ERs, ORs and PEs

If you haven't visited a hospital in a while, you may be surprised to find some very high-tech gadgetry, such as the latest in diagnostic imaging equipment; architecture and décor resembling a hotel more than a health-care facility; and patient rooms equipped with data ports for medical professionals to download patient information to a personal digital assistant (PDA) instead of a c...

By Barbara Horwitz, Associate Editor April 1, 2002

If you haven’t visited a hospital in a while, you may be surprised to find some very high-tech gadgetry, such as the latest in diagnostic imaging equipment; architecture and decor resembling a hotel more than a health-care facility; and patient rooms equipped with data ports for medical professionals to download patient information to a personal digital assistant (PDA) instead of a clipboard.

Even behind the walls things have changed: more robust chilled-water systems and high efficiency particulate air (HEPA) filters are in place to meet stricter surgical requirements; there’s also increased redundant power to keep hospitals more fully functioning during emergencies and blackouts; and hybrid gas/electric or heat recovery and cogeneration systems are being installed to trim escalating energy bills.

With technology and patient care changing so dramatically, engineers have had to stay on their toes to provide the supporting M/E infrastructure, and often on a limited budget.

“It’s a challenge that we face every day to balance optimizing our systems with operating costs, patient health, safety and comfort, as well as infection control,” notes Brian Heideman, P.E., manager of health-care engineering services for Ross & Baruzzini, St. Louis.

Whether it’s a retrofit of the lighting in patient rooms for a softer look, an increase in floor-to-floor heights to accommodate more M/E equipment or a change to instantaneous water heating systems that eliminate Legionella problems, it takes a savvy engineer to stay on top of the trends, and on budget.

OR imperatives

One of the places where design changes have been most profound is in the operating room (OR). For starters, the size of these rooms has well surpassed the traditional 400 sq. ft., and now must be at least 500 sq. ft., if not 600 sq. ft. or more, according to Marc Rowland, AIA, a partner with Thomas Miller & Partners, Brentwood, Tenn.

Rowland adds that floor-to-ceiling heights have also increased from between 12 and 12.5 ft. to between 15.5 and 16 ft. in order to make room for more M/E and medical equipment.

In addition to increased space needs, temperature variation and ventilation rates have changed as well.

According to JoAn Mende, P.E., a mechanical engineer with Albert Kahn Associates, Detroit, OR temperatures—formerly between 68°F and 72°F—now may need to get as low as 60°F to accommodate adhesive cement used for orthopedics, which tends to set too quickly in warmer temperatures.

As a result, a conventional chilled-water system must be supplemented with a glycol system, explains Paul D. VanDuyne., P.E., vice president, KJWW Engineering Consultants, Rock Island, Ill.

To meet more stringent IAQ levels, air changes must occur more frequently and at a low airflow velocity. As a result, it can be a challenge to properly locate air diffusion vents in the OR.

To address the issue of frequency, Phil Leader, P.E., also with Albert Kahn, has specified new types of air-handling systems, including one unit which exclusively circulates outside air, and another dual-path air handler that treats outside air separately before it mixes with the building’s return air.

As a further precaution, Leader says more and more hospitals are opting to exceed ASHRAE-recommended 90% filtering levels by utilizing HEPA filters capable of achieving 99.7% efficiency. Another option is installing ultraviolet lights over the air-handling coils and drain pans. Leader has also specified silver-coated ductwork, a relatively new product that limits microbial growth.

The costs of IAQ

Improved IAQ, however, comes at a cost, according to Von Lambert, the director of engineering at Carle Hospital in Urbana, Ill., who claims that the amount of electricity required to power a bigger fan is phenomenal, making it impractical, especially in attempting to combat a threat like anthrax.

In any case, improved IAQ won’t necessarily control nosocomial infection—every hospital owner’s nightmare. While many think that this kind of infection—which patients can sometimes contract while in the hospital—is airborne, the reality is that the majority of nosocomial infectious strains are surface-borne, according to Dick Rittelmann, AIA, vice chairman of Burt Hill Kosar Rittelmann Associates, Butler, Penn. Therefore, the correct approach is utilizing easy-to-clean materials and surfaces, he says.

To further combat the spread of infectious disease, engineers are fielding more requests for isolation rooms. These pressurized rooms, equipped with UV lights, can be very effective controlling diseases like tuberculosis, but they’re not a panacea, according to Robert Rutkowski, P.E., an associate with van Zelm Heywood & Shadford, West Hartford, Conn. For example, he points out that their use is rather limited when it comes to chemical, radioactive and certain kinds of viral infections—new threats that have recently come onto hospital radar screens.

Sanitary plumbing

Waterborne contaminants—namely Legionella—are another major factor to consider. Consequently, large storage tanks for domestic hot-water heaters have been replaced with instantaneous heaters, says Russ Sullivan, P.E., a senior associate at Burt Hill. To kill Legionella bacteria, hot water temperature must reach at least 130°F, says Clark Brenner, P.E., a project manager with Arnold & O’Sheridan, Madison, Wis. But then the water temperature has to be lowered to 105°F before coming out of the faucet. As a result, tempering valves must be used.

For sanitary reasons, hospitals are making the switch to sensor-operated faucets and flush valves, which also conserve water, notes Warren Wertz, P.E., a project manager with Hayes, Seay, Mattern & Mattern, Roanoke, Va.

In the wake of Sept. 11, another emerging plumbing trend is hospitals requesting alternate access to domestic water. “We are already putting in some emergency well systems for clients,” says Heideman.

Additionally, more attention is being paid to decontamination areas outside of emergency rooms. For example, if a patient has been exposed to chemicals, a small shower area is utilized to hose down a patient. But in an emergency situation, where 50 people show up at the ER, the vast majority of hospitals are ill-equipped to deal with this, Rutkowski points out.

Standby for power

One thing most hospitals are equipped to handle is power outages. In fact, hospital owners are requesting that more of their facility’s functions be placed on backup power—even non-critical ones such as medical offices and food service, says Chuck Geiger, P.E. a vice president and health care market sector leader for Arnold & O’Sheridan’s Brookfield, Wis. office.

The motivation is twofold. During emergencies, hospitals want to be able to serve as centers of refuge. And on a more practical level, procedures such as CAT scans and MRIs are so heavily booked that operators would prefer not to have to reschedule in the event of a power outage.

This, of course, has meant an increase in redundancy and on-site power, as well as growing interest in cogeneration, and the practice of selling power back to the utility. Some hospitals, Geiger notes, are also requesting that engineers design features into their standby power system to qualify for utility programs that provide incentives for reducing power bills.

Because hospitals are such energy-intensive facilities—consuming twice as much energy per sq. ft. as an average office building—any energy-saving proposals are largely embraced. For example, at a hospital in California, a dual-fuel boiler that converts fermented soybeans into methane is now in use, notes Walt Vernon, P.E., a principal with Mazzetti & Associates, San Francisco. Rutkowksi predicts that microturbines, when they become more economically viable, will be the next power technology that health-care facilities embrace—perhaps making them first market sector to institute them on a large scale.

Consequently, with more money budgeted for power systems, the percentage of electrical costs on hospital projects has increased at a rapid rate. In fact, even though mechanical systems still carry a larger price tag, electrical systems are beginning to catch up, points out Bill Sigma, P.E., BSA Design, Indianapolis.

Another issue is power quality, but certain advances have eased the burden. For example, manufacturers of diagnostic medical equipment, says VanDuyne, have started building power conditioning into their products, which eliminates the need for end users to purchase and install this additional equipment.

In addition, the use of closed transition transfer switches is allowing backup power generators to be connected in parallel, thereby transferring power without an outage.

Another important power-quality issue is dealing with electromagnetic (EMI) and radio frequency interference (RFI) which can emanate from unexpected sources.

“We all love our laptops, cell phones and palm pilots, but it’s throwing more and more dirt into the electromagnetic environment,” says Rittelmann.

Sam Reed, P.E., of BSA Design, concurs adding that EMI and RFI is so temperamental that the balance could be set off by something as simple as an unenclosed ballast. In fact, Reed’s colleague Bob Boellner, P.E., says that all of a facility’s systems should be carefully audited.

“Older technology can [electromagnetically] interfere with newer technology, so you have to constantly look at things to see how they interact,” he says.

Life after 9/11

Taking such a holistic approach to hospital design is crucial, especially due to the complexity of issues that these health-care facilities must deal with.

Yet another area wrought with complications is the changes which may come on the heels of the terrorist attacks of Sept. 11.

“I think we’re just scratching the surface of what we’re going to see post-9/11,” observes Burt Hill’s Sullivan. “We’re just getting involved and I think it’s going to pick up a lot more.”

Michael D. Roberts, P.E., administrator of plant operations at Pitt County Memorial Hospital in Greenville, N.C., asserts that general security has always been a big issue in hospitals, but now security of utilities has come to the fore.

Whereas Pitt County Hospital had been protecting its oxygen source with a chain link fence and a padlock, Roberts, along with his team of security professionals, is now considering concrete walls and road barriers, in addition to putting alarms, cameras and potentially card-access systems on mechanical room doors.

At the same time, consultants warn that when it comes to utilizing the latest technology to beef up security, it’s important that the decision be well thought out—with the assistance of qualified security designers—to ensure that it integrates with overall operations and site layout.

“A major mistake institutions make is relying on vendors to design their security systems. While vendors are very familiar with the products they represent, they are limited to those products and typically have no security-management experience upon which to base their recommendations,” explains Jim Francis, CPP, a vice president at security firm Kroll Schiff & Associates’ Bastrop, Texas, office. “It’s not just hanging cameras and controlling doors. It must be part of a comprehensive program.”

An example of how such a coordinated approach to design is beneficial is hospitals opting to become fully sprinklered, explains Warren Wertz. P.E., a project manager with Hayes, Seay, Mattern & Mattern, Roanoke, Va. With full sprinkler coverage, designers have more flexibility with issues like egress distances and building materials.

Hospitals have also seen an increase in the use of fire-suppression systems, especially as the cost of medical diagnostic equipment—which is prone to water damage—continues to rise, says Rutkowski, who also serves as the design team leader for health-care facilities at van Zelm Heywood & Shadford. The engineer points out that as these MRI and CAT scan machines have moved away from film, data networks in hospitals have been forced to handle the distribution of massive digital image files through the system.

“Not only does a hospital need a data, voice and digital network, but a separate, dedicated fiber-optic distribution network as well,” adds Rutkowski.

What’s the hold up?

While telecom upgrades have become commonplace in hospitals, many security-focused retrofits have yet to happen at this point.

“Money is an issue. Things like moving outside air intakes can be a very expensive proposition,” notes Sullivan.

However, Sullivan anticipates that these upgrades are being budgeted for this fiscal year.

“We’re seeing the beginning of a trend in hospitals related to 9/11 issues,” concurs Rutkowski, “but I don’t think we’ve seen 9/11’s effects on security yet.”

Just judging by the extent to which hospital design has changed so significantly in the past couple of years, it’s inevitable that such security enhancements, along with a slew of other new hospital requirements—necessitated by new technology and methods of patient care—are most likely just around the corner. Stay tuned for details.

A Lighter Look

Not only have mechanical and electrical specifications changed in hospitals, but lighting, for the most part, has been significantly revamped.

Hospital lobbies have taken on the appearance of hotels, and the use of natural light and skylights has really caught on.

“From a lighting perspective, we’re seeing a bit more of a healing environment concept taking hold,” says Bob Rutkowski, an associate with van Zelm Heywood & Shadford, West Hartford, Conn. “Communication to the outdoors, windows and direct natural light seem to benefit healing.”

Lighting designers are also working with color rendition to produce warmer light in patient rooms, which enhances skin color, says Paul D. VanDuyne., P.E., a vice president with KJWW Engineering Consultants, Rock Island, Ill. For example, the typical 2-in.-by-4-in. fixture on the wall above the bed has been replaced with decorative wall sconces, according to Brian Heideman, P.E., manager of health-care engineering services for Ross & Baruzzini, St. Louis.

Elsewhere, hospitals, in general, have been changing out T8 lamps with T5s. Heideman, however, points out that it’s been a slow process since hospitals tend to have lots of T8s in stock.

AIA Updates Design and Construction

A hospital design guide compiled by the American Institute of Architects, and adopted by close to half of all U.S. states, has recently been updated.

The 2001 edition of the Guidelines for Design and Construction of Hospital and Health Care Facilities includes a number of changes aiming to improve patient comfort, according to Marc Rowland, AIA, a partner with Thomas Miller & Partners in Brentwood, Tenn.

Some of the changes call for:

Installation of handwashing stations in all patient bedrooms and bathrooms.

Increased space in patient rooms from 150 sq. ft. to 200 sq. ft.

At least one airborne-infection isolation room.

At least 24 hours of continuous emergency backup power in facilities with fuel storage.

A minimum of six air changes per hour in labor/delivery rooms.

A minimum of four air changes per hour in the patient, dining and activity rooms.

For more information, visit AIA’s web site at

Another resource for health-care design is the American Society of Healthcare Engineering,

How Drugs Can Change the Architecture of a Hospital

When psychosporen A, an anti-rejection drug, came out on the market, the time that organ transplant patients had to stay in an acute care wing for organ rejection monitoring was cut in half from one month to two weeks, explains Dick Rittelmann, AIA, vice chairman of Burt Hill Kosar Rittelmann Associates, Butler, Penn.

As a result, the new drug was enabling the University of Pittsburgh medical center to move more patients through in a shorter period of time. However, the configuration of patient units wasn’t designed to accommodate this. Suddenly, the medical center found that it had too many acute care beds, and not enough beds for surgical intensive care unit (ICU) patients.

Consequently, Rittelmann’s firm was brought in to redesign the ICU and acute care units… thanks to psychosporen A.