Be Prepared: Hospital Protection for Catastrophic Events

As healthcare engineers, it's one thing to know the Boy Scout motto—and another to design for it. It's almost impossible, not to mention cost-prohibitive, to plan for every unforeseen occurrence. But natural and manmade catastrophes occur all too often, and when they do, they drive home the importance of designing hospitals to withstand potential disasters.

By Michael Sheerin, PE, LEED AP; James Ferris, PE; James D. Worth, PE, LEED AP; June 1, 2008

As healthcare engineers, it’s one thing to know the Boy Scout motto—and another to design for it. It’s almost impossible, not to mention cost-prohibitive, to plan for every unforeseen occurrence. But natural and manmade catastrophes occur all too often, and when they do, they drive home the importance of designing hospitals to withstand potential disasters.

Chapter 1.1 of the 2006 American Institute of Architects “AIA Guidelines for Design and Construction of Health Care Facilities,” Section 5, “Provisions for Disasters,” gives fair warning to hospital owners and designers to consider the implications of disasters, and the ability to remain operational after such events. But the prescriptive requirements to accomplish this task are left to the design teams themselves, based on a facility’s specific operational plan.

The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations, under its Environment of Care requirements, requires that a facility have an emergency operation plan that identifies how it would handle 96 hours without support from the local community. Total evacuation is allowable under this plan. However, in its 2003 document, “Healthcare at the Crossroads: Strategies for Creating and Sustaining Community-Wide Emergency Preparedness Systems,” TJC recommends that a facility “ensure a 48—72 hour standalone capability.” TJC also recognizes that for a hospital to serve its purpose, it must be able to withstand challenges with rigor, and if it should fail, to fail in a controlled fashion, which they refer to as “graceful degradation.” The goal is to “maintain its ability to provide care” and “avoid having the health system become a victim of the assault.”

Following the disastrous hurricane seasons of 2004 and 2005, in which numerous major hospitals in Florida and all along the Gulf Coast were totally incapacitated, the American Hospital Assn. advised all hospitals to assess their electrical capacity. Many hospitals sustained hurricane wind, water, and debris damage, which spawned several types of upgrade projects—none of which were required by code, but which the hospitals saw as a “bare minimum” to enable them to survive similar disasters in the future by remaining as fully functioning as practical. These projects included:

• Replacing generators with larger generators to serve loads that have been considered non-essential by the code books. These loads include laundry facilities, air conditioning, bathroom exhaust fans, and all of the cooking equipment.

• Implementing water-resistant central utility building designs. A significant issue during a storm is water penetration, where water blows through window glazing, walls deflect several inches from the force, and water flows into the building through every crack and unsealed conduit. Hospitals have had to go back and waterproof central energy plants that became virtual bathtubs due to water intrusion.

• Enacting greater code detail with respect to wind debris impact. Most states have specific wind loading requirements, but few go further into details of wind debris impact. Florida has building code requirements for both, plus specific guidelines for hurricane preparedness for new hospitals and additions. Many facilities have even taken steps to bring their grandfathered facilities up to modern code.

• Developing a “hardened shelter” within the hospital building itself, which one coastal hospital has done. The philosophy is “bend, don’t break.” During the highest category storms (when the first floor could be flooded and the windows blown out), they withdraw patients and staff to an interior space that has dedicated heating, power, and communications; the rest of the hospital shuts down to prevent short-circuiting and other catastrophic infrastructure failures.

Engineers face two major challenges in upgrading the power at a hospital: service interruption and scalability. Service interruption is the single most daunting challenge, because a hospital cannot tolerate any interruption of service. Often, new electrical systems must be built in parallel with an existing system with a single tie-in/changeover date. Electrical systems for healthcare often are designed to accommodate life-safety issues rather than first-cost criteria. The only thing sure about hospitals is that they will grow—often much faster than healthcare clients realize. Any design that doesn’t anticipate a large addition within five years is shortsighted.

In the following project case studies, all from U.S. locales that are likely to experience natural disasters, disaster planning played a key part in the project design and decision-making process.

Florida: All Children’s Hospital

Florida has long been a magnet for hurricanes forming in the Atlantic Ocean, and most healthcare administrators in Florida can attest to the importance of hurricane preparedness and provide real-life examples and gripping first-person accounts.

This is why when All Children’s Hospital in St. Petersburg planned to build a new 10-story children’s hospital and central plant, administrators made disaster preparedness a top priority.

The heart of the hospital’s disaster preparedness plan, the central plant, is designed to withstand Category 5 hurricane winds and any storm surge that might flood the first floor. The boilers, chillers, and normal service switchboards are all located on the second floor, and the third floor houses the emergency power system and the cooling towers. All openings to the exterior are protected by louvers or doors that have been tested to withstand the impact of a flying 2×4 moving at 150 mph. In a hurricane, the breaching of a door or window can allow winds, water, and flying debris to wreak havoc on a building’s interior; in the case of a home, it could be enough to lift the roof from below.

All Children’s central plant is designed to include three chillers and associated pumps, with the peak usage being slightly more than two chillers until shell areas are filled out. The emergency power system is designed to completely back up everything in the hospital and in the plant. Furthermore, the emergency system is split into two systems—A and B—each of which includes a parallel switchgear and three 2-MW generators, for a total of 12 MW of emergency power. Of the 12 MW of emergency power, 8 MW can be running in 10 sec., suitable for all Priority 1 essential loads. Figure 1 is a one-line drawing of the B side generator system.

All too often, the evaluation of a hospital or central plant results in too many “if only” statements: If only the prior design had allowed for expansion to the building; if only the generator was one size larger; if only the chiller piping was one size larger. Staff at All Children’s, aware of these concerns, determined that the new hospital plant needed to be designed for expansion so that it could serve future as well as current needs. The entire facility is designed with enough infrastructure to double in capacity, including all piping, wire, and distribution. The current building layout includes N+1 redundancy, plus housekeeping pads for a second for a second normal service, a fourth chiller, two additional generators, and an additional boiler. In addition, the building master plan includes a future horizontal expansion that includes two more chillers, four more generators, another boiler and additional pumps—all without replacing the existing mechanical and electrical infrastructure.

The plant serves a campus that includes the hospital, a new medical office building, and the plant itself. The campus distribution is designed with numerous connection points to expand and accommodate future loads as they are added on the campus.

“Designed to operate as an island” is a common phrase in healthcare engineering. It refers to the need for a hospital to be able to function by itself for an extended period of time. Hospitals have gone without power for two weeks or more after a hurricane. All Children’s learned from others’ experience and decided to have a total of 150,000 gal. of diesel fuel storage belowgrade, suitable for generator operation at 100% for seven days.

However, All Children’s did not want the disaster preparedness to end with the central energy plant; it applied the same philosophy to the hospital design itself. The building has two normal service entrances, which serve the A side and B side, with the A side emergency power fed from the B side for redundancy. HVAC equipment, rather than being located on the roof, is all housed within the hospital building where it is protected from debris impact, allowing the air-handling units to maintain operation during and after a disaster.

All Children’s disaster preparedness gives the facility full functionality during a catastrophe. And if a disaster should strike, it will enable them to focus on patient care, not on the power.

Hawaii: Queen’s Medical Center

On Oct. 15, 2006, Hawaii was struck by an earthquake centered just offshore and measuring 6.7 on the Richter scale. At Queen’s Medical Center, Honolulu, power was out for 12 hours, leaving the state’s primary trauma center without enough power to operate at 100% capacity.

“Although our emergency power system operated flawlessly, we quickly learned how difficult it is to run a hospital only on emergency power,” said Todd Kanja, PE, director of engineering services.

The hospital’s five emergency generators enabled code-required critical loads such as lights, ventilators, and other critical care and life support functions to continue operating. But there wasn’t enough power for adequate air conditioning, which prevented use of computerized tomography, magnetic resonance imaging scanners, and major operating room equipment. Overall, it was a vivid reminder that an increasing amount of equipment is required to be on emergency power, especially during a disaster and its aftermath. Queen’s wasn’t the only hospital affected by the earthquake; indeed, for those 12 hours, no hospital in Hawaii had enough emergency power to maintain 100% operation.

At the time of the earthquake, Queen’s had approximately 1.25 MW of emergency power, while the facility peak demand is slightly more than 6 MW. Coupled with the fact that Hawaii’s electric company, HECO, isn’t on a grid that stretches from other states and cooperates with other utilities, hospital administrators could see the writing on the wall. Queen’s needed to upgrade its emergency power system.

The Aloha State is beautiful, but during a single one-week period in August 2007, Hawaii experienced a hurricane warning, an earthquake, a tsunami warning spurred by the earthquake, and flash fires on one or more of the islands. Disaster preparedness in Hawaii is a must, so the hospital’s electrical system had to be redesigned to withstand most any disaster. The medical center needed only an additional 5 MW of power to supplement its existing power, but the age of the existing generators—and the benefits of the redundancy—made it clear that the redesign should include extra capacity. The emergency power system also should be above flood level.

Based on space constraints and emergency planning, the hospital building was designed in four levels (see Figure 2). Each level was designed to withstand up to a Category 5 hurricane, with the building overall capable of withstanding the seismic activity in Honolulu. As a result of the power system redesign, Level One includes a new utility service entrance 11.5-kV switchgear, upgrading the existing service from two feeds from the same substation to three feeds from two different substations. The emergency system was designed to include 8 MW of power at 11.5 kV, the current distribution voltage throughout Hawaii and on the Queen’s Medical Center campus. The parallel switchgear was designed to accommodate four 2-MW generators, without future generator space for expansion, and is located on Level Two. The addition of these generators provides Queen’s with sufficient capacity to handle the current load with any single generator in the system down. Even with two 2-MW generators down, the system can handle the majority of the load with the existing generator system and the new system online. The switchgear provides power throughout the campus through a dual-radial system, which serves most of the buildings via a belowgrade tunnel. Queen’s is evaluating the potential to modify the system to a loop configuration to further enhance reliability.

The generators, which have direct-mounted radiators, are on Levels Three and Four. Providing the radiator as a directly coupled unit was a design challenge based on the space available—but worth the effort. If remote radiators were located on the roof, they would need to be protected from flying debris in a hurricane, and because the radiators were required to operate when the generator operates, significant safeguards would have been required for both. The generator design also includes provisions to allow oil changes during operation, a feature typically found in prime-rated generators.

Queen’s administrators and facilities personnel worked with the local utility on the project from the start and plan to join the utility’s load demand program. Not only does the new emergency power system offer payback in the form of sound sleep, it offers discounts and rebates on the hospital’s utility bills. Overall, the improvements made by Queen’s to the emergency power system will alleviate power concerns and allow the hospital to maintain a high level of care for Hawaii residents when they need it most.

Alaska: Mat-Su Regional Medical Center

Alaska’s arctic environment and seismic forces drove the design for Mat-Su Regional Medical Center. The replacement hospital is located approximately 40 miles north of Anchorage, Alaska, in Mat-Su Valley, which sits along the Castle Mountain fault. This fault has produced a major earthquake, as large as magnitude 7.0, every 700 years, according to research geologists with the U.S. Geological Survey. And a major quake is just about due. The structural engineer designed the building with 40×40-ft spread footings to help the building achieve the rigidity necessary to withstand seismic forces. These footings are monolithically tied to poured-in-place concrete shear walls that are 2-ft thick, 15-ft long, and rise to the top of the building. All internal components including sprinkler pipes, conduit, ducts, light fixtures, wall partitions, and medical equipment, were seismically braced.

Design considerations also included daylighting, specialized insulation, and vapor barrier systems. In the winter, frigid temperatures and short days (some with only four hours of daylight) made it difficult to bring in natural light while minimizing heat transfer through the windows. The design team opted for dual-paned windows with a single argon-filled cavity, low-emissive glass, with extra large windows in the patient rooms. Interior lighting levels were enhanced to exceed international standards to offset the seasonal darkness. Outside, heated paving was incorporated into the walkways in critical areas to melt the snow. This system is served by an oversized boiler that feeds a continuous hot-water loop running beneath key sidewalks, hospital entry points, and the handicapped parking areas. All air-handling and boiler systems and accessories are powered by the emergency power system.

Water vapor in the airtight conditions required in Alaska also necessitated a specialized design approach. In the winter, vapor can be trapped within the walls by the building’s exterior insulation finish system and freeze. When it melts in the spring, the water can work its way down conduit and into the receptacles. To prevent this intrusion, the team designed a vapor barrier assembly immediately behind the wallboard on the inside face of the building. Initially, the hospital was designed with independent systems for well water, pumps, water storage, and sewage holding because these systems were not available during the project at the job site. These now serve as redundant systems for emergency needs.

Georgia: Sumter Regional Hospital

Sometimes, planning of any kind is overwhelmed by circumstances. When a record 21 tornados struck Georgia in March 2007, the Sumter Regional Hospital in Americus, along with many homes and businesses, was devastated. This meant not only the temporary loss of the place of refuge and caring on which the city’s residents relied, but also that a major regional employer was essentially knocked out of business. The staff at Sumter, after ensuring the safe transfer of 60 patients to other hospitals and relief to the storm’s injured—remarkably there were no fatalities at the hospital—began the process of assessing what was left of their facility and what they could do with it.

An F-3 tornado, with winds up to 206 mph, had blown out windows and torn off sections of the roof. Brick walls and debris had destroyed their MRI unit. As had occurred in many buildings during Hurricane Katrina, the rain and water intrusion of the storm created an additional concern. Wet interior building materials meant the possibility of electrical hazard, and mold and mildew made the facility untenable. Ultimately, everything removed from the facility needed to be sterilized before being re-used in patient care areas. The day after the storm, temporary tents were in place to serve urgent care functions, complete with generator-driven lights and power. The big challenge, apart from just being operational, was getting enough data service bandwidth to accommodate transmitting X-ray imaging files to remote radiologists. Many hospitals outsource these specialty services.

Within a month, modular buildings were laid out onsite to allow more hospital functions to be restored and more staff back in action. The Federal Emergency Management Agency (FEMA) provided much of the funding for a temporary facility, with modular interlocking trailers called COGIN units built in Italy and shipped through Houston to the site, after depletion of the available stockpile of units FEMA had in Alabama. As the concrete pad from which to start, they used the slab of their demolished medical office building. The temporary facility grew to more than 300 modules, condensing an approximately 250,000-sq.-ft hospital into fewer than 70,000 sq. ft, and creating an 80-bed, fully functioning hospital in less than six months. It is expected to be in use for three years until a new replacement “brick and mortar” hospital can be designed and built. Apart from fitting it out with MEP systems for specific hospital functions, an ongoing strain has been putting adequate phone and data in place to provide access to electronic medical records, electronic medication systems, and relocated functions. Billing services were backed up for more than two months due to network system and computer availability.

On a parallel path to creating a temporary facility was the process of determining a long-term permanent replacement hospital. With the current buildings constructed in 1953, 1975, and 1999, designers determined that the costs of refurbishing and bringing them up to code would be comparable to building a new architecturally efficient and energy-efficient facility, one that would resolve issues of patient flow and adjacency.

Though still in the planning stages, there is little doubt that disaster preparedness will be a top priority in the hospital’s design decision-making process. This will include hardening protection of tele/data systems, wind-loading and impact protection, concern for the roof system and roof-mounted equipment, and planning flexible use of areas. They have learned some hard lessons, and through improvisation, perseverance, and commitment to their mission, have taught others how to survive another day.

Oklahoma: Broken Arrow

During the ice storm that hit Oklahoma in December 2007, the St. John Health System in Tulsa experienced a power outage that swept the entire region for many days. During this time, authorities discovered compromises and shortcomings in their facility-wide emergency power system. Design is underway for a new satellite hospital and medical office building in the Broken Arrow area for St. John Health System. With the pain of the recent ice storm still fresh, the design team is challenged to provide a method to provide auxiliary emergency power even to non-critical systems to avoid such a catastrophe in the future. The cost of permanently installed generators to service critical and non-critical loads for the entire facility was found to be cost- and space-prohibitive.

Engineers devised a method of configuring the normal power system such that connection points are located on the exterior of the central plant where a temporary standby emergency generator (such as those located on a flat-bed trailer) can be pulled up to the plant and connected quickly to the hospital’s power distribution system. This design is independent of the code-required emergency power system for critical and life safety systems and in no way interferes with the operation of that system. This approach affords the security of full backup power without the prohibitive cost of installing and maintaining the required equipment on a permanent basis.

All of these case studies show that proper disaster preparedness planning during the design phase can go a long way toward keeping hospitals up and running when we need them most.

Run longer, run cleaner

In the quest for greater sustainability, even hospital emergency power systems are being greened. One South Florida hospital system has incorporated a natural-gas-supplemented fuel source to all of its new and existing generators. This bi-fuel system has the primary benefit of reducing fuel oil consumption by using as much as a 50/50 mixture of fuel oil and natural gas, thus extending up to 100% the potential available run time of the system (i.e., from three days fuel storage to six days) without increased on-site storage of fuel oil. With the rising costs of fuel oil, the treatment costs of stockpiling ever larger quantities to meet longer outages, and the sheer capital costs of large or additional fuel oil tanks, the system offers real savings and can be retrofitted to most existing generators. The green benefit, of course, is much cleaner emissions when running in the mixed-fuel mode.

Hospitals also are looking at bio-diesel fuel as a part of their pushes for reducing their impacts on the environment. Running a mixture of bio-diesel and petro-diesel can greatly reduce the particulate emissions level of generators. A few caveats: Bio-diesel can be more troublesome in very cold weather, can be aggressive to natural rubber components such as may be in the fuel system, and may result in higher nitrous oxide (smog-producing) emissions. Consult with the generator manufacturer to ensure that a unit is configured or capable of being modified for bio-diesel.

Hospital hostages

After a person with a gun took a physician hostage at a hospital in Wales, U.K., the hospital was besieged by police, the SWAT team, and the media. For the safety of patients and staff, all except the most critically ill were relocated to other hospitals as time wore on during the two-day-long standoff. Though resolved without incident—the man gave himself up to police negotiators—it highlighted something that the hospital’s emergency management plan didn’t anticipate: the incident occurring inside the hospital in the first place. The hospital’s next steps, similar to the increased security at most hospitals nowadays, includes extensive IP-based closed-circuit television monitoring (CCTV), panic/emergency call stations, after-hours lockdown capability of non-occupied areas, and radio communication with location tracking for security staff.

Author Information
Sheerin is director of healthcare design in TLC’s Orlando office; Ferris is an electrical engineer, also based in the Orlando office; Kemp is division director of the Nashville office; Worth is senior mechanical engineer and Versluys is senior electrical engineer, both with the Jacksonville office.