How to design medical buildings
- Randall Ehret, PE, Senior Vice President, Environmental Systems Design, Chicago
- Timothy Larson, PE, LC, LEED AP, Principal, RTM Engineering Consultants, Milwaukee
- Melisa Rodriguez, PE, SET, Director of Fire Protection Engineering, LEO A DALY, Minneapolis
- Matt Volgyi, PE, LEED AP, Principal Engineer, Southland Engineering, Garden Grove, Calif.
- Mike Zorich, PE, LEED AP, Associate Principal, IMEG, Rock Island, Ill.
CSE: What’s the No. 1 trend you see today in the design of hospital, health care, and medical campus structures?
Randall Ehret: Similar to last year, we see that most stand-alone medical facilities are affiliated with a health care system. They are being used not only as a location to provide distributed care on an outpatient basis, but also as a feeder system for the parent hospital. To this end, branding has become important. This branding often dictates that certain design standards must be applied to the facility. These standards can cover a multitude of mechanical, electrical, plumbing (MEP), fire protection (FP), and technology (T) systems and often have not been refined to meet an outpatient-facility proforma. We are also seeing an increased interest from our clients for National Efficient Price pre-study site selection services. We are assessing potential sites and informing the owner as to language that should be worked into their lease agreements to best protect them.
Timothy Larson: A growing trend that we are seeing within the health care industry is the use of mixed occupancies in a single building, such as medical offices, ambulatory surgical centers (ASCs), and emergency departments. There is a transition shifting away from large, full-scale hospitals; instead, we’re seeing community-based sites add on an emergency department and perhaps a surgical center. These microhospitals don’t have full hospital functionality, but they can provide immediate care more locally in the community, which caters to those who want access to more personal care where they live.
Melisa Rodriguez: We are moving toward more modular options in design and modifications of fire protection systems through the use of flex heads for sprinklers.
Matt Volgyi: Increasing attention to energy efficiency and lifecycle cost. While infection control and patient comfort have remained the driving forces in hospital HVAC design, health care providers are increasingly looking at ways to improve the energy efficiency of their health care facilities caused by the cost growth of electrical, gas, and water utilities and their direct impact on profitability.
Mike Zorich: We are seeing more focus on outpatient facilities including clinics, ambulatory surgery centers, and stand-alone emergency departments. FGI 2014 Guidelines for Design and Construction of Hospitals and Outpatient Facilities has specific sections pertaining to these outpatient facilities, but the level of patient care and safety remains the same as with inpatient facilities.
CSE: What other trends should engineers be on the lookout regarding these projects in the near future?
Rodriguez: The changing landscape of health care delivery is requiring careful vetting of codes and applicable separations in settings that combine ambulatory, outpatient, and inpatient spaces.
Volgyi: They should watch for increasing energy code coverage of health care facilities. There is a growing need to be able to measure the energy efficiency of health care facilities as compared with an established industry-standard baseline facility using current HVAC technology. Health care facilities are often exempt from energy code requirements, with patient and staff and visitor safety overriding energy considerations. Evaluating health care facilities with energy codes and energy-modeling software developed for office-type occupancies will result in unrealistic results and diminished savings. Also, look for increased use of variable air volume (VAV) systems in health care. OA
Ehret: As more stand-alone facilities are being developed, regulatory agencies will be looking closely at the suitability of the MEP infrastructure for the intended use of the space. This may dictate more in the way of generators, filtration, and medical gases. Uptime for electronic medical records is also more of a concern than in the past. As more care modalities are transferred from hospitals to outpatient facilities, buildings must be more adaptable to change. System-performance expectations/requirements vary greatly for different modalities.
CSE: Please describe a recent project you’ve worked on—share details about the project including location, systems engineered, team involved, etc.
Zorich: We recently completed the $150 million campus-integration project at Genesis Medical Center East Campus in Davenport, Iowa, with Flad Architects. We provided MEP/T services for the central utility plant upgrade and the 7-story surgical and patient-care bed tower. The main mechanical room that contained all the VAV air handling units (AHUs) was located between the surgical floor and patient floor. All supply- and return-air boxes for the 16 operating rooms (ORs) were located within the mechanical room above the surgical floor to allow staff easy access to the boxes without having to gown up to access the sterile area.
Ehret: One recent project was a replacement suburban hospital. This hospital was a recent acquisition to a health care system headquartered in a large metropolitan area. A lot of time was spent setting expectations between the infrastructure standards applied at the main campus versus the needs for the new suburban hospital. A complete smoke-management system was provided in lieu of a fan shutdown in fire mode. This allows the facility to more effectively continue to provide patient care during a fire event. An N+1 emergency power supply system (EPSS) including paralleling gear was used. A centralized uninterruptible power supply (UPS) was provided for all the imaging modalities on the project. A separate centralized UPS was provided for all the intermediate distribution frame (IDF) closets.
Larson: We recently worked on a 130,000-sq-ft health care facility; the main section is a medical office building offering outpatient services with an ASC suite. In a different part of the building, the facility will open an urgent care center, which will evolve into an emergency department in the future. The medical office building and the ASC are classified as B occupancies, generally used for medical offices or outpatient clinics. The urgent care center/emergency department, however, has an I-2 occupancy classification, which is used for medical, surgical, psychiatric, nursing, or custodial care on a 24-hour basis for more than five people who aren’t capable of self-preservation. Because of these occupancy changes and each facility’s requirements, we needed to develop three separate emergency systems powered by a single generator to comply with the code.
Volgyi: We worked on the St. Jude Medical Center NW Tower in Fullerton, Calif. The project used a 100% outside air (OA) handling system design for maximum flexibility and high indoor-air quality combined with runaround heat recovery to eliminate the otherwise resulting energy penalty. The building zoning was developed to allow partial shutdown of building floors, partially due to smoke alarm or AHU fan or motor failure, while all other areas in the building are unaffected. Also allowed the minimum of 10 of the 16 ORs to remain in uninterrupted operation during such events. Two-position airflow controls are provided for all ORs to allow airflow setback to 30% flow during unused hours for any operating rooms. The team involved McCarthy Building Companies, Taylor Design architects, and Southland Industries as the design-build mechanical engineer and contractor.
Rodriguez: LEO A DALY is currently designing a government clinic building in a major U.S. city. As part of our scope of work, we are providing life safety protection for the 3-story structure, which has an anticipated total of 157,000 sq ft. The clinic has outpatient-care facilities throughout the first and second floor as well as a portion of the third floor. The third floor also contains a number of surgical suites for performing same-day surgeries as well as radiology services. A portion of the third floor contains surgical and recovery suites and is large enough to meet the definition of ambulatory health care, thus triggering certain smoke control measures as directed in NFPA 101: Life Safety Code. The project requires careful coordination between the requirements from the International Building Code (IBC) and from NFPA 101. Also, LEO A DALY fire protection engineers and architects completed a Statement of Conditions Life Safety Assessment Survey for the VA Long Beach Health system located in Long Beach, Calif. The 1.4 million-sq-ft medical campus includes health care, ambulatory health care, and business occupancies. The project scope includes an onsite life safety assessment survey to identify life safety code deficiencies and the completion of the “Plan for Improvement,” which is required for the Joint Commission hospital-accreditation process.
CSE: Have you designed any such projects using the integrated project delivery (IPD) method? If so, describe one.
Volgyi: Temecula (California) Valley Hospital is probably the best example. IPD allowed the project to be designed, permitted, and constructed at a pace unmatched in the industry at a significantly lower cost than similar health care facilities.
CSE: What are the challenges you face when designing such facilities that you don’t normally face for other projects?
Larson: Having an ASC, emergency department, and medical office reside in the same building is pretty typical; however, the challenge comes when designing the systems for each, as they won’t have the same requirements. For instance, an ASC needs to be designed similar to a full-scale hospital; an office building isn’t required to have an emergency power system supplied by a generator, but an ASC is; and an ASC and an emergency department have similar emergency power requirements with three branches of power for life safety, critical power, and equipment. Because they reside in different occupancies, they must have separate systems. Additionally, the medical office building isn’t obligated to have the three branches of power and only requires life safety capabilities (fire alarms, emergency lighting, etc.). To address these challenges, we designed an optional standby power system using the onsite generator. This system manages power loads that the facility prioritizes in an emergency, such as those associated with running the call center to contact patients.
Rodriguez: Tight fits in the plenum space above the ceilings is a perennial concern when designing health care facilities. The plenum space is often larger than other buildings by necessity and is usually filled to capacity. Excellent coordination between the different disciplines involved on a project, such as structural, mechanical, electrical, life safety, and fire protection systems, is the only way to make sure everything fits.
Volgyi: Designing a health care building in California presents unique challenges you will not find on other projects. Health care facilities have their own codes to comply with as described throughout the California codes. With the high complexity of codes regulating hospital design and construction comes a variety of code-interpretation issues, which can add a highly unpredictable element for California health care projects. Seismic compliance in California is essential, especially in health care facilities, resulting in significantly more stringent structural and mechanical seismic-compliance requirements. Most mechanical equipment to be used in hospitals must have seismic certification obtained after shake-table testing.
CSE: What are some unique elements/considerations when retrofitting or renovating such facilities?
Ehret: Interim life safety measures and infection control are fairly unique in the health care market. These considerations often will require a complex level of phasing be added to the project plan. Downtime is also a major consideration in health care. Major infrastructure projects, such as EPSS upgrades and air handler replacements, need to be carefully planned and coordinated. In addition to design and construction considerations, commissioning these systems is very important and very challenging. Thorough testing of these systems can impact the ability to provide patient care. Close coordination with the facilities engineers, the users, the safety manager, and the infection-control manager is vital to the overall success of the project.
Volgyi: Probably the most significant challenge is that continuous operation of the remodeled facility is required. This requires careful phasing, often temporary equipment, and ensuring code compliance throughout the project delivery. Another often significant challenge is the evolution of codes throughout the years as they relate to health care design. We work on hospitals built in the 1960s or earlier; remodels often trigger significant code upgrades, often presenting significant increases to the project scope and cost. As-built drawings for these older facilities are often unavailable, requiring extensive field investigation to allow remodels in these buildings and to demonstrate code compliance.
Rodriguez: Phasing and infection-control procedures play a huge role during the construction process. Maintaining appropriate levels of protection for occupied spaces during construction, both above and below the ceilings, is critical to patient safety during renovations and retrofits. Coordination of building systems is also a challenge, as the plenum space above ceilings is already crammed full of systems runs in a retrofit scenario. Another unique consideration relates to the heavy/large equipment used in hospitals. Structural requirements must be evaluated before any new equipment can be added to a facility. A new MRI needs a path into the building, and the space/ building construction has specific requirements as well.
CSE: Is your team using BIM in conjunction with the architects, trades, and owners to design a project? Describe an instance in which you’ve turned over the BIM model to the owner for long-term operations and maintenance.
Volgyi: BIM has been used on all of our recent and current hospital projects. In health care facilities, it is increasingly critical that reliable as-built documentation is provided at the end of a construction project to allow future remodels to be performed. At the present time, most clients require AutoCAD and PDF as-built drawings at the end of the project, likely because most are not familiar yet with the use of Revit or NavisWorks. On all of our current projects, however, full 3-D coordination is provided using these tools and often required by contract—so the coordinated 3-D BIM model is available for the owner.
CSE: There are two trends in this field—combining many services into one structure and creating standalone facilities for non-life-threatening needs (pharmacies, immediate care, etc.). How are these trends impacting the engineering of the facilities, and how do the needs of these two compare?
Rodriguez: For facilities that have multiple uses, determining the dominant occupancy classification as compared with the incidental occupancy can be a challenge. There is a threshold at which one occupancy’s requirements take precedence over others, but finding that occupancy requires extensive experience and ingenuity. For example, in a health care clinic with predominantly B occupancy, the inclusion of a surgical area will trigger stricter requirements for smoke control, fire ratings, and building construction. Meeting those requirements as efficiently as possible is always a driver in design decision making, requiring coordination among different disciplines.
Volgyi: We have seen the trend of many health care providers developing smaller, more specialized facilities and moving certain functions, such as laundry, imaging, sterilization, etc., into separate buildings. Having these functions remotely located may significantly reduce the project cost and construction duration, as buildings with no patient-care areas will not have to comply with the same rigorous standards.
Zorich: The engineering topic that often comes up when planning a stand-alone, non-life-threatening health care facility versus a traditional multiservice facility is the level of mechanical or electrical redundancy. Depending on the building classification, certain redundancies may be required by code, but typically, the level of redundancy required for a non-life-threatening facility is less stringent. The staffs at these facilities sometimes request redundancy in their emergency power or cooling systems because they are accustomed to these at the larger multiservice facilities. With these levels of redundancy not required by code in the non-life-threating facilities, and the likelihood it is also not included in the construction budget, it is important that we as design professionals educate the owners and the occupants early on in the design process.
Larson: Combining many services into one structure from an electrical power perspective, we have seen an increase in the emergency power density per square foot. There are very similar services offered in a microhospital as compared with a large full-scale hospital, but we have typically seen less storage, office space, and back-of-house areas than in a hospital.
Ehret: First of all, I am not certain I would classify these as conflicting trends. Every project is unique in both its program and the standards that must be applied. Success is earned by simply applying a diligent approach to understanding the codes and standards applicable to the project and clearly communicating the infrastructure necessary to support the project back to the owner and the design team. While a pharmacy might not contain patients with “life-threatening needs,” it still has its own set of stringent criteria (especially USP800 labs) that must be adhered to.
CSE: With budget concerns, how are engineers designing buildings to reduce initial costs while remaining code-compliant and maximizing patient needs?
Volgyi: It is critical to choose the right systems for these buildings to provide a safe environment, infection control, code compliance, and high levels of comfort for the patients. In our experience, the majority of budget overruns are contributed to two main sources, the first being misinterpretation of codes. As the codes are quite stringent, it is important that the design does not exceed the code requirements unless it is fully justified. For instance, providing 10 air changes for a space where four air changes are completely sufficient should be avoided. The second source of budget overruns is energy efficiency upgrades with no payback. We come across many projects where we see a multitude of energy efficiency upgrades that often cancel out each other’s benefits—and often with no payback. For example, adding a small chiller for nighttime loads to increase efficiency at low loads. The significant first cost and relatively low annual energy savings may result in a 40-year payback. However, if the chiller is estimated to last 25 years, the addition of the chiller will not pay back.
Zorich: Our engineers are taking a more active approach in the prefabrication process of MEP systems. This process starts with our initial layout of major MEP spaces and then continues with planning pathways for systems. We are not only looking at prefabrication for toilet groups or patient headwalls, but with the use of BIM, our engineers are looking at opportunities to rack multiple utilities together. The prefabrication process is most impactful when you have the engineering team working closely with the mechanical and electrical contractors as early as possible in the process. We continue to see the prefabrication process as an effective way to improve overall quality and help the project budget and schedule.
Larson: Ensuring that there is a clear understanding of the codes and guidelines required to be met, and open communication with the authority having jurisdiction (AHJ), have helped keep costs down upfront.
CSE: How do you work with architects and interior designers to make the facility both aesthetically pleasing and functional?
Volgyi: The best results come from architects learning about HVAC design to understand how best the systems work. Along with this, HVAC engineers need to learn about architectural design so all parties can understand each other’s goals and come up with optimal solutions. On the best projects, 3-D rendering tools were used to virtually create important rooms, such as patient rooms, to illustrate the design and get feedback from all design partners and users, such as doctors and nurses.
Rodriguez: In working with multiple disciplines on complicated projects, the initial coordination and communication efforts are crucial. Be upfront with the architects and interior designers regarding the need to expose or not expose certain system elements, such as piping. In patient rooms, the fire protection engineer needs to be very clear about specifying sprinkler system types and heads, such as recessed versus concealed heads, and discussing the cost difference upfront. There is an architectural trend toward exposing structure in public spaces, such as front lobbies. In those circumstances, it’s especially important to coordinate early with the architect to ensure that the vision for the space is upheld across all disciplines.
Larson: There are many ways in which we attempt to add aesthetic design considerations to a facility’s utilities. A few examples include:
- Lighting and controls: Industry lighting and control trends are moving toward designing the lighting and associated controls to feel more residential and allow for personal customization. This may include using a warmer color temperature for decorative lighting and lobby spaces, wall sconces throughout corridors, fixtures that change color temperature throughout the day to follow the patient’s circadian rhythm, controls systems that allow for patients to dim the lighting to a non-exam level, user (patient) control of systems (lights, television, blinds, etc.) at the bedside with use of nurse call pillow speakers, and color-changing light fixtures so patients can customize their space during procedures (CTs, MRIs, etc.).
- Power: To keep electrical equipment out of public view, locating panelboards in an electrical room or closet in lieu of in corridors and nurses’ stations. This both improves the space aesthetically and enhances the security of the equipment.
- Fire alarm: Use of white devices on white ceilings helps reduce “ceiling noise.” Additionally, using the fire alarm system for paging can reduce installation/equipment cost of speakers and lessens the quantity of devices seen throughout a space.
- Nurse call systems: Especially in residential care units, nurse call systems are being developed that use wall-mounted sconce fixtures to alert staff of patient calls in lieu of the more clinical-looking ceiling-mounted dome lights. Another option (where allowed by code) is to use wearable device technology for staff and patients, which reduces the appearance of clinical devices throughout the spaces’ walls and ceilings.
- Finishes/mounting heights: Coordinating the height of devices with wall protection and tile work, as well as discussing finish options for light fixtures and wiring devices (ceiling and wall), may also help bring a space together aesthetically.