Operating on medical and hospital projects
Larry Anderson, PE, RCDD, CDT, Principal, TEECOM, Oakland, Calif.
Jeremy Jones, PE, LEED AP, EDAC , Healthcare Market Leader, Affiliated Engineers Inc., Chapel Hill, N.C.
Daniel S. Noto, PE, LEED AP BD+C, Healthcare Studio Leader-Southeast Region, exp, Atlanta
Eric Reuther, PE, LEED AP BD+C, Principal, McClure Engineering Associates Inc., St. Louis
Jonathan B. Slagel, PE, LEED AP, HFDP, Principal/Vice President York Office & Healthcare, Barton Associates Inc., York, Pa.
Bill Talbert, PE, BEMP, LEED AP, Senior Mechanical Engineer, MEP Associates LLC, Verona, Wis.
CSE: What’s the No. 1 trend you see today in the design of hospitals and medical campuses?
Eric Reuther: We are seeing our hospital clients become more interested in providing redundancy for their mechanical, electrical, and plumbing (MEP) systems. This has ranged from more emergency power requirements to more demand for emergency cooling. We are being asked to provide additional redundancy in HVAC systems design so that spaces can remain functioning even throughout a power loss or equipment failure.
Larry Anderson: We continue to see the convergence and integration of technologies into the infrastructure of hospitals. For example, data from the nurse call system can be used to collect information on call times. The data can then be used to support a hospital’s consumer assessment of health care providers and systems (CAPHS) score. There has been an increase in wireless communications infrastructure within hospitals to support connected medical devices along with patient and family mobile devices. Many connected medical devices can now directly populate the patient’s medical record and the hospital’s security systems.
Jeremy Jones: Health care systems are shifting everything they can to lower acuity, community-based care. We are seeing an increase in freestanding emergency departments (where allowed by local codes), ambulatory surgical centers, wellness centers, and the like. Hospitals aren’t going away, but the main hospital is transitioning to handle the higher acuity needs, such as trauma, surgery, and intensive-care units (ICUs). We suspect that this is driven by changes in reimbursement criteria from the Affordable Care Act. Uncompensated re-admissions will go down if patients stay out of the hospital and/or can receive the care they need closer to home, but outside a heavily clinical setting.
Daniel S. Noto: The biggest trend throughout the health care industry is the move toward locating acute care that doesn’t require an overnight stay to medical office buildings (MOBs). MOBs used to be filled with general practitioners, pediatricians, OB/GYNs, etc., but now we’re seeing ambulatory surgery centers, cancer-treatment facilities, and imaging centers. Ten years ago, all of these were located in hospitals.
Jonathon B. Slagel: One of the most overarching trends we are seeing in the health care industry is the decentralization of health care services. Much of the health care development we have been seeing is investment in outpatient treatment and surgery centers and medical service complexes. While health systems continue to invest in their acute-care hospitals, we have seen that the bulk of that investment is focused on updating existing services or technologies. With the health care industry increasing focus on preventive and outreach care, we have seen a decline in projects focused on increased inpatient bed capacity and services.
Bill Talbert: We see resiliency of systems to maintain critical operations during disruptive events and adaptability of systems to meet changing needs over a building’s lifespan.
CSE: What other trends should engineers be aware of for hospitals and medical campuses in the near future (1 to 3 years)?
Reuther: Imaging equipment seems to have a high turnover rate due to the growing technology. We are seeing replacement of magnetic resonance imaging (MRIs) and computerized tomography (CTs) in fewer than 5 years. We also are seeing a trend of services traditionally provided in a hospital going to outpatient services. This has included imaging services, lab services, etc.
Slagel: With some of the natural and man-created events we have experienced over the past several years, the health care industry continues to drive focus on disaster planning and preparedness. While much of this planning and training is focused on the health care and facility staff’s readiness to respond, there is an increasing focus on the building’s mechanical, electrical, and plumbing (MEP) infrastructure systems. We have been seeing an increasing trend of hospitals focusing on the expansion of emergency power systems to provide capacity beyond the required loads in the hospital. Many facilities are starting to look at installing generator farms that can support required life safety and critical patient services during short-term power outages as well as full power-service backup during extended power outages. These projects develop a more reliable infrastructure system that can better support hospital functions in the event of a catastrophic event.
Noto: From an engineering perspective, the No. 1 concern in all of our designs should be to prevent and control hospital-borne infections.
Anderson: Three years or less is too short of a time frame for hospitals. Some of the hospitals we have designed took up to 10 years to design and construct. In 10 years, there can be dramatic changes in technology. We see some technology systems, especially in the audio/video discipline, change every 6 months. Because of this, we must design flexibility into the building’s technology infrastructure to accept new technologies that will be available at the time the hospital opens. One trend that we see is the integration of mass notification systems, which are now required by code. The voice-annunciation component of this system requires high intelligibility, like a public address system, but also needs to meet survivability and be monitored, like a fire alarm system. Today, there are systems available that can serve all three purposes for public address, fire alarm, and mass notification annunciation. Sound masking may also be added. Combining these into one system can save the hospital money and reduce the number of devices mounted to the ceilings and walls that would have been required by separate systems.
Jones: One significant trend is the increased role of technology and information technology (IT) systems in the actual delivery of medicine. This increase has been slowly taking place for decades, but is now growing exponentially. A hospital’s CIO and IT team are now common participants in every stage of health care project planning. IT infrastructure requirements are exploding, and future expansion of this infrastructure must be understood and planned appropriately. We are also seeing an increase in building automation system (BAS) trending and record keeping. A facility engineer might be called upon to report on historical temperatures, humidity, and room pressurization that individual patients or individual operating rooms have experienced. This capability is much easier to plan at the beginning versus as a retrofit.
CSE: Please describe a recent hospital or medical campus project you’ve worked on-share details about the project including location, building type, systems engineered, team involved, etc.
Reuther: The surgery addition at Herrin Hospital, in Herrin, Ill., is currently under construction. An addition above the existing emergency department of the hospital will provide a new surgery suite with seven operating rooms. A three-phase project allows the hospital to keep its three operating rooms functioning throughout the construction until the project is completed. When the project is finished, all seven rooms will be opened along with a renovated and larger prep and recovery area, as well as four new procedure rooms. The project was designed by Lawrence Group Architects with McClure Engineering as the MEP consultant, SSE as the structural consultant, and Asaturian Eaton and Associates P.C. as the civil consultant. The project is being built by McCarthy Building Companies.
Talbert: I most recently provided sustainable-design consulting and analysis for the University of Minnesota Health Clinics and Surgery Center with my previous employer. This is a 5-story, 342,000-sq-ft outpatient facility located in Minneapolis. I am currently working on a complete air handling system retrofit for the Thomas E. Creek VA Medical Center in Amarillo, Texas. This is a 4-story, 120,000-sq-ft primary-care facility with surgery, ICU, imaging, laboratory, kitchen, and pharmacy services.
Jones: One project we are exceedingly proud of is the North Tower expansion to the Moses H. Cone Memorial Hospital. This project included a 225,000-sq-ft addition, which added 16 new operating rooms and 96 patient beds, relocated the emergency department, expanded central sterile and materials management, and replaced the existing central utility plant all while hospital operations continued without major interruption. Team members included Perkins + Will, Hammes Co., Brasfield & Gorrie, and Affiliated Engineers Inc, among many others. As the first project in our area to use active chilled beams for patient care spaces, the project received a lot of national attention. We measured the performance of many facets of this project over the 2 years following occupancy. Major successes include a reduction in historical infection rates (which were already very low) and a significant decrease in patients’ temperature complaints. In addition, with the improvement in energy efficiency via new certified energy procurement professional (CEP), active chilled beams, solar hot-water heating, etc., the heating and cooling energy consumed by the facility actually went down despite adding 225,000 sq ft of conditioned space.
Anderson: The new 2.8 million-sq-ft Parkland Memorial Hospital-the largest public health care project in the country built in one phase-opened its doors August 2015 in Dallas. The new hospital, which encompasses 862 licensed beds, 96 neonatal intensive care unit rooms, and a 120-bay emergency department, has been hailed as a model of digitally supported health care. We planned and designed the integrated-technology systems that enable the hospital’s innovative model of connected care. Our integrated-technology design services included telecommunications, security, audio/video, network, and wireless as well as onsite IT project management services. The integrated-technology systems we designed for Parkland Memorial Hospital captures and records data, enhances security, and enables efficient operation in many ways.
Slagel: Our firm recently completed work for a multiphased expansion/remodel of the surgery and central sterile processing departments in a central Pennsylvania hospital. The project included construction of 10 new operating rooms and one endoscopy procedure room along with new pre-operation and post-anesthesia care unit space. The project also constructed a new area for the central sterile processing department to locate it in closer proximity to the operating theater. One of the key drivers for the MEP systems on this project was high reliability. Each operating room was designed with a pair of isolation power panels, with each served by a separate transfer switch and central uninterruptible power supply (UPS) source to ensure continuous power supply via redundant pathways. The HVAC system was designed to use multiple air handlers serving the surgery department such that equipment failure of one system would only impact a portion of the suite, permitting staff to continue procedures in the remaining available spaces.
CSE: Describe your experience working with the contractor, architect, owner, or other team members in creating a BIM model for such a project.
Anderson: All of the large projects we are involved with use BIM, which is usually managed by the architect or program manager. On a typical project, engineering firms will upload a model to a cloud-hosting, secured website at the end of the week and download copies of the other firm’s models at the beginning of the week. It is important for the managing firm to publish a BIM execution plan and then marshal it. The BIM software has a lot of flexibility and can be used in multiple ways. For each firm’s model to link to another firm’s model, all parties have to use the same model parameters. We have been on projects where the BIM execution plan has not been enforced, and it has been a difficult experience. During the design process, the BIM is created by the design firms. This model is used for coordination during design and is eventually issued in the form of 2-D stamped-and-signed drawings for permit. However, we often see construction teams starting from scratch to create their fabrication/construction model. The construction model may have more detail, based on fabricated materials. It will also reflect the actual location of equipment, or at least the intended location of equipment for installation. Creating two models for a project appears to be inefficient. There is definitely an opportunity to improve on this process.
Jones: Revit is the BIM tool for almost every major project these days. They have finally reached the point where the MEP tools within Revit have caught up with architecture and structural, which opens up a lot of the benefits of a true multidiscipline BIM. We have seen a dramatic reduction in fit-related coordination issues. Sophisticated contractors are now able to supplement the design model with submittal and observations and measurement data to make the product that is turned over to the owner more valuable. We expect continued improvement in the quality and richness of these models as the market continues to move toward early contractor involvement, design assist, and integrated project delivery (IPD) methods.
CSE: Have you designed any such projects using the IPD method?
Jones: We are now seeing this trend make its way to the East Coast. Our office’s first, true IPD project with a multiparty contract is beginning on a major hospital expansion in Greensboro, N.C. The initial phase involves a big-room, lean process by which the major decisions will be flushed out so that, once design begins in earnest, the design duration will be greatly reduced. The major subcontractors will have a role in the production of the documents, which will result in greater buy-in on major decisions and MEP space planning. The architect, construction manager, trade partners, and engineers will all share in the savings generated by this lean process. We are just getting started, but so far, this process has really started to break down traditional barriers between our individual firms. We are excited and hopeful that this project will be successful for all involved.
Anderson: The new University of California San Francisco (UCSF) Medical Center is the first hospital in the nation designed and constructed under an IPD method. By using this approach, the design and construction team worked together in one office location, specifically built to enhance collaboration and keep the project on schedule. Our IT project manager was onsite and in the office full time, interfacing with UCSF IT project and construction teams to ensure they were making the right decisions to not impede on the construction schedule. In addition, the entire design and construction team attended the Stanford University’s Center for Integrated Facility Engineering, a research center dedicated to architecture, engineering, and construction industry projects, to kick off the project and apply best practices and methods for project delivery in the office.
CSE: What unusual requirements do hospitals and medical campuses have from an engineering standpoint?
Reuther: There are a number of unique requirements in a hospital that do not necessarily apply to other projects. First of all, there are several requirements including ASHRAE, NFPA, and health department codes that apply to these projects that engineers may not be familiar with if they are not doing health care work. Additionally, hospitals are very concerned with infection control and go to great lengths to ensure that construction projects do not negatively impact the health or safety of patients in the hospital. Most hospitals have infection control groups that will dictate requirements during construction in order to control dust and maintain safe pressures so that the active hospital adjacent to these projects remains safe. Third, phasing and shut-downs are critical in a hospital facility that remains active 24/7. Engineers must understand the impact on existing systems that all of their designs will have and have a plan for how this can be accomplished while keeping the facility functioning.
Noto: The higher-than-average airflow quantities and more strict humidity control are typically the toughest engineering considerations when designing a health care facility.
Slagel: One of the biggest requirements for MEP systems in hospitals and medical campuses is that they support the safe care of patients and continuous operation of the health care facility. For example, HVAC systems for licensed health care facilities require a higher level of filtration than most commercial buildings. Minimum airflow and space-pressurization requirements must also be considered while designing these systems, all of which are defined to protect patients and clinical workers from contagions. Electrical systems for hospitals require the development of distinct branches of emergency power within the facility, with each branch dedicated to specific functions and operations. The separation of emergency power distribution in hospitals is driven to minimize the risk of downtime for those systems serving functions essential to patient and staff safety, such as medical equipment in ICU bays and life safety systems including fire alarm and emergency egress lighting. These examples, as well as others, add costs to health care facilities but are necessary to ensure that a safe environment is maintained for patients, visitors, and health care professionals.
Anderson: Patients may have the expectation that the health care received from one hospital will be similar to that of another hospital. However, from an engineering standpoint, every hospital organization is unique. This requires us, as designers, to have an open mind in providing our clients with engineering solutions and an engineering approach for project delivery. The way a hospital has organized its departments may have an impact on the way we engineer a system. For example, from an engineering standpoint, it may make sense to install converged technology systems equipment in one technology room. However, the project design may require splitting up technology systems into multiple spaces. We have also seen clients completely separate their facility’s data network from their IT network. This requires us to design two completely separate technology infrastructures for the hospital.
Jones: Downtime in a hospital’s electrical, HVAC, and medical gas systems have the potential to negatively affect patient outcomes. As a result, significant thought must be given to redundancy, reliability, and maintainability so that this risk is minimized or eliminated. Most hospitals must remain functional during and following natural disasters. This is important for the existing patients as well any new patients. The result is an increase in the need for emergency power, domestic-water storage, fire-water storage, and general redundancy of MEP systems. Many health care spaces have code-mandated temperature and humidity requirements that are well below what is required for nonclinical settings. Clinical needs often drop these requirements even further. One of the most significant examples is that many surgeons require temperatures well below code requirements. A request for 60°F or colder in an operating room is not uncommon. The result is a need for creativity beyond traditional 42°F chilled-water cooling coils, such as subcooling by glycol or heat-recovery chillers, wrap-around heat pipes, or desiccant dehumidification to drop supply dew points so that low temperatures can be achieved while keeping relative humidity below 60%. Accomplishing all of this while keeping energy efficiency in mind only adds to the excitement.
CSE: Describe the commissioning process for a hospital or medical campus project. At what point was your team brought in, and what changes or suggestions were you able to implement via commissioning?
Reuther: Typically, we engage our commissioning group during design as an extra set of eyes to help review the project. The commissioning group is often able to provide valuable feedback on controls system design as they have a lot of experience in the field trying to make the sequence of operation work that the design engineer writes. On a recent air handling unit (AHU) replacement job, our commissioning team was able to identify a problem with the unit not performing as shown on the shop drawings. At first glance, the unit seemed to be working fine and operating per design. After further testing, it was determined that the unit had a significant internal pressure drop not shown in the manufacturer’s shop drawings and the outside airflow station was not reading correctly.
Ultimately, this was resulting in a section of the hospital not being properly balanced due to the incorrect outside airflow. Furthermore, the additional pressure drop was using up the extra capacity designed for future expansion. The commissioning team was able to work with the unit manufacturer to help identify the problems. This led to the AHU manufacturer coming out to the site and modifying a section AHUof it to correct the unnecessary pressure drop as well as modifying the section with the outside airflow meter so that it would read correctly. Without the additional testing and monitoring of the commissioning group, these issues would have probably gone unnoticed.
Jones: Most of our clients no longer see commissioning for major health care projects as optional. For most hospital projects, the commissioning agent is brought on board around the end of the schematic design or the beginning of the design development. One of the largest values a commissioning agent brings to a project is experience in MEP system start-up. The most significant changes they can make are the ones that seem the smallest, such as additional valves to aid in isolation and future service or control-sequence tweaks that increase functionality.
Anderson: We don’t often get involved with the commissioning of our design in hospitals. We may provide the performance criteria to the commissioning agent and do our own field verification of the design. We most often see the project owner hire their own independent commissioning agent.
CSE: Describe a large hospital or medical campus project you recently worked on.
Noto: We just completed a vertical expansion at the Northside Hospital-Forsyth in Cumming, Ga. The project consisted of enclosing the roof to make it a mechanical floor and then adding two patient floors above that. One of the patient floors is a "standard" patient room floor. The other floor is dedicated to oncology patients, thus it required high-efficiency particulate air (HEPA) filtration and higher air changes to ensure a higher-quality environment for immunocompromised patients.