I DeveloDments in Fed@r tate and Civilian HosDitals By Johr. W. Cronin, M. D. C@Lie ,iv sion of 7'ospital Fac4lities Public --@ieal-'uh Service ',",elfare hosp-@ta'is today reflect the total struggles of man to Surv4@ve. 'L.,! the organization of the hospital., its operation, its achievements, and its failures we find the story of our civilization. Perhaps no other public service facility more nearly portrays the rise and L'all oL' mere man as he has traversed the paths of time. It is pertinent here to look back through the years to the very beginning 4 of what we know aoout the practice of medicine. @'-rom the ancient civilization of Egypt, Babylon, Persia,, 'Lndia., and Greece comes our earliest heritage of the practice of medicine, and it was closely allied with religion. Medical care was provided through the temples. The teachings of the Ohr4st-' n religion pointed . a out the need and desire of man to help his fellow. This promoted great advances in the care of the sick as a humane and charitable activity. It was in the Fourth Century that we first had specialized hospitals. in 375, the 300 bed charity .hospital at Edessa was established by St. Ephraim. Ot4%ers were founded at Alex%ndr-la, Ephesus,, Constant-'@ne, Bagdad., Cairo, and in S@n.@ St. Aug,,istine o Canterbury led the religious in England in 59b to accept the sick and poor as responsibilities according to the-teachinas of Christ. The bishop of Faris established @.'Otel Dieu of rsr-Ls in @60. 'U'otel Dieu of Lyons had been starte d in 542. it must be recognized,that the early hospitals served mostly as resting places for travelers and the weary rather than the purposes they serve today., The beginning of several o-isterho@s and Brotherhoods aro traced back to the Sixth Century and are directly related to salvation tbrb.-igh goc,d.works. In fact during Presented on November 4, 1954, at the @@14-nth Inter-Agency institute for Federal p4 Hos @tal Adm3-nistrators, Walter I-leed Ar--,iy ,.,edical Centcr, Washington, D. 2 the years of the great religious crusades (1196 to 1291) many hospitals we:;.-a established to care for persons travelling to Jerusalem. 4.' I 9. 00 CS D4 '..,.e -L s were 1-m exis+,en,,-@e in El,=oDe. @@hese usually were infirmary-almshouses caring for tile aged, infirm, and sick,, along with places for pilgrims to rest, and then houses for lepers beyorA the gates. It was in fee 14bli and 15th Centuries that the decrees of the Church Lloroade bloodlett4 n@ by the monasteries. As a result a new profession of tonsors-barbers and bloodletj4jers came into existence. This group was not trained and undoubtedly accounted for many of those who pas @ on. The Renaissance saw the new science of Botany and A-natony while the knowledge of physics and chemistry expanded. During the Reformation the decline of papal authority also saw the decline of hospitals. It soon became apparent that the hospitals were needed and again we see the cycle begin to swing up again. The lbth Century was fraught with wars. Hospitals were established as municipal in authority and were typical of politically controlled institutions with all the abuses and disadvantages. In 1519 when Cortez came to iNbxico he was @essed by the Aztec Civiliza- tion and partially as an avenue of his own salvation he built the Hospital of .Lmmaculate Conception in liexico City. in l@-)33 the rame of this hospital was changed to the Hospitc&l of Jesus of Nazareth. it is still in existence today and is the first hospital in North America. The second hospital in i4orth America was founded in 1639 by three nurses of the Sisters of St. Augustine and three Ursiline nuns in Quebec. it is the Hotel Dieu in @bee and sti7l serves mankind. Hotel Dieu of Entreat came into existence in'1641+. The Seventeenth Centiry was not a productive one as far as hospitals were concerned in North America. in fact, in Europe hospitals were At a new low as far as sanitary conditions and management were concerned. 3 Tn the "i;7hteenth Century we saw the instruments of precision - stethescope, ,-71se watch and percussion ,,-I come to the front along with greater knowledge in P,@,,- 3.--,,-, 0 g Y, s Ur s r Y, ni d w e r, r c ri e r", 3 a-Tict a@pi -, ed sciences. Be'!'-evue in New York and Charity in New Orleans were started in 1.736. These latter @,wo, along with the Philadelphia in 1713, and Charleston in 1734, were really aimsho-ases and did not really fill the need as we know it today for p4 a hos Ltal. As a result, Penncylvaua Hospital in 1751, the first voluntary hospital, came into being. Assachusetts General came along in 1812, and also New York Hospital in 1769. The first Protestant Church Hospital in the country was established in 1849 in Pittsburgh by ihstor Theodore Pliedner and Reverend Willi-am A. Passavant of Pittsburgh First English Lutheran Church. Later the Episcopal, i@sthodist, and Baptist Chureli groups founded hospitals throughout tile 'rewish, i 4or country. Later, the -mon Seventh Day Adventist, and other reli.--,ious .1 Im groups followed. As a result, we have today the three basic types of hospitals: (a) governmental; (b) voluntary-nonprofit; and (c) proprietary. -do currently have about 7,000 hospitals in the United States, exclusive of the Federal hospitals. We have nearly I,,100,000 acceptable beds and about 1(:)Oooo nonseceptable beds, according to the Hi.U-Burton standards. Cur national ho.9 'tal Pi bed deficit has b in excess of een estimted to be 800$000 beds. The Federal age ncies operating hospitals are the Army, Navy, Air Force, Public Health @D'erv,,ce., indian Service, and Veterans Administrat--on. The latter three Federal agencies serve civilian population and in the aggregate have about 13.7,000 beds In operation today. Now I bave taken considerable time describing the developments of hospitals @or a specific reason. 1 hope I have indicated that the hospital is the answer J. 40 a need for a service as seen and responded to by the hospital worker and by ,',.hose who plan and build hospitals. T'4.1e -Lospitals are rearranged, rebuilt, or even replaced because of a need for a new and frequently different type of @"-7e to provide better patient care. 4 The modern hospital provides more facilities for the treatment and care of the patient than ever before. New and improved tools are placed at the disposal o f t',-. e -- hLrs-4@c4-an f or the treatment ,.@.e 7:a,4.ent and the cat-Lent -4.s 2a.-ad under greatly improved conditions, The modern hospital is a better place to work in than its predecessors for everyone from the chief surgeon to the orderly.. and if you must be sick, it's a better place to be sick in. The physician has for his use larger a.-id more complete adjunct facilities. For example: (1) larger x-ray suites, including therapy and built-in x-ray units have made their appearance in operating rooms; (2) larger pharmacies with space for manufacturing and storage; (3i@ more physical therapy; (4) radioisotope laboratories; (5) blood banks; and (t)) electroencephalography. Fscovery rooms are being provided more frequently for the observation of the patients during the critical period after surgery. There is a definite movement toward the provision of rehabilitation facilities on varying scales for the treatment of many formerly considered beyond rehabilitation. After a very slow start, more hospitals today are providing outpatient departments. Psychiatric units for the early care of mentally disturbed patients are appearing in some of the laroer hospitals, @kny smaller hospitals provide facilities Lor mental patients where they can be held pending transportation to a mental hospital. This eliminates the local jail as the unfortunate first stop for many patients. Hospital collaboration with public health centers do broaden patient care. Nursing units have become somewhat larger although operating experience -beLs not been long enough to say whether this is good or bad with surety. Almost without exception, toilets adjacent to bedrooms are being provided. Use of color throughout t.qe hospital has become general resulting in more il.j-trActive patients' rooms, lounges and solaria. Its use in nor.-patient areas 5 cc-atributes to the efficiency of the staff and employees. -@or the V-S4'ors we find on-site park4ng, gift shops, fathers, rooms and _u @-,ac'K ',.,ar. ,7ire-sa-'e planning and construction are now to be found in all new hospitals. Where ventilation was provided for OB and surgery to provide comfort for personnel and reduce hazardj there is now a definite swing to the inclusion of cooling for summer even in the northern-most states. Although they comprise only a relatively small percentage of total instal- lations, there are appearing here and there designs which provide a measure of air conditioning throughout the hospital. An air duct system supplements the normal heating system in winter and serves as the conductor for cooled air during the summer months. Such systems are not designed for extreme summer conditions but under average conditions do help maintain a more effective comfort level by a measure of cooling and the addition of some fresh air. LNiurseries, central supply and x-ray departments are receiving greater attention by air conditioning de4@gners. Sound control features are seen through the use of so@d-proofing of rooms, corridors, and many other areas, Inter-com systems between patients and the nurses' desk-are effective features. Recovery rooms for surgical patients are common., and, for obstetrical patients are frequently found. Piped oxygen systems have become a standard of design. This provides oxygen where and when needed with no delay, reduces hazards of storage and transportation within the hospital and conserves,space at the point of administration. r rt of the drudg- .xarbage grinders for kl@tchen use are eliminating a large pa e.-y and unsanitary conditions which result from garbage collection, storage and -Disposal, as well as conserving space normally a!-lotted to can wash and garbage 0 refrigeration. The se,@fage system is being cilenged due to garbage grinding. New developments in hospitals come about as the result of someone's for- ward-looking thinking. Such thinking considers not only present requirements but looks into the future to try to -auge what develodin- medical advances will mean 'lo the hospital as the -es@4 of -@odern patient cars. Home care programs and programs for chronic patients each influence hospital facilities. To assure a modern up-to-date hospital where modern medicine can bq practiced this thinking must be developed into a building program. This is as important a step as youtll take in the construction of a hospital plant. A building program contains all the information the architect will need to design a hospital. It is the product of a team consisting of physicians, admin-, istrators, nurse, architect'. engineer, dietitian, and others who will, in exhaustive detail, consider the services to be offered, the staff required to operate the services, the method of operation and the physical Facilities requirer.. It is axiomatic that form follows function. Such a program assures your getting the building you want, prrmiotes smooth flow of work during the planning and on construction stages. It would be an error to conclude without mentioning several 1-capi-tal programs currently being carried on which have an impact on hospital care art our total econorW,, the fullest extent of which has not been fuJly realized or as yet felt in this nation.. We have the hospital program of the Veterant, Adain-@stratiori; the hospital program of the United li4ine Workers in Kentucky, Welit Virginia, are Virginia; the Permnents Plan in California; and the Hospital Su?vey and Constr-.Iction (Hill- Burton) Program. Since my assignment in the U. S. Public health Service is the administration of,the Federal aspects of the Hill-Burton Frcf@am@ I wish to cite the important facts of this Federal, State and community e4operati-,re endeavor. 7 1. As of September 30, 1954@ 2336 projects have been approved, which will 4- add 111,903 beds. These projects also include 493 health cenuers. Total cost of These ects 7evreserts one -"on ei-',,t 'Lurdred ninet,,-seven mill-!-on dollars of which the Federal Govev nt is contributing over 631 mi'Llion and the sponsors more than one billion two hundred sixty-six million. 2. Seventy-three (73) percent of all the projects (with 91,468 beds) are for general hospitals and general hospitals in combination with public health centers; 16 percent are public health centers; the remaining 9 percent (with 20,435 beds) are mental, tuberculosis, and chronic disease I,.f.-sl)itals. 3. There are 1,709 of these projects (or 73 percent)', adding 75,13.5 last which are open and in operation; 527 (23 percent), which will provide beds, are under construction; the remaining projects with 5,728 beds are iti I.-re- construction stages. Of the projects which have been opened and are in operation, 1,254., or 73 percent, are general hospitals. These projects have added over 61,300 beds to our hospital resources. About 148 other hospital projects aTe open for i.ise; these have added over 13,700 beds in tuberculosis, mental,, and chr)nlc disease c,-it.,-,,,,)ries. 4. New facilities now approved amount to 1,351 or ftfty-nire percent of the total number of projects; additions or alterations to existing facilities comprise the remining 41 percent. 5. Of the new general hospitals approved, the ralority (.58 percent) are located in communities of less than 5,000. Only 8 per.-,ant are in cities of 50,000 or more people. Additions and alterations to existir[i general hospitals tend to occur in the larger communities; 20 percent are in communities of less than 50000 people; 31 percent are in communities of ovec 50,000. 6. Of the 907 completely new general hos,,Atal projects, 505 (56 percent) are located in areas which had no hospitals y-lor to the Hospital Survey and t-,ozi- struction Program; 193 (21 percent) are lor.@ted in areas which had onlj non-. 8 acceptable facilities; the remaining new facilities are being built in areas w,'-,,ich were deficient in facilities prior to the program. "he :,.-4or4t approved zro4ects are 'ocated -.Ln -@' '-out-ern @tates, @j @ T o.L -i 'ile @ 44 - This census region has 1207 projects or 53 percent. The remainder are distributed as follows: 500 (22 percent) in the North Central States;,315 (14 percent) in the North East States; and 269 (11 percent) in the Western States. 8. New hospitals are relatively small in bed capacity: 57 percent have r fewer than 50 beds 22 -ercent have from 50 to 99 beds, onl, 21 percent lia,;e 1C)i) or more. Hospitals to which alterations or additions are being iade are larger - 65 percent of these projects are hospitals with 100 or more beds. 9. The bed deficit of the nation is still great. Estimates by the @Otates, reflected in current State plan revisions indicate that over 812 000 additional beds in all categories of hospitals are still required to meet the nation's total peacetime needs. The !4edical Facilities Survey and Construction Act of 1954 (Public l,aw 142, 83rd Congress) amended the Hospital Survey and Construction Act to provide a greater inducement to the States and local communities to p@;4 -L'or and const.,-tict facilities for the care of the chronically ill and impaired. This Act aut@iorizea- $2,000,000 and it was subsequently appropriated, to assist the States, on a dollar for dollar matching basis, to survey and plan four specific types of facilities. These types are (1) chronic disease facilities; (2) diagnostic centers or diagnostic and treatment centers; (3) nursing homes; and (4) rehabilitation facilities. These facilities, like those general, tuberculosis, chronic, mental hospitals.,'public health centers authorized by the original Act, must be nonprofit in character, render,a community service and not discriminate against race, creed, or color. The 1954 amendments also authorized 60 million dollars for appropriation to assist in paying part of the construction of the approved facilities. Ai,-,ouiits authorized annually through 1957 fiscal year are: (a) @,1?20 million for chronic 9 disease facilities; (b) $20 million for diagnostic centers or diagnostic a@.ic', treatment centers; (c) $10 million for nursing homes; (d) $10 million for For fiscal year 1955 the Congress made available $21 million for the new amendments and $75 million for the older program. in order to be approved for construction grants the project must be in accordance with the State p-.an, of high priority, and meet the minimum reqitire,,Ineiits as provided by law and the Federal and State regu tions. The Hospital Survey and Construction Program has provided a natLoi-@.wj.'.'a program of planning for and the construction of hospitals and related health facilities through a cooperative relationship of local community, and State :L,l Federal authorities to acquire better facilities and better patient care. Lii addition, the program has helped riral communities to attract and retain emphasized coordination and integration of hospitals on a State-wide -.rc-,Ited an interest among the citizens of this and other cotirtries in the:@-r iic-,ol--tL.Ili res@irces and facilities; stimulated construction of hospitals outside the program; c@t',.Pitllated a fusion between curative, preventive and restorative medicine to protaote iae,,lt@l maintenance for our people and, established the State agency as the admin--!.sti@ati.ve authority to which applicants must first go for approval in order to acquire subsequent Federal approval and financial assistance. The developmental trends in relationship to the technical details of the hospital in serving the public are also outstanding. Tilese trends are tlie direct result of the o@es in medical care and the application of an ever-growing body of knowledge concerning mn and his relationship to his fellowman, to all other living and nonliving elements of our world and maybe of other worlds about 1.41-liell we my be in the process of learning. So at best the trends reflect our-efforts to meet a state of flux which does not appear to show any inclination to stabilize. 10 - The hospital of today is truly tie health center of the community. As '.,Iealth maintenance programs develop tile public health center and the hospital come closer -L,-,l @@imes of National or 1-ocal emergency of a --a'kas-@urophic or r@-ar catastrophic nature it is frequently the hospital and its laboratory which is called upon for health protective services in addition to its routine contribution to the health of tile community. In conclusion, the hospital is our health university and as such aff'ect@-, the lives of all of us in direct proportion to t'.1e way we use it.