Hospital

A hospital is a health care institution providing patient treatment by specialized staff and equipment.

Hospitals are usually funded by the public sector, by health organizations (for profit or nonprofit), health insurance companies, or charities, including direct charitable donations. Historically, hospitals were often founded and funded by religious orders or charitable individuals and leaders.^[1] Today, hospitals are largely staffed by professional physicians, surgeons, and nurses, whereas in the past, this work was usually performed by the founding religious orders or by volunteers. However, there are various Catholic religious orders, such as the Alexians and the Bon Secours Sisters, which still focus on hospital ministry today, as well as several Christian denominations, including the Methodists and Lutherans, which run hospitals.^[2]

In accord with the original meaning of the word, hospitals were originally "places of hospitality", and this meaning is still preserved in the names of some institutions such as the Royal Hospital Chelsea, established in 1681 as a retirement and nursing home for veteran soldiers.

Etymology

During the Middle Ages hospitals served different functions to modern institutions, being almshouses for the poor, hostels for pilgrims, or hospital schools. The word hospital comes from the Latin hospes, signifying a stranger or foreigner, hence a guest. Another noun derived from this, hospitium came to signify hospitality, that is the relation between guest and shelterer, hospitality, friendliness, hospitable reception. By metonymy the Latin word then came to mean a guest-chamber, guest's lodging, an inn.^[3] Hospes is thus the root for the English words host (where the p was dropped for convenience of pronunciation) hospitality, hospice, hostel and hotel. The latter modern word derives from Latin via the ancient French romance word hostel, which developed a silent s, which letter was eventually removed from the word, the loss of which is signified by a circumflex in the modern French word hôtel. The German word 'Spital' shares similar roots.

Grammar of the word differs slightly depending on the dialect. In the U.S., hospital usually requires an article; in Britain and elsewhere, the word normally is used without an article when it is the object of a preposition and when referring to a patient ("in/to the hospital" vs. "in/to hospital"); in Canada, both uses are found.^{[citation needed]}

Types

Some patients go to a hospital just for diagnosis, treatment, or therapy and then leave ('outpatients') without staying overnight; while others are 'admitted' and stay overnight or for several days or weeks or months ('inpatients'). Hospitals usually are distinguished from other types of medical facilities by their ability to admit and care for inpatients whilst the others often are described as clinics.

General

The best-known type of hospital is the general hospital, which is set up to deal with many kinds of disease and injury, and normally has an emergency department to deal with immediate and urgent threats to health. Larger cities may have several hospitals of varying sizes and facilities. Some hospitals, especially in the United States, have their own ambulance service.

District

A district hospital typically is the major health care facility in its region, with large numbers of beds for intensive care and long-term care;

Specialized

Types of specialized hospitals include trauma centers, rehabilitation hospitals, children's hospitals, seniors' (geriatric) hospitals, and hospitals for dealing with specific medical needs such as psychiatric problems (see psychiatric hospital), certain disease categories such as cardiac, oncology, or orthopedic problems, and so forth. In Germany specialized hospitals are called fachkrankenhaus; an example is Fachkrankenhaus Coswig (thoracic surgery).

A hospital may be a single building or a number of buildings on a campus. Many hospitals with pre-twentieth-century origins began as one building and evolved into campuses. Some hospitals are affiliated with universities for medical research and the training of medical personnel such as physicians and nurses, often called teaching hospitals. Worldwide, most hospitals are run on a nonprofit basis by governments or charities. There are however a few exceptions, e.g. China, where government funding only constitutes 10% of income of hospitals. (need citation here. Chinese sources seem conflicted about the for-profit/non-profit ratio of hospitals in China)

Specialized hospitals can help reduce health care costs compared to general hospitals. For example, Narayana Hrudayalaya's Bangalore cardiac unit, which is specialized in cardiac surgery, allows for significantly greater number of patients. It has 3000 beds (more than 20 times the average American hospital) and in pediatric heart surgery alone, it performs 3000 heart operations annually, making it by far the largest such facility in the world.^[4][5] Surgeons are paid on a fixed salary instead of per operation, thus the costs to the hospital drops when the number of procedures increases, taking advantage of economies of scale.^[4] Additionally, it is argued that costs go down as all its specialists become efficient by working on one "production line" procedure.^[5]

Teaching

A teaching hospital combines assistance to patients with teaching to medical students and nurses and often is linked to a medical school, nursing school or university.

Clinics

The medical facility smaller than a hospital is generally called a clinic, and often is run by a government agency for health services or a private partnership of physicians (in nations where private practice is allowed). Clinics generally provide only outpatient services.

Departments

Hospitals vary widely in the services they offer and therefore, in the departments (or "wards") they have. Each is usually headed by a Chief Physician. They may have acute services such as an emergency department or specialist trauma centre, burn unit, surgery, or urgent care. These may then be backed up by more specialist units such as:

• Emergency department
• Cardiology
• Intensive care unit
  • Paediatric intensive care unit
  • Neonatal intensive care unit
  • Cardiovascular intensive care unit
• Neurology
• Oncology
• Obstetrics and gynaecology

Some hospitals will have outpatient departments and some will have chronic treatment units such as behavioral health services, dentistry, dermatology, psychiatric ward, rehabilitation services, and physical therapy.

Common support units include a dispensary or pharmacy, pathology, and radiology, and on the non-medical side, there often are medical records departments, release of information departments, Information Management (aka IM, IT or IS), Clinical Engineering (aka Biomed), Facilities Management, Plant Ops (aka Maintenance), Dining Services, and Security departments.

History

Early examples

The earliest documented institutions aiming to provide cures were ancient Egyptian temples. In ancient Greece, temples dedicated to the healer-god Asclepius, known as Asclepieia functioned as centres of medical advice, prognosis, and healing.^[6] Asclepeia provided carefully controlled spaces conducive to healing and fulfilled several of the requirements of institutions created for healing.^[7] Under his Roman name Æsculapius, he was provided with a temple (291 BC) on an island in the Tiber in Rome, where similar rites were performed.^[8]

Institutions created specifically to care for the ill also appeared early in India. Fa Xian, a Chinese Buddhist monk who travelled across India ca. 400 CE, recorded in his travelogue that:The heads of the Vaisya [merchant] families in them [all the kingdoms of north India] establish in the cities houses for dispensing charity and medicine. All the poor and destitute in the country, orphans, widowers, and childless men, maimed people and cripples, and all who are diseased, go to those houses, and are provided with every kind of help, and doctors examine their diseases. They get the food and medicines which their cases require, and are made to feel at ease; and when they are better, they go away of themselves.^[9]

The earliest surviving encyclopaedia of medicine in Sanskrit is the Carakasamhita (Compendium of Caraka). This text, which describes the building of a hospital is dated by Dominik Wujastyk of the University College London from the period between 100 BCE and CE150.^[10] According to Dr.Wujastyk, the description by Fa Xian is one of the earliest accounts of a civic hospital system anywhere in the world and, coupled with Caraka’s description of how a clinic should be equipped, suggests that India may have been the first part of the world to have evolved an organized cosmopolitan system of institutionally-based medical provision.^[10]

According to the Mahavamsa, the ancient chronicle of Sinhalese royalty, written in the sixth century A.D., King Pandukabhaya of Sri Lanka (reigned 437 BC to 367 BC) had lying-in-homes and hospitals (Sivikasotthi-Sala) built in various parts of the country. This is the earliest documentary evidence we have of institutions specifically dedicated to the care of the sick anywhere in the world.^[11][12] Mihintale Hospital is the oldest in the world.^[13] Ruins of ancient hospitals in Sri Lanka are still in existence in Mihintale, Anuradhapura, and Medirigiriya.^[14]

Roman Empire

The Romans constructed buildings called valetudinaria for the care of sick slaves, gladiators, and soldiers around 100 B.C., and many were identified by later archeology. While their existence is considered proven, there is some doubt as to whether they were as widespread as was once thought, as many were identified only according to the layout of building remains, and not by means of surviving records or finds of medical tools.^[15]

The declaration of Christianity as accepted religion in the Roman Empire drove an expansion of the provision of care. Following the First Council of Nicaea in 325 A.D. construction of a hospital in every cathedral town was begun. Among the earliest were those built by the physician Saint Sampson in Constantinople and by Basil, bishop of Caesarea in modern-day Turkey. Called the "Basilias", the latter resembled a city and included housing for doctors and nurses and separate buildings for various classes of patients.^[16] There was a separate section for lepers.^[17] Some hospitals maintained libraries and training programs, and doctors compiled their medical and pharmacological studies in manuscripts. Thus in-patient medical care in the sense of what we today consider a hospital, was an invention driven by Christian mercy and Byzantine innovation.^[18] Byzantine hospital staff included the Chief Physician (archiatroi), professional nurses (hypourgoi) and the orderlies (hyperetai). By the twelfth century, Constantinople had two well-organized hospitals, staffed by doctors who were both male and female. Facilities included systematic treatment procedures and specialized wards for various diseases.^[19]

A hospital and medical training centre also existed at Gundeshapur. The city of Gundeshapur was founded in 271 CE by the Sasanian king Shapur I. It was one of the major cities in Khuzestan province of the Persian empire in what is today Iran. A large percentage of the population were Syriacs, most of whom were Christians. Under the rule of Khusraw I, refuge was granted to Greek Nestorian Christian philosophers including the scholars of the Persian School of Edessa (Urfa)(also called the Academy of Athens), a Christian theological and medical university. These scholars made their way to Gundeshapur in 529 following the closing of the academy by Emperor Justinian. They were engaged in medical sciences and initiated the first translation projects of medical texts.^[20] The arrival of these medical practitioners from Edessa marks the beginning of the hospital and medical centre at Gundeshapur.^[21] It included a medical school and hospital (bimaristan), a pharmacology laboratory, a translation house, a library and an observatory.^[22] Indian doctors also contributed to the school at Gundeshapur, most notably the medical researcher Mankah. Later after Islamic invasion, the writings of Mankah and of the Indian doctor Sustura were translated into Arabic at Baghdad.^[23]

Medieval Islamic world

The first prominent Islamic hospital was founded in Damascus, Syria in around 707 with assistance from Christians.^[24] However most agree that the establishment at Baghdad was the most influential; it opened during the Abbasid Caliphate of Harun al-Rashid in the 8th century.^[25] The bimaristan (medical school) and bayt al-hikmah (house of wisdom) were established by professors and graduates from Gundeshapur and was first headed by the Christian physician Jibrael ibn Bukhtishu from Gundeshapur and later by Islamic physicians.^[26]

In the ninth and tenth centuries the hospital in Baghdad employed twenty-five staff physicians and had separate wards for different conditions.^[27] The Al-Qairawan hospital and mosque, in Tunisia, were built under the Aghlabid rule in 830 and was simple, but adequately equipped with halls organized into waiting rooms, a mosque, and a special bath. The first hospital in Egypt was opened in 872 and thereafter public hospitals sprang up all over the empire from Islamic Spain and the Maghrib to Persia. The first Islamic psychiatric hospital opened in Baghdad in 705. Many other Islamic hospitals also often had their own wards dedicated to mental health.^[28]

In contrast to medieval Europe, medical school under Islam did not have faculties and did not develop a system of academic evaluation and certification^[29]

Medieval Europe

Medieval hospitals in Europe followed a similar pattern to the Byzantine. They were religious communities, with care provided by monks and nuns. (An old French term for hospital is hôtel-Dieu, "hostel of God.") Some were attached to monasteries; others were independent and had their own endowments, usually of property, which provided income for their support. Some hospitals were multi-functional while others were founded for specific purposes such as leper hospitals, or as refuges for the poor, or for pilgrims: not all cared for the sick. The first Spanish hospital, founded by the Catholic Visigoth bishop Masona in 580AD at Mérida, was a xenodochium designed as an inn for travellers (mostly pilgrims to the shrine of Eulalia of Mérida) as well as a hospital for citizens and local farmers. The hospital's endowment consisted of farms to feed its patients and guests.

The Ospedale Maggiore, traditionally named Ca' Granda (i.e. Big House), in Milan, northern Italy, was constructed to house one of the first community hospitals, the largest such undertaking of the fifteenth century. Commissioned by Francesco Sforza in 1456 and designed by Antonio Filarete it is among the first examples of Renaissance architecture in Lombardy.

The Normans brought their hospital system along when they conquered England in 1066. By merging with traditional land-tenure and customs, the new charitable houses became popular and were distinct from both English monasteries and French hospitals. They dispensed alms and some medicine, and were generously endowed by the nobility and gentry who counted on them for spiritual rewards after death.^[30]

Early modern & Enlightenment Europe

In Europe the medieval concept of Christian care evolved during the sixteenth and seventeenth centuries into a secular one. After the dissolution of the monasteries in 1540 by King Henry VIII the church abruptly ceased to be the supporter of hospitals, and only by direct petition from the citizens of London, were the hospitals St Bartholomew's, St Thomas's and St Mary of Bethlehem's (Bedlam) endowed directly by the crown; this was the first instance of secular support being provided for medical institutions.

The voluntary hospital movement began in the early 18th century, with hospitals being founded in London by the 1710s and 20s, including Westminster Hospital (1719) promoted by the private bank C. Hoare & Co and Guy's Hospital (1724) funded from the bequest of the wealthy merchant, Thomas Guy. Other hospitals sprang up in London and other British cities over the century, many paid for by private subscriptions. St. Bartholomew's opened in London in 1730, and the London Hospital in 1752.

These hospitals represented a turning point in the function of the institution; they began to evolve from being basic places of care for the sick to becoming centres of medical innovation and discovery and the principle place for the education and training of prospective practitioners. Some of the era's greatest surgeons and doctors worked and passed on their knowledge at the hospitals.^[31] They also changed from being mere homes of refuge to being complex institutions for the provision of medicine and care for sick. The Charité was founded in Berlin in 1710 by King Frederick I of Prussia as a response to an outbreak of plague.

The concept of voluntary hospitals also spread to Colonial America; the Pennsylvania Hospital opened in 1752, New York Hospital in 1771, and Massachusetts General Hospital in 1811. When the Vienna General Hospital opened in 1784 (instantly becoming the world's largest hospital), physicians acquired a new facility that gradually developed into one of the most important research centres.^[32]

Another Enlightenment era charitable innovation was the dispensary; these would issue the poor with medicines free of charge. The London Dispensary opened its doors in 1696 as the first such clinic in the British Empire. The idea was slow to catch on until the 1770s, when many such organizations began to appear, including the Public Dispensary of Edinburgh (1776), the Metropolitan Dispensary and Charitable Fund (1779) and the Finsbury Dispensary (1780). Dispensaries were also opened in New York 1771, Philadelphia 1786, and Boston 1796.^[33]

19th century

English physician Thomas Percival (1740-1804) wrote a comprehensive system of medical conduct, 'Medical Ethics, or a Code of Institutes and Precepts, Adapted to the Professional Conduct of Physicians and Surgeons (1803) that set the standard for many textbooks.^[34]

In the mid 19th century, hospitals and the medical profession became more professionalized, with a reorganization of hospital management along more bureaucratic and administrative lines. The Apothecaries Act 1815 made it compulsory for medical students to practice for at least half a year at a hospital as part of their training.^[35]

Florence Nightingale pioneered the modern profession of nursing during the Crimean War when she set an example of compassion, commitment to patient care and diligent and thoughtful hospital administration. The first official nurses’ training programme, the Nightingale School for Nurses, was opened in 1860, with the mission of training nurses to work in hospitals, to work with the poor and to teach.^[36]

Nightingale was instrumental in reforming the nature of the hospital, by improving sanitation standards and changing the image of the hospital from a place the sick would go to die, to an institution devoted to recuperation and healing. She also emphasized the importance of statistical measurement for determining the success rate of a given intervention and pushed for administrative reform at hospitals.^[37]

By the late 19th century, the modern hospital was beginning to take shape with a proliferation of a variety of public and private hospital systems. By the 1870s, hospitals had more than trebled their original average intake of 3,00 patients. In continental Europe the new hospitals generally were built and run from public funds. The National Health Service, the principle provider of health care in the United Kingdom, was founded in 1948.

During the nineteenth century, the Second Viennese Medical School emerged with the contributions of physicians such as Carl Freiherr von Rokitansky, Josef Škoda, Ferdinand Ritter von Hebra, and Ignaz Philipp Semmelweis. Basic medical science expanded and specialization advanced. Furthermore, the first dermatology, eye, as well as ear, nose, and throat clinics in the world were founded in Vienna, being considered as the birth of specialized medicine.^[38]

Criticism

While hospitals, by concentrating equipment, skilled staff and other resources in one place, clearly provide important help to patients with serious or rare health problems, hospitals also are criticised for a number of faults, some of which are endemic to the system, others which develop from what some consider wrong approaches to health care.

One criticism often voiced is the 'industrialised' nature of care, with constantly shifting treatment staff, which dehumanises the patient and prevents more effective care as doctors and nurses rarely are intimately familiar with the patient. The high working pressures often put on the staff can sometimes exacerbate such rushed and impersonal treatment. The architecture and setup of modern hospitals often is voiced as a contributing factor to the feelings of faceless treatment many people complain about.^[39]

Funding

In the modern era, hospitals are, broadly, either funded by the government of the country in which they are situated, or survive financially by competing in the private sector (a number of hospitals also are still supported by the historical type of charitable or religious associations).

In the United Kingdom for example, a relatively comprehensive, "free at the point of delivery" health care system exists, funded by the state. Hospital care is thus relatively easily available to all legal residents, although free emergency care is available to anyone, regardless of nationality or status. As hospitals prioritize their limited resources, there is a tendency for 'waiting lists' for non-crucial treatment in countries with such systems, as opposed to letting higher-payers get treated first, so sometimes those who can afford it take out private health care to get treatment more quickly.^[40] On the other hand, some countries, including the USA, have in the twentieth century introduced a private-based, for-profit-approach to providing hospital care, with few state-money supported 'charity' hospitals remaining today.^[41] Where for-profit hospitals in such countries admit uninsured patients in emergency situations (such as during and after Hurricane Katrina in the USA), they incur direct financial losses,^[41] ensuring that there is a clear disincentive to admit such patients. In the United States, laws exist to ensure patients receive care in life threatening emergency situations regardless of the patient's ability to pay.^[42]

As the quality of health care has increasingly become an issue around the world, hospitals have increasingly had to pay serious attention to this matter. Independent external assessment of quality is one of the most powerful ways to assess this aspect of health care, and hospital accreditation is one means by which this is achieved. In many parts of the world such accreditation is sourced from other countries, a phenomenon known as international healthcare accreditation, by groups such as Accreditation Canada from Canada, the Joint Commission from the USA, the Trent Accreditation Scheme from Great Britain, and Haute Authorité de santé (HAS) from France.

Buildings

Architecture

Modern hospital buildings are designed to minimize the effort of medical personnel and the possibility of contamination while maximizing the efficiency of the whole system. Travel time for personnel within the hospital and the transportation of patients between units is facilitated and minimized. The building also should be built to accommodate heavy departments such as radiology and operating rooms while space for special wiring, plumbing, and waste disposal must be allowed for in the design.^[43]

However, the reality is that many hospitals, even those considered 'modern', are the product of continual and often badly managed growth over decades or even centuries, with utilitarian new sections added on as needs and finances dictate. As a result, Dutch architectural historian Cor Wagenaar has called many hospitals:

"... built catastrophes, anonymous institutional complexes run by vast bureaucracies, and totally unfit for the purpose they have been designed for ... They are hardly ever functional, and instead of making patients feel at home, they produce stress and anxiety."^[44]

Some newer hospitals now try to re-establish design that takes the patient's psychological needs into account, such as providing more fresh air, better views and more pleasant colour schemes. These ideas harken back to the late eighteenth century, when the concept of providing fresh air and access to the 'healing powers of nature' were first employed by hospital architects in improving their buildings.^[44]

The research of British Medical Association is showing that good hospital design can reduce patient's recovery time. Exposure to daylight is effective in reducing depression. Single sex accommodation help ensure that patients are treated in privacy and with dignity. Exposure to nature and hospital gardens is also important – looking out windows improves patients' moods and reduces blood pressure and stress level. Eliminating long corridors can reduce nurses' fatigue and stress.^[45]

Another ongoing major development is the change from a ward-based system (where patients are accommodated in communal rooms, separated by movable partitions) to one in which they are accommodated in individual rooms. The ward-based system has been described as very efficient, especially for the medical staff, but is considered to be more stressful for patients and detrimental to their privacy. A major constraint on providing all patients with their own rooms is however found in the higher cost of building and operating such a hospital; this causes some hospitals to charge for private rooms.^[46]

See also

• History of medicine
• List of hospitals
• Burn centre
• Hospital information system
• Trauma centre
• The Waiting Room (documentary)

References

Bibliography

History of hospitals

• Brockliss, Lawrence, and Colin Jones. "The Hospital in the Enlightenment," in The Medical World of Early Modern France (Oxford UP, 1997), pp. 671–729; covers France 1650–1800
• Chaney, Edward (2000),"'Philanthropy in Italy': English Observations on Italian Hospitals 1545–1789", in: The Evolution of the Grand Tour: Anglo-Italian Cultural Relations since the Renaissance, 2nd ed. London, Routledge, 2000. http://books.google.co.uk/books/about/The_evolution_of_the_grand_tour.html?id=rYB_HYPsa8gC
• Connor, J. T. H. "Hospital History in Canada and the United States," Canadian Bulletin of Medical History, 1990, Vol. 7 Issue 1, pp 93–104
• Crawford, D.S. Bibliography of Histories of Canadian hospitals and schools of nursing.
• Gorsky, Martin. "The British National Health Service 1948–2008: A Review of the Historiography," Social History of Medicine, Dec 2008, Vol. 21 Issue 3, pp 437–460
• Harrison, Mar, et al. eds. From Western Medicine to Global Medicine: The Hospital Beyond the West (2008)
• Horden, Peregrine. Hospitals and Healing From Antiquity to the Later Middle Ages (2008)
• McGrew, Roderick E. Encyclopedia of Medical History (1985)
• Morelon, Régis; Rashed, Roshdi (1996), Encyclopedia of the History of Arabic Science 3, Routledge, ISBN 0-415-12410-7 
• Porter, Roy. The Hospital in History, with Lindsay Patricia Granshaw (1989) ISBN 978-0-415-00375-9
• Risse, Guenter B. Mending Bodies, Saving Souls: A History of Hospitals (1999), 716pp; world coverage excerpt and text search
• Rosenberg, Charles E. The Care of Strangers: The Rise of America's Hospital System (1995) history to 1920 table of contents and text search
• Scheutz, Martin et al. eds. Hospitals and Institutional Care in Medieval and Early Modern Europe (2009)
• Wall, Barbra Mann. American Catholic Hospitals: A Century of Changing Markets and Missions (Rutgers University Press, 2011). 238 pp. ISBN 978-0-8135-4940-8

External links

Wikimedia Commons has media related to Hospital.

• Medical History open access scholarly journal; quarterly since 1957
• Jean Manco, The Heritage of Mercy (medieval hospitals in Britain)
• Last Resort: Hospital Care in Canada (an illustrated historical essay)
• Medieval Hospitals of England, by Rotha Mary Clay, historyfish.net (1909 book, now in the public domain)
• Directory and Ranking of more than 17000 Hospitals worldwide, hospitals.webometrics.info
• Best Hospitals, Best Cardiac Hospitals,starhospitals.in/
• Best Hospitals, Best Orthopaedic Hospital AgkneeClinic.in