Equipping a casualty department in Bangladesh: designing for the surge, not the average

Casualty departments fail at their busiest hour, not their average one. How to size resuscitation bays, triage space, trolley fleets and crash carts around peak load, and which cheap items to over-buy because they are the ones that strand a patient.

A casualty department is quiet for most of its life and then suddenly is not. An equipment list written after a walk round on a Tuesday afternoon describes a department that works on Tuesday afternoons. The one that matters is at eleven at night when a bus has come off the highway, or in the third week of a dengue season, or on the evening before Eid when half the city is travelling.

Sizing for the average is the commonest mistake in emergency procurement, because the shortfall never shows up in a report. It shows up as a patient managed on the floor, and nobody writes that into next year's tender either.

Size the department from its worst hour

The data to do this properly is already in your register. It takes one person a week to extract it and it changes what you buy.

1. Pull twelve months of attendance by hour of arrival, not by day. Daily totals hide everything that matters.
2. Identify the twenty busiest hours in the year and look at what caused them. In most Bangladeshi hospitals the list is dominated by road traffic incidents, festival travel, seasonal fever and, near industrial areas, single site incidents that arrive all at once.
3. For each of those hours, count the maximum number of patients who needed a trolley at the same time, and the maximum number who needed a resuscitation position at the same time.
4. Buy trolleys and resuscitation positions against those two numbers, not against your bed count or your daily mean, then decide in writing what happens above that. Surge capacity that has been thought about is a plan. Surge capacity that has not been thought about is a corridor.

The output is usually uncomfortable, and usually points at the trolley fleet rather than at the expensive equipment. That is convenient, because trolleys are the cheap half of the answer.

The resuscitation bay

A resuscitation bay is defined by access rather than by area. You need to be able to work from both sides and from the head, at the same time, with a monitor visible to everyone in the bay and nothing on the floor that a person can trip over during a chest compression.

• Put it near the door. The commonest layout error we see is a resuscitation bay at the far end of the department from the ambulance entrance. Every metre of that is paid for on every critical arrival, forever.
• Get services off the floor. Wall or pendant mounted oxygen, vacuum and power keep the floor clear. Where the building will not take that, run services down one side and keep the other free.
• Two suction sources per position. One piped, one mobile. During an airway emergency a single blocked or occupied source is a total failure.
• A surface that goes flat immediately. Whether a resuscitation trolley or a bed with a CPR release of the D8d class, the release must work one handed from either side without moving furniture.
• Imaging without transfer. A trolley with an X-ray capable backrest, of the SKB041-3 class, removes a transfer from the sequence. Every transfer avoided is time saved and a line that does not get pulled out.
• Overhead task lighting. A mobile lamp of the SK-LLY400Z class is the usual answer where a ceiling mount is not possible, but give it a parked position or it lives in the walkway.

Triage: the smallest space that makes the biggest decisions

Triage is usually given a desk and a chair and treated as an administrative position. It is a clinical assessment area, and what it lacks turns a five minute assessment into a fifteen minute one.

• An examination couch that adjusts. An X36 or X41 class table lets the assessor lay a patient down without walking them into the department first. A fixed height couch an unwell adult cannot climb onto is not usable at triage.
• A wheelchair kept at triage. Not shared with the department, not borrowed by porters. An SKE691 class chair parked in a marked position, so that a patient who cannot walk stops being a two person carry.
• A trolley within reach. The patient who deteriorates at triage is the reason triage exists. If moving them means fetching a trolley from elsewhere, that time is unrecoverable.
• Task lighting, a hand hygiene point and a paediatric weighing facility. The first two are omitted constantly and are cheap at first fix. The third matters because paediatric dosing depends on a weight, and estimating that weight is a known source of error.

Trolleys, stretchers and the transfer chain

Patients arrive on one surface and leave the department on another, sometimes through three intermediate ones. Every handover between surfaces is a manual handling risk and a delay. The fleet should be chosen as a chain, not as a shopping list of individual items.

Stage	Equipment class	What to check before ordering
Scene to ambulance	SKB2B01 scoop stretcher	That it splits and rejoins reliably under load, and that there is one per ambulance plus a spare in the department, because scoops are routinely retained by receiving hospitals
Field carry and stairs	SKB1A02 foldable stretcher	Folded dimensions against where it is stored, and whether it can be found in the dark by someone who did not put it away
Ambulance to door	SKB039(D) ambulance stretcher trolley	Loading height against the floor height of the vehicles you actually operate, including the older ones, not the vehicles in the brochure
Department to imaging	SKB041-3 patient transportation trolley with X-ray capable backrest	Whether a film can be taken in place; also whether the trolley fits your lift with a pole and a monitor attached
Ambulatory movement	SKE691 wheelchair, or the SKE180 electric chair for long internal routes	Castor size against your door thresholds, ramp gradients and corridor floors
Admission to ward or ICU	Ward, HDU or ICU bed	That the trolley height range and the bed height range overlap, so lateral transfers can be done flat rather than uphill

That last row is worth dwelling on. Buying trolleys in one lot and beds in another, from two suppliers in two different years, is how a hospital ends up with a transfer chain where every handover is a lift rather than a slide. Ask for both height ranges on paper and check they overlap before either order is placed.

Crash carts and the discipline that keeps them useful

An emergency trolley such as the SK-ET75077A is furniture with a defibrillator shelf, a cylinder holder and drawers. What makes it work is the system around it, which costs nothing to design and is constantly neglected.

1. Standardise the drawer layout across the whole hospital. Same drugs in the same drawer in casualty, on the wards and in theatre. A nurse who has come to help from another department should not have to read labels during an arrest.
2. Use numbered break seals. A sealed cart with an intact tag is verifiably complete. A cart with a padlock and a signature book is not, because the book gets signed on Friday for the whole week.
3. Tape a printed contents list to the top. Not inside a drawer, not in a folder at the nurse station.
4. Restock immediately after use, not at shift end. The second arrest of the night finds the empty drawer.
5. Check cylinder pressure and the defibrillator every shift, and record it on the cart itself. A record kept elsewhere is a record nobody checks.
6. One cart per resuscitation position, plus one per inpatient floor. Carts shared between floors are carts that are always on another floor.

Suction is the first thing to fail

Suction is used more often and more urgently in emergency work than anywhere else in the hospital, and it fails for reasons that have nothing to do with the pump. The commonest cause of an unusable unit in a Bangladeshi casualty department is a jar that is full, dirty or missing; the second commonest is tubing cannibalised for another machine.

• Two independent sources at every resuscitation position. Piped vacuum plus a mobile unit of the SK-EX122 or SK-EX123 class. A portable battery unit such as the SU-510 covers transport and the lift.
• Two full jar sets per machine. One in use, one clean and ready. A department with three suction machines and one jar has one suction machine.
• Standardise the model. If every unit takes the same jar, seal and tubing, stock control becomes possible. Mixed fleets bought over five separate tenders are why store rooms hold consumables that fit nothing.
• Hold seals, float valves and tubing by the roll. These are small, cheap and the actual failure points. A perished lid seal presents as a pump that has lost suction, and tubing ordered from abroad runs out in the week you most need it.

Buying for surge: quantities, storage and lot structure

Surge capacity is mostly cheap. The expensive items scale slowly and the cheap items are the ones that actually strand patients, which means the correct buying strategy is deliberately lopsided.

• Buy the cheap things deep. Foldable stretchers, blankets, jars, tubing, catheters, IV stands, castors. None has a service contract and all of them decide whether an extra patient can be managed.
• Buy the expensive things to peak, not to peak plus one. Idle monitors and ventilators are a real cost. What matters is a written plan, agreed with theatre and ICU in advance, for where the next one comes from.
• Store surge stock where it can be deployed in minutes. Equipment in a locked basement two floors down, with one keyholder, is equipment you do not own during a surge. Mark the store, put a contents list on the door, audit it quarterly.
• Split your tender lots by service response, not by product family. An e-GP package that lumps beds, trolleys, wheelchairs and consumables into one lot produces a single winner who is strong on one line and weak on the rest. Trolleys need a supplier who can send a castor or a hydraulic ram quickly; consumables need one holding local stock. Pretending those are the same capability is how a department ends up with a fleet it cannot maintain.
• Write spares into the same contract. Ask for a priced spares list with lead times as part of the technical offer. A bidder who cannot produce one has not thought past delivery.
• Test at handover the way the kit gets used. Load every trolley to its rated capacity over the thresholds it crosses daily, and record each battery unit's runtime against its serial number, repeating that measurement every six months so ageing batteries are found before a transfer finds them.

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