Healthcare Facilities Journal Autumn 2022

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Editor’s Message National President’s Message CEO’s Message Letters to the Editor News

37 45 49 53 57

BRANCH REPORTS 10 13 17 18 21







ealth Outcomes Associated H With Ultraviolet (UV) Airstream Disinfection he Role of the Building in T Reducing Hospital Acquired Infections

Cover: IHEA Healthcare Facilities Management Conference 2022 – Perth. Venue and Sponsors.

IHEA NATIONAL OFFICE Direct: 1300 929 508 Email: Website: IHEA NATIONAL BOARD National President Jon Gowdy

69 75 78

Is There a Devil in the Detail? 4D Asset Audit Process Smart Electrification eeping Australian Healthcare K Systems Cybersafe sset Management in A Healthcare – Maximising Value From Existing Assets ovid’s Impact on the Future C of Project Management I t’s 2022. Why Are We Still Using Spreadsheets and Legacy Systems? educing Waterborne Pathogen R Risk in Healthcare Premises

he Future of Refrigerants for T Hvac

Visit the Institute of Healthcare Engineering online by visiting or scanning here →

Standards Coordinator Brett Nickels Directors Steve Ball, Rob Arian, Mark Hooper IHEA ADMINISTRATION Chief Executive Officer Clive Jeffries Finance Jeff Little

National Vice President Darryl Pitcher

Membership Nicole Arnold (FMA),

National Treasurer Rohit Jethro

Editorial Committee Darryl Pitcher, Mark Hooper

Membership Registrar Michael Scerri


ontribution: Why Healthcare C Organisations Should Invest in Workforce Management

National Immediate Past President Peter Easson

Communications Darryl Pitcher


IHEA MISSION STATEMENT To support members and industry stakeholders to achieve best practice health engineering in sustainable public and private healthcare sectors.

63 ADBOURNE PUBLISHING PO Box 735, Belgrave, VIC 3160 ADVERTISING Melbourne: Neil Muir T: (03) 9758 1433 E: Adelaide: Robert Spowart T: 0488 390 039 E: PRODUCTION Sonya Murphy T: 0411 856 362 E: ADMINISTRATION Tarnia Hiosan T: (03) 9758 1433 E:

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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s we finalise this Autumn 2022 Edition of Healthcare Facilities, I am happy to be writing this editorial from Ontario, Canada. After more than two years of restrictions, it is a relief to many that international and national travel has begun to occur again. With family spread across Australia, Canada and USA, we are glad that restrictions have been relaxed to allow travel, and of course that is a great thing also for the upcoming National Conference in Perth. This trip to North America has proven for me that the challenges we have faced in Australia have been replicated in these parts of the world as well. The uncertainty and fear of the growing pandemic in early 2020 resulted in a similar reaction within healthcare environments worldwide. As I’ve chatted with people here, including with members from the Canadian Healthcare Engineering Society (CHES) the same responses to the pandemic emerged across the global community. The challenges facing residential aged care, primary and tertiary healthcare have been remarkably similar, as has been the move towards COVID-normality as prepandemic activities resume.

Whilst here I have met with the chair of the committee planning the IFHE Congress in Toronto later this year. I encourage anybody planning to travel internationally, to consider coming to this beautiful location in September to attend the first ‘in-person’ international Congress since IHEA hosted the IFHE in Brisbane in 2018. The program and activities planned are outstanding and will provide an excellent global perspective on innovations in healthcare engineering. I am happy to present the Autumn 2022 Healthcare Facilities journal, which includes an excellent array of technical articles including some international perspectives, and an interesting dialogue presented under the first “Letters to the Editor” on page xx. If you’d like to share your perspectives on any related matter, please contact me via email at Once again thank you to everybody who has contributed, and to our sponsors and advertisers.

Regards Darryl Pitcher – Editor






had hoped that I could write a report without the word COVID so won’t labour the fact that these have been certainly the toughest years we have ever faced as an organisation. In some respects, the disruptions have been even more challenging to manage as rules seemed to change more frequently. I understand that for many in our industry, this has been a difficult time from a professional and personal standpoint. I equally understand that involvement in an organisation like IHEA is an optional extra – it’s something our members take on in addition to their day-to-day business activities. So upfront, let me say how deeply I appreciate the ongoing support and active commitment of our members. Your support for IHEA’s events and your active involvement with industry leading initiatives such as our Future Leaders

Program is invaluable. Moreover, it is helping IHEA to strengthen its profile and position as a voice of influence among decision-makers. It is vital that decision-makers are hearing that voice at the present time, given this industry’s central role in supporting the national healthcare system. On a lighter note its exciting to hear that with the easing of the recent border restrictions the National IHEA Conference 2022 “21st Century Healthcare Engineering” is going full steam ahead in Perth on the 11th – 13th May. This event is an important opportunity for us all to reconnect and provide some much needed support to both our organisation and our sponsors so hope to see you all there! Stay Safe Jon Gowdy – IHEA National President



CEO’S MESSAGE * Information * Knowledge * Ideas * Learning


ell it has been a couple of very tough years for everybody and no less so for our Institute and its on-going operations amid the most challenging of circumstances. It is with optimism and confidence for the first time during these past two years that IHEA members can look forward to collectively collaborating ‘in person’ at the upcoming national conference in Perth during May. The annual national conference has been and will continue to be at the core of what IHEA delivers to members and stakeholders in terms of opportunity and value, and an important element of IHEA’s annual performance. I write this as my final thoughts and observations in the role of CEO with IHEA. What started out as a short term business development assignment has become nearly two years with all the dynamics of the pandemic and its dramatic impact on our organisation, members and key stakeholders involved in the Australian healthcare sector. Two years without a national conference and without that annual injection of revenue that this essential event contributes has indeed been a tricky time for the Institute. For me it is now time to move onto other challenges and opportunities, but I depart with the confident knowledge that the Perth conference is going ahead. This will surely be a fabulous event for members to come together

again as the peak body for healthcare engineering and facilities management in Australia. During this period, our corporate members, industry suppliers and other commercial partners have been a critical component in supporting IHEA through these unprecedented challenges. I would like to take this last opportunity to acknowledge and thank all of our current association sponsors, forthcoming conference sponsors and the many sponsors of the past couple of years for their valuable contribution and support. This commitment has been essential to the Institute being able to navigate through these uncertain times enabling IHEA to look confidently to the future. I have greatly enjoyed the camaraderie, challenges, learnings and change we have worked on together over this time in what has been an extraordinary experience. I very much appreciate the opportunity that was presented to me by the National Board and the support I received particularly from the Executive Committee during my tenure. Thanks and best wishes, Clive Jeffries – CEO



LETTERS TO THE EDITOR As a membership publication, we welcome feedback and communication from readers, and are happy to share with you communication from Mr Roy Aitken from the WA branch. Roy read with interest an article in the Summer 2021 edition on “All Electric Hospitals”. Roy’s letter was shared with Simon Witts, National Division Director for the Engineering sector with VA Sciences, who authored the article, and this resulted

in a profitable exchange, which is reproduced below for your interest. We welcome your contributions to this section of the Journal, on this or any other matter of interest, bearing in mind comments from readers do not necessarily reflect the position of the IHEA, the Editor, Publishers or advertisers of this Journal.

Hi Darryl, Congratulations on yet another excellent journal. One particular article in the December 2021 edition I found thoroughly thought-provoking – ‘All Electric Hospitals’ by Simon Witts.’ There are many challenges in the objective of achieving all electric hospitals by 2050, if indeed that is practicably achievable. There are many complex issues to address eg: • Possible exemption to retain diesel and gas for emergency power • Robust, reliable electrical supply by supply authorities • Change of government policy to permit deployment of Small Modular Reactors • Potential for hydrogen to become an alternative fuel source In my mind, a critical risk management process needs to be undertaken probably or hopefully by a progressive State Government (pardon the oxymoron), preferably sooner than later. Alternatively, this would be an ideal issue to workshop at a future national conference (perhaps Simon Witts could moderate). State branches could hold their own forums and

feed into a national forum. In turn, branches could lobby their respective authorities. If past action by governments on implementation of carbon-reducing technologies is anything to go by, then the sceptic in me suggests such an objective is a pipe dream both technically and financially in the time frame. As the author clearly emphasises, this is a critical-to-life scenario and as such requires comprehensive risk and life cycle cost analysis. Notwithstanding my scepticism, there need not be an over-zealous approach to achieving a 2050 objective. If there is a clearly articulated plan with progress and achievement in this plan, it will not be the end of the world. The key is to move on this very exciting and challenging issue. Best wishes and good luck Roy Aitken FIHEA, ret

Good afternoon Roy, I have long had a concern over the way hospitals are just bundled up into “building stock”, especially in the ESD space. Don’t get me wrong here, I want buildings to have as lite a footprint on the earth as possible, but having said that, sustainability applied wrongly to hospitals is possible the root cause of this dilemma. As I said in my thought piece, the all-electric commercial building is easy, minimal hot water, very minimal outside air requirements (although the pandemic may have kicked that one about), occupants able to tolerate relatively wide temperature bands and UPS systems capable of powering down critical data servers in the even of a prolonged power outage. No one gets upset other than possibly having to walk down a few flights of stairs. If you view hospitals as more akin to a holistic process than a building

you begin to think about them differently, you don’t see much press about the all-electric factory. To make acutely sick people better ultimately needs energy and lots of it, and with the move to telehealth and the care in the home models the cohort of patients attending hospital are getting more acute, my feeling is if we track average length of stay in the next few years it will start to increase, not due hospital inefficiency, but patient acuteness. That has implications for the engineering services and in particular reliability. I would love to chat more about this, Take care. Simon





hope that everybody has survived the challenges of summer – we think especially of North Queensland colleagues as they pass out of the monsoon season and our SEQ colleagues as they deal with the aftermath of the flooding that is occurring as this edition goes to press. Wild weather and natural disasters present a challenge at the best of times and place a significant pressure on health infrastructure – our desire to come out of this relatively unscathed compared with previous years, has been dashed by the recent and ongoing traumatic events impacting on communities across SEQ and northern NSW. The pressing need for healthcare facilities to be ready and able to respond to sudden and emerging crises has been powerfully impressed upon us yet again as flooding increases pressured on infrastructure, on top of the continuing pressure created by our COVID-related activities. COVID Responses COVID continues to place pressures on our health systems with the OMICRON variant placing an unexpected strain on health care infrastructure – we are seeing the crest of the wave passing over us and are coming to grips with whatever the new normal is. Throughout Queensland, processes and infrastructure are still being put in place or modified to cope with short- and long-term requirements for meeting COVID

Redcliff fever clinic

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requirements. This has varied from questions around how to maintain the mobile air purifiers that have multiplied in wards, standing up facilities again for testing and vaccinations and developing innovative approaches to providing safe wards to care for patients presenting with COVID. Included in this report are several photographs of initiatives that have been shared by our members. We are always interested to hear stories from our members, so please continue to submit written and photographic articles of interest. Country Professional Development Seminar (postponed) and Mid-Year Conference COVID was not willing, and the QLD Branch Committee has postponed plans for a Country Professional Development Seminar until later in the year. This is in recognition of the difficulties of holding such an event and the additional demands on our member’s time in these times. We will keep you updated. We are still planning however to hold the mid-year conference in July in Brisbane. The intention is to run a one-day event to minimize costs and maximize attendance through a reduced time commitment, especially given the ongoing impacts of COVID. We are a planning a packed agenda and compressing more into one day than we have

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in past events. More than ever the networking associated with the trade show in the evening will be appreciated, as we created the opportunity to resume gatherings! Membership I have not been advised of any new members to welcome but if you are a first-time QLD reader yet to connect with the local branch, or if I have overlooked a new member – please drop us a line to introduce yourself. We have also been reaching out to members to get up to date on outstanding subscriptions and personal details. Being unable to run our normal Annual Conference events, the finances of IHEA have taken a significant hit in the last couple of years, and it is more important than ever to keep up to date so that we can all continue to enjoy the services and networking opportunities that the organization provides.

Committee of Management Our COM members currently are: President

Brett Nickels

Vice President

Matt Smith


Michael Ward


Danny Tincknell

National Board Rep

Adrian Duff

Committee Member

Christopher Aynsley-Hartwell

Committee Member

Arthur Melnitsenko

Committee Member

Darren Williams

Committee Member

David Gray

Committee Member

David Smith

Committee Member

Peter White

Committee Member

Mark Fasiolo

Committee Member

Mark Collen

If you would like to communicate with the QLD Branch via email, please do so at . We wish all of our members and community well as they endure the pain and agony of recent flooding, and are reminded of the power of community as we see everybody pitching in to assist with the recovery efforts. Hope to catch up with as many as you as possible at the national conference. Redcliffe extra outdoor staff areas

Redcliffe COVID activities

Brett Nickels President, QLD Branch

Redcliffe COVID activities


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ue to the current pandemic pressures the Victoria/ Tasmania branch has been restricted in many activities over the past quarter. In an effort to revitalise and renew, the Committee of Management continue to meet monthly to review opportunities to meet inline with the latest COVID-safe advice. We are looking for more opportunities to meet face to face. The November 26th branch meeting at the Royal Melbourne Hospital, was a great opportunity (in the brief pause between COVID variants) to catch up with members and discuss ‘where to’ with the branch. There was an interesting presentation from Mr Anthony Gallwey from Holyoake sharing a recent case study on supplying a CARES unit to Royal Brisbane Hospital. This presentation entitled “Pandemic-Ready Patient Rooms” gave members an insight into the extensive product range available from Holyoake along with practical options for retrofitting existing areas with clean air management systems. Following this there was an open discussion with Mr Lyall Douglas from Engineers Victoria regarding the registration of engineers in Victoria and potential impact of this legislative

change on those involved with engineering and management of healthcare facilities. We also had a general discussion with members around the concept of introducing a 20 minute open Zoom catch up for members to discuss issues, to plan and discuss local events and just to stay in contact. It is planned for this to be introduced in 2022. Please jump online with the Branch committee to share your ideas on how to reconnect with the Vic-Tas branch – we welcome all input. The PD event evening was capped off with a social and networking catch up at the Castle Hotel in North Melbourne. The opportunity to meet in person and share a drink and reconnect was appreciated by everybody It is planned for the Branch to meet early in 2022 to visit and explore the Melbourne Metro new Parkville Station Project. This site visit will be a little different to anything previously undertaken, but given this new station will be a critical link with the Melbourne Biomedical Precinct it will play an important part in the Victorian healthcare service delivery. Another recent contribution to IHEA members was the development of the Monash Health Asset Management strategy, some details of which are shared below for the interest of members locally and across the country.

Michael McCambridge (VicTas Branch) introduces Anthony Gallwey of Hollyoake



As the largest health service in Victoria, the assets under Monash Health’s control are extremely resource-intensive to manage individually. So, we have been implementing a new approach to help direct our time and resources where they are needed most. To begin this process, we undertook a detailed asset audit on four of our major sites and used this to develop a baseline for the condition of our assets and forecast our spending. In developing asset management plans for these sites, we now take a pulse check of each of our asset classes. For example, the graph below shows the current condition of all assets within a specific asset class on a particular site. This pulse check allows our team to look at the subclass groups in the worst condition. We can then ask questions about why that is. Is it because the assets are old? Is their maintenance regime inadequate? Are they impacted by weather or physical damage? Were they rated correctly? By grouping our assets and asking these types of questions, we are able to start to change our focus from a reactive to a predictive maintenance model.

Don’t Settle for Less

Condition is not the only factor to consider when reviewing asset strategies, it is also important to look at the asset criticality and the history of the asset: mean time between failure and repair costs. By utilising these metrics we are better situated to make informed decisions based on facts, and we can focus our resources where they are needed most. Michael McCambridge Vic-Tas Branch President

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ollowing the end of year celebrations on the 10th of December 2021, the IHEA WA branch took a welldeserved break over Christmas and new year. From early Feb 2022 the WA branch committee of management has been meeting regularly via Zoom to plan professional development events and assist to coordinate the national conference. The planned February branch meeting was for a site tour of the brand-new Genesis Cancer Care facility constructed at the Murdoch Saint John of God Hospital. Unfortunately (you know where this is going) WA transitioned from virtually no COVID cases into widespread community transition, and WA healthcare Facilities implemented various increasing prevention and management mechanisms – to ensure that Hospitals were safe places for any patient to come to receive treatment. Consequently, visiting restrictions meant that this site visit was unfortunately delayed. We look forward to when Mr John Bose at MSJOG is able to allow the IHEA WA members to visit his wonderful new facility in the future. The March 2022 branch meeting is being planned in a slightly different way. WA is now approaching the modelled peak COVID infections, and the day in the life of healthcare professionals is a long day. We recognise the need to avoid burn-out and fatigue, and that many working from home arrangements are seeing us physically disconnected from our peers in challenging arrangements requiring flexibility. We are exploring non-traditional engineering excellence sites for professional development. Brewery tours are high on the list and a few micro-breweries approached in the Perth area have indicated they would support an IHEA branch meeting. Touring their production facilities will provide a slight alternative to our usual PD events, but will demonstrate engineering solutions of a different kind and will provide an excellent opportunity for networking refreshments afterwards. We are excited by the coming opportunity to finally recognise our 2021 Engineer, Tradesperson, and Apprentice of the year formally at our first 2022 WA Branch Event, as award winners were unable to attend the end of year function in 2021. We are even more excited to show the whole of Australia the fantastic speakers, presentation, tours and events that the May 2022 National Conference will provide in Perth, and help all IHEA members re-connect across state and even international borders. Book it now, and see you soon! Andrew Waugh, IHEA WA Branch State Secretary

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SA/NT BRANCH REPORT Activities End of Year event, 8 December 2021 The SA/NT membership was generously hosted by Ecas4 Australia. During the event held at their Mile End headquarters, Daniel Romeo of Ecas4 showed off their newly developed product eBoosterTM and explained how its electrochemical inline disinfection technology delivered a dual effect benefit to facility water supplies. The Water purification system used to kill bacteria started as ‘flower power’ and is now a water purification system ridding hospitals of legionella bacteria and slashing power bills in the process. A trial of the Ecas4 water treatment system in Adelaide’s North Eastern Community Hospital (NECH) has virtually eliminated legionella bacteria in their pipes. Tony Amorico, of Tony’s Flowers, started using the Italian system to extend the shelf life of his flowers, using it in farms and greenhouses to kill bacteria in water.

The system uses an electrochemical process to destroy the organic biofilm habitat of bacteria — including the legionella bacteria — leaving a potable water product. When a friend of Mr Amorico’s died of a bacterial infection in a public hospital, he decided to try to have the system tested in health care. The NECH team acknowledged that legionella bacteria was virtually always present in hospital water systems at low levels, and chlorine and high water temperatures were traditionally used to reduce it. A random conversation about Tony’s use of the Ecas4 system to attack the biofilm habitat of the bacteria in the flower industry that was supporting better quality and longer lasting flowers prompted a desire to test the methodology in hospital water systems. The NECH is a relatively small hospital with a desire for innovation, and with an already low legionella count were not dealing with a significant risk, but ambitious to do anything to improve safety prompted them to become the first hospital in

SA Members touring flower cool rooms

Tony Amorico describing how Ecas4 moved from flower power to healthcare

Daniel Romeo describing the Ecas4 water purification system

The latest iteration of the technology



Australia to trial it. The legionella count is now maintained at virtually zero. The trial was independently evaluated by UniSA. The Ecas4 eBoosterTM is able to convert the existing salt chlorides present in the water into active chlorine, allowing a disinfection activity which also eliminates other pathogens such as E.coli, listeria, salmonella, campylobacter and MRSA (golden staph). The generous support by Ecas4 of the IHEA SA-NT branch Christmas Event was appreciated as members were able to tour the flower holding and quarantining facility, and see some of the largest cold rooms used for this purpose at the event. A very enjoyable meal, and networking event was well supported by Branch members. Upcoming events The SA / NT committee is developing a number of exciting and informative Professional Development networking events for 2022 including: • Vertical transport innovations • Considering global best practice in the local context • Environmental Social Governance and compliance

• • • •

ew SA Women’s and Children’s Hospital development N Theatre and medical imaging technologies Patient wayfinding and support technologies Optimising healthcare design for cognitively compromised consumers Look out for more information coming to your inbox soon!

2023 Conference Planning for the 2023 Conference continues and will ramp up in the lead up to the Perth Conference. We hope to see you at Perth in May where further details will be announced. SA / NT Committee of Management President

Michael Scerri

Vice President

Andrew Russell


Andrew Russell


Daniel Romeo

State National Board Rep

Michael Scerri

Committee Member

Darryl Pitcher

Committee Member

John Jenner

Committee Member

Richard Bentham

Committee Member

Gary Clifford

Committee Member

Adam Walding

Committee Member

Damien Breen

Committee Member

Max Sankauskas

Please communicate with the SA/NT branch via email at Michael Scerri President, SA/NT Branch

Daniel Romeo showing the earlier version of the anolyte production system.


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e are a little over 2 years into a complex medial emergency event, arguably the most complex any of us have ever experienced in NSW. We have probably settled with the fact that this event is likely to persist for many months to come and any opportunity to improve our response and to adopt more effective, sustainable strategies should be explored. This race to ensure that NSW’s health care facilities were prepared to treat the influx of very sick patients resulted in huge expansions of patient care space, due in part to collaboration and innovation within the field and now as the facilities are preparing for the new business as usual, all our colleagues across the state are sharing their experiences and lessons learnt with one another. The NSW / ACT Branch of the Institute of Healthcare Engineering Australia is still assessing the situation relating COVID-19 in order to hold a Professional Development Conference, Trades Display and Branch General Meeting at the C,ex Club Coffs, Coffs Harbour in July 2022. The event confirmation and details will be disseminated in the next few months. Currently there’s a greater focus on running Professional Development days when possible. The commitment to coordinate and hold these events on a regular basis will be part of NSW/ACT 2022 branch strategies to re-engage with the membership community. Membership A reminder to members who are yet to pay their 2021-22 subscriptions to please do so as the Branch membership coordinator is planning to send reminders for renewals and actively engage with the members to understand their expectations. The Committee of Management is discussing a variety of strategies on an ongoing basis to serve our members better and meet their expectations. All members are encouraged to continue to engage with the IHEA LDApp.

NSW-ACT Committee of Management President

Rob Arian


Mal Allen

Vice President

Jason Swingler


Marcus Stalker

Committee Member

Greg Allen

Committee Member

Brett Petherbridge

Committee Member

Jon Gowdy

Committee Member

John Miles

Committee Member

Richard Dyer

Committee Member

Cameron Ivers

Committee Member

Justin Walker

To connect with and engage with the branch committee, please email us at Rob Arian NSW/ACT Branch President

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DAY ONE: WEDNESDAY 11 MAY 2022 9.30am - 12.30pm

Optional Masterclass Workshop - Proudly sponsored by Ecosafe International This workshop is an additional cost and registration is required Speakers: Rebecca Hannan, Rosco McGlashan, Dr Nicholas Mabbott Location: Level 2, Meeting Room 8, Perth Convention and Exhibition Centre Inclusions: Morning tea & lunch

From 1.30pm

Optional Technical Tours

Tickets required. Delegates must have pre-registered for a technical tour.

5.00pm - 7.30pm

Registration Desk Open for Welcome Reception

Location: Level 3, Perth Convention and Exhibition Centre 5.30pm - 7.30pm

Welcome Reception sponsored by Grosvenor Engineering

Location: Exhibition Area, BelleVue Ballroom 1, Level 3, Perth Convention and Exhibition Centre Dress: Smart Casual

DAY TWO: THURSDAY 12 MAY 2022 7.00am - 5.00pm

Registration desk open

Location: Level 3, Perth Convention and Exhibition Centre All conference sessions will be held in the BelleVue Ballroom 2, Level 3, Perth Convention and Exhibition Centre 8.30am

Official Conference Opening & Housekeeping Fred Foley, IHEA 2022 Conference Convenor


IHEA National President Address Darryl Pitcher, IHEA President


Welcome To Country James Webb


Official Conference Opening

Dr David Russell-Weisz, Western Australian Director General of Health 9.05am

Gold Sponsor Address

Schneider Electric 9.15am


10.15am - 10.45am

Morning Tea & Exhibition


How can deep learning improve the healthcare servicing sector: an initial study Ali Maraci, AppTegral


Innovative Low Energy Twin Duct Air Conditioning System for Hospitals Steven Logan / Aurecon


Innovations in Indoor Air Quality (IAQ) management for healthcare environments Julie Sullivan, Bill Sullivan / Greencap


LDP IHEA Learning & Development Program Peter Easson / IHEA


IHEA Annual General Meeting

12.15pm - 1.30pm

Lunch & Exhibition (Extended lunch break due to IHEA AGM)


The All-Electric Building is a Great Foundation Stone for a Low Carbon Economy, but are the Implications of such a Requirement too Great to Achieve?

Matt Williams / LCI Consultants 1.50pm

Controlled power outage tests are an important aspect of ongoing emergency preparedness Andrew Waugh / Serco FSH


A discussion about passive house and a simple water saving idea

Steven Ball / Epworth Healthcare 2.30pm - 3.10pm

Group Photo of IHEA delegates / Afternoon Tea & Exhibition


How will your building infrastucture evolve? Gary Gilbert / Anixter


KEYNOTE PRESENTATION The Royal Flying Doctor Service - An Operational Perspective The Royal Flying Doctor Service


Conference Sessions Conclude

6.30pm - 11.00pm

Conference Dinner

DAY THREE: FRIDAY 13 MAY 2022 8.30am - 3.15pm

Registration desk open

Location: Level 3, Perth Convention and Exhibition Centre All conference sessions will be held in the BelleVue Ballroom 2, Level 3, Perth Convention and Exhibition Centre 9.00am

Conference Welcome & Housekeeping Fred Foley, IHEA 2022 Conference Convenor


Gold Sponsor Address



10.20am - 10.50am Morning Tea & Exhibition 10.50am

Building Cybersecurity Resilience for operational technology - The what, why and how Alan Lang, James O’Malley / Honeywell


Managing Cyber Risk in the built environment Cameron Exley / Grosvenor Engineering Group


Is there a devil in the detail? How risks associated with lead and opportunistic plumbing premise pathogens stack up for the healthcare sector Paul Molino, Claire Hayward, Jason Hinds, Harriet Whiley / Enware


Ultraviolet light surface and air disinfection systems Scott Summerville / Opira Pty Ltd

12.10pm - 1.10pm

Lunch & Exhibition



Professional Peter Newman


2023 Conference Presentation IHEA National President Address Darryl Pitcher, IHEA President


Conference Close & Prize Draws

Matthew Kennedy, Frazer-Nash Consultancy 2.20pm

2020 Conference Presentation


Conference Close & Prize Draws

Fred Foley, IHEA 2022 Conference Convenor 3.00pm

Conference Concludes



1. Introduction Real-world evidence for the impact of ultraviolet (UV) disinfection of moving airstreams on pathogens and demonstrated health benefits for building occupants is slowly accumulating in scientific literature. Unlike ultraviolet germicidal irradiation (UVGI) targeting surfaces on cooling coils, hospital wards or upper UV air disinfection, very few case studies on the impact of UVGI on air quality and heath outcomes have been reported to date. Such information is important for building owners and facility managers considering airstream disinfection, particularly with advent of the COVID pandemic and heightened awareness for the potential of disease spread within indoor spaces via aerosols.

2. What is UV airstream disinfection? Ultraviolet airstream disinfection involves the installation of UV lamps to irradiate moving air within mechanical air systems of buildings. Laboratory studfooies have shown that sufficient UV doses applied to moving air is effective in killing most infectious diseases spread by air transmission in healthcare settings. A typical UV air disinfection installation is shown in Figures 1-2 where the air in the return air duct is treated with UV to kill pathogens. Figure 3 shows an operating lamp and Figure 4 shows a schematic diagram of the UV airstream disinfection process. UV airstream disinfection systems are typically sized to permit adequate irradiation dosage of the air stream, calculated as a function of duct size and air speed. This UVGI dosage expressed in Joules per centimeter squared is proportional to the product of the UV source power per unit area expressed in Watts per square meter and the exposure time in seconds. Consequently, the power requirements for these installations are far higher than surface disinfection given the very short residence time of air passing the UV lamps. The exposure time of moving air to obtain the necessary dose can be as little as half a second on a single pass depending on the air speed and size of the UV lamps within the duct.

Companies installing UV airstream disinfection systems currently use proprietary software to size the lamp installation appropriately. These often allow selection of specific infectious disease such as Tuberculosis, Influenza A and SARs-CoV-2, with each having different exposure tolerances for UV light (measured as LD90). Moulds and spores can also be targeted by UV air disinfection but are far less susceptible to UV and require multiple passes through the system before they are sterilized.

3. St Luke’s Hospital Study In a major study recently published in the journal Surgery, over 1000 patients spread across three wards were tracked over a 12-month period to determine the effects of UV airstream disinfection on pathogen levels and hospital-acquired infections. The patients were separated into three different zones (Figure 5) with all zones having HEPA filtration of recirculated air, but with two of the three zones also benefiting from the ‘advanced air treatment’ technology involving a combination of UVGI and activated carbon filtration. The study found that the advanced air UV treatment applied to both Zone A and Zone B patients resulted in: • >90% reduction in airborne and surface pathogen levels in UV treated zones compared to non-UV treated zones. • 39% reduction in hospital length of stay in the hospital for patients occupying UV treated zones compared to non-UV treated zones. • Associated 20% reduction in hospital fees and charges incurred by patients in the UV treated areas. This study is one of the first large scale field-test investigating the effectiveness of UV air disinfection on clinical patients in a hospital setting and that can help the decision of many healthcare facilities to install UV air disinfection systems in their buildings. The air treatment system employed also used activate carbon filters to reduce volatile organic compounds (VOCs).



Figure 2 – View of UVGI lamps mounted within the return air duct Figure 1 - Installation of an in-duct UVGI system

Figure 4 – Schematic of UVGI air disinfection installation Figure 3 – Cut-out view of operating in-duct UVGI

4. Implications for HEPA Filter Performance on Filtering Pathogens High Efficiency Particulate Arrest (HEPA) filters have typically been used in high-risk settings such as hospital and fertility clinics. While it is known that HEPA filters do not screen all particle sizes with some 0.1-0.3 micro particles able to penetrate through the filter, there is a widely held perception in the industry that HEPA filters work equality as well as UV air disinfection. The results from this study, particularly in terms of the prevalence of bacteria and fungi, indicate that HEPA filtration alone does not achieve the necessary removal of pathogens so as to limit the spread of hospital acquired infections. The size of viruses and bacteria ranges from 0.1 to 5 microns (SARS-CoV-2 is 0.12µm while Tuberculosis can range in size from 0.2- 0.5µm in width) and it would theoretically be expected that HEPA filters would capture most of these particle sizes. A recent study of the penetration of small particle sizes through MERV filters (less filter efficiency than HEPA filters) has highlighted the potential for HVAC filtration to perform well below modelled performance standards for aerosols in the 0.5-4 micron range when tested in a central ventilation system. This study did not test HEPA filters,


however, the result of the St Luke study suggest this question also needs to be examined. Consideration also needs to be given the to the cost of operating HEPA filtration systems. A 2013 study by P. Azimi and B. Stephens (2013) showed the relative costs of filter operations plotted against the relative risk of infection (Figure 6). This study suggests that MERV13 filters provides the optimal filter performance in terms of pathogen removal rates. ASHRAE’s COVID19 guidance also recommends a minimum filtration standard of MERV13. Installation of UV air disinfection does not remove the need for air filtration but rather complements it. UV lamps can become fouled by airborne particulates and air filtration is required to minimise this effect. The effectiveness of UV also relies direct irradiation of pathogens in the air stream. An unfiltered airstream can result in larger particulates protecting pathogens from the UV light.

5. Adoption of UV airstream disinfection in Australia Given the familiarity of the healthcare sector with surface and upper air UV disinfection technologies, it follows that


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The energy produced by the UVC lamp focuses on the surface to disinfect the coil. This maximises the efficiency of a single unit and extends its product life. The reflectors also protect the lamps against fouling. The modules containing the ballasts display LEDs indicating the lamps status for easy maintenance, and include dry contacts for BMS.

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Figure 5 - Summary of St Luke’s Hospital UV airstream disinfection study

this sector has been an early adopter of UV airstream disinfection. Currently only a handful of metropolitan regional hospitals have installed this technology in Australia but with the COVID-19 pandemic and increased awareness of aerosol-facilitated spread of disease this is likely to change. Meanwhile, specialist healthcare sectors such as assisted reproductive centres are already heavily invested in this technology because of the very stringent air quality Figure 6 - Relative risk of influenza transmission vs annual cost of filter operation and equivalent outdoor standards required to minimise the air (OA) rates. cytotoxic effects on embryos. • The power requirements to disinfect air are far higher than While there are many Australian suppliers of surface UV the levels to successfully sterilise cooling coil surfaces technologies involved in cleaning coils within air handling units, resulting in a far higher number of UV lamps being placed very few suppliers offer a dedicated UV air disinfection systems in front of the coil with much greater power consumption. and even fewer have the necessary software to size the units • The cooling effect of the coils significantly reduces UV correctly. Many suppliers seek to ‘kill two birds with one stone’ intensity of lamps positioned downstream of the coil by by attempting to install very high-powered UV air disinfection more than 50% and this cooling effect reduced the UV lamps in front of the cooling coils of air handling units to also irradiance of the lamp and results in a significant loss of disinfect air. This approach can result in very high power usage efficiency. and very low pathogen kill-rates due to the following:



The orientation of coil cleaning bulbs facing the coil surface means that the air stream is exposed to the UV light for only a very short period that is insufficient to provide the LD90 dose necessary to kill the target pathogen(s). • There is no opportunity to install UV reflective materials in front of a coiling coil to concentrate the UV light as is done within in-duct UV installations and resulting in a far lower kill efficiencies per kWh of electricity used. Combining coil cleaning applications with air disinfection is inefficient from a power consumption perspective and does not achieve either objective effectively. This approach can result in an insufficient LD90 or excess power consumption with little or no benefit in terms of pathogen removal.

6. Conclusion The St Luke’s Hospital study is one of the first large scale field-tests demonstrating the effectiveness of UVGI air disinfection on clinical patients in a working hospital and providing evidence to support the decision of many healthcare facilities to install UV air disinfection systems in their buildings. These UV systems have been installed to complement existing filtration methods rather than replacing them. When selecting UV systems for air disinfection, particularly in a healthcare setting, it is critical that the installation is sized correctly for the target pathogens considering residence time of the airstream in the duct, as well as duct size and shape.


Vlachokostas, A., Burns, C. A., Salsbury, T. I., Daniel, R. C., James, D. P., Flaherty, J. E., ... & Pease, L. F. (2022). Experimental evaluation of respiratory droplet spread to rooms connected by a central ventilation system. Indoor air. 8 Azimi, P., & Stephens, B. (2013). HVAC filtration for controlling infectious airborne disease transmission in indoor environments: Predicting risk reductions and operational costs. Building and environment, 70, 150-160. 9 ASHRAE Filtration and Air Cleaning Summary. Retrieved from: filtration-disinfection#mechanical 10 Morawska, L., Tang, J. W., Bahnfleth, W., Bluyssen, P. M., Boerstra, A., Buonanno, G., ... & Yao, M. (2020). How can airborne transmission of COVID-19 indoors be minimised? Environment international, 142, 105832. 11 Morbeck, D. E. (2015). Air quality in the assisted reproduction laboratory: a mini-review. Journal of assisted reproduction and genetics, 32(7), 1019-1024. 12 Lau, J., Bahnfleth, W., & Freihaut, J. (2009). Estimating the effects of ambient conditions on the performance of UVGI air cleaners. Building and Environment, 44(7), 1362-1370.

Endnotes 1

ASHRAE Handbook (2019). Chapter 62 Ultraviolet Air and Surface Treatment. Retrieved from: https://www.ashrae. org/file%20library/technical%20resources/covid-19/i-p_ a19_ch62_uvairandsurfacetreatment.pdf 2 Kowalski, W. (2009). Ultraviolet Germicidal Irradiation Please visit us At Australian Healthcare Week, Handbook (UVGI) for Air and Surface Disinfection. 2018 Springer-Verlag Berlin Heidelberg. Retrieved from: https:// At Darling Harbour, Sydney March 21 – 23 We will be launching our latest technology in 3 Stawicki, S. P., Wolfe,and S.,High Brisendine, C., Eid, S., Zangari, Plant Control, Smart Monitoring Level M., Ford, F.,Interface ... & Burfeind, W. R. (2020). The impact of BMS Coms comprehensive air purification on patient duration of stay, discharge outcomes, and health care economics: A retrospective cohort study. Surgery, 168(5), 968-974. Retrieved from: article/pii/S0039606020304657 4 Details of the technology can be reviewed at: https:// 5 ASHRAE Filtration and Air Cleaning Summary. Retrieved from: filtration-disinfection#mechanical 6 Let there be light. Ecolibrium, April 2021. Retrieved from: 2021/04-21-Eco-003.pdf

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With thousands of hospital staff contracting COVID cases in the workplace, are we prepared for the pandemics of the future?

Australian Public Heath experts are understandably worried about the quality of our healthcare and quarantine infrastructure with respect to its impact on the spread of COVID. We instinctively know that even a small public outbreak will raise hospital admissions and increase the likelihood of our untiring doctors, nurses and hospital staff becoming infected. This places additional demands on hospital risk management programmes and increasing the need to provide clean, fresh air to all hospital occupants. So as the COVID-crisis rolls on and as the mould risk escalates, many facility managers are proactively rethinking their Air Quality Risk Management Plans (ARPM) They understand that improved air quality and air tightness of building envelope and compartments in their hospital can jointly protect patients and front-line staff from the dangers of infection and external contaminants. The Covid Pandemic has made it clear that front line staff are under threat of nosocomial infection from poorly

functioning air control measures and sub-optimal air barriers within buildings. More than 11,600 people died after catching Covid in NHS hospitals, UK data reveals. Figures show thousands of patients who went into hospital for unrelated illnesses contracted the disease, with fatal consequences. The Chief Medical Officer, Professor Andrew Wilson’s investigation into Victorian hospital virus transmission has certainly provided insight into the risks of cohorting patients and infection control measures. However, until we understand the full picture, it is important we act to ensure facility standards are being met across every parameter of air quality. Air tightness, of not only each building’s external envelope but intra-building barriers separating CSSD’s, operating theatres, isolation rooms/wards and positively pressured staff areas in the hospital are the most effective tools to prevent Hospital acquired infections. Of course, carefully designed air distribution systems, well-



placed air intakes and discharge points and are key areas of risk minimisation. ASHRAE 170, for example, requires that an isolation area be routinely tested with smoke trials to test for leaks, ensure the correct pressure, isolate infection and isolate fumigating disinfectant. Unfortunately, this is only currently implemented in a limited number of facilities. Whilst Air Permeability testing is increasingly being used to test the integrity of the external building envelope for sustainability reasons, the use of ‘intra-building’ leakage testing is a powerful tool to manage air flow from sterile to non-sterile areas whilst minimising air leakage. Improved air permeability also has the benefit of reduced energy use. Conducting Air Permeability testing using blower door fans is relatively simple under the internationally recognised methods such as AS ISO 9972, AS 2243.3 and ATTMA TSL2.

DOES THE AGE OF A HEALTHCARE FACILITY IMPACT THE REQUIREMENT FOR A NEW RISK MANAGEMENT PLAN? In theory, newly constructed hospitals benefit from preoccupancy tests which validate some of the best designed ventilation and filtration systems in Australia. In practice, however, many hospitals, both old and new, have air systems that, when independently tested, are found to be working sub-optimally. Testing has shown air permeability can change even over a short time frame. A meta-analysis applauded at the AIVC Conference in 2017, highlighted the decreasing durability of building air tightness. Air Tightness durability decreased most in the first 3 years post construction due to structural movements, shrinkage, drilling of the air barrier with the installation of new equipment, and normal ageing of assembly and products. Older facilities, according to CETEC, a leading scientific air quality consultancy, will see factors such as the loading of filters, the wear and tear of the door, wall and floor seals affecting pressure balance during its operational lifespan. This is why we are seeing percipient hospitals, irrespective of age are reviewing their ARMPs before a crisis erupts. Thus it is important that consideration must be given at the early design phase of any new build or refurbishment to ensuring that the building materials, components (Doors, windows, louvres and dampers), and accessories (sealants, tapes) are chosen and correctly applied to create an effective and durable air barrier, not just for the exterior envelope but in compartment walls. One of the earliest decisions to be made to obtain a GreenStar rating is to determine how airtight your building will be. For a Hospital, best practice requires the envelope leakage rate to be less than 5m3/hr/m2,but leakage through intrabuilding walls may be required to be 80% lower to prevent patients and staff from Hospital acquired infections.


Similarly there is a need to consider the introduction of air locks at entrances to reduce the reliance on door seals. Unfortunately Australia is lagging behind Europe and USA when it comes to Building airtightness, as the current industry experience is that Australia’s buildings leak at 3 times the best practice rate. Another key benefit of an airtight building is preventing unwanted moisture transfers through the wall, providing a greater ability to control indoor relative humidity and therefore mould growth, by minimising condensation on clod surfaces. This is particularly important recently due to the deluge in the Eastern states where the introduction of excessive humidity has made management of Mould a major challenge for all building operators.


The potentiating calamity of the flooding in eastern Australia will further increase our reliance on a hospital’s air tightness and air management practices due to mould risk. To avoid disruption, damage and the forced closure of hospital services, necessary remediation and ARMPs need to be undertaken pre-emptively.

PRIORITIES FOR HIGHPERFORMANCE HOSPITAL It has been an incredibly challenging year for healthcare with our eyes trained on one crisis after the next. But with the help of Chemical, Microbiology and Engineering Consultants at companies like CETEC, we can implement ARMPs in readiness for future floods, pandemics and bushfire seasons. CETEC, ATTMA-accredited consultants Adam Garnys and Alan Venn-Brown advise the following actions for Hospital Engineers:

•  Conduct Indoor Air Quality Testing to baseline and identify pollutant sources for the hospital. •  Conduct HVAC hygiene inspections, mould swabbing and air testing and review filtration specification. •  Confirm adequate ventilation by CO2 tracer-gas decay testing •  Air Tightness Testing to understand building and zone envelope leakage. •  Review Type 5 isolation rooms for conformance to HB260 and AS2243.3 •  Evaluate the ventilation and pressure relationship between COVID areas and adjacent wards. •  Develop a hospital-wide Air Quality Risk Management Plan. Whilst we consider the compound risk of COVID and extreme weather events on air quality, its important to be on the front foot. Reviewing the ARMP and investing in good risk management expertise will help set our hospitals up for a resilience.

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IS THERE A DEVIL IN THE DETAIL? How risks associated with lead and opportunistic plumbing premise pathogens stack up for the healthcare sector Paul Molino, Jason Hinds, P Molino, Claire Hayward, Harriet Whiley Enware The last few years have been a time of wide-ranging discussion and significant change in the plumbing industry in Australia. This discussion has largely centred on the issue of lead contamination of potable water via the leaching of lead from brass plumbing components, and how best to address the issue. Lead is an environmental contaminant of concern due primarily to its known impacts on the cognitive and neurological development of infants and young children. It has become a highly topical issue in Australia in part due to the widely publicised reports of elevated lead levels detected in potable water in the Perth Children’s Hospital, Western Australia,1 and in public drinking fountains in Geelong, Victoria2. In both instances lead leaching from brass plumbing components was determined to be the likely cause. The public awareness around this issue has been heightened by the relatively recent large scale potable water lead contamination events in the US in Washington, DC in 20003, 4, and Flint, Michigan in 20145, which saw high levels of lead contamination of household water supplies due to changes in water treatment, chemistry and/or supply source, leading to accelerated corrosion of lead piping. Australia has historically been a leader in initiatives to maintain a safe and secure potable water supply, with lead piping being replaced with copper from the 1930s onwards, meaning we are far less susceptible to a similar event here. In 2020, the Australian Building Codes Board (ABCB) released a consultation regulation impact statement (CRIS) on ‘Lead in plumbing products in contact with water’6 aimed at engaging discussion with stakeholders on the issue of lead contamination from brass plumbing products in Australia, and options through which associated risks can be mitigated. This

consultation resulted in the adoption of a prescribed maximum lead level (0.25%) for plumbing products in contact with potable water (current materials have been reported to contain up to 6% total lead content7). It is estimated that up to 90% of copper alloy plumbing products contain lead, and therefore the scale and impact of these regulation changes for the industry will be widespread and significant. For the consumer, it provides uncertainty over product selection and availability, not to mention a considerable increase in the estimated cost of reduced lead copper alloys and other metal substitutes. The change in prescribed lead levels in plumbing products was made in spite of assurances from the then Australian Chief Health Officer, Prof Brendan Murphy, that “There is no evidence of adverse effects on human health from the consumption of lead in drinking water in Australia”, and “The concentration of lead set in the drinking water guidelines is very conservative so that it can be sure to protect the most vulnerable people, such as very young children and pregnant women”. The earlier noted cases of non-compliance of lead in water in Australia appear to be largely isolated cases where several factors conspired to contribute to the elevated lead water concentrations, including use of non-compliant materials, unsatisfactory water system management, and significant periods of stagnation. It is therefore difficult to determine whether these examples represent a wider problem reflective in potable water sourced by the public across the population,



and as such, what the quantifiable health benefits from the prescribed changes in material properties will be. This was further supported by the ABCBs 2021 Regulation Impact Statement (RIS) where it was concluded that significant evidence exists to suggest the contribution plumbing makes to the problem is much smaller than that presented by the Consultation RIS, and may be negligible relative to all other sources. This would further support the view expressed in the Consultation RIS that Australia’s drinking water is currently very safe. Evidence presented in the RIS highlighted that surveillance monitoring of blood lead levels in Victoria between 2011 – 2014 showed that the vast majority of persons recording a blood lead level (BLL) above the notifiable level of 10µg/ dL had an occupational risk factor as the identified source (81%)8. For those with a non-occupational risk factor, only 3% (2011) and 6% (2014) were linked to potable water as a risk factor, with no cases linked to lead in plumbing in 2012 and 2013. Further, several studies have determined lead from potable water to contribute a relatively minor proportion of the overall lead consumption for children > 1 year old and for adults, with other exposure sources such as food, dust and soil, being of far more concern9-11. Where comparable data are available, the likely health risks associated with lead contamination of potable water in Australia are considerably lower than those associated with infections from microbial contamination of potable water systems with bacterial opportunistic pathogens, termed opportunistic premise plumbing pathogens (OPPPs). For example, in Queensland, the number of infections from the OPPP non-tuberculosis mycobacterium (NTM) is many times greater than the number of BLL cases above a moderate level (5 µd/dL) that have a non-occupational source as the identified risk factor (Figure 1a). While sources of NTM may be water, soil or dust12, recent evidence has suggested that plumbing materials and water supplies are a major contributor to NTM cases13. NTM are a particularly pervasive group of opportunistic bacterial pathogens that often result in slowly progressive and destructive disease that can affect both immune compromised and healthy individuals14, 15. The number of NTM infections in Queensland have in recent years been on the rise, a trend that mirrors that occurring internationally16-22 (Figure 1b) (the broader health impacts of OPPPs are discussed later in this article). This raises the question as to why such significant resources have been assigned by regulators and governing bodies to address the issue of lead in water, while little, if any, consideration has been given to addressing the likely far greater problem of microbial contamination of building water infrastructure; a problem that is widely recognised as being of immediate and significant concern for the healthcare sector23.

Overall, the plumbing industry has been broadly supportive of the goal of reducing lead levels in plumbing products and materials in contact with potable water. However, there have been concerns from some stakeholders and those in the scientific community that there has been a rush to implement changes without proper consideration of the potential unintended consequences that the policy changes may have on other important aspects of water quality that affect public health. Of particular concern is how the increasing use of replacement materials, including low-lead copper alloys (i.e., low-lead brass), stainless steel, and polymers (i.e., polypropylene, polyethylene, acetal copolymer, and others) may have a far greater impact on the quality of our drinking water due to the problem of microbial contamination of drinking water infrastructure by OPPPs. Microbial contamination of potable water infrastructure has been of growing concern, with studies in several countries highlighting the role of OPPPs in the spread of waterborne infections12, 24-31. The ‘opportunistic’ in OPPP comes from the fact these organisms preferentially infect individuals with underlying illnesses or weakened immune systems. It is therefore of no surprise that in the healthcare industry infections from OPPPs have already been identified a public health crisis, with waterborne opportunistic pathogens noted as a major and preventable source of hospital acquired infections (HAIs). In the U.S.A, 1.7 million nosocomial infections occur each year, with 1 in 7 people dying as a result of a HAI32. While nosocomial infections may be derived from a number of sources, hospital tap water has been described “as the most overlooked, important and controllable source of HAI”23, 33, with the most common OPPPs including Pseudomonas aeruginosa, non-tuberculosis mycobacterium (NTM), such as mycobacterium avium complex (MAC), Burkholderia cepacian, Acinetobacter spp., and Legionella pneumophilia34-38. It is estimated that hospital acquired pneumonia infections caused by waterborne Pseudomonas aeruginosa alone are responsible for 1,400 deaths per year in the U.S. healthcare system23, 39, 40. Legionella spp. has also been identified as a leading cause of drinking water outbreaks in the U.S.,41 with annual economic costs of infections requiring hospitalisation estimated at USD$430 million, with costs for NTM estimated to be USD$425 million42. Numerous studies have confirmed a direct link between OPPPs present in a hospitals water infrastructure with the organism isolated from the patient using molecular relatedness studies (see Anaisse et al.23 for review). Considering the diversity of opportunistic pathogens known to be present within potable water supplies, and the broad range of illnesses and infections they can cause, it is little wonder that healthcare



experts are becoming increasingly concerned with waterborne pathogens in healthcare facilities, with the potential for associated illnesses in healthcare settings to be enormous23. Microbial contamination of potable water systems can occur at both distal and proximal to the mains supply in the building water system; however, it is contamination of end-of-line plumbing devices and components, such as taps, aerators, shower heads and valves, where OPPPs have been found to be far more prevalent relative to the rest of the building plumbing infrastructure43. End-of-line fixtures and devices are more likely to present niche microenvironments for organisms to adhere-to and colonise, are frequently subjected to heating/cooling of water to levels known to be beneficial to microbial growth, suffer from stagnation, and lower concentrations of free chlorine relative to regions of the plumbing system more proximal to the building/municipal source supply. The presence of pathogens at these end-ofline locations provides them with a direct avenue of infection for the end user, making contamination of these locations the highest risk for end user health. Importantly, it is many of these end-of-line components and fixtures that are most likely to be impacted by the prescribed changes in plumbing materials. OPPPs may enter the premise plumbing system from the mains supply (e.g. L. pneumophilia), or from transfer during hand washing and outlet handling (i.e. P. aeruginosa). After contacting the material surface, the microbes may more permanently adhere to the surface and form (or embed into an existing) biofilm that protects the cells from attempts at physical and chemical disinfection of the system. The route of exposure to the water outlet user may be via direct contact, ingestion or aspiration of contaminated water, or inhalation of contaminated aerosols. Such exposure can cause a range of serious illness in vulnerable individuals, including skin and soft tissue, respiratory, gastrointestinal, blood and neurological, pathologies. As discussed earlier, low-lead copper alloy materials, as well as metal (e.g. stainless steel) and polymer (polypropylene, acetal) alternatives are already being used to replace traditional brass components found in plumbing fixtures and devices. Several studies have demonstrated copper and copper alloys, including brass, to inhibit the growth of several waterborne pathogens44, 45 relative to other more benign metals and polymers. For example, studies that compared bacterial adhesion and biofilm formation on stainless steel, PVC and copper in a simulated plumbing system over 24 days illustrated copper to present the lowest adhered bacterial numbers, followed by PVC, and with stainless steel demonstrating the highest number of adhered bacteria46. Another study investigated the biofilm formation potential (BFP) of different plumbing materials (stainless steel, copper, chlorinated poly vinyl chloride, polybutylene, polyethylene and steel coated with zinc), finding copper to present the lowest BFP for all tests, with stainless steel consistently presenting amongst the


greatest BFP of all materials47. Stainless steel materials (304 and 316) have also been demonstrated to readily harbour a range of OPPPs after 12 months in a large building plumbing distribution system, with a mixture of bacteria identified to be growing on the materials, including Pseudomonas spp., Methylobacterium spp., Acinetobacter spp. Corynebacterium/ Arthrobacter spp. and Micrococcus spp48. Our own preliminary research into the initial adhesion and growth of the waterborne pathogen P. aeruginosa illustrated dramatic differences in the ability for the bacteria to adhere-to and colonise the surface of various plumbing materials. After 20 hrs exposure, bacterial numbers were greatest on Stainless Steel 316, followed by Stainless Steel 304, Acetal co-polymer, low-lead brass and brass (Figure 2,3). The number of live bacteria on Stainless Steel was 212x (316) and 108x (304) greater than that on Brass after 20 hrs, while bacteria numbers on Acetal copolymer were 80x greater than brass (Figure 3). Currently available information and studies investigating the role of plumbing material on microbial contamination is however limited, and in some cases contradictory49. There is a critical need for future research to provide a comprehensive understanding of the influence of plumbing material on OPPP contamination and end-user exposure, including how water properties and chemistry, stagnation, pH and temperature all interact to influence associated risks. It remains unclear as to why the problem of OPPP contamination of potable water infrastructure, and the associated public health risks, has been given a back seat relative to other perceived risks for potable water safety. One thing however is clear, and

Figure 1. a. Rate of NTM infections and blood lead levels (BLL) ≥ 5µg/dL in Queensland for the years 2014 and 2015. b. Yearly notifications to Queensland Health of non-tuberculosis mycobacterium (NTM) infections for the years 2014 – 2018. The number of notifications per 100,000 population are also listed. Reproduced from Molino et al.22.


to ensure water will be regularly purged, reducing stagnation and metal leaching risks. • Continuous operational monitoring of the water distribution system that will alert when the system has identified outlets that present high-risk conditions (i.e. temperature, stagnation, chlorine residual) in order to initiate effective actionable control measures and responses to mitigate the identified risks.

Figure 2. Representative fluorescence images of live (green) and dead (red) stained bacteria on Acetal, Stainless Steel 304, Stainless Steel 316, Brass 352 and Special Brass.

Figure 3. Live (green) and dead (red) cell counts from adhered Pseudomonas aeruginosa cells on test polymeric and metallic materials (Acetal, Stainless Steel 304 (SS 304), Stainless Steel 316 (SS 316), Brass Special, and Brass 352). All data points represent data from triplicate samples, and error bars represent 95% confidence intervals around the mean. Cells were stained with Baclight Live/Dead fluorescent stain after 20 hrs on the surface, with the number of live and dead cells determined from confocal laser scanning microscope images.

that is that the risks of not addressing this problem are significant and will be magnified with our aging population, and the associated increase in vulnerable individuals whom are at greatest risk from OPPPs. It is up to facility managers, plumbing material manufacturers and service providers to work together to find ways to mitigate the associated risks of OPPPs contamination of their building potable water systems. This may include: • Establishing a cross functional Water Quality Risk Management (WQRM) team that has sufficient knowledge to assess the risks and create an operational plan to better manage them. • Continuous surveillance and monitoring of both heated and cold water temperatures throughout the whole water distribution system. • Operational monitoring of low water movement and stagnation at distal points throughout the whole water distribution system. • Monitoring of disinfection strategies and effectiveness at maintaining appropriate chlorine residual at high-risk locations in the building premise plumbing system. • Optimisation of building plumbing system design to minimise dead legs and ensure regular replenishment of water to all distal points throughout the system. • Product selection of compliant WaterMark plumbing products that employ intelligent technology and automation


1. Laschon, E., Perth Children’s Hospital lead contamination in water pipes supplying site, audit finds. ABC News 2017. 2. Kines, L., Greater Victoria schoolds get lead out of water with new drinking fountains. Times Colonist 2018. 3. Edwards, M., Fetal Death and Reduced Birth Rates Associated with Exposure to Lead-Contaminated Drinking Water. Environmental Science & Technology 2014, 48 (1), 739-746. 4. Edwards, M.; Triantafyllidou, S.; Best, D., Elevated Blood Lead in Young Children Due to Lead-Contaminated Drinking Water: Washington, DC, 2001−2004. Environmental Science & Technology 2009, 43 (5), 1618-1623. 5. Hanna-Attisha, M.; Lachance, J.; Sadler, R. C.; Champney Schnepp, A., Elevated Blood Lead Levels in Children Associated With the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. American Journal of Public Health 2016, 106 (2), 283-290. 6. Board, A. B. C., Lead in plumbing products in contact with drinking water: Consultation Regulation Impact Statement. 2020. 7. Taylor, M. P.; Harvey, P. J.; Morrison, A. L., Lead in plumbing products and materials. 2018. 8. Government, V. S., Surveillance of notifiable infectious diseases in Victoria, 2011-2014. 2018; pp 1-222. 9. Organisation, W. H., Quantitative Microbial Risk Assessment: Application for Water Safety Management. 2016. 10. Agency, U. S. E. P., Lead: Human Exposure and Health Risk Assessment for Selected Case Studies. 2007, 2. 11. Zartarian, V.; Xue, J.; Tornero-Velez, R.; Brown, J., Children’s Lead Exposure: A Multimedia Modeling Analysis to Guide Public Health Decision-Making. Environmental health perspectives 2017, 125 (9), 097009. 12. Nishiuchi, Y.; Iwamoto, T.; Maruyama, F., Infection Sources of a Common Non-tuberculous Mycobacterial Pathogen, Mycobacterium avium Complex. Frontiers in medicine 2017, 4, 27. 13. Gebert, M. J.; Delgado-Baquerizo, M.; Oliverio, A. M.; Webster, T. M.; Nichols, L. M.; Honda, J. R.; Chan, E. D.; Adjemian, J.; Dunn, R. R.; Fierer, N., Ecological Analyses of Mycobacteria in Showerhead Biofilms and Their Relevance to Human Health. mBio 2018, 9 (5), e01614-18. 14. Prince, D. S.; Peterson, D. D.; Steiner, R. M.; Gottlieb, J. E.; Scott, R.; Israel, H. L.; Figueroa, W. G.; Fish, J. E., Infection with Mycobacterium avium complex in patients without predisposing conditions. New England Journal of Medicine 1989, 321 (13), 863-868. 15. Karakousis, P. C.; Moore, R. D.; Chaisson, R. E., Mycobacterium avium complex in patients with HIV infection in the era of highly active antiretroviral therapy. The Lancet infectious diseases 2004, 4 (9), 557565. 16. Shah, N. M.; Davidson, J. A.; Anderson, L. F.; Lalor, M. K.; Kim, J.; Thomas, H. L.; Lipman, M.; Abubakar, I., Pulmonary Mycobacterium avium-intracellulare is the main driver of the rise in non-tuberculous mycobacteria incidence in England, Wales and Northern Ireland, 2007-2012. BMC infectious diseases 2016, 16, 195. 17. Ringshausen, F. C.; Wagner, D.; de Roux, A.; Diel, R.; Hohmann, D.; Hickstein, L.; Welte, T.; Rademacher, J., Prevalence of Nontuberculous Mycobacterial Pulmonary Disease, Germany, 20092014. Emerging infectious diseases 2016, 22 (6), 1102-5.



18. O’Brien, R. J.; Geiter, L. J.; Snider, D. E., Jr., The epidemiology of nontuberculous mycobacterial diseases in the United States. Results from a national survey. The American review of respiratory disease 1987, 135 (5), 1007-14. 19. Cassidy, P. M.; Hedberg, K.; Saulson, A.; McNelly, E.; Winthrop, K. L., Nontuberculous mycobacterial disease prevalence and risk factors: a changing epidemiology. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America 2009, 49 (12), e124-9. 20. Prevots, D. R.; Shaw, P. A.; Strickland, D.; Jackson, L. A.; Raebel, M. A.; Blosky, M. A.; Montes de Oca, R.; Shea, Y. R.; Seitz, A. E.; Holland, S. M.; Olivier, K. N., Nontuberculous mycobacterial lung disease prevalence at four integrated health care delivery systems. American journal of respiratory and critical care medicine 2010, 182 (7), 970-6. 21. Winthrop, K. L.; Baxter, R.; Liu, L.; Varley, C. D.; Curtis, J. R.; Baddley, J. W.; McFarland, B.; Austin, D.; Radcliffe, L.; Suhler, E.; Choi, D.; Rosenbaum, J. T.; Herrinton, L. J., Mycobacterial diseases and antitumour necrosis factor therapy in USA. Annals of the rheumatic diseases 2013, 72 (1), 37-42. 22. Molino, P. J.; Bentham, R.; Higgins, M. J.; Hinds, J.; Whiley, H., Public Health Risks Associated with Heavy Metal and Microbial Contamination of Drinking Water in Australia. Int J Environ Res Public Health 2019, 16 (20). 23. Anaissie, E. J.; Penzak, S. R.; Dignani, M. C., The hospital water supply as a source of nosocomial infections: a plea for action. Archives of internal medicine 2002, 162 (13), 1483-1492. 24. Feazel, L. M.; Baumgartner, L. K.; Peterson, K. L.; Frank, D. N.; Harris, J. K.; Pace, N. R., Opportunistic pathogens enriched in showerhead biofilms. Proceedings of the National Academy of Sciences 2009, 106 (38), 16393-16399. 25. Chern, E. C.; King, D.; Haugland, R.; Pfaller, S., Evaluation of quantitative polymerase chain reaction assays targeting Mycobacterium avium, M. intracellulare, and M. avium subspecies paratuberculosis in drinking water biofilms. Journal of water and health 2015, 13 (1), 131-9. 26. Donohue, M. J.; Mistry, J. H.; Donohue, J. M.; O’Connell, K.; King, D.; Byran, J.; Covert, T.; Pfaller, S., Increased Frequency of Nontuberculous Mycobacteria Detection at Potable Water Taps within the United States. Environmental Science & Technology 2015, 49 (10), 6127-6133. 27. Falkinham, J. O., 3rd, Nontuberculous mycobacteria from household plumbing of patients with nontuberculous mycobacteria disease. Emerging infectious diseases 2011, 17 (3), 419-24. 28. Ichijo, T.; Izumi, Y.; Nakamoto, S.; Yamaguchi, N.; Nasu, M., Distribution and Respiratory Activity of Mycobacteria in Household Water System of Healthy Volunteers in Japan. PLOS ONE 2014, 9 (10), e110554. 29. Nishiuchi, Y.; Tamura, A.; Kitada, S.; Taguri, T.; Matsumoto, S.; Tateishi, Y.; Yoshimura, M.; Ozeki, Y.; Matsumura, N.; Ogura, H.; Maekura, R., Mycobacterium avium complex organisms predominantly colonize in the bathtub inlets of patients’ bathrooms. Japanese journal of infectious diseases 2009, 62 (3), 182-6. 30. Briancesco, R.; Semproni, M.; Della Libera, S.; Sdanganelli, M.; Bonadonna, L., Non-tuberculous mycobacteria and microbial populations in drinking water distribution systems. Annali dell’Istituto superiore di sanita 2010, 46 (3), 254-8. 31. Thomson, R.; Tolson, C.; Carter, R.; Coulter, C.; Huygens, F.; Hargreaves, M., Isolation of Nontuberculous Mycobacteria (NTM) from Household Water and Shower Aerosols in Patients with Pulmonary Disease Caused by NTM. Journal of Clinical Microbiology 2013, 51 (9), 3006. 32. Klevens, R. M.; Edwards, J. R.; Richards, C. L., Jr.; Horan, T. C.; Gaynes, R. P.; Pollock, D. A.; Cardo, D. M., Estimating health careassociated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007, 122 (2), 160-166.


33. Lindsay, D.; von Holy, A., Bacterial biofilms within the clinical setting: what healthcare professionals should know. Journal of Hospital Infection 2006, 64 (4), 313-325. 34. Australian Commission on, S.; Quality in Health, C.; National, H.; Medical Research, C., Australian guidelines for the prevention and control of infection in healthcare. 2010. 35. Conger, N. G.; O’Connell, R. J.; Laurel, V. L.; Olivier, K. N.; Graviss, E. A.; Williams-Bouyer, N.; Zhang, Y.; Brown-Elliott, B. A.; Wallace, R. J., Jr., Mycobacterium simae outbreak associated with a hospital water supply. Infect Control Hosp Epidemiol 2004, 25 (12), 1050-5. 36. Blanc, D. S.; Nahimana, I.; Petignat, C.; Wenger, A.; Bille, J.; Francioli, P., Faucets as a reservoir of endemic Pseudomonas aeruginosa colonization/infections in intensive care units. Intensive Care Medicine 2004, 30 (10), 1964-1968. 37. Whiley, H.; Keegan, A.; Giglio, S.; Bentham, R., Mycobacterium avium complex – the role of potable water in disease transmission. Journal of Applied Microbiology 2012, 113 (2), 223-232. 38. D’Antonio, S.; Orazi, D.; Magini, E.; Altieri, A.; Alma, M. G.; Puglisi, G.; Sanguigni, I.; De santis, R.; Paone, G., Non tuberculous mycobacteria (NTM) contamination in a hospital water supply network: Association with pulmonary infection in respiratory wards. European Respiratory Journal 2015, 46 (suppl 59), PA2682. 39. Trautmann, M.; Michalsky, T.; Wiedeck, H.; Radosavljevic, V.; Ruhnke, M., Tap water colonization with Pseudomonas aeruginosa in a surgical intensive care unit (ICU) and relation to Pseudomonas infections of ICU patients. Infect Control Hosp Epidemiol 2001, 22 (1), 49-52. 40. Richards, M. J.; Edwards, J. R.; Culver, D. H.; Gaynes, R. P., Nosocomial infections in medical intensive care units in the United States. National Nosocomial Infections Surveillance System. Crit Care Med 1999, 27 (5), 887-92. 41. Benedict, K. M.; Reses, H.; Vigar, M.; Roth, D.; Roberts, V.; MAttioli, M.; Colley, L.; Hilborn, E.; Wade, T.; Fullerton, K.; Yoder, J.; Hill, V., Surveillance for Waterborne Disease Outbreaks Associated with Drinking Water - United States, 2013 - 2014. Morbidity and Mortality Weekly Report (MMWR) 2017, 66 (44), 1216 - 1221. 42. Spagnolo, A. M.; Orlando, P.; Perdelli, F.; Cristina, M. L., Hospital water and prevention of waterborne infections. Reviews in Medical Microbiology 2016, 27 (1), 25-32. 43. Cristina, M. L.; Spagnolo, A. M.; Casini, B.; Baggiani, A.; Del Giudice, P.; Brusaferro, S.; Poscia, A.; Moscato, U.; Perdelli, F.; Orlando, P., The Impact of Aerators on Water Contamination by Emerging GramNegative Opportunists in At-Risk Hospital Departments. Infection Control and Hospital Epidemiology 2014, 35 (2), 122-129. 44. Mehtar, S.; Wiid, I.; Todorov, S. D., The antimicrobial activity of copper and copper alloys against nosocomial pathogens and Mycobacterium tuberculosis isolated from healthcare facilities in the Western Cape: an in-vitro study. The Journal of hospital infection 2008, 68 (1), 45-51. 45. Varkey, A., Antibacterial properties of some metals and alloys in combating coliforms in contaminated water. Scientific Research and Essays 2011, 5, 3834-3839. 46. Morvay, A.; Decun, M.; Scurtu, M.; Sala, C.; Morar, A.; Sarandan, M., Biofilm formation on materials commonly used in household drinking water systems. 2011; Vol. 11, p 252. 47. Yu, J.; Kim, D.; Lee, T., Microbial diversity in biofilms on water distribution pipes of different materials. Water Science and Technology 2010, 61 (1), 163-171. 48. Percival, S. L.; Knapp, J. S.; Edyvean, R.; Wales, D. S., BIOFILM DEVELOPMENT ON STAINLESS STEEL IN MAINS WATER. Water Research 1998, 32 (1), 243-253. 49. Loret, J.-F.; Dumoutier, N., Non-tuberculous mycobacteria in drinking water systems: A review of prevalence data and control means. International Journal of Hygiene and Environmental Health 2019, 222 (4), 628-634.

SMART ELEVATORS KEEP HEALTHCARE MOVING 24/7 With KONE 24/7 Connected Services we can predict, maintain and take action before breakage. For you it means improved safety, full transparency and ease of mind, because if something were to happen, we’d already know.


4D ASSET AUDIT PROCESS Donald Macdonald Macdonald Lucas Macdonald Lucas have developed, in collaboration with a prominent healthcare organisation, and their strategic partners RMIT and AG Coomb’s a new approach to asset auditing, the 4D Asset Audit Process. Macdonald Lucas’s director Donald Macdonald discusses it in the following case study. Introduction The 4D Asset Audit Process has several key features that enables it to establish asset condition more accurately than tends to be achieved by more conventional approaches, these key features include: 1. Maintenance and operational inputs provided by the client and their subcontractors 2. Desktop review of relevant data 3. BMS interrogation 4. High level technical assessment of the entire asset base 5. Detailed engineering analysis of critical assets 6. Deep dive analysis of those critical assets exhibiting cause for concern 7. RMIT’s CAMS asset data collection and life cycle modelling software.

Background Aging assets and finite budgets are the reality for engineers and other maintainers in the healthcare sector. It is therefore essential that they have an accurate and robust picture of the asset base that they are maintaining: 1. To enable peaks and troughs of asset replacement expenditure to be accurately predicted. 2. To ensure that maintenance expenditure is fully optimised over the asset life. 3. To manage the expectations of senior management regarding the effective funding of asset management. A number of strategies are commonly used to help achieve these outcomes: 1. What did we spend last year plus x%? 2. Service records and reports from subcontractors. 3. Walk through visual surveys. “What did we spend last year plus x%?” fails to consider the episodic nature of asset replacement costs (lifecycle works) and the fact that as assets age the cost of maintaining them tends to rise. It also assumes that last year’s operating environment will be the same as next years, an assumption which the COVID pandemic has shown to be deeply flawed.

If other, more valid strategies are used in isolation, a holistic view of asset condition can be frustrated as can the achievement of a standardised consistent point of view. Against this background, we have in collaboration with our clients and developed the 4D Asset Audit Process.

Overview Entitled the 4D Asset Audit Process because it aggregates four dimensions of the asset base that are secured by scrutinising and assessing it from four different perspectives: • The Operational Dimension secured from anecdotal and operational insights provided by the client and their subcontractors. • The Technical Dimension provided by Macdonald Lucas through their visual audit of the entire asset base and their analysis of other reference material e.g., drawings, service reports and CMMS records. • The Engineering Dimension provided by AG Coombs through their: – Review of BMS data – Analysis of critical assets, and, – Deep Dive analysis of critical assets that are a cause for concern. • The Technology Dimension provided through RMIT’s CAMS asset auditing and life cycle modelling software.

The 4D Asset Audit Process The process comprises three distinct phases. The 4D Asset Audit Process starts with the team undertaking all mobilisation activities including Safe Work Method Statements (SWMS), risk assessments and inductions. It also sees the preparation of RMIT’s CAMS asset audit tool, meetings with the site team and review of available documentation. Ensuring that the team are ready to ‘hit the ground running’ upon commencement on site. The 4D Asset Audit Process proceeds onto the deployment of the team onsite leveraging their extensive experience to capture asset data efficiently and accurately for subsequent analysis and review. Macdonald Lucas



undertake the bulk of the audit and interview the client and their subcontractors on how the assets are performing on a day-to-day basis. AG Coombs attend site to undertake a more detailed analysis of critical engineering plant and equipment. They also, where appropriate, recommend a ‘deep dive analyses’ on any plant that appears to warrant it. The 4D Asset Audit Process concludes with all of the data being analysed by Macdonald Lucas using the CAMS life cycle modelling tool. Key outputs from the 4D Asset Audit Process are: • An accurate validated asset register. • A standardised approach to rating of asset condition across the portfolio. • A life- cycle model that sets out asset replacement liabilities over the short, medium and longer term. • A report describing the methodology, identifying key trends in the data and providing a record of when, where and how the audit was delivered. Additional activities at end of the 4D Asset Audit Process can include: • Presenting the findings to key stakeholders, and, • Reconciling forecast capital works with available budgets to assist with responsible fiscal management going forward.

The Team The roles of each of the members of the 4D Asset Audit Process are as follows: The Client Our clients provide the strategy and vision to which the 4D Asset Audit Process is applied, often as part of an AS ISO 55000 aligned methodology, including compliance with the following sections of AS ISO 55001: • 9.1 Monitoring, Measurement and Evaluation • 9.2 Internal audit • 10.2 Preventative Action • 10.3 Continual Improvement Macdonald Lucas Macdonald Lucas are a specialist FM consultancy established by Donald Macdonald and Brendan Lucas, who shared a vision to fill a gap in the market. To bring robust, researchbased consultancy support to the FM and asset management sectors. Key facets of their business include: • A directly employed team. • Subject matter expertise in asset management and facilities management. • A multi- disciplinary team of professionally qualified staff in a variety of disciplines including surveying, engineering, law, and commerce. • A strong partner network of complimentary consultants.


Macdonald Lucas’s goal is to help organisations drive down cost and improve quality of their non-core business. Freeing clients up to concentrate on the reasons that they go to work. Macdonald Lucas take carriage of the entire process ensuring single point accountability for the client. They conduct a comprehensive visual inspection of the asset base and collaborate with the other members of the team to secure their informed and timely participation. They provide regular updates and reports, and act as lead consultant and project manager. RMIT RMIT, led by Professor Sujeeva Setunge- Associate Deputy Vice Chancellor, Research, and Innovation, provide, the following through the CAMS tool: • Asset data collection software, • Cloud hosted asset data base, and, • Life cycle modelling and reporting functionality. AG Coombs Founded in 1945, the A.G. Coombs Group is the leading Australian building services company that provides an integrated range of whole-of-life technical services for all systems in buildings. From advice and design through to installation, commissioning, maintenance and ongoing operation and management. Its expertise is in air conditioning and mechanical services, fire protection, hydraulics, electrical services, and lighting, and building control technologies. A.G. Coombs has a national capability with major operations on Australia’s eastern seaboard. A.G. Coombs, provide specialist consultancy input undertaking a rigorous review of key engineering assets. They feed their findings back to Macdonald Lucas for inclusion in the key deliverables. They also identify any assets that would benefit from greater analysis. What we call a ‘Deep Dive’.

Summary The benefits of the 4D Asset Audit Process are many and include: • Assistance with managing the asset base within the constraints of available budgets. • The ability to model the impact of asset management decisions e.g., postponing asset activities or refurbishing rather than replacing assets. • Continuous improvement.

At QA Electrical, we are a team of multidisciplined specialists providing electrical and data services in the health, education and government sectors. Whether your project is large or small, QA Electrical have the team, experience and latest technology to design an integrated electrical and data solution that meets your needs. Local Service, National Coverage – It’s the service you expect from your local contractor with the scale and capability of a national service, 24 hours a day. With offices in two states, we provide multi-disciplined teams for regional, state and national projects.

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— H+ Line Service continuity and reliability in medical locations

Particularly in hospitals and healthcare facilities, continuity of operations and single-fault safety are crucial. To prevent serious implications, ABB has been offering state-of-the-art solutions to leading hospitals for more than 10 years. H+ Line range consists of ABB products specifically designed for group 2 medical locations, where service continuity and reliability are key requirements for patients’ and medical staff’s safety and protection. Scan QR code to download the technical guide for patient areas in medical locations or call 1800 60 20 20


SMART ELECTRIFICATION Ian Richardson Building Solutions Technical Specialist, Electrification ABB Australia The ancient Greek physician Hippocrates is considered the father of western medicine. Many of the philosophies of modern medicine have been attributed to him or to his teachings. Among his teachings, Hippocrates believed environmental factors could greatly influence the health outcomes of patients. We define a hospital or healthcare facility as a place in which sick or injured persons are given medical or surgical treatment. We are concerned for the well-being of the patients, staff and visitors of these facilities, and rightly so. Our focus on care should go beyond the occupants of the facility, to the health of the facility itself. Buildings have a complex infrastructure of systems, just as the human body has a complex anatomy of parts that interact to form a functional unit. Central to the human body is the nervous system, but could a healthcare facility have a central nervous system? It certainly can. A smart electrification network is the central nervous system for the most resilient healthcare infrastructure and is a necessity for any future facing medical facility. Everyone involved in designing or managing modern healthcare facilities faces intense pressure, from increasing resource efficiency to delivering more effective patient outcomes. Smart electrification delivers the resilience that is urgently needed to power modern resource-intensive medical treatments, provide care for vulnerable patients, and meet the sustainability and return on investment (ROI) targets of the stakeholders. Becoming smart is no longer optional, it is a strategic imperative of modern infrastructure. Working as a hospital’s central nervous system, ABB’s systems deliver an intelligent power network for today’s most efficient and effective healthcare facilities. The flexibility of the systems enables rapid adaptation to changing conditions and challenges, reducing compliance risk and dramatically cutting operating costs.

The smart network powers all facility functions. This enables a dynamic response to the changing environment, protecting both systems and patients from the catastrophic consequences of power loss. According to the Australian Bureau of Statistics, people over the age of 65 will increase from 15% of the population in 2017 to between 21% and 23% in 2066. This aging population will place further pressure on the healthcare system. Healthcare facilities will need to adapt to provide treatment and longer-term care for this influx of patients. New illnesses and medical challenges are also constantly emerging. Some are the result of the aging population; others come because of greater globalization, or simply an evolution of natural mutations. More recent challenges, like COVID-19, place new restrictions on physical contact or face-to-face work. All of these changing factors put added pressure on resources and create demand for more adaptable medical services. With an increased patient backlog, far-sighted healthcare managers need to plan for a wave of future admissions.



Hospitals also account for 4.4 percent of global greenhouse gas emissions. They are increasingly challenged by standards compliance and efficiency mandates as well as new budgetary constraints. The pressure to be greener however competes with pressure to be cost-efficient. Like other smart buildings, smart healthcare facilities are powered by a system of connected devices. These building-wide solutions, from medium-voltage switchgear to in-room sockets and sensors, reach deep into a facility. They distribute, monitor, and manage the flow of power to every major function in the facility and return data on how efficiently those resources are being deployed. Solutions are most effective when the technology is calibrated to the application. The best solutions encompass the best technical and economic compromise, and are the result of experience, system choices and component choices. The overall performance of a healthcare facility must satisfy some basic needs: environmental sustainability, health and comfort, life cycle cost and value; and future performance. These basic needs can be broken down to seven performance criteria that measure the quality of the building itself. Connectivity: The building must allow its intelligent components to connect as well as ensuring proper cyber security measures are observed. Efficiency: The building must optimize energy consumption and support the efficient use of resources. Total cost of ownership: The building should provide transparency of the operating and maintenance costs. Predictive alerts should occur before a major fault and prevent unexpected downtime. Sustainability: The building must run with the best CO2 footprint, in accordance with the sustainability goals of the stakeholders and community expectations.


Productivity: The building should enhance the productivity of employees and set the right conditions for light, air quality, temperature etc, adapting to the occupancy and expected performance. Flexibility: The building technology must allow it to adapt easily to new usage requirements. Well-being: The building technology must keep employees and visitors safe and healthy. As an element of the building’s central nervous system, ABB’s openstandard i-bus® KNX is compliant with the Australian Technical Specification for building Automation, SA/SNZ TS ISO/IEC 14543.3, and can reduce staff workload by automating core building functions such as lighting, shutter control, heating, ventilation, security, and energy management. Patient rooms can be automatically configured to respond to individual needs, saving staff time while maintaining high-quality service. Tracking power usage can also help identify underexploited resources, which can be brought back into circulation while poorly used facility space can be repurposed to better leverage value. A smart facility can become an active player in optimizing the health of those in its care. The benefits for both the patient and the medical/financial performance of the facility are clear: improved patient experience, speedier recovery, minimized in-facility accidents and increased energy efficiency. By automatically adjusting the lighting phasing and intensity, staff working overnight stay more alert, which cuts down on errors. This adjustment of light intensity is especially crucial for pharmacies, where pharmacists need optimized light for color discrimination. Emergency lighting luminaires and systems give clear instruction and help minimize injuries in high-risk and emergency evacuation situations. In non-emergency situations, lighting can also be used to practically designate use, reflecting room occupancy or the role of a specific treatment area. Post-operative care can also be optimized by adjusting lighting along with bed height and HVAC in individual patient rooms. Automation control solutions can allow greater control over the air we breathe, keeping the air in rooms clean and safe ––especially important in a pandemic environment. Fine-tuned ventilation can manage CO2 in the atmosphere


or create positive-pressure rooms for immunocompromised patients. Whether the facility is a large hub hospital or a suburban clinic, maximizing uptime and minimizing downtime is essential. Ensuring continuity and regularity of power is notnegotiable in most medical facilities, as outages can be a matter of life or death. Modern uninterruptable power supplies (UPS) systems are essential to maintain power continuity. Modular architectures protect the supply to areas that cannot tolerate any kind of power disruption, such as operating theatres and pharmacies, as well as safety systems like smoke extraction and other critical load systems. Automatic transfer switches can also ensure the integrity of power supplies for the facility. In the smartest hospitals, intelligent electrification is used to not only monitor but to quickly predict or detect issues and then deploy the right response. Harmonic changes in a medical scanner, an air conditioning system or a switch can be an early indication of a fault. Predictive maintenance algorithms make identifying and fixing this type of error faster and less expensive. They allow hospital facility managers and end-users to remotely monitor the power system health 24 hours a day, via a cloudbased energy management platform. Users can optimize facility performance in real-time and move from schedulebased maintenance to needs-based intervention, so servicing is only performed when necessary and the risk of downtime is reduced. A smart hospital can be like a self-healing network –– fixing a failure in the power supply loop increases reliability, safety and improves the user experience. Predictive maintenance of this type is not restricted to greenfield developments or closed single supplier ecosystems. The ABB Ability™ Energy and Asset Manager is an example of an open standard cloud platform that integrates easily with third-party hardware and application programming interface (API) platforms, making it ideal for both new build and retrofit upgrades. Better energy management is also key to improved asset return on investment (ROI) and maximum energy efficiency. Smart metering and monitoring systems help ensure facilities have flexible and scalable access to the power they need. With the right system, facilities can expect a 7 percent improvement in energy efficiency, facilitating verification ratings such as Nabers and Green Star, and typical ROI in less than 3 years. Cost reductions of 50-60 percent are also achievable thanks to reduced energy use and longer asset lifecycles, using solutions like KNX single room and KNX ventilation control alone. Modern medical facilities are some of the most complex buildings ever developed. It can be a challenge for designers and managers to balance a host of competing demands.

Whether you are working on a new build or a refurbishment, you’re probably already thinking holistically about the overall goals of the stakeholders you represent. Smart electrification should also be considered with a holistic mindset. A healthcare facility is a network of electrical services and functions that must work together smoothly. An energy audit is an essential first step to understanding your power requirements. It also provides the ability to discover opportunities for optimized productivity, safety and efficiency solutions that might not have been originally considered. Major healthcare projects have planning stages that last several years, involving a range of different key stakeholders and technology partners, and collaboration is fundamental to the overall success. The right technology can facilitate an added layer of seamless collaboration within healthcare electrification projects. For instance, Building Information Modeling (BIM) enables the creation of a digital 3D model that includes data associated with physical and functional characteristics. BIM allows stakeholders to collaborate in real-time on coordinated models, with the ability to digitally add a wide range of electrical solutions and assess how well they will integrate. This leads to faster, more precise design and planning, which cuts project execution time, reducing workloads and saving costs. It also closes the gap between construction and maintenance phases, allowing team members to continue collaborating on the BIM model of a project right across its lifecycle, using existing data stored in the model for future projects. There are growing pressures to be more cost-efficient in energy and resource use. Facilities must optimize their processes while delivering more effective and ever-improving patient experiences. Healthcare infrastructure is a critical environment, and the resilience of the power supply is more important than ever in the modern medicine world. Added to this is the wider social pressure on medical facilities of all sizes to operate sustainably and reduce their overall waste and emissions footprint, as well as contributing to the well-being of patients, staff and visitors. Fortunately, solutions are available to apply on a holistic level from medium voltage point of supply through to low voltage distribution, cloud based smart asset management, active energy management, supervisory control systems, integrated building automation, emergency lighting, HVAC control, energy management and EV charging. Hippocrates may not have envisaged the advances and challenges of the modern medical facilities of today, but his fundamental belief that environmental factors have an influence on health outcomes is valid in today’s world.



KEEPING AUSTRALIAN HEALTHCARE SYSTEMS CYBERSAFE By Robert Nobilo Director of Sales, Australia and New Zealand, Virsec

Recently, the Australian Cyber Security Centre (ACSC) issued its annual Cyber Threat Report. According to the report, the health sector reported the second highest number of cyber security incidents and was a “significant target of ransomware attacks.” As a result of these incidents, medical staff were locked out of patient records, surgeries were delayed, and patients seeking emergency care were diverted to other facilities. As Australians increasingly depended on the Internet during the pandemic, the attack surface increased as well, with cybercriminals “targeting Australians’ desire for digitally accessible information or services.” In addition, the pandemic has significantly disrupted healthcare organisations and their services. New systems have been rapidly deployed out of necessity, and digital transformations already underway have

been brought forward: changes that might have taken a year were implemented in mere days and weeks.

Ransomware is Rampant According to the latest ACSC Cyber Threat Report, there was a 15% increase in ransomware cybercrime reports over the past year. Ransomware poses one of the most significant threats to Australian organisations, including healthcare. Attackers can target sensitive patient data, as well as the systems healthcare organisations use to deliver care and treatment – which are increasingly connected to the Internet and therefore, potentially vulnerable. The developers and users of ransomware are becoming increasingly sophisticated, both in the techniques they use



to gain access to systems and, once they have successfully compromised a target, how they are able to evade detection while they seek out the most valuable, and critical data.

The Challenge of Compliance In addition to increased threats, healthcare organisations need to meet increasingly stringent regulatory requirements being imposed by governments everywhere. These requirements add to the burden of responsibility for IT managers and IT departments. These requirements include the Health Insurance Portability and Accountability Act (HIPAA) and the EU’s General Data Protection Regulation (GDPR). In NSW, the Government’s policy directive on electronic information security requires local health organisations to implement security measures that reduce risks to ‘an acceptable level’ and to balance these against the potential business impact of security failures.’

Protecting Runtime a Priority The deluge of ransomware attacks faced by organisations is not going to abate any time soon, but the right security measures can significantly reduce the likelihood of a successful attack. Attackers generally seek to exploit weaknesses in the perimeter security or vulnerabilities in applications and system software. Endpoint security and other security tools can provide protection against such attacks, but not where it is needed most and where the damage takes place: during the runtime of an application. When deterministic protection is deployed, it ensures all components of applications are correct and unmodified before they can execute. This protection is thus able to thwart both known and unknown attacks. Using this approach, all application components are monitored, mapped and checked to ensure they match normal activity patterns previously recorded for that application. This includes files, processes, libraries, memory usage and web inputs. Any abnormality in application behaviour is assumed to be the result of compromise, and is automatically prevented.

Protecting operational healthcare technology According to the ACSC’s Health Sector Snapshot, vulnerabilities in industrial control systems and control systems, which are vital to healthcare operations, are being also being exploited by attackers. For example, vulnerabilities have reportedly been found in medical devices such as implantable defibrillators, health record-connected hospital beds and other IoT-connected devices throughout healthcare facilities. The problem is that operational technologies (OT) traditionally operated in isolation from modern IT systems. However, OT and IT is increasingly being interconnected, such as in the case of healthcare facilities, which require this


to upload their data, and enable more efficient and improved patient monitoring and treatment. This interconnection between OT and IT is not unique to healthcare: it is becoming widespread in every industry and bringing with it new security headaches. Operational technologies often use proprietary protocols, and cannot be patched as frequently as modern IT applications. They create a whole new landscape of vulnerabilities that can be challenging to monitor, manage and harden against attack. And, once compromised they can provide an avenue of access to IT systems, applications and data throughout the rest of a facility. As IT and OT converge, and as sensitive control systems become increasingly vulnerable, runtime application protection can be deployed to ensure that applications associated with OT behave as intended and are not corrupted or hijacked by advanced exploits. Runtime protection can provide protection from attacks that are able to bypass conventional endpoint protection (EPP) and endpoint detection and response (EDR) techniques. An important point of reference for any healthcare engineers and facility managers is the international standard ISA/IEC 62443. It was developed to provide a flexible framework to address and mitigate current and future security vulnerabilities in industrial automation and control systems. Furthermore, in 2019, the Medical Device Innovation, Safety, and Security Consortium (MDISS), a US based nonprofit organisation focused on medical device cybersecurity, announced it was developing a set of recommended practices and profiles specifically for securing medical systems based on this standard. Such initiatives are desperately needed, to ensure ongoing cyber security compliance within healthcare facilities. In the meantime, healthcare organisations will need to leverage every means available to counteract the evolving security threats to their operations and the welfare of their patients.

Preparing for Tomorrow The rise of ransomware in healthcare has been spectacular and its success, from the perpetrators’ perspective, outstanding. Attackers will continue to evolve their strategies, seeking to exploit opportunities created by pandemics or any other event that impacts widely on organisations. To keep their systems, their staff, their patients, and their data safe, healthcare organisations will need to keep investing in cybersecurity tools to protect their legacy systems as well as innovative technologies to stay one step ahead. These responsibilities do not fall only on IT, but also to the people responsible for the computer systems that manage patient records, staff payrolls and rosters and all the other myriad administrative tasks in any healthcare organisation. A more secure Internet is a safer world for all of us – we can no longer wait to take action.




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ASSET MANAGEMENT IN HEALTHCARE – MAXIMISING VALUE FROM EXISTING ASSETS Nick Adcock Lucid Consulting The value that healthcare facilities provide in the delivery of health services to local communities warrants a deliberate and coordinated asset management approach. Healthcare facilities are culminations of some of the most complex aspects of the modern built environment, and appropriate management of the assets which comprise these facilities is a key factor in the delivery of patient care.

Asset Management is the coordinated activity of an organisation to realise value from its assets. This is achieved through the practice of organising, planning, designing, and controlling the acquisition, care, refurbishment, and disposal of assets to support the ongoing delivery of services. An Asset Management System balances costs, opportunities, and risks with respect to the desired or optimal performance of asset portfolio to guide technical and nontechnical decision making. Asset management can increase the availability of assets, provide greater certainty for OPEX and CAPEX forecasting, maintain compliance with regulatory and legislative requirements, and improve amenity for patients and staff. Asset Management practices fit into a broader hierarchy which can focus on assets from the macro to the micro scale, as detailed in Figure 1. Whilst every facility is different,

Figure 1 - Asset Management Hierarchy.

there is a benefit to all facilities at various levels of the asset management hierarchy. Operational Asset Management is the day-to-day management of assets to ensure that they are operational and is achieved by conducting planned and reactive maintenance activities. The effective useful life of assets themselves is considered at this level. When assets begin to reach their end of expected life, they typically become more prone to unplanned failures, and spare components may be more difficult to source. This is particularly problematic in a healthcare environment, where service delivery is paramount. The day to day of asset replacement and repair is firmly based in the realm of operational asset management, but consideration of the medium-term future of assets can ensure that there are sufficient budgets and plans to undertake these works. Lucid have undertaken in-depth condition assessment of healthcare facilities throughout Australia. By providing specialist, engineering based assessments, we assist the asset owners and operators in achieving thier desired objectives for their assets. To support our capability and service offering in condition assessments, Lucid have invested in the use of drones and other point cloud technologies to undertake inspections where required. Drone footage can be used to to generate 3D asset models using photogrammetry, enabling the extraction of site date such as geometry. Creation of accurate 3D models reduces the need for subsequent inspections, allowing clients with remote facilities to benefit from reduced



Figure 2 - 3D Model of Adelaide Art Gallery

travel requirements, and increased accessibility of information within the organisation. Lucid has used this process to help familiarise clients with their assets, and to provide them with data on large scale or remote assets for ongoing use without the need to continually visit site. Tactical Asset Management considers how the operation of an asset aligns to the objectives of the business. At this level the compliance, condition, and performance of an asset is assessed. Undertaking an assessment at the tactical level can be used to generate a medium term (~10 Year) program of works. The program of works informs the asset owner when they should renew their assets based on various factors. This may include end of commercial life replacements, alignment with newer technologies, conformance with regulation or compliance updates, or to increase capacity to facilitate growth or change in function as required. Establishing an asset management plan aligned with the businesses strategic direction and forward planning can smooth the incorporation of new assets into healthcare facilities considerably. Lucid have developed a Tactical Asset Management plan with a client which incorporated the renewal of critical electrical and mechanical infrastructure as part of an imminent refurbishment and extension of their healthcare facility. This enabled infrastructure considered to be at their end of commercial life to be appropriately re-sized to facilitate the proposed upcoming works. Through linking the client’s growth strategy to the supporting site infrastructure requirements, Lucid was able to assist the client with being able to


Figure 3 – Ashford Private Hospital thermal plantroom.

understand the impact of their proposed changes resulting in a more cohesive approach to the asset renewal process. Strategic Asset Management aligns organisational objectives with long-term wholistic asset planning which is measured against community and business needs. This requires a wholistic assessment of the organisation’s healthcare facility portfolio, their assets and enterprise environmental factors. This is developed into the strategic asset management plan (SAMP) which provides the framework for the tactical and operational asset management activities to occur.


Investment priorities and funding requirements over the short, medium, and long term, and how these link to health service delivery objectives. Comprehensive risk assessment of the investment priorities and how these risks could be mitigated. Opportunities to improve asset management practices. Lucid combines first principles engineering with asset management strategy, meaning that clients benefit from recommendations tailored to the engineering realities of their assets. The SAMP reflected this unique combination of expertise, providing the client value by demonstrating the critical links between their health service delivery objectives and the management of their assets. This ensures that funding allocated to assets achieves their business objectives. There are multiple levels of Asset Management ranging from the organisational scale to the level of the individual asset, all of which have their place in ensuring healthcare facility operation. Asset Management is a valuable tool in the belt of healthcare operators, allowing them to achieve their clinical outcomes in response to varying social and economic influences.

Figure 4 - Artist’s depiction of the new Adelaide Women’s and Children’s Hospital.

LUCID has undertaken the development of a SAMP for a state managed Health Network. This plan considered the health service delivery objectives and associated asset management objectives, the demand drivers, and projections, such as population and demographics, and combined them with data on the current local health networks assets to generate the SAMP. The output of the SAMP included: High level gap analysis between health service delivery objectives and current built asset performance.

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COVID’S IMPACT ON THE FUTURE OF PROJECT MANAGEMENT Ing. Daniela Pedrini IFHE President, President of the Italian Society of Architecture and Engineering for Healthcare (SIAIS)

Italian Society of Architecture and Engineering for Healthcare (SIAIS) President Daniela Pedrini explains how – in a world beyond COVID-19 – project management remains the key to success for many healthcare projects and building work. The impact of COVID-19 has been profound for all aspects related to healthcare project management, but the development of project management techniques can become extremely important and useful for the future, especially in the post-emergency reconstruction phase. The global experience in dealing with the COVID-19 pandemic has been strongly results oriented – overcoming the barriers of professional belonging and organisational ones that limited the ability to work together. Throughout the emergency, everyone had to and knew how to go immediately to the heart of the problems and find the best solutions together to give people an adequate response – both in the different phases of evolution of the pandemic and in the management of the largest vaccination campaign ever faced. The joint work of all healthcare professionals has highlighted a great added value determined by multiprofessionalism and interdisciplinarity, demonstrating that the managerial skills are not something extraneous and additional to the technical and professional skills of those who work in the hospital and healthcare world, but an integral part of the professional identity. All professional roles and positions of responsibility move in highly dynamic contexts, in which not only knowledge and know-how count, but knowing how to deal with others, in conditions of great uncertainty.

In particular, the function of middle management is precisely that of being authoritative and recognised in terms of technical and professional skills and that of knowing how to move and relate within the company by leading their group or operating unit. A more complete figure is thus outlined, who knows how to make use of managerial tools through which to influence corporate decision-making processes more effectively. The development of managerial skills comprises in particular: being authoritative in providing/implementing provisions and enforcing the rules; being influential in the work of others, sharing increasingly complex objectives; and being able to delegate and empower their collaborators with a view to professional growth. Good management is closely connected to responsibility. By placing itself in an intermediate position between the strategic top and the more operational divisions, middle management plays a fundamental role in the chain of responsibilities and in the pursuit of corporate objectives. Having outlined the managerial skills, it will be possible to better orientate the training planning and the development and enhancement policies of the various professional figures and at the same time rethink many of the themes of innovation and challenges contained in the Italian National Recovery and



Resilience Plan as common construction sites, for which the ability to work together, in a more cohesive and faster way, will allow us to make a leap in the design and implementation dimension of plans and activity programmes. If we make an international comparison, it is clear that reflection and investment on managerial skills in the public sector and in the health sector are a common priority in many countries, including the US, UK, France and Switzerland. The novelty of the approach is to enhance them not as mere professionals, but as real managers, increasingly responsible and protagonists in the management of change alongside company management.

COVID-19 as a stress test The problems related to the impact of COVID-19 have been and, in some respects, continue to be a real-world stress test for the ability of companies, bodies, public administrations and organisations in general to be able to carry on and finish projects and programmes successfully. The pandemic has exposed the fragility of work organisations and the answers to the problem have been very varied, but it is still possible to draw a common scenario from a first moment of disorientation to a general reorganisation of work that factors in a new balance. It is the responsibility of the managers – portfolio, programme and project managers – to create and determine all the ways and means necessary to allow a successful conclusion of their activities, using the disadvantages and advantages of the new reality that has arisen. Surely the perception of IT tools by those who, up to that point, considered them unreliable has also changed and it will be possible to resort to a greater percentage of working remotely, having acquired practices and methodologies – as well as a certain confidence – to the management of the mix of activities in presence and remotely. The approach within companies will presumably change in terms of selection and delivery of projects as will the role of the project manager. For many, even during the period of the health emergency, it was productive to start planning and planning reconstruction actions, taking into account the changes induced by the emergency both in the way of working and in people’s attitudes. There will, therefore, be a great need for project management and also for innovation to make the best use


of the new operating methods that we have been forced to experiment and/or use on a large scale due to a global health emergency that has influenced our lifestyles and our values.

No turning back Nothing will be the same again and the recovery must be supported by a large investment programme that needs qualified project managers who are indispensable to manage the investment projects of companies and to support the economic initiatives that will be implemented by public institutions to encourage recovery. Italy is usually observed and taken as an example for its ability to respond to emergency management, but we are instead lacking in the ability to prevent and prepare in advance. To guide this reconstruction, it is essential to have widespread project management skills as well as a considerable number of highly qualified project managers. This is all the more true for Italian public administration, which must plan and guide, at the same time, both how to deal with the emergency and how to direct the reconstruction phase. Surely the discipline of project management can help to tackle these initiatives with greater probability of success, most of which are real projects or better still, programmes? As is well known, even if the decisions are initially political, they reverberate on the whole public administration and consequently on all of us. The programme and project management can help in the operational phases to deal with the emergency, and perhaps even more so in the previous planning phases, i.e. those of prevention of the emergency itself. Therefore, competent people must be involved at all levels, and related measures and actions must be planned and implemented consistently.

New opportunites New rules must be agreed, also in terms of cooperation and solidarity. This is precisely the time to put people back at the centre. Stakeholder-centred values have always been valid, and can constitute a fundamental reference for living both in health and in wellbeing. For example, with the arrival of extraordinary funds – in addition to ‘ordinary’ planning – there will be many opportunities for project management in which innovation


and digitization can lead to progress and benefits in the most diverse and heterogeneous areas. Indeed, we all share two key challenges that face our world: the pandemic and climate change. The role of artificial intelligence is not only important as a technology for the future, but also as a tool that can bring benefits to healthcare and make healthcare accessible to more people. We have to make sure that the technology is used to benefit the people who need it most, especially those in low-income countries or in countries where healthcare simply is not affordable for many. Participating in calls for proposals and drawing up projects that are innovative requires two things. Firstly, profound competence in project management issues, as a structural element through whose disciplines we can create a framework capable of supporting the project initiative. The other component needed alongside project management, is the ability to coagulate, in a project proposal, multiple skills, with a multidisciplinary character. In a world beyond COVID-19, project management remains the key to success for many healthcare projects and construction works. The pandemic has demonstrated that the future of project management lies in working remotely yet implementing this mode of work for project management is not easy.

Building a digital team Building a digital team requires addressing the issues of collaboration, responsibility and culture. To best manage a virtual team, project managers need to focus on clear lines of communication, clear expectations and objectives, and direct feedback. When managed properly, working remotely offers many benefits to an organisation, project managers and teams including: increased productivity; access to the best talent globally; reduced turnover rates; reduced stress levels; and better work-life balance. It is essential to pay more attention to the control of suppliers and operators necessary to complete the project, to carefully analyse contracts and perform risk analyses to prevent the risk of interruption arising from a lack of reliability. Lockdowns and border closures have created serious problems for supply chains, resulting in higher costs and longer lead times. Project managers need to be proactive to limit the potential threat of a supply chain disruption. This can include the storage of critical materials or the procurement of local alternatives.

For better or for worse, the way project managers work has changed. With this change comes the growing need for retraining staff to improve operational practices and achieve successful project results. To manage people, given that cultivating the best talent and inspiring innovation does not come easily through a computer monitor, it is essential to improve skills in order to learn new collaborative approaches and lead in a virtual environment. Project managers thus help guide companies in terms of futureproofing, which is why improving everyone’s knowledge to keep pace with emerging technology is critical for long-term success. Finally, small budgets leave little or no margin for error in managing a project.

Agile management Agile management has also become a common way to manage the organisation and the unexpected. Decisions in conditions of uncertainty, short planning horizons, adjustment of activities which are based on pandemic indicators. Among the impacts that COVID-19 has made on the role of project manager, one of the most relevant is the change in communication inside and outside projects – internal and external communication – that occurred very quickly. Among the negative aspects, the loss of some pieces of informal communication on the context of the project and the nuances that are acquired in normal conversations over coffee should be emphasised. There is no face-to-face contact and online communication requires more effort and concentration. The main key competences of project managers at the time of COVID-19 and post-COVID are: • Communication skills in a virtual environment and mastery of technologies. • Personal agility: adaptability and rapid reaction to changes in the environment. • Resilience and stress management. • Coping with complexity and the ability to select the most valuable information. • Knowing how to motivate people using empathy and emotional intelligence. • Leadership based on human values, values of sustainability and trust.

Complexity science Complexity science views healthcare organisations as complex adaptive systems operating in highly complex and unpredictable environments. The view assumes that much of



organisational life is unknowable, uncertain or unpredictable and therefore cannot be standardised and controlled. In this context, all the effective responses to the COVID-19 pandemic proposed by the top and middle management of hospitals and health systems, consistently with the principles of the science of complexity, have emphasised communication, collaboration and innovation. Insights from complexity science can help healthcare organisations increase their agility, resilience and learning to more effectively cope with future surprise events. The COVID-19 pandemic is a powerful reminder that we live in a highly complex and unpredictable world and that, when the future is unknown, it is necessary to create resilience and agility. Furthermore, an open and humble leadership is necessary, favouring interaction, interdependence and creative tension and identifying the right person at the right time (beyond roles and hierarchies). All of these processes have occurred in health organisations that have responded effectively to pandemic. In the construction field, hospital and healthcare construction was one of the few types of non-residential buildings that increased over the course of 2020.

Impact on healthcare estate Contagion control and security protocols put in place at the start of the pandemic are becoming standard for new projects and renovations. The pandemic has created opportunities for design and construction, as it is understood that health systems must continue to bring their services closer to where patients live. The system is looking for ways to design and futureproof by organising structures to accommodate whatever happens next, which are flexible and able to cope with present and future crises. It is essential to rethink current and future space needs, deconstructing buildings in order to understand what is and what is not essential. These reevaluations have opened the door to more flexible design options that include adaptive reuse, so as to leave patients in their own environments as much as possible. Alternative forms of patient care are being embraced, particularly telemedicine. With the help of technology, telemedicine will bring about changes in the physical building and plant environments; waiting rooms in the outpatient and diagnostic areas will give way to waiting for patients in the individual examination rooms. Regardless of space decisions, structures must be made as controllable as possible with respect to the spread of infections. While it was recognised during the pandemic that healthcare facilities lacked the infrastructure design to be converted quickly and efficiently to meet infection control needs, new designs must have those requirements. As a result, the pandemic has triggered a dramatic need


for building controls, improved air quality, increased HVAC capacity and overall facility resilience. Futureproofing is now part of the planning lexicons of most health systems. Every aspect of each facility, from arrival to discharge, is reviewed and reconsidered during the design of new or renovated spaces. During the pandemic, emergency facilities were built very quickly. The design and build speed mentality now permeates all hospitals and healthcare projects internationally, even if there is no real consensus on which delivery method is the most efficient. In this regard, in countries where it is possible, more new delivery models are being developed that can accelerate projects. These include integrated project delivery (IPD), progressive design build (PDB) and modular design and construction (MDC). The fixed point is that build projects will fall within budget and on schedule.

New tools for a new time The pandemic has made it more difficult to keep up with the demands of healthcare companies and hospitals. To this end, prefabrication and modularity have become important tools. Even if we return to a new normal, some principles will be fixed points in imagining the places of territorial and hospital healthcare. Telemedicine will continue to expand and the evolution of telemedicine could establish new patient-health system relationships especially in rural areas where services are often scarce. It will be possible to create real ‘command centres’ that are powering telemedicine solutions, allowing doctors from all over the world to consult and maintain visibility on the condition of a remote patient and to act as a ‘central call centre’ for the facility or the system. The energy consumption of hospitals is typically three times that of other commercial buildings and attention must certainly be paid to controlling and ideally limiting/reducing energy consumption.

Conclusion Today, we have to work with new technologies, new project management tools and we have to be agile in the way we work and in how we communicate, with new working model as well as new engineering processes. We need to develop flexible working systems, whether it is remote work or upskilling to improve operation practices. Above all, we have to keep our people safe, inside and outside our healthcare systems and hospitals, from COVID-19 and future pandemi-cs and we have to do that without harming our planet and ecosystems. We also have to guarantee that we do not compromise our fight against climate change in our preparation against pandemics. This is our great challenge.


Bibilography Fiaso G. Sviluppo e valorizzazione delle competenze del middle management del SSN. Egea 2021; 162-80. Marinelli M. Emergency Healthcare Facilities Managing Design in a Post Covid-19 World. IEEE Engineering Management Review; 48 (4): 65-71. Pedrini D. Rivedere, Integrare, Migliorare - Panorama Sanit , 3/2021, March; 35-37 Pedrini D. Covid-19 and beyond: the Italian experience. IFHE Digest 2021; 17-20. Pirozzi M. The fight against Coronavirus (COVID-19) seen from the perspectives of projects and project management. PM World Journal - Italy Project Management Roundup, April 2020; IX (IV) []. Tanese A. Middle management. Panorama Sanit 2021; 8: 10-11. Id=6671305950122541056. finance/us-covid-19-impact-construction-landscape.pdf.

Daniela Pedrini Daniela is President of the International Federation of Healthcare Engineering; director of the technical, planning, development and investments department of the Hospital-University Authority of Bologna – Sant’Orsola Polyclinic; and current President of SIAIS (Italian Society for Architecture and Engineer for Healthcare). At Hospital-University Authority of Bologna – one of the major hospitals of Italy, Daniela is project manager for renovations and new hospital construction. Daniela has a long career in the health sector, with important roles in the management of technical aspects of hospitals, and teaches for many healthcare engineering courses and university Master’s programmes. Daniela is 1st Vice-President of the International Federation Hospital Engineering (IFHE) and a former President of IFHE-EU. Daniela has been honoured with a medal of the Italian Republic Order of Merit. First published in the IFHE Digest, 2022

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IT’S 2022. WHY ARE WE STILL USING SPREADSHEETS AND LEGACY SYSTEMS? Richard Ham FM Clarity Technology has come to play a big role in revolutionising the facilities and asset management industry - from allowing us to let go of manual paper-based systems, to helping us come up with better strategies for our business, streamline processes and provide insights to guide important business decisions. And this is before we talk about sensor-driven, predictive maintenance and analytics, cloud-based BMSs and more. Why then, do many organisations still appear to be stuck using legacy systems designed on old technologies or even worse, the infamous excel spreadsheet? The answer could be that the facilities management sector believes that the software of yesterday has not changed and that there is little value in going through the perceived massive effort of change to achieve an outcome that is not fit for purpose, or at best, less than ideal. In some sectors, such as aged care, organisations are being mandated to implement a computerised maintenance management system (CMMS) so that they can effectively manage capital budgets in a more transparent and real-time way rather than an asset register that is a static picture as at the date of the last audit. The new updates to the Retirement Villages Act 1999 and the Retirement Villages Regulation 2017 in New South Wales, require every operator of retirement villages to prepare and keep up to date compliant and detailed Asset Management Plans. Although this requirement only covers NSW for now, it is already on the way for Victoria and Queensland - and it is very likely that the remaining states will also have to follow it very soon. Released in February 2021, the amendment requires all operators to keep an asset register, a 10-year maintenance schedule for each asset, and a three-year maintenance report to accompany the village’s annual budget. It also recommends the use of a CMMS or an Asset Information Management System (AIMS) to create and maintain an effective plan - spreadsheets are not recommended due to the potential large amount of assets to keep track of. For the hospital sector, digital management of assets, particularly management of the highly regulated biomed assets, this is not anything new. However, given that the software was generally implemented quite some time ago, this has meant that many organisations are still using

outdated, legacy software designed and built on old technologies. As with many other large occupiers, the perceived effort of change for hospitals can often put the project into the toohard basket. However, the evolution of software in this space in the last 5-10 years has meant that the underlying premise of a complex, hard-to-use system with implementation lasting 6 months to years is no longer accurate. Now, next-generation, Commercial-off-the-Shelf (COTS) solutions can deliver rapid implementation times with highly targeted, intuitive workflows. Learning Management Systems and mobile applications, as simple as the apps we use everyday, has meant that adoption is also no longer such an issue. Another major advantage is the availability of mobile apps and the mobility it offers to our staff. Allowing them to be able to remain active while in the field and becoming more agile and productive by using a single app solution instead of siloed tools or excel – we all know that many FMs hate being dragged back into the office to ‘do the paperwork’. And of course, a younger workforce expects that we should no longer be using yesterday’s technology that doesn’t allow always-on mobility and simple workflows. In relation to asset management, harnessing standardised classification systems, such as Virtual Building Information System (VBIS), allows organisations to rapidly assess and compare across asset classes. This now makes it a simple exercise to perform a capital expenditure budget in real-time as well as making it significantly easier to focus on the assets that really need attention. All of this has meant that the opportunity cost of not changing is significant. Is now the time that organisations realise that old premise no longer holds true? Technology brings a lot to the table when it comes to the facilities and asset management industry and it is continuing to evolve. Our team at FMClarity lives and breathes technology and FM; if you’d like to have a chat or check out the latest in FM Tech please contact us at





Bio-aerosols containing harmful pathogens can come from a number of apparatus within healthcare premises including showers, taps, washbasins, sinks, and toilets. This article explains the risks of waterborne pathogen risk in healthcare premises and outlines how to prevent it. The need to reduce the risks of splashing and airborne pathogenic aerosol has never been more important. In the wake of COVID-19 recent research findings have starting to confirm what many already suspected – that COVID-19 acts like many existing pathogens in the ways it can be transmitted via water-borne particles and poor hand hygiene. Unacceptable levels of sickness and deaths have long been associated with poor hand hygiene, close contact with infected people and inadequate cleaning. In many countries, initiatives addressing education, cleaning and audit, together with compulsory reporting of infections, have brought about benefits leading (in some cases) to the reduction of headline rates of infections, such as methicillinresistant Staphylococcus aureus (MRSA), Clostridium difficile (C.diff) and Legionnaires’ disease. It is now readily accepted that a common mode of transmission is contact between the patient, the staff and the environment. Inappropriate hand hygiene practice has been identified as a significant contributor to numerous disease outbreaks. Several studies have shown the impact of improved hand hygiene on the risk of healthcare associated infection and multi-resistant pathogen cross-transmission. To date, most studies have focused on methicillin-resistant Staphylococcus aureus. Bacteria present on human skin can be considered as belonging to one of two groups: resident and transient flora. Transient flora colonises the superficial layers of the skin. It has a short-term persistence on skin, but a high pathogenic potential. It is usually acquired by healthcare workers during direct contact with patients or contaminated environmental surfaces adjacent to the patient, and is responsible for most healthcare associated infections and spread of antimicrobial resistance resulting from cross-transmission.

Resident flora is attached to deeper skin layers and has a low pathogenic potential unless introduced into the body by invasive devices. It is also more difficult to remove mechanically. Hand hygiene decreases colonization with transient flora and can be achieved either through hand washing or hand antisepsis.1 Whilst this and other studies have shown that outbreaks can be reduced by improved hand hygiene compliance and better cleaning of the environment. Transmission of infection by the air has often been less well investigated, leading sometimes to a complacency in this mode of transmission. It has been proven already that Norovirus can be transmitted by aerosol and is difficult to contain in a hospital ward without sufficient single rooms with ensuite toilets. Now with the additional battle against COVID-19, the transmission by aerosol now needs to be urgently considered and the risks substantially reduced. Although the direct transmission from infected person(s) is the primary source of aerosols and droplets, other scenarios such as medical procedures, surgeries2, fast-running tap water and toilet flushes3 also generate aerosols contaminated with infectious pathogens. The most common types of viruses causing infections in the respiratory tract through aerosol transmission are influenza viruses, rhinoviruses, coronaviruses, respiratory syncytial viruses, and parainfluenza viruses.4 Some articles have postulated three modes in which the influenza virus can be transmitted: aerosol transmission, droplet transmission, and self-inoculation of the nasal mucosa by contaminated hands. Historically, natural ventilation was seen to be beneficial in hospital wards and was part of hospital design. With the advent of sealed high-rise buildings and forced ventilation, expensive negative pressure rooms have been sometimes



been introduced to house patients with infections thought likely to be transmitted by aerosol. Aerosols can be defined as liquid or solid particles suspended in the air by humans, animals, instruments, or machines. Bio-aerosols are aerosols consisting of particles of any kind of organism. The characteristics of bio-aerosols differ depending on environmental influences such as humidity, air flow, and temperature. Aerosols, which are responsible for the transmission of airborne micro-organisms by air, consist of small particles named droplet nuclei (1–5μm) or droplets (>5μm). Droplet nuclei can stay airborne for hours, transport over long distances and contaminate surfaces by falling down. In a review article from 2006 the authors found for SARS‐CoV‐1 that “particles of diameters 1–3 µm remained suspended almost indefinitely, 10 µm took 17 minutes, 20 µm took four minutes, and 100 µm took ten seconds to fall to the floor”.5 The article notes that aerosol transmission is a well‐known and important exposure pathway for infectious agents such as influenza and other viruses including coronaviruses. SARS‐ CoV‐1 viral RNA was found in air samples, and long‐range aerosol transport was implicated as the cause of the spread of the disease in several studies. It has been proven that droplets can contaminate surfaces in a range of over two meters.7 The droplets are also capable of penetrating deep into the lungs, offering a potential route

Example of an Angel Guard washbasin designed to limit the risk of aerosol and splashing.


of infection.8 The susceptibility of acquiring an infectious agent is determined by factors such as: virulence; dose; and pathogenicity of the micro-organism; and the host’s immune response.8-10 Humans generate bio-aerosols by talking, breathing, sneezing or coughing.6 Based on the infectious status of a person, the bioaerosols can contain pathogens including influenza11,12 Mycobacterium tuberculosis8, Staphylococcus aureus, Varicella Zoster Virus, Streptococcus spp. or Aspergillus spp.12 Moreover, bio-aerosols can be generated by devices such as ventilation systems, showers, taps and toilets. Showers and tap water are also able to spread environmental microbes such as Legionella spp.9,10,13 It is now commonly accepted that bio-aerosols containing harmful pathogens are very much a common and serious contributor to healthcare-acquired infections but are these connections new and what was known of such threats in the past? In 1985 Dr. Gary E. Bollin et al conducted an air sampling test in showers and sink areas at the Youngstown Hospital. 15 A total of two paired water and air samples were obtained from each of the two shower rooms. All four water cultures grew L.pneumophila. Low numbers of aerosolized L. pneumophila (3 to 5 CFU/15ft3 [0.43m3] of air) were recovered when the air was sampled above the shower doors with the six-stage sampler. Equal numbers of organisms were recovered in the first and second 15-minute sampling periods. A total of 19 paired water and air samples were obtained from 14 hot-water taps. A total of 17 of the water cultures grew L. pneumophila. Two colonies of L. pneumophila (one on stage 1, one on stage 3) were recovered from air around one of the three taps tested with the six-stage unit. A total of 11 colonies were recovered (six on stage 1, five on stage 2) from five of the remaining 13 taps tested with the two-stage unit. All positive air cultures from the two-stage unit were obtained during the period when the tap water was running. None were ever obtained before the tap water was turned on or after it was turned off. No air cultures were positive more than once among the rooms that were tested two and three times. Showers, taps and washbasins are not the only means of transmission via aerosol. Toilet flushing is another large risk area. Bio-aerosol production during toilet flushing was first reported in the 1950s by Jessen14 who ‘seeded’ several types of toilets with Serratia marcescens (then termed Bacillus prodigiosus) and measured bio-aerosols produced by flushing. Agar-filled ‘settle plates’ caught bio-aerosols that fell out of the air because of gravity, and a Bourdillon slit impactor collected air samples. Cistern-fed, gravity-flow toilets and a mains-fed pressure-valve toilet were examined. In addition to colonies found on the floor-based settle plates, microbes were still being captured from the air eight minutes after the flush, indicating collection of ‘droplet nuclei’ bio-aerosols. Droplet nuclei are the tiny particles that remain


after the water in a droplet evaporates. They have negligible settling velocity and will float with natural air currents. Jessen observed that the amount of bio-aerosol increased with increasing flush energy. In 2011 Best et al16 performed in-situ testing, using faecal suspensions of C. difficile to simulate the bacterial burden found during disease, to measure C. diff aerosolization. They also measured the extent of splashing occurring during flushing of two different toilet types commonly used in hospitals. Their findings were as follows: C. diff was recoverable from air sampled at heights up to 25cm above the toilet seat. The highest numbers of C. diff were recovered from air sampled immediately following flushing, and then declined eightfold after 60 minutes and a further threefold after 90 minutes. Surface contamination with C. diff occurred within 90 minutes after flushing, demonstrating that relatively large droplets are released which then contaminate the immediate environment. The mean numbers of droplets emitted upon flushing by the lidless toilets in clinical areas were 15-47, depending on design. C. diff aerosolization and surrounding environmental contamination occur when a lidless toilet is flushed.

They concluded that lidless conventional toilets increase the risk of C. difficile environmental contamination, and they went onto suggest that their use should be discouraged, particularly in settings where C. diff is common. Unfortunately, despite these findings, it is still common practice in UK healthcare that toilets within clinical areas have no lid and the aerosol created continues to create a risk of infection within a healthcare environment. It has also been found that the use of hand dryers, especially the increasingly common jet air dryers might have the potential for increasing the risk of aerosols. In a recent study undertaken by Best et al17 it concluded that multiple examples of significant differences in surface bacterial contamination, including by faecal and antibiotic-resistant bacteria, were observed, with higher levels when jet air dryers were present versus paper towel in washrooms.

Conclusion In conclusion, it is now understood that bio-aerosols containing harmful pathogens can come from a number of apparatus within healthcare premises including showers, taps, washbasins, sinks, and toilets. Hand dryers are also a potential cause for concern. I believe that in order to reduce the instances of people becoming sick and sometimes dying due to healthcare-acquired infections caused by such bioaerosols, manufacturers should continue to innovate and design better products that reduce aerosol risk. These new designs need to ensure that aerosol production and contamination is minimised, for example the unique tubular washbasin which is part of the Angel Guard clinical unit that helps to reduce aerosol dispersal and splashing. In addition, there should be very careful consideration of when and where to site sanitary apparatus and the risks associated with toilets within an immunocompromised patient area.

References 1. How coronavirus is spread through aerosol through the air. Credit: Getty Images.


3. 4. 5.

6. 7.

8. Water from a tap produces significant aerosol dispersal.

Pittet D., Mourouga P., Perneger T.V. et al, Compliance with hand washing in a teaching hospital. Annals of Internal Medicine, 1999. Tellier R., Li Y., Cowling B.J., Tang J.W., Recognition of aerosol transmission of infectious agents: a commentary, BMC Infectious Diseases, 2019. Morawska L., Cao J. Airborne transmission of SARS-CoV-2: the world should face the reality, Environment International, 2020. Judson S.D., Munster V.J., Nosocomial transmission of emerging viruses via aerosol-generating medical procedures. Viruses, 2019. Tang, J. W., Li, Y., Eames, I., Chan, P. K. S., & Ridgway, G. L., Factors involved in the aerosol transmission of infection and control of ventilation in healthcare premises, Journal of Hospital Infection, 2006. ASHRAE, ASHRAE Position Document on Airborne Infectious Diseases, 2014. Barker J., Jones M.V, The potential spread of infection caused by aerosol contamination of surfaces after flushing a domestic toilet, Journal of Applied Microbiology, 2005. World Health Organization, Infection prevention and control measures for acute respiratory infections in healthcare settings: An update, 2007



9. 10.


12. 13.





Szymanska J., Dental bioaerosol as an occupational hazard in a dentist’s workplace, 2007. Laheij A.M., Kistler J.O., Belibasakis G.N., Valimaa H., de Soet J.J., Healthcare-associated viral and bacterial infections in dentistry, Journal of Oral Microbiology, 2012. Brankston G., Gitterman L., Hirji Z., Lemieux C., Gardam M. Transmission of influenza A in human beings, The Lancet Infectious Diseases, 2007. Tellier R., Aerosol transmission of influenza A virus: a review of new studies, Journal of the Royal Society Interface, 2009. Tuttlebee C.M., O’Donnell M.J., Keane C.T., Russell R.J., Sullivan D.J., Falkiner F. et al, Effective control of dental chair unit waterline biofilm and marked reduction of bacterial contamination of output water using two peroxide-based disinfectants, Journal of Hospital Infection, 2002. Roberts K., Smith C.F., Snelling A.M., Kerr K.G., Nafield K.R., Sleigh P.A., Beggs C.B, Aerial dissemination of Clostridium difficile spores, BMC Infectious Diseases, 2008. Bollin G.E., Plouffe J.F., Para M.F., Hackman B., Aerosols containing Legionella pneumophila generated by shower heads and hot-water faucets, Applied and Environmental Microbiology, 1985. Best E.L., Sandoe J.A., Wilcox M.H., Potential for aerosolization of Clostridium difficile after flushing toilets: the role of toilet lids in reducing environmental contamination risk, Journal of Hospital Infection, 2012. Best E., Parnell P., Couturier J., Barbut F., Le Bozec A., Arnoldo L., Madia A., Brusaferro S, Wilcox M.H., Environmental contamination by bacteria in hospital washrooms according to hand-drying method: a multi-centre study, Journal of Hospital Infection, 2018.

Elaine is director of operations for both of Angel Guard and Water Kinetics. Over the last three years, Elaine has been fully involved in the setting up of both of companies having just launched cutting-edge and highly innovative plumbing products. Elaine began her working career working in the building and construction sector and coowned a distribution company by the age of 24. Elaine is Six Sigma trained, has written articles for newspapers and magazines, been editor of a leadership magazine, and has done both television and radio work. Elaine has extensive experience in public speaking and has recently been awarded membership of the Royal Society of Public Health. Published with permission and thanks to The Health Estate Journal UK




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CONTRIBUTION: WHY HEALTHCARE ORGANISATIONS SHOULD INVEST IN WORKFORCE MANAGEMENT Darren Kilmartin Head of Healthcare, UKG Healthcare organisations typically strive to achieve a trifecta of outcomes: excellent clinical results, improved patient (and family) satisfaction, and lower costs. Technology, which is at the heart of streamlining systems and processes, is a major enabler of this; empowering staff to focus on what they are dedicated to doing and helping those in need.

However, burnout is undermining the health system. Manual processes and outdated technology represent huge threats to productivity and bloat the workloads of already overloaded staff. Effective workforce management solutions have the ability to immediately ease the extra administrative burden. Automated rostering, payroll, and timekeeping can unburden care providers to centre attention on their core roles and strike a healthier work-life balance. Research has shown that nurse leaders are grappling with morale and burnout (67 per cent) and staffing shortages (65 per cent).1 Nurses agree that mental well-being and resiliency support are important priorities for the next 10 years and believe that addressing administrative challenges including long hours, understaffing, and administrative burden, will be critical. These findings are supported by an Australian study by the Rosemary Bryan AO Research Centre, showing that emotional exhaustion was ‘approaching a high level’.2 Resource planning and agility have become even more critical for healthcare organisations due to the pandemic. An integrated workforce management solution can provide rostering visibility and flexibility that just isn’t possible with manual systems helping to alleviate some of these pressures. Centralised staffing and scheduling solutions can drive timely, informed staffing decisions. Allocating staff to the areas of greatest need at short notice can be a significant factor in delivering improved clinical results. Automated call lists and SMS outreach to qualified available staff to help fill open shifts can help managers adjust staffing throughout the day to meet fluctuating care needs. Importantly, centralising these processes adds a layer of staff empowerment. Self-scheduling increases staff engagement and eases shift covering pressures.

Modern human capital management solutions track overtime, turnover, job hours, holidays, and time accrued, all from one dashboard. A granular, real-time view of the workforce is a powerful tool to drive efficiencies and understanding of how the organisation is resourced. When HR is equipped with a solution that unifies its functions with the rest of the organisation, healthcare organisations can strive to improve employee experiences, process information in real time, and contribute more strategically to business planning. Personalised data delivered direct to mobile devices can also help employees feel engaged, valued, connected, and empowered. Real-time visibility and ongoing communication nurtures a bond with the organisation, encouraging staff retention. The effects of the pandemic are also having a dramatic impact on HR teams, particularly in healthcare organisations with a large frontline workforce. Efficiently managing an ever-changing regulatory landscape during a pandemic is a complex task, and having the right technology is a key factor for success. Automation can help deliver the best tools, solutions, and knowledge to comply with changing federal, state, and company policies. This includes storing



and managing compliance documentation. Over the last two years, increased compliance requirements have imposed a huge workload burden; however, efficient software can lighten that load. There’s no doubt that workforce and human capital management solutions can improve business efficiencies; however, that doesn’t mean automation takes away the human element and focus on people. Quite the opposite. The right technology leaves healthcare professionals to focus on business improvement and better patient care. Centralised staff management means more people can be rostered where they’re needed most. Letting technology take over the administrative roles of timesheets, payroll, and rostering leaves more time to spend at a patient’s bedside. Patient care is paramount in any healthcare organisation; however, cost savings are unequivocally high on the list of priorities too. A clear and pre-determined return on investment benchmark lays a solid foundation for the implementation of any new technology. There are clear indicators that workforce and human capital management solutions can deliver significant cost savings by reducing the time it takes to complete many organisational tasks and providing the data insights to take action in the moment that minimises unnecessary overspending on labour. However, technology

can also help redesign the future of work in new ways, generating data and information to drive ongoing efficiency, simplifying processes, and empowering staff to perform to their best capability individually and within teams.

References 1. 2. 2e22d331348daf2/covid-19-and-workforce-wellbeing-survey_ report_final.pdf

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THE FUTURE OF REFRIGERANTS FOR HVAC Jamie Park Senior Engineer, A.G. Coombs Advisory

As the world grapples with rising temperatures caused by the emission of greenhouse gases, refrigerants are under renewed scrutiny, as common refrigerants are classified as greenhouse gases which can be hundreds or even thousand times worse from a Global Warming Potential (GWP) than the equivalent volume of natural refrigerants such as carbon dioxide (CO2). This article provides an update on refrigerants in the commercial HVAC industry. HFC Phase-down Since the phase-out of chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs) the most common type of refrigerant available in the market today are hydrofluorocarbons (HFCs). HFCs are synthetic, manufactured refrigerants, that were widely implemented predominantly due to their inability to break down and deplete the ozone layer (also known as having Zero Ozone Depletion Potential – ODP). HFCs are beneficial due to their efficient heat transfer properties, whilst being both inert and non-toxic. The major problem with HFCs arise from their global warming potential (GWP). GWP is a physical property of greenhouse gases which indicates the propensity of the gas to trap atmospheric heat. The Montreal Protocol on Substances that Deplete the Ozone Layer is an international agreement made in 1987. It was designed to stop the production and import of ozonedepleting substances and reduce their concentration in the atmosphere to help protect the earth’s ozone layer. The global phase-down under the Montreal Protocol was agreed in 2016 in Kigali. This amendment will phase-down HFC production and importation by 85% between 2019 and 2036. In response to this, the Australian Government has initiated a “HFC Phase-down”, in line with many developed nations around the world. The HFC Phase-down sees a gradual reduction in the maximum amount of HFCs permitted to be imported into Australia.

Current Refrigerant Market The structure of the Australian Government HFC Phasedown is geared towards limiting the importation of HFC gases, with a view to encouraging market forces to


determine the best solution. As such, it is useful to observe the market to see what changes, trends and innovations are taking place.

HFC Alternatives Awareness of the issues with HFCs preceded the implementation of the government phase-down in 2018. HVAC equipment manufacturers, especially those with a global presence, had been working on developing equipment that functions on alternative refrigerants for some time. Currently, the alternatives can be split broadly into three separate chemical groups. They are: • Hydrofluoroolefins (HFOs) – These compounds are synthetic organic compounds composed of hydrogen, fluorine and carbon. These compounds generally have low GWPs, however they can be slightly flammable. • HFC-HFO Blends – A transitionary family of refrigerants blends that leverage the respective benefits of both HFOs and HFCs. These blends are a short-term solution which have a GWP approximately half that of HFCs. • Natural Refrigerants – These are refrigerants with simple chemical composition, such as Ammonia (NH3) and carbon










AU: 1300 680 898 - NZ: +64 (0) 7 5771560 - * Performed by a Tristel RA Engineer. **Applies to Tristel RA Series 3 and above.

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dioxide (CO2). These refrigerants are typically not as easy to use and require significantly more complex engineering in the machinery. Despite this, these compounds and their applications are generally very well understood. Furthermore, both substances have 0 ODP, and a GWP of 0 and 1 respectively. A broad comparison of the different families of refrigerants is displayed in the table below.

Current Refrigerant Trends When reviewing refrigerants, it is also important to understand their safety classification, and in particular, their flammability. ISO established a system for assigning safety classifications and is adopted in AS/NZA 5149. Current refrigerant trends with regard to chillers available in the Australian market are outlined as follows: • R134a (HFC) is the current predominant refrigerant in the Australian market and has an A1 safety rating. R134a is included in the phase-down due to its high GWP of 1300. • R1234ze (HFO) is mostly used through Europe and Asia and is currently the most developed HFO refrigerant, with excellent full load and part load efficiencies. Its GWP is less than 1; however, it has an A2L safety classification (meaning a low flammability rating) which may require additional ventilation in plantrooms. • R1233ze (HFO) is the predominant HFO offered in North America, with its A1 safety rating and low GWP of 4.5. R1233ze Chillers are typically negative pressure machines which are generally heavier compared to positive pressure machines at the same capacity therefore are better suited to new builds compared to retrofitted due to their additional structural impacts. • R513a is a HFC/HFO blend and is used as a direct replacement (“drop-in”) for R134a. It provides a reduced GWP to 631 with only a slight reduction in capacity and efficiency. This is an interim option as it is not clear yet if this blend will be impacted by the HFC phase-down.

What does this mean for commercial HVAC systems? With the phase-down of HFC refrigerants, there will be reduced supply, and this is likely to result in increasing cost of the gas over time. This effect has been observed with the cost of R134a increasing over the past 5 years as the phase-out date approaches. In common with the previous refrigerant phase-outs, the following actions are recommended to pre-empt and prepare for this issue: 1. Keep an accurate asset schedule of all equipment incorporating HCFC and HFC refrigerants. This should list the plant age, refrigerant, refrigerant charge and chiller capacity. 2. Speak with your mechanical maintenance providers to identify any plant that is currently operating with HCFC and HFC refrigerant and consistently requires additional gas replenishment or ‘gas topping’ over its life, as this will impact on energy consumption and operating costs due to the rising cost of the refrigerant. 3. Prepare a refrigerant management plan reviewing the existing plant design, condition, age and capacity of airconditioning equipment and identify whether a retrofit or replacement strategy is proposed for the asset/s 4. Review your chiller plant replacement strategies to assess the available HFO chiller refrigerant options, part load efficiencies, plant ventilation requirements, weight and impact on the building structure and overall impact on the total cost for replacement of the asset. 5. Review your need for reverse cycle chillers (or heat pumps) as we move away from gas-fired plant for space heating and adopt electric heat pumps for heating applications. Consideration of systems that can offer both cooling and heating at the same time to leverage cost efficiencies during capital upgrade works. It should be noted that the Kigali agreement is a phase-down and not a phase-out, meaning there are no HFC production bans as are with hydrochlorofluorocarbons (HCFCs) such as R22; however, it is still important to consider the selection of the refrigerants in any new and replacement plant. It is also important to understand that as the demand for HFO refrigerants grow, the list of approved HFC substitutes will likely expand and better alternatives may enter into the market, whilst at the same time the new HFO machines’ pricing will likely become more competitive. For more information about Refrigerant Management contact Jamie Park, A.G. Coombs Advisory, Tel: +61 3 9248 2700, Email:

Reference: AS/NZS ISO 817-2016


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TRISTEL RINSE ASSURE As of June 2021, healthcare facilities are required to have completed a gap analysis for AS/NZS-4187, in line with NSQHS Advisory AS18/07. Additionally, a documented remediation plan is required by December 2021. While these Standards cover a number of elements, one of the most discussed topics is Final Rinse Water; specifically Tables 7.2 (Manual Cleaning Manual Disinfection and Washer-Disinfectors) and 7.3 (Washer Disinfectors in Accordance with ISO 15883-4 For Thermolabile Endoscopes) and the conundrum of final rinse water in Endoscopy. Tristel’s long history and foundations in Endoscopy has led to the development of Tristel ‘Rinse Assure’ – a unique system designed specifically to produce bacteria-free, AS/NZS-4187 compliant water for EWDs. The Rinse Assure system combines filtration and RO, along

with chemical dosing using trace amounts of Tristel’s chlorine dioxide chemistry. These are all calibrated depending on a site’s requirements. Tristel Rinse Assure is a compact, affordable and permanent solution. Rinse Assure’s unique design means that RO water can be stored in an internal tanks, with different sizes depending on the requirements of the EWD bank. If RO is already present, a small system without RO can easily be installed. Tristel’s dedicated service engineer can provide free site and requirement assessments, as well as water testing. Additionally, chlorine dioxide has been found to be effective against biofilm; Tristel is currently undertaking studies and testing to explore Rinse Assure’s capacity to make this claim. Tristel Rinse Assure: the total solution for EWD final rinse water.

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• Capture permit documentation • Track compliance, time and attendance. Keep on top of regulatory and legislative changes; have visibility of their contractor compliance; limit access to contractors who are non-compliant; and receive and create registrations through LinkSafe’s dashboard. LinkSafe’s contractor management solution is the solution for companies serious about compliance and safety.

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WHAT’S THE POINT OF DISINFECTING AND SANITIZING IF YOUR SOLUTION ISN’T UP TO STANDARD? Test strips are an effective, affordable, and easy solution that can work for everyone. Test strips have been around since the late 1930’s and ever since then have been getting better in terms of reliability and accuracy whilst also increasing the testing parameters that can be measured. Test strips are a fast, reliable, and affordable way to monitor sanitizer concentrations; and can help give you the reassurance that your working environment is not only clean, but safe. There are a range of cleaning and disinfection solutions which need to be made at the time of use from concentrations. The concentrations need to be closely monitored to ensure the sanitizer is working effectively. Too little sanitizer will allow the growth of harmful bacteria and too much can be toxic and corrosive to equipment. The most common test strips to verify a particular solution will generally show measurements in ppm (part per million) or mg/L (milligram per liter). Food preparation or site disinfection sanitizers may consist of one of the following: • Peracetic Acid Solutions, up to 2000ppm


•  Hydrogen Peroxide Solution, up to 1000ppm •  Quantitative Ammonia Compound Solution, up to 1000ppm • Chlorine Solution, up to 800ppm • pH test strips, 0 to 14 Depending on the application for sanitization, will determine the necessary concentration. Tests strips can confirm instantly if a readymade solution would be satisfactory. They are also the cheapest method to get a reliable, accurate result.

Contact Vendart Diagnostics Pty Ltd Phone: 02 9139 2850 14/128 Station Rd, Seven Hills NSW 2147 Email: Website:


EFFECTIVE LIFE CYCLE PLANNING As the health care sector emerges, cautiously, from the pandemic enforced lock down, stiff competition from core business for increasingly constrained budgets is likely to be the order of the day. In this environment a major challenge for healthcare engineers will be securing support for asset replacement projects. It has always been the case, understandably, that business cases for the replacement of non- core assets such as chillers and boilers are much more difficult to make than those for the replacement of core business assets. Of course there are many reasons for this that include: • It is difficult to make the case that an asset requires replacement when it appears to be operating effectively; • Engineering assets often fail in service gradually and stakeholders get used to ‘living with’ the inconvenience of unreliable operationmaking it difficult for the need to replace them to be perceived; and, • Key decision makers typically have a better understanding of the need for core business assets than they do for non- core business assets. Faced with these challenges a number of healthcare engineers are turning to RMIT’s CAMS life cycle modelling tool to help communicate their long term asset replacement needs to senior management. Developed over the last twelve years by PhD students using a

range of statistical analytical tools, a suite of 900 curves have been developed that model asset degradation over time. These curves are initially applied at individual asset level. CAMS then uses a selflearning algorithm informed by asset condition data, that is uploaded over time, to model how each individual asset is deteriorating in the field. Asset data can be analysed and reported at both micro and macro level, assets can be classified in any way the client specifies, for example from the point of view of risk, priority or asset type. Key to CAMS’s success has been the ability to present technical data about asset life in a way that is intuitive to senior management from a non- technical background. A large number of healthcare organisations, throughout the country have found success in deploying CAMS and see it as an essential tool in planning asset replacement activities. Helping to prioritise these works over time and to manage the expectations of senior stakeholders. Particularly when planning major items of future capital expenditure.

For further details please visit our website

AUSTRALIAN MEDICAL SUCTION When it comes to Medical Suction Systems the Australian Standard AS 2896:2021 states “Over-sizing of the plant has a major impact on both cost and construction.” It’s not just the over-sizing that can be an impact on the cost, but the system’s ability to adapt to a constantly changing load demand that can dramatically increase running costs over the life of the system. Why buy a minibus when you only have one child to drop to school or have a powerful sports car only to drive in peak-hour traffic that averages 22km/h? How do these analogies apply to the vacuum pumps used in Medical Suction Systems? AS 2896:2021 establishes, the system and capacity of the pump shall be such that the suction of at least -60 kPa is achieved. If -60 kPa is required at the suction terminal, why then would you need a pump that can reach -99 kPa as its ultimate pressure? The two most common types of vacuum pumps used in Medical Suction Systems are the rotary vane type, with some manufacturers supplying 100% oil-free whereas others supply oil-flooded pumps. The difference between the two is that the vacuum level you can achieve in an oil-free pump is -90 kPa, whereas the oil-lubricated pumps can achieve -99.99 kPa. Oil-lubricated pumps cost more to run and maintain with costly oil-separators needing to be changed regularly. One benefit of oil-free pumps is that they can be supplied with VFDs which will reduce the energy consumption and extend the life of the pumps. Over time the running costs of your system will outweigh the capital cost, so it pays to get the most efficient system up front.

For more information contact AMS on 1300 579 177 or email


FULL STEAM AHEAD “A “A Focus Focus on on Sustainable Sustainable Hot Hot Water Water Infrastructure” Infrastructure”

Hospitals Hospitals or or (HSO’s) (HSO’s) have have much much to to consider consider around around what what infrastructure infrastructure to to include include as as part part of of aa new new build build or or equipment equipment replacement replacement that that will will remain remain relevant relevant in in the the future. future. Modern Modern advancing advancing technologies technologies such such as as the the digital digital monitoring monitoring networks networks are are advancing advancing so so quickly quickly that that the the reality reality of of what what aa hospitals hospitals diagnostics diagnostics control control system system will will look look like like in in the the future future will will likely likely be be vastly vastly different different to to what what is is in in place place today. today. Therefore Therefore building building in in flexibility flexibility to to aa design design is is key. key. Striving Striving to to achieve achieve aa “zero “zero energy energy building” building” will will be be aa target target for for all all HSO’s HSO’s at at some some point point and and certainly certainly when when considering considering aa healthcare healthcare facility facility in in general general has has double double the the energy energy intensity intensity and and uses uses around around six six times times more more water water than than aa commercial commercial office office building building11.. Energy Energy monitoring monitoring and and aa supporting supporting AI AI network network is is coming coming fast fast and and aims aims to to predict predict wasteful wasteful or or ininefficient efficient equipment equipment however however the the core core mechanics mechanics of of the the equipment equipment will will need need to to also also have have flexibility flexibility built built in in and and be be able able to to achieve achieve aa more more efficient efficient operation operation ifif controls controls advance. advance.

Fig Fig 1.0 1.0 –– WIOD WIOD emission emission sources sources

In In general, general, HSO’s HSO’s heating heating and and cooling cooling systems systems together together constitute constitute around around 44-47% 44-47% to to overall overall energy energy usage usage along along with with other other equipment equipment being being aa further further substantial energy energy intense intense process process 22-27% 22-27%11.. AA substantial within within HSO’s HSO’s contributing contributing largely largely to to this this is is hot hot water water generation. generation. The The requirements requirements of of heating heating water water for for both both domestic domestic (DHW) (DHW) and and low low temperature temperature (LTHW) (LTHW) remains remains aa substantial substantial thermal thermal load load on on aa hospital. hospital. Traditionally Traditionally aa storage storage calorifier calorifier was was commonly commonly used used however however the the risk risk for for legionella legionella growth growth from from stagnate stagnate cooling cooling water water conditions conditions was was prevalent prevalent so so storage storage of of water water is is becoming becoming aa thing thing of of the the past. past. Gas Gas fired fired hotwater hotwater systems systems are are now now days days aa common common installation installation which which can can remove remove the the need need for for large large storage storage volumes volumes however however looking looking further further ahead ahead may may potentially potentially contribute contribute to to aa longer longer term term sustainability sustainability and and infrastructure infrastructure challenge. challenge. It’s It’s recognised recognised that that the the distribution distribution of of electricity, electricity, gas gas usage usage for for heating heating and and cooling cooling accounts accounts for for around around 40% 40% of of the the three three emitting emitting scopes scopes within within aa This is is well well known known within within industry industry hospital hospital22.. This so so substantial substantial investment investment is is being being made made into into more more efficient efficient combustion combustion gas gas designs designs that that eventually eventually will will likely likely be be aa mix mix or or replaced replaced by by aa form form of of biogas, biogas, low low NOx NOx gas gas or or hydrogen. hydrogen. Additionally Additionally options options to to integrate integrate aa larger larger means means for for electrification electrification and and renewables renewables is is on-going. on-going. The The reality reality is is the the best best solutions solutions is is probably probably aa combination combination of of both, both, certainly certainly for for the the short short to to medium medium term term and and will will be be aa longer longer journey journey towards towards aa net net zero zero admitting admitting hospital. hospital. So So what what are are the the options options now now when when itit comes comes to to steam steam infrastructure infrastructure and and this this future future integration? integration? This This becomes becomes aa question question of of ““what what is is the the best best method method of of generating generating thermal thermal heat heat for for an an accumulation accumulation of of assets assets now now but but has has the the flexibility flexibility for for change change later”? later”? ItIt is is far far better better to to generate generate heat heat as as aa critical critical mass mass at at one one location location with with an an efficient efficient boiler boiler operation operation and and then then distribute distribute high high pressure pressure

Spirax Sarco Sarco Packaged Packaged Easiheat Easiheat System System Spirax

steam steam to to those those required required applications applications namely namely because: because: 1. 1. Once Once steam steam is is generated generated itit no no longer longer needs needs pumps pumps –– This This reduces reduces the the need need for for circulating circulating pumps pumps reducing reducing further further electricity electricity requirements requirements 2. 2. Once Once steam steam gives gives up up its its heat heat energy, energy, itit returns returns back back to to condensate condensate which which retains retains up up to to 10% 10% of of the the heat heat energy energy used used to to generate generate it. it. Condensate Condensate can can then then be be returned returned naturally naturally for for re-use re-use OR OR its its heat heat recaptured recaptured at at the the point point of of use use for for aa lower lower temperature temperature process process 3. 3. The The piping piping infrastructure infrastructure remains remains simple simple and and intact intact within within the the hospital hospital network network 4. 4. Modern Modern boiler boiler generating generating systems systems remain remain flexible flexible for for combustion combustion fuel fuel advancements advancements such such as as electricity electricity or or cleaner cleaner gasses gasses in in the the future. future. This This means means the the internal internal HSO HSO infrastructure infrastructure remains remains and and the the modernisation modernisation of of the the thermal thermal generation, generation, control control and and monitoring monitoring can can then then be be integrated integrated as as advancements advancements allow. allow. Couple Couple this this with with aa modern modern plate plate heat heat exchanger exchanger to to generate generate hot hot water water fitted fitted with with aa pumping pumping trap trap for for active active condensate condensate removal removal means means that that virtually virtually all all thermal thermal heat heat loss loss is is eliminated eliminated at at the the process process end. end. Elimination Elimination of of exchanger exchanger stall stall and and flooding flooding by by aa correctly correctly designed designed exchange exchange system system means means better better response response and and more more accurate accurate control control of of the the water water

output output temperature temperature which which is is critical critical ifif needing needing to to maintain maintain temperature temperature for for Legionella Legionella control control without without the the need need for for large large volumes volumes of of water water storage. storage. Further Further to to this, this, aa heat heat exchanger exchanger package package can can easily easily be be integrated integrated with with renewable renewable offset offset technology technology such such as as heat heat pumps pumps and and or or solar solar PV PV systems. systems. Waste Waste heat heat can can be be utilised utilised for for initial initial loading loading with with aa wellwelldesigned designed heat heat system system applying applying the the final final temperature temperature control control as as needed needed or or by-passing by-passing ifif not. not. This This theretherefore fore provides provides aa flexible, flexible, intergratable intergratable solution solution that that can can used used within within existing existing infrastructure infrastructure and and for for the the next next generation. generation. Surveys Surveys and and Audit: Audit: To To start, start, aa steam steam plant plant thermal thermal audit audit may may be be aa good good option. option. AA review review carried carried out out on on the the distribution distribution efficiency, efficiency, along along with with potential potential energy energy recovery recovery opportunities opportunities to to reduce reduce OR OR offset offset fuel fuel usage usage initially initially is is possible. possible. It’s It’s important important to to choose choose the the right right partner partner for for this, this, one one experienced experienced to to understand understand the the importance importance of of aa thermal thermal plant plant and and how how this this can can integrate integrate into into the the next next future future hospital. hospital. Contact Contact your your local local Spirax Spirax office office to to discuss discuss what what can can be be done done now now to to ensure ensure your your hospitals hospitals steam steam infrastructure infrastructure is is providing providing the the most most benefit benefit for for the the now now and and into into the the future. future. 11


Rajagopalan, Rajagopalan, PP && Elkadi, Elkadi, H H 2014, 2014, ‘Energy ‘Energy Performance Performance of of Medium-sized Medium-sized Healthcare Healthcare Buildings Buildings in in Victoria, Victoria, AustraliaAustralia- AA Case Case Study’, Study’, Journal vol. Journal of of Healthcare Healthcare Engineering, Engineering, vol. Healthcare Healthcare without without Harm Harm –– Climate Climate smart smart green green paper paper Sep2019 Sep2019

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