CHF Spring 2019

Canadian

HealthcareFacilities JOURNAL OF CANADIAN HEALTHCARE ENGINEERING SOCIETY

Volume 39 Issue 2

Spring/Printemps 2019

BREATHE EASY PM#40063056

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CONTENTS

CANADIAN HEALTHCARE FACILITIES Volume 39

Issue 2

Clare Tattersall claret@mediaedge.ca EDITOR/RÉDACTRICE

24

PUBLISHER/ÉDITEUR Kelly Nicholls kellyn@mediaedge.ca PRESIDENT/PRÉSIDENT

Kevin Brown kevinb@mediaedge.ca

SENIOR DESIGNER/ CONCEPTEUR GRAPHIQUE SENIOR

Annette Carlucci annettec@mediaedge.ca

PRODUCTION MANAGER/ DIRECTEUR DE PRODUCTION

Rachel Selbie rachels@mediaedge.ca

CIRCULATION MANAGER/ Anthony Campbell DIRECTEUR DE LA circulation@mediaedge.ca DIFFUSION

CANADIAN HEALTHCARE FACILITIES IS PUBLISHED BY UNDER THE PATRONAGE OF THE CANADIAN HEALTHCARE ENGINEERING SOCIETY.

DEPARTMENTS

HEALTH & SAFETY

6

8

22 Dare to Achieve An Ontario hospital’s journey to accreditation success

Editor’s Note President’s Message

10 Chapter Reports

INNOVATION & TECHNOLOGY 16 Get Smart How robots can improve workflow, logistics for better patient outcomes 18 Cultivating a Growth Mindset Understanding new ways to provide emergency power to healthcare facilities

24 Building Therapy The healing power of indoor air

SCISS JOURNAL TRIMESTRIEL PUBLIE PAR SOUS LE PATRONAGE DE LA SOCIETE CANADIENNE D'INGENIERIE DES SERVICES DE SANTE.

CHES Canadian Healthcare Engineering Society

SCISS

Société canadienne d'ingénierie des services de santé

PRESIDENT VICE-PRESIDENT PAST PRESIDENT TREASURER SECRETARY EXECUTIVE DIRECTOR

INFECTION PREVENTION & CONTROL 28 When Risk Becomes Reality Behind the scenes of an aspergillus investigation 30 A Change is Afoot

Un changement se prépare

Preston Kostura Roger Holliss Mitch Weimer Craig B. Doerksen Kate Butler Donna Dennison

CHAPTER CHAIRS

Newfoundland & Labrador: Colin Marsh Maritime: Helen Comeau Ontario: Jim McArthur Quebec: Mohamed Merheb Manitoba: Tom Still Saskatchewan: Greg Woitas Alberta: Tom Howard British Columbia: Norbert Fisher 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: ches@eventsmgt.com www.ches.org Canada Post Sales Product Agreement No. 40063056 ISSN # 1486-2530

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EDITOR'S NOTE

TAKING CARE OF BUSINESS ACROSS THE COUNTRY, wintry weather topped the news multiple times in January and February. Back-to-back snowstorms walloped many cities, causing power outages, gas shortages and school closures, and generally disrupting everyday life. But regardless of the scale or frequency of Mother Nature’s rage, it was always business as usual at Canada’s hospitals. Healthcare workers don’t take snow days and when a massive storm approaches, they put their facility’s emergency plans into action to ensure they can care for current patients as well as any increase due to snow-related events.

With (I hope) the worst of the season behind us now, I’m looking forward to spring. Working on this annual issue of Canadian Healthcare Facilities always helps me through this time of year when the change in seasons is not too far off but it seems like winter’s wrath is never going to end.

This issue focuses on three key areas of interest: innovation and technology; health and safety; and infection prevention and control. Articles cover a variety of topics, from robotic process automation to new ways to provide emergency power in healthcare facilities to a Toronto hospital aspergillus investigation.

I’d like to thank those who have shared their knowledge and written for the magazine. If anyone is interested in contributing editorial or there’s a topic you’d like to see covered, please don’t hesitate to contact me.

Clare Tattersall claret@mediaedge.ca

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.

NATIONAL CONFERENCE | 2019 | SEPTEMBER 22-24 | SASKATOON ARTS & CONVENTION CENTRE, TCU PLACE | SASKATOON, SK

SAVE THE DATE! The CHES 2019 National Conference will be held in Saskatoon, Sask., at the Saskatoon Arts & Convention Centre, TCU Place, September 22-24, 2019. The Saskatoon Arts & Convention Centre, TCU Place, is conveniently located near downtown and local amenities.

A block of rooms has been reserved at both the Hilton Garden Inn Saskatoon Downtown, starting at $199 plus applicable taxes single/double occupancy, and the Holiday Inn Saskatoon Downtown, starting at $167 plus applicable taxes single/double occupancy.

The theme of the 2019 conference is The “HUB” that enables resiliency in healthcare The CHES 2019 Education Program is still under development but will once again feature dual tracks with talks on relevant industry topics from high-profile experts in the field. We have booked Mark Black as our Keynote Speaker. Mark is a Resilience Expert, Heart and DoubleLung Transplant Recipient and 4-Time Marathon Runner born with a congenital heart defect.

Mark has beaten all the odds and uses his new gift of life to inspire people to “live life with passion and purpose.”

The Great CHES Golf Tournament will be on Sunday, September 22, 2019.

Join us for the CHES President’s Reception and Gala Banquet again in 2019! The banquet will celebrate the accomplishments of our peers with the 2019 Awards presentations, while enjoying great food and entertainment with friends.

See you in 2019 in Saskatoon!

For more info visit our website at www.ches.org Follow us on Twitter!

@CHES_SCISS

PRESIDENT'S MESSAGE

ALL EYES FORWARD IT’S BEEN A ROUGH Canadian winter, with some provinces weathering it better than others.

I would like to thank all grounds crews and maintenance staff for keeping us safe during the season. As the weather warms, remember to wear appropriate personal protective equipment when sweeping (or creating dust) during spring clean-up to prevent inhalation of silica.

The Saskatchewan chapter is in the final planning stages of the 2019 CHES National Conference, which will take place Sept. 22-24, in Saskatoon.

While more than a year away, I encourage you to mark your calendars now for the 2020 CHES National Conference. The Maritime chapter will host the event in Halifax, Sept. 20-22, 2020.

In 2019, CHES will continue to provide educational offerings through webinars and in-person courses. As a reminder, the webinars are generally one hour in duration, so they don’t require a large time commitment in comparison to other educational sessions.

CHES has again reinvested in its members by registering for at least 15 CSA standards, which are accessible to all members.

In the last few years, our membership count has struggled slightly. Please ensure you sign-up and consider inviting a colleague to join. It’s worth the value!

I am now in my final year as CHES national president. Roger Holliss is very excited to assume the role in September. As a result, we are currently looking for nominations for the vice-chair position, as well as the roles of secretary and treasurer.

I have no doubt that 2019 is going to be a great year. Remember to challenge yourself and try something different.

Preston Kostura 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 2019 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/GQRKGHZ 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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CHAPTER REPORTS

MANITOBA CHAPTER

MARITIME CHAPTER

The 2019 Manitoba Education Day will be held April 23, at the Canad Inns Destination Centre Polo Park in Winnipeg.

The theme is, ‘Innovation and Technology.’ We have a topnotch lineup of presentations. Changes have been made to the format, which includes a keynote speaker (Red River College’s Paul Vogt), social event at the end of the day and two grand prize draws for a trip to the CHES National Conference in Saskatoon, Sept. 22-24. If you have any questions about the event or would like to volunteer your time, please contact a member of the executive team.

To encourage our members to excel in their field, the chapter will cover the cost of the Canadian Certified Healthcare Facility Manager (CCHFM) practice/self-assessment exam for those attempting it for the first time. Details are on the Manitoba chapter section of the CHES website.

—Tom Still, Manitoba chapter chair

The 2019 Maritime Spring Conference will be held at the Delta hotel in Moncton, N.B., May 5-7. The planning committee is working hard to deliver another successful event. This year’s theme is, ‘Healthcare Infrastructure: Understanding the Risks.’

Session topics include: fire and life safety (Derwin Swimner, Nova Scotia Department of Environment and Labour); transfer switch operation and maintenance (Phil Blasdel, Asco Power Technologies); hospital wayfinding design (Allison Moz, Eye Candy); CSA Z8002, Operations and Maintenance of Health Care Facilities (Robert Barss, Nova Scotia Health Authority); and 3-D imaging in healthcare facilities (Andy Bardsley, CFM).

The first planning committee meeting for the 2020 CHES National Conference in Halifax was held in February. Planning is well underway.

The chapter is able to balance its books while offering several financial incentives to its members in the way of student bursaries, contribution to Canadian Certified Healthcare Facility Manager (CCHFM) exam fees, webinars, the fall education day and other rebates.

—Helen Comeau, Maritime chapter chair

NEWFOUNDLAND & LABRADOR CHAPTER The Newfoundland and Labrador chapter kicked off 2019 seeking nominations for the positions of vice-chair and secretary. Both roles have been vacant for some time and we are excited to fill them.

We are currently planning our next professional development day. Last year, we decided not to move forward with it in lieu of hosting the 2018 CHES National Conference.

Given that we just came off that event, the chapter executive has decided to postpone this year’s professional development day until September. It is tentatively booked for Sept. 8-9, at the Ramada St. John’s.

Chapter treasurer Doug Kennedy has advised that we are sitting in a solid financial position. All expenses incurred as a result of last year’s CHES National Conference have been paid. The executive team has decided to send two members along with the chapter chair to the 2019 CHES National Conference in Saskatoon, Sept. 22-24. We are also looking at investing in our membership, as well as creative ways to give back.

Chapter membership has been consistent with approximately 45 active members. To increase our membership, the chapter is actively pursuing recruitment of vendors/suppliers, consultants and other healthcare dependents.

The chapter executive has been brainstorming ways to bring CHES across the geographically-challenged province of Newfoundland and Labrador. We’re considering taking CHES on the road and hosting the chapter’s professional development day in other towns and cities across the province.

To do this, however, we need buy-in from our CHES membership and vendors within each respective health region as well as province-wide. The chapter executive will continue to discuss ideas to further CHES’s reach and welcome input from our membership.

—Colin Marsh, Newfoundland & Labrador chapter chair 10 CANADIAN HEALTHCARE FACILITIES

ONTARIO CHAPTER As we anticipate the arrival of warmer weather, the chapter’s conference planning committee is putting the final touches on the annual spring conference, which will take place June 2-4, in Hamilton. Ron Durocher and his team of volunteers have developed an excellent program for the conference, which is expected to be well-attended.

The chapter is planning another education day for the fall. The exact date and location is still to be determined.

The Canadian Healthcare Construction Course (CanHCC Course) is scheduled for Oct. 31-Nov. 1, in Toronto.

Our education chair Rick Anderson has tendered his resignation (effective September). In 2015, Rick retired as director of building services at Woodstock General Hospital, after 22 years of service. He has been a CHES member since 1991, and has served as the chapter’s education chair for more than 20 years.

During this time, Rick established many of the chapter’s college scholarships, CHES member tuition grants and family member bursaries. He also developed many of the programs for our education days and chaired several regional meetings, some of which I had the pleasure to attend. I’d like to thank Rick for all his work and dedication throughout the years. His passion for CHES will certainly be missed.

As we say goodbye to Rick, I’d like to extend a warm welcome to Derek Lall of London Health Sciences Centre, who will fill the role of education chair. Derek and Rick will work together over the next few months to ensure a seamless transition in September.

—Jim McArthur, Ontario chapter chair

CHAPTER REPORTS

BRITISH COLUMBIA CHAPTER

ALBERTA CHAPTER

A new year comes with a new beginning for the B.C. chapter executive. I’d like to welcome Steve McEwan (past chair), Sarah Thorn (vice-chair), Ken Van Aalst (secretary), Rick Molnar (treasurer), Mitch Weimer (public relations), Arthur Buse (membership), Mark Swain (communications) and Caroline Reid (education). Mike Hickey also deserves an honourable mention for letting his name stand for the vice-chair nomination.

Planning for this year’s chapter conference is well underway.

It will be held May 26-28, in Penticton. The theme is, ‘Safety First: Our Mandate for Responsible Healthcare.’ The keynote speaker is Phil Gothe of Technical Safety BC. I look forward to seeing everyone at the conference and sharing safety stories and experiences.

Be sure to keep an eye on your e-mail as we will be sending out proposed bylaw changes for your review. They will be voted on at our annual general meeting during the chapter conference. Please plan to attend on May 27.

I encourage everyone to check out the webinars available on the CHES website. They make for a great ‘lunch and learn’ session for you and your staff. Sign-up as a B.C. chapter member and we will pay the webinar costs.

If you have any questions about CHES, courses or standards supported by CHES, or are interested in getting involved in the organization, please don’t hesitate to contact me or any member of the chapter executive. We look forward to hearing from you.

—Norbert Fisher, British Columbia chapter chair

I would like to introduce myself as I will transition into the role of chair from vice-chair at the upcoming Clarence White Conference and Trade Show in April. I have been with Alberta Health Services (AHS) and its former iterations for almost 30 years. I was originally hired as an electronics technician at Calgary’s Rockyview General Hospital in 1989.

Currently, I am the facility manager at the Peter Lougheed Centre, which is also in Calgary. I’m excited to be part of this great team, and can only hope to emulate the previous chapter chairs and the great job they have done throughout the years.

In preparation of the transition, I’d like to recognize Tom Howard as his term as past chair comes to an end. Tom has injected much energy and dedication into the positions he has held with the Alberta chapter, and will be greatly missed. However, I am sure we can count on Tom as a resource. He’s a wealth of information given his many years of support of CHES. This year’s Clarence White Conference and Trade Show will take place April 16-17. The theme is, ‘Smarter Buildings, New Challenges.’ Planning for the event is almost complete. I have been told we are well ahead of previous years’ planning. I would like to thank our planning committee for their hard work: Liana Sousa, Cora Husoy, Geri Sklenar, James Prince, Jeff Smith, Peter Jarvis, Paul Teterenko, Ken Sunderman and Tom Howard.

Immediately following the event, AHS will host the provincial heliport managers conference on April 17. This takes advantage of the many miles AHS staff have to travel to attend these conferences.

The Alberta chapter will host the Canadian Healthcare Construction Course (CanHCC) in Calgary, Oct. 16-17. I hope you can make time to attend or send interested staff to this seminar.

More information about CanHCC can be found at https://ches.org/ pd/canadian-healthcare-construction-course.html.

In my last chapter report, I wrote about the enjoyment of venturing outside to take advantage of winter activities and the gorgeous scenery. Since then, Alberta has experienced an extended cold snap, as have other provinces. My thoughts go out to the first responders and trades that have to deal with these extreme weather conditions as they go about their duties. By now (I’m hoping), the weather has warmed and we’re seeing brighter days. If not, hang in there. Spring is just around the corner.

—Dan Ballantine, Alberta chapter vice-chair

Preparations are well underway for the 2019 CHES National Conference, Sept. 22-24. The venue has been booked (TCU Place in Saskatoon) and various committees have been put into place. At the same time, we are planning the chapter’s 2020 conference and trade show, which will be held in Regina.

Looking back, it was a busy fall. In September, three executive team members attended the 2018 CHES National Conference in St. John’s, Nfld. We gleaned much from the event, which will help guide us as we prepare to host the upcoming CHES National Conference.

About a month afterwards, from Oct. 22-23, the Saskatchewan chapter held its annual conference and trade show. The conference planning committee did an excellent job organizing the two-day event, which saw a record number of 69 delegates in attendance. The 35 vendor booths that filled the trade show floor also contributed to the event’s success.

Our annual general meeting was held on the last day of the chapter conference, with approximately 35 members present.

Our Member of the Year award went to Jim Allen who has led constant change and development within the province’s everchanging healthcare environment.

—Greg Woitas, Saskatchewan chapter chair

t

SASK ATCHEWAN CHAPTER

The 2019 CHES National Conference will be held Sept. 22-24, in Saskatoon.

SPRING/PRINTEMPS 2019 11

CHAPTER REPORTS

QUEBEC CHAPTER

It’s Chaos Without Us

The Quebec chapter is strong in 2019. Its relaunch began with a new, motivated executive committee to improve services to the province’s healthcare system.

The first event of the year took place in January, as a conference dinner. A presentation was given to explain the different methods used to verify high-efficiency particulate air (HEPA) filters and the composition of aerosols used in filter integrity testing. More than 30 people attended, including several hospital managers, demonstrating the healthcare community’s interest in this type of event.

The Quebec chapter has other events planned for April 23 and Oct. 23, so save the dates. More details to follow shortly.

Please do not hesitate to contact any member of the chapter executive for more information or if you wish to provide comments or feedback.

—Mohamed Merheb, Quebec chapter president

CHAPITRE DU QUÉBEC Le chapitre du Québec se voit fort en 2019. Son relancement a débuté avec un nouveau comité exécutif motivé pour améliorer les services offert au réseau de la santé québécois.

Le premier évènement de l’année a eu lieu en Janvier sous forme d’un souper-conférence. Il s’agissait d’une présentation ayant pour but d’expliquer les différentes méthodes de vérification des filtres à haute efficacité (HEPA) et la composition d'aérosols utilisés lors de tests d'intégrité de filtres. Plus d'une trentaine de personnes étaient présentes dont plusieurs gestionnaires d’hôpitaux démontrant ainsi l’intérêt de la communauté de la santé pour ce type d'évènement.

L’année ne fait que commencer alors plusieurs évènements sont encore à venir. Nous vous invitons d'ores et déjà à réserver dans votre emploi du temps les 23 Avril et 23 Octobre afin d’assister aux prochains évènements dont les détails suivront prochainement.

N’hésitez pas à nous contacter pour obtenir plus d'information ou nous donner vos commentaires.

—Mohamed Merheb, président du chapitre du Québec

t 12 CANADIAN HEALTHCARE FACILITIES

The Quebec chapter has two more events planned for 2019, both to be held in Montreal in April and October.

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INNOVATION & TECHNOLOGY

GET SMART How robots can improve workflow, logistics for better patient outcomes

By Anthony Pugliese

A

hospital administrator’s work focuses on two primary objectives: deliver outstanding patient care and do it at a reasonable cost.

When programs and initiatives further the quality of patient outcomes while minimizing the expense of delivery, hospitals benefit and so do the communities they serve.

Thoughtful design around operational workflow and logistics hold great potential to further these objectives, with automation serving as a powerful lever that enables skilled clinicians to do more of their best work.

Engineers and planners can bring about scalable and measurable positive change by helping hospitals deploy automation to improve patient care in cost-effective ways. To do that, it’s critical to first gain insight into a hospital’s strategic and operational imperatives, as well as the process and workflow necessities of the clinical staff to avoid costly and often irrevocable decisions with new builds, expansions and renovations.

TODAY’S HOSPITAL CHALLENGES

The healthcare industry is increasingly consumer-driven.

Technology has helped blur the lines between industries, and consumers no longer differentiate between them. Their expectations for quality experiences are high, like those in e-commerce and banking. As a result, there are new challenges that hospitals now face.

16 CANADIAN HEALTHCARE FACILITIES

With more power and responsibility to take an active role in their own healthcare, patients look to providers for more information and higher-touch, continuous care.

Rising in tandem, but perhaps divergent to a hospital’s preparedness to meet these rising expectations, is the increase in care requirements brought about by a more complex care landscape. An aging patient population and growth in volume strains hospital resources. Many disease processes that were once terminal are now survivable for the long-term. Treating those illnesses can tax the workforce and hospital budgets. While care delivery costs may be difficult to pinpoint precisely, it’s reasonable to say the general cost of spend is unsustainable.

The skilled workforce shortage is the flip side of the costminimization coin. With more people in need of care and an inadequate number of caregivers, it’s important to maximize the throughput of the workforce. To maintain high levels of care with reduced staff while mitigating costs, hospital administrators should look to automation and robotics as part of their strategy to improve efficiencies.

THE VALUE OF ENGINEERS AND PLANNERS

Industry leaders can help hospitals retire inefficient, labour-intensive processes in favour of more efficient, cost-effective ones.

Measures of hospital performance, including quality scores, readmissions and patient experience, impact the balance sheet and overall perception of a hospital brand. Before initiating a project, interviews between engineers/planners and hospital frontline and clinical staff can help pinpoint areas of frequent bottlenecks, communication and logistic breakdowns, and other areas in need of improvement.

FUNCTIONAL IMPACT OF WORKFLOW DESIGN

Circumstances like skilled labour shortage and workforce dissatisfaction (traced back to repetitive, mundane tasks) reduce the available time clinicians have for direct patient care and influence the quality of the patient experience.

Manually transporting blood, specimens, medications or critical supplies is inefficient and open to risks, including misdirection, task interruption and loss. Bottlenecks can occur when items for transport are batched, affecting processes like testing and resulting.

Manual transport can also lead to specimen or blood waste caused by delivery delays. A 2016 survey of more than 240 U.S. hospitals found that interrupted tasks, long walking distances and delays in patient care are among the top five issues healthcare facilities face.

Automated material transport, including pneumatic tube systems and intelligent robots, can be the catalysts for improved workflows and logistics, creating greater and measurable efficiencies across a spectrum of criteria.

APPLYING AUTOMATION TO HEALTHCARE

The healthcare industry is typically slow to adopt technology and tools that hold the power to reduce labour costs, improve efficiency, increase safety and facilitate the redirection of skilled resources to more fulfilling work at the top of their licensure. One reason may be a lack of competitive pressure found in other industries. In healthcare, productivity only recently emerged as a key metric. In light of the challenges hospitals currently face, automation is increasingly necessary.

As an established technology, pneumatic tube systems remain extremely viable as a means for quickly moving materials from point to point. The demands of modern hospitals drive development of specific capabilities, like authorized load retrieval, load holding and carrier tracking.

Autonomous service robots are a natural complement to pneumatic tube systems. The devices may also stand alone to service facilities where pneumatic tube systems aren’t feasible due to cost, facility layout or other reason.

Automated material movement has a direct impact on hospital staff operations and workflow, as well as a valuable secondary impact on patient experience and care. Automation supports smooth, just-in-time workflow, makes material movement reliable, consistent and trackable, and frees up clinicians’ time to attend to core tasks.

Anthony Pugliese is senior vice-president of North America sales for Swisslog Healthcare, a leading supplier of solutions and services for material transport, medication management and supply chain management. The company has installed facility-wide transport and pharmacy automation systems in more than 3,000 hospitals worldwide. It offers integrated solutions from a single source, from consulting to design and implementation to lifetime customer service.

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SPRING/PRINTEMPS 2019 17

INNOVATION & TECHNOLOGY

CULTIVATING A GROWTH MINDSET Understanding new ways to provide emergency power to healthcare facilities

By Troy Savage & Walt Vernon

T

he silent operation of a hospital microgrid illustrates a paradigm shift. The rapid advancement of technology is forcing people to reevaluate the opportunities and, resultantly, regulations for how power is provided to critical facilities like hospitals. Codemaking organizations, hospital facility planners and teams must understand how the combination of economics and technological advancements has bent the concept of ‘emergency power’ to the breaking point. For the sake of the safety of healthcare facilities and the benefit of patients, new ways of thinking about, and designing for, emergency power generation are required.

18 CANADIAN HEALTHCARE FACILITIES

HISTORY OF NOW

While the first ‘utilities’ were small in scope and distributed, economies of scale and the need for large capital outlays in the power industry dictated the advent of central utilities, providing power to customers through a distribution system. The problem with the centralized power distribution system is the inevitable times when it does not provide power, either due to planned or unplanned outages. Yet, hospitals and other sensitive facilities cannot afford power outages.

To avoid them, hospitals have typically secured an alternative source to power critical systems (at a minimum). Historically, that source was a diesel generator. So, the

central utility provided ‘normal’ power and the generator could provide ‘emergency’ power to the circuits deemed critical to function during an emergency.

Obviously, having power when the ‘normal’ source goes down is critical. For this reason, hospitals always needed generators even though they were rarely used, expensive to maintain, required periodic testing and were relatively inefficient and environmentally destructive to run. This ‘all or nothing’ paradigm formed the basis for the modern emergency power codes. These codes required backup power sources to run only during failure to the ‘normal’ power supply. This was to protect the life and reliability of the backup source.

INNOVATION & TECHNOLOGY

MICROGRIDS ARE COLLECTIONS OF SOURCES, STORAGE ASSETS AND GENERATION/ TRANSFORMATION ASSETS WITH CONTROLS THAT ALLOW A GROUP OF LOADS TO SELECT THE RIGHT SOURCE FOR ANY PARTICULAR SET OF CONDITIONS.

As energy markets evolved, new opportunities to leverage on-site power resources emerged. An early example is the opportunity for peak shaving. Facing timeof-use electricity rates, owners could save money by running an on-site ‘emergency’ generator during peak hours, effectively reducing the amount of electricity purchased from the utility at its peak rate. Similarly, demand response programs provided another way to save on energy costs by running the on-site ‘emergency’ generators.

Next came co-generation; and so, the codes bent and allowed hospital operators to use their ‘emergency’ generators for nonemergency uses as long as there was enough redundancy (N+1) to ensure sufficient capacity in the event of some system failure.

Then, new technologies emerged.

Hospitals began experimenting with on-site electricity generation using fuel cells. These devices provide clean power with low emissions relative to most utilityprovided power. Their problem, though, is their long start-up times. As a result, they must run all the time (to be effective at the time of need). Since the codes allow an emergency source to operate in non-emergency situations, fuel cells became feasible emergency sources, even though they must run at all times.

Accordingly, the codes bent even more; the on-site ‘emergency’ generator was now operating all the time and the ‘normal’ utility service was only needed for the normal loads.

T he next ne w t e c h n o l o g y — microgrids — is going to force people to break the old mindset of ‘normal’ and ‘emergency’ sources. Microgrids are collections of sources, storage assets and generation/transformation assets with controls that allow a group of loads to select the right source for any

particular set of conditions. The microgrid controller might want to take power from a utility grid in some circumstances. It might also want to use its batteries (or other energy storage assets) when utility power is most costly.

Or, it might want to use some on-site generation source.

When any grouping of sources can supply any grouping of loads at any time, what is ‘normal’ and what is ‘emergency?’

And so, the codes are evolving again.

NFPA 99, which helped pioneer the expansion of emergency systems for peak shaving, cogeneration and generation by fuel cell, is now exploring permitting the replacement of a ‘normal’ and an ‘emergency’ service with a requirement for any set of source assets and distribution pathways that provide sufficient reliability.

As follows, the concept of ‘normal’ and ‘emergency’ service is replaced by reliability.

power with a different connected source or reduce load, or some combination of the two. This ability to adapt to new requirements is the epitome of resiliency.

Now consider a microgrid that has several generation assets, such as fuel cells, battery storage and solar. The microgrid controller makes adjustments to optimize power provision from these various sources. If power from any of those sources dips or fails, the others can be used to provide adequate power. The number of available sources and their reliability can be calculated and the system can simply be designed to meet a particular reliability factor.

A CHANGE IN TOPIC

It is this idea of resiliency that shifts the emergency power conversation. To date, hospital systems have lived in the ‘normal’ and ‘emergency’ paradigm. This can be problematic; when both the ‘normal’ and ‘emergency’ sources fail, there is unmitigated disaster. Microgrids change the conversation to one of resilience and reliability. Hospitals can design a microgrid, include numerous generation sources and design it to a particular reliability factor (for example, 99.999 per cent uptime). The paradigm shift has the added benefit of allowing hospitals to take better advantage of demand response and peak shaving opportunities.

MEET THE MICROGRID

LEADING THE CHARGE

In 2018, a medical centre in California implemented America’s first microgrid to serve a hospital emergency branch. The project included a 250-kilowatt solar panel array and battery with 1 megawatthour capacity. This relatively simple microgrid allows clean energy to be produced, stored and distributed to optimize the entire ecosystem.

The key to this and all other microgrids is the microgrid controller, which serves to balance generation sources, loads and interaction with the grid. The controller directs battery recharging and demand response (load shedding) as applicable, helping minimize grid energy use.

The medical centre’s microgrid demonstrates its potential in a healthcare setting. If a hospital has multiple sources and one fails, the system can modulate to replace

Because of their size, load profiles and need for emergency power, hospitals can be key catalysts to lead the paradigm shift. Their relative energy consumption and expenditures, and the imperative to reduce costs, prime them as models. Hospitals have new opportunities to use such technologies and operating strategies to achieve both resilience and cost-effectiveness.

Troy Savage is a project manager with Mazzetti. Walt Vernon is the CEO. Mazzetti is a global provider of mechanical, electrical and plumbing (MEP) engineering design and technology, as well as IT consulting, focusing primarily on healthcare and other highly complex markets. The company has also designed a hospital microgrid. Troy and Walt can be reached at tsavage@mazzetti.com and wvernon@mazzetti.com, respectively.

SPRING/PRINTEMPS 2019 19

SPONSORED CONTENT Enbridge Smart Savings

Bringing Energy Solutions to the Hallways of Healthcare Saving energy and costs in a complex environment Healthcare facilities face a number of unique challenges when it comes to pursuing energy efficient operations. That is, beyond the typical challenges related with facility retrofits and equipment replacements, hospitals must take extra care to ensure these projects do not negatively impact patients, strain budgets, or distract medical staff from their day-to-day routines.

It's a balancing act for sure, which is where Paul Morrison, Energy Solutions Consultant (ESC) at Enbridge comes into play. “When it comes to hospital operations, patient well-being and care take precedence above all else," says Morrison. "Providing 24-hour patient care is an energy-intensive business, which means it is crucial to find ways to exercise energy efficient options wherever possible."

SPONSORED CONTENT

Over the past two decades Morrison has been doing just that–helping customers identify energy efficiency opportunities that re d u c e e n e rg y c o n s u m p t i o n a n d t h e associated costs without impacting an already complex and budget-conscious ecosystem.

Over those 20 years, he has amassed proven energy efficiency measures hospitals would do well to consider. They include: Reviewing the ventilation system: Assess the facility's air balance, temperature, and humidity setpoints to determine whether re-balancing the ventilation system is an opportunity for savings.

Having ventilation frequency drives (VFDs) on air supply systems can also generate electrical savings and provide natural gas savings by enabling the systems to be fine-tuned and scheduling automated setbacks for areas during unoccupied times.

upgrade their heating equipment with a more energy-efficient model, searching for low-cost solutions to save energy and improve the efficiency of their operations, or looking to calculate the carbon emissions and energy costs they can save to justify implementing specific energy efficiency measures.”

Among those services are a free site assessment to help optimize heating and ventilation systems, no-cost assessments of a facility's energy management practices and reviews of other critical systems to find opportunities for more efficient upgrades.

Morrison's job also involves pointing customers to Enbridge initiatives like the Comprehensive Energy Management Program

and available financial incentives for investing in energy efficient space heating and water heating measures, as well as a range of ENERGY STAR® qualified natural gas equipment. For example, Morrison explains, “Enbridge customers can earn financial incentives to cover up to 50 per cent of the cost up to $100,000 per efficiency project. This is something customers aren't usually aware of until I've had a chance to get into the building and explore their options.” * Identifying and implementing energy-efficient upgrades in a healthcare setting can be challenging. Fortunately, there are best practices, industry incentives, and energy consultants like Morrison which can take the pain out of the process.

*Commercial/Industrial Customers are within the Enbridge Gas Inc. (operating as Enbridge Gas Distribution) franchise area (Ontario) only.

Maintaining the balance of your steam system: Functioning steam traps are critical in optimizing the efficiency of a steam system and represent a significant loss if left leaking or failed. “Enbridge will cover 50 per cent of the cost of a steam trap study and further c o nt r i b u t e t o t h e re p l a c e m e nt of a ny malfunctioning traps that are identified,” Morrison explains, adding, “A review of steam lines, valves, and steam system components may also identify insulation opportunities, such as the application of fixed or removable insulating jackets, which typically provide an excellent natural gas saving value.”

Testing boilers as part of a facility's annual maintenance and tuning them at the same time for optimal efficiency: The regular maintenance of natural gas appliances is a best practice, and that includes testing boiler efficiency. “Keeping the test strips, and tracking changes that may be occurring over time will alert you if efficiency is starting to drift so that the necessary adjustments can be made to bring it back to its optimal operating condition,” adds Morrison.

If an equipment upgrade or replacement is deemed necessary, it is also important to know which energy efficiency investments will represent the greatest value and return on investment. It pays to collaborate with an ESC to quantify the potential natural gas savings and gain access to Enbridge's many incentive programs.

“We offer a number of free services and financial incentives designed to help hospitals identify and quantify energy efficiency opportunities,” explains Morrison. “These can be helpful in a number of scenarios, whether a client is looking to

For more information on Enbridge Gas Inc. (operating as Enbridge Gas Distribution) energy-saving programs, incentives, and services visit enbridgesmartsavings.com/business, call 1-866-844-9994, or email energyservices@enbridge.com

DARE TO ACHIEVE An Ontario hospital’s journey to accreditation success

By Marek Kubow

L

ondon Health Sciences Centre (LHSC) has been awarded accreditation with exemplary standing by Accreditation Canada, a not-for-profit organization that works with patients, policy-makers and the public to improve the quality of health and social services for all.

This is the highest designation available through the hospital accreditation program.

LHSC met 100 per cent of the required organizational practices (ROPs) categorized in six safety areas: safety culture, communication, medication use, worklife/workforce, infection control and risk assessment. LHSC also met 99.7 per cent of Accreditation Canada standards — the criteria and guidelines required to provide high-quality care and service.

When LHSC president and CEO Dr. Paul Woods began his tenure in January

22 CANADIAN HEALTHCARE FACILITIES

2 0 1 8 , h e i m m e d i at e l y d e c l a re d ‘accreditation-ready everyday’ as a top priority since it directly relates to quality and safety of patient care. Both senior operational and medical leadership led by example, participating in weekly ‘tracers,’ which follow the care experiences a patient has during their hospital stay, from pre-admittance to discharge. This helped staff feel more comfortable with the accreditation process.

LHSC also brought together a team to focus on Accreditation Canada’s ROPs. It included leaders, patient safety and clinical risk specialists, as well as seconded individuals representing a wide range of clinical roles from each vice-president portfolio to prepare for Accreditation Canada’s November 2018 on-site survey, and, more importantly, to solidify a culture of patient safety and continuous quality

improvement within the organization.

Their work involved developing and implementing rapid assessment and improvement plans, educating staff, conducting ‘tracers’ on clinical units and patient rounds. The team was also actively engaged in the implementation of specific ROPs and standards, and supported clinical areas in carrying out all initiatives.

Staff involvement in the projects and processes brought credibility and a frontline perspective to the changes.

Mid-way through accreditation preparations, LHSC launched a new vision, mission and values, as well as strategic plan, both of which incorporate the patient voice. Being ‘accreditation-ready everyday’ supports the strategic direction to deliver exceptional quality and safety, and aims to make sure patients and families get the care they need, when and

HEALTH & SAFETY

where they need it. In addition, it ensures accreditation readiness is sustainable.

LHSC’s quality and performance team also integrated accreditation standards into its performance reporting framework and process. In April 2018, new indicators were added to the LHSC corporate balanced scorecard to highlight key areas of focus aligned to accreditation ROPs. Preventative maintenance was chosen as a pilot indicator and leaders were provided with monthly reports about equipment in their area that was overdue for preventative or planned maintenance. Next, two indicators related to this were added to quarterly technical reports, which leaders must monitor and report on. In only six months, the biomedical engineering team went from having 1,800 overdue items in March 2018, to 83 in September 2018.

This represents a significant achievement as 93.4 per cent of required preventative maintenance was completed LHSC-wide within 31 days.

Beginning in October 2018, two additional accreditation-related indicators were added to the LHSC balanced scorecard. Transfer of information and accountability, another ROP, ensures

IN ONLY SIX MONTHS, THE BIOMEDICAL ENGINEERING TEAM WENT FROM HAVING 1,800 OVERDUE ITEMS IN MARCH 2018, TO 83 IN SEPTEMBER 2018. patients are transferred in a reliable, safe and patient-centred manner when they are moved from one part of LHSC to another.

The related scorecard indicator measures how many patients were transferred using direct communication between their primary caregivers within a defined time, thereby evaluating the effectiveness of patient transfers within LHSC. Medication reconciliation (med rec) at all points of transition is a critical patient safety and quality practice that holds implications for patient outcomes, patient experience and organizational efficiency, and is also an ROP. While the adoption of med rec for inpatients is a standard best practice in acute care hospitals, it is not yet widely adopted in outpatient settings, despite evidence that medication-related problems occur in high rates among

some ambulatory populations. Measuring the rate of completion for med rec at all points of transition will ensure continued improvement in this important safety indicator.

As a result of the investment in accreditation readiness, there is a collective feeling at LHSC that the hospital is living and breathing its promise to ensure patient safety. This commitment was evident in the patient safety and quality education days held in June 2018, which saw nearly 2,200 nurses, 780 health discipline staff and 135 organizational leaders take part.

Marek Kubow is a communications consultant with the corporate communications and public relations department at London Health Sciences Centre.

Representing all areas of London Health Sciences Centre, the accreditation team focused on ensuring compliance with Accreditation Canada’s required organizational practices and standards.

SPRING/PRINTEMPS 2019 23

t

24 CANADIAN HEALTHCARE FACILITIES

HEALTH & SAFETY

BUILDING THERAPY The healing power of indoor air

By Stephanie Taylor

H

uman beings are living in an era that is both frightening and exciting.

The global emergence of new infectious viruses and bacteria, combined with the reemergence of pathogens that people thought they were safe from, has healthcare personnel on edge. These microorganisms not only carry the threat of severe illness; many are resistant to antiviral or antibiotic treatment. In addition to the increased risk of infection, the percentages of people suffering from autoimmune and inflammatory diseases are on the rise. On the bright side, there are new tools that can assist with understanding why these alarming disease trends are occurring and reveal strategies to lower the risk of becoming ill.

Still, why are the rates of some diseases rising despite extensive vaccination programs, and sophisticated medical diagnostic and treatment protocols?

The answer may lie in the pages of an old elementary biology textbook. In 1859, Charles Darwin published On the Origin of Species. He described how living organisms adapt to their environment — their shapes and physiological processes evolving in order to survive and reproduce within the surrounding fields of gravity, magnetic forces and chemical reactions.

Now, 160 years after the publication of Darwin’s theory, ‘survival of the fittest,’ modern-day humans spend more than 85 per cent of their time in buildings. This means the conditions created in the indoor environment have become powerful evolutionary forces.

Which begs the questions: How does the indoor environment impact both humans and microbes? Are buildings being designed and operated in a way that selects the bacteria and viruses that cause disease while simultaneously weakening the immune systems of human occupants? Are the microbial communities in buildings contributing not only to acute infectious diseases but also to chronic inflammatory conditions and autoimmune disorders that people are suffering from?

Thanks to the same genetic analysis tools that were used to crack the DNA code of the human genome, such questions can now be answered. These tools, generally referred to as metagenomic techniques, can identify the communities of microbes in buildings and human occupants.

Information revealed by metagenomics has provided a completely new understanding of the relationships humans have with microbes. Prior to these revelations, bacteria, viruses and fungi were thought of as ‘germs’ that cause disease and needed to be eradi-

cated as soon as possible. However, this is incorrect. The human body is a living ecosystem, host to trillions of microbes that actually outnumber human cells tenfold. These tiny microbes not only cohabitate on and in the body but they take up residence in people’s homes and in other occupied buildings. Most of these microbes support human health by contributing to food digestion, training the immune system, modulating neurotransmitters to support mental health and protecting skin from penetration by harmful microbes. A small percentage, however, are pathogenic (disease-causing) microbes.

Understanding the intersection of buildings, indoor microbes and humans is not simply theoretically interesting; it is an urgent topic for everyone, especially hospitalized patients. Healthcare associated infections (HAIs), often from antibiotic resistant bacteria, are claiming the well-being and lives of hundreds of thousands of patients every year in the U.S. alone.

How much does the design, operation and management of the hospital building contribute to this HAIs epidemic?

New information is emerging from studies that correlate patient HAI rates, indoor climate (temperature, humidity, carbon dioxide, outdoor air, SPRING/PRINTEMPS 2019 25

HEALTH & SAFETY

and so on) and building design, and the indoor microbiome. Evidence suggests the microbial communities in mechanically ventilated buildings are both less diverse and more closely related to pathogens when compared to microorganisms outdoors or in buildings with operable windows.

Another startling finding is that buildings with indoor relative humidity (RH) below 40 per cent contain more infectious microbes, as well as more occupants suffering from infections and psychological stress. Conversely, indoor climates with RH between 40 and 60 per cent have the greatest number of health-promoting microbes and healthy, productive human occupants.

Studies on the relationships between the built environment, indoor microbial communities and occupant health in other building types are yielding similar results.

How can this be?

Ambient conditions with RH less than 40 per cent promote infectious pathogens, while simultaneously hampering people’s ability to combat disease.

Dry air contributes to this disastrous combination for several reasons: indoor communities of microbes are less diverse and skewed toward pathogenic species; infectious aerosols coughed or shed from occupants shrink and are transmitted farther and longer in tiny desiccated droplets, capable of reaching more vulnerable secondary hosts through inhalation or skin exposure; Biomedical_CHF_Winter_2017_FINAL.pdf 1 when water vapour is low, the actual virility or infectivity of many viruses and bacteria is greater, though for reasons still not understood; and human physiological barriers and

natural immunity are impaired when water vapour is lacking.

These findings offer new tools to control patient infections, reducing avoidable suffering, death and healthcare costs.

This is not entirely new information, though. A 1985 study found that RH between 40 and 60 per cent was advantageous to humans and decreased pathogenicity of microbes.

So, why aren’t buildings that are occupied by humans humidified?

In short, there’s worry about water condensation within walls in cold climates and increased energy costs from running humidifiers. And then there’s the issue of ongoing maintenance.

The best course of action is to design buildings with adequate envelopes and insulation to contain healthy water vapour (humidity) levels without preventing the dew point from being reached in interstitial spaces such as walls. Building codes must be updated to protect human occupants, not simply to prevent immediate disasters like fires and to keep energy consumption down.

It’s now known that proper humidification does not necessarily mean higher energy consumption. When the RH in operating rooms is maintained at 40 per cent, fewer infectious aerosols settle into the sterile field compared to a RH of 20 per cent. For this reason, room air change rates can be reduced because infectious particles settle down rather than being resuspended 2017-10-23 4:45 PM in dry, turbulent air. Another energy-saving benefit comes from decreased evaporation of moisture from the skin of occupants.

This results in people feeling comfortably

warm at thermostat settings several degrees lower than temperatures needed for comfort in dry air.

Ultimately, maintaining proper water vapour between 40 and 60 per cent RH will achieve cleaner environments with healthier occupants. Research across multiple building types and climactic regions consistently show that adequate water vapour must be provided for all occupants.

To motivate building owners to create indoor spaces that truly support human health, return on investment models must be developed to capture the financial benefits of healthy and productive building occupants. When building engineers and medical professionals learn to work together, united in ongoing research and implementation of proper indoor humidification systems, building occupants will benefit from fewer infections and other diseases exacerbated by the built environment.

Stephanie Taylor is CEO of Taylor Healthcare Consulting Inc., a physician-led company that evaluates the built environment from the perspective of occupant well-being.

Stephanie received her doctor of medicine from Harvard Medical School, after which she practiced pediatric oncology at the Dana-Farber Cancer Institute and conducted research in cellular growth mechanisms.

Alarmed by the high number of patients acquiring infections during their inpatient treatment, Stephanie became determined to better understand the role of the built environment in patient outcomes and obtained a master’s degree in architecture. She can be reached at 860-501-8950 or md@taylorcx.com.

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WHEN RISK BECOMES REALITY Behind the scenes of an aspergillus investigation

By Jessica Fullerton & Susy Hota

A

spergillus is a fungus ubiquitous in nature and an important cause of life-threatening infections in immunocompromised patient populations, including those with prolonged neutropenia, stem cell transplant, solid organ transplant and inherited or acquired immunodeficiencies. When aspergillus infections arise in patients who are admitted to hospital, healthcare exposure, especially related to construction and renovation activities, is often implicated.

THE PECULIAR PROBLEM

Between May and November 2013, an increased incidence of invasive pulmonary aspergillosis (IPA) was observed among heart transplant recipients at a University Health Network (UHN) acute care facility in downtown Toronto.

Nosocomial or hospital-acquired aspergillosis is very difficult to ascertain due to the insidious nature of the infection, particularly for patients that are admitted for long periods of time. The incubation period (time 28 CANADIAN HEALTHCARE FACILITIES

between exposure and symptoms) can vary depending on the exposure dose and progression to active infection, which relies heavily on the immunocompromised status of the individual.

Given these issues, a conservative assessment was used when classifying a case as nosocomial, with the predominant risk factor being length of stay. Several other factors were taken into account, including previous hospital visits, occupation, recreational activities such as gardening, drug use, previous chest X-ray/CT scan, onset of new respiratory symptoms and any previous respiratory symptoms.

A THOROUGH EXAMINATION

The hospital’s infection prevention and control (IPAC) department launched an extensive, thorough investigation that spanned several months. Each circumstance was analyzed in terms of case definition, bed history, procedures performed, clinic visits, proximity to maintenance and/or construction work, and timing and scope of such work.

It was determined that no other transplant organ groups within the facility were affected. The organization responsible for coordinating organ donation in Ontario, the Trillium Gift of Life Network, had no reported donor-related issues (donor infections, contaminated tissues, harvesting or transportation process concerns). No common patient links prior to admission (for example, hotels) could be identified. There were also no shared environmental connections (common operating rooms or procedure rooms) once patients were admitted.

A heart transplant recipient was followed through the course of their admission, from pre-operative care to operating room to recovery, providing a geographical footprint of potential exposure sites. No obvious source was identified and no major breaches in IPAC procedures were observed.

Air sampling as well as environmental sampling were taken at each location, but again no clear source was identified. As all cases involved pulmonary infection, particular attention was given to the maintenance

INFECTION PREVENTION & CONTROL

large renovation projects were conducted within the facility, including one within the medical device reprocessing department and another within the cardiac clinic space. All IPAC construction records and reports were reviewed, including hoarding inspection reports and negative pressure logs. No significant hoarding breaches were identified.

Numerous excavation and demolition projects outside the walls of the facility were also occurring at this time. Another healthcare facility and an old nursing residence tower were demolished within a two-block radius. Although misting techniques were employed to minimize dust disturbance, this could not be ruled out as a potential source.

The front entrance of the hospital was also undergoing significant landscaping, resulting in soil disturbance. Again, misting techniques were utilized but the entrance remained functional during the work.

INVESTIGATION DISCOVERY

of equipment in the medical device reprocessing department and respiratory therapy reprocessing and storage areas.

Building heating, ventilation and cooling systems were investigated, including ductwork, outdoor air intakes and filters. All systems were on a six-month preventative maintenance program. The facilities department was able to confirm the air handling units (AHU) were routinely serviced and cleaned, and filters changed as required. No concerning drip pans or sources of water were identified within the AHU. The filters were all inspected and none were observed to be loaded or improperly installed. The ductwork was also on a six-month inspection protocol that included cleaning of the ductwork, if necessary.

Implementation of a ductwork inspection protocol had recently been employed for high-risk areas of the facility to help ensure adequate air quality.

Investigation of interior and exterior construction/maintenance work spanning the exposure period was also carried out. Several

Although the epidemiology supported a nosocomial cluster, no clear source was identified within the hospital. This is typical for fungal outbreaks as the dispersion of fungi can occur at specific points in time that cannot be detected with subsequent sampling. Combined with ongoing cases, the decision was made to start all heart transplant patients on antifungal prophylaxis medications for the first three months after transplant. Prophylaxis continues to this day.

The financial impact of such an extensive investigation included many man hours, air and environmental sampling costs, additional medication and procedural costs, and extended length of stay. The patient impact was immeasurable for those affected, including families.

NEXT STEPS

Ongoing vigilance to activities that result in spore disruption is critical to protecting a hospital’s most vulnerable patient populations. Tight prevention measures need to be in place to control dust generation and prevent dust that may contain fungal spores from infiltrating patient care areas,

whether inside or outside the walls of a facility. A robust IPAC construction program with enough manpower to adequately review hoarding plans, inspect hoarding set-up and monitor construction activities in addition to routine building maintenance is critical to ensuring patients are protected. The integration of IPAC and construction/renovation/ maintenance activities into a facility incident report management system has made identification and follow-up of environmental issues or incidents much more streamlined at UHN. It cannot be overstated that contractors knowledgeable in healthcare requirements for infection prevention and control are essential. Facilities should strongly consider a requirement for all contactors to be certified to CSA standard Z317.13-17, Infection Control during Construction, Renovation and Maintenance of Healthcare Facilities.

This investigation highlights the importance of routine, ongoing fungal surveillance in immunocompromised patients and the need to have an accurate baseline to detect increased incidence in cases promptly. IPAC needs to be well-integrated into the multi-disciplinary care team as connection with frontline clinicians is fundamental to early identification of cases and/or issues. These events have also emphasized the importance of working collaboratively with a multidisciplinary team, including physicians, surgeons, nursing staff, support service staff, facility maintenance staff, capital project managers and planners, and external construction/renovation contractors to ensure healthcare facilities are functioning optimally to support and protect the most vulnerable patients.

Jessica Fullerton is the construction lead with the infection prevention and control (IPAC) department at University Health Network (UHN). Susy Hota is medical director of the IPAC and medical device reprocessing department at UHN, and assistant professor in infectious diseases at the University of Toronto.

They can be reached at jessica.fullerton@uhn.ca and susy.hota@uhn.ca, respectively.

SPRING/PRINTEMPS 2019 29

A CHANGE IS AFOOT

Un changement se prépare By/Par Robert Kravitz

T

he U.S. Centers for Disease Control and Prevention (CDC) has revised its stance on floor care in healthcare facilities.

Previously, its position was that extraordinary cleaning and decontamination of floors was unwarranted. This was based on studies that demonstrated the disinfection of floors offered no advantage over regular detergent/water cleaning, and had minimal or no impact on the occurrence of healthcareassociated infections (HAIs).

In further defence of its reasoning, the CDC stated people in hospitals rarely touch floors and they only need to be cleaned when visibly soiled, with the exception of operating rooms, which should be mopped at the end of each day.

In 2016, a group of researchers decided to test the CDC’s conclusions. They enrolled 10 hospital patients in a study. For each patient, a section of floor adjacent to their hospital bed was inoculated with sterile water containing bacteriophage, a virus that can infect bacteria and potentially destroy it. The floor areas were then allowed to dry.

None of the patients knew of the precise area of the inoculation and hospital staff was not made aware of the study.

All cleaning protocols remained the same during the research 30 CANADIAN HEALTHCARE FACILITIES

L

es Centers for Disease Control and Prevention (CDC) des États-Unis ont révisé leur position sur l’entretien des planchers dans les établissements de santé.

Auparavant, leur position était que le nettoyage et la décontamination extraordinaires des planchers n’étaient pas justifiés. Cette recommandation se fondait sur des études démontrant que la désinfection des planchers n’offrait aucun avantage par rapport au nettoyage régulier à l’eau et aux détergents et n’avait que peu ou pas d’impact sur l’occurrence des infections nosocomiales.

Pour étayer leur raisonnement, les CDC soutenaient que les gens touchaient rarement les planchers et que les planchers ne devaient être nettoyés que lorsqu’ils étaient visiblement souillés, à l’exception des salles d’opération, qui devraient être nettoyées à la fin de chaque journée.

En 2016, un groupe de chercheurs a décidé de tester les conclusions des CDC. Ils ont recruté 10 patients hospitalisés dans le cadre d’une étude. Pour chaque patient, une section du plancher adjacente à leur lit d’hôpital a été inoculée avec de l’eau stérile contenant un bactériophage, un virus qui peut infecter les bactéries et potentiellement les détruire. On a ensuite laissé sécher les surfaces.

Aucun des patients ne connaissait la zone précise de l’inoculation et le personnel hospitalier n’a pas été informé de l’étude.

INFECTION PREVENTION & CONTROL

period. High-touch and commonly touched surfaces were cleaned with bleach and wipes each day. Following the CDC’s recommendations, floors were only cleaned when visibly soiled.

Just one day after commencement of the experiment, researchers detected bacteriophage on multiple surfaces near the patient beds. Within three days, the bacteriophage was detected on various surfaces within three feet of the beds. After three days, contamination was found on high-touch surfaces in adjacent hospital rooms, the nursing station and on portable equipment, such as wheelchairs, medication carts and vital signs equipment.

The researchers concluded the bacteriophage was likely acquired during direct contact with the contaminated floor adjacent to the hospital bed. During removal of footwear, patients could easily acquire the virus on their hands, with subsequent transfer to touched surfaces and other skin areas.

The finding of contamination in adjacent rooms and the nursing station suggests that healthcare personnel contributed to the dissemination. This happened after acquiring the virus during contact with contaminated patients or surfaces.

According to ISSA education manager Mark Werner, people can have as many as 50 direct and indirect contacts with potentially contaminated floors everyday. Contact may occur, for instance, when picking up items like pens, pencils or paper

Tous les protocoles de nettoyage sont demeurés les mêmes pendant la période de recherche. Les surfaces souvent touchées étaient nettoyées chaque jour avec de l’eau de Javel et des lingettes. Conformément aux recommandations des CDC, les planchers n’étaient nettoyés que lorsqu’ils étaient visiblement souillés.

Un jour seulement après le début de l’expérience, les chercheurs ont détecté des bactériophages sur plusieurs surfaces adjacentes aux lits des patients. En trois jours, les bactériophages ont été détectés sur diverses surfaces à moins d’un mètre des lits. Au bout de trois jours, on a trouvé de la contamination sur des surfaces très souvent touchées dans les chambres d’hôpital adjacentes, au poste de soins infirmiers et sur de l’équipement portatif, comme des fauteuils roulants, des chariots à médicaments et des moniteurs de signes vitaux.

Les chercheurs ont conclu que le bactériophage avait probablement été propagé lors d’un contact direct avec le plancher contaminé adjacent au lit d’hôpital. Pendant le retrait de leurs chaussures, les patients pouvaient facilement attraper le virus sur leurs mains et le transférer ensuite sur les surfaces touchées et d’autres zones de la peau. La découverte d’une contamination dans les pièces adjacentes et au poste de soins infirmiers suggère que le personnel de santé a contribué SPRING/PRINTEMPS 2019 31

INFECTION PREVENTION & CONTROL

IN FURTHER DEFENCE OF ITS REASONING, THE CDC STATED PEOPLE IN HOSPITALS RARELY TOUCH FLOORS AND THEY ONLY NEED TO BE CLEANED WHEN VISIBLY SOILED, WITH THE EXCEPTION OF OPERATING ROOMS, WHICH SHOULD BE MOPPED AT THE END OF EACH DAY.

that have accidently fallen onto floors or tying shoelaces that have been in contact with floors.

It’s also possible to inhale floor contaminants. A 2016 study published in the Journal of Applied Microbiology determined that from the floor, air currents, human movements over the floor and other factors that aerosolize or provide an airborne opportunity for the organism may occur, causing human infections via inhalation, horizontal or cross-contamination from other persons, clothing or equipment that the organism resettles upon.

So, what can be learned from these studies?

The CDC failed to recognize that people make scores of contacts with floors on a daily basis and pathogens on floors can become airborne. As well, while ‘extraordinary’ steps may not need to be taken to properly clean floors, the health protection agency’s claim that disinfectants are not required goes too far. An effective floor care program should comprise the use of effective disinfectants, detergents, cleaning agents and tools.

Speaking of tools, the CDC suggests that mops be used to clean floors. However, it’s well known that mops spread pathogens. No-mop floor cleaning alternatives like sprayand-vac systems were just being introduced in 2003, so it is possible the CDC was not aware of them at that time.

Spray-and-vac has since been supplemented with dispense-and-vac and other no-mop cleaning systems, all of which have become standard floor care equipment in the cleaning industry.

The CDC also neglected to address cleaning frequency. In most healthcare facilities, keeping floors both visibly clean and healthy requires dividing floor care into three steps based on need: daily, periodic and yearly maintenance.

Daily maintenance involves the removal of dry soils on the surface. Vacuuming instead of sweeping is the healthiest way to perform this type of cleaning. Alternatively, floors can be cleaned using a no-mop floor care alternative.

Periodic maintenance consists of scrubbing floors with an auto-vac floor cleaning system or automatic scrubber.

Once per year, floors should be refinished. This involves the removal of all finish from the floor and a new finish applied. However, if daily and periodic maintenance are 32 CANADIAN HEALTHCARE FACILITIES

à la dissémination. Cela s’est produit après l’acquisition du virus lors d’un contact avec des patients ou des surfaces contaminés.

Selon Mark Werner, responsable de la formation à l’International Sanitary Supply Association (ISSA), les gens peuvent avoir chaque jour jusqu’à 50 contacts directs et indirects avec des sols potentiellement contaminés. Le contact peut se produire, par exemple, lorsque vous ramassez des objets comme des stylos, des crayons ou du papier qui sont tombés accidentellement sur le sol ou lorsque vous attachez des lacets de chaussures qui ont été en contact avec le sol.

Il est également possible d’inhaler les contaminants du plancher. Une étude publiée en 2016 dans le Journal of Applied Microbiology a déterminé qu’à partir du sol, les courants d’air, le va-et-vient et d’autres facteurs qui aérosolisent les pathogènes peuvent se produire, causant des infections humaines par inhalation, par contamination horizontale ou croisée d’autres personnes, vêtements ou équipements.

Alors, que peut-on apprendre de ces études?

Les CDC n’ont pas reconnu que les gens établissaient quotidiennement de nombreux contacts avec les sols et que des agents pathogènes présents sur les sols pouvaient devenir aéroportés. De plus, bien qu’il ne soit peut-être pas nécessaire de prendre des mesures extraordinaires pour nettoyer correctement les sols, la déclaration de l’agence de protection de la santé selon laquelle les désinfectants ne sont pas nécessaires va trop loin. Un programme efficace d’entretien des sols devrait comprendre l’utilisation de désinfectants, de détergents, d’agents de nettoyage et d’outils efficaces.

En parlant d’outils, les CDC suggèrent d’utiliser des vadrouilles pour nettoyer les planchers. Cependant, il est bien connu que les vadrouilles répandent des agents pathogènes.

Des solutions de rechange pour le nettoyage des planchers sans vadrouille, comme les systèmes d’aspersion et d’aspiration, n’ont été introduites qu’en 2003, de sorte qu’il est possible que les CDC ne les connussent pas à l’époque. Depuis lors, les systèmes de pulvérisation et d’aspiration ont été complétés par des systèmes de distribution et d’aspiration et d’autres systèmes de nettoyage sans vadrouille, qui sont tous devenus des équipements d’entretien des sols standard.

Les CDC ont également négligé la fréquence des nettoyages.

Dans la plupart des établissements de santé, pour que les sols restent visiblement propres et salubres, il faut diviser les soins en trois étapes en fonction des besoins : entretien quotidien, périodique et annuel.

L’entretien quotidien consiste à enlever les saletés sèches en surface. Passer l’aspirateur au lieu de balayer est la façon la plus saine d’effectuer ce type de nettoyage. Il est également possible de nettoyer les planchers à l’aide d’un produit d’entretien sans vadrouille.

L’entretien périodique consiste à nettoyer les planchers à l’aide d’un système de nettoyage des planchers par aspiration automatique ou d’un laveur automatique.

Une fois par année, les planchers doivent être repolis. Ceci implique l’enlèvement de tout le fini du plancher et l’application d’un nouveau fini. Cependant, si l’entretien quotidien et périodique est effectué fréquemment et correctement, cette dernière étape peut être retardée jusqu’à deux ans.

CHES Canadian Healthcare

SCISS

Société canadienne d'ingénierie

Engineering Society des services de santé CALL FOR NOMINATIONS FOR AWARDS

CALL FOR NOMINATIONS FOR AWARDS 2016 2016 Hans Burgers Award

Wayne McLellan Award of Excellence

For Outstanding Contribution to 2019 Hans Burgers Award Healthcare Engineering

In Healthcare Facilities Management

2019 Wayne McLellan Award of Excellence In Healthcare Facilities Management April 30, 2019 DEADLINE: DEADLINE: April 30, 2016

for Outstanding Contribution to Healthcare Engineering DEADLINE: April 2019 DEADLINE: April 30, 30, 2016

Tonominate: nominate:Please use the nomination form posted on theTo nominate: To nominate: Please use the nomination form posted on the To  Please use the nomination form posted on use theand nomination form posted on  Please CHES website and refer to the Terms of Reference.

CHES website refer to the Terms of Reference. the CHES website and refer to the Terms of 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 The award shall of behealthcare presentedengineering. to a resident of capital project, energy efficiencycare program, environmental facilities that have demonstrated outstanding Canada as a mark of recognition of outstanding stewardship program or team building exercise. success in completion of a major capital achievement in the field of healthcare Award sponsored by project, energy efficiency program, engineering.

Award sponsored environmental stewardship program, or by 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, ches@eventsmgt.com Fax: 866-303-0626 www.ches.org / About CHES / Awards Send nominations to; CHES National Office ches@eventsmgt.com Fax: 613-531-0626

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INFECTION PREVENTION & CONTROL performed frequently and correctly, this last step can be delayed for as much as two years.

The CDC has realized its past errors when it comes to floor care. Its recent guidelines place considerable emphasis on the need to keep floors clean and disinfected as much as possible in order to protect human health. They include: cleaning floors on a regular basis, when spills occur or visibly soiled; following manufacturers’ instructions for proper use of disinfecting products; preparing disinfecting solutions as needed and replacing with fresh solution frequently (for example, mopping solution should be changed after every three patient rooms and no less than at 60-minute intervals); decontaminating mop heads and cleaning cloths regularly to prevent contamination; and using an Environmental Protection Agency (EPA) registered hospital disinfectant designed for housekeeping purposes in patient care areas where there is uncertainty about the nature of the soil on the floor (for example, blood or body fluid contamination versus routine dust or dirt) or the presence of multi-drug resistant organisms. The CDC now also has specific floor cleaning recommendations for when patients have certain, very contagious diseases. For instance, daily cleaning is required if a patient has Ebola, and the floor must be thoroughly cleaned and disinfected once that patient moves out of the room.

Les CDC ont reconnu leurs erreurs passées en matière d’entretien des sols. Leurs lignes directrices récentes insistent beaucoup sur la nécessité de garder les planchers propres et désinfectés autant que possible afin de protéger la santé humaine. Ils incluent : nettoyer les planchers régulièrement, lorsque des déversements se produisent ou que la saleté est visible ; suivre les instructions du fabricant pour l’utilisation appropriée des produits désinfectants ; préparer des solutions désinfectantes au besoin et les remplacer fréquemment par une solution fraîche (par exemple, la solution de nettoyage devrait être changée après trois chambres et au moins aux 60 minutes d’intervalle) ; utiliser un désinfectant hospitalier homologué par l’Environmental Protection Agency (EPA) à des fins d’entretien ménager dans les aires de soins aux patients où il y a incertitude quant à la nature de la saleté sur le plancher (par exemple, contamination par le sang ou des liquides organiques par rapport à la poussière ou la saleté courante) ou à la présence d’organismes multirésistants. Les CDC ont aussi des recommandations spécifiques pour le nettoyage des sols lorsque les patients ont certaines maladies très contagieuses. Par exemple, un nettoyage quotidien est nécessaire si un patient est atteint d’Ebola, et le plancher doit être nettoyé et désinfecté à fond une fois que le patient quitte la pièce.

Robert Kravitz is a frequent writer for the professional cleaning industry.

Robert Kravitz est un chroniqueur de l’industrie du nettoyage professionnel.

• 200,000 people in Canada get an infection from a hospital each year • 5% (10,000) will die • Healthcare acquired infections cost us $4-5 billion EACH year Join the Coalition for Healthcare Acquired Infection Reduction (CHAIR)

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