Medical gas panel

Edward Hood, HH Angus’ Medical Gas Specialist, recently joined an expert panel discussing the issues around medical O2 in the fight against the COVID-19 pandemic. Here is a summary of his presentation for the Canadian Healthcare Engineering Society webinar:

Challenges of increasing the numbers of oxygen outlets to an existing system with a fixed supply pipe size

Since the start of the COVID-19 pandemic, hospitals have experienced extraordinary increases in oxygen consumption due to high numbers of patients admitted to intensive care units. A complicating factor in their care has been the challenge of adding oxygen outlets to an existing zone for the purpose of treating COVID patients. Why is this a challenge? Simply put, many existing oxygen zones within a healthcare facility were not sized for large increases in oxygen flow. Many older healthcare facilities had their oxygen zones sized on oxygen outlet counts, which applied a diversity factor. That approach changed in the last few editions of CSA Z7396.1, which now focuses on understanding specific high demand zones (critical care for example), and designing robustly-sized piping infrastructure to those zones. However, the outcome is the same – many existing oxygen zones were never designed for “overflow” condition; as such, loading up existing oxygen zones by adding outlets or high flow oxygen devices must be managed very carefully.

Why is that? Substantially increasing oxygen flow in an existing oxygen zone will introduce increased pipeline pressure drops in the zone. A drop to 40 PSI at a zone valve will normally trigger the low alarm at the zone valve.

For this reason, it is important to analyze anticipated flow demand within the zone with the size of the oxygen service available in order to manage acceptable pressure losses that will not trigger alarm conditions.

Medical gas alarm

Factors affecting how many COVID patients can be treated in an existing medical gas zone

In hospitals, typical patient room usage is 5 L/min of oxygen; however, oxygen usage for COVID-19 patients can be up to 60 L/min or possibly higher, depending on the types of high flow oxygen devices in use. In order to manage pressure drops within a zone and avoid low pressure alarms, table E.5 in CSA Z7396.1 provides some guidance regarding expected pressure drops per 100ft of copper piping for a given pipe size. These pipeline pressure drops are:

  • ½ inch pipe @ 190 L/min will have .5 pressure drop per 100ft
  • ¾ inch pipe @ 500 L/min will have .5 pressure drop per 100ft
  • 1 inch pipe @ 1000 L/min will have .5 pressure drop per 100ft
  • 1 ¼ inch pipe @ 1800 L/min will have .5 pressure drop per 100ft

In other words, the following occupancy adjustments should be considered:

  • ½ inch pipe
    Non-COVID use = 38 patients in a zone
    COVID use = 3 patients in a zone
  • ¾ inch pipe
    Non-COVID use = 100 patients in a zone
    COVID use = 8 patients in a zone
  • 1 inch pipe
    Non-COVID use = 200 patients in a zone
    COVID use = 16 patients in a zone
  • 1 ¼ inch pipe
    Non-COVID use = 360 patients in a zone
    COVID use = 30 patients in a zone

Concluding recommendations for ensuring adequate oxygen supply

  • Before admitting COVID patients to a typical patient room, facility staff need to check the zone valve to verify pipe size in order to determine occupancy limits. Larger-sized zone valves are typically an indicator of a zone having greater capacity to flow oxygen with lesser pressure drops.
  • Have a pandemic plan to identify where best to convert existing beds to COVID rooms. Consider the size of the oxygen zone valve serving the zone.
  • If you are designing for a new hospital, consider designing a pandemic floor with medical gas pipelines capable of the worst-case scenario load, and consider the pressure drops from the bulk pad/source equipment to the zone in order to keep pressure drop for the pipeline to below 5 PSI per CSA Z7396.1 requirements.

Edward Hood, P.Eng., B. Eng.
Technical Leader and Senior Mechanical Engineer
edward.hood@hhangus.com

Internet of things low poly smart city 3D wire mesh.

The world continues to embrace the Internet of Things (IoT), and emerging technologies are taking on a growing importance within built environments.

A confluence of innovation in big data processing, ultra-low power wireless networks, embedded sensor technology, and energy management has accelerated the emergence of smart buildings. As these become widespread, we have witnessed a reciprocal, or better yet, exponential growth in the planning activities to successfully introduce the sophisticated automation and enhanced user experiences they promise. In particular, hospitals, commercial offices, entertainment, retail, airports and education facilities all have clients who will be directly impacted by these advances in technology. This paper highlights the opportunities to provide a proactive change management plan for a redevelopment or capital project.

A redevelopment project provides an opportunity to introduce a large range of new technologies; however, the ‘big bang’ approach that is associated with the opening of a new facility can hinder the adoption. The role of technology should be understood from a functional perspective long before the walls and bricks are in place, so that proper infrastructure exists to support the smart building.

Any successful Digital Strategy and Transformation Project must consider aligning a change management approach to engage users to be prepared for opening day. The vast amounts of change can overwhelm staff when they move into a new building with new technologies, from new floor layouts and different staffing models, to the introduction of more mobile technology, more paperless systems, and automation of tasks that staff previously performed manually. It is imperative to address the capacity for change well in advance of the Opening Day.

The principles of Change Management and what is unique about a redevelopment project

Change really occurs when it is done at scale – throughout the organization - across all levels and stakeholder groups. There are several industry-recognized principles listed below for adopting change in large organizations. However, given the degree of complexity, number of stakeholders and length of project, there are unique factors that need to be considered with redevelopment.

The Principles

Change is Rolled Out

Redevelopment Project Considerations

Redevelopment projects have many external stakeholders as well as internal stakeholders; employees and project delivery teams have creative authority that can turn into resistance

Change Starts at the Top

The redevelopment project cycle covers many years and the leaders may change; executives are often insulated from the reality of day-to-day operations by layers of the organization

Change is Engineered

A change management program can be planned, coordinated and monitored; however, it is not like a construction project in that it involves breaking new ground and cannot be predetermined fully in advance

With So Many Stakeholders, What Matters Most?

With the variety of stakeholders involved in a capital project, such as end-users, executive team, information technology department, facilities/operations teams, government oversight and taxpayers, there are differing and opposing drivers for each of these groups, which include expected benefits, cost containment and scope definition. There is a need for a framework to define a course of action and for leadership to remain committed to it. Finding the common goals between all the stakeholders will be critical to the long-term success.

In a redevelopment project, the ideas and inspiration for change often come from parties outside the end-user stakeholder groups, such as the design team, the information technology department, facilities engineers, or other support services. Ideally, these ideas are then sponsored by the executive leadership with input from users; however, this is not always the case. It often happens that use cases for the functionality of technology are brainstormed by someone “higher up” or by the IT department, and then rushed straight into design. There is no wrong party to support idea generation; however, the important component is to ensure that end-users have been engaged and have faith that the new technologies will create a better environment. One method of engaging these users is to visualize the changes, and to write and approve the use cases for their workflows. This approach uses Lean thinking and iterative cycles to build consensus. It is critical that time be set aside to ensure that these use cases are considered by end users and validated.

It is important to note that not all parties will see the changes as necessary, especially if they don’t belong to the organization or share the same vision. To address this, create a cross-functional project team, map out the impacted stakeholders and address their unique needs. You will likely appreciate that some people are not able to easily adapt to new technologies. Doing so requires both willingness and capability; mindsets get in the way of actually making use of the technology. Therefore, it helps to have champions and support available. There will also be employees in the organization who are very keen to embrace change that results in a more automated and sophisticated building. Support these individuals in advance of the redevelopment projects by leading change on a smaller scale; for example, by introducing new mobile technologies or smart boards in meeting rooms.

Engineer standing in front of a presentation screen and pointing to it while explaining details to the audience.

Change Starts at Every Level

IT IS IMPORTANT THAT EMPLOYEES
CONTINUE TO SEE AN IMPACT AND BE
INVOLVED IN KEEPING UP THE MOMENTUM.

Long before shovels are in the ground, the organization’s leaders are visioning what the new facility will look like and how it will operate. However, project cycles of up to 10 years can be a significant deterrent for senior leaders seeing their vision through to completion. On one hand, they may perceive what seems to be ample time to prepare for the coming changes; on the other hand, they may also feel that getting ready for a change so far in the future is futile. Therefore, it is important that employees continue to see an impact and be involved in keeping up the momentum.

Communication and setting the stage for the ultimate change may be the most critical factor in successful deployments. This requires an engineered approach to obtaining buy-in. To ensure the cultural ‘soil’ is ready before planting the seeds of change, develop a bi-directional communications plan that allows questions to be addressed. The objective is to prepare employees to understand the benefits of the change, as well as the necessity of the change, and for them to be emotionally ready to execute the change. This requires a two-way dialogue to give staff sufficient time to provide feedback. Employees who fully support the change can be invited to co-develop a plan to describe the benefits and address concerns with sufficient support and training.

Conclusion

FACILITATING CHANGE DOESN’T NEED TO
BE DIFFICULT OR ONEROUS.

As a final consideration, recognize that silos in your organization may create barriers to disseminating your plans. I have often seen change initiatives fall apart when different groups that are equally impacted refuse to take ownership for action. They wait for the other department to come up with a plan and take the lead, while their own group sits back and provides “constructive criticism”. This reveals a culture that is resistant to change. It is important as a leader to break down these barriers. Bring employee groups together to understand the shared objectives and then identify what barriers may get in the way. It may be that both departments are experiencing the strain of increased workload from a large volume of change. However, facilitating change doesn’t need to be difficult or onerous. Following Lean principles, create small batches of work, and plan to stretch these batches out over time.

6 Steps to Successful Technology Change Management

As a strong leader, you can set the stage for successful technology change by adopting these six Change Management steps:

  1. Identify the common goals between all stakeholder parties
  2. Engage end users in depicting the use cases for technology
  3. Communicate the benefits of these use cases
  4. Recognize change champions and providing them with support and training
  5. Test technologies in advance by using pilot studies
  6. Bring together stakeholders to voice their concerns

A change management program needs to be adapted to its unique situational factors. Multiple stakeholders - from financiers, end users, IT, facilities, architects and engineers - can make implementation of your plan more challenging, but by following the steps above, you can ease the process.

If you have questions or would like to learn more about change management, we are happy to start a conversation to see how we could help.

Megan Angus

Megan Angus, RN, Lean, EDAC
Division Director, Angus Connect

megan.angus@hhangus.com

We’re excited to be part of the team, led by EllisDon Infrastructure Healthcare (EDIH), that will build the new Bayers Lake Community Outpatient Centre in Nova Scotia. HH Angus’ Health Division will be providing mechanical consulting engineering services, working with Dillon Consulting in Halifax. This is the first P3 healthcare project in Nova Scotia, and will be an important facility for both the community and the entire province. According to Kim Spencer, HH Angus Health Division Director, “we’re very pleased to be able to support this new facility with HH Angus’ deep experience in the P3 delivery model, and proven track record in thoughtful healthcare design.”

The 134,000 ft2 Outpatient Centre will built on a 15-acre site in Halifax’s Bayers Lake Business Park. Planned services include primary care; clinics such as physio and occupational therapy; high blood pressure, diabetes and orthopedic assessment; 17 examination rooms; 24 dialysis stations; diagnostic imaging (x-rays and ultrasounds); blood collection; and post-surgery or post-treatment follow-up appointments.

Image courtesy of EDIH

COVID 19-Response: Creating Healthcare Spaces for COVID-19 Patients

HH Angus invites you to join The Canadian Centre for Healthcare Facilities’ (CCHF) webinar, featuring a panel of healthcare leaders from across the country, including HH Angus’ Nick Stark. The panel will be discussing how they are addressing patient needs in this new environment, some challenges and solutions, and offering opportunity for insights and discussion.

Date: May 1, 2020

Time: 10:00 – 11:00 am Vancouver | 1:00 – 2:00 pm Toronto

Register in advance for this FREE webinar:
https://us02web.zoom.us/webinar/register/WN_yS8tlKOfQJSs9jghRYu5yA
After registering, you will receive a confirmation email containing information about joining the webinar.

Panelists:
Miriam Stewart, Regional Program Director Critical Care Vancouver Coastal Health/Providence Health Care, Chief Clinical Planning Officer, St. Paul’s Redevelopment, British Columbia

Nick Stark, Vice-President, Knowledge Management, HH Angus

Scott Olsen, Provincial Lead, Asset Management & Safety, Clinical Engineering – Centre of Expertise, Alberta Health Services

John Switzer, Strategic Capital, Space Management and Real Estate

Pierre-Marc Legris, Director Technical Services McGill University Hospital, Quebec

Michael Keen (TBC), Vice-President of Facilities and Planning and Chief Planning Officer, Unity Health Toronto, Ontario

Lynn Wilson Orr, Principal, Parkin Architects Limited

Moderator:
Gordon Burrill, Teegor Consulting, Fredericton, New Brunswick and CCHF Board President

covid-19 infected patient on bed in quarantine room with quarantine and breakout alert sign at hospital with disease control experts try to make disease treatment

In the context of the current COVID-19 pandemic, healthcare facilities are looking more closely at options for safe  and fast conversions/retrofits of hospital infrastructure to increase their numbers of patient beds that can serve as airborne infection isolation rooms, as well as ensuring the safety of their operating rooms for performing surgical procedures on confirmed or suspected COVID-19 patients. Recently, HH Angus’ Nick Stark, Vice President, and Jessica Fullerton, Construction Lead – Infection Prevention and Control at The Ottawa Hospital, presented a webinar organized by the Canadian Healthcare Engineering Society, in which they discussed some of the critical design aspects of isolation rooms in healthcare facilities. Nick is Chair of CSA Z317.2, Special requirements for HVAC systems in healthcare facilities. Jessica is Chair of CSA Z317.13, Infection control during construction, renovation or maintenance of health care facilities.

With recent serious outbreaks such as SARS, MERS and now COVID-19, the design of healthcare facilities should take into consideration how these buildings can better address infectious disease control during pandemic crisis situations such as we are currently experiencing. Isolation rooms are one tool that hospitals can utilize as part of their overall approach to safely dealing with certain types of infectious diseases.

Key takeaways from the webinar and our firm’s experience with building systems serving infectious disease control procedures include:

Isolation Room Types

Isolation rooms are grouped under ‘Special Precautions Rooms’. They are sometimes confused with other types of isolation, such as segregation or seclusion rooms; for the purposes of this communication, the term refers to rooms that provide airborne isolation vs contact precautions.

The three main types of isolation room are:

  1. Airborne Isolation Room (AIR) or Airborne Infection Isolation Room (AIIR) — designed, constructed, and ventilated to limit the spread of airborne micro-organisms from an infected occupant to the surrounding areas of the healthcare facility. AIRs are designed to maintain negative pressurization relative to adjacent areas. The AIR room category also includes exam/treatment rooms, which require anterooms. ERs require an internal washroom, and these are recommended for Ambulatory Care areas.

     

  2. Protective Environment Room (PER) — designed, constructed, and ventilated to limit introduction of airborne micro-organisms from the surrounding areas to an immuno-compromised or immuno-suppressed occupant. PERs are designed to maintain positive pressurization relative to adjacent areas.

     

  3. Combination Airborne Isolation and Protective Environment Room (AIR/PER) — designed to protect immunocompromised patients who are also infectious.

Operating Rooms for Infectious Patients

These should be treated like a combination airborne isolation room/protective environment room (AIR/PER), and include operating rooms (OR) for infectious patients, along with the OR anteroom that serves as an airlock for stretchers.

The OR anteroom would be negatively pressurized relative to the both OR and corridor.

The OR air handling unit (AHU) requires 100% outdoor air.  Method of Procedure issues must also be addressed; for example, the movement of sterile supplies, identifying a site for intubation, and transportation of the patient to avoid cross contamination. 

Air Handling Unit (AHU)

Isolation Room Design Criteria

Key room design factors include high level air separation (7.5 Pa of negative or positive pressure, 12 air changes per hour and directional airflow, with non-aspirating diffusers and low-level exhaust near the head of the patient bed.) Also required: a higher level of airtightness to maintain pressure, and consideration of pressure testing during construction to verify effectiveness.

An important tip: during construction, ensure contractors clearly understand what the room will be used for, why sealing is so critical, and why it is vital that there be no leakage.

Regarding ‘grandfathering’ of existing rooms - these require a risk assessment to identify any deficiencies that must be addressed in order to meet the revised standard. Some common leakage sources include lighting fixtures, conduits, sliding doors and uneven floors.

Redundancy

Isolation rooms are designated as a Type 1 space under CSA HVAC standards, requiring uninterrupted operation for airflow, pressurization, temperature, exhaust systems for AIRs, and supply systems for PERs. AHUs require redundancy with parallel, interconnected systems with automated controls and emergency power.

Filtration

AIR supply air requires two-stage filtration. PER and combination AIR/PER supply air requires three-stage filtration, with HEPA filters downstream of MERV 8 and MERV 14 filtration. HEPA filters can be AHU mounted, duct mounted or terminal. All require accessible means of testing.  On the exhaust side, AIR and AIR/PER exhaust air is treated as contaminated exhaust, and must comply with CSA Z317.2 requirements.  Additionally, recent design improvements for contaminated exhaust include bag-in/bag-out HEPA filters on the exhaust system, in order to reduce the potential for outdoor wind, building wake zones and surrounding buildings to disperse contaminated air.

Anterooms

Anterooms are now required for all AIRs, per Z8000-18, to offer additional controls against unwanted air movement, and for the donning and removal of PPE, among other considerations. Air flow should be negative relative to the corridor and positive relative to the isolation room. Also required – dedicated exhaust from both patient room and anteroom, with the adjacent washroom connected to the dedicated exhaust.

Studies provide strong evidence supporting the use of anterooms, due to the re-emergence of infectious diseases, such as tuberculosis. The CSA has completed a research study of pressure differentials, which interested readers may benefit from consulting: “Pressure Differential in Health Care Facility Airborne Isolation Rooms”. The study, a comprehensive examination of available literature, is helping to inform CSA standards, as well as zoning for pandemic requirements. For example, one finding is that anterooms provide significantly improved containment of particles at pressure differentials above 2.5 Pa, especially during healthcare provider movement through doors. Other systems proven effective in augmenting traditional cleaning are ultraviolet germicidal irradiation systems (UVGI).

Pandemic Planning and Catastrophic Event Management

Designing for planning and management of pandemic and catastrophic events requires consideration of zoning, and how healthcare facilities can isolate entire areas of a healthcare facility. As well, the facility will need the ability to switch between 100% outdoor air to 100% recirculated air, depending on where contaminants originate.  Negative pressure ‘pods’ for ERs and ICUs are also a design consideration, providing the ability to lock down larger areas of a hospital. 

Outbreak Control Zone

These zones have already been in place in British Columbia for the past 12 years, primarily in inpatient areas and ICUs. To create an isolation pod, a typical 16-bed unit is identified and planned as an outbreak control zone. It is designed as a standard patient care unit, but one that can be self-contained. Within the walls of the unit, allowances have been made for clean and soiled holding areas in order to reduce traffic in and out of the control zone. In addition, the area design should provide for a relatively simple procedure to convert it to negative pressure. Also required are defined space for an anteroom that meets the standards for whole unit isolation with all air being exhausted, as well as pressure monitoring and alarms. In addition, controls must be programmed into the Building Management System at the required isolation unit settings, in order to provide single command implementation. These systems are then commissioned, balanced and demonstrated to the facility as part of the verification process.

Operations and Maintenance

CSA Z8001 Commissioning and CSA Z8002 Operation and Maintenance (O&M) standards both offer useful information for O&M processes. Some design considerations to facilitate O&M are: including accommodations for testing and precautions for those who will need to provide O&M for isolation rooms; accessible locations for safely changing bag-in/bag-out HEPA filters; servicing for ductwork inspection and cleaning (annually for CSA and semi-annually for MOL). 

Of special note:  isolation rooms tend to lose pressure over time. For HVAC performance, this stems from degradation of doors and frames, wall openings for maintenance work that were subsequently not properly sealed, damage to walls, and poor sealing of services penetrating walls above ceilings.

Reactivation, Conversion and Retrofits

During the current COVID-19 pandemic, hospitals are seeking to better protect healthcare workers from getting sick, as well as looking at options for safe and fast reactivation of medical and surgical beds to respond to increased demand, including conversions/retrofits of hospital infrastructure to enable this reactivation.

Other options for some healthcare facilities may involve identifying beds/units that were initially designed to serve as AIRs, but were since repurposed. These would require detailed inspection and testing, along with any attendant servicing to ensure the rooms/units meet all relevant codes and standards for patient and staff safety.  

In identifying potential conversion space, hospitals should look for an existing patient area where access to the area can be controlled to minimize interaction between COVID-19 patients and healthcare staff/other patients. The space should also have the ability to be converted to outside air/exhaust that can enable a slightly negative pressure condition relative to the adjacent space which helps in controlling the spread of infectious germs from patients throughout the area. Alternatively, consider modifying an existing private room(s) with individual ductless units which do not circulate through ductwork into a central HVAC system.

For any AIR, the key is to control airflow to manage all contaminants, whether gases or droplets. The air handling strategy utilized (mixed ventilation, displacement ventilation or other) will depend on the size of the room, layout and other factors.

Because speed of construction and becoming operational is critical, effective collaboration and trust between hospital administrators, engineers, designers and contractors is essential. The entire team has to get these rooms designed, approved, built and operating quickly.  

Guidance Documents

Canadian Standards Authority guidance documents dealing with standards for isolation rooms include:
CSA Z8000 Canadian health care facilities | latest issue 2018

CSA Z317.2 Special requirements for HVAC systems in health care facilities

CSA Z317.1 Plumbing

CSA Z317.13 Infection Control

CSA Z317.12 Cleaning and Disinfection – coming soon

Cancer Care Ontario Position Statement – Hospital isolation practices for hematopoietic stem cell transplantation

CSA Study Executive Summary:
Pressure Differential in Health Care Facility Airborne Isolation Rooms
Advisory Panel members include HH Angus’ Nick Stark and Rita Patel

If you would like to discuss any aspect of the design of your facility’s isolation rooms or plans, please contact:

Nick Stark


Nick Stark
, P.Eng., CED, LEED® AP, ICD.D
Principal | VP Knowledge Management
nick.stark@hhangus.com

Kim Spencer

Kim Spencer, P.Eng., LEED AP
Principal | Division Director, Health
kim.spencer@hhangus.com