Hospital Engineer Vol 38 No 1 Autumn 2015

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Seismic Risk Mitigation Energy Efficiency Finance John James Memorial Foundation PP 100010900

SUMMIT MATSU CHILLERS, FOR CRITICAL OPERATIONS matsu.com.au 1300 CHILLERS 2

IHEA National Board of Directors National President Darren Green

CONTENTS

National Immediate Past President Mitch Cadden

BRANCH NEWS

National Vice President Brett Petherbridge

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National President’s Message

National Treasurer Peter Easson (State Elected – WA)

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State Branch Reports

National Secretary/ CHCFM Coordinator Scott Wells (State Elected – QLD)

TECHNICAL PAPERS

Membership Registrar Alex Mair (Nationally Elected)

14 Improving boiler efficiency in hospitals

Standards Coordinator Steve Ball (Nationally Elected)

20 The risky business of information security

Asset Mark Coordinator Mark Stokoe (Nationally Elected) Director Rod Woodford (State Elected Vic/Tas) Communication Darryl Pitcher Secretariat/Website Administrator Heidi Moon Finance/Membership Jeff Little Editorial Committee Mitch Cadden, Darryl Pitcher, Scott Wells IHEA Mission Statement To support members and industry stakeholders to achieve best practice health engineering in sustainable public and private healthcare sectors.

Adbourne Publishing 18/69 Acacia Road Ferntree Gully, VIC 3156 PO Box 735, Belgrave, VIC 3160 www.adbourne.com ADVERTISING Melbourne: Neil Muir T: (03) 9758 1433 F: (03) 9758 1432 E: neil@adbourne.com

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25 Managing legionella: Achieving best practice 28 Seismic risk mitigation 38 The role of refrigeration and air conditioning in energy efficiency and GHG emissions reduction 40 Energy efficiency finance can deliver costcutting tonic for hospitals

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48 John James Memorial Foundation Healthcare Campus Community Energy Efficiency Program project outcomes 55 Operating theatre ventilation system review 62 Contractor management

PRODUCT NEWS

70 Product news

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Adelaide: Robert Spowart T: 0488 390 039 E: robert@adbourne.com PRODUCTION Emily Wallis T: (03) 9758 1436 E: production@adbourne.com Administration Robyn Fantin T: (03) 9758 1431 E: admin@adbourne.com

Visit the Institute of Hospital Engineering online by visiting www.ihea.org.au or scanning here ➞ The views expressed in this publication are not necessarily those of the Institute of Hospital Engineering Australia or the publisher. The publisher shall not be under any liability whatsoever in respect to the contents of contributed articles. The Editor reserves the right to edit or otherwise alter articles for publication.

Adbourne Publishing cannot ensure that the advertisers appearing in The Hospital Engineer comply absolutely with the Trades Practices Act and other consumer legislation.

The responsibility is therefore on the person, company or advertising agency submitting the advertisement(s) for publication.

Adbourne Publishing reserves the right to refuse any advertisement without stating the reason. No responsibility is accepted for incorrect information contained in advertisements or editorial. The editor reserves the right to edit, abridge or otherwise alter articles for publication.

All original material produced in this magazine remains the property of the publisher and cannot be reproduced without authority. The views of the contributors and all submitted editorial are the author’s views and are not necessarily those of the publisher.

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TECHNICAL PAPERS

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THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

National President’s Message Introduction

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elcome all to the first Edition of ‘The Australian Hospital Engineer’ for 2015, I trust you are all now ‘back in full swing’ and I’m personally am looking forward to a productive year ahead. With summer now behind us, we move into autumn and look forward to some milder conditions which are much less burdensome on our facilities, plant and of course our patients and residents.

The Board has continued to monitor and address our business needs during the past period. It is particularly pleasing to note the positive results around both the National QLD Conference and professional development sessions held by various Branches, well done to all involved.

Your IHEA National Board Members

Name

Position

Email

Darren Green

National President

Brett Petherbridge

Vice President (VP)

brett.petherbridge@act.gov.au

Mitch Cadden

Immediate Past President (IPP)

Mitch.Cadden@gsahs.health.nsw.gov.au

Peter Easson

National Treasurer

Peter.Easson@health.wa.gov.au

Scott Wells

National Secretary

scott_wells@health.qld.gov.au

Alex Mair

Membership Registrar

Vacant

Chief Executive Officer

Mark Stokoe

Director

Mark.Stokoe@health.wa.gov.au

Darryl Pitcher

Director and IFHE Council Executive

d.pitcher@bethsalemcare.com.au

Steve Ball

Director

STEVE@BarwonHealth.org.au

Rod Woodford

Director

rwoodford@castlemainehealth.org.au

Executive Committee

darren.green@gsahs.health.nsw.gov.au

ama58500@bigpond.net.au Ex-officio

ceo@ihea.org.au

February Board Proceedings and Summary of Key Activity I would like to present to you, our members, the most recent summary of proceeding and outcomes from the February Board Meeting which was held in Melbourne, at the Royal Melbourne Hospital Facilities Meeting room.

• The 2018 International Federation of Hospital Engineering (IFHE) Congress, Brisbane was discussed and planning will now move forward. Brett Petherbridge was nominated and supported as the Congress Convener. As previously advised Darryl Pitcher is the nominated IHEA representative and will step through the IFHE executive hierarchy from 2nd Vice President (2014-2016), Vice President (2016-2018) and President (2018- 2020).

• Our CEO recruitment review is nearing completion and a special Board meeting (phone conference) will consider the position paper which has been compiled by a small working party. Once the Board has finalised this matter further updates will be provided.

• The February finance report was presented to the Board by our Treasurer (Peter Easson) with a good result reported for the period. Noteworthy was an increase in revenue and decrease in expenditure against budget, these results were THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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predominantly attributed to the successful National Conference (QLD) and the vacant CEO position.

• Within Finance and Risk portfolio Peter Easson has also commenced a review of the organisational Risk Register, Delegations Manual, Travel, Social Functions and Reimbursement Policies all of which will be included as an agenda item for the next Board meeting.

• The 2014 QLD National Conference Report and an update on planning for the 2015 WA National Conference (September 9 -11) were presented. Both the pleasing results from QLD and advanced planning for WA were commended by the Board and our gratitude was passed.

• Mitch Cadden provided an update on the IHEA Constitution review and there was a general agreement from the Board that during the final stages of completion a final review from a peer group of senior members will add value to the process.

Once this is completed IHEA members will be provided a summary of suggested changes and will be required to endorse any suggested changes before they could be adopted.

• AssetMark was reported by Mark Stokoe and some new initiatives have recently been proposed and appraised with Mercury Systems (BEIMS). Further work will be completed in

the near future, members and users of the system will be made aware of advances in the near future. All IHEA member are encouraged to evaluate the systems capabilities and consider advantages it would provide to your organisation.

• It was pleasing to learn that a number of IHEA members are currently completing studies through Schneider Electric University online courses. IHEA members are encouraged to see how the free Schneider online courses might benefit you, visit www.MyEnergyUniversity.com • Steve Ball provided an update on the Standards Portfolio, our undertaking is to reconnect IHEA with regard to input into relevant standards development and reviews. It was noted some of the challenges revolve around the reduced number of active health related standards currently under review.

• It was agreed that Darryl Pitcher will progress the upgrade of our website; an external provider has been engaged to complete a refresh with advanced interactive transaction capabilities. This will improve new member application processes (with suitable approvals), annual membership renewals and provide links to e-commerce solutions such as BPay, EFT, PayPal and use of credit cards.

• The next ‘face to face’ Board Meeting will be held in Brisbane to facilitate a review of the Brisbane Convention and Entertainment Centre (BCEC) facilities 24 and 25 April.

This will underpin planning of the 2018 IFHE Congress, provide an opportunity to review and tentatively book the venue and forge ties with the BCEC International Convention Team.

Summary In closing, I would encourage all members to stay in touch with IHEA Branch and National events as well as communicating with your IHEA Branch Committee of Management (CoM) and National Board. Feedback from members is always welcomed and greatly assists the Board to act in the best interest of our members. I have included an image of our previous CEO Jim Cozens which was taken during our handover meeting at which time I presented Jim and Beverley a small token of appreciation from the IHEA by means of a Christmas Hamper. I have recently been in communication with Jim who passes on his best wishes to his friends at IHEA and looks forward to catching up at future IHEA functions.

For those of you in NSW/ACT, I look forward to our upcoming conference in May, for others, see you in Perth in September.

Regards Darren Green M.I.H.E.A., C.H.C.F.M. IHEA National President www.ihea.org.au

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Hospital Sensor Simple, safe, essential lighting.

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The BEG PD4-M-2C-DS hospital sensor from iAutomation dispenses with much of the duplication of traditional lighting motion sensor systems. By connecting both regular and standby power supplies directly to the sensor, essential and non-essential lighting is delivered from a single unit.

An extra low-voltage connection to the switch plate means the system can be controlled with a single switch - a huge time-saving feature that also significantly reduces installation costs.

For more information call 1800 225 063 or visit www.iautomation.com.au THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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STATE BRANCH REPORTS

State Branch Reports WA branch REPORT – Branch October 2014 Meeting, Joondalup Health Campus

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ver 20 members headed to the North of Perth to attended October’s branch meeting hosted by Mr Jason Ambrose, Engineering Service Manager for Joondalup Health Campus.

The evening’s sponsor, Eco Diagnostic, an emerging new company established within WA, who specialise in molecular diagnostics of ecological and environmental samples. Mark Catalanelli gave an informative presentation in regards to performing real-time pathogens screening detection of bacteria such as Legionella, Salmonella, Vibro Cholerae and Escherichia coli. An intuitive new PCR detection technique reduces the sample screening results being returned within hours, in comparison to traditional plating method results being returned anywhere between 7- 10 days.

Branch November Meeting 2014, Perth Children’s Hospital

The PCH will have a total of 298 beds, 48 more than its PMH predecessor, with a total active floor space area of over 125,000 m², the design of the building also allows for future expansion. At the time of the visit, 1,230 construction workers were engaged on site, contributing to over 4 Million man hours being spent on the project thus far. The new Hospital will also hold a few unique features such as an enclosed walk bridge reaching over to the adjacent Kings Park, giving both the patients and their families a chance to stroll directly to the adjacent inner-city native bushland of Kings Park.

Also, the much respected and established Telethon Kids Institute research team are in-line to take up tenancy on two levels at the new hospital in 2016. Relocating from their current premises in Subiaco, the institute will be housed in state-of-the-art premises, thus providing their professional research staff to work alongside the state’s most innovative and progressive child health clinicians. This team work will ensure strong and progressive collaborations in the fight against childhood illness and disease.

The evening’s sponsor Murray Taylor from G&M Taylor Property Services, provided a working demonstration of a completely

Perth Children’s Hospital – Conceptual View

Over 35 members headed to the construction site of the Perth Children’s Hospital (PCH) to attended November’s branch meeting, hosted by Mr John Dransfield, North Metropolitan Area Health Service.

The $1.2 Billion new hospital is being built on the QEII Medical Centre site in Nedlands and will replace Princess Margaret Hospital (PMH) as the State’s dedicated children’s hospital, providing specialist paediatric care for children and adolescents of WA. Construction of the new hospital began in January 2012 and is due to open late 2015.

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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STATE BRANCH REPORTS self-contained ceiling access system that provides a mobile workspace, high in portability, low maintenance and with a minimal set-up time. The Hepacart is delivered complete with an internal HEPA-filtered, Negative Air Machine and with a certified at air-cleanliness Level V (Class 100). The unique design and functionality of Hepacart provides a high level of dust containment, dust abatement and infection control through its advanced engineering and HEPA-filtration system.

VIC/TAS branch REPORT – Rod Woodford, Branch President

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he branch has been very active over the months of 2014 with a newly formed Committee of Management in place, they are:

Position

Name

Organisation

State President

Rod Woodford

Castlemaine Health

State Vice President

Michael McCambridge

Royal Melbourne Hospital

December 2014 Christmas Function, Mosman Park Bowling Club

Treasurer

Steve Ball

Barwon Health

Top: Santa’s unconventional arrival Bottom: Santa’s gift time

State Secretary

Steve Ball

Barwon Health

The WA branch Christmas social function was held at the Mosman Park Bowling club under a clear blue sunny sky.

Members were invited to bring their families to meet Santa ‘on the green’ and over 15 excited children obliged with their undivided attention upon his arrival – on a bicycle. The fun afternoon was filled with lawn bowling activities, gifts, games, barbeque food and drinks all round to celebrate and unwind from the end on another busy year. A special mention goes to Greg Truscott for ‘assisting’ with the Santa Claus duties for the day.

Committee

Kim Bruton

Northeast Health Wangaratta

Peter Crammond

Wimmera Health

Howard Bulmer

Leighton Constructions Melbourne

Simon Roberts

Registered Accom Assoc Vic (RAAV)

Jason Corneliusen

Albury Wodonga Health

Sujee Panagoda.

Monash Health

National Board Nominees State Elected

Rod Woodford

Castlemaine Health

Nationally Elected

Steve Ball

Barwon Health

The branch held the Annual Dinner at the Rising Sun in North Melbourne and was well attended by 31 people. It was an opportunity to catch up after another long year. It is also the opportunity to commemorate the long service of branch members by way of service certificates.

Condolence Notice Michael Joseph Della Franca 1960 - 2015 It is with deep sadness we report the passing of Michael Della Franca.

Michael was an active member of the WA Branch for many years, offering both his photography skills at major IHEA events and also serving on the Committee of Management. Michael will be sadly missed. The Institute extends their deepest sympathy and condolences to Michael’s family.

The other award to be presented was the Vic/Tas Engineer of the Year Award. This year it went to Kim Bruton of Northeast Health Wangaratta for his valued long service to the industry and the IHEA additional to his contribution as Editor of the Journal in the past and the current role he has naturally taken up as a mentor to fellow engineers.

We must also congratulate Dean Farnsworth of St John of God, Geelong who represented the IHEA as the ANZEX delegate. His

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THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

STATE BRANCH REPORTS paper was on a study of energy efficient lighting installed into the St John of God Hospital Geelong as a trial and will now be expanded across the St John of God network Australia wide.

The Kiwis always put on a great conference and members are able to attend. We Aussies are always welcome to attend and attendance adds CPD points towards Certified Health Care Facility Manager Programs. The Aussies beating the rest of the world at lawn bowls.

For those who could not attend the IHEA National Conference in Brisbane, it was excellent and full credit goes to the organising committee. The Keynote speakers were Li Cunxin – author of Mao’s Last Dancer, also Michael McQueen – with Winning the Battle for Relevance both moving and thought provoking presentations.

The branch calendar for 2015 is shaping up to be a very busy year and we invite members Australia wide to participate if they in the locality at the time.

• February – Plumbing Industry Climate Action Centre.

• May – A site visit of the new Victorian Comprehensive Cancer Center • August – A site visit to the $65M Echuca Hospital rebuilding project.

The branch has had some churn with new members and retirees including: Doug Moore has resigned due to his retirement and we wish him well in that endeavour.

We would like you to join us in welcoming our newest members; Frederic Jeunet, Steve Grubissa and Claude Di Rosso.

Also our new corporate members; BallTech Australia P/L and Ballarat Health.

It is with regret that we need to mention the passing of 2 of our branch members. The Institute conveys its sympathy to Ken’s and Damien’s families in remembrance of a great friendship and colleagues who served the Institute with dignity.

VALE - Kenneth (Ken) Albert St Clair After a long and happy life Ken passed away at Abbeyfield, Mortlake, Western Victoria on November 13th 2014 aged 90 years.

Ken was a long standing member of the Institute. Following a successful marine engineering career, He joined the IHEA on the Eighteenth of April 1956 from his position of Chief Engineer at the Royal Melbourne Hospital where he served in this capacity until his retirement in 1985.

Ken was a keen advocate for the advancement of hospital engineering standards and a driving force in progressing IHEA forums for this purpose. He served the Institute at National level in varying capacities including: President • 1969/72 • 1974/75 • 1976/77 Vice President • 1972/76 IHEA Representative • Standards Australia Committee – Emergency Power Generation.

Service Recognition • Senior Member 11/07/61 • Honorary Fellow 04/07/81 • Life Membership 07/09/2006 Ken will be remembered by his contemporaries for his mentoring and guidance. Also known for his conference presentations on a range of technical and professional development subjects of relevance to the industry.

VALE – Damien Victor Parker: 22/07/1968 – 07/01/2015 It is with great sadness that we announce the sudden passing of Damien Parker, aged 46. Damien started at Bendigo Health in December 2001 as an engineer located on the Bendigo Health, Anne Caudle Campus. Damien was promoted to Director of Facilities Maintenance in 2011. Damien was a well-respected engineer in our industry, a stickler with his health care budget and led a range of initiatives including chairing a panel for the Institute of Hospital Engineers working on the new maintenance standards for critical areas in Victorian health facilities. Damien was awarded the title of IHEA’s - Engineer of the Year for 2011.

Damien was very well respected, an adoring husband and father and will be sadly missed by all his friends and colleagues at Bendigo Health and the Institute of Hospital Engineers.

In closing we note long serving Vic /Tas member Jim Cozens has retired from the position of IHEA CEO along with the National Board we would like to thank him for the contributions he has made during his time in office. We are certain that it will not be too long before Jim enters into another project somewhere in the world.

Finally we cannot go past asking the question, how can the Chief Engineer and Maintenance Supervisor at a Hospital in the northeast of Victoria, one recently presented with an award, get stuck in a faulty lift whilst trying to repair it? hmmm.

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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Institute of Hospital Engineering Australia NSW/ACT Branch Annual Conference

STATE BRANCH REPORTS

“Health Care Compliance Matters” Friday 8th, Saturday 9th May 2015 Newcastle NSW

NSW/ACT Report – Peter Lloyd, Branch President

Venue: Club Macquarie 458 Lake Rd Argenton NSW 2284

March 2015

Introduction

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n behalf of the NSW/ACT Branch I take this opportunity welcome all readers of the IHEA Journal and acknowledge the continued support of the NSW/ACT IHEA Branch Committee of Management (COM), all Branch members, National Board and our many and varied sponsorship partners.

NSW State branch Conference Detailed planning is well underway in the lead up to the IHEA NSW / ACT Branch Conference in May. Details for the conference to be held in Newcastle form part of this report and I sincerely encourage all of our members to support this year’s conference with any ideas, presentations or through attending accompanied by their partners to really get the most out of the opportunity. The Committee of Management believe this year’s choice of venue will facilitate access and engagement of as many NSW/ACT Branch members as possible.

Ph: 02 4958 7033 www.clubmacquarie.com.au

AFM Online AFM online (NSW Health, Computer Maintenance Management Program) is progressing state wide with training and familiarisation occurring for each Local Health District occurring leading up to rolling the system out through 2015/16.

Committee of Management Contact details Name

Position

Phone

Email

Peter Lloyd

President

0428 699 112

peter.lloyd@gsahs.health.nsw.gov.au

Peter Allen

Vice President

0408 869 953

peter.allen@hnehealth.nsw.gov.au

Mitchell Cadden

Secretary

0408 228 419

mitch.cadden@gsahs.health.nsw.gov.au

Branch awards for service and achievements will form part of our Conference in Newcastle, with requests for nominations to all NSW LHD’s early April. Please look out for the award nomination forms which provide an excellent opportunity to reward deserving Facilities Management staff in your area.

Mal Allen

Treasurer

0467 761 867

mal.allen@hnehealth.nsw.gov.au

Steve Dewar

Member

0428 119 421

steve.dewar@gsahs.health.nsw.gov.au

Darren Green

Member

0418 238 062

darren.green@gsahs.health.nsw.gov.au

Members Invitations, Registrations, etc are being transmitted regularly through E Bulletins so please get your registration underway!

Helmut Blarr

Member

0411 152 898

helmut.blarr@sswahs.nsw.gov.au

Glen Hadfield

Member

0409 780 228

glen.hadfield@swahs.health.nsw.gov.au

Trevor Stonham

Member

0414 899 363

trevor@sah.org.au

Brett Petherbridge

Member

(0418 683 559

brett.petherbridge@act.gov.au

Summary

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In closing and on behalf of the IHEA NSW/ACT COM I look forward to seeing as many current, retired and potential new members at the Newcastle conference as possible, continuing our professional development and networking with peers in what is a rapidly developing area of Health Care.

EFFICIE

CONSOLIDATED FIRE & STEAM

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CONSOLIDATED

STATE BRANCH REPORTS SA State Branch Report – Peter Footner, State Branch President Activities n 20th February 2015, the SA Branch held a very successful seminar on Water Quality & Legionella Management in Health and Aged Care Settings.

The nearly full day event involved presentations by SA Health speakers covering Legionella regulations and risk management processes as well information on the application of the Safe Drinking Water Act to hospitals and aged care institutions.

These presentations were supplemented by sessions by various corporate members/event sponsors (HydroChem, Ecas4 and Nalco) covering lessons from the field, technologies in the control of Legionella and maintaining cooling water systems.

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There were nearly 100 attendees, from across a diverse range of organizations - including IHEA individual and corporate members, SA public hospitals (facilities managers and infection control staff), SA Health facilities management providers (country and metro), aged care FMs, private hospital reps and engineering, plumbing & other companies. The subject matter clearly hit a nerve with the FM community given the exceptional level of interest and attendance.

We took the opportunity to canvas attendees views on PD topics that might interest them and some of these suggestions will be built into the planning for future PD events.

The Branch Executive is continuing to review and update of membership records for the Branch. We are taking the opportunity not only to ensure personal & contact details are correct but also to re-engage with past members and to identify potential members who might be unaware of the benefits of IHEA membership.

Actions Following the inputs from participants at our recent PD seminar, planning towards other professional development events across the rest of the year is underway. We are hopeful of delivering the following events for members in the next 6-12 months: • A site visit to the New Royal Adelaide Hospital;

With a large number of non-members attending, we were hopeful of generating further interest in membership of the Branch and our hopes were subsequently realized with several new corporate and individual memberships taken up.

• A seminar on risk management principles and processes with a particular practical emphasis on infection control during redevelopment and emergency management/business continuity management issues.

The Branch considers the seminar to be a great success and owes much of that success to our treasurer, Mike Ellis, his very helpful and capable wife, Tania, and to Darryl Pitcher for their efforts in organizing the speakers/program, garnering some corporate support for the event and for drumming up interest across a wide range of industry participants. Thanks also go to Trudy Wearne from Lyell McEwin Hospital for arranging the facilities for the day and to Narelle Turner from Transfield Services for her assistance on the day.

• A PD event on commissioning processes in relation to revelopment projects (prior to, during and after completion of projects).

Some photos from the event are included for the interest of members.

We are also considering the value and viability of a country visits program (in the forma of a Q&A session in various sites on topics of interest to our country members).

Following the changes to the roster of state-organised national conferences (to accommodate the planned IFHE International Congress in 2018 in Brisbane), work has now commenced to plan for the IHEA national conference in South Australia in 2016.

Membership As noted, the recent PD event generated a number of new memberships. We are also still confident that, as Spotless moves to take up its expanded role as the FM provider for many SA public hospitals and other Government agencies, many new memberships in the Spotless name will be taken up. We believe that a number of other, additional new membership will shortly be taken up, which caps off a successful last six months or so, with good membership growth being achieved.

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS

Improving boiler efficiency in hospitals Lasath Lecamwasam I CPEng MIEAust MAIRAH MCIBSE MASHRAE

Hospitals are energy intensive buildings, typically consuming more than 400kWh/m² (1,500MJ/ m²). They account for 14% of the energy usage within the Australian commercial buildings sector with CO2 emissions of 3.2Mt/y, predicted to rise to 4Mt/y by 2020 (Pitt & Sherry).

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t is important for Hospital Engineers to consider improving the efficiency of heating systems, for the following reasons:

• Hospitals in temperate climate zones of Australia typically have gas fired boilers that provide space heating. With gas prices forecasted to rise steeply, with some estimates predicting increases ranging from 200% to 300% over the foreseeable future, the efficiency of the installed boilers, their optimised operation and the application of best practice maintenance is important.

• Hospitals typically have a high energy demand for space heating due to long operating hours and specific ventilation requirements (that use a high proportion of outside air) for infection control.

Therefore improvements to the efficiency of the heating system will deliver significant savings in energy costs.

• Reducing energy costs will release more money for patient care.

This article focuses on improving the efficiency of Low Temperature Hot Water (LTHW) heating systems. Steam boilers for space heating and other uses such as sterilisation are not covered.

Where gas fired boilers are installed for space heating, they produce heating hot water which is circulated to air handling units, fan coils or other forms of heat emitter such as radiators which provides heating to the spaces. The gas consumption for space heating can account for 20-40% of the total energy consumption of a hospital. The use of natural gas has often been the obvious

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choice as the energy source for space heating due to its lower cost, convenience of distribution and lower greenhouse gas emissions which is typically 80% less than the CO2 emissions from grid connected electricity.

For reducing greenhouse gas emissions, manufacturers of boilers have developed technologies that have seen the thermal efficiency increase from around 65-70% thirty years ago to about 95-97% for a boiler with condensing type technology.

As a point of reference the National Construction Code (BCA) 2014 mandates the thermal efficiency for a new boiler to be at least 80% or 83% for boilers >750kW which are both fairly low targets, considering the options readily available.

Condensing type boilers have been successfully used in overseas countries (such as Europe) for around 30 years.

Therefore users and installers in these countries are well aware of their advantages, shortcomings and system design characteristics for optimised operation. Boiler efficiency regulations in many European countries are such that only condensing type boilers are now able to be installed for new buildings and retrofits.

In Australia, condensing type boilers are now being installed, however there are misconceptions about the optimal application of these boilers and this article attempts to address some of these issues. Engineers and contractors often specify and install condensing boilers without fully appreciating the factors that

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

make them condense, thereby denying the owner the potential benefits.

Condensing boilers are more efficient than non-condensing boilers mainly because they have bigger (better) heat exchangers that extract more useful heat from the hot gases produced during combustion. Such boilers also have more sophisticated burners and controls which increase efficiency. Due to higher efficiency these boilers emit less greenhouse gases (CO2) to the atmosphere and since combustion occurs at lower temperatures the emission of harmful nitrogen oxide gases (NOx) is also reduced.

Condensing boilers have the potential to reduce gas consumption for space heating by as much as 15-30% (in comparison to an existing inefficient boiler), providing there are carefully selected and controlled properly.

The term ‘condensing’ is used to describe these boilers because under favourable conditions of operation, these boilers extract heat from the flue gas (exhaust) products to such an extent that the water produced in the flue gases condense into a vapour, thereby giving a visible plume. This effect is somewhat similar to the visible vapour trail of an aircraft at high altitude or the plume of exhaust from a motor vehicle on a cold day when the cool exhaust system acts as a condenser.

Figure 1 shows how the efficiency of condensing boilers falls fairly steeply with rising return temperature, up to about 55°C (the dew point of flue gases), at

TECHNICAL PAPERS Such conditions are readily available when these boilers are used for low temperature heating circuits.

Conventional heating systems typically have heating flow and return temperatures of 82-71째C respectively, and under such conditions condensing boilers will not condense, therefore maximum efficiency will not be achieved and the boiler will lose about 10% of heat through the flue gases. Since a condensing boiler typically costs 30-50% more than a non-condensing boiler it is important that designers and installers consider the factors that would optimise the operation of these boilers under condensing conditions.

To condense or not to condense? which point no condensation occurs and the appliance performs as a high efficiency boiler beyond this.

When compared to conventional boilers, the thermal efficiency of condensing boilers is highly dependent on heating flow and return temperature, especially the return temperature.

Under full load conditions, a condensing boiler typically has a thermal efficiency of around 93-95%, in comparison to a non-condensing boiler which tends to have efficiencies of around 85%.

Another advantage is that under partload conditions, the efficiency of most condensing boilers improves slightly, whereas conventional boilers suffer from decreased efficiency at part load.

When comparing thermal efficiencies of boilers, the convention is to use the gross calorific value of the fuel, rather than the net calorific value. The former includes the latent heat of vaporisation of the water vapour produced, therefore is approximately 10% higher than the latter which excludes the latent heat of vaporisation. When expressing thermal efficiency, should the latter value be referenced, this results in a somewhat exaggerated value which exceeds 100%. Therefor it is important to check whether the efficiency stated by the boiler manufacturer is referenced to the gross calorific value.

Condensing boilers are designed to positively encourage condensing of the flue gases whereas conventional boilers are corroded by condensation. Therefore, condensing boilers are more efficient than non-condensing boilers under typical operating conditions, and their efficiency significantly improves when the flue gases are cooled below 55째C, which is the dew point. For this to be achieved, it is essential for the return water from the heating circuit to enter the condensing boiler at temperatures below 50-52째C.

For applications that involve low temperature heating circuits, the heat exchangers can be sized that the return temperature to the boiler is below 50째C, therefore the boiler will always operate in condensing mode, delivering maximum efficiency. Such applications include swimming pools, underfloor hydronic heating, greenhouses, pre-heating domestic hot water and low surface temperature radiator or perimeter skirting type heaters.

For new installations, which have long operating hours (such as hospitals in cooler climates) where energy efficiency is paramount for achieving exceptional

Figure 2

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TECHNICAL PAPERS performance, it may be cost effective to oversize heat exchangers to enable operating the heating circuit at lower temperatures, that provide condensing conditions. Heat exchangers sized for low hot water flow and return temperatures will be physically larger when compared to those sized for conventional temperatures of around 82-71°C, therefore this will lead to extra cost and space requirements for the larger heat exchangers.

However, for most applications in Australia, if the seasonal heating load is established accurately using means such as a building simulation, a result similar to the following will be evident.

Fig 2 shows the annual heating demand profile for an office type building which had boiler plant with total capacity of 500kW, sized for winter design conditions of -2°C. The graph shows that most heating demand is only a small proportion of the maximum boiler capacity of 500kW. Therefore even if the heat exchangers are sized for conventional flow and return water temperatures (82 & 71°C), they can be operated during the low load conditions using a condensing boiler, with the flow and return temperatures reduced, to enable condensing conditions at the boiler. As the heating load increases (during colder weather and/or early morning warm up), the boiler flow temperature can be automatically increased by the building management system (BMS) and if the heating demand is such that the condensing boiler has reached its full capacity with the flow temperature at around 82°C, other non- condensing type boilers can be sequenced. Such an arrangement is referred to as lead-lag operation and the condensing boiler will always operate as the lead unit with the others providing reserve capacity.

For most new applications such an approach is likely to give the best return on investment rather than specifying the most expensive option with all boilers being the condensing type. Having all boilers to be of condensing type will no doubt be slightly more efficient but the payback period will be much longer because the additional costs associated with lag boilers being of the condensing type will not deliver significant savings,

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because the plant will be used for very short periods in the year.

are not visible to the BMS, the latter will be a satisfactory solution.

Similarly, when retrofitting condensing boilers to existing heating systems the likelihood is that the existing heat exchangers are somewhat oversized for the required duties due to traditional design safety factors being applied and the heat losses from the building reducing over the years due to upgrades to thermal insulation and the building façade. The impacts of global warming are also likely to have reduced the heating loads slightly.

Under such circumstances the best design approach is likely to install a condensing boiler as the low load (lead) boiler and to schedule the heating flow temperature upwards as heating demand increases and then to sequence conventional boilers.

A poor outcome is achieved in terms of return on investment, when condensing boilers are installed without including a controls strategy in the BMS for achieving condensing conditions whenever possible.

For smaller applications, having heating demands around 300-500kW, it may prove cost effective to use a modular boiler arrangement where all boilers are condensing type. There are manufacturers who offer this arrangement complete with modularised heating pipe headers and flue arrangements and the simplicity of this arrangement could be advantageous.

Based on the author’s experience, most hospitals will benefit cost effectively through the installation of a (small) condensing boiler as the lead boiler to provide the space heating base load through most of the year with the existing conventional boilers providing back up capacity for the relatively short spells of extreme weather.

The BMS must be configured to ensure that the condensing boiler is operated for as long as possible with its return temperature below 50-53°C. When additional heating is required, the heating flow temperature should be sequenced (or re-set) upwards to 82-85° (or as recommended by the manufacturer) before the conventional boilers are fired. For reasons given in the next section, conventional boilers must not be operated for long periods with the return temperature below 55°C. This temperature re-set can be achieved by the BMS through an algorithm that uses feedback from the positions of the modulating heating control valves or through ambient weather compensation.

For existing installations where the positions of the heating control valves

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

Important Factors to Consider Flues: The condensate from condensing boilers is acidic, as shown in the chemical reaction below CH4 + 2O2 => CO2 + 2H2O (water vapour) => H2CO3 (carbonic acid) Natural gas (mainly methane) when burnt, produces carbon dioxide and water vapour which combine to form carbonic acid which has a pH of around 3.

Therefore it is important that the flues for condensing boilers are made from acid resistant materials such as stainless steel 316 or high temperature plastics (only if approved by the gas regulator).

Significant condensation occurs in flues for condensing boilers when compared with conventional boilers, therefore the integrity at flue joints is important. Where spigot/socket type joints are used, the sockets must face upwards. Horizontal flue joints must either be flanged/gasketed or have generous overlapping spigots/ sockets with a high temperature silicone sealant applied where appropriate, to avoid water leakage into the plant room.

Horizontal runs must be graded upwards at least 5° towards the discharge.

The flue discharge from a condensing boiler has very little residual thermal energy hence low buoyancy. Therefore a plume of water vapour will be visible and this could cause aesthetic or nuisance issues near windows, to neighbouring properties, balconies or semi enclosed courtyards where patients or visitors walk past or congregate. The plume is harmless, apart from being slightly acidic and will have fewer impurities than the flue from a conventional boiler because of the scrubbing effect from the vapour which will be drained. The UK publication Guide to the Condensing Boiler Installation Assessment Procedure for Dwellings,

TECHNICAL PAPERS

Power HT

To order or for specification advice (03) 9588 1299 hydroheat.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS

Qi

Medical Gas Services

Preventative Maintenance. Compliance, safety, reliability and efficiency.

With over 60 years experience providing gas solutions and support, BOC’s Qi Maintenance program’s dedicated resources are backed by the technical expertise and professional standards that the hospital environment demands.

The development and maintenance of a hospital’s medical gas system is Qi. Australian Standards (AS) and equipment manufacturer recommendations form BOC’s benchmark for service. Our routine maintenance tasks are performed to BOC best operating practice which meet these requirements.

recommendations. The service of your equipment at regular intervals includes testing, maintenance repair, parts replacement and tuning.

BOC’s preventative maintenance program is designed to operate efficiently and improve the life of your medical gas system. Creating a robust and reliable system avoids unplanned interruptions to supply, builds system confidence and contributes towards greater patient safety.

With our broad Qi Medical Gas Services portfolio, BOC can help you meet the considerable challenges of compliance and safety in today’s healthcare environment. At the same time, we provide balanced insight and flexible tools to improve control and coordination of medical gases throughout your facility.

Ask us how we can help you manage your servicing needs with a tailored servicing and repair plan for best practice preventative maintenance for: – Breathing air testing – Gas manifolds – Air and vacuum plant – Medical gas alarms – Medical Gas Devices – Zone isolation boxes – Medical gas outlets

Maintenance plans are carried out by our skilled service technicians according to applicable standards and the manufacturers’ servicing

For more information call us on 1300 363 109, email hospital.care@boc.com or visit www.bochealthcare.com.au

Depending on the design of your individual system, BOC can customise a program that includes 12 monthly service and maintenance of your hospital’s medical gas reticulation system, including surgical tool control units, medical gas pendants, regulators, flow meters, compressors, vacuum plant and other medical gas related equipment.

BOC: Living healthcare Details given in this document are believed to be correct at the time of printing. While proper care has been taken in the preparation, no liability for injury or damage resulting from its use can be accepted. BOC is a trading name of BOC Limited, a member of The Linde Group.© BOC Limited 2013. Reproduction without permission is strictly prohibited. HGD010 EQUAUS 1013 V1

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TECHNICAL PAPERS available from the internet provides guidelines for domestic type applications.

For commercial applications, similar principles apply and it is important to seek advice from manufacturers.

Condensate Removal: Condensate from the boiler and flue must not be drained into copper, cast iron or lead pipes, which typically exist in older buildings. In commercial (non- domestic) boiler installations, condensate should be neutralised prior to connection to drainage, which may even be a local authority requirement if trade waste charges are to be avoided. Manufacturers supply acid neutraliser kits which contain consumable neutralising agents (alkalis) which need to be periodically replaced through scheduled maintenance. This must be written into operating and maintenance manuals, if not it could be overlooked and expensive remedial work may be required to copper or cast iron sewer pipes.

System Cleanliness: When fitting condensing boilers (or any modern boiler with compact heat exchange passages) to an existing heating system it is essential for the system to be thoroughly flushed and a good water treatment regime to be installed.

If the existing system is extensive (long pipe runs) and has steel pipework (rather than copper), it is advisable to install a good quality dirt (and air) separator in addition to conventional strainers.

Water Treatment: When retrofitting condensing boilers to existing systems that have a mixture of metals such as steel, copper and brass, it is especially important to ensure that the heat exchanger of the condensing boiler is made of corrosion resistant metal such as stainless steel 316. There are many reputable condensing boilers available with heat exchangers made of Aluminium/Silicon for reasons of lower cost. However for these to have a good lifespan, the quality of flushing and water treatment in the heating system is paramount. Aluminium corrodes at a high pH, because the passivation layer deteriorates above a pH >8.5, with such conditions being acceptable (or even desirable) for conventional heating systems that have steel components. Therefore It is very important to maintain the system pH and other important parameters such as chlorides and total dissolved solids (TDS)

as recommended by the boiler manufacturer. For such boilers, it is typically recommended to avoid NaOH and tannin based water treatment and instead to use inhibitors having orthophosphates or molybdite. It is very important to consult a reputable water treatment specialist and to maintain a good water treatment regime, to prevent the premature (and costly) failure of modern high efficiency boilers.

Back End Corrosion in Conventional Boilers: Condensing boilers are designed to encourage condensation to occur within them. They have heat exchangers made out of metals that withstand the condensate which is acidic in nature with a pH value of around 3, the same as tomato juice. If conventional (non-condensing type) boilers are used with return water temperatures below 55°C for prolonged periods, they will eventually suffer from corrosion and premature failure due to acidic condensate attacking the heat exchangers, which is termed ‘boiler back end corrosion’.

Therefore it is important when conventional boilers are operated in conjunction with condensing types, the return water temperature to the conventional boilers are always maintained above 58°C or higher as recommended by the manufacturer. For energy efficiency, it is also important to prevent standing losses from off line boilers through the automatic shut- down of water circulation through motorised valves, with slow re-opening on demand, to reduce any thermal shock.

Some engineers and energy auditors recommend the heating flow temperature to be re-set downwards based on prevailing outside temperature, in order to save energy losses from the heating distribution pipework systems. This can lead to severe back end corrosion in conventional boilers, if they are operated for prolonged periods with the return temperature below 55°C. The replacement cost of the boiler will far exceed any energy cost savings.

Best Practice Maintenance and Operation: It is important to assess the build quality and service provision from the suppliers of the condensing boiler. Some of the condensing boilers appearing in the Australian market are the cheaper end products available overseas. The quality

of the secondary heat exchanger is important because it has to withstand corrosion. Other factors to consider are that components such as burners are more complex due to arrangements such as premixing and control of excess air, therefore it is important that these units are installed and commissioned strictly in accordance with the manufacturer’s instructions and maintained as recommended by competent contractors with the necessary specialist knowledge about the equipmentideally gained through attending training courses accredited by the manufacturer.

Unless the owner and the designer give consideration to these factors, it is unlikely that the condensing boiler will deliver a return in investment.

Hospitals operate for long hours with high expectations for reliability and patient comfort. Therefore the use of optimised controls strategies through BMS is essential for efficient operation.

The use of BMS for energy efficiency will be covered in a future article.

For further information on best practice maintenance, refer to the Guide to Best Practice Maintenance and Operation of HVAC Systems for energy efficiency, which is available as a free download at www.industry.gov.au

About the Author: Lasath is a Chartered Professional Engineer and the director of Engineered Solutions for Building Sustainability (ESBS) – www.esbsconsult.com.au with 30 years’ experience on building services design and maintenance management in England, Scotland, New Zealand and Australia.

Lasath has a passion for sustainable design and operation of building services, being the lead author of the Guide to Best Practice Maintenance and Operation of HVAC Systems for Energy Efficiency- published by the DCCEE. Two of Lasath’s recent projects have won recent awards – 4 Mort Street was awarded the 2012 AIRAH Engineering Excellence Award for the Most Sustainable HVAC Retrofit Project, presented by the NSW NABERS Team and the Old Parliament House Heating Upgrade won a 2014 National Trust Award for an Outstanding Project. (www.airah.org.au “Old Buildings New Boilers”). Lasath has performed more than 100 energy audits including hospitals and this knowledge gives him a unique perspective of the potential causes for inefficient operation in buildings and how to avoid them. If you have any questions regarding this article, please address them to: Lasath@esbsconsult.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS

The risky business of information security John Glaser

With growing threats to patient privacy and increasing sanctions by regulators, make data security central to your business.

B

ecause of the mandatory breach notification requirements of the HITECH Act, reports of material data breaches have become somewhat commonplace.

While each incident is a serious matter and the penalties can be significant, unless the breach involves a famous person or a record-breaking fine, these stories rarely raise an eyebrow.

However, as an industry, we must not let the frequency of such incidents lull us into complacency.

In fact, we know the common causes all too well: the lost or stolen unencrypted laptop, endpoints left unsecure in a bring-your-own-device environment, lack of enforced policies and procedures, and unintentional human error or employee negligence. Additionally, many information technology departments trying to keep their proverbial heads above water might view safeguard investments in electronic protected health information, or ePHI, as low priority. This is especially true when other high-visibility projects demand their attention. As we know, making information more secure simply does not bring in revenue and, frankly, can make the system harder for harried clinicians to use.

Yet, the growth of health care data from electronic health records, patient portals, mobile devices and other technologies has led to the accumulation of more sensitive electronic information. It has also spawned the distribution of that information throughout the enterprise and across the community, thereby creating new risks to ePHI. Against this backdrop, several industry influences are shaping security and privacy. Regulatory enforcement is strengthening, and it’s creating a higher likelihood of financial sanctions for those organisations that do not mitigate risks.

Industry competition also has raised a business interest in managing the patient perception of securing data, which is significantly impacted by sensationalised events and highprofile data breaches. Moreover, meaningful use incentive dollars and eventual penalties are tied to the completion of risk management activities, such as performing a security risk analysis and implementing reasonable and appropriate security measures.

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Numbers Don’t Lie Given these pressures — and with some 30 million patients having been affected by data breaches involving 500 or more individuals since 2009, when large breach reporting requirements went into effect — one would assume the time has come for the industry to step up its information security game. But the statistics tell a different a story.

A 2014 study by the Ponemon Institute found that 90 percent of health care organisations have experienced at least one data breach within the past two years, with 38 percent reporting they had had more than five. The multiple offenses suggest the importance of performing thorough and frequent risk analyses to identify and address vulnerabilities. Even more disturbing, this same study reports that criminal attacks on health care systems have risen a startling 100 percent since 2010.

Another study of all data breaches in 2013 by the Identity Theft Resource Centre found that the health care sector suffered the highest number of attacks last year, outscoring the business sector for the first time in nearly a decade. Granted, the health care number may be distorted due to industry regulations that call for public disclosure of large breaches, but this is surely not a list one ought to feel comfortable topping.

Also troubling, a 2012 Ponemon Institute study on patient privacy and data security suggested that 69 percent of respondents’ IT security and/or data protection activities did not include the security of FDA-approved medical devices.

This mirrors a growing concern that our information security and risk management consultants are seeing in their work.

Additionally, while the numbers can vary by study, it appears that upward of 90 percent of health care organisations permit employees and clinicians to use their own mobile devices such as smartphones and tablets to connect to a provider’s network or enterprise systems. The bring-your-own-device trend has further complicated the challenges of protecting sensitive ePHI, while increasing the risk quotient for provider IT and compliance departments. With mobile devices continuously blurring the lines between our work and personal

TECHNICAL PAPERS lives, all too often we read about the well-intentioned employee who shifts data from a work device to devices or systems outside the safeguards and controls of a secure network. This is the definition of disaster waiting to happen if strict policies and procedures are not in place to govern bringing your own device.

Warding Off Danger As health care organisations face increasingly complex federal, state and regional privacy and security regulations along with corresponding fines, Health & Human Services doled out penalties ranging from several thousand dollars to well over $1 million per incident in 2013. And the bucks don’t stop there. Given legal and breach investigation fees, costs for providing free credit monitoring services to impacted parties, staffing hotlines to handle inquiries, and a host of other miscellaneous damage control steps, the Ponemon Institute estimates the average economic impact of a data breach in health care to be about $2 million.

Providers that do not have their privacy and security house in order also can get tagged with meaningful use noncompliance violations resulting in reduced reimbursements and lost incentive payments. And, perhaps, more difficult to quantify is the diminished patient loyalty and poor public image that can result from high-profile cases.

Our organisation, like others, provides security consulting services. With so much at stake and new information security threats constantly evolving, a key piece of advice our privacy and security consultants offer providers is this: “If you are engaging our services as only a function of ‘checking the box,’ you will remain at risk.” Compliant is not always secure.

Indeed, safeguarding ePHI against unauthorised use and disclosure requires constant vigilance and a comprehensive, enterprise-aligned program for information security risk management. This includes a collaborative and integrated security technology framework, experienced and credentialed resources to operate that framework, and adherence to formal procedures and established best practices to ensure the efficacy of operations. If you want to enhance your information security posture, consider the following actions: Develop a comprehensive risk management program and execute against it.

In a security consulting methodology such as ours, a three-step process can metaphorically create a shield of protection for providers. The first step is to design the shield by performing a series of risk and threat assessments — a starting point for developing a broader, long-term security and privacy program. Next, thicken the shield by implementing administrative, physical and technical safeguards across the

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS IT enterprise to mitigate the risks associated with maintaining ePHI. Ultimately, the goal is to preserve the shield through continuous formal risk management efforts, supported by the appropriate level of governance, documentation and ongoing remediation of security weaknesses.

Name a dedicated information security executive.

With many CIOs already wearing multiple hats and reaching their workload limit, the burden of maintaining sole responsibility for a comprehensive enterprise security program often can be too much. Relying on an ace network guy to take on the task while giving him little to no authority to drive substantive change will not work either. Hence, there is a trend toward naming a chief information security officer, or CISO, to lead this key operational function. We are seeing this empowerment of a dedicated security executive in health care and across other industries. In fact, retail giant Target recently named its first CISO in the wake of its data breach last year.

Conduct regular risk analyses and follow through on findings.

Increased enforcement efforts by the Office of Civil Rights under HIPAA, as well as new sanction guidelines under HITECH and significant meaningful use dollars at risk, have coalesced to spur many organisations to conduct the required risk-analysis activities. But as mentioned earlier, avoid bringing a check-the-box mentality to the table, and instead, truly invest in these activities. Re-evaluate and re-architect when the findings call for it. Use the regulations not only to compel consistency of action, but also to earn the trust of patients and staff by demonstrating a committed and focused stance on ensuring patient privacy and information security.

Get prescriptive with security controls.

A key difference between approaches to privacy and to security is that the guidelines for disclosing a potential breach of sensitive information are much more prescriptive. In fact, the industry has become quite good at handling such matters.

However, in security, there is constant inherent risk in the acquisition and transfer of data and a vast array of options for safeguarding it. Aside from encryption, few security controls are prescribed. Often, we find that an organisation is taking a particular security measure simply because that ace network guy happens to know he should, or because the CIO read an article about a fellow provider’s incident and saw his own organisation’s shortcomings in the media report.

As most who have been forced to overhaul their information security and compliance practices can attest, taking a much more prescriptive approach to applying security controls at both the industry and provider levels can go a long way toward reducing the loss or theft of ePHI. Don’t overlook medical device security.

Advances in electronic documentation, automation of clinical workflow and increased network integration have prompted providers to assimilate biomedical devices into their organisations’ complex health care IT infrastructure. In fact, newer medical device technology often takes advantage

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of the same operating systems and protocols favoured by mainstream IT developers. As such, these devices and platforms are susceptible to viruses and other threats that must be protected with diligence, given a device’s critical function in the delivery of patient care, whether diagnostic or life-sustaining.

For example, medical devices using wireless networks can be especially vulnerable to attackers who monitor the network to obtain passwords. Perhaps most worrisome is the denial-of-service attack in which a device is taken offline or prevented from functioning as required. As a baseline safeguard, establish an inventory of devices connected to the hospital’s network and catalogue those who have access to those devices. Furthermore, when performing a risk analysis, be sure to identify the effects of a security breach on each networked medical device.

Not If, but When Few hospitals will be the place where a star struck staff member sneaks a peak at the next Kardashian baby’s birth record. But for the majority of providers, it is entirely possible that an unencrypted device takes a walk, an email containing ePHI accidently travels to the wrong recipient at the hands of a harried nurse, or a malicious attack strikes a vulnerable network. These are real threats that will not disappear even for the Fort Knox of all health systems.

As the exchange of ePHI among providers’ increases through participation in accountable care organisations and health information exchanges, and more and more care is being delivered outside the acute care environment, make data security a central component to how you manage your overall operations.

While it may feel like an uphill battle, you can easily find that the cost of not investing in improving your information security posture can far outweigh the costs of doing so.

John Glaser, Ph.D., is the CEO of the Health Services business unit of Siemens Healthcare in Malvern, Pa.. Andrew Frazier, lead for information security risk management consulting, and Shawn Burgess, information security risk management consultant, Siemens Healthcare, contributed to this article.

2015

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Air Conditioning Range

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THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS

Because your staff need to concentrate on patient care Hills Health Solutions brings together the patient care expertise of Merlon, Questek and HTR. By integrating them into a single health-technology platform, we allow health care managers at hospitals and aged care facilities to focus on patients.

We bundle leading edge solutions for patient entertainment, phone service, nurse call, radio pendant systems and security. We’re applying ingenuity, not just to make life easier for patients, but also for the healthcare professionals who take care of them.

hills.com.au

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TECHNICAL PAPERS

Managing legionella: Achieving best practice

Cold water systems – The hidden danger Stuart Lloyd I Senior Hydraulics Designer

Legionella; the name of an infamous and well-documented bacteria, any Facilities Manager should be aware of the implications it presents, particularly within Healthcare.

T

he industry has been aware of Legionella for 35 years since it was first identified following the 1976 outbreak in Philadelphia which resulted in 221 cases of which 34 proved fatal1.

Following the identification of bacteria, cases of Legionella were subsequently proven to have occurred as far back as 19472, at that time cases would have been attributed to other, better known infections.

It is common knowledge within the related industries that Legionella is a waterborne bacteria, and is contracted by inhalation of contaminated water droplets that remain in suspension in the air when an aerosol or spray is generated.

Legionella is predominantly associated with evaporative cooling towers and air conditioning systems, with little recognition given to the risks that both hot and cold water services present.

There is limited guidance available within Australian Standards and the various Guides with respect to control of domestic hot and cold water services.

There are numerous sources that present a potential risk of Legionella colonisation and transmission. Some of these risk systems are humidifiers, nebulisers, emergency drench showers/eye washes, water softeners, hydrotherapy/spa pools, dental equipment, fountains, irrigation systems as well as decorative water features, fountains and firefighting/ suppression systems. The common factor being that all these systems supposedly operate using cold water and have a

means of transmission by generating an aerosol.

More recently, Legionella received overwhelming media publicity during a 2013 outbreak in a private health facility in Brisbane, Queensland with two confirmed cases resulting in a single fatality. Following the subsequent investigations, it was proven that the Legionella was contracted from warm water systems3. This case brought Legionella to the forefront as an issue and in particular the relevance of domestic water systems, resulting in a review of guidelines.

The Australian Standard AS/NZS 36664 mentions, albeit minimally, domestic water services with a section relating to heated water and a passing reference to cold water systems. AS/NZS 3666 does however reference AS/NZS 3500 part 15 and 46 , both of which contain reference to legionella prevention and control; and in turn circularly reference back to AS/NZS 3666. At the time of the Brisbane outbreak, there was interstate guidance available for healthcare premises, again they mention hot/warm water systems with only minimal reference to cold water systems.

The typical temperature range for the proliferation of legionella (when present) is between 20ºC and 50ºC with an ideal breeding temperature of 37ºC7.

This is why the literature available on this subject is geared predominantly toward hot and warm water systems; however, the operating temperatures of cold water

systems, particularly systems exposed to heat sources, i.e. ceiling voids, solar gains, etc. should also be considered.

Although Australian Standards do not quote a preferred operating temperature for domestic cold water services to assist in the prevention of Legionella, it is quoted as 20ºC within NHMRC (2010) Australian Guidelines for the Prevention and Control of Infection in Healthcare, Commonwealth of Australia.

Due to the higher Ambient temperatures experienced in Australia, cold water temperatures regularly exceed 20ºC with anecdotal reports of temperatures up to 30ºC regularly being experienced in Northern Queensland and Northern Territory, where infrastructure pipework can regularly be seen installed above ground running alongside roads. This then places the cold water temperature within the range for Legionella to multiply.

UK guides and legislation have long recognised the importance of thermally insulating not only hot water pipework but also cold water pipework. Although in the UK cold water pipe insulation is predominantly for frost protection purposes due to the colder temperatures experienced, it also serves the dual purpose of minimising heat gains thus keeping the cold water pipes and their contents cold.

UK legislation has been in place since 1987 in the form of Health and Safety Executive (HSE) guidance note EH48 which in 1991 became HS(G)70 and in 2001 evolved to become HSE L88 with

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TECHNICAL PAPERS

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TECHNICAL PAPERS the latest version released 2013, which is available for download9. More recently, a supplementary document HS(G)27410 has also been published by HSE, HS(G)274 provides guidance and again is available for download11.

HSE L8 Is an Approved Code of Practice and places a legal obligation on employers, building owner/operators and those responsible for maintaining buildings with HS(G)274,which provides practical advice on maintenance tasks and their frequency in order to comply with their legal obligations. These documents apply to all buildings, not just health care premises. HSE L8 sets the minimum requirements for installations and their operation and maintenance and if complied with the nominated responsible person is deemed to have complied with their legal obligations. HSE L8/ HS(G)274 recognises and provides guidance on good practice and methods of prevention and control of Legionella, including the installation and operation of both hot and cold water systems in addition to the other potential sources mentioned previously.

AS3500 only requires insulation of cold water pipework in locations where pipework may be subjected to the potential of freezing. As northern regions such as Queensland are not subjected to freezing temperature, it is very common that bulk cold water storage tanks and associated pipework is not insulated.

As tanks and pipework are not insulated, tanks, pipes and their contents are subject to heat gains due to high ambient temperatures as well as solar heat gains (where exposed to direct sunlight). The consequence of elevated temperatures within cold water systems is that this places the water within the temperature range for Legionella to proliferate.

As the cold water service supplies hot and warm water systems any Legionella colonisation of the cold system would be readily introduced to the entire site.

Furthermore, cold water is distributed to showers, basins and other outlets via mixer taps and thermostatic mixer valves.

These outlets are also serviced by hot water which can result in ambiguity around the source of the original

colonisations. It should be noted that if a sample from a shower head or mixer tap returns a positive result it does not necessarily determine which service, (hot or cold) is actually colonised.

Another concern is the cleanliness of bulk cold water storage tanks and hot water calorifiers. HSE L8 stipulates specific maintenance tasks for each of these items of plant and specifies periodic internal inspections and regular cleaning regimes. In Australia, there is no such equivalent requirement that these tasks be undertaken. The reason for the periodic inspections and cleaning is that sediment readily and frequently enters cold water storage tanks via the incoming water supply. In addition, hot water storage heaters frequently scale up, particularly in medium to hard water areas. This sediment and scale provide both nutrients as well as an ideal hide out for the bacteria legionella. If neither chlorine nor heat from pasteurisation can reach the bacteria due to the sediment or scale, it renders both of these exercises futile and pointless.

The new guidelines introduced by the Queensland Government in Dec 201312 significantly fill this gap as they provide greater obligations on the owner/operator in regards to legionella prevention, monitoring and resultant action. As recognised in the initial government report there is also a need to review the current AS/NZS 3666.

In the longer term this review should also be extended to certain aspects of AS/NZS 3500.

References 1. h ttp://www.nytimes.com/2006/08/01/ health/01docs.html?pagewanted=all&_ r=1& 2. WHO – Legionella and the prevention of Legionellosis 2007 3. Queensland Government Chief Health Officers Report – Review of the prevention and control of Legionella Pneumophila infection in Queensland Sept 2013 4. AS/NZS 3666: Air handling and water systems of buildings – Microbial control.

5. AS/NZS 3500:1 Plumbing and Drainage Part 1:Water services 6. AS/NZS 3500:4 Plumbing and Drainage Part 4: Heated water services 7. Health and Safety executive L8 – Legionnaires disease-The control of legionella bacteria in water systems.

Approved Code of Practice and guidance.

8. Health and Safety executive L8 – Legionnaires disease-The control of legionella bacteria in water systems.

Approved Code of Practice and guidance.

10. Health and Safety Executive HS(G)274 parts 1 - 3 Legionnaires disease: Technical guidance 11. http://www.hse.gov.uk/pubns/books/ hsg274.htm 12. G uidelines For Managing Microbial Water Quality In Health Facilities, State Of Queensland (Queensland Health) 2013

In the meantime until such reviews are completed, facility owner/operators should give consideration as to their current maintenance practices as well as reviewing their design and installation standards. Although owner/ operators have an obligation to comply with Australian Standards, the AS is a minimum standard and there is no reason their own requirements should not exceed those currently stipulated. Besides which, should the worst happen and you were called to an independent enquiry, could you, with your hand on your heart, honestly say that you complied with Industry best practice?

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TECHNICAL PAPERS

Seismic risk mitigation Trent Fairey

Seismic Risk mitigation is not a new process in the New Zealand built environment.

However, the recent seismic events in Christchurch have triggered a wave of inquiries and reviews into the current building act, the building code and the associated standards that support the code. This short essay will inform on the current situation in New Zealand, the effect on the existing building assets and the result that site wide compliance and robust governance can have on a healthcare facility.

Introduction

I

n a major disaster the regional healthcare facility acts as a critical hub in a post disaster response. New Zealand’s healthcare facilities are designed and built with resilience towards natural disasters including flood, fire, volcanic activity and earthquakes (all possible on the two islands). Of the last four environmental situations it is earthquakes which present the greatest risk, they are totally random and extremely violent.

The recent experience in Christchurch has shown us all how quickly these events can unfold, and how powerless we are to control them. However through good long term planning, strict compliance and thoughtful governance we can mitigate the damage and loss that our infrastructure and services will suffer.

The Christchurch event has prompted many queries from central government, local authorities and boards of directors.

Fig ure 1: Ten Years of shallow Earthquakes in New Zealand

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• What seismic risk policies are in place?

• How does the building code relate to seismic remedial work?

• What standards are being adhered to?

Historical events Earthquakes are a regular occurrence throughout the Pacific rim and throughout both islands of New Zealand. Thousands of earthquakes have occurred in the last 100 years, ranging from unnoticeable at magnitude 2 through to catastrophic at magnitude 7.8. However two major events are etched into the nation’s memory.

Napier, 1931 10:47 am on Tuesday 3 February 1931, a major earthquake hit the Hawke’s Bay region. It remains New Zealand’s deadliest natural disaster with 256 people killed. It lasted for two and a half minutes and measured magnitude 7.8. It completely devastated the city of Napier, and destroyed the city’s infrastructure. Catastrophic collapse of the key post disaster facilities occurred. All Hospitals, Fire stations and Police stations were reduced to rubble with deaths in these services.

Fig ure 2: Napier Nurses Home and Private hospital 1931

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TECHNICAL PAPERS

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TECHNICAL PAPERS

Fig ure 4: Landscape view of central Napier 1931

Fig ure 3: Napier Nurses Home and Private hospital 1931

Christchurch, 2011 February 2011 Christchurch earthquake severely damaged New Zealand’s second-largest city with a population of 400,000. The Christchurch earth quake measured magnitude 6.7 but also induced a 2.2g vertical force, the highest ever recorded in New Zealand. In total 181 people lost their lives and the cities centre was severely damaged. Of the 3,000 buildings within the Four Avenues of the central city by 3 March 2011 45% had been given red or yellow stickers to restrict access because of safety problems. Of the 220 buildings that were more than five stories tall, 110 are, or are going to be demolished. Although the majority of collapsed buildings occurred in the older unreinforced buildings two multi story buildings of the 1960s era also collapsed. Between these two buildings 133 lives were lost. The emergency services of Christchurch continued to function from their premises. Although damage did occur to these facilities none of them suffered catastrophic collapse and no emergency service personnel or members of the public were seriously injured or killed in their facilities from the event.

Fig ure 5: Christchurch Hospital 2012

Fig ure 6: Christchurch Street and the PGG building collapse.

Compliance In New Zealand, the building of houses and other buildings is controlled by the Building Act 2004. It applies to the construction of new buildings as well as the alteration and demolition of existing buildings.

The Building Act 2004 sets out the law on building work.

The Building Code sets out performance standards that all building work must meet. It covers aspects such as structural stability, fire safety, access, moisture control, durability, services and facilities. All building work must comply with the Building Code.

Fig ure 7: Christchurch Street and the PGG building collapse.

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TECHNICAL PAPERS The building control framework comprises mandatory and non-mandatory documents.

Standards, which are created by the organisation Standards New Zealand, come into the non-mandatory category.

Many Compliance Documents refer to them in Acceptable Solutions or Verification Methods.

for design of concrete, steel and timber structures, were cited in compliance documents in September 2008 (B1/VM1).

B1.3.3 Account shall be taken of all physical conditions likely to affect the stability of buildings, building elements and site work, including:

When a standard is published or revised, the Department reviews it to determine whether it is suitable to be used in the Compliance Documents. Depending on the outcome of the review, the Department may cite the entire Standard or parts of it in a Compliance Document.

It may also cite the Standard subject to certain modifications.

After the Napier Earthquake in 1931 there was a fundamental shift in New Zealand’s attitude towards construction.

No longer was the tried and proven brick masonry construction acceptable.

New safer construction methods were embraced. After 1931, earthquakes were considered in design standard NZS95:1935. This standard, with amendments in 1939 and 1955 provided the basic loads and forces to be considered in design. An amendment in NZS1900 (1965) explicitly prohibited unreinforced masonry. These kept improving with time, ductility and capacity design provisions being first incorporated in NZS4203:1976. While some documents for designing reinforced concrete and steel buildings for ductility were available in the early 1970s, it was not until 1982 and 1989 that NZ concrete structure, and steel structure, standards considering earthquake were developed.

Before 1992, building bylaws were adopted by most but not all local authorities, so there was no national building standard.

In July 1992 (B1/VM1) NZS4203 was cited in compliance documents making it part of the national building standard. As part of closer cooperation with Australia, the NZS1170 series were developed to describe the forces or actions acting on structures from different sources, including earthquake. NZS 1170, and Standards

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have a low probability of causing loss of amenity through undue deformation, vibratory response, degradation, or other physical characteristics throughout their lives, or during construction or alteration when the building is in use.

(a) self-weight, (b) imposed gravity loads arising from use, (c) temperature,

B1 Structure

(d) earth pressure,

The building code, under which standards are written, “Clause B1— Structure Provisions Limits on application” states the following:

(e) water and other liquids,

Objective B1.1 The objective of this provision is to: (a) safeguard people from injury caused by structural failure, (b) safeguard people from loss of amenity caused by structural behaviour, and (c) protect other property from physical damage caused by structural failure.

Functional requirement B1.2 Buildings, building elements and site work shall withstand the combination of loads that they are likely to experience during construction or alteration and throughout their lives.

Performance B1.3.1 Buildings, building elements and site work shall have a low probability of rupturing, becoming unstable, losing equilibrium, or collapsing during construction or alteration and throughout their lives.

B1.3.2 Buildings, building elements and site work shall

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(f) earthquake, (g) snow, (h) wind, (i) fire, (j) impact, (k) explosion, (l) reversing or fluctuating effects, (m) differential movement, (n) vegetation, (o) adverse effects due to insufficient separation from other buildings, (p) influence of equipment, services, non-structural elements and contents, (q) time dependent effects including creep and shrinkage, and (r) removal of support.

B1.3.4 Due allowance shall be made for: (a) the consequences of failure, (b) the intended use of the building, (c) e ffects of uncertainties resulting from construction activities, or the sequence in which construction activities occur,

TECHNICAL PAPERS (d) v ariation in the properties of materials and the characteristics of the site, and (e) accuracy limitations inherent in the methods used to predict the stability of buildings.

Of particular note is for healthcare facilities is B1.3.4 the intended use of the building. Not all buildings are expected to survive a Maximum Credible Earthquake (MCE), in fact the majority of the building stock would not, however the expectation that the most important structures in society should survive is logical.

All buildings are rated on their importance to society in a post disaster situation. The following importance categories are shown in figure 8.

Healthcare facilities are usually a collection of categories, a blend from Importance level 2 (IL2) through to Importance level 4 (IL4). And as illustrated above the higher the importance level the more resilient the structure is designed.

Effectively making an IL4 structure up to 40% more resilient than an IL2 structure All of the above compliance existed before the Christchurch event, and is still current today. The act is robust, and the systems are in place; it is the timeframe of refurbishment that has been questioned.

Governance Local territorial authorities in NZ formed policies around the upgrading of existing structures in the mid 90s through to 2005. These policies introduced a rapid assessment tool for building owners, the local councils and occupiers. The process was mandatory over time, with the onus on the building owner to complete the assessment and submit to the local councils for review. All building owners, both public and private completed the Initial Evaluation Procedures (IEP) on their assets. This was effectively a desktop exercise which took into account, age, condition, intended use, construction type and irregularities of structure. From this assessment a percentage grading compared to the current New Building Standard (NBS) was established.

Under the Act, a building that scores under 33% is deemed “earthquake prone” However, this may not be the case as the assessment is a desktop exercise. In most cases a building that is identified as earthquake prone through the IEP will then undertake a detailed seismic assessment, a costly exercise but essential if the owner is to understand the actual structural integrity of the building.

If the building after the detailed assessment is deemed “earthquake prone” the local council will serve a “notice of repair”. The owner will, depending on the council have a limited time to upgrade or demolish the structure.

In some instances this will be 10-20 years from notification.

Prior to the Christchurch event local councils had been slow to implement their policies, with many building owners resisting and stalling the upgrades required. The upgrades were seen as restrictive, uneconomic and due to the time since the major earthquake of Napier people had started to feel that the risk was medium to low. Of course Christchurch has changed this perception over night. Central government has since undertaken major reviews of the Building act, its codes and the standards associated with them. To date changes have occurred to standards and some detail in the Act, however only minor changes have been noted in new building construction. The majority of Christchurch’s modern buildings performed well, there are 2 major exceptions and a Royal commission of Inquiry is underway into these failings.

Governance of healthcare facilities in New Zealand is undertaken by regions District health Board (DHB). These DHBs are responsible for providing the majority of secondary and primary health services in their district. They are also responsible individually for the procurement and maintenance of their assets.

These boards in turn report through to the National Health Board and ultimately to the Ministry of Health.

Due to this structure each board will govern within the local territorial authorities bylaws and implement the mandatory acts and requirements.

However, as mentioned earlier the local bylaws may only require seismic upgrades within 10 to 20 years of the asset being confirmed earthquake prone.

Thankfully, throughout most DHBs, good governance is being shown with thorough investigations being undertaken on all assets. Assets failing to meet the standards are usually closed until extensive structural upgrades are complete.

The National Health Board has taken a proactive step in collating all assets onto a national register, giving them an overview of all building stock and its comparison to the New Building Standard, Facility Importance Level and proposed future works by the individual DHBs.

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TECHNICAL PAPERS Practical implementation Hawkes Bay District Health Board In 2005 the Hawkes Bay District Health Board (HBDHB) undertook a Initial Evaluation Procedure on all its 82 built assets, of the 82 assessed 7 of the buildings returned poor results and returned scores in the 1-33% New Building Standard. Of concern 4 of these building are classed as Importance level 4 buildings and included Wards blocks, Centralised Services, Electrical and generator complexes. Potentially the heart of the Hospital had returned poor results and the majority of the wards blocks showed unfavourable results.

Figure 9: District Health Boards in New Zealand

Figures 10 & 11: HA32 A Block wards and HA29 B Block wards

The next step of the process involved the Detailed Seismic Assessments. The large multistory Wards blocks were modelled as per their construction drawings and assessed against various earthquake scenarios, (as illustrated in Figures 10 and 11).

On completion of the recommendations made in the detailed assessments all the Wards blocks returned favourable results.

By combining the results of previous strengthening work, careful review of original structural drawings and minor upgrades to identified weak columns and beams the wards blocks achieved a 67% NBS for an Importance Level 4 structure. (with minimal financial cost) Once the main wards blocks had been researched and upgraded the structural team turned their attention to the services area of the campus. Although these buildings are not housing staff or patients, the hospital would cease to function without the services they supply.

Therefore all these buildings and their support installations are categorised as importance level 4 structures.

The main Switchgear room and associated Generator change-over facility was subject to demolition with a new IL4 structure built around the existing services.

The boiler house however was structurally sound but had to have all the masonry brick infill walls removed, and replaced with steel cross braces and a light metal cladding.

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TECHNICAL PAPERS

Figure 12: Removal of masonry walls from boiler complex

On completion of these facilities the HBDHB seismic upgrade team then moved to upgrade the lifelines from the centralised core through to the main hospital campus. This is an ongoing project which includes construction of new service tunnels, replacements of essential cables, installations of pipe bridges and installations of hundreds of seismic braces. An example of new service pipe bridges and tunnel is shown in figures 14-16.

Risk Mitigation Risk mitigation for Seismic events has required long term planning and implementation. The District Health Boards cannot change overnight the state of their historical infrastructure. By initiating assessments in the late 1990s through to the current day the state of the healthcare infrastructure is in good shape.

Progressive planning, upgrades and demolition over multiple capital years has progressively reduced the risk of structural damage during a seismic event.

Figure 13: Completed facility

TECHNICAL PAPERS

Figure 14: Pipe Bridges and services

Figure 17: HBDHB campus aerial photo 2013

Figure 15: Retrofitted seismic braces

The aerial view below shows the current condition of the HBDHB hospital campus green buildings are in the 67-100% New Building Standard, with Orange in the 34% to 66% and finally 2 Red buildings indicate closed buildings with “earthquake prone” status.

This is a typical scenario throughout New Zealand’s District Health Boards; all boards have faced the same issues of

Figure 16: New service tunnels

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achieving compliance. However through good governance from the Facilities management teams the Boards, and local territorial authorities gradual reduction in risk has been achieved over years of careful capital planning. The framework of the building Act, the Building codes and NZ/AS standards are providing facilities managers with clear path in Seismic risk mitigation for existing healthcare facilities.

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TECHNICAL PAPERS

The role of refrigeration and air conditioning in energy efficiency and GHG emissions reduction Tim Edwards

D

espite the fact that Air Conditioning and Refrigeration (HVAC&R) is an important contributor to economic performance and the quality of life its contribution to energy consumption and Greenhouse Gas Emissions (GHG) is broadly misunderstood and understated.

The industry makes a central contribution to fundamental industries including the built environment, food and pharmaceutical production and distribution, healthcare and hospitality and virtually all other human activities; effectively everyone, everywhere.

The importance of the HVAC&R industry in Australia is demonstrated by the following statistics1: • 45 M individual installations, • 2% of GDP, $26B annual spend, $ 6B capital investment PA, perhaps $100 B installed HVAC&R infrastructure at current $ value, • 22% of electricity consumption, • 12/14 of national CO2e emissions (GHG emissions)2,

• 20,000 firms, 170,000 direct employees, of whom about 70,000 are licensed to handle fluorocarbon refrigerants.

The industry offers major sources of energy efficiency and the resulting cost savings. The ARA believes Australia has the opportunity to reduce the energy cost of HVAC&R infrastructure by 60/70% over the next 15 years, a saving of $8/10 Billion PA.

The Role of International Agreements on Refrigerants A central determinant of HVAC&R

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technology is refrigerant selection and the impact of international agreements to phase down the use of Ozone Depleting (OD) and High GWP synthetic refrigerants. The Montreal Protocol calls for the elimination of OD refrigerants that are also High GWP refrigerants (CFC, HCFC) by 2020 in the industrialised world, in Australia by 2015. The EU has passed legislation that calls for the phase down of High GWP synthetic refrigerants (HFC) by 2030 to 21% of the current use. This same policy has been adopted by the Climate and Clean Air Coalition (CCAC) led by UNEP, US and China. Australia supports this policy. The Montreal Protocol is seen as the best vehicle for the phase down of HFCs having proven highly successful in the reduction of CFCs and HCFCs. The implication is that the use of High GWP synthetic refrigerants will be dramatically reduced over the next fifteen years. This will require replacement of a large proportion of HVAC&R infrastructure because low GWP refrigerant-based technology requires new HVAC&R equipment. As a result Original Equipment Manufactures (OEMs) worldwide are transitioning to Low GWP refrigerant equipment development and production – now.

The Low GWP refrigerants include the Natural Refrigerants (ammonia, carbon dioxide and hydrocarbon refrigerants) and low GWP synthetic refrigerants (HFOs). Both Natural Refrigerants and low GWP synthetic refrigerants are more energy efficient than High GWP synthetic refrigerants. Natural refrigerant- based technologies have been embraced in every sector of the HVAC&R industry to the extent that major multinational

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

suppliers, end user organisations and governments now promote their use. For instance the Consumer Goods Forum representing over four hundred of the world’s leading multinational food retailers and food suppliers are now calling for all HVAC&R applications to use Natural Refrigerants.

HVAC&R Energy Efficiency The transition to high HVAC&R energy efficiency offers major cost savings subject to HVAC&R engineers and contractors appreciating the full range of considerations and innovation.

Whilst it is inappropriate to generalise about the degree of energy efficiency made possible by Low GWP refrigerant technology because there are many factors to consider, it is a fact that the thermal absorption of the Natural Refrigerants is far greater than that of High GWP synthetic refrigerants. For instance the thermal absorption of a typical hydrocarbon refrigerant is 496 kj/kg compared to 256 kj/kg for R410A – an improvement of 48%. The same pattern applies across the range of Natural Refrigerants as compared to High GWP synthetic refrigerants.

Whilst the capital cost of Low GWP refrigerant technology will tend to be higher in the short term it is the energy efficiency of this technology that will deliver major cost savings over the life of the equipment.

Whilst the transition to Low GWP refrigerant technology is commercially warranted it requires HVAC&R specifiers to be aware of the sources and management disciplines required.

TECHNICAL PAPERS The use of Life Cycle Costing and increased Life Cycle Management of HVAC&R equipment is fundamental to enabling HVAC&R energy efficiency to be fully realised. Only through the use of Life Cycle Costing will the cost savings of energy efficient Low GWP refrigerant technology be fully appreciated. Only through the use of Life Cycle Management systems will the energy efficiency of Low GWP refrigerant technology deliver the optimal degree of energy efficiency of HVAC&R equipment.

The sources of HVAC&R energy efficiency include both the mechanical devices that use Low GWP refrigerants and the use of integrated heat load management systems spanning the full range of methods for reducing the energy demand for heating and cooling. These include the many ways to reduce the temperature change required of HVAC&R equipment like control systems, greater use of insulation systems like double glazed windows, reflective paints and low heat lighting. It is fundamental that HVAC&R specifiers recognise and deliver integrated energy efficiency solutions that optimise HVAC&R energy efficiency.

HVAC&R GHG Emissions The contribution of HVAC&R to greenhouse gas emissions also tends to be misunderstood and understated.

HVAC&R is seldom recognised individually as a source of GHG emissions despite the fact that it is

in fact a major source: 12/14% of national emissions.

The energy consumption of the HVAC&R industry (indirect emissions) is extremely high (22.3% of electricity use, about 10% of national emissions) reflecting the many operating systems and their continuous use. It is direct emissions that are little understood and pervasively misrepresented. The Australian national accounts report refrigerant emissions to be about 1% of national emissions. This understates the volume of direct emissions for a series of reasons that defy logic and give rise to a great deal of misunderstanding; principally the failure to include High GWP ozone depleting refrigerant emissions in Kyoto accounting.

The real impact of the HVAC&R industry in Australia is in the order of 14% of national emissions. This is comprised of 10% of national emissions due to energy consumption and 4 % due to unintentional and intentional High GWP synthetic refrigerant emissions.

This understatement matters a great deal.

It has the effect of failing to recognise HVAC&R as a primary potential source of emissions reduction. It has the effect of failing to recognise that there are solutions available in Natural Refrigerants for which direct emissions would be minimal because their GWP is negligible compared to High GWP

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The use of integrated energy efficiency solutions in association with high efficiency HVAC&R equipment has the potential to further reduce total energy consumption and indirect emissions.

ARA HVAC&R Energy Efficiency Seminars The ARA is comprised of organisations that offer Natural Refrigerant technologies and the associated sources of HVAC&R energy efficiency. Because we feel the full range of solutions needs to be better understood by the users of HVAC&R systems we are offering full day seminars in the use of these technologies in November 2014, in Brisbane, Sydney and Melbourne. For more information please visit the website for this seminar series: ARA HVACR Energy Efficiency Seminars.

References 1. C old Hard Facts 2, Dept of the Environment, 2013 (A taxonomy of the HVAC&R industry) 2. This is the ARA’s estimate. Cold Hard Facts 2 says this is 11.7%. Contact ARA for explanation.

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TECHNICAL PAPERS

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Energy efficiency finance can deliver cost-cutting tonic for hospitals Contributed by THE CEFC

Energy efficiency and renewable energy technologies have a vital role to play in the economic health of Australian hospitals trying to absorb rapidly increasing electricity costs.

H

ospitals can use nearly twice as much energy per square metre as a commercial buildings and around six times as much water.

Apart from the expected base building energy use, there are energy costs associated with the need to provide 24-hour care, diagnostic imaging and operating theatres. With many hospitals in service years longer than their original design intended, inefficiencies resulting from aging equipment can be added to that picture.

But Clean Energy Finance Corporation CEO Oliver Yates says the good

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news is that the energy efficiency and renewable technologies helping commercial properties reduce energy costs are also making significant savings inroads for the health care sector and that the CEFC can help finance such projects.

“In a climate of electricity price uncertainty, it’s more important than ever for Australian public and private hospitals to be aware of their energy use and to know what tools are available to them so they can act now to keep operating costs down and

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deliver the health services Australians need,” he said.

The high energy intensity issues faced in the hospital sector aren’t unique to Australia, nor is the potential for finance to accelerate uptake of energy efficiency measures.

In the UK, the CEFC’s counterpart, the Green Investment Bank (GIB), earlier this year launched an Energy Efficiency Program to finance energy efficiency projects in National Health Service (NHS) hospitals. The GIB estimates the NHS could reduce its energy costs by 20 per cent a year with a capital

TECHNICAL PAPERS investment requirement of up to STG1.5 billion.

In the US, a 2011 management survey of more than 4,800 hospitals revealed that while organisations were devoting more resources to energy conservation initiatives since the Global Financial Crisis, opportunities were still being missed due to lack of available finance.

The majority of projects being carried out were considered “common sense” measures involving Heating, Ventilation and Air Conditioning (HVAC) and lighting upgrades, or were incorporated into upgrades by facilities that were putting increased effort into disaster planning.

Australian health care energy use In Australia, energy use of public hospitals and healthcare facilities was analysed in a 2012 Australian Government report into Baseline Energy Consumption and Greenhouse Gas

Emissions in Commercial Buildings in Australia, prepared by pitt&sherry. Its broad findings reveal that electricity accounts for about 49 per cent of total hospital energy use, while natural gas represents 47 per cent and LPG makes up the remainder.

HVAC accounts for 47 per cent of total electrical use, with other electrical and lighting accounting for 27 per cent and 17 per cent respectively.

Victoria and New South Wales have both documented the energy efficiency improvements of their public hospitals in recent years. Victorian public health services have been implementing energy efficiency for more than a decade with common initiatives including installation of LED lighting, motion sensor and timer installations, newer air conditioning, and improving the maintenance of building systems. In the four years to 2012, NSW Health reduced its building energy use by two per cent, despite increases in hospital

activity. In the private sector, operators like Ramsay Health Care have ongoing commitments to improving sustainability and are also targeting air conditioning, lighting and managing waste streams as opportunities for energy savings.

CEFC projects are making savings Finding the upfront finance to cover implementation of energy saving technologies is a critical success factor.

The CEFC has financed a range of building retrofits, lighting upgrades, and solar PV installations in projects that are replicable and relevant for health sector buildings.

For example, CEFC finance was accessed to reduce the carbon emissions and lighting energy costs of three car parks by 30 per cent per year at two Sydney Hospitals. The lighting upgrade was undertaken by Metro Parking, which operates St George Hospital’s Belgrave Street and Gray

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TECHNICAL PAPERS impressive results. Finance to Tumut Shire Council in New South Wales helped the local government upgrade its administration building with energy efficient lighting and upgraded air conditioning system and solar PV which reduced its grid electricity costs by a better than expected 66 per cent.

Meanwhile, finance to Bankstown Sports, in south-western Sydney, helped it upgrade a chiller system to make it 50 per cent more efficient and enabled the club to install solar PV at its Baulkham Hills Sports Club, to generate about 10 per cent of that site’s energy needs.

Hospitals benefiting from energy efficiency Other examples of how energy efficiency projects have cut the energy use of Australian hospitals include:

Street car parks and the Sydney Eye Hospital’s car park on behalf of owner International Parking Group (IPG).

All up, 1,141 bays at the St George Hospital car parks and 390 bays at the Sydney Eye Hospital car park benefit from the upgrade. The new lights consume less power and won’t need as much maintenance resulting in further savings estimated at $A50,000 per annum.

Emergency power supplies are critical for hospitals to provide the levels of care Australians expect. The CEFC has financed a number of cogeneration and trigeneration installations that are providing onsite gas-fired power sources as well as by-products such as heat and steam that can be used for

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other onsite purposes. Wagga Wagga City Council installed a cogeneration system at its Oasis Regional Aquatic Centre in 2013 and halved the centre’s annual energy costs. The system, estimated to reduce carbon emissions by about 1000 tonnes a year, can provide up to 85 per cent of the centre’s electricity demand and supplies hot water for space heating and for the swimming pools. The CEFC provided finance of $208,000 towards the upgrade which also received an Australian Government grant.

Solar is also an increasingly sought-after way of helping organisations reduce their grid electricity needs. The CEFC has financed solar installations as part of larger building retrofits with some

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• Upgrades to the 189-bed Alice Springs Hospital, in the Northern Territory, including better air conditioning and cooling systems, solar hot water systems, variable speed drives and the replacement of a boiler, that resulted in annual savings of over $190,000 on its power bill and a reduction of carbon emissions by 700 tonnes. The savings were made despite extensions to the hospital including a new Emergency Department wing. An audit carried out before work began revealed that 57 per cent of electricity was used for heating, ventilation and air conditioning and 24 per cent for lighting.

• The 88-bed Bethesda Hospital in Claremont WA, installed energy efficiency lighting and voltage optimisation for its air conditioning units in 2010 as part of a major redevelopment project. The installations of a Smartcool system across two screw chillers and five APAC package units reduced chiller energy consumption by 16 per cent and 18 per cent reductions on the package units.

• The 580-bed Flinders Medical Centre – a public teaching hospital and medical school in Adelaide -

TECHNICAL PAPERS

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TECHNICAL PAPERS undertook a lighting upgrade that resulted in a reduction of 700 tonnes of carbon emissions about a 20 per cent saving to energy bills.

• Beaufort Hospital in Victoria installed a wood chip fuelled heating boiler earlier this year so it could use local sawmill waste to provide most of the hospital’s heating needs and significantly reduce its heating costs.

• Westmead Hospital in NSW, which won the NSW Government’s 2014 Green Globe Awards Energy Efficiency Award, has upgraded its lighting and cooling systems to achieve reductions of 36 per cent to lighting energy use and 28 per cent in cooling system energy use.

The CEFC is able to finance these sorts of projects and types of technologies.

How does CEFC finance work?

The CEFC has developed innovative finance models that are designed to help overcome funding barriers. These models use the savings made through the deployment of energy efficient technologies to pay back the loan.

In partnership with Commonwealth Bank, the CEFC is financing an Energy Efficient Loan program designed specifically for not-for-profits, including public hospitals, to save on energy costs.

Commonwealth Bank enters into individual loan agreements with eligible customers and will negotiate terms and conditions on a case-by-case basis.

Loans can be for either the full value or part of a project’s total cost and terms of up to 12 years are offered to allow energy savings to repay the finance, providing a cash flow positive or cash flow neutral outcome.

Earlier this year the CEFC announced several programs that will help make it easier for organisations to access solar PV and make significant energy cost savings.

The new financing models are being offered by established, experienced and accredited installation companies

and suppliers. They provide a no-money down way to finance solar installations involving solar leasing or power purchase agreements.

“We’re hoping to further expand our commitment to solar to provide the Australian health sector and other economic sectors with as many different avenues as possible to take up solar.

Solar makes sense, given Australia’s solar resources,” Mr Yates said.

The CEFC also co-finances building retrofits through Environmental Upgrade Agreements (EUAs), which involve the building owner, financiers and local councils and allow building owners get competitive long-term finance to meet upfront capital needs of retrofit projects.

Loan repayments are made through a local council charge on the land.

CEFC-financed EUA retrofits, have involved installing new energy efficient elevators, improved air-conditioning, building management systems and lighting and the installation of a tri-generation plant at a combined residential and commercial development. The projects have generally resulted in base building energy use reductions of up to 45 per cent.

EUAs are available for commercial properties in Sydney and Melbourne and a number of regional centres in

NSW. Legislation is in train in South Australia to enable EUAs in that state.

What’s ahead The Clean Energy Finance Corporation has invested $900 million to catalyse clean energy investments of more than $3 billion since it began investing in renewable, energy efficient and low emissions technology in July 2013.

The Corporation is continuing to explore opportunities that catalyse investment to help Australian organisations, including the health sector, reap the energy productivity benefits of low emissions technologies.

The CEFC invests for a positive return, with its more than 40 direct investments and 25 projects co-financed under aggregation programs expected to achieve a positive return for the CEFC and for the taxpayer.

These CEFC investments are expected to achieve abatement of 4.2 million tonnes of CO2e per annum with a positive net benefit to the taxpayer in the order of $2.40 per tonne CO2e. They help to improve energy productivity for businesses across Australia, develop local industries and generate new employment opportunities.

To learn more about the CEFC and its finance please visit its website: www.cleanenergyfinancecorp.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS

ATLAS COPCO VACUUM, GHSVSD+ THE FUTURE OF MEDICAL SUCTION A "plug and play" package that offers massive energy savings of over 50%. Based on the famous Atlas Copco oil injected screw element and other tried and tested components. vac@au.atlascopco.com

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THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

ADVERTORIAL

Does efficient packaging, of inefficient equipment, make it efficient?

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id you know that Atlas Copco has internal targets for saving our customers energy? This is the driving force behind every design improvement or new innovation. We are truly committed to sustainable productivity and the GHSVSD+ supports this motto like nothing before.

What is a GHSVSD+?

This is an oil injected rotary screw vacuum package. It is a self-contained “pump” complete with variable speed drive, sound enclosure, monitoring, inlet filtration, starter, pressure control, multifunction inlet valve with nonreturn......... We call it “plug and play”.

Is a GHSVSD+ efficient?

Efficiencies on this range are almost unbelievable! We have designed the unit to perform in pressures where it matters. Thanks to Atlas Copco’s know how in packaging and control of industrial equipment, the range offers the advantage of one motor size down from comparative flow pumps. The combination of oil injected screw and variable speed drive offers an efficient flow range and a huge turndown. An example of this is the GHS730VSD+, with 730m3/h and 13.6kW, down to 78m3/h and 1.4kW.

It must be expensive?

Actually, it’s not. This is where a global manufacturer with over 144 years of experience can choose to design an evolution with “readily available” components. Some components on this range are also used on Atlas Copco compressors and offers remarkable savings in manufacturing. We admit that it’s not the same purchase price as a pump, but then, this is no pump, and the GHSVSD+ generally offers a quick return on investment thanks to energy and service savings.

What about servicing?

In a typical medical suction application, a GHSVSD+ running 24/7, would only require two service interventions per annum. Any major work will only be required after six years.

once the ultimate vacuum is reached.

A GHS730VSD+ has a capacity 16% larger, motor 27% smaller in kW, and a reduction in power (turn down) of 90%.

We conservatively state energy savings of 50%.

Sounds complicated, but will it be reliable?

At the heart of these machines are components tried and tested in all conditions all over the world. Motors, drives, screw elements, coolers, the famous Electronicon controller. All previously proven, then combined to complete rigorous endurance testing in the harshest applications. The GHSVSD+ is born with components generally overdesigned, like the element, originally designed for compressed air applications with pressure ratios + 10 times higher than those in vacuum applications.

How does this compare with existing pumps?

The predominant technology used is oil sealed rotary vane pumps. These are simple, freely available, inexpensive to buy and generally reliable. A major disadvantage is the limited control options available, ether due to manufactures scope or technology limitations. This results in energy inefficiencies that has become acceptable as no reliable alternatives were available. There is only a handful of reputable vacuum pump manufactures. Unfortunately their main focus is on OEM applications were pumps are purely a necessary component controlled by a PLC. There is little regard for the end user and there energy consumption:

Energy savings Let’s consider a 630 m3/h oil sealed rotary vane pump. This will have an installed motor of 15kW and should offer a reduction in power of +\- 17%

Monitoring The GHSVSD+ is equipped with the renowned Atlas Copco Electronicon MKV Graphic controller. This takes care of the full operation of the pump, pressure control, temperature control and monitoring, warning and safety shutdowns, gas ballast adjustments....

The unit also offers remote monitoring and control. As an option we also offer “Smartlink” a live link between your machine, our service teams and your nominated contacts.

Install one now, it’s easy.

There is no need to engage in major project type activities to install one at your facility and start benefiting from the savings. Think of it as a pump replacement. The footprint is small and installation simple. The GHSVSD+ can be installed in the existing system effectively taking over the function and duty if the existing pumps. The existing pumps will become the backup as required by the standard.

If your facility is looking to reduce costs, increase reliability, reduce its carbon footprint, or simply keep up with technological advancements, the GHSVSD+ is your number one choice.

Thank you for taking interest in our new innovation. Please feel free to contact us at vac@au.atlascopco.com for more information.

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS

John James Memorial Foundation Healthcare Campus Community Energy Efficiency Program project outcomes Gary Whatling I Energy and Sustainability Services

Executive summary

I

n February 2013 JLL developed a package of energy efficiency upgrade works for the John James Memorial Foundation (JJMF) hospital campus in Deakin, Canberra. A Community Energy Efficiency Program Federal Government grant was awarded which funded 50% of the total project cost of $1.2 million.

The project scope of works included: • upgrades to the main hospital building air conditioning system serving the operating theatres consisting of a new chiller and pumps; • upgrades to one of the largest buildings on the Healthcare Campus, the Peter Yorke Building, including: heating hot water boiler replacement; installation of variable speed drives on the condenser water pumps; upgrading a packaged AC unit to improve the coefficient of performance; lighting upgrades in common areas including restrooms, fire stairs, lift lobbies and common area corridors; and installation of energy submeters and a program of building tuning based on monitoring and analysis of energy consumption; and • upgrades to the internal and external car park lighting.

The works were carried out in 2014, with ongoing monitoring and validation continuing through 2015.

Total annual energy savings were estimated to be approximately $96,500 giving a predicted payback of approximately 10 years. Taking into account the CEEP grant

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funding, the payback to the hospital owner will be about 5 years.

Key success factors for the project were the availability of the CEEP grant funding, plus on-going energy cost saving for the not for profit operators of the buildings.

The client The John James Memorial Foundation Ltd is a Non-Profit Medical Charity which owns the John James Healthcare Campus at 173 Strickland Crescent, Deakin, ACT. The

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

campus includes Canberra’s largest private hospital. The main hospital buildings are leased on a long term basis to Calvary Private Healthcare Canberra Ltd, who run the hospital business.

In February 2013 JLL supported the owners, JJMF to apply for a Federal Government Community Energy Efficiency Program (CEEP) grant. The CEEP grants program was a $330m Government fund allocated during 2012 and 2013 based on a meritsbased competitive application process. It provided co-funding for energy efficiency

TECHNICAL PAPERS

initiatives at buildings owned by local governments and not-for-profit community organisations. The range of initiatives funded under the CEEP grants covered the installation or upgrade of energy efficiency technologies including: lighting; heating, ventilation and air conditioning (HVAC) system upgrades; building fabric performance improvements such as insulation, draught sealing, double glazing; and low carbon energy systems such as solar hot water systems; as well as building energy management systems and variable speed drives to save energy through improved control of motors running HVAC fans and pumps.

The John James Hospital CEEP grant application sought dollar-for-dollar matched funding from the Government to carry out a range of energy efficiency works across the healthcare campus. The project scope of works included: • upgrades to the main hospital building air conditioning system serving the operating

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS plant served an operating theatre area of approximately 2,000m2 and runs for over 12 hours a day, 360 days a year. It was one of the major energy consuming items across the hospital campus.

The existing air conditioning system was estimated to be operating in the order of 15-20% worse than its initial system efficiency due to its age. The new best practice air cooled chiller equipment technology is expected to offer efficiency increases of a further 15-20% beyond the previous system’s original design.

A new air cooled water chiller and chilled water pumps were proposed to improve the efficiency of this key system. JLL carried out an energy audit to identify a suitable high efficiency chiller replacement. A Carrier air cooled screw chiller was selected, which was predicted to result in a 14% electrical energy saving of 19,542 kWh per annum compared to the old chiller.

The sizing and replacement of the air cooled chiller was performed by the chiller manufacturer Carrier. Carrier’s selection software used the specific efficiency and operating characteristics of the existing machine and de-rates the current efficiency for the age/wear and tear on that machine. The proposed high efficiency replacement chiller is then modelled and compared against the de-rated existing chiller energy consumption.

theatres consisting of a new chiller and pumps; • upgrades to one of the largest buildings on the hospital campus, the Peter Yorke Building, including: heating hot water boiler replacement; installation of variable speed drives on the condenser water pumps; upgrading a packaged AC unit to improve the coefficient of performance; lighting upgrades in common areas including restrooms, fire stairs, lift lobbies and common area corridors; and installation of energy sub-meters and a program of building tuning based on monitoring and analysis of energy consumption; and • upgrades to the internal and external car park lighting.

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The total project cost was $1.2M, of which $502,567 was funded by the CEEP (Community Energy Efficiency Program) Grant from the Federal Government.

The details of the energy efficiency upgrade projects carried out are described below.

All return on investment calculations were based on electricity costs of $0.18/ kWh.

Hospital building chiller and pump replacement project The main chiller plant serving the hospital operating theatres was installed in 1989. The main components of the air conditioning system were between 12 and 23 years old. The hospital building chiller

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

The project commenced in June 2013, with the plant installed in December 2013 and January 2014. The works involved the supply and delivery of: a new air cooled chiller, which had to be craned up to the plant room on the roof of the 3 storey building; condenser air discharge ductwork and chilled water piping alterations and new chilled water pumps were installed; an electrical energy meter was installed on the chiller; and electrical and controls wiring was installed, as well as a new electrical sub-mains.

There were no existing electrical energy submetering systems for the chiller or pumps, so estimates of the predicted savings had to be made. JLL estimated that 303,832kWh of electricity was consumed per annum by the existing 1989 era roof top air cooled chiller and associated pumps at an annual cost of $54,690. The new chiller and pumps delivered an annual energy cost

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TECHNICAL PAPERS saving of $7,676. The total project cost was $222,866 giving a payback of 29 years. However, commercial payback was not the only consideration. Reliability and continuity of service to the operating theatres was the main priority, necessitating the replacement of the existing end of life chiller. The old and inefficient machines were swapped out for new best practice machines.

A major project challenge was to provide continuity of service to the operating theatres during the works. This necessitated the use of a temporary air conditioning unit to serve the operating theatres for the two weeks while the main system was off-line during the upgrade works. Project costs were high for this type of work as there was a need to hire temporary chiller systems to maintain the critical function of the operating theatres during the works and carry out the works both during and after normal business hours on consecutive shifts to complete the work in a rapid time frame, as well as coordinate operational schedules and access with the hospital operator whilst the works took place. Twelve percent of the cost of the Hospital building chiller and pump replacement project was associated with hire of the temporary chiller to maintain operational continuity during the works.

Peter Yorke Building upgrade works The Peter Yorke Building is a 4 storey building of approximately 4,200m2 located on the John James Healthcare Campus. It averages 13 hours operation per day from approximately 7am through to 8pm. The upgrade works involved lighting replacements, a new heating hot water boiler, plus sub-metering and ongoing monitoring and analysis of energy consumption.

The first aspect of the work involved lighting upgrades to the internal common areas including the fire stair, the restrooms, lift lobby and Internal car park.

A JLL audit identified that the restroom lighting was a mix of 50W halogen down lights with magnetic ballasts and T8 fluorescent fittings with electronic ballasts.

There was an opportunity to replace the halogens with LEDs and the T8s with T5 fluorescent light fittings.

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The internal fire stair was lit with surface mounted twin T8 lights with magnetic ballasts. LED lights with motion detector controls (“Chameleon” product from enLighten Australia) were identified as a suitable replacement with the potential to reduce stair case lighting energy use by up to 93%.

Lift lobbies and common area corridors were lit with a mix of 50W halogen down lights with magnetic ballasts and T8 fluorescent fittings with electronic ballasts and compact fluorescent light (CFL) fittings with magnetic ballasts. Halogens and CFLs were replaced with LEDs, and T8s were upgrade to T5 fluorescent lights.

The Peter Yorke Building lighting upgrade works commenced in June 2014 and were completed in November 2014.

The building common area lighting systems were consuming approximately 47,500 kWh per annum. The lighting upgrades reduced that to approximately 28,000 kWh/annum, a saving of 19,500 kWh/year. The lighting upgrades cost approximately $46,000 and generated energy savings of approximately $3,500 per year.

The second aspect to the Peter Yorke Building upgrade works involved selective upgrades to the central plant, including: replacing the end of life heating hot water boilers; modification of the outside air ductwork system; installation of variable speed drives (VSDs) on the condenser water pumps; and package unit isolation valves.

These works commenced in June 2014 and were completed in August 2014.

The JLL audit also identified an opportunity to improve the operating parameters of the central plant through sub-metering, monitoring and tuning. Energy sub-meters were installed to separately monitor cooling, heating, fan energy, general lights & power and lifts. The sub-meters were installed in October 2014. JLL’s Energy and Sustainability Platform (ESP) software was implemented to monitor the sub-meters, and analysis was carried out by an engineer to identify further opportunities for improvement through tuning operational parameters and control set points. The ESP system includes data collection, storage, graphical display of current versus historical performance compared to the energy reduction target.

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

Regular analysis by a JLL engineer, including monthly reports, monthly performance review meetings and recommendations for ongoing improvement will be carried out during 2014. Energy savings of 10% in the first year associated with increased visibility of performance through sub-metering, monitoring, and monthly trend analysis, leading to building tuning and controls modifications were predicted to save $76,350.

The total project cost for the Peter Yorke Building scope of works was approximately $530,000 and is projected to deliver savings of approximately $86,400.

Engagement with the engineering services maintenance teams via the metering and monitoring process will be the key to success on these projects.

Hospital campus car park and external area lighting upgrade There is a large two storey covered car park built in the 1990’s on the hospital campus, as well as extensive open external car parks. These fittings operate for over 12 hours a day, 365 days a year. The JLL energy audit identified a range of light fittings which presented an opportunity to reduce lighting energy consumption.

An upgrade of the car park light fittings to current best practice LEDs was predicted to cut up to 50% from the energy consumption of the existing fittings. Baseline energy usage for the covered and open area car parking areas was estimated by counting the number of fittings and multiplying this by the wattage and hours of operation.

There are two levels to the covered parking area with an area of approximately 3,500 m2. The lighting within the covered car parking area was in the order of 12 -15 years old.

Existing light fittings in the lower-storey under-cover car park area were 600x600mm surface mounted fittings each with 4x 18Watt T8 fluorescent tubes with magnetic ballasts. The open upper deck was lit by five 84 watt sodium vapour fittings on 4 meter poles. Together these lights had an estimated annual consumption (before the upgrade project) of 5,931kWh per year.

TECHNICAL PAPERS The JLL energy audit identified a range of replacement lights, including LEDs ranging from 3 to 45 watts, and T5 fluorescent tubes. The estimated project cost was $32,000, with estimated annual cost savings of approximately $600.

The open external car park and driveways cover an area of approximately 11,440 m2 (excluding gardens & vegetation), which were lit by light fittings of a range of types and efficiencies, between 10 and 20 years old. There were seven different types of light fittings mounted on light poles ranging in height from 3 to 8 meters tall around the main parking areas and driveways across the campus. The pole mounted lights included incandescent lamps and mercury vapour fittings, and there were some surface mounted twin T8 lights with magnetic ballasts in weather proof enclosures. Together these external light fittings had an estimated annual consumption (before the upgrade project) of 20,413 kWh per year.

The JLL energy audit replacement LED replacements ranging from 9 to 130 watts which was predicted to reduce energy consumption by up to 50%. The estimated project cost was $55,000, and with predicted annual savings of approximately $1,800. The estimated savings from both covered and external car park lighting upgrades were $2,400 annually.

The lighting upgrade works took place in November 2014. Project costs were high for this type of work due to the requirement to hire mobile access platforms for the duration of the work and manage public access parking restrictions whilst the works took place.

Conclusions The total project cost was $1.2 million, and was predicted to deliver total year 1 electricity savings of about $96,500, meaning the payback of the package of works was about 8.7 years.

The key factors influencing the recommended upgrade works were: the age of the existing plant (in many instances in excess of 20 years old); long hours of operation (the hospital operates 7 day week, 365 days a year, and many services also operate 24 hours per day); the requirement for no disruption to the

healthcare operation during the upgrade works, and completion in a short timeframe; and the requirement for both improved energy efficiency and high operational reliability.

The John James Memorial Foundation (JJMF) donates all of its revenues after expenses to charitable purposes both disadvantaged and special needs groups in the ACT and to disadvantaged groups in low socioeconomic regions such as the Northern Territory where indigenous communities are a focus. It also supports medical education and other community service activities.

Savings from energy efficiency measures translate directly to more funds being available the JJMF’s charitable works.

Beyond the financial benefits of the upgrade works, the outcomes from the John James Memorial Foundation energy efficiency project will be shared with the Calvary John James Hospital (the tenant group which operates the hospital), which will be a valuable case study for the wider Calvary Hospital Group, who operate a national network of hospitals including: – Private Hospitals o Calvary John James Hospital, Deakin, Canberra, ACT o Calvary Private Hospital, Bruce, Canberra, ACT o Calvary Central Districts Hospital, Elisabeth Vale, SA o Calvary North Adelaide Hospital, SA o Calvary Rehabilitation Hospital, SA o Calvary Wakefield Hospital, Adelaide, SA

– Public Hospitals oC alvary Health Care, Canberra, ACT oC alvary Health Care Bethlehem, Melbourne, Vic o Calvary Health Care, Sydney, NSW o Calvary Mater Newcastle, NSW o Clare Holland House, Barton, ACT – Aged Care alvary Retirement Communities oC Hunter-Manning, Newcastle, NSW oC alvary Retirement Community Canberra, ACT oC alvary Retirement Community Cessnock, NSW oC alvary Retirement Community Ryde, Sydney, NSW oC alvary Community Home Care providers o Calvary Silver Circle, Sydney, NSW The lessons learned will also be shared in the JJMF newsletter which will inform and educate approximately 250 individuals and organisations in the Australian not for profit sector. A new JJMF website will provide access to information about energy efficiency on the hospital campus to the general public.

JLL’s Project & Development Services (PDS) project managed the upgrade works, with technical input including energy audits, upgrade recommendations, specification wording and tender reviews being carried out by JLL’s Energy and Sustainability Services (ESS) team.

o Calvary Health Care Riverina, Wagga Wagga, NSW o Calvary Health Care Tasmania Lenah Valley Campus o Calvary Health Care Tasmania St John’s Campus o Calvary Health Care Tasmania St Luke’s Campus o Calvary Health Care Tasmania St Vincent’s Campus

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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Operating theatre ventilation system review Andrew Sutherland I ASC Engineers

(This paper is broken into two parts, Part 2 has been published in this edition of the journal, Part 1 was published in the previous edition of the journal.)

Part 2 Introduction

T

he cost of construction and maintenance of health care facilities is substantial and the cost effectiveness of procedures systems and facilities is under constant review. Reduction in hospital acquired infections can have a significant impact on improved patient outcomes and minimising the cost to the health care facility for the delivery of clinical services.

Strategies to improve outcomes are both clinical and engineering. One area of ongoing discussion is the role of operating theatre ventilations systems and system design to assist in the reduction of surgical site infections (SSIs).

Development in microbiology has made surgery safer, but the overall instance of associated infections remains high and represents a substantial burden of disease.[1] This section Part 2 completed the Part 1 of the paper previously published.

Laminar Air Systems Operating Theatre Ventilation Systems should provide a reduction of potential contaminants in the operating theatre by conveying air with low levels of potential pathogens to the surgical site and provide good environmental control.

Laminar air-flow units are generally two types; ceiling-mounted (vertical flow) or wall-mounted (horizontal flow). There are inconveniences associated with both types. Generally the major problem

associated with laminar air-flow is flow disruption. With vertical laminar flow, it is the heat generated by surgical lamps creates air turbulence while with horizontal laminar flow it is the surgical team that disrupt the air-flow [17].

Although with the introduction of LED surgical lights the thermal influence on turbulence due to surgical lighting has been negated in modern vertical laminar flow systems.

Laminar air-flow systems are mainly used in implant surgeries where even a small number of microorganisms can cause infection. In joint replacement surgeries, one of the main causes of early (within 3 months) and delayed (within 18 months to 2 years) deep prosthetic infections was found to be colonisation which occurred during surgery [18].

• Most modern operating theatres have conventional ventilation with filtered air and HEPA filters to remove airborne particles of 0.3 µm and above with an efficiency of 99.97%. The arrangement of diffusers in a typical theatre with large gaps for light troffers and other components ultimately create turbulence in the space and would be unacceptable by ISO Class 1 to Class 4 clean room standards, • HEPA-filtered laminar air-flow supplied by ceiling-mounted (vertical flow) units.

• Vertical laminar air-flow generates fewer bacteria at the operating site and they are 3 to 8 times more effective than the horizontal systems [16].

Laminar airflow is desirable to minimise turbulence and produce predictable

movement of particles away from the sterile field.

• UCV systems installed in operating rooms are claimed to reduce the joint sepsis rate after total joint replacement surgery to approximately half that found in a conventionally-ventilated operating room.

• In a study by Bosanquet DC et al (Ann R Coll Surg Engl (2013) Jan; 95(1):15-9),170 procedures overall were analysed. The study suggests that laminar flow may reduce incidences of SSI, especially in the subgroup of patients receiving arterial grafts.

• Turbulence is undesirable because particles are allowed to float undirected, eliminating any ability to predict where they may settle.

• In Orthopedics Today, January 2009 an article by David Backstein, MD, MEd, FRCSC; Yona Kosashvili, MD, MHA, they discuss the Interposition of the head between the air source and the wound causes contamination that can be reduced significantly if hats, masks and occlusive gowns are worn.

Of the facial areas left exposed when wearing standard theatre hats and masks with visors, the ears shed the most bacteria.

• Knobben [18] reported that behavioural changes, including use of body coverage and new guidelines for patient workup, as well as restricting activity in the operating theatre combined with enhancing the technical properties of their laminar flow system, lowered the incidence of intraoperative

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS contamination and deep wound infections in postarthroplasty surgeries.

• A recent study conducted by Kakwani [22] found that laminar air-flow systems are effective in reducing the reoperation rate in Austin-Moore hemiarthroplasty.

• Their study compared the reoperation rate between theatres with laminar air-flow and theatres without laminar air-flow systems. A cohort of 435 patients who had Austin-Moore hemiarthroplasties at Good Hope Hospital in Birmingham between August 2000 and July 2004 were selected for this study. Of those 435 patients, 212 had operation in laminar air-flow theatres and 223 had operation in non-laminar air-flow theatres. Data was collected by reviewing case notes and radiographs.

For all cases antibiotics were administrated and water impervious surgical gowns and drapes were used.

In the non-laminar air-flow group it was found that the re-operation rate for all indications in the first year after hemiarthroplasties was 5.8 % (13/223), while in the laminar air-flow group it was 1.4% (3/212). Analysis found that there was no statistically significant relationship between the re-operation rate and water impervious gowns and drapes (p=0.15), while the use of laminar air-flow found a statistically significant drop (p=0.0285) in the re-operation rate within the first year after hemiarthroplasties. They found that the re-operation rate in no-laminar air-flow theatres was four times greater than that in laminar airflow theatres.

• In their study Brandt [23] found that the infection rate was substantially higher in theatres with laminar air-flow system.

This was a retrospective cohort-study based on routine surveillance data from German national nosocomial infections surveillance system (KISS - Krankenhaus Infektions Surveillance System).

Hospitals which had performed at least 100 operations between the years 2000 and 2004 were selected for this study. The type of ventilation technology installed in the operation rooms of the selected hospitals was collected separately through questionnaires from infection control teams in the participating

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hospitals. Surgical departments were grouped into categories according to the type of ventilation system installed.

Departments using artificial operating room (OR) ventilation with either turbulent or laminar airflow was included in this study. A total of 63 surgical departments from 55 hospitals was included in this study. Analysis was performed on the data set created by merging the questionnaire data on OR ventilation and surveillance data from the KISS data base. The data set analysed contained 99,230 operations with 1,901 single site infections (SSIs). Age and gender of the patient was found to be a significant risk factor of SSIs in most procedures.

Univariate analysis conducted found that the rate of SSIs was high in departments with laminar air flow ventilation.

Multivariate analysis also confirmed this finding. The Authors note that; horizontal laminar flow systems enclosed by walls, or semi enclosed systems with partial walls are not recommended by German National Guidelines and have not been routinely used.

• Benefitting fully from Laminar Airflow requires proper design and adoption of more stringent requirements, similar to those used in clean room environments that are inclusive of contamination control. However, the debate over laminar airflow systems illustrates how difficult this process can be without the benefit of similar design guidelines and standards.

• Utilisation of a laminar flow diffuser does not necessarily guarantee the desired results of a laminar flow system in a critical environment. Proper laminar flow design requires that a strict set of rules be followed to optimise its effectiveness.

The authors comment that: • The unexpected findings require further discussion and noted that the department based factors analysed, such as academic status of the hospital and bed number, have been shown to be significant factors for some operative procedures.

• This may be because operative severity is not yet exhaustively considered in the patient based risk index variables.

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

• Due to surveillance-induced infection control activities, lower infection rates have been described in departments with long-term participation in the surveillance system.

• A confounding factor was whether prophylaxis was administered was not documented individually for each patient in the surveillance data analysed in the study.

• Patient-based factors such as smoking and obesity are missing in the database.

• Details of perioperative management that may influence surgical site infection were not considered and may have influenced the results.

• Improper positioning of surgical personnel may also increase the risk of infection.

• The work concentrated on patient outcome and did not consider any data on OR air quality or other infection reduction schemes (occlusive clothing).

• The Brandt [23] study splits, conventional turbulent ventilated (with HEPA filtered air) and laminar airflow ventilated theatres (from HEPA filtered supply air diffusers). The article does not provide a description on the conventional turbulent ventilated or laminar air flow ventilated theatre either technical or descriptive, so we are not sure how the German laminar flow system compares with the design standards. We are aware that some laminar flow systems imported into Australia have considerably lower supply air velocities at the operating theatre table level compared to the Australian health care facility design standards for laminar flow ventilation systems.

• Sample size was 99,230 operations (of various types), the general outcome was that there was no advantage and possible a slightly higher risk.

• There was no reference to laminar ceilings.

• It is based on German facilities that only recommend vertical laminar flows, and do not include the use of body suits/exhaust.

• The was no reference to the prevailing environmental conditions in the theatres,for example supply

TECHNICAL PAPERS air temperature relative to room temperature and the potential influence of buoyancy effects, or the use or otherwise of warming blankets.

• Whether, Prophylaxis PAP was administered was not documented for each patient. The assumption is made that guidelines are generally followed and that about +98% of patients receive PAP. • Conclusions suggested that Laminar flow did not provide a benefit of reduced infections (SSIs), but had the tendency toward a greater number of infections. SSIs however need to be investigated further to examine why. Further studies are suggested to include PAP, external risk factors such as obesity and smoking and surgical technique.

Hirsch [33] commented on the Brandt Study [4] that neither an effectiveness control of the load turbulence displacement airflow system was made, primary comorbidities such as pre-existing acute or chronic disease, intake of immunosuppressive medication, abuse of nicotine and alcohol or obesity, were considered, and therefore the results are only restrictedly usable.

• Medical Research Council Trials [19] have shown the ineffectiveness of horizontal laminar flow systems and note in many cases the incidence of wound sepsis was significantly higher with horizontal flow system compared to conventional systems in adjacent theatres (also ref. Hospital for Special Surgery New York).

• Knobben [18] conducted an experimental study to evaluate how systemic changes together with behavioural changes can decreases intra-operative contamination. This study was conducted in the university Medical Centre Groningen, The Netherlands. A random sample of 207 surgical procedures which involved total knee or hip prosthesis from July 2001 to January 2004 was selected for this study. Two sequential series of behavioural and systemic changes were introduced to ascertain their role in reducing intra-operative

contamination. The control group consisted of 70 cases. Behavioural changes (correct use of plenum) were introduced to the first intervention group (Group 1) of 67 operations.

Intense behavioural and systemic changes were introduced to a second intervention group (Group 2) of 70 operations.

The systemic changes introduced were the installation of new laminar flow with improved airflow from 2,700m3/h to 8,100m3/h. Two samples each were taken from used instruments, unused instruments and removed bones. Control swabs were also collected to make sure that contamination had not occurred during transport and culturing. Early and late intra-operative contamination was also checked. All patients were monitored for any wound discharge while in hospital and followed-up for 18 months to check whether intra-operative contamination affects post-operative infection.

Among the control group contamination was found in 32.9% while in intervention Group 1 it was 34.3% and in intervention Group 2 it was 8.6%.

Except in Group 1 (p=0.022) late phase contamination was not significantly higher than early phase contamination.

During the control period wound discharge was found in 22.9% of patients and 11.4% of them had wound infection later. Deep periprosthetic infection had been found in 7.1% of them in the followup period. Deep periprosthetic infection was found in 4.5% of cases of first intervention group and in 1.4% of cases in second intervention group in the followup period. But none of these decreases were found statistically significant.

Contamination, prolonged wound discharge and superficial surgical site infections were found to have decreased after both first and second intervention.

But a statistically significant reduction was found only in second intervention (contamination p=0.001, wound discharge p=0.002 and superficial SSI p=0.004). This study concluded that behaviour modifications together with improved air flow system can reduce intra-operative contamination substantially.

• It is found that laminar airflow is more effective when used in conjunction with occlusive clothing Charnley, 1969 cited in Sandiford and Skinner [12].

• Scaltriti [20] conducted a study in Italy to examine effectiveness of welldesigned ventilation systems on air quality in operation theatres. They selected the operation theatres of a newly built 300 beds community hospital which has ventilation systems designed to achieve 15 complete outdoor air changes per hour and are equipped with 0.3 µm, 99.97% HEPA filters.

Passive and active samples of microbiological air counts were collected as well as air borne particle counts.

Details of the surgery, number of people in the room, door opening rate and estimated total use of the electrocautery unit were also collected.

The study concluded that there was a positive correlation between particle contamination, surgical technique (higher risk from general conventional surgery), electrocauterisation and operation length. Researchers suggest that human movement rather than human presence is the factor that determines airborne microbial contamination. It was found that average particle concentration in the theatres did not exceed the European ISO 14 644 standard limits for ISO 7 clean room, and so concluded that a welldesigned ventilation system is effective in limiting particulate contamination.

• Clarke [21] conducted a quantitative study to examine the effectiveness of ultra-clean (vertical laminar flow) theatres in preventing infections by unidentifiable organisms.

They used the molecular technique, Polymerase Chain Reaction (PCR), to detect bacteria presence. Their study compared the wound contamination during primary total hip replacement (THR) performed in standard and ultra clean operation theatres. 20 patients were recruited for this study and underwent primary THR from 1999 to 2001. Patients with previous incidents of joint surgery or infection were excluded.

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS The standard operation theatres had 20 air changes per hour and CFU count was 50 CFU/m3, while ultra-modern theatres had 530 air changes per hour and CFU count was 3 CFU/m3.

The contamination rate in the standard theatre at the end of the surgery was significantly greater than at the beginning. The contamination rate in the ultra-clean theatre at the end of the surgery was not significantly different than from the beginning.

• Further reading indicated that laminar flow ventilation systems were beneficial and suggests possible factors that may have influenced the Brandt [23] Study results.

• There is a lack of consistency in the classification and analysis of ultra-clean air system data used in the study of the influence on surgical site infections.

• Clean air/laminar flows had a greater impact prior to the use of antibiotics and in particular, PAP. • The greater the air change rate, the faster the response on the number of particles in the room (laminar flow theatres typically had higher airflow rates) • Memarzadeh [24] comments: “it appears that the main factor in the design of the ventilation system is the control of the central region of the operating room.”

• Backstein [25] comments: “In a study of 435 patients undergoing Austin Moore hemiarthroplasty, the rate of reoperation for all indications in the non- laminar air flow theatre group was four times greater than in the laminar air flow group. Similarly the use of laminar flow has shown reduced infection rates after posterior spinal fusion.”

• Bosanquet [26] Study Conclusion: “This study suggests that laminar flow may reduce the incidence of SSIs, especially in the sub group of patients receiving arterial grafts.”

• Scaltriti [20] Study concluded that there was a positive correlation between particle contamination, surgical technique, electrocauterisation and operation length.

• Kakwani [22] found that the reoperation rate in non-laminar air flow

58

Ventilation System

Description

Supply air Volume

Diffuser face velocity (average)

Results Mean Bacterial Burden

OR A

Open able Windows

-

-

13.3 CFU/h

OR B Supported Air Nozzle Canopy (Weiss)

Canopy 3mx3m Room 260 m3

3,000 m3/hr (833 l/s)

0.093 m/s

6.4 CFU/h

OR C Supported Air Nozzle Canopy (Weiss)

Canopy 3mx3m Room 126 m3

3,000 m3/hr (833 l/s

0.093 m/s

3.9 CFU/h

OR D Low Turbulence Displacement (LUWA)

Canopy 2.4mx2.8m

3,600 m3/hr (1,000 l/s)

0.15 m/s

3.4 CFU/h

OR E Low Turbulence Displacement (LUWA)

Canopy 2.4mx2.4m

4,500 m3/hr (1,250 l/s)

0.217

0.8 CFU/h

OR F Low Turbulence Displacement with flow stabiliser

Laminar flow Canopy 3.2mx3.2m

9,000 m3/hr (2,500 l/s)

0.244

0.7 CFU/h

Window Type Ventilation

theatres was four times greater than that in laminar airflow theatres.

• The number of people in the theatre did have a substantial effect on infection rates; rather the activities they were doing did.

• Training of the personnel using laminar flow hoods about the correct operational procedures reduced infection rates (Knobben [18]).

• Laminar airflow is more effective when used with occlusive clothing.

(Charney 1969 and cited Sandiford and Skinner [12]) • The wearing of exhausted body suits was more effective than laminar flow at reducing infection, [27] reduced infection.

The last two items above, may suggest that the issue is the theatre staff are introducing the infection to the patient (occlusion clothing removes it at the source, laminar flow attempts to keep it away, leaning over the patient causes entrainment of infection carrying particles and hence higher infection levels).

In the UK, the limit is 35 cfu/m³ for an empty operating theatre and in activity it should not exceed 180 cfu/m³ for an average 5 minute period In an ultra-clean air operating theatre the limit is set at less than 10 cfu/m³ sampled within 30cm of the wound using conventional clothing.

The limit is set at less than 1 cfu/m³ of air when total body exhaust gowns are used [16]. Most countries have set their own standards.

The table above summarises the study by Hirsch [33] which assessed the bacterial contamination adjacent to the surgical site for a number of ventilation systems. The results indicated a relationship between mean bacterial burden and the operating theatre ventilation system installed with the higher velocity systems producing the highest efficiency.

Operating Theatre Standards Few countries have set bacterial threshold limits in conventionally-ventilated operating theatres, although most recommend 20 Air Changes per Hour (ACH).

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

Hybrid Operating Theatres A variety of factors have lead to widespread interest in the development of Hybrid Operating Theatres which

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TECHNICAL PAPERS incorporates conventional operating room capability with state of the art imaging.

Hybrid Theatres require planning and foresight to allow a broad spectrum of conventional surgery and state of the art imaging and allow for more complex procedures to become commonplace where the imaging is essential. The design and implementation of hybrid operating rooms is a multi-disciplinary process. The significant investment in the operating theatre suites requires productive and efficient utilisation to improve the efficiency and quality of care for complex patients.

Summary • Reviews of current research shows that there is a lack of consistency in the classification and analysis of ultra clean air system design data used in the studies of the influence on SSIs. • Kakwani [22] found that the reoperation rate in non-laminar air-flow theatres were four times greater than that in laminar airflow theatres.

• Brandt [23] found the SSI rate was high in hospitals with laminar flow although further studies have been suggested to determine why this unexpected result occurred.

The work concentrated on patient outcome and did not consider any data on OR air quality.

The author suggests further clinical trials using defined case finding methods for risk factors, medical treatment and surgical technique. Further study and data may enable a comparison with the Laminar flow ventilation system performance parameter adopted by TS11 and AHFG.

reduce intra-operative contamination substantially.

• The study by Scaltriti [20] concluded that a well-designed ventilation system is effective in limiting particulate contamination.

• The work by Clarke [21] found that the contamination rate in the standard theatre at the end of the surgery was significantly greater than at the beginning. The contamination rate in the ultra-clean theatre at the end of the surgery was not significantly different than at the beginning.

• Current literature suggests that understanding the source of contamination in an operating theatre and knowing the relationship between bacterial virulence, patient immune status and wound environment will help in improving the infection rates [28].

• The activities in the operating theatre including non-adherence to the principle of asepsis by a surgical team has been identified as a significant risk factor of infections. Hectic movement of surgical team members in the operating room and the presence of one or more visitors were also found as major causes of SSIs [29].

• The study by Creedon [30] argues that infections can reduce up to one third if staff follow best practice principles.

• To further progress our understanding and reduction of SSIs, continued quality improvement is needed and it should be based on evidence based research and on-going assessment of information [31].

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1. F inn Gottreup et al. An Overview of Surgical Site Infection: aetiology, incidence and risk factors. University of Southern Denmark; Department of Surgery: Sept. 2005.

2. Leaper DJ et al. Surgical Site Infection – a European perspective of instance and economic burden. Int Wound Journal 2004: 1 (4): 247-273.

3. DiPirio JT et al. Infection in surgical patients: effects on mortality, hospitalization and postdischarge care. Am J Health Syst Pharm 1998; 55(8): 777-81 4. Berard F et al. Post Operative Wound Infections: the influence of ultraviolet irradiation of the operating room and various other factors. Ann Surg 1964; 160 (Suppl 1): 1-192.

5. US National Nosocomial Infection Surveillance (NNIS) System.

6. Cruse PJ et al. The epidemiology of wound infection. Surg Clin North Am 1980; 60(1): 27-40.

7. Cruse PJE. Classification of operations and audit of infection. Infection in Surgical Practice. Oxford University Press, 1992; 1-7.

8. Culver DH et al. Surgical Wound infection rates by wound class, operative procedure and patient risk index. NNISS. Am J Med 1991; 91(3B):152S-157S 9. Ferraz EM et al. Wound infection rates in clean surgery: a potentially misleading risk classification. Infect Control Hosp Epidemiol 1992; 13(8):457-62.

10. A ction Plan to Prevent Healthcare Associated Infections: Department of Health and Human Services; June 2009.

11. Woods; 1996 12. N A Sandiford, J Skinner et al: Surg Technol Int; 2009.

German Standards DIN 1946-4 (E.5.2) recommends a mean velocity between 0.23 and 0.25 at 1.2m above the floor level which is a lower velocity than that recommended by the DHS - Vic Design Guidelines (6.84.00) and AHFG – TS11 (6.22.30) guidelines which recommend 0.3m/s at the working height.

• The study by Knobben [18] concluded that behaviour modifications together with improved air flow system can

References

13. J A Weigelt et.al; American Journal of Infection Control: Volume 38-Issue 2, Pages 112-120, March 2010

Summary of the relationship between infection rate & operating room variables [32]:

THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

14. C how T.T, Yang X.Y: Ventilation performance in the operating theatre against airborne infection: Numerical study on an ultra-clean system. J. Hosp. Infect.

2005; 59:138–147.

15. Neil; 2005.

TECHNICAL PAPERS 16. N ational Health Service, England (NHS);1994.

24. Memarzadeh F et al; Comparison of Operating Room Ventilation Systems in the Protection of the Surgical Site; ASHRAE Transactions: 2002: Vol 108. Pt 2.

17. D haran S et al; J Hosp Infect;June;51(2):79-84.Environmentalcontrols in operating theatres; 2002.

25. Backstein D et. al; Orthopedics Today, January 2009.

18. Knobben J Hosp Inf; 2006.

26. Bosanquet et al; Laminar flow reduces cases of surgical site infections in vascular patients; Ann R.Coll Surg Engl; 2013 Jan; 95(1):15-9.

19. W hyte,W & Shaw BH;1973 and MRCDHSS trials; Lidwell, O M et.al;1982 20. S caltriti S et.al; 2007:Risk factors for particulate and microbial contamination of air in operating theatres. J Hosp Infect 664: 320–6

27. Miner et al.;2007. Deep Infection After Total Knee Replacement: Impact of Laminar Airflow Systems and Body Exhaust Suits in the Modern Operating Room. Infection Control and Hospital Epidemiology 28:222-226.

21. Clarke MT et.al; Contamination of primary total hip replacements in standard and ultra-clean operating theaters detected by the polymerase chain reaction. Acta Orthop Scand; 2004.;75:544-585.

28. Byrne AM et al; Outcome following deep wound contamination in cemented arthroplasty: Int Orthop; 2007 February;31(1):27–31.

22. K akwani RG et.al; The effect of laminar air flow on the results of Austin-Moore hemiarthroplasty. Inury 2007;38:820-823.

29. Beldi G et al; Impact of intraoperative behaviour on surgical site infections: The American Journal of Surgery; 2009:198,157-162

randt C et.al; Annals of Surgery – Volume 23. B 248:695-700 November 2008.

30. C reedon, S; 2005. Healthcare workers’ hand decontamination practices: compliance with recommended guideline.

Journal of Advanced Nursing, 51(3), 208-216.

31. H ughes S et al; 2009: Oxford Handbook of Perioperative Practice; Oxford University Press.

32. H ambraeus A. Institute of Clinical Bacteriology, Department of Hospital Hygiene, Uppsala University Hospital.

33. H irsch T et. al; “Bacterial Burden in the Operating Room: Impact of Airflow Systems,” American Journal of Infection Control 40 (2012) e228-3.

34. B aumgarth S et. Al; Compendium of Air Conditioning Technology; Vol 1: Basics.

4th Ed. Karlsruhe (Germany): 2000.

35. C EN, Ventilation for Buildings – test procedures and measuring methods for handing over installed ventilation and air conditioning systems. German Version EN 125999; 2000.

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Contractor management Soudi Noori I Director of Safety and Risk Engineering Solutions

“Under the Work Health and Safety Act 2011 (WHS Act), a contractor is a worker and is owed duties by the person conducting a business or undertaking (PCBU). Where PCBUs engage contractors to perform work, effective contractor procurement and management is essential to make sure WHS duties both to the contractors as workers, and third parties, are met.”

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orkers have a right to a safe workplace. Under section 7 of the WHS Act, a worker is broadly defined as a person who carries out work in any capacity for a person conducting a business or undertaking (PCBU). This includes employees, outworkers, apprentices, trainees, students gaining work experience, volunteers, contractors, subcontractors and their employees working for a Commonwealth or non-Commonwealth licensee business or undertaking.

The Work Health and Safety Act 2011 (WHS Act), states that a contractor is a worker. When contractors are engaged to perform work, a PCBU should take the following steps to ensure health and safety in the workplace: • Select contractors based on their expertise and their work health and safety record—this may require contractors to provide documented safety records.

• Insist on a culture that demonstrates the contractor’s commitment to safety.

• Provide induction training for all contractors prior to commencing work for the PCBU.

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• Ensure all contractors have a legislated right to be represented in the workplace by a health and safety representative (HSR).

• Assess the risks in consultation with the contractors and seek to find ways to employ the hierarchy of controls in managing those risks Contractors also have a duty as workers under the WHS Act. While at work, a contractor must take reasonable care for his or her own health and safety and take reasonable care that their acts or omissions do not adversely affect the health and safety of others.

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Most facilities engage contractors from time to time to perform certain kinds of work such as maintenance, repair, cleaning and gardening.

Building owners and top management are responsible for the health and safety of contractors who are exposed to a variety of hazards. Some of these hazards are obvious, such as, noise,

TECHNICAL PAPERS chemical, electrical shock, electrocution...etc. Others, such as musculoskeletal disorders (MSDs), back injuries or slips and falls incidents may not be as obvious.

As a building owner or manager, you must have a comprehensive and structured approach to manage contractors to perform work in a safe manner at your facility. A Contractor Safety Program is a plan of action, designed to manage contractors and prevent accidents. The Contractor Safety Program (CSP) outlines facility safety policy and identifies the requirements that contractor must adopt when performing services at facility.

How to Create a Contractor Safety Program (CSP) –Facilities The first step to create Contractor Safety Program (CSP) is top management and building owners support. They must be on board. If they are not, Contractor Safety Program will compete against core business issues such as profitability, a battle that will almost always be lost. They need to understand the need for Contractor Safety Program and be willing to support it.

A genuine commitment from building owners and managers to protect contractors will give CSP strength and sustainability.

The basic structure of a Contractor Safety Program follows a model similar to this: 1. D evelopment and implementation of a facility Safety Policy 2. Comply with the legal duties under the Acts and regulations 3. E valuation of contractor Health and Safety Management System 4. Training and consulting with contractors 5. Explanation of safety responsibilities 6. Discipline and incentive procedures 7. Monitoring and supervising

Safety cultures consist of shared beliefs, practices, and attitudes that exist at an establishment. Culture is the atmosphere created by those beliefs, attitudes, etc., which shape our behaviour.

Creating a safety culture takes time. It is frequently a multi-year process.

A facility with a strong safety culture establishes an atmosphere where safety is a primary responsibility of everyone from the newest apprentice to the director, owner or contractor.

The facility safety policy provides the preliminary foundation for development of a strong safety culture by setting the value of workers safety believed by all workers and top management.

Safety programs, training, responsibilities, accountability and rewards build off the fundamental philosophy of that policy.

Evidence of a top management’s commitment to a safety policy can include: • Establishing a formal safety budget:  accident investigation expenditures  special safety training events  new safety equipment and worn safety equipment replacement  incentive program prizes  safety committee budget • Hiring a safety consultant or director with specific safetyrelated duties1

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The Facility Safety Policy ensures that hazards are identified and their risk is managed so that all activities are conducted safely by providing a framework for: • Minimising the likelihood of incidents or accidents; • Managing workplace health and safety; • Protecting human health and the environment; and • Promoting a positive safety culture.

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It is for this single reason that developing these cultures should be top priority for all managers and supervisors.

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TECHNICAL PAPERS • Establishing safety goals and objectives • Providing regular safety training • Establishing and enforcing disciplinary procedures • Developing a defined structure of management, employee and contractors accountability and responsibility

2. Acts, Regulation and Codes of Practice Acts and regulations set out the key principles, duties, rights and responsibilities in relation to workplace health and safety.

By law, employers must provide a safe working environment for their workers, so far as is reasonably practicable.

Occupational Health and Safety Act 2004 In Victoria, workplace health and safety is governed by a system of laws, regulations and compliance codes which set out the responsibilities of employers and workers to ensure that safety is maintained at work.

The Occupational Health and Safety Act 2004 (the Act) is the cornerstone of legislative and administrative measures to improve occupational health and safety in Victoria.

Occupational Health and Safety Amendment Regulations 2014 (OHS Amendment Regulations) come into effect on 1 July 2014.

Under Victorian OHS laws, employers are also responsible for the health and safety of all workers, including labour hire personnel or contractors, at their workplace.

In Victoria, the Compliance codes provide practical guidance to those who have duties or obligations under the OHS Act. They aim to provide easy to understand information on how to comply.

protection for the general public so that their health and safety is not placed at risk by work activities.

Work Health and Safety (WHS) Codes of Practice offer practical guidance to achieve the standards of health, safety and welfare required in the Work Health and Safety Act 2011 (WHS Act) and Work Health and Safety Regulations 2011(WHS Regulations).

WHS Codes of Practice are admissible in court proceedings.

Courts may regard a code of practice as evidence of what is known about a hazard, risk or control, and rely on it to determine what is reasonably practicable in the circumstances.

Following another method, such as a technical or an industry standard may achieve compliance with the WHS Act and Regulations, if it provides an equivalent or higher standard of work health and safety than the code. An inspector may refer to an approved code of practice when issuing an improvement or prohibition notice.

The following Codes of Practice came into effect in the Commonwealth in 2012: • How to Manage Work Health and Safety Risks • Managing the Work Environment and Facilities • Work Health and Safety Consultation, Co-operation and Co-ordination • Managing Noise and Preventing Hearing Loss • Hazardous Manual Tasks • Confined Spaces • Managing the Risk of Falls at Workplaces • Preparation of Safety Data Sheets for Hazardous Chemicals • Labelling of Workplace Hazardous Chemicals • How to Manage and Control Asbestos in the Workplace

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• Communicating occupational health and safety across languages*

• First Aid in the Workplace • Construction Work

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• First aid in the workplace*

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• Excavation Work

• Removing asbestos in workplaces

• Demolition Work

*These compliance codes replace existing Codes of Practice.

• Safe Design of Structures

Work Health and Safety Act 2011 The Work Health and Safety Act 2011 (WHS Act) provides a framework to protect the health, safety and welfare of all workers at work. It also protects the health and safety of all other people who might be affected by the work. This includes employees, contractors, subcontractors, outworkers, apprentices and trainees, work experience students, volunteers and employers who perform work. The WHS Act also provides

• Spray Painting and Powder Coating • Abrasive Blasting.

3. Health and Safety Management System Health and safety management system (HSMS) is defined as a combination of the management organisational arrangements, including planning and review, the consultative arrangements, and the specific program elements that combine to improve THE AUSTRALIAN HOSPITAL ENGINEER I MARCH 2015

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TECHNICAL PAPERS health and safety performance. Specific program elements include hazard identification, risk assessment and control, contractor health and safety, information and recordkeeping, and training.

Contractors are responsible to develop and maintain Health and Safety Management System for their own employees and sub-contractors. This includes an evaluation of the work to be performed and the hazards likely to be encountered.

As a part of Health and Safety Management System evaluation, contractors required providing safety director or consultant with their procedures. The procedures may include but not limited to; • Asbestos • Safety Signage • Pressure Vessels • Chemical Management • Compressed Gases • Confined Space • Cranes and Hoists • Dust Abatement to • Electrical Safety • Emergency Procedures Excavation and Trenching • Fall Protection • Portable Power Tools • Hot Work • Air-Conditioning Systems • Ladders and Stairs • Lockout/Tagout • Noise/Nuisance Abatement • Odours Control • Personal Protective Equipment (PPE) • Powered Industrial Lifts and Trucks (e.g. forklifts) • Respiratory Protection • Waste Generation • Working Alone • Working at Height Examples of SWMS and risk assessments relevant to the contract are to be included in the contractor evaluation as verification of the contractor’s Health and Safety Management System.

4. Contractor Inductions and Consulting

onsultation on identifying hazards, assessing risks and 2. C making decisions about eliminating or minimising those risks 3. O n-the-job consulting, e.g. Toolbox Talks The PCBU should determine the level of induction by the location and risk of the work being undertaken on behalf of the PCBU and be in line with other induction programs the PCBU delivers to all workers.

For example, the Contractor must know; • emergency procedures • permits required for hot work, working at height,... etc • fire prevention methods • lockout/tagout program • WHS Management Plan • site-specific induction before starting work and signing off that they have completed this induction • safety policies and procedures and site rules roles, such as; • the Essential Services Logbook must be completed, • review the Asbestos/Hazardous Materials Register and ensure asbestos is not disturbed, • must sign in and sign out each day, • must wear a contractor’s sticker or badge while on premises, • maintain a log of all machines and equipment that are locked out and/or tagged out during the performance of the work of while under contract, • not leave electrical boxes, switch gear, cabinets, or electrical rooms open, • must not perform work over the heads of people or leave tools or equipment overhead, • hazardous wastes are not permitted to be drained, spilled, leaked, deposited or otherwise placed on, • abide by all posted signage and • immediately report unsafe acts or conditions affecting.

It is essential to maintain records for specific site induction that each contractor has completed.

The broad definition of a ‘worker’ under the WHS Act means that you must consult with your employees plus anyone else who carries out work for your business or undertaking. You must consult, so far as is reasonably practicable, with your contractors and sub-contractors and their employees, on-hire workers, volunteers and any other people who are working for you and who are directly affected by a health and safety matter.

This section of a Contractor Safety Program will set out the programs, for contractor training, consulting with contractors and informing all contractors of site specific requirements.

Contractors are entitled to take part in consultation arrangements and to be represented in relation to work health and safety by a health and safety representative who has been elected to represent their work group.

The type of training and consulting that is conducted as a part of the Contractor Safety Program includes:

5. Responsibilities

1. Annual safety Induction

This portion of the Contractor Safety Program, sets out the duties that various team members will be responsible for in the management of contractor safety.

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TECHNICAL PAPERS The name and contact information for the facility safety director or consultant should be listed along with the duties and responsibilities of that position. These may include: 1. E nsuring that all contractors receive a copy of the Contractor Safety Program 2. E stablishing a comprehensive training schedule for contractors, etc.

3. V isiting jobsites for compliance inspection of Safe Work Method Statements (SWMS), JSA, permits, risk assessments and equipment 4. S electing safety equipment, training materials and first aid supplies

4. A pplying Contractor Safety Program with discipline and incentives 5. E nsuring that proper and complete training of all contractors is done before they come onto the jobsite The duties and responsibilities of contractors must also be set out in some detail. These may include: • Understanding and following safety rules and procedures • Promptly reporting accidents and injuries • Taking part in training sessions and safety meetings • Wearing Personal Protective Equipment (PPE)

5. Preparing and maintaining injury forms

• Working in a safe manner making use of all safety equipment required by their job duties

6. P roviding feedback on safety policies to management for amendment or addition to safety program

• Reporting unsafe conditions, equipment or work practices of other workers

Similarly, duties and responsibilities of facility manager, maintenance manager or chief engineer must be detailed.

These may include:

6. Discipline and incentive procedures

1. A ttending, setting up or conducting safety meetings as required

The Contractor Safety Program (manual or online policy, procedures and forms) must set out, in clear language.

Contractors must know that if they fail to follow Safety Program, they will be disciplined according to a strict, concise and clear process.

2. Participating in safety committee process and review of work practices 3. R egularly inspecting and observing job sites for safety compliance

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TECHNICAL PAPERS Incentive programs are limited only by your imagination in calculating what workers would appreciate as rewards for doing excellent work in maintaining a safe workplace. In addition, incentives should be short-term and narrowly targeted to a specific behaviour change. Long-term programs tend to lose enthusiasm and connection with intended goals.

The point is that Contractor Safety Program, which includes promoting a positive safety culture, risk assessment, evaluation of contractor’s Health and Safety Management System, induction and consultation, explanation of responsibilities, and regular inspection of the work perform by contractors is the key to contractor safety in general- anywhere, any time.

7. Monitoring and Supervising

Safety and Risk Engineering Solutions (SRES) can assist you in meeting your legal duty of care to ensure adequate health and Safety information, instruction and training to your independent contractors – www.sres-australia.com.au, Tel: 1300 721 348

Management of the contractors involves monitoring and supervising to ensure they are being undertaken the work in accordance with legislation, standards and safe procedures. A list of designated inspections should be implemented following each stage of works. Risk assessments and safe work plans should be reviewed during works and updated as required.

One of the facility manager’s responsibilities is to provide the necessary field feedback on the implementation of the Contractor Safety Program. It needs to determine what works, what doesn’t and why.

Safety is everybody’s business – from the team workers in office, to the engineers in the plant room to the General Manager of the facility and contractors.

References 1. N OTE: Section 22(2)(b) is designed to ensure that employers, so far as is reasonably practicable, obtain advice from suitably qualified persons to help them make informed decisions about how to comply with their duties under Part 3 of the OHS Act. The factors in section 20(2) apply when determining what is ‘reasonably practicable’.

Membership of a professional association that requires continual development of knowledge, skills and experience is an important part of assessing whether a person is suitably qualified to provide Health and Safety advice to workplaces.

2. http://www.comcare.gov.au/the_scheme/the_whs_act/codes_of_ practice

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PRODUCT NEWS

Product News True cloud-based, mobile-first design temperature monitoring platform for your facility It’s amazing how quickly we’ve come to rely on our mobile devices for answers. In just a few short years it’s become a part of our DNA. That’s what makes the introduction of the Primex Wireless OneVue™ Intelligent Monitoring platform so exciting. Because OneVue is cloudbased, healthcare organisations of all sizes can now manage the monitoring processes for storage temperatures and room temperature and humidity on any wireless or desktop device using any web browser.

shipment so they automatically find the appropriate network when they are plugged in at the site, delivering true plug-and-play simplicity.

The key to OneVue’s intuitive user interface is its mobile-first, responsive design that automatically adjusts to fit the screen and optimise the presentation on smartphones, tablets, laptops or desktop computers.

All without downloading any mobile apps or plug-ins.

However, what makes OneVue truly unique is that data generated by the sensors is tied to the room, the physical equipment (such as refrigerators) or the inventory (such as pharmaceuticals or nutritionals) being monitored, rather than to the sensors. A comprehensive data trail stays with the monitored asset, meaning users don’t have to merge records to get the complete compliance picture each time a sensor is changed or assets are moved. You’ll always have complete, historical data trails for compliance audits, preventative maintenance, benchmarking, cost comparison, etc.

That, combined with its low cost of entry, makes OneVue ideal for organisations of all sizes, from small clinics or pharmacies to large, multi-site health systems.

Robust functionality with mobile accessibility is essential in today’s healthcare facilities struggling to manage a growing number of sites with fewer resources. The OneVue Intelligent Monitoring Platform delivers.

In fact, because OneVue is a true cloud-based application, the only IT assistance required is configuring the OneVue platform for an organisation’s network. There are no servers or software to maintain, and all application updates are applied by Primex. Facilities personnel can even pre-configure the PrimexTEMP or PrimexIAQ sensors before

For further information or a demonstration please call Multitone (Primex’s Australasian Partner) on 03 9888 1244.

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