Hospital Ambulance Bay Design

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Design Requirements and Operational Guidelines for Hospital Ambulance Bays

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Design Requirements and Operations Guidelines for Ambulance Bays ______________________________________________________________________________

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October 26, 2014

Design Requirements and Operational Guidelines for Hospital Ambulance Bays

Jason Laberge, Human Factors Specialist, Patient Safety

Don Sharpe, Senior Paramedic, Emergency Medical Services Alberta Health Services, Calgary, Canada

Project Background This document contains draft recommendations resulting from a human factors evaluation at Alberta Health Services. The proposed design described in the Appendix is a concept only and has not been fully implemented. Ongoing efforts focus on both validation of the requirements and guidelines and integration with provincial facility design guidelines. The recommendations, guidelines, and concept have been shared for discussion purposes only.

A. Introduction An ambulance bay connects Emergency Medical Services (EMS) personnel and their patients to the tertiary care staff and equipment of a local hospital. An ambulance bay is a place to get into and out of as quickly as possible, a transitory location for everyone. However, not all ambulance bays are efficient and safe. Contaminated equipment, presence of non-EMS supplies, congestion due to the location of cabinets/waste containers/other storage, and foot traffic from unauthorized staff can all delay access to the bay and the emergency department for patient transport. Every ambulance bay needs to be designed with one primary goal in mind: to get patients to triage and EMS personnel back on the streets as quickly and safely as possible. A human factors1 evaluation was recently completed in Alberta Health Services (AHS) to identify design requirements and operational guidelines for ambulance bays. The evaluation focused on several safety and efficiency considerations:

Timely transport of patients from the ambulance bay to the emergency department Safe treatment of patients in the bay if required Minimizing bumps of both EMS personnel and patients Infection prevention and control from contaminated equipment Potential trips/falls for staff Overall cleanliness and organization

1 Human factors is the study of how people interact with spaces, equipment, and others.


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The purpose of this document is to communicate recommendations for effective design and operation of ambulance bays. This document can be used to assess a hospital’s ambulance bay from the perspective of safety and efficiency. This document can also be used to help plan and design new ambulance bays and renovation projects. Lastly, information in this document can be used to enhance sections in Healthcare Facility Design Guidelines in Canada (CSA Z8000), the United States (FGI), and elsewhere. A proposed ambulance bay design concept is included as an Appendix for reference. The design represents one possible solution for satisfying the design requirements that are described in this document. A1. What is a Design Requirement? A design requirement specifies the needs or conditions that must be satisfied in an ambulance bay taking into account multiple stakeholders. A requirement differs from a design solution, which is one possible way to meet a requirement. Typically there is more than one design solution that can satisfy a requirement.

A2. What is an Operational Guideline? An operational guideline is a statement by which to determine a course of action for operating an ambulance bay. Guidelines streamline operations practices and work processes based on an analysis of best practice from human factors evaluations. Following a guideline is not mandatory but is used to help make actions more predictable and of higher quality. A3. Development Process Requirements and guidelines were compiled based on interviews, observations, and usability surveys. Thirty one interviews with urban and rural EMS personnel using a large metro hospital ambulance bay helped to identify issues and opportunities for improvement. Over 20 hours of observations in five large metro hospitals and more than 160 photos helped to validate the issues identified in the interviews as well as provide evidence for additional requirements and guidelines. Usability surveys focused on perceptions of usable space, layout, workflow, efficiency, cleanliness, clutter, access to supplies, and patient flow. All the data from the interviews, observations, and surveys was compiled and categorized into specific safety and efficiency issues that are relevant to ambulance bays. Requirements and operational guidelines were identified to address each issue. Improvement suggestions from the interviews and surveys helped inform the proposed ambulance bay design that is described in the Appendix.


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B. Design Requirements Specific design requirements are listed below. Requirements have not been prioritized pending additional feedback from stakeholders and other subject matter experts. B1. Ambulance Access To and Egress from the Hospital Ambulance Bay Approaching the Bay

On approach, EMS personnel should be able to determine if there is sufficient space in the ambulance bay.

The overall hospital site design should minimize pedestrian traffic around the ambulance bay.

Pedestrian crosswalks that intersect with ambulance bay access or egress routes should be a minimum of 30 meters from the ambulance bay doors.

All pedestrian crosswalks along ambulance bay access or egress routes should be well marked.

There should be a mechanism at all crosswalks that intersect with ambulance bay access or egress routes to inform pedestrians that “Ambulances have the right away”.

The ambulance bay access and egress routes should be well marked as dedicated for “Emergency Vehicle Use Only”.

The ambulance bay access route should not require traversing over speed bumps. The ambulance bay access route should have dual drive lanes for sites that have higher

call volumes. Egress from the ambulance bay should have sufficient clearances to minimize potential

collisions. Egress from the ambulance bay should require minimal turns and avoid blind spots and

tight turning radiuses. When planning the egress routes, consider higher travel speeds for crews that need to

depart the ambulance bay with “Lights and Sirens” to respond to emergency calls. Parking in the Ambulance Bay

There should be sufficient space for each parked ambulance to fully open/close all doors when the bay is full without colliding with walls, pillars, equipment or other ambulances.

Ambulance parking spaces should be clearly indicated so that drivers know exactly where to park.

Access to equipment (e.g., decontamination shower, ladders) and supplies (cabinets, O2, linens, etc.) should not be impacted by ambulance parking lanes.

EMS crews should be able to access and egress from any parking spot in the ambulance bay without having to move other ambulances.

There should be space inside the bay for ambulances with code patients to park immediately beside the entrance to the emergency department.


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Inter-facility transfer patients that are brought to the hospital should not compromise parking for emergency response ambulances inside the ambulance bay.

Overhead doors should open at a minimum speed of 20 inches per second2. Overhead doors should open at a recommended speed of 50 inches per second.

Overflow Parking

Have a designated ambulance overflow parking area with stalls that are clearly marked. Ambulance overflow parking should be immediately adjacent to the ambulance bay. Ambulance overflow parking should be marked with signage indicating “Emergency

vehicle parking only”. Police, Sheriff and other emergency vehicles should use the ambulance overflow parking

when required. Overflow parking area design should not hamper egress from the ambulance bay. Drainage grates in overflow parking area should be forward of rear wheels on all

ambulances. Drainage grates in overflow parking area should have sufficient drainage to ensure that

water does not pool and/or freeze. Patient transport from the overflow parking area should be paved and level (i.e., sloped

only what is necessary for drainage). Sloping for drainage in the overflow parking area should be minimal such that stretchers

will not roll on their own (i.e., should not require application of stretcher brake). Overflow parking area should have equivalent lighting to inside of ambulance bay (i.e.,

minimum of 500 lux). Swipe card controls to open overhead doors should be accessible from the outside for

both access and egress doors to facilitate rapid movement of patients and EMS personnel. B2. Access from the Ambulance into the Emergency Department

Parked ambulances should not impact the patient access path to the emergency department.

Patient access to emergency department should not require passing by any potentially hazardous materials (garbage, bio, sharps, equipment, piping, supplies, etc.).

Patient access path to emergency department should be clearly marked from all ambulance parking spots.

Clearance for patient access to emergency department (patient + stretcher + EMS crew) from any point in the ambulance bay must consider any turning radius requirements and speed of transport.

Access doors from the ambulance bay to the emergency department must open automatically based on proximity.

2 Door and Access Systems Manufacturing Association


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Access doors from the ambulance bay to the emergency department must open at a minimum speed of 20 inches per second3. This means that a six foot opening made of up two 36 inch sliding doors would open in approximately 1.8 seconds.

Drainage grates in an ambulance bay should not be directly under patient unloading area for any ambulance sizes.

Sloping for drainage in the ambulance bay should be minimal such that stretchers will not roll on their own (i.e., should not require application of stretcher brake).

B3. Re-supplying Ambulances Supply Storage

Access to supplies should not be impacted by ambulance parking and/or patient access routes to the emergency department.

Supply storage inside the ambulance bay should follow the same medication and supply storage system as the ambulances (bins, colors + labelling).

Supplies should be stored in one central location to ensure easy access from all ambulance parking spots.

Supplies should be easy to access and contents and quantities must be visible without having to open cabinet doors.

Secure access to supplies must be provided. O2 Storage

Access to O2 cylinders should not be impacted by ambulance parking and/or access routes to the emergency department.

Separate storage space is required for full and empty large O2 cylinders O2 cylinders should be located to ensure easy access by EMS and the vendor Vendor access to the O2 cylinders should not affect EMS ambulance parking or the

access route to the emergency department. Secure access to O2 cylinders must be provided.

Cleaning Ambulances

All ambulance parking spots should have access to equipment and supplies needed to clean the inside of the ambulance.

There should be space inside the ambulance bay for washing the outside of the ambulances. The ambulance wash area can be directly in front of an exit door as long there is at least one other exit door that is accessible by all ambulances.

Ensure all sensitive equipment (including overhead door openers) is protected from splashing water and weather.

There should be a minimum of one mop bucket for every two ambulances parked in the bay.

Mop buckets should be located adjacent to the ambulance parking spots they serve.



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There should be a central location inside the bay where EMS staff can empty and fill mop buckets.

There should be a minimum of one disposal station for every two ambulances parked in the bay. The station should consist of (at minimum) a garbage can, biohazard bin, and sharps container.

Disposal stations should be located adjacent to the ambulance parking spots that it serves. There should be one garbage can adjacent to, but not inside, the resupply area. Staff should have easy access to cleaning supplies like brooms, brushes, dust pans, etc. The ambulance bay should include a dedicated hand washing sink. The ambulance bay should include a large sink/wash station for EMS equipment.

B4. Keeping the Ambulance Bay Clean Routine Cleaning

There should be a separate dirty equipment holding room adjacent to the ambulance bay. Contaminated equipment should not be stored adjacent to walkways or impact access

along the patient pathway to emergency department. Ambulance bay floors should be finished with an easy to clean and anti-slip surface. Ambulance bay should have sufficient drainage to ensure that water does not pool

anywhere in the bay. Dirty and clean linens should be physically separated as per Infection Prevention and

Control (IP&C) policy to ensure that dirty linens are not mixed with clean linens. There should be cleaning supplies available (minimum of a large and small broom,

shovel and a squeegee) inside the ambulance bay for routine cleaning4. Decontamination Area

The decontamination area should be located in a separate room adjacent to the ambulance bay to minimize exposure to other patients/staff.

A decontamination shower should be located in a separate room so as not to impede walkways, patient access paths or ambulance parking.

The decontamination area should include a self-contained contaminated water system that is isolated from the regular water / drainage water drainage system.

B5. Environmental Design

The interior of the ambulance bay should be bright using a combination of painted walls and ceilings, lighting, and natural lighting.

Average temperature inside the ambulance bay should be between 19 °C and 26 °C. Temperatures should not be below 16 °C at any point in the ambulance bay.

4 Brooms, shovels, and dustpans can be hung on a brightly coloured shine station affixed to the wall in a low traffic area. These shine stations serve as visible reminders to keep the area clean.


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Temperatures should not drop more than 2 °C in the middle of the ambulance bay when overhead doors are opened or closed during access or egress.

Average relative humidity should be between 35% and 65%. Relative humidity can range between 20% and 85% but only for short periods of time. Any ambient noise levels should be between 50 dB and 70 dB in the ambulance bay. Peak noise levels should not be higher than 90 dB anywhere in the ambulance bay. Lighting in work areas of the ambulance bay (office area, resupply area, decontamination

area, etc.) should be a minimum of 1000 lux. Lighting in other areas of the ambulance bay should not be lower than 500 lux.

B6. Comfort and Convenience

Ambulance bays should have an EMS office that is accessible from the ambulance bay or in an adjacent space.

EMS office should have a closable door for security (e.g., stored medications) and privacy (e.g., patient information) reasons.

EMS office should have at least one work space for every two ambulance parking spots inside the bay.

Ambulance bays should have an EMS staff washroom accessible from the bay or in an adjacent space.

Ambulance bays should have hand sanitizers at all entrances and exits from the ambulance bay.

There should be an eye wash station inside the bay that is easily accessible from all ambulance parking spots.

The ambulance bay should have a ventilation system to minimize exposure of staff and patients to vehicle fumes and other air pollutants.

B7. Maintenance Considerations

All automatic doors (e.g., overhead, access to ED, supply room) in the ambulance bay should be classified as ‘high performance’ doors, requiring minimal maintenance despite a high number of cycles per day (i.e., 100 or more cycles per day)5.

Overhead doors should have some tolerance for bumps with ambulances. All serviceable equipment inside the ambulance bay must be located to ensure easy

access by maintenance personnel. Servicing any one piece of equipment should NOT require closing the entire ambulance

bay. B8. Security

There should be no public access to the ambulance bay from the outside.



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Access to the ambulance bay from the outside should be well signed and secured. Access to the ambulance bay from any outside man door should require secure swipe

card access. C. Operational Guidelines Operational guidelines reflect observed best practices in Alberta Health Services and elsewhere. C1. Accountability

Assign responsibility for ALL aspects of the ambulance bay to an individual or team to ensure ownership and accountability.

Accountability for placing any additional hospital equipment or supplies within the ambulance bay would rest with this group or individual. .

Develop and track metrics for ambulance bay operations that align with individual roles and responsibilities. For example, cleaning compliance could be tracked via cleaning check sheets. Efficiency and patient safety could be tracked using periodic audits of patient transport times from ambulances to the ED doors.

Clearly post signage indicating who to call for maintenance, housekeeping and overall responsibility for the ambulance bay.

C2. Re-supplying Ambulances

EMS crews should resupply as soon as possible by transferring patients off EMS stretchers and onto an emergency department bed. One member of the EMS crew should stay with the patient; the other member should immediately begin the ambulance resupply process.

Ambulances should clear the ambulance bay within 15 minutes in all but exceptional circumstances.

Only EMS and ambulance bay cleaning supplies should be stored in the ambulance bay. Non-EMS storage may be adjacent to the ambulance bay but must be accessed from

elsewhere. C3. Keeping the Ambulance Bay Clean

Assign roles, responsibilities, staffing, and time to clean the ambulance bay on daily basis.

Develop ambulance bay cleaning check sheets to track progress and compliance. Develop a work process to audit the ambulance bay to evaluate compliance with the

check sheets and cleaning schedule Develop a routine de-cluttering program to help maintain the ambulance bay.


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Roles, responsibilities and work processes should support regular cleaning / removal of dirty / contaminated equipment in the ambulance bay.

Roles, responsibilities and work processes should support cleaning or bagging contaminated EMS equipment before it is stored in the holding area.

All contaminated equipment should be cleaned or bagged before transferred to the contaminated equipment holding area.

Roles, responsibilities and work processes should support regular emptying of linens/garbage in the ambulance bay and overflow parking area.

Define a schedule (i.e., 7am/7pm) for when cleaning staff will empty linens and garbage in the bay.

Contaminated equipment should not stay in the contaminated equipment holding area for more than 24 hours before it is removed.

Roles, responsibilities and work processes should support fast removal of out of town equipment from the ambulance bay.

Cleaning staff should clean windows on overhead doors daily to ensure visibility. Cleaning staff should empty and fill mop buckets at least once per day.

C4. Decontamination

Procedures must exist for usage of decontamination equipment including showers. Procedures must include how contaminated patients will move through the ambulance bay into the emergency department.

C5. Maintenance

Potholes or broken pavement along the ambulance bay access and egress routes should be a priority to repair.

Ambulance bay floors should have a routine preventative maintenance program to ensure that cracks and crevices do not impact patient or staff safety.

Power washing and painting the ambulance bay should be done as part of a regular preventative maintenance program.

Ambulance bay overhead doors should have a routine preventative maintenance program (including periodic inspection) to ensure safe operation.

Work processes must ensure that access paths from overflow parking are clear of obstructions, snow, mud, etc.

Assign responsibility to someone to monitor bays for flooding on snow days and to initiate de-clogging when required.

C6. Security

There should be a policy that restricts access to the ambulance bay. EMS staff should be encouraged to challenge any non-EMS personnel that are in the

ambulance bay.


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C7. Operations Planning

There should be an operations plan for all scenarios where the ambulance bay becomes unusable.

D. Additional References The following Healthcare Design Guidelines provide additional information on ambulance bay design. As mentioned, one purpose of this document is to generate discussion that may lead to enhancements to the sections of the guidelines that address ambulance bay design.

Canadian Standards Association. CAN/CSA Z8000-11. Canadian Health Care Facilities - Planning, Design and Construction (Section 6.1.7.3). Canadian Standards Association; 2011.

Facility Guidelines Institute. FGI Guidelines for Design and Construction of Hospitals

and Outpatient Facilities (limited coverage in Section 1.2). Facilities Guidelines Institute; 2014.

The following articles provide some project background and a summary of the research findings and recommendations:

D. Sharpe. How Ideal is Your Ambulance Bay? Part 1. Canadian Paramedicine; August – September 2013.

D. Sharpe & J. Laberge. How Ideal is Your Ambulance Bay? Part 2. Canadian

Paramedicine; November 2013. A. DiNardo. Emergency Response: Using Lean Thinking to Solve Inherent Design

Challenges of Ambulance Bays. Healthcare Design; March 2014.


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E. Author Contact Information We are interested in hearing your questions and feedback on this document. Please feel free to contact us via email: Jason Laberge, Human Factors Specialist, Patient Safety, Alberta Health Services [email protected] Don Sharpe, Senior Paramedic, Emergency Medical Services, Alberta Health Services [email protected] F. About Alberta Health Services Alberta Health Services (AHS) has over 104,000 employees and is the provincial health authority responsible for planning and delivering health care and promoting wellness for 3.7 million Albertans in Canada. Programs and services are offered at over 450 facilities throughout the province, including 100 acute care hospitals. Almost all of the acute care hospitals have some kind of ambulance bay. The AHS mission is to provide a patient-focused, quality health system that is accessible and sustainable for all Albertans.


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Appendix: An Ambulance Bay Design Concept

Design Features

1. Dual access doors – ambulances access the ambulance bay from the right side using one

of two high speed overhead access doors. If one door becomes disabled, ambulances can access the bay using the other door.

2. Angled parking – ambulances park on an angle so that parking does not impede access to the bay, access to the ED or egress. Ambulances parked in the bottom row can drive around to the left to exit the bay. Ambulance parked in the top row can drive ahead to exit.

3. Multiple exit doors – ambulances egress from the bay from the top left using one of the designated exit doors. If one door becomes disabled, ambulances can egress the bay using the other doors.

4. Code parking – ambulances carrying a coding patient can park just outside the emergency department foyer doors at the bottom if the ambulance bay is full.

O2 C

abinet

Decon RoomEMS WashroomED FoyerEMS Supplies

Code

Linen

Rack

Shine

Shine

Trench Drain

Hose Hose

Exit Door Controls

Entrance DoorControls

BariatricStretchers

Wash Bay

EMS Office

Wash sink

WC

WC

WC

Wheel Chairs

Shine

WC WC

ShineStation

1

1

33

5

6

7

8

9

10

11

12

13

14 15 16 17 18 19

2021

2

11

12

13

1110

6

6 6

9

7

4

3 3 3 3

Linen

Rack


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5. ED access routes – all access routes from ambulances to the ED are marked with ‘keep clear’ striping.

6. Disposal stations and dirty linen – disposal stations include (at minimum) a garbage, biohazard bin, and sharps container and are located between every 2 to 3 ambulances. Dirty linen baskets are collocated with the disposal stations.

7. Trench drainage – continuous trench drains run under ambulances between the front and rear wheels to minimize any risk of flooding.

8. Wash bay – an ambulance wash bay is located in front of one of the exit doors. The bay includes a power wash wand like in a manual car wash. When in use, all ambulances exit via the other exit door.

9. Water hoses – provided at either end of the ambulance bay for staff to clean both their ambulances and the ambulance bay.

10. Exit / entrance door controls – separate control panels for the exit and entrance doors. Panels are located close to the doors they serve.

11. Shine stations – located throughout the ambulance bay to ensure easy access to cleaning supplies such as brooms, shovels, etc.

12. Wheel chair parking – dedicated parking for wheel chairs will ensure they do not congest the ambulance bay or block access paths to the ED.

13. Stretcher parking - dedicated parking for stretchers (including at least one bariatric) will ensure they do not congest the ambulance bay or block access paths to the ED.

14. EMS office – the EMS office is easily accessible from inside the bay, but far away from ambulance traffic and exhaust. The EMS office would have up to six work spaces for an 11 unit ambulance bay.

15. EMS supply room – a centralized supply room that is accessible from inside the bay. Supply room doors would open/close automatically using swipe card secure access.

16. Wash sink – a wash sink for EMS staff. 17. ED foyer – access doors to the ED foyer would open/close automatically based on

proximity. 18. EMS washroom – dedicated washroom for EMS staff that is accessible from inside the

ambulance bay. 19. Decontamination room – location of decontamination shower and storage area for

contaminated equipment. 20. Linens – large blue bin for dirty linens with adjacent rack for clean linens. 21. Oxygen storage – small O2 storage via single storage cabinet. Large O2 storage via

separated storage racks for full and empty cylinders. O2 storage is located between the ambulance bay entrance doors to provide protection against collisions from ambulances during access and egress.


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Efficiency Analysis Link analysis (also known as pathway mapping) was used to assess the expected efficiency of the proposed design. Link analysis plots the paths that personnel would take to complete typical tasks inside the ambulance bay. When all the paths are shown, the resulting diagram can be used

O2 C

abinet

Decon RoomEMS WashroomED FoyerEMS Supplies

Code

Linen

Rack

Shine

Shine

Trench Drain

Hose Hose

Exit Door Controls

BariatricStretchers

Wash Bay

EMS Office

WC

WC

WC

Wheel Chairs

Shine

WC WC

ShineStation

1

1

33

7

8

9

10

11

12

13

14

20

2

11

12

13

1110

6

6 6

9

7

3 3 3 3

LinenRack

6

5

4

18 19171615

21

Entrance DoorControls

Wash sink

Ambulance to ED

Cleaning Stretcher

Cleaning Ambulance / Bay

Re‐supply Ambulance

O2 Vendor Restocking

EMS Restocking

Housekeeping

Contaminated Equipment


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to identify inefficiencies. For example, personnel travelling long distances to complete tasks would be inefficient. In addition, many paths in the same area could indicate potential congestion. Results from the link analysis show that:

Access to the ED - the route to the ED from ambulances is free of congestion and obstructions. Primary access is via the central access route from the top parking spots. The left and right routes are alternate routes when needed.

Cleaning stretcher – linen baskets are co-located with disposal stations between every few ambulances so they are close to where stretchers are typically cleaned at the back of the ambulance.

Cleaning ambulance - mop bucket and disposal stations improve efficiency for cleaning ambulances because EMS crews do not have to travel very far to access these commonly used supplies and disposal options. Shine stations require longer travel distances, but they are used less frequently.

Re-supply ambulance - the central EMS supply room works well for ambulances parked along the bottom row of the bay. However, the room is quite far for the ambulance parking spots at the top of the bay. An alternate (but more expensive) design might have two supply rooms --- one at the top and another at the bottom of the ambulance bay.

O2 vendor restocking - O2 stocking should be efficient for the vendor since they have easy access via the two access doors. O2 vendor restocking should have minimal impact on the rest of the ambulance bay.

Housekeeping - staff have to enter the ambulance bay to empty and refill mop buckets, empty the disposal stations, and manage linens. This is expected to happen at least once per shift. Hence, the longer travel distances for housekeeping staff must be traded off when considering to the frequency that EMS staff must access these supplies.

Contaminated equipment - goes from the ED directly into the decontamination room if an adjacent dirty supply room is not available. The relatively direct route minimizes exposure inside the ambulance bay.

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