VOL 39
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September 2016
the australian
engineer HOSPITAL S
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IHEA Healthcare Facilities Management Conference 2016 MANAGING CHANGE/CHANGING MANAGEMENT 19-21 OCTOBER 2016 I ADELAIDE OVAL, SOUTH AUSTRALIA
PLATINUM PARTNER
SILVER PARTNERS
Where the hell are we? – Part 2 Safety in designs Hospital Class N isolation rooms PP 100010900
+
= compliance Designed by tradesmen, built by project managers and proven by facilities managers our OM system provides an effective, usable building information management process that is simple to use. It takes the pain out of collating a set of fully‑compliant O&Ms documents.
Using the data collected with our OM system, our FM system ensures the smooth and efficient running from practical completion for the life of a facility.
• Monthly checklists ensure no documentation is forgotten
• Easily establishes maintenance schedules for effective negotiation of maintenance contracts
• Progress indicators quickly show which trades are lagging behind
• Ensures maintenance records are always available for insurance and compliance audits
• Saved in the cloud, all documents are quickly and easily accessed by those with the authority to do so
• Creates a full set of service manuals, allowing service contractors to quote every task for every asset in the facility, to Australian standards
• Transparency for all parties during the build
• Provides a financial management tool for capital allowance and tax depreciation
• Provides a comprehensive record of all the assets in a facility and their current condition
Email richard@oandms.com.au to book a 15 minute, one‑on‑one demonstration at the 2016 IHEA Healthcare Facilities Management Conference.
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oandms.com.au
IHEA NATIONAL OFFICE Direct: 1300 929 508 Email: admin@ihea.org.au Address: PO Box 6203, Conder ACT 2900 Website: www.ihea.org.au Conference: http://hfmc2016.org.au
CONTENTS
BRANCH NEWS
5
National President’s Message
7
CEO’s Message
National Immediate Past President Darren Green
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State Branch Reports
National Vice President Peter Easson
TECHNICAL PAPERS
IHEA NATIONAL BOARD National President Brett Petherbridge
National Treasurer Mal Allen National Secretary/Communications Darryl Pitcher
16 Planning for facility management during a build 20 Design considerations for hospital Class N isolation rooms
Membership Registrar/ CHCFM Coordinator Alex Mair Peter Footner
28 Trigger points for forced hospital building upgrades
Standards Coordinator Rod Woodford
41 The importance of maintaining doors and hardware in a hospital environment
Asset Mark Coordinator Greg Truscott
44 Integrated fire mode testing
IHEA ADMINISTRATION Secretariat/Website Administrator Heidi Moon Finance/Membership Jeff Little Editorial Committee Darryl Pitcher, Brett Petherbridge and Darren Green 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
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Where the hell are we? – Part 2 33
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Power quality 48 51 Healthy water savings in hospitals 55 Safety in designs First results of an Electrochemical Water 63 Management System in Australia
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69 Does BIM have a role in the Internet of Things? 70 Forget me not – Waste management 73 Hydrotherapy pools and Legionella Copper surfaces reduce the rate of 76 healthcare-acquired infections in the intensive care unit
PRODUCT NEWS
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89 Product news
Melbourne: Neil Muir T: (03) 9758 1433 F: (03) 9758 1432 E: neil@adbourne.com Adelaide: Robert Spowart T: 0488 390 039 E: robert@adbourne.com PRODUCTION Emily Wallis T: (03) 9758 1436 E: production@adbourne.com ADMINISTRATION Tarnia Hiosan 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 SEPTEMBER 2016
National President’s Message • National Conference Update was provided by convener Peter Footner. Registrations opened on 13th June 2016 and the program has been completed. Site technical tours include the new Royal Adelaide Hospital site which will be close to completion. • The May Financial report was presented by our treasurer Mal Allen. Also presented and approved was the forward budget for the ensuing 12 months. It was noted that membership renewals need to increase in the next 12 months due to the larger than anticipated unfinancial members effecting revenue. A review of membership subscription fees was undertaken and endorsed by the Board for the 2016/17 year.
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elcome to this edition of “the Australian Hospital Engineer”. Our Hospital Engineer journal continues to provide members interesting and technologically sound articles and impending technology challenges within the Healthcare engineering space. IHEA National Board of Directors
Name
Position
Brett Petherbridge
National President
Peter Easson
Vice President
Darren Green
Immediate Past President
darren.green@gsahs.health.nsw.gov.au
Darryl Pitcher
Secretary
D.pitcher@bethsalemcare.com.au
Mal Allen
Treasurer
Mal.Allen@hnehealth.nsw.gov.au
Karen Taylor
Chief Executive Officer (ex officio)
ceo@ihea.org.au
Alex Mair
Membership Registrar
ama58500@bigpond.net.au
Peter Footner
Director
pesarash@adam.com.au
Roderick Woodford
Director
rwoodford@castlemainehealth.org.au
Greg Truscott
Director
Greg.Truscott@health.wa.gov.au
Michael McCambridge
Director (co-opted)
Michael.McCambridge@mh.org.au
Executive Committee
brett.petherbridge@act.gov.au Peter.Easson@health.wa.gov.au
JUNE BOARD PROCEEDINGS AND SUMMARY OF KEY ACTIVITY • The June Board meeting was hosted at the Royal Melbourne Hospital Facilities Management Department, a special thank you to Michael McCambridge for his assistance with these arrangements
• The Membership database update was provided by Darryl Pitcher with a focus on having the 2016/17 year renewals out to members by no later than 18/7/16. A strategy for addressing the unfinancial members was also discussed and endorsed. • The draft Directors Handbook, Code of Conduct, document Version Control and document storage and retention policies were all reviewed and endorsed by the Board. A draft Privacy policy is currently being drafted for review at the October Board Meeting. • Reports on AssetMark, ANZEX, Standards and Membership were all tabled as read. A further call for an ANZEX Delegate for 2016 to New Zealand was approved. Jeff Turner – Engineering Manager Logan & Beaudesert Hospitals in Queensland was endorsed as our delegate – post the Board meeting. • Directors Annual Portfolio reports were called for to be completed along with the financial audit of our financial result by external auditors
NATIONAL CONFERENCE The National Conference registrations are well underway and from report this will be a well attended event. The 2 day program is very comprehensive and great interest has been shown in the Master class event on the Wednesday preceding the conference commencement. I urge all members to register and attend. Kind regards, Brett Petherbridge IHEA National President
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS
Qi
Medical Gas Services Preventive 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 preventive 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 preventive 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 2015. Reproduction without permission is strictly prohibited. HCD246 EQUAUS 0515 V2
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
CEO’s Message
I
t is with much excitement and anticipation that we approach our National Conference in Adelaide at the fabulous Adelaide Oval in October. We have an exciting program beginning with an opening/keynote address from the South Australian Health Minister The Hon Jack Snelling MP, excellent technical tours including the New Royal Adelaide Hospital and of course terrific social activities to catch up with colleagues and friends from around the country. The conference provides an outstanding opportunity for you all to network and engage in informative, relevant professional development. The response to the opening of registrations has been outstanding and I encourage those of you who are still to register to do so as soon as possible to ensure your first pick of technical tours. This will be my second National Conference and I hope to see you there! Much work has been happening behind the scenes to validate our member records to ensure a smooth renewal process for all members. Invoices were emailed to all in July and many of you have paid your 2016/17 subscription already. Reminders will be sent in early September to those who have not yet renewed. I encourage you all to renew promptly. All subscriptions to IHEA are used to improve your association and ultimately provide you with better services and better value for your membership. Governance work continues with all processes and policies being reviewed, Director training conducted and importantly prudent and robust financial management continually being monitored and improved. Updating of the Constitution has also been completed and members will be contacted closer to the AGM about the work done. Early investigations into possible partnerships that would benefit IHEA members has begun, more on this as possibilities progress. Members can be sure that your association is in good shape and is continuing to improve. This task can only be achieved in an ongoing way with members help and input. To this end I encourage you all to consider becoming active within your State Committee and of course by joining us in Adelaide in October! Kind regards, Karen Taylor CEO
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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STATE BRANCH REPORTS
State Branch Reports WA BRANCH REPORT – GREG TRUSCOTT, BRANCH PRESIDENT Branch Meeting June 2016, Sir Charles Gairdner Hospital ir Charles Gairdner Hospital’s social club room was the venue for the first breakfast meeting of the year, with dual hosts Shaun Ensor and Jeff Wade welcoming attending members. The fast-approaching special general meeting and state conference were the main agenda issues tabled during the morning.
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The meeting sponsor Blueforce was represented by Sam Lofts and Rob Foley, who presented their wide range of turnkey ELV solutions. Established in August 2002, Blueforce is a leading integrator of security, safety, access control, surveillance, staff duress & nurse call systems throughout Australia. Their mission is to deliver innovative, integrated and interactive security and life safety solutions across all sectors. Backed by a local 24-hour monitoring centre and a team of mobile and highly-skilled technicians, Blueforce provides a reliable and friendly service. Special General Meeting 7th July 2016, Graylands Hospital The branch Special General meeting, attended by 21 members was called to order by the State Vice President Mr Greg Truscott, who presented and tabled the Annual Report on behalf of the State President Mr Craig Aggett and acknowledged the work undertaken by the CoM during the past 12 months. Mr Peter Klymiuk then spoke to and tabled the Branch Secretaries Report. Given this meeting was so early in July the Branch Treasurer, Mr Rohit Jethro was unable to present the full Financial Year report, but reiterated the main points of the previous months report confirming that IHEA at both Branch and National levels was in a financially sound position.
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Mr Frank Woods was then called upon to dissolve the current Committee of Management and conduct the process of members electing a new WA Branch Committee of Management and Office Bearers for 2016/17. The results of the Election are as follows: Branch Office Bearers State President Mr Greg Truscott State vice President
Acting – Mr Peter Easson
State Treasurer
Mr Rohit Jethro
State Secretary
Mr Peter Klymiuk
of delegates, presenters and sponsors, attending, totalling 77. The Conference was opened by Wayne Salvage, Chief Executive of the North Metropolitan Health Service, who, in providing a detail overview of the financial situation across WA Health, confirmed the importance of the theme of the Conference, “Financial Management in Healthcare” and that it was even more critical to be of the highest standard.
State National Representative Mr Greg Truscott Committee of Management Members Mr Steve Dallas Mr John Dransfield Mr Peter Easson Mr Robert Falls Mr Alex Foster Mr Robert Foley Mr Mark Stokoe Mr Rishi Wakle Mr Craig Aggett (immediate past President) The Committee wish to thank the immediate past State President, Mr Craig Aggett and recognise Craig’s contribution during his service to the WA branch. WA Annual State Conference – August 2016 Date: 12th August 2016
Mr Wayne Salvage delivering the Opening Address.
Keynote speakers Cliff Chalon (“Why most Training is a waste of time and money”), Jose Jomon (“Biomedical Engineering management”) Ryan Milne/Colin Nicol (“Legionella/water compliance tool”) Justin Shute (“Electrical Design outcomes”) and Peter Easson (IHEA National Vice President) who did a presentation on both the content of the International Federation of Hospital Engineering (IFHE) Conference, held in the Hague, and the fact finding for and promotion of the next IFHE Conference which will be conducted by IHEA in Brisbane, Queensland.
Venue: Joondalup Resort, Perth ‘Financial Management in Healthcare’ The Western Australian State Conference was held on the 12th August at the Joondalup Resort, Perth with Mr Lionel Delamotte as the Master of Ceremonies for the day. The WA Branch annual conference was again well attended, with the number
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
Delegates enjoying the presentations at the Conference venue.
Also presenting was John Dransfield and Karen Pascott of Department of Treasury
STATE BRANCH REPORTS and Matt Tomasini and Abby Chittick of John Holland P/L, who played major roles in delivering the $1.2B new Perth Children’s Hospital, which is opening this year. Following their individual presentations a Q & A Panel session was conducted.
L-R, Abby Chittick, Tom Tomasini, John Dransfield and Karen Pascott during the Panel session.
At the conclusion of the conference speaker’s presentations, Mr Peter Easson, was called upon to present the WA annual achievement awards to the following people who have excelled in the Health Care Facilities Industry: • Health Facilities Manager/Hospital Engineer of The Year, was awarded to Mr Steven Dallas of Royal Perth Hospital (RPH). Steve has built up a vast knowledge and experience over the 43 years he has worked within Hospital Engineering at RPH. Starting out as a tradesman (Carpenter), then Trades Supervisor roles and obtained his Builders Licence in 1983. Steve then moved into the Office which designs and procures new building works, where he became proficient at AutoCad Drafting and all aspects of Hospital design and construction. Steve has continued to improve his knowledge
through participating in professional development and actively supporting the IHEA. Congratulations on your achievement.
• Apprentice of the Year was awarded to Mr Shane Listing. Shane is in his 4th Year with Mechanical Services Australia and described as a very conscientious, confident and hardworking young man who has an excellent work ethos. We look forward to Shane continuing to excel and contributing much to this Industry for many years to come. Congratulations on your achievement.
Steven was overseas and unable to attend and receive his award at the conference. Pictured above is Steve with his Award Certificate.
• Tradesperson of the Year was awarded to Mr Chris Burden. Chris has demonstrated broad, strong skills across all areas of his electrical trade at RPH, including HV switching, challenging fault finding and knowledge of complex control systems. Chris has shown good leadership and management skills that has impressed his Management Team. Congratulations on your achievement.
Mr Shane Listing receiving the Apprentice of the Year Award from Mr Peter Easson.
The conference would not have been possible without our sponsors and the WA Branch would like to acknowledge and thank Sponsors who delivered a presentation at the Conference: Arup, BSA/Burke Air and Softlogic and those who set up a trade stand: ibms, Enware, Foster’s Services/UV Clean Solutions, Centigrade, A & M Medical Services and QED.
Mr Chris Burden receiving the Tradesperson of the Year Award from Mr Peter Easson.
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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STATE BRANCH REPORTS VIC/TAS BRANCH REPORT – RODERICK WOODFORD, BRANCH PRESIDENT Branch Activities he Vic/Tas branch held its third Professional Development seminar at Bendigo Health on Friday the 19th August 2016. There were 38 members present at the Bendigo Hospital project.
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The new $630 million Bendigo Hospital PPP contract secures the delivery of integrated medical services to the people of Bendigo and the wider region. This will be a world-class, stateof-the-art facility, providing high quality healthcare for the greater Bendigo community. It has generated more than 770 construction industry and supply chain jobs, with at least 300 jobs maintained for a minimum of three years during the peak construction period for the hospital. The new hospital has 372 inpatient beds, 72 same-day beds and 11 operating theatres, an integrated cancer centre and mental health unit and a helipad connected by a bridge link to the main hospital facilities. Importantly the hospital will provide 75 mental health beds, including a 35-bed adult psychiatric unit, a 20-bed aged psychiatric unit, and a 20-bed secure extended care unit. The new hospital also features a five-bed mother and baby unit.
We thank the presenters for their input and willingness to share this exciting project with our members with special thanks to Lachlan Morrison, Construction Manager, Lend Lease Pty Ltd; Ashley Marriot, Ben Castle and Stephen Patterson, Norman Disney Young and Vanessa Beever from E-Water. IHEA members had the opportunity to inspect the new hospital in its commissioning stage, with most equipment installed and operational, the day was well attended and highly informative with information on the UPS systems and the diesel and natural gas power generation. Members are asked to note that the Vic/Tas end of year branch function is scheduled for the 19th November to be held in Melbourne on the River Yarra with a meal and cruise. It will be a great evening to share together with your peers, and network with your colleagues and reflect on 2016. Keep an eye out for details over the next few months. Future Planning The Vic/Tas Branch will be hosting the 2017 IHEA National Conference in Melbourne and dates have been tentatively set for 11th to the 13th October 2016. The planned venue is the Pullman at Albert Park, which is a short tram ride from the CBD. The theme for the premier IHEA event of 2017 will be “Compliance in Motion”, and we have engaged Iceberg Events as the Conference Organiser and planning is well underway. There will be a special promotional presentation made at the 2016 conference in Adelaide in October and we look forward to seeing you all there.
The new age of high efficiency condensing boilers AIRATHERM
As energy costs increase it has become more important than ever to consider the long term benefits of choosing the next generation of high efficiency appliances for any building application and the greatest benefits are gained in 24 hour, 7 days a week applications such as hospitals.
H
ospitals with their high heating and hot water demands are uniquely placed to take the greatest year round advantages of high efficiency condensing boilers, with efficiency gains of up to 15% over traditional boiler systems found in many existing installations. Along with reducing energy costs, life cycle durability is a critical concern when considering which type of condensing boiler is most suitable. By nature a condensing boiler recovers its additional energy from absorbing the final
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energy held in water vapour cooled and condensed to liquid condensate in the flue system. This waste liquid condensate also traps small quantities of flue gas by products and becomes slightly acidic, therefore corrosion management is a critical concern for condensing boilers. Most condensing boilers originate from Europe and USA and, due to the corrosive issue, a variety of construction techniques are utilised including aluminium, 316 stainless steel or a combination of both with varying success. As an alternative to these commonly used materials there has been a long history of specifying heavy duty DUPLEX
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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THE DUPLEX 2205 STAINLESS STEEL ADVANTAGE Heavy duty DUPLEX 2205 stainless steel was developed for the chemical and mining industries for superior strength and corrosion resistance compared to standard 304 and 316 stainless steel variants commonly used in most imported condensing boilers. DUPLEX 2205 stainless steel has almost twice the strength and corrosive resistance to 316 stainless steel when used at higher temperatures normally experienced in hot water boilers. Compared to imported condensing boilers, the AIRATHERM FTC TITAN is uniquely AUSTRALIAN MADE utilising DUPLEX 2205 stainless steel throughout the entire condensing section in contact with the corrosive flue condensate produced by a condensing boiler. The long term benefits of DUPLEX 2205 can be easily determined by thegraph shown.
Strength and Relative Corrosion Resistance Duplex 2205 vs 304/316 Stainless Steel
Australian made Highest Quality Huge flexibility of design Up to 97% efficiency Multiple control options Indoor or Outdoor 2205 Duplex stainless steel in the condensing chamber 150 - 3000 Kw capacity Dualfuel NG LPG or Oil Fired option
OPTIONS • • • • • •
Operating pressure up to 1100kPa Hi level BMS Interface MODBUS/BACNET VSD fan modulation control 10:1 modulation turn down with option up to 15:1 Weatherproof cabinet Condensate neutraliser kit
AIRATHERM Head Office - Victoria 144 Colchester Rd Bayswater North VIC 3153 Tel: 03 8739 5444 Fax: 03 9761 4732 airatherm@airatherm.com.au THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016 11
www.airatherm.com.au
STATE BRANCH REPORTS NSW/ACT REPORT – JON GOWDY, BRANCH PRESIDENT Introduction s this is my first report I would like to begin by expressing my appreciation to the NSW/ACT Branch COM and state members for accepting my nomination and also to thank past President Peter Lloyd for his valuable contribution to the IHEA over the past years – I have some big shoes to fill.
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Activities The NSW/ACT COM have been busy this month putting together the 2016/2017 strategic planner, the planner will form the basis for the next 12 months activities for the branch and will enable members to schedule important dates. Planning is underway for a Professional Development day to held at Royal Prince Alfred Hospital in November 2016, included in the day’s events will be a session at the recently completed fire and evacuation training simulator that is well worth seeing. It has been very encouraging to see the strong level of interest being shown by major suppliers and service providers in the IHEA post our May state Special Meeting. It is vital for the strength and relevance of our organisation to build strong
partnerships with industry leaders particularly in maintaining innovation as one of our core values. One of the key focus areas for the COM over the next 12 months is to build on our membership base, active recruiting will be taking place specifically targeting the Sydney metropolitan area as this has been a largely untapped resource in recent years. I would like to take this opportunity to remind all NSW/ ACT Branch members that our annual renewals are due and if you have not yet made payment please do so at your earliest convenience. I would also encourage all members to make time visit our website and update any changes to your personal details. Timely payments and regular updates of the website improves the capability of the IHEA to manage members accounts and outgoing communications. On a local note, the Royal Prince Alfred Clinical Skills and Transplant Research Building was recently opened by the NSW Health Minster Jillian Skinner. This building represents a milestone in clinical skills development in Australian and will be of particular interest to IHEA members as it was designed, constructed and commissioned completely by in house engineering staff. The other element of interest is the striking murals on the building’s exterior that were painted by local area street artists Committee of Management Contact details
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It’s all about being as close as we can to the patients. Giving them what they need when they are under care Ascom’s unique combination of integrated workflow solutions for healthcare and the groundbreaking Ascom Myco smartphone for nurses makes a big difference in the ability to respond to patients. Closer to the people that really matter
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
Name
Position
Phone
Jon Gowdy
President
0411 040 834
Jon.Gowdy@sswahs.nsw.gov.au
Steve Dewar
Vice President
0428 119 421
steve.dewar@gsahs.health.nsw.gov.au
Darren Green
Secretary
0418 238 062
darren.green@gsahs.health.nsw.gov.au
Mal Allen
Treasurer
0467 761 867
mal.allen@hnehealth.nsw.gov.au
Peter Allen
COM
0408 869 953
peter.allen@hnehealth.nsw.gov.au
Helmut Blarr
COM
0411 152 898
helmut.blarr@sswahs.nsw.gov.au
Glen Hadfield
COM
0409 780 228
glen.hadfield@swahs.health.nsw.gov.au
Trevor Stonham
COM
0414 899 363
trevor@sah.org.au
Brett Petherbridge
COM
(0418 683 559
brett.petherbridge@act.gov.au
Peter Lloyd
COM/PP
0428 699112
peter.lloyd@gsahs.health.nsw.gov.au
STATE BRANCH REPORTS QLD BRANCH REPORT – SCOTT WELLS, BRANCH PRESIDENT
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he 2016 Queensland Branch Conference was held at the Victoria Park Complex in Brisbane on the 28th and 29th July. The Conference centred on the Theme: Patient Safety – The Health Facility Manager’s Role and was delivered over one and a half days, with plenary sessions focussing on: • Safety in Water • Safety in Air • Safety in Design, and • Safety in Management. The Conference was well attended with some 45 delegates, with several delegates attending an IHEA function for the first time. Particular interest was shown on the first afternoon which was dedicated to Safety in Water, covering contemporary water quality technologies, legislation and management, and presented by industry specialists Dr Richard Bentham (Hindmarsh Water Treatment), Glenn Pinna (Biotech Laboratories) and Mark Collen (Veolia). The Conference Trade Show was held on the first evening, preceded by each of the Sponsors being allocated “One Minute of Fame” during which they could address the Plenary Session attendees. The second day was attended by a smaller, but no less enthusiastic, complement of delegates. Technical presentations were delivered on safety in design, infection control, lighting, air filtration, vacuum systems and CCTV security systems.
Support from sponsors was very encouraging with Armstrong Flooring, Higgins and Clevertronics providing major contributions to the event. A further 12 minor sponsors joined the three mentioned above to provide a comprehensive and informative Trade Show. Major
Armstrong Flooring
Higgins
Clevertronics
Minor
Becker Pumps
AG Coombs
Air Restore
Armstrong Flow Control
ARA Security
Integrated Water Management
Opira
Securcom
Symbio Laboratories
Thomas & Betts
Veolia
ZG Lighting
Technical presentations from the Conference are now posted on the IHEA website.
On the social side, and for the first time at our Conference, several hearty souls hit-off early on the first day at the Victoria Park Golf Course and a prize was presented for the Most Remarkable Round (enough said). On the final evening, eighteen people (attendees, some sponsors and some partners), got together for dinner at Augustine’s Restaurant in the Brisbane CBD. A most successful Conference.
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
STATE BRANCH REPORTS SA STATE BRANCH REPORT – PETER FOOTNER, BRANCH PRESIDENT Activities he major focus for the Branch activities during the last quarter has been to continue with the planning for the National Conference, to pursue membership retention and growth for SA members and to arrange & conduct the Special State Meeting for this year. In addition, where possible, opportunities have been pursued to develop topics for future professional development events and to assist with national membership activities for the Board.
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The Branch Special General Meeting was held on Friday, July 12th with a small group attending. The group was given a brief presentation from new State Corporate member, and conference platinum sponsor, OandMs, and then moved on to the business at hand. As a result of elections, the following Committee of Management (CoM) appointments were endorsed: Position
Member
President
Peter Footner
Vice President
John Jenner
Treasurer
Peter Footner
Secretary
John Jenner
National Council Rep
Peter Footner
National Council Rep Proxy
John Jenner
Committee Member 1
Darryl Pitcher
Committee Member 2
Vince Russo
Committee Member 3
Tony Edmunds
by visiting the conference website, http://event.icebergevents.com.au/ihea-2016/ Membership The Branch Committee of Management has noted the reasonable and pleasing growth in membership for the Branch, particularly with corporate membership, over the last year or two. The current challenge for the Branch is to identify non-renewing members after the recent round of membership renewals, to investigate the reasons for these non-renewals and to encourage retention of membership. There is also the long-standing need to identify and encourage new members. There is still a particular need to achieve a better balance between corporate and individual memberships to ensure a viable and productive Branch structure that delivers benefits to all types of members, and this will be a focus for the incoming CoM. Actions As noted above, the new CoM will shortly meet to finalise the conference planning work that remains outstanding and will then move to progress planning around membership retention and growth – and to review, update and deliver the Branch professional development program for the coming year. Early planning has already commenced for a PD event for later in the year, after the national conference.
VACUUM SOLUTIONS – Tailored to your needs The incoming CoM thanked the outgoing committee members, Mike Ellis and Mike Frajer, noting the circumstances that prevented them continuing on with the Committee. Particular thanks went to Mike Ellis, acknowledging his sterling service in a variety of roles to the SA Branch and National Board over a very long period.
Please visit us at IHEA Healthcare Facilities Management Conference Oct 19th-21st, 2016 – Adelaide Oval
The relatively low number of individual members in the Branch and attending the meeting meant that a number of CoM roles were shared across only a few people and this highlights the need to work to improve individual memberships and participation in the affairs of the Branch. The planning for the national conference has continued to dominate activity for the Branch and we are moving in to the final stretch as far as planning is concerned. We are pleased at how the conference program has come together, thanks to the efforts of our CoM members and our professional conference organiser, Iceberg Events. The planning group believe that we are on track to provide a diverse, challenging and rewarding conference program that will be of great benefit to members, delegates, sponsors and exhibitors. Members, exhibitors and sponsors who have not yet taken up the opportunity to get involved are encouraged to do so
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1300 733 665 www.vacuumsolutions.com.au THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS
Planning for facility management during a build It can (and should) be done
DAVID BISHOP I DIRECTOR AND CHAIRMAN OF OANDMS PTY. LTD.
As-built documentation, practical completion, defects liability period, completion documentation, certification, CAFM, O&Ms, handover, PC… all these words are used to describe the final process from architects, engineers and construction companies (AEC) in delivering the “keys” to your new building.
A
re today’s processes serving our facility managers in a manner that enables them to do their jobs efficiently and effectively? Are the “keys” to our buildings unlocking the doors they want opened?
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
We are talking about the delivery of construction operation and maintenance manuals (O&Ms). As boring as they are, they are necessary. What are they? What does the industry need? Is the format of your O&Ms correct?
THE CURRENT, SAD STATE OF AFFAIRS For the last 25 years the industry has been delivering O&Ms in the traditional project operation and maintenance manuals form of four ring binders and paper manuals. If and when they are delivered, they are a mixture of technical data, drawings, reports and manufacturers’ literature in hard copy – or via a medium that is not easily accessible – and they are usually lacking in integrity. The industry has not been teaching tradespeople, graduate engineers and architects about the operation and maintenance manuals specified in contract documents – or even why they are needed. In addition to these various shortcomings, consultants no longer want to be held accountable for the content or integrity, preferring to “review” rather “approve” the as-built documentation contracted for delivery. What happens if an asset owner is faced with a design or construction issue in their new building 18 months after practical completion? These building issues should not have to be fixed from a facility managers’ maintenance budget. If an FM can demonstrate the issue is design or construction based it relieves them of the financial responsibility of having to rectify it.
TECHNICAL PAPERS Commissioning and tuning is another area where important data can be lost forever, resulting in FMs playing catch up to understand and get a handle on their new building. Why do asset lists disappear so quickly from a facility? A comprehensive list of every asset seems to be a bridge to far post practical completion. Why is it so hard to get and maintain this basic information?
IF OUR CURRENT O&MS PRACTICES ARE NOT ACCEPTABLE, WHAT DO WE NEED TO DO? It’s about time we made some changes to our so-called best practices. Documentation completion is only the starting point to the better risk management of a building. When you buy a new car it comes with a manual that sets out the service requirements for the life of the vehicle… a service plan that specifies its first service is to be at 1,500 kilometres (the initial DLP), the next at 10,000 kilometres and so on. Each of these services are planned with specific predetermined tasks to ensure the safety of the owner and passengers. Our new buildings today should have the same – a facility management service plan (an FMSP) for the life of the building.
THE NEED TO INTRODUCE A NEW PRACTICE Compliance and regulation is creating a need to gather more and more data about buildings and the way they affect the occupants and general. The risk of non-compliance comes in the form of massive fines and possibly even jail time for the building’s owner and its directors. With the growth of technology, WH&S compliance requirements and legislation changes over time it is envisaged that a commercial and economical building life cycle is approximately 20 years before a total refit or demolition is required. The facility management service plan will only be as good as the documentation from which it is built. For this reason, we must determine the document types, structure, format and detail required to create an effective, functional FMSP.
STEPS TOWARD EFFECTIVE, EFFICIENT FACILITY MANAGEMENT The first step in developing an FMSP is to identify the FM asset data required using BIM. This should ideally occur between the final design stage and completion of the design
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TECHNICAL PAPERS
documentation. This will allow us to build the FMSP during the construction phase of a project. Utilising BIM, we can define the documentation required to build the FMSP. The FMSP requires as-built or completion documentation of the highest available quality, so it can contribute effectively to the day-to-day management of the facility throughout its commercial life. For the facility management service plan to be created and delivered at practical completion the documentation must be defined and specified during the design documentation phase, consolidated and confirmed at tender and collated during the construction phase.
DELIVERY OF DOCUMENTATION The timely delivery of completion documentation is critical to the delivery of a facility management service plan at practical completion. In almost all instances each of the documents can be delivered upon completion of the related task. Some documents are simply a record of the construction history – they are not a critical completion document requirement. While review and approval must be undertaken, there is flexibility in the delivery timing. The delivery of all completion documentation should be a requirement for practical completion being granted to the builder or managing contractor by the superintendent.
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KEY DOCUMENTATION REQUIRED This list identifies the completion documentation the facility management team require at practical completion. It is these documents that will be used to create an FMSP for the life of the facility. • System descriptions • Schematic drawings • The COBie register • System operating procedures • Manufacturers’ literature • Maintenance instructions • Certificates of compliance, certification and approvals • Testing, commissioning reports and tuning data • Warranties for all equipment, components and systems • As-built drawings and specifications The structure of these completion documents have been developed to create an FMSP that provides the facility management team with the documents required for managing dayto-day operation and any emergency situations effectively. Completion documents should be approved and delivered to construct an FMSP prior to practical completion being granted.
MAKING FM SIMPLER At OandMs we have developed systems that simplify both the collection of operations and maintenance manuals and their utilisation in creating an efficient, effective FMSP.
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
We have developed checklists in our OM module that ensure the timely delivery of documentation and highlights the trades that are lagging behind in their delivery of documentation. Progress indicators give an instant appraisal of the state of O&Ms collection, with the click of a button. Then, once PC has been granted, our FM module utilises that data to automatically generate regular maintenance schedules that not only ensure the facility and its assets are maintained to a high standard but allows service contractors to instantly see the scope of works for quick, accurate costing. The net result is that what was once seen as a boring, mundane task becomes much easier – for everyone involved. To find out more about the design and implementation of an OM/FM system for your facility visit our website – oandms.com.au May all your temperatures meet your tenant’s expectations – David Bishop
ABOUT THE AUTHOR David has over 25 years’ experience in the construction industry and 15 years’ experience in facility management. He has a unique perspective when it comes to building information and meeting the needs of facility managers. He is passionate about raising the bar and setting a new standard for operation and maintenance manuals.
TECHNICAL PAPERS
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TECHNICAL PAPERS
Design considerations for hospital Class N isolation rooms KRISTIAN KIRWIN (B.ENG MECHANICAL) AND SHANNON ROGER (B.ED) AIREPURE AUSTRALIA 2016
There will always be a requirement for isolation rooms within hospitals. Factors such as the rapid urbanisation of our cities, increased volume and frequency of overseas travel and the emergence of new and drug resistant organisms have forced these facilities to prepare for patients with infectious afflictions or unidentifiable illnesses.
T
he fundamental function of an isolation room is to reduce the transmission of airborne infectious pathogens and contaminated droplets from patients to health care workers and to patients outside of the room. While this aim is clearly desirable, and simple enough to describe, the pathway to achieving this aim requires the complex interplay of air flow, air filtration and treatment systems, temperature and humidity control, state and federal regulations, building sealing, room design and layout, and several other factors. This article will focus on Class N Isolation rooms, serving to highlight some important design considerations of the current state-of-understanding as it pertains to the Australian environment, and give some perspectives on overseas trends that would be worthy of consideration here.
CLASS N (NEGATIVE PRESSURE) ISOLATION ROOMS Class N- negatively pressurised rooms are typically used for patients with known or unknown but suspected infectious diseases that spread via airborne droplet nuclei (such as chicken pox, disseminated shingles, measles
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or pulmonary tuberculosis) and require airborne droplet nuclei isolation. The main operation method of negative pressure isolation rooms is to utilise the exhaust air system to contain the infectious contamination within the isolation room and prevent transmission to corridors and attached rooms. Many design aspects such as total effective air-change rates, access doors, sealing walls and floors, and surface finishes all play a part in the overall room function. Most hospital guidelines nominate a ratio number of isolation rooms to standard bed bays, and address the basic requirements needed for the isolations rooms. Typical requirements for a Class N negative pressure isolation room include: • Ante room/Bed Bay/Ensuite • -10 to -15Pa between rooms • Architectural construction to be consummate with the sealing and possible pressure extremes (including possible pressure events) • System redundancy (the need for duty/fan standby equipment and equipment failure mode alarms)
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
• Exhaust air systems that are independent of common exhaust air systems • Vertical stack discharges • Where contamination or re-entrainment is possible from the discharge, HEPA filters on the exhaust systems • Pressure monitoring and alarms (visual and audible)
ACHIEVING NEGATIVE PRESSURE Pressure balancing is the generally accepted way to set up a Class N negative pressure isolation room. This involves the provision of a set of pressure regimes, whereby each area leaks to the adjacent lower pressure areas, allowing a net migration of air into the isolation room and then out via the exhaust system. Rooms within a system are typically set up with a -10 to -15Pa differential, between each zone. The supply air quantity is defined by the greater of, the required air change rate (ACH), AS1668 minimum ventilation air, or the air required to condition the space. The ACH is the usual driving factor – set by hospital design guidelines and good practice. The room pressures are then obtained by balancing the exhaust airflows and
TECHNICAL PAPERS adjusting the total exhaust system fan discharge volume. Factors that can and will affect the pressure balance during operation include the loading of filters and the wear and tear of the general facility door, wall and floor seals etc. The facility Building Management System (BMS) would typically adjust the exhaust system fan discharge volume to maintain the required negative pressure. Pressure control systems are a fine balancing act to provide adequate pressurisation and system stability, with door interlocks to prevent alarms and control adjustment when they are opened and closed – response timing is critical. One of the most difficult items to achieve is the effective changeover between duty and standby systems, particularly in failure mode scenarios. Often direct electrical interlocks work faster and more effectively than the BMS due to slow response times.
are then set based on expected flow differentials to achieve the desired goal (quantity of flow and approx. pressure differential). Generally established air leakage rates through door seals, door louvres etc. will be used, to set an exhaust value that achieves the desired (but not critical) nominal pressure regime. Confidence is provided by the knowledge that there is a” net inward flow” of air into the isolation room system, which is then exhausted. The use of constant airflow regulators means that as door seals wear down, doors are opened and closed, the net airflow into the system does not vary – the pressure will vary, but should always remain negative.
Figure 2: Schematic of isolation room with terminally mounted fixed flow HEPA’s (airflow balanced)
Figure 1: Schematic of isolation room with terminally mounted HEPA’s (pressure balanced)
Airflow balancing is not as commonly used, and places less importance on the pressure and more on the direction of air movement. Set airflows are used to provide a net negative inward airflow into the isolation room system, which is then exhausted, creating a negative, but not “pressure controlled” system. Airflow is typically controlled by constant airflow regulators on each branch. Once again the supply air is based on calculations undertaken to meet the greater value of room conditioning requirements, ventilation rates (AS1668) and hospital ACH design guidelines. The exhaust air flow rates
GRILLE PLACEMENT AND SWIRL DIFFUSERS It is very important to ensure that there are no stagnant areas of air within the isolation room. Supply and exhaust grille placement is critical to ensure effective operation of the isolation room, while still considering patient comfort and temperature control. The general idea is to sweep each room with air, drawing contaminants away from entry points. Bed Bays High level supply grilles are most often placed near the entry to a room with the air directed (dragged) away from the entry, across the patient, toward the low level exhaust grille at the far side of the room or near the bed head. This
provides a clean sweeping motion and minimizes airflow turbulence. Ante Rooms Ante rooms may or may not need supply and exhaust outlets and are often set up to utilise the flow of air leakage through the door seals/door grilles (or in wall pressure stabilising dampers) to create the flow or pressure regime. Ensuite The ensuite usually only has an exhaust grille located at high level due to the wet services within the room. Make up air is provided from door leakage, (via a door undercut, a door grille or a pressure stabilising damper) from the bed bay. It is worth considering prefiltration here and if terminal mounted HEPAs are used, oversizing the HEPA size – the pressure drop across the HEPA is affected by steam/moisture in the air from the shower, which in turn can affect room pressures. Swirl Diffusers We are often asked if swirl diffusers can be used. This is an option that the system designer may consider within general hospital spaces; however within an isolation room, contaminant control is the primary directive and we do not recommend them. The general intent of the existing standards and guidelines is to create a low velocity non turbulent (and predictable) sweeping motion across the bed bay to control contaminants. Swirl diffusers provide good mixing of the supply air, and as such provide good comfort conditions for the patient. This mixing provides dilution of contaminants within the space, but does not necessarily facilitate their removal; as such, contaminants can end up randomly distributed throughout the room and may pose a risk to staff/attendees.
EXHAUST FILTRATION AND HEPA REQUIREMENTS High Efficiency Particle Arrestance (HEPA) filters are designed and constructed to meet extremely specific particle capture requirements, and are rated at H13 (99.97% efficiency @ 0.3 micron),
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS H14 (99.995% efficiency @ 0.3 micron) or U15 (99.9995% efficiency @ 0.3 micron). The “value”, 0.3 micron particle size is used as the test point as it is generally regarded as the Most Penetrating Particle Size (MPPS) – whereby particles above and below this size – are generally easier to capture – and these are the most “elusive” particles to capture.
access needs to be available to physically view and scan the HEPA face. Access to, or a connection point upstream of the filter is needed to introduce the challenge aerosol. Whether the HEPA filters are located in terminal housings or inline within the duct; access and testing need to be considered. Terminal Mounted HEPA Containment Systems Terminally mounted exhaust filtration systems allow contaminants to be contained within the isolation room; the HEPA filters are installed within the room exhaust grille housings, most often at low level in the bed bay wall and at high level ceiling in the ensuite. As the ductwork is protected by the HEPA filter, there is a reduced risk of a potential contagion or contaminant spreading in the ceiling service spaces and therefore the need for fully welded/sealed ductwork can be reviewed. As there are multiple rooms within the isolation room system (bed bay, ensuite and sometimes ante room), multiple terminal mounted HEPA’s will be needed, and due consideration should be given to the requirements of prefilters and suitable access for annual validation testing of the HEPA filters and decontamination procedures.
Image 1: Mini-pleat HEPA filter with H14 efficiency rating to EN 1822:2009
Regardless of the method used to achieve negative pressure within the isolation room, a risk analysis is required to evaluate if there is a need for exhaust HEPA filtration for the discharges. This should be designed to identify the potential risks and the potential spread, both within the facility and externally. A typical risk analysis is dependent on the following factors: • Location of the facility • Admittance potential for possible contagions or contaminants • Possible types of high level contagions or contaminants • Isolation room location within the facility • Isolation room discharge location • Chance of re-entrainment and spread to neighbouring systems To be operated in a cost effective manner, pre-filtration should be considered to protect and extend the life of the HEPA filters. HEPA filters require adequate protection from general dust, lint and contamination by inexpensive, disposable filters to stop premature loading, replacement and as such, retesting. The higher the rating of the pre-filters, the longer the HEPA will last. To confirm the performance of the HEPA filters, they must be tested on installation and be retested and validated each year by a NATA accredited testing agent. During certification testing, the HEPA media and housing is exposed to a challenge agent, with the downstream side of the filter and housing scanned for leakage. To perform testing, adequate
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
Image 2: Pre filtration for terminally mounted exhaust filtration system – 20mm disposable flat panel filter with G4 efficiency rating to EN779:2012
As space within hospitals is at a premium, there is minimal space for pre-filters to protect the HEPA filter (particularly important for damp ensuite areas). Access to the air-off side of the HEPA filter is also required for annual NATA certification. Subject to the HEPA module type, this can be performed via an access panel from an adjacent space or from a room side access panel. If the access door is located within the space, this panel must be cleanroom grade sealed. Testing is often difficult to arrange as the room may be in regular or short notice use. Generally, decontamination of the room is undertaken via conventional cleaning and wipe down methods. This process does not facilitate the decontamination of the exhaust HEPA’s
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TECHNICAL PAPERS which would need either specific gaseous decontamination or to be included when the room undergoes decontamination. If contaminants are unknown, gaseous fumigation of the HEPA filters is recommended prior to filter change-outs to ensure the HEPA filter does not harbor any contagions or contaminants. PPE must be used as per facility guidelines. In an ideal world, a system would have gas tight or bubble tight isolation dampers on the duct prior to the supply inlets and behind the HEPA filters on each exhaust. This provides a barrier to stop the spread of the decontamination gas during fumigation, and prior to discharge of the decon gases to atmosphere via the exhaust. (Refer to optional dampers in Figure 1). Advantages
Disadvantages
• Contaminants are contained within the isolation room (theoretically, the duct is clean after the HEPA filters)
• Multiple HEPA’s serving each room within the isolation bed bay, therefore, multiple HEPA test locations, pre-filter change-out locations
• Ductwork is protected by the HEPA’s, reducing the risk of spread in ceiling spaces and the need for fully sealed duct
• Minimal space for pre-filters to protect the HEPA’s (particularly important for ensuite areas)
• In the event of positive pressurisation, contaminant leakage is only from the room (not the associated ductwork)
• Potential risk of damage to HEPA by staff or occupants • Access to the air off side of the HEPA filter is needed for annual validation (either from an adjacent space or a sealed in room panel) • Access to patient areas is needed: Organising when to schedule testing if area is occupied? Is there sufficient space for testing? (traditionally limited ceiling space in ensuite) If suction is lost when terminal access panels are opened, a positive pressure fan may be needed for testing
• In theory, when the room is decontaminated, decon can be undertaken up to the face of the HEPA
• Unless gaseous fumigation of the HEPA is undertaken, it may still harbor contaminants/ contagions after room decon
In this scenario, decontamination can be undertaken up to and including the face of the HEPA filter.
Image 3: Channel seal terminal HEPA module with access door to air off side of the HEPA filter (fascia removed).
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
It is possible for HEPA modules to be made to include pre filters and an access door to the air-off side of the HEPA filter for testing if prior design consideration is undertaken. These require more space and have their own drawbacks. Inline Containment Systems Inline containment exhaust filtration systems are typically located in plant or roof spaces away from the isolation room. As such, they can be larger in size than terminal HEPA modules, and in turn provide sufficient space for higher grade, high capacity pre-filters and high capacity HEPA filters. A single inline HEPA housing can replace multiple terminal HEPA modules, which is a potential testing saving. A bypass around the inline HEPA housing can also be considered to minimize fan energy use when discharge protection of the negative isolation room is not needed.
Image 4: Pre-filtration for inline containment exhaust filtration system – 100mm disposable pleated panel filter with G4-F7 efficiency rating to EN779:2012
Although the exhaust duct is in a negative state, fully welded, 100% sealed duct from the isolation room exhaust intake point to the inline HEPA housing may still be considered to minimize possible risk of leakage to void spaces in a positive state scenario. Cleaning and decontamination of this duct is often difficult, and this needs to be considered. If the plant space is located externally, the HEPA housing and duct construction must also be made weatherproof. If the units are in a plant space that is used as an outside air intake plenum, there is a potential risk of contamination into other systems through their intakes. Advantages
Disadvantages
• Single location for HEPA testing, access is outside of patient areas
• Additional plant space needed
• System size can facilitate a single high capacity HEPA (instead of multiple per room within isolation bed bay)
• Often fully welded 100% sealed duct is required
• High efficiency pre-filters can be located in the inline housing (further protection for HEPA)
• If located externally, duct construction must be made weatherproof
• Basic pre-filters can be located at the room exhaust intakes (removal will not affect the HEPA)
• Difficulty cleaning/decontaminating ductwork from the intake point to the HEPA filters
• HEPA bypass can be provided when not in a negative isolation mode, providing energy savings
• In the event of positive pressurisation, possible contamination to void spaces from ductwork
TECHNICAL PAPERS The type of inline containment system can also vary greatly, depending on the potential risk and housing location. An inline system may be as simple as an upstream injection port for introducing challenge aerosol in the duct system and an inline HEPA housing, containing a HEPA filter and an access door for scan testing.
Decontamination/fumigation ports are valved and capped connection ports that allow fumigation gases to be introduced to provide housing and filter decontamination of microbial life forms.
PANDEMIC WARD SCENARIOS Isolation rooms provide the ability to house individual patients; however, some agencies and health boards are looking to build new facilities or have sought the ability to adapt existing facilities to house larger numbers of potentially contagious admittances (such as patients with tuberculosis or influenza) when required. Possible scenarios include modifying existing wards to operate as isolation “Pandemic” wards with a single pass scenario – supply consisting of 100% outside air and the return/exhaust all being discharged to atmosphere. This can be done from a safely located discharge stack or if needed via HEPA filtered housing systems.
Image 5: Inline HEPA module with access door for scan testing (filter access door removed – HEPA filter and pre-filter shown).
As the potential risks increase, and the system requirements become more complex – laboratory type Bag-In/BagOut (BIBO) systems are used. Inline HEPA systems can become BIBO style housings used for designated Class Q (negative pressure quarantine) isolation rooms. This type of system would typically include bubble tight isolation dampers, decontamination/fumigation ports, a remote scan arrangement for testing and BIBO arrangements for filter change out.
Common plant and duct requirements can provide potential savings in capital cost, maintenance and testing. Further operational advantages can also be gained through staged fan operation, system redundancy and heat/energy reclaim. A number of factors should be carefully considered (see summary table below). Advantages
Disadvantages
• Common plant location – reduced number of HEPA’s and fan systems (potential saving in capital cost, maintenance and testing)
• Duty/standby (lead lag) requirement for filter change-out
• Common/reduced duct requirements (If isolation rooms are in close proximity)
• Each branch (supply and exhaust) requires a constant airflow regulator (quality cost)
• If spare system capacity is provided, adding additional isolation bays is relatively simple
• When combined, duct systems can be more difficult to fit within the facility
• Staged fan operation for operational flexibility and optimal performance (areas can be set into unoccupied mode with low flow)
• If isolation rooms are not in close proximity, long duct runs are required • Unless spare system capacity is provided, adding additional bed bays could be costly
Image 6: Bag-In Bag-Out (BIBO) inline housing with bubble tight isolation dampers, decontamination/fumigation ports, pre filter and HEPA filter access and remote scan arrangement (access doors removed).
Bag-In/Bag-Out is the term used where sealed gloved bags are installed over service points and access openings to provide an additional protective barrier to operators when changing out or testing filters. When BIBO functionality is required or simply “requested” it introduces a whole new facet and layer of complexity to the design of an inline containment housing; as all operations need to be undertaken from outside of the housing or through a sealed bag. Bubble tight isolation dampers when closed provide near zero leakage and are used to isolate sections of the systems for emergency contamination control or decontamination processes.
• System redundancy is possible
• If system redundancy is not designed, installed and setup correctly, the whole system could deviate out of the negative state
• Heat/energy reclaim is possible, practical and beneficial (when temperature differences are significant)
• When temperature differences are minimal, additional static is added to the system (no heat reclaim benefit)
Figure 3: Schematic of existing wards (black) with overlaid modifications to become pandemic ward (pink)
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TECHNICAL PAPERS COST AND ENERGY SAVING CONSIDERATIONS OF COMBINED SYSTEMS Current Australian guidelines and standards specify that negative pressure isolation rooms must have dedicated duty/standby exhaust fan systems which should not be combined with any other discharge systems. In short, each type N room must have its own dedicated duty/standby exhaust system. A progressively more common approach overseas is to combine multiple negative bed bay exhaust duct streams via manifolding (similar to how fume cupboards can now be treated with the changes to AS 2243.3). The combining of exhaust streams for isolation rooms is a potential capital cost saving; allowing multiple bed bay systems to have common systems and redundancy. There is also the ability to common the exhaust containment filtration systems. The large duct systems provide volume stability and control, and potential fan optimization for energy savings. From a HVAC and energy point of view, the manifolding of an entire “pandemic ward” system would seem attractive to the end user. Single pass air-conditioning systems are very costly to operate, and small individual systems (350-500 L/s each) can make the implementation of heat reclaim cost prohibitive. Combining the supply and exhaust system allows a scale at which
the use of heat reclaim is possible and economically viable. The use of run around coil type systems can be undertaken with minimal outlay to provide peak energy savings on high load days, while providing supply and exhaust system separation. Run around coil systems are preferred as they still provide complete separation of the exhaust and supply air systems without the possibility of cross contamination. Heat wheels are not recommended at all due to the risk of cross contamination, and air to air heat exchanges (AIR/AIR HX) only have a single layer of separation against cross contamination. If the HX is located after the HEPA filtration system, cross contamination is highly unlikely, but still possible in the event of HEPA failure. A manifolded type approach to exhaust ducting uses constant airflow regulators to maintain airflow to individual branches, and as such they require flow, pressure containment.
FINAL THOUGHTS Whilst there are many factors affecting the design, implementation and maintenance of Hospital Class N Isolation rooms; there are guidelines and sound recommendations available to assist with your compliance to relevant standards and individual hospital guidelines, as well as your specific objectives for safety, performance and cost.
Figure 4: Schematic of manifolded pandemic ward with heat reclaim
Key considerations for exhaust filtration include: • Suitable access to testing and validation by a NATA accredited testing agent • Pre-filtration for the protection of HEPA filters (especially in the ensuite) • If terminal mounted HEPA containment are used, oversizing the HEPA filter located in the ensuite to compensate for pressure drop affected by steam/ moisture • If deemed necessary by the risk assessment, gas tight/bubble tight dampers for use during decon/ gaseous fumigation Airepure Australia offer a range of products, services and consulting expertise that can assist you with your compliance to ACHS, DHS VIC Guidelines (and equivalent for QLD, WA and NSW), ISO/IEC 17025:2005 Requirements, AS 1668.2, AS/NZS 2243.3:2010 and AS/ NZS 2243.8:2014. Airepure is a national air filtration company providing unique, powerful and integrated air filtration solutions, ranging from basic HVAC filtration and odour control right through to high end HEPA/ULPA filtration and airborne containment technologies. Airepure recommends ELTA and Fantech Fans. For more information, visit www.airepure.com. au or call 1300 886 353.
REFERENCES AS 1668.2: The use of ventilation and air conditioning in buildings. Part 2: Mechanical ventilation in buildings: SAI Global Limited 2012 Victorian Advisory Committee on Infection Control: Guidelines for the classification and design of isolation rooms in health care facilities, Victorian Government DHS, 2007 Infection Control Management of Infectious Diseases: Summary Table, Department of Health and Aging, Government of South Australia, 2015 International Health Facility Guidelines: Part D Isolation Rooms, Version 4, 2015
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Trigger points for forced hospital building upgrades
DEREK HENDRY I THE HENDRY GROUP
AUST – Each year various aspects of the Building Code of Australia (BCA) and Australian Standards are amended according to industry and community consultation and feedback, and also according to the agenda and direction identified and adopted by the Council of Australian Governments (COAG).
E
xamples of these are the enhancements to Bush Fire protection requirements, the adoption of the Disability Access provisions within the BCA and the inclusion of energy efficiency provisions for commercial and residential buildings. Since premises are designed and constructed
to comply with the BCA applicable at the time, it stands to reason that as each new edition of the BCA is published, there will be a growing list of building elements in hospitals that will, in compliance terms, become outdated. As these buildings become increasingly non-compliant with the current BCA, factors such as whether the building still serves the original design intent, and whether the building elements in question are still ‘fit for purpose’ and still provide for the health, amenity and safety of the building occupants sufficiently enough, come into question. These questions are generally considered when a particular trigger initiates the review process of a hospitals compliance, culminating in the need for either, or all of, a building upgrade to the building itself, a change of building classification or an update to the procedures practiced within the building. These are some of the most common triggers and outcomes for building updates that hospital engineers and/or occupiers face:
BUILDING NOTICES AND BUILDING ORDERS Building notices or building orders can cover the broad aspect of public health and safety such as dangerous buildings, fire report matters, and closure of unsafe public assembly buildings, and only a local authority (because of the restrictions in legislation) can serve building notices or building orders in relation to public safety measures provided in an existing building. Building notices provide the means by which the municipal building surveyor can require the building owner to show cause as to why an existing building should not be subject to building work in order to provide a level of public
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
TECHNICAL PAPERS safety which meets with community expectations under the building regulations. An existing building does not have to be upgraded to the same standard as is required for new buildings under building orders or building notices. If the managers do not respond satisfactorily to building orders or building notices by undertaking the required works, then the municipal building surveyor/ council can proceed to issue building orders or take court action which, if not complied with, will ultimately incur penalties, or even closure of the hospital building.
EXTENSIVE ALTERATIONS While most building control legislation is not retrospective for existing buildings, legislation of some states do contain provisions that can trigger an upgrade of an existing hospital building. Where alterations to a building exceed more than 50 percent by volume (within a three year time-frame in the case of Victoria), the event can trigger a requirement for the whole building to comply with all the current regulations (BCA). Other states have no time limits applicable, and calculations may vary in the interpretation of the volume. Some building surveyors include simple partition changes in the volume calculations, while others only calculate the volume associated with a refurbishment which includes significant modifications to services. An upgrade to fire safety and/or structural capacity may also be determined because the modifications to services may compromise the essential safety measures contained in the building, and may be determined to be inadequate to protect persons using the building. Upgrades may be determined to facilitate egress from the building in the event of a fire, and/or to restrict the spread of fire from the building to other buildings nearby.
DISABILITY ACCESS Recent moves to improve the commonality of the disability access provisions for buildings in the BCA and the Disability (Access to Premises – Buildings) Standards 2010 have substantially harmonised the BCA with the Disability Discrimination Act. As a result, the integration of the disability access code with the BCA carries significant implications for building owners, tenants, and property managers and hospital engineers. The Premises Standards contain detailed disability access information specifying the circumstances and types of building where the Standards apply: to a new building, a new part of an existing building, and the affected part of an existing building. For disability access, the affected part of a building means:
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TECHNICAL PAPERS • Any part of an existing building that contains a new part, that is necessary to provide a continuous accessible path of travel from the entrance to the new part. Generally, the affected part of a building must comply with the new access requirements where alterations and/or additions are proposed to an existing building, and the proposed work is subject to a building permit/ complying development certificate or a construction certificate/building permit. The affected part of the building, relative to disability access, does not apply to: • Existing parts of buildings outside the area of the new work and the affected part upgrade • An access way from the allotment boundary, from any accessible car parking space on the allotment or between other buildings on the allotment. Upgrading works for an affected part may include the following disability access works: • Accessibility of upper floors to new work • Providing lift access features such as Braille or tactile buttons • Signage • Removing a step at a building entrance • Upgrading handrails on a ramp • Minimum width requirements of doorways or passageways, including passing/turning spaces. As a consequence of the disability access provisions, the BCA now more extensively covers features such as lifts, stairs, ramps, toilets and corridors in buildings such as hospitals, office blocks, shops, hotels, motels, and common areas of new apartment buildings.
ENERGY EFFICIENCY COMPLIANCE Energy efficiency requirements, as detailed in Section J of Volume One of the BCA (and applicable to all building Classes 2-9, unless otherwise stated), apply to the construction of all new buildings, as well as the refurbishment, alteration or extension of any existing building. The energy efficiency requirements allow commercial and public buildings to achieve minimum levels of energy efficiency compliance through the performance-based provisions of the BCA. In essence, these measures are designed to reduce the use of artificial heating and cooling, improve the energy efficiency of lighting, air conditioning and ventilation and reduce energy efficiency loss through air leakage.
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
Assessments generally cover building elements such as the building fabric, external glazing, building sealing, air movement, air conditioning and ventilation systems, artificial lighting and power, and access for maintenance. Energy efficiency compliance with the BCA can be achieved by complying with the deemed to satisfy requirements of the BCA or by developing an energy efficiency alternative solution that demonstrates that the proposal meets the relevant BCA performance requirements. Where energy efficiency alternative solutions are sought or additional information is needed, software-based energy efficiency analysis can also be deployed to assess the energy contribution of various building components such as building fabric, air filtration and natural ventilation, internal heat sources, air conditioning systems and vertical transport systems.
EMERGENCY PLANNING Emergency plan development, emergency response procedures, evacuation diagrams, emergency procedures training, and emergency response exercise program implementation are just some of the requirements of the emergency planning obligations under AS 3745-2010 ‘Planning for emergencies in facilities’. When a building undergoes alterations, some or all of these requirements can be impacted by the changes in the building, and hospital engineers need to give due consideration to ensuring their emergency planning remains effective, up to date and AS 3745-2010 compliant, in order to provide a safe work environment for staff, building occupants and visitors alike. While the basic intent of the BCA is to ensure the provision of safe buildings for occupancy that provide a level of amenity commensurate with public expectations, the application of the BCA can be open to interpretation. Building Surveyors are quite often called upon to provide expert advice or witness, and to provide sound planning advice in maximising your building asset.
ABOUT THE HENDRY GROUP Derek Hendry is the Founder of the Hendry Group, a property compliance solutions consultancy whose services include building surveying, disability access, essential safety measures, emergency planning and work health and safety. Hendry pioneered the private certification system of building approvals in Australia and operates nationally in all facets of building control. Hendry is aware of the importance of sharing knowledge, and regularly distributes industry news and updates through publications such as ‘Essential Matters’ Hendry’s e-newsletter, blog sites and website. For more information please visit www.hendry.com.au
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WHERE THE HELL ARE WE? (FINDING A WAY TO WAYFIND)
GREG TRUSCOTT, B.ARCH MIHEA I MANAGER, INFRASTRUCTURE & NEW WORKS, ROYAL PERTH HOSPITAL, BENTLEY HEALTH SERVICE & ARMADALE HEALTH SERVICE
Part 2 of a paper presented at the IHEA 2015 National Conference & the NZIHE 2015 Annual Conference. (Part 1 was published in the March 2016 edition of The Australian Hospital Engineer and this Part 2 is a continuation of the same project case study)
1. ABSTRACT:
T
his is a case study of a project I am carrying out at Royal Perth Hospital (RPH) to improve its wayfinding and signage system. Although the existing wayfinding system, had been developed with great consideration and a very comprehensive system installed 15 years ago, I assessed much of it was flawed. Part 1 of the paper described the existing system including its Style Guide, the problems it had and then described the actions implemented to rectify those problems. A quick summary of the key elements/issues presented in Part 1 were: 1.1 The Main Directory Boards: • Having a counter-intuitive arrangement – with the solution being to reverse the arrangement from listing the buildings with the entities (clinical areas i.e. “the destination”) within, to listing the entities under six key groups, then alphabetically with their location appended. • Reducing the entities listed, from 252 (which was every entity) to the 87 which related to patients and visitors. • Changing from a 3-dimension “helicopter view” of the site, to a simpler 2-dimensional plan, with
buildings relevant to patients and visitors highlighted. • Eliminating colours and identifiers of site precincts and buildings and using colours only as identifiers for the 7 banks of lifts across the site. Colours are powerful identifiers; however in a system which had 5 different shades of green demarcating, a precinct, three buildings and a bank of lifts, when this was incorporated into the signage system, it was lost in translation. Signage was therefore simplified to the universally recognised, compliant for colour contrast, blue lettering on white background. 1.2 Building Identifiers: The existing system of using both AngloSaxon names (difficult for those with limited English language) and numbers (confusion with levels) was changed to building identifiers being a letter of the alphabet. 1.3 Signage – Subdirectories and directional signage: The existing system of having signboards at each corridor or change of direction, listing all entities in all directions was very expensive and was so prolific, it became, what I termed “clutter”. The new approach focused signage on giving directions to buildings (so, bold signs using only the building letter identifiers) then Subdirectories listing entities within the
building, were installed at the building’s entry. This reduced the cost and “clutter” of signage. That final issue of the prolific number of signs and the amount of information on them is extended upon in this paper, in its first topic, titled “Too much clutter”. This is followed by details on the installation of interactive digital wayfinding touch screens at the five main entry points to the hospital. The final topic is building fabric strategies employed to assist wayfinding. Before commencing, I will reiterate, good wayfinding will save hospitals money by reducing the time staff lose directing people. It will also reduce the incidence of patients arriving late for clinics and as a result being frustrated, stressed and even aggressive toward staff.
2. TOO MUCH CLUTTER: Part 1 of the paper identified the issue which I termed “noise” (signs, containing elements that are not recognised, understood or retained by most people) and “clutter” which is the number of signs and the large amount of information on them. When added to this is an array of unofficial and even management sanctioned signs, messages and billboards the visual clutter makes the task of people using the wayfinding system very difficult. All of the examples listed below
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TECHNICAL PAPERS were on the walls along the main thoroughfares and therefore highest traffic areas of RPH. These areas are the entry points and major routes for those wayfinding, but not surprisingly, also for those wanting to get their own message across and often trying to outdo others in getting people’s attention.
Figure 1: Main corridor from multistorey car park to the largest building on site
Figure 1 is an example of how the existing signage can be drowned out. In this case, it is surrounded by RPH management, message posters or those with their approval. Other locations may also include well meaning posters on fund raising for Health or notices giving directions to one-off meetings, blue tacked to lift lobby walls and along corridors. Often meeting participants don’t have to use the wayfinding system at all. They can just follow the brightly coloured A4 photocopies conveniently adhered to walls marking out their journey.
for deeds I couldn’t discern from the Certificates. They were removed.
I sent an image of that document (Refer to Figure 4) to the PathWest in-house laboratory when asking them how important it was to be there. No one at the Laboratory particularly knew about it or could guess how long it had been there. They did say that the Form was several years out of date and besides, nearly all the Doctors submitted the forms online now. It was removed from the wall.
Figure 3: Typical clutter at lift lobby – Note: one solution is TV screens with scrolling messages.
Figure 5 & Figure 6 (before and after images) shown in Part 1 of the paper for a number of other reasons, also illustrates the benefit of de-cluttering.
Figure 3 shows a number of issues of clutter adjacent a major bank of lifts, which were addressed. The large poster is one in a series of either patient’s stories about the wonderful health care they received or group pictures of staff and stories about what they do in RPH. The small posters are repeats of the large posters and they were many in number. I did secure agreement that the small versions would all be removed, partially because even though they were sanctioned, being that size, they seemed to encourage others who believed they had an important message, that the walls were fair game for their A3 paper message to be blue tacked alongside. Also, note the white document box alongside the large poster.
Figure 5: The Brown Lifts (before)
Figure 6: The Brown Lifts (after)
3. DIGITAL TOUCH SCREENS: RPH was the first Hospital constructed in Perth, in a down town location with 720 beds at its peak. Figure 7 shows the Complex on this ever expanding site with building ages spanning 160 years. The buildings are interconnected at multiple levels, including 3 bridges across 2 major Public roads. Wayfinding in this Complex is very challenging, so the opportunity to introduce digital screen technology to illustrate the journey an individual needs to take, was very important to pursue.
Figure 2: Award(s)? received 16 years ago, for doing something? or not doing something?
Another type of clutter is the Award Certificates that have lost their importance due to the passage of time or in this case relevancy. Refer to figure 2 showing two framed Award Certificates both about 400mm x 600mm in size hung in the main Hospital thoroughfare. They were awarded in 1999 by the Beverage Industry Environmental Council,
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Figure 4: Correct Use of Laboratory Request Form (although out of date). Helps pass the time, while waiting for a Lift
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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Figure 7: RPH Circa 1997
When first considering installing this technology, I had envisaged that, even though my Office processed AutoCad drawings of all levels of every building and they were all loaded onto SISfm, there may need to be, new expensive software and associated computer programing for it to run all sorts of algorithms to generate the myriad of journeys to be displayed. Could my budget handle that? It then occurred to me, given any journey starts from the screen being used, the journey from that screen to whatever the destination is, never changes. In fact in it crudest form a simple hand drawn mud map for each destination could be loaded on the computer and appear on the screen when that destination was selected. I felt encouraged again, however the biggest stroke of luck was discovering that the Medical Illustration department at RPH had already done some of this for some one-off specific wayfinding requirements and they had all the knowledge and skills and even the Software (called “Flash”) to drive this process entirely. All I had to do was fund the components of the system.
Figure 8: Main Entrance, Main Directory (before)
Figure 8 shows the original Main Directory Board (252 listed entities) at the Main Entrance (with Lotterywest message “Clutter” adjacent – although, it is hard to refuse them, given their monetary support). Figure 9 shows, the new replacement Directory Board (87 listings, intuitively arranged, patient and visitor focused under 6 Groups and an improved 2 dimensional site graphic). In front of the Board are two of the digital touch screens, mounted onto purpose designed stands – wheelchair height friendly, which we assisted by keeping touch selections in the bottom half of the screen. Six off 81cm (32 inch) touch screens were purchased at a cost of $2300 each (not including the stands). RPH had spare second hand computers which could be used, because each only driving one screen and the wayfinding program. We didn’t even have the cost of connecting them to the network, because it was not difficult to visit each of the six screens with a thumb drive containing any updates and load it onto each. The Medical Illustration team did a great job with the graphics and loading the different journeys (due to the different location and therefore starting points of the screens) to the 87 entities listed on the physical Main Directory Board. What about the other 165 entities removed from the Main Directory Board ? The digital screens were in fact one of the reasons we were comfortable removing those entities. The new Main Directory Board contains the caption “if you cannot find where you want to go, on this Board, type it into the search window of the wayfinding screen, to receive its location details”. The journey to those particular entities is not shown – only the building block and level details, which is the same as that provided on the previous physical Directory board. The journey could, however, be loaded at a later date, if desired and resources permitting.
Figure 9: Main Entrance, Main Directory and touch screens (after)
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
Figure 10: Interactive digital wayfinding touch screens
Figure 10 shows a close up of the home screen, which aligns with the 6 main groups of the physical Directory, the search function and symbols to select ATMs, Public phones, toilets and other locations with one touch. In all cases once the destination is nominated a plan view of the relevant building(s) appear, and from the “You Are Here” point, a dotted line of the journey rolls out, with some landmarks called up along the way, the colour of the lifts to be used (if required), the level to get off at, and the remainder of the journey on that level, shown. This is quite typical of those at large shopping centres or airports. Our System however, will show a picture of the entrance/ reception counter of the destination, which assists the user to recognise it upon arrival. In fact an idea to film the whole journey to the destinations and have it play back on the screen (sped up to maybe 3 or 4 times real time, to reduce replay time) would also allow users to retain a few landmarks in their memory. That would provide confirmations during their journey. The screen carries the caption “Take a picture of this image on your mobile phone if you wish”. The user would then have an image of the journey on their mobile.
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TECHNICAL PAPERS Extending on from the use of mobile phones, it will not be too far away that via an app or 2D Data Matrix the user’s journey can be downloaded onto their phone. Finally with WiFi and GPS tracking, you can track yourself or know when you have deviated. At that point, you have your own personal Concierge in the palm of your hand. Given RPH applied for funding (unsuccessful, this year) for an extensive rollout of Wi-Fi, this is a realistic future possibility.
4. BUILDING DESIGN, FABRIC AND LANDMARKS TO ASSIST WITH WAYFINDING In a “Green Field” building project opportunities are readily available for: • Logical planning and layouts which assist wayfinding • Main Entry points designed to be easily recognised • Detailing of Reception Counters to make them obvious and informative.
bed Hospital, opened in Perth in late 2014. I thought I would share this, as an observation of a Main Entrance that is not easily recognised. Figure 11 shows an image visitors have, when approaching the building from a major multistorey car park, which is one of two major access journeys. The road and parking is a drop-off loop for the Main Entrance, which although only 60 metres from this view point, is not discernible (it is in the distance, looking to the right of the car, between the car and the white pole). Nor is the signage strong (it is on the brown suspended box, in top left of the image). All the buildings of the complex have a similar high tech. steel and glass palette of materials, which doesn’t help much with landmarks/orientation. Figure 12 is closer to the entry with the Brown hanging box signs more obvious. Due to the Concourse over, a weather canopy which may have marked the entry is not required. The final arrangement of two glass sliding doors, in a wall of glass, is just too subtle in my opinion.
• Views to the outside, to assist in wayfinding • Use of Art/Sculptures as landmarks, to assist in wayfinding. • Interior Décor e.g. building fabric colours schemes, different for each level. Figure 12: Fiona Stanley Hospital, Perth, Main Entrance
Figure 11: Fiona Stanley Hospital, Perth, finding the Main Entrance
Before describing the limited opportunities I had in this regard (and none within the wayfinding/ signage only budget, I had) during my research I was surprised at the design of the Main Public Entrance of the Fiona Stanley Hospital, a new $1.8BilIion “green field” site, 783
Returning to my more modest project, at about the same time there was a maintenance project to replace all the floor coverings through the main entrance and the major thoroughfares. These thoroughfares connect the key buildings and include bridges across two major public roads, for a total journey of 680 metres. Carpet was going to be replaced with sheet vinyl. This presented the potential to incorporate within the design, some wayfinding elements at key nodes/crossroads.
Figure 13: Proposal for floor vinyl design incorporating wayfinding.
Figure 13 shows the floor plan of one proposal I designed, using coloured panels to provide relief and interest along some wide, very long corridors. In the bottom right corner where you enter the building is the Hospital’s Logo (a Crest), which I intended reproducing in a simplified outline form, using a different coloured vinyl flooring welding rod. Then along the corridors, there would be sheet vinyl colour panel inserts based on deconstructed shapes (same size, proportion and arrangement of the RPH Crest). Although all subtle, the familiar shapes have a connection with the Crest. This was a bold design and some considered it didn’t sufficiently respect the RPH Crest, while others liked the artistic representation. Further along at a crossroad is the shape of a red apple. It is modelled on the Apple computer company logo, which may or may not be a problem, given context, but it does add familiarity, in terms of describing it to a non-English speaking person. Figure 14 is another image of this scheme. The apple is intended to be a landmark for wayfinding (i.e. “when you get to the apple turn right”) and has an advantage that it could be described to a non-English speaking person by the simple gesture of pretending to bite an apple. So, good landmarks are those that can be easily described. If it is a large painting, an abstract painting is more difficult to describe, rather than say, “turn at the painting of the boat” or “the painting of the naked lady” (well, perhaps not). The advantages of embedding wayfinding into floor coverings are; that they can be very large and when centred, difficult to obstruct or for there to be any other distraction
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS Figure 14: Proposal for floor vinyl design incorporating wayfinding.
understand, it is easier to do in the digital age and therefore they have a high expectation for it to be accurate and up to date. 5.5 Building Fabric/design and Art 5.5.1 Can be as simple as a large distinctive painting on a wall and this can have the benefit of being wayfinding tool/ Cultural Artefact/ decoration or point or interest. 5.5.2 Can be as simple as painting the lift lobbies of each level a different colour.
within the floor. The same cannot be said for walls, as has already been demonstrated.
Director of Facilities Management, so I simply rip unauthorised material down, before they start breeding.
Using a large piece of sculpture can be an effective landmark, however if employed, particularly at a four way crossroad, it helps significantly, if it looks different from each approach direction. A shiny chrome ball looks exactly the same from every approach and provides much less help for orientation.
5.3.3 Educate staff to add to their electronic requests, a link to the Hospital’s Map with directions, whenever inviting external parties to their Office or to Seminar rooms.
5. CONCLUSION: This, the second part of my paper focussed on identifying and removing “clutter”, so a wayfinding system has a chance to be seen, installing wayfinding technology and the use of building fabric/ design and Art as wayfinding tools. In my conclusion/ summary below, I commence with the first two key strategies as listed in Part 1, because they apply across all systems of wayfinding. 5.1 Design your system assuming it is being used by a first time visitor to the hospital. 5.2 Design your system assuming the user has limited English language skills and or other cognitive or physical disabilities. 5.3 Clutter: 5.3.1 Do an audit, say quarterly, of what is currently on the walls of the main wayfinding thoroughfares and remove anything not essential. 5.3.2 RPH has a policy, that nothing can be attached or posted on walls of thoroughfares without approval of the
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5.3.4 Consider a single Bulletin Board at Hospital entrance which can be used to list meetings/Seminars occurring that day. 5.3.5 For general health or information type messages to be conveyed to the public, consider installing TVs, with these messages continually scrolling through. 5.3.6 For staff wide (e.g. “remember to wash your hands”) reinforcement type messages, use e-bulletins or build them into screen savers/home pages. 5.4 Technology systems: 5.4.1 Embrace them, because they are cheaper and easier to implement than many of you will have thought. 5.4.2 It is important for the Technology to align with the physical directories and signage, in both presentation and nomenclature. This is universally important. The system fails if a patient has an appointment to a Clinic and the name of the Clinic on the wayfinding system is different to that on the Appointment Card in his hand. 5.4.3 Keeping them up to date is important, particularly as users
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
5.5.3 Floor coverings can also be a useful wayfinding tool, although the follow me coloured lines on floors have problems and in my opinion are unattractive. If these are glued to the floor, traffic and floor cleaning scrubs them off. If this method is desired, another approach is to run coloured lines around the walls just above the skirting, so no foot traffic or cleaning wear occurs. 5.6 Use the two reference documents listed below. They are both, recently published and written by Australian State Government Health Departments. Together, they will cover everything you need to know.
ABOUT THE AUTHOR Greg Truscott has a degree in Architecture and obtained registration as an Architect in 1991. He completed a Diploma in Management in 2013. The first 10 years of his working life was for private Architectural firms in Western Australia and Toronto, Canada. Projects he worked on included Office towers, retail complexes, University buildings, a Hotel and large upmarket homes. In 1993 he commenced working in the Health Capital Works arena and has been captivated by it ever since. His latest roles have included the Manager, Major Capital Works, SMHS (half of Perth Metropolitan area’s health system) and currently Manager, Infrastructure and New Works, RBA Zone.
REFERENCES: (1) NSW Government, Ministry of Health: Document number GL2014_018; Wayfinding for Healthcare Facilities, p.6, (October 2014), (2) The State of Queensland (Queensland Health): (2010) Appendix 7 of Queensland Health wayfinding design guidelines, pp.32-34 (December 2010)
TECHNICAL PAPERS
The importance of maintaining doors and hardware in a hospital environment The front entrance of a health building is a place of special transition, symbolising the first steps on the path of recovery, or of a new life of coming to terms with a condition. It is the point of entry to other hospital departments and provides the key to the hospital’s circulation routes. It is also the place to receive clients; an occasion for courtesy and hospitality. Exit and entry points to hospitals are many, but imagine if the main entrance door or emergency entrance failed at a particular time of emergency; we all know the saying “First impressions count”. This failed entrance could have dire consequences in an emergency when time is critical.
D
oors in hospitals which number many are literally a life line providing access and egress points including but not limited to applications such as emergency exits, passage smoke doors, ward doors, surgery doors and back of house operations to name just a few. Maintenance of doors and the associated mechanisms whether it be an automatic door operator, a movable wall or door hardware is critical to ensure a hospital operates seamlessly. Many manufacturers have recommendations for maintaining doors to prolong life and in some cases standards and regulations dictate requirements for door inspections and the necessary service criteria a hospital operator should meet. So let’s have a look at a few differing types of entrance systems found within hospitals that would benefit from routine service. Automatic door operators whether sliding or swing doors (hinged) benefit greatly from regular maintenance and an inspection program ensuring that wearing components are replaced before they become a problem. Regular maintenance helps prevent accidents, prolongs the life of the product and ensures the safety of users
while reducing breakdowns and the accompanying inconvenience. By engaging an automatic door specialist to provide regular service, the life of the product is extended, heating and cooling costs and power consumption can decrease whilst improving security and safety which is paramount. Australian standard AS5007 “Powered Doors for Pedestrian Access and Egress”, Clause 5.1.3 states that it is the obligation of the owner to ensure their automatic entrance undergoes service and maintenance at intervals no longer than four months. Automatic doors can cycle open and close hundreds of times every day, so part of routine maintenance must also include the checking of activation and safety sensors. All too often dust, cob webs and other air borne particles prevent these items from functioning correctly and these will benefit from a light dusting as part of the general cleaning performed at a hospital. By engaging the right service contractor they will be able to advise you on all facets of the door or assist you with product options that you may like to discuss. For example, a number of market leading automatic operators
provide door management systems that permit easy single point control of all automatic doors within the building. This allows you to control and monitor parameters including locking, opening distances, motion sensors all from the click of a button. One example of this is a feature called a pharmacy function which enables automatic doors to open just enough to complete transactions with a customer and pass through the entrance prescription drugs particularly after hours when security is of the upmost importance. While the internal sensor is activated the door will open to a set distance (adjustable) and lock in this position. Fire Doors Most of the time fire doors function just like any other door, however when a fire emergency occurs they perform a vital role; by providing a safe route to escape and an effective barrier to delay the spread of fire and smoke. An example of this type of door often seen in hospital buildings are pairs of doors along passageways which are generally held open by electromagnetic hold open devices and released by the fire control panel when it receives a signal of smoke or fire within the hospital.
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Smart access means reliability TECHNICAL PAPERS
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
TECHNICAL PAPERS A fire door is more than just the door leaf. It is the complete assembly including: door leaf, frame, vision panels, intumescent seals and all attached door hardware. Fire door assemblies are currently tested in Australia to meet AS1530.4 & AS1905.1, compliance of all components must meet the rigorous demands of a fire test which is legislated and documented in the National Construction Code (NCC). The most commonly specified integrity for fire doorset assemblies installed in hospitals are rated to either one hour, two hour and in some cases up to a four hour period. Fire doors must be self-latching at all times so deadbolts cannot be installed nor European style locks that include a latch bolt and deadbolt. The reason deadbolts cannot be used is that the bolt could be left extended whilst the door is in the open position and prevent the door from closing fully, thus rendering the fire door assembly worthless in the prevention of smoke and fire. Fire doors must also be self-closing at all times to ensure the door closes after every use. Holding open fire doors can only occur if the device is either an electro mechanical or electro hydraulic hold open device that releases the door upon sensing fire or smoke, wedging open doors certainly does not comply. Door closers perform a very important job in ensuring the door remains closed so selecting the right door closer is highly important. Door closers often need to overcome air pressure differentials even on internal doors such as those fitted in stair wells and as such selecting the right strength of door closer is important. Australian standard AS4145.5 or European Standard EN1154 provides information pertaining to door closer sizing and contains a guide to assist selection of closers based on door widths. If your fire door is not closing efficiently it maybe that the closer installed has inadequate strength or simply if the closer model permits some additional spring adjustment. A professional expert or service team can assist with adjustment or advising you of the right model and installation for your application.
Australian standard AS1851 Routine service of fire protection systems and equipment requires building owners to conduct fire and smoke door inspections every six months for hinged doors and every three months for sliding fire doors. Doors that are of high usage may require a more rigorous routine service. Some of the inspection criteria is as follows, the door frame is not distorted, door leaves and frames are tagged in accordance with AS1905.1, door gaps are in accordance with AS1905.1, ensure hinges, latch, door closer and sequencing device (if present) are functioning and securely fastened, perimeter seals are in good condition and that the door leaf is not delaminating or damaged. Inspection of the fire door and frame should also include a check to ensure they are free from non-approved fittings and fixtures or attachments. All items installed on to a fire door or frame must be approved for use by a NATA fire testing laboratory, and have a certificate of compliance non-conforming items would need to be removed. All routine service and inspection records are to be kept as part of your obligations. These are just some of the requirements for routine inspection and more details can be found by reading AS1851.
delayed closing function. Often this function is not used or adjusted despite many users within a hospital who could benefit from this function. The delayed closing function when set dwells the doors closing cycle when the door is opened beyond typically 70 degrees. This allows people more time to pass through the door unhindered. Patients in wheelchairs or using walking aids can benefit greatly from having increased time to move through a door way. Even staff who move patients on stretchers or hospital beds from one location to another can benefit by delayed closing, avoiding doors from rubbing against beds and patients as they are wheeled through entrances. Prevention is better than cure wellmaintained doors, operators and hardware can provide safe and efficient use over many years and are vital to the smooth operation of any business. Consider the risks of inefficiently operating doors and operable wall systems – reduced security and safety, increased downtime, productivity loss, customer complaints, acoustic reduction, soaring air-conditioning and heating costs. This article is courtesy of Dorma Kaba
Door closers further to the requirements of smoke and fire doors, door closers serve many functions in the hospital environment they assist with climate control (loss of heating or cooling), security, acoustics and prevention of infectious diseases in isolation airlocks. Properly adjusted door closers are more than just the speed control. Often door closers are sped up to close a door which results in doors slamming and are very unsafe. Consider the young child resting a hand on the frame when a door closes violently or an elderly or injured patient that is knocked as a result of the door closing too fast. Spring strength of the door closer should be adjusted to ensure the door closer has enough strength to close the door and speed control valves adjusted to close the door in a safe manner. Another adjustment for door closers often required in a hospital is a
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TECHNICAL PAPERS
Integrated fire mode testing GEOFF FLOWER* I SENIOR ENGINEER (FIRE) A.G. COOMBS ADVISORY
Modern fire protection systems are now often integrated into other building systems and require a comprehensive testing approach to assure they will operate when required.
I
n the past, fire protection systems in buildings were relatively straightforward and generally operated independently of other systems. Over the last 10 years, due mainly to the introduction of performance based solutions, these systems have become increasingly integrated with other building systems,
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especially air conditioning and ventilation systems. While system integration can have significant benefits, it usually results in more complex systems that have a higher susceptibility to failure. Additionally, the failure of highly integrated system can have the potential to escalate the impact
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
of a fire. For instance, an air conditioning system operating incorrectly in fire mode may actively spread smoke throughout a building. Another issue with integrated systems is that they can be very challenging and time consuming to test and maintain to the level required to provide a high degree of surety of operation and
TECHNICAL PAPERS adequately discharge duty of care obligations. In responding to this change, installation and maintenance standards have had an increasing focus on integrated fire mode testing. In responding to this change, installation and maintenance standards have had an increasing focus on integrated fire mode testing. However it is important to understand the extent of testing required by these standards and the level of integrated systems surety it provides: • Testing of individual fire systems confirms the operation within the system but provides only limited confirmation of system interfaces and overall integrated operation. • Typical interface tests in line with the requirements of Australian Standard AS 1851 Maintenance of Fire Protection Systems, confirms interfaces between a detection zone and a ventilation system zone or sub system level. This may not confirm the successful operation of all items of equipment (e.g. door operations) under alarm conditions or multiple alarm zones within a building zone. Complex integrated systems need a clear framework for testing.
Integrated Fire Mode Testing (IFMT) is a comprehensive approach to the testing of integrated systems and involves the operational testing of the functional interfaces between systems in fire mode. Undertaken in conjunction with, or in addition to, individual system commissioning and testing IFMT will confirm that the integrated systems operate together as intended. A key aspect when considering IFMT is determining the extent of testing needed to achieve the required level of operational surety. Idyllically, each input device in the entire integrated system would be initiated and the operation of each output or response would be confirmed. But regularly conducting such detailed testing would result in impractical timeframes and unaffordable costs. Alternatively, simple tests that verify minimal high level interfaces may not be adequate to address duty of care concerns. The appropriate level of testing to suit the installed systems and operational requirements must be determined for a particular facility. This may include testing a number of detection Alarm Zones and confirming operation of individual items of Equipment.
The key to a successful IFMT approach is a well-documented interface cause and effect matrix; usually called an Integrated Fire Mode Matrix. This is particularly important in buildings with performance based ‘fire engineered’ solutions where non typical interfaces are present that are not well covered by generic standards. If a complete and accurate Fire Mode Matrix is not available this should be developed by an appropriately qualified and experienced fire services specialist. This matrix assists in addressing the building’s prescribed essential safety measures by defining the basis of the testing regime, the appropriate scope and extent of testing, and how correct operation is to be verified. The matrix also provides insights into coordination between systems specialists. A detailed test plan should be documented to assure the operation of integrated fire systems and address duty of care requirements. *Specialising in Fire Safety and Fire Protection Engineering for 20 years Geoff has held senior positions with consulting engineers, fire testing laboratory, system installers and maintainers. Geoff Flower, Senior Engineer (Fire) A.G. Coombs Advisory, T: +61 3 9248 2700 E: gflower@agcoombs.com.au
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The Institute PAPERS of Hospital Engineering, Australia (IHEA) are TECHNICAL pleased to invite you to the OandMs IHEA Healthcare Facilities Management Conference (HFMC 2016) to be held on 19 -21 October 2016.
CONFERENCE THEME This year’s conference theme is ‘Managing Change / Changing Management’ and the conference aims to provide some insights into the challenges that change presents and the opportunities available to address these challenges, to provide delegates with some solutions/ information to apply to their work in future and to provide access to new systems, processes & equipment to improve delivery of healthcare engineering and other facility management services.
CONFERENCE PROGRAM HFMC 2016 are pleased to introduce two keynote speakers: ANDREW HORABIN is a professional speaker, facilitator, author, comedian and award-winning singer/songwriter. Over 22 years, he has worked with big and small business, Government departments, local councils, professional associations and NGO’s across Australia and overseas – with groups and audiences totalling hundreds of thousands of people. He has trained state, federal and international police, including undercover officers, surveillance operatives, informant handlers, intel analysts and senior managers of serious crime – working with police from 40 countries. Andrew is the author of three books including BULLSHIFT: How to get more honesty and straight talk at work. GRAEME COWAN is one of Australia’s leading speakers and authors in the area of mental health at work and is a frequently sought-out expert opinion on the causes of workplace stress & stress management in the workplace, mental health awareness & managing change in the workplace. Graeme is obsessed with helping to create robust cultures that thrive. Best known for his award-winning BACK FROM THE BRINK book series and the report Best Practice in Managing Mental Health in the Workplace, he is also the creator of R U OK? Day, the national suicide prevention campaign, and the Director of R U OK? at Work.
OPTIONAL MASTER CLASS WORKSHOP The Conference will also be offering an optional master class workshop on Development & Implementation of National Legionella Guidelines. The master class will include presentations from key parties involved in the development of the enHealth “Guidelines for Legionella Control in the Operation and Maintenance of Water Distribution Systems in Health and Aged Care Facilities”, showcase some technologies available for the control of Legionella and outline some tools available to ensure compliance with guidelines.
TECHNICAL SITE TOURS HFMC 2016 will also feature 3 pre-conference technical site tours to be held on the afternoon of Wednesday 19 October 2016: • South Australian Health & Medical Research Institute (SAHMRI) • Adelaide Oval • New Royal Adelaide Hospital (NRAH)
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
TECHNICAL PAPERS
19-21 OCTOBER 2016 | ADELAIDE OVAL, SOUTH AUSTRALIA
IHEA Healthcare Facilities Management Conference 2016
MANAGING CHANGE / CHANGING MANAGEMENT
REGISTER NOW AT HFMC2016.ORG.AU Visit www.HFMC2016.org.au to secure your attendance at this year’s Conference including: • Plenary Sessions • Optional Master Class Workshop • Technical Tours • Welcome Reception at 2KW Bar • Trade Night at Adelaide Oval • Conference Dinner at Adelaide Oval • Partners Program The conference aims to bring together all the key contributors to the delivery of healthcare FM services and we look forward to you joining us in October.
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS
Power Quality
and what it means for your health care facility LUKE STRATFORD I MANAGING DIRECTOR OF QUALITY ENERGY
Power quality issues are becoming extremely important as more medical equipment use microprocessor controls & switched DC power supplies. Externally, internal induced power surges & harmonics can have a dramatic effect on equipment performance which for most industries is less than ideal, in hospitals in can be a life & death scenario. That might seem dramatic but why not look & consider Power Factor Correction to improve your power efficiency & greatly reduce your power costs?
T
he effectiveness of successful equipment management can be greatly affected by poor power quality in today’s hospitals. Resolving power quality problems can have a dramatic impact on equipment performance, uptime & cost of maintenance. In a hospital setting lives depend on electrical power. Hospitals have a responsibility to the public to provide a reliable power system. Unfortunately however specified and reliable systems are too often cut back to code minimums during the engineering phase of a project. There are five types of power problems that are most common in health care & other institutional facilities: • Outages – Power outages occur when utility power goes out and emergency generators come on line. • Brownouts & sustained over-voltage – Brownouts occur when the electrical voltage level dips below or rises above the specified range. Equipment is still powered but is often damaged as the voltage level is lower or higher than the equipment can handle • Voltage surges – These short-period increases in voltage — commonly referred to as voltage spikes — can damage electronics within medical equipment and data servers. • Noise – Electrical noise consists of small but rapid & repetitive power fluctuations that cause an inconsistent flow of a sine wave of power to equipment. • Harmonics – Harmonics are voltages or currents at frequencies that are a multiple of the fundamental frequency. In most systems the fundamental frequency is 50 hertz. Harmonics can cause overloading of conductors, transformers & overheating of motors, blown fuses & unlexplained tripping of circuit breakers.The cost to replace this equipment as well
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as a loss of productivity because of system downtime are other causes for concern. Any of these problems can cause chaos in the electrical system of a health care facility, emergency power systems should be designed so that each potential problem is taken into account & addressed, if at all possible. The design engineer is responsible for passing on any information regarding critical facility systems to the facility executive & architect during the design process, as well as ensuring that this information is received & understood. For those of you that are looking more towards cost reduction one simple way to reduce your power bill is to improve your power efficiency. That’s not news to anyone but it’s become a bigger issue these days because many more power distributers are charging a kVA demand tariff on medium to large businesses power bills. The end result is that businesses with a poor Power Factor are being penalised heavily on their power bills. Many of them, however don’t realise that. A lot of businesses focus only on their consumption charges also known as their kilowatt hour rate, which are the charges that are passed on by their power retailer. They don’t pay the same attention to their network charges which are passed on by the power distributer. Unfortunately these network charges can account for as much as 75% of a company’s total power bill. Recent demand tariff changes by Energex in South East Queensland, Citipower & Powercor in Victoria have meant that larger energy consumers’ power bills may have increased due to these changes. The recent switch from a “kW demand” to a “kVA demand” means that if customers are running at a poor power factor (which accounts for almost all businesses) there will be a significant increase in the power costs associated with these changes. Don’t think that if you are not in Victoria or SEQ
TECHNICAL PAPERS you have escaped the worst of it. These recent changes are helping bring Energex, Citipower & Powercor in line with other distributers around Australia who have already been charging the additional costs. Inefficient electrical systems tend to use a large quantity of ‘reactive’ power (kVAr), which represents the power lost in the operation of inductive equipment such as transformers and electric motors. This invariably increases the total power load represented by your kVA – and reduces your overall energy efficiency, or ‘Power Factor’. Power Factor is the ratio between your kVA or total power load & your kW or the actual power working for your business. Power Factor is measured on a scale of between 0 to 1.0 inductive, 1.0 to 0 capacitive with 1.0 representing optimal energy efficiency. Here is a simple example of a business that has a maximum demand of 500 kVA & is operating with a Power Factor of 0.8. If they were to improve their Power Factor to 0.99, their kVA would drop considerably to 404 kVA. When you consider some business are being charged as much as $22 per kVA, this makes a considerable difference on their electricity bill. Demand Charges 500 kVA x $22 per kVA = $11,000 404 kVA x $22 per kVA = $8,888 That’s a savings of $2,112 each month. As you can see above a poor Power Factor can have a large impact on the price you are paying for your electricity. By installing Power Factor Correction equipment you are minimising wasted energy, improving plant efficiency & saving your business money. Why pay your power distributor for your reactive power when you can generate your own? Power Factor Correction equipment can also rectify many overloading issues & give you the option to expand your plant without upgrading transformers or supply equipment. Everywhere you look in Australia the demand and need for Power Factor Correction is growing. Generally it’s just a matter of being informed enough to know the right questions to ask to help identify if your business could benefit from PFC equipment. Whether your Hospital or Health Care Facitlity is experiencing power quality issues, looking to future proof your electrical system or even save money on your power bill there are options alplenty to help with this. Luke Stratford is the Managing Director of Quality Energy. Quality Energy are leading the electrical industry in commercial and industrial power quality. They specialise in Power Quality Audits, supplying Power Quality Products and the design, manufacture, installation and maintenance of Power Factor Correction Systems throughout Australia and New Zealand. With over 20 years experience and some of Australians largest hospitals as current clients, Quality Energy would be happy to answer any questions you may have. For more information, visit http://www.qualityenergy.com.au/
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TECHNICAL PAPERS
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Healthy water savings in hospitals GUENTER HAUBER-DAVIDSON MANAGING DIRECTOR OF WATERGROUP
Paying $30,000 to $80,000 less for water per year is readily possible – with the right approach.
H
ospitals use around 200,000 litres of water per bed per year. Typically at least 15 to 25% of this water consumption could readily be saved. For a mid-size 300 bed hospital that translates into 10 to 15 million litres of water every year, or $35,000 to $50,000 per year at a very attractive payback of three to five years.
they are ready to save as much water and money as possible within a five year payback period. A company like WaterGroup can then prepare a full assessment of all possible savings measures. It can even provide funding stretched over a longer payback period making the process not just entirely cost neutral but in fact cash flow positive from day one.
For cash strapped health services that is not just a welcome avoided cost, but also a great environmental outcome. Where would you rather have your cash: Down the drain or in your pocket available for other urgent tasks?
For example, if a study identifies $50,000 worth of annual water savings related to an investment package of $250,000 then repayment of this loan can be organised stretching over 7 years. That would make it $35,000 plus interest, thus a saving of $15,000 from year One, and a water saving of 15 ML/yr on top of that. That’s six Olympic size pools worth of water every year!
If the story is so good why don’t more hospitals grab these savings? The problem is often a perception that it is too hard to do, not knowing where to start and the believe that it is not worthwhile, says Guenter HauberDavidson, Managing Director of WaterGroup a company specialised to bring performance contracted water savings to the Australian health care sector. He agrees that the old method of doing an audit, identifying a set of discrete measures, then writing a business case for it, fighting to have it put into the budget, then seeing it taken out, waiting again, until eventually a small individual measure such as flow restricting taps can be implemented, is way too hard. Instead, he advocates quite a different, much more holistic way. A hospital, or a health area service, declares that
A number of health care services such as Gippsland Health in Victoria or Northern Rivers by NSW Health have recently undertaken such a process as part of an Energy Performance Contract. These contracts are often part of larger government programs. They can become lengthy, complex and unwieldy. However, it need not be like that. An arrangement like this could readily be drawn up for just water alone making the process much simpler, quicker and less bureaucratic. Performance contracting water savings compared to energy involves far less complex measures, a lower contract volume and less disruption to the hospital’s processes and operations
during its implementation. It can thus be done with far less overhead and input. It places little demands on the resources of stretched health facility managers – for a great financial and environmental return.
WHERE DO SAVINGS COME FROM? Savings are typically broken down into three key categories: • Water Efficiency Measures. These intend to achieve the same outcome with reduced water use. This comprises low flow and low flush solutions such as flow restrictors on taps and basins, showers and toilet/ urinal modifications (although these often do not fit into the specified payback criteria). • Water Management. This measure intends to provide a hospital/ health area with greater knowledge and control of their water consumption. More details below. • Water Substitution. This includes initiatives such as rain and stormwater harvesting, condensate, reverse osmosis and steriliser water reuse, all of which provide alternative water supplies to meet non-potable water demands. Some examples follow.
WATER MANAGEMENT Smart metering key water uses is an effective way of monitoring water consumption and the early detection of abnormal use patterns. WaterGroup,
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TECHNICAL PAPERS which has considerable experience with hospitals, can identify significant water saving options (a key part of which will be via the active leak detection capabilities). To detect significant leakage using smart monitoring, we would collect detailed diurnal water usage data to check the day/night and weekdays/ weekend variations. As more data is collated, we will include seasonal patterns. Smart monitoring is to analyse and check: • the base flow rates; • periods when a section should be using no or little water; and • sub-metered volumes against the total. This can then form the basis for more pinpointed leakage detection or abnormal consumption.
WATER SUBSTITUTION MEASURES This comprises rain or storm water harvesting, reuse of water from sources such as at the central sterilisation system, RO reject water from dialysis machines and the capture of condensation from air handling units. Existing rainwater harvesting systems – which we often find in a dysfunctional state or running far below capacity. Fully enabling and enhancing these usually is a well worthwhile measure. Our preferred feed in point for this water are toilet flushing header tanks or cooling towers. No treatment of this water is required as the existing cooling tower water treatment system is already capable of dealing with a far worse quality of water, and it is heavily regulated and regularly checked and audited. WaterGroup has installed a number of such systems like without any issues due to the sound engineering rational and good design principles behind it.
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TECHNICAL PAPERS • Further sub-metering beyond a basic level where implementation costs typically exceed available savings leading to a poor payback.
OTHER MEASURES OFTEN CONSIDERED BUT SELDOM INCLUDED Due to poor payback there are always some measures that may not be feasible. Depending on site conditions these may include: • Water reuse schemes where due to a lack of a central feed in point such as e.g. a header tanks it becomes too difficult to retrofit a water reuse system. Long complicated routes between capturing the water, storing it and delivering it to the intended reuse is another “killer”. • Sadly, this often applies to new rainwater harvesting systems where
So there you go. Achieving fantastic water savings at hospitals and health care centres for a healthy return is possible.
the existing infrastructure does not readily support implementation or expansion of schemes, increasing capital costs. • Stormwater harvesting where capital costs, especially for an involved treatment and control system, are just too high. • Toilet replacements. To reliably increase toilet water efficiency at hospitals and health care centres, often toilet pans would need to be replaced to avoid potential blockage issues with low volume flushes for pans not suitable for it. • Waterless urinals. A high retrofit cost and ongoing O&M costs make this an economically less attractive retrofit option.
Best of all, it does not need to cost the world. In fact, it can be arranged to be cash flow positive from day one. Properly set up, a comprehensive water savings program can deliver $30,00 to $50,000 in annual cost savings to just about any mid-size hospital for a relatively small input in terms of time and resources from the Hospital’s or Area Health Centre’s facility and management staff. For further information contact Guenter Hauber-Davidson, Managing Director, WaterGroup, www.watergroup.com.au ghd@watergroup.com.au ph 02 9499 8795.
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ADVERTORIAL
How to avoid upfront costs for a professionally painted building On-going painting maintenance keeps your hospital looking well-presented. Cost and affordability, however, can prevent this from being implemented.
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o counter this, look for a long-term painting maintenance solution that lets you complete as much work you’d like upfront, while allowing you to amortise the cost of these works over the agreed maintenance period so you don’t incur immediate costs. The maintenance component ensures your building stays well-presented, and because costs are broken down into smaller payments over time, you’ll better manage your budget and cash flow. This also lets you sustain maintenance for longer periods.
Furthermore, surface preparation, building repair works as well as fixing broken down paint on windows and doors are part and parcel of preventative painting maintenance. This delivers lasting, quality finishes able to extend asset life span and stave off expensive replacement costs. Meanwhile, to retain that ‘as new’ look, annual pressure washing removes dirt and grime before painted surfaces soiled by time and weather are repainted. Engaging specialists in property maintenance like Programmed for such painting maintenance also gives you access to unique expertise, such
as abseil painting teams who can paint high, difficult to access areas. You won’t have to hide your hospital’s façade’s behind scaffolds during a repaint. All associated risks are also managed on your behalf. Don’t wait until paint cracks and peels. Speak to the experts at Programmed today and see how a maintenance programme can be tailored to modernise your hospital’s appearance and keep it in good condition – without the upfront cost. 1800 620 911 programmed.com.au
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TECHNICAL PAPERS
Safety in design –
Compliance that saves time, money and lives CARL SACHS I PRINCIPAL CONSULTANT, WORKPLACE ACCESS & SAFETY
Making changes with a pencil rather than a builder saves a lot of time and money. It can also save lives.
T
he duty of designers to eliminate hazards – whether they are introduced in the construction phase, or in the decades of maintenance that follow – makes facility managers and tenants the big winners from Australia’s Safe Design of Structures Code of Practice. Why? Because buildings designed to be safer are also inherently easier to manage over their lifetimes. There is less paperwork, simpler equipment and fewer problems
finding people to get the job done. Fall prevention for safety is particularly complex and clients love facility managers and fall prevention/access designers who can cut down the compliance burden. Almost anyone with a pencil is a “designer” who can win savings for facilities managers.
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TECHNICAL PAPERS
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TECHNICAL PAPERS Under work health and safety legislation, anyone making decisions that influence the design outcome is obliged to consider safety in design, including architects, designers, engineers and builders operating under design and construct (D&C) contracts. Even a contractor carrying out design work as part of their brief, such as a fire engineer, has duties and obligations. The obligation concerns structures including buildings and towers or any component of a structure.
FALL PREVENTION SIMPLIFIED WITH SMART DESIGN Many serious height safety hazards are particularly easy to eliminate at the design stage. For example, footpaths can be widened and strengthened to accommodate elevated work platforms (EWPs) and scissor lifts, eliminating the need for costly and high risk abseil access. Gutters can be repositioned so that they can be safely serviced away from exposed edges that would require rope access systems and highly skilled, expensive labour.
TRANSFERRING INFORMATION TO THE CONSTRUCTION STAGE (SECTIONS 22 AND 295) Designers are required to transfer information to the builder and occupant relating to: • the purpose for which the structure was designed; • how it is to be maintained and result of any calculations, testing, analysis or examination. In particular, the COP deals with features that present access problems; for example, how to clean a façade with architectural features that impede abseil access. In practice, this means providing a safety report that includes the designer’s risk assessment and actions the designer has considered to control risks. If, for example, the designer controls risks with a static line system, the safety report would include test results of the anchorages, commissioning testing information and a layout/rigging plan for the user documenting the purpose of the system.
The working at height hazards to be addressed at the design stage will vary with each building but facility managers and design consultants should begin by considering the routine maintenance of common building elements and plant, such as: • external windows and façade • cooling towers • air-conditioning/HVAC • gutters • fire extraction and fire services • solar systems The following sections are extracts from the recently amended Work Health and Safety (Safe Design of Structures) Code of Practice (2015) (COP).
CONSIDER THE LIFECYCLE AND FREQUENCY OF ACCESS (SECTION 22) Aside from the features of the building, designers need to be aware of how the asset will be maintained throughout its life and apply lifetime costing accounting while observing the hierarchy of controls. This means understanding the likely competency and capability of the people actually performing the work. For instance, planning to deploy highly skilled rope access workers with rescue procedures backed up by medical crews may be realistic for oil rigs and mine sites. Trying to rescue a suspended worker on a high-rise building in the CBD is not as manageable, and different control measures would be appropriate.
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS
FOUR STAGES OF SAFE DESIGN The Safe Design of Structures Code of Practice recommends an approach that “integrates the risk management process in the design phases and encourages collaboration between a client, designer and constructor” and describes four stages: 1. Predesign 2. C onceptual and schematic design phase 3. Design development phase 4. Review of control measures. 1. Pre-design • Establishing the design context in terms of the structure, scope, complexity of access, level of hazard;
• consulting with stakeholders, identifying hazards (understanding safety requirements, access locations, maintenance points); and • researching control measures (BCA requirements, industry stats, hazard alerts, research and testing done on similar designs) 2. Conceptual and schematic design phase • Systematic hazard identification (examples from Table 1) relating to fall prevention are: o f loor surfaces to prevent slips and trips om aintenance access to plant and equipment o safe access and egress o t raffic management (specifically drop zones below work areas)
• competency of users;
o installing lifts
• roles and responsibilities of different people involved in the project;
o window heights and cleaning
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
o anchorage points for building maintenance and cleaning o scaffolding o surface characteristic such as fragility, slip resistance and pitch o atriums o working alone o confined spaces o voids o facades o plant rooms o solar o telecommunications Hazards should be systematically identified as early as possible in the development of the concept. Regulation 61 deals with musculoskeletal disorders arising from particular tasks (eg: working on very steep inclines).
TECHNICAL PAPERS
Item
Frequency of access(times per annum)
Windows
2
Façade
1 every 5 years
Cooling towers
24
Air-conditioning
6
Extraction
4
Fire exhausts
2
Gutters
1
Table 1
3. Design development phase Here the structures are converted into detailed drawings and technical specifications. Control measures are finalized and construction documentation prepared. The completed design is given to the client.
3.1 Developing a set of options in accordance with the hierarchy of control. 3.2 B alancing the costs with the benefits and risk mitigation.
This involves:
3.3 Evaluating the design solution. 3.4 F inalising the design and preparing the safety report and other risk control documentation for the structure’s lifecycle.
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TECHNICAL PAPERS
Assess what would happen if someone was exposed to the hazard, and the likelihood of it happening. This provides guidance on the emphasis to be placed on risk mitigation measures. The more serious the degree of harm, the more time and effort should be diverted to eliminating or minimising the risks. Controls are to be implemented from recognisable standards, such as the BCA, NCC and Australian Standards. 4. Review of control measures Review the measures and fine tune them during the construction process, looking for opportunities to refine the design and further reduce risk.
SAFE DESIGN FOR THE FIVE STAGES OF A BUILDING’S LIFE CYCLE The model Safe Design of Structures Code of Practice also describes five
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stages of a structures life cycle that must be managed safely: • Design for safe construction • Design to facilitate safe use • Design for safe maintenance • Modification • Demolition and dismantling Although this article focuses on stage two – design to facilitate safe use – there is overlap between control measures used at this stage and at the tail-end of the construction stage, particularly during building detailing and defects liability periods.
GET IT RIGHT FROM THE START Safe design in structures is now an obligation for designers. It’s also an opportunity to make a building demonstrably more functional throughout its entire life cycle. While
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
the concept is simple and intuitive, the height safety details that make safe design a reality are not. Get the expert advice from specialists, document the results and pass on the information to the grateful client.
ABOUT Carl Sachs is principal consultant of market leading fall prevention consultancy Workplace Access & Safety. The company was recently appointed to act as Fall Prevention Consultant on the ABC’s $176 million upgrade in South Melbourne, Monash University’s $140 million new Learning and Teaching Building and the City of Sydney’s heritage listed $400k St Peters Town Hall. Independently accredited by the National Association of Testing Authorities and SAI™ Global for design services, Workplace Access & Safety’s team of consultants compromise the most highly accredited providers of fall prevention design services in Australia. Phone contacted on 1300 552 984, or go to www.workplaceaccess.com.au.
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TECHNICAL PAPERS
First results of an Electrochemical Water Management System in Australia SERGIO FERRO I TONY AMORICO I ERICA DONNER
S
ite-specific water quality management plans are increasingly being implemented in Australian health and aged-care facilities in an effort to prevent water-borne infections in vulnerable patients. Newly developed guidelines, such as the enHealth ‘Guidelines for Legionella control in the operation and maintenance of water distribution systems in health and aged care facilities’ (Australian Government, 2015), underline the importance of operational controls such as the installation of continuous in-line disinfection systems and regular flushing of outlets for limiting Legionella bacterial counts and other microbiological risks. Legionella bacteria are the causative agents of Legionnaires’ disease (characterised by severe pneumonia) and Pontiac fever (a milder form of respiratory infection). Legionnaires’ disease is extremely serious in vulnerable patients (e.g. the immunocompromised, elderly, and newborn babies), with mortality rates as high as 40% for patients contracting the disease in health-care settings. This paper demonstrates successful Legionella risk mitigation in an Australian health-care facility following installation and optimisation of an on-site electrochemical water disinfection system. In May 2016, an in-line Ecas4 water disinfection system (WDS) was installed at the North Eastern Community Hospital (NECH) in Adelaide, where microbiological water quality monitoring had indicated systemic Legionella contamination of the water
distribution system. This not-for-profit, community owned, private hospital and government-funded residential aged-care facility was established in 1973 and currently has 60 beds, including a day surgery unit (8 beds), two operating theatres and a gastroenterology procedure room, as well as an aged care facility that provides permanent and respite accommodation for 84 residents. Substantial investment in building works have resulted in significant structural changes over the last 40 years, including a $2.5 million hospital extension in 1991 and the addition of the purpose-built aged-care facility in 2001. Importantly, the increased complexity of water distribution systems caused by building extensions is one of the Legionella risk factors identified in the enHealth Guidelines for Legionella control. Extensions and renovations often result in lengths of pipe being cut-off or capped, for example, thereby creating ‘dead legs’ with reduced water flow which are ideal environments for Legionella colonisation and biofilm growth. This is therefore a common issue in large, complex structures such as hospitals. This particular facility is organized over three storeys and has an average annual water consumption of about 8000 cubic metres. The hot water system comprises four circuits and two risers. In order to minimize the risks of waterborne disease, the hot water was previously heated to 80 °C, so as to be delivered to the thermostatic mixing valves prior to points of use at approximately 70 °C. Despite the
high energy costs, this approach proved to be insufficient, as Legionella and microbial cell counts (measured by standard plate count methods) have exceeded potable water quality guideline limits on multiple occasions in the last few years. Heat disinfection of water supply networks in healthcare facilities is complicated by the installation of mixers to prevent patient scalding hazards. This can result in sections of the pipe prior to the point of delivery frequently holding warm water suitable for Legionella growth. In order to manage proactively this risk, an in-line Ecas4 WDS was installed. This technology facilitates continuous dosing of low amounts of Anolyte, a diluted, slightly saline solution that contains active chlorine mainly in the form of hypochlorous acid (HOCl). Hypochlorous acid is a neutral (i.e., uncharged) molecule with low molecular weight that is better able to penetrate the cell walls of microorganisms than other forms of chlorine, and is thus a powerful disinfection agent, effectively inactivating bacterial cells. Continuous in-line dosing of the dilute Anolyte solution is, however, safe for higher organisms (e.g. humans) and thus suitable for use in potable water. Due to its neutral pH, it is also less aggressive on treated surfaces and infrastructure than many other disinfection agents (e.g. bleach). The Anolyte synthesis is done on-site in the Ecas4 WDS reactor (subject to worldwide patent). This is equipped with four reaction chambers and special anodes, and uses a catalytic
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS mixture of ceramic metal oxides (not including ruthenium or other hazardous components). A minimal dose of Anolyte is injected into the hot and cold water distribution systems to provide continuous disinfection without altering the potability of the water. This continuous dosing facilitates the elimination and ongoing control of microbiological contaminants, including pathogens such as Legionella. In addition, it can also help prevent the build-up of biofilms (sessile microbial communities) that are commonly found on the surfaces of pipe materials and typically implicated in increased microbiological risks. Installation of the Ecas4 dosing system at the NECH was preceded by baseline sampling of the tap water throughout the hospital and of the biofilms on the internal surfaces of copper and plastic water distribution pipes in order to determine the initial contamination level and facilitate appropriate verification monitoring of the disinfection process and other water management activities. Microbiological water quality monitoring was conducted using multiple methods in this case study. Total microbial counts (heterotrophic colony counts) and Legionella plate counts (Legionella pneumophila serogroups, and other Legionella species) were conducted by a NATA accredited laboratory used by the hospital for regular monitoring, while complementary diagnostic and verification monitoring, including DNA-
based quantitative polymerase chain reaction (qPCR) analysis of the total microbial load and Legionella burden was carried out by researchers at the University of South Australia. Baseline sampling was conducted on two occasions in the week prior to the system installation on the 12th May. Post-installation sampling was conducted on the first and eight day after installation and fortnightly thereafter. On each sampling occasion, samples are collected from the hot water taps of the ensuite hand basins in eight private rooms, and from the hand basins in three shared bathrooms. A sample is also taken from the rooftop water storage tank. Further samples are taken as needed for diagnostic purposes, e.g., to test the quality of the incoming potable water and holding tank water, to investigate the effects of more frequent tap flushing, to test the quality of water in the boilers, the quality and temperature of water in the return pipes, etc. Samples are analysed for water temperature at the point of sampling, free and total chlorine, redox potential, pH, electrical conductivity, heterotrophic colony counts, Legionella plate counts (serotyping) and Legionella genomic units (qPCR). Table 1 reports the results obtained by the hospital’s regular NATA accredited testing laboratory using the heterotrophic colony count (HCC) and Legionella plate count methods. Legionella pneumophila serogroup 1
and serogroups 2-14 have not been detected in this system either before or after installation of the WDS. However, there had been consistent positive results for other Legionella species during baseline testing and during the WDS installation and start-up. As is often observed during water quality intervention programs, the water quality was negatively impacted in the period shortly following installation as the active agent in the treatment system presumably interacted with the biofilms in the pipe network and microbial debris was subsequently released and flushed from the system. Additional tap flushing was implemented by the hospital staff during this period as an extra measure to help flush the debris from the system and maximise the mixing of the Anolyte solution within the affected pipe network. By the third post-installation sampling event (Day 22 post installation), the plate count results showed consistently improved water quality throughout the system, with no sample points returning positive Legionella plate counts since that time. The positive effect on the water quality following installation of the WDS was further confirmed by the Legionella qPCR analysis. This is a DNA-based method which is significantly more specific and sensitive than the plate count method and highly reproducible. The method is very specific to Legionella species as it directly targets a DNA sequence that is characteristic of these bacteria. This specificity gives
Table 1. “other Legionella species” counts – data from the NECH’s monitoring lab.
Sampling location
4th May (baseline)
9th May (baseline)
13th May (Day 1)
20th May (Day 8)
3rd June (Day 22)
17th June (Day 36)
1st July (Day 50)
29th July (Day 78)
12th August (Day 92)
Room A
<10
<10
<10
<10
<10
<10
<10
<10
<10
Room B
<10
100
500
600
<10
<10
<10
<10
<10
Room C
<10
<10
<10
<10
<10
<10
<10
<10
<10
Room D
100
<10
<10
10
<10
<10
<10
<10
<10
Room E
<10
100
<10
10
<10
<10
<10
<10
<10
Room F
<10
200
<10
<10
<10
<10
<10
<10
<10
Room G
<10
<10
20
<10
<10
<10
<10
<10
<10
Room I
100
<10
<10
<10
<10
<10
<10
<10
<10
Room J
<10
<10
<10
<10
<10
<10
<10
<10
<10
Room K
<10
<10
<10
<10
<10
<10
<10
<10
<10
Room L
<10
<10
<10
600
<10
<10
<10
<10
<10
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
TECHNICAL PAPERS the qPCR method a lower risk of false positives than the currently standard plate count method. In this case study, the qPCR data (which are expressed in genomic units per mL of water, Figure 1) show very clearly that the Legionella counts in the tested ensuites and bathrooms decreased significantly following installation of the Ecas4 in-line dosing system. Figure 1 shows the average qPCR results from the same 11 rooms sampled repeatedly throughout the case study. The large error bars on the baseline samples to the left of the graph indicate the extremely variable water quality that was typical in this water distribution system prior to the installation of the WDS. This is common under such conditions as the water quality can vary significantly depending on the length of time since the tap was last used. Legionella water quality testing is done by taking the first water that comes out of the tap, so if the water has been sitting in the pipe for some time it
may be carrying a high bacterial load when the tap is first turned on. Figure 2 clearly demonstrates however, that the Legionella load decreased significantly over the course of this case study, and a consistently low Legionella cell count was achieved within 2-3 weeks of continuous treatment.
Figure 2. Correlation between free chlorine and qPCR Legionella species quantification data for water sampled from the hot water taps of basins in 11 hospital rooms; the same 11 rooms were sampled on each occasion.
Figure 1. DNA-based Legionella species quantification data for water sampled from the hot water taps of basins in 11 hospital rooms; the same 11 basins were sampled on each occasion.
The improvement in water quality illustrated in Table 1 and Figure 1 is linked to the establishment of increased chlorine residual in the water supply network as a result of the Anolyte dosing. For example, Figure 2 shows
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS the correlation of positive Legionella species counts and free chlorine in the sampled tap water. In Figure 2, red dots indicate baseline data, red asterisks are samples taken during the Ecas4 start-up and transition period, and green triangles represent the most recent data. This figure implies a relationship between the amount of free chlorine in the water and Legionella counts: in particular, a lack of free chlorine is a risk condition that allows the Legionella load to increase. Although potable water suppliers in Australia aim to deliver a suitable chlorine residual for disinfection purposes, this varies between buildings depending on their distance from the treatment plant and on-site water management within healthcare facilities may inadvertently exacerbate this situation. For example, water softeners are often installed with the intention of improving water quality, but they also remove active chlorine present in the system, thereby adding to the challenge of maintaining adequate microbiological quality in the water supply. By adding the Ecas4 Anolyte, a significant improvement in chlorine residual is readily obtained, although it take time for free chlorine levels to stabilise throughout the system as the interaction of the Anolyte with bacterial cells and biofilms effectively consumes free chlorine.
As HOCl is uncharged and has a relatively low molecular weight, it is better able than other chlorine species such as OCl- to penetrate cell walls. It also reacts more rapidly than other chlorine species, in both oxidative and substitution reactions, with organic matter, including critical components of bacterial cells. In contrast with other biocides (e.g., chlorine dioxide, which is often considered as the most powerful disinfectant), hypochlorous acid is more likely to oxidise the polysaccharides that constitute biofilms, and may help decrease this ongoing source of microbial contamination within the pipe network. As noted above, the detachment/ dislodgement of biofilm during treatment is the most probable cause for the peaks in HCC and Legionella counts recorded during the first weeks of operation. Water management optimisation at this facility is ongoing, and the next steps will include a monitored, progressive decrease of the hot water temperature to save energy and reduce the heat stress on infrastructure and equipment. In addition to ongoing verification monitoring, DNA sequencing of bacteria from biofilm and water samples will also be completed, in order to characterise the bacterial diversity present in the system, and to identify the dominant species before and after implementation of the Ecas4 WDS.
ABOUT THE AUTHORS
TempReportâ&#x201E;˘ Data logging is now so much easier! The T-TEC RF data loggers stay in fridges, freezers, coolrooms, refrigerated trucks and send automatically to your PC screen. Actual temperatures available anytime.
Sergio Ferro, Technical Manager at Ecas4-Australia. He recently moved to Australia from Italy, where he worked as a researcher at the University of Ferrara, and has extensive knowledge of chemical and electrochemical processes, particularly in relation to water treatment and disinfection. Tony Amorico, Owner of Ecas4-Australia. He brought this technology to Australia a few years ago after a personal friend contracted MRSA in an Australian hospital and died sometime later. Seeking to actively address this risk, Tony subsequently took it upon himself to introduce Ecas4 into Australian healthcare facilities. Erica Donner, Associate Research Professor with the Future Industries Institute at the University of South Australia. She works primarily in the field of environmental biogeochemistry, with a major emphasis on water/wastewater chemistry and microbial ecology.
ACKNOWLEDGEMENTS The authors acknowledge Euan Smith, Gianluca Brunetti, Sotirios Vasileiadis, and Enzo Lombi for their valuable contributions to the monitoring program and analyses. The assistance from Scott Williams, Daniel Walker and Sharon Piro from the NECH, as well as that from Simon Crabb and Daniel Vallelonga (from Ecas4) has also been greatly appreciated.
Temperature Technology
263 Gilbert Street Adelaide SA 5000 www.t-tec.com.au
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TECHNICAL PAPERS
Ecas4 The most effective and efficient ‘solution’ for removing Legionella & biofilm from your water supply ®
The problem: the biofilm The viscous, organic biofilm that builds up within water pipelines protects micro‑organisms, creating a source of contamination in the water. Ecas4‑Anolyte solution eliminates Legionella from hot water systems by attacking and destroying the viscous biofilm structure of the bacterium Legionella pneumophila. We are experienced in the field of Legionella within hospitals and will be pleased to meet with you to discuss the details of our technology.
A highly efficient, non-toxic disinfection solution that eliminates both pathogens and biofilm. How Ecas4-Anolyte compares to other purification and disinfection systems SYSTEM
Barrier Effect
Deposit Effect
Disinfection with No Corrosion
No Halomethane Formation
Biofilm Elimination
Cost Benefits
Thermal Treatment Chlorination Chloride Dioxide Copper + Silver Positive Ions
Not compatible with zinc surfaces
Ozone Filtering Ultraviolet Rays Ecas4-Anolyte HIGH
MEDIUM
LOW
Unit 8, 1 London Rd, Mile End South SA 5031 | T +618 8122 7165 | info@ecas4.com.au | ecas4.com.au THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS
Space & Assets
Move
Maintenance
Reserva�ons
Strategic Planning
Real Estate
Project Management
Workplace Survey
Sustainability
FM:Mobile
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
TECHNICAL PAPERS
Does BIM have a role in the Internet of Things? DON HITCHCOCK I DIRECTOR, ADVANCED SPATIAL TECHNOLOGIES
WHAT IS THE INTERNET OF THINGS? (IOT)
T
here is now increasing interest and hype around the ‘Internet of Things’ (IoT) which is gaining momentum across the AEC/FM industry. According to Wikipedia a British entrepreneur first used the phrase, “Internet of Things” in 1999 to reference a global network of RFID connected devices. The definition of IoT has expanded since then, to include WiFi enabled devices, which can be located in many places including vehicles, buildings and the wider environment. It now also includes different data transmission protocols and methods and almost anything with a built in sensor that communicates data externally in a network of devices. The usefulness of these internet connected devices is tremendous and ranges from enhancing life safety and security to Building Automation Systems (BAS) control, and reporting. A direct result of all these disconnected IoT devices is the huge amount of data they can transmit, and which typically needs to be collected and analysed to truly realise their usefulness.
BIM AND IOT POSSIBILITIES So the question remains that since hospital buildings are where many of these devices are being installed, how does BIM play a role in the IoT? On the surface it’s quite easy to say yes, BIM does play a role, but perhaps it deserves a bit more attention as we learn to better understand exactly how it does or can fit. One issue that needs to be considered is; how do we define BIM? I’ve heard it defined in many ways including, BIM is simply a model created in a 3D modelling tool such as Revit all the way to, BIM as a collaborative process for designing, engineering, constructing and operating facilities. In reality the 3D geometry itself is less important to IoT than the data that comes from the model, such as ‘Spatial’ and ‘Asset’ data, which is important to the building lifecycle. Both of these data types provide a framework for the organisation and analysis of IoT data in a way that is meaningful to building operations and therefore provides a basis for considering BIM as a potential component of IoT and how it relates to buildings. Figure 1 shows the concept of these ideas, and how the IoT could apply to a range of buildings operations. It also demonstrates the breadth of the devices and the data that can be transmitted and used to better understand and manage buildings. Without some type of organising element from a data analytics and a workflow standpoint, the information
Environmental Control
Figure 1
Building Equipment Cameras
Ligh�ng
Water and Wash Environmental Protec�on
Mobile Tools
Smart Grid Access
Access Control Space and Occupancy Monitoring Building Control / Monitoring System
Power
Wireless Assets
coming from these disparate systems can be at best silos of information which don’t provide value for the overall operational picture.
COLLABORATIVE SYSTEMS AS AN IOT ORGANISER A collaborative data system approach to a building centric IoT is really the key to success for building owners and operators who want to be able to get meaningful information out of their building systems data in a way that can be analysed and actionable. There are cloud based applications with dashboards, developed for integrating sensor based data for building automation and control, and in particular, energy and sustainability management. These approaches are good but I believe they are missing an opportunity to take on the bigger picture? I believe the best solution is to take a comprehensive BIM based ‘building lifecycle’ approach using IoT in the building industry, by connecting building models to a Cloud-based Integrated Workplace Management System (IWMS) to help manage Space, plan Maintenance and more. True building lifecycle integration maintains a live integration between the building models, the sensors and systems throughout the lifecycle, not only for individual buildings, but for the whole hospital building portfolios. This approach can begin with construction when sensors and equipment are installed, moves into operations, and ultimately ends in building decommissioning when a facility has come to the end of its useful life. Editorial Information for this article courtesy of FM:Systems THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS
Forget me not –
Waste management in new hospital developments ANDREW QUINN I PRINCIPAL ENVIRONMENTAL CONSULTANT – WASTE MANAGEMENT AT GHD
THE FORGOTTEN SERVICE
E
very now and then I get a frantic call from an architect or developer asking whether we prepare waste management plans for development applications. When I say ‘Yes we do’, they reply with ‘How quickly can you get one done? We want to lodge the DA on Friday!’ Property is not the only sector in which waste management is too often forgotten or left until the last minute, but it is one where the consequences can be long lasting and costly. Examples of what happens when waste management is not carefully considered when designing new developments are only too easy to see. Hospitals are not immune to this problem. Bins lined up in loading docks too small to store them or overflowing onto driveways and landscaped areas are only too common. These problems cost staff, cleaners and contractors extra time to use hospital waste systems not to mention increasing safety risks. Improper handling of clinical waste, and other potentially dangerous waste types could have severe consequences in hospitals. But it doesn’t have to be like this!
wherever possible. DCPs set out the requirements for waste storage and handling through the demolition, construction and ongoing use phases, covering developments of all types including residential, commercial, industrial and mixed use. DCPs are generally overarching documents and provide detailed specifications only for common developments like residential buildings. Specialist developments like hospitals are not normally covered, so having a specialist waste management advisor on board is all the more important. GHD is assisting the NSW EPA in developing its new model DCP and we have also prepared the EPA’s guidelines for waste management and recycling in commercial developments in NSW (http://www.epa.nsw.gov.au/ resources/managewaste/120960-comm-ind.pdf).
PREPARING A WASTE MANAGEMENT PLAN When preparing a waste management plan for a new hospital development, the DCP is the first place to start. This is followed by close examination of development documentation including drawings. Questions to consider through this phase include: • How many beds will there be?
Early engagement of an experienced waste management consultant can add significant value and improved efficiencies thanks to properly sized bin rooms, safe and workable waste handling solutions and more straightforward development approval.
• What other sources of waste will there be? How many retail outlets, offices, kitchens and cafes?
WASTE PLANNING CONTROLS
• Are garbage and recycling compactors required and how much material will they have to handle?
Councils are most often the approval authority for new developments and thankfully more and more are specifying minimum requirements for waste facilities as a condition of development approval. In NSW this is usually done through Development Control Plans (DCPs). Some other jurisdictions have similar systems, but others have nothing. The NSW EPA is currently revising its model waste DCP chapter. Many councils in NSW had adopted the previous version or developed their own waste sections for DCPs. The EPA is encouraging councils to have a waste chapter in their DCPs and to use the model chapter, or a variation of it,
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THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
• What are the sources of clinical waste? Operating theatres, clinics and treatment rooms.
• What size and type of bins can and should be used? • Where will the waste collection take place? Loading dock, car park, street. • How will full bins get from storage areas to the collection point? • What about food waste, bulky waste, furniture, old equipment and garden organics? • What requirements are there for the separation, storage and security of clinical, cytotoxic, chemical and other waste types?
TECHNICAL PAPERS • What requirements are there for the separation of incoming materials (linen, food and other supplies) and outgoing materials (clinical and other waste) at the loading dock? The most important task is calculating the amounts of waste likely to be generated as this will determine the options for bin sizes, bin room areas and waste handling methods. There are no firm formulas for calculating waste quantities. DCPs often provide ‘typical’ waste generation rates for certain business types, but hospitals are rarely among them. Data from existing systems on-site, or similar systems at other hospitals, could be used. Good consultants will have access to reliable hospital waste generation data and will know how to interpret it and apply it to the relevant development. One of the complicating factors is that different waste types will require different collection methods and different collection contractors. This is where there is sometimes an overlap between design issues and ongoing management issues. Architects may be unfamiliar with the precise collection methods used in each case. The design has to be flexible enough to accommodate most of the usual collection methods as well as those for special waste types. An experienced waste management consultant knows what collection systems are typical and suitable for the situation, and what is required in the design to allow them to be safely and effectively implemented.
made about how the waste system will work at a hospital, long before it is constructed and occupied.
CONCLUSIONS Poor design for waste management can cost money and affect the staff, cleaners and contractors at hospitals for a long time. Increasing use of enforceable conditions for waste storage and handling in new developments is helping to reduce these problems. Hospitals require specialised technical expertise to obtain the right data, do the calculations and apply them. Experienced waste consultants can advise architects and developers on safe, suitable and likely waste collection systems so that appropriate features can be incorporated into hospital design.
OTHER PROBLEMS So that’s the hard part done, right? Not quite. Problems often crop up in two other areas: the collection point (the location where bins are collected) and transporting bins from within the building to the collection point. Councils like waste collections to be as unobtrusive as possible so as not to disturb neighbours or affect traffic. Hospitals usually have loading docks incorporated into the design and waste bins can be stored and collected from there. However, advice will be needed on vehicle specifications, overhead clearances and turning circles, so that bins and compactors can be safely serviced. Getting bins to the collection point from within the building, or other areas where they may be stored, also brings work, health and safety requirements into consideration. Cleaning and property management staff should not be required to push bins too far or up steep gradients or over kerbs or steps. DCPs usually cover these conditions and may specify maximum distances that bins can be pushed on foot. DCPs also often specify that a drawing showing bin travel paths be included in the DA submission. At large hospital developments, cleaners or property managers may use tow motors or tractors to tow a train of bins from storage locations around the site to the loading dock or collection point. This is another area where design and management overlap and where a consultant’s experience will help with the assumptions that need to be
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HEALTH RISKS AND TRANSMISSION Illnesses that may be transmitted in hydrotherapy and spa pools from pathogenic micro-organisms such as bacteria, viruses and protozoa. Cryptosporidium is easily transmitted as oocysts are highly resistant to standard levels of chlorine and bromine used
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TECHNICAL PAPERS for pool disinfection, transmission of the micro-organism can pose a serious health risk.
in 1976 in the US, Legionella has been researched often and the well proven facts regarding legionella briefly are:
Other documented outbreaks that have been linked to swimming pools include: the skin infection folliculitis (caused by P. aeruginosa), respiratory illnesses (caused by Legionella and adenovirus), gastroenteritis (caused by Giardia, echovirus, norovirus, hepatitis A virus, E. coli and Shigella), haemolytic-uraemic syndrome caused by E coli O157 and pharyngo-conjunctivitis caused by adenovirus.
• Legionella is carried in water droplets
Pool operators should never allow disinfectant concentrations to fall below recommended levels and should anticipate high bather loads and raise disinfectant levels in advance.
POOL MANAGEMENT REQUIREMENTS Reliable pool operation depends on regular maintenance of filtration equipment, probes, electrical and hydraulic equipment. Hydrotherapy and spa pools are categorised as high risk under state health legislation and guidelines. A management program must include frequent water analysis with an approved water testing equipment such as a photometer not test strips and results recorded in a log book. Analysis of Microbiological testing regime NATA lab approved, management of TDS levels and biofilms, control of body oils and faecal matter that collect in the recirculation system. Chemical management must include safe storage, handling and use a chemical register and SDS. Signage to include pool rules. Most states it is a requirement that management of these pools must be by an approved technical operator. Testing Frequency in most states or local laws is a mandatory requirement that the following disinfection criteria and pH levels are checked frequently. Refer to your states specific Health legislation. Extracted from NSW Health for hydrotherapy HIGH risk pools:
TESTS Minimum Daily*
TESTS Weekly
TESTS Monthly
Free chlorine/bromine
Turbidity and or/clarity
Total Dissolved Solids TDS
Total/combined chlorine
Ozone
Dimethylhydantoin (BCDMH systems)
pH
Cyanuric Acid
Microbiological
Alkalinity
Water balance
The *manual daily testing frequency is based on automatic control dosing system. Non-automatic continuous dosing/ metering, tests must be conducted prior to opening and thence every two hours.
LEGIONELLA FACTS Legionella is a continuing major health concern and focus for hospitals, aged care facilities and institutions. Since discovery
• Legionella is easily aerated entering the human body via the nose and airways • Persons with compromised respiratory systems are higher risk
LEGIONELLA PREVENTION IN HYDROTHERAPY POOLS It is worth noting legionella outbreaks in hydrotherapy pools are rarer than in commercial cooling towers where outbreaks are relatively common. Documented cases most commonly occur when: • The water being used is not adequately treated • There is poor chemical or disinfection control • There is no regular testing or monitoring of the hydrotherapy pool water • There is infrequent or no replenishment of water contained in the hydrotherapy pool • There is inadequate or no cleaning process for the hydrotherapy pool filter and pipework systems • Bathers/users do not shower before entering and using the hydrotherapy pool • Cross contamination from air conditioning units, warm water loops and cooling towers occurs There is no absolute guarantee even a treated hydrotherapy pool will never get a legionella issue but the likelihood is significantly reduced by addressing the above issues.
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TECHNICAL PAPERS
Copper surfaces reduce the rate of healthcare-acquired infections in the intensive care unit CASSANDRA D. SALGADO, MD;1 KENT A. SEPKOWITZ, MD;2 JOSEPH F. JOHN, MD;3 J. ROBERT CANTEY, MD;1 HUBERT H. ATTAWAY, MS;4 KATHERINE D. FREEMAN, DRPH;5 PETER A. SHARPE, MBA;6 HAROLD T. MICHELS, PHD;7 MICHAEL G. SCHMIDT, PHD4
Objective Healthcare-acquired infections (HAIs) cause substantial patient morbidity and mortality. Items in the environment harbor microorganisms that may contribute to HAIs. Reduction in surface bioburden may be an effective strategy to reduce HAIs. The inherent biocidal properties of copper surfaces offer a theoretical advantage to conventional cleaning, as the effect is continuous rather than episodic. We sought to determine whether placement of copper alloy–surfaced objects in an intensive care unit (ICU) reduced the risk of HAI. Design Intention-to-treat randomised control trial between July 12, 2010, and June 14, 2011. Setting The ICUs of 3 hospitals. Patients Patients presenting for admission to the ICU. Methods Patients were randomly placed in available rooms with or without copper alloy surfaces, and the rates of incident HAI and/or colonisation with methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in each type of room were compared. Results The rate of HAI and/or MRSA or VRE colonisation in ICU rooms with copper alloy surfaces was significantly lower than that in standard ICU rooms (0.071 vs 0.123; ). For HAI P = .020 only, the rate was reduced from 0.081 to 0.034 (P = .013). Conclusions Patients cared for in ICU rooms with copper alloy surfaces had a significantly lower rate of incident HAI and/or colonisation with MRSA or VRE than did patients treated in standard rooms. Additional studies are needed to determine the clinical effect of copper alloy surfaces in additional patient populations and settings.
Infect Control Hosp Epidemiol 2013;34(5):479-486
I
n the United States, 4.5% of hospitalised patients develop hospital-acquired infections (HAIs), resulting in an estimated 100,000 deaths and adding $35.7–$45 billion to healthcare costs.1,2 Furthermore, patients with HAI have longer length of stay (LOS; 21.6 vs 4.9 days), higher readmission rates within 30 days (29.8% vs 6.2%), and greater mortality (9.4% vs 1.8%).3 Intensive care unit (ICU) patients are at further risk for HAI because of severity of illness, invasive procedures, and
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frequent interaction with healthcare workers (HCWs). Movement of organisms within hospitals is complex and may depend on microbes residing on environmental surfaces, indwelling devices, a patient’s own flora, and transiently colonised HCWs’ hands, clothing, and equipment.4-7 Environmental contamination may contribute to acquisition of microbes responsible for HAIs, and microbes can persist for weeks on materials used to fabricate objects in hospitals.8 Patients admitted to rooms where previous patients were infected with
THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), or Clostridium difficile are at increased risk for acquiring these organisms during their stay, suggesting persistence of these organisms in the environment.9,10 Numerous strategies have been developed to decrease HAIs. The central venous catheter insertion bundle has perhaps been the most widely adopted, but other measures include enhanced hand hygiene and screening for multidrugresistant organisms.11
TECHNICAL PAPERS placed adjacent to control rooms prior to patient assignment. Bedcontrol personnel were masked as to which rooms contained copper, but treatment teams were not. A total of 650 admissions to 16 study rooms (8 copper, 8 standard) in the ICUs occurred between July 12, 2010, and June 14, 2011 (Figure 1). This study was approved by each site’s institutional review board and the Office of Risk Protection of the US Army.
figure 1. Flow diagram of patients included in the trial. ICU, intensive care unit; LOS, length of stay.
The Centers for Disease Control and Prevention recommends routine and terminal cleaning for prevention of HAIs.12 Evidence for enhanced cleaning or self-sanitising surfaces is uncertain.13 Novel methods using ultraviolet light and hydrogen peroxide mist have been shown to reduce environmental burden, but clinical efficacy for reduction of HAIs is still unresolved.14,15 Metallic copper has intrinsic broadspectrum antimicrobial activity. In vitro, copper surfaces reduce bacterial concentration by at least 7 logs within 2 hours,16-21 including bacteria commonly encountered in health care.22,23 Others report that placing copper alloy–surfaced materials in the patient environment significantly reduced burden, but clinical efficacy was not measured.24-28 We conducted a clinical trial to determine the efficacy of placing 6 copper alloy–surfaced objects in patient ICU rooms.
METHODS Study Hospitals The study was conducted at 3 medical centres: (1) the Medical University of South Carolina (MUSC), a 660bed tertiary care academic hospital with 17 medical ICU beds; (2) the Memorial Sloan-Kettering Cancer Center (MSKCC), a 460-bed academic cancer hospital with 20 medicalsurgical ICU beds; and (3) the Ralph H. Johnson Veterans Affairs Medical
Center (RHJVA), a 98-bed hospital with 8 medical ICU beds. Each site screened patients for nasal MRSA colonisation. MUSC and MSKCC used Chromagar (Becton Dickinson) to identify colonised patients, as described elsewhere,29 and RHJVA used polymerase chain reaction–based tests for detection of the organism, as described by Jain et al.30 Perirectal VRE screening was conducted only at MUSC and MSKCC, using routine culture methods described elsewhere.31 Each facility followed preexisting comparable cleaning protocols with hospital-grade disinfectants: Virex 256 (Johnson-Diversey) for routine (at least daily) and terminal cleaning, Dispatch (Caltech Industries) for rooms housing patients with C. difficile, and Cavicide (Metrex) for spot cleaning of rooms and equipment. No additional cleaning measures were adopted.
Patient demographics and clinical characteristics of patients were captured by a data extractor masked to room status. The ICU offered an opportunity to study patients generally confined to their room, reducing potential interactions with nonstudy environments. During the study, no participating hospital introduced new HAI, MRSA, or VRE reduction measures, and no outbreaks of HAIs or epidemiologically important organisms occurred. Each ICU monitored hand hygiene compliance. Study Environment and Objects Surfaced with Copper Alloy MUSC and MSKCC had 3 rooms with copper-surfaced objects and 3 control rooms with standard-surfaced objects, and RHJVA had 2 of each. On the basis of previous work to determine the burden of ICU objects, 6 – those with a consistently high burden as well as those frequently touched – were chosen to be fabricated from copper alloys. Four items were identical at all
Study Design and Population To determine the impact of copper alloy surfaces on the incidence rate of HAI and/or MRSA or VRE colonisation, copper alloy–surfaced objects were introduced into ICU study rooms in each hospital. At admission, respective bed-control services randomly assigned patients to an available ICU study room. To better control for nursing exposure, room conditions, and potential bias due to the presence of copper surfaces, intervention rooms were
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TECHNICAL PAPERS hospitals: bed rails, overbed tables, intravenous poles, and arms of the visitor’s chair. The other 2 items varied slightly: the nurses’ call button (MUSC and RHJVA) and computer mouse (MSKCC), and the bezel of the touchscreen monitor (MUSC and MSKCC) and the palm rest of a laptop computer (RHJVA).25 Objects were fabricated by the same manufacturers for each site from a variety of solid copper alloys selected on the basis of ease of fabrication for each component, durability, ability to withstand cleaning, and aesthetics.25,32 Each alloy was registered with the US Environmental Protection Agency (EPA) for its antimicrobial ability.16 Environmental Sampling Weekly sampling of the 6 objects was performed in study rooms across the sites. A sterile template was laid over the surface with the exposed area wiped 5 times horizontally and 5 times vertically with uniform, vigorous pressure. Samples were transported to MUSC for processing. Microbiologic methods have been described elsewhere.25,33 The temperature of samples was maintained at 4 ºC using a frozen refrigerant pack in accordance with the manufacturer’s specifications, and this was continuously monitored using a Dickson SP425 data logger. Samples exceeding 20º C for more than 3 hours during shipping were discarded. The shipping protocol used to establish the concentration of microbes on surfaces at MSKCC and RHJVA was validated by placing defined concentrations of MRSA, VRE, Pseudomonas aeruginosa, Acinetobacter baumanni, and Escherichia coli onto premoistened swabs, which were assessed before and after shipping. No appreciable differences in concentrations of the microbes were observed. To control for bias toward cleaning objects differently in copper versus standard rooms, a noncopper object (bed footboard) was sampled in each room unbeknownst to participating study clinicians, environmental services, or healthcare teams.
Outcome Measures The primary outcome was incident rate of HAI and/or MRSA or VRE colonisation. Patients were prospectively monitored from ICU admission to hospital discharge. Incident HAI or colonisation with MRSA or VRE was determined using National Healthcare Safety Network definitions by a study clinician at each hospital masked to room status.34 Colonisation could have been identified by surveillance or clinical cultures.
HAI or colonisation was attributed to the ICU if it occurred more than 48 hours after ICU admission or within 48 hours after ICU discharge. Demographics, clinical characteristics, and outcomes were recorded on a web-based form automatically transferred into an electronic database for analysis. Independent clinicians at each hospital, masked to study group, validated all patients with HAI and a random sample of twice this number of patients without HAI. Statistical Analysis Distributions of continuous characteristics were assessed for normality using normal probability curves with the ShapiroWilk test and were presented as means with standard deviations (SDs) or medians with interquartile ranges (IQRs). Differences between intervention and control groups were analysed using t tests or Wilcoxon rank sum tests if assumptions of normality were not met. Categorical data were presented as relative frequencies, and differences were analysed using the x2 or exact tests; the primary analysis of the difference between groups with regard to incidence rate of HAI and/or colonisation was tested similarly. Secondary analyses exploring potential confounding and effect modification were performed as follows: in preparation for determining independent factors to be included in logistic regression models to assess the effect of demographics and clinical characteristics on dichotomous outcomes, bivariate associations between each of these factors and the primary outcome were tested using the methods described above. Additionally, logistic regression models were used to identify whether individual factors (ie, age, sex) may be effect modifiers of the association between room assignment and the dichotomous outcome of new infection and/ or colonisation. Initial multivariate models to control for confounding and effect modification included variables with bivariate associations yielding P less than .20. Final models retained only independent variables and/or interactions significant at P less than .05. With regard to agreement between original HAI determinations and those for the validated subsample, a k statistic and corresponding 95% THE AUSTRALIAN HOSPITAL ENGINEER I SEPTEMBER 2016
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TECHNICAL PAPERS confidence interval (CI) were derived. SAS, version 9.2 (SAS Institute), was utilised. Analysis revealed that to obtain at least 90% power (for a 2-sided test with a ∝ = .05) to detect a 50% difference in HAI and/or acquisition of MRSA or VRE colonisation rates between intervention and control groups, a total of 620 patients (310 per group) was required. We assumed that the rate for control patients was 20% and accounted for 10% dropout.
RESULTS
The trial included 614 patients. Mean age was 60.4 years (SD, 14.9 years); 69% were white, and 62.9% were male. Median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 23 (IQR, 18–28), and 47.6% presented with infection on ICU admission. Demographic and clinical characteristics between patients admitted to rooms with copper-surfaced objects and those admitted to noncopper rooms were comparable (Table 1). Because of movement of furniture necessitated by patient care, 46.6% of patients in copper rooms had all 6 of the copper-surfaced objects remain in the room throughout their ICU stay. In contrast, 86.6% of those assigned to noncopper rooms were never exposed to a copper object during their stay. Rates of HAI and/or Acquisition of MRSA or VRE Colonisation Forty-six patients (7.5%) developed HAI (36 with HAI only, 10 with HAI and colonisation), and 26 (4.2%) became colonised with MRSA or VRE (16 with colonisation only). Compared with that among patients admitted to noncopper rooms, the proportion who developed HAI and/ or colonisation with MRSA or VRE was significantly lower among patients admitted to copper rooms (0.071 vs 0.128; P = .020; Table 2). Additionally, the proportion developing HAI alone was significantly lower among those assigned to copper rooms (0.034 vs 0.081; P = .013). MRSA or VRE colonisation was also decreased by 2.7-fold among patients admitted to copper rooms, but this failed to reach significance (P = .063). Forty-two organisms were identified among the 46 patients who developed HAI (Table 3). There were no differences between the distribution of types of HAIs or associated microbiology between patients treated in copper and non-copper rooms.
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ICU LOS was not different between groups (median for both, 4 days; P = 0.74). Mortality also was not different (14.3% in copper rooms, 15.0% in control rooms; P = .64), nor was average ICU LOS prior to development of HAI (12.3 days in copper rooms, 8.8 days in control rooms; P = .20). The HAI rate did not vary significantly over the study period in copper rooms or standard rooms (P = .30 for both), and hand hygiene compliance, which ranged from 61% to 95%, was not significantly associated with HAI rates (P = .53). Bivariate analysis to determine whether demographic or clinical characteristics were effect modifiers of room assignment or whether they independently increased the risk of HAI or colonisation revealed that higher APACHE II scores were significantly associated with incident HAI or colonisation (P = .011). Infection on admission was a significant effect modifier of room assignment (P = .047); among those in noncopper rooms with infection on admission, the rate of further HAI or colonisation was 16.6%, compared with 5.7% among patients in copper rooms. However, in multivariate analyses controlling for APACHE II score, infection on admission was neither a significant effect modifier of room assignment figure 2. Quartile distribution of healthcare-acquired infections (HAIs) nor independently stratified by microbial burden measured in the intensive care unit (ICU) associated with the room during the patient’s stay. There was a significant association between burden and HAI risk (P = .038), with 89% of HAIs occurring among patients incidence of HAI cared for in a room with a burden of more than 500 colony-forming units or colonisation. (CFUs)/100 cm2. The final model indicated that both APACHE II score (P = .011) and room assignment (P = .027) were significantly associated with incident HAI or colonisation. Validation analysis revealed a k statistic of 0.52 (95% CI, 0.34–0.70). In the vast majority of instances when there was disagreement on validation, it was due
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TECHNICAL PAPERS
to a case of pneumonia. Difficulty in consistently defining pneumonia has been previously documented.35 Fifty percent of 614 patients had environmental sampling of their room while receiving care in the ICU. Thirtyseven HAIs occurred among this subpopulation. Burden was stratified into quartiles regardless of the presence or absence of copper. There was a significant association between burden and HAI risk (Figure 2). Cumulative burden was lower for rooms with coppersurfaced objects. Of the 4,450,545 bacteria recovered during the trial, only 17%, rather than an expected 50%, were isolated from rooms with copper objects (0.76 log reduction; P < .0001).25 Of note, the mean burden of the standardsurfaced footboard was not significantly different between copper and control rooms (2,786 vs 2,388 colony-forming units [CFUs]/100 cm2).
DISCUSSION Our study demonstrated that placing a copper alloy surface onto 6 common, highly touched objects in ICU rooms reduced the risk of HAI by more than half at all study sites. We believe that HAI reduction was due to the continuous antimicrobial effect of copper on environmental pathogens. We previously reported that copper surfaces
reduced burden by 83%, compared with standard surfaces in patient rooms.25 Patients in rooms with high burden were significantly more likely to develop HAI than were those in rooms with low burden, regardless of the presence or absence of copper. This may relate to the possibility that persons with active infection are more likely to shed bacteria captured by environmental sampling, but this does not fully explain the difference; the environment of patients with infections or colonisations showed an array of bacteria.25 Additionally, mean ICU stay prior to HAI did not differ between patients cared for in the 2 room types. We feel our approach is novel and the implications far-reaching. Previous attempts to reduce HAIs have required HCW engagement with such approaches as prevention bundles, hand hygiene, and patient screening. Additionally, systems designed to decrease burden, such as hydrogen peroxide mist, ultraviolet light, and increased cleaning, may be limited because of regrowth of organisms after the intervention.26 In contrast, copper alloy surfaces offer a passive way to reduce burden. Staff need not take additional steps, follow complex algorithms, or obtain buy-in from other providers. Additionally, because the antimicrobial effect is a continuous property of copper, rapid regrowth of
microbes is mitigated. Importantly, in this study copper surfaces were shown to work in tandem with standard infection prevention practices to significantly reduce burden and HAIs. There were study limitations. Because of the kinetic nature of care, all 6 copper objects were not always present in copper rooms. Daily inventory found that 53.4% of patients assigned to copper rooms had at least 1 of the copper objects removed during their stay. The most common reason was substitution of a nonstudy bed into a copper room to accommodate patient needs. Similarly, 13.4% of patients assigned to noncopper rooms had some exposure to copper objects, most often through introduction of a chair with copper arms by visitors. However, these events likely led to an underestimation of the effect of copper on HAIs and colonisation. It was not possible to definitively ascribe lower HAI rates in rooms with copper objects solely to a reduction in burden. Other explanations are possible; most notably, since rooms appeared different, the effect may have been mediated by a change in HCW behaviour. Because this study was a first-of-its-kind proof of concept, we did not conduct it under double-blind conditions. Effective blinding is dubious because copper alloys have a distinct look and may emit a distinctive
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TECHNICAL PAPERS odour. Arguing against the possibility that the observed reduction was mediated by HCW behaviour change is the fact that copper objects were placed in rooms 9 months prior to the beginning of the trial, and ICU staff were not made aware of when the clinical phase of the study commenced. Furthermore, as previously stated the burden was significantly lower in copper rooms (P < .0001) at each of the sites.25 Additionally, the burden from a standard-surfaced object, sampled unbeknownst to personnel and staff, was not different in copper versus control rooms. Finally, the HAI rate did not vary significantly over the study period in copper or standard rooms. That this rate was not lower in the beginning months of the study suggests that HCW behaviour as a cause of the observed reduction in HAIs in copper rooms was minimised. Moreover, our study design does not make it entirely possible to respond to other potential limitations of copper proposed by other researchers, such as the effect of soiling and tarnishing.22,36 However, the US EPA requires that registered antimicrobial copper materials exert a 99.9% antimicrobial activity after 8 successive applications of 1x106 CFUs of viable pathogens without cleaning.16 Each hospital required that frequently touched surfaces in the patient setting be cleaned at least daily. Furthermore, over the 2 years of environmental monitoring tarnishing was minimal and the antimicrobial activity of the copper surfaces did not diminish with time. Consequently, while soiling and or tarnishing are possible, given the scope of burden encountered on copper surfaces (average, 465 CFUs/100 cm2) and the requirement for daily cleaning, it is not likely that they had a significant impact on the effectiveness of copper. We have shown a reduction in incident HAIs and MRSA/VRE colonisation in patients treated in ICU rooms with copper alloy–surfaced objects. This represents the first time an intervention designed to reduce burden has had a clinical impact among ICU patients. Because this was a pilot study, it may raise more questions than it resolves. Development of HAIs is complex and influenced by multiple host (underlying disease, immunosuppression) and external (indwelling devices, receipt
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of antibiotics) factors. Environmental contamination may contribute to HAIs by contaminating hands, clothing, and equipment of HCWs, who subsequently may transmit microbes during routine patient and device (central venous catheter, endotracheal tube, bladder catheter) care. Our findings suggest that reduction in environmental contamination could lead to fewer HAIs, presumably by decreasing the likelihood of introducing microbes into the patient. However, our study was not powered to assess which HAIs are more likely to be influenced by burden reduction. Additional studies are necessary to address this important issue, to determine whether reduction in burden is a central element to the control of HAIs, and to confirm the observed efficacy of copper alloy surfaces. If confirmed for other patient care environments, these findings could have a substantial impact on preventing HAIs.
ACKNOWLEDGMENTS We acknowledge assistance and technical support from Dr Lisa Steed and Sally Fairey of the Medical University of South Carolina; Dr Hadi Baag of the Ralph H. Johnson Veterans Affairs Medical Center; Susan Singh, MPH, and Dr Urania Rappo of the Memorial SloanKettering Cancer Center; Chuck Stark, Dennis Simon, Alan Tolley, and Kathy Zolman of the Advanced Technology Institute, North Charleston, South Carolina; and Adam Estelle, Wilton Moran, and Jim Michels of the Copper Development Association. Financial support. This study was funded by a grant from the US Army Materiel Command, US Department of Defense (DOD; contract W81XWH-07-C-0053). The funding source was not involved in the preparation, submission, and review of the manuscript. Potential conflicts of interest. C.D.S., K.A.S., J.F.J., J.R.C., H.H.A., K.D.F., H.T.M., and M.G.S. report receiving salary support from the US Army Materiel Command, US DOD, to conduct the study. P.A.S. reports acquiring and purchasing materials from vendors using funds from the US Army Materiel Command, US DOD. K.A.S., H.H.A., and M.G.S. report receiving grant
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support from the Copper Development Association to study the placement of copper surfaces in other non–patient care environments. C.D.S. reports receiving grant support from the Agency for Healthcare Research and Quality to study healthcare-acquired infections as well as serving as an educational consultant for continuing medical education activities for Outcomes, Inc. K.D.F. reports serving as a consultant for Ortho-McNeil-Janssen. P.A.S. reports providing expertise on issues relevant to technology transfer and application of antimicrobial copper equipment and furnishings for the Copper Development Association and Olin Brass. H.T.M. reports being employed by the Copper Development Association. M.G.S. reports serving as a consultant for Olin Brass and Coldelco and receiving funding from the Ministry of Health of Chile to serve as an external consultant for a clinical trial investigating the consequences of placement of antimicrobial copper on the rate of healthcare-acquired infections. Additionally, M.G.S. reports receiving travel support from the Copper Development Association. All authors submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest, and the conflicts that the editors consider relevant to this article are disclosed here. Address correspondence to Cassandra D. Salgado, MD, 135 Rutledge Avenue, Division of Infectious Diseases, Charleston, SC 29425 (salgado@ musc.edu). Presented in part: 49th Annual Scientific Meeting of the Infectious Diseases Society of America; Boston, Massachusetts; October 20–23, 2011. The views, opinions, and/or findings presented here are those of the authors and should not be construed as an official US Department of the Army position.
REFERENCES 1. Klevens RM, Edwards JR, Richards CL, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep 2007;122:160–166. 2. Scott RD. The Direct Medical Costs of Healthcare-Associated Infections in U.S. Hospitals and the Benefits of Prevention. Atlanta: Centers for Disease Control and Prevention, 2009.
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TECHNICAL PAPERS 3. Martin J. The Impact of Healthcare-Associated Infections in Pennsylvania. Harrisburg, PA: Pennsylvania Health Care Cost Containment Council, 2011. http://www.phc4.org. Accessed February 28, 2013. 4. B oyce JM. Environmental contamination makes an important contribution to hospital infection. J Hosp Infect 2007;65:50–54. 5. B lythe D, Keenlyside D, Dawson SJ, Galloway A. Environmental contamination due to methicillin-resistant Staphylococcus aureus (MRSA). J Hosp Infect 1998;38:67-69. 6. D uckro AN, Blom DW, Lyle EA, Weinstein RA, Hayden MK. Transfer of vancomycin-resistant enterococci via health care worker hands. Arch Intern Med 2005;165:302-307. 7. H ayden MK, Blom DW, Lyle EA, Moore CG, Weinstein RA. Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant Enterococcus or the colonized patients’ environment. Infect Control Hosp Epidemiol 2008;29:149–154. 8. K ramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infect Dis 2006;6:130. 9. H uang SS, Datta R, Platt R. Risk of acquiring antibiotic-resistant bacteria from prior room occupants. Arch Intern Med 2006;166: 1945–1951. 10. S haughnessy MK, Micielli RL, DePestel DD, et al. Evaluation of hospital room assignment and acquisition of Clostridium difficile infection. Infect Control Hosp Epidemiol 2011;32:201-206. 11. H uskins WC, Huckabee CM, O’Grady NP, et al. Intervention to reduce transmission of resistant bacteria in intensive care. N Engl J Med 2011;364:1407-1418. 12. R utala WA, Weber DJ; Healthcare Infection Control Practices Advisory Committee. Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008. Atlanta: Centers for Disease Control and Prevention, 2008. http://www.cdc.gov/hicpac/Disinfection _Sterilization/acknowledg.html. Accessed February 28, 2013.
peroxide vapor to decontaminate rooms in a busy United States hospital. Infect Control Hosp Epidemiol 2009; 30:574-577. 15. Rutala WA, Gergen MF, Weber DJ. Room decontamination with UV radiation. Infect Control Hosp Epidemiol 2010;31:1025-1029.
27. Casey AL, Adams D, Karpanen TJ, et al. Role of copper in reducing hospital environment contamination. J Hosp Infect 2010;74:72-77.
16. US Environmental Protection Agency. EPA registers copper-containing alloy products. http://www.epa.gov/opp00001/factsheets /copper-alloy-products.htm. Published 2008. Accessed February 28, 2013.
28. Karpanen TJ, Casey AL, Lambert PA, et al. The antimicrobial efficacy of copper alloy furnishings in the clinical environment: a crossover study. Infect Control Hosp Epidemiol 2012;33:3-9.
17. Michels HT. Anti-microbial characteristics of copper. Stand News 2006;34:28-31.
29. Freitas EF, Harris RM, Blake RK, Salgado CD. Prevalence of USA300 community-acquired methicillin-resistant Staphylococcus aureus among patients with nasal colonization identified by active surveillance. Infect Control Hosp Epidemiol 2010;31:469-475.
18. Noyce JO, Michels H, Keevil CW. Potential use of copper surfaces to reduce survival of epidemic methicillin-resistant Staphylococcus aureus in the healthcare environment. J Hosp Infect 2006;63:289-297. 19. Warnes SL, Green SM, Michels HT, Keevil CW. Biocidal efficacy of copper alloys against pathogenic enterococci involves degradation of genomic and plasmid DNAs. Appl Environ Microbiol 2010;76:53905401. 20. Weaver L, Michels HT, Keevil CW. Survival of Clostridium difficile on copper and steel: futuristic options for hospital hygiene. J Hosp Infect 2008;68:145-151. 21. Weaver L, Noyce JO, Michels HT, Keevil CW. Potential action of copper surfaces on methicillin-resistant Staphylococcus aureus. J Appl Microbiol 2010;109:2200-2205. 22. Grass G, Rensing C, Solioz M. Metallic copper as an antimi-crobial surface. Appl Environ Microbiol 2011;77:1541–1547. 23. Mehtar S, Wiid I, Todorov SD. The antimicrobial activity of copper and copper alloys against nosocomial pathogens and Mycobacterium tuberculosis isolated from healthcare facilities in the Western Cape: an in-vitro study. J Hosp Infect 2008;68:45-51. 24. Marais F, Mehtar S, Chalkley L. Antimicrobial efficacy of copper touch surfaces in reducing environmental bioburden in a South African community healthcare facility. J Hosp Infect 2010;74: 80-82.
tter JA, Yezli S, French GL. The role played 13. O by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol 2011;32:687–699.
25. Schmidt MG, Attaway HH, Sharpe PA, et al. Sustained reduction of microbial burden on common hospital surfaces through the introduction of copper. J Clin Microbiol 2012;50(7):2217-2223.
14. O tter JA, Puchowicz M, Ryan D, et al. Feasibility of routinely using hydrogen
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30. Jain R, Kralovic SM, Evans ME, et al. Veterans Affairs initiative to prevent methicillin-resistant Staphylococcus aureus infections. N Engl J Med 2011;364:14191430. 31. Olivier CA, Blake RK, Steed LL, Salgado CD. Risk of vancomycin-resistant Enterococcus (VRE) bloodstream infection among patients colonized with VRE. Infect Control Hosp Epidemiol 2008;29:404-409. 32. Sharpe PA, Schmidt MG. Control and mitigation of healthcare-acquired infections: designing clinical trials to evaluate new materials and technologies. Herd 2011;5(1):94-115. 33. Schmidt MG, Anderson T, Attaway H, et al. Patient environment microbial burden reduction: a pilot study comparison of two terminal cleaning methods. Am J Infect Control 2012;40:559-561. 34. Horan TC, Andrus M, Dudeck MA. CDC/ NHSN surveillance definition of health careassociated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36:309-332. 35. American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospitalacquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 2005;171:388-416. 36. Weber DJ, Rutala WA. Self-disinfecting surfaces. Infect Control Hosp Epidemiol 2012;33:10-13.
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PRODUCT NEWS
Introducing the latest from Japan – The Hug, a Mobility Support Robot Hug is designed with supporting people who face mobility issues. It allows you to move a person from bed to wheelchair or wheelchair to the toilet. Hug assists when needing to transfer a person to a sitting position or in situations where standing for a period of time is required, such as getting dressed. Hug supports those who have the ability to stand on their own, but for a particular reason, have limited mobility when standing. Hug is ready to use, anytime. Hug does not use a sling or harness, which means no consuming setup time. Hug does not only raise a person, but brings them forward in a sliding motion to stand, effectively distributing their weight to the backs of the heels and allowing the person to feel comfortable while standing up. The Hug allows and gives people their dignity as they are reluctant to move because they do not wish to burden others with heavy lifting. The Hug robot can now take over the lifting work that has been the domain of care workers to ensure less physical stress and the avoidance of back injuries. Contact: Gerald Koh, Kobot Systems Pty Ltd Tel: 04-1996-1978 Email: gkoh@kobot.com.au
OandMs platinum sponsors for this year’s IHEA Healthcare Facilities Management Conference OandMs are excited to be the platinum sponsors for this year’s IHEA Healthcare Facilities Management Conference to be held from 19 to 21 October at the Adelaide Oval. The conference theme of “managing change/changing management” resonates clearly with the goals we have set for OandMs. Whereas Architects, engineers and construction companies have embraced digital technology in many areas of their practices, the collection of O&Ms data stubbornly remains in the 20th century… most systems are still paper-based. A medium that is not easily accessible and they are usually lacking in integrity. We started OandMs to improve the way O&Ms are collected and delivered. Our simple, cloud-based facility management software connects people with the right building data anywhere, anytime and on any device.
We’re proud to be helping transform AEC groups in the way they do business and we are just getting started. Founded in 2013 in Australia, OandMs is one of fastest growing software as a service companies. We have implemented the simplest system and process designed by tradesman, developed by project managers and proven by facility managers. With the strength from one of the biggest software and data storage partners in the world, and growth of over 1000% we are able to manage any size organisation, building project or facility. Architects, engineers and constructions companies literally build the world we live in – it’s the engine room of the global economy. We want AEC groups to embrace the digital change they are driving and apply it to the O&Ms process so we can provide strategic information to the people who need it most – facility managers and their property owners.
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PRODUCT NEWS
Gerflor’s advanced technology provides floor and wall solutions for VCCC Introducing and gaining confidence in a new generation product was not without its challenges, according to Gerflor project leader, Andrew Fenner. “There was initially some resistance to a product that had not been tested in this local market. We knew Symbioz would deliver lower maintenance costs due to new Evercare technology that eliminates sealing, polishing and dry buffing. Our challenge was to engender that confidence in others,” Andrew said. Grocon PCL Project Manager Joseph Taouk saw firsthand that confidence spread throughout the project team. “After rigorous review and testing against comparative products we were satisfied the product was the best application for the VCCC and we continued with the selection process,” Joe said. Advanced new technologies and surface treatments are inherent in Gerflor vinyl floor and wall surfaces found throughout the Victorian Comprehensive Cancer Centre. The facility features a variety of Gerflor products in wards, clinical areas and laboratories. The majority of the approximately 100,000 square metres of Gerflor products installed is made up of new generation homogenous Gerflor Symbioz. Its low maintenance features, together with market-leading stain resistance, equip it well for demanding settings including pathology and cytotoxic laboratories.
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Tente AGV castors for automated guided vehicles Tente’s AGV’s are particularly effective for use in hospitals. These castors feature a Spring Loaded Directional Lock, if a castor loses ground contact, it automatically aligns in the direction of motion again. This is provided by a spring inside the castor. It prevents uncontrolled panning and ensures a smooth passage through doors, elevators and narrow alleys.
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Due to stainless steel components and sealed ball bearings, it can easily be cleaned and provides protection against splashing water and detergents which is a crucial advantage in a medical environment. The optional XSX wheel provides additional safety, electrically conductive wheels protect against discharges.
The castors are rated up to 350kg per castor and can easily be relubricated with a grease nipple. Available in a total or modular directional lock as well as with brakes. Contact Tente Australia for further information 1300 836 831 – sales@tente.com.au
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