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:

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.
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.
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.

IMG_2692 - Air handling unit — 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, P.Eng., CED, LEED® AP, ICD.D
Principal | VP Knowledge Management
nick.stark@hhangus.com

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

Guest Speakers: Michael Hyatt | Dr. Rueben Devlin | Andrew Day

Across the board disruption, led by the rapid advance of technology, is changing everything about the delivery of healthcare, from how we think about healthcare, and how we plan tools and strategies for the future and implement these, to what hospitals, primary care, and long term care facilities are going to look like and how they will function in the coming decades.

On October 29^th, HH Angus invited leaders from Ontario’s healthcare sector, as well as the financial, real estate, architecture, engineering and construction industries who focus on healthcare, to join us for our Ideation: Healthcare Reimagined. The conference explored how delivery of care will evolve and benefit from the digital transformation disrupting nearly every industry today.

We’re sharing a few of the many fascinating insights from this event to help frame the degree of disruption ahead and the change that will be necessary to successfully deliver better healthcare. We’d like to thank our speakers for their insights into the impact of technology disruption, the evolution of change in the healthcare industry, and for allowing us to share highlights from their presentations.

Technology Disruption

Michael Hyatt is one of Canada’s top entrepreneurs, and a Founding Partner and Fellow at the Rotman School of Management’s Creative Destruction Lab. He examined the larger view of how disruption is both prevalent and good, and how we must embrace it to create positive change.

Michael shone a spotlight on the sheer unlikeliness of most disruptive changes, which explains the tendency of human beings to not see these big changes coming. Disruption isn’t new; it has been changing the nature of work since the Industrial Revolution, leading to better and more productive work than ever. The explosion of computing power is increasing predictive capacity, with far-reaching consequences and untold benefits. Knowledge is compounding exponentially and the growth in machine learning will bring myriad new opportunities and make obsolete low value, repetitive work. Which is good, Michael said, because studies show that autonomy and a sense of purpose mean more to employees than money when it comes to job satisfaction. Sponsoring creativity, invention and random thinking days in your organization will bring unexpected positive results. Despite the public spotlight on technology, innovation is still about people, and leaders need to focus on keeping staff engaged if they want their organizations to innovate.

The Future of Healthcare in Ontario

Dr. Rueben Devlin is an orthopedic surgeon and an experienced health care executive with demonstrated success working in hospitals and the health care industry. The former CEO of Humber River Regional Hospital, North America’s first fully digital hospital, Dr. Devlin is currently Special Advisor and Chair of the Premier’s Council on Improving Healthcare and Ending Hallway Medicine in Ontario, and is well positioned to influence the future of health care delivery in Ontario.

Dr. Devlin highlighted the need to take action with a long-term view in mind, in order to significantly improve health outcomes—to plan for services and the facilities that will be needed ten to fifteen years from now, not just next year. The Council’s second report identified a roadmap for the future of healthcare delivery, outlined under four headings: integration, innovation, efficiency/alignments, and capacity. Enabling all of these are digital supports, the tools that replace processes and tools now at the end of their useful life, such as outdated fax technology. Digital supports enable improvements in service delivery and make interactions with the health care system more effective for patients and providers.

Integration

Patient-centric health care systems allow medical staff to connect easily with patients and to share information safely and securely among the health care team to the benefit of each patient. He noted that we need to improve patients’ ability to navigate the health care system, ensuring primary care is the foundation of an integrated health care system. We need to connect multiple health care providers to ensure better integration and a simpler, smoother patient/caregiver experience.

Innovation

Improved options for health care delivery include increasing the availability and use of virtual care options, both synchronously and asynchronously. The latter allows patient/practitioner to interface at times that are convenient for both. Patients and providers should be able to use technology to access health services in the most efficient way possible. For example, Ontario has the opportunity to modernize home care, and provide better alternatives in the community for patients who require a flexible mix of health care and other supports.

Efficiency and Alignment

Improvements happen by doing things differently. Data should be strategically designed, open and transparent, and actively used throughout the healthcare system to drive greater accountability and to improve healthcare outcomes. Two examples are:

Ensure Ontarians receive coordinated support by strengthening partnerships between health and social services, which are known to impact the social determinants of health.
As the healthcare system transforms, design financial incentives to promote improved health care outcomes for communities and increase value for taxpayers.

Capacity

This includes bricks and mortar, human resources and collaborative inter-professional leadership. We need strong leadership throughout the system—we can’t just simply be caretakers of the current system, because if you are caretakers of the system, you continue to get what you’ve already got.

What could be achieved if we made bold changes?

Imagine a health care system where patients can conveniently and securely access their own personal health care information and make healthy choices by accessing preventive services in the community after talking with their primary care provider.
Imagine a system where providers are working in a team environment and have access to a full continuum of care for their patients, in addition to digital tools and professional development support and resources.

Moving Forward

Dr. Devlin describes one of his main tasks as the identification of barriers in order to make the system work more effectively.

“What are we going to look for? More virtual options for patients and providers. Data used as a management tool—how do we exchange it, how do we share it across the province, and how do we start using it for predictive analytics so it works for us? We need to think about coordinated treatment plans, designed and delivered by integrated and inter-professional teams as well as upstream interventions, how to modernize our funding system and use Predictive intelligence and predictive analytics. When data is used strategically, information becomes relevant for decision making and we will be better positioned to connect patients to the right care at the right time.”

The Health System of the Future

Andrew Day is a Principal with GE Healthcare Partners where he leads their global analytic consulting team and the design of GE’s real-time data analytics for hospital command centres. He has extensive experience in the US, Canada, UK, Asia and Australia, working with clients to focus on the future of healthcare facility design to improve operational efficiencies and deliver better health outcomes.

Andy explored the trend he is seeing towards localized community care. Overwhelmed tertiary and large urban healthcare facilities can’t grow beds or services quickly enough to meet demand—budgets simply do not allow for this. Instead, they are partnering and trying to leverage other care settings (community care and outpatient strategies) as a matter of necessity, not as a matter of convenience. The focus is on how the acute care facilities and the community can work together to solve for the system-wide solution.

Digital Twinning

For new hospital development, digital twinning and simulation models provide the ability to test how systems and spaces will work together prior to construction. It’s vital to redesign the care delivery system itself—it’s not enough to simply digitize the status quo; the actual process of delivering care in the new setting has to change. By changing the workflow, changing the dynamics and leveraging automation, delivery of care can be done better.

Command Centres

Command centres across a range of industries have common elements. The first is individual operators, individual experts from different functions, co-located, with their own transactional and operational systems in front of them. They also have a wall of analytics providing shared visibility to what’s going on across the system which alerts them to situations they need to act on. Key is that these alerts need to be in near real time and they need to be very specific. The best ones are about a specific patient that needs a specific action right now – or better yet, to forecast that it will be needed before it happens.

In designing a command centre, Andy recommends starting with the problem that needs to be solved, design the action, design the trigger for that action, and then make sure the right people are in the room and empowered with the right culture and the right tools to deliver care more effectively and at a higher utilization rate.

The analytics, or tiles, available in the command centre are also available on tablets as staff move around the hospital, and available on any terminal for staff to log in.

What’s Next for Command Centres?

Andy is looking ahead to broader adoption of command centres to ensure better integration between healthcare units. Optimizing and connecting care across healthcare systems beyond single campuses. Leveraging AI/Machine Learning (ML) to forecast discharge date, likelihood of re-admission, etc. Guided ML being applied to limited but reliable variables is what is needed for using ML in real time. ML, neural networks, and simulation in the loop are useful forecasting tools and the basic building blocks of true AI, and they are already starting to quietly be applied in healthcare.

Key Take-aways From the Event

The pace of change is phenomenal. Humans initially tend to be afraid of change but time and again history has proven that change has improved our lives dramatically. We’re only seeing the opening act of what technologies like artificial intelligence will do. In healthcare, artificial intelligence will impact the role of health professionals and how they do their jobs, as well as the design of and access to healthcare facilities.

Currently, the hospital is seen as the epicenter for receiving healthcare. However, as demographics and technology changes, we will see a decentralization of healthcare. Healthcare will likely be distributed close to where it is needed – from clinics to homecare to even your phone. Hospitals will continue to be important, but their role will evolve to one more of facilitating and optimizing the system, as opposed to just focusing on the acute care piece of it.

Technology will be critical to the transformation of healthcare. The ability for patients to have access to their electronic health records and to easily transport this to the healthcare provider of their choice will significantly reduce friction in the system and lead to better care. As healthcare becomes decentralized, command centres will play a key role in integrating the various players.

The importance of change management cannot be overlooked. The transformation of healthcare will involve dramatic changes. Governments, healthcare professionals, patients and other stakeholders" need to be informed to the opportunities and buy into a collective vision for the future.

What Will Be the Role of Engineers?

Reflecting on the above highlights, Harry Angus (HH Angus’ CEO) foresees the use of current and foreseeable technology changing the face and means of healthcare delivery in profound ways and, if properly constructed, enabling far better knowledge and control for all patients.

Nice in theory but, practically, how can current leaders of healthcare effect the changes necessary at this point? Although the following is by no means comprehensive, here are some thoughts.

The formation of Ontario Health teams will mean that all health providers within a defined geographic district will need to agree how health care should be managed going forward, which institution or provider is to provide what service, how they will cooperate in creating comprehensive electronic health records and intra-communications systems, and who will assume the role of primary responsibility across a continuum of care.

To fund the changes necessary to address the above points, it will be necessary to create efficiencies out of a district’s cumulative budget, a goal made more difficult in light of the aging demographics of many areas and the fact that the many healthcare providers in the geographic region currently have their own priorities, management structures, and methodologies. It will be a huge change management task and a testament for the leaders who successfully take it on.

There are many areas for consideration; following are our thoughts in areas where we as engineers might be of assistance.

Assessment of facilities located within a geographic region and evaluation of which are up to the task going forward; e.g., would it help to have sole practitioners be co-located, to move non-intensive activities to a different level of facility, or close down some facilities due to age/condition, operating costs, or inability to support on going medical procedures?
As the combined vision of healthcare delivery is developed with the team, recommending strategies for how team members will share information, across which systems and infrastructure.
Engage with healthcare facilities at the outset of strategic visioning to determine how hospital operations will be reimagined/modified to take advantage of current best practices.
Understand how team members will take advantage of alternative technologies and delivery systems, such as virtual care and augmented reality; e.g., how a paramedic might quickly access enhanced medical expertise necessary to a patient.
Consider and make recommendations on how remote monitoring may be utilized in proactive and beneficial ways.

The next ten years will witness rapid change in healthcare delivery, due in part to the advancement of technology. The scope and speed of change will be disconcerting to many, but welcome news to every patient who will have the opportunity to access their own comprehensive medical records, much as other industries have already converted their systems.

By proposing a model of healthcare delivery based on geography and a co-ordinated full continuum of care for every individual in that region, the province has served notice that the status quo will disappear. What the new model will look like, and how it will function, will likely vary between regions due to local needs. Technology will be the enabler to move the necessary changes forward.

A game-changer in the wireless communications industry, 5G represents the fifth generation of cellular connectivity and a significant leap forward in performance compared to 4G and LTE. However, in order to plan for its impact in industries such as healthcare, smart cities and commercial buildings, we have to understand its opportunities, limitations and design challenges.

What is 5G?

First, it’s important to differentiate 5G from other wireless communication protocols such as Wi-Fi.

5G (along with previous standards like 3G, 4G and LTE) is a standard for wireless cellular communications, and uses licensed frequency bands which must be purchased by the carrier. Wi-Fi, on the other hand, refers to technologies commonly used for wireless local area networking – connecting users to a building or residential network which is often owned and operated by the building owner. Wi-Fi uses unlicensed frequency bands which are available for anyone to use, and which can result in an increased risk of signal interference. The new 5G standard augments existing Wi-Fi and LTE standards rather than replacing them – in fact, Wi-Fi 6 (802.11ax) is set to also dramatically change the performance of Wi-Fi communications.

With that in mind, let’s look at how 5G differs from previous generations of cellular technology:

Latency, or the amount of time it takes for information to travel from the sender to the receiver is reduced to a theoretical <1 millisecond end-to-end, which is on par with many wired networks. As a comparison, typical home Wi-Fi latency is 2-5 milliseconds, and cable/DSL connections can have latency up to 100 milliseconds. Reduced latency increases the responsiveness for applications like self-driving cars, and can help data speeds appear higher to the end user.
5G supports a higher density of users (up to 1 million per square kilometre or 100 times the density of previous generations). This is a limitation of many existing networks and key to supporting the expansion of the Internet of Things (IoT) and the myriad connected devices carried by people all over the world.
Transmission speed, or the amount of data that can be sent in a given period of time, is increased from a maximum of 1Gbps with LTE to a theoretical limit of 10-100Gpbs with 5G. It is anticipated that actual speeds will be an estimated 200Mbps-1Gbps in the field, which is still significantly higher than what most users experience with LTE.
Ultra-high reliability of 99.999%, which translates into downtime of less than 5 minutes and 15 seconds per year, and meets the typical standard for mission-critical data centres and networks.
Reduced power consumption, which is key for extending the life of battery-powered field devices and IoT.

Although most users won’t notice the difference, 5G also uses different radio frequencies from past standards. Current cellular protocols typically operate on radio frequencies between 1900MHz and 2700MHz; however, 5G uses two distinctly different frequency bands: below 6GHz, which supports standard cellular connectivity (600-700MHz and 3.5GHz in Canada), and above 6GHz, which is focused on point-to-point data transfer (millimetre wave or 28-35GHz) and can only be used for line-of-sight applications. This change has implications for existing infrastructure, as radio frequency communications are highly dependent on the hardware that supports them.

When is it coming?

Frequency auctions are already happening across North America and Europe. Canadian 600MHz frequencies were auctioned off in early 2019, and higher frequencies, including 3.5GHz, are expected to be auctioned in late 2020 and early 2021. Bell Media and Rogers Communications are expected to be the major players at the 3.5GHz auction in Canada, while Ericsson, Qualcomm and other major US cellular carriers indicate that they are ready with 5G infrastructure and can deploy as soon as they own the rights to the frequencies. Some carriers in the US have already launched 5G networks on the 3.5GHz frequency band, and some frequency bands above 6GHz have been auctioned off as well, with more to come later in 2021.

What is the potential impact of 5G on the design, construction and real estate industries?

5G has the potential to support radical advances in technology, and is anticipated to become the new standard for wireless mobile connectivity. However, it doesn’t replace wired networks which still set the standard on data transfer and latency, or Wi-Fi, which uses unlicensed frequency bands to distribute wireless connectivity throughout a building, often at a significantly lower cost per gigabyte.

So where is 5G anticipated to have the greatest impact?

While typical cellular users will experience enhanced performance, better connectivity and higher data speeds, the impact of 5G will mostly be experienced by devices rather than people. Devices such as self-driving cars and robotics which must be able to analyze and react quickly to situations will benefit from the low latency of new technology, and high-bandwidth mobile applications such as virtual reality (VR) and extended reality (XR) will make use of the increased data transmission speeds. 5G also has the capability to connect to a greater number of devices and use less power than previous generations, opening up a wealth of opportunity in the effortless deployment of battery-powered, highly mobile and flexible networks of 5G sensors and devices without the need for additional wiring.

Healthcare: the reliability of 5G connections is well suited to supporting critical healthcare applications, such as continuous monitoring. Higher data transmission speeds will be instrumental in facilitating high-mobility communications for telemedicine, data collection, predictive analytics, machine learning and artificial intelligence. The ultra-low latency wireless connections will also support applications like mobile robotic surgery and virtual reality.

Commercial and Smart Buildings: the explosion of connected devices within buildings will rely heavily on the increased density of connections available under the new 5G standard. Buildings are becoming more connected, IoT devices and sensors are becoming more ubiquitous, and occupants have higher expectations around connectivity and performance. The lower power requirements of 5G also makes it easier and more cost-effective to deploy highly mobile, battery-powered devices throughout the building without significant infrastructure costs. This, along with enhanced reliability, will also support mission-critical applications such as monitoring of building systems.

Smart Cities: navigation systems and self-driving cars will benefit significantly, as will increased density of sensors and users – particularly in areas like stadiums and transit terminals. However, higher frequencies necessitate high density of end-points compared to previous generations, which could have aesthetic implications as antennas move from towers to street level.

In all of these examples, properly designed distributed antenna systems (DAS) will become increasingly critical in the extension of 5G coverage throughout buildings and other areas with limited signal coverage; however, the building itself can have a significant impact on the operation of these systems and must be carefully considered in the early stages of design.

How do we design differently for future technologies like 5G?

When technologies change every five to ten years but buildings can last anywhere from 30 to 50 years (or even more), designing infrastructure to adapt to evolving requirements is critical to ensuring the building will be able to meet the needs of its occupants both today and for decades to come. One of the key changes with the evolution to 5G is that the new standards rely heavily on optical fiber infrastructure to achieve the required data transmission speeds, rather than traditional copper infrastructure. This means that legacy buildings may need to replace their existing infrastructure in order to deploy 5G throughout their building, and new construction should not only plan for the latest fiber infrastructure, but also install spare capacity to accommodate future generations of technology. It also means that 5G networks are not able to take advantage of Power over Ethernet (PoE) which supplies both data and power over a single cable, since PoE requires copper cable in order to deliver the power component. That being said, there are significant opportunities for PoE and other types of low-voltage distribution to work in conjunction with 5G by powering end-use devices and sensors.

From a building perspective, DAS that supports 5G requires a different topology from previous generations (known as a centralized radio access network or C-RAN topology), which may require changes to pathways and spaces compared to traditional DAS infrastructure. When designing 5G systems, it is also important to consider that higher frequencies do not penetrate buildings or obstructions as well as lower frequencies due to the inherent nature of the electromagnetic signal. Past generations such as 3G, 4G and LTE have used frequencies in the range of 1.9 to 2.6GHZ which had reasonable penetration, but the proposed 5G bands in Canada are significantly higher at 3.5GHz. While 3.5GHz provides better bandwidth and data transmission speeds than lower frequencies, it will also experience higher signal degradation and will require a higher density of antennas. This, along with the requirement for the latest fibre optic infrastructure, can create some unique challenges when performing upgrades in existing buildings which weren’t originally designed to accommodate 5G infrastructure. There are a number of solutions on the market to help ease the transition – and, in some cases, it is worth evaluating whether there are other technologies which could serve the same purpose with a lower capital investment.

Finally, the move towards more energy-efficient buildings can have a significant impact on deployment of wireless technologies of all types, and must be addressed early on in the design of the system. Many modern building materials have a negative effect on wireless signal penetration, meaning that a higher density of antennas is required to provide sufficient coverage. Additional testing may also be required after installation to optimize the system for the unique building environment.

Leveraging 5G in a Data-Connected World

5G has the potential to radically change our experience of connectivity and how we design the built environment. From smart cities to virtual reality, the world is becoming more connected every day – and technologies like 5G are playing a key part in the evolution of our environment. Designing buildings and systems to support these changing technologies in the decades to come will be critical as users increasingly expect a seamless integrated experience, no matter where they are.

Author:

September 27, 2017.Photo by Brett Gundlock

Kim Osborne Rodriguez,P.Eng., RCDD

kim.osbornerodriguez@hhangus.com

Kim Spencer, P.Eng., LEED®AP, Principal, brings to her new role a wealth of experience in the healthcare sector, with two decades as a successful and multifaceted manager and mechanical engineer with HH Angus. The Health Division is the firm’s largest service group, with millions of square feet of health care facilities designed by HH Angus in the last 5 years alone. Kim leads a large team of professionals providing design and engineering services to a range of facilities across Canada, including acute care, long term care, complex continuing care, mental health, children’s care, cancer centres, elder care, and rehabilitation centres.

“Kim’s promotion into this senior leadership role not only reflects her capabilities but also underscores the quality of our people, in that we are able to grow and develop leaders from within the firm,” said Paul Keenan, President, HH Angus. “Her deep understanding of the healthcare sector, communication skills and a client-centric approach will continue to grow our Health practice.”

Kim has earned a reputation for innovative engineering, sustainable design and successful project management, as well as a deep understanding of the healthcare sector. Equally, she is widely respected for a strong focus on clients and for her leadership skills in managing both people and projects. Kim’s portfolio includes new construction, expansion and renovation of acute care, complex continuing care, long-term care and mental health facilities, and experience with all forms of procurement, including P3s.

Kim is also an effective and timely communicator who understands that responsiveness is critical to successful project implementation and to building excellent client relationships. A few notable clients include: UHN, Michael Garron Hospital (formerly Toronto East General), Thunder Bay Regional Health Sciences Centre, South Bruce Grey Health Centre, ,Northern Health, Alberta Health Services, Quinte Healthcare, among many others.

“I’m very excited about my new role,” states Spencer. “I’m fortunate to work with such a talented team and look forward to contributing even further to the success of our clients and the firm.”

If you would like to contact Kim to find out how HH Angus can help you with your healthcare project, you can reach her at ;

Kim Spencer| Associate Director, Health Division, HH Angus and Associates Ltd

+1 (416) 443 8200

kim.spencer@hhangus.com

hhangus.com

Whether planning a small departmental renovation, major redevelopment or infrastructure renewal, there are a number of important questions to ask at the outset. Having clear answers will have a positive impact on the project outcome.

In particular, project phasing can be greatly informed by asking the right questions about existing and required mechanical, electrical and plumbing services in order to arrive at a successful design solution that supports the project objectives, continued operation of the healthcare facility and safety of its patients.

So, what makes a renovation project a success?

Some key markers are meeting the schedule, staying on budget, minimally disrupting operations and having no safety issues.

Since each facility and project is unique, however, there may be additional, more specific considerations that arise.

Scoping it out COPING IT OUT

One of the most important questions is, What is the project scope? At a higher level, What problem/need will the project solve?

It may be an identified need for redevelopment of a particular area or a key piece of equipment has been failing regularly and funding is now available to address it.

Be aware that the scope may grow beyond the initial assessment based on the requirements of current codes and standards, and existing equipment capacities, among other factors. It is essential to fully understand these impacts and determine how to deal with them.

Conditions specific to the site may dictate changes to the planned scope. For example, there may be a need to run new services into the renovation area from a distribution shaft; replace existing services and equipment to accommodate a renovation, unless alternative approaches are feasible (such as rearranging or reworking equipment to facilitate the increase in load); or phase renovations in critical areas, such as the emergency department, so they can remain operational.

Realize, too, the quality of project work is constrained by three factors: budget, deadlines and scope. A trade-off between constraints is possible but changes in one will usually mean adjustments in the other two to compensate, otherwise the quality of work will suffer.

FACING THE UNKNOWN

It’s imperative to identify and mitigate risks in advance as much as possible. A good question to ask is whether there are plans and budgets for the unexpected, such as discovering ‘serviceable’ equipment is actually on its last legs or the capacity of a generator won’t permit additional load.

One form of technology that can help mitigate the risk of the unknown is 3-D scanning of systems infrastructure, which can greatly improve the reliability of ‘as-built’ information. Scanning is performed within a space to collect ‘as-built’ data and the resulting point cloud is reconstructed into a 3-D model. The model can accurately capture the scanned space and size of services and objects within. This approach works particularly well for plant spaces where services are exposed.

Another way to mitigate unknown risk is by pre-demolition of a space prior to finalizing the design. After demolition of walls and ceilings, the design team can physically view existing services, identify conditions that may not be observable prior to demolition and update documents accordingly. When this is possible, the schedule cost of approximately three to four weeks is often well worth it to alleviate the impact of the unexpected. Other ways to confirm the current condition and capacity of services include review of maintenance records, pipe thickness tests, drain scoping, air and water audits, and metering existing services. Unknowns are always a risk to the budget, schedule and project scope. No matter how diligent the preparations, carrying an allowance as part of the project budget is recommended.

ACCORDING TO SCHEDULE

Questions around schedule are also critical: How quickly does the project need to be designed, constructed and in operation? Is there a fixed deadline (for example, driven by financing mechanisms such as the Health Infrastructure Renewal Fund (HIRF) or Hospital Energy Efficiency Program (HEEP))? How has the schedule been developed? Have representatives been engaged from across the
hospital team? What about the design team? And, depending on how the project is being delivered, is construction team input required?

In building the schedule, it’s important to allow time for considerations such as long delivery equipment items, after-hours work, proper infection prevention and control, and construction phasing. If phasing includes multiple phased occupancies of various areas, time should also be allotted for testing, adjusting, balancing and approvals from authorities having jurisdiction at the conclusion of each stage.

Other scheduling-related questions include: Are plans in place to meet required procurement timelines and processes? Are requests for qualifications and/or proposals or tenders being released through a procurement department? Is the facility posting for competitive bids? If so, does the schedule account for the required bidder response times?

Engaging a design team experienced in healthcare renovation will greatly assist in arriving at reasonable and reliable answers to these questions. The team will also need to understand future plans for the facility. For example, if replacing boilers and the five to 10-year plan includes building an addition, consider whether reasonable allowances can be made in the boiler project to facilitate future expansion. Sometimes spending a few extra dollars now can save on future capital and operating costs.

A MATTER OF PRINCIPLES

Answers to the preceding questions will inform the establishment of the project’s key principles; in other words, the most important factors driving the project. When faced with a difficult decision during the project, these principles will serve as a guide for making decisions. The principles may be driven by budget, schedule, patient experience or a combination of these, plus other factors. Whatever is identified as key principles, share them with the team to assist in setting expectations and defining the scope.

When key principles are established, the sum of the parts may not lead to the outcome originally envisioned. For example, getting things done quickly does not always lend itself to the lowest cost; off-hours/overtime work may be required to meet a compressed schedule. A well-worn axiom sums up this challenge: All successful projects require sufficient time, money and quality. If one is missing, there better be lots of the other two.

PHASING IMPACT

Construction phasing — the general sequence in which the renovation work needs to be performed in order to meet project requirements — is a culmination of addressing all the foregoing issues. Phasing is developed by considering factors such as schedule, departmental operations, hospital operations, infection prevention and control, and budget.

The earlier construction phasing is established, the better. For a departmental renovation, for example, the ideal situation is to shut down the entire area; however, this is often not possible due to operational constraints, so phasing becomes critical.

When establishing phasing, consider how different phases will affect existing mechanical, electrical, plumbing and information technology services. These services often do not respect a renovation project’s physical boundaries. For instance, ductwork supplying one area may continue through to a completely unrelated area but the renovation may impact both. If the team includes multiple design disciplines and professionals, encourage the architect to engage the engineers early and often in the phasing planning to help mitigate some of these risks.

In the early stages of multi-phase projects, execute enabling works for later phases. For example, leave valved/capped connections for extension of medical gases; rough-in junction boxes/empty conduit; allow for proper raceways; and consider placement of any new equipment to permit easy access to expand in a future phase. These simple steps can help ease some of the challenges of building a project over multiple phases.

Minimizing disruption to operations is typically one of the most important factors in a healthcare renovation project. Some schedule-friendly approaches include seasonal replacement of infrastructure (for chiller replacement, schedule construction in non-cooling months; conversely, schedule boiler replacement in summer) and the use of pre-fabricated equipment to assist with overall schedule and phasing/turnover.

FUTURE OUTLOOK

If the initial project scope doesn’t include infrastructure upgrades, it’s important to assess the equipment serving the renovation area and clearly understand its life expectancy and operating costs. While the budget may not allow for it, investigate if spending a little more now (from the capital budget) can reduce future operating costs.

And while looking into the future and thinking about operating dollars, consider the facility’s master plan.

Can this current renovation reasonably accommodate parts of future planned renovations?

Those accommodations could include purchasing additional capacity for particular equipment, leaving space for future equipment in a location conducive to expansion or choosing modular equipment that can be readily expanded.

CODES OF PRACTICE

It’s essential to understand the impact of current codes and standards on the project. The design team can help sort through which activities and replacements should be undertaken versus those that must be done. Understanding how codes and standards relate to the project is critical as they can potentially have a major impact on the project scope and, accordingly, the budget and schedule as well.

GROUNDWORK FOR SUCCESS

For the best chances of delivering a successful project, it is important to ask the right questions. In particular, clarity around the project’s scope and problems it addresses is vital. Determine phasing and related impacts early. As much as possible, identify and mitigate risks in advance. Finally, engaging a design team with verified healthcare renovation experience is a valuable asset in achieving these goals.

Published in the Canadian Healthcare Facilities
Summer 2018

September 28, 2017.Photo by Brett Gundlock

Kim Spencer, P.Eng.
kim.spencer@hhangus.com

Jeff Vernon, P.Eng.
jeff.vernon@hhangus.com