Operating on medical and hospital projects: codes and standards
Engineers tasked with working on hospital and medical campuses find themselves tackling unique challenges: evolving technology, increased specialization, and maintaining operations while under construction. Here, professionals with experience on such facilities share advice on how to finish projects following codes and standards and report a clean bill of health.
Larry Anderson, PE, RCDD, CDT, Principal, TEECOM, Oakland, Calif.
Jeremy Jones, PE, LEED AP, EDAC , Healthcare Market Leader, Affiliated Engineers Inc., Chapel Hill, N.C.
Daniel S. Noto, PE, LEED AP BD+C, Healthcare Studio Leader-Southeast Region, exp, Atlanta
Eric Reuther, PE, LEED AP BD+C, Principal, McClure Engineering Associates Inc., St. Louis
Jonathan B. Slagel, PE, LEED AP, HFDP, Principal/Vice President York Office & Healthcare, Barton Associates Inc., York, Pa.
Bill Talbert, PE, BEMP, LEED AP, Senior Mechanical Engineer, MEP Associates LLC, Verona, Wis.
CSE: Please explain some of the codes, standards, and guidelines you use as a guide. Which codes/standards should engineers be most aware of in their design of such projects?
Reuther: In addition to the normal ASHRAE standards that engineers would look at, ASHRAE 170: Ventilation of Health Care Facilities has requirements for health care facilities, specifically. NFPA 99: Health Care Facilities Code also lists requirements for electrical and medical gases in health care facilities. The International Energy Conservation Code (IECC) also is applicable depending on whether it is adopted by the local city or state. Depending on the area of the hospital, there might be other special codes to look at as well. For example, the pharmacy area is governed by USP 797: Pharmaceutical Compounding - Sterile Preparations and is specifically written for these spaces.
Slagel: Outside of local building codes, the two most important codes/guidelines related to health care work are the Facility Guidelines Institute's (FGI) Guidelines for Design and Construction of Health Care Facilities and NFPA 101: Life Safety Code. These documents have been adopted by most states as a requirement for Department of Health review and licensure as well as by the Centers for Medicare & Medicaid Services (CMS), which dictates requirements that must be met for health care facilities to participate in Medicare and Medicaid reimbursement programs. A host of additional standards is referenced in NFPA 101 that must also be followed, such as NFPA 99: Health Care Facilities Code, which contains additional requirements on systems including electrical and medical gases. As always, it is important to verify all applicable codes with the local authority having jurisdiction (AHJ) to ensure that designs incorporate the correct edition of each particular code or guideline and any state- or local-specific codes that also apply.
Noto: From an HVAC point of view, ASHRAE Standard 170-2013: Ventilation of Health Care Facilities should be considered the bible of health care design. It covers all aspects of acute-care HVAC design and should be used as a starting point in all health care designs.
Jones: When new graduates or even seasoned staff who are new to health care ask this same question, they expect the answer to be simple. The truth is that it is often very difficult to get to the bottom of many code-related issues in health care. It is also true that the answer greatly depends on the location of a project. One root problem is that there is a lot of overlap in the subjects governed by different codes. These codes are continually being updated, but by different individuals with varying interests, and on different update cycles. It is important to understand the latest changes to NFPA 99, but know that they might not necessarily apply to a given project yet, because many jurisdictions are literally decades behind in the adoption of new versions. For example, although many states are governed by FGI guidelines, 14 states use their own alternatives to those guidelines. Even among the states that follow FGI guidelines, six different versions are being enforced, some going back more than 20 years. In addition, standards like ASHRAE are adopted as code in some jurisdictions (like ASHRAE 170 into FGI), but merely viewed as good practice or recommended practice in others. With that being said, every health care engineer needs a working understanding of FGI (even if your state hasn't adopted it yet), NFPA 99, NFPA 101, and the various ASHRAE standards.
Talbert: The FGI's Guidelines for Design and Construction of Hospitals and Outpatient Facilities and ASHRAE 170 are two critical publications for the design of hospital HVAC systems. These documents provide direction on ventilation, infection control, filtration, and temperature and humidity conditions. They have been adopted by many codes and accreditation organizations.
Anderson: We have designed several health care facilities in California. This requires compliance with California Title 24, the state's building standards code, and the regulations outlined by the Office of Statewide Health Planning and Development. Each state has its own requirements. Something that may be mandatory under Title 24 may not be in another state that is following the International Building Code. Other guidelines or standards we apply include FGI's 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities, ANSI/TIA 1179: Healthcare Facility Telecommunications Infrastructure Standard, and UL 1069: Standard for Hospital Signaling and Nurse Call Equipment.
CSE: Please explain how you are addressing ASHRAE Standard 188-2015 Legionellosis: Risk Management for Building Water Systems. How is ASHRAE 188 impacting projects for hospital or medical campus buildings?
Jones: Legionella is a dangerous bacterium that thrives in water systems, especially where the water is warm (~70 to 110°F). It is particularly dangerous in a health care setting where many occupants are immunocompromised or in some other vulnerable state. The good news is that we know how to kill it, because it can't survive at temperatures above 140°F-which is a simple task for a domestic, hot-water system. The bad news is, it is difficult to properly treat incoming cold water and very difficult to identify and prevent stagnation and growth of water containing Legionella once present. ASHRAE 188 will mean increased treatment of domestic cold-water systems and a much greater emphasis on recirculation, down to the fixture level.
CSE: What are the most challenging codes and standards to follow for hospitals and medical campus buildings? What makes them so challenging?
Reuther: It is important to recognize that following the code or standard is not always enough. The engineer must understand the operation of the room, rather than just designing a space to the code's minimum requirements. We have found that for many spaces in a hospital, the codes and standards are not aligning with what we are seeing the users doing in the spaces. For example, ASHRAE 170 states that an operating room should be kept as low as 68°F. I have not found too many operating rooms where the doctors are satisfied with 68°F in the room. We are seeing requirements closer to 62° to 66°F, which makes a big difference in the HVAC system. It is important for the designer to discuss these requirements with the owner during design rather than just assume they can design per the codes and standards.
Noto: ASHRAE 170-2013 is a very challenging HVAC standard that most jurisdictions (excluding Florida and California) adopt into their health care design code. What makes them challenging is understanding that the air-change rates in the standard are just a minimum and shouldn't be the design intent. Additionally, having a full understanding of the different pressure relationships (positive, negative, or neutral) are key to a successful project.
Anderson: The codes themselves are not as big of a challenge as the interpretation. We can design to the same code in two different jurisdictions, but have two different AHJ interpretations. There have been times when we thought we applied a reasonable interpretation of a code based on AHJ approval in other jurisdictions only to have it interpreted differently for the next project. Unfortunately, this does not get discovered until either the drawings are fairly complete and submitted for permit or, worse, when the project is being inspected during construction.
Jones: Health care code challenges fall into several categories. The following are two examples. First, when they conflict with outside requirements. For example, the 2012 version of NFPA 99 removed the requirement for smoke evacuation in windowless anesthetizing locations. However, until this past summer, CMS hadn't adopted NFPA 2012. This is quite a conflict because CMS is a regulatory agency that reviews existing hospitals for compliance. They have no role in design approval or initial licensure. Basically, the design community was free to delete smoke evacuation, but we had to install it anyway because CMS would still cite a hospital for not having it. Even now, many designers are reluctant to delete it without having certain confirmation that CMS' recent adoption truly means they won't continue to look for it. A second challenge is when compliance is impossible. For example, ASHRAE 170 (codified by the FGI guidelines in most states) requires 70% of the area above a surgical table (plus a 12-in. extension on all sides) in most types of operating rooms to be laminar air distribution. In the case of a ceiling-mounted hybrid, however, the overhead support for the hybrid equipment will almost always make the 70% requirement impossible. In many jurisdictions, the code authorities are open to discussing these types of conflicts during design. Where they are not, we are often stuck crossing our fingers and hoping that the code authority understands the impossibility, but that is an uncomfortable position to be in.
CSE: How are codes, standards, or guidelines for energy efficiency (such as California Title 24) impacting the design of hospitals and medical campus buildings?
Talbert: Energy codes and standards are continuously advancing performance requirements, requiring designers to implement systems that simultaneously meet the hospital's primary HVAC needs for air quality and infection control with energy performance. Providing adequate filtration, air-change rate, and outdoor air while reducing energy use often requires consideration of systems with which owners may not be familiar. It is the designer's responsibility to help owners understand the operational requirements and energy benefits to ensure the long-term performance of the system.