How are hospitals being designed differently?
Hospitals and health care facilities are changing and their engineered systems must transform with them
- Mark Chrisman, PE, PhD, Healthcare Practice Director, Principal, Henderson Engineers, Lenexa, Kansas
- Mike Fialkowski, PE, RCDD, LEED AP, Technology Services Market Leader, Affiliated Engineers Inc, Madison, Wisconsin
- Zach Frasier, PE, Mechanical Engineer, Moses Engineering, Gainesville, Florida
- Steve Lutz, PE, LEED AP, Associate Director, Harris, St. Paul, Minnesota
How has COVID-19 changed your work in the past 18 months?
Mark Chrisman: Many projects slowed down or stopped in spring 2020. However, this was immediately followed by increased demand for negative isolation rooms. Some projects that were paused resumed by last fall and several new projects were kickstarted at that time. Since the beginning of 2021, there’s been a whirlwind of health care projects of all types, many of which are addressing needs that weren’t dealt with last year. In terms of being on-site at health care facilities, there are additional policy and personal protective equipment requirements as well as some scheduling challenges, but we’re working diligently with health care facilities to make things work as smoothly as possible.
Mike Fialkowski: The pandemic has shown the need for design teams to embrace remote working tools and adapt how we engage teams to advance complex topics. Where we traditionally would start sketching on a whiteboard during a meeting, we’ve had to augment our remote conversations with graphics and images on-the-fly. Leading a meeting requires the use of voice, video and imagery to engage stakeholders. Engineers must be equipped with both technical knowledge and personal communication skills to be successful in project advancements.
Zach Frasier: In the State of Florida, we are essential services. As a result, we were instrumental in developing emergency COVID-19 measures for our hospital clients including conversion of entire hospitals to airborne infection isolation facilities.
Steve Lutz: Many projects have been put on hold or deferred to a later date. We have helped hospitals set up temporary and permanent patient isolation precautions (rooms and floors) for COVID-19 patients. With highly transmissible respiratory diseases, these specialized spaces have become more critical and must be correctly engineered to be effective.
What’s the current trend in hospitals, health care facilities and medical campus projects?
Mike Fialkowski: Facility design continues to show the need for rigorous analysis of design options and system selections. We continue to analyze multiple variables at each decision point — from how we improve the patient experience and supporting care teams to making the built environment more efficient; all in addition to the life cycle cost considerations. Flexibility in operation must be considered so clients know what their spaces and systems can do in the future, either in capacity or features that can be turned on as needed. Resiliency analysis — the ability to recover from disaster-scale events — ensures mission critical features are deployed correctly and accurately.
Mark Chrisman: The most prevalent trend is standalone ambulatory surgical centers. COVID-19 surges have disrupted surgical procedures, which are often lucrative. Health care systems with standalone ambulatory surgical centers can provide surgical procedures uninterrupted while treating COVID patients at their main facilities.
Medtail, the intersection of health care and retail, is another key trend. Primary care, radiology, dental and other functions that are historically located near or on health care campuses are taking advantage of retail real estate near or on retail developments. This offers the convenience of being easier to access for patients, who can run errands nearby.
Lastly, there’s an increase of medical education projects that blend health care, higher education and science and technology. These are often located on or near academic medical centers or university campuses and assist with training health care staff, in addition to providing research space and incubator space for health care startups.
What types of challenges do you encounter for these types of projects that you might not face on other types of structures?
Steve Lutz: Like any hospital renovation project, being aware of the construction we are doing and how it might affect patients, staff, visitors and construction workers is imperative. To deliver a project in a functioning, occupied health care facility, it is crucial to develop a strategy and schedule so occupants know what to expect — and when to expect it. Construction cannot disrupt patient services and there must be a very detailed plan and regular communication. At Harris, we are well-versed in the operational model for building within acute care facilities such as intensive care units, critical care units, trauma centers and nuclear medicine environments. We also place crucial importance on safety awareness, working directly with the project team to ensure the safety of all patients, staff and visitors.
Mark Chrisman: Almost every building system is more complex within health care facilities as patients are incapable of self-preservation and the facilities are often large and complex themselves. Beyond that, we often deal with existing facilities that operate 24/7, aging infrastructure, extensive regulations/code compliance requirements and limited space. This makes renovations, expansions, additions and even equipment replacements a challenge. However, as health care engineers, we appreciate these hurdles because we love to solve problems at our core.
Zach Frasier: Health care facilities have mission critical safety requirements that must be met with every direct patient care area. These requirements often override the industry’s move toward energy efficiency.
What are engineers doing to ensure such projects meet challenges associated with emerging technologies?
Zach Frasier: The general trend in the industry is to design to ASHRAE Standard 62.1: Ventilation for Acceptable Indoor Air Quality and ASHRAE Standard 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings whether the functional requirements of the project warrant this approach or not. ASHRAE Standard 170: Ventilation of Health Care Facilities is being rewritten by the steering committee to align it with 90.1 which poses a safety risk that will not manifest in facility data for another 10 years.
Steve Lutz: Our in-house designers and engineers are constantly reviewing the latest literature and working with top medical planners and architects to best understand the likely evolution of new medical equipment and what that may mean for the supporting heating, ventilation and air conditioning or plumbing systems. This has especially been around the need for more flexibility in hospital design and construction as some medical equipment becomes more mobile and can impact ceiling layouts or systems connections.
Mark Chrisman: Even before the pandemic, we were deliberating at length with both colleagues and clients about new technologies that are emerging. At Henderson, our health care technical leaders and our quality control experts continually help us vet the latest information from vendors and manufacturers. We’re then able to advise clients on how new technologies work and where they may be beneficial for specific applications. Once a client decides to implement a new technology, we involve the respective manufacturer or vendor early to help with coordination and any specific requirements that need to be addressed during design and/or construction.
Mike Fialkowski: Technology and communication systems in health care continue to rely on core infrastructure (information technology, power and cooling). This core size and capacity must be scaled so emerging technologies (complex patient monitoring, a multimedia-enabled care team, artificial intelligence enabling sensors) can be added to augment, not replace, human-to-human care.
Connectivity technologies like 5G enables another channel for moving data, but still requires additional equipment within the facility: cabling, antennas and access points. Technology systems are the most frequently updated systems in the built environment, so engineers must enable designs that allow for replacement of systems every few years while continuing to provide care. This includes core IT spaces that accommodate new equipment, wired and wireless infrastructure that are accessible and upgradeable and system selection that leverages integration to evolve.
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?
Mark Chrisman: One project involved retrofitting existing patient rooms into fully exhausted negative pressure swing rooms. Existing buildings are not often sealed tight enough to provide the pressure requirement for a true isolation room. Coordination expectations of room pressure setpoint are important as a fully exhausted negative pressure room may be able to be obtained without other changes to the space envelope.
Zach Frasier: During our reconfiguration of an entire hospital to an AII facility, we were forced to develop methods of compliance to meet the intent of the TAII guidelines set forth in the Facility Guidelines Institute. There was no useful guidance issued by FGI, the state health care authorities having jurisdiction or the Army Corps of Engineers; and many of the consulting firms in Florida shut down during the lockdown when this reconfiguration work was in progress. We determined that the best approach was to coordinate enhanced PPE for the staff and configure the facility like the Centers for Disease Control and Prevention did during the 2004 SARS outbreak in Taiwan.
Steve Lutz: We gave the option for a hospital to have a certain floor go into full exhaust mode for when the COVID population rises. With the retrofit we added return and exhaust modulating control dampers, an exhaust fan, ductwork and repositioned the supply and return/exhaust grilles in each of the patient rooms.
How are engineers designing these kinds of projects to keep costs down while offering appealing features, complying with relevant codes and meeting client needs?
Mark Chrisman: Being knowledgeable about relevant codes is important in ensuring systems are not overdesigned. Designs should be centered around spaces that will have the biggest impact in reducing infection risk for patients and staff. Understanding the source of infection risk and how each technology or system can decrease that risk helps focus the design on fewer critical areas in lieu of spending money to treat an entire building.
Steve Lutz: At Harris, we are continuously reviewing the costs of the systems we design, install and maintain. From the earliest stages of design, we look at system options studies, which can offer different levels of provision to meet different needs. These discussions allow our clients to have full visibility to what their options are and how it affects cost. Maintaining the minimum level of code, standards and other guidelines is critical in these discussions. We are familiar with many different codes from coast to coast and ensure that the right and best systems are detailed to meet these needs.
How are hospitals, health care facilities and medical campus buildings being designed to be more energy efficient? How will new outside air requirements affect this energy efficiency?
Zach Frasier: The FGI 2018 edition for inpatient facilities amended ASHRAE 170 requirements to allow for ASHRAE 62.1 critical zone methods to be performed in lieu of the prescriptive air change requirements for the spaces. Additionally, the ventilation requirements were revised to allow patient rooms to only include the breathable zone (i.e., 6 feet 6 inches above finished floor and below) in calculations. Simply using the code-preferred ventilation calculation methodology will necessarily yield significant energy savings.
Mark Chrisman: Humidity and air change requirements have the largest impact on overall energy use. Greater energy savings can be achieved by reducing humidity setpoints and the air change rate in unoccupied spaces.
Steve Lutz: The most important aspect of engineering design for a health care facility is providing for the safety, wellness and comfort of the patients, staff and visitors occupying the facility. Many patient care and support areas have code required standards that help to determine the mechanical system design. With that, much of the actual equipment sizing and capacities are determined by design standards.
To save energy, high-efficient equipment should be selected. High energy use areas should be identified, such as operating room areas and off-hour turn down of air flows should be considered. The use of occupancy sensors should be considered in office and support areas, with potential lighting and airflow turndown savings as well. Where appropriate, low-flow plumbing fixtures should be used.
Additionally, chiller and boiler plants consume large amounts of energy and these should be reviewed to consider energy conservation measures in the central utility plant. Such systems to be considered should be: variable-primary pumping, heat recovery chillers with domestic hot water integration, low-temperature chilled water series arrangement, pressure independent control valves, heat recovery on boiler stacks and condensing boilers. Renewable energy systems such as solar thermal collectors can generate hot water without burning gas.
Because more outdoor air will increase the energy use of the building systems, energy recovery should be considered on all air systems. As we move to a higher electrification of buildings in general, these high-demand facilities will need higher levels of innovation and systems integration to make this switch while delivering the reliability that is expected.
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?
Steve Lutz: More attention is being spent during the design phase to consider the what-ifs of potential pandemic and other catastrophic events. Spaces are being designed to be flexible so that they can change in function when special events occur. In regard to potential pandemics, the first engineering considerations are usually to provide 100% outdoor air and increased filtration efficiency. This has an impact on the fans that are required due to increased pressure drop. The use of more outdoor air can also have a substantial effect on the size of the head-end cooling and heating equipment. Due to the high energy cost of additional outdoor air delivery, more effort and upfront capital expenditures are considered for providing energy recovery on the systems.
Mark Chrisman: When designing a new facility moving forward, engineers, architects and other key players will need to designate its main role during a pandemic based on the services offered by health providers nearby and the makeup of the local community. A facility designated to treat infected patients will therefore be designed differently than those designated to treat the noninfected. Overall, some basic items will differ at every facility. This includes the number of negative pressure rooms and the level of control over patient and visitor waiting rooms.
Mike Fialkowski: Pandemic-tolerant facilities will be supported through implementation of technology in a variety of ways. Design and retrofit projects will need to include telemedicine considerations from the floor plan programming level to room design. COVID-19 has demonstrated that remote engagement of patients and families provides more than a follow-up consultation function. Telemedicine keeps patients in inpatient care engaged with their support team, who may not be able to enter a facility in pandemic mode. This requires infrastructure and systems for connectivity in inpatient facilities with robust wireless connectivity to support personal patient devices.
Additionally, space and systems for care providers to remotely engage patients outside of the facility must be considered. A telemedicine-enabled design will become the norm of new patient care spaces.
Zach Frasier: The pandemic was an outlier that highlighted two issues; use of a diversity factor (particularly in medical oxygen systems) is a gamble that a statistically remote outcome will occur and that viral hardening was never a consideration in the code. Moving forward, the industry will have to address viral versus bacteriological hardening. This standard of care will require mechanical, electrical and plumbing engineers to address peak oxygen demand and specific viral environmental requirements.