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Purpose: Stereotactic radiosurgery (SRS) historically has been used to treat multiple brain lesions using a multiple-isocenter technique-frequently associated with significant complexity in treatment planning and long treatment times. Recently, given innovations in planning algorithms, patients with multiple brain lesions may now be treated with a single-isocenter technique using fewer total arcs and less time spent during image guidance (though with stricter image guided radiation therapy tolerances). This study used time-driven activity-based costing to determine the difference in cost to a provider for delivering SRS to multiple brain lesions using single-isocenter versus multiple-isocenter techniques., Methods and Materials: Process maps, consisting of discrete steps, were created for each phase of the SRS care cycle and were based on interviews with department personnel. Actual treatment times (including image guidance) were extracted from treatment record and verify software. Additional sources of data to determine costs included salary/benefit data of personnel and average list price/maintenance costs for equipment., Results: Data were collected for 22 patients who underwent single-isocenter SRS (mean lesions treated, 5.2; mean treatment time, 30.2 minutes) and 51 patients who underwent multiple-isocenter SRS (mean lesions treated, 4.4; mean treatment time, 75.2 minutes). Treatment time for multiple-isocenter SRS varied substantially with increasing number of lesions (11.8 minutes/lesion; P < .001), but to a much lesser degree in single-isocenter SRS (1.8 minutes/lesion; P = .029). The resulting cost savings from single-isocenter SRS based on number of lesions treated ranged from $296 to $3878 for 2 to 10 lesions treated. The 2-mm planning treatment volume margin used with single-isocenter SRS resulted in a mean 43% increase of total volume treated compared with a 1-mm planning treatment volume expansion., Conclusions: In a comparison of time-driven activity-based costing assessment of single-isocenter versus multiple-isocenter SRS for multiple brain lesions, single-isocenter SRS appears to save time and resources for as few as 2 lesions, with incremental benefits for additional lesions treated., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Standby generators are an essential piece of life-critical in every hospital. While acknowledging, however, that the generators represent a large capital investment, and that maintaining them in reliable running order 'represents a necessary, but significant expense', Leigh Preece, service director of Power Electrics Generators - one of the UK's leading names in the supply and maintenance of standby generation equipment - explains that there are ways for users both to amortise their outlay, and, in the process, to cut their overall electricity costs by 15-20%.

As one of the largest consumers of electricity in the country, the NHS is exceeding its reserved capacities and putting further strain on al already stretched electrical supply network, says Kevin Furey, Electrical Portfolio manager at Eastwood Park. Here he examines the issues facing the NHS in maintaining sufficient and sage electrical supplies that will also cope with the service's needs for the future.

With the growing influence of digital applications in building maintenance, and the considerable pressures on NHS budgets, the Building Engineering Services Association (BESA), examines some of the latest digital advances, and the potential cost savings for the health sector by harnessing them. One key focus is the SFG20 maintenance standard owned and maintained by the Association -'the UK's leading professional body for building and engineering services contractors' -which is about to be expanded again 'to provide comprehensive support for healthcare facilities by incorporating a Healthcare Functional Set developed in collaboration with IHEEM'. The new 'module' will be launched at this month's Healthcare Estates event.

The NHS in England could save £1 bn annually if all NHS acute Trustsachieved the median level of estates and facilities running costs, the second (and 'final') report by Lord Carter and his team into the 'productivity and efficiency' of acute NHS Trusts across England, published on 5 February,suggests. As HEJ, editor, Jonathan Baillie reports, Lord Carter's team'songoing recent discussions with senior personnel working in a range of disciplines at 32 NHS Trusts--which followed dialogue with an initial 22 Trusts--identified 'unwarranted variation' in the use of resources ranging from staff to land and buildings on such a scale that effectively addressing this 'variation' could, the DH-commissioned team says, potentially reduce by £5 bn annually the NHS in England's costs.

The authors of the interim report relating to the Review of Operational Productivity in NHS providers, published in June of this year, are, as many will know, developing a set of Adjusted Treatment Index (ATI) metrics, and are also to publish a model of their interpretation of what an estates department should look like in terms of its operational productivity and cost. This article argues that the underlying reason for the past failures was the creation of static 'point-value' metrics similar to the ATIs proposed, and that this can only be overcome by designing and populating a series of non-linear dynamic simulation models with feedback control of an organisation's estate in relation to its asset base and condition with respect to time, together with the resultant financial capital and revenue consequences. It concludes by calling on IHEEM's Council to urgently make representation to the authors of the June 2015 report, and suggests that the Institute's members be fully involved in the design, testing, and interpretation, of the estates model and ATIs. IHEEM's Technology Platforms are ideally placed to play a central role in this.

Expounding the status of the current domestic medical equipment maintenance management, and puting forward the strategic thinking of medical maintenance for the challenges of equipment maintenance management in the hospital. This discussion can be performed to control the maintenance costs of hospital effectively, increase the income and social benefits of the hospital.

Writing on behalf of the Building & Engineering Services Association (B&ES), Ewen Rose, an experienced journalist specialising in building engineering services, reports on a number of presentations at October's IHEEM Healthcare Estates 2014 conference where the focus was very much on how healthcare estates and facilities and healthcare engineering teams can save energy and cut carbon emissions through more efficient monitoring, and, if necessary, subsequent adjustment, of key HVAC plant. Among the key conclusions were that basic energy efficiency measures could 'shave millions of pounds from NHS estates' running costs', and that hospitals and other healthcare buildings face both 'an air-conditioning legal crisis', and a growing threat from outdoor air pollution.

With the NHS having committed to reduce its carbon footprint by 10% by 2015, Alan Newman, a partner at building services engineers, Troup Bywaters + Anders (TB+A), describes how, with the company's expertise and help, customer, the East and North Hertfordshire NHS Trust, 'surpassed the targets two years in advance'. As he explains, the key element of an ambitious carbon reduction scheme that won the 2013 IHEEM Healthcare Estates Sustainability Award (HEJ - November 2013) was a new combined heat and power-based energy centre at the Trust's Lister Hospital in Stevenage.

managing director of Mycologia & Mould Worx, MSc, B.(Env. Sci.), TAE40110, examines the topic of mould exposure in healthcare facilities, and the associated duty of care for hospital facility managers and engineers. The article, published here in slightly adapted form, also focuses on the need for additional training of key personnel on the risks associated with exposure to environmental microbial contamination.

This paper presents sensitivity and resilience analyses for a trigeneration system designed for a hospital. The following information is utilized to formulate an integer linear programming model: (1) energy service demands of the hospital, (2) technical and economical characteristics of the potential technologies for installation, (3) prices of the available utilities interchanged, and (4) financial parameters of the project. The solution of the model, minimizing the annual total cost, provides the optimal configuration of the system (technologies installed and number of pieces of equipment) and the optimal operation mode (operational load of equipment, interchange of utilities with the environment, convenience of wasting cogenerated heat, etc.) at each temporal interval defining the demand. The broad range of technical, economic, and institutional uncertainties throughout the life cycle of energy supply systems for buildings makes it necessary to delve more deeply into the fundamental properties of resilient systems: feasibility, flexibility and robustness. The resilience of the obtained solution is tested by varying, within reasonable limits, selected parameters: energy demand, amortization and maintenance factor, natural gas price, self-consumption of electricity, and time-of-delivery feed-in tariffs.

Objectives: To clarify the procedures related to mechanical ventilation in the intensive care unit setting: allocation of ventilators, team education, maintenance and reference documents., Study Design: Declarative survey., Methods: Between September and December 2010, we assessed the assignment and types of ventilators (ICU ventilators, temporary repair ventilators, non-invasive ventilators [NIV], and transportation ventilators), medical and nurse education, maintenance of the ventilators, presence of reference documents. Results are expressed in median/range and proportions., Results: Among the 62 participating ICUs, a median of 15 ventilators/ICU (range 1-50) was reported with more than one trademark in 47 (76%) units. Specific ventilators were used for NIV in 22 (35%) units, temporary repair in 49 (79%) and transportation in all the units. Nurse education courses were given by ICU physicians in 54 (87%) units or by a company in 29 (47%) units. Medical education courses were made by ICU senior physicians in 55 (89%) units or by a company in 21 (34%) units. These courses were organized occasionally in 24 (39%) ICU and bi-annually in 16 (26%) units. Maintenance procedures were made by the ICU staff in 39 (63%) units, dedicated staff (17 [27%]) or bioengineering technicians (14 [23%] ICU). Reference documents were written for maintenance procedures in 48 (77%) units, ventilator setup in 22 (35%) units and ventilator dysfunction in 20 (32%) ICU., Conclusions: This first survey shows disparate distribution of ventilators and practices among French ICU. Education and understanding of the proper use of ventilators are key issues for security improvement., (Copyright © 2013 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Last month's HEJ saw editor, Jonathan Baillie, report on 'the first half' of a recent roundtable debate staged jointly in London by IHEEM and multidisciplinary engineering consultancy, Crofton Design. Participants considered the topic: 'The taxpayer is losing millions of pounds in poorly procured healthcare buildings due to the lack of construction expertise within NHS Trusts; the Government urgently needs to redress this if the losses are not to spiral out of control'. With the first hour's discussions focusing primarily on existing procurement skill levels, and the reasons behind significant 'skills gaps', the final 'half' saw debated how best to attract able new entrants to the healthcare estates and allied professions, ensuring effective procurement of healthcare buildings well into the future.

'Estates as the enabler' was the title of an interesting debate session on the morning of the second day of November's Healthcare Estates conference, in which participants focussed on what part healthcare buildings and other 'built assets' would play in a future UK care landscape potentially quite different from that of today. HEJ editor Jonathan Baillie reports.

The interest of centralization of preparations of chemotherapy drugs is in addition to its economic aspect, to secure drugs circuit. The aims of this study are to determine needs in employees and equipments of 11 theoretical levels of production from 1,000 to 50,000 preparations per year and to determine the cost of chemotherapy's preparation for each theoretical unit. The operating cost was divided in four areas of expenditure: employees (66-78%), investment (5-15%), maintenance (3-15%) and consumables (4-16%). If we consider the 11 units, the theoretical cost varies between 27.4 € for a unit with 50,000 preparations per year and 114.1 € for a unit with 1,000 preparations per year. This study shows the importance of setting up an optimal unit of preparations according to its activity and highlights the high cost's variation in relation to the activity of the unit.

Independent consultant to the healthcare sector Dr Melvyn Langford says a "fundamental flaw" in the way the long-established NHS "5 x 5" criticality grid used to assess the urgency of backlog maintenance has been interpreted could be giving NHS estates and facilities personnel, and in turn Trust boards, a distorted picture of the true risk being posed by the condition of key hospital buildings, plant, and equipment.

Objective: Using clustering techniques for characterising companies providing health institutions with maintenance services., Methods: The study analysed seven pilot areas' equipment inventory (264 medical devices). Clustering techniques were applied using 26 variables. Response time (RT), operation duration (OD), availability and turnaround time (TAT) were amongst the most significant ones., Results: Average biomedical equipment obsolescence value was 0.78. Four service provider clusters were identified: clusters 1 and 3 had better performance, lower TAT, RT and DR values (56 % of the providers coded O, L, C, B, I, S, H, F and G, had 1 to 4 day TAT values:

Jeremy Dodge, business manager at Marshall Tufflex Energy Management, explains how a voltage optimisation system that, in a claimed industry first, uses "auto-transformers" to reduce incoming mains electricity voltage so that electrical equipment receives precisely the "outgoing feed" it needs to function optimally and no more, thus significantly reducing wastage, can help major electricity users cut their bills "by as much as 25%".

Jonathan Jones, European product manager at Tyco Thermal Controls, explains the economic and other benefits of using electrically trace-heated single pipe distribution, in place of the more "traditional" flow and return system, for hot water supply.

In this adapted version of an article from The Australian Hospital Engineer, Kim Bruton, MIHEA, the magazine's editor, and chief engineer at the Wodonga Hospital campus of the newly-formed Albury Wodonga Health Service in Victoria, Australia, describes a project to both analyse the impact of regular maintenance on plant performance, and significantly reduce energy consumption across the hospital estate in the future.

Speaking at the most recent Healthcare Estates conference, Ed Baldwin, of international built asset consultancy EC Harris LLP, examined the role of benchmarking and market-testing--two of the key methods used to evaluate the quality and cost-effectiveness of hard and soft FM services provided under PFI healthcare schemes to ensure they are offering maximum value for money.

Aim: To solve problems concerning patient equipment with emphasis on patient care, nursing quality and better nursing management., Methods: A monitoring system, designed to follow the patient around in the hospital was discovered. Based on this concept a special, standardized pool system managed by the Clinical Engineering Department was developed., Results: An all-department standardization of monitors and pumps was tried. With pumps it was a success. With monitors, two of 21 departments preferred non-standardized equipment. The equipment pool has successfully been run for 5 years., Conclusions: An evaluation showed that nursing care is better and that only 2% of those asked disapproved of the system. The pool eliminated problems like lack of equipment when needed, the wrong type of equipment found, lack of fitting disposables, the items that could be found being out of order or too dirty to be used. Nurses no longer waste time searching for equipment ready for use. Bedside equipment in working order can always be found in one of the storerooms. As a result, patient safety was greatly enhanced. We also show that this is economically a good system.

Tanzanian hospitals suffer from underfunding and poor management. In particular, planning and strategic thinking need improvement. Cultural values such as subordination, risk aversion, and high time preference, together with a long history of socialist government, result in lack of responsibility, accountability, and planning. This has been addressed by the health sector reform with its focus on decentralization, strengthened by the introduction of basket funding facilitated by the Comprehensive Council Health Plans. As a consequence of this the next logical step is to improve the authority of regional and district hospitals in the use of their resources by introducing hospital development plans. These strategic plans were introduced as tools of strategic planning in 2001 by the Kreditanstalt für Wiederaufbau in close collaboration with the Tanzanian Ministry of Health, binding the release of rehabilitation funds to presentation of a strategic hospital plan. This study examines the rationale and content of hospital development plans. Initial experiences are discussed. The quality of presented plans has steadily improved, but there is a tendency for hospitals with a close connection to development partners to present well prepared reports while other hospitals have severe problems fulfilling the requirements. For many hospitals it is in fact the first time that they have had to define their functions and future role, thus breaking ground for strategic thinking.