How to maintain hospital functionality during construction

Learning Objectives

As hospitals and health care facilities react to the federal adoption of the 2018 editions of NFPA 99: Health Care Facilities Code, NFPA 101: Life Safety Code and other NFPA codes, upgrading the mechanical, electrical, plumbing, fire protection, medical gas and technology systems will inevitably require outages to existing systems.

Designers can learn to identify and predict system impacts and outages early during the design phase so the conversation can occur before construction. Proper outage mitigation and planning will save time, stress and money during construction, while minimizing concerns to patient comfort and safety.

There are no provisions in code to suspend the requirements of an occupied facility for any duration of time. The expectation of a state licensing authority or other authority having jurisdiction is that the facility will meet code requirements when occupied. While remodel or alteration projects are expected to have impacts to the building systems, the facility is not absolved of patient care or safety risks during those times.

System upgrades or replacements may be due to end-of-life replacements, AHJ enforced improvements or they can be desired by the owner after performing the risk assessment referenced in NFPA 99 Chapter 4. The risk assessment process will also help the team determine how to prioritize outages.

Four categories are defined as:

• Category 1: loss of life potential.
• Category 2: major injury potential.
• Category 3: disruption potential.
• Category 4: annoyance potential.

When replacing existing infrastructure, designers and owners should evaluate applicable codes and risks associated with maintaining existing locations and configurations. In many cases, a one-for-one replacement may not be recommended or allowed by applicable codes. Identifying these impacts during the project budgeting stage is important to prevent designs exceeding previously approved budgets.

Engineers and designers can provide valuable input during the owner’s project planning stage to assist with determining scope and costs. When project costs do not align with project budgets, delays can be costly and exacerbate the associated risks.

Health care projects that affect existing departments or systems can have localized or widespread effects on a wide variety of health care departments or systems required to provide patient care. Affected systems or departments can include:

• Catherization labs.
• Critical or intensive care units.
• Dietary/kitchen coolers and equipment.
• Elevators for patient transport.
• Emergency department.
• Imaging (CT, X-ray, MRI).
• Information technology: data, phone, paging.
• Labor, delivery and recovery.
• Nurse call.
• Medical dispensing or storage.
• Morgue coolers.
• Nursery.
• Pharmacy.
• Sterile processing department.
• Surgery or procedure rooms.
• Telemetry.

Electrical systems: Chapter 6

When remodeling patient care areas, the engineer should identify if the existing electrical system is properly grounded, as referenced in Section 6.3.2.4. One of the common areas of concern is the bonding of critical branch and normal branch panelboards serving the same patient care area and the presence of an equipment grounding conductor. This section of code is addressing the possibility of a difference in potential on the equipment casing or grounding connections in the presence of a patient.

Another area of electrical concern is the segregation of essential branches for life safety, critical and equipment branch loads. Commonly termed “comingling,” as areas are remodeled or revised, the engineer should identify appropriate sources for emergency branches and notify the project team when appropriate branches are not available.

An older facility often will have only one general emergency branch panelboard serving both life safety loads (fire alarm, lighting, medical gas alarms, etc.) and critical loads (patient bed receptacles, telemetry, nurse stations, etc.). NFPA 99 Sections 6.7.5.1.2 and 6.7.6.2.1.5 apply to the life safety branch of a Type 1 and Type 2 essential electrical system, respectively, while Section 6.7.5.1.3 applies to the critical branch of a Type 1 EES.

Equipment branch loads defined in Sections 6.7.5.1.4 or 6.7.6.2.1.6 should remain separate from life safety and critical branch panels. When remodeling an existing facility, the engineer should perform a careful study of the existing panelboards and identify when additional panels or even additional transfer switches are required to establish legal branches for use on their project. No section of code permits remodel projects connecting to illegitimate essential electrical system branches for cost or convenience.

NFPA 99 references NFPA 110: Standard for Emergency and Standby Power Systems for the systems that supply the EES. NFPA 110 Chapter 7 includes requirement to maintain separation between emergency power supply system equipment and normal service equipment greater than 1,000 amperes and larger than 150 volts to ground. EPSS equipment includes transfer switches and the distribution equipment serving the emergency side of transfer switches.

Even though this requirement dates back to the 1999 edition of NFPA 110, it is common for older facilities to have both EPSS and normal service equipment in the same room. When projects require additions or replacements of EPSS equipment, the installations should comply with current applicable codes, which may require the creation of a new emergency electrical room. The additional space required will need to be coordinated with the owner early in the design phase so an appropriate cost-effective alternate location can be provided.

When electrical equipment is modified, altered or replaced, the engineer should discuss electrical outage impacts with the owner and affected clinical departments. Outages can occur on the normal service equipment, emergency power supply generator sets and paralleling gear, transfer switches, distribution equipment or panelboards themselves. In each case, a specific outage impact plan should be discussed to determine when the work can occur and what temporary provisions will be required to maintain patient care.

In some instances, the design team may need to identify alternate locations for trauma, surgery or caesarian section procedures, which will be required regardless of the project schedule. Furthermore, high-acuity patients in the ICU, neonatal intensive care unit, pediatric intensive care unit, nursery or labor, delivery and recovery may require supplemental power to remain in their respective locations. When temporary relocation is possible, the alternate locations will require prior approval and planning.

Other areas affected by electrical outages include general lighting and elevator service. Because many health care facilities have multiple levels, temporary illumination of stairwells may be required during associated outages. Vertical transport (elevator) outages need to be carefully evaluated so that patients in beds are not prevented from traveling between floors if a trauma event occurs. In these cases, relocation of patients to the same level as surgery may be required to ensure transport ability.

Refrigeration equipment for the kitchen, morgue, pharmacy or medicine storage are unlikely able to tolerate extended outages. Laboratory and inpatient pharmacy departments are often required to operate continuously and any outage will need to include provisions for alternate sources of power and lighting. When outages impact emergency departments and trauma rooms, the health care facility may need to go on “trauma bypass,” meaning that other area hospitals are informed that incoming cases will be diverted. The use of this scenario should be highly scrutinized, as it represents a loss of revenue and high levels of coordination with administration.

When connecting to or extending existing EPSS equipment, outages occur even when the work is on the de-energized emergency supply portion. Because the standby EPS equipment can be called upon at any time, work that requires a lock-out of the EPS equipment puts the facility and its occupants at risk. EPS or EPSS outages require careful planning and those plans may be subject to approval by the AHJ and or state public health department.

Technology systems: Chapter 7

Modern health care facilities require a constant flow of data for patient information, paging systems, medicinal needs and patient vitals. When projects affect the telecommunication equipment rooms, provisions for electrical power or cooling should be provided to prevent the loss of system functionality during construction. NFPA 99 Sections 7.3.1.2.3.7 and 7.3.1.2.3.8  identify the power requirements and environmental requirements, respectively, for telecommunication systems spaces. When outages to the electrical system are planned, the design team should identify temporary or additional permanent power additions as part of the construction documents.

While dual power supplies with dual sources may be currently used in the network racks, not all systems or components will have this level of redundancy. The current use of any uninterruptable power supplies will need to be evaluated and coordinated with the expected outage duration.

During remodeling projects, engineers should evaluate the existing cabling supports above accessible ceilings and plan for corrections to cable supports for compliance with NFPA 70: National Electrical Code Article 800, which requires that the communication cables not prevent access above ceilings. Exhibit 800.2 illustrates communication cables being prohibited from laying on top of suspended ceiling systems. Section 800.25 requires the removal of abandoned cables, which may be discovered or caused by the remodel project.

As projects impact existing paging systems, and paging systems are classified as emergency communication systems, the associated equipment may fall under the provisions of NFPA 72: National Fire Alarm and Signaling Code Chapter 24, requiring upgrades to both hardware and cabling. Where outages affect nurse call systems, the design team needs to coordinate with the owner for procedures to monitor patients and communicate patient needs, which will determine the timing and duration of outages or any temporary provisions.

Existing phone systems and radio systems may be affected by electrical outages as well. While some systems may have an UPS, the current available runtime of the UPS will need to be evaluated and may require supplemental power if the expected outage is longer than the runtime of the UPS.

Plumbing systems: Chapter 8

NFPA 99 Section 8.3 references the Facility Guidelines Institute for potable, nonpotable and heating water requirements. The 2018 edition of the FGI Guidelines documents for the design and construction of health care facilities is broken out into three categories: hospitals, outpatient facilities and residential health and care and support facilities.

Adoption of the FGI Guidelines varies by state, except where required by NFPA 99. Designers will reference the appropriate documents for their project, noting that infection control risks can exist and the requirements of the Appendix Table A2.1-a for the maximum length of hot water system pipe and the concerns expressed in section 2.1-8.4.2.5 for heated potable water distribution systems.

Because the piping systems are typically hidden behind walls and above ceilings, the designers should spend time discussing the ability to isolate piping with the facility plumbers and staff and incorporate outage mitigation efforts into the design. The impact of system outages due to extensions, rework or demolition will vary based on the system and presence of isolation valves (for pressurized systems).

It is common for older buildings to lack isolation valves by department or floor and designers should consider adding isolation valves when outages are scheduled to reduce future impacts during other construction phases or other projects.

Gravity piping is a common source of conflict in remodel projects for multilevel health care facilities because installation requirements prohibit vertical piping offsets that are allowable with pressurized systems. This means that gravity piping takes precedence over other systems and may impact routing options for new systems. As a result, designers encounter the challenge of coordinating with the underfloor sanitary serving the floor above. The project should identify what rework, if any, will need to occur to existing infrastructure in order to execute the proposed new work. Additionally, any removal or addition of sanitary for the project will affect the spaces below.

It may not be immediately obvious to the entire design team that access from below may be problematic. If the project is above an ICU or a surgery suite, the impacts are exacerbated and the level of coordination required increases. Closing departments or relocating patients to facilitate plumbing work may be avoided by revising the project’s floor plan — something that is easier done during the programming or schematic design phases. The design team should review impacts of proposed plumbing systems on adjacent areas and discuss strategies with the owner and clinical teams.

HVAC systems: Chapter 9

NFPA 99 Section 9.3 references ASHRAE 170: Ventilation of Health Care Facilities. This section also includes ventilation requirements for areas where medical gases are stored. National energy codes, such as International Energy Conservation Code or the ASHRAE Standard 90.1: Energy Standard for Buildings Except Low-Rise Residential Buildings, have an impact on how HVAC systems are designed.

Remodeling or retrofit projects are unlikely able to meet the new requirements using existing equipment. Furthermore, the age and condition of mechanical equipment may justify replacement. It is common for designers to need more system capacity and a one-for-one replacement scheme may not be feasible for two primary reasons. First, the physical size of new equipment may not fit in the existing location. Second, using existing locations means long system outages that are only tolerable if the equipment serves the construction area only.

In health care remodel, renovation or addition projects, temporary ductwork and temporary heating, ventilation and air conditioning equipment should be discussed and planned for during design. Long outages to heating equipment cannot be tolerated during winter months while long outages to cooling equipment cannot be tolerated during summer months; the severity of each is largely due to the longitudinal location of the facility.

Because of the relationship between seasonal temperatures and HVAC equipment, projects can either be scheduled to minimize impacts or plan for temporary equipment. Rooms storing medicines or vaccines will have strict temperature requirements and a plan for either providing temporary conditioning or relocating the sensitive items should be determined. The risk assessment will identify financial impacts and patient care impacts if medicines or vaccines are negatively impacted due to remodel efforts.

When construction occurs in or adjacent to existing occupied areas or where projects have phased occupancy, the HVAC system may likely require multiple balancing and control iterations. Engineers should coordinate expected balancing events with the project schedule.

The quantity and scope of system balancing needs to be clearly identified on the construction documents for each phase of construction. Where supply, return or exhaust systems are impacted during construction, room pressure relationships in adjacent occupied areas can be impacted. Section A1.2-4.2.2.1 (2) of the 2018 FGI Guidelines for hospitals addresses HVAC system outages being discussed as part of the infection control risk assessment.

Medical gas, vacuum systems: Chapters 5, 15

The continued operation of medical gas and vacuum systems will vary based on the classification of system category, as defined in Chapter 4. When outages to Category 1 systems are required, the design team and facility need to work together to either relocate patients to unaffected areas or develop alternate systems, such as portable gas bottles and portable vacuum equipment.

When outages to Category 2 or Category 3 systems are required, the solution may be a combination of convenient scheduling of work and temporary systems. Alarm and warning systems defined in NFPA 99 Section 5.1.9 should be evaluated when projects alter or extend the existing systems. The requirement for two or more alarm panels includes the requirement for independent wiring to the initiating devices, as noted in 5.1.9.2.3.1.

The certification requirements for medical gas and vacuum systems extend the duration of outages that alter or modify existing infrastructure. If the designer intends on reusing existing piping for different systems, Section 5.1.10.11.9.1 apply, requiring full compliance with the provisions for the new system. Medical gasses for oxygen, nitrogen, nitrous oxide, carbon dioxide, instrument air, helium, waste anesthesia gas disposal should be clearly identified, as described in Table 5.1.11. When existing zone valves for gas or vacuum systems are affected by project alterations, the engineer is responsible for determining the compliance of the existing location and making adjustments as directed by the AHJ and as noted in Section 5.1.4.6.

Health care projects present numerous challenges to the design team and coordination with existing occupied areas is another layer of complexity. Impacts to the existing facility are not limited to the discussions above — they also include system routing outside the areas of construction. Identifying outage impacts early in design can allow for design alterations that can reduce or even prevent outages and impacts to adjacent departments. With proper planning, the design team can reduce the occurrence of outages and thus reduce negative impacts to patients and care providers.

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