be essential. These are of specialiseddesign and will also have pressure control filteredventilation systems.

5.27 As might be expected, family members maythemselves require social and psychological care. Thiswill typically be facilitated within the paediatric cancerfacility. Meeting rooms and accommodation for familysupport groups will be needed.

5.28 Long in-patient stays necessitate on-site educationfacilities. This must include school rooms and facilitiesfor the accommodation of teachers and the preparationof education materials.

5.29 Teenage patients will require an informal room withentertainment facilities. Care must be taken in siting thisto avoid noise nuisance and to ensure security.

5.30 Paediatric rehabilitation will be essential as adedicated facility and should include a modestgymnasium.

5.31 Dedicated information and help centres will beneeded for paediatric facilities. The material stocked willdiffer noticeably from that available in adult facilities.

SPECIAL CONSIDERATIONS IN PAEDIATRIC CARE

21


22

FACILITIES FOR DIAGNOSTIC TECHNIQUES

Introduction

6.1 Diagnostic medicine is a key, intrinsic feature ofhigh-quality patient care in the whole range of cancerdiseases. Much of the science is highly developed andrecent years have seen a high pace of advance.

6.2 The role of the diagnostic services extends to anumber of features, which are aimed at enhancingpatient survival rates and minimising pain ordiscomfiture. The essential elements include primary orpreliminary diagnosis, differential diagnosis, whichspecifically refines the picture, and tumour stagingcoupled with treatment monitoring.

6.3 Fundamentally the services required divide into threecategories with variable levels of specialisation tocancer. The non-specific techniques are mentioned butnot described here. The categories are: pathologyservices; imaging including cross-sectional work; patientand physiological assessment. The latter is general andnot detailed here.

Pathology services

6.4 Pathology services will be provided by the parentinstitution related to the cancer care centre with thepossible exception of specialised histopathology andcytology, which are related to the examination of celltypes sampled from the patient, in some cases bybiopsy. These services may be specifically developed forcancer care centre use or be part of that centre. Otherservices such as clinical chemistry, biochemistry,haematology and microbiology are all important tocancer. However, other than refinements to the range oftests offered and a possible need for an increase inservice capacity, the descriptions given in NHS Estates’guidance ‘HBN 15 – Accommodation for pathologyservices’ apply without change where a cancer carecentre is present.

Imaging services

6.5 The importance of these has risen sharply in recentyears and given rise to a national modernisationprogramme under the New Opportunities Fund (NOF)initiative, which has increased the quality and capacityof the service offered to patients. This work has focused

particularly on CT and MRI though almost all modernimaging techniques are used in connection with cancer.Again the parent institution will provide the majority ofthe service and an influence on capacity requirements ingeneral X-ray, vascular imaging services and ultrasoundwill be found. The role of image-assisted minimalinvasive therapies is also developing rapidly and againhas capacity implications in fluoroscopy, ultrasound andcross-sectional imaging (CT and MRI).

6.6 Minimal invasive therapy has a marked influence onthe design of the rooms used, particularly in fluoroscopyand angiography. This is described in detail in NHSEstates’ guidance ‘Facilities for diagnostic imaging’.

6.7 Specifically within cancer care centres the intensiveuse of CT – and increasingly MRI – mean that dedicatedunits will be required as an essential feature. These aredescribed in further detail below as well as in NHSEstates guidance ‘Facilities for diagnostic imaging’.

GENERAL PATHOLOGY

6.8 The reader is referred to NHS Estates’ guidance‘HBN 15 – Accommodation for pathology services’.

HISTOPATHOLOGY

6.9 These laboratories are used as part of the nationalcervical screening programme. Although cervicaldisease can be treated by the Manchesterbrachytherapy system and also by medical oncologicalor chemotherapy means, early diagnosis is known tohave a significant effect upon prognosis.

6.10 Cervical screening involves the taking of a cellscrape from the cervix in a room that ensures effectiveclinical work under discreet conditions. The so-called‘cervical smear’ is transferred to a laboratory forpreparation and microscopic examination byhistopathologists and specially trained screening staff.

6.11 The Medical Devices Agency (MDA) document97/31/S has generated advice and standards in thisarea. In addition, NHS Estates’ guidance ‘HTM 67 –Laboratory fitting out systems’ and ‘HBN 15 –Accommodation for pathology services’ also provideadvice in this respect. The histopathology laboratoriesused for these purposes differ little from those generally

6 Diagnostic services including pathologyand specialist radiology

described by NHS Estates for this area of pathology.However, recent work has drawn attention a number ofkey items:

a. The standards of concentration and care required toachieve reliable diagnosis in this area are particularlyhigh. Accordingly, the environment must be quiet andthe number of persons accommodated for the size oflaboratory will be relatively low. The use of carpets inthese laboratories is increasingly widespread becauseof the added comfort and noise suppression, whichthis form of floor surface can provide.

b. Long periods of work in which the operator focusescarefully through a binocular microscope to examinespecimen slides can lead to eye fatigue. Accordingly,windows permitting the operator to view a distanthorizon and relax the eyes by focusing on infinity areneeded.

c. Seated ergonomics have been demonstrated byindependent study to be important in this area.Variable height seating using stools or chairsequipped with backrests, coupled with a similarability to vary the height of the working surfaceswhich support microscopes and other equipment hasbeen held to be necessary. Care is needed overlighting levels and variable control. Light diffusionwithin the room is also a key factor.

GENERAL RADIOLOGY

6.12 The reader is referred to NHS Estates guidance‘Facilities for diagnostic imaging’.

X-RAY MAMMOGRAPHY

6.13 This modality has two related basic methods bywhich diagnosis can be achieved. The first of these ishigh-resolution X-ray imaging while the second uses aspecial form of such imaging to guide a breast biopsy.The material removed at biopsy is then sent forlaboratory characterisation in histology in order to detectthe presence or absence of cancer cells.

6.14 The service is often intimately associated with abreast care unit, which is a key feature of most adultcancer care centres. The imaging technique will be usedearly in the cancer journey for those with suspected orconfirmed breast disease.

6.15 A technology change is in progress at the time ofwriting and as a result some units may continue to beprovided with film-based imaging whilst others aremoving to filmless techniques involving digitalradiography (DR). The former requires very high qualityfilm processing in a small but specially equippeddarkroom. Daylight film processing is available formammography but is less useful in the low throughputcancer care centre environment than is the case forhigh-volume scanning conducted elsewhere. Digitalimaging removes the need for a darkroom but creates anecessity to house imaging viewing and processingcomputers and requires a local area network (LAN).

6.16 During imaging examinations mammography X-raysuites will be required to accommodate only thespecially trained radiographer and the patient within theX-ray or examination room itself. However, when thefacility is used for needle aspiration or biopsy employingstereotactic methods and equipment, occupancypressures amount to three or four persons. These willinclude a radiologist in addition to the patient andradiographer. Preferably a nurse will also beaccommodated, though this is dependent on localpractice.

6.17 The mammography room itself will beaccompanied by modest waiting facilities typically largeenough to accommodate six people. In view of thepotentially stressful nature of the examination, thewaiting area should be of a quiet and relaxing characterand positioned away from busy circulation space, etc.

6.18 The radiation quality or beam harness used inmammography is very low and soft. Accordingly, whilethe X-rays are classified as penetrating, they are muchmore heavily attenuated by ordinary building materials,including dense studded partitions, than is the case inbroader general X-ray. This being the case, levels ofshielding in terms of lead equivalence are substantiallylower than encountered elsewhere. Typically,equivalence of less than 0.5 mm of lead will be neededto generate levels of attenuation, which will protectpersons in accordance with the requirements of theIonising Radiation Regulations 2000.

DIAGNOSTIC SERVICES INCLUDING PATHOLOGY AND SPECIALIST RADIOLOGY

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COMPUTED TOMOGRAPHY (CT) SUITE

7.1 CT scanning is an X-ray diagnostic technique. Thebasic principle involves an X-ray source or tube, whichrotates quickly about the patient. The X-ray beam isattenuated by the dense structures, such as bone,within the patients’ head or body and the resultingchanged beam is intercepted by an imaging detectormounted in a gantry opposite the X-ray tube. The imageis then produced by the use of a powerful computer anddisplayed on a monitor or printed to laser film.Essentially the product images are slices through theanatomy at selected points.

7.2 The image is captured in digital format fortransmission over computer networks both fordiagnostic viewing and also for special use inradiotherapy treatment planning (RTP), for which CT isincreasingly essential. This latter function requires theprovision of one or more CT scanners within a cancercare centre and good standards of access in cancercare units.

7.3 Recent developments in CT have led to ‘spiral CT’techniques for faster image production and shorterscanning times giving increased capacity. Furthermore,‘multi-beam’ CT is now being commonly installed withstill further benefits for throughput. The NOF schemeincludes the broad modernisation of CT capacityincluding that used in the care of cancer patients. Thesenew machines often enable minimal invasive proceduressuch as tumour biopsy.

7.4 Technological developments in the acquisition andprocessing of CT images are enabling cancer carecentres to use CT simulation instead of traditionalsimulation for many – but not all – simulated treatmentsin radiotherapy. This development is expected to lead toa reduction in the number of simulators employed butan increased need for CT, with larger centres requiringtwo machines.

7.5 The machine consists of three major modules.These are the scanning gantry and patient support, acontrol console and a number of electronics orcomputing racks. A dedicated control room will housethe console and provide a direct view of the scanningroom through an X-ray protected window. Theelectronics racks will be placed in a dedicated ‘machine

room’.

7.6 As the scanning process involves the use of X-raysthere is a need to construct the walls, doors andpossibly windows of the scanning room from high-density X-ray attenuating materials. The shieldingspecifications must meet the requirements of the 2000IRR and the advice of the local radiation protectionadvisor (RPA) must be sought by statutory obligation.

7.7 Visual and audio contact with the patient during theCT scan is maintained through a protective glass screensupplemented by CCTV and intercom. Patient accesson foot, in wheelchair, bed or trolley is obligatory.

7.8 The reader is referred to NHS Estates’ guidance‘Facilities for diagnostic imaging’ for further details.

Components of a CT suite

• Scanning room

• Scanning control room

• Data/image review room

• Patient preparation room

• Clean utility (where applicable).

MAGNETIC RESONANCE IMAGING (MRI) SUITE

7.9 MRI is a diagnostic facility utilising magneticresonance signals to generate detailed cross-sectionalimages at selected blocks or slices across the length ofthe patients’ head and/or body. The technique ispowerful in the ability to image both normal and tumourtissues at high resolution and often with good sensitivityto the presence and nature of disease. Use of MRI inthe support of treatment through both minimal invasivetherapy and radiotherapy is also established.

7.10 In outline technical terms MRI combines a powerfulmagnet, smaller time-varying magnetic fields, radiosignals and a sophisticated computer to produce high-quality images that display the soft tissues of the body.The digital information generated can be used to formcross-sectional, three-dimensional or moving images,which may be stored and distributed in a variety ofways. This can be a complex process but in essencethe images generated may be viewed on a television


24

7 Specialist cross-sectional imaging andpositron emission tomography

SPECIALIST CROSS-SECTIONAL IMAGING AND POSITRON EMISSION TOMOGRAPHY

25

monitor or produced as laser hard copy, similar to X-rayfilm.

7.11 The scanning process takes place in a room whichis constructed from normal building materials but whichis surrounded internally by a Radiofrequency (Rf) cage.The cage is essentially a bonded wire or sheet screenused to protect both the MRI and adjacent equipmentfrom unwanted Rf signals or radiation. The strongmagnetic field generated by the MRI unit may also giverise to a design challenge – part of the field (describedas ‘the stray magnetic field’) will be present in thesurrounding environment. In the past this frequentlygave rise to the need for magnetic shielding in the formof ferrous sheets or plates fitted to the room wallsoutside the Rf shield. Current units, often including theincreasingly common 1.5 Tesla (T) type have veryeffective ‘self shielding’, reducing or removing theexternal shielding requirement. Protection against themagnetic stray field down to 0,05mT or less is neededin order to protect persons (particularly those fitted withcardiac pacemakers) and also to ensure normaloperation of electronic equipment in surrounding rooms.

7.12 The machine consists of three major units. Largestand weighing two to five metric tonnes is the gantryunit, which consists of the imaging magnet and patientsupport system. A control console will be required andis housed in its own room adjacent to the scanningroom and with a sight provision generated by a specialwindow – itself part of the Rf shield, as is the specialscanning room door. Lastly a number of electronicsracks must be accommodated in a separate butadjacent machine room.

7.13 Visual and audio contact with the patient duringthe scan is maintained through a protective glass screensupplemented by CCTV and intercom.

7.14 Cryogenic gases will ordinarily cool the strongmagnet though resistive electromagnets and permanentmagnet types are also used in smaller, less capablemachines. Where cryogenic gases, such as liquidhelium, are used, an emergency external ‘quench’ pipewill be essential and the need to bring cryogenicmaterials to the suite must also be considered.

7.15 Much of the suite design is orientated towardproducing a patient-friendly environment but theexistence of hazards and the need for control of accessalso has a strong influence.

7.16 The reader should consult MDA safety publicationsand NHS Estates’ guidance ‘Facilities for diagnosticimaging’.

Components of an MRI suite

• MRI scanning room


• Patient waiting and changing area

• Machine and computer room

• Outer controlled area

• Data/image review room.

POSITRON EMISSION TOMOGRAPHY (PET)SUITE

7.17 This relatively new technique has gainedconsiderable importance in the United States and someother overseas areas but is in the relatively early stagesof development within the UK. The principle cancerapplication is in the detection and evaluation of possiblesecondary cancer growths or metastases. PET also hasa number of important non-cancer applications in theneurosciences and elsewhere so that shared facilitiesmay be a relevant consideration.

7.18 The technique uses very small amounts of glucosesugar in a modified form (DG), to which trace quantitiesof the positron-emitting radioactive material Fluorine-18are attached by chemical bonding to produce FDG.Positrons are novel anti-matter particles, whichannihilate matter to generate two gamma rays, whichtravel in opposite directions to each other. This specialproperty allows a positron camera to detect, and bytomography locate, the position of the radioactivematerial within the patient’s anatomy. This in turnhighlights the presence of secondary tumour growth.

7.19 In clinical terms, although as yet unproven, thetechnique may help doctors to determine which patientswould benefit from radical (curative) treatment andwhich should proceed to palliative care and a paincontrol programme. The progress of treatments mayalso be monitored by this modality or approach.

Practicalities and the built environment

7.20 Producing FDG is very difficult: it can only beproduced by a cyclotron; it must be an infection-freematerial; and Fluorine-18 has a short half-life (only a fewhours). Accordingly specialist and quite major facilitiesare necessary. These may occasionally be on-site with alarge cancer care centre but, more commonly, will belocated in regional centres or produced commercially.The production centre will need to be within three hours’transport time of the cancer centre if the material is tobe usable.


26

7.21 The patient journey requires attendance at a PETscanning centre, which will not necessarily itself belocated close to the cancer care centre, though somelogistical advantages may be observed in easy patientflow and care. It is important that the patient is verycalm before the scan can successfully be undertakenand accordingly the reception and waiting areas shouldbe particularly restful in character. A similar argumentapplies to the transfer of non-ambulatory patients. Thegiving of muscle relaxant drugs within a calm individualwaiting or preparation room is often regarded asstandard practice.

7.22 The patient must change into an examination gownand all metallic objects, etc., placed safely in a locker orsimilar repository.

7.23 The FDG is given as an intravenous injection andafter a waiting period – again in a very calm environment– the patient will be taken for scanning. This work usesa positron camera or in some cases a modified nuclearmedicine gamma camera to generate the tomographicscan described above. This scanning process takesabout 45 minutes and again the scanning room must becalming, and reduced but safe lighting levels are oftenused.

7.24 It is important that WC facilities for the exclusiveuse of the patients are provided. These must be closeto the waiting and clinical areas of the PET diagnosticsuite. There must not be steps, floor slopes, etc., in thelinking space as these may increase the patient’sexertion and compromise the quality of rest required.

7.25 After scanning the recovery time is short and themajority of patients may leave for home. However, asthe patient is slightly but not insignificantly radioactive,special transport arrangements or a delayed departuremay be necessary. These transport requirements mayinvolve the use of patients’, relatives’ or friends’ vehiclesand thus special thought must be given to convenientvehicle access and parking.

Safety and special design considerations

7.26 The radioactive material used and medicalconstraints present have important considerations forbuilding design. F-18 has higher radiation energy whencompared with most if not all nuclear medicineradioactive materials. This (and a number of similarfactors) gives rise to an increased need for heavierradiation shielding, protection by the use of distanceand other controls.

7.27 In suite design the use of shielding local to theradioactive materials as well as within the buildingstructure should be considered in consultation with thelocal RPA. The shielding will consist of lead protectivecontainers and enclosures combined with dense blockwall construction. The rooms used to store and

separately administer the FDG should be separated byat least a few metres from the scanning room in order toavoid unwanted detection of stored materials by thecamera during scanning. The scanning room will requirean adjacent control room with shielded viewing windowand CCTV.

7.28 Protection against radioactive contamination isimportant and the essential measures differ only in detailfrom those used in nuclear medicine. However, thestandards, which must be achieved are higher andplace a premium on detailed design and the selection ofimpermeable materials.

7.29 The need to constrain both the radiation andradioactive contamination will also affect the care ofinpatients and the environment in which they are nursed.The spacing of beds in wards will require review and thepresence of low-level radioactivity in the patient’s bodyfluids gives rise to the need for monitoring in respect ofcontamination and the provision of modest containmentfacilities. The bedding and other materials brought intocontact with the patient may need to be storedseparately as part of this containment. Equally theprovision and storage of a ‘spill kit’ is essential in orderto deal safely with the results of minor incidents orincontinence.

7.30 There are requirements under the RadioactiveSubstances Act that relate to storage, use and disposalof radioactive materials. These generate manyimplications particularly in terms of security againstsource theft and the possibility of fire. Disposal byradioactive decay in short-term stores speciallyconstructed and shielded for the purpose will beneeded.

7.31 The reader is referred to NHS Estates’ guidance‘Facilities for diagnostic imaging’.

Components of a PET diagnostic suite

• Patient scanning room


• Patient preparation and pharmaceuticaladministration area

• Pharmaceutical preparation laboratory

• Waste disposal facilities

• Patient rest area.

7.32 An example layout for a PET diagnostic suite isgiven in Appendix 2, Figure 3.

RADIOTHERAPY

Introduction

8.1 The provision of radiotherapy is a key feature of allcancer care centres.

8.2 There are three forms of radiotherapy treatmentusing sealed and unsealed sources of radiation:teletherapy in which an external beam is generated bya machine source of radiation; brachytherapy in whicha tumour is treated by placing a radioactive sourceinside the body. The source of radiation is normallyplaced into a tube or applicator device that has beenimplanted or inserted at surgery. This approach ofplacing the radioactive source after surgery is known as“afterloading”. The insertion of the radioactive sourcecan be manual, or more commonly, conducted by aremote afterloading machine. Among many advantages,afterloading protects the staff against the problems anddoses associated with handling radioactive materials inthe operating theatre.

8.3 Another way of treating disease from within is byusing unsealed radioactive sources. These are usuallyadministered to the patient in the form of a liquid (takenas a drink), a capsule or by intravenous injection.Guidance on the use of of unsealed radioactive sourcesis contained in Chapter 10.

8.4 All three forms of radiotherapy outlined aboverequire dedicated facilities, which must be carefullydesigned to match ergonomic, patient care and safetyrequirements. Safety will include protection against fire,electrical hazards and radiation and radioactive material.

Radiotherapy equipment and outline treatmentroom requirements – teletherapy

Linear accelerator

8.5 This is a powerful electrical device, which, as thename suggests, accelerates electrons to very highenergies by using radiofrequency waves, generated by amagnetron or klystron within a high-vacuum waveguide.The electrons are then either emitted into the air as abeam directed towards the patient or used to produceX-rays by being guided into a transmission target. Thebeam is then shaped to match the treatmentrequirements using an electron applicator or X-raycollimating jaws as appropriate.

8.6 This specialist equipment requires installation in apurpose-designed linear accelerator bunker with veryheavy protective shielding built into the construction.Traditionally reinforced concrete and steel have beenused but new materials (for example, “Ledite” – seeAppendix 2, Figure 8) are now providing alternativeapproaches, which may have advantages in terms of re-usability and reduced footprint. The bunker entrance willnormally be protected against the escape of X-rays intothe adjacent environment by a concrete maze; however,some recent designs have seen the reintroduction ofheavy protective doors without the provision of a maze.

8.7 Linear accelerators may be categorised as singlemode or multi-mode. The former are used for X-raytreatments only while the latter can produce externalelectrons in addition to X-ray beams. Multi-mode linearaccelerators may have, special built environmentrequirements over and above an X-ray protective bunker– particularly if used to generate X-rays above a definedenergy threshold. These relate to the need to protectpersons against unwanted neutrons produced byinteractions involving the high-energy X-rays. Neutron attenuation and absorption favours theuse of light materials such as wax and plastics.

8.8 Radiotherapy treatments must be precise andaccurate in terms of aiming the beam at the intendedtarget. This requirement means that almost all linearaccerators use a base frame set into the floor whichlinks the accelerator gantry to the patient support deviceor couch.

8.9 The recent introduction of two new technologies hashad a small but important influence on treatment roomdesign. The first of these is the multi-leaf collimator, adevice that accurately shapes the beam to the tumourand has reduced the need for special low-melting point(LMP) lead blocks, which were previously used for thisfunction and required local storage. Secondly, imaging isnow possible before or during treatment by digitalmeans, using electronic portal imaging.

Cobalt 60 machines

8.10 This technology is based upon the production of agamma ray beam from a very large cobalt radioactivesource contained inside a protective housing equippedwith mechanical shutter and basic beam-shaping

THERAPEUTIC SERVICES INCLUDING RADIOTHERAPY AND CHEMOTHERAPY

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8 Therapeutic services includingradiotherapy and chemotherapy

collimators. The relative simplicity of such machines isan advantage but a lack of flexibility and theenvironmental challenge of radioactive waste disposalmeans that only small numbers of machines remain inuse today. The possibility of new installations orupgrades cannot be excluded, however.

8.11 The treatment rooms or bunkers used are similar inconcept to those described for linear accelerators, butthe special high-energy considerations are not relevant.

Superficial X-ray treatment machines

8.12 These devices use conventional though powerful X-ray tube technology to produce lower-energytreatment beams. The emergence of linear acceleratorelectron treatments has reduced demand for superficialX-ray treatments but some disease conditions remainmost effectively treated with this older technology.

8.13 The X-ray tube is mounted on a simple but robustand accurate floor or ceiling suspension and is poweredby a conventional X-ray generator system. Thetreatment couch will be mobile and is not mechanicallylinked to the X-ray tube mounting.

8.14 Treatment rooms are similar to those used indiagnostic X-ray and may incorporate thin lead shieldingor be constructed from conventional dense buildingmaterials. Protective doors and viewing windows willalso be used. A maze is not needed in protectionagainst these low-energy radiations.

Orthovoltage X-ray treatment machines

8.15 In common with superficial X-ray treatmentmachines, these X-ray systems use a conventional tubeand generator though they are considerably morepowerful than their superficial counterparts. The needfor these machines is in marked decline and it is likelythat few will be installed in future unless new clinicalapplications develop.

8.16 The treatment rooms are more heavily shielded thatthose used for Superficial treatment and a small maze isa viable alternative to heavy door construction.

Radiotherapy equipment and outline treatmentroom requirements - brachytherapy

Manual afterloading

8.17 This technique is declining in use but may beoffered for Iridium 192 wire treatment of tongue orbreast as well as a number of other applications. Theapproach involves the patient in a visit to the operatingtheatre for the insertion or implantation of applicatortubes under general anaesthetic. This is followed by theinsertion of the pre-prepared encapsulated wires in asuitably shielded single patient side ward.

8.18 The shielding is intended to protect clinical andnursing staff as well as visitors and the public. As aresult of these requirements ‘shadow shields’ are mostlikely to be employed. These consist of very heavy leadcastings or plates supported on mobile frames andstrategically positioned to shadow key areas around thepatient’s bed. In modern installations structural wallshielding is also likely to be employed but local RPAsmust be consulted on this issue.

8.19 The wires are prepared for use in a shieldedworkstation within a medical physics sealed sourcelaboratory. Such facilities contain the shieldedworkstation together with a storage safe for the sealedsources. The preparation varies with the treatmentrequirement but will always include assay of theradioactivity present and may involve source sterilisation.

Machine afterloading

8.20 In order to reduce operator dose and afford greatertreatment flexibility, the widespread introduction ofmachine-based afterloading has occurred. In this groupof techniques the source is contained within a shieldedstore built into the afterloading machine. Usingsophisticated computer-based control the machineachieves mechanical or pneumatic transfer of thesource(s) from the store into the applicators, which havebeen previously implanted or inserted in the ward oroperating theatre environment.

8.21 The sources may be automatically withdrawn tothe storage safe when nurses, visitors, etc., enter theroom. Safety interlocks are always applied. With thesources withdrawn nursing may be conducted in anunhurried and normal way. Compliance with IRRrequirements is also aided substantially.

8.22 The treatment room will always be wall- rather thanshadow-shielded, though the level of shielding requiredwill be greatly influenced by the dose regimes asoutlined below. All control functions and some routinemonitoring of the patient will be conducted from ashielded area outside the treatment room. The use ofCCTV observation is helpful in removing the need tointerrupt treatments by the withdrawal of sources on anexcessive number of occasions. Intercomcommunication with the patient is an essentialrequirement. A typical machine afterloading system isshown in Figure 7.

Low dose rate (LDR) machine afterloading

8.23 In LDR brachytherapy the treatments will last from18 to 48 hours in terms of source exposure time. Only asingle treatment fraction is used. The patient will remainin bed within the shielded room for a total of about twodays after which the applicator tube will bedisconnected from the machine. Following this the


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patient will undergo applicator removal surgery on theside ward or in the operating theatre.

8.24 In common with medium dose rate (MDR)treatments the tumour volume is continuously irradiatedthroughout the source exposure time. The treatmentmachines are also of similar design to those used inMDR, that is to say self-contained units of 150 to 250kilogrammes weight and being less than two metres tall.Some machines require a separate compressor,mounted or housed so as to control noise. In the UK themajority of systems employed use multiple Caesium 137or Iridium 192 radioactive sources. A minority ofcurrently installed units may still support the use ofradium and gold sources in some LDR applications.

8.25 In the modern era, treatment flexibility requirementswill give rise to the need for multi-use brachytherapyfacilities. It is envisaged that a single shielded side roomwith shielded en-suite shower room and toilet will beprovided. With care in design this may be used formanual afterloading, LDR and MDR treatments asrequired. The room may also be used for routine nursingbut not with unsealed source treatments.

8.26 The control panel will be mounted in a securelocation outside the treatment room and is duplicatedon the machine itself. TV monitors must also be locatedso as to preserve privacy while permitting observationby nurses. The use of independent radiation monitors isadvised.

8.27 The provision of external windows is desirable andmay be achieved at ground level by the use of shieldingwalls outside, acting as shadow shields to the externalenvironment. The area between the window andshielding wall will require rigorous access control.

Medium dose rate (MDR) brachytherapy

8.28 MDR treatments typically take around two to fourhours’ source exposure time, depending on the type oftreatment undertaken. Unlike pulsed dose rate (PDR)brachytherapy, the tumour is continuously irradiated.The treatment prescribed may include the use ofmultiple or single radioactive seeds. These machinestend to be larger and carry more sources than a highdose rate unit (described below). The majority ofsources utilised in the units are either Caesium 137 orIridium 192. In common with LDR, some manufacturersbuild machines that incorporate the option to treat twopatients simultaneously. This will require two adjacentshielded treatment rooms.

8.29 Where suites are required to facilitate MDR, thedesign will be broadly as for that described above.However MDR brings with it additional shieldingrequirements and these may have greater structuralimplications.

Pulsed dose rate (PDR) brachytherapy

8.30 In this instance a single radioactive Iridium sourceis used. This has a level of radioactivity of about threetimes that used, per source, in MDR treatments.Treatment times last up to 48 hours.

8.31 In this treatment method, the single source ismoved into an applicator within the treatment site for upto 10 minutes per hour and is then retracted by thebrachytherapy treatment unit and placed into the nexttube or applicator location. The principle benefit of thistreatment is to obtain the same radio-biologicalproperties as LDR brachytherapy treatments and yetallow the use of a single source and greater flexibility innursing time.

8.32 Suite design is as described for LDR but withreconsideration of the shielding requirements. Highinstantaneous dose rates make the use of externalwindows more difficult and the advice of local RPAsmust be sought.

High dose rate (HDR) brachytherapy

8.33 This modern patient treatment approach differs inmany respects from those discussed for LDR/MDR andPDR above. The dose rates used and levels ofradioactivity are much higher, giving rise to greatlyreduced treatment times and the need for fractionationin many cases. As the source exposure time willnormally be of the order of 10 to 25mins the nature of


29

Figure 7 Machine afterloading system

the care process and the required built environment areunique to this form of therapy.

8.34 A single highly radioactive sealed source of Iridium192 or Cobalt 60 is used. This is moved within theapplicator to generate the required dose distributionwithin the tumour. In common with the other machine-based afterloading techniques, the source may bewithdrawn under remote control to a safe within themachine.

8.35 The patient journey, like the care process, hasimportant differences to the techniques describedearlier. The patient will generally be taken to anoperating theatre where the applicator will be inserted,implanted or placed under radiological control using amobile or permanently installed image intensifier. Herethe journey has two mutually exclusive options – thechoice being dependent on the built environment designselected by the care team.

8.36 In the first option the intermediate standardoperating theatre is built with heavily shielded walls andthe facility to monitor the patient from an adjacentshielded area. The HDR machine is housed in thetheatre and following the placement of the applicatorwithin the patient the HDR machine is coupled andtreatment may commence. This option worksparticularly well where the applicator is or may be readilyinserted and removed. The patient will return onsubsequent days for the administration of further dosefractions as necessary. During treatment all personsother than the patient must leave the treatment room,which is then an exclusion area.

8.37 The second option is more conventional andinvolves the patient being taken from the operatingtheatre where the applicator(s) have been inserted to aseparate treatment room. This may involve moving ananaesthetised patient – with the safety problems thatare attendant to this action. Accordingly it may begreatly desirable to position the facilities so as to easeand/or shorten this transfer. In some centres a Cobalt orlinear accelerator treatment room may be used; othershave constructed purpose-designed shielded rooms.The former choice reduces building and maintenancecosts but interrupts the use of the teletherapy treatmentequipment. The specially constructed room is free ofthese objections but may not offer great advantages interms of cost and flexibility compared to the shieldedintermediate operating theatre.

8.38 Regardless of the option selected above, the roomin which the applicator is inserted must be large enoughto support a surgical team in aseptic conditions and toallow the use of an image intensifier. Full anaestheticsand patient monitoring facilities will be required. ColourCCTV is needed to monitor anaesthetised patientsduring treatment.

8.39 The relevant regulations and codes of practicerequire that HDR treatment procedures are undertakenin relatively highly radiation shielded areas incorporatingthe use of a small maze entrance.

Brachytherapy treatment planning

8.40 The majority of brachytherapy treatments willrequire careful planning in terms of treatment choice,dose used and dose distribution obtained from a givenapplicator position. This may entail an X-ray or otherexamination to show the location of the applicator in-situ.

8.41 A dedicated treatment planning system, connectedto a network, will be needed in some instances whileother technical choices will permit this function to beperformed by a planning computer also used forteletherapy.

Components of a radiotherapy suite

• Treatment room and maze for use with linearaccelerator

• Linear accelerator control areas

• Physics equipment store and laboratories

• Pre-treatment interview room (radiotherapy)

• Information area and library

• Brachytherapy source storage and preparation

8.42 See Appendix 2: Room layouts, for examplelayouts.

CHEMOTHERAPY

Chemotherapy treatment techniques and facilities

8.43 Chemotherapy involves the use of cytotoxic drugseither individually or in combinations to treat cancers.The drugs are usually given by the intravenous route,either as a bolus over minutes or an infusion over hoursbut may in some cases be taken orally as a tablet orcapsule. In principle the drugs are toxic to both cancercells and normal cells of the body. The treatment intentis to effectively poison the tumour cells whilst giving adose to normal tissues that is low enough to assure thepatients’ survival.

8.44 Chemotherapy can be used to treat metastatic(secondary) and primary disease simultaneously andoften is the treatment of choice in diffuse, non-focaldisease.

8.45 In recent times new drugs and methods haveimproved this treatment in terms of reduced patientsuffering and morbidity. Selective administration of thedrugs, using lines or catheters placed into the tumour or


30


31

adjacent vascularity, can be helpful and is increasinglypractised. The use of chemotherapy as part of theoverall treatment strategy, which also involves hormonetherapy, tumour suppressive drugs and radiotherapy, isa common and necessary practice.

8.46 Patient-specific fractionation treatment protocolswill be adapted from standardised procedures to suitthe type of tumour, proliferation rate stage, etc. Onefraction may consist of a combination of drugs givenover a period of one or two weeks, or two or morecytotoxic drugs administered over a period of one day.In essence a cycle of chemotherapy drug administrationis configured and prescribed before the course ofchemotherapy treatment is commenced and thenrepeated until the entire prescription is completed or acure is established. In some instances where there islittle or no response from the tumour then the regimemay be changed during or at the end of the initialtreatment. The patient will be subject to regular imaginginvestigations and pathology tests to validate orotherwise the success of the treatment.

8.47 Treatment can take from two months to two yearsdepending on the type of cancer.

8.48 The patients must have a blood test prior totreatment to determine the final composition of drugsand other clinical factors. This may take place at a GPsurgery or local hospital up to 24 hours beforetreatment. When testing is conducted immediately priorto treatment there will be a waiting period of 30 minutesbetween taking the blood sample and the delivery ofdrugs – patients may wait in a waiting area or treatmentarea depending on throughput and care strategy.

8.49 The patient journey involves chemotherapy andassociated care being given on a day-case basis or asan outpatient in the majority of cases. However, aschemotherapy may be used with those whose diseaseis at an advanced and debilitating stage, in-patient caremay be needed. In the majority of cases patients will bemobile, although attached to a drip during theadministration of the cytotoxic drugs.

8.50 For those patients receiving lines, e.g. Hickmansystem or drug administration catheters, the journey willinvolve a visit to a purpose-designed interventionalradiology facility or standard operating theatre. Theprocedures are relatively minor and will have only a shortrecovery time though general anaesthetic is sometimesused. There is no express need for these facilities to bewith the cancer care centre but such incorporation isoften helpful in avoiding treatment delays and ensuringcontinuity of care.

8.51 Long term or ‘stochastic’ reactions can includestunted growth and development in older paediatricpatients as the cytotoxic drugs inhibit thyroid function.

The tight integration of other acute medical services istherefore vital to the overall care of the patient. Inaddition it is known that certain cytotoxic drugs canhave an effect on cardiac function and this needs to bemonitored in at-risk patients during and after treatment.

8.52 Hair loss as a result of the toxic effects of thesedrugs is a declining but still prevalent patient care issue.The use of ‘cold caps’ as a means of reducing hair lossis increasingly common though not always successful.The use of these caps requires the provision of storagefacilities and a domestic refrigerator/freezer. For somepatients the fitting of wigs will be necessary though onlya minority of facilities incorporate this service with thechemotherapy facilities.

8.53 Books, televisions, etc., and other patiententertainment facilities should be a feature ofchemotherapy day-care units and wards. Essentially thepatient remains on a treatment chair or couch forperiods of 30 minutes to several hours. It is oftenbeneficial if relatives, friends or hospital staff can remainwith the patient and some units will give social care asan integral part of the treatment process. Commonlyday-care treatment rooms will accommodate six to 12patients in an open area with good nursing observation.Typically such units will also incorporate side rooms orseparated areas for those requiring treatment in moreprivate circumstances.

8.54 The cytotoxic drugs will have a deleterious effecton the patient’s immune system and greater emphasisshould be placed on designs that enable staff to keepthe treatment unit or ward clean and as free frominfection as is reasonably possible while providing acomfortable environment. Immediate reactions to thedrugs may include nausea and vomiting, though this isless common with modern techniques. However, theroom design should be such as to facilitate easycleaning and decontamination.

8.55 Further to the above, patients occasionally have amore severe adverse reaction to the treatment. Nursingfacilities must include oxygen and suction outlet in agroup room plus an emergency box with fullresuscitation facilities near at hand.

8.56 Chemotherapy facilities should include at least onearea where a tuberculosis (TB) patient can be cared foras tumours may develop as a consequence orcomplication of this disease. Similar considerations mayalso need to be applied to the care of patients with HIVor Aids without discriminating against them.

8.57 Access for people with disabilities to chemotherapyfacilities should be regarded as essential.

8.58 Special equipment requirements withinchemotherapy areas will be variable and should be

subject to local consultation. However, the cytotoxicdrugs are hazardous and regulatory requirementsextend to secure storage in locked and alarmedfacilities, which will include the need for refrigeration inmost instances. Facilities for manual or computerisedrecord keeping are essential. Records must permit readyaudit of cytotoxic drug use and administration toindividual patients. In addition, patient-monitoringequipment must be available though occasional ratherthan routine use is expected.

Cytotoxic drug preparation, storage, transport anddisposal

8.59 Pharmacy facilities, purpose-built or adapted, arerequired by regulation. Cytotoxic drugs for use inchemotherapy must be prepared in an asepticpharmacy preparation room – this may be located in amain hospital or as a pharmacy outpost in the cancercare centre.

8.60 The nature of the facilities depends on aclassification of the work done under the pharmaceuticalregulations. This is concerned with the extent to whichdrugs are being manufactured or more simply prepared.In all cases operator protection against toxic aerosolsand surface contamination is an essential feature andimplies the use of a controlled environment housingcontainment and safety cabinets. Ease ofdecontamination is an essential feature and dictates theuse of impermeable and smooth floor, wall and benchsurfaces.

8.61 The discharge of cytotoxic materials into theenvironment is also regulated. Accordingly specificroutes for disposal must be agreed and described inlocal rules and protocols.

8.62 The suite will be designed to facilitate controlledaccess for those with appropriate authorisation only. Theuse of protective clothing is necessary and requires theprovision of storage and modest changing facilities.

8.63 Cytotoxic drugs may be delivered by hand or bypneumatic tube, however, the means of delivery mustbe secure and traceable.

Components of a chemotherapy suite

• Chemotherapy treatment room

• Inpatient chemotherapy ward

• Chemotherapy storage, use and disposal facilities

• Chemotherapy pharmaceutical preparationlaboratories

8.64 See Appendix 2: Room layouts for examplelayouts.


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MEDICAL PHYSICS SERVICES

33

THE ROLE OF MEDICAL PHYSICS

9.1 The provision of medical physics services or clinicalscience support is undoubtedly essential to theprovision of a range of modern cancer care services,particularly in the area of radiotherapy. The following listillustrates the range of contributions which clinicalscientists and medical physics technicians may beexpected to provide:

a. Radiation protection advice and scientific support ofsafety provision.

b. Calibration and output monitoring facilities for deviceswhich generate radiation beams, including linearaccelerators, etc., used in teletherapy and alsoradioactive sources applied in brachytherapy.

c. The provision of quality assurance services in boththerapeutic and diagnostic facilities applied to cancercare.

d. First line and, in some cases, more comprehensiveservices for the maintenance of cancer careequipment, particularly linear accelerators andradiotherapy simulators.

e. The design and construction of accessory devicesused in routine teletherapy such as shielding blocksand other modifying items.

f. The provision of patient dosimetric services to includepatient surface dose measurement by thermoluminescent dosimetry (TLD) and the use of radiation-sensitive diode arrays.

g. Clinical scientist and medical physic technicians havea learned role in terms of maintaining the scientificand technical standards of understanding within adepartment and also supporting the researchendeavours of other professional groups.

h. A role in the maintenance of good standards inrespect of imaging, including the use of imagecomputing and the development of such facilities.

i. Provision of scientific and technical support to theradiotherapy treatment planning process for bothteletherapy and brachytherapy.

j. A 'troubleshooting' role related to the correction ofdeficiencies in operational protocols and the routinefunctioning of radiotherapy departments and, in someinstances, medical cancer facilities.

FACILITIES REQUIRED

9.2 The following rooms or facilities are needed toaccommodate the long list of functions for medicalphysics above:

a. The provision of offices suitable to accommodateadministrative and academic functions.

b. Laboratory space with suitable benching and under-bench storage to permit the conduct of physicalscience experiments over a very broad range ofobjectives but to include instrument calibration andthe development of bespoke devices.

c. Storage facilities for an extensive range of equipmentincluding delicate instrumentation and qualityassurance devices as well as sundry materials usedin mould rooms and engineering workshops.

d. Metal fabrication and general engineering workshops.The scale of these workshops will be dependentupon the technological choices made for the deliveryof teletherapy services in particular, though themajority of departments also support a broader role.

9.3 Detailed guidance on these facilities is given inChapter 16.

9 Medical physics services


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UNSEALED SOURCE THERAPY

10.1 Unsealed radioactive sources are simplyradioactive materials present in a non-encapsulatedform – normally implying a liquid solution, though gases,droplet suspensions and powders are also occasionallyused. Rigorous care and attention to safety matters isalways an important component in unsealed source use,storage and disposal. This care requirement and the useof strict protocols significantly influences cancer carecentre design.

10.2 In clinical terms these materials may be used forboth diagnostic and therapeutic applications. In bothcases the underlying principle employs biochemical andphysiological mechanisms of substance uptake. Forexample, the sugar glucose is taken up from blood andmetabolised by the brain. If this sugar is ‘labelled’ by the attachment of the radioactive substance Technetium 99m to form an injectable unsealed sourcethen the brain may be imaged using the very low levelradiation produced.

10.3 In therapeutic terms the objective is clearly not toimage but is instead to deliver a large radiation doseselectively to a tumour or cancerous tissue. The mostcommonly used example employs unsealed Iodine 131to treat cancer of the thyroid gland by taking advantageof the natural uptake of iodine by that organ.

10.4 The availability of both diagnostic and therapeuticunsealed source related services is intrinsic to the careof cancer patients in a cancer care centre.

10.5 Cleanliness – and often sterility – are important inthe medical use of unsealed sources. For substancesgiven to the patient orally (for example the iodine drinkor capsules referred to above) high standards ofcleanliness are essential. For injectable (IV) materials fullpharmaceutical standards must be met such thataseptic and sterile considerations are to be respected.

10.6 Unsealed sources clearly emit ionising radiationsand thus all the issues sorrounding the shielding of thesources and environment apply equally here. However,for unsealed materials an additional challenge isgenerated by the need to avoid spillage and to controlthe spread of radioactive contamination from suchsources. These two requirements influence design

significantly both in terms of structure used and surfacefinishes applied. There are also important implicationsfor material choice due to chemical considerations, forexample the often irremovable nature of iodinecontamination of stainless steel. The detailed advice ofthe local radiation protection adviser (RPA) should besought at an early stage.

10.7 The use of some, though not all, radioactiveunsealed sources has a significant environmentalinfluence which is considered in detail in ‘Basis inenvironmental protection’.

10.8 A full background description and design advice onthe diagnostic uses of unsealed radioactive sources isprovided in NHS Estates’ guidance ‘Facilities fordiagnostic imaging’.

THE PATIENT JOURNEY

10.9 The patient journey for those cancer patientsreceiving unsealed source therapy differs greatly fromthe general case. An outline description with notes onthe built environment implications is given below:

• Referral for unsealed source therapy will follow fromdiagnostic procedures and a meeting with thepatient’s responsible consultant, who may be fromone of a number of disciplines.

• The patient will be admitted as an in-patient for themajority of treatments, most particularly for iodinetreatment of the thyroid. This is necessary both forclinical safety reasons and owing to the need tocontrol the potentially hazardous materials andradiation used.

• A side room with special facilities is needed toaccommodate the patient during treatment. Keyfeatures include protection against both radiation andradioactive contamination.

• In the majority of instances the unsealed source drinkor capsule will be given to the patient in the sideroom – treatment suite. This minimises the risk ofcontamination spread in the hospital and promotespatient-centred care.

• The administration of the substance will be given by aclinician often accompanied by a clinical scientist and

10 Facilities for the use of unsealedradioactive sources

FACILITIES FOR THE USE OF UNSEALED RADIOACTIVE SOURCES

35

nurse. Monitoring of the radiation level will beconducted for both safety and treatment controlpurposes with the patient in bed.

• The patient will remain confined to the treatmentroom until the radiation level drops below a definedthreshold, after which transfer to the general ward ordischarge will be considered. In older designs oftreatment room the use of shadow-type protectiveshields alone implied that the patient must remainlargely in the bed. However, modern designs givegreater freedom and have en-suite facilities for thepatient’s use. This latter feature has the majoradvantage that radioactive urine and faeces aredischarged by the soil drainage system, of specialdesign, within the treatment room. Equally a washingmachine, washing-up sink and hand wash basin foruse by staff play a useful role in preventing thespread of contamination.

• During the long period of confinement within thetreatment room, good design and the use of shadowshields will permit the patient to have visitors on alimited basis, and afford the possibility of less minimalnursing. Some advanced designs also incorporate awindow and use external shielding as a gardenfeature. Patient groups indicate that such features arehelpful in relieving the effect of treatment room staysof typically two to five days. Such solutions mayrequire controls on outside access.

Components of unsealed source rooms – therapysuite

• Iodine treatment room, en-suite facilities

• Storage facilities for unsealed radioactive materials

• Delivery facilities for unsealed radioactive materials

• Unsealed source preparation laboratory

• Contaminated items store – decay store

• Monitoring instruments store

• Storage facilities for spill kit

• Personnel decontamination facilities.

CARE OF THE DISABLED

10.10 Generally within cancer care centres there is littleor no reason why design elements should not beincorporated to permit access for the full range ofdisabled persons to all facilities without compromise togeneral or specialist safety requirements. However, forwheelchair users a special problem is thought to exist inboth access and control of contamination for iodine andsimilar treatments. This arises from the use of waterbars at strategic points within the treatment room. Todate no fully effective solution to this challenge has beenidentified.

CHARACTERISTICS AND APPLICATIONS OFCANCER SURGERY

11.1 Although radiotherapy, chemotherapy and hormonalwork have all gained substantial ground in recent years,the majority of clinical referrals continue to be directed tocancer surgeons. This reflects the very high value ofcancer surgery both in palliative work and radicalcurative applications. Although greatly variable across theUK, the majority of surgery will form part of an integratedtreatment programme, as required by Calman–Hine,making use of many parts of the portfolio described inthis document.

11.2 The profile of cancer surgery continues to changemarkedly and is the subject of constant learnedadvanced and technological development. This isreflected in the increasing range of surgical techniquesand broadening envelope of use as well as improvedoutcomes. The boundaries of surgical activity are lessdistinct than hitherto owing to the rise of minimal invasivetherapies, which may supplement or replaceconventional surgical techniques.

11.3 As might be expected for surgery as a whole, thelevel of invasion and severity of procedures is broad. Thefollowing list, although not fully comprehensive, isrepresentative of commonly applied techniques whichmust be supported by cancer care centres:

• Laser ablation for the treatment of cervical pre-cancerand a range of other relatively accessible lesions.

• The removal of surface or skin lesions by conventionalor cryosurgical means.

• Cancer-related uses of endoscopy.

• The insertion of lines and catheters, includingHickman-type, by surgical or minimal invasive means,often under X-ray control.

• The insertion or implantation of brachytherapyapplicators or tubes, for machine controlledafterloading radiotherapy. Occasionally pre-loading ofsealed radioactive sources in the operating theatremay still be required.

• Breast surgery as a part of a comprehensive breastcare service. This will range from relatively modest

lumpectomy procedures to radical mastectomy,including the removal of lymph nodes. (For thepurposes of this guidance, the commonly appliedtechnique of mammography guided needle biopsy isconsidered to be non-surgical.)

• Some centres will be offering surgery to the prostate,including robotic procedures, though not all suchwork is cancer-related.

• A broad category of investigative surgery continues inuse. This area is in modest decline owing to theincreasing contribution of cross-sectional imaging byCT and MRI.

• De-bulking of benign, and some forms of malignant,tumours. Such surgery can be radical in nature and isfrequently a precursor to other forms of treatment.

• Surgery with direct curative intent on largely non-metastatic low-invasion tumours.

• Surgical biopsy. This range of techniques continues tobe very important as it permits the sampling ofsuspected cancer tissues for histologicalexaminations, which may confirm or deny thepresence of malignancy. This area is developingquickly in technological terms owing to theincreasingly common introduction of both stereotacticand navigational techniques. These technologies,which have their origins in neurosurgery, are nowmore broadly applied. Images from CT and MRI areused to enable this type of surgery.

• Reconstructive surgery. There is a greatly increasingdemand to reconstruct parts of the body that havebeen damaged by cancer or the processes of surgery.These procedures are particularly common in thebreast and are increasingly seen as indicators of high-quality care.

11.4 The above clearly represents an extensive portfolioof techniques which places a range of demands onoperating theatre design and availability. In consideringprogrammes to modernise cancer care centre provision,project teams should evaluate, at local level, the numberof operating theatres and associated facilities required.The nature of such facilities are dealt with later in thisguidance.


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11 Cancer surgery requirements

CANCER SURGERY REQUIREMENTS

37

OUTLINE CLASSIFICATION OF REQUIREMENTS

11.5 The range of surgical facilities needed toaccommodate the above techniques is wide and variablein nature. In order to simplify planning and designchallenges, this document uses a simple but arbitraryclassification scheme. This scheme grades operatingtheatres from Levels 1 to 4 according to the protectiverequirements in terms of possible infection. In addition,three categories are used to indicate the extent to whichthe theatres concerned are standard, modified to suitcancer treatment or largely devoted to such treatment.These groups represent categories 1, 2 and 3respectively following the convention used throughoutthis advice. See Table 6.

11.6 The Chief Medical Officer advises continued andincreased vigilance concerning the quality of the builtenvironment used for the decontamination, sterilisationand storage of surgical instruments. Mention of thesefacilities is made below. However, attention is drawn tothe NHS Estates’ compendium of documents and advicepublished on CD-ROM. For the latest information ondecontamination see NHS Estates’ website atwww.nhsestates.gov.uk and the Department of Health’swebsite at www.doh.gov.uk/decontaminationguidance.

BUILT ENVIRONMENT REQUIREMENTS

11.7 The following provides an outline description of therequirements for cancer surgery using the categorisationdescribed above. For general advice the reader isreferred to NHS Estates’ guidance HBN 26 – ‘Operatingdepartment’.

Facilities for relatively minor procedures

11.8 This environment is perceived as being appropriatefor procedures where the risk of infection is relatively lowand the period of immediate recovery short. As may beseen from the above table, most of the surgery is to theskin or body orifices though some simple biopsy workwill be included. General advice on the largely similar

‘treatment area’ concept is given in NHS Estatesguidance HBN 40 Volume 2 – ‘Common activity spaces:treatment areas’.

11.9 The rooms broadly have the characteristics requiredfor general minor procedures. Particular attention isdrawn to the need for easy-to-clean surfaces, devoid ofdust traps. The drive toward reduced infection rates putsparticular emphasis on good quality clinical handwashing facilities. Some local teams may also requirescrub-up facilities, which may be located adjacent to, orin a corner of, the procedures room. A simple supportsuite for reception of patients, who will mostly beambulatory, should be provided together with facilities toreceive patients in wheelchairs or on trolleys.

11.10 Within the procedures room basic medical gassupply including air, oxygen and vacuum/suction will beneeded, though general anaesthesia is not envisaged atthis level. A low-power, ceiling-mounted operating lightwill be needed together with a single surgical pendant.The introduction of the pendant is now seen as anessential requirement in the interests of improved patientservice arising from the greater dependence ontechnology use in these rooms. The need to eliminate orreduce hazard to staff from trailing cables has also beenconsidered. Mechanical ventilation, using a coarsefiltered air supply, will be required but the business ofmicropore filtration and accurate airflow control is notseen as a key requirement. The room shall incorporatefacilities for cryosurgery where local demand can bedemonstrated.

11.11 The suite should include a recovery room sufficientfor two patients, storage facilities for lay-up of smallsurgical trolleys, drugs, etc., and a separate dirty storageroom for the short-term accommodation of contaminatedsurgical equipment. The local decontamination andrecycling of surgical equipment is not recommended.

11.12 Three options for the location of the cancer minorprocedures facility should be considered:

TABLE 6 OPERATING THEATRE FACILITIES REQUIRED FOR CANCER SURGERY

Surgical technique Theatre Level Room category

Laser ablation 2 2Surface cryosurgery 1 2Cancer endoscopy 1 2Insertion of lines and catheters 2 2Brachytherapy implants 2/3 1 (HDR 3).Breast surgery 2/3 1Prostate procedures 2/3 2Investigative surgery 2/3 1Tumour debulking 2/3 1Curative surgery 3 1Surgical biopsy (stereo) 3/4 3Reconstructive 4 1 (3)


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Option one

Close to the out-patients’ department or facilities usedfor general cancer patient care.

Option two

As part of a theatre complex but located toward theperiphery of the theatre grouping in a relativelypatient-accessible location. This should be such as toensure the absence of need for the patient to enterthe clean theatre corridor other than under the fullcontrol of staff.

Option three

Adjacent to in-patient wards and other treatmentareas.

Facilities for intermediate level procedures

11.13 These may be characterised as operating theatresfor full, but not especially prolonged, anaesthesia andincorporating a full operating couch, surgery lamp(s),monitoring facilities and be of sufficient size to allow for afull operating team of six persons. Full scrub-up facilitiesadjacent to the operating room must be provided. Thetheatre shall be equipped with a full filtered air systemwith pressure and flow regulation but ultra clean facilitiesare not envisaged at this level.

11.14 The theatre suite shall incorporate a recovery roomwith full observation facilities, trolley lay-up or preparationroom (clean supply), separate used trolley storage or, iflocal conditions allow, trolley breakdown room withadjacent decontamination facilities.

11.15 In order to promote efficient and safe operatingtheatre use, there is a clear requirement for a separatebut adjacent anaesthetic and patient preparation room,equipped with full medical gases as for the theatre itself.

11.16 Some specific cancer specialisations presentthemselves in relation to facilities of this type. Wherelocal treatment approach so requires, the insertion ofbrachytherapy applicators will be supplemented byfacilities to permit high dose rate machine afterloadingtreatment. Such facilities are an observably effectiveoption to the provision of treatment rooms specialised forHDR only. Where incorporated into operating facilities,HDR will require room shielding-based radiationprotection and remote protected observation/control.Colour closed circuit TV (CCTV) will be needed forpatient observation. The design of the facility should besuch as to afford the anaesthetist an acceptable level ofconfidence while HDR procedures take place whilst thepatient remains under anaesthetic.

11.17 Theatre-standard finishes and general facilities asdescribed in NHS Estates’ guidance HBN 26 ‘Operatingdepartment’ are fully applicable but particular attentionshould be paid to the need for mobile C-arm or image

intensifier access and use. Special storage facilities forHickman lines, catheters, guide wires, etc., will beneeded. These should be within or immediately adjacentto the operating room.

11.18 Where cervical and other Class 3 laser treatmentprocedures are to be offered, the special considerationsprovided by Medical Devices Agency guidance must befollowed. This will include special power supplies forlaser equipment, reduced or no use of polished surfacesand the provision of window blinds, laser safety signs,etc. The laser radiation protection advisor (LRPA) mustbe consulted on theatre design, the declaration of a lasercontrolled area and the provision of warning lights, etc.

11.19 Options are readily identified in terms of theprovision of this facility:

Option one

A location adjacent to other cancer in-patient facilitiesas a satellite of the main hospital operating theatres.

Option two

This option entails that the theatre simply be a part ofthe hospital’s main theatre unit. This may pose aspecial challenge if HDR facilities are incorporated andthe theatres are above the ground floor. This difficultyarises from the need for heavy radiation protectionshielding and its consequent structural loading.

Locations adjacent to radiotherapy facilities are seenas undesirable owing to the need for full theatreconditions and possible out of hours use.

11.20 Although this group of facilities may be reasonablyseen as little more than a limited modification of generaloperating theatre design concepts, a thoroughconsultation with the broad cancer care team isrecommended at an early stage in design. Particular careshould be paid to engineering requirements and energyuse in these theatres. Further advice is provided inAppendix 1: ‘Specialist engineering requirements’.

Facilities for high level procedures

11.21 A proportion of cancer surgery requires a longerperiod of anaesthesia and particular care over protectionagainst infection. This being the case, access to a largearea, high category operating facility will be necessary forthe majority of cancer care centre teams. However, theprovision of dedicated facilities will be needed only wherelocal treatment programmes and specialisations mayrequire. Thorough consultation with cancer surgeons andtheir support teams will be needed in this area.

11.22 The procedures conducted at this high level are ofincreased complexity and make use of both additionaltechnologies and may require further members of staffwhen compared to the less elaborate proceduresaccommodated by the facilities described above.

CANCER SURGERY REQUIREMENTS

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11.23 Complex organ surgery, which may encompassvascular aspects, and relatively new techniques that usestereotactic or navigational technologies are includedwithin this area of activity. (Some will be based on andapplied in neurosurgery.) Of these, the image-basednavigation approach is developing quickly and requiresthat image data derived from pre-operative imaging, oralternatively imaging during procedures, is utilised. In thefirst instance, the images are transferred by disk ornetwork to a navigation computer, which must beaccommodated within the operating room. Thesemachines are relatively bulky and are associated withspecial cameras, also to be accommodated, which trackthe position of surgical instruments within the patient’sanatomy. Such surgery was originally confined to brainand spine but is now finding increasing applications overa broader range of anatomy.

11.24 Reconstructive surgery provides further examplesof surgical tasks requiring this level of facility that aresubject to the need for particular care in order avoidpatient infection. This gives rise to a need for specialobservation in detail design to reduce dirt and dusttraps. Further, the standard filtered mechanical ventilationsystem, typical of the operating theatres described underintermediate level procedures, will require furtherimprovement. Attention to the use of micropore filtrationto further reduce particle size and abundance isappropriate. Systems are further augmented by the useof exacting theatre room atmosphere pressure controland ventilation portals. These will require detailedengineering consultation at local level. Further informationis provided under ‘ultra-clean ventilation’ in NHS Estates’guidance HBN 26 – ‘Operating department’.

11.25 The use of overhead service pendants is requiredand care should be taken both in the numbers selectedand their position relative to the operating couch,surgical lamps and any plenum canopy used with theultra-clean air system. The use of navigational computersand some other surgical aids will require that power andother services be provided to computer/instrumentssystems. This is frequently best achieved by the use of apendant partly or wholly devoted to this purpose. Whileall operating system power supplies will be connected tohospital back-up or generator systems, the use of anuninterruptible power supply (UPS) will frequently benecessary in order to safeguard proper operation ofsome of these computerised instruments.

11.26 Operating microscopes are worthy of particularattention in terms of the power supply considerationsmentioned above, and also because of the exceptionalbulk of some examples. These instruments, particularly inrobotic form, are especially space consuming, beingapproximately two metres deep and requiring a lateralmovement of one and a half metres, which must be freeof obstruction. Similar considerations may be expected

to apply in future to other forms of robotic surgery andtelesurgical technologies. Extending theseconsiderations, the optical devices mentioned have aparticular sensitivity to mechanical vibration, which mayinfluence decisions in terms of theatre siting and someelements of construction.

11.27 Storage facilities associated with operatingtheatres used for the specialised applications mentionedabove will need to be larger than is otherwisecontemporary and subject to special considerations onpositioning so as to ease the movement of equipment.As this equipment will require frequent maintenance, thestorage facilities or alternative areas should be sized soas to permit access by one or two service engineers.The provision of task lighting arrangement and powersupplies to support this activity should also beconsidered.

11.28 The need for specialist decontamination ofelectronic surgical instruments should be evaluated.Many of these are unsuitable for conventional steam loadporous sterilisation.

11.29 The use of imaging technology and the specialistnature of some of the cancer-related surgery will placeadditional requirements on design in terms of datacommunication and teaching facilities. Theatres at thislevel must be equipped with a wide-bandwidth opticalLAN to support image and general data communicationat reduced risk of interference from Rf-generatingsurgical instruments, such as bi-polar forceps.Observation of procedures by staff and students intraining is likely to be a frequent requirement.Consideration should be given to the possibility ofelevated viewing windows or the lower cost alternative ofCCTV systems.

11.30 The long periods of time spent by surgical teams,particularly the leading surgeon and their assisting nurse,give rise to a need for careful consideration ofergonomics, some aspects of lighting and the possibilityof eye strain. At the current state of understanding NHSEstates is not able to prescribe design solutions, butasks design teams to discuss these issues at local levelwith the staff concerned.

11.31 The siting of this category of operating room isessentially restricted to the principal theatre complex ofthe host hospital. It is important that the theatre has fulllocal access to auxiliary accommodation and post-operative patient care facilities.

12 Offices and support facilities

12.1 In general terms the office and generalaccommodation of a cancer care centre does not differgreatly from that of other hospital-based facilities ofcomparable size. However, a number of points requiringspecial care do arise.

OFFICES

12.2 Consultation rooms used for sensitive discussionswith seriously ill patients and their relatives requirecareful siting. There is a need for discretion in terms ofsound control, use of induction loop hearing aids, and ofaccess and departure arrangements.

12.3 As a part of the business of advancing cancerservices the great majority of centres are engaged in arange of clinical trials. These have special office needsto accommodate staff with roles such as record keepingand data analysis.

12.4 The National Cancer Registry is an intrinsic part ofthe drive towards better cancer outcomes and like theclinical trials endeavours may give rise to the need fortemporary or permanent accommodation of a high-levelclerical team.

12.5 The introduction of new technologies which bettercombine and handle patient treatment data, particularlyin radiotherapy, has given rise to the need for data entryand review facilities for use by radiographers and otherkey treatment delivery staff. These can be accommodated in an open plan office suite adjacent to theradiotherapy facilities.

12.6 Office accommodation for those responsible forpsychological and social care of patients and theirfamilies will be required. These must include openaccess rooms for patient information services.

EDUCATIONAL FACILITIES

12.7 The widespread increase in the sophistication ofapproach to cancer care and the near-ubiquitous needfor continuous professional development (CPD) hasplaced an increasing emphasis on education facilities.Key points in relation to cancer care centres include:

• The clear need for a seminar or lecture room withmodern audio-visual facilities and good computersystems access is now well established. In order topromote effective use this should be located close topatient care areas.

• Library facilities and Internet access points are key tomodern cancer care services. It is essential toconsider providing private study space with easymeans to make effective use of publications.Remotely located facilities have been shown toexhibit poor level of uptake and use. Convenient staffaccess is accordingly an important parameter.

• Many cancer care centres have specialist stafftraining facilities for the basic and postgraduateeducation of staff members such as radiographers,physiotherapists, etc. (Design details are not withinthe scope of this guidance.)


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INFORMATION SYSTEM REQUIREMENTS

41

13.1 The range of data types that must be used incancer care is very large. Calman–Hine recommendsbringing together multi-disciplinary teams, and using abroad range of equipment, to optimise the treatment ofpatients and also to ensure that the treatment deals withthe whole patient and not merely some aspect of theirdisease. Intrinsically this requires that disparate data bebrought together in a coherent way to generate clearclinical information.

13.2 In some traditional radiotherapy and cancer carecentres within the NHS, the whole information processcan be dealt with on film and paper sincemethodologies exist and very large spaces are availablefor storage.

13.3 In new and reconfigured cancer care centres, thefeasibility of maintaining so complex a record on hardcopy file materials is thought to be dubious. A moveaway from paper and hard copy materials is likely to beappropriate in some established centres from aneconomic and operational viewpoint. This may alsoassist a centre in complying with Calman–Hineprinciples. However, there is a substantial impact onbuilt environment design when paper storage spacesare replaced by IT facilities.

13.4 In light of the above, the use of comprehensivecomputerisation at new centres is one preferred optionand is in keeping with a trend in that direction by othermajor NHS centres. Consequently, a distributive robustnetwork architecture of multiple computer workstationservers is needed and this should be reflected in thebuilding design. Suitable rooms should be allocated inwhich these servers and the associated network hubunits can be placed. Network structures should beincorporated into service ducts, etc. Data entry andreview rooms are also needed.

13.5 The multi-disciplinary nature of the work in cancercare requires that most of, if not all, the servicespresently offered by the hospital remain but that theybecome intimately associated, where necessary, withnew services provided. This being the case, anynetwork used must have close ties to any networkwithin the host hospital itself. Furthermore, if the hospitalnetwork is of relatively modest bandwidth, someupgrades within the hospital will undoubtedly benecessary.

13.6 The Royal College of Radiologists and a number ofother learned bodies have drawn to the attention of themedical community the critical nature of delays,interruptions and errors in chemotherapy andradiotherapy treatments. This being the case, it isimportant that data is secure, not only against intrusion,but also against loss. Interruptions in or the inability totransmit data from places of storage to places of usemay also be detrimental to patient service quality.Accordingly, if a digital option is to be pursued, abackbone network with extensive route duplication anddual connection of servers and other critical devicesappears to be necessary.

13.7 If the option above is to be pursued, theoperational and design consequences should becarefully considered when developing or adapting acancer care centre.

13.8 Changes in the way information is handled willhave a great effect on the patient's cancer journey andtreatment schedule when compared to traditional filmand paper methodologies. In particular reduced waitingtimes and more rapid throughput have been observed inradiotherapy departments modernised in this way.

13.9 The computer-based option may also free up somespace in respect of the previous allocation to largestorage and film libraries. However some of this spacemay be taken up by servers and other computerequipment as mentioned above. There may be also be aneed to store some data media in more than onebuilding in order to protect against loss in the event offire.

13.10 The computerised option will allow centres tocommunicate with cancer care units and primary carepractices using telemedical means. This will almostcertainly have an effect on patient journeys throughoutcancer treatment by easily allowing some routinemonitoring and follow-up to be carried out at localcancer care units and at primary care level.

13 Information system requirements – image, pathology and radiotherapy data;computerised management of care processes

INTRODUCTION

14.1 This chapter gives detailed guidance on theplanning and design of accommodation in a cancer carecentre. It

• outlines the planning process;

• gives a detailed description of room requirements indiagnostic, treatment and support areas;

• highlights general design considerations.

14.2 Details of activities, equipment, environmentalconditions and finishes will be given in NHS Estates’Activity DataBase. Detailed schedules ofaccommodation and cost information will be publishedin a separate document that will include cardiac anddiagnostic imaging data.


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14 Description of accommodation

Relationship between clinical functions and rooms or facilities used

TreatmentConsulting/examination

reviewCobaltLinear accelerator (Linac)WaitingChangingInterviewTotal body irradiation (TBI)Superficial/orthovoltage

ImagingComputed tomography (CT)X-rayPositron emission tomography (PET)Magnetic resonance imaging (MRI)UltrasoundNuclear medicineIodine

Education/researchSeminar roomsClassroomsLibrary

Brachytherapy – could be ward basedDay-care supportHigh dose rate brachytherapy (HDR)Medium dose rate brachytherapy (MDR)Pulse dose rate brachytherapy (PDR)Theatre also has pain control

Administration - radiographerOffices – consultantSecretariesManagementMeeting roomsMedical records

Patient supportInformationComplementary medicineGroup supportDieteticsPhysiotherapyOccupational therapySpiritual carePalliative carePorters

OPD/chemotherapyChemotherapyOPDPharmacyPhlebotomyPathology

Staff – multi-disciplinaryContrastChanging MR workshop

MediationEngineering workshopMedical physics

Pre-treatmentSimulator

MR/CT patientConsent room

Sub-wait/reception

} link to ward

DESCRIPTION OF ACCOMMODATION

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THE PLANNING PROCESS

14.3 Throughout this guidance detailed attention is paidto considerations of safety, risk control and theimplications for design. The requirement to give suchattention in building projects is embraced by SI 1994 No3140 The Construction (Design and Management)Regulations. These are broad-based but ascribeparticular and specific duties to both designers andothers who contribute to the shaping of designsolutions. The regulations were subject to technicalamendment in 2000 with a clarification on the statutorydefinition of a designer.

14.4 The primary duty is due regard to health and safetyin design work. This includes a requirement to conductrisk assessments both in respect of the product buildingand the process of its construction. In addition to anoverall consideration of broad risk categories, theregulations also instruct on the need for safety and riskanalysis at the detailed design level. There is arequirement to evaluate design options in terms of riskreduction and the cost of such, though a balancedapproach with due consideration of many other factorsis described as appropriate.

14.5 A large part of the design process must alwaysconsist of close collaboration and consultation with end-users of the new development and those responsible forexisting buildings within the same or closely relatedinstitutions. The regulations may be interpreted asrequiring broad care in respect of overall design andfacilities management as well as technical alignment.There is a particular need to avoid solutions that may betechnically acceptable but not compatible withorganisational and operational requirements.

14.6 In all instances there are duties for the designerand planning supervisor but those of the client or end-user must also be respected. This will often requireclose co-operation and collaboration betweenemployers including all participant parties in privatefinance initiative (PFI) and public private partnership(PPP) agreements.


14.7 This listing covers the full range of builtenvironments that may be used by cancer care centrepatients, related healthcare professionals, support groupmembers and relatives.

14.8 Some aspects of the accommodation listed will belargely or wholly devoted to the care of cancer patientswhile other spaces will be of only limited relevance. Thisguidance covers the dedicated accommodation in detailbut also describes any cancer-related specialisation oradaptation to more general rooms.

14.9 The full design details for the standard rooms aregiven in other NHS Estates publications. Informationprovided in other NHS Estates publications issupplemented or updated as necessary.

Common spaces

Main entrance

14.10 Ambulances and taxis may deliver and/or collectpatients. The entrance canopy should be large enoughto afford adequate weather protection for patientsalighting from and entering vehicles, and high enough toclear lights and aerials on ambulances. The spaceshould be well lit and suitable for use by those withdisabilities.

14.11 Access to and from the main entrance should bethrough a draught lobby with automatic doors. Thelobby should be large enough to allow people to standaside to permit the passage of a patient accompaniedby an escort and also to allow pushchairs andwheelchairs to pass. Consideration should be given toproviding a smoking facility in order to avoid peoplecongregating outside the main entrance.

14.12 For further information refer to:

NHS Estates’ guidance ‘The design of hospital mainentrances (Design Guide)’

NHS Estates’ guidance HBN 40 – ‘Common activityspaces’ Vols 1 to 4

14.13 Attention is drawn to the need for the installationof induction loops for those with hearing difficulties.

14.14 The main entrance will be the principal route inand out of the centre for the majority of visitors andstaff.

Reception and waiting areas

14.15 The reception and waiting areas will be the firstpoint of contact for patients and carers when they visitthe facility. It is important not to miss the opportunity toprovide a reception that warmly greets all those whoenter with a feeling of support and reassurancebalanced with a sense of efficiency. A well-consideredreception with friendly staff and well-managedappointments will help to reduce stress to both patientsand staff. The benefits available from good interior andenvironmental design has been well researched anddocumented.

The influence of information technology

14.16 Conventionally equipped and managed treatmentfacilities and appointment systems generate waitingareas well represented in the NHS Estates guidancereferred to above. However, centres with fully integrated,


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LOUNGE/RECEPTION AREA AT THE LINDA JACKSON MACMILLAN CENTRE

RECEPTION FOR CHEMOTHERAPY WAITING AREA. NOTE LOW DESK SECTION FOR TALKING TO THOSE IN WHEELCHAIRS


45

computer-managed equipment and appointmentsystems and a well designed patient flow pattern withsub-waits, are likely to result in smaller waiting areaswhose character is calmer, less stressful and morehumane. Reduced waiting times benefit the patient andpromote a more efficient and relaxing environment.Examples of this arrangement are at Derriford Hospitalnear Plymouth and at the Karolinska Institute inStockholm, Sweden.

Diagnostic facilities

14.17 The diagnosis processes will involve the use ofone or more of the following departments. (Dependingon the circumstances of the cancer care centre thesemay be located in an adjacent building if the unit is partof a hospital, or the patient may have to visit a remotefacility.)

Radiology

14.18 In the cancer care environment, the purpose of aradiology department is to provide a range of facilitiesfor the investigation of patients by means of radiologicaland complementary techniques. Investigations andprocedures are selected by an oncologist supervisingthe patient’s care in consultation with a radiologist.Radiology Departments carry out investigations andreport on the results as quickly as is reasonablypracticable.

14.19 For further information refer to NHS Estates’guidance ‘Facilities for diagnostic imaging’.

Haematology

14.20 Haematology is the study of blood, its functionand disorders. Refer to NHS Estates guidance HBN 15– ‘Accommodation for pathology services’.

Consulting rooms

14.21 These will be used for consultation, examination,taking and recording of blood pressure, and for minordiagnostic and treatment procedures. Space is neededfor a desk and chairs, and an examination couch,screened by curtains. There should be sufficient spacewithin the curtained area for a patient to undress/dressin privacy, with assistance when required. Theexamination couch should be accessible from bothsides. Space is needed for storing small items ofequipment and small quantities of supplies and for amobile adjustable examination lamp. Clinical hand washfacilities are required.

14.22 Consulting rooms should be large enough toaccommodate a multi-disciplinary medical team as wellas the patient (who may be in a wheelchair), and anescort. This will allow an integrated and balancedconsultation to be delivered when appropriate. (Asrecommended by Calman–Hine.)

14.23 The layout of the room should allow patient andconsultant to be seated facing each other in an informalarrangement without any intervening barrier such as adesk, and should ensure maximum privacy, especiallywhen the door is opened. Communicating doorsbetween adjacent consulting rooms may facilitate themovement of staff, but they are not recommended astheir use intrudes upon both the patient's privacy andthe consultation.

Computed tomography (CT) suites

14.24 The scanning process involves the use ofequipment that generates X-rays and therefore takesplace in a room that is constructed from radiationshielding materials placed between adjacent roomsincluding the control room associated with the CTscanner.

14.25 Audio-visual contact with the patient during thescan is maintained through a protective glass screensupplemented by CCTV and intercom.

Magnetic resonance imaging (MRI) facilities (whole- and part-body)

14.26 The scanning process takes place in a room thatis constructed from normal building materials but whichis surrounded by a bonded wire screen to protectadjacent equipment from the strong magnetic field thatis generated by the MRI unit.

14.27 Audio-visual contact with the patient during thescan is maintained through a protective glass screensupplemented by CCTV and intercom.

14.28 For further information see NHS Estates guidance‘Magnetic resonance imaging’ (Health Guidance Note).

Cytology laboratories and cervical screening

14.29 Cytology screening, particularly in respect ofcervical cancer, constitutes a major establishedprogramme within the overall strategy for cancer careacross the UK. The practice is to utilise microscope-based observations of cells or tissue samples obtainedby the use of a speculum to scrape material directlyfrom the cervical anatomy.

14.30 The process is vulnerable to error and inconsequence, subject to very rigorous quality control.Audit measures are applied at every stage.

Accommodation and design

14.31 The cytology screening room is a dedicatedcancer facility. The room will differ fundamentally incharacter from general pathology laboratories becauseof its special role and the very great need for care inergonomic design. The walls should be finished in anti-glare neutral colours much as for the benches. Thefloors will be carpeted in heavy-duty material again with

similar attention to the colour. (Carpet is used in order tosuppress sound and also to soften the generalcharacteristics of the room.) Ceiling design shouldincorporate sealed light fittings and be constructed tominimise dust traps.

14.32 Some temporary storage of microscope slides, aswell as auxiliary equipment will be needed within theroom.

14.33 It will be necessary to accommodate PC orsimilar computer equipment for access to pathologyrecord systems and, in some instances, dedicatedcytology screening records.

14.34 Windows should be largely restricted to thosedescribed under ergonomics to permit relaxation of theeyes by focusing on the outside horizon. Overheadnatural daylight is unhelpful.

14.35 There are no special privacy considerations butfull laboratory security measures are necessary. Accessto the room will be restricted to professionals andauxiliary staff only. No patient access or access forrelatives is required.

14.36 Professionals carrying out cytology screening maybe disabled, and access and accommodation for thedisabled, including wheelchair users, is an appropriateconsideration.

14.37 The use of pendant-type service installationsabove some benches should be considered. Thisfeature is particularly helpful over the height-adjustableisland benches used for teaching, training and review asdescribed earlier.

Information requirements

14.38 The keeping of records, both on paper andcomputer, is an important function.

14.39 For information on pathology facilities, many ofwhich may be used as a part of the cancer careprocess, the reader should refer to NHS Estatesguidance HBN 15 – ‘Accommodation for pathologyservices’. Information on the fitting out of laboratories isgiven in NHS Estates guidance HTM 67 – ‘Laboratoryfitting out systems’.

Therapeutic facilities

Nurse practitioner accommodation

14.40 A room of broadly clinical character with surfacesshould be selected to promote easy decontaminationand to reduce the risk of cross-infection.

14.41 Good standards of lighting with variable light leveland a modest examination lamp, which may be eitherfloor standing or ceiling suspended by an articulated

arm but is specifically suitable to permit the examinationof surface anatomy or natural body orifices.

14.42 The room will contain an examination couch in anarea that may be curtained off or otherwise separatedfrom the remainder of the accommodation. Within thecouch area basic monitoring facilities to include thosenecessary for blood pressure measurement shall beincluded. Facilities for phlebotomy and the collection ofreadily accessible tissue samples are also required.

14.43 The examination or couch part of theaccommodation must be large enough to accommodatethe nurse practitioner and at least two other healthcareprofessionals as well as the patient.

14.44 In view of the potential for unpleasant odoursarising from the procedures undertaken, the use ofsimple mechanical ventilation is required, 20–30 airchanges per hour to allow for heated make-up fresh air.More complete mechanical air handling may beconsidered desirable where this is compatible withoverall building design.

14.45 A consulting area in which the nurse practitionermay sit comfortably with the patient and up to tworelatives should be provided. This should be of arelatively domestic character and the provision of coffeetable and soft furnishings should be considered. Theintention is to generate an environment where difficultissues can be discussed without undue formality. Thenurse practitioner will require the use of a standard deskto be equipped with a personal computer suitablyinterfaced both to a LAN and through that to a WAN asrequired for communication with other medical sourcesincluding a local cancer care unit. The location of thedesk and space afforded around it should be such as topermit small conferences with up to two otherhealthcare professionals in a relatively formal setting.

14.46 The nurse practitioner accommodation shall takethe form of a fully enclosed room and access forpatients by a light control or an enunciator system willbe needed. It is also important that personal safety andsecurity considerations in respect of the healthcareprofessionals utilising the room are considered. Thefitting of an alarm button and use of CCTV areappropriate.

14.47 Nurse practitioner accommodation shall bepositioned so as to permit easy access from the patientwaiting area(s) and to other clinical consultation roomsused by GPs, etc.

14.48 A small refrigerator will be needed for the storageof body fluids, etc. A small lockable cupboardcomplying with the appropriate regulations for thestorage of prescription drugs will be needed.


46


47

14.49 Filing cabinets and other means for the storage ofpaper records will be needed, though the requirementsin this area are likely to decline as progress with theelectronic patient record (EPR) advances at primary carelevel.

Minor procedures room

14.50 A room of clinical character with surfacesselected to promote easy decontamination and toreduce the risk of cross-infection.

14.51 Patients may be brought to the room on a bed ora trolley, in a wheelchair or on foot: members of staffand an escort will possibly accompany them. The doorshould be wide enough to permit easy access. Doorswings should not impede movement or activities withinthe room.

14.52 Procedures may be carried out by doctors,nurses and appropriate other staff, with the patient lyingon a bed, a trolley or an examination couch; sitting in awheelchair or a chair; or standing. Access is required toall sides of a patient. The examination couch should bemobile so that it can be moved easily to allow access topatients who need to be treated on a bed or a trolley.

14.53 The treatment room should be equipped withoutlets for oxygen, vacuum, an X-ray viewing facility anda mobile examination lamp.

14.54 A preparation area is required where sterilepacks, lotions and drugs for immediate use are storedand prepared for use, and where trolleys can beprepared for use and/or held. The preparation areashould be separated from the procedures room bymeans of a partition wall, with the preparation areainterfacing the standard treatment room and circulationspace from which entry is made. Emergency call point,and clinical hand wash facilities are also required.

14.55 Clinical-quality colour-rendering light sourcesshould be provided and walls, ceilings and floors shouldbe of suitable colour and reflectance. The room shouldbe sound attenuated. Natural light is preferred but notessential. Mechanical ventilation should be provided.

Endoscopy unit

14.56 Endoscopy is a general term relating toexamination of a body passage or organ by means ofan endoscope for purposes of diagnosis or treatment.Sophisticated diagnostic imaging may be employedwhere appropriate.

14.57 Further information and guidance including unitschedules of accommodation and room relationshipsare contained in NHS Estates guidance HBN 52, Vol. 2.– ‘Accommodation for day care, endoscopy unit’.

Nuclear medicine

14.58 The broad range of facilities including storage ofradioactive waste is addressed in NHS Estates guidance’Facilities for diagnostic imaging’.

Chemotherapy treatment rooms

14.59 A preparation area is required where sterilepacks, lotions and drugs for immediate use are storedand prepared for use, and where trolleys can beprepared for use and/or held. The preparation areashould be separated from the standard treatment roomby means of a partition wall, with the preparation areainterfacing the standard treatment room and circulationspace from which entry is made.

14.60 The standard treatment room should have easyaccess from the consulting room(s) and bedrooms andbe positioned between the clean and dirty utility rooms,with direct access for staff to each from the preparationarea. A fridge should be available for scalp coolers.

Facilities for cancer surgery (special aspects ofoperating theatre suites)

14.61 The volume of cancer-related surgery casesgenerated will not normally justify a dedicated theatresuite. However good links with a general operatingfacility are essential. The theatre facilities do notgenerally differ in character from other theatre facilities(for example, laser equipment will be needed in somecases – techniques that are commonly found ingynaecological surgery).

14.62 Consultation with the laser protection advisor (LPA) atan early stage of the design process will identify operational,safety, engineering and built environment issues.

In-patient wards and related accommodation

14.63 Refer to NHS Estates’ guidance HBN 4 – ‘In-patient accommodation: options for choice’. Thegeneral character will not differ from that of normal wardaccommodation. However, a number of areas aredifferent and will significantly affect the design.

14.64 Consultation early in the design process thatrelates to these areas is recommended in order tounderstand fully the implications for engineering servicesand the built environment.

14.65 Special side wards for those receiving treatmentwith unsealed radioactive sources. These consist of en-suite single bed accommodation. The enclosingstructure is heavily shielded to prevent radiation passingfrom the room into the surrounding areas. The enclosingstructure typically consists of concrete in the order of500 mm thick with shielding doors and sophisticatedelectronic patient monitoring.


48

Radiotherapy reception

14.66 A well-considered reception with friendly staff andwell-managed appointments will help to reduce stress toboth patients and staff. The benefits available from goodinterior and environmental design have been wellresearched and are documented. For further informationrefer to NHS Estates’ guidance – ‘The design of hospitalmain entrances’ (Design Guide), and HBN 40 –‘Common activity spaces’, vols 1 to 4.

General design considerations

14.67 Reception desk design should balance the needto provide adequate data protection of appointmentworkstations and low sections of counter for exchangewith patients in wheelchairs.

14.68 Reception counters will need to accommodate anumber of workstations that will vary from facility tofacility (number depends on areas served), networkpoint/s and printer. They should also afford adequateclerical desktop workspace and cupboard space forstationery, etc.

14.69 The waiting area, entrances and exit pointsshould be visible from the reception desk.

14.70 Good wayfinding is essential to help reducestress to both patients and staff and contribute to acalm well-organised atmosphere. For further informationrefer to NHS Estates guidance ‘Wayfinding’.

14.71 Sub-reception points should be near to entranceroutes and near to treatment rooms. One sub-receptionpoint is required per two linear accelerator treatmentrooms or simulators.

Radiation therapy facilities (radiotherapy)

Patient changing facilities

14.72 Wherever possible changing facilities should beadjacent to the treatment/planning facility andpositioned so that patients cannot be seen by othersonce they have changed.

14.73 To assist with effective throughput, a minimum oftwo changing rooms per facility are required. Oneshould be of sufficient size to permit changing for thedisabled. Ideally, there should be a two-doorarrangement where the patient enters the changingroom from the waiting area, changes then exits into thetreatment room/maze.

Treatment room

14.74 The dominating nature of a linear accelerator andthe mass of high-tech equipment are likely to present adaunting experience for patients, which may be furtherexacerbated by equipment haphazardly placed around

the room (often due to the lack of adequate storagespace).Therefore every opportunity should be taken withthe interior design to minimise these effects. The aimshould be to create comfortable and cheerfulsurroundings with a sense of order and reassurance.

14.75 Lighting will play an important role. It will need tovary from subtle – for patient relaxation; low level –when using laser alignment light; to normal levels forroutine access and duties and high levels formaintenance tasks.

Maze

14.76 The maze, the entrance and entry into thetreatment room, must allow access for the treatmentmachine and subsequent replacement equipment. Itshould be wide enough to admit a hospital bed withadditional equipment, trolleys, wheelchairs and largeheavy components for linear accelerators. Corner/wallprotection against damage by equipment wheelchairs,stretchers, beds, etc., should be provided.

14.77 If there is a particularly long maze, considerationshould be given to having a fold-down seat for moreinfirm patients.

14.78 Access control gates and/or infra red beamsmust be provided.

14.79 Lighting should be subtle and not glaring.

Engineering services

14.80 The usual way for environmental services to gainaccess to the shielded treatment area is by way of theceiling void of the maze. The effectiveness of theshielding in the maze is often increased by concretedownstand baffles. These overlap to stop the directpath of radiation but are offset from each other andpositioned in such a way as to allow services to weavethrough the chicane of concrete baffles.

Linear accelerator treatment room (general purpose)

14.81 This room must be easily accessible fromchanging cubicles and sub-waiting areas.

14.82 The size of this room is critical – there must beenough room for storage of equipment and easyaccess, enough space for easy movement around theroom and space for patients on beds, trolleys andwheelchairs.

14.83 For total body irradiation treatment, considerationmust be given to the positioning of the treatment unitwithin the room to ensure the adequate distance isachieved between the treatment unit and the patientcouch. The couch is usually placed against the wall, i.e.the treatment unit is often found off-centre in the roomto achieve this relationship.


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SINGLE PATIENT TREATMENT COUCH IN A CHEMOTHERAPY DEPARTMENT USED WHERE PATIENT PRIVACY IS NEEDED

CHEMOTHERAPY TREATMENT AREA

14.84 The trenches and floor chases required for hiddencables and support frames will be extensive and willvary from one from one manufacturer to another. It maybe possible to establish through consultation withmanufacturers and specialist agencies the extent andcritical dimensions of these features. It is essential thatthis information is available to the design team at anearly enough point in the design programme to allowthese features to be incorporated into the drawingsused for the construction of the concrete shieldingstructure or treatment room.

14.85 A floor trench between the wall of the treatmentroom and control area is needed to gather all servicespassing between control area and treatment machine.

14.86 A duct passes between the floor trench and asimilar trench in the control area The trench and ductsmust not compromise the radiation shielding offered bythe shielding walls or floor in the case of a treatmentroom with radiation sensitive areas beneath.

14.87 Recess is needed for the base frame and tablefloor, this will need to allow service connection back to

treatment machine base and floor trench.

14.88 A lifting beam will be located over the centre ofthe treatment machine.

14.89 Supports are required for heavy ceiling-mountedequipment such as the frames of data monitors.

14.90 Rigid support is needed for wall-mountedalignment lasers.

14.91 Consultation with the local radiation protectionadvisor at all stages is essential.

Storage

14.92 The range of medical equipment, immobilisationdevices applicators, etc., used on a regular basis inthese rooms can result in a very untidy situation arisingwith even the most diligent staff. The consequentenvironment encountered by patients can provealarming and not conducive to reducing fear and stress.Bespoke designed storage facilities, repeated in similartreatment facilities or technically matched treatmentmachines, will allow staff to move between these areas


50

LINEAR ACCELERATOR TREATMENT ROOM SHOWING CUSTOMISED STORAGE FACILITY

and work more efficiently as they will be more familiarwith the arrangement from room to room.

14.93 Shelving and cupboards must be adequate for allstorage requirements and designed individually for eachdepartment (it is essential to liaise with users andmachine specialists).

14.94 Specialised storage is needed for immobilisationdevices; special lead blocks if no MLC; vacubags andbody casts, etc. It should be noted that futurestereotatic techniques will require a greater use ofvacubags. The resulting storage requirements will growaccordingly, probably demanding separate storage andlogistics arrangements.


51

LINEAR ACCELERATOR TREATMENT ROOM SHOWING TREATMENT GANTRY WITH ENCLOSED MACHINE CABINET

CONTROL AREA FOR RECENTLY CONSTRUCTED LINEAR ACCELERATOR TREATMENT ROOMS


52

LINEAR ACCELERATOR TREATMENT ROOM WHERE LINAC FASCIA PANEL IS USED TO CREATE A MACHINE ROOM

LINEAR ACCELERATOR TREATMENT ROOM WITH EXAMPLE OF LINAC EMPLOYING AN INDEPENDENT MACHINE GANTRY


53

14.95 It is essential that accessory equipment (e.g.breast boards, etc.) should have dedicated storage,either in cupboards, on shelves or hanging.

14.96 Where necessary adequate storage must beprovided for total body irradiation equipment.

Other design features

14.97 These will be accounted for will vary from projectto project. The following is an indication but is notexhaustive:

• Drinking water

• Dispensers

• Wall-mounted dispensers for paper towels, papercups, soap, paper sheets, etc.

• Alignment lasers firmly bolted to structure, linked tolaser generator using fibre-optic cable

• Last-man-out button located near entrance to maze

• Independent radiation monitor, wall-mounted

• Music for patient relaxation

• Nurse call system

• CCTV cameras mounted at high level to monitorpatient during unaccompanied periods

• X-ray viewers, wall mounted

• Miscellaneous medical stands and trolleys.

Environmental considerations

14.98 Ventilation number of air changes must beadequate.

14.99 In rooms where anaesthetics are administered,there must be adequate scavenging for gas/airextraction.

14.100 Local variable temperature control is required.

14.101 It should be possible to dim the lighting. Aspotlight is required at the foot of the bed.

14.102 Music facility for the patient’s own tapes/CDs,etc., should be considered.

14.103 CCTVs are required – the number is optional,depending on deptartment practice. CCTV must havepan and zoom facility and secrecy switches. It shouldnot be interlocked to the entry system to the mazebecause there are occasions when it is necessary to see what is happening in the room between times.

14.104 X-ray viewing boxes are optional, depending ondepartment practice.

14.105 Two-way intercom to control area/room –optional.

Finishes and artwork

14.106 Murals and paintings on walls, ceilings withdecorative or entertaining features, etc., are allconsidered to be of value in occupying the patient’smind and offering some measure of distraction.

14.107 The artwork and forms of patient distractionshould be considered at an early point in the designprocess to allow adequate and timely consultation withthe user to allow debate on the suitability of theproposals.

14.108 As there are MRSA cross-infection issues, theuse of carpet is not considered appropriate.

Linear accelerator control areas

The notes on the control areas, treatment preparationarea and check-room need to be read in conjunctionwith this section.

14.109 The processes carried out in each area will bedependent on local work practices but space willneeded for the activity to be performed in one or theother of the areas.

14.110 The number of computers, keyboards,workstations, etc., will be dependent on local practice.

14.111 Early consultation is recommended to establishthe full complement of equipment to be accommodatedin the control area and its position relative to the mazeentrance and patient areas to achieve efficiency ofpatient observation; ease of staff movement; dataprotection. When planning it should be remembered thatas well as the operational staff there will often be othermembers of staff present who are undergoing training.

14.112 Control areas must afford space for themovement of all staff and easy access to the treatmentroom maze. Consideration must be given to the abilityof the staff to see patients approaching the mazeentrance, whilst shielding from view the monitorsdisplaying patient information. It is essential for blindentrances to have a gate and CCTV monitoring theentrance to the maze.

14.113 The minimum depth of worktops must be 1000mm to accommodate large computer monitors. Aminimum of 9 metres length will be required for eachlinear accelerator. There must be sufficient spacebetween the control desk and the wall to allowradiographers to move behind each other.

14.114 Worktop height will need to be determinedlocally but must address health and safety issues, suchas VDU use. Keyboards may be on the worktop, on


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pull-out shelves underneath or a combination of thetwo.

14.115 Consideration must be given to issues ofventilation, dust protection, noise, heat and cabling.

14.116 The requirement for X-ray viewing boxes will bedetermined locally.

14.117 Daylight in the control area is highly desirable butmonitors must not be subject to glare from direct sunlight.

14.118 There will be a need for a large number ofsockets and computer network points in the controlareas. Trunking systems that offer flexibility and changemay be considered appropriate.

14.119 Easy access to a direct connection between thecontrol area and the treatment room for QA monitoringcables is required. This penetration of the shielding wallmust be aligned so that the radiation shielding is notcompromised.

14.120 Consultation with the radiation protectionadvisor at all stages is essential.

High-energy treatment room

14.121 To the patient, the appearance of a high-energytreatment room will be similar to that of a low-/medium-energy treatment room. The maze will probably belonger and the linear accelerator bigger and somedifferences will occur with other equipment. Apart fromthis little else will change visually.

Artwork

14.122 The comments made previously about the needto enhance the environment apply with equal measure inthis treatment room. However, certain types of paintmedia are affected by the high-energy radiation beams.Care must therefore be taken when positioning artworkto avoid sites within the primary beam zone. Adviceshould be obtained from the radiation protection advisorabout the likely effect on any artwork proposed for usewithin high-energy installations

Construction issues

14.123 Despite similarities with low-/medium-energytreatment rooms, differences will be apparent when theconstruction of the structural enclosure is examined.These will arise from the need to protect againstincreased levels of radiation energy. The concreteshielding enclosure, including the primary beam collar,will be thicker. The geometry of the shielding will bedifferent, altering the shape of the room as well as thelength and layout of the maze.

14.124 When the treatment prescribed requires thesemachines to be operated at high energies, a further

hazard is produced in the form of free neutrons.Neutrons behave in a different way to radiation beams;as a result other measures are added to deal with thehazard that they present.

14.125 A full-height vertical recess is formed in thestructural wall of the maze in the vicinity of the treatmentarea. The geometry of the slot or trap (as it is referredto), and the proprietary wax-like material placed in it,help to attenuate the energy of neutrons entering themaze. This wax is supported in place by a framework ofhardwood studs held together with brass screws.Further attenuation takes place by positioning similarmaterial above the suspended ceiling over the linearaccelerator as well as using boron coated paper to linethe walls and ceiling of the maze. For a fuller descriptionof the protection requirements refer to the section onenvironmental considerations in this document.

Pre-treatment interview room (radiotherapy)

14.126 The ideal is to have one pre-treatment interviewroom per treatment room but this will depend on spaceand local practice. Room specification is similar to anyother interview room. Location and area served: near toentrance/exit of treatment rooms; a minimum of one pertwo linear accelerator or simulators is required.

Information area and library

14.127 The information area and library will be sitedlocally within the radiotherapy department in closeproximity to the treatment areas.

14.128 Natural light is preferable. Facility for the displayof leaflets and support group booklets is required, thatis, a small library with information readily available forradiographers to give to patients. Appropriate seatingwhich is comfortable and a mixture of chair heights.Other requirements include: tables; IT points for Internetaccess, etc; lockable cupboards; telephone; TV/videofacilities; facilities for making beverages.

Superficial and orthovoltage treatment

Treatment room

14.129 The treatment room must be of sufficient sizethat all areas of the body can be treated with thepatients lying/sitting in a stable position.

14.130 Typically the room will need to contain: specialistshelving to house the beam defining applicators – in thecase of orthovoltage these could be heavy and need tobe stored at a height to meet the requirements ofcurrent health and safety legislation; a shielded windowor CCTV to view the patient during the treatmentexposure; a treatment couch; a bed with movementssimilar to a dentist chair is recommended; wash handbasin; sink; lockable drugs cupboard; spotlight;interlocked door between treatment and control room.


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14.131 Interior design and the provision of piped musicshould be considered to improve the atmosphere for thepatient.

14.132 The floor must be washable.

Control area

14.133 The control area should be adjacent to the doorto the treatment room. There should be sufficientworkspace to contain all the equipment associated withthe machine. There should be data points to supportany networking requirements. There should be sufficientsockets and telephone points to meet local need.

14.134 In some cases, particularly where a highworkload is undertaken, a dedicated clinic roomadjacent to the treatment room may be an advantage.

14.135 Sufficient space is needed to accommodatestaff being trained as well as those providing treatment.

Generator room

14.136 Provision for a sound-proofed area or room forthe treatment machine generator is recommended.

Pre-treatment area

14.137 This should take the form of a completelyintegrated suite, encompassing interview rooms,simulators, mould room, treatment planning, dedicatedCT or equivalent. Darkroom and film storage will dependon local practice.

Simulator room

14.138 The simulator room must be large enough toaccommodate full rotation of the couch without collisionhazards.

14.139 The orientation of the simulator within the room(diagonal or straight) will depend on space and localdecision, but easy access to the couch by stretchers,beds and wheelchairs is required.

14.140 If the simulator and couch are not offset forviewing the patient, consider windows being offset togive the best possible view of the patient duringsimulation procedures as well as the equipment as itmoves by remote control.

14.141 CT attachment is essential, particularly where accessto diagnostic scanners for treatment planning is minimal.

Control area

14.142 This is usually a very busy area withradiographers, planning staff, doctors, students, etc., allneeding access from time to time during the simulationprocedures. The control area therefore needs to beappropriate for the working practices of the department.

14.143 Ideally there should be a separate room adjacentto the control area where conferences between differentstaff groups can be carried out pertaining to thepatient/s of the day. Teleconferencing facilities may behelpful in the future for split-site cancer care centres. Iflack of space precludes a separate discussion room, thecontrol area should be large and remote enough forpatients not to hear inappropriate conversation. If nodoors separate the simulator room from the controlroom, a separate area needs to be allocated for generaldiscussions.

14.144 Viewing boxes will be required even ifdepartment is digital – they will be used for films fromexternal sources.

14.145 Other requirements include a workbench withnetwork points (depending on equipment purchased) fordoing calculations, etc., is needed, cupboards/drawersfor storage (medical notes, treatment sheets, etc.),spotlight, telephone, lockable drug cupboard, shelving;general cupboards and workbench, sink, mirror, drinkingwater, etc.

14.146 A simulator ante-room for preparation of patientsrequiring barium, catheterisation, etc., is required.

14.147 Changing cubicles – see linear accelerators.

Treatment planning

14.148 A minimum of one workstation per two linearaccelerators is needed to cope with increasinglycomplex techniques. This will depend on local practiceand on treatment planning systems used (some systemsare slow even for production of breast plans). It will alsodepend on use of conformal treatment planning.

14.149 There should also be a special workstation forbrachytherapy and stereotactic work because of thetime taken to plan.

14.150 A planning system to network to simulator, CTand MRI is essential as well as links to linear accelerator.

14.151 Modem links are required to supplier of thetreatment planning system for ‘remote diagnosticstesting’ as part of service agreements.

14.152 Radiotherapy target definition and associatedimage process and display suites.

14.153 Accommodation for paper and/or computer-based record keeping and treatment management.

14.154 Film processing and laser imager rooms.

Mould rooms and patient immobilisation facilities

14.155 During the delivery of the treatment, it willfrequently be necessary to immobilise the patient to

ensure the safe, accurate delivery of the radiotherapytreatment. To achieve this, a mask is made from thinplastic sheet, individually produced to match thepatient’s features, so that it can be fitted on to thepatient and secured to the treatment couch, thusrestricting movement during treatment.

14.156 To align the part of the body to receive radiationtreatment, it may often be necessary to prop or supporta particular part or limb of the body. This is achievedwith air-filled sacks or foam blocks that may be readilyavailable as standard items or may have to be speciallyproduced to accommodate a particular situation. Theseitems are custom-made in the mould room suite.

Patient fitting room

14.157 This is the room in which the patients will befitted with immobilising shells or supporting devices. Theprocess may be lengthy and unpleasant, and mayinvolve the taking of impressions using plaster of Paris.To ease the process for the patient, the room shouldoffer a light, airy environment and be as comfortable aspossible.

14.158 The technicians will need to view imaging dataand carry out clerical work and reporting. A workstationshould be provided with a computer network point,sockets, telephone, filing cabinet, etc.

14.159 The patient will usually need to remove clothing,therefore changing facilities with a curtained area will beneeded.

14.160 The dignity of the patient should be consideredwhen locating the couch in relation to doors.

14.161 Ceilings may be designed with some point ofinterest to relieve patients’ boredom.

14.162 Background music with facilities for patientchoice may be considered.

14.163 A shower and changing area with mirror, shelf,seat, shelf, curtain or door, coat hooks will be required.

14.164 Seating should be provided for relatives orcarers accompanying patients. Mobiles, stencils, toys,etc., for children are useful for relieving boredom.

14.165 Wheelchair/bed access is essential.

14.166 Locally adjustable heating and ventilation to givepatient and staff relief from local heat gain and smells isessential.

14.167 The floor covering should be linoleum or vinylwith coved skirting for ease of cleaning.

14.168 The plaster trap sink will require a tiled or otherform of splash-back.

14.169 A hot water bath will be required if usingthermoplastics for immobilisation.

14.170 Alignment lasers and variable height treatment tomimic the treatment area are needed.

14.171 A height-adjustable couch will be required.


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MOULD ROOM WORKSHOP SHOWING TYPICAL PATIENT PREPARATION AREA


57

14.172 A dentist chair, relocatable frames, etc., will berequired for departments intending to use stereotactictechniques instead of shells.

Machine room and workshop

14.173 The immobilising shells and supporting devicesare fabricated here. The processes include:

• Vacuum forming techniques

• Injection moulding

• Cold setting resin formulations

• Epoxy/polyester techniques.

These processes are essentially light engineering incharacter. Workshop conditions are required withappropriate floor and wall surfaces. A good general levelof lighting is needed with task lighting at workstations.

14.174 Ideally the machine room should be separatefrom the workshop assembly area, as assembly andadjustment require concentration and cleanerconditions.

14.175 Good ventilation is essential. Local extraction willbe required over processes generating dust and fumes.Consideration needs to be given to the provision ofthree-phase electrical supply and a floor drain.Equipment will depend on project requirements but islikely to include: LMP cutter/compensator maker and

MOULD ROOM WORKSHOP SHOWING PROFILE MACHINE, LOW TEMPERATURE ALLOY SMELTING AREA WITH EXTRACT HOOD

MOULD ROOM WORKSHOP AREA


58

melting pot in laminar flow cupboard or equivalent;vacuum forming machine with compressor; contouringdevice (this will depend on local practice); electricfurnace; electric oven; saws; bandsaw; bench drill;bench grinder; bench sander and polisher; hot wirecutter; wax bath; various hand-held tools andworkbench (this could be mobile, on a trolley); bunsenburner; work benches; storage cupboards; compressedair outlet; wall-mounted viewing boxes; telephone andnetwork point to planning and HIS; plaster trap sink.

14.176 Staff should be able to leave the machine roomand workshop without having to pass through thepatient fitting room.

Storage

14.177 Adequate and appropriate storage is essential inall areas of this key supporting facility. The activitiescarried out are diverse in nature, requiring access to awide range of materials and tools including plastermodels, bandages, Uvex sheets, etc. (size will dependon local activity and practice). To carry out this workeffectively, work areas and conditions generally need tobe well organised.

Stereotactic radiotherapy facilities

14.178 The design of the treatment couch is such thatit will accept interchangeable body shells, uniquelymoulded to fit each patient’s body shape. The bodyshell will need to be kept for as long as the patient isreceiving treatment and may, during this period, needreplacing to allow for changes in the patient’s body.

14.179 This technique will generate a considerabledemand for storage of body shells. They will alsorequire labelling and cataloguing. Early consultationwith the project team will be essential to assess theextent of storage if stereotactic radiotherapy isproposed.

Quality assurance and dosimetric laboratory

14.180 Quality control and calibration of machinery isan essential and regularly performed task. Much of thework will be performed on machines and equipmentlocated in their respective room or area which will,more often than not, be located some way away fromthe medical physics department. For this reason it isseen as important to provide a suitable room, near tothe cancer care facility, to act as a local base for thisfunction to be carried out.

14.181 Considerations for inclusion within this areaincude: secure room; storage of manuals and records;storage of measuring equipment; worktop for bench-mounted equipment including bunsen burner; worktopfor routine tasks; computer workstation; telephone.

Paediatric facilities

Procedures room

14.182 A procedures room used to carry out minortreatments and procedures such as dressing changeswill be necessary close to bedroom accommodation.Ideally there should be two procedure rooms for every15 beds and they should be located away from thebedroom areas so that those remaining in their roomsare not disturbed by noise from the procedure room.The rooms should take the form of a treatment room asdescribed in NHS Estates guidance HBN 23 – ‘Hospitalaccommodation for children and young people’.

Recovery area

14.183 To provide for the recovery of the patient afterprocedure often involving anaesthesia. The recovery canbe supervised without preventing the use of theprocedures room for further patients.

SHELVING STORAGE FOR WIG MODELS.THIS IS AN ESSENTIAL FACILITY FOR PATIENTS WHO

SUFFER FROM HAIR LOSS RESULTING FROM TREATMENT


59

Offices

14.184 Outreach nurses play an important role. Manypatients will spend time at home between periods inhospital and the outreach nurse will give support duringthis period. Close liaison between the staff involved witha patient in hospital and the development of arelationship with the patient in hospital is very important.The office accommodation should be integrated with, orbe as close as possible to, the children’saccommodation.

14.185 Offices for social workers will be required. Therewill be a greater number of social workers and othersupporting staff associated with a children’s cancerfacility than other children’s illness or other departmentsof a hospital, as a result of the traumatic effect that thisillness can have, not only on the patient but their wholefamily.

Other accommodation

14.186 Other accommodation is required as follows:

• Play therapy room

• School room

• Rehabilitation room

• Office for anaesthetist

• Single bedrooms with parent accommodation

• Single bedrooms for barrier nursing with air-conditioning or special ventilation arrangements

• Iodine treatment room, en-suite, with radiation barrier,to allow visitors into room

• Brachytherapy room

• Recreation room with access restricted to ‘youngpeople’ only

• Parent accommodation suite for longer stay –separate but nearby

• Interview rooms/multi-disciplinary rooms/seminar stafftraining rooms.

Clinical support spaces

Medical physics and bioengineeringaccommodation

14.187 The medical physics department will serve theneeds of many departments in the hospital. However,certain facilities within medical physics are essential tothe routine operation of cancer care facilities.

Mechanical workshop

14.188 In PFI schemes it is common for theresponsibility for maintaining linear accelerators andother equipment to be transferred to a third party,usually the equipment manufacturer or its agent. Wherethis is the case, the provision of facilities for mechanicalmaintenance is likely to be modest. However,workshops will be needed where equipmentmaintenance remains largely in-house or where bespokeengineering devices are required for research purposes.

14.189 The workshop character is generally one of awell-equipped engineering workshop with a selection oflathes, drills, grinders, saws, etc. Consideration shouldbe given to the provision of a three-phase electricalsupply.

14.190 The construction and layout of equipment mustmeet the requirements of current health and safetyregulations. Storage will be needed for tools. Facilitiesfor lifting heavy objects will be required – overhead railand hoist required.

14.191 Robust wall finishes, slip and oil resistantflooring will be essential. Good natural and artificiallighting is essential. Solar control and mechanicalventilation will be needed. Air extract systems requiredto remove fumes caused by welding, etc.

14.192 Storage of a full range of materials should belocated conveniently for retrieval and use. Access fordeliveries by lorry to the store should be considered.Working facilities for equipment should be provided.Floor gulley required.

Quality control and audit facilities

14.193 Quality control and audit is an essential andregularly performed task. Much of the work will beperformed on machines and equipment located in theirrespective rooms or areas, which are likely to be locatedremotely from the medical physics department. For thisreason it is seen as important to provide a suitableroom, near to the cancer care facility, to act as a localbase for this function to be carried out.

Secure room

14.194 Functions and requirements include storage ofmanuals and records; storage of measuring equipment;worktop for bench-mounted equipment includingbunsen burner; worktop for routine tasks; computerworkstation; telephone.

Sealed source store brachytherapy

14.195 The function of this room is to provide a suitableenvironment for the receipt, storage and handling ofsolid or sealed radioactive materials, which are used to

administer radiation treatment by either local applicationor interstitial insertion.

14.196 The design must comply with the Code ofPractice for Ionizing Radiation.

14.197 An area will be needed for recording radioactivematerials in stock and in transient use. Storage will berequired for shielded containers used for transportingradioactive materials and for applicators andaccessories for regular use.

14.198 A shielded workbench, normally constructedusing lead, is required to allow staff to handle andprepare radioactive sources for clinical use. Because ofthe weight of lead shielding needed localised floorloading will be abnormal and will need to be taken intoaccount, either by design of the structure or siting.

Medical physics support accommodation

14.199 A number of offices are needed:

• Senior physicist’s office

• Secretary’s office

• Physicist’s office

• Laboratory/physicist’s office

Record keeping facilities

14.200 Cancer registration, ie the careful keeping ofrecords of treatments and outcomes is essential to thesuccessful development of cancer care. Thedissemination of information to the cancer registriesallows comprehensive data to be compiled allowingtrends related to epidemiology of the disease, treatmentand survival rates to be carried out. Office facilities willbe necessary, as will storage for paper records beingprocessed.

Phlebotomy – venepuncture rooms

14.201 Facilities will be required for taking and testingblood specimens.

14.202 A venepuncture room may need toaccommodate more than one patient at the same time.In order to preserve patient privacy and dignity in suchcases the venepuncture room should include individualcubicles.

14.203 Each venepuncture area will require avenepuncture chair, storage facilities for a working stockof sterile and other supplies, and clinical hand washfacilities. Normally, only the phlebotomist will attend thepatient.

Bereavement facilities

14.204 Refer to NHS Estates’ guidance ‘Facilities formortuaries and post-mortems’. It will be necessary to


60

SEALED SOURCE STORE SHOWING

SHIELDED

WORKSTATION


61

provide facilities where relatives and those close tosomeone deceased can come and spend some timewith the body.

14.205 The aim of the interior designer should be tocreate a serene and reassuring surroundings usingcolour, texture, lighting and environmental control tobest effect.

14.206 It is important to remember that the area shouldbe able to accommodate those religions and culturesthat are likely to use the facilities.

Mortuary accommodation

14.207 Refer to NHS Estates’ guidance ‘Facilities formortuaries and post-mortems’.

14.208 Some bodies received from cancer facilities willstill contain radioactive materials administered duringtreatment. It will be necessary to provide body storagefacilities that are shielded with lead-lined materials,including doors and roof to the enclosure. The leadthickness will be in the order of 2 mm (readers shouldconsult the local radiation protection advisor).

14.209 Protection will be needed to the roof of the bodystore because the refrigeration machinery is usuallylocated here and access will be needed for routine andemergency maintenance.

14.210 Within the body store the drawers used forstorage should be fabricated from non-ferrous materials.This will typically be a ceramic material.

Contaminated articles store

14.211 Articles, materials or equipment that arecontaminated with radiation will need to be stored in asafe place until the radiation has fallen to a safe level. Thisis commonly dealt with by collecting the articles in ashielded container and taking them to the contaminatedarticles store for storage until safe. The contaminatedstore is described elsewhere in this document.

Electronics workshop and development facilities

14.212 An electronics workshop will be needed so thatthe task of maintaining the integrity and safety of thewide array of electronic equipment that will be found ina radiotherapy facility can be performed.

MICROBIOLOGICAL SAFETY CABINET USED IN

RADIO-PHARMACY PREPARATION AREA


62

14.213 The standard of work carried out is demanding,requiring considerable expertise. Therefore theconditions for performing this work are important. Aclean, dust-free environment is important, as is goodquality general lighting with task lighting at theworkbench positions. Natural lighting and ventilation butsolar control and mechanical ventilation may be neededto maintain suitable temperatures for working.

14.214 Other requirements include: generous benchingwith cupboards and drawer under; bench-mountedtrunking to allow power outlets as required; space toperform record keeping and logs; shelving for manuals;bookcases; and a computer workstation.

Patient support spaces

Complementary medicine facilities

14.215 Complementary therapy requires a relativelyrelaxed environment of a domestic character, with use ofdiffused low light levels, although the ability to increase thelight level during therapies may be necessary on occasion.

14.216 A relatively small room is preferred and thisshould be capable of comfortably accommodating thepatient and up to two professionals, together withpossible attendance by a relative or friend.

14.217 The patient will ordinarily be supported using aclinical couch with a low permeability soft finish capableof easy cleaning, particularly in respect of oilysubstances. The couch must feature a tilting or backrestfacility, which may be used to ease access to thepatient’s back during aromatherapy, while in reflexology,the patient would normally be in the supine position.

14.218 It is important that the sound levels in the room,especially arising from extraneous sources, should bewell controlled. Accordingly, consideration should begiven to the use of sound insulating materials in walls,doors, etc. It may also be important to locate the roomin a part of the building where the other surroundingactivities are themselves quiet and where the traffic ofpersons is light. The floors should be finished in readilycleaned materials such as welded vinyl or linoleum,though rugs may be utilised in order to soften theappearance and give a more domestic quality. Wallsrequire non-glossy finishes in colours chosen togenerate a relatively subdued and relaxed character.

14.219 For aromatherapy it may be necessary tochange from one oil to another with widely differingaromatic qualities. Accordingly, there is a need toremove the scent of the preceding treatment. In light ofthis, some degree of mechanical ventilation to the roomallowing for occasional rapid air changes will be needed,at least 20–30 air changes per hour. This need not implya fully integrated mechanical system where this is notgenerally provided within the remainder of the building.

Reasonable standards of temperature control arerequired in order to promote effective use of thearomatherapy and reflexology technique.

14.220 The use of potted plants as a feature withinthese rooms is common. Use carefully designed wall-wash lighting or uplighters. Similarly, waiting rooms thatare partly or wholly devoted to serving suites used foralternative therapy should be relatively relaxed andsubdued with soft furnishings and plants. In someapplications, devices to generate pleasant aromas withinwaiting areas have been used successfully.

Support group rooms

14.221 See also NHS Estates’ guidance HBN 36 –‘Local healthcare facilities’, vol.1, 4.91.

14.222 As part of the patient support movement thatunderpins both therapeutic and palliative treatment ofcancer, patient collaborative or support groups play aninvaluable part in improving the quality of life for patientsand their carers.

14.223 Cancer care centres should include a multi-purpose room that will accommodate between 10 and15 people. This may be sufficient to meet the needs ofcancer patients as well other patients. Local needs andresources should be reviewed.

14.224 Consideration should also be given to theprovision of the following:

• Patient information facilities

• Links to NHS Direct

• Telemedical facilities

Psychological and psychiatric accommodation

14.225 Accommodation will be required for patientcounselling or use for giving psychiatric help. Smallrooms, capable of accommodating up to four people inan informal setting are required for this purpose.

Patient retreat facilities

14.226 It is considered to be very important thatpatients can retire at times to an area that is dedicatedto their use and free from all clinical staff. The natureand position will vary but should be informal in nature.The area or room should allow individuals or smallgroups to use the facility.

GENERAL DESIGN CONSIDERATIONS

Internal routes of access and departure

14.227 Patient and staff flow patterns normally used forday-to-day use will have been established. These willinvolve the use of identified entrances and exits from the


63

building. However advice has been received fromnumerous sources, not least a report for NHS Estatesby Cancerlink, highlighting the need for a discrete exitfrom the building for those who have just received badnews. The support for this facility makes anoverwhelming case for inclusion in any new work. Itshould also be considered as an improvement to anyexisting building where appropriate.

Building access considerations

14.228 Access to the building and its facilities for bothpatients and staff is a fundamental consideration.Guidance dealing with basic design considerations andbuilding management to ensure the continuance ofaccess and means of escape is available in existingpublications and regulations. These cover access fromthe perimeter of the site, approaches to the building anduse within the building. References include:

• NHS Estates’ guidance HBN 40 – ‘Common activityspaces’.

• The Building Regulations

• NHS Estates’ guidance HBN 45 – ‘External works forhealth buildings’.

The Disability Discrimination Act (DDA)

14.229 DDA 1995 introduces new laws and measuresaimed at ending the discrimination that many disabled

people face. Over time, the act gives disabled peoplenew rights and places new duties on, among others,employers and service providers. References include:

• Guides and checklists issued by the NHS

• Code of practice issued by the Secretary of State inconjunction with the National Disability Council.

It is recommended that readers consult bodies such as:

• Local disabled user group organisations

• The Centre for Accessible Environments.

Special facilities for individual or small groupcatering

14.230 Patients suffering from disease or from theeffects of their treatment often do not wish to eat atprescribed times. They may have very specific dietaryrequirements or other difficulties with eating that requirespecial measures. For these reasons it is recommendedthat catering facilities be provided for in-patientaccommodation that will meet these special situations.

14.231 In some cases where particular difficulties areexperienced when eating, staff advice and patientpractice may be needed. This should take place in aroom away from the main accommodation areas wherepatient dignity can be maintained.


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USE OF RADIATION IN CANCER SERVICES

15.1 Radiation that may be detrimental to a wholehealthy living organism can conversely be helpful wherethe damaging effects of the ionising radiation areconcentrated on a tumour or other form of cancer. It isthis basic phenomenon which is responsible for thetreatment uses of radiations in cancer care services.There are also a range of diagnostic uses where the aimis essentially to minimise the amounts or dose ofradiation involved, while maximising the information yieldfrom the test concerned.

15.2 When planning and designing for radiation uses incancer care services, early consultation with the localradiation protection advisor, ordinarily employed by orcontracted to an NHS Trust, is advised and may berequired by statute. Each existing centre, department,etc., will also have appointed a radiation protectionsupervisor who is necessarily a member of staff. ThisRPS will be a good source of information on localpractices and safety rules.

15.3 Therapeutic uses of ionising radiation in cancercare services divide into two categories, previouslydescribed in detail. These are:

a. Teletherapy, in which X-ray or gamma beams aregenerated by a machine and used to treat a tumourwith the X-ray source being outside the patient'sbody.

b. Brachytherapy and unsealed source treatments.These are basically the same except that they will usechemical or nuclear sources of radiation and thesewill be within the patient's body, either as a solidmaterial, for brachytherapy, or as a solution inunsealed source treatments. Unsealed sourcetherapies would include treatment for thyroid cancerusing radioactive Iodine 131.

CONTAINMENT OF RADIOACTIVE MATERIALSAND THE PREVENTION OF CONTAMINATION

15.4 The use of radiations of nuclear origin as unsealedradioactive sources, essentially liquid solutions, has

15 Radiation protection in cancer services

EXTERNAL ENVELOPE HOUSING A LINEAR ACCELERATOR BUILT USING ALTERNATIVE MATERIALS

RADIATION PROTECTION IN CANCER SERVICES

65

been mentioned above and is dealt with in detailelsewhere in the document. As these radioactivematerials are liquid solutions, there is clearly a possibilitythat they will escape from the containers or containmentwithin which it is intended that they will remain. This isparticularly true when the radioactive material is given tothe patient as a drink or introduced into the body by anintravenous injection. In the former instance, theradioactive solution itself may be subject to leakagefrom its container or to accidental spillage. In thesecond instance, the patient's urine, sweat and otherbody fluids may become radioactive due to thepresence of the radioactive material in solution.

15.5 Coming into contact with these unconstrainedradioactive solutions is known as radioactivecontamination. Simply, the contaminated surface orperson has the liquid radioactive solution present andthis in turn may give rise to the possibility of ingestion.Clearly, as in these circumstances, there is noseparation between the radioactive source and theperson concerned, so the probability that high radiationdoses will be delivered may be expected to beincreased.

15.6 Much design work in regard of the facilities withinwhich these unsealed sources are used is aimed at

minimising the risk of radioactive contamination andbeing able to deal with it quickly and easily should itoccur. This implies the use of impermeable and easilycleaned smooth surfaces and careful attention tojointing. Sinks will be such as to resist permanentcontamination, particularly if used for waste disposal.Wash hand basins are an essential provision and theseshall be of ceramic construction with foot or elbowoperated taps.

CONSTRAINT OF RADIATION DOSE AND THEUSE OF SHIELDING

15.7 The reasoning behind the need to restrict orminimise radiation dose has been established. There arethree essential mechanisms by which dose can bereduced. These are:

a. Minimising the time or period of exposure to theradiation.

b. Maximising the distance between the radioactivesource and any persons who may be present.

c. The introduction of a barrier or shield between thesource of radiation and the people to be protected.

15.8 The amount of shielding that will need to be used

INTERNAL VIEW OF LINEAR ACCELERATOR BUNKER UNDER CONSTRUCTION USING BLOCKS OF ALTERNATIVE SHIELDING MATERIALS. JOINTS ARE FORMED USING SPECIALISED PROPRIETARY

MORTAR. SHOWS SERVICES ENTERING FROM MAZE CORRIDOR AND STEEL JOISTS SUPPORTING ROOF STRUCTURE

in any given circumstance depends essentially on thequantity of radiation being produced; the distance fromthe point of production to the area needing to beprotected; and thirdly, the type of radiation involved. Itwill be readily appreciated, therefore, that shieldingtypes and magnitudes vary markedly. Detailed accountsare given at appropriate points within this document butthe following summarises the common shieldingstrategies:

a. Teletherapy involving the treatment of patients with X-ray beams derived from linear accelerators or gammaray beams from Cobalt 60 machines. Here, theeffectiveness of the shield is controlled in part by thesheer mass of material present. This being the case,the use of dense materials, most commonly concreteand steel, is favoured. The masses involved will besuch as to have major design and structuralimplications for the building used. In very recenttimes, alternative materials such as 'Ledite' havebecome available and these will in some instancesoffer special advantages in terms of reducing thevolume or space occupied by the shield.

To some degree the effectiveness of all shields isinfluenced by their shape and geometry but in thecase of linear accelerator bunkers and their shieldingwalls, this is particularly important.

b. Neutron protection. This is an exception to the high-energy radiation beam shielding methodologies brieflymentioned above. Neutrons are only produced by avery small minority of linear accelerators, specificallythose operating at above 8.5mV, with the problem orchallenge being especially notable above 12mV. Theneutrons penetrate heavy and dense materialsrelatively easily, unlike X-rays or gamma rays, but arestopped by relatively light materials such as plasticsor wax. Accordingly for the special high-energy linearaccelerators where neutrons are produced as anunwanted by-product, the use of very low densityshielding materials in addition to the concrete and

steel will be necessary. The design of these neutronshields is a highly specialised process requiringdetailed advice from a qualified source.

c. Sealed and unsealed radioactive sources. Again, theradiations produced by these sources will lead todetriment if adequate shielding of the sources is notused. However, in the majority of cases, it is morepractical to surround the source with the shieldingmaterial (often lead), rather than to surround the roomwithin which they are contained. In some instances,however, both strategies will be needed in order tomeet practicalities and provide an adequate level ofshielding to ensure reasonable safety.

d. Lower-energy X-ray beam shielding. For the moremodest energy teletherapy treatments, such assuperficial and orthovoltage as well as all diagnosticX-ray uses, room shielding will be more modest butnevertheless essential. Here, doors, window frames,etc., will often be shielded by modest thicknesses oflead, say, 1–3 mm. High-density building blockoptions are also frequently employed. Lastly, as themasses required a relatively modest glass containinglead salts or equivalent plastic base materials can beused to allow for windows with high standards ofvisibility into the area where the radiation source,normally an X-ray tube, is present.

UK LEGISLATION

15.9 There are three major items of UK legislation thataffect the design and operation of cancer care facilitieswith particular emphasis on some diagnostic and allradiotherapy departments. These are as follows:

a. The 1999 Ionising Radiations Regulations and HSCapproved Code of Practice.

b. The Ionising Radiation (Medical Exposure)Regulations 2000.

c. The 1993 Radioactive Substances Act.


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BASIS OF ENVIRONMENTAL PROTECTION

67

16.1 The potentially toxic materials used in clinicalaspects of cancer care services require careful handlingand use but particular concern centres on disposal.Equally, cancer services buildings can be of particularlyheavy construction, for example in radiotherapydepartments, so the environmental impact of demolitionmay be significant.

CONCEPT OF RADIOACTIVE DISCHARGE

16.2 In essence, just as there is background radiationso there is also background radioactive material presentin the normal environment. Principally this will consist oflong-lived derivatives of natural uranium, whichultimately gives rise to so called 'soil gas' or, morecorrectly, radon. This gas makes a marked contributionto natural irradiation of the population. Given that this isthe case, it is clearly important that we restrict thedegree to which we add to the level of radioactivitypresent in the environment. Broadly, the use of relativelyshort half-life radioactive materials in medicine countersthis challenge effectively but some longer half-lifematerial is also used.

16.3 Wherever reasonably practical and permitted bylaw, radioactive materials will be dealt with by the simpleexpedient of leaving them to decay until they reach anessentially safe or non-radioactive state. This will involvethe construction of suitable storage facilities known as‘decay stores’. However, for longer-lived materials, somedischarge to the drainage system of the hospital or intothe air as a result of disposal by burning, in approvedincinerators, will be necessary. Discharge to drains orinto the air may also occur routinely in the use ofradioactive materials or as a result of accident.

16.4 It is important that the design of the building withinwhich these radioactive materials are used constrainstheir release into the general outside environment to beat or below levels that have been pre-determined andagreed with the Environment Agency. This agency hasthe responsibility to licence such disposals under theRadioactive Substances Act.

MINIMISATION OF DISCHARGE ANDENVIRONMENTAL IMPACT

16.5 In principle, the discharge minimisation springsfrom concepts devised by the International Commission

for Radiation Protection (ICRP), which states thatradioactive materials should only be used where there isno viable alternative. However, where their use cannotbe avoided, we are required to model and assess thelevels of radioactive contamination that may beexpected in the environment, particularly in respect ofwatercourses into which radioactive fluids may bedischarged. Dilution factors are critically important here;if a discharge can be rapidly diluted by enabling a drainto join with others of larger flow and capacity at anearlier stage, so the dilution will minimise radioactiveconcentrations and the hazards associated with that,though the overall discharge is unaffected. This isimportant to the water system engineering of manycancer care services buildings.

16.6 The administrative structure for the control ofradioactive discharge and environmental protection willbe common with that used for radiation protection in thegreat majority of healthcare institutions. Accordingly, theradiation protection advisor will also render advice onthe environmental impact and will be responsible for thegeneration of environmental impact models as needed.

16.7 When undertaking building design, the estimationof the environmental impact of radioactive dischargesshould be considered at an early stage. The presence orabsence of such discharges as well as the levels thatmay be expected will be critically dependent upon theclinical tasks undertaken. In particular, nuclear medicineand the treatment of patients by the use of radioactiveiodine will influence the level of discharge significantly. Itis important to note that patients who have receivedradioiodine or other unsealed materials will dischargethese in the form of body fluids, most obviously urine.For some of these treatments a great majority of theradioactive material administered will appear in urine andwill accordingly be discharged over a short period oftime, a few hours, into the drainage system of thehospital or other healthcare environments. This elementof radioactive discharge is, in practical terms,unavoidable.

POPULATION RADIATION DOSE AND EFFECTIVECONTROL

16.8 Clearly the discharge of radioactive materials fromsites or institutions that make use of such contributes to

16 Basis of environmental protection


68

population dose. However, the contribution from medicaldischarge is small and although this will be taken intoaccount in modelling conducted by the radiationprotection advisor, it is unlikely that this will result inconstraint on medical activities on a given site. However,local limits for discharge exist and these should becarefully observed at an early stage in the planningprocess.

Decommissioning of facilities

16.9 Essentially, wherever radioactive materials areused, be they sealed or unsealed, the possibility of thelong-term build-up of radioactive contamination mayexist. However, in the modern era, the controls exertedon sealed sources should, particularly in healthcareinstitutions, be such as to mean that their chronic losswill not be tolerated or encountered. Accordingly, theneed to examine the built environment for such sourcesis no longer prevalent, though incidents mayoccasionally occur and rooms where such sources arehandled should be designed with this in mind.Specifically, it is helpful if gaps and surface discontinuityare avoided.

16.10 More commonly, unsealed radioactive sourcespresent as liquid solutions may give rise to chroniccontamination of the rooms in which they are used andmost especially the drainage system from that room ifdischarge to drains is permitted. In this case, theradiation protection advisor should be consulted andrecords examined to determine the nature of theradioactive materials present and, in particular, their

effective half-life in that environment. If the half-life isshort, it may be wise to delay dismantling the pipework,etc., for an appropriate period of time so thatradioactive decay can effectively remove the hazard.Where the half-life is long or such delay cannot beaccommodated, special precautions will be necessaryand the pipework itself may constitute solid radioactivewaste. Should this be the case, the radiation protectionadvisor will write a decommissioning scheme of workand will also undertake to work with the EnvironmentalAgency to ensure appropriate ultimate disposal of thematerials.

16.11 In respect of the above decommissioning ofunsealed radioactive source sinks, drains, etc., there isa particular need for care if chemical agents are beingused to reduce the radioactive burden. In particular, caremust be taken when decommissioning teams usechemicals, including bleach, since these may oxidisesome radioactive materials in solution, rendering theminsoluble. Such process may then result in radioactivegases being released into the immediate environment –giving rise to an increased hazard to workers. Detailedprofessional advice must always be obtained for eachspecific situation and the use of general rules is unwise.

16.12 Generating radioactive materials within thestructure of machines or in the built environment thatcontains them is often poorly understood as a part of adecommissioning process. In the great majority ofcases, the X-ray or gamma ray beams employed by X-ray machines and linear accelerators do not generateradioactive induction in the built environment or

SINGLE BED LDR/MDR TREATMENT ROOM

SHOWING WINDOW IN EXTERNAL SHIELDING

WALL. SHIELDING CONTINUITY IS MAINTAINED BY

USE OF A FREE-STANDING CONCRETE

SHIELDING WALL ENCLOSING A CONTROLLED

AREA THAT CAN BE LANDSCAPED FOR THE

BENEFIT OF THE PATIENT

structures around them. Accordingly, for the hugemajority of such installations, there are no specialdecommissioning criteria and no special precautionsneed be taken in respect of radioactivity.

16.13 Linear accelerators operating at above 8.5MV arecapable of inducing radioactive activation in their ownstructures, most notably the collimators or jaws as wellas parts of the couch. In very unusual instances, thisactivation may extend to the built environment of thebunker shielding that surrounds the machine. However,good design can virtually eliminate this as aconsideration while in older, poorly designed units, theextent of activation and the half-life of the radioactivematerials present is such that special precautions arenot likely to be needed. However, when high-energylinear accelerator bunkers are being decommissioned, aradioactivity site survey should be conducted and theradiation protection advisor consulted as to whether ornot special precautions are needed in the specificinstance. It is unlikely that the move toward newmaterials such as ‘Ledite’ will materially affectradioactive activation, though the potential re-use of‘Ledite’ is a factor.

ECONOMIC CONSIDERATIONS

16.14 The decontamination and radiation control issuesmentioned above are not likely to add severely todecommissioning costs in radiotherapy and nuclearmedicine facilities. However, the business of usingpossibly very large amounts of shielding does have apotential impact and the problems associated with thedisposal of that shielding at the end of the useful life ofthe facility should be considered.

16.15 Reinforced concrete structures are amenable toremoval only by on-site breakage and demolition. Thewaste materials are then conventionally removed fromsite using heavy vehicles and are disposed of by landfillor, in some instances, a recycling process, whichinvolves crushing the material. By contrast some of thenew shielding materials, ‘Ledite’ being the best knownexample, are amenable to re-use and can simply bedismantled and either returned to the supplier or re-deployed in new buildings. In considering the overallcosts within a business plan, particularly for aradiotherapy development, an assessment ofenvironmental protection and impact in respect ofdemolition or reuse of materials is a relevantconsideration.

BASIS OF ENVIRONMENTAL PROTECTION

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HDR CONTROL AREA SHOWING THE AFTERLOADING MACHINE CONTROL AND MONITORS


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17.1 Infectious diseases and healthcare-associatedinfection represent an increasing problem forhospitalised patients and a major cause of morbidityand mortality in patients with compromised immunesystems. Readers are referred to NHS Estates guidance‘Infection control in the built environment, design andplanning’

17.2 All patients, staff and visitors to healthcareinstitutions are subject to a measure of exposure topossible cross-infection due to the obviousconcentration of disease within such buildings. There isaccordingly a clear duty of care, frequently reinforced bygovernment measures, to minimise such risk at everyreasonable opportunity. Control is dependent upon thegeneration of suitable policies and protocols at locallevel, but also necessarily involves attention to detail inbuilding design.

17.3 Readers are referred to NHS Estates’ guidanceHTM 2040 – ‘The control of legionellae in healthcarepremises – a code of practice’. Further detailed adviceon the prevention of infection spread throughpharmaceuticals is contained within HBN 29 –‘Accommodation for pharmaceutical services’. Much ofthe latter advice will apply to radiopharmaceuticals.

VULNERABILITY OF CANCER PATIENTS –GENERAL AND SPECIFIC

17.4 The group of patients included in this documentmay have a broad variation in immunological functionand for this reason and because individualimmunological functions will vary according to the stageof treatment, it is difficult to be prescriptive.

17.5 The risk of infection for cancer patients as a grouphas not been shown to differ substantially from otherssuffering acute illness. However, an exception exists forthose who are immuno-compromised as part oftreatment for a range of diseases, most commonlyleukaemia. Such treatment may involve total bodyirradiation followed by a bone marrow transplant and along period of infection-protective nursing. This is aparticular consideration in paediatric services.

17.6 Cancer patients may have complications in termsof other diseases that potentially give rise to enhancedvulnerability. The skew in patient–age distribution

towards older age groups should also be noted.

SOURCES OF RISK

17.7 A number of diseases pose quantifiable levels ofrisk for infection in healthcare premises, particularlyhospitals. Prominent among these is methicillin-resistantStaphylococcus aureus (MRSA) but the range ofhospital-acquired infections (HAI) is wide and theprevalence amongst patients is as high as 10-12%. Thiscan give rise to a significant additional hurdle that mustbe overcome in the provision of satisfactory care forcancer patients. A summary is provided in The Socio-economic Burden of Hospital-acquired Infection,available from Public Health Laboratory Service or theDepartment of Health Web site(http://www.doh.gov.uk/haicosts.htm).

17.8 Infection may spread by a variety of routesincluding patient-to-patient, patient-via-staff and contactwith building fittings or furniture previously contaminatedby the infectious agent.

17.9 Transmission of infection within a hospital requiresthree elements to be considered:

a. Sources of potentially pathogenic organisms.

b. Susceptible hosts.

c. Means of transmission.

Sources of potentially pathogenic organisms

The environment

17.10 The environment has been increasingly implicatedas a source of infection in the hospital setting andbacteria such as MRSA have been shown to survive indust and on equipment for long periods.

Hands

17.11 Hand washing is without doubt the mostimportant intervention in the control of cross-infectionand it is important that hospital accommodation isdesigned to encourage hand washing (see “Clinicalsinks – design for clean hands” in NHS Estates’guidance ‘Infection control in the built environment:design and planning’).

17 Control of infection in cancer patients

Patients’ own endogenous flora

17.12 This is a difficult area to control and may beaddressed by pharmaceutical means. Intravenousadministrations can also be implicated in cross infection.

Other human sources of infection

17.13 Occasionally staff, patients and visitors may be asource of infection as they also may be incubating adisease or be colonised with bacteria.

17.14 Inclusion of single bedrooms or small two-bedbays into the design of new build healthcare facilitiescan help to overcome some of these problems.

Susceptible hosts

17.15 Factors such as age, immune status, underlyingdisease, certain treatments and breaks in the first line ofdefence are all possible problems that may render thisgroup of patients more susceptible to infection.

Means of transmission

17.16 Transmission of potentially pathogenic organismoccurs by:

• Contact (usually staff to patient) either direct orindirect which involves contact of a susceptible hostwith a contaminated object or the environment.

• Airborne transmission – coughing, sneezing, talkingor during certain procedures such as bronchoscopy.Droplets containing micro-organisms that remainsuspended in the air for long periods of time or dustparticles containing infectious agents. Infectionspread in this way can be dispensed widely and maybe inhaled by susceptible hosts either within theimmediate environment or over longer distances.Special air handling or ventilation is required toprevent airborne transmission.

• Isolation precautions are designed to preventtransmission of infection in hospital and especially forthis patient group during periods of susceptibility(temporary periods of neutropenia).

17.17 During periods when they are not undergoingtreatment some patients may have other underlying riskfactors such as a break in skin integrity through aHickman line/CVP, or problems with other metabolicfactors such as malnutrition, etc. In these circumstancesbasic infection control procedures apply in the sameway as to any other hospitalised patient.

PREVENTATIVE MEASURES

Built environment and facilities management

17.18 Exposure to exogenous pathogens should bereduced. This can be assisted by attention to the built

environment by providing the following:

a. Single rooms/small two-bed/four-bed bays withdoors.

b. Space around the beds.

c. Hand wash facilities.

d. Staff change areas.

e. Decontamination facilities.

f. Design for a clean environment.

g. Appropriate ventilation.

h. Suitable furnishing/fixtures, fittings and flooring.

i. Potable water

j. Catering facilities.

k. Hand wash facilities for patients and visitors.

l. Reverse isolation/barrier nursing.

m. An environment that is easily cleaned and thenactually kept clean.

n. A high standard of decontamination ofequipment/instruments and medical devices, etc.

Specific infection control issues duringrenovation/refurbishment or construction

17.19 It is important that the infection control team isconsulted early in the planning stage of eitherrefurbishment or renovation of existing buildings or inany new schemes for healthcare buildings. For timing ofinclusion and areas of consultation see NHS Estates’guidance ‘Infection control in the built environment:design and planning’

17.20 It is also important the infection control teamcarry out risk assessments for any building work that willtake place in patient areas (especially in areas whereimmuno-compromised patients are looked after) andproduce a policy for contractors. Continued monitoringis then necessary and can be achieved by carrying outenvironmental rounds once the building work is underway.

17.21 General care in design should extend to theavoidance of design elements that promote theaccumulation of dirt or microbial growth. Particularlyattention should be paid to wall, floor and bench surfacefinishes where care to ensure the absence ofdiscontinuity and promote ease of cleaning is required.This will apply particularly in chemotherapy treatmentrooms and minor procedures facilities. Extensiveadditional information is available in NHS Estatesguidance HBN 40 ‘Common activity spaces’.

CONTROL OF INFECTION IN CANCER PATIENTS

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17.22 Debris arising from building operations or from thebreakdown of building materials, including some ceilingtiles, is known to promote infection by some speciesincluding fungi such as Aspergillus spp.

17.23 Infection control issues during refurbishment andnew build include:

• Timely notification and involvement of the infectioncontrol team.

• Design to support infection control practice, i.e.,ventilation, single rooms, hand washing basins,fixtures/fittings/furnishings.

• Utility rooms, storage and space.

• Dust and debris control (the problems of Aspergillusspp.).

• Prevention of contamination of patient rooms, wardareas and supplies/equipment.

• Impact of work being carried out around at-riskpatients.

• Interruption of services (ventilation, water).

• Water contamination.

• Flooring, i.e., carpets versus hard floor.

17.24 The spread of infection from hand-to-handcontact is a particular challenge that may be counteredby the provision of hand wash basins in sufficientnumbers, and located so as to promote their frequentuse, particularly by staff on wards and in treatmentareas. This challenge must not be neglected in specialistareas such as radiotherapy treatment facilities.

17.25 Restriction on the spread of infection should be adesign priority in the provision of natural or mechanicalventilation. The reader is referred to NHS Estatesguidance HTM 2025 – ‘Ventilation in healthcarepremises’.

17.26 The operating theatre is an area of particularconcern. Some elements of advice are contained withinthis document in respect of common cancer-relatedprocedures. Readers are referred to NHS Estatesguidance HBN 26 – ‘Operating department’ for generaladvice.

Facilities for immuno-compromised patients

17.27 The use of total body irradiation as part ofleukaemia therapy and other treatments (with thesubsequent need for infection-protective nursingand high levels of precaution against infection withsuch patients) will be a special concern for somecancer care centres. Patients will beaccommodated in individual rooms, often groupedaround a common nursing and access area. Highlevels of nursing supervision and access controlare necessary. Level 4 microbiological containmentstandards are required.

17.28 The design team must include the control ofinfection team, specialists in theatre levelventilation systems and a clinical consultant withspecial interest in this specific patient group.

17.29 The patients’ rooms will be subject tospecial consideration on surface finishes, with veryhigh standards of surface continuity beingconsidered essential. The choice of materials willalso reflect the need for frequent disinfection andrigorous chemical cleaning. The selection offurnishing must also be cautious in terms ofcleanability, the avoidance of loose fibres and thenear total exclusion of environments in whichbacteria or fungi may be able to grow.

17.30 Mechanical ventilation, with a microporefiltration system, is necessary and will itselfpreclude the non-controlled use of naturalventilation. The use of over-pressure to ensure aconstant outflow of air, such as to excludeuncontrolled air leakage into the room will beessential.

17.31 The use of local article sterilisation facilitiesshould be considered.

17.32 Staff will require local dedicated changingfacilities to permit the use of theatre standardclothing and very high standards of personalhygiene. Some staff will require scrub facilities.

AppendicesEngineering

Room layoutsFire safety

A TYPICAL MACHINE ROOM LOCATED BEHIND A LINEAR ACCELERATOR FASCIA PANEL

INTRODUCTION

1 This appendix describes the engineering servicescontained within facilities for cancer services and howthey integrate with the engineering systems serving thewhole site. The guidance should acquaint the engineeringmembers of the multi-disciplinary design team with thecriteria and material specification needed to meet thefunctional requirements. Specific requirements should beformulated in discussion with both end-users andmanufacturers of specialist equipment. Some issuesparticularly those related to radiation safety will requirespecific and detailed discussion with other professionalconsultants including the local radiation protectionadvisor.

MODEL SPECIFICATIONS AND TECHNICALMANUALS

2 The National Health Service Model EngineeringSpecifications are sufficiently flexible to reflect local needs.In addition the attention of the reader is directed towardsthe range of Health Technical Memoranda (HTMs) relevantto cancer care centres. Specific references are providedthroughout the text.

ECONOMY AND VALUE ENGINEERING

3 Engineering services are a significant proportion of thecapital cost and remain a continuing charge on revenuebudgets. The project design engineer should thereforeensure:

a. economy in initial provision, consistent with meetingfunctional requirements and maintaining clinicalstandards;

b. optimum benefit from the total financial resourcesthese services are likely to absorb during their lifetime.Consideration should be given to generating ‘lifetimecostings’, particularly if private finance iscontemplated.

4 Where various design solutions are available, theconsequential capital and running costs should becompared using the discounting techniques described inthe Capital Investment Manual.

5 PFI and PPP solutions will require evaluation. Thesesolutions must generate a financial advantage over

straightforward capital investment. The finance gains arerequired to be sustainable over a reasonable working lifefor the building and the engineering that it contains.Accordingly maintainability and the cost of maintenanceare key factors in both business planning and the PFIevaluation process.

6 The economic appraisal of various locations and designsolutions should include the heat conversion anddistribution losses to the point of use. Where buildings arelocated remote from the development's load centre,these losses can be significant.

7 Energy management should be part of the hospitalbuilding management system (BMS) and this should alsoinclude metering of all services where practical. If ahospital BMS is not available, the energy management forthis department should be stand-alone. It should also besuitable for subsequent integration with a future BMS.Further detailed guidance is contained in HTM 2005 –‘Building management systems’.

8 In view of the increasing cost of energy, the projectteam should consider the economic viability of heatrecovery and combined heat and power systems (CHPs).Further guidance on CHPs can be found in NHS Estates’‘A strategic guide to combined heat and power'.Designers should ensure that those services which useenergy, do so efficiently and are metered wherepracticable.

MAXIMUM DEMANDS

9 The estimated maximum demand and storagerequirement (where appropriate) for each engineeringservice should be assessed individually to take account ofthe size, shape, geographical location, operationalpolicies and intensity of use of the department.

10 Details of power consumption and load patterns ofsignificant individual items of equipment must be soughtfrom manufacturers and/or suppliers. Most commonly thegain of this information will be part of the equipmenttendering process.

11 Estimated maximum demands for one high-energylinear accelerator suite are given below, as a guide andfor preliminary planning purposes only.


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Appendix 1 Specialist engineering requirements

ENVIRONMENTAL SPECIFICATIONS FOR LINEAR ACCELERATORS

Earthing for all linear acceleratorsRecommended – 0.1W but must not exceed 0.2W when measured between any point in the systemand the ERT.

Example: Siemens – Mevatron Linear Accelerator

Mass of machine• Weight of accelerator when installed – 7030 kg• Heaviest component when being transferred to bunker – 4082 kg

Power requirements • 480V or 380V preferred to 208V source when available • three-phase delta to wye at 50/60Hz with +/- 1Hz frequency variation permitted• Power use or requirements – 30kVA• System input voltage – 208V line to line• 120v – line to neutral• Line voltage variation – +/- 10% maximum• Phase balance – 2% between 2 phases• Line impedance <= 0.050W maximum line to neutral at secondary of conditioner• Surges and sags 10% above and below line voltage – 20msec maximum duration• High frequency noise – no single event greater than 10.0V in the range 10kHz and 2MHz.• Spikes – no single event greater than 100% of the nominal line to line voltage expressed as peak voltage (208 peak for 208V input)• Circuit protection – 80A

Heat dissipation into air• 13989 BTU/HR when operated or 14kW/hour approximate• 6824 BTU/HR when in standby or 6.9kW/hour

Noise at 1m distance• 75dB(A) – maximum value

Room temperature requirements• Relative humidity without condensation• Room temp not to exceed 26°C and 65% relative humidity• Atmospheric pressure – treatment room must not differ by more than +/- 250mbar when compared to control area.

Air filtering • Class EU 4 (B2) and observe German standard DIN 1946

Room air changes• The air-conditioning should be capable of at least seven air changes per hour to allow for a maximum duty cycle of 15 minutes perhour and an ozone concentration of less 0.05ppm

Accelerator water supply• Closed-loop chiller water system• Water temp – 10°C minimum, 25°C maximum• Flow rate – 30l/minute at 25°C• Dissolved solids in facility water cooling system must not exceed 0.01%• Heat dissipation to water – typical consumption – inlet temp of 14∞C and patient load of six per hour would use between 2 and 4litres/minute

Physical distance between cables• Standard cabling length from control console/accelerator interface is 24m and allowance must be made 3m from conduit exit pointto the interface on the linear accelerator or control console. Maximum conduit length is 18m.

Example: Varian Oncology Systems – Dual Energy Clinac

Mass of machine• 17508 kg when installed• Largest component – 4240kg when moved onto bunker

Power requirements • Dual Energy Clinac – 45kVA• Typical international requirements – 360 to 440VAC 50/60Hz line to line, three-phase supply four wire plus ground wye configuration,line voltage regulation +/- 5

Heat load • 12kW per hour

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These examples are typicalat the time of writing but

care due to the rapid rateof change in technological

requirements is advised.Several additional suppliers

also provide linearaccelerators to the NHS.

ACTIVITY DATA

12 Environmental and engineering technical data andequipment details are described in the relevant ActivityDatabase department information. This should be referredto for space, temperatures, lighting levels, outlets forpower, telephones, equipment details, etc. Significantgains in both management and patient service areas maybe expected from the provision of a wide-bandwidth LAN and associated computingequipment. This is especially true in the areas ofradiotherapy and some parts of diagnosis and treatmentplanning.

SAFETY

13 The Health and Safety at Work Act 1974, as partlyamended by the Consumer Protection Act 1987, togetherwith the Management of Health and Safety at WorkRegulations (1992), the Workplace (Health, Safety andWelfare) Regulations (1992) and the Provision and Use ofWork Equipment Regulations, impose statutory duties onemployers and designers to minimise any risks arising fromthe use, cleaning or maintenance of engineering systems.One of the requirements of this legislation is to ensure, sofar as is reasonably practicable, that design andconstruction is such that articles and equipment will be safeand without risks to health at all times when they are beingset, used, cleaned or maintained by a person at work.

14 The Ionising Radiation (Medical Exposure) Regulations2000 and the associated Codes of Practice placeonerous requirements upon engineering aspects ofdesign and operational practices in cancer care centresand units. Over and above this, there are additionalrequirements from the 1993 Radioactive Substances Actin respect of storage, use and disposal of radioactivematerials. The local radiation protection adviser andcustodian of radioactive substances must be consulted.

NOISE AND SPEECH PRIVACY

15 Excessive noise and vibration from engineeringservices, whether generated internally or externally andtransmitted to individual areas, or noise from othersources (for example, speech which can be transmittedby the ventilation system) can adversely affect theoperational efficiency of the department and causediscomfort to patients and staff. The limits and means ofcontrol advocated in NHS Estates guidance HTM 2045– ‘Acoustics’ should provide an acceptable acousticenvironment.

16 In addition to designing for control of noise levels,there may also be a need to ensure speech privacy, sothat confidential conversations are unintelligible inadjoining rooms or spaces. This will be important inconsulting/examination rooms, particularly where theseare located adjacent to waiting areas. The use ofinduction loop facilities for those with hearing impairment

should be considered but the need for privacy inconversations conveyed by such means should equalthat granted to able-bodied persons.

ENVIRONMENTAL REQUIREMENTS

17 Detailed environmental requirements for specialistequipment should be obtained from manufacturers. Thecomfort of patients and staff should be considered inrespect of temperature stability and the effects of wasteheat derived from high-powered diagnostic or treatmentsystems. Humidity control is often a key feature ofsuccessful design.

SPACE FOR PLANT AND SERVICES

18 Space for plant and services should provide easy andsafe means of access, protected as far as possible fromunauthorised entry. This will be needed for frequentinspection and maintenance. Sufficient access panelsshould be provided for this purpose. In the provision ofpanels and access points consideration must be given toensuring that the integrity of fire barriers and the controlof smoke is appropriately maintained.

19 Consideration must be given to the need for theeventual removal and replacement of plant.

20 Recommended spatial requirements for mechanical,electrical and public health engineering services arecontained in NHS Estates guidance HTM 2023 –'Accommodation for plant and services'. Reference isalso made in HTM 2023 to the Construction (Design andManagement) Regulations. The information in this HTM isspecifically intended for use during the initial planningstages when precise dimension details of plant are notavailable.

21 The distribution of mechanical and electrical servicesto final points of use should, wherever possible, beconcealed in walls and above ceilings. Heat emittersshould be contained within a 200mm-wide perimeterzone under window sills and critical dimensions should betaken from the boundary of this zone. The 200mm zoneincludes the floor area occupied by minor verticalengineering ducts and is included in the buildingcirculation allowance.

22 Services contained in the space above the falseceiling, with the exception of drainage, should beconfined to those required for the department.

23 All mechanical and electrical services entering roomspotentially containing radiation must be routed throughspecially designed access ports so that shielding is notcompromised. It may also be necessary to design-inchanges in direction of ductwork, and cable containmentsystems to provide protection against radiation breakout– services into linear accelerators will all pass through themaze, with possibly an additional chicane for high-energylinear accelerators.


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24 In other situations – existing installations, for example,– services may pass into the room at low level and riseinto their final position. The precise arrangements will beproject-specific and should be determined with theinstallation specialist.

25 Access to control and isolation devices must beconsidered. Devices for control and safe isolation ofengineering services should be:

a. Located in circulation rather than working areas.

b. Protected against unauthorised operation.

c. Clearly visible and accessible, where intended foroperation by the facility’s staff.

26 In a diagnostic or treatment simulation area the accessarrangements must not compromise the radiologicalprotection provided for these rooms. Considerationshould be given to the comfort as well as safety ofpatients and others. It may be appropriate to use a“double knock” system whereby attempted unauthorisedaccess first initiates an audible warning and only whenthe access attempt is continued is radiation-emittingequipment switched off. However, the hazard levelspresent with therapy equipment require a more stringentapproach in which any intrusion will trigger beamshutdown.

ENGINEERING COMMISSIONING

27 The engineering services should be commissioned inaccordance with the validation and verification methodsidentified in the latest HTMs. Engineering services forwhich a specific HTM is not currently available should becommissioned in accordance with ‘Engineeringcommissioning' published by the Institute of HealthcareEngineering and Estate Management. Flow measurementand proportional balancing of air and water systemsrequire adequate test facilities to be incorporated at thedesign stage. Guidance is also contained incommissioning codes A and W published by theChartered Institute of Building Services Engineers.

28 The services for linear accelerators may require to becommissioned early in the engineering contractprogramme. This is to ensure that the linear acceleratorscommissioning is completed prior to the first patientarriving. Parts of this commissioning are concerned withradiation safety and the approval of the local radiationprotection advisor must be obtained for the processesand schedules used.

MECHANICAL SERVICES

Heating

29 Spaces heated by low-pressure hot water systemsshould use radiators of the low surface temperature type.Surface temperatures should not exceed 43°C. Exposed

hot water pipework, accessible to touch, should beinsulated. Further guidance is contained in NHS Estates’Health Guidance Note – ‘"Safe" hot water and surfacetemperatures'.

30 Radiators should normally be located under windowsor against exposed walls with sufficient clear spacebetween the top of the radiator and the window sill toprevent curtains reducing the output. There should beadequate space underneath to allow cleaning machineryto be used. Where a radiator is located on an externalwall, back insulation should be provided to reduce therate of heat transmission through the building fabric.Special care is needed when radiators are installed inrooms where unsealed or liquid radioactive sources areused. Protection of such fittings against radioactivecontamination will be essential.

31 It is recommended that radiators are fitted withthermostatic radiator valves. These should be of robustconstruction and selected to match the temperature andpressure characteristics of the heating system. Thethermostatic head, incorporating a tamper-proof facilityfor presetting the maximum room temperature, should becontrolled via a sensor, located integrally or remotely asappropriate. To provide frost protection at its minimumsetting, the valve should not remain closed below a fixedtemperature. In calculating heating requirements caremust be taken to include heat yield from high-poweredequipment.

32 Radiators may also be used to offset building fabricheat loss in mechanically ventilated spaces.

33 Flow temperatures to heating appliances should becontrolled by the BMS in accordance with spacerequirements and external temperatures. The systemshould be zoned to suit the building.

Ventilation (general)

34 Wherever possible, individual spaces should benaturally ventilated. Deep planned spaces may needmechanical ventilation. Planning should, therefore, seek tominimise the need for mechanical ventilation by ensuringthat, wherever practicable, core areas are reserved for:

a. Rooms that require mechanical ventilation for clinicalor functional reasons, irrespective of whether theirlocation is internal or peripheral (for example, sanitaryfacilities, dirty utility and beverage preparation areas).

b. Spaces that have only transient occupation and,therefore, require little or no mechanical ventilation (forexample, circulation and some storage areas).

35 The majority of the areas within the facility will requiremechanical ventilation, due to equipment heat gains,patient/staff numbers and clinical/radiology reasons.


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36 Air movement induced by mechanical ventilationshould be from clean to dirty areas, where these can bedefined. The design should allow for adequate flow of airinto any space having only mechanical extract ventilation,via transfer grilles in doors or walls. However, sucharrangements should avoid the introduction ofuntempered air and must not prejudice the requirementsof fire safety or privacy.

37 Mechanical ventilation should ensure that both supplyand extract systems are in balance, and take account ofinfiltration as appropriate.

38 Fresh air should be introduced via a low-velocitysystem and should be tempered and filtered before beingdistributed via high-level outlets. Diffusers and grillesshould be located to achieve uniform air distributionwithin the space, without causing discomfort to patients.

39 The supply plant for ancillary accommodation shouldbe separate from plant serving the cancer care facility.

40 A separate extract system will be required for ‘dirty’areas, for example, toilet facilities. It should operatecontinuously throughout the day and night. A dual motorfan unit with an automatic changeover facility should beprovided.

41 Fume cupboards and microbiology cabinets will berequired and their exhaust locations will need carefulconsideration. These items are used for a range ofspecific containment tasks such as dealing with cytotoxicdrugs or radioactive materials. Equipment types andinstallation requirements will vary significantly with theapplication and hazards involved. Detailed local advicemust be sought from the appropriate scientists andpharmacists.

42 External discharge arrangements for extract systemsshould be protected against back pressure from adversewind effects and should be located to avoidreintroduction of exhausted air into this or adjacentbuildings through air intakes and windows.

43 Further detailed guidance is contained in NHS Estatesguidance HTM 2025 – 'Ventilation in healthcare premises,Design considerations'.

44 Consideration should be given, in discussion with theuser, regarding the possible use of aromatherapy via thecentre ventilation system. This may be effective as anenvironmental enhancement and there is some limitedevidence of particular benefit to this patient group. Thesmell-masking produced may also be of value.

Ventilation of therapy rooms and bunkers

45 The possibility of excessive heat emission from someequipment such as linear accelerators, etc., and thespecial and often prolonged nature of the procedures,may require that the air supply to these rooms be

mechanically cooled. Discussions should take placebetween the users, manufacturers and engineers toensure an appropriate temperature is achieved. Wheredeep planning of other continuously occupied spaces (forexample, offices) is unavoidable, there will also beoccasions when acceptable levels of comfort can only bemaintained by air-cooling.

Ventilation of pharmaceutical services rooms

46 Details of specialist ventilation of pharmaceuticaldepartments are included in NHS Estates HBN 29 –‘Accommodation for pharmaceutical services’. However,the use of cytotoxic drugs in chemotherapy generates anadditional series of considerations. These include theneed to effectively control toxic fumes and the preventionof environmental contamination. Specially adaptedmicrobiological safety cabinets and other containmentdevices will be needed. Discharge filtration will beapplicable in the majority of instances.

Ventilation controls

47 Supply and extract ventilation systems shouldinclude local controls and indicator lamps to confirm theoperational status of each system. Where the system isused in a regular daily pattern, timeswitch control withmanual override for a limited period should beconsidered – staff-controlled boost ventilation for alinear accelerator after some patient treatments wherethe control of odours may be important. The indicatorsfor a system serving a particular space should be in orimmediately adjacent to that space. It may beappropriate to locate all indicators at the staff base.Where manual controls are available for staff use, theyshould be provided with labels that clearly define theirfunction. Such manual controls are more likely to beneeded in cancer care because of the need to clearodours generated by some types of tumour. Localconsultation with healthcare professionals is advised.

Ventilation (control of substances hazardous to health)

48 Local exhaust ventilation will be required whereexposure by inhalation of substances hazardous to healthcannot be controlled by other means. In the publicationEH40, ‘Occupational Exposure Limits’, which is updatedannually, the Health and Safety Executive sets limitswhich relate to the Control of Substances Hazardous toHealth Regulations 1999 (COSHH).

Ventilation filtration

49 Ventilation supply plant should include air filters havinga minimum arrestance of 85% when tested in accordancewith BS EN 779. In urban or other areas of highatmospheric pollution, a higher standard of filtration maybe economically justified to reduce the level of staining tointernal finishes. Filters must be readily accessible for

replacement and should be provided with a pressure-differential indicator.

Ventilation of isolation rooms

50 The facility may require isolation rooms to protectpatients and/or staff. Guidance should be sought fromthe project team or end user.

51 The mechanical ventilation system for isolation roomsshould be designed to provide a ‘simultaneous sourceand protective isolation’ simple non-changeover systemthat provides balanced supply and extract ventilation toeach room and gowning lobby is proposed. A ‘constantmode’ system has a number of advantages and avoidsthe complications and reliability problems associated withchangeover systems.

52 The gowning lobby, which functions as an airlock, willrequire a relatively high and balanced supply and extractair change rate to be effective against airborne organismsmoving between circulation areas and the rooms. For thisreason, the gowning lobby should be relatively small.

53 Staff entering the gowning lobby from the corridor willgo through a clinical hand-washing procedure and duringthis period, the ventilation system will dilute the airentrained from the corridor. Further entrainment anddilution occurs as staff move from the gowning lobby tothe room. The amount of air and number of organismstransferred from the corridor to the room through thisprocess should be exceptionally low and will be inverselyproportional to the time spent gowning up. The reversewill also apply as staff leave the single bedroom.

54 The mechanical ventilation system should also includemechanical cooling and provide for a range oftemperatures which can be adjusted by staff. Thehumidity within the single room should also be controlled.

Hot and cold water services

55 Guidance on the design and installation of hot andcold water supply and distribution systems is contained inNHS Estates’ guidance HTM 2027 – 'Hot and cold watersupply, storage and mains services'.

56 All cold water pipework, valves and fittings should beeconomically insulated and vapour sealed to protectagainst frost, surface condensation and heat gain.

57 The domestic hot water supply should be taken fromthe general hospital calorifier installation at a minimumoutflow temperature of 60°C ± 2.5°C and distributed toall outlets such that the return temperature at the calorifieris not less than 50°C. See NHS Estates guidance HealthGuidance Note – '"Safe" hot water and surfacetemperatures'.

58 The requirements for the control of legionellae bacteriain hot and cold water systems are set out in NHS

Estates’ guidance HTM 2040 – 'The control of legionellaein health care premises – a code of practice'. Outlettemperatures shall be controlled as highlighted in clause8.13.

59 Architects and engineers should collaborate to ensureany landscape design/water features are included in thedesign.

Piped medical gases and vacuum

60 Guidance on piped medical gas systems, anaestheticgas scavenging and gas storage is contained in NHSEstates guidance HTM 2022 – 'Medical gas pipelinesystems'. There is a high likelihood that such services willbe needed in selected treatment rooms. Localconsultation is essential.

61 Special non-ferrous fittings will be needed ifequipment may also be used in MRI scanning rooms.

Pneumatic tube transport

62 Pneumatic tube transport may provide a viablealternative to porters for moving specimens to thepathology department. Factors to be assessed will include:

• distance, time and cost of travel between the twolocations;

• time to process specimens in the laboratory;

• proportion of specimens which require urgent results;

• whether general post, etc., will be transported in thesystem.

63 The total capital and revenue cost of each optionshould be determined in accordance with the principlesset out in the Capital Investment Manual. Furtherguidance on pneumatic conveyor systems will becontained in NHS Estates’ guidance HTM 2009 –'Pneumatic air tube transport systems’.

Bedhead services

64 Depending on the type of care being provided, it maybe desirable to provide a more domestic environment. Toachieve this, bedhead services can be concealed within acupboard or behind some other movable feature.However to enclose such services requires care to ensurethat there is adequate ventilation in the event of gasleakage. Sufficient space must be provided. Currentclinical practice is to leave devices permanently insertedinto medical gas outlets and plugged into electricsockets.

ELECTRICAL SERVICES

Electrical installation

65 Electrical installation should comply in all respects withBS 7671 – ‘Requirements for Electrical Installations'; IEE

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Wiring Regulations 16th Edition (and subsequentamendments) and NHS Estates guidance HTM 2007 –'Electrical services: supply and distribution'. Zonal earthcircuit provision should be considered in consultation withequipment manufacturers.

66 The point of entry for the electrical supply should be aswitch cupboard housing the main isolators anddistribution equipment. This space will also be thedistribution centre for subsidiary electrical services.Supplies should be metered and, whenever possible,equipment should be mounted at a height that gives easyaccess from a standing position. Switchgear should belockable in the "off" position.

67 The electrical installation in occupied areas should beconcealed using PVC-insulated cable and screwed steelconduit or trunking (in certain circumstances, mineralinsulated, metal-sheathed or other cable with resistanceto extreme temperatures and physical damage may beused depending on requirements). External installationsshould use PVC-insulated cables in galvanised screwedsteel conduit with waterproof fittings.

Electrical interference

68 Care should be taken to avoid mains-borneinterference, electrical radio frequency and telephoneinterference affecting physiological monitoring equipment,computers and other electronic equipment used here orelsewhere on the site.

69 Electrical products, systems and installations shouldnot cause, or be unduly affected by, electromagneticinterference. This requirement is in the form of an ECDirective on Electromagnetic Compatibility (89/336/EECas amended by 91/263/EEC and 92/31/EEC). ThisDirective has been implemented in UK law by theElectromagnetic Compatibility Regulations 1992 (SI No2372).

70 Advice on the avoidance and abatement of electricalinterference is contained in NHS Estates guidance HTM2014 – 'Abatement of electrical interference'.

71 Fluorescent luminaires should comply with BS EN55015.

Lighting

72 Colour finishes and lighting throughout the departmentshould be co-ordinated to create a calm and welcomingatmosphere. Practical methods are contained in theCIBSE Lighting Guide LG2 – 'Hospitals and Health CareBuildings'.

73 Architects and engineers should collaborate toensure that decorative finishes are compatible with thecolour rendering properties of the lamp and that thespectral distribution of the light sources is not adverselyaffected.

74 Architects and engineers should collaborate withartists and landscape designers to ensure servicesrequirements are co-ordinated within the facility.

75 Luminaires should be manufactured and tested inaccordance with the requirements specified in therelevant sections of BS 4533. Their location should affordready access for lamp changing and maintenance, butwith the overriding requirement that the recommendedstandard of illuminance is provided to the task area in alltreatment rooms.

76 The number and location of luminaires connected to acircuit and the number of switches and circuits providedshould allow flexibility in the general and local level ofillumination, particularly in areas away from windowswhere daylight can vary significantly. Some areas of thefacility that may be unoccupied for long periods may alsobe suited to automatic/presence switching.

77 Generally, energy-efficient luminaires should be usedwherever possible. Intermittently and infrequently usedluminaires may be fitted with compact fluorescent orincandescent lamps.

78 Mobile examination luminaires, where provided, shouldoperate at extra low voltage (normally fed from an in-builtstep-down transformer), be totally enclosed and beequipped with a heat filter. The temperature of externalsurfaces should be such as to avoid injury to patients andstaff.

79 Where visual display terminals (VDTs) are to be used,the lighting should be designed to avoid bright reflectionson the screen and to ensure that the contents of thescreen are legible and meet the Health and Safety(Display Screen Equipment) Regulations 1992, whichcame into force on 1 January 1993. The Regulationsimplement a European directive, No. 90/270/EEC of 29May 1990, on minimum safety and health requirementsfor work and display screen equipment. Further guidanceis contained in the Chartered Institution of BuildingServices Engineers Lighting Guide LG3.

80 The lighting of corridors, stairways and othercirculation areas, (areas not normally covered by ActivityDatabase A-Sheets), should be in accordance with theguidance contained in NHS Estates guidance HBN40/SHPN 40 – 'Common activity spaces, Volume 4'.

81 Safety lighting should be provided on primary escaperoutes in accordance with NHS Estates’ guidance HTM2011 – 'Emergency electrical services' and BS 5266.Emergency lighting of control rooms should also bearranged in accordance with the requirements of usersand the guidance in HTM 2011.

Lighting treatment rooms

82 An examination luminaire should be provided over thetreatment chair/table. It should be adjustable in pitch androtation to allow the beam to be directed locally.


80

APPENDIX 1

81

Reasonably shadow-free illumination, with negligible heatdevelopment, should be provided to avoid injury topatient and staff. The examination luminaires should bemanufactured and tested in accordance with therequirements specified in the relevant sections of BS 4533.

83 For linear accelerators and some other treatmentmachines automatic switching to low-level room lightingwill be needed to facilitate the use of field marker lightsand low-power alignment lasers. Conversely, high levelsof lighting are needed for equipment maintenance.

Illuminated signs

84 At each entrance to a radiodiagnostic or radiationtreatment room (except entrances used only by patientsunder the direct control of staff already inside the room,for example, those from walk-through changing cubicles),a safety sign and a warning lamp must be provided inorder to comply with the statutory requirements forradiological protection. The warning lamp must give aclear indication in red when it is energised and mayincorporate the legend “do not enter”, visible only whenilluminated. All warning lamps should have incandescentfilaments energised from a suitable power source withinthe room and switched via appropriate devicesinterlocked with the operation of the diagnostic ortherapeutic equipment.

85 Other illuminated signs may also be required within thefacility. All such signs should be connected to essentialsupplies where necessary. For therapy equipment, whereexclusion of persons other than the patient is essentialthe warning systems must work with interlocks and bespecifically approved by the local Radiation ProtectionAdvisor.

Controlled drugs cupboard

86 A red indicating lamp should be provided on eachcontrolled drugs cupboard and, where appropriate,outside the doorway to the room in which the cupboardis located and at a continuously staffed location. Thelamps should be interlocked with the cupboard and alarmsystem to give visual and audible indication at thecontinuously staffed location of unauthorised entry to thecupboard.

87 An indicating lamp denoting that the circuit isenergised should also be fitted to each cupboard. Thesupply circuits for the lamps and alarm system should bederived from essential circuits. The cupboards shouldcomply with BS 2881. Further information is contained inNHS Estates’ guidance HTM 63 – 'Fitted storagesystems'.

Socket outlets and power connections

88 Sufficient 13-amp switched and shuttered socketoutlets, connected to ring or spur circuits, should be

provided to supply all portable appliances likely to beused simultaneously. The installation of twin outletsshould be considered where activities occur injuxtaposition.

89 Switched socket outlets should be provided incorridors and in individual rooms to enable domesticcleaning appliances with flexible leads (nine metres long)to operate over the whole facility.

90 Appliances requiring a three-phase supply, or thoserated in excess of 13-amp single phase, should bepermanently connected to separate fused sub-circuits.The sub-circuits should be fed from the distribution boardand terminate at a local isolator. Fixed appliances, lessthan 13-amp rating, should be permanently connected toa double-pole switched 13-amp spur outlet. The spuroutlet should contain an indicating light, whereappropriate, and a suitable fuse.

91 Depending on local circumstances, consideration mayneed to be given to the quality of the electrical supply tocomputer and other equipment. Much equipment hasover-voltage and surge protection built-in butsusceptibility to harmonics and other supply distortionshould be discussed with the manufacturer to establishthe parameters required. Additional power-factorcorrection should be built in as required. Advice shouldbe sought from manufacturers and suppliers at an earlyopportunity.

92 Isolation switches should be provided adjacent to allengineering plant and equipment for use by maintenancestaff.

93 Socket outlets in areas for consultation, examinationor treatment and wherever X-ray films are processed,reported on or stored, should be connected such thatwithin each area a supply is available from at least twoseparately fused circuits of the same phase.

94 Socket outlets should be connected to essentialcircuits in accordance with the advice contained in NHSEstates’ guidance HTM 2011 – 'Emergency electricalservices'.

Electrical supplies to diagnostic and therapy equipment

95 The electrical supply connections to all medicalelectrical equipment should comply with BS EN 60 601-1-2: 1993.

96 Advice on the power supply and requirements for fixedand mobile radiodiagnostic equipment is contained inNHS Estates’ guidance HTM 2007 – 'Electrical services:supply and distribution'. Individual project requirementsshould be discussed at an early stage with manufacturersand suppliers of equipment.

97 The earth connection at the power termination shouldbe suitable for the functional earth requirements specifiedby the radiology equipment manufacturer, and bearranged to receive a direct connection from the earthreference terminal which should be provided ordesignated in every radiodiagnostic room. Furtherguidance on the purpose, characteristics andperformance criteria of an earth reference terminal aregiven in HTM 2007.

Emergency electrical supplies

98 Guidance on emergency electrical supplies iscontained in NHS Estates guidance HTM 2011 –'Emergency electrical services'.

99 Requirements for connection of individual circuits anditems of equipment to UPS and/or standby generationsystems should be discussed with users and withequipment suppliers. Items for consideration includepotential discomfort and any medical implications for thepatient, and the memory capabilities and reversioncharacteristics of the equipment.

Personal alarm transmitters

100 Local security policies should determine at theplanning stage whether or not staff are to be issued withpersonal alarm transmitters. If personal alarm transmittersare not “self contained”, conduits and accommodation fortransmitting/receiving equipment and propagatingdevices, such as induction loops and/or aerials, will berequired to suit the selected system.

Security alarms

101 A security alarm actuating switch or button may berequired to be located unobtrusively at the reception deskand staff base. It should be connected to a continuouslystaffed area such as the hospital telephone switchboardon the porters' room. Guidance should be sought fromthe project team and end users.

Staff location system

102 The hospital staff location system should beextended to include this facility. Further guidance iscontained in NHS Estates guidance HTM 2015 –'Bedhead services'. There are particular advantages tothe use of such systems in cancer care. Patients’ groupshave emphasised the value in continuity of contact with afamiliar care team and individual members of staff.

Patient/staff and staff/staff call systems

103 The patient/staff and staff/staff call systems may behard-wired or radio systems. In all cases they must beelectromagnetically compatible, taking account ofelectromagnetic interference likely to be generated.

104 Patient/staff call points should be provided in allspaces where patients may be left alone temporarily, such

as rooms for consultation, examination and treatmentrooms and patient WCs. Each call unit should comprise apush button or pull cord, reassurance lamp and resetunit. The audible alarm signal initiated by patients shouldoperate for one second at ten second intervals withcorresponding lamps lit continuously until cancelled.Particular care will be required in choosing and siting callunits for use whilst a patient is undergoing treatment, forexample, within a linear accelerator.

105 Staff/staff call points should be provided in all spaceswhere staff consult, examine and treat patients. Call unitsshould generally comprise a switch (pull to call, push toreset) and reassurance lamp. The audible alarm signalinitiated by the staff should operate intermittently at halfsecond intervals with corresponding lamps flashing onand off at the same rate.

106 A visual and audible indication of operation of eachsystem should be provided at the staff base to giveresponding staff unambiguous identification of the callsource. Further guidance is contained in HTM 2015 –‘Bedhead services'.

Telephones

107 Central telephone facilities for internal and externalcalls will normally be available and should be extended toserve this department. Telephones will normally be of thedesk pattern.

108 At least one ex-directory line should connect directlywith the local ambulance services control centre,depending on local policy. It should have a distinctive bellor buzzer.

109 Coin- and card-operated payphones and freephone(s) for taxis, depending on local policy, should beprovided in the main waiting area.

110 Self-contained intercommunication systems arerelatively inflexible and limited in the extent of theireconomic application. Any subsequent modifications tothem usually involve disproportionate cost. Very rarelycan such systems be justified for functional or clinicalreasons.

111 A properly planned telephone system will provideprompt intercommunication facilities between allextensions. Abbreviated dialling can be used for a rangeof frequently called extension numbers. Consequently,reasons for providing a separate intercommunicationsystem should be clearly shown.

112 Further guidance on telephone systems is containedin NHS Estates guidance HBN 48 – 'Telephone services'and HTM 2055 – ‘Telecommunications (telephoneexchanges)’.


82

Intercom systems

113 The character of the diagnostic techniques usedwithin cancer services may make it appropriate to provideintercom stations in addition to the telephone and callsystems. These permit ‘hands-free’ speech contact,either staff/staff, patient/staff or staff/patient.Consideration should be given to the local circumstancesand treatment methods.

Data and equipment links

114 Conduits will be required for cables to interconnectelectronic equipment. The extent to which these conduitsshould link all workstations in this facility and the mainhospital system or elsewhere will depend on the localpolicy for automatic data processing. Conduits may alsobe required to link CCTV between the control areas andtreatment areas.

CCTV

115 CCTV should be provided where required to monitorpatients undergoing treatment in restricted areas. Theinterference to which such equipment may be subjectshould be taken into account when it is specified, toensure acceptable electromagnetic compatibility. Careshould be taken in the positioning of monitors in order topreserve patient privacy.

116 Security CCTV may be required to interface to thewhole hospital system.

Clocks

117 Clocks may be of impulse, synchronous orbattery/quartz type, except in any anaesthetic room orresuscitation room where they should display ‘real time’,‘elapsed time’ and have a sweep second hand.

Music and television

118 Conduits for television/video and background musicsystem outlets should be provided to public areas, bedheads and treatment rooms.

119 The provision of an independent or independently-controlled music distribution system from the rest of thehospital should be considered in light of local patientneeds.

Lightning protection

120 Protection of the building against lightning should beprovided in accordance with NHS Estates guidance HTM2007 and BS 6651.

Internal drainage

121 The primary objective is to provide an internaldrainage system that:

• uses the minimum of pipework;

• remains water- and air-tight at joints and connectors;

• is sufficiently ventilated to retain the integrity of waterseals;

• includes labelling of waste pipes that may containradioactive waste or effluent.

122 The design of internal drainage should comply withthe relevant British Standards and Codes of Practice,including BS EN 12056-2, and the current buildingregulations. Recommendations for spatial and accessrequirements for public health engineering services arecontained in NHS Estates guidance HTM 2023 andCIBSE Guide G, ‘Public health engineering’ by theChartered Institute of Building Services Engineers.

123 The gradient of branch drains should be uniform andadequate to convey the maximum discharge to the stackwithout blockage. Practical considerations, such asavailable angles of bends, junctions and their assembly,as well as space considerations, usually limit theminimum gradient to about 1:50 (20 mm/m). For largerpipes, for example 100 mm diameter, the gradient maybe less, but this will require workmanship of a highstandard if an adequate self-cleaning flow is to bemaintained. It is not envisaged that pipes larger than 100mm diameter will be required within interfloor or groundfloor systems serving this facility.

124 Provision for inspection, rodding and maintenanceshould ensure ‘full bore’ access and be located tominimise disruption or possible contamination. Manholesshould not be located within this facility.

Chemical and radioactive contaminated effluent

125 Providing that there is adequate dilution and thesilver content has been effectively recovered, effluent canbe discharged into the internal drainage system. Projectteams are advised to establish the acceptable levels forsilver and other processing chemicals at the planningstage of a scheme, as these are subject to change.

126 The drain from the toilet and shower associated withthe diagnostic room where nuclear medicine imaging isundertaken will carry slightly radioactive effluent. It mustbe sealed throughout its run to the main sewer and itsroute chosen with regard to the areas likely to be affectedif leaks develop. It is recommended that drainage for thispurpose should not be into a pumped system.

127 At an appropriate early stage in the design processthe project proposals for the collection and discharge ofchemical and radioactive contaminated effluent should bediscussed and verified with the local authority. Some localauthorities may impose restrictions on the quantity andrate of discharge of such effluent into public sewers.(Refer to the section within this guidance onenvironmental protection).

APPENDIX 1

83


84

Appendix 2 Room layouts

SIMULATOR

CONFERENCE

TREATMENT PLANNING

CONTROLAREA

allow for full rotationof couch

wall-mounted alignment laser

bed access

storage

shielded observation

planning computer and workstations

light table andx-ray illuminators

equipment controlcabinets

Figure 1 Simulator with treatment planning and conference suite

APPENDIX 2

85

Figure 2 Iodine treatment room with ensuite shower/WC

IODINE TREATMENTROOM

EN-SUITESHR/WC

views for patient

barrier

barrier

concrete shielding walls

ENCLOSED GARDEN

STAFF GOWNINGAREA

lead doors

access controlled gate for maintenance

washing machineand preparation workstation

illuminated radiationwarning signs

radiation monitor


86

Figure 3 A typical PET suite

APPENDIX 2

87

Figure 4 Example layout radiopharmacy suite

.

.

micro-biologicalsafety cabinet

Am

erca

reS

afet

y C

abin

et

mic

ro-b

iolo

gica

lsa

fety

cab

inet

micro-biologicalsafety cabinet

GOWNINGLOBBY

STORAGE/DELIVERIES

TECHNETIUMDISPENSING

BLOODPRODUCTS

RADIOPHARMACY PREP


88

Figure 5 Example layout of medium-energy accelerator treatment roomS

H09

ceiling-suspended

data display monitors

incoming services

negotiate concrete

lintol chicane above

suspened ceiling

Primary shielding

equipment

cupboard

equipment

cupboard

access control to maze

MEDIUM TREATMENT ROOM

laser

CCTV

CCTV

CCTV

laser

primary shielding

laser

MAZE

.

.

.

SH

09

service duct below floor level

duct connecting services trench in treatment

room to service trench in control area

penetration through shielding wall to allow

quality control procedures to be carried out.

(angle penetration to prevent radiation transfer

to adjacent area)

laser alignment light rigidly mounted to

structure and connected to laser generator using

fibre optic cables

(1)

(2) data monitor

(3) laser generator

(4) stabiliser

(5)

(6)

last person out button

cctv patient monitoring cameras, fixed focus and

or pan/tilt zoom

primary beam and intermediate scatter cone(7)

(1)

(1)

(1)

(2)

(2)

(3)

(4)

(5)

(6)

(6)

(6)

(7)(7)

(7) (7)

5M4M3M2M1M0.50

SCALE

gate interlocked with

equipment and or passive

infra-red detection

APPENDIX 2

89

Figure 6 Example layout of high-dose radiotherapy suite

CONTROL

CLEAN UTILITY

STERILISING

DIRTY UTILITY

ANAESTHETIST

treatment position

prep position

warning lights

mobile image intensifier

doors withaccess control

services from control equipment enters treatment room at high levelvia. the maze

5M4M3M2M1M0.50

HDR TREATMENT ROOM

SCRUB-UP

sevices penetrating shielding wall over doorwill require shielding precautions

osilloscopemonitors

brackytherapymachine


90

Figure 7 Example layout high-energy linear accelerator treatment room

maze

access control to maze using passive infra-red detection

110

gate interlocked with treatment equipment

neutron attenuating boron coated paper lining to plasterboard wall finish and suspended ceiling

full height L-shaped recess, filled with neutron attenuating proprietary wax blocks supported in a timber frame

in-coming services negotiateconcrete lintel chicane above suspended ceiling

CONTROL AREA

timber frame supported above suspended ceiling filled with neutron attenuating proprietary wax blocks

CCTV

CCTV

CCTV

5M4M3M2M1M0.50

PRIMARY SHIELDPRIMARY SHIELD

wall-mounted alignment laser

wall mounted alignment laser

wall-mountedalignment laser

MPLE LAYOUT HIGH-ENERGY LINEAR ACCELERATOR TREATMENT ROOM

91

APPENDIX 2

Figure 8 Example layout showing comparison between footprints of high-energy linear accelerator rooms constructed usingconcrete shielding walls and alternative proprietary shielding material

PRIMARY SHIELDPRIMARY SHIELD

5M4M3M2M1M0.50

MAZE

FOOTPRINCONSTRUAND TECH

EXAMPLE LAYOUT SHOWING COMPARISION BETWEEN FOOTPRINTS OF HIGH ENERGY LINEAR ACCELLERATOR ROOMS CONSTRUCTED USING CONCRETE SHIELDING WALLS AALTERNATIVE PROPRIETARY SHIELDING MATERIAL

Footprint of treatmentroom and short mazeconstructed usingalternative shieldingmaterials and techniques


92

Figure 9 Cross-section through treatment room and maze showing shielding chicane and entry for services

1] lifting beam over treatment machine

2] wax block neutron attenuation supported in timber cradle

5] services negotiate concrete downstand 'chicane' as they enter treatment room

6] downstand faced with wax block neutron attenuation

MAZETREATMENTROOM

1]

2]

3]

4] treatment machine and patient couch

[4

5]6]

in line with treatment beam cone shadowthicker concrete forming primary shielding collar

2100

3200

TB

D

7] wall mounted alignment laser securely fixed to structure

Service void to be determined at project level

5M4M3M2M1M0.50

3] suspended ceiling. NB. access required to lifting beam during equipment installation and maintenancelifting eyes required attached to concrete soffite behindline of machine gantry

APPENDIX 2

93

X X

1 ] wax block neutron attenuation supported timber cradle

2 ] concrete down stands (faced with wax block neutron attenuation)

3 ] services negotiate down stand 'chicane' as they pass into treatment room

4 ] concrete shielding walls

TREATMENT ROOM

MAZE

[ 1

[ 2 [ 3 [ 4

current safety standards may require additional chicane points in the maze

Figure 10 Plan of treatment room and maze at ceiling void level. Showing diagrammatic service route along maze passing throughshielding chicane and into treatment room


94

Figure 11 Example layout of chemotherapy treatment day space showing combined shared space and single patient rooms

.. .

.

E E E E E

E

E LST

.

5M4M3M2M1M0.50

1] coat hooks

2] clinical hand wash basin

3] sack holder

5] easy chair

8] bedside locker

9] cubicle curtain track

10] easy chair

12] curtains

EXAMPLE LAYOUT OF CHEMOTHERAPY TREATMENT DAY SPACESHOWING COMBINED SHARED SPACE AND SINGLE PATIENT ROOMS

1]

2]

2]

3]5]

6] reclining chair

6] 6]

4] worktop

4]

7] examination light and services

7] 7] 7]

9] 9]

11] trolley

11]

11]

13]

13]

bed

8]

8]

11]

7]

5]

2]3]

1]

APPENDIX 2

95

Figure 12 Example layout of chemotherapy treatment day space for six patients using beds

5M4M3M2M1M0.50

1] 2] 3] 4]

5]

6]

7]

8] 9]

10]

11]

1] coat hooks

2] clinical hand wash basin

3] sack holder

4] x-ray viewer

5] easy chair

6] bed

8] bedside locker

9] cubicle curtain track

10] easy chair

11] coffee table

12]12] 12]

12] curtains

1]

13] television

13]

6]

7] 7]

7]

5]

8]

EXAMPLE LAYOUT OF CHEMOTHERAPY TREATMENT DAY SPACE FOR 6 PATIENTS USING BEDS

PAULLEY ARCHITECTS

RIVER STUDIO

perimeter of balcony protected with secure glazing to height of 2.000m

BALCONY

9]

access to balcony


96

Figure 13 Example layout of chemotherapy treatment day space for six patients using reclining chairs

PAULLEY ARCHITEC

RIVER STUDIO

TWICKENHAM

1 ]

1 ]

2 ]

2 ]

3]

3]

4]

4]

5]

5]

6]

6]

7]

7]

8]

8]

9]10]

11]

sack holder

wall shelf

reclining chair

cicular table

curtains

chair9 ]

wall mounted television

10]

11]

coat hooks

notice board

dressings trolley

vanity unit

5]

9 ]

6]

10]

7]

12] sliding doors with access to balcony

12]

EXAMPLE LAYOUT OF CHEMOTHERAPY TRATMENT DAY SPACE FOR 6 PATIENTS

BALCONY

perimeter of balcony protected with secure glazing to height of 2.000m

patient views

2 ]

5]

5M4M3M2M1M0.50

APPENDIX 2

97

M

CCTV01

BRACKYTHERAPY TREATMENT ROOM WITH EN-SUITE SHOWER/WC

concrete sheilding wall

ENCLOSED GARDEN

views for patientmonitored gate

for mantenancebarrier

barrier

5M4M3M2M1M0.50

TREATMENT ROOM

EN-SUITESHR/WC

after loading

treatment machine

lead lined doors

control panel for after-loading treatment machine

radiation monitor at entrance

CCTV patient monitor

ceiling mounted TV

lead lined doors with access control

Noteafter -loading equipment uses compressed air during the treatment process.Suitable accommodation will be required to afford sound attenuation and access for routine maintenance

A

B

C

D

E

F

AA

G

windows can be included if alternative radiation protection is provided.In this arrangement an external garden area was created with concreteshielding walls

enclosing structure constructed from concrete 450mm thick. Job specific advise should be obtained from the Radiation Protection Advisor

B

C

D

E

E

F

G

G

G

F F

Figure 14 Brachytherapy treatment suite with en-suite shower/wc

BACKGROUND

1 For the majority of rooms within a cancer care centrethe fire risks and precautions will not differ from othersimilar rooms within a hospital. However a special caseis identified for radiotherapy treatment rooms.

2 Linear accelerator bunkers may potentially be a seatof fire. Clearly the linear accelerator itself employs high-tension electricity so that the potential for electrical fireexists. The figures on the extent of risk are significantlyvariable from country to country and it is difficult to givea clear quantitative view at this time.

3 The design of the engineering services should complywith the recommendations of NHS Estates guidanceFirecode, which includes HTMs 81, 82 and 83. Designguidance for fire precautions in new hospitals iscontained in HTM 81. Technical information concerningthe design and specification of fire alarm and detectionsystems is contained in HTM 82. This HTM replaces ormodified certain clauses of BS 5839 Part 1 to meet theneeds of healthcare buildings. More general advice onfire safety in healthcare premises is contained in HTM 83.

FIRE COMPARTMENTS

4 Despite some concerns over operational efficiency,NHS Estates recommends the use of 30-minute fireresisting doors to FD30 standard at the entrance tolinear accelerator bunker maze structures. The intentionis to restrict the spread of both fire and smoke.However, a special problem arises since the Codes ofPractice constructed under Ionising RadiationsRegulations require that some form of access control orwarning device be used at the entrance to linearaccelerator bunkers. Commonly, in order to avoid delaysin terms of radiographers moving in and out of thesespecialist rooms, the Code of Practice requirements aremet by the use of a light or infrared beam connected toboth a warning system and linear accelerator beamcontrol. Clearly such an arrangement will be moredifficult, though not impossible, if fire protective doorsare employed. This requirement should be discussedwith the local radiation protection advisor.

5 The use of smoke or fire detector-actuated fire doordetents is considered helpful. Fire dampers should also

be incorporated into the service duct or otherpenetrations, which enter the treatment room.

MEANS OF ESCAPE

6 With a single entrance dead-end conditions apply inall linear accelerator bunkers. This has important safetyimplications and places a premium on fire prevention,detection and control. The following specific precautionsshould be incorporated:

a. The fire loading within the bunkers is to be kept to aminimum (see ‘fire loading’).

b. Automatic fire detection should be provided (see ‘firealarm system’).

c. The walls and doors separating the bunker from theadjacent accommodation must meet the half-hourfire-resisting standard and should be to FD30Sstandard and fitted with effective self-closing devices.

d. In order to assist in the rescue of patients in theevent of a fire occurring, it is recommended that asmoke reservoir be created in the ceiling void abovethe bunker where feasible. This has significant designimplications where radiation baffles are used but thedetermined false ceiling height will be 3.1m with adoor height of 2.1m. The space created may beusefully adapted. The elevated internal ceiling heightforming a reservoir, that is to the concrete or Lediteshield above, is likely to be an advantage in terms ofradiation protection and the reduction of radiationdose rates in the accompanying maze. However thisshould be referred to the local radiation protectionadvisor.

e. The circulation space outside the bunkers must bemaintained free of combustible materials.

7 The construction of linear accelerator bunkers inreinforced concrete using supplementary steel shielding,where necessary, is a common and accepted practice.However, there is now a movement toward the use ofnew materials including Ledite. Some of thesealternative materials lend themselves to design changes,which include the provision of heavy shielding doors asa partial but not complete replacement for the provisionof a maze. Where this is the case, clearly the fireprotective nature of these doors will require evaluation.


98

Appendix 3 Fire safety in radiotherapytreatment rooms

FIRE LOADING

8 Consideration should be given to the minimisation offire loading or available fuel in these environments.Attention is drawn to the following points:

a. Wax or plastic blocks are used in some locations, notnecessarily corners, to absorb particular radiations,specifically neutrons. Such radiation protectionmeasures are only necessary in linear acceleratorinstallations where X-rays are produced at energies ofroughly 10MV and above. Accordingly, the use ofthese materials will not be encountered in themajority of linear accelerator installations.Consideration should be given to encasing thesematerials within removable plasterboard or other fire-resistant cladding. The performance of individualcladding solutions has not been evaluated at the timeof writing.

b. The equipment will frequently use oil insulators andmay be heavily greased.

c. Benches are frequently constructed in wood and maysupport linen, plastic and polycarbonate shells andother combustible materials. The use of enclosedcupboards is most helpful in this and other regards.

FIRE ALARM SYSTEM

9 A fire alarm system conforming to BS 5839: Part 1:1988 and NHS Estates’ guidance HTM 82 must beinstalled throughout the linear accelerator suite.

10 Each manual call point must be boldly indicated by anotice to clearly identify the fire alarm operating pointand conforming to the Health and safety (Safety Signsand Signals) Regulations 1996.

11 An analogue addressable, automatic fire detectionsystem comprising smoke and heat detectors asappropriate should be installed throughout the proposedsuite. Positions for the detectors will be dependent onthe ceiling layout and compliance with the BritishStandard.

12 The alarm and detection system should also includethe ceiling voids and should be integrated with theexisting hospital alarm system in accordance with NHSEstates guidance HTM 82 and local hospital policy.

13 In respect of degradation of components within fireand smoke detectors, these units will have a shorter lifewithin the linear accelerator bunkers than may be thecase in other environments. The effect is at its mostsignificant if the detectors are placed within the belt ofheavy radiation protection shielding that encircles thelinear accelerator in such a way as to capture theprimary or direct beam. The life of these units orcomponents will be very much better if fire and smoke

detectors are positioned outside the area irradiated bythe primary beam. Further, a few instances of falsealarms have been recorded due to the irradiation ofsmoke detectors by the primary beam of linearaccelerators.

EMERGENCY LIGHTING

14 In addition to the normal lighting, an electricalemergency lighting system must be installed, capable ofilluminating all exit signs, doors, the maze and treatmentroom interior. In addition this must cover corridors andall such routes of egress including the external routes tosafety. The installation should comply with NHS Estates’guidance HTM 2007 and the British Standard Code ofPractice 5266: Part 1: 1988.

INDICATION OF FIRE EXITS

15 All exits providing access to means of escape mustbe clearly indicated, as appropriate, by suitable signsthat should be positioned where they can be seenclearly.

16 The signs should take the form of a pictogram withthe words “fire exit” and where appropriate incorporatea directional arrow. Fire safety signs must comply withthe relevant requirements of the Health and Safety(Safety Signs and Signals) Regulations 1996.

FIRE FIGHTING EQUIPMENT

17 The use of fire blankets within the linear acceleratorbunker is seen as particularly valuable since these areespecially direct in terms of their action.

18 The installation of carbon dioxide fire extinguishers isrequired for linear accelerator bunkers followingconsiderations at NHS Estates. However, where theseare used, they should be installed outside the areairradiated by the primary beam of the linear accelerator,particularly if this is of the high-energy type operatingabove the 10-12MV thresholds mentioned earlier.Extinguishers should be mounted on brackets, fixedsecurely to the walls or other upright structures, so thatthe top of each one is approximately one metre abovefloor level.

19 Inert gas fire suppression will be used within theequipment housing or an equipment room. In the formercase this would require that the machine have a sealwith controlled leakage in order to achieve 10 to 20%gas concentration.

20 The use of multi-criteria interlocked inert/fire-suppressive gas extinguishant system in the treatmentroom and supporting “machine/modulator” roomsshould be evaluated. Such systems may use Argonite or FM 200. In the selection of extinguishing agent caremust be taken to avoid corrosive gas options in view of

APPENDIX 3

99

the high value of the treatment equipment. This measuregives an equipment protection option but is notspecifically thought to benefit patient or staff fireprotection and thus is not adequate used alone.

21 Some new systems use directional inert/firesuppressive gas techniques. Although automaticallyactivated they may be evaluated for use in linearaccelerator rooms without interlocks.

22 Where separate “machine/modulator” rooms areused, 60 minutes fire compartment arrangements areappropriate. Fire suppression gas systems areparticularly suitable for rooms of this type in protectingequipment and giving early suppression of fire.

FIRE NOTICES

23 Printed instructions as to the action to be taken inthe event of a fire should be displayed adjacent to eachfire alarm call point.

24 Fire safety signs must comply with the relevantrequirements of the Health and Safety (Safety Signs andSignals) Regulations 1996.

OPERATIONAL IMPLICATIONS

25 An emphasis on safety in connection with high-tension electricity is clearly appropriate. Fire teamsshould be made aware that linear accelerators containhigh-storage-value electrical capacitors, which takesome considerable time to discharge following theisolation of the linear accelerator from its power supply.

26 In operational terms and when considering fireemergency/contingency plans, it is important that therebe careful liaison with those responsible for radiationprotection. Clearly any precaution that is taken toprotect against radiation should also be appropriate inthe fire context and vice versa. In addition to the localradiation protection advisor already mentioned,consultation with the radiation protection supervisor whowill be a senior professional member of the radiotherapyor oncology staff is also of value. The fire rules shouldbe appended to or contained within the radiationprotection local rules for the reasons already mentioned.


100

RIGHT ALWAYS CARRIES THE SECTION TITLE

101

APPENDIX 3 SPECIAL CONSIDERATION ON FIRE SAFETY IN RADIOTHERAPY TREATMENT ROOMS

Glossary References

THE INFORMATION LIBRARY AT THE LINDA MACMILLAN CENTRE

A&E Accident and emergency

BMT Bone marrow transplant

CCTV Closed circuit television

CT Computed tomography

DDA Disability Discrimination Act

DR Digital radiography

EPR Electronic patient record

F-18 Radioactive substance – Fluorine-18

FD30 30 minutes fire resisting door

FDG 2 - (Fluorine-18) Fluoro-2 - Deoxy-0-Glucose

GP General practitioner

HBN NHS Estates Health building note

HIS Hospital information system

HSC Health & Safety Commission

HTM NHS Estates Health Technical Memorandum

ICRP International Commission for RadiationProtection

IRR Ionising Radiations Regulations

IT Information technology

LAN Local area network (computercommunications)

LA Linear accelerator treatment machine

LDR Low dose rate brachytherapy

Linac Linear accelerator

LMP Low melting point

LPA Laser radiation protection advisor (MDAguidance)

MDA Medical Devices Agency

MDR Medium dose rate brachytherapy

MLC Multi-leaf collimator for LA

MRI Magnetic resonance imaging

NICE National Institute for Clinical Excellence

NOF New Opportunities Fund

NSCLC Example of modern chemotherapytechniques

PDR Pulse dose rate brachytherapy

PET Positron emission tomography

PFI Private Finance Initiative

QA Quality assurance

Rf Radio-frequency radiation or transmissions

RPA Radiation protection advisor (1999 IRR)

RPS Radiation protection supervisor (1999 IRR)

RTP Radiotherapy treatment planning

Shr/WC Shower/toilet

T Tesla magnetic field strength

TBI Total body irradiation usually by LA

TLD Thermo luminescent dosimetry

UVEX Polycarbonate material used in immobilisationof patients

VRM Verification record and management oftreatment data

WAN Wide area network


102

Glossary of terms and abbreviations

ACTS AND REGULATIONS

Consumer Protection Act 1987. The Stationery Office, 1987.

Disability Discrimination Act 1995. The Stationery Office, 1995.(http://www.legislation.hmso.gov.uk/acts/acts1995/Ukpga_19950050_en_1.htm)

Health and Safety at Work Act, 1974. The Stationery Office, 1974.

Radioactive Substances Act 1993. The Stationery Office, 1993.(http://www.legislation.hmso.gov.uk/acts/acts1993/Ukpga_19930012_en_1.htm)

SI 1991: 2768 The Building Regulations. The Stationery Office, 1991.(http://www.hmso.gov.uk/si/si1991/Uksi_19912768_en_1.htm#tcon)

SI 1999: 77 The Building Regulations (Amendment) Regulations. The Stationery Office, 1999.(http://www.legislation.hmso.gov.uk/si/si1999/19990077.htm)

SI 1994: 3140 The Construction (Design and Management ) Regulations. The Stationery Office, 1994.(http://www.legislation.hmso.gov.uk/si/si1994/Uksi_19943140_en_1.htm)

SI 1999: 437 The Control of Substances Hazardous to Health Regulations (COSHH). The Stationery Office,1999. (http://www.hmso.gov.uk/si/si1999/19990437.htm)

SI 1992: 2372 The Electromagnetic Compatibility Regulations. The Stationery Office, 1992(http://www.hmso.gov.uk/si/si1992/Uksi_19922372_en_1.htm#tcon)

SI 1996: 341 The Health and Safety (Safety Signs and Signals) Regulations. The Stationery Office, 1996.(http://www.legislation.hmso.gov.uk/si/si1996/Uksi_19960341_en_1.htm)

SI 1992: 2792 Health and Safety (Display Screen Equipment) Regulations. The Stationery Office, 1992.(http://www.legislation.hmso.gov.uk/si/si1992/Uksi_19922792_en_1.htm)

SI 1999: 3232 The Ionising Radiations Regulations. The Stationery Office, 1999.(http://www.legislation.hmso.gov.uk/si/si1999/19993232.htm)

SI 2000: 1059 The Ionising Radiation (Medical Exposure) Regulations. The Stationery Office, 2000.(http://www.legislation.hmso.gov.uk/si/si2000/20001059.htm)

SI 1999: 3242 The Management of Health and Safety at Work Regulations. The Stationery Office, 1999.(http://www.legislation.hmso.gov.uk/si/si1999/19993242.htm)

SI 1998: 2306 The Provision and Use of Work Equipment Regulations. The Stationery Office, 1998.(http://www.hmso.gov.uk/si/si1998/19982306.htm)

SI 1992: The Workplace (Health, Safety and Welfare) Regulations. The Stationery Office, 1992.(http://www.hmso.gov.uk/si/si1992/Uksi_19923004_en_1.htm#tcon)

Council Directive 89/336/EEC of 3 May 1989 on the approximation of the laws of the Member Statesrelating to electromagnetic compatibility. Official Journal L 139 , 23/05/1989 p. 0019 - 0026(http://europa.eu.int/eur-lex/en/lif/dat/1989/en_389L0336.html) Amended by 392L0031 (OJ L 126 12.05.1992 p.11)Amended by 393L0068 (OJ L 220 30.08.1993 p.1) Incorporated by 294A0103(52) (OJ L 001 03.01.1994 p.263)

REFERENCES

103

References

http://www.legislation.hmso.gov.uk/acts/acts1995/Ukpga_19950050_en_1.htm

http://www.legislation.hmso.gov.uk/acts/acts1993/Ukpga_19930012_en_1.htm

http://www.hmso.gov.uk/si/si1991/Uksi_19912768_en_1.htm#tcon

http://www.legislation.hmso.gov.uk/si/si1999/19990077.htm

http://www.legislation.hmso.gov.uk/si/si1994/Uksi_19943140_en_1.htm

http://www.hmso.gov.uk/si/si1999/19990437.htm







http://www.hmso.gov.uk/si/si1998/19982306.htm


http://europa.eu.int/eur-lex/en/lif/dat/1989/en_389L0336.html

Council Directive 90/270/EEC of 29 May 1990 on the minimum safety and health requirements for workwith display screen equipment. Official Journal L 156 , 21/06/1990 p. 0014 - 0018. The Stationery Office, 1992.(http://europa.eu.int/eur-lex/en/lif/dat/1990/en_390L0270.html)

DEPARTMENT OF HEALTH

Access to health service premises: audit checklist. NHS Executive, 1999.

Capital Investment Manual

Overview, NHS Executive, The Stationery Office, 1994.

Project organisation, NHS Executive, The Stationery Office, 1994.

Private finance guide, NHS Executive, The Stationery Office, 1994.

Business case guide, NHS Executive, The Stationery Office, 1994.

Management of construction projects, NHS Executive. NHS Estates, The Stationery Office, 1994.

Commissioning a health care facility, NHS Executive, The Stationery Office, 1994.

IM&T guidance, NHS Executive, The Stationery Office, 1994.

Post-project evaluation, NHS Executive, The Stationery Office, 1994.

Guidance on the application of the minimum ergonomic working standards for personnel engaged in thepreparation, scanning and reporting of cervical screening slides (Addendum to MDA/97/31) Sep-97MDA/97/31S NCSP. Medical Devices Agency, 1997.

The NHS cancer plan: a plan for investments, a plan for reform. Department of Health, 2000.(http://www.doh.gov.uk/cancer/cancerplan.htm)

The NHS Plan. Department of Health, The Stationery Office, 2000. (http://www.doh.gov.uk/nhsplan/default.htm)

Our healthier nation. Department of Health, The Stationery Office, 1998.(http://www.doh.gov.uk/ohn/ohnexec.htm)

A policy framework for commissioning cancer services : a report by the expert Advisory Group on Cancer(Calman–Hine Report). Department of Health, 1995. (http://www.doh.gov.uk/cancer/pdfs/calman-hine.pdf)

The statement of fees and allowances for general medical practitioners (HSC 1999/071) withattachments. Department of Health, 1999. (http://www.doh.gov.uk/publications/coinh.html)

NHS ESTATES

The design of hospital main entrances (Design Guide). NHS Estates, the Stationery Office, 1993.

Infection control in the built environment: design and planning, the Stationery Office, 2001.

Magnetic resonance imaging (Health Guidance Note). NHS Estates, the Stationery Office, 1997.

"Safe" hot water and surface temperatures (Health Guidance Note). The Stationery Office. 1998.

Health Building Notes (HBNs)

HBN 4 In-patient accommodation - options for choice. NHS Estates, The Stationery Office, 1997.

HBN 6 Radiology department. NHS Estates, The Stationery Office, 1993.

Supplement 1 Accommodation for magnetic resonance imaging. NHS Estates, The Stationery Office, 1994.

HBN 15 Accommodation for pathology services. NHS Estates, The Stationery Office, 1991. (under review)

HBN 20 Mortuary and post-mortem room. NHS Estates (new edition in preparation)


104

http://europa.eu.int/eur-lex/en/lif/dat/1990/en_390L0270.html

http://www.doh.gov.uk/cancer/cancerplan.htm

http://www.doh.gov.uk/nhsplan/default.htm

http://www.doh.gov.uk/ohn/ohnexec.htm

http://www.doh.gov.uk/cancer/pdfs/calman-hine.pdf

http://www.doh.gov.uk/publications/coinh.html

HBN 23 Hospital accommodation of children and young people. NHS Estates, The Stationery Office, 1994.

HBN 26 Operating department. NHS Estates, The Stationery Office, 1991.

HBN 29 Accommodation for pharmaceutical services. NHS Estates, The Stationery Office, 1997.

HBN 36 Local healthcare facilities. NHS Estates, The Stationery Office, 1995 (new edition in preparation).

HBN 40 Common activity spaces

Vol 1: Public areas. NHS Estates, The Stationery Office, 1995.

Vol 2: Treatment areas. NHS Estates, The Stationery Office, 1995.

Vol 3: Staff areas. NHS Estates, The Stationery Office, 1995.

Vol 4: Circulation areas. NHS Estates, The Stationery Office, 1995.

HBN 45 External works for health buildings. NHS Estates, The Stationery Office, 1992.

HBN 48 Telephone services. NHS Estates, The Stationery Office, 1997.

HBN 52 volume 2 Accommodation for day care : endoscopy unit. NHS Estates, The Stationery Office, 1994.

Health Technical Memoranda (HTMs)

HTM 63 Fitted storage systems. NHS Estates, The Stationery Office, 1989.

HTM 67 Laboratory fitting out systems. NHS Estates, The Stationery Office, 1993.

HTM 81 Fire precautions in new hospitals. NHS Estates, The Stationery Office, 1996.(http://www.nhsestates.gov.uk/knowledge/guidance.html)

HTM 82 Alarm and detection systems. NHS Estates, The Stationery Office, 1996.(http://www.nhsestates.gov.uk/knowledge/guidance.html)

HTM 83 Fire safety in healthcare premises – general fire precautions. NHS Estates, The Stationery Office,1994. (http://www.nhsestates.gov.uk/knowledge/guidance.html)

HTM 2005 Building management systems

Management policy. NHS Estates, The Stationery Office, 1996.

Design considerations. NHS Estates, The Stationery Office, 1996.

Validation and verification. NHS Estates, The Stationery Office, 1996.

Operational management. NHS Estates, The Stationery Office, 1996.

HTM 2007 Electrical services supply and distribution





HTM 2009 Pneumatic air tube transport systems


Design considerations and good practice guide. NHS Estates, The Stationery Office, 1995.

HTM 2011 Emergency electrical services

REFERENCES

105

http://www.nhsestates.gov.uk/knowledge/guidance.html




106





HTM 2014 Abatement of electrical interference





HTM 2015 Bedhead services



Validation and verification/Operational management. NHS Estates, The Stationery Office, 1995.

HTM 2022 Medical gas pipeline systems

Design, installation, validation and verification. NHS Estates, The Stationery Office, 1997.


HTM 2023 Access and accommodation for engineering services


Good practice guide. NHS Estates, The Stationery Office, 1995.

HTM 2025 The Control of legionellae in health care premises - a code of practice.





HTM 2027 Hot and cold water supply, storage and mains services





HTM 2040 The control of legionellae in healthcare premises – A code of practice





Good practice guide. NHS Estates, The Stationery Office, 1994.

HTM 2045 Acoustics



Validation and verification/Operational management. NHS Estates, The Stationery Office, 1996.

Audiology. NHS Estates, The Stationery Office, 1996.

HTM 2055 Telecommunications (telephone exchanges)





BRITISH STANDARDS

BS 2881:1989 Specification for cupboards for the storage of medicines in healthcare premises. BritishStandards Institute, 1989. (Confirmed 1994)

BS 4533 Luminaires. British Standards Institution. (produced in various sections)

BS 5266: 1999 Emergency lighting. Code of practice for the emergency lighting of premises other thancinemas and certain other specified premises used for entertainment. British Standards Institute, 1999.

BS 5839: 1988 Fire detection and alarm systems for buildings. Code of practice for system design,installation and servicing. British Standards Institution, 1988. (under review)

BS 6651:1999 Code of practice for protection of structures against lightning. British Standards Institute,1999.

BS EN 779:1993 Particulate air filters for general ventilation. Requirements, testing, marking (withamendments). British Standards Institution, 1993. (under review)

BS EN 12056-2:2000 Gravity drainage systems inside buildings. Sanitary pipework, layout and calculation.British Standards Institution, 2000.

BS EN 55015:2001 Limits and methods of measurement of radio disturbance characteristics of electricallighting and similar equipment. British Standards Institution, 2001. (1996 edition remains current)

BS EN 60601-1-2: 1993 Medical electrical equipment. General requirements for safety. Collateralstandard. Electromagnetic compatibility. Requirements and tests. British Standards Institution, 1993.

OTHERS

Access and facilities for disabled people (Approved document M). Department of the Environment, Transportand the Regions, The Stationery Office, 1999.

Air distribution systems (Commissioning code A). The Chartered Institution of Building Services Engineers(CIBSE), 1996.

Cancer services : investing for the future: A report of the Cancer Working Group. Northern IrelandDepartment of Health and Social Services, 1996.

The Disability Discrimination Act: access to goods, facilities and services (DL 80). Department of SocialSecurity, 1996.

Guidance on the structure and function of cancer centres. Board of Faculty of Clinical Oncology, Royal Collage

107

REFERENCES


108

of Radiologists, 1996.

Guidance to engineering commissioning. Institute of Healthcare Engineering and Estate Management, 1995.

Improving Health in Wales – a Plan for the NHS with its partners. National Assembly of Wales, 2001.

Lighting guide: Hospital and health care buildings (LG2). Chartered Institution of Building Services Engineers(CIBSE), 1989. (under review)

Occupational exposure limits (EH40). Health and Safety Executive, HSE Books, issued annually.

Plowman, Rosalind, et al. The socio-economic burden of hospital-acquired infection. Public Health LaboratoryService, 1999. (issued in three volumes)

A Policy framework for commissioning cancer services. The Royal College of Obstetricians andGynaecologists and The British Gynaecological Cancer Society, 1997.

Public health engineering (CIBSE Guide G). The Chartered Institution of Building Services Engineers (CIBSE),1999.

The visual environment for display screen use (LG3). The Chartered Institution of Building Services Engineers(CIBSE), 1996.

Water distribution systems (Commissioning code W). The Chartered Institution of Building Services Engineers(CIBSE), 1994.

Work with ionising radiation: Ionising Radiations Regulations 1999: approved code of practice andguidance. Health and Safety Commission, HSE Books, 2000.

About NHS Estates

The Agency has a dynamic fund of knowledge which ithas acquired during over 30 years of working in the field.Using this knowledge NHS Estates has developedproducts which are unique in range and depth. Theseinclude:

Design Guides – complementary to Health BuildingNotes, Design Guides provide advice for planners anddesigners about subjects not appropriate to the HealthBuilding Notes series. SO

Estatecode – user manual for managing a health estate.Includes a recommended methodology for propertyappraisal and provides a basis for integration of theestate into corporate business planning. SO

Concode – outlines proven methods of selectingcontracts and commissioning consultants. Reflectsofficial policy on contract procedures. SO

Health Building Notes – advice for project teamsprocuring new buildings and adapting or extendingexisting buildings. SO

Health Guidance Notes – an occasional series ofpublications which respond to changes in Department ofHealth policy or reflect changing NHS operationalmanagement. Each deals with a specific topic and iscomplementary to a related HTM. SO

Health Technical Memoranda – guidance on thedesign, installation and running of specialised buildingservice systems, and on specialised buildingcomponents. SO

Health Facilities Notes – debate current and topicalissues of concern across all areas of healthcareprovision. SO

Encode – shows how to plan and implement a policy ofenergy efficiency in a building. SO

Firecode – for policy, technical guidance and specialistaspects of fire precautions. SO

Capital Investment Manual Database – softwaresupport for managing the capital programme.Compatible with Capital Investment Manual. NHS Estates

Enquiries about NHS Estates publications should beaddressed to:

NHS Estates, Knowledge Unit, Department of Health, 1 Trevelyan Square, Boar Lane, Leeds LS1 6AE. Telephone 0113 254 7000.

http://www.nhsestates.gov.uk

Items noted "SO" can be purchased from StationeryOffice Bookshops in London, Edinburgh, Belfast, Cardiff,Manchester, Birmingham and Bristol; from PO Box 29,Norwich NR3 1GN; or through good booksellers.

http://www.nhsestates.gov.uk

Published by The Stationery Office and available from:

The Stationery Office(mail, fax and telephone orders only)PO Box 29, Norwich NR3 1GN General enquiries/Telephone orders 0870 600 5522Fax orders 0870 600 5533www.thestationeryoffice.com

The Stationery Office Bookshops123 Kingsway, London WC2B 6PQ 020 7242 6393 Fax 020 7242 639468–69 Bull Street, Birmingham B4 6AD 0121 236 9696 Fax 0121 236 969933 Wine Street, Bristol BS1 2BQ 0117 926 4306 Fax 0117 929 45159–21 Princess Street, Manchester M60 8AS 0161 834 7201 Fax 0161 833 063416 Arthur Street, Belfast BT1 4GD 028 9023 8451 Fax 028 9023 5401The Stationery Office Oriel Bookshop, 18–19 High Street, Cardiff CF1 2BZ029 2039 5548 Fax 029 2038 434771 Lothian Road, Edinburgh EH3 9AZ 0870 606 5566 Fax 0870 606 5588

The Stationery Office’s Accredited Agents(see Yellow Pages)

and through good booksellers

http://www.thestationeryoffice.com

Documents

STATUS IN WALES