Designing, retrofitting hospitals during COVID
While COVID-19 has changed many aspects in a health care facility, some things remain identical
- Luis Alvarez Colon, PE, Associate, Page, Austin, Texas
- Allison Graves, PE, Principal, RTM Engineering Consultants, Chicago
- Jeff Hankin, PE, LEED AP, Senior Principal, Stantec, San Diego
- Reed Paitich, PE, Associate, Wold Architects and Engineers, Saint Paul, Minn.
- Keith D. Prata, PE, LEED AP BD+C, Mechanical Department Manager, Bala Consulting Engineers, Boston
- Donald R. Stevens, CHFM, CHC, Director – Health Care Facilities, Lockwood Andrews & Newnam Inc. (LAN), Austin, Texas
What’s the current trend in hospitals, health care facilities and medical campus projects?
Luis Alvarez Colon: Hospitals tend to require spaces that will allow the staff to treat a range of patients, from general to critical care, in the same room. We are seeing more emphasis on incorporating energy efficient designs such as advance lighting controls and LED lighting in all spaces. Additionally, there is a big focus on solutions in technology to address cleaning protocols to reduce harmful bacteria that causes hospital-acquired infections. Automated continuous environmental disinfection technology is often used for operating room light fixtures.
Allison Graves: We are seeing that many of our health care clients are beginning to recover from the initial onslaught of the COVID crisis. Patient wings that were emptied to make room for COVID-positive patients have been reactivated for elective procedures. Business as usual seems to be taking the place of the hysteria that was experienced earlier this year. However, many of the capital improvement projects that were put on hold or shelved remain so. While the medical centers are beginning to financially recover, they are not releasing funds for new work, opting to see what will happen this fall with a second wave of COVID infection.
Jeff Hankin: Facilities and organizations are closing the gap on revenue streams between inpatient and outpatient services, due in part to technological advances in clinical care, value-based payments, science and discovery and the COVID-19 pandemic and future surge/pandemic planning. Further, trends see facilities and organizations focused on virtual and community health, health equity and the shift that will occur moving some clinical care away from the hospital setting. Health care facilities, particularly hospitals, will adapt their business models toward narrower physical offerings, focused on high-acuity, complex cases and with increased virtual offerings. Technology and data will be pervasive and transform delivery models. Smart spaces and digitally enabled health care facilities will be a necessity given consumer demands.
Donald R. Stevens: Current trends are more of a wait and see approach. New projects that were already underway will be allowed to continue. New projects are on hold until it can be determined what type of construction will be required/requested to treat COVID-19 patients. This will include separate barriers and path of travel once patients are inside the building, as well as determining what type of air handling equipment will need to be modified or replaced.
Reed Paitich: We see a lot of our health care clients focusing on upgrading their facilities to add more negative-pressure airborne infection isolation rooms. Many smaller facilities only have one or two rooms and are trying to expand by reusing existing equipment and resources to limit their expenses in these uncertain times. Another common project is optimization building automation system verification and test and balance. With older facilities, the current code required ASHRAE 170: Ventilation of Health Care Facilities ventilation air changes per hour are often falling short. Optimizing the BAS along with some test and balance rework can usually bring facilities up to current code.
How has COVID-19 changed your work in the past six months?
Allison Graves: Over the past six months, our workload has not changed much in terms of projects for medical facilities. Many of the larger projects that were in progress at the time of the initial COVID crisis continued to more forward, albeit slower than usual. New safety protocols, video conferencing, etc. have completely changed the landscape of how we implemented active projects, but they continued to move forward. Now, six months later, we find much of the work slowing down, larger projects finishing up and little prospect for new work going into the new year.
Jeff Hankin: It felt like we hit a brick wall and had to pivot very quickly to learn as fast as we could and address the growing concerns and needs. Things seemingly changed overnight for everyone in the health care industry. At Stantec, we had (and still have) a core group of thought leaders and delivery experts focused on COVID-19 responses and on post-pandemic and surge planning, while the balance of our health practice was working to delivery on existing and new commitments for our clients.
Donald R. Stevens: Most of the change is in the interaction (or the lack thereof) by using virtual meetings of all types to interact with the owner and the contractor. All hospitals only allow essential workers to enter their campus and those workers who have taken extra training on precautionary measures on working in a health care environment. All planning and other meetings are held virtually.
Reed Paitich: Ventilation system enhancements have really been a focus on most projects. Identifying existing building system features to improve the effectiveness in removing virus contaminants is a priority. Three common inquiries from owners include confirmation of building controls to properly maintain 40% to 60% relative humidity, ultraviolet sanitizing lights (both at the air handler and within the occupied zone) and bipolar ionization technology. It’s important to consider the potential unintended health risks sometimes associated with UV and bipolar ionization systems. We recommend working with your design professionals to safely employ some of these technologies.
Luis Alvarez Colon: COVID-19 has changed the way we communicate within our groups as well as with external disciplines. Most of our team members have shifted to remote work. Our production is done primarily remotely. We have meetings via video conference to maintain our commitment as an integrated design firm. The number of physical visits has declined. Site visits are done either off hours, when the construction workers are less likely to be working, or digitally. We are relying on the general contractors to document current conditions via photos and videos instead of personally going to the site. Overall, it has worked very well. There are some instances where, due to the complexity and precautions on-site, we are not going.
Keith D. Prata: COVID-19 has forced us out of the office and to our kitchen tables at home. The boundaries between home and work have never been more blurred. Work days and subsequent meeting times are starting much earlier and ending much later than ever. The managerial aspect alone, keeping touch with and directing your in-house team, is exacting a higher quantity of hours and forcing the workday to be even longer. Per my observation the entire architecture/engineering design industry is suffering a lack of efficiency and effectiveness because we can no longer have five-minute conversations at a white board to describe and detail a particular issue. These simple five-minute conversations now easily take 30 minutes to assemble a Bluebeam sketch and arrange an online meeting; and at the end, the message is not always clear.
What types of challenges do you encounter for these types of projects that you might not face on other types of structures?
Allison Graves: The biggest challenges have been related to actual construction and on-site presence within the hospitals or medical facilities. With patient and employee safety being the No. 1 priority, the construction teams on-site need to completely document their every move throughout the facility. Maintaining and adhering to these new guidelines and procedures has had a drastic effect on overall production and efficiency.
Donald R. Stevens: The challenge is that the expectations can change more rapidly than getting the work completed. Everyone is using the best information that they have available at the time of design. Construction will start and then a new best practice is revealed and working in the moment is now real. Change orders are more prevalent and using on a cost-plus basis because the design is constantly changing. That is why most work is on hold until more is known on how to deal with this virus.
Reed Paitich: The most challenging part of projects during COVID-19 is modifying existing infrastructure while still remaining operational within the occupied hospital, specifically the medical-surgical and emergency departments. It’s critical that organizations are able to stay operational and continue to bring in revenue during the crisis. Careful planning between the owner, construction partner and design professional before and during the projects is required. All facilities shall complete a NFPA 99: Health Care Facilities Code risk assessment and ensure all project team members are informed on the outcome of the assessment.
Keith D. Prata: The challenges to building a new hospital are the same as for nearly all ground-up projects to date: construction budget must be maintained, change management must be an active, not a passive activity, and the building opening date must be met. The challenges to renovating an existing hospital are all of the above with the added challenge of phasing the new construction around an active hospital.
Luis Alvarez Colon: The most noticeable challenges and differences between health care projects and other project types are the electrical distribution systems. Given the fact that there are spaces in which the failure of equipment can cause major injury or death to the patients, the distribution is divided into normal and essential systems. The essential systems are divided into three branches: life safety, critical and equipment. Each one has specific loads to provide the necessary care to the patients that need it the most. The required loads are dictated by NFPA 99: Health Care Facilities Code Chapter 6.4 and NFPA 70: National Electrical Code Article 517. Life Safety and Critical branches have strict requirements to be kept independently from all other wiring and equipment to maintain their integrity in case of an emergency power outrage or fire.
Jeff Hankin: We were involved early in the planning and design for alternate care site conversions, which challenged our facility and clinical planners to think creatively to make more out of less. It was certainly inspiring to see how we partnered with nontraditional partners to bring health care to spaces and places we would not have thought could be viable alternatives.
What are engineers doing to ensure such projects meet challenges associated with emerging technologies?
Donald R. Stevens: It is a new day for everyone so everyone is listening to their peers and especially their customers on delivery approach changes and that is now considered a best practice. Podcasts and seminars are prevalent on dealing with the most current proven methods and means to deal with this issue.
Reed Paitich: Before immediately installing potentially expensive UV and bipolar ionization technologies, design engineers need to work with owners to ensure the existing building systems are operating to their full potential. Simple, minimal-cost tasks include replacing filters more regularly, inspecting filter racks to ensure a tight seal and limit bypass air, cleaning contaminated coil surfaces, checking outside air damper operation and reviewing air delivery within each space to ensure diffusers and grilles are open and unobstructed. More in-depth considerations should include increasing outside air ventilation where possible, containing contaminated air and finding a path to exhaust it outside and maintaining ideal temperatures and humidity levels.
Jeff Hankin: Emerging clinical, operations and analytical technologies are driving engineers to think and plan differently. I often talk about the hospital as a docking station, one with robust and resilient infrastructure that can withstand the pace and volume of technology and data driven solutions. Whether artificial intelligence, virtual/augmented reality or digital twin, there is so much that the engineering design community is focused on to help the health care facility community meet the aggressive pace of technology change. Beyond that, engineers are now faced with bringing health care more into communities, spaces and places and residential environments when those situations just 5 to 10 years ago were not widely considered.
Luis Alvarez Colon: In the health care sector it is common to have renovations of 20-year-old spaces. Upgrading these spaces to current standards is very complicated as the infrastructure of the building and systems were not design for such technologies to be implemented. For new buildings, the design approach is to try and have an integrated lighting and power system. This should include access control, nurses’ station, security (child abduction), etc. Even if all of the elements are not immediately implemented, having them in the design ensures that the infrastructure is in place for future implementation and upgrades that eventually will need to be done. Also, it is fundamental to plan for future expansion in the capacity of the electrical distribution as well as the physical space to be able to adjust and provide enough power to all the different critical spaces. For renovations, the design is often a stand-alone approach rather than an integrated method, like we do for new buildings, because of the limitations of the physical structure already in place.
How are engineers designing these kinds of projects to keep costs down while offering appealing features, complying with relevant codes and meeting client needs?
Reed Paitich: Cost estimating is an important step that’s often overlooked because many consulting engineers do not perform their own estimating services. Working within a trusted team of the owner, architect and contractor has allowed our firm to provide in-house engineering estimates, as well as successfully work with the contractor to fine tune budgets if pricing does not align with scope. All itemized options with estimated costs, schedule and operational impact can be reviewed as an owner, architect and contractor team. The owner may not be able to afford everything they had wished for, but transparency on the items they can afford puts clients at ease.
Donald R. Stevens: Total costs are always used as the guiding principle as these types of projects are considered since the longevity of the design that is proposed is unknown. Architectural influence is minimal. Economical products that provide separation of patients in waiting areas and safe travel patterns in the hospital are at the forefront. Other design considerations, especially air flows and air changes, must also be considered.
Luis Alvarez Colon: Designing with the latest technology while also trying to keep the project cost low is a challenge. Implementing energy efficient systems helps in the long run with a higher rate of return over the typical 30-year life of a building. It is important to communicate this to the client. Also, important to consider is designing technology with dual purposes such as lights with integrated UV light fans to disinfect spaces or lighting with continuous environment disinfectant. Both minimize the cost of disinfectant crews and chemicals that require labor.
Jeff Hankin: It’s all about making smart, informed choices. That means having a full understanding of existing conditions and their past performance and then using that information to help drive solutions that leverage the existing systems. Examples would be enhanced filtration or increased outside air or air exchanges. We always try to collaborate with our trade partners who help us focus on constructability, real time modeling and cost analysis, ultimately helping us gain smarter, quicker insights into solutions and their ROI.
How are hospitals, health care facilities and medical campus buildings being designed to be more energy efficient? And, if you have experience in this area, how will new outside air requirements affect this energy efficiency?
Luis Alvarez Colon: From the electrical stand point, LED lighting, advance lighting controls and power monitoring for loads that are more than 10% of the load consumption of the building are important design elements for efficiency. Monitoring power allows the clients to see where the load is concentrated and gives them the visibility and flexibility to adjust and be more efficient depending on their needs.
Keith D. Prata: A long-term trend we have seen is a centralized approach to delivering and treating outside air to the whole facility. Many health care facility HVAC designs separate the treatment of the building’s outside (ventilation) air requirements by using dedicated outside air handling units with energy recovery enthalpy wheels to serve specific areas of the hospital, such as operating rooms, emergency rooms, intensive care units and patient wards. The centralized approach of treating the outside air provides greater energy efficiency for the entire facility. However, on the short-term, implementing some energy saving solutions are being reconsidered and/or deferred until after the pandemic has subsided.
Donald R. Stevens: A very large portion of energy costs in a medical facility is for heating, ventilating and cooling the air in the spaces. Operating rooms have been served with treated 100% outside air for quite some time now. In extreme climates, this is expensive. With COVID-19, more spaces are requiring more outside air, higher air change rates, better filtration and other measures, UV light, Ionizing units, etc., to make the spaces safer. All of these are being implemented at the expense of energy efficiency. Engineers will need to find ways to economize these changes without sacrificing safety as well as find new ways to economize in other areas to make up for the new expense of treating the air.
Jeff Hankin: Recognizing the role of HVAC systems in the distribution and bio-burden of infectious aerosols, in April 2020, ASHRAE released a position paper providing recommendations on the design, installation and operation of HVAC systems, local exhaust ventilation systems and non-HVAC strategies, including facility management protocols, to decrease the risk of infectious disease transmission. Of note is the recommendation to increase outdoor air ventilation by disabling demand-controlled ventilation and increasing the run time of ventilation systems to 24/7 where possible.
As a team of sustainability-minded professionals, we are acutely aware of the link between building energy use and climate-related impacts such as poor air quality. We questioned whether this recommendation for addressing human health at the building scale would increase long-term energy consumption and negatively impact air quality and therefore human health at the community scale due to increased carbon emissions, a known factor in increasing public health vulnerabilities to respiratory illness. Would this engineering solution to an immediate health threat also contribute to long-term public health vulnerabilities, thereby increasing the likelihood of future recurrences of the very health threat we are currently reacting to? What is the likely impact on annual energy costs in different climates and will these measures face resistance from building owners, operators and tenants?
To answer these questions, we modeled a baseline medical office building under four HVAC scenarios, in six locations spread across five climate zones. The simulation results presented are in the context of the impact on cooling energy use, heating energy use, total building energy use intensity, annual energy costs and carbon emissions.
In summary, increasing the run time outside air to 24/7 does not result in an energy penalty and in fact can have a positive impact on reducing annual energy use, when combined with a heat recovery heat pump approach. Increasing outdoor air rates in light of post-pandemic design conditions does not necessarily mean increased energy consumption and carbon emissions. Through the application of intelligent design solutions, we can find synergies between increased ventilation requirements and reduced energy consumption and carbon emissions.
Looking ahead with pandemics in mind, how do you think hospitals and health care facilities will be designed? What aspects of the engineered systems will change?
Luis Alvarez Colon: I am anticipating the implementation of more automation, especially in lighting systems. Even though lighting has come a long way, there are still huge opportunities to implement more automation to mitigate touching surfaces where viruses can spread easily.
Keith D. Prata: We believe the requirements for outside (ventilation) air will be increased, particularly inpatient rooms and intensive care units. This increase of outside air will have a direct impact on the annual operations budget of the facility.
Donald R. Stevens: I see major changes happening in the clinical space with segregating the clinics or treatment space by facility rather than trying to treat all patients in the same locations. Quicker and easier conversion to generated power will be essential to new treatment facilities. In addition, AHUs will need to be flexible with air flows to provide positive/negative environments and air exchanges at the flip of a switch.
Jeff Hankin: I believe there will continue to be a much greater focus on resiliency as well as surge planning, where surge could be a natural disaster, man-made event or pandemic. Acuity adaptable spaces will increase and therefore a more flexible infrastructure system for HVAC, medical gases, emergency power, etc. There will likely be an increased focus on ensuring ventilations systems, disinfection, antimicrobial surfaces and patient/staff/guest flow and circulation are designed to meet the changing needs due to resiliency and surge planning.
Reed Paitich: I believe health care facilities will be designed for maximum space flexibility in the future. Isolation of hospital suites or skilled nursing resident neighborhoods will be a priority. Increasing outside air ventilation rates will further dilute indoor air and help mitigate the risk of virus transmission in enclosed indoor environments. Air handling units can be engineered to handle multiple indoor and outdoor conditions, adjusting to different spatial pressure requirements through the BAS and allowing for up to 100% outside air, if required.
Allison Graves: I believe hospital design moving forward is going to involve flexibility. Having the ability to quickly convert spaces from one use to another without needing to rework infrastructure systems will be key to thoughtful design. HVAC systems that can be easily adjusted from the building automation system, going from positive pressure to negative pressure, altering air-change rates, etc. will form the basis of most design moving forward.
How has your team incorporated integrated project delivery (IPD), virtual reality (VR) or virtual design and construction (VDC) into a project? Define the owner’s project requirements and how the entire team fulfilled them using these methods.
Jeff Hankin: As a global design firm, Stantec has many practitioners and offices in North America, the United Kingdom, Australia and the Middle East who have been involved in successful IPD projects and continue to use VR and VDC tools and practices on projects small to large. It’s true that the nature of the alternative project delivery team (consisting of owner, A/E and contractors) varies based upon the owner’s project requirements. One example would be large health care project in the U.S. where the owner, A/E and contractors all signed a tri-party integrated form of agreement. An agreement like this creates and necessitates a fully collaborative and aligned project team to ensure that the owner’s project goals and those of the IFOA partners are met at every stage of the project.
Allison Graves: RTM’s project teams are fully immersed in the IPD process. Partnering from the very beginning with the owner, general contractor, architect and sub-contractors, the team works together to develop the project scope, establish budgets, allocate work effort, determine phasing, etc. to ensure the successful completion of the project. We recently used IPD on a $105 million renovation project within an active adult hospital. The team identified and developed 14-plus individual projects, which encompassed the overall goal of fully renovating the hospital for continued patient care.
Reed Paitich: We utilized virtual design and construction with two recent projects: a new standalone cancer center in Carroll, Iowa, and a new critical access hospital in Wrangell, Alaska. Both clients were struggling to visualize the finished interior and future patient flows. We were able to use real-time rendering from Autodesk Revit and SketchUp through Endscape and allow the users to walk through their spaces in real time. We also imported MEFP utilities and used them for coordination with the architects and contractors through the wire-frame view within Enscape.
Tell us about a recent project in which you retrofitted a hospital or portion of a hospital to help treat additional COVID-19 patients. What was unique? What did you learn?
Jeff Hankin: We helped a health care organization reactivate an old hospital that was replaced with a newer one several years ago. We considered the old ICU and medical/surgical wings to be retrofit to become negatively pressured spaces suitable for patient cohorting and virus containment. A few items of note that we learned were to really understand the existing ventilation systems to ensure optimal outside air, air exchanges and directional flow could be well controlled. We also learned early when ventilator needs were heavily relied on that most Med/Surg spaces with medical air were not sized adequately to absorb the added load of multiple ventilators brought online. Lastly, when reactivating an old facility, it’s important to flush and test the HVAC and plumbing systems, as well as electrical, to ensure performance and life safety.
Donald R. Stevens: Most projects involve maintenance or retrofitting existing facilities by segregating paths of travel and treatment for COVID patients versus regular hospital patients. Separating treatment facilities, admissions, visiting policies and clinical visits are all common practice.
Reed Paitich: A hospital client in Wray, Colo., recently asked us to review their ICU for an influx of COVID-19 patients. We found many challenges with patient flow and achieving negative pressure in the suite. Instead, we developed a plan to isolate the end of their existing med surg wing, which allowed us to use an existing exterior door as patient access and the family room could be utilized as that, or a temporary staff space. This eliminated patient and staff traffic in and out of the COVID-19 area. Open communication through multiple Zoom meetings allowed us to meet their needs.
Allison Graves: At the very beginning of the COVID crisis, we were contacted by a medical center in Chicago, inquiring about adding ventilation to their back-of-house corridor where the emergency department staff had been screening patients for COVID-19. Within 24 hours, our team had reviewed the as-built drawings of the area, developed concept plans and met with a team consisting of general contractor, mechanical, electrical and plumbing contractors, along with the owner’s representative to develop a strategy for providing temporary ventilation. Working directly with the contractors to source equipment, our team modified the designs to make use of readily available products. Within 48 hours, the equipment was ordered and ready to be delivered on-site. Commercial rooftop units were headered together to provide code-compliant ventilation for a triage space.
As the units were being sent, the Medical Center decided to expand their operational space into a 6,000-square-foot shell space adjacent to the corridor. Our team worked with the contractors to immediately change the design, source available circulating fans and HEPA filters and was able to expand the system to properly meet the air-change requirements of this larger volume area. All construction was complete and the space was fully operational within one week of RTM first being contacted.
In the process of completing this retrofit project, our team learned the value in thinking outside the box and being quick on our feet. This project in particular had several different disciplines involved simultaneously, so when the design requirements changed suddenly, working together as a team and having clear communication were priorities for everyone.