Technological development and construction of Venezuelan hospitals in the twentieth century.
1 Architect (UCV, 1973). Master in architecture (University of Washington, 1978). PhD in architecture. (UCV, 2006). SPI-CONICIT Researcher (since 1990) Professor IDEC FAU UCV. Research areas: medical-care buildings. Programming buildings. Venezuela. email@example.com
The paper describes the historical evolution of technology development and design that has accompanied the development of knowledge of medical science. The construction technology in the early twentieth century made possible the replacement of the type of pavilions for the multi-storey block, with emphasis on the functionality and efficiency of the circulations. The development of computer technology incorporated into diagnostic and treatment techniques has forced changes to the design of hospitals. The count of hospitals conducted through official programs in major cities, reflecting the incorporation of different types and technological advances in line with the time they were built.
The work describe the historic evolution of the technical development and design That has gone with the expansion of knowledge in medical science. Construction technology at the beginning of the Twentieth Century has made possible for the replacement of pavillions’ for That typology of blocks of several floors, Emphasizing functionality and efficiency of the circulations. The development of technological computing incorporated to diagnosis and treatment techniques have Compelled the introduction of Modifications in the design of hospitals. The inventory of the hospitals Through Carried out official programs in the main cities of the country Reflects the incorporation of the different typologies and technical advances in consonance With The Time When They Were built.
Descriptors: Construction of hospitals in Venezuela; Hospital insurance; Type of pavilions
Received 01/06/07 – 26/06/07 Accepted
Evolution of hospital buildings
Historical, cultural, social, economic, medical and technical factors operating in society at any given time have affected the way hospitals and other health care buildings. As Prior (1988) stated: “the plans of the hospitals are essentially an archaeological record that contains within itself a genealogy of medical science”.
The evolution of hospital design can be analyzed through the influence of several significant ways:
• The influence of the development of medical science
• The influence of technological development in the construction
?? The influence of service delivery systems
• The influence of the development of computer science and its application in medicine and communications.
The design and development of medical science
The architecture of the hospitals has developed and evolved in tandem with the beliefs and knowledge of society about health and disease.
The most typical form of the wards for centuries was a large open living room with an altar or chapel in the center, so that patients could see and hear the religious ceremonies from your bed. The other common form, with the same advantages of patient participation in religious activities, was cross-shaped room with an altar in the center of the cross and open rooms in areas that correspond to the arms.
In the late eighteenth century the hypothesis that the hospital building itself, could affect the care of patients, irrespective of therapy administered to them, a proposal that was championed in England and France was held. This idea was based on the fact that soldiers recovered more quickly in a simple shop in the conventional hospital which is explained by the effect of ventilation. This was supported by the prevailing theory of the origin of the disease, called the miasma theory, according to which diseases were due to the inhalation and exhalation of air, which led to the development of type hospital ward that consisted of a series of low buildings , each containing a rectangular open room. The rooms were connected by a corridor and each had its own services. The emphasis in the room design was able to use as much fresh air and natural lighting. The rooms were ventilated on both sides by neighboring windows and canopies were separated enough not to interfere with the ventilation and lighting of each (Figure 1).
The “hospital wards,” according to Thompson and Goldin (1975), was the first building designed specifically for the healthcare function. The composition and building patterns were determined by the health aspects and ease the supervision of nurses. The first hospital of this type was built in England in 1762 but did not become the dominant form until the mid-nineteenth century. The type of room remained open until after the twentieth century and was known as Nightingale room in honor of Florence Nightingale, founder of the Red Cross, who insisted strongly on the adoption of this type of living in England since 1850.
By the late nineteenth century the structure of medicine completely changed and emerged a medical model of etiology, diagnosis and treatment of diseases with scientific bases. The traditional treatment methods were inefficient and useless. For the first time the relief of doctors began to achieve significant results in helping patients and relieving their suffering, which meant the recognition of doctors as a new professional authority.
The image gradually changed hospitals to be repulsive to become attractive places where you could apply the new social institutions therapeutic procedures. This development was essentially connected with some scientific and technological innovations in the nineteenth century, with inevitable effects on the planning of hospitals. The surgery represented the lowest hierarchical level in the profession. After entering the ether and chloroform for general anesthesia and morphine for pain relief, surgery gained more respect.
With the introduction of aseptic technique and sterilization of instruments in 1865, infections from wounds diminuyeron drastically. The adoption of aseptic principles is a real breakthrough in the history of medicine. Pasteur, with its revolutionary discovery of microbiology, he found that microbes were the cause of infectious diseases. Röntgen discovered X-rays in 1895 and its practical applications were quickly accessible. Diagnostic procedures and treatment gradually became essential functions of the hospital. Until then, the halls were the main elements in the hospital fabric buildings but the rapid growth of successful surgery, X-ray examinations and diagnostic laboratories required in other types of spaces. There was the need to create a whole new department to accommodate new techniques, when enough was previously a room in a ward (Teikari, 1995).
The latest domestic traffic also increased hospital because patients had to be moved around the building between the different units. Transport distances in large pavilions became intolerable. That kind of hospital, under the new conditions, large areas of land needed. There were reasons for hospital buildings became more concentrated and consolidated with new emphasis on functionality and efficiency. The new microbiological explanations for infectious diseases became clear that the standard rooms pavilions were not healthier than other buildings.
To prevent disease transmission between patients and also to provide more privacy subdivided rooms that replaced the type of open living Nightingale developed.
The design and development of the construction
Around the end of the nineteenth century the technology of buildings with steel and concrete structures, elevators, mechanical ventilation and artificial light made it possible to replace the type of “hospital wards” with solutions of multi-storey blocks. Hospitalization and other departments joined together, leading to functional concentration, economy construction and maintenance and use of personnel.
The vertical type for large hospitals most commonly used in the Western world for decades was the type “tower on a podium.” The elements in the vertical tower housing the rooms of hospitalization and horizontally podium element contains the department and outpatient diagnostic and treatment departments together with ancillary services. The horizontal portion has a deep structure inevitably large lights lit and artificially ventilated areas. This basic building typology of hospital is still built, but is limited by the lack of appropriate expansion possibilities. Traffic arrangement also vertically, which falls largely on the operation of elevators leads to create problems.
The most favored today is probably the type that derives from the hospital ward type, low-rise hospital freely organized as a villa. It consists of a set of separate buildings with various heights forming a horizontal floor with open feasible unpredictable endings growth and continuous change. More compact, checkerboard-like structures with courtyards open and closed (Figure 1) are also used
Technological facilities of hospitals
With the development of the construction industry came new technologies supplies and equipment that have influenced the evolution of design, such as:
• Technical installations: electrical, medical gases, pneumatic, steam, hot water, air conditioning, forced ventilation, burning, champagne cooling, sound insulation, lighting.
• communication facilities: telephone, intercom, call nurses, data network (Internet, intranet), radio, pager, music.
• Safety facilities: alarm, fire protection systems, escape routes, door locks, access control, CCTV.
• vertical circulation elements: lifts, tire tubes.
• Control of intra-hospital environmental contamination: microbiological, radiation, waste management, maintenance.
• Creating healing environments: humanization, environmental awareness, comfort, equipment and furniture, healing gardens.
Currently it has developed the concept of safe hospitals due to the complexity of installations and the risks they are subject buildings and users.
A hospital building is highly vulnerable therefore the amount, the nature and level of complexity of the facility that houses and because much of its occupants, whether inpatient or outpatient, have variety of physical conditions and disabilities, low defenses, with diseases, convalescence, and in different states of physical and emotional sensitivity. The variety of users are elderly, children, pregnant, men and women, appropriate to their age and condition requirements.
The building has a density of greater use than others because it is used 365 days a year, day and night, and concentrates a large number of users and health workers. The procedures performed require precision equipment, conditioning the physical environment, energy supply, materials and supplies without interruption since at risk the lives and physical integrity of the users. This situation creates a high risk for which plans have been developed to produce control hospital insurance (Argentina Association of Hospital Architecture and Engineering, 2005).
The design and service delivery systems
The increase in outpatient services, including outpatient surgery and treatments mode day hospital, is reflected in the change in the percentage of areas of hospitalization and ambulatory use areas showing ratios of 2: 1 between areas outpatient and inpatient use (Cedrés Bello, 1996).
The introduction of new methods of diagnosis and treatment due to advances in medicine and medical procedures is reflected in the design of new spaces for its location, as are the areas of Imaging, Radiotherapy, Hemodynamics, Endoscopy and Unidosis among others. Some of these procedures have been developed to the point of being decentralized to be included within the different specialty consultations, as the case ecosonograms and endoscopies. We also have the case of satellite laboratories, warehouses of materials and supplies, pharmacy and decentralized operating rooms located in the emergency services, gynecology, orthopedics, ophthalmology, hematology, etc.
The location of patients in relation to their care needs has introduced the concept of intensive care, intermediate care and observation, which also reflected in the design and distribution of space.
The increase in demand in emergency rooms because of the guarantee of immediate attention 24 hours a day has made changes in the internal organization of the department, with areas of trauma, immediate external consultation, diagnosis, treatment and observation, reaching formed as small hospitals within the hospital (Cedrés Bello, 2006).
In recent years the use of contracted systems to external suppliers (outsourcing or outsourcing) services for laundry, kitchen, dining and maintenance have made changes in the design and programming of areas of hospitals (Venezuelan Association of Managers Health Services, 1999). When laundry services are contracted, they are performed outside the hospital, eliminating programming areas that were previously destined for that service. Reducing the power supply to the employees and workers due to the change of the procurement system it is reflected in the reduction of kitchen and dining areas.
The design and development of computer
Computed tomography (CT), published in 1971 in England, was considered the most revolutionary discovery in Radiology from X-rays In a few years since CT technology has developed rapidly and has become an important piece of equipment doctor (Nakano, 1987). In the eighties there has been tremendous progress in the development of other types of diagnostic imaging, such as MRI, without involving ionizing radiation (x-rays and gamma rays), but electromagnetic emissions coupled to a computer to transmit and record images. It has also popularized the use of ultrasound or ultrasound, non-destructive procedure (does not use ionizing radiation), mechanical, whose operation is based on application of high frequency sound waves to produce images.
The development and application of computer advances in medicine and communications has had a major impact on the design of the hospital buildings from the nineties until today. The introduction of imaging equipment (CT, MRI) and radiotherapy treatment equipment (accelerators, simulators, brachytherapy, cobalt) and hemodynamics, have brought a major change in the buildings as most of them are bulky and heavy and require special environmental conditioning for operation and location (photos 1 and 2).
The amount of this new equipment has changed the nomenclature of the Department of Radiology for Imaging, broader term that includes both equipment using ionizing and non-ionizing radiation. Many of the ultrasound equipment are so popularized that are already part of the team of examination and treatment stations, offices, cubicles emergency, intensive care, operating rooms, etc. increasing the need for more space within these functional units and the creation of new spaces, which results in additions and renovations in existing hospitals.
When designing a radiotherapy service working with high-intensity radiation protection particular problems faced against ionizing radiation, which is why it seeks to isolate the rest of the hospital department. This is usually placed in service and buried separately and connected to the main body of the hospital building to avoid the proximity of adjacent premises occupied by people permanently (Cedrés Bello, 1999).
New communications technologies bring with them new demands for design. As wireless technology to strengthen its presence in hospitals, continue to affect the workflow as well as environmental and equipment requirements. They will be redefined adaptable rooms, decentralized nurses stations and work processes (Juett and McIntire, 2005).
Public hospitals in Venezuela
Venezuela has about 24 million inhabitants (OCEI, Census 2000) by more than half, lacking HCM private insurance which, come to public hospitals and Social Security (IVSS). Alongside the public health system we have the private system with modern and specialized but smaller hospitals in their attention span and represent 20% of installed capacity in the country.
Venezuelan hospitals with 25-50 years of constructed, presented adaptations and upgrades during its existence. Currently they are mainly intervening Images departments as a result of a massive replacement of medical equipment in order to update equipping them with technology (Ministry of Health and Social Development, 2005). The increased use of emergency rooms due inter alia to increased crime and traffic accidents in recent years, becoming the gateway to hospitals (Cedrés Bello, 2006) is also observed.
The first modern hospital built in Venezuela in the late nineteenth century was the Vargas Hospital of Caracas, following the revolutionary setting standards set by a commission of the Academy of Sciences in Paris, first used in 1854 in the design of Lariboisière Hospital. The plans of this French hospital were repeated in the Vargas hospital, which became separate example of hospital wards (Figure 2). But in addition to this innovative architectural type, the Vargas Hospital launches a revolution of greater importance: anesthesia and antisepsis, who came with great difficulty practiced by doctors in their offices and private clinics. The teaching of medicine is always hit its practical aspect in hospitals, but at this stage the hospital where medical culture acquires its most perfect expression (Zúñiga, 1955).
Building hospitals and large public infrastructure works have been executed in periods demarcated by the plans and policies of the government. Therefore, for purposes of explanation outlining this process, we have divided the different stages in periods that coincide with those of various governments in the country (dictatorships and democracy).
After the construction of the hospital Vargas, first modern hospital in 1892, during the era of the dictatorship of Juan Vicente Gómez, at the beginning of the twentieth century, the general course of the country stops and built too few hospitals.
First National Plan of hospital construction (1936-1945)
In January 1936, the political change that followed the death of Gomez, the Ministry of Public Works (MOP) a reorganization of all its internal structure but also a reorientation of policy and its functions are performed not only as a result development ministry. In the same year the Ministry of Health and Welfare is created which prepared the rules Clinical and Nursing Homes.
From that time a new concept of national welfare and health arises. He emphasized on that occasion the almost total lack of hospitals to care for the Venezuelan people and the lack of equipment for medical care at the level of development of science (Zúñiga, 1955).
With the exception of Vargas Hospital and the hospitals of the oil companies, there was no other in the country that deserved the name. In this respect the situation was dramatic enough for even had private clinics that could fill that void.
In 1941 he began the construction of the hospital in Valencia, first modern hospital, planned and scheduled technically began. Children’s Hospital and Asylum in Caracas and Maracay Civil Hospital was also built. In Maracaibo oil companies build hospitals: Medical-Surgical Hospital and Maternity of Maracaibo and Joint Hospital of Lagunillas, prefabricated fabric buildings orginaly for farms brought and affordable solution to temporary field hospitals. Coromoto Hospital was also built through an agreement between oil companies and the government. This hospital is still today unique reference center in the country for its highly specialized service caumatología, has a heliport to transport the injured by burns from all the country’s oil fields and even in Central America and the Caribbean (photo 3).
Almost all cities demanding the construction of hospitals. In the city of Caracas they were built in that period (1936-1945) the following hospitals (Arcila Farias, 1974):
• 1936: Antineoplastic Luis Razetti in Listed
• 1938: Concepción Palacios Maternity Hospital, in San Martin
• 1940: Sanatorium Simon Bolivar in Antímano
• 1941: Jose Gregorio Hernandez Hospital in Listed
• 1943: Hospital JM de los Rios; Hospital San Juan de Dios
• 1945: Poliovirus Hospital
(Children’s Orthopedic Hospital today)
• 1947: Municipal Hospital Rísquez in Listed
• 1947: Clinica Santa Ana, San Bernardino
• 1950: Medical Center. Private Hospital, designed by a specialized company Chicago.
On October 2, 1943 began the construction of one of the largest fabric hospital buildings throughout Latin America and the largest in Venezuela, the Hospital of the University City, with capacity for 1,200 beds (photo 4) was given. This hospital was designed by architect Carlos Raul Villanueva and programmed by a committee of doctors and engineers from the Ministry of Health and Public Works and a US expert. It was opened in 1955 (Hernández de Lasala, 1999). The design of this hospital maintains the concept of hospital wards, but on several floors, general inpatient room type open, cross, natural lighting and ventilation sun exposure, handled during the early nineteenth century (introduced by Nightingale) as providers a healing environment. Semiprivate rooms with two to four beds are also incorporated.
The hospitals built in this stage correspond to modern typologies that use new technologies multi-storey building to house the wards on the upper floors and diagnostic services and treatment on lower floors.
Parallel to the construction of hospitals regulations, technical standards and procedures for the execution of projects and works, which contributed to technological development in the construction and the formation and consolidation of professional and construction companies were developed.
At the end of this period, the Ministry of Health and Social Assistance (MSAS), in its Hospital Division and the Planning Commission of Medical-care institutions (created in 1945), a new National Plan for hospital development was prepared to be developed in 10 years during the period 1946-1956.
Some of the significant events that helped develop this process were, says Arcila Farias (1974): the creation in 1949 of the Department of Medical-care fabric buildings in the MOP and in 1950 the Section of Hospital Architecture that established guidelines and concepts set for building construction standards and guidance on the type of building according to the assigned functions. This section was led until 1959 by Fernando Salvador Arq., A pioneer of hospital architecture in Venezuela, who played an important role in the hospital plan in relation to the physical plant. (Martin F., 1998: 32).
The new national ideal (fifties)
It corresponds to the historical period of the dictatorship of Marcos Perez Jimenez and was characterized by the pursuit of modernization of Venezuela, which was intended to overcome the state of poverty and backwardness, by his own assessment, characterizing the country (Faria and Quijano , 2000).
To transform this reality, the government gave way to the so-called New National Ideal which included a lavish public works plan that sought to equate to Venezuela with the most advanced nations. Great works are well built, including medical-care. The huge project was in crisis at the end of this decade, culminating with the fall of the dictator.
As an example of this period we Maracaibo University Hospital, with 600 beds, opened in 1960 (its construction lasted 10 years), performed with all the magnificence that characterized the works of the time and with the application of a high building technology . Its structure was conceived as a structural system composed of a supporting facade with columns spaced at 1.20m. supplemented with internal columns, connected by ribbed slabs in one direction and armed armed flat slabs in both directions. It was designed in Switzerland. The package contained facility design, structure and equipment as well as staff training. Today the building of 75,000 m2 building, which seemed exaggerated to the point, is insufficient for the region (SAHUM, 2000) (Figure 5).
The Carlos Arvelo Military Hospital in Caracas became operational in 1960. Its construction took four years (1955-1959) with a capacity of 1,000 beds, and presumably was designed by architect Luis Malaussena supported by an excellent collection of information related with the physical construction and operation of health centers recognized in Europe and the Americas. Created to meet the members of the Armed Forces and their families, today serves all age groups (Sader, 1990) (Figure 6).
The design and implementation of these three mentioned hospitals: the University Clinic and the Military in Caracas, and University of Maracaibo occurred in parallel with the movement of modern architecture that is exhibited in Europe and who were his models, which were designed and built with the most advanced principles and concepts of medical and construction technology. Incorporating courtyards guaranteeing light and ventilation to all environments shows the intention of adapting the modern scheme both local needs and the weather conditions. The use of Romanillas and quiebrasoles shows tropicalization of modern architecture.
The magnitude of the services and the functionalist approach of this modern conception expressed in the fragmentation of the hospital in a series of blocks arranged in a linear system containing different departments and hospital services, linked through corridors, walkways and patios, which in turn gives vitality to set and emphasizes its human building. In Maracaibo Clinical separate blocks are located in the four basic hospital services: Medicine, Surgery, Obstetrics and Gynecology Pediatrics.
At the end of the decade, in 1959, Architecture Section MSAS rose to the rank of Division and produced the Hospital Plan 1959-1969.
The type projects (1960-1980)
In the period 1964-1969, the medical care services were provided with 27 new fabric structure buildings, bringing in nearly 4,500 beds quota of hospital facilities (Iranzo and Sánchez, 1969b and 1969c).
In 1970 the Committee for Medical-Building programs Relief was created by joint resolution of MSAS and MOP, which had the function programming and evaluation of projects to build.
Between 1970 and 1980 120-150 hospitals and 200 beds, and 320 regional hospitals, 400 and 600 built in the state capitals were beds, all in the form of such projects, with some exceptions such as cases hospitals and Carupano Coro (photo 7).