HealthcareFacilities JOURNAL OF CANADIAN HEALTHCARE ENGINEERING SOCIETY
Volume 37 Issue 2
GRADE 'A' SAFETY
Technology, planned processes and procedures key to protecting hospital patients, staff
Vibration Control New Wayfinding Standard High-Resistance Grounding
ASCO invites you to explore 3 to 18 cycle and 30 cycle power transfer switches 88%* of engineers agree — Selective coordination requires choice, not compromise Selective coordination demands the ability to choose. After all, since no two emergency and backup power systems are alike, why settle for a cookie-cutter selective coordination design? ASCO Power Transfer Switches: • • •
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CANADIAN HEALTHCARE FACILITIES Volume 37
Stephanie Philbin email@example.com
EDITOR/RÉDACTRICE Clare Tattersall firstname.lastname@example.org PRESIDENT/PRÉSIDENT
Kevin Brown email@example.com
SENIOR DESIGNER/ CONCEPTEUR GRAPHIQUE SENIOR
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PRODUCTION MANAGER/ Paula Miyake DIRECTEUR DE email@example.com PRODUCTION CIRCULATION MANAGER/ Aashish Sharma DIRECTEUR DE LA firstname.lastname@example.org DIFFUSION
MAINTENANCE & OPERATIONS
30 Medical Air Checkup Most common quality breach comes from desiccant dryers, report says
Editor’s Note President’s Message
10 Chapter Reports
32 On the Pulse The importance of good vibrations in healthcare environments
SCISS JOURNAL TRIMESTRIEL PUBLIE PAR SOUS LE PATRONAGE DE LA SOCIETE CANADIENNE D'INGENIERIE DES SERVICES DE SANTE.
CHES Canadian Healthcare Engineering Society
Société canadienne d'ingénierie des services de santé
PRESIDENT VICE-PRESIDENT PAST PRESIDENT
SAFETY & SECURITY 12 Talking Technology A look at its role in creating safer, smarter healthcare facilities
CANADIAN HEALTHCARE FACILITIES IS PUBLISHED BY UNDER THE PATRONAGE OF THE CANADIAN HEALTHCARE ENGINEERING SOCIETY.
REGULATORY UPDATE 36 Wayfinding Standard En Route La norme de signalisation fait son chemin
16 When Sparks Fly Surgical fire prevention, suppression and response 20 Code Red Alert Runnymede Healthcare Centre enhances fire safety with training, partnerships
SECRETARY EXECUTIVE DIRECTOR
Mitch Weimer Preston Kostura Peter Whiteman Craig. B Doerksen Sarah Thorn Donna Dennison
Newfoundland & Labrador: Colin Marsh Maritime: Helen Comeau Ontario: Roger Holliss Manitoba: Reynold J. Peters Saskatchewan: Alan F. Krieger Alberta: Tom Howard British Columbia: Steve McEwan FOUNDING MEMBERS
H. Callan, G.S. Corbeil, J. Cyr, S.T. Morawski CHES
4 Cataraqui St., Suite 310, Kingston, Ont. K7K 1Z7 Telephone: (613) 531-2661 Fax: (866) 303-0626 E-mail: email@example.com www.ches.org
22 Ready for Inspection HSC Winnipeg performs life safety test to prove intended level of building performance achieved
Canada Post Sales Product Agreement No. 40063056 ISSN # 1486-2530
24 Power Play High-resistance grounding provides safer, more reliable electrical distribution for healthcare facilities
Committed to service excellence
Structural Restoration Structural Engineering Building Science Parking Facility Design
Read Jones Christoffersen Ltd. Engineers 4 CANADIAN HEALTHCARE FACILITIES
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HARD AT WORK WHILE ATTENDING THE University of Toronto, I’d pop in on my mother at work as it was a short walk from the downtown campus. As a nurse manager at Toronto General Hospital and then executive director of operations for the cardiac program at the University Health Network, she was often attending to pressing matters upon my arrival, which meant I’d ‘hang’ in her office until she was free. Instead of wisely spending my time catching up on class readings, I frequently found myself reading a poster of standard emergency response codes and wondering what it must be like for hospital staff when alerted to a code red, for example. It wasn’t until I took over the editorial reins of Canadian Healthcare Facilities two years ago that I began to understand (and appreciate) all the work that goes on behind the scenes and well in advance of an emergency situation to ensure all runs smoothly in the event one occurs. A good example of this can be found in Code Red Alert, which details Runnymede Healthcare Centre’s effective fire management strategies. They must be exceptionally efficient in order to meet the needs of its patients, the majority of which have limited mobility. You can read all about the healthcare facility’s fire evacuation processes on page 20. Code Red Alert is just one of a handful of stories this issue that address hospital safety and security. For instance, When Sparks Fly addresses surgical fire prevention, suppression and response, and Ready for Inspection delves into the life safety test, which is a process of proving that the intended level of performance of a hospital building’s life safety systems has been achieved. But to begin, we delve into technologies that hospitals can use to better secure patients, staff and visitors in Talking Technology. While safety and security is the main theme this issue, we also look at maintenance and operations issues, including the on-site production of medical air and vibration control in healthcare environments. Rounding out this issue is our regulatory update. Andrea Holbeche of the CSA Group guides us through the new soon-to-be-released wayfinding standard, Z317.14. This article can be read in both English and French — a first for the journal (and it won’t be the last). À la prochaine!
Clare Tattersall firstname.lastname@example.org
Reproduction or adoption of articles appearing in Canadian Healthcare Facilities is authorized subject to acknowledgement of the source. Opinions expressed in articles are those of the authors and are not necessarily those of the Canadian Healthcare Engineering Society. For information or permission to quote, reprint or translate articles contained in this publication, please write or contact the editor. Canadian Healthcare Facilities Magazine Rate Extra Copies (members only) $25 per issue Canadian Healthcare Facilities (non members) $30 per issue Canadian Healthcare Facilities (non members) $80 for 4 issues A subscription to Canadian Healthcare Facilities is included in yearly CHES membership fees.
6 CANADIAN HEALTHCARE FACILITIES
La reproduction ou l’adaptation d’articles parus dans le Journal trimestriel de la Société canadienne d’ingénierie des services de santé est autorisée à la condition que la source soit indiquée. Les opinions exprimées dans les articles sont celles des auteurs, qui ne sont pas nécessairement celles de la Société canadienne d’ingénierie des services de santé. Pour information ou permission de citer, réimprimer ou traduire des articles contenus dans la présente publication, veuillez vous adresser à la rédactrice. Prix d’achat du Journal trimestriel Exemplaires additionnels (membres seulement) 25 $ par numéro Journal trimestriel (non-membres) 30 $ par numéro Journal trimestriel (non-membres) 80 $ pour quatre numéros L’abonnement au Journal trimestriel est inclus dans la cotisation annuelle de la SCISS.
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THE NEXT STEP AS I WRITE THIS LETTER for the Spring 2017 issue, the weather outside my window is much like it was when I penned my last president’s message — snowy. Southwestern B.C. (like many parts of the province) has experienced record-breaking snowfall this winter, and my colleagues elsewhere in Canada have enjoyed ribbing me about it during our past few teleconferences. I’ve been a CHES National board member for more than seven years now. During this time, I’ve seen a lot of leadership transitions, witnessed several people step up to help guide our great organization and learned much from many mentors. 2017 is an election year for CHES National, and some very qualified people have approached me about running for office. Nominations for vice-president, secretary and treasurer are now open. The closing date is April 30, with voting expected to take place in May. I’m excited about the future of CHES and the level of interest in helping to steer the ship. I urge every CHES member to vote when the time comes. The governance committee met every two weeks over the past year to review and update all our policies. It was a tough slog but well worth it. Other committees have been working equally hard behind the scenes. We have recently reviewed and recommitted to our partnership agreement with the Canadian College of Health Leaders (CCHL). We continue to work closely with the CSA Group to help guide and develop healthcare standards, as well as with other partner organizations such as the American Society for Healthcare Engineering (ASHE), International Federation of Hospital Engineering (IFHE) and Canadian Coalition for Green Health Care (CCGHC). I am excited to share that a dedicated team of CHES members is working toward finalizing a chapter in ‘La Belle Province.’ The seeds were planted many years ago by previous visionaries. All the hard work of the past, including the 2012 CHES National Conference in Montreal, is now starting to pay off with CHES members in Quebec making great strides in the formation of a new chapter. The Ontario chapter conference team continues to work diligently planning the 2017 CHES National Conference. The team is close to finalizing the education sessions. Niagara Falls will once again be a great host city. It’s a time of considerable activity for most other CHES chapters as they are deep into planning their spring conferences. 2017 promises to be a great year for education and innovation. I know all the chapters are eager to welcome friends and colleagues back for another round of conferences in their host cities. I’m looking forward to meeting many members from across the country. We’ve expanded our CHES webinar series this year. Visit the website for an up-to-date list and to read all the other great information we offer online. As you read this edition of Canadian Healthcare Facilities, keep in mind the journal relies on information and articles submitted by our membership. Please take some time to submit your editorial pitches to the MediaEdge team. Mitch Weimer President, CHES National
EARN CONTINUING EDUCATION CREDITS FROM CHES Members of the Canadian Healthcare Engineering Society can earn free continuing education units (CEU) by reading the Spring 2017 issue of Canadian Healthcare Facilities and passing a quiz based on articles in the issue. Once you’ve read the issue from cover to cover, simply go online to www.surveymonkey.com/r/B58DPQK to take the quiz. CHES members who pass the quiz will be able to claim one contact hour (0.1 CEU) on their CanHCC or CCHFM certificate renewals.
8 CANADIAN HEALTHCARE FACILITIES
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The chapter’s conference planning committee continues to make good progress on the 2017 CHES National Conference in Niagara Falls, Ont. The education portion is coming together nicely, though it’s proving difficult to finalize the program because of the great pool of submissions. As conference details and content advance, we are starting to prepare for the promotional stage, with the goal of releasing early conference correspondences for potential attendees in the near future. The public review period for CSA Z7396-12 — Medical Gas Pipeline Systems - Part 1: Pipelines for Medical Gases, Medical Vacuum, Medical Support Gases and Anesthetic Gas Scavenging Systems — closed Feb. 7. The next edition of the standard is still on track to be released in mid-2017. Thanks to all members who took the time to provide commentary. The Ontario chapter continues to support the provincial Ministry of Environment/Ontario Centres of Excellence (MOE/OCE) initiative aimed at reducing/eliminating greenhouse gases linked to the release of anesthetic gas into the atmosphere. The current structure of this MOE/OCE grant is such that approximately $10 million will be set aside for the design, installation and some operational costs of anesthetic gas scavenging systems within Ontario hospitals. A formal expression of interest, listing approximately 16 hospitals that are interested in being part of this grant application, was submitted in January. We are now waiting to hear whether it is accepted. If so, the initiative transitions to developing timelines and involves more formal financial commitments by all stakeholders.
The 2017 Maritime Chapter Spring Conference & Trade Show will be held at the Delta Hotel in Halifax, May 14-16. The planning committee is working hard to deliver another successful event. This year’s theme is, “Adjusting to the Changing Times in Healthcare.” We are very excited to have world-class humorist and motivational speaker, Bill Carr, deliver our keynote address. Carr is expected to leave listeners feeling empowered and ready to take on the challenges facing the healthcare industry. Other conference speakers include: Kate Butler (Service New Brunswick) who will discuss the energy management program and initiatives within the Horizon Health Network; Robert Barss (Nova Scotia Health Authority) and Halyard Health’s Daniel Constant and Andy Straisfeld, whose presentation will cover wrap recycling in operating rooms; Nova Scotia’s deputy fire marshal, Derwin R. Swinemar, who will discuss the inspection process for sprinkler and fire alarm systems; infection control practitioner Suzanne Rhodenizer Rose, whose presentation will look at waterborne pathogens and their impact on patient safety; Jeff Young (Paladin Security) who will cover the integration of a consolidated healthcare security service; Thomas Marks (Preston Phipps) who will discuss containment testing of fume hoods; and Stantec’s Jean Molina and Chris Russell, whose presentation will address commissioning of healthcare facilities The chapter is able to balance its books while offering several financial incentives to members in the way of student bursaries, contributions to Canadian Certified Healthcare Facility Manager (CCHFM) examination fees, webinars, the fall education day and other rebates. The present bank balance is approximately $46,000.
—Roger Holliss, Ontario chapter chair
—Helen Comeau, Maritime chapter chair
NEWFOUNDLAND & LABRADOR CHAPTER
Plans for the chapter’s spring conference are well underway. The 2017 Clarence White Conference & Trade Show will be held April 10-11, in Red Deer, Alta. The theme is, “Succession Planning Legacy: What Are You Leaving Behind?” Trade show registration is now available on the CHES website. Just a reminder to any potential vendors that booth spots are filling up quickly. For vendors and companies interested in sponsoring any part of the conference, information is available on the website. As in years past, we have a block of rooms reserved at the Sheraton Red Deer Hotel. The Alberta chapter’s annual general meeting will follow the conference on April 11. 2017 is an election year. The positions of vice-chair, secretary and treasurer are open for nominations. If you are interested in putting forth your name or you would like to nominate someone, please do. My involvement with CHES has been nothing but positive. The experiences and friendships I’ve made over the past years are something I would not want to have missed. The chapter is hosting the Canadian Healthcare Construction Course (CanHCC) in Leduc, Alta., Oct. 20-21. You can register for the course on the CHES website.
The Newfoundland & Labrador chapter is working with CHES National to fill vacant positions on the chapter executive. We are actively seeking a replacement for the vice-chair role and a new treasurer. The chapter is confident the vacancies will be filled prior to its Professional Development Day, May 7-8. More details on the event, to be held at the Ramada St. John’s on Kentmount Road, will be posted to the CHES website in due course. The wheels are in motion for the 2018 CHES National Conference. The opening reception has been selected and contract signed. The new St. John’s Convention Centre will host the main event. The chapter is currently seeking someone to be part of the executive team to liaise with CHES National on the conference. Over the course of the coming months, we will be looking for members to sit on the conference planning committee. The chapter is constantly seeking new membership. At present, there are 41 active members. The chapter recently recruited another member and is in the process of signing up two corporate members, both service providers to the healthcare industry. The chapter is sitting in a solid financial position with more than $45,000 in the bank.
—Tom Howard, Alberta chapter chair
—Colin Marsh, Newfoundland & Labrador chapter chair
10 CANADIAN HEALTHCARE FACILITIES
SASK ATCHEWAN CHAPTER
BRITISH COLUMBIA CHAPTER
The only constant is change. Earlier this year, the Saskatchewan government announced it is moving to a single health authority for the province, resulting in the amalgamation of all 12 health regions. The Athabasca Health Authority, in the far north, is to remain intact. The healthcare industry hasn’t seen a shakeup like this since 2002, when the province went from 32 regional health authorities to 12. While it’s unclear how the current health regions will be dismantled and the sole health authority will operate, we do know that the consolidation process is to be finalized by end of year. This means all existing boards and regional senior leadership teams will be replaced with one board and one leadership team. There will also be amalgamation of many support services. It’s definitely going to be an interesting year for healthcare in Saskatchewan as this monumental change is put in place. Planning for the 2017 chapter conference is well underway, with Candace Hahn serving as conference chair. It will be held Oct. 1-3, at the Delta Regina Hotel. This year’s conference theme will likely be building envelopes, with a special focus on remediation in occupied facilities. This is a hot topic given the industry’s aging facilities. The casino night will be back. I’m sure it will be a crowd-pleaser once again. A floor plan and registration forms will soon be posted to the Saskatchewan chapter section of the CHES National website. The chapter is in the process of setting up an account to accept payment by credit card for all transactions. This should make things much easier for everyone in the future. The 2019 CHES National Conference will be held in downtown Saskatoon, at TCU Place, Sept. 22-24. Saskatoon is beautiful at this time of year and we will try to keep up with the high standards set by other host cities. Detailed conference planning has not yet begun but will soon.
The B.C. chapter conference planning team has been busy working on this year’s spring conference. To be held at the Penticton Trade and Convention Centre May 28-30, the theme is, “Transforming Healthcare’s Aging Infrastructure: Facility and Workforce.” The call for education abstracts has closed and we have begun the difficult task of shortlisting the submissions. The education program is shaping up to be one of the best yet. The trade show sold-out in a record 11 days and only a few sponsorship opportunities are still available. I’m excited to announce the conference keynote address will be given by Chris Mazurkewich, president and CEO of the Interior Health Authority. Chris rejoined Interior Health after spending four years at Alberta Health Services, most recently as executive vice-president and COO. In this role, he worked in close partnership with the chief medical officer, overseeing the clinical operations of the Alberta health service delivery system, including approximately 100 hospitals, community and residential care programs, and support services. Prior to his move to Alberta Health Services, he was the COO, strategic and corporate services, for Interior Health from its inception in 2002 to 2009. Following the conference, the B.C chapter will host a two-day Canadian Healthcare Construction Course (CanHCC), which will be held at the Penticton Lakeside Resort. The education committee has been approved to fund the enrolment of chapter members in all 2017 CHES National webinars. The committee has already approved five education grants this year. —Steve McEwan, British Columbia chapter chair
—Alan F. Krieger, Saskatchewan chapter chair
MANITOBA CHAPTER The chapter is well on its way to completing planning for its 2017 Education Day. To be held April 27, at the Canad Inns Destination Centre Polo Park in Winnipeg, this year’s theme is, “Confronting Building Operations Challenges Head On.” Sessions will cover a range of topics, including documentation systems, computerized maintenance management systems, roofing, plumbing, and electrical and fire systems. The day will end with a lessons learned roundtable. With the recent announcement by Manitoba’s Progressive Conservative government that it is scrapping more than $1 billion in new healthcare infrastructure projects (approved by the previous NDP administration) to reel in provincial spending, our industry will be further challenged to ensure existing healthcare facilities continue to operate effectively to provide the best possible patient care. This makes the chapter’s upcoming education day even more relevant and one you won’t want to miss. —Reynold J. Peters, Manitoba chapter chair SPRING/PRINTEMPS 2017 11
TALKING TECHNOLOGY A look at its role in creating safer, smarter healthcare facilities By Mike Hugh
afety is a prime concern for healthcare organizations. However, budget constraints and code requirements can present obstacles when attempting to integrate different types of safety-oriented technology into a facility. To navigate these challenges, facility management teams often conduct a risk assessment to determine their buildingâ€™s biggest threats. Security consultants and integrators are generally involved in this process, providing comprehensive risk reviews that include suggested strategies to mitigate loss, enhance physical security and ensure regulatory compliance. Based on the outcomes, security professionals can assist operations managers in assessing prevailing 12 CANADIAN HEALTHCARE FACILITIES
threats and even recommend technologies that fit the specific needs of the facility. INNOVATIVE SOLUTIONS
Existing technologies that were originally designed with a single task in mind continue to evolve, resulting in expanded applications and usefulness. Nurse call systems, asset management solutions, access control systems, video surveillance, panic alarms and mass notification systems all offer new innovative features to provide safer, more secure environments. Staff activities in a healthcare facility can change depending on the challenges faced during a particular time period. Modern
nurse call systems allow staff to connect with patients or caregivers in real-time via mobile communication devices to help assess needs quickly and clearly. To further expedite patient care, these systems can help pinpoint the location of appropriately skilled response personnel. Asset management solutions supplement traditional security systems, providing both security and operational efficiencies. When connected to critical high-value mobile medical equipment, asset tracking devices can reduce the incidence of theft. On a more functional level, asset tracking can be used to locate a piece of equipment and expedite repairs to non-functional equipment by facil-
SAFETY & SECURITY
itating work order generation automatically. No need to fill out paperwork — just place the defective equipment in a defined ‘repair zone’ to allow the system to identify the asset type and then notify the appropriate repair team that it has work to do. Asset tracking systems can leverage similar location-specific information to trigger security team responses. This is accomplished by capturing real-time location, time/date and movement tracking information of the protected asset and then alerting security when illicit asset tampering or unexpected asset movement is detected. Due to the ease of implementation, an asset protection system can often be a cost-effective measure to help protect thousands of medical assets in challenging indoor/outdoor environments. At any time of day, a constant stream of people enters and exits a healthcare facility. Monitoring human traffic and limiting access to the facility when necessary aids management in safeguarding the building. An access control solution can help protect a single entry point or be used across a multibuilding campus. This technology allows
management to control and monitor people’s access to the facility for improved employee and visitor safety. In addition, these systems can be used to limit access to items vulnerable to theft, such as medical supplies and pharmaceuticals, and to recall the last known location of a person, especially during times of duress. A properly designed access control system can generate muster reports to easily confirm ‘who is in’ and ‘who is out,’ when required. Another staple in any building security strategy is a video surveillance system, which can be used to monitor high-traffic locations, assist in investigative procedures and resolve visitor or customer complaints. Modern video technology provides far greater capability than just capturing and recording video, though. Some systems are able to continuously monitor video feeds to help detect movement or even the presence of smoke or flames — all in an effort to affect prompt response by appropriate personnel. In facilities that face the threat of harm to staff, panic alarms can be particularly useful and cost-effective. Panic alarms not only give a sense of security to employees but they also
have the potential to be life-saving. Devices that monitor doors, windows and exits, wireless panic devices, and holdup buttons or duress systems offer the ability to relay notifications when there is a threat, allowing responders to be dispatched. Mass notification systems (MNS) allow response personnel to efficiently communicate with building occupants, alerting them of threats, advising of an appropriate plan of action or announcing a threat has cleared. A MNS has the flexibility to broadcast messages to a specific area in a facility, whether it’s a certain ward, an entire floor or a campus of buildings. A comprehensive MNS can leverage the reliability of the fire alarm system by utilizing the voice paging system, if present. In addition, a MNS can incorporate textbased technology, such as digital display screens and message boards located in the facility’s lobby, parking lot, elevators and patient waiting rooms. If integrated into the overall MNS, these connected devices can serve as vital assets to communicate building safety and emergency information, as well as non-emergency notices. SPRING/PRINTEMPS 2017 13
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MASS NOTIFICATION SYSTEMS ALLOW RESPONSE PERSONNEL TO EFFICIENTLY COMMUNICATE WITH BUILDING OCCUPANTS, ALERTING THEM OF THREATS, ADVISING OF AN APPROPRIATE PLAN OF ACTION OR ANNOUNCING A THREAT HAS CLEARED.
Developing your content strategy By Steven Chester Minutes after sending that first tweet, thousands of passive onlookers instantly turn into clients and advocates, with media buzz sending audiences flocking to your door. If only it worked that way. Without a content strategy behind those social media pushes, your message is very quickly on its way to being lost in the plethora of brand noise. Think about the story you want your organization to tell and how you can position it as a thought leader. What questions are being asked in your industry that your business can answer? Write down your ideas, and generate some compelling content. Think of visuals as well – if your business designs or installs anything, you’ve got it made. Otherwise, are you attending any events? Presenting to audiences? Taking part in charitable events? Winning awards? What about something lighthearted around the office where you’re showing some personality? Then, create a content calendar that illustrates what you’re going to say. Mix those content posts – at least two each week – with shares from other groups and influencers you want to impress. In that calendar, sandwich between those posts the one thing you’re really there for: marketing. People get it. They know you’re a business. As long as you’re not hammering away the marketing messages, you can get away with slipping a weekly marketing message in between that great content. Steven Chester is the Digital Media Director of MediaEdge Communications. With 15 years’ experience in cross-platform communications, Steven helps companies expand their reach through social media and other digital initiatives. To contact him directly, email email@example.com or call 416.512.8686 x224.
NEW PERFORMANCE ENHANCEMENTS
There are many other ‘everyday’ technologies that also continue to evolve. New phone system enhancements, applications for access control technology, video system features and fire alarm system technology can help create greater safety, security and efficiency in a healthcare facility. Depending on the type of care being provided in a facility, traditional phone systems used to request and control door entry may not provide the degree of safety and security required to match a given threat assessment. Newer phone technologies supplement the audio connection with an inherent video connection to assist security staff in positively identifying visitors. The use of mobile smartphone devices in physical security systems has become commonplace. Near-field technology allows the system to read a user’s credentials directly from their smartphone via Bluetooth transmission. If their credentials authorize access, the door unlocks. Although this specific technology is still in its early stages of deployment, it has been gaining more attention as cost becomes more attractive. As the IT world wrestles with issues surrounding personal information and data security, the importance of cyber security, especially in the healthcare industry, continues to escalate. To restrict access to this type of information, expect to soon see physical security solutions being utilized to help protect assets online. Card access technology may expand beyond its doorunlocking applications to include controlled access to databases, healthcare forms, patient history and prescriptions. In addition to speeding up existing manual authorization processes, new uses for preexisting technology may help healthcare
facilities reduce reliance on standard passwords. The days of security personnel sitting for hours on end staring at video monitors are coming to an end. With the move from old analog video systems to Internet Protocol (IP)-based digital systems, remote video monitoring is a growing trend. As single building hospitals continue to merge to become ‘health networks,’ with multiple facilities located far apart and staff providing care across a variety of diverse geographic locations, remote video feeds will continue to become a stronger player in the healthcare environment. When addressable detection technology was introduced to the fire alarm industry 25 years ago, it revolutionized fire responder protocol by pinpointing the origin of the fire condition. To provide faster response and greater patient safety, this technology is a must-have in healthcare facilities. More recently, addressable technology has been incorporated into fire alarm notification devices, providing the ability to individually control fire alarm speakers. This enables the system to broadcast specific messages to targeted areas of a building — providing the precision required to enhance response activity and reduce disruption to non-alarm areas. In addition, new self-test features virtually eliminate disturbances to staff and patients during annual testing procedures, as all audible/visible testing is accomplished within just a few seconds. This combined feature of addressable detection and notification provides a more reliable fire alarm solution and a safer environment for healthcare facilities. Mike Hugh is a field sales manager at Tyco Integrated Fire & Security.
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WHEN SPARKS FLY Surgical fire prevention, suppression and response By Darryl Culley
hen an event seems rare or implausible, itâ€™s often not given the attention it deserves, which can have deleterious effects. In the U.S., there are approximately 650 surgical fires a year, according to estimates by the Food and Drug Administration. While this is a very small number compared to the approximately 50 million surgical procedures 16 CANADIAN HEALTHCARE FACILITIES
performed annually stateside, surgical fires can have devastating consequences for patients, staff and the healthcare facility as a whole. They can cause life altering injuries and even death. Surgical fires can also seriously damage the reputation of, and confidence in, the healthcare organization as itâ€™s often subject to sensationalism by mainstream and social media. Given this
potential for disaster, all staff must be aware of the risk of fire, take appropriate precautions to mitigate the risk and be prepared to deal with a fire, should one occur. IGNITION POINT
Surgical fires are fires that occur around, on or in a patient who is undergoing a procedure in an operating room.
SAFETY & SECURITY
If these three elements are combined at the right quantities, a fire will ignite. Most surgical fires occur in oxygen-rich environments. Fuel sources will burn more quickly and intensely, escalating the potential damage done by a fire. An ignition source combined with supplemental oxygen creates a significant risk of fire even in material that is normally fire-resistant like surgical drapes. Oxygen accumulates around the oxygen source, especially with an open system like a nasal cannula or oxygen mask. A study by the University of Michigan Health System demonstrated that it can take up to four minutes after oxygen is turned off for levels to dissipate to below 30 per cent near the source, and up to 15 minutes in a tented environment. Further, oxygen can become trapped under drapes or other fabric, extending the time to dissipate. Suction, room ventilation and smoke evacuators can assist in removing higher concentrations more rapidly. Some facilities post clear warnings on oxygen flow valves in the operating room as a constant reminder to staff that the open delivery of oxygen greatly increases the risk of a surgical fire.
Three elements are necessary for a fire: an ignition or heat source, combustible fuel and an oxidizing agent. These interdependent ingredients, all of which are present in a surgical suite, are part of the fire triangle â€” a three-sided model that illustrates whatâ€™s needed to start and sustain a fire. Ignition (heat) sources include electrosurgical and electrocautery equipment, lasers, defibrillators, fibre optic light sources, and even sparks from high-speed surgical drills and saws. Fuel sources may include alcohol-based skin preparation agents, surgical drapes, sponges, dressings, airway tubing and even KEEPER OF THE FLAME the patient. Since the causes of surgical fires are wellOxidizing agents include room air, nitrous known, they are preventable. The first step is oxide and, most commonly, oxygen. to create awareness among all persons
working in the operating room. Fire safety education should include staff orientation on the fire/smoke detection, alarm and suppression/containment systems specific to the operating suites and unit. This includes sprinklers, the types of fire extinguishers available and their appropriate use, medical gas shut-off valves, fire zones and evacuation instructions. Prior to surgery, staff should confirm the following items are immediately available in the operating room: sterile saline; a carbon dioxide or clean agent fire extinguisher; replacement tracheal tubes, guides, face masks and other medical equipment; and replacement drapes and sponges. As well, before using any potential ignition source on or near the patient, it is important to inspect any application of an alcohol-based preparation agent to ensure it has dried and not pooled. Alcohol-based sanitizers are a high-risk fuel source. They have a flash point below 38 C (100 F), which means they give off sufficient vapours to form an ignitable mixture with air near the surface of the liquid. Three to four minutes is normally required to ensure the prep agent has dried; however, more time is required if it has pooled in the skin folds, under the patient or it is in the patientâ€™s hair. Many facilities have incorporated a fire risk assessment into their pre-procedural SPRING/PRINTEMPS 2017 17
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checklist. To avoid disrupting workflow, the anesthesiologist often conducts the assessment using the fire triangle model. The risk of fire is very low if the model is incomplete. No further action or discussion is required. A moderate risk of fire exists if the model is complete. This should be brought to the attention of the surgical team and the location of fire suppressing tools (saline bottles and fire extinguishers) pointed out. If the model is complete and surgery is above the diaphragm with the presence of supplemental unconfined or poorly confined oxidants, the risk of fire is high. Discussion among the surgical team is paramount to determine ways to manage, minimize or eliminate the risk of fire. During surgery, potential ignition sources such as hot light cords and electrocautery equipment are not to be placed on drapes or dressings and must be stored properly after use (for example, in a storage holster). Lasers should always be in standby mode unless the surgeon is actively using it. When using an open oxygen source, the area should be wellventilated. Suction or smoke ejectors can assist in dissipating the oxygen accumulation. Staff must remain vigilant throughout surgery to ensure compliance with established procedures. SOUND THE ALARM
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In the event of a fire in the operating room, the REACT emergency process should be utilized, where possible. This five-step approach involves removing persons in immediate danger; ensuring doors are closed to reduce the spread of smoke and fire; activating the fire alarm; calling the emergency number; and trying to extinguish the fire, if safe to do so, or assisting with evacuation. These steps can be taken simultaneously when there is adequate staff. If a fire occurs on a patient, immediately turn off and safely store the ignition source. Next, stop oxygen to an open source (nasal cannula or oxygen mask) until the fire is out. Any burning material should be extinguished with saline, if possible, and then removed from the patient. The patient should then be fully assessed, including under the patient, to ensure the fire is out, and then medical treatment provided as necessary. Should a fire occur in a patientâ€™s airway, stop the gas flow. Disconnecting the breathing circuit is the quickest way to do this. Next, remove the tube from the patient while maintaining the airway. Extinguish the fire and remove any segments of burned tube that remain in the airway. Staff, other than the anesthesiologist, should extinguish the removed tube and other smoldering materials. Reestablish the airway and resume ventilating with air until certain nothing is left burning in the airway. Provide oxygen when safe to do so. Lessons are frequently learned from both accidents and near misses. It is important to document when either occurs so that they can be investigated and prevention strategies examined and adjusted accordingly, if required. Darryl Culley is president of Emergency Management & Training Inc., an international consulting firm. Darryl and his team assist healthcare facilities with risk assessments, emergency plans and procedures, training and exercises. He can be reached at email@example.com.
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CODE RED ALERT Runnymede Healthcare Centre enhances fire safety with training, partnerships By Michael Oreskovich
t Runnymede Healthcare Centre, implementing effective fire management strategies supports the hospital’s top priority: patient safety. Its most recent fire safety inspection, conducted in cooperation with Toronto Fire Services, revealed many leading practices and solidified the hospital’s reputation as a centre of excellence. Runnymede’s fire evacuation processes must be exceptionally efficient in order to meet the needs of its patients, as the majority have limited mobility due to injury or medically complex conditions. The emergency policies and procedures at Runnymede address this identified need by outlining staff members’ responsibilities and specific methods for safely transferring patients to designated areas that are out of harm’s way. The policies and procedures adopt the standardized language recommended by the Ontario Hospital Association, and include a code red for fire and code green for evacuation. Also advancing patient safety at Runnymede is a dedicated staff member who performs regular safety inspections at the hospital. The health and safety specialist collaborates closely with Runnymede’s management team to provide insights and recommendations related to safety, including fire and emergency preparedness. Excellent policies and leadership are only half of the equation. Ensuring all hospital staff are well-trained and have the necessary supports to respond to a code red and code 20 CANADIAN HEALTHCARE FACILITIES
green is also crucial. Runnymede trains all new staff on emergency policies and procedures as part of the hospital’s orientation program. After orientation, online education tools like videos, policy documents and other resources are available for staff to review on an as-need basis. To further embed awareness of fire safety policies and procedures in staff, Runnymede runs monthly fire drills and annual mock evacuations, with staff members acting as ‘stand-ins’ for patients. The evacuation exercises, conducted in partnership with Toronto Fire Services, help to ensure Runnymede’s code red and code green policies and procedures can be effectively executed not only on paper but in practice as well. When the latest annual mock code red and code green exercise ran in November 2016, it demonstrated a true test of the strength of Runnymede’s emergency preparedness by simulating a worst-case scenario: a fire starting in a ward room of four patients with the number of on-site staff at its minimum. Runnymede staff cleared patients from the simulated fire zones in under 20 minutes — significantly faster than the 85-minute time limit allotted by the fire inspector. A debrief with Toronto Fire Services highlighted that in the event of an actual emergency, Runnymede’s extensive sprinkler coverage would help minimize the speed of a fire’s spread and buy staff extra time to remove patients from affected areas.
The debrief also recognized Runnymede’s implementation of new technology that enhances connections between the hospital’s heat detectors and communications systems. When a heat detector is triggered, the hospital’s receptionist is notified of the precise location of the alarm. At the time of the fire department’s arrival, reception personnel are able to convey, hospital-wide, exactly where the alarm was generated. This information is passed on to first responders upon arrival as well, so they don’t lose time searching for the source of the fire. Triggered heat detectors also cause electronic signage around the hospital to display the location of the alarm. This ensures all staff instantly have information about where the fire can be found. Runnymede shares insights like these with its peers through a collaborative team of member hospitals from across the Greater Toronto Area. Called the Toronto hospital emergency preparedness quality improvement committee, or THEPQIC, the team’s purpose is to enhance best practices in emergency preparedness for hospitals in the region. Through its relationships with peer hospitals, Runnymede is able to exchange strategies about managing crisis situations, like fires. By leveraging partnerships through THEPQIC, the hospital is able to share its expertise while gathering new perspectives that strengthen its commitment to quality improvement. Michael Oreskovich is a communications specialist with Runnymede Healthcare Centre.
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“HealthAchieve has truly outdone itself this year. No other professional event has ever struck such a perfect balance of offering events that touch us both professionally AND personally as HealthAchieve has. Truly outstanding. Thank you.” Simone Tronciu 2016 Delegate
“HealthAchieve is a fantastic conference to attend as it gives you the opportunity to learn what is new to health care. This year was my second time attending and I’ve already marked my calendar for next year.” Angela Mirabelli 2016 Delegate
“Certainly for current and future leaders in health care in Ontario – this is THE forum that enables participants to think at a higher level and see the big picture, in terms of both the achievements and needs of our hospitals, agencies, community partners, patients, in short – our province.” Heidi Letham 2016 Delegate
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SAFETY & SECURITY
READY FOR INSPECTION HSC Winnipeg performs life safety test to prove intended level of building performance achieved By Christie Nairn
new building at a healthcare facility must pass rigorous inspections before it can open to staff, patients and the public. The life safety test (LST) assures the new addition and its systems are operating correctly. Smoke control systems, fire alarms, elevators, sprinklers, emergency generators and emergency lighting are all covered in the LST process, which is typically conducted by facility management staff prior to substantial completion. Once the building passes the test, occupancy permits and substantial completion follow. PROJECT TEAMWORK
Health Sciences Centre (HSC) Winnipeg has embraced an integrated commissioning process instead of the old ‘post-substantial performance inspection and test method.’ The traditional method often delayed occupancy and stretched out the resolution of issues encountered in construction. HSC facility management staff are stakeholders at the design development stage of a building and conduct installation quality and equipment access inspections at the start of the construction process. Facility management staff are also involved in the total building systems commissioning process. As a result, they are in an ideal position to conduct the LST for the City of Winnipeg. To facilitate the process, a project lead is assigned to ensure all life safety systems are functioning and ready to be put to an integrated ‘real-life’ test at the time of inspection. This approach is quite labour intensive; however, HSC’s relationship 22 CANADIAN HEALTHCARE FACILITIES
with the City of Winnipeg has made the process relatively straightforward for all involved. The first major project to undergo this integrated LST process was the HSC Ann Thomas building (formerly the critical services redevelopment project) in 2007. The facility management team learned the city’s requirements and 10 years later the same team continues to undertake the integrated commissioning process, which has proven effective for HSC’s newest addition, the Diagnostic Centre of Excellence. In a few months, the new Women’s Hospital at HSC will undergo the LST. DIAGNOSTIC CENTRE OF EXCELLENCE
The seven-storey, 91,000-square-foot Diagnostic Centre of Excellence opened in December 2016. Connected to the new Women’s Hospital via overhead walkway and directly linked to the Children’s Hospital and the Ann Thomas building, the Diagnostic Centre of Excellence consolidates a variety of sophisticated medical equipment into one location on the HSC campus. As well as housing Manitoba’s first dedicated pediatric MRI machine, a new CT scanner and several outpatient services, it is the first healthcare facility in the province to have a rooftop heliport with direct elevator access to the emergency departments and operating rooms. These factors combined made for a very complex LST process. They necessitated the separation of buildings with special fire precautions (for example, doors, pressurization and fan sequences) and the creation of eleva-
tor procedures during emergencies like a code blue and patient arrival via air ambulance. All alarm sequences needed to be coordinated and tested to ensure the appropriate response occurred in every scenario. A LST procedure form was used to test each system, the designed response, the actual response when the system was tested and the team member assigned to monitoring the specific test. NEW WOMEN’S HOSPITAL
Scheduled to open in June, the state-of-theart 170-bed Women’s Hospital will provide a warm and welcoming space for mothers, babies and their families through childbirth, as well as offer surgical and consultation services for women of all ages. At 410,000 square feet, the facility is three times larger than the current facility and features private in-patient rooms with ensuite bathrooms. Conducting the LST in the larger Women’s Hospital may seem more difficult than the smaller Diagnostic Centre of Excellence building but, in fact, it will be easier. There are specific protocols associated with operating rooms and a tunnel connection in this building; however, the experience of the HSC facility management team as well as detailed documentation of the LST process in earlier construction projects will make this test process more efficient and easier to execute. Christie Nairn is the environmental sustainability coordinator, and communications and public relations assistant, facilities management division, at Health Sciences Centre Winnipeg.
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Ontario region. Labour Canada has fully “acknowledged” scopefully of Labour Canadathehas work provided inthethescope semi“acknowledged” of annual inspection program. work provided in the semiIn addition, the program. written annual inspection documentation contributes In addition, the written greatly to thecontributes hospital documentation accreditation greatly to programs. the hospital accreditation programs. Further we are always pooling the knowledge resources Further we are always poolingof Infection Control and Engineering the knowledge resources of Groups like CHES, the ventilation Infection Control and Engineering inspection is in a constant Groups likeprogram CHES, the ventilation evolution meet future needs for inspectiontoprogram is healthcare in a constant patients evolutionand to staff. meet future healthcare needs for patients and staff.
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SAFETY & SECURITY
POWER PLAY High-resistance grounding provides safer, more reliable electrical distribution for healthcare facilities By Ajit Bapat, Nick Carter & Sergio Panetta
igh-resistance grounding is relatively simple and easy to apply in radial distribution systems. It has been used in the healthcare industry for many years, considered to be best practice for hospitals. The concept is well-known, recognized by the Canadian Electrical Code and driven by four basic factors: power is not interrupted in the event of a single ground fault; negligible damage at the point of fault, resulting in lower repair costs and faster return of equipment to service; negligible arc flash hazard in the event of a single ground fault; and negligible risk of a single ground fault escalating into a damaging line to line or three phase fault. 24 CANADIAN HEALTHCARE FACILITIES
It is best practice to have the low voltage (600V) and high voltage (4,160V) systems equipped with high-resistance grounding. This has often taken the form of a neutral grounding resistor applied between transformer neutral and ground. An alarm is raised on the occurrence of a ground fault in the distribution as required by the installation codes. In modern relays, the zero-sequence sensor signal causes a pick up, then the simultaneous presence of unbalanced voltage to ground is verified before an alarm is indicated. To avoid the possibility of nuisance alarms caused by inrush currents and nonlinear loads, the zero-sequence current sensor output is filtered and only the
fundamental signal is extracted. These measures have been effective in avoiding nuisance alarms and trips in sensitive ground fault relays. VANTAGE POINT
The use of high-resistance grounding offers many benefits. Arc flash and blast hazard for a line to ground fault is prevented. For systems up to 4,160V, where the resistor let-through current is 10A (amperage) or less, the arc blast is unlikely. Such systems can continue to operate with one ground fault. The fault does not escalate so the distribution system is safer. Accidents causing line to ground
Canadian Healthcare Engineering Society
Société canadienne d'ingénierie des services de santé
CALL FOR NOMINATIONS CHES BOARD OF DIRECTORS CHES members are invited to submit nominations for the following positions: Vice President Secretary Treasurer A member in the Regular Membership Classification is eligible for office.
Nominations can be received either by: • Members identifying and nominating eligible qualified candidates • Members who are interested in standing may submit their own name as a candidate. Basic function and responsibilities of a board member: • Set policy and direction of the Society • Serve as a spokesperson for the Society • Represent the interests and discipline of the Society • Serve as technical resource for Society education programs, publications and advocacy • Promote membership and Chapter affiliation • Participate in Society committees
In fulfilling these duties, the Board member: • Serves a two-year term, after which he/she is eligible for re-election • Attends Board Meetings by conference call and at annual conference (financial assistance provided for conference travel expenses) • Carries out projects as assigned by the President • Prepares written report of activities for each Board meeting
Candidates must be active in and a participating member of the Society for a minimum of two years. Candidate should be in compliance with all provisions of the By-Laws, having the ability to carry out the fundamental duties of the assignments of the Board. Candidates should obtain the approval of their superior for permission to serve on the Board.
Nominations must be received by April 30, 2017 and should be sent by fax or email to: CHES National Office Fax: 866-303-0626 firstname.lastname@example.org Sincerely.
Peter Whiteman Chairman, Nomination & Elections Committee Past President, CHES
SAFETY & SECURITY
THE PRIMARY BENEFIT OF USING HIGH-RESISTANCE GROUNDING IS THE FAULTED FEEDER DOES NOT NEED TO BE ISOLATED ON THE OCCURRENCE OF A PHASE TO GROUND FAULT. faults will not produce a hazardous blast or arc flash. Fault damage at the point of fault is very low and can be easily repaired. It minimizes maintenance repair costs. Motor and generator laminations will not get burnt and winding repair costs will be small. For systems up to 4,160V, where the resistor let-through current is 10A or less, the line to ground fault can be kept on the system continuously. No fault isolation needs to occur per Canadian Electrical Code 10-1100 through 1108. Damaging voltage transients that can occur on ungrounded systems are avoided since the system is grounded. On the other hand, four application concerns arise when resistance grounding is applied to distribution. All cables need to have a line to ground voltage rating of line to line voltage for the maximum duration of the line to ground fault. This is not an issue at low voltage, such as 600V. The standard cables have adequate ratings. Lightning arrestors and surge suppression devices that are connected line to ground also need to be adequately rated. Voltage to ground impressed on capacitors will also increase to line to line value. The circuit breakers and contactors employed in resistance grounded systems must be able to break line to line voltage across one pole of the device. For example, a three pole 600V breaker must be able to open fault current and withstand 600V across one pole, which most 600V breakers are capable of. However, some breakers only have a 347/600V rating. This means they are able to interrupt only 347V across one pole, making them unsuitable. The same would apply to contactors.
fer switches. The transfer switches get power from both the normal power system and the generator power system. In this scenario, a ground fault occurs in the switchboard downstream of a transfer switch. This fault could have a number of causes. In the solidly grounded system, the ground fault results in a large current flow creating significant damage within the switchboard, vapourizing components and coating the inside of the switchboard with semiconductive residue. The high fault current subjects the upstream transformer to high stresses and causes the upstream breaker to trip. All power to the critical loads is lost. The loss of power is sensed at the transfer switch, which starts the emergency generator and transfers the critical load over to the generator. Since the switchboard is contaminated with residue from the previous fault, another fault occurs and this further damages the switchboard. It also stresses the generator with a high magnitude fault current and causes the generator breaker for the transfer switch to trip. The critical loads, including the emergency department and intensive care
unit, are shutdown and remain so until their feeders can be cut away from the failed switchboard, spliced and extended to another source of power â€” a process that takes many hours and leaves the critical loads on normal power only. The hospital is forced into emergency mode and must transfer critical patients to other areas of the hospital, which were not designed for their care, and in some cases to another hospital. Full restoration of the system requires replacement of the switchboard. This takes many months as switchgear is built to order. In the resistance grounded system, the ground fault results in an alarm. There are no power interruptions, the main transformer is not subjected to the stresses of a fault, and the generator does not start and is not exposed to a fault current. Most importantly, the damage to the switchboard is minimal requiring the replacement of a single insulator, which is scheduled for a time when the hospital can accommodate the short shutdown necessary to perform the work.
26 CANADIAN HEALTHCARE FACILITIES
In a typical hospital, there will be a 600V normal power system and a 600V generator power system. The most critical loads are fed from the emergency power distribution, which is downstream of one or more trans-
In this scenario, a ground fault occurs in the switchboard downstream of a transfer switch.
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The primary benefit of using high-resistance grounding is the faulted feeder does not need to be isolated on the occurrence of a phase to ground fault. While the faulted system continues to operate, there is a possibility that another phase to ground fault may occur on a different phase in some other weak spot in the distribution system. With the presence of a second fault, the fault current is no longer limited by the resistor and will be a higher magnitude fault. The zero-sequence sensors continue to monitor the fault current and if a significantly higher current than that limited by the resistor is detected, then the system recognizes that a line to ground to line fault exists and identifies the two feeders involved. Only one feeder breaker needs to be tripped to revert the rest of the system to a single fault condition. A level of priority can be assigned based on the relative importance of the feeders. The one feeder with lower priority is tripped. Fast operation provides protection and minimizes fault damage. Such systems have been in use for a long time and this first fault alarm and second fault trip is best applied to monitor specific loads.
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A major functional enhancement occurs when detection and alarm of ground faults is supplemented with monitoring of all the feeders to indicate which feeder is faulted and administer assistance for quickly locating the fault. To provide assistance in locating a fault in high-resistance grounded systems, the fault current is modulated by oscillating it between values such as 5A-10A, typically at one cycle per second. This is accomplished by changing the resistor value using a contactor, which has been called ‘pulsing’ in the industry. The pulsing is manually started. A flexible zero-sequence sensor or a clamp on the current transformer (CT) encircling all phase conductors is used to provide an oscillating signal to a handheld multimeter. Readings are taken on the faulted feeder moving away from the switchboard. The signal will disappear once the fault location is passed. Often, two or three measurements are sufficient to point to the fault location. Readings are taken from the outside of the grounded raceways, conduits or busways, while the system is energized and running. This technique has been in use for many years. It is quite effective for voltages up to 4,160V.
IMPROVING THE SYSTEM
On low voltage systems and systems up to 5 kilovolt (kV), highresistance grounding provides a safer and more reliable distribution system. The arc flash hazard in the event of a line to ground fault can be eliminated and power continuity maintained. The performance of the distribution system can be enhanced by using high reliability neutral grounding resistors with low temperature coefficients, monitoring the neutral ground resistor continuously, using a pulsing system to find ground faults and using coordinated selective second fault tripping. In many applications, it is more beneficial to apply the neutral grounding resistor at the main bus. In such a case, the incoming supply feeders can be monitored for ground fault very costeffectively by applying multi-circuit relays. Ajit Bapat, P.Eng., is owner of Power Solutions, Nick Carter, P.Eng., is a principal at H.H. Angus & Assoicates Ltd., and Sergio Panetta, P.Eng., is vicepresident of engineering at I-Gard Corp.
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MAINTENANCE & OPERATIONS
MEDICAL AIR CHECKUP Most common quality breach comes from desiccant dryers, report says By Paul Edwards
t has been three years since Air Liquide Healthcare launched Canada’s first parametric batch release quality control system. Designed for hospitals that produce medical air on-site, the system helps validate the gas is consistent in quality and purity to that made in the company’s medical cylinder filling plants. Air Liquide is currently working with hospitals in British Columbia, Alberta, Ontario and Quebec to continuously sample and analyze the chemical elements specified in medical air USP (United States Pharmacopeia), a drug regulated by Health Canada. Each of Air Liquide’s quality control modules is collecting eight data points per minute. The company now has more than 40 million records in its data lake.
Data collected has found all hospitals produce medical air of USP quality most of the time; 30 CANADIAN HEALTHCARE FACILITIES
however, none of them produce USP compliant product all the time. USP quality is defined as samples returning measurements of oxygen between 19.5 per cent and 23.5 per cent volume/ volume (v/v), carbon monoxide less than 10 parts per million (ppm), carbon dioxide less than 500 ppm, nitrogen dioxide and nitric oxide combined level less than 2.5 ppm, sulphur dioxide less than five ppm, and dew point less than -5 C at 50 pounds per square inch (psi). When Air Liquide first started measuring the full spectrum of USP chemical elements in 2015, it anticipated that random variations in outdoor air quality could impact the quality of medical air entering the building pipeline. The company’s assumption was correct. It has recorded carbon dioxide and nitrogen dioxide breaches caused by medevac helicopter and delivery truck exhaust. Air Liquide has also seen cases of high oxygen content (greater than 23.5 per cent v/v) and low oxygen
content (less than 19.5 per cent v/v). On more than one occasion, its hygrometer disagreed with the hospital’s pipeline dew point monitor. And at one site, it recorded high levels of carbon monoxide attributed to the hospital’s diesel power generator. Most often, the logged quality breaches have been rather short in duration, lasting no more than four to six minutes. Some, however, have lasted days. They occur without warning, day and night, and conditions may change with the wind. The element that most commonly exceeds its USP limit is carbon dioxide. In determining the root cause, Air Liquide first looked to medevac helicopter records. However, through a deep data dive, it found a strong correlation between carbon dioxide and humidity, which pointed the company toward the hospitals’ medical air dryer systems. Every site uses desiccant dryers, charged with activated alumina, molecular sieve or a combination of the two. With ample research
confirming both desiccant materials have an affinity for carbon dioxide as well as humidity, it became apparent the dryers are catching the gas and then releasing it as moisture loads. So, although Air Liquide’s 2015 predictions proved correct, it turns out the most common USP quality breach is not environmental; rather, it’s created by the industry standard method of drying the compressed air. BEST PRACTICES
Based on these findings, it’s recommended healthcare facilities that make medical air on-site employ good manufacturing practices (GMP). The hallmark of GMP is robust quality control to prove the product meets the desired specification. Taking a GMP approach starts with knowing the specification required by clinicians at the hospital. CSA standard Z7396.1-12 — Medical Gas Pipeline Systems Part 1: Pipelines for Medical Gases, Medical Vacuum, Medical Support Gases and
Anesthetic Gas Scavenging Systems — prescribes USP or such other formula as adopted within the facility’s formulary. If clinicians want a specification other than USP, document this in the facility’s standard operating procedures for medical air production. With production, use a quality assurance system design and rigorous quality control to prove the product. CSA Z7396.1-12 provides quality assurance design guidance. Continuous sampling, analysis and automatic means to prevent off-specification product from entering the distribution pipeline is recommended. Ensure maintenance standard operating procedures include regular validation and calibration of the hygrometer and carbon monoxide monitor, if present. Many hygrometers and all chemical-based carbon monoxide monitors fail ‘happy,’ meaning the sensor will always return a zero ppm reading when its sensing element fails. Don’t be fooled by a failed monitor.
Review the facility’s code grey protocol to ensure it includes medical air production. If the outdoor air quality drives the hospital to put HVAC systems on 95 to 100 per cent recirculation, it likely should not be drawn into the pipeline serving the facility’s most fragile respiratory patients. Employ desiccant dryers with controls to manage both humidity and carbon dioxide. Design and manage the hospital’s high-pressure cylinder manifold as a reserve supply for both short-term quality backup and longer ter m compressor system downtime. The best design splits the two, making cylinder replacement manageable. Paul Edwards is vice-president, medical gas, at VitalAire Canada Inc., which operates nationally under the Air Liquide Healthcare, GH Medical and Campbell Medical brands. Air Liquide is the developer of aerALin, a trademarked quality control service. SPRING/PRINTEMPS 2017 31
MAINTENANCE & OPERATIONS
ON THE PULSE The importance of good vibrations in healthcare environments By Brian Howe
here is greater awareness and scrutiny today of noise and its effects on healing, well-being and productivity in and around healthcare settings. Less often acknowledged but no less important are the repercussions of vibration in this same environment, with one important distinction — vibration does not directly affect patients and staff; rather, it impacts the sensitive diagnostic and surgical equipment used in healthcare facilities. Even the slightest amount of vibration on equipment such as MRI machines, CT scanners and laboratory or operating microscopes can skew diagnostic or lab results, as well as put patients potentially at risk during delicate procedures when steady hands and stable surgical tools are paramount for successful outcomes. This is further compounded by the fact that the thresholds of vibration that impact these types of sensitive healthcare technologies are often imperceptible to humans. VIBRATION CONTROL
Traditionally, operating rooms and diagnostic imaging systems have been situated on grade to alleviate vibration’s 32 CANADIAN HEALTHCARE FACILITIES
impact on sensitive equipment. The innate stiffness and mass of the soil directly below the grade base tends to act as a natural form of vibration mitigation. The inherent damping properties of soil can effectively reduce the amplitude of resonant vibration by converting a portion of the energy into low-grade heat. Several present-day factors, however, have driven healthcare architects, structural engineers and planners to move beyond this grade-level vibration prevention measure. One new reality is it is no longer a given or a viable option to keep diagnostic imaging systems and operating rooms on grade. Modern space planning practices lean toward putting patient intake, lounges, food courts, loading docks, mechanical rooms and the like at-grade. Further, high density urban planning, among other concerns, is forcing hospitals to build or expand vertically rather than horizontally, creating multi-storey highrises instead of traditional lowrise campuses. Then there are the recent advances in building systems and structural engineering that allow diagnostic equipment and operating rooms to be relocated and their static
loads supported by elevated slabs on higher floors. While innovative, these lighter weight and increasingly flexible structural floor systems are more prone to vibration interference from sources throughout the building structure. What’s more, diagnostic and operating room imaging and surgical support technologies have become increasingly sophisticated and sensitive relative to earlier generations that operated at-grade, making mitigation efforts more challenging today. SPACE PLANNING AND DESIGN
Good space planning practices with consideration to vibration sources, as well as early and meaningful collaboration and consultation between vibration specialists and project architects, structural engineers and planners before, during and after construction, can go a long way to minimizing the impact of vibration on sensitive equipment and, by extension, patient and staff health and well-being. Key to a successful impact assessment is the review of architectural drawings early on in the design process to identify potential vibration sources within the building structure. This involves looking for operating,
diagnostic or lab areas that may contain vibration-sensitive equipment, as well as structural areas that may be particularly prone to footfall or other event-induced vibration. Based on this review, a catalogue of vibration-sensitive uses and internal processes or equipment that will generate vibration can be developed, and equipment with the greatest potential for vibration sensitivity identified. A preliminary design guideline for vibration control can then be prepared for use by the design team during space planning. The guideline will provide information relevant to developing specifications for vibration isolation of mechanical equipment, including appropriate isolator static deflections, and general guidance for avoiding bridging of isolation systems. The guideline can also provide general direction to avoid potential issues caused by problem juxtapositions, such as high-traffic corridors on elevated floors near or in the same structural bay as sensitive spaces. Another example of a questionable juxtaposition might be a ceiling-mounted surgical microscope that is hanging from a lightweight structural floor. Vibrations of the
floor above (caused by human or mechanical activity) may impact the surgical microscope in the operating room below. In this scenario, an effective space planning solution would involve moving the operating room to a less impacted, more optimal bay location. Outdoor vibration sources are another space planning consideration and would include, for example, looking at the location of major drive lanes in relation to MRI machines. Something as seemingly innocuous as a speed bump or other discontinuities on a drive lane could lead to performance consequences on a nearby MRI machine. In this scenario, a simple planning consideration would be to restrict truck use in the drive lane or limit speed to a crawl if passage through the lane is unavoidable. VIBRATION CRITERIA AND IMPACT
With a catalogue of vibration sources now in hand, and input and feedback on proposed spaces and layouts given, a vibration specialist can review criteria standards for MRI machines and CT scanners, which are supplied by the equipmentâ€™s manufacturers. Each manufacturer will have different and
fairly stringent equipment specification criteria because the vibration responses of the machine lines are variable and unique. In addition, each manufacturer has specific criteria peak levels for transient and steady state vibration as a function of frequency. Transient vibration is intermittent and produced by such things as pedestrian and cart traffic in corridors, emergency generators, elevator operations, loading dock activities and helicopter landings. Steady state is a continuous, regular source of vibration that typically originates from HVAC, mechanical and building systems, such as fans, pumps, cooling towers and chillers. However, early in the planning and design process, the exact brand of MRI machine or other sensitive equipment may not be known. Consequently, the criteria used for evaluation purposes at that stage must be derived from generic vibration classes or allowable uses, as defined in several Canadian, U.S. and international guidelines and standards. In an existing facility where a retrofit or expansion is underway, measurements can be conducted to obtain ambient levels and SPRING/PRINTEMPS 2017 33
MAINTENANCE & OPERATIONS during simulated foot traffic. At the same time, measurements can be taken to determine the fundamental resonant frequency, damping and mode shape of the vibration of representative bays, which is useful in determining any necessary structural upgrades. The measurement results can then be analyzed against the established criteria to define the vibration class and typical allowable uses. Where areas with heightened potential for adverse vibration impacts are identified due to the preliminary structural design, it is prudent to undertake a dynamic finite element analysis of the building structure. While mechanical systems can be effectively mitigated at source, footfall-induced vibration typically needs to be addressed through the structural design. Required improvements can be identified with finite element analysis. Vibration specialists can work with the design team to prepare specifications and details for the location and isolation of major mechanical systems. At the same time, they can also work with the structural engineer to ensure that recommendations to address specific areas of concern are identified and
remedied, and to try and accommodate other considerations as they arise, which can affect potential stiffening or other remedial measures. MITIGATION STRATEGIES
In general, there are some typical base strategies that can be implemented or considered to mitigate vibration impact on MRI machines and other sensitive equipment. One strategy is to situate a MRI machine on a column line for added stiffness, with the closest corridors located near the perimeter of the bays. Installing a MRI machine on a concrete block that is two to three times thicker than the neighbouring slab is another way to further reduce the vibration from sporadic impacts. This block can serve to increase the inertia and reduce the transfer of vibration to the block from bending waves in an adjoining slab. In the case of a ceiling-mounted surgical microscope, a mitigation solution may involve reinforcing the ceiling or isolating the microscope while also increasing its inertia with lead, steel or concrete.
CHES Canadian Healthcare Engineering Society
Any new or future expansion construction activities near an existing MRI machine are likely to be of concern if the system is situated against an exterior wall. Using a jackhammer or breaker on concrete within a bay or two is presumably going to produce vibration exceeding criteria. Generally, pile driving outside an exterior wall will also exceed vibration criteria. Drilling for caissons will produce less vibration than pile driving but could still be an issue depending on the soil. Similarly, heavy construction activities should not occur in an area where MRI procedures are occurring concurrently. Brian Howe is president and principal engineer at HGC Engineering, an acoustical consulting group. The firm specializes in the analysis and design of noise and vibration controls for mechanical and building services, as well as architectural acoustic design for residential, commercial and institutional spaces, including acoustic optimization, sound intelligibility and privacy solutions.
Société canadienne d'ingénierie des services de santé
CALL FOR NOMINATIONS FOR AWARDS
CALL FOR NOMINATIONS FOR AWARDS 2016 2016 Hans Burgers Award
For Outstanding Contribution to 2017 Hans Burgers Award Healthcare Engineering
Wayne McLellan Award of Excellence In Healthcare Facilities Management
For Outstanding Contribution to Healthcare Engineering DEADLINE: April 30, 30, 2016 DEADLINE: April 2017
2017 Wayne McLellan Award of Excellence In Healthcare Facilities Management DEADLINE: DEADLINE: April 30, 2016 April 30, 2017
To nominate: To nominate: To nominate: Please useform the posted nomination To nominate: Please use the nomination form posted on the Please use the nomination on form posted on the Please use the nomination form posted on CHES website and refer to the Terms CHES website and refer to the Terms of Reference. the CHES website and refer to the Terms of of Reference. the CHES website and refer to the Terms of Reference. Reference. Purpose: To recognize hospitals or long-term care facilities that Purpose: The award shall be presented to a resident of Canada Purpose have demonstrated outstanding success in completion of a major asPurpose a mark of recognition of outstanding achievement in the field To recognize hospitals or long-term care The award shall of behealthcare presentedengineering. to a resident of capital energy efficiency program, environmental facilities that project, have demonstrated outstanding Canada as a mark of recognition of outstanding stewardship program, or team success in completion of a major capitalbuilding exercise. achievement in the field of healthcare Award sponsored by project, energy efficiency program, engineering. environmental stewardship program, or by Award sponsored team building exercise. Award sponsored by Award sponsored by
For Nomination Forms, Terms of Reference, criteria, and past winners www.ches.org / About CHES / Awards For Nomination Forms, TermsNational of Reference, and past winners Send nominations to: CHES Officecriteria, firstname.lastname@example.org Fax: 866-303-0626 www.ches.org / About CHES / Awards
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WAYFINDING STANDARD EN ROUTE La norme de signalisation fait son chemin
36 CANADIAN HEALTHCARE FACILITIES
eing in a hospital is often stressful, whether a patient or visitor. Wayfinding is generally one of the first sources of anxiety because of the sheer size and complexity of the environment. Add complicated and emerging medical terminologies, an endless supply of abbreviations, difficult to understand signage and mazelike traffic patterns, and it’s no wonder patients and visitors can become disoriented and even lost. These types of inadequate wayfinding systems are frustrating at best. At worst, they can lead to errors or delays in care. In an effort to improve hospital navigation, the CSA Group has developed a standard that sets out requirements for wayfinding systems. Here, CSA’s Andrea Holbeche discusses the first edition of Z317.14, Wayfinding in Health Care Facilities, which is expected to be published in spring.
How long has the standard been in the making?
The technical subcommittee’s first meeting was in 2014; however, the need for the standard was identified during the development of the first edition of Z8000, Canadian Health Care Facilities. At that time, while Z8000 included some requirements on wayfinding, the committee recognized wayfinding could merit a more comprehensive approach in a document devoted just to this topic.
tre dans un hôpital, qu’on soit patient ou visiteur, est souvent une source de stress. La signalisation est généralement l’une des premières sources d’anxiété, en raison de la taille immense et de la complexité de l’environnement. Quand on y ajoute la terminologie médicale, la kyrielle interminable de néologismes et d’abréviations, les affiches indéchiffrables et le labyrinthe de corridors, on ne s’étonne pas que les patients et visiteurs soient désorientés, parfois même égarés. Ces systèmes de signalisation inadéquats sont contrariants dans le meilleur des cas. Au pire, ils peuvent conduire à des erreurs ou à des retards dans les soins. Le Groupe CSA a donc élaboré une norme qui définit les exigences relatives aux systèmes de signalisation. Dans cet article, Andrea Holbeche CSA répond à nos questions sur la première édition de la norme Z317.14 qui doit paraître au printemps pour encadrer la signalisation des établissements de santé.
Depuis combien de temps cette norme est-elle en préparation?
Le sous-comité technique a tenu sa première réunion en 2014, mais la nécessité d’une norme de signalisation est apparue durant l’élaboration de la norme Z8000 sur les établissements de santé. Cette dernière donnait déjà quelques indications sur la signalisation, mais le comité a trouvé nécessaire d’y consacrer un document entier.
What does Z317.14 apply to?
The standard sets out requirements for wayfinding systems in healthcare facilities. This includes processes to help users understand where they are in an environment or building, where their desired location is and how to get to their desired destination from their present location. Wayfinding design consists of a diverse selection of interior and exterior coordinated elements designed to capture the specific needs of all users to help them find their way while minimizing stress, and reinforcing and optimizing independence.
À quoi s’appliquera la norme Z317.14?
What principles are driving the new standard?
Quels principes sous-tendent la nouvelle norme?
Most importantly, there’s the need to find out what wayfinding is and what it is not. Contrary to what some might first think, wayfinding is a lot more than just signage. It’s made up of four equally important components: places, people, wayfinding elements and continual improvement.
On doit avant tout saisir en quoi consiste ou non la signalisation. Contrairement aux idées reçues, c’est beaucoup plus qu’un simple système d’affichage. La signalisation se compose de quatre éléments, tous essentiels: les lieux, les personnes, les éléments de signalisation et l’amélioration continue.
La norme définit le cahier des charges des systèmes de signalisation dans les établissements de santé. Il s’agit d’aider les utilisateurs à savoir où ils se trouvent, à repérer leur lieu de destination et à trouver leur chemin entre les deux. La conception de la signalisation comprend divers éléments intérieurs et extérieurs destinés à aider les patients et visiteurs à trouver leur chemin tout en réduisant leur stress et en les rendant plus autonomes.
SPRING/PRINTEMPS 2017 37
Using a ‘right information at the right time’ approach provides users with sufficient information to determine and follow the appropriate path and enhances their entire user experience. The standard also includes general requirements for the wayfinding plan and the types of multidisciplinary support that must be provided to make a wayfinding system successful.
L’approche de la ‘bonne information au bon moment’ livre assez de renseignements aux utilisateurs et patients pour déterminer leur parcours et rehausser leur expérience. La norme comprend aussi des exigences générales pour le plan de signalisation et les types de soutien pluridisciplinaires qui doivent être fournis. Quels sont les faits saillants de la norme?
What are the main highlights of the standard?
Z317.14 is structured around requirements for the four equally important components. Places includes the site of the facility itself, the architectural design and features, as well as planning and design of interior and exterior spaces. These are the foundational elements that provide the organization and spatial arrangement of the facility. Human orientation and interaction from staff and volunteers provide personal assistance where needed to navigate the environment. Wayfinding elements such as design, signage, technology and emerging approaches provide the needed visual and tactile information. Continual improvement includes general maintenance programs and follow-up to keep the system up-to-date. Examples of how to use the standard are featured in an annex containing images of the key principles in real application. Also, as wayfinding is about meeting the needs of a diverse group of users, the standard addresses the issue of inclusive washroom signage.
Z317.14 est structurée autour des quatre éléments essentiels. Les lieux comprennent l’emplacement de l’établissement lui-même, son architecture de même que la planification et la conception des espaces intérieurs et extérieurs. Ce sont les éléments fondamentaux qui assurent l’organisation et la disposition spatiale de l’installation. L’orientation humaine et l’interaction avec le personnel et les bénévoles fournissent une assistance personnelle en cas de besoin. Les éléments de signalisation comme la conception, l’affichage, la technologie et les approches émergentes fournissent les informations visuelles et tactiles nécessaires. L’amélioration continue inclut les programmes d’entretien général et de suivi pour maintenir le système à jour. Des exemples de la façon d’utiliser la norme sont présentés dans une annexe contenant des images des principes clés en application réelle. En outre, comme la signalisation vise à répondre aux besoins d’un groupe diversifié d’utilisateurs, la norme traite de la question des affiches de toilettes inclusives.
Who will benefit from the standard?
Effective wayfinding for healthcare facilities requires a design of the system that is both universal and inclusive, and reflects the needs of a diverse user population. The focus of the standard is to make the concept of wayfinding more intuitive, accessible and understandable for all patients and visitors, as well as staff. The key to creating an excellent patient experience is focusing on the patient’s entire journey — starting from their home to the healthcare facility entrance, through reception to their treatment or procedures, followed by the full journey back through these steps. All parts of this journey are equally important, as is the time taken to complete the route.
Qui bénéficiera de la norme?
La signalisation efficace nécessite une conception à la fois universelle et inclusive — et reflétant les besoins d’une population d’utilisateurs diversifiée. L’objectif de la norme est de rendre le concept de signalisation plus intuitif, accessible et compréhensible pour tous les patients et visiteurs, ainsi que pour le personnel. La clé pour créer une excellente expérience se concentre sur tout le parcours du patient — de son domicile à l’entrée de l’établissement, puis à travers la réception et pendant son traitement. Toutes les parties du parcours sont importantes, tout comme le temps de déplacement.
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