MECHANICAL ELECTRICAL PLUMBING POWER AN ENGINEERING SOLUTION CENTER
ENVIRONMENTS THAT HELP HEAL Patient-Centered Design Considerations for Healthcare
A Strategic Direction Report Prepared by West Plains Engineering, Inc.
September 2018
westplainsengineering.com
CONTENTS Mike Drahos, P.E.
Jonathan Kennedy, P.E.
O3 O4 O5 12 13
The Introduction Implementing Empathetic Design The Issue Positive Patient Experiences The Approach Safety, Comfort and Care The Take Away Gaining Perspective
Works Cited
About the Authors Mike Drahos, P.E. is a mechanical engineer and manager of our Cedar Rapids office. He has more than 25 years in the A/E/C industry, and has worked extensively as both a consulting engineer and mechanical contractor with healthcare organizations across Iowa and Minnesota. mike.drahos@westplainsengineering.com Jonathan Kennedy, P.E. is an electrical engineer in our Sioux Falls office. During his more than 15 year career, he has designed electrical systems for hospitals, clinics and specialty care facilities, including both the Sanford and Avera systems of care. jonathan.kennedy@westplainsengineering.com
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The Patient Experience
From surgeons to security guards, anyone involved in a healthcare setting is focused on one thing – the patient. It’s no surprise that medical facilities, and by extension those that design them, are expected to do the same.
The need for healthcare, and healthcare facilities, is skyrocketing in our
country. According to the U.S. Bureau of Labor & Statistics, the healthcare industry will grow faster and add more jobs in the next decade than any other sector. (Healthcare Occupations, 2018) For healthcare workers, having a facility that supports their practice is essential to care. These buildings are ground zero for providing a healing, peaceful environment for patients – but the delivery of that environment has changed over the years. Facilities were once designed as evidence-based functional spaces, but that approach has evolved into experiential environments created with the knowledge that patients heal best when they feel calm, comfortable and secure. It’s a trend known as empathetic design.
Wyoming Medical Center McMurry West Patient Tower Our largest healthcare project to date is the $30 million McMurry West Patient Tower at the Wyoming Medical Center in Casper. This 101,150 square foot, four-level facility delivered a new mother/baby unit, orthopedic and spine care patient rooms, kitchen/dining area, imaging and support spaces.
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The Issue Writing a white paper on engineering design considerations for healthcare is kind of like trying to boil the ocean – there’s simply too much to do it all at once. On the mechanical and electrical side alone, there are literally hundreds of unique challenges and approaches an engineer only faces in medical facilities. Where do you begin? If we’ve learned anything from our healthcare clients – it’s that the most important thing, no matter what, is the patient. That’s how they approach their work, and it’s a key take away for the design team. Our job is to create an environment that helps heal, and to do that, each discipline must collaborate to develop spaces that are safe, comfortable and deliver quality care. The mechanical and electrical systems are no exception. As always, reliable power, HVAC and plumbing systems are critical. But in recent years, mood-lifting lighting schemes, complex telecommunications networks and efficient green design are an increasing standard.
Additionally, healthcare today is delivered through the lens of the patient experience. That means even designers need to understand not only the physical care that patients receive, but also the emotional and psychological impact various facility design elements can have on healing. It’s known as empathetic design and studies have shown, if done right, it can play a big part in patient care. (Freihoefer, 2018) In this Strategic Direction Report, we’ll part the ocean of healthcare design considerations to address these specific issues and others focused around safety, comfort and care. From emergency power systems and patient-focused lighting schemes to infection control and support for life saving medical equipment – we’ll share our approach to delivering on client expectations and budgets. It may seem like just a drop in the bucket for this complex industry, but if it’s patient-centered, it’s the right place to start.
But there are obvious challenges to meeting these goals. Modern medical construction is some of the most regulated of any industry, and at times those high standards come with an equally lofty price tag. As margins shrink and patient volumes increase, funds are already tight. It’s up to the design team to get creative with solutions that fit both the standard, and the budget.
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The Approach
1 Patient Safety 2 Comfort & Care
Patient Safety
1
Medical facilities are considered places of safe refuge. Hospitals are required to be constructed to a very high standard, which is evident when noting the myriad of codes and published standards that apply to the design, construction and maintenance of these complex buildings. The mechanical and electrical systems are no exception. As owner user groups, architects and engineers collaborate on construction projects, both large and small, it is inevitable that these teams spend significant time reviewing the needs of the patients, as well as the expectations of the keepers of the facilities, and balancing these needs and expectations with the requirements set forth by governing codes. It’s very easy to become lost in the details. However, it’s important to consider the key requirement: creating a safe place for expert professional care. Electrical Systems & Technology Electrical and technology systems in medical facilities are critical to successful operation, and the safety of patients and residents. It’s expected that most, if not the entire facility can operate without interruption; and in the case of critical-access hospitals and long-term care nursing facilities – there is no exception. In addition to reliable primary power, a backup power source is necessary for the continued operation of life support systems. Emergency power is expected to operate heating systems for facilities in cold climate areas, and air conditioning in hot regions. But it’s not only the environment that’s critical. Backup power for information technology and data systems may also be a strong consideration, because down-time results in loss of revenue. Clearly, the reliability of the electrical infrastructure should be a key consideration to facility design teams. It can affect a number of decisions very early in the project. For example, the location of the electrical service. Where the utility service to the building is in relation to physical surroundings may be subject to problems caused by natural disasters (downed trees, flooding, etc.). By understanding these scenarios from the start, the team can make better decisions to safeguard the entire infrastructure. Behind the Scenes Safety When it comes to keeping medical facilities safe, there’s a lot that goes on behind the scenes – particularly with emergency power. Obviously, generators come to mind in supplying this power, but it’s equally important to monitor these systems to assure that they perform when they’re needed most. Recently, UIHC installed new remote emergency generator annunciator panels, which monitor generator status, in the central dispatch area of their facility. Although not a direct patient care location, this is a 24/7 area where the status of critical emergency power can now be closely and remotely watched.
There are 11 generators located throughout the facility, and this project added annunciator panels for all of them. Monitoring includes generator status items such as low fuel level, low coolant level, battery charger failure and high coolant temperature. Due to the age of a few of the generators, our team also upgraded the control panels, so they could be connected to the new annunciator panels. The ability to quickly identify any faults with the emergency power system is critical to maintaining reliable power – and patient safety.
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The Approach
1 Patient Safety 2 Comfort & Care
Patient Safety
1
Telecommunications Telecommunications systems are fast-evolving, and the use of such technology within medical facilities is not only commonplace, but it is an essential requirement. These systems touch virtually ever level of patient care, enhancing both safety and treatment. The ability to communicate with and monitor patients has never been more comprehensive. Nurse call systems have evolved beyond simple pull cords and dome lights to sophisticated two-way communication devices which promote care provider-to-patient dialogue. Additionally, patient tracking monitoring systems allow patients to maintain mobility, while wander management systems may be implemented where there is a risk of patients or long-term residents straying outside of a safe and secure area. Protecting, accessing and collaborating over Patient Health Information (PHI) is more important than ever. With the federally-mandated Electronic Health Record (EHR) initiative, all facilities were to adopt and demonstrate meaningful use of electronic medical records (EMR) by January 1, 2014 in order to maintain their existing Medicaid and Medicare reimbursement levels. Far from the days of paper charts, these new computer and data IT systems allow the interconnection of computer systems throughout a facility or multiple facilities so that caregivers at any location, at any time, have the information they need to make the right treatment decisions.
Life Safety Improvements West Plains provided the mechanical and electrical design for a series of Life Safety Improvements at the State Veteran’s Home in Hot Springs, SD. These improvements included an updated Nurse Call System, campus-wide remote Resident Tracking network and video surveillance to add extra safety and security for both residents and staff.
Other important telecommunications considerations include cell phone signal boosting systems, which are available to rectify problem areas in facilities that might otherwise experience poor cellular telephone service in certain, if not all parts of a building. In the same vein, fire fighter two-way radio communication enhancement systems are present in many facilities to allow emergency personnel the ability to effectively communicate, while fire alarm systems also now broadcast alarms as pre-recorded voice messages in lieu of traditional horn systems.
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The Approach
1 Patient Safety 2 Comfort & Care Positive vs. Negative Pressure Isolation Patient rooms and operating suites can be designed with either positive or negative airflow to pressure relationship. In simple terms, this means that air either flows out of the room (positive), or into the room (negative). Positive airflow is utilized to prevent outside contaminants from infecting an immune suppressed patient, while negative airflow prevents transmittable infections from traveling outside of the patient room to public spaces. The graphic below illustrates this concept.
Figure 1. Airflow Testing and Certification. (2011, August 10). Retrieved August 30, 2018, from https://www.achrnews.com/articles/102890airflow-testing-and-certification
Patient Safety
1
Infection Control Infection control is a critical mechanical design component in protecting the patient from foreign contamination sources. It’s possible that some patients could be immune suppressed, making fighting outside sources of infection very difficult. It’s best practice to design patient care areas to have a slightly positive airflow/pressure relationship with respect to adjacent corridors and other public spaces. Unless, of course, the patient has a known transmittable infection that would require them to be in a negative pressure isolation patient room. Air filtration is a design measure used to assure good quality air is being supplied to the inpatient care areas by removing potential airborne particulates. ASHRAE Standard 170 and AIA/DHS Health Care Facilities Guidelines prescribe minimum filtration efficiences at the air handling unit for various patient care and facility support areas. Humidity control is also essential in healthcare environments. Proper design and selection of air handling equipment is important to maintain low humidity levels in the facility. Innovations in custom air handling systems designed specifically for healthcare facilities are implementing energy recovery wheels and dedicated desiccant dehumidification equipment to improve humidity control, while not overburdening the chilled water system.
Some regulatory agencies are requiring that healthcare facilities become more stringent in monitoring the environmental temperature, humidity and differential air pressure at the patient care areas. Because of this change, the automatic temperature control design for new and remodel construction should be reviewed with the owner to include additional sensors, devices and control trending strategies to meet these requirements. When it comes to plumbing for infection control, Legionella is a well-known concern that needs to be addressed when designing and commissioning potable water systems. Since Legionella bacterium thrives in warm, stagnant water, it’s important that the design of the domestic hot water system keeps the hot water circulated and minimizes the length of run-outs to fixtures. A proper startup and commissioning procedure must be written to assure potable water systems are disinfected, flushed and tested before public use. It may be common for large healthcare facilities to have a maintenance program to proactively manage the risk of Legionella in potable water systems and cooling towers. Otherwise, the engineer can assist the facility engineering department in establishing a Legionella control and management program, including routine monitoring and testing.
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The Approach
1 Patient Safety 2 Comfort & Care
Patient Safety
1
Safety During Construction Healthcare facilities are continually changing and undergoing construction for expansions, renovations and infrastructure upgrades. Infection control takes on special meaning during these medical renovations and upgrades. The design of any construction project within an existing healthcare facility cannot overlook the ongoing safety of the patients. At no time can the services to the patient care areas be interrupted, unless temporary services have been successfully planned, designed and installed. These temporary mechanical services may include plumbing, medical gas, HVAC distribution, heating hot water, chilled water, and temperature controls. Mechanical infrastructure upgrades can become extremely challenging. In some cases, temporary air handling units, boilers and chillers need to be installed to maintain the occupancy of the patient care areas while new equipment is being installed. During construction planning within a healthcare facility, an infection control risk assessment and interim life safety plan needs to be developed to ensure safety of the patients. This planning and design is done in collaboration with the facility’s risk assessment team. At smaller healthcare facilities, the infection control and life safety measures would be developed by the Architect and Engineer.
Mechanical control measures during construction may include: Close off all ductwork communicating between the construction area and adjacent occupied spaces. Seal all ducts that pass through the construction area. Seal all wall penetrations of pipe and ductwork that pass through the construction area barrier. Install air scrubbers within the construction area. An air scrubber is a portable filtration system that removes particles, gases and chemicals in the air within a given area. In small construction spaces, air scrubbers may be recirculated within the construction zone. In larger construction spaces, air scrubbers will act as a negative air machine to be ducted outdoors in order to ensure a negative pressure within the construction zone. Install a visual differential pressure gauge assembly to ensure negative pressure is maintained in the construction zone.
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The Approach
1 Patient Safety 2 Comfort & Care
Comfort & Care
2
Every decision made in healthcare today takes into account the patient experience – how that person and their family encounters and is impacted during treatment. Many medical caregivers frequently go on what are called gemba walks, short first-hand walks through the facilities to see and talk to patients and get a better understanding of what they’re experiencing. Architects and engineers need to approach medical facility design in much the same way. They need to think outside the box to create calm, comfortable healing spaces. That means even design teams need to understand not only the physical care patients receive, but also the emotional and psychological impact facility design elements have on healing. It’s known as empathetic design, and studies have shows that it can play a big part in patient care. Lighting Lighting system trends have evolved along with facility design. The use of LED lighting throughout a facility (both indoors and outdoors) is a must. Indirect lighting methods can be considered in illuminating spaces where patients may be sensitive to direct lighting, such as corridors and patient rooms. Conversely, the use of high-lumen fixtures is necessary in spaces where examination is required. Dimmable light fixtures are widely available today and implementing dimming in many spaces throughout a facility is beneficial for multiple reasons including visual comfort and energy savings. Lighting controls are equally important. As mentioned, dimming lights allow for energy savings, but there may also be spaces in a medical facility where dimmable lighting is crucial to patient recovery. Tunable lighting,
for instance, incorporates lighting controls and specific LED fixtures that allow the color temperature of lighting to vary throughout the day. The intent of tunable lighting is to mimic the feel of daylight inside the building. For instance, lighting can be tuned to a very warm hue at dusk and during nighttime hours (i.e. 3000 Kelvin - warmer lighting temperatures have a yellow hue). As the day progresses, lighting can be tuned to a cooler, brighter temperature (i.e. 5000 Kelvin), which mimics mid-day sunlight (cooler lighting temperatures have a blue hue). The intent in varying color temperature (i.e. tuning the light) is to aid in maintaining more natural circadian rhythms within the human body. This is not only beneficial to patients, but also to staff, especially in spaces where natural daylighting is not available.
Tunable Lighting This photo shows the differences in tunable LED lights in a corridor at the ACC Care Center in Sacramento, CA. With no windows to provide daylighting, the tunable system still allows patients and caregivers to experience the changing light from morning to afternoon to night. Photo: Sacramento Municipal Utility District
Morning
6500K @ 66% output
Daytime
4000K @ 66% output
Nighttime
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The Approach
1 Patient Safety 2 Comfort & Care
Comfort & Care
2
Space Temperature Control Space temperature control is an extremely importance characteristic in providing a healing environment for the patient. Individual thermostatic control in each patient room is a must. The placement of the room thermostat should be reviewed to assure it is in the best location to represent the actual space temperature. The design team should make sure there is no equipment or lights near the thermostat and refrain from locating thermostats on exterior walls. Placement and type of supply air diffusers should be reviewed for proper application. This can sometimes be challenging when coordinating with all the devices in the ceiling. It’s important to provide sufficient ventilation air to the patient breathing zone, but caution should be taken so that the diffuser airflow is not causing drafting or dumping air on the patient. The diffuser size and performance characteristics must be selected to minimize noise, while proving proper mixing of air in the design airflow range. Perimeter heating is frequently utilized to accommodate building envelope heat loss from walls and windows. In patient care rooms, it is best to provide perimeter heating to supplement the overhead air distribution rather than size overhead air distribution system to handle the building envelope heat loss. In colder climates, the heated airflow rate required to overcome the building envelope loss, for systems not utilizing perimeter heating, may be uncomfortable for the patient. Thus, supplemental perimeter heating is desired. Perimeter heating can be implemented with the use of baseboard finned tube radiation or radiant ceiling panels. Although baseboard finned tube radiation is most common and more effective, it introduces an undesirable source of contamination from dust/ debris collecting on the finned tube elements. In many installations, it is very challenging to clean the finned tube elements and is often ignored or forgotten by maintenance staff. It is recommended to utilize radiant ceiling panels as the preferred method of perimeter heating. Be aware that radiant ceiling panels may not be feasible due to large windows, high ceilings, or ceiling device conflicts.
Open MRI Relocation In 2016, our Sioux Falls team provided mechanical and electrical design to relocate an MRI machine at the Sioux Falls Specialty Hospital. The project involved the installation of the MRI equipment, re-connections to the associated X-ray equipment and modifications to the existing building to support the space.
Equipment Support Healthcare technology is changing every day with regards to new types of imaging, robotic surgery, hybrid operating rooms, etc. The mechanical systems required to support these specialty procedure rooms (process loads and environmental conditions) will be substantial and need to be coordinated closely with the manufacturers of this new equipment.
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The Take Away The first step in designing for healthcare facilities is simply a willingness to take on the proper perspective. Nearly everyone, at some point in his or her life, has been a patient themselves and/or been a support system for a family member in care. By drawing on these experiences, and respecting their importance alongside functional and regulatory requirements, the design team will approach a project from much the same angle as the owner – creating an environment to help heal without hurting the bottom line. The West Plains Difference Our engineers learned long ago that the most important consideration in designing for healthcare is the safety, comfort and confidence of the people inside. And that goes beyond the patients. Our team also recognizes that, for healthcare workers, having a facility that supports their practice is essential. We’re not only focused on empathetic design for patients, but to creating HVAC, plumbing, medical gas systems, nurse call, surgical suites, lighting and much more that works as hard as the people behind them. From hospitals to medical campuses, we carefully consider the unique needs of the space and craft solutions to help heal. For more information on our firm’s detailed approach to MEP Engineering for the Healthcare Industry, call any of our five regional offices and ask to speak with an office manager. Rapid City: Sioux Falls: Bismarck: Casper: Cedar Rapids:
(605) 348-7455 (605) 362-3753 (701) 751-7322 (307) 234-9484 (319) 365-0030
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Works Cited Figure 1. Airflow Testing and Certification. (2011, August 10). Retrieved August 30, 2018, from https://www.achrnews.com/articles/102890-airflow-testing-and-certification Freihoefer, K., PhD, CID, EDAC, LEED ID C. (2018, August 02). Getting A Feel For Empathetic Design. Retrieved from https://www.healthcaredesignmagazine.com/trends/perspectives/ getting-feel-empathetic-design/ Healthcare Occupations. (2018, April 13). Retrieved from https://www.bls.gov/ooh/healthcare/home.htm
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