Health care building design model shifts

As hospitals and health care facilities evolve, the engineered systems within them must change

By Consulting-Specifying Engineer November 8, 2022
Courtesy: P2S Inc.

Hospital, health care insights

  • Hospitals, health care facilities and related medical buildings are changing to meet the needs of resiliency, new outpatient facility demands and energy efficiency.
  • The complex and fast-moving industry of designing hospitals requires engineers to remain vigilant, and aware of new technologies.

Respondents

  • Tanner Burke, PE, Senior Fire Protection Engineer, ACS Group, Austin, Texas
  • Derek Cornell, Senior Associate, Certus Consulting Engineers, Dallas, Texas
  • Beth Gorney, PE, Assistant Project Manager, Dewberry, Raleigh, North Carolina
  • Sierra Spitulski, PE, LEED AP BD+C, Associate Principal/Studio Leader/Mechanical Engineer/Project Manager, P2S Inc., Long Beach, California
  • Kristie Tiller, PE, LEED AP, Associate, Team Leader, Lockwood Andrews & Newnam Inc. (LAN), Dallas, Texas.
Tanner Burke, PE, Senior Fire Protection Engineer, ACS Group, Austin, Texas; Derek Cornell, Senior Associate, Certus Consulting Engineers, Dallas, Texas; Beth Gorney, PE, Assistant Project Manager, Dewberry, Raleigh, North Carolina; Sierra Spitulski, PE, LEED AP BD+C, Associate Principal/Studio Leader/Mechanical Engineer/Project Manager, P2S Inc., Long Beach, California; Kristie Tiller, PE, LEED AP, Associate, Team Leader, Lockwood Andrews & Newnam Inc. (LAN), Dallas, Texas.

Tanner Burke, PE, Senior Fire Protection Engineer, ACS Group, Austin, Texas; Derek Cornell, Senior Associate, Certus Consulting Engineers, Dallas, Texas; Beth Gorney, PE, Assistant Project Manager, Dewberry, Raleigh, North Carolina; Sierra Spitulski, PE, LEED AP BD+C, Associate Principal/Studio Leader/Mechanical Engineer/Project Manager, P2S Inc., Long Beach, California; Kristie Tiller, PE, LEED AP, Associate, Team Leader, Lockwood Andrews & Newnam Inc. (LAN), Dallas, Texas.

What’s the current trend in hospitals, health care facilities and medical campus projects?

Tanner Burke: There is currently a greater emphasis on resilience in health care facilities to protect the vulnerable occupants expected to use the facility. This involves implementing design, construction and operational strategies to mitigate natural disasters and infrastructure failures. The ultimate goal of resilience is to maintain the quality care and patient experience intended for the facility by considering structural integrity, mechanical, electrical and plumbing system reliability, physical security and cybersecurity. We are seeing retrofit efforts to make hospitals more resilient by protecting critical fire protection infrastructure such as pumps and water tanks from flooding, earthquakes and external fire exposures.

Derek Cornell: It is not news that the health care model continues to shift to outpatient. In recent years, we have seen a lot of health care systems building more stand-alone facilities for specialized care and outpatient services such as surgical and imaging. However, with the demand for materials, procurement delays and cost escalation, more projects are trending toward investing in existing facilities calling for heavy renovation and equipment upgrades. As owners are being forced to do more with less, we are seeing a heightened need for more flexible spaces that are able meet multiple functions and even combine multiple procedural operations within shared square footage.

Beth Gorney: Health care systems are building outpatient facilities to transition less critical features outside of the main hospital. Outpatient facility construction is generally less expensive than traditional hospital construction and has fewer construction requirements. These facilities are more convenient for patients; they do not have to travel as far or navigate through a large major hospital. Outpatient facilities in rural areas can provide the majority of the community health care needs with only the more critical needs being sent to larger hospitals. Examples of outpatient facilities including ambulatory surgery, cancer treatment and infusion, imaging, clinics and emergency departments.

Sierra Spitulski: P2S Inc. has decades of health care experience up and down the West Coast and we’ve seen lots of changes and growth in the industry during that time. Right now, we’re finally seeing a push toward energy efficiency in new ways we haven’t seen before. Within patient care centers, patient health is the most important thing of course. However, recent code updates and behind-the-scenes research are encouraging facilities to also take energy efficiency measures into account more. There are some upcoming kickbacks for existing facilities to incentivize refurbishments that push decarbonization efforts.

Kristie Tiller: Many hospitals are at a point now where they are no longer seeing an influx of COVID-19 patients. This means they have the ability to strategize and use funds to begin implementing tactical measures to increase their effectiveness and safety during the next major event. Some of these measures include increased isolation units and new and improved heating, ventilation and air conditioning systems.

What types of challenges do you encounter for these types of projects that you might not face on other types of structures?

Sierra Spitulski: The complexity and uncertainty that comes with planning a new or replacement health care facility can be truly daunting. Hospitals are considered emergency response centers and are typically overseen by various jurisdictions; these buildings are held to different standards that force facility owners to demonstrate resilience to all kinds of natural disasters. Disaster resiliency takes various shapes depending on your state, but whether you’re combating earthquakes, pandemics, tornadoes or hurricanes, it’s our responsibility as engineers to ensure these facilities can withstand these challenges until operations are fully back online or patients can transition safely. With that in mind, P2S Inc.’s highest goal is to provide our health care clients with peace of mind while creating healing and restorative environments for their patients and staff.

Derek Cornell: Construction costs have escalated in all sectors. In health care, the reimbursements will not increase to match the increase in construction costs, so it is difficult to make the Performa work. With the current construction price escalations and supply chain issues, we have seen a larger trend toward renovation and expansion of existing facilities. Balancing best design with code minimum to meet both user and owner expectations is magnified when dealing with aged systems and existing infrastructure. Because health care design is largely governed by codes and standards that are constantly updated, it presents its own set of challenges in working with these existing systems.

Tanner Burke: It is critical to keep as much of an existing hospital operational as possible while remodel work is occurring in select areas of the facility, so as to not reduce the number of patient beds available for care. This may present challenges such as maintaining means of egress and compartmentation, as well as the potential impairments to building systems, such as fire suppression, detection and alarm systems. Because all buildings are typically more vulnerable to fire when they are undergoing alterations, NFPA 241: Standard for Safeguarding Construction, Alteration and Demolition Operations should be used for guidance and requirements for how to protect patients and staff in occupied portions of the building.

Kristie Tiller: Health care design is very detailed and has specific code requirements that typical office-type buildings don’t have. Specifically, HVAC requirements are much more stringent to ensure the health, safety and well-being of patients while they are in a health care facility.

What are engineers doing to ensure such projects meet challenges associated with emerging technologies?

Kristie Tiller: Our engineers are well-versed in code requirements specific to this industry and go above and beyond to ensure patient safety and satisfaction. They are also constantly looking at opportunities to improve technical operations.

Derek Cornell: New technologies are continuing to make way into the construction market. As engineers, we must perform constant due diligence on new technologies to ensure we are providing a reliable solution; health care facilities must be built to last. Relationships and communication are key to ensure every project meets client expectation. Performing early assessments of systems allows us to make informed decisions. Cost analysis and return on investments plays a heavy role in these assessments which we are able to perform leveraging the assistance of our trusted trade partners. It is our job as engineers to balance the differences between what is new and better versus what is tried and true.

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?

Beth Gorney: We were asked to create isolation wings for housing the anticipated surge in COVID patients. We identified which areas of the hospital could be modified for full outside air and exhaust/purge systems. To create a negative pressure zone for those areas, we evaluated the existing building pressure relationships with on-site testing and what measures would be required to develop negative pressure COVID wings. In some cases, additional exhaust fans and ductwork were required and in other cases HEPA carts typically used for exhausting construction zones were used to exhaust COVID patient rooms through an exterior window.

Kristie Tiller: We are currently working on a medical living facility to enhance their HVAC system to meet and resolve COVID-19 concerns. We’re overseeing enhancements, which include increased outside air, added air filtration inside individual patient rooms, ionization at the air handling units and the construction of a dedicated COVID isolation unit. To properly retrofit the HVAC system at the care facility, we needed to take many things into consideration including pressurization changes to the building, which can affect the building envelope and added load on the electrical system. On this particular project construction phasing will be a major consideration because this is a live-in facility with more than 90% patient occupancy.

Sierra Spitulski: For one recent project, we were asked to create a pandemic ready pod within the Emergency Department for highly contagious patients. To protect the staff and nurses working around patients, computational fluid dynamic (CFD) modeling of air distribution was performed on a typical emergency department scenario. This allowed us to design the HVAC distribution in a way that optimized infection control which can help reduce spread of disease and illness.

P2S Inc. used laser scanning to create 3D models of the central utility plant and the mechanical and electrical rooms at the hospital and medical office building. Courtesy: P2S Inc.

P2S Inc. used laser scanning to create 3D models of the central utility plant and the mechanical and electrical rooms at the hospital and medical office building. Courtesy: P2S Inc.

Derek Cornell: In a hospital, real estate is at a premium and it is not practical to build out new rooms based solely on what we now know that may sit empty or may even compromise a patient when in normal use. Instead, health care clients are looking for a solution that can be implemented relatively quickly should a surge or reoccurrence of a similar pandemic arise. On one facility, we implemented a design for pandemic mode, which provides the hospital governing body the option to make an entire patient wing negative pressure. The key to this design is that it specifically and intentionally requires human intervention. Once the decision is made and the right commands are input to the front-end system, dampers are automated to close off return and direct all air directly to the outside.

What types of smart buildings or campuses are you designing for hospital clients?

Derek Cornell: As facilities are faced with staffing shortages and skilled, technical engineers, automation of as many systems as possible is crucial. Automation of the emergency power supply systems (EPSS) testing is something we are seeing a lot of in recent years. Basically, the automated system runs the tests and evaluates conditions in real time and automatically compiles the data. This replaces the tedious task of manually recording the data, which requires someone to travel to the equipment during a test. While this automation is a relatively easy technology to include in a brand-new facility, we work in many aged facilities with EPSS infrastructure dating back to the 1950s or older. We work with these facilities to provide upgraded controls, new signal wires and integrated logic that allow for automated and more importantly, a more reliable system.

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?

Sierra Spitulski: We work with health care providers, builders and designers to create reliable, energy-efficient facilities that safeguard their patient’s health and comfort while simultaneously reducing operating costs. Lately, we’ve been leveraging current code exemptions to decrease airflows in specific areas of the hospital during unoccupied hours through strategic zone level controls, finding creative ways to decarbonize such as rejecting boiler fuel heat to raise the temperatures of the domestic hot and heating hot water systems, in addition to more obvious decarbonization efforts such as heat recovery chillers and electric boilers. New outside air requirements can help or hinder energy efficiency attempts depending on climate and system control. To optimize the system performance, we recommend continuous trending, evaluation and troubleshooting of the new systems until design criteria and energy targets are met.

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?

Beth Gorney: Our clients are asking for flexible systems that can be converted during a pandemic. The air handling systems they are requesting include a purge mode for 100% exhaust and 100% outside air, tight fitting smoke rated dampers for relief air and mixed air to isolate exhaust from supply, filter racks capable of housing MERV 16 or HEPA filters and higher intensity ultraviolet lamps to achieve deactivation of virus particles. They are also asking for additional chilled water and preheat capacity to support the added outdoor air loads when in pandemic mode. This may be achieved with connections for temporary equipment.

Sierra Spitulski: We are constantly updating our knowledge on issues involving indoor air quality and infection and disease control and we are continuously learning so that we can provide the most effective solutions for your health care facilities. As a result of the COVID-19 pandemic, flexibility and disaster resiliency is now at the forefront of facility owner’s minds and we have to look at communities as a whole picture. Maybe one hospital is a regional burn center and another is best suited for infection control. Regardless of specialization and the needs associated with each, these emergency response centers will need to be fitted to survive natural disasters, long periods disconnected from the grid and sudden significant spikes in patient occupancy to support the needs of the communities they serve. Is there infrastructure in place for that? We all need to be looking at things like tanker truck hookups for water or waste, on-site storage tanks for 72-hours minimum of maintained operations at reduced capacity and 96-hours of emergency generator fuel oil reserves to ensure hospitals and communities have the support they need to be resilient.

Tanner Burke: A major theme with the recent pandemic was the limited capacity of hospital beds in some areas of the country. I think future hospital projects will provide flexibility for quickly increasing the capacity by providing additional shell space that can be built out at a later date or wings with open concepts that can be quickly reconfigured to accommodate added beds. This raises questions during the planning stages for fire protection systems to ensure that the infrastructure is suitable for future expansion or reconfiguration. We do this by providing a robust sprinkler design density for shell spaces and using flex-heads to facilitate sprinkler reconfiguration due to added or removed partitions in a space.

Derek Cornell: As the recent pandemic is still on the forefront of our minds, there is a growing list of infection prevention measures that we are looking at on all of our health care designs. Items such as ability to switch an entire floor to the negative pressure, more touchless technologies (door operators, lighting controls, sinks, toilets) and more handwashing features and less shared touchpoints, to name a few. We are seeing the plumbing scope extend in areas of a hospital that you wouldn’t normally see, such waiting areas or main lobbies. This has the ramifications of possibly counteracting water saving strategies, which are also a growing concern.

Kristie Tiller: Two years removed from the start of the COVID-19 pandemic, the most significant changes we see in health care facilities is the trend toward isolation units. We also see entire hospitals and most public institutions augmenting their HVAC systems. The medical facilities are increasing natural ventilation and introducing technology such an ionization. When it comes to the expansion of COVID treatment areas, we do see hospitals funneling more resources and design thought to isolating pandemic patients and treating them in separate quarters from the general population.