VOLUME 43 I NUMBER 1 I APRIL 2020
CORONAVIRUS – HVAC AND COVID-19 LEGIONELLA THE HEADLINE – PSEUDOMONAS THE REAL ISSUE ASSET DATA – MEASURE IT AND IT WILL IMPROVE
National President’s message
31 Engineers need to drive sustainability
77 News BRANCH REPORTS 10 QLD 13 VIC/TAS 14 WA 19 SA
41 Legionella maybe the headline Pseudomonas is the real issue 51 Asset data: Measure it and it will improve 57 Pushing healthcare technology boundaries INTERNATIONAL
65 Healthcare infrastructure planning & design in the Western Cape Province, South Africa
24 2 019 NZIHE Conference in New Plymouth
71 A risk management culture that works
SPECIAL FEATURE 26 HVAC and COVID-19
Visit the Institute of Healthcare Engineering online by visiting www.ihea.org.au or scanning here ➞
IHEA NATIONAL OFFICE Direct: 1300 929 508 Email: IHEA.email@example.com Address: PO Box 6203, Conder ACT 2900 Website: www.ihea.org.au Conference: www.hfmc2019.org.au IHEA NATIONAL BOARD National President Peter Easson National Immediate Past President Brett Petherbridge National Vice President Jon Gowdy National Treasurer Mal Allen Communications Darryl Pitcher Membership Registrar Peter Footner
Standards Coordinator Brett Nickels Directors Michael McCambridge, Peter Klymiuk, Mark Hooper IHEA ADMINISTRATION Chief Executive Officer Karen Taylor Finance Jeff Little Membership Angeline Canta (FMA), firstname.lastname@example.org Editorial Committee Darryl Pitcher, Mark Hooper IHEA MISSION STATEMENT To support members and industry stakeholders to achieve best practice health engineering in sustainable public and private healthcare sectors.
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The views expressed in this publication are not necessarily those of the Institute of Healthcare Engineering Australia or the publisher. The publisher shall not be under any liability whatsoever in respect to the contents of contributed articles. The Editor reserves the right to edit or otherwise alter articles for publication. Adbourne Publishing cannot ensure that the advertisers appearing in The Hospital Engineer comply absolutely with the Trades Practices Act and other consumer legislation. The responsibility is therefore on the person, company or advertising agency submitting the advertisement(s) for publication. Adbourne Publishing reserves the right to refuse any advertisement without stating the reason. No responsibility is accepted for incorrect information contained in advertisements or editorial. The editor reserves the right to edit, abridge or otherwise alter articles for publication. All original material produced in this magazine remains the property of the publisher and cannot be reproduced without authority. The views of the contributors and all submitted editorial are the author’s views and are not necessarily those of the publisher.
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Our world has changed…” shouted the headline of a recent email, one of many that is streaming into my inbox, as the whole world tries to come to terms with the present crisis … COVID-19. “Unprecedented” … “Once in 100 year event” (and many more similar phrases) are no longer shocking us like they might once have. Coming on the back of some of the most devastating fires this country has ever seen during our recent summer, the present crisis seems to dwarf all others before it. And while we are yet to experience the full impact, there is no doubt, our world has changed. The imposition of new measures at a Federal and State government level are intended to slow the spread of infection and minimise the impact on community – and the healthcare system. Clearly these systems have been overrun in other parts of the world, and “flattening the curve” of infection rates is the objective of the present restrictive measures. It’s hard to contemplate what the world might look like on the other side of the present situation.
the function and form of clinical spaces to treat highly infectious respiratory illnesses. Consequently, when I put the urgent call out for information that we could share in this publication specific to the present situation – most of our contributors were still scrambling to find and implement solutions. Consequently this edition is a traditional preCoronavirus edition, and we will look to future editions to share the learning of our members and our industry.
And never before have healthcare executives looked to their engineering professionals for guidance, advice and support to prevent healthcare systems collapsing from an influx of patients and rushing to significantly changing
Regards Darryl Pitcher – Editor
Now is the time to look to your peak body, supporting healthcare engineering, to network, learn and share. Inside you will see that a new “Healthcare Organisation Group Discount” has been launched, so if you have multiple personnel who could benefit from membership, now is also a good time to take advantage of group discounts on annual IHEA membership. I hope you enjoy this edition of Healthcare Facilities, and if you have any experiences or solutions that you feel we could share with others nationally and globally, please get in touch with me at email@example.com
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NATIONAL PRESIDENT’S MESSAGE
s we enter the 71st year of the IHEA’s existence I’m excited by the prospects of what the next 12 months has to offer our membership. The development of the online training program (LDP) continues to mature, and as it does so I strongly encourage all members to share their experiences in using the system with others.
The updated strategic plan and board meeting minutes are available to members on the IHEA website.
Only by doing this can we adapt and grow the program to provide a more integrated and accessible learning pathway that will align with skillset growth expectations for all participants in the curriculum.
The ANZEX delegate is a member nominated by the respective Boards of IHEA and NZIHE and is sponsored for a visit to New Zealand or Australia to attend and participate in the two countries National Conference and to visit hospitals and healthcare facilities.
The IHEA National Board Meeting held in Adelaide in early February had a particular focus on building a foundation for our organisation that will enhance membership participation and provide strong advocacy for our industry throughout the various levels of governance within healthcare. The development of the new strategic plan during our February meeting reflects the board’s contemporary thinking with one of the key objectives now linked to maintaining relevancy and increasing recognition in our sector. Aligned with these initiatives will be the implementation of an enhanced communications plan which will target on sharing information and opportunities across a variety of media.
The ANZEX exchange program with the New Zealand Institute of Healthcare Engineering (NZIHE) is now open for nominations. Whilst there is some uncertainty about the future months, we are still calling for nominations.
The ANZEX delegate is selected annually by the National Board after having considered nominations received from the membership, state branches or national board. I have personally participated in this program in my early years with the IHEA and found it a great experience to meet and learn from our colleagues in New Zealand. This is a timely reminder to all Committees of Management to get the message out to members in their respective states, to ensure we get good candidates in this excellent exchange program. Details of the opportunities and expectations of involvement can be found on the IHEA website or contact your state branch for more information. Jon Gowdy – IHEA National President
STOP PRESS – COVID-19 UPDATE – REMEMBER TO TAKE CARE OF YOURSELF… Working in the healthcare industry during the current COV19 crisis we are all trying to respond in our various capacities and it is timely to take stock of the impact on ourselves and colleagues’ welfare, this is a period where many of us are experiencing feelings of anxiety, distress and concern in relation to the Coronavirus (COVID-19). Please be aware there are resources such as Beyond Blue that has resources which can assist: https://www.beyondblue.org.au/the-facts/looking-after-your-mental-health-during-the-coronavirus-outbreak
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Strategic Planning: Why Do We Need To Do It?
n early February every year the IHEA Board and CEO meet to review the current strategic plan. Every three years a new plan is developed. On Feb 6th 2020 we met to develop a new plan for 2020-2022. Why do we do this? Why does any organisation do this? Regardless of whether your business is small or one of the biggest players in the industry, you will likely have heard stories of how other organisations have achieved success through well thought-out strategic planning. Is strategic planning still relevant for businesses today, and how exactly does it help an organisation? Effective strategic management can bring many benefits to any business – these include the following four. It outlines a clear path for IHEA No business can hope to succeed by not having a plan and simply hoping to stumble across success. You’ve probably all heard the adage attributed to Benjamin Franklin, “If you fail to plan, you are planning to fail.”
It brings a sense of focus Because a strategic plan establishes a direction for IHEA to take, it will help it sharpen our focus in order to get there. Strategic planning can therefore help IHEA to develop the right goals and targets and assist everyone to focus their efforts on meeting them. This year we have allocated a lead Director to each of our five Strategic Objectives. Each Directors is responsible for developing a more detailed Business Plan against each Strategic Objective in order to have clear tasks and accountabilities as we work towards success in each area. It improves IHEA's self-awareness Taking the time to establish a comprehensive strategic plan means IHEA has a better awareness of its strengths and weaknesses and where it stands in the market, both individually and in relation to competitors. It gives IHEA something to work towards Strategic planning gives everyone in IHEA a sense of purpose.
A strategic plan works like a roadmap, clearly defining the best route to take in the years ahead. Whether it covers one, three or five years into the future, a strategic plan can help IHEA meet the challenges that lie in wait.
With a definitive mission and clear goals and objectives to work towards, our efforts are rewarded with outcomes and ultimately count towards something substantive.
Like a road-map, clear markers of progress are also helpful, so creating measurable targets also allow us to “mark off” progress against the plan.
You can watch our progress via the IHEA website where the current Strategic Plan is now available and we will regularly communicate progress updates against each of the objectives agreed to. Karen Taylor – CEO
QLD BRANCH REPORT Branch Activities Feb PD
n the 20 February 2020, the Queensland Branch hosted at the Pineapple Hotel, a Professional Development (PD) seminar on the new Mechanical Services licensing arrangements introduced for Queensland. The PD was well attended with approximately 60 attendees (including a significant contingent of non-members) from both healthcare and engineering service providers joining in.
Townsville Hospitals and the Asset Management Unit of Queensland Health. The Branch is exploring options to make a recording of this PD and the December 2019 PD (not streamed live) available. We also look forward to exploring this medium for providing other PD opportunities to our members. A special thanks to BOC, Opira and Air Restore for sponsoring the event.
Without sponsors, our PD events would not be possible. Unfortunately due to the outbreak of Coronavirus the planned PD country meeting in Mackay has been postponed until further notice. We apologise for this inconvenience. Membership We are happy to advise that our branch is experiencing gentle but steady growth, as new healthcare professionals see the benefit of IHEA membership.. Committee of Management
The topic was timely, and questions raised by attendees helped to highlight scenarios specific to the healthcare sector, some of which will be followed up by the Queensland Building and Construction Commission (QBCC). Presentations from the QBCC, BOC and Dawson Technical Services (DTS) provided the perspective from not only the legislator but also from service providers who have been engaged in the process and very knowledgeable on the issue. Thank you to Stewart Marshall (BOC), Evan Dawson (DTS) and Graham Easterby (QBBC) for their well-considered presentations. The PD was also a first for the Queensland Branch in that we successfully employed ZOOM online meetings to live stream the presentations to staff at the Mackay and
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Christopher Ansley Hartwell
If you would like to communicate with the QLD Branch via email, please do so at email@example.com Adrian Duff President, QLD Branch
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VIC/TAS BRANCH REPORT Autumn 2020
t has been an eventful start to the year with many of our regional Victorian members either facing the threat of bushfire damage or fighting fires with the CFA. Even those of us in more urban areas have been dealing with the challenges of high smoke levels in and around the buildings that we manage. This has led to a number of discussions around bushfire mitigation and smoke management and exposed vulnerabilities in some fire alarm systems, particularly alarms on VESDA systems often used in data centres. A new area that the Vic/Tas Committee of Management is currently investigating is involvement with the Strategic Industry Research Foundation Round Tables. SIRF Roundtables are a business improvement framework, bringing together government and research bodies through industry-led networks. This provides a secure and structured environment for members to meet and learn together. The environment is aimed at seeking out and sharing leadingedge practices and facilitating information sharing among members. The membership is restricted (no consultants or vendors) to ensure worthwhile outcomes, and the facilitators utilised by SIRF have extensive real-world industry experience.
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As most of us are aware it can be challenging to find new materials or venues for professional development days so this certainly represents some exciting opportunities for the professional development of our members. As communicated previously the National Board has access to Zoom Webinar and we intend to utilise the online streaming service for our Parch PD on Section J of the BCA - “Operational Building Energy Efficiency” Please keep an eye out for the e-Bulletin advising of the time of the Webinar. These usually only run for an hour so this is a great way to get information without the need for travel and leaving the workplace. Another option available to our members is the IHEA Learning and Development app available for downloaded on your smart device. We would encourage all members to download the app, enter some training that has been done and even complete some of the courses on the app. The more engagement we can get with this the better we can make it for everybody. Feedback on the usefulness and functionality of the app can be sent to firstname.lastname@example.org. To contact the Vic-Tas branch of the IHEA, please reach out to us on Facebook, or email at email@example.com.
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WA BRANCH REPORT
he WA Branch celebrated the end of a busy 2019 at the Varsity Bar in Northbridge on Friday 29th November with the Annual Xmas Sundowner and Awards Night. Over 50 members and guests attended the evening with great food, cold drinks, fellowship and (tall) stories from colleagues, renewed friendships. Quite a few laughs were had at the slideshow of images from during the year, projected on the back wall during the evening. Festivities were finally called to order for the President’s address by Mr Peter Klymiuk and announcement of the annual award winners decided by the Committee of Management from a substantial pool of high quality nominations. The award winners included the 2019 Healthcare Apprentice of the year was Ryan Harris form Snap Plumbing, The 2019 Healthcare Tradesperson of the year was Nathan Miller from Sir Charles Gardiner Hospital, and the 2019 Healthcare Engineer of the year was Mr John Pereira from Serco at Fiona Stanley Hospital. It was a great evening and many thanks to IHEA WA committee members who organised the event Mr Alex Foster, Darryl Carter and John Bose. WA branch members took a break from our Professional Development sessions over the Christmas and New Year period, however 2020 National Conference Convenor Mr Fred Foley and the WA Committee of Management members continued to plan an exciting national conference agenda, technical tours and social events to highlight the relaxed lifestyle of the Western Australian destination of Perth, and to showcase both healthcare and infrastructure facilities of excellence. The IHEA Healthcare Facilities Management Conference (HFMC 2020) will be held on 21-23 September 2020 at the Perth Convention and Exhibition Centre (PCEC). This year’s theme is “21st Century Healthcare Engineering” which aims to give delegates an insight into the developing trends in information and biomedical technologies that may impact on how we deliver Healthcare Facility Management Services into the 21st Century. Healthcare is one of the leaders in the development of new technologies. The worlds of Healthcare Engineering and Facility Managers have to change to stay in tune, what we did yesterday is different to what we do today and who knows what we will do tomorrow? The entire IHEA WA membership looking forward to welcoming you to Perth, 21-23 September 2020! The call for abstracts is open and we encourage you to share your experience. If you are preparing an abstract, please submit your work before 9 March 2020 via the conference website link: https:// event.icebergevents.com.au/ihea-2020/call-for-abstracts or visit the full conference website via: https://event. icebergevents.com.au/ihea-2020
Additionally over the break the WA Branch president Mr Peter Klymiuk attended the National Strategic Planning Session and tabled items on behalf of WA members for the IHEA national board. The Committee of Management voted to install a new state secretary Mr Andrew Waugh, to allow the exiting State Secretary Mr Fred Foley to focus upon National Conference convenor duties and ongoing
Vice Presidentâ€™s role. Thank you to Fred for his stewardship as the IHEA WA State Secretary on behalf of all members, and setting a high standard to follow. The first Professional Development event in 2020 was held on 14th of February at Saint John of God Hospital Midland. Mr Daryl Carter provided his candid thoughts and shared
technical talks on: Utility challenges of increasing solar power generation penetration and impacts on Hospitals connected at Medium/High Voltage (i.e. above 1kV); Analysis and discussion of Western Power’s network performance and fault management during a recent bushfire in Baldivis impacting 330 kV transmission lines; and shall conclude with a Network Operations Control Room tour observing live operations. Any contact with the WA branch is welcomed via ihea. email@example.com
his journey of “The joys of a Modern Hospital – 5 years on”. Darryl shared his journey from HVAC into Hospital facility Management at Midland from commissioning and into operations. His candour and personal presentation style was engaging and generated audience contributions during the discussion unearthing similar anecdotes, experience on topics that resonated – UPS systems, water quality, grounds – to name a few. Many thanks to the February PD session sponsor Snap Plumbing, for refreshments at the conclusion of the evening session. Looking ahead IHEA WA branch Professional Development session shall be on 5th March at Western Power, the Western Australian electrical power transmission and distribution utility company. The agenda includes
WA Branch Role
Immediate Past President
CoM – Journal Representative
Peter Klymiuk WA Branch President
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SA BRANCH REPORT
t the February 2020 board meeting there was unanimous support for broadening the regional coverage of the SA branch into a new SA/NT branch. The SA/NT Committee of Management officially welcomes members from the Northern Territory and looks forward to creating opportunities to engage and connect with you. The prevailing coronavirus pandemic is already placing great pressure on our hospitals and aged care facilities. Our members are feeling the impacts and responding with operational changes to the way they work, and likewise we are considering alternative pathways to engage with members.
SA/NT Branch Committee of Management President and National Board Representative
Treasurer and Secretary
Richard Bentham Tony Edmunds Ross Jones Darryl Pitcher Daniel Romeo Andrew Russell Vince Russo
Michael Scerri President, SA Branch
Whilst this planning is is being considered, and consistent with the advice from the Board, we have taken immediate action to suspend upcoming planned events including the legionella awareness training, the regional state meeting, and professional development delivered in association with partner organisations. Your committee will turn attention towards considering how we can continue to drive benefits for members under the prevailing conditions. Please matters visit us At Australian Healthcare Week, Onto of membership, the Committee continue 2018 to consider new engagement and membership growth At Darling Harbour, Sydney 21 â€“ 23meetings. The SA/NT strategies at each of itsMarch monthly We will be launching our latest technology in branch is especially pleased to welcome new member Plant Control, Smart Monitoring and High Level Damien BreenInterface to our ranks. BMS Coms
At its last meeting, the SA/NT committee also commenced planning discussions for the 2021 National Conference â€“ and we will be applying considerable effort to this in the next few months to begin the planning process. Thoughts ideas and feedback are always more than welcome to make this important national event a huge success again in 2021.
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If you have any queries about SA/NT branch activities or would like to offer any suggestions please email ihea.sa@ ihea.org.au. The Committee is always happy to receive feedback and understand how it can deliver greater value for members.
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NSW/ACT BRANCH REPORT PD Day Report
n the 29th of November NSW/ACT Branch held a Professional Development Day in Newcastle hosted by HNELHD at John Hunter Hospital. The day was opened by Mellissa Harvey, Acting Manager, Operational Support and Facilities John Hunter Hospital, John Hunter Children’s Hospital, with the theme for the day being Fire & Safety, which is topic that many members are very interested in especially with the current issues surround bushfires in Country NSW. There were a number of presenters on the day which covered a number of areas within the theme of Fire & Safety. The speakers included, Cindy Xin Yi, FM Global, “Mitigate hospital Risk”, Col Whiteman, CIRCA Solutions, “Fire and Safety”, Steve Robins, Safe Work, “Hazardous Materials” and Boyd Conrick, Fire & Rescue Hazmat Newcastle, covering Hazmat Operational Planning and Risk Management during incidents. There was also an interactive session with delegates as part of Col Whiteman’s presentation which covered and was well received by delegates.
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ACT/NSW Branch President Rob Arian
Justin Walker, Kelly Bell, Phil Hanbury HNELHD Rob Arian, Jim Meldrum, Mellissa Harvey
The day concluded with a short presentation by myself overviewing the LDP program and live demonstration utilising the App for collection of detail to gain points for professional development and also an open forum to discuss future events. Delegate registration was very pleasing with close to fifty delegates attending the day from various areas across ACT/NSW including delegates from a number of country areas.
Delegates – interactive session
Introducing the Young Professionals Group! We’re looking for tomorrow’s leaders by establishing a bi-monthly meeting of young branch members to help continue to shape the future of the organisation. To have your voice heard, register interest at the email below and join us on April 21st at 11am ACDT.
For more information contact email@example.com
2019 NZIHE CONFERENCE IN NEW PLYMOUTH By Rob Arian – 2019 ANZEX Representative & IHEA NSW/ACT President
In early 2019 I was honored to be nominated as Australian Australia New Zealand Exchange (ANZEX) delegate to attend the 83rd NZIHE annual conference in New Plymouth, New Zealand. I felt fortunate to carry on this long standing tradition of collaboration between our institutions and to represent IHEA as many have done before me.
y journey to New Plymouth started on November 6th 2019. New Plymouth is the major city of the Taranaki Region on the west coast of the North Island of New Zealand. It is named after the English city of Plymouth from where the first English settlers to New Zealand migrated. The New Plymouth District, which includes New Plymouth City and several smaller towns, is the 10th largest district (out of 67) in New Zealand, and has a population of 74,184 – about two-thirds of the total population of the Taranaki Region and 1.7% of New Zealand’s population. I arrived at Sydney airport in early hours of morning to catch my first flight to Auckland. The flight from Sydney to Auckland was pleasant an uneventful. Unfortunately that was the best part of my travelling itinerary as the rest of trip to New Plymouth had a few surprises for me. My flight from Auckland to New Plymouth was canceled due to poor weather conditions so I was sent to Wellington. In order to make it to the conference opening on time the best option was to drive to New Plymouth on 7th November 2019 early in the morning. The 4.5 hour drive was a great way of exploring NZ’s beautiful landscape and before long I was there. There I was greeted by conference organisers and a few members of NZIHE Committee. They all made me feel welcomed. Gavin Carey-Smith (President NZIHE) and Michael Brown (Vice President) whom I met at our Sydney conference were both very welcoming and we had a few discussions around our future collaborations and how our organisations
can assist each other in developing standards and knowledge sharing. I was given the opportunity to take part in the ANZEX delegate session and present my conference papers. During the conference I realised that the challenges health engineers are facing, are very similar on both sides of the Tasman and the solutions are complex. The NZIHE conference is unique as it brings together Clinical Engineering and Facilities Management and provides a true healthcare engineering forum experience. Having both biomedical engineering and facility management exhibitors in one location allows the delegates to discuss all technical and operational issues with vendors at the same time which in return will provide a more comprehensive experience and creates opportunities for collaborations between the two technical streams. The 8th of November was the conference second and final day. The second day of the conference was all about networking and I met with as many delegates as I could during the intervals between presentation and exchanged contact details. I was honored to have met a very dedicated and professional group of engineers and once again I felt proud to consider myself one of them. The return trip home was as complicated as the trip to NZ however the invaluable experience made it all worthwhile. Finally I would like to thank IHEA and NZIHE for giving me this opportunity to be part of this experience.
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HVAC AND COVID-19 Matthew Peacock, Senior Mechanical Engineer, A.G. Coombs Advisory
There is considerable interest in the role that HVAC may play in the transmission of COVID-19. This Advisory Note provides an overview on viral transmission, how HVAC systems work, and the practical HVAC operational measures that can be considered along with possible design changes to reduce the likelihood of the virus spreading.
oronaviruses are a family of viruses that can cause illness to humans and animals. A new coronavirus known as COVID-19 was first reported on 31 December 2019 in Wuhan City in China. Symptoms of the virus can range from mild illness to pneumonia. People with COVID-19 may experience fever, flu-like symptoms such as coughing, sore throat, fatigue and shortness of breath. At the time of writing the transmission mechanisms are not fully understood. It is believed that the virus can be transmitted from person-to-person, most likely through close contact with an infectious person, or contact with droplets of fluid from an infected person’s cough or sneeze. It is also believed that transmission can occur by touching surfaces that have droplets from an infected person, and then touching the mouth or face. It is believed that the virus may survive for up to 9 days on some surfaces in the right conditions. When a person infected with an illness coughs or sneezes, pathogens can be encapsulated within droplets of fluid and discharged into the air. Different illnesses are known to result in differing droplet sizes. It is not yet certain what size droplets are produced by people infected with COVID-19. It is known that large droplets (>60 µm) normally are too large to remain suspended in the air and usually fall and land on surfaces. In some instances, some of the fluid can evaporate and the large droplets can transform into smaller particles called droplet nuclei and these can remain suspended in air. Droplet nuclei (2.5 to 10 µm) are believed to be able to remain suspended in air for hours and therefore be entrained into HVAC systems.
HVAC SYSTEMS EXPLAINED Heating Ventilating and Air Conditioning (HVAC) systems exist in many formats. The diagram depicts a typical HVAC system commonly found in commercial and institutional buildings. It is fundamentally a recirculating system with a portion of outside air added continually whilst a similar portion is exhausted. The outside air rate can be varied in many systems. Air is filtered before recirculation and moved around the system using fans. Heating and cooling are typically provided by finned coils using heating or chilled water.
The journey that a virally infected droplet would experience to arrive back in an occupied space would typically include extended ducted air pathways, multiple changes in direction and air velocity, and multiple impacting surfaces including air filters, fans, dampers and grilles. There is a good likelihood that a particle would impact, entrain and dry on a surface. Whilst published research on healthcare ventilation systems and scenarios suggests that the transmission of droplets containing viral material is theoretically possible in these situations, it is thought to be less likely in a well-designed and properly maintained typical HVAC system in a public setting. There are a number of practical HVAC operational measures that can be addressed along with possible system changes to reduce the likelihood of a virus spreading including the following: • Maintenance Regimes and Essential Safety Measures • Cleaning and Disinfection • System Commissioning and Operation, and Outside Air Rates • Air Filtration and Cleaning Options
MAINTENANCE REGIMES AND ESSENTIAL SAFETY MEASURES The continued application of good housekeeping and preventative maintenance regimes are imperative. HVAC maintenance should be carried out as prescribed by the recognised standards and maintenance procedures should be adhered to. It is important to remember that in the majority of modern buildings, operating HVAC systems form part of the essential safety measures and are therefore required for occupancy. The scheduled statutory maintenance of these systems along with fire protection and other essential systems is mandatory. Whilst facilities may scale down operations and occupancy as the COVID-19 situation evolves generally these essential safety systems must continue to be maintained in accordance with regulations to ensure the ongoing compliance of the buildings. Building operators should confer with service providers if measures are being considered to preclude or restrict maintenance technicians from accessing buildings. Air filters should be replaced as scheduled or more often as required. PPE (Personal Protective Equipment) including P2 mask or appropriately rated respirator, coveralls and gloves and should be worn by trained technicians when
servicing dirty filters. After turning off the air handling unit, filters should be carefully removed to avoid dust or other particles being released into the air, and the dirty filters should be bagged and tied, and the bag disposed of in an appropriate waste disposal process. Surfaces should be cleaned to remove any residual particles. Service of washable air filters should be carried out with similar approved procedures and use of PPE.
CLEANING AND DISINFECTION Standard HVAC systems are typically very difficult to clean and disinfect effectively because of the lack of access to many of the system components and ductwork. Some systems in acute care health facilities or laboratories are designed to provide adequate access and other features to facilitate regular and effective cleaning. In commercial HVAC systems air filters can be readily changed, and cooling and heating coil surfaces can be cleaned and disinfected using approved methods and chemicals. Most other features and surfaces in HVAC systems typically cannot be readily cleaned physically. In HVAC systems that include wall mounted or console type induction type units or chilled beams it is practical to clean these units if required. Fogging or fumigating using approved methods and chemicals for disinfection can be applied in facilities and HVAC systems that are designed for this treatment. Typically, these are in laboratories and some acute care areas. Fogging or fumigating is not recommended for normal facilities and standard HVAC systems that are not specifically designed for this treatment. It is very likely to be ineffective and may be hazardous in these situations.
SYSTEM COMMISSIONING AND OPERATION, AND OUTSIDE AIR RATES It is important to ensure that HVAC systems have been properly commissioned and are operating correctly. Commercial HVAC systems are typically designed to produce internal conditions with a relative humidity of 40 – 60% RH. Published research suggests that this humidity range may have a positive impact on virus deactivation, human susceptibility to virus’s and cross infection rates. Minimum statutory outside air rates should be in place as a basic requirement. Increased ventilation (circulation) rates can assist in diluting contaminants in room air and potentially reduce the likelihood of infections. In systems with modulating outside air systems, or where adjustment is possible, increasing outside air rates may be possible. This will also require increasing the system’s exhaust air rate and will help dilute any contaminants in the circulating air.
It should be noted that increasing outside air rates and or ventilation rates will generally result in increased energy usage and in some circumstances may result in difficulties in the system maintaining the desired internal temperature and humidity conditions.
AIR FILTRATION AND AIR CLEANING OPTIONS Air filtration typically installed in standard HVAC systems will not be effective in filtering droplet nuclei or viruses, should these reach the filters. The addition of increased efficiency particle filtration is likely to reduce the airborne load of infectious particles. HEPA (High Efficiency Particulate Arresters) filtration systems filter 99.999% of dust particles and airborne contaminants such as viruses and bacteria. These filters are typically used in hospital operating rooms, acute care areas and clean rooms. HEPA filters are unlikely to be a practical option for most existing HVAC systems due to their high pressure drop. Additionally, HEPA filters require specific housings and cannot be retrofitted as a direct replacement for traditional filter media. Conventional air filters with an improved Minimum Efficiency Reporting Value (MERV) between 13 and 15 (F7 to F9) can reduce levels of droplet nuclei but are not likely to be effective at stopping any unattached virus particles. These filters could assist in reducing the likelihood of droplet nuclei from spreading and may be within the fan capabilities of existing systems. As a general rule, more efficient filters have higher pressure drops which can increase energy consumption, though advancements in technology mean this is not always true Another practical method of air cleaning is Ultraviolet Germicidal Irradiation (UVGI). UVGI technology involves the production of short wavelength light which is capable of disrupting the DNA of microorganisms including viruses. The effectiveness of ultraviolet radiation depends on the intensity of the light and the time period that a given pathogen is exposed to the light. Units are available as induct devices that are installed in ductwork or air handling units.
SUMMARY OF RECOMMENDATIONS The risk of a well-maintained HVAC system in a modern commercial building causing transmission of the COVID-19 is understood to be low. There are however some practical measures that building owners and operators can take to further reduce the risk including: • HVAC preventative maintenance should be carried out as prescribed by the recognised standards and maintenance procedures should be adhered to.
• Building operators should confer with service providers if measures are being considered to preclude or restrict maintenance technicians from accessing buildings. • It is important to ensure that HVAC systems have been properly commissioned and are operating correctly. Check the outside air flow rates and controls to confirm that the minimum outside air rates are being achieved as a basic requirement and ideally if possible, increasing the outside air rates. • Internal humidity should ideally be maintained in the range of 40-60% RH. • An audit of the air conditioning system filtration and general cleanliness together with a review of the preventive maintenance inspection records would be prudent to confirm duty of care responsibilities have been met in the operation of the facility. • Checking the current air filtration type and condition and upgrading or replacing the filter media to F7 - F9 grade subject to fan capacity limitations. This can reduce any transmission of the virus through the system. • If cleaning or disinfecting of the system is required: oA ir filters should be changed, and cooling and heating coil surfaces can be cleaned and disinfected using approved methods and chemicals. o If the HVAC system includes induction type units or chilled beams, these units can be cleaned and disinfected using approved methods and chemicals. oM ost other features and surfaces in HVAC systems typically cannot be readily cleaned physically. o F ogging or fumigating is not recommended for normal facilities and standard HVAC systems that are not specifically designed for this treatment. HVAC systems can be used to assist in reducing the spread of infections, but there is only so much that can be achieved. The role of HVAC systems in controlling the
transmission of infection should be considered a part of a broader multi-modal infection control strategy in buildings.
REFERENCES AND RESOURCES Airepure. 2015: Filter Efficiency - Cross Reference Guide of Filter Efficiencies. Melbourne, Victoria, Australia. https://www.airepure. com.au/products/airepure-filter-efficiency-guide/. 18 March 2020. American Society for Microbiology. Effects of Air Temperature and Relative Humidity on Coronavirus Survival on Surfaces. Lisa M. Casanova, Soyoung Jeon, William A. Rutala, David J. Weber, Mark D. Sobsey. https://aem.asm.org/content/76/9/2712.short. March 2010 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). The ASHRAE Position Document on Airborne Infectious Diseases., Atlanta, Georgia, USA; Reaffirmed by Technical Council, https://www.ashrae.org/, 5 February 2020. American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE). ASHRAE Standard 52.2-2012, Method of Testing General Ventilation Air-Cleaning Devices for Removal
Efficiency by Particle Size. Atlanta, Georgia, USA. https://www. ashrae.org/. Published 2012 Australian Institute of Refrigeration Air conditioning and Heating (AIRAH). Application Manual DA8, HVAC&R An Introduction. https://www.airah.org.au/ItemDetail?iProductCode=DA08. Published 1998. Commonwealth Government of Australia. Coronavirus (COVID-19) resources. https://www.health.gov.au/resources/ collections/novel-coronavirus-2019-ncov-resources. 18 March 2020 New England Journal of Medicine. A Novel Coronavirus from Patients with Pneumonia in China, 2019. https://www.nejm.org/ doi/full/10.1056/NEJMoa2001017. Published 20 February 2020, New South Wales Government. Novel coronavirus (COVID-19) - Frequently asked questions. https://www.health.nsw.gov.au/ Infectious/alerts/Pages/coronavirus-faqs.aspx. 18 March 2020. World Health Organization. 2020: Coronavirus disease (COVID-19) advice for the public. https://www.who.int/ emergencies/diseases/novel-coronavirus-2019/events-as-theyhappen. 18 March 2020.
NOW HEALTHCARE FACILITIES CAN JOIN THE CIRCULAR ECONOMY
nnually, Australians send over 5 million tonnes of food waste to landfill and when food goes into landfill, the environment suffers because of the carbon in food. Micro-organisms break them down producing methane gas – one tonne of food waste sent to landfill creates 2.8 tonnes of methane gas. Methane gas is bad for the climate as it traps significantly more heat than carbon dioxide, and damages our ozone layer, adding to climate change.
Sustainability program enrich360® provides operations with unavoidable food waste like hospitals, with dehydration equipment, which reduces the volume of that waste by up to 93 per cent saving on storage space and collections. The enrich360® dehydrator system, turbo charges the food waste decomposition process through accelerated dehydration and agitation, reducing the original waste volume by between 80 and 93%. Food waste (meat, fish, fruit, vegetables, coffee grinds, flower displays) is placed inside the food dehydrator for dehydration, sterilisation and volume reduction. The process is takes approx. between 8 and 24 hours to complete depending on the size of the unit. The machine is then emptied, ready to receive the next load and can be run seven days a week. The product from this system is a directly-applied fertiliser and compost. It also creates reusable green water of around 75 litres per 100kg of food waste. The Princess Alexandra Hospital in Brisbane is a major healthcare facility that has recently installed an enrich360® food waste 360kg dehydrator. Noel Matson, Director of Operational services at the hospital says,” We’re now processing 370-390 kgs of food waste every day. It’s reduced our waste removal task significantly.” The fertiliser product is used on the hospital grounds and waste water helps the hospital gardens. Every institution involved in the enrich360® program, is a member of our circular economy. Facilities will be able to undergo a Certification Audit and receive enrich360® Accreditation which also creates Public Relations opportunities for your facility. For further information: www.enrich360.com.au or call Dean Turner 0n 0499 360 360
ENGINEERS NEED TO DRIVE SUSTAINABILITY:
WHAT ARE THE LEGISLATION, COST DRIVERS AND TOOLS THAT WILL ASSIST YOU By Wendy Hird, Sustainability Manager, South Western Sydney Local Health District
ngineers have always been sustainable: but you have probably called it being efficient. Engineers love systems and processes and to mitigate risk and reduce costs. Below I discuss some ways to improve the following four systems: • Waste management • Water management • Resource management and metrics • Climate change and risk
REDUCE WASTE THROUGH DONATIONS AND ASSET REDISTRIBUTION SWSLHD have two easy and proven ways to dispose of unwanted assets. • It works, has value and is sold. • It doesn’t work and is disposed of to landfill, e-waste, metal skips, or other streams. That leaves a big gap of what to do with working items with little or no resale value. The best option is to redistribute within the hospital or district or donate to charities. It happens now, but the process is less streamlined, has substantial barriers to implementation and is generally undertaken on an individual level rather than being a systemic procedure. It difficult to track and there is rarely a record of what was donated and who it went to. In most cases it can be simpler to dispose of the equipment. Barriers include: • Storage can be in short supply • Timing - you have stuff to get rid of - today! • How to match up the current owner and the new owner • The assets’ owner does not always see the disposal cost and the burden they are placing on the budget by not utilising an asset effectively.
• Doing the paper work, sign off re liability etc • Uncertainty about the rules and who can authorise Concerning medical equipment specifically, in the last year SWSLHD has donated 10 monitors, an ultrasound machine, and 30 pressure relieving overlays to be used at East Timor or Papua New Guinea. Donation is cost effective. The overlays would have cost $2340 to be disposed of at landfill ($78 each). We will be donating more viable assets in the future as not all current assets can talk to the new Electronic Medical Records system. Therefore we need a more streamlined process. The solution To improve the redistribution and donation process SWSLHD are trialling an online software solution called Warpit <https://www.warp-it.co.uk/>. In its simplest form it is a commercial version of E-Bay or Gumtree. In Australia, Warpit is used by James Cook University and University of Queensland. In the UK it is used by 30% of UK NHS trusts. The Warpit system normally goes live with all categories available. NSW Health is undertaking a NSW wide pilot with only biomedical category. It will start at SWSLHD and then roll out to the other biomedical departments across NSW Health. The cost is $8,400 p.a. and it should be cost effective with a 1-2 year payback. The Biomedical equipment e-waste disposal costs for Liverpool Hospital were $7,600 for 2017/18. The other 15 districts would have similar costs relative to their size. The $8,400 cost can certainly be offset by the reduced expenditure to dispose of old biomedical equipment across all of NSW Health within 1-2 years. This does not include the cost saving to the new owner from not buying equipment.
Unlike Gumtree or E-bay, there are 3 priority levels and you have more control over who gets your asset.
If the system is opened to all categories of assets the internal savings are potentially much higher.
• Priority 1 are the Warpit users in your company
SWSLHD staff purchased $234,000 of chairs in the last year (425 units). Add to that there was $2M of other assorted furniture purchased. There was $110,000 spent in furniture removal and tip fees? Extending the Warpit categories to furniture and other assets allows for much bigger gains in re-distributing assets as opposed to outright purchasing.
• Priority 2 are other Warpit users in other companies who you accept as friends • Priority 3 are the charitable groups who get to use Warpit for free, but again only ones you accept as friends. The Warpit software has: • Tracking and reporting functions making it easy to track donation volumes, potential savings from deferred purchase cost and also possible misuse • Capacity for addition of files such as manuals and maintenance records
Warpit League tables (https://www.warp-it.co.uk/leagues) show that NHS Greater Glasgow and Clyde (38,000 staff) has saved over £26,000 a month by redistributing assets internally ($46,000 per month or $552,000 p.a.1) and diverted 127tonnes from landfill.
• Wish list tracking and prioritisation: you can make a wish list and get notified if something you want becomes available • The ability to post donations with long lead times, forecasting when they are available (i.e. building decommissioning), giving recipients time to plan or fundraise for transport and minimise storage time. The restricted biomedical asset pilot is being undertaken so we can start small, with the highest risk, low volume items so any associated risks will be proactively identified and managed by the appropriate District subject matter experts. Discussions have already been held with SWSLHD infection control and clinical governance.
Fig 2 – Warpit league table (As of publication the Warpit Biomedical program has been opened up to SWSLJHD biomedical staff and training/promotion is underway)
BETTER WATER MANAGEMENT PRACTICES With a continuing drought in NSW it is a good time to focus on water management. Part of the problem is that, for a lot of people, no-one cares about water till there is a drought or there’s a big leaks that destroys other assets. But good water management practices should be an integral part of maintenance. Remember, while water and waste water is cheap, treated and heated water is expensive, ranging from eight to 20 times the cost of standard domestic water per kL. 80% of water management is 2 things: reduce water use and manage leaks. Reducing legitimate use is easy. It’s hard to buy a toilet cistern with a 20l flush nowadays. 3 and 6l flushes are standards. Fig 1 - Screenshot of the NSW Biomedical Warpit with a trial post of a fake syringe pump
The trial started mid-February 2020 and if successful, the Warpit solution will also be extended to low risk and high volume assets such as furniture.
So I’ll focus on the 2 main ways to reduce leaks: proactive maintenance, and simplifying reporting.
room they are calling from, and they key in a code for leaking toilet or leaking showers. I had a similar system in the BlueScope Pt Kembla Steelworks where the cleaners rang a set phone number and left a voice message about the leaks they found which were added to a job list. With almost everyone having a mobile phone, you can: • Set up a dedicated mobile for water based maintenance texts or voice messages only • Set up key words, short cuts and codes • Promote the number, particularly to cleaners and janitorial staff • Put the room number/name/asset number and the leak phone number on a sticker on the bathroom mirror Chart 1 – Hospital leak pie chart
Studies by Sydney Water (2011) across 35 Sydney Hospitals averaged a leak rate of 22%2. That is better than similar studies at hotels, shopping centres and commercial buildings3 which showed an average of 30% leaks. I worked with 22 hotels who improved their water management from an average leak rate of 30% (in 2006) to 8% (2011), and 5 hotels had zero leaks. I recommend that hospitals follow the two practices they undertook 1. Proactive maintenance: The best way to prevent leaks to implement a proactive maintenance regime. A 500 room hotel will take 10 rooms out service once a week while the plumber replaces all washers and toilet cisterns rubbers. 500 rooms: 10 rooms a week for 50 weeks. In large scale hotels they replace them annually - the higher replacement cost is offset by the lack of complaints of a dripping tap $400 /night room. For hospitals I’d start with 3 years, keep track of any leaks that turn up and then extend or reduce as you see fit. The advantages include: • Streamlining the plumbing costs over the year and reduce the management time • Planning in advance which bathrooms and toilets you are going take out of service 2. Improve reporting by staff. Detecting simple water leaks is easy. You have cleaners and staff going into toilets, kitchens and showers all day long. Part of the problem is that in hospital maintenance systems – SWSLHD system at least - you need to record individual events and you need both computer literacy and computer access to do so. Most major hotels solved this years ago. The cleaner uses the room phone to leave a message with maintenance. In some cases they don’t even talk, the system knows what
• Start a single work order for a plumber per hospital per month to work through the list of work. Advantages – • Reduced water losses (average of 22% leaks across all hospitals in the trial) • Reduced cost ( 22% would be $450k at SWSLHD) • Reduced management time. (As of publication these practices are not in use at SWSLHD though I am still promoting to engineering)
CARBON REPORTING SOFTWARE State governments have been fine tuning the policies about climate change response and adaption: • NSW: Climate Change Policy Framework have an aim to be Net zero by 20504 • Queensland: Human Health and Wellbeing Climate Change Adaptation Plan.5 • Victoria: Victoria’s Climate Change Framework also have an have an aim to be Net zero by 20506 Along with the Federal National Greenhouse and Energy Reporting Scheme (NGERs) it has also provided some great tools to help engineers. Carbon Reporting Software A classic process engineering saying is “You can’t control what you can’t measure”. My codicil is that unless you are compiling that measured data into simple and easy to understand graphs and charts, using appropriate KPI, and making them easily available at the right frequency to the right people so they can act on the information, you are wasting your time. Carbon reporting software is part of the solution. You might not be interested in calculating and reporting your carbon footprint, but you should be interested in tracking and
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trending everything that goes into making up your carbon footprint: electricity, gas, and fuel consumption and waste generation. SWSLD has three electricity providers, three natural gas providers, two water utilities and 3 main waste contractors covering 28 waste streams. They cover multiple sectors with multiple sites, on different reading and billing schedules, with different key performance indicators applicable to different sectors.
• Waste streams compilation tracking for general service managers • Individual reports for community centres office managers showing water, waste, electricity and gas trends • Hospital level reports for general managers • Detail short terms reports for engineers doing specific projects. This can drive action and focus expenditure.
Fig 3 – Sector rollup for SWSLHD
Since 2008 when the NGERs came into legislation carbon reporting software options have expanded. There are various brands that range from basic bill amalgamation to those that provide in depth analysis on chiller performance and amalgamate BMS data. The choice is yours, and you (generally) don’t have to buy the full package but can expand in modules. At a basic level they will: • stream all your waste, water, gas, electricity and fuel data into a portal via direct connection to the utility provider or emailed data or via manually filled out forms. Some can map physical invoices directly file, or manually transfer data for you. • prorata the data automatically as required where billing covers multiple months so you get monthly data • apportion the data to the appropriate site • roll up the sites into sectors then district level • utilise multiple Key Performance Indicators (KPI) at the appropriate level
Fig 4 – ECOSAVE mock up for discussion purposes and does not reflect real data
A simple example of the benefits of utilising data is the graph below of a hotels water use. The rise in month 6 was due to leaking hot water system level control valve that sent 100kl/day of 60oC hot water straight to sewer via the overflow. It was not noticed for five months until I bought it to their attention. They manually read water sub-meters every 8 hrs, but as they only wrote the numbers down and didn’t calculate the difference or graph them, they missed the incident. There were at least 3 other people who should have seen the increase in monthly water bills and increased gas use and cost and acted on it: the chief engineer, the general manager and the accountant. This would have been a significant rise, about $10,000 in water/waste water and $30,000 in gas a month (2019 costs). But because the data from invoices wasn’t being utilised properly it was missed.
• produce a variety of automated reports with graphs at set periods emailed out as required – this can be costly so check T&Cs • allow in depth drill down at any level for any stream in a portal The use of this software doesn’t negate getting an invoice sent to a general service manager or facility manager who approves the invoice. It does allow tracking, trending and benchmarking, generally delivered via email to a broad range of people at different levels of details: • Quarterly district level report for the board and CE
Chart 2 – Hotel water leak chart (As of publication the ECOSAVE program being used is being populated with back history, efficiency metrics etc. and will launch mid March)
occurring which have impacted hospitals. • In 2006, Cyclone Larry. Herberton Hospital had no mains or emergency power, and closed much of Innisfail Hospital.7 • In 2009, one-in-100-year storms caused floodwaters to isolate Coffs Harbour, Dorrigo and Bellingen hospitals. People needing urgent medical treatment had to be sent up to 80 kilometres away.8 Fig – Why should SWSLHD care about climate change?
CLIMATE RISK MANAGEMENT Climate risk is a real and valid issue. While some of climate risk for hospital is about increases in presentations and maintaining supply chains, building and equipment resilience is
also an issue. Engineering is all about mitigating risk. Is climate change that big an issue? Storms and fires have always been an issue but in recent years there have been some extreme weather events
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• 2013, Queensland Bundaberg’s hospital was evacuated due to rising floodwaters which came in the aftermath of Tropical Cyclone Oswald9 • 2016 After super-cell thunderstorms blacked out South Australia, backup generators failed at an Adelaide hospital. Seventeen patients had to
be transferred from Flinders Medical Centre to Flinders Private Hospital. It also has an impact on the community and operability as far as increased presentations. The “MJA Lancet Countdown on health and climate change: Australian policy inaction threatens lives”10 details how climate change is impacting Australian Health. When Hurricane Sandy hit the USA in October 2012 it caused $70billion in damages. In New York it forced the evacuation of more than 6,400 patients from six hospitals and 31 residential care facilities.
We have a consultant for 30 hrs as part of the NSW Department of Planning, Industry and Environment (DPIE) Sustainability Advantage program. At the end of the 30hrs we will have a roadmap to develop a bow tie risk analysis. Some questions include: • What are the anticipated climate variability due to climate change? Flood, overflooding, rainfall, temperatures, storms, wind. Our government funded consultant used climate projections from AdaptNSW tools for bushfire, heat and cold events, overall temperature, and rainfall:
What is SWSLHD doing in this area?
• How do these impact on existing building infrastructure?
SWSLHD are at the very early stages of this process.
• How will this impact hospital operability?
• Do we need to review building standards for our new builds? The ones in construction now and the ones planned for 8 years’ time. We’ll turn these answers into a bowtie analysis for the strategic objective: to minimise the impact of climate change on hospital infrastructure and operability When Hurricane Sandy hit the USA (2012) it also revealed a lack of planning and awareness among USA based hospitals. The USA National Institute of Environmental Health Sciences (NIEHS) created a guide, the Primary Protection: Enhancing Health Care Resilience for a Changing Climate11 with example of hazards and risk, and an Excel based self-assessment toolkit12 to allow hospitals to work through various
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elements of risk associated with hospitals. While it is not Australian, it covers a broad range of issues:
• Kitchen, server room and primary utility distribution are on the fourth level
• Climate risk and community vulnerability
• Emergency room is 20 feet (6m) above base flood elevation
• Land use building design and regulatory context • Infrastructure protection and resilience planning • Essential care and service delivery planning • Environmental protection and ecosystem adaption The following is an extreme example from that guideline, far removed from what SWSLHD is facing. The Southeast Louisiana Veterans Health Care Centre was completed in 2016. This 1.7 million ft2 (160,000m2) campus run by the US Department of Veterans Affairs, replaced two hospitals closed by Hurricane Katrina (2005), damaged due to the failure of the city’s levees. The new medical centre: • Supplies for up to 1,000 people • Enough diesel fuel to power its generators at full strength for 1 week (1.2Ml) • On-site sewage treatment plant to process and hold a week’s worth of waste
• Ambulances use a dedicated ramp that doubles as a boat launch.13 • 30-acre site maintains a fully securable perimeter in the event of civil unrest or national emergency.14 Where to start. • Look at your local council – most have undertaken a climate risk assessment as part of work by EPA • Look at building issues and emergencies you have already had as an indication of your resilience • Start a better paper trail of events that are climate related: for ease of research and statistical purposes so you can use them to build a better case in future i.e. #climate risk for all incident that may be climate change related. • It’s not just your buildings, but supplies in and out: power, phone and water, linen, medical supplies and staff access. Most of this should already be in Business
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Continuity Management Plans, though it may be the trigger is not climate related • Review the National Institute of Environmental Health Sciences toolkit discussed above. It will make you think about what you are doing. Why? • There may be a cost reduction in insurance if you undertake a climate risk assessment? • There may be a cost benefit – i.e. you get funding only if you have undertaken a climate change risk review • You might not have a problem, but are you someone else’s solution? i.e. are they relying on your hospital and services to be an air conditioned emergency shelter in heat extremes for the old. In closing, there are several systems and processes that can be used by engineers to mitigate risk and reduce costs across the health sector while enhancing sustainability.
REFERENCES 1. Warpit league tables <https://au.getwarpit.com/leagues> Viewed 16/09/2019
threatens lives” MJA, Vol 209, No.11, <https://www.mja.com. au/journal/2018/209/11/mja-lancet-countdown-health-andclimate-change-australian-policy-inaction> Viewed 16/09/2019 11. Guenther,R and Balbus, J, Primary protection: enhancing health care resiliency for a changing climate: A Best Practices Document under the HHS Sustainable and Climate Resilient Health Care Facilities Initiative, U.S. Department of Health and Human Services, Dec 2014 <https://toolkit.climate.gov/sites/ default/files/SCRHCFI%20Best%20Practices%20Report%20 final2%202014%20Web.pdf> Viewed 16/09/2019 12. Toolkit, HHS Sustainable and Climate Resilient Health Care Facilities Initiative https://toolkit.climate.gov/sites/default/ files/SCRHCFI%20Checklist%20Composite_Form_0.pdf Viewed 16/09/2019 13. Seltenrich,N Safe from the Storm: Creating Climate-Resilient Health Care Facilities, Environmental Health Perspectives, 1020011 126(10) October 2018, <https://doi.org/10.1289/EHP3810>, Viewed 16/09/2019 14. Collins,K Southeast Louisiana Veterans Health Care System, Prepared for future disasters, US Department of Veteran Affairs, Monday, August 6, 2012, <https://www.neworleans.va.gov/ features/Prepared_for_future_disasters.asp> Viewed 16/09/2019
2. Sydney Water Best Practice for Hospitals (no longer available on line – see attached) 3. Sydney Water Best Practice for Commercial Building and Shopping Centres, Sydney Water <https://www.sydneywater.com. au/web/groups/publicwebcontent/documents/document/ zgrf/mdu0/~edisp/dd_054580.pdf> Viewed 16/09/2019 4. NSW Government Office of Environment and Heritage, NSW Climate Change Framework <https://www.environment.nsw. gov.au/research-and-publications/publications-search/nswclimate-change-policy-framework> Viewed 16/09/2019 5. Queensland: Human Health and Wellbeing Climate Change Adaptation Plan <https://www.qld.gov.au/__data/assets/pdf_ file/0022/64237/h-cap-qld.pdf> Viewed 16/09/2019 6. Victoria Environment, Land, Water and Plannng, Victoria’s Climate Change Framework <https://www.climatechange.vic. gov.au/victorias-climate-change-framework> Viewed 16/09/2019 7. The Queensland Cabinet and Ministerial Directory, Queensland government acts immediately on Cyclone (Larry) damage, March 1, 2016 <http://statements.qld.gov.au/ Statement/Id/45207> Viewed 6/9/2019 8. Dunlop, ABC, Flooded Coffs Harbour declared disaster zone, 1 Apr 2009 <https://www.abc.net.au/news/2009-04-01/floodedcoffs-harbour-declared-disaster-zone/1638018> Viewed 16/09/2019 9. Hunt, CNN World, Hospital evacuated as Australia hit by heavy flooding, Jan 29 2013 <https://edition.cnn.com/2013/01/29/ world/asia/australia-queensland-flooding/index.html> Viewed 16/09/2019 10. Zhang,Y (and others) 2018,”MJA-Lancet Countdown on health and climate change: Australian policy inaction
LEGIONELLA MAYBE THE HEADLINE PSEUDOMONAS IS THE REAL ISSUE By Charles Cheesman
Legionella maybe the headline, however, could it be that Pseudomonas is the real issue? Let us reflect on this briefly.
e constantly hear about Legionella in the media, journals and publications, about the hazards and threats to human health that it poses. However, we never hear about the threat that Pseudomonas poses, it is rarely, if ever mentioned.
• in bone
By the end of this presentation, you will have some understanding of the magnitude of this issue.
It also affects heart valves. Possibly, it’s this and these less common infections that give us a clue to that high mortality rate that we saw previously.
Let’s start with some facts. A study conducted in Seoul, South Korea found that Pseudomonas was the most commonly found bacterial infection in hospitals. 78.7% of cases were acquired in hospital and the shocking statistic is that the 30-day mortality rate was 39%!
Pseudomonas is becoming increasingly drug-resistant. This is a huge problem facing mankind. In fact it is listed as an MDRO (multi drug resistant organism). It is also one of the ESKAPE group of organisms.
A significant part of the issue with Pseudomonas is that it has the ability to attack the body on a number of fronts. The most common infections from Pseudomonas are found in: • The respiratory tract • The urinary tract • On the skin – folliculitis is probably the most prevalent Pseudomonas skin condition. It is common, especially in aged care facilities. • It is found in the eyes – conjunctivitis is the product of Pseudomonas • In the ears – middle ear infection, also known as swimmers ear. Pseudomonas also affects our blood stream. On the externals of our bodies, where you see any yellow to greenish puss or discharge, it is a good indicator of Pseudomonas. The discharge from the eyes with conjunctivitis is also an indicator of infection by this organism. Less common infections, but still quite prevalent, are found:
• in the joints • the brain and the central nervous system • the gastrointestinal tract
ESKAPE is an acronym made from the first letters of their scientific names and a reference to their ability to escape the effects of commonly used antibiotics. The ESKAPE pathogens (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter species) are the leading cause of nosocomial infections throughout the world. Also we need to consider VBNC. V B N C stands for Viable But Non Culturable. What this actually refers to are bacteria that are in a very low state of metabolic activity where they don’t divide. However, they are alive and they have the ability to become culturable once they’re resuscitated. The organism basically shuts down and and becomes dormant. It shrinks, it changes shape and it is no longer recognisable as the organism that it really is. It becomes a little round hard ball and the biggest problem is that once an organism has entered into the VBNC state, they no longer show up on a plate count, i.e., they are not culturable. So our methods of detecting
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these organisms fail us. They’re still alive and very much still present but we can’t see them on the plate and we are not aware of their existence.
• Pseudomonas syringae
On resuscitation from the VBNC state, the cells resume normal function and regain culturability. Of course they then have the renewed ability to cause infection in the human body. This phenomena occurs when the organism is stressed and from that it can be assumed that the VBNC state is actually a survival strategy. As mentioned before, this alludes to why we have this phenomena of MDRO, Multi Drug Resistant Organisms, and the ESKAPE group. It is all to do with VBNC State. Quite a number of microorganisms are understood to enter into the VBNC state if the right conditions are met, including Pseudomonas, Legionella and Yersinia.
• Rhizobium meliloti
Here is an extensive list of organisms determined capable of entering into the VBNC state, demonstrating that this is not unique to just a couple of organisms.
• Vibrio campbellii
• Aeromonas salmonicida • Agrobacterium tumefaciens • Burkholderia cepacia • Burkholderia pseudomallei • Brettanomyces bruxellensis • Campylobacter coli
• Ralstonia solanacearum • Rhizobium leguminosarum • Salmonella enterica • Salmonella Typhi • Salmonella Typhimurium • Serratia marcescens • Shigella dysenteriae • Shigella flexneri • Shigella sonnei • Streptococcus faecalis • Vibrio anguillarum • Vibrio cholerae • Vibrio harveyi • Vibrio mimicus • Vibrio parahaemolyticus • Vibrio shiloi • Vibrio vulnificus (types 1 and 2) • Xanthomonas campestris • Xanthomonas axonopodis pv. citri
• Campylobacter jejuni
• Yersinia pestis
• Campylobacter lari
Changing direction now, lets look at how Pseudomonas relates to biofilm. Most people have heard of the term biofilm. But not many may be aware that Pseudomonas is the main culprit for producing it.
• Cytophaga allerginae • Escherichia coli (including EHEC) • Enterobacter aerogenes • Enterobacter cloacae • Enterococcus faecalis • Enterococcus hirae • Enterococcus faecium • Erwinia amylovora • EscFrancisella tularensis • Helicobacter pylori • Klebsiella aerogenes • Klebsiella pneumoniae • Klebsiella planticola • Legionella pneumophila • Listeria monocytogenes • Micrococcus luteus • Mycobacterium tuberculosis • Mycobacterium smegmatis • Pasteurella piscicida • Pseudomonas aeruginosa
What does biofilm look like? This is a good cross-sectional shot of a pipe which is heavily fouled with biofilm. The material you can see attached to the pipe wall and in the bottom half has been produced by micro-organisms. From a practical, hands on perspective, I would suggest that this pipe was subject to very low flows, probably stagnation. This second photo is possibly more typical of what we expect to see from biofilm. If you want to explore biofilm yourself, probably the easiest or best way to to have a look at some biofilm is to take the lid off a toilet cistern. In the corners of the cistern, especially plastic ones, with tight corners and strengthening ribs, you’ll see that there’s a usually grey, with maybe a pale pink, bluish tinged film present. If you rub your finger on it, it’s quite greasy and slippery to the touch. That is biofilm! Here is another view of the material. Let me just say here that nature isn’t quite this exotic and pretty. The slide has been stained for easier viewing and identification. This picture is actually Pseudomonas bacteria emerging from
biofilm. The organisms are the little green sausages and the mauve is the biofilm.
becomes irreversible attachment where you really can’t get them off the surface anymore.
Pseudomonas as well as a number of other bacteria exist in two distinctly different forms: The first form is called ‘planktonic’ – the free-floating form. The organisms are freely moving in the water. It could be said “swimming”; The second form bacteria take is known as ‘sessile’. In the sessile form, the bacteria is attached to a solid surface and firmly anchored to it. Surprisingly, the DNA of the organism changes depending on which state they are in. So as they move from planktonic to sessile and back to planktonic, the DNA actually changes.
Afterwards, the organisms mature and create an extensive colony of their own kind and of course, inviting other friends in!
Laboratory tests have found that planktonic Pseudomonas can attach to electropolished stainless steel in less than 30 seconds, so you can appreciate how quickly this happens. If you consider the surfaces of the pipework and constituents of a water distribution system, of course they are far from polished. You are going to get significant buildup very quickly, once these organisms enter into the water distribution system. As part of; and during this attachment process the organisms secrete a sticky conglomeration of extracellular polysaccharides, proteins, lipids and DNA.
As this goes on, we reach advanced maturation. They get into their more senior years and prepare for the next phase of their life cycle. For humans this would mean retirement, however for bacteria, it is now the dispersion phase of the cycle. This is where the biofilm gets to the point where it ruptures and it expels organisms which then become planktonic again. It goes back to start of the cycle and the whole process starts over again, continuing to infiltrate the water distribution system. Bacteria, when residing in a biofilm display resistance to biocides that may be considered stunning. Back in 1988 LeChevallier demonstrated that biofilm associated bacteria may be 150 to 3000 times more resistant to free chlorine and a hundred times more resistant than monochloramine than their free-floating counterparts.
This material is what we refer to as BIOFILM
What this is suggesting is that once they get into that biofilm they’re pretty bomb-proof.
Let’s think of this secreted material as a really viscous, waterproof mucus!
A very interesting study was done by Roger Anderson at the CDC in Atlanta Georgia in the U.S.
The reason for producing this is threefold:
He incubated plastic pipes with two strains of Pseudomonas for eight weeks.
1. T o anchor themselves to the surface. It assists by acting as a glue or an adhesive. 2. P rovide catchment area for nutrients. Think of the organism like a spider. The spider spins a web so it can effectively catch food over a wider area. It is exactly the same principle that the bacteria employ. 3. M ost importantly for what we are discussing here, it is to protect themselves from environmental attack. There are organisms that don’t produce biofilm but they happily live in the biofilm that the Pseudomonas has created. Legionella is one of those organisms. There are five stages of biofilm development. Initially, we have the free-floating, planktonic bacteria moving through the water. It comes in contact with a surface and forms the initial attachment. They exude polysaccharides and lipids, the mucus, as one could say, and that is the start of the biofilm process. This quickly
He then emptied the pipes and refilled them with heavyduty biocides, which he then left in the pipes for one week. He then again emptied the pipes and refilled them with sterile water. The result when he tested the sterile water was that both strains survived the disinfection treatment of the pipes and went on to release planktonic organisms back into the sterile water. This clearly demonstrates that the disinfection process did absolutely nothing. Another study by Mittelman, found that it is virtually impossible for microorganisms to develop a general resistance to compounds such as chlorine. However bacteria in a biofilm can resist the biocides because they are shielded in the slime. May I add here that these tests were done before VBNC was known about and understood, so that needs to be taken into account.
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Here we have a graph of this and you can see there’s a healthy population of bacteria in his test rig up to where he applied the biocide. [Image 1.]
We have different methods or types of disinfection processes that can be grouped into categories, the first category which we will discuss is also the most important one. [Image 2]
Upon the introduction of the biocide, the bacterial counts naturally went to zero. At day seven, they removed the biocide and replaced it with sterile water. From that point, the bacterial growth steadily increased until by day twenty it was virtually back to where it started. So the introduction of the biocide, when you look at the long term scenario, did absolutely nothing! Astonishing really!
This is ‘Systemic Disinfection”. Systemic simply means that it’s effective across the entire water distribution system. It is system wide.
Let’s now look at some control measures. There is absolutely no point in telling you about all these problems unless we can offer you some solutions!
The next category is focal disinfection. Focal means that it is only active in a portion of the water distribution system. It is focused on a specific point.
To further cloud the story, we then have temporary disinfection. Temporary sources of disinfection have a limited period of efficacy. They are present for only a short time. Finally, the optimal classification, is residual disinfection. What this means is that the biocide is continuously active over a long period of time. Obviously, if it is residual, it will then be system wide, or Systemic as well. [Image 3] shows a chart of commonly employed methods of disinfection. It is basically split into two lists. To the right, we have our focal and temporary sources which I would suggest are not to be considered for widespread everyday use, then on the left, we have systemic, or system wide disinfection types. The coloured boxes indicate the quality of each particular attribute. Green is obviously a good attribute to have. Yellow is a neutral attribute that doesn’t offer an advantage or a negative trait and red is an undesirable attribute. Straight away we note that the first row is effective against biofilm. This is the single most important feature of a disinfectant. There are only two disinfection methods that get the green light on this: Copper silver ionisation and Chlorine dioxide. Somewhat ironically, continuous chlorination is listed as not being effective if biofilm is present! To quote a man I very much admired: Professor Julius Somner Miller; Why is it so? What we call chlorine for the purpose of this discussion, is really hypochlorous acid. As we know, this compound reacts, or oxidises organic material. This is how it works as a bleach and kills micro-organisms. As the reaction takes place, the hypochlorous acid is consumed in the reaction. Eventually there is none left. As an example, I am aware of a public hospital that has 3ppm of free chlorine at the water meter. At the further most tap of the facility, there is no measurable chlorine! It has been consumed, reacting with the biofilm in the pipework. Incidentally, these measurements can also be used to ascertain whether there is biofilm present in a water distribution system. They can, in some circumstances even allude to how much is present. In this example, obviously quite a lot! Back to the right hand side of the table, we see listed, ultraviolet light, ozonation and heat and flush.
Let us now revisit the topic of VBNC. Thermal flushing and continuous low-level chlorination induce the VBNC state in many organisms. Several studies have also suggested that these forms of control also cause the weaker bugs to die off and allow the more resistant strains of organisms to proliferate when these conditions are again met. This is why we have the rise of superbugs. We’re killing off the weaker ones and the organisms that can adapt become very resilient. Control measures: The first point that needs to be addressed is UV light. It was listed in the chart. Whilst it is an accepted method of disinfection, it is a focal disinfection. It only works at that precise point where the UV light is situated. It doesn’t work downstream in the water distribution system. More importantly though, what we also need to consider is that in the water treatment industry, UV light is an accepted method of decomposing chlorine! As an example: Reverse osmosis membranes are quickly destroyed by free chlorine. The easiest way to deal with this problem is to put a UV light in front of the membrane to break down the chlorine and destroy it before it does damage to the membrane. Whilst we have already seen that chlorine may not a good form of controlling microorganisms in water distribution systems, it is the only line of defence a facility has unless unless an onsite systemic disinfection source is installed. So having UV in your water distribution system and may I add, many facilities have them, will remove the chlorine, the last line of defence you had against microorganisms. This is extremely self-defeating! Another misunderstood item is TMV’s, They are designed to mitigate the risk of scolds and burns from hot water. They are not a method of disinfection. Many people have this confused. The pipework downstream of the TMV constitutes by definition a warm water system and must be treated as such. The risks are real. In closing what is the take-home message? It is this: Only systemic; system-wide forms of disinfection that give a measurable residual at every outlet connected to the water distribution system can be employed in health and aged care facilities.
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MEASURE IT AND IT WILL IMPROVE By David Wiley
I had the pleasure of experiencing many different sectors across a variety of countries during my time as an asset management consultant. One key observation is the significant variation in the level of maturity in the asset management process being applied by these organisations. Whilst it would be unrealistic to expect all sectors to apply the same level of rigour to managing assets, I was surprised by the differences within sectors managing similar asset classes.
or example, correctional facilities and hospitals. Both manage similar assets such as building structures, fabric and finish, and services such as HVAC, yet they are managed in very different ways. I had a recent experience with several Victorian correctional facilities while conducting a certification audit against ISO 55001, the international standard for asset management systems. The first thing that struck me was the atmosphere on the inside. It was not only quite intimidating for visitors like myself, but the one thing that struck me really hard was the serious psychological affects the environment must have on inmates. The next thing I noticed was the surprisingly good condition of the facilities. I had preconceived ideas that prisons were undermaintained and dirty facilities but my experiences were the complete opposite. During the audit I concluded that the maturity of the systems used to manage these assets was of a similarly high standard. Whilst my client was contracted by the government to manage these assets and there were many contractual mechanisms in place to manage the services, the level of systematic processes in place was nothing short of impressive. The utilisation of their computerised maintenance management system was probably the highest I have seen in any facilities management environment. And the processes used to manage defects was very structured with a high degree of visibility provided through reporting processes in place. In stark contrast, my recent experience with the hospital system was incredibly disappointing. Whilst the age and condition of the few hospitals I have visited recently varies, I was appalled with the condition of several of them.
One example in particular was my experience with my terminally ill mother who needed to be hospitalised in the public system at different stages. The condition of the facility was nothing short of disgusting and I couldn’t blame my mother for wanting to get out of there even though it was probably the best place for her and the family. Having had previous experience with asset management practices in the public health system across Australia, I shouldn’t have been surprised at the poor condition of certain hospitals. My observation was the level of sophistication of asset management practices was inappropriately low for the nature of the services these assets provide to the community and the amount of investment tied up in these assets. The key differences between the correctional centre and hospital experiences were at a very fundamental level. One had a very good handle on: • what assets were owned • where they were • what condition they were in • what risks they posed to the achievement of objectives • what risk mitigations were in place and how much they cost and the other clearly did not. My experience tells me that if these fundamentals are not well understood, it is very difficult to justify the funding required to achieve a certain level of service. This issue is compounded when such a large organisation is screaming for a share from the same funding pot. And at the next level, how do they expect to justify funding when they cannot quantify the impact to
the community, and they are in competition with other government agencies for funding? After years of consulting in a technical discipline, I can’t help but think that the solution to this problem lies in general business management. Peter Drucker, once described as the founder of modern management, has developed some very well-known quotes over the years. One of my favourites that comes to mind in this context suggests that “What gets measured gets managed”. This ideal suggests that systematic quantification leads to the focus of the business on what is important which then results in improvement. The question is; what needs to be measured in order to seek the desired improvement in the case of the hospital system? If the goal is to better justify the funds required to manage the facilities within the portfolio, there is generally a minimum amount of information required around asset attributes, maintenance requirements and feedback, and planning parameters needed to forecast. This minimum data is fundamental to the management of assets and is illustrated in Figure 1. Figure 1 - Minimum asset data requirements
But simply providing access to this asset data alone will not solve the problem. Often, the amount of data is too overwhelming for organisations with large asset portfolios to know what to do with it. Imagine managing a portfolio of 500 facilities spread across the state and trying to decide how much funding to provide each of these facilities to appropriately manage risk. This is where a structured methodology is required to analyse this data and turn it into information to start driving appropriate decisions. One such example of this methodology is AssetFuture’s asset intelligence platform. AssetFuture’s proven cloudbased technology platform provides the methodology and computing power to quickly turn data into strategic insights and help drive improvement in funding allocation leading to improved risk and performance management.
Asset management has evolved into a broad collection of disciplines but is often simply described as identifying the “right things to do, at the right time in the right manner”. The combination of AssetFuture and quality asset data enables the identification of the right time to do the right maintenance. Sure, carrying out the work efficiently is an important piece of the puzzle, but based on my years of asset management consulting, the biggest waste is generated when maintenance is carried out either too early, leading to unnecessary overmaintenance, or too late, leading to the realisation of the consequences of failure of the asset which in some cases can be catastrophic. Take the aircraft industry as an example. Back in the 1960’s flying commercial aircraft was statistically a very risky mode of transportation. Today it’s known to be one of the safest forms of transportation thanks to a process of analysis that determines the right time to do the right maintenance. This analysis technique has developed into what is known today as Reliability Centred Maintenance (RCM). RCM recognises the value of condition-based maintenance implemented with an understanding of asset degradation. AssetFuture’s platform combines fundamental asset data with proven asset degradation modelling to provide insights to the maintenance activities required over time, the costs associated with these activities, the forecast condition and risks posed over time. This enables organisations to plan and budget effectively making the right trade-off between performance, cost and risk based on the strategy of the business and limitations to funding. Such technology enables efficient analysis of large sets of data, significantly reducing the amount of time taken to analyse and produce budget forecasts. Producing forecasts for a twenty year period is now carried out at the press of a button as opposed to weeks of time for someone to trawl through paper-based systems or disparate data sets to try to make a sensible decisions on only part of the information required to do so. An example of an organisation faced with the challenge of planning for a large asset portfolio is NSW Department of Education (DoE). DoE has been on a journey of increasing asset management maturity over the past seven years. The starting point of this journey involved annual asset condition assessments and spot audits conducted by the Department of Public Works. These assessments were brought in-house over time, with Treasury deeming their methodologies to be insufficient for lifecycle costing back in 2011, resulting in a reduction in allocated funding compared to their initial request. This triggered an initiative involving AssetFuture providing the core methodology used to analyse maintenance and funding requirements. This engagement supported funding submissions to Treasury that were initially met with scepticism, with
Treasury engaging external consultants to stress test the methodology and resulting funding levels. This testing resulted in Treasury’s endorsement of the methodology and provided them with the confidence in subsequent funding submissions using the AssetFuture platform. AssetFuture is proud to have been part of DoE’s journey in asset management planning and is pleased that it has significantly contributed to the recent allocation the funding required to reduce the maintenance backlog to zero across the state. Not only has this significantly improved the asset management practice at DoE, it has resulted in an environment that is more supportive of good earning outcomes for NSW students which will no doubt have a positive impact on the State’s economy.
Figure 2 -The benefits of good asset planning
So if your organisation is struggling to justify the funding required to achieve business objectives, you may want to take heed of Peter Drucker’s advice and start measuring your assets in a way that enables data driven decisions.
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Coronavirus and UVC
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CORONAVIRUS AND UVC
oronaviruses are a large family of viruses that are common in many different species of animals, By Clean-Air Australia ncluding swine, cats, cattle, camels and bats. Rarely, animal coronaviruses can infect people and then pread between people such as with MERS, SARS, and now with COVID-19.
The 2019 Novel Coronavirus, or COVID-19, is a new respiratory virus first identified in Wuhan, tâ€™s important to note that how easily a virus spreads person-to-person can vary. Some viruses are highly Hubei Province, China. ontagious (like measles), while other viruses are less so. There is much more to learn about the ransmissibility, severity, and other features associated with COVID-19 and investigations are ongoing.
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vulnerability to UVC at varying via respiratory droplet nuclei Itâ€™s important to note that how dosage (see chart A). Viruses that produced when an infected easily a virus spreads person-toreviousperson Corona family of viruses haveperson shared similar traits of vulnerability to UVC at varying dosage are airborne can be safeguarded coughs or sneezes, like can vary. Some viruses are see chart A).contagious Viruses that are airbornehow caninfluenza be safeguarded against with high of UVC ininthe against withdoses high doses of UVC and other respiratory highly (like measles), the Airstream. Clean-Air Australia has pathogens spread. These droplet while other viruses are less so. There Airstream. Clean-Air Australia has control mechanisms to stop that spread.
54 most effective microbial control, Clean-Air Australia UV germicidal Emitters are installed on or the
FEATURE ADVERTORIAL ARTICLES The recirculating air in HVAC systems creates redundancy in exposing microorganisms to UVC, ensuring multiple passes so the light energy is effective against large quantities of airborne The recirculating air in HVAC systems creates redundancy exposing microorganisms to UVC, microorganisms. Clean-Air Australia UVC delivers the highestinUVC output, driving HVAC system ensuring multiple passes so the light energy is effective against large quantities of airborne efficiency while improving indoor air quality. microorganisms. Clean-Air Australia UVC delivers the highest UVC output, driving HVAC system efficiency while improving indoor air quality.
control mechanisms to stop that spread.
How Clean-Air Australia Emitters inactivate airborne Infectious Droplet Nuclei:
For the most effective microbial control, Clean-Air Clean-Air Australia AustraliaUVis the first Clean-Air Australia is the first germicidal Emitters areof installed manufacturer UVC manufacturer of UVC on the supply side of the solutions for thesystem, air and air downstream fromair theand cooling solutions for the air coil handlers. Since 1994, and above the drain pan. This handlers. Since 1994, from this company location solutions provides more effective have consistently been solutions from this company biofilm and microbial control than found to be the highest in-duct UVC installations. have consistently been
output of UVC of found to intensity be the highest The recirculating air in HVAC systems any commercially intensity output of UVC ofavailable creates redundancy in exposing products. Clean-Air Australia also microorganisms to available UVC, ensuring any commercially utilises a software configuration tool that allows a customised solution to be easily configured and multiple passes so the light energy products. Clean-Air Australia also Clean-Air Australiaâ€™s shows the intensity of UVC being generated. Clean-Air Australia's SmartToolTM provides an is effective against large quantities utilises a environment software configuration that allows a customised solution be easily and SmartToolTM an the needs of airborne microorganisms. Cleanto design thetool system that bestprovides addresses for ato science basedconfigured UVC solution to TM environment to design Air Australia UVC delivers the highest provides an shows thethe intensity of UVC being generated. Clean-Air Australia's SmartTool problems of airborne viruses. the system that best UVC output, driving HVAC system environment to design the system that best addresses the needs for a science based UVC solution to addresses the needs for efficiency while improving indoor air If yourofgoal is to maintain indoor air quality the problems airborne viruses.higher a science based UVCand protect those in your environment, then your quality.
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PUSHING HEALTHCARE TECHNOLOGY BOUNDARIES HEALTHCARE ENGINEERING ACCOMPLISHMENTS NOW AND LOOKING TO THE FUTURE By Rafx Hamilton, (IHEA Member – Vic/Tas Branch)
Case Study: Cabrini Health Gandel Building Development
n the modern healthcare environment fast and reliable communication and data transfer becomes a more critical and expected part of the infrastructure landscape with multiple options available. As technology moves forward to enable the sharing and storing of data and communications information and the lines between various support functions blurs, “future proofing” of infrastructure as best as possible becomes more difficult for health care engineers. Different user groups within a hospital have different information and connectivity requirements. Thoughtful infrastructure development can improve communication and connectivity, drive efficiencies and most importantly enhance the experience of the patient, practitioner and others using the health care facility. This case study will provide an overview of the infrastructure installed in the recently completed Cabrini Health Gandel building to facilitate data sharing and communications, and some of the considerations that led to the installation of that infrastructure. Cabrini Health is a Catholic, not for profit, healthcare organisation located in the south eastern suburbs of Melbourne. We are owned by the Missionary sisters of the Sacred Heart of Jesus, (the Cabrini Sisters). The age of the buildings at our main Malvern site ranges from the late 1950’s through to 2019. We have just completed construction of our new “Gandel Wing” named for John Gandel – one of our principal donors. This building has state of the art architecture and engineering and includes a high tech data backbone and connectivity designed to assist us to deliver the best outcomes for patients, families, doctors and staff.
This new Gandel building was recently featured in a Vogue Living article in August under the title “Is this the world’s most beautiful hospital?” So how did we go about creating this new building on our existing site? We first had to relocate the basement plant room contents of an existing building and all infrastructure within it – as this plantroom was located within the footprint of the proposed Gandel Wing. This infrastructure included 4 chillers that supplied chilled water to most of the existing facility, key pipelines in the medical gases infrastructure, including the main oxygen feed to the entire facility, key parts of our electrical infrastructure, including a substation that supplies 4 of our other existing buildings. Once the plant room was relocated into the basement of another building we demolished the existing 4 level 1970s building, (2 down, 2 up), that was sitting metres away from the rest of the operational buildings on the site. Excavation then began to prepare the site for the new building of 11 levels in total: (4 down, 7 up). The new building includes two radiation therapy bunkers in the B4 basement, and multiple levels of basement car parking with end of trip change and shower facilities on level B1 accessible from the outside. We expanded our existing A&E department on the ground floor, our cardiac facilities on the first floor, and our maternity facilities on the second floor, with other general medical wards above that including an oncology infusion treatment area. The level of the wards in the new building complements the other wards and medical precincts in the buildings that that surround them.
The new Gandel building was designed by Bates Smart and it was built by Kane Constructions. To quote a recent Vogue magazine article on the building, “The Bates Smart approach was about creating spaces for healing, rather than simply treating illnesses,” The Gandel building took 8 years of planning, 2 years to construct, and was opened in July 2019 at a cost of approximately $120M. We wanted to incorporate cutting edge design and the latest technologies with the aim of enhancing patient comfort & safety, improving energy efficiency over our existing building stock and to provide work spaces that enable staff, doctors and support services to deliver the best possible care and outcomes. To achieve some of these outcomes we had to look closely at the activities within the hospital, the building orientation, and we often became heavily involved in data networks that blurred the line between IT and building equipment and infrastructure. Some of the new (to us) mechanical infrastructure we have installed: • A chilled beam system to all patient rooms. While this is actually old technology, it is the first time we have used this type of system and it was selected for its energy efficiency. • The main air supply system for the chilled beams is fed from four air handlers, one for each façade of the
building to allow for expected variance of weather conditions and their impact on each aspect of the building. • All exhaust air leaves the building via a large plant room heat exchanger that provides pre heating for the fresh air supply from the top floor plant room, which acts as a plenum chamber. • Rain water from the roof is collected in basement tanks and reused for flushing in the ground floor visitor’s toilets. Data networks are essentially a highly flexible communications infrastructure. People often use the term the “Internet of Things” and I have taken and amalgamated a few definitions of the internet of things into this one: “The Internet of Things refers to the ever-growing network of stand-alone physical objects (natural or man-made) that feature an IP address to transfer data over a network, that allows for monitoring or control of that object and other objects. It includes the communication that occurs between these objects and other Internet-enabled devices and systems and the networks that join them. It essentially describes an intersection between IT networks and physical items in the environment.” The truth is that we have had a lot of this type of data infrastructure for a long time. Some common examples of this are the BMS & security systems common to many
buildings. These systems have used data networks for their distributed architecture and communication to high level interfaces (HLI) or hard wired interfaces of plant and equipment for a long time. In the industrial world we have used programmable logic controllers (PLC) and system control and data acquisition (SCADA) systems to control and monitor all sorts of plant and equipment for over 40 years, and these technologies have always utilised various data networks and communications protocols to monitor and control equipment. So the internet of things is really nothing new. What is new about these networks is the variety of ways things can interconnect, (including the physical infrastructure and the communications protocols used), the greater variety of things that can be connected and can communicate with each other and the speed and volume of data communication enabled by the new infrastructure and protocols. This communications technology is developing quickly and whatever you install today you can bet it will not be the latest thing in 12 months’ time, but it is not rocket science, (or at least it doesn’t have to be). In the modern world people expect to have access to lots of data quickly and easily. In the health care setting this can apply to patients and their families within the facility, and patients outside the facility accessing home
based care and the staff delivering that care, but also other user groups. We were looking for efficiencies and functionality outcomes for all users. To achieve this we had to consider the needs of all key user groups, patients, doctors, hospital administration, support staff etc. We considered many aspects such as what patients and families want during their hospital stay, what doctors want when interacting with their patients, what the hospital management wants to enable efficiencies and monitor performance, and then we considered how the internet of things could enhance the facility functions to enable these outcomes. Good communication technologies can assist to build the right connections between the relevant user groups and equipment, and can enable them to transfer that information quickly and efficiently. One of the things we discovered on this journey is that there are lots of way to achieve an outcome. Everyone will claim to have the solution you need…. and they will often try to baffle you with bull. Sometimes they can deliver on their promises, but this may come at a significant cost that you may not want to or be able to pay. There are other traps in setting up these complex data networks and trying to use them to connect “things” in your facility and to share information. Some examples of these traps are that not everything will talk to everything else easily, not everyone will live up to their promises, and not everyone will play ball when you need them to do
something to achieve your desired outcome. You need to have a really strong IT department on your side when you start developing this sort of technology. You also need to be really detailed in your scope of works to try to ensure you catch every possible variable. Another thing you need is to select a good middleware provider who can customise their software to suit your requirements and will provide the correct level of support. Some of the suppliers of this software will charge outrageous prices for their products, while others may not. I believe that all software used in this type of scenario needs to have a good user interface part of the offering. A good user interface will enable simple monitoring of data transfer/movement and should provide easy troubleshooting of the network if faults do occur. The key to a good interface is that it should enable the people on the ground to be able to trace data pathways to determine where a data stream failed. So a lot of this internet of things infrastructure that we have installed is outside of the engineering realm. But a lot of it is also shared because of the nature of the network and the things attached to, communicated to and controlled by it. Our infrastructure data network took a number of different vendors to achieve the outcome and it is tied together by a key piece of custom built integration software. There are definitely risks in developing this type of data network. There is a risk in using custom built software, we needed to find a provider we considered reliable and able to provide the backup and support we needed. They also needed to be savvy enough to take our vision and develop a package that would achieve our desired results and then implement it reliably. And finally, we needed them to be able to provide effective service support. So it was a case of finding a balance between a large and inflexible supplier and a small flexible supplier that couldn’t provide the required support. The starting point of our data network is our Patient Allocation software, (PAS). This software allows us to know key patient details and where they are located in the hospital. PAS is connected to a variety of devices and servers that communicate with each other, an internal mail server to distribute emails as required to report and notify people of events, Patient food management software to enable efficient, timely and cost effective delivery of the correct food to patients, and communications software to utilise a variety of communication options for patient’s and staff. We integrated the nurse call software and the BMS and security systems to provide enhanced communications
and service levels. The new Building Management System we have installed includes plant monitoring and management, including power, gas and water consumption throughout the facility, with totalisation, data logging and alarming. The BMS also provides mechanical services control, alarming to remote devices, and integrated security for door control and cameras. The installation of a Digital Addressable Lighting Interface (DALI) smart lighting system was installed that integrates with the nurse call system and means we can program day and night modes for the wards to subdue lightning after hours and enable patients to control their room lighting as they wish. Interconnection of the lighting control with the nurse call system also means an emergency nurse call will automatically override any local settings and bring the relevant room lighting to full brightness. All handrails in the building have hidden digital lighting installed to light main pathways around the ward and to provide subdued lighting between the bed and the toilet in the patient room We are trialling a Bluetooth wandering system to monitor babies and other patients that will either alarm if a baby leaves the area or potentially lock down doors if a wandering patient gets too close to them. We installed remote fire panel monitoring across the entire site to improve fire alarm response. In event of a fire alarm, messages are distributed to key personnel to immediately advise them of the locality of the alarm. In the patient and medical space we installed Room Information Screens (RIS) at the room door to display patient information, nurse calls, maintenance requests and basic food service requests. The Patient Entertainment Screens (PES) located at the bedside are linked to big screen TVs on the wall to allow the patient internet, TV and radio access, and to display medical and hospital information to the patient at the touch of a button. Food monitoring software enables patients and staff to order food from the bedside (within their dietary restrictions) and have it delivered by local support services staff. We have installed Point of Care PCs in each room allow doctors to connect their device to show patients information on their TV screen or mobile device and to record information electronically in the patient room. The nurse call system we installed is distributed, but messaging from the handsets is sent via the middleware software to mobile devices carried by ward staff. New multifunction “smart” handsets allow SMS, email and phone messages to be easily sent to key personnel. They are connected to the nurse call system to directly
inform a nurse of a call, with an escalation protocol that expands the message to more recipients if the initial call is not responded to in a timely manner. It also enables us to monitor the connection of each primary nurse call controller in each room. This enables pre-emptive warning of a nurse call controller failure prior to it being detected by the patient or the nurse. Mail and messaging servers on the network enable messages and alarming across the organisation to a variety of devices via a many methods. In some areas where wards crossed between new and old buildings we had to integrate the existing nurse call system and the new nurse call system. This involved some clever programming and data flows in the middleware software to enable us to take messages from the old system and insert them into the new system and then enable the new system to display those messages across both wards. The new communications system we installed needed to be flexible and carry a lot of data traffic. This required use of multiple servers to perform different functions within the system and distribute the data traffic load. To make our communication network function as desired we needed to amalgamate our new communications devices and network with our existing mobile, DECT and pager networks. The new system enables us to communicate as required between old and new devices and software. We can send messages from the Room Information Screen for a maintenance request or the Patient Entertainment Screen for a food request. These messages are sent to the required type of device carried by each relevant staff member, and that staff member acknowledges the request on the RIS when they attend. All these movements are traceable so response times can be managed. You would think that with all this data transfer and communication networks the possibility of issues would be relatively high. So what issues did we have when we opened the new building? Not the ones we would have expected. The chilled beam system gave us issues due to placement of sensors and averaging across zones and the tuning of the main air supply controls took a while. We had plumbing leaks in mechanical, domestic water supplies and sewerage systems. We had vinyl flooring issues in bathrooms causing drainage problems.
system, some lights just stopped working, and others would come on and off of their own accord. And we had difficulty getting accurate information about issues from staff to help with fault finding. The nurse call handsets operation was confusing to staff and patients and we had many issues with people not being able to operate the volume controls to hear the TV. The cause turned out to be dual volume controls on the handset, with one of them unlabelled. Our new building has a cooling tower located on the 7th floor. Our old cooling towers are on the 3rd floor. When attempting to integrate the two systems to provide increased flexibility the engineers ran in to a lot of unexpected trouble. The sets of interlocked valves installed to manage the variance in condenser water head pressures did not function as designed. At the time of writing this issue has yet to be resolved. Some key points to take away from this build are that modern data technologies can assist us to deliver improved healthcare outcomes and increased efficiencies. The concepts behind these technologies are not new but the applications and delivery methods are forever expanding the opportunities. In our Gandel wing we have created a high tech hospital building with the needs and desires of patients, staff and the hospital in mind. Utilising the internet of things and clever data transfer methods we aimed to assist the health care staff to deliver the safest, most comfortable facility with the latest technology to assist them to deliver the best possible health care outcomes. The limitations to what you can do are really only in your imagination and the size of your organisationâ€™s wallet and there are lots of options available to achieve whatever outcome you desire. Some vendors will unfortunately make promises that they cannot deliver on. And to deliver the desired outcomes you will require a collaborative approach between management, medical staff, engineers, vendors, and a highly capable IT department. Having a good middleware provider is also critical to enable these types of data and communications networks. The middleware is the hub of your network that brings all the equipment together and allows you to achieve your aims. Does what we have installed achieve our vision? While not perfect, I think it does.
Some staff did not like the way the DALI lighting system operates or its controls and were a bit rebellious toward it and did not want to understand it. We also had faults with the Digital Addressable Lighting Interface (DALI) lighting
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HEALTHCARE INFRASTRUCTURE PLANNING & DESIGN IN THE WESTERN CAPE PROVINCE, SOUTH AFRICA – FINDING APPROPRIATE SOLUTIONS TO INAPPROPRIATE PROBLEMS By Duncan Rendall, Chief Architect, Western Cape Government: Health, Western Cape Province, South Africa
Perhaps as a bit of a counter to the impressive array of amazing new health facilities that tend to be presented at conferences like this one, I thought it might be interesting to provide you an insight into some of the less glamourous aspects of the environment within which we operate. As a developing nation we face some interesting challenges which can give rise to some equally interesting design solutions, of which some are architecturally notable while others, by their nature, are perhaps best described as purely ‘functional’!
GEOGRAPHIC AND SOCIO-POLITICAL CONTEXT
In terms of our current constitution, the provision of health services is the responsibility of the Provincial Governments.
e have a population of approximately 55 million people and the country, which is divided into 9 provinces, is larger than the combined sizes of UK, France, Germany, Belgium and the Netherlands.
As one of the wealthier Provinces in the country, the Western Cape has experienced an influx of people coming into the province, both from other Provinces as well as significant numbers from other African countries, in search of employment and better living standards. Informal settlements have developed on the outskirts of many towns and the numbers of people needing access to basic services such as Healthcare continues to grow.
The Gini co-efficient equality measure shows South Africa to be one of the most unequal societies with as many as 55% of our population living below the poverty line according to a recent article in South Africa’s ‘Times’ newspaper (4 April 2018). The Western Cape, where I am based, covers an area just less than the size of England with an estimated current population of approximately 6.6million people (as opposed to the Englands population of 53 million). The city of Cape Town is the provincial capital and has a population of approx. 3.8 million people. The remainder of the province is characterised by a network of rural towns and villages that developed largely around an agriculture driven economy, although that has changed significantly in more recent years. George in the Southern Cape is the next biggest town with a population of just under 120 000.
Unemployment levels in the province are just above 20%, which is slightly below the national average, and the social ills such as alcohol and drug abuse that often characterise these conditions are rife. The health demographic that characterises these communities is known as a ‘quadruple burden of disease’ in that it includes high levels of interpersonal violence and road traffic accidents, escalating levels of chronic disease including mental health, high levels of TB and HIV, which often present as co-morbidities, and lastly maternal and child related health challenges. (Ref Western Cape Government: Health, 2030 Road to Wellness Strategic plan)
Our Health statistics show for instance, somewhat startlingly, that the number of autopsies being carried out by our forensic pathology services has increased by 25% over the last 5 years and the firearm related deaths increased by as much as 50 % in some areas between 2016 and 2017. So it is no surprise then that Emergency Centres (EC’s) and Mental Health facilities are currently key focus areas of our infrastructure planning programme. We have in the region of 250 Primary Healthcare clinics across the province and 41 acute hospitals of which the vast majority are small rural facilities which refer to a network of 5 level 2 facilities and 3 central or Level 3 hospitals. As I believe is the case in many countries, our service is structured into ‘Levels’ with Primary Healthcare, which includes Home Based Care, clinics and intermediate care facilities, addressing the less acute day to day health needs and then the hospitals where a Level 1 (also known as District) hospital is the typical general hospital which would then refer up to a Level 2 (also known as Regional) hospital offering more specialist treatment and then a Level 3 (also known as Central or Teaching / Academic Hospitals) being the most specialised. We also have a number of dedicated specialised TB, psychiatric and physical rehabilitation facilities. Public healthcare services are free of charge at primary healthcare level with only limited payment according to means for hospital treatment. We are slowly making inroads into addressing historical apartheid era health service access challenges through expanding our service footprint and our departments health outcomes continue to show significant improvement. The province for instance has the highest life expectancy in the country both for males (66.8yrs as opposed to the national average of 61.1yrs) as well as females (71.8yrs as opposed to the national average of 67.3)
As mentioned, many of the communities in which our facilities are located not only have a high disease burden but are also characterised by extreme levels of violence, crime and gangsterism. Unfortunately the facilities often get ‘caught in the cross – fire’, literally. At the Hanover Park Community Health Centre in Cape Town for instance we have had to install steel plate extensions to the tops of the wall around the facility to deflect bullets; having had one too many near misses where bullets have passed through the building, most of which is an old timber framed and clad structure. I am pleased to be able to report that we have commenced design on a replacement facility! In a number of similar communities we have had to introduce high fences and turnstiles more often associated with football stadiums or even prisons than health facilities to enable the security staff to manage access to and from the facilities and most facilities also now have CCTV systems Our Hospital Emergency Centres inevitably tend to bear the brunt of the violent incidents. At one of our largest Emergency Centres, in fact at our most famous hospital, Groote Schuur, the site of the first heart transplant in the world, we had to move the resuscitation bays, generally located close to the ambulance drop off zone, deeper into the facility following an incident where a gang entered the unit to try and finish off a patient who was from the opposition gang while he was being resuscitated!
Our most difficult projects therefore tend to be the ones where we need to adapt or expand these existing buildings or implement emergency replacements of dysfunctional facilities to enable appropriate health service delivery to continue.
At the risk of doing our tourism industry a disservice, I emphasise that the environments I am describing represent a reality generally only encountered in areas significantly removed from the average tourist’s itinerary. The extent of the problem is no exaggeration however. In an episode of a recent documentary titled ‘Extreme South Africa’ made by British journalist, Reggie Yates, the challenges faced by our clinical and ambulance services in Cape Town’s largest so-called ‘township’ area of Khayelitsha where we have recently opened a new hospital, are graphically captured.
I have selected a few recent examples of both new-build projects as well as installations implemented to mitigate security risk, which illustrate a range of responses to service challenges associated with the socio – economic conditions.
In the same Emergency Centre featured in the documentary, an access issue of quite another kind was experienced recently. A group of protesters entered the Unit, posing as patient visitors, and once within the main clinical area took off their jackets to reveal t-shirts from
Where infrastructure is concerned however, the vast majority of our current facilities are over 30 years old and invariably designed for a very different service environment based on a very different operational model and serving significantly less people than is currently the case.
SECURITY AND ACCESS CONTROL
a well-known activist organisation. They proceeded to verbally abuse and even manhandle some of the staff supposedly to protest apparent reports of poor service. Quite how they felt this was going to help improve service delivery is not clear but it served to again highlight the ever increasing need for improved levels of security and access control. We are now installing security screens and other additional access control measures at the facility. Unfortunately this sort of disruptive protest action, although rare at a health facility, has become a characteristic of our broader political environment, particularly in the Western Cape, the only province under the control of an ‘opposition’ political party, and with a national election scheduled for 2019, we are likely to see the incidence of this sort of activity escalate. It’s not necessarily only violent or disruptive behaviour that has become an issue however. We have recently been approached by the head of the Emergency Centre in one of our Level 2 Hospitals just outside Cape Town, to ask us to install an access control system not dissimilar to what you would expect to find in a bank ie, allowing access
to one person at a time. This in response to increased levels of theft being experienced from treatment areas where people, again posing as patient visitors, have been stealing surgical stock and medical devices at an alarming rate! So, as much as we try and encourage salutogenic design with more passive safety and security design strategies being employed in our new build projects, many of our facilities are fast beginning to look like places of detention instead! But there are positive stories involving Emergency Centres too…
SERVICE DELIVERY PRESSURES Ensuring we provide the right service in the right location is a core function of a public health service anywhere in the world. Our Department is constantly trying to balance expenditure on clinical services and staff with the need to modernise our infrastructure while continuing to ensure services are delivered as effectively and efficiently as possible. We are often called upon to implement
infrastructure projects which side step our normal planning processes due to an urgent service need.
in under a year which, for a highly serviced facility of this nature in our world, is good going.
Heideveld Emergency Centre, Cape Town
A lot of innovative thinking went into the way engineering services such as power, gas and water are reticulated through the wall panels and specifically located strengthened structure within the panels ensured wall mounted fittings could be adequately supported. The overall finish both internally and externally is also low maintenance, an aspect we spend inordinate amounts of money on at many of our facilities.
In 2013 it was decided to decommission a hospital in a particularly violence afflicted part of Cape Town due to it no longer being fit for purpose. The bulk of the service was relocated to a new hospital a few kilometres away but it was felt that an Emergency Centre closer to the original hospital site was required due to the demographic of the area. The unit needed to be large (1000m2), cost effective, potentially relocatable and had to be built as quickly as possible as the old hospital was in the process of being decommissioned! The design team, in collaboration with our Works Department, came up with an essentially industrial solution using steel portal frames, sheet metal cladding to the external envelope and prefabricated ‘cold room type’ internal partitioning. While the design development process perhaps took somewhat longer than planned the construction was largely completed
The simple plan form lends itself to this type of construction and the largely ‘open plan’ trolley areas with a support services ‘spine’ is a model that is working well operationally. The patient areas have good levels of natural lighting and the general ‘feel’ in the space contrasts with the more traditional dull institutional approach which characterises so many of our older facilities. This particular facility is built on the site of an existing large Community Day Centre through which ‘walk in’ patients (as opposed to ambulance drop offs) have to pass so the
arrival, triage and ‘green’ treatment area is site specific. While we are not currently looking at it as a service model, with some minor modifications and further simplification of certain elements, this design could easily be seen as a benchmark for a self-contained Emergency Centre were that ever to be considered viable from a service perspective.
OVERCROWDING With the ever increasing population our Cape Town facilities, in particular, are struggling to cope with the rising patient numbers and we have inevitably had to resort to the use of temporary structures to expand the capacity. Typically this involves the deployment of a simple ‘off the peg’ prefabricated structure (which we refer to as ‘prefabs’) but not always…
…which is exactly what we did a few years later when a very similar scenario played itself out in the suburb of Mfuleni, a very similar community to Du Noon, in another part of Cape Town. In this instance the patient numbers were significantly higher and no suitable warehouse type structures existed in the area. The solution saw us collaborating with the City of Cape Town to build the ‘warehouse’ ourselves and then insert nearly 60 converted containers. What makes this project even more innovative is that the ‘warehouse’ is in fact designed to align with the City’s standard specifications for a multi-purpose sports hall so when we build the planned new permanent Mfuleni Community Day Centre in a year or two, this building will be handed over to the City and will form part of a sports complex they have planned.
Du Noon and Mfuleni Community Day Centres, Cape Town In 2013 the community of Du Noon, a recently established and rapidly expanding low income suburb of Cape Town, took to the streets to express their dissatisfaction at the service they were receiving at the clinic in the area and forced the closure of the facility. The original clinic was built and operated by the City of Cape Town about 20 years ago, and was typical of many primary healthcare facilities of that era, having been designed to serve a significantly lower number of patients with a very limited service package. An undertaking was given to provide temporary premises while a new permanent facility was planned and constructed. With limited land availability for new build structures we looked to existing buildings in the area to see if any could be easily converted to achieve the required accommodation. Given that the area was only fairly recently settled the options were limited. An adjacent, recently built, industrial park however offered a possible solution. Over the years we have often used shipping containers to expand facility storage capacity and occasionally to add a consulting room or two. In this instance we developed that idea to another level literately and figuratively. A warehouse in the industrial park was available for rent and a design team managed by our Dept of Public Works colleagues produced a design which used almost thirty converted shipping containers in a double storey configuration to produce a temporary clinic which would be used while the new permanent facility was developed nearby. The installation of the containers was quite a logistical puzzle but ultimately we were able to produce a workable facility in a comparatively short period of time. What’s more, almost every component was able to be dismantled and potentially moved on to another location.
Almost all the containers from the clinic at Du Noon were transferred over to the Mfuleni facility along with the stairs and mezzanine level walkway structure and even elements of the mechanical ventilation system. Given that this facility will need to operate for slightly longer we also added a ramp to avoid the need for a lift. I have never felt comfortable with the notion that poorer communities should accept this type of accommodation as a permanent health facility but in terms of addressing
urgent service pressures and essentially â€˜buyingâ€™ time for the planning of a permanent facility the design has certainly provided an appropriate interim facility.
CONCLUSION As architects in the public health sector we are faced daily with the challenge of balancing the desire to encourage design excellence with the need to deliver projects that are functional, cost effective and can be implemented more rapidly than in the past. With the benefit of the internet and conferences such as this we are all aware of current trends in international health facility design which makes it all the more difficult to sign off on some of the compromised solutions which are a day to day reality for us. Based on this presentation, you would be forgiven for thinking that our infrastructure estate comprises largely
of a range of old, poorly maintained buildings and fortified temporary structures but I assure you we are also developing many new facilities worthy of presentation at conferences such as this, as some of you may have seen from my Public Works colleagues earlier. As much as we are trying to move to a more pro-active long-term infrastructure planning approach to reduce the frequency of projects which require a short term solution, the current reality is that the health system demands are changing and evolving faster than we can build. For the foreseeable future our environment will continue to be characterised by projects where we are forced to resort to perhaps less aesthetically pleasing but hopefully still appropriate solutions to our many and varied inappropriate problems!
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THE EXPERIENCE OF THE TECHNICAL TEAM AT UZ LEUVEN HOSPITAL IN BELGIUM By Eddy De Coster, ir head of department, Technical facilities UZ Leuven
UZ Leuven is the largest university hospital in Belgium with 1500 hospital beds and a revenue of 1200 million US dollar.
e are part of the KULeuven, the catholic university of Leuven, in the Dutch speaking part of Belgium in Western Europe.
Our technical department is staffed with 250 employees and has an average turnover of 36 million US dollar on maintenance costs and more than 60 million US dollar in construction development and renovation a year. We have a long history starting in 1426. Around that time also a brewery was founded in Leuven which still exists today: Stella Artois, now part of AB Inbev and which made Belgium the land of beer and chocolates. I hope you already had the occasion of tasting one of them. In 2003 we started a masterplan to reduce the hospital campus from 4 sites to 2, which are the main plant, the Health science campus Gasthuisberg, and the rehabilitation plant in Pellenberg. The masterplan foresaw in reducing the duration of the hospitalisation but also the deploying of more ambulatory cure. As a result of building a network of hospitals in Belgium working together with UZ Leuven, severe patients come to Leuven less severe are staying in the local hospitals, hereby intensifying the complexity of patientcare and technical needs to do so. The plan also accommodated the request for full integration of the research and development sections and the educational part of the medical faculty on the campus Gasthuisberg. It took about 4 years to start the construction of the first building of the masterplan. In the masterplan there is a distinct place for education, research and development, hospital and ambulatory care. We started with an energy masterplan and a mobility plan. The latter included a
strong need for parking lots due to the special location of the hospital within the city (more than 5000 parking places). All new parking spaces are provided underneath the new buildings. With regards to energy management we planned for high redundancy and high reliability combined with an important sustainability and energy efficiency. When we compare the health science campus Gasthuisberg with a residence, we have a consumption of: • Electricity 64,300,000 KWH or the equivalent of 15,000 residences • Gas for heating 82,000,000 KWH or the equivalent of 3,600 residences • Water 333,000 m³ or the equivalent of 3,300 residences Now we have more than 300.000 m² of hospital buildings and about 200.000 m² of education and research buildings. We at UZ Leuven are proud to be the first JCI (Joint Commission International) accredited hospital in Belgium and that since 2010 with a last survey in 2016. The goal of JCI is creating and exploring a patient safe hospital. For the technical services the most important issues are safety and security of energy, medical equipment, clean air, fire safety, infection prevention. What do we do at UZ Leuven to reduce the risks of technical installations and technical activities on the patient safety? First of all we always need to remember that it are the people working in and for the technical department that are the most important link in the chain of looking after a patient safe environment.
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Therefore we trained our technical personal by giving them a ten points program: 1. Keep technical areas tidy, always close the door. 2. P revent risk of falling, keep corridors free of ceiling panels, loose cables, etc. 3. K eep the working environment organised and clean, avoid spreading of dust and debris in the hospital. 4. R estrict access to the construction site for unauthorised people, take care of the signalisation. 5. R equest a ceiling permission when the ceiling will be opened for more than one day. equest a fire permission when grinding, welding, flame 6. R cutting, burning off of paint, etc (except in workshops) 7. What to do in case of fire? 8. B e recognisable, wear your badge and uniform, register yourself at the services. 9. K eep dangerous tools and products away from children and other vulnerable patients. Keep your work cart locked. 10. In doubt, ask for advice of your supervisor. It is a work of more than ten years now and today our people themselves have the know-how of making risk assessments required in a hospital. We have to cover risks originating from maintenance control, as well as risks related to the construction works in own execution and tasks that are performed by contractors: renovation, building and technical equipment. Starting from energy continuity the most important energy source that we have to secure is electricity. We made a double net on 10,000 V. That we have completely renewed from 2009 till now. We have a “NORMAL” distribution net coming from the external energy distributor, and we have a second “NOOD - Emergency” net that in normal conditions is fed from the normal net. When something goes wrong on the external distribution, we go on emergency and a set of 4 DIESEL-ALTERNATOR-groups take over within 15 seconds, giving electricity for the most necessary patient-connected needs. In normal condition we have a peak use of 12 MW and in Emergency we can supply a maximum of 4 times 2 MW. For the most essential uses we have a distributed net of UPS (uninterruptable power supply) for instance the lighting and medical equipment in the operating theatres. We test this every month and once a year we do a life test by asking the energy supplier to turn off the hospital from the electricity net for 5 minutes.
For heating we use a centralised boiler-room with 4 boilers ( with a total of 40MW heating capacity). To secure this we have mixed-burners who can work on oil and on gas. Medical gasses, like compressed air and oxygen, are crucial for life support of some patients. Medical gasses are regulated by pharmaceutical laws in Belgium and Europe and so a lot of rules have to be followed. Most important rules are to assure supplying the right gas therefor you always need the ability to deliver from 3 separate sources and always under pharmaceutical hygienic conditions. Water Although Belgium has a very extended net of water supply, the challenge is to get the water in good condition to the patient. Water is very important for instance for haemodialysis, sterilisation, for those use cases we can rely on the delivery of water coming from external supply that we treat in the hospital by reverse osmosis so we can guarantee the quality of the water. For drinking water the law is very strict, in our hospital only patients with reduced immunity get water in bottles all the rest is coming from external supply. To assure sufficient water supply at all times we have a reservoir controlled by the external supplier for several days. And the supply to our hospital comes in by three separated ways. All the new water pipes for both cold and hot water are insulated so the temperature is correct and can be measured and alarmed. We do water tests every month at 100 points chosen by our experts as the most critical points. Air quality For special applications, in operating theatres, cleanrooms for pharmaceutical use… we have clean air coming from hygienic groups and by the use of absolute filtering we can guarantee the quality of the air. Particle counting is applied every year on air samples to be sure that the quantity of particles does not succeed the acceptable maxima conform the norm. Data and voice In the patient treatment of today all essential technical installations and equipment are coupled on a digital information system. All the necessary parameters are analysed and an alarm informs the nurses on the patient parameters, and technical and fire alarms are sent to the technical services. 24 hours a day 7 days a week we have a manned dispatch who treat all these alarms. There is also a highly schooled technician in the hospital 24/7 to handle the first necessary actions, technicians from all disciplines can be alarmed at home to come to support. What to do when something gets really wrong? Therefor we use our hospital incident management system (HIMS). We have analysed all sort of risks (not only the technical risks but also the risks of lack of nurses,
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pharmaceutical products, severe weather….) First we establish preventive measures that we use every day to prevent incidents from occurring. For instance we do preventive maintenance on all equipment, and we have the most essential spare parts in our own technical store in the hospital. But if an incident happens, and we all know that it will happen whatever we do preventive, we must have procedures to tell the people what they have to do in those emergency situations. We have made a lot of emergency procedures and we store them in an digital system called MUZLIDOC. A special feature of this system is that it offers the possibility to have the procedure approved by several stakeholders, but also that after a certain period all these people have to review the procedures. Having procedures is not enough, you have to train your staff on those procedures, because hopefully they occur rarely. In case we don’t get control of the incident there is a possibility to switch to the state of “disaster management”. The possibilities are to receipt; evacuate, isolate or relocate, the patients from or to other locations in our hospital. But let’s all hope we never need these plans. We have so far addressed the technical risks in exploitation, but there is also a special risk in the building process of hospitals. And as we all know there is a lot of construction work to do in hospitals in order to have buildings and equipment that are up to date for our patient care. The most important risks to be treated are infection prevention coming from dust and water. We start with determining the risk index, before starting with the study of the work and the search for a contractor. The contractor needs to know what kind of execution methods he needs to apply for minimising any inconvenience for the patients during the works, especially noise, vibrations, circulation. The risk index from 1 to 4 is based on a decision table that primarily rates the risk for infection of the patient. The second parameter is the type of work to be performed, going from just opening a ceiling for inspection to the demolition of a concrete wall. Based on the index we have to take measures in order to have no dust in the patient environment. We close doors, make temporary walls in wood (not plastic, they must be there during the whole working period), and consider how to transport the materials from and to the construction site. We have a strict signalisation on every entrance door of the construction yard listing the point of contact for information and action. All contractors must have a badge with the name of their organisation. But most important is that all installations have to be checked 100 % by the contractor, the engineering bureau, if necessary the official inspection agency, and the engineer from the technical service. If all
those stakeholders have given their approval, the hospital prevention engineer will allow that patients can be treated in this area. We have a culture of reporting near-accidents (however small they might be), with the analysis of all those reports we succeed to prevent real accidents. We recently started a Last Minute Risk Analysis (LMRA) to enable and encourage our staff to think ahead and be optimally prepared for any safety concern related to a task upfront. So I have given an overview of how the technical service in the University Hospital of Leuven (Belgium) deals with risks from technical installations and buildings. You never can be sure of having no accidents, but it is necessary that the responsible people can sleep well every day by thinking we have done what is possible for us to limit the consequences from our operations in the technical services on the well treatment of the patient. And that is very important to the people of the technical services.
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FULL STEAM AHEAD HEAT EXCHANGE In previous editions of this journal we have looked at what makes steam an ideal thermal energy medium and considered how steam generation can be made more efficient. This article continues with the “Full Steam Ahead” series to examine steam Heat Exchange. The main use of steam heat exchange in healthcare (or indeed hotels and institutions) is for heating water, both as Domestic Hot Water (DHW) and Heating Hot Water via a Low Temperature Hot Water (LTHW) Loop. There are many different options when it comes to steam to water heat exchange, and for efficient and reliable operation the design must be given careful consideration. Traditionally the storage calorifier was commonly used for DHW, however the risk of Legionella, maintenance and cleaning requirements and the large floor space required in plant rooms has seen a move towards more compact heat exchange solutions, that heat water on demand.
Steam side control with active condensate removal
In the past the focus may have been on capital cost of a heat exchange unit, meaning it was likely implemented in its most simple form of a heat exchanger with a steam control valve and a steam trap to remove the condensate. The steam control valve controls the steam flow and pressure (temperature) into the heat exchanger to suit the differing load conditions, and so this is referred to as steam side control. The issues here are that a smaller heat exchanger (small size/area used to reduce capital cost), will require higher steam pressure, which in turn can produce flash steam that, if not utilised, will result in losses and inefficiency. In addition the use of a standard steam trap on these units limits the turndown possible before stall and flooding of the heat exchanger causes problems with accurate temperature control and possibly even damage to the heat exchanger over time. With energy efficiency and the need to reduce carbon emissions becoming a driving factor, the focus turns to a heat exchanger
package that will help meet these targets. A modern DHW steam heat exchanger unit will often use a plate heat exchanger, with large surface area and high heat energy transfer, coupled with active condensate removal using a pump trap. The large area of the heat exchanger, coupled with active condensate removal allows low steam pressure to be used, without the risk of stall or flooding (lower steam pressure also increases gasket life of the plate heat exchanger, and so improves reliability). The combination of using low steam pressure, the design of the heat exchanger and the fact that the water temperature is relatively low (usually 60°C output) mean that flash steam can be virtually eliminated, making for better efficiency. And the elimination of stall and flooding mean better response and more accurate control of the water temperature (critical if needing to maintain temperature for Legionella control). For Heating Hot Water (HTG) the water temperature is higher than DHW, typically up to 80°C. This, combined with much higher heating loads, can make it more challenging to eliminate flash steam using a steam side control heat exchanger unit (even with a plate heat exchanger and active condensate removal). However HTG applications are usually very stable with slow and steady changes to load conditions. This allows an alternative control method to be explored, which is condensate side control. Here the steam is applied to the heat exchanger at a constant low pressure and a control valve is used to control the rate of condensate removal. The heat exchanger is thus purposely flooded, with the degree of flooding, and hence the area exposed to steam where high heat transfer takes place, being controlled by the condensate side control valve. The flooding and sub-cooling of the condensate eliminate flash steam, and can provide good control, provided the load changes are gradual. This type of control is not suitable for DHW, where load changes can be rapid. Even with a well-designed unit, suited to the application, consideration should be given to monitoring and performance tracking, by way or metering steam and water flows and logging temperatures, to ensure maximum efficiency is maintained. When it comes to steam heat exchange there are many options, and it is important that the unit is designed and engineered to meet the requirements of the application, with energy efficiency and reliability being key considerations.
Condensate side control
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