The Australian Hospital Engineer Vol 39 No 2 by Adbourne Publishing

VOL 39

NO 2

June 2016

the australian

engineer HOSPITAL S

Keukenhoff in Spring time

Brett Petherbridge, IHEA President, promoting the 2018 IFHE Congress in Australia

Darryl Pitcher, IFHE Vice-President introducing the Australian Ambassador

The IHEA Delegation attending the IFHE Congress

Fire safety: preparing staff Complexities of waste management Legionella contamination PP 100010900

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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

IHEA NATIONAL BOARD OF DIRECTORS

CONTENTS

BRANCH NEWS

National President’s & CEO’s Message

National President Brett Petherbridge

State Branch Reports

National Immediate Past President Darren Green

IFHE Congress News

National Vice President Peter Easson National Treasurer Mal Allen National Secretary Darryl Pitcher Membership Registrar/ CHCFM Coordinator Alex Mair Peter Footner Standards Coordinator Rod Woodford Asset Mark Coordinator Greg Truscott Communication/Marketing Darryl Pitcher 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

15 The International Federation of Hospital Engineering Congress 2016

TECHNICAL PAPERS

20 Prevalence and nature of Legionella contamination in aged care facilities in Australia 25 The complexities of waste management

15 20

32 3D surgery and remote surgical viewing for St. John of God Ballarat Hospital 37 Fire safety: preparing staff for emergencies 43 Water scarcity – mitigating the risk 45 Considerations for Kitchen Exhaust Design and Specification in Hospital Environments

53 The modern approach to managing indoor air quality in health care facilities 60 Water Hygiene Workshop 66 Hospital Engineers & Emergency Planning Committee Liabilities 68 The Building Information Modelling solution

PRODUCT NEWS

74 Product news

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32 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.

TECHNICAL PAPERS

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

National President’s & CEO’s Message

elcome to the winter edition of the IHEA journal, The Australian Hospital Engineer, our cornerstone publication providing members with technical papers and communication on industry trends that keep us at the forefront as the peak body in Healthcare engineering.

THE 2016 INTERNATIONAL FEDERATION OF HOSPITAL ENGINEERING (IFHE) CONGRESS The twenty-fourth congress of the International Federation of Hospital Engineering Congress was a resounding success. The congress was attended by 930 participants from 37 different countries along with 120 business partners at the exhibition stands and 22 key-note speakers from 11 different countries. The key-note speakers delivered the participants a relevant state of the art program of high quality key-note presentations. Our 2016 delegation included the following: Mr Brett Petherbridge – IHEA National President and 2018 IFHE Congress Convenor. Ms Karen Taylor – Chief Executive Officer, IHEA. Mr Peter Easson – IHEA National Vice President – will be IHEA National President in 2018. Mr Darren Green – IHEA Immediate Past President. Mr Darryl Pitcher – IFHE Executive Committee member and IFHE Vice President. Ms Jodie Parker – CEO, Iceberg Events. IHEA has contracted Iceberg Events as our Professional Conference Organiser. Jodie’s attendance was essential to better understand the IFHE context to ensure we convene the best possible event in Australia. Booth at The Hague

The IHEA delegation and our Professional Conference Organiser (Icebergs) hosted a promotional booth for the 2018 Congress with “clip on” koalas, inflatable kangaroo – Kevin (who now resides in Japan), small jars of vegemite, Minties/ Fantails and a rolling visual display of Australia’s iconic landmarks and cities. The booth was extremely successful and well attended with many delegates wearing the koalas and engaging with the Aussie team. We received very positive feedback from all delegates and sponsors with many committing to the 2018 Congress in Brisbane. The delegation wore Chambray shirts and Aussie hats and really stood out. At the conference closure we presented an update on the 2018 Congress, highlighting Brisbane City, the event THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

venue, accommodation and social options. Australia’s Ambassador to the Netherlands, Dr Brett Mason provided a presentation in support of the IHEA.

2018 INTERNATIONAL FEDERATION OF HOSPITAL ENGINEERING (IFHE) CONGRESS – BRISBANE Professional Development It is pleasing to see many states have conducted successful Professional Development seminars for members over the past 3 months. The State Branch reports within this edition outline these events in more detail. In particular, Brett recently attended the NSW/ACT Conference, AGM and Annual Awards event held at Wisemans Ferry in late May. A very successful event with awards presented for Engineer of the Year, Manager of the Year and Tradesperson of the year. The event was well attended by members and a noteworthy mention to Mr Charles (Charlie) Shields, our longest serving member having surpassed 60 years continuous service in January 2016. Charlie will be attending the IHEA National Conference in October 2016 where he will be presented with his 60 years of service award. Summary of key activities • IHEA Constitution “Draft” was peer reviewed following the final legal examination following the February Board

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Meeting. The “draft” is now ready for Members to review and vote at the AGM. • A review of the IHEA Rules has been undertaken and will be discussed at the next Board Meeting. • Monthly financial reports have been distributed by the National Treasurer to all States. • ANZEX agreement has been reviewed and accepted by the NZIHE. This agreement has been updated to reflect more current travel options for delegate’s attendance. • Our standards coordinator has completed an expression of interest (EOI) for member participation on committees. Please keep an eye out for that e-bulletin. • The IHEA business plan has been circulated to Board members for review and comment. The final document will be presented at the next Board meeting for endorsement. • The next face to face Board meeting is to be held in Melbourne on the 17th June 2016. This meeting will focus on end of financial year reporting requirements, preparation for the Annual General Meeting and progress on the National Conference. The National Conference is being held in Adelaide between 19-21st October and will be upon us before we know it. Early Bird registrations are now available and we encourage all members to attend this year’s event. We look forward to catching up with many of you at that time. We would like to acknowledge the work being undertaken behind the scenes by the IHEA National Board and State COM’s, Business partners and the core teams of dedicated members working hard in the background for the growth and betterment of the IHEA. Kind regards, Brett Petherbridge IHEA National President Karen Taylor CEO

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

Executive Committee

brett.petherbridge@act.gov.au Peter.Easson@health.wa.gov.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

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STATE BRANCH REPORTS

State Branch Reports WA BRANCH REPORT – CRAIG AGGETT, BRANCH PRESIDENT Branch Meeting March 2016, Water Corporation he Water Corporation’s CEO, Sue Murphy welcomed the attending 40 members to their headquarters in Leederville and delivered an engaging and interesting briefing regarding planning strategies to provide ongoing water supplies to the Perth and surrounding region. Every day we all use water to sustain our lives and give us the lifestyle we enjoy. Sue’s presentation focused our attention to the staff responsible for managing the problems faced in supplying the water demanded by both domestic and commercial users.

areas. The plan commenced after the announcement of the second desalination plant. The project allowed for the development of a long-term framework for Perth. In 2012 the Water Corporation also released a Water Forever – Whatever the Weather, a 10-year plan for Perth. This plan was devised to eliminate the reliance on dams over a 10-year period by continuing to reduce demand, expand desalination plant operation, build groundwater replenishment and progressively move to groundwater abstraction to the deeper aquifers. Key Areas Targeted are: • Reduce Water Use • Increase Water Recycling • Develop New Water Sources • Climate Resilience • Increasing Population Growth • Less Environmental Impact

Attending Members

Alarming issues, such as ongoing sustainability, planning and the initiatives undertaken to maintain our supply for the future are managed through a raft of strategies. For example, looking at the changes in weather patterns, alternative water sources (namely desalination), changes to the ground water supply feeding our dams and reoccurring public awareness campaigns to highlight important messages to reduce water leakage, wastage and improve water efficiency. Water Forever Plan Water Forever is the Water Corporation’s 50-year plan to secure sustainable water and wastewater services to Perth and surrounding

Country Conference April 2016, Kalgoorlie The theme for this year’s country conference is ‘Golden Potential’. As a downturn in the mining industry continues, this does not necessarily reflect the opportunities and possibilities for HealthCare in regional WA. The gold mining town of Kalgoorlie was the location for the conference and the Kalgoorlie Health Campus hosted the conference.

Geraldine Ennis, the Regional Director of the Goldfields Country Health Service, welcomed the 45 members, guests and partners to the campus and delivered an engaging opening address including the building challenges of redeveloping an operational aging facility to meet both contemporary standards and maintain the expected clinical services. The $60 Million regional redevelopment project was delivered in 4 stages and included upgrades to the following areas: • Emergency Department • Maternity Ward • X-Ray Department • Palliative Care • Renal Services • Cancer Services • Mental Health Services • Surgical Services • Primary Health Care Units – Laverton

Geraldine Ennis – Regional Director of the Goldfield Country Health

Conference Delegates

Cathy Parker from the Royal Flying Doctor Service was invited to present an overview of their WA operations, supplying medical evacuation and support services for a wide range of Kalgoorlie Health Campus

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

STATE BRANCH REPORTS people located in remote communities, mine sites, mining exploration teams, cattle stations, farms and tourism. Cathy also explained some interesting annual RFDS operational figures, namely:

• 41,200 Tele-health phone calls registered. • 9,132 flights completed. • 8 Million kilometres flown. • 15 Aircraft in service. • 27,715 patient contacts made. • 18,582 patients attending clinics.

Examination Room

Following the presentations, host Colin Crabtree guided the delegates on a front-of-house and back-of-house tour of the redeveloped campus and expertly fielded many engineering questions along the way. The conference was also made possible with support from the following sponsors – Burke Air, 4 Health Care, Integrated FM, A&M Medical, Safe Systems and BMSS.

Engineering (AIHE) at Sir Charles Gairdner Hospital. Mr John Dransfield hosted the meeting and welcomed the 55 members to the facility and included a guided tour of the nearly completed Perth Children’s Hospital (PCH). The $1.2 Billion facility being built on the QEII Medical Centre site in Nedlands, will replace Princess Margaret Hospital (PMH) as the State’s dedicated children’s hospital, providing specialist paediatric care for children and adolescents of WA. Construction of the new hospital began in January 2012 and is due to open late 2016. As the meeting sponsor, Glen Flanagan from Wood & Grieve presented their diverse engineering capabilities and key completed projects with WA in a range of market sectors such as health, aged care, retail, sports, culture and the arts.

Greg and Debra Truscott enjoying the Conference Dinner Emergency Department Entry

• RFDS WA cover an area of 2.5 million square kilometres.

VIC/TAS BRANCH REPORT – RODERICK WOODFORD, BRANCH PRESIDENT

ic/Tas has held two Professional development days this year with the Annual Branch meeting held on the 20th May. Vic/Tas election of the committee of management also took place on the 20th May at the conclusion of PD2 with the following results: Vic/Tas President, Roderick Woodford Branch secretary, To be advised. Branch Treasure, Roderick Cusack Committee of Management: Peter Crammond, Howard Ballmer, Simon Roberts, Sujee Panagoda, Mark Hooper and Michael McCambridge.

Branch Meeting May 2016, Perth Children’s Hospital A combined branch meeting was held with the Australian Institute of Hotel

PCH nearing practical completion

Followed by,

Nation Board representatives: Michael McCambridge and Roderick Woodford. Professional Development Seminars for 2016 PD one; the theme was, Fire Risk Management in Health Facilities, Essential Services & Building Code compliance VENUE: Engineers Australia, Level 31, 600 Bourke Street, Melbourne VIC 3000. DATE: Monday 22nd February 2016, attended by 34. With the first speakers from; Department of Health, Fire Risk Management Unit presenting on Guidelines for Fire Risk Management in Victorian Health Facilities by Hank Van Ravenstein, Stephen Kip, Dr Ian Bennetts.

• Speaker; Brian Sherwell, Brian Sherwell & Associates, Presenting on The BCA and Fire Risk Management, a Building Surveyors perspective. • Sponsors Presentation; Narelle Turner from Broadspectrum. • Speaker; Gary Lake, Lake Young & Associates Presenting on Fire Safety Audits, interpreting the Series 7 guidelines and conducting audits. • Speaker; Tony Stokes, Stokes Safety; Building Safety and Compliance. Essential Safety Measures, regulatory requirements and best practice. PD Two; Theme Warm Water Systems Compliance and Reverse Osmosis Water Quality Testing to AS 4187

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

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THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

STATE BRANCH REPORTS VENUE: Engineers Australia, Level 31-600, Bourke Street, Melbourne VIC 3000. DATE: Friday 20th May 2016, attended by 40 • Speaker; Stuart Adcock, Team Leader, Legionella Health Protection Branch Department of Health and Human Services • Speaker; Travis Hale, CETEC; Legionella & water quality in healthcare facilities AS/NZS 3896:2008

QLD BRANCH REPORT – ALEX MAIR, ON BEHALF OF BRANCH PRESIDENT SCOTT WELLS

Queensland Branch Report February – June 2016 he first part of 2016 has seen a resurgence in activity within the Branch. Workloads continue to impact involvement and outside factors influence how we operate, however the Branch has been quite active over the period.

Toowoomba Country Meeting Our normal Toowoomba Country meeting was delayed this year as a result of work on the racetrack. The Meeting was held 18-20th March. The weekend started with a dinner at Seasons on Ruthven. This evening was sponsored by Asburner Francis who provided the table wines. Saturday morning started at the Heritage listed Empire Theatre with our half yearly Branch meeting. This was followed by a technical tour of the mechanical services. It was extremely interesting as we looked at the special issues around air-conditioning a live performance theatre where not only temperature is important, but also noise. This challenge was only complicated by the fact that the building is heritage listed. One of our members, Alan Davis had a key had role in the design of the air-conditioning system when the building was refurbished a few years ago. Since then there have been a number of minor upgrades and these have been quite difficult because of the

• Speaker; Renwick Chan | Technical Compliance Officer Water Program, Health Protection Branch DHHS • Speaker; Romain Latour, Integra Water AS 4187 Reverse Osmosis Water Quality Testing. Some of the discussion centred around the testing of the final process rinse water to AS 4187 requirements and whether it was the supply water to the machine or the water from the drain after the process has been completed.

access issues. There were a number of innovative solutions to air conditioning the Auditorium and the back of house flexible performance and rehearsal spaces. We also went up into the original bio box where the arc lamp projectors sat in a past era and we could see the scorch marks from the heat of the projectors and evidence of a fire as a result of that older technology. The race meeting was the usual success and the small profit was again donated to the Toowoomba Hospital. Sunday morning saw us meeting again at the Ortem restaurant for a leisurely breakfast before returning home or going on to other local activities. May PD We held a PD afternoon on 12th May with a theme of integration of Nurse Call Systems with BMS. The afternoon was well attended by a record number of delegates across the SE Queensland. An excellent afternoon hosted by Craig Byth, the Operations Manager for Rauland along with his team Andrea Panapassa, Lynley Jury our two Key State Account Managers and State Operation Manager Stephen Creese. Craig reintroduced us to their Nurse Call flag ships – Responder 5 and the 4000 Nurse call systems and how its introduced into the health facility and the integration of components of it with existing systems. The afternoon was capped off with the last speaker Gregg Wyatt, Gregs the Director of System Design Drafting & Analysis Solutions and is the in house

PD Three; is programmed in for the 12th August to be held at Bendigo Health where we will have the opportunity to inspect their new 640 million dollar Hospital project. The CoM also formed a Branch Conference subcommittee for the up and coming 2017 National Conference to be held in Victoria.

contractor for RBWH, he majorly looks after the Austco patient call system and spoke about dealing with aging technology and the pit fall faced when considering refurbishing & upgrading. Gregg also provided information on As3811 standard, what the changes mean to facility managers. The evening concluded around the Rauland display’s enjoying a few light refreshments and catching up with the members and invited guests. July Mid-Year Conference. This year the conference will be held at the Victoria Park Golf Course. We have used this venue previously and it has proved satisfactory because of the large area available for the trade display and unlike the CBD there is free parking. We are in the process of finalising the contract with the venue and sorting our the program. These activities are expected to be completed within the next week. Advertising has commenced and some sponsors are now ready to sign up, including 2 Majors. The theme of the conference will be Patient Safety – Engineering Aspects. Sessions will centre around: 1 Water safety 2 Safe Design 3 Fire Safety 4 Case Studies We have had to alter the dates for the conference because of a clash of bookings. New dates for the conference at 28/29 July. This conference will include our Branch Special Meeting as required prior to the AGM in Adelaide.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

STATE BRANCH REPORTS NSW/ACT REPORT – PETER LLOYD, BRANCH PRESIDENT Introduction he NSW/ACT Branch held its Annual State Conference + AGM at the Retreat – Wisemans Ferry 27th May – 28th May 2016. The conference “Integration – Operational Engineering” was attended by up to 30 delegates plus partners and well supported by 15 sponsors, some who have been long time IHEA supporters and a few new sponsors providing a great mix of new technologies.

Extensive planning provided members significant Professional Development (PD) opportunities for their attendance. I sincerely thank members, trade sponsors and all others who have supported this year’s conference.

For 2016 there were no nominations for Apprentice of the year, however we received 2 very strong nominations which were unable to be split in the Tradesperson of the Year category, a decision was made by the CoM to have two Tradesperson awards for 2016. NSW/ACT Branch Service Awards At the National Conference held in Perth September 2015 Member’s years of service awards were announced. 30 years of service awards for Ross McLean and Geoffrey Simkus. 10 years’ service awards for Mitchell Cadden, Geoffrey Sole and Brett Petherbridge. It is also noteworthy to mention that Mr Charles (Charlie) Shields attained 60 years membership in January 2016, our longest serving member. Charlie will receive his certificate at the National Conference in Adelaide in October 2016

Delegates to The NSW-ACT Branch conference May 2016

NSW/ACT Branch – Institute of Hospital Engineering 2016 Annual Achievement Awards NSW/ACT Branch Annually seeks nominations for achievement awards in 4 categories, this being:Apprentice of the year – Not Awarded Tradesperson of the year – Tony Day & Stephen Hannan Manager of the year – Fiona Gruber Engineer of the Year – Peter Lloyd

Left: Dual Tradesperson of the year Tony Day; Right: Dual Tradesperson of the year Stephen Hannan

Charles and Colleen Shields, with a gift to acknowledge 60 years membership with IHEA

AGM 2016 The NSW/ACT Branch held its AGM and the appointment of Mr Jon Gowdy as State President was overwhelmingly supported. Congratulations to Jon and to all the Committee of Management appointed members.

Name

Position

Phone

Jon Gowdy

President

02 95158041

mailto: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/IPP

0428699112

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

Current Committee of Management Contact details

Left: Engineering Manager of the year Fiona Gruber; Right: Engineer of the year Peter Lloyd

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

STATE BRANCH REPORTS Summary Finally on behalf of the NSW/ACT branch members I wish to acknowledge the great efforts of last year’s COM and appreciate their efforts and support and look forward to working closely with the new committee to move forward for the IHEA NSW/ACT Branch with various initiatives the COM have taken on board to build the branch.

(L-R) Helmut Blarr, Peter Allen, Glen Hadfield, Brett Petherbridge, Peter Lloyd, Jon Gowdy, Steve Dewar, (Front Row) Darren Green, Mal Allen.

SA STATE BRANCH REPORT – PETER FOOTNER, STATE BRANCH PRESIDENT Activities he Branch Committee continues to progressively update its rolling program of professional development and networking events. The most recent PD event was sponsored by Schneider Electric and was held at their facility in Gepps Cross on March 17th. The event theme was New Technologies in Electrical Design & Energy Management Savings and involved:

• Presentation: Smart clean energy to help ZERO your power bill (Go Zero) • Presentation: ‘Looking Ahead’ – New Technologies in Electrical Design (Schneider Electric)

E H I

Membership A number of organisations have indicated interest in both State and National corporate membership and these continue to be followed up as necessary.

The next PD event is scheduled for June or July and will focus on Developments in Hydraulic Systems.

Various communications with members have taken place over recent months, alerting members to development opportunities through relevant, non-IHEA events that might be of value to the membership. Many of the current Branch Committee members have very heavy workload involvement in major capital projects and other significant activities associated with the SA Government’s “Transforming Health” initiative and, as a result, they have had limited time to devote to IHEA matters. What time has been available has been directed towards planning for the national conference and, as a consequence, other branch activities have suffered somewhat as a result.

E L A

Actions The Branch executive has continued with its dual role as the A 2016 National Conference Organising Committee, withF additional input from the IHEA CEO, Karen Taylor, T Hwhere L A organisers, necessary, and our professional conference E Iceberg Events. Planning is well underway H and we are confident of developing a challenging, rewarding and G Nwill be attractive to members, I enjoyable conference that T other healthcare and FM providers R and sponsors, exhibitors O P alike. The Committee expects to shortly release the draft P U program and the call for delegate registrations.

f o E T U S T I T S IN

• Site tour of the manufacturing facility

I G N

The Branch Committee is aware of the need to continue to identify and recruit new individual members from across the public health, private hospitals and aged care sectors to sustain the local branch.

S O H

T I P

LI I C

Recent conference planning activities have focussed on: • Fleshing out of the conference theme and delineation of possible streams for the various presentations. • Release and promotion of sponsorship and exhibitor prospectuses. • Consideration of keynote and other invited speakers. • Assessment of the responses to the call for abstracts. • Drafting a conference program structure based on streams and with initiatives to improve delegate/exhibitor interaction. • Consideration of venues for social aspects of the conference. THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

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IFHE CONGRESS NEWS

The International Federation of Hospital Engineering Congress 2016 Every two years international global Healthcare Engineering Institutes and organisations similar to the Institute of Hospital Engineering, Australia (IHEA) can bid to host the prestigious International Federation of Hospital Engineering (IFHE) Congress event. In 2014 the IHEA submission to host the 2018 IFHE congress in Brisbane was accepted by the IFHE Council.

IFHE 2016

Madurodam

o support and promote the 2018 congress, representatives from the organising committee attended the twenty-fourth congress, hosted by the Dutch Association of Technology in Healthcare (the NVTG) held in the Hague World Forum, Netherlands. The Madurodam, a miniature park and home to a range of 1:25 scale model replicas of famous Dutch landmarks, historical cities and large developments was the venue for the welcome party where new friendships were made and old acquaintances were renewed. Conference Convenor and NVTG National President, Douwe Kiestra welcomed guests to The Hague and

looked forward to a successful 2016 congress. Handing the Presidency to Douwe Kiestra, outgoing IFHE President Lilliana Font thanked the IFHE for the opportunity to lead the organisation and reflected on the past two years of her Presidency. After welcoming the 930 delegates and sponsors, Douwe declared the congress open and invited the audience to witness a spectacular display of sand artistry, delivered by Zandtovenaar (The Sand Magician) who linked the NVTG and the IFHE promoting the congress theme â&#x20AC;&#x153;Sharing Knowledge for Better Healthcare Worldwideâ&#x20AC;?.

During the two days of the congress, delegates from 35 different countries attended 22, presentations delivered by speakers from 11 countries across a wide and varied range of topics. The number of presentations required that two of the World Forum theatres be utilised with presentations being run in parallel which limited the number of presentations an individual could attend. The Australian contingent attempted to make sure that they had representation within each theatre to make best opportunity of the occasion. The World Forum Exhibition Space situated between the two theatres was the venue for the international business exposition where 120 companies and organisations supporting the IFHE 2016 Congress were able to demonstrate to delegates and visitors how healthcare sector products and services were constantly being updated and improved. Morning and afternoon refreshment breaks served within the

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

IFHE CONGRESS NEWS exposition area ensured that delegates had ample time to circulate and meet and engage with the 106 businesses, many of whom would be familiar to IHEA members, whose support was paramount to the provision of a successful congress. The IHEA booth with the added attraction of Jodie and Karen was particularly popular with delegates and sponsors alike. The Australian contingent promoting Brisbane 2018 and recognisable in their Akubra Hats and Chambray shirts, were only too pleased to hand out toy Koala bears, pins and Australian lollies to visitors who expressed an interest in attending the 2018 congress. Vegemite was offered but, despite best efforts, few jars were accepted. The IHEA Booth

Day one of the congress concluded with drinks at business exposition while delegates awaited the return of their partners who visited the historical city of Delft The congress dinner or “Party Night” was held in the Louwman Museum. Opened in 2010, it is purposely designed to display the unique Louwman family collection of over two hundred and fifty antique and classic motor cars. Reputed to be the oldest private collection of automobiles in the world open to the public the collection includes horse drawn wagons, the first self-propelled vehicles, luxury cars from the end of the 19th century, post-war “affordable cars” and the first racing cars. The collection includes unique specimens such as the boat-car, the beach-car and the swan-car as well as famous cars such as James Bond’s Aston Martin from the film Goldfinger and the customised Cadillac Fleetwood of Elvis Presley.

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THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

A very successful evening ensued with participants being treated to traditional Dutch food such as Bitterballen (deep fried crispy meatballs), Kibbleling (battered and deep fried morsels of white fish), Stamppot (mashed potatoes with other

IFHE CONGRESS NEWS

Presentation Title

Presented By

Country

Quality of Utility Services at the Antwerp University Hospital, Monitoring and Risk Analysis

Dirk de Man, Antwerp University Hospital

Belgium

Preinstallation requirements on site to support the processes of hospital design and construction

Carolina Francisca Navarrete Guarda, Ministry of Health, Santiago

Chile

Designing intensive care unit facilities on single-patient room basis: Evicures project

Tiina Yli-Karhu, Seinäjoki Central Hospital

Finland

New surgical ventilation system in operating rooms

Clemens Bulitta, Technical University of applied sciences, Weiden

Germany

Optimising of hospital engineering

Cord Brüning, CoSolvia engineering consultancy

Germany

Hospital Buildings or Building Hospitals? Renewing University Hospitals: Two different solutions

Cristina Chiarinotti & Carlo Besta, Neurological Institute of Milan

Italy

Immigrants emergency: Preventing diffusion of infective diseases into hospitals

Amedeo De Marco & Maria Addolorata Vantaggiato, Hospital Cosenza

Italy

Diagonal clean airflow systems for hybrid operating rooms

Yoko Yamada, Shimizu Corporation Institute of Technology

Japan

Hospital design in the cases of various disasters

Kana Egawa & Yasushi Nagasawa, Tokyo University

Japan

Total integration of technical installations is essential to make buildings flexible for changing usage during the buildings’ lifetime

Trond Thorgeir Harsem & Janne Grindheim, Norconsult

Norway

The Netherlands Dutch healthcare system and Vision on future healthcare facilities

Mark-Erik Nota, Sweco (formerly Grontmij)

The Netherlands

The Netherlands Demand for Healthcare is Increasing, but the Hospitals’ Size is Reducing

Rianne Scott & Patrick Barske, Arcadis

The Netherlands

The Netherlands A medical city in the city of Rotterdam

Liesbeth van Heel, Erasmus University Medical Center & Willemineke Hammer, EGM Architects

The Netherlands

The Netherlands BREEAM-NL certification of Maastricht University Medical Center

Eric Scholten, Deerns engineering consultancy

The Netherlands

The Netherlands Care in a Sustainable and Healing Environment – A Different Approach

Wim van Houdt, Tergooi hospital & Jörn-Ole Stellmann, Wiegerinck architects & Antonin van de Bree, LBP Sight engineers

The Netherlands

The Netherlands Human factors simulation in the design process

Kirsten Schreibers & Ingeborg Griffioen, Intergo

The Netherlands

Transition from health and social care buildings to user-needs oriented environment of care for people living with dementia

Efthimia Pantzartzis & Andrew Price, Loughborough University & Ruben Peeters, Royal Haskoning

The United Kingdom

The Netherlands Reliable Hospital Data Centre

Karl van Ginderdeuren, Deerns engineering consultancy

The Netherlands

A role for logistics in the optimisation of a hospital

Dirk Joubert, Royal Haskoning

The Netherlands

The Netherlands Green Deal for sustainable operational business in the healthcare sector

Minister of Health, Welfare and Sport, Ms Edith Schippers

The Netherlands

United States Health in the Green Economy

Walt Vernon, Mazzetti/World Health Organisation

The United States of America

Venezuela Improving Hospital’s functionality through evaluation of vulnerability

Karla León, Central University

Venezuela

IFHE 2016 Dinner

Chairman of the congress, Philip van de Poel, and moderator Ruud Koolen opened the proceedings of day two The Dutch Minister for Health, Welfare and Sport, Ms Edith Schippers was scheduled to present the final key-note of the conference but was unfortunately unable to attend. Bas van den Dungen the Director-General of Curative Care agreed to deputise, delivering the final key-note on “The Netherlands Green Deal for Sustainable Operational Business in the Healthcare Cector”. Douwe Kiestra, NVTG President closed the congress at 16:45 and handed over the stage to IFHE Vice President and IHEA Secretary, Mr Darryl Pitcher who thanked the Dutch organisers and complimented them on a fantastic congress, before inviting the Australian Ambassador to The Netherlands, Mr Brett Mason to the stage to offer his support for the 2018 IFHE Brisbane congress.

vegetables), Raw Herring and Dutch Fries, being prepared and cooked within centralised open areas located in the middle of the museum and affording guests the opportunity to witness the preparation of such delicacies, while being entertained by acrobats and musicians alike.

Darryl Pitcher went on to introduce the organising committee for the 2018 congress, and following a short promotional video, Mr Brett Petherbridge the IHEA President, invited guests and partners to attend an Australian themed “cocktail party” held in the World Forum Café.

Possibly as a result of the previous nights over indulgence, reduced numbers were in attendance at beginning of day two.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

IFHE CONGRESS NEWS The international jury awarded first prize to the Ashikaga Red Cross Hospital. This Japanese hospital, according to the jury, deserves special praise due to the way its philosophy of “good treatment, pleasant care and joy in working”

TECHNICAL VISITS Delegates had the option to visit both the Erasmus Medical Centre in Rotterdam and the Reinier de Graaf hospital in Delft, or tour a number of care homes of the GemivaSVG Group where “people who as a result of handicaps, chronical diseases or other limitations” are cared for.

CULTURAL VISITS Around 40 delegates joined in the cultural tour where the first stop was one of the world’s largest flower gardens, the Keukenhof, (the “kitchen garden”). The park, where approximately 7 million flowers were in full bloom, dates back to the 15th century.

A tired Australian, Kevin the deflatable kangaroo

After walking around the Keukenhof for two hours, delegates were bused to the Zaanse Schans, a stunning living and working community that dates back to the 18th and 19th centuries.

The party was a great success with delegates from all corners of the world who, after having received a small taste of the friendly Australian culture expressed a real enthusiasm to attend the 2018 Brisbane congress.

A slow bus drive back to the World Forum allowed ample opportunity for viewing and photographing of the remarkable Dutch countryside.

THE FIRST INTERNATIONAL NVTG IFHE BUILDING AWARD

• Karen Taylor – CEO IHEA

During 2015 organisations that had recently realised, or been involved in, a building project in healthcare, were invited to compete for the International NVTG Building Award 2016. The NVTG Building Award is a prestigious Dutch building award that has been presented five times since 1997. Previous winners of the NVTG Building Award were all state of the art facilities for Dutch healthcare institutions but given the conference theme, the invitation was opened up to include international participants. Only projects that had been completed during or after 2011 were considered for the award, and the projects had to be in use when they were entered for the Contest. All healthcare sectors were eligible to enter a project. The NVTG Building Award focused on new builds as well as renovation or remodelling projects. Over forty projects from all over the world were submitted for the NVTG IFHE Building Award. Twenty-two of which represented the cure sector, fifteen represented the care sector and the remaining projects represented both. All shared the theme “A healing environment for all users”.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

The Australian delegation • Jodee Parker – Managing Director, Iceberg Events • Brett Petherbridge – IHEA National President • Darryl Pitcher – IHEA National Secretary and IFHE Vice President • Darren Green – IHEA National Immediate Past President • Peter Easson – IHEA National Vice President IHEA Member, Trevor Stonham who was touring around Europe and attended the conference was also co-opted into the Australian delegation. The IFHE 2016 congress web page is located at http://www.ifhe2016.info/

TABLE OF PRESENTATIONS From a personal point of view several presentations stood out, in particular; The Netherlands Dutch healthcare system and Vision on future healthcare facilities – Mark-Erik Nota, Sweco The heading “Keep Politicians and amateurs out of healthcare” captured the international audience’s attention. Mark-Erik Nota’s presentation on the influences of economic, society expectations and technical changes on healthcare delivery and infrastructure introduced many thought provoking ideas.

IFHE CONGRESS NEWS The need for specialised and localised healthcare to support a rapidly growing population, an ageing workforce, disillusioned staff leaving to seek employment elsewhere, infrastructure that was no longer fit for purpose, no long term or poor strategic planning, unforeseen risks such as potential terrorist attack and/or natural disasters all impact on the ability to maintain sustainable healthcare across the world. In order to address these issues, the development of technological solutions which allows for the remote diagnosis’s, treatment and monitoring of ailments, is reducing the need for the traditional large centralised general hospital. The trend towards localised primary healthcare delivery facilities, meeting the local population’s requirements, without political influence or the top heavy bureaucracy prevalent in first world countries, funded by local employers, health insurers, healthcare professionals and major companies, all with an interest in providing affordable and localised healthcare, is gaining momentum. “Hospitals should be built, run and operated by Engineers, Doctors and Nurses for the benefits of the local populace” The World Health Organization: Health in the Green Economy – Walt Vernon, CEO Mazzetti, U.S.A. With healthcare facility activities being estimated to represent 3–8% of the climate change footprint in developed-

countries, the World Health Organisation’s “Health in the Green Economy sector” was the topic of the presentation which examined health’s impact on climate change and the mitigation strategies being considered. The concept of an internationally agreed standard approach to benchmarking, while acknowledging the difficulties associated with climate, location, age, construction and service provision was discussed raising the potential of the IHEA’s own AssetMark, with some further refinements and developments, having a far wider, international market A role for logistics in the optimisation of a hospital – Dirk Joubert, Royal Hakoning, The Netherlands Logistics are fundamental to the operation of a hospital. Anything that moves and is required to be in the right place at the right time such as laundry, waste, equipment, medicines, food and information are all part of the logistics process as are staff and patients. Logistics must be planned as efficiently as possible. Optimising the planning and design of hospitals can significantly help to provide sustainable hospitals for both patients and staff. The presentation explored the vital role that logistics plays within a hospital setting.

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THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

Prevalence and nature of Legionella contamination in aged care facilities in Australia ROSS JONES, LYN POPE, AND RICHARD BENTHAM I HINDMARSH WATER TREATMENT

The release of the enHealth Guidelines for Legionella control in health and aged care facilities has put a new focus on the management of potable water systems. Of interest is that the guidelines address all water distributions systems. Historically there has been an emphasis on warm water systems as the major culprits as they operate in the optimal growth range for legionella bacteria. The new guidelines coverage of hot and cold outlets reflects the growing body of evidence that has shown these may also be sources of contamination and infection. The recent media coverage of contamination and infection attributed to icemachines is a clear demonstration of the role cold water systems may play in harbouring Legionella. A uniform approach to all water distribution systems makes good microbiological and technical sense.

t least 50% of Legionnaireâ&#x20AC;&#x2122;s disease notifications are attributable to sporadic cases of disease, such as those associated with health care facilities. Advances in treatment and diagnosis of the disease have meant that the fatality rate has dropped from between 20% and 25% of cases to between 10% and 15% of cases. However, fatalities associated with health care premises can be as high as 40% due to the health status of those infected. Aside from fatalities it is common for those who recover from the pneumonia to suffer long term health effects as a result of contracting the disease. These sequelae may include breathlessness, muscle aches, depression, chronic fatigue and neurological symptoms. Global estimates are that approximately 65% of large building water systems have detectable Legionella contamination. Systems where

Legionella have previously been detected are significantly more likely to experience cases of disease. In the majority of cases where Legionella are detected in a large building the contamination is systemic i.e. the system is colonised throughout. There has been a continuing upward trend in disease notifications over the past two decades. It is suggested that the reasons for this increasing trend are in part due to better diagnostic techniques, but also due to the increasing aged population and persons with compromised immune systems. There is also growing body of evidence to show other organisms may also cause a variety of infections including pneumonia via the same route. These opportunist pathogens include Mycobacterium Avium Complex, Acinetobacter spp., Pseudomonas spp. and Stenotrophomonas maltophilia and others. It is proposed that notified

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

cases of disease are an underestimate and that the upward trend is likely to continue. Global opinion is that Legionella and other infections from building water system are preventable but require a concerted effort on the part of the facility operators and maintenance staff.

TWO YEAR REVIEW OF SAMPLING DATA In this study we reviewed data from water sampling at 124 aged care facilities in SA, QLD and NSW in the period between November 2013 and October 2015. Facilities included hot and warm water systems. The intention was to get a handle on the prevalence and nature of contamination in these facilities. The data set also serves as a baseline against which the efficacy of the implementation of water safety and risk management plans, like those outlined in the enHealth guideline, can be measured.

TECHNICAL PAPERS

Positive and negative Legionella test results for 124 aged care premises

36%

Positive Sites Negative Sites

64% Contaminated thermostatic mixing device at an aged care facility

Chart 1. Positive and negative Legionella test results for 124 aged care premises.

Legionella detections in facilities with no disinfection and

In this period 757 water samples were were still returned in systems receiving continuous disinfection taken and analysed for Legionella by disinfection. Investigation of these culture at NATA accredited laboratories positive results routinely demonstrated 40 Positive and negative Legionella test results for using the Australian Standard method. either contaminated fittings (see 124 aged care premises Of the35sites sampled 36% returned photographs of contaminated outlets positive below) that had not been routinely 30 Legionella test results (see chart 1). cleaned, or stagnation due to infrequent Regular Dosing 25 use of 36% the outlets. Positive Sites Of the positive sites 83% (38) did not 20 Contamination from a removedNo Regular Dosing diffuser at a health care facility. Negative Sites receive any disinfection and 17% (8)38 were 15 continuously dosed with low concentrations 64% of chlorination at site 10 point of entry (see chart 2). Application of a continuous disinfection 5 8 system is one of the operational controls 0 suggested by the enHealth Guidelines. Positive Sites The data presented demonstrates the value of disinfection as an operational control. However positive culture results

Distribition of Legionella culture results (cfu/mL) from aged care facilities Legionella detections in facilities with no disinfection and continuous disinfection6% 39%

40 26% 35

51-100

30 25 20

10-50

29%

101-500 Regular Dosing 38

No Regular Dosing >501

Legionella plate count results showed a Poisson distribution of cfu/mL with counts in the range 10-50 cfu/mL comprising 39% of the sample set and counts greater than 500 cfu/ mL comprising 6% (chart 3). This is consistent with previously reported data on Legionella isolations from contaminated systems. Negative (not detected) sample results are the most common. Positive sample results are predominantly in the 10-100 cfu/ mL range. This is explainable by the fact that Legionella multiply in biofilms and not in the water column. So that in frequently used outlets only small amounts of Legionella will be seeded into the water because of the flushing effect of the water. High counts are associated with large amounts of biofilm detachment which is often the result of stagnation. In support of this notion we compared the percentage of positive test results from different outlets. We discovered that shower samples returned 41% of positive results, basin returned 26% of positive results and sinks and baths 18 and 15% positive results respectively (chart 4). These figures may be explained by long hoses on showers creating greater surface area for biofilm, diffusers on basins creating collection areas for debris and biofilm, and the common absence of hoses or aerators on baths and sinks giving the lowest positivity.

15 10 757 Water samples taken over 124 sites 5 8 0 Positive Sites

Positives n=114

Distribition of Legionella culture results (cfu/mL) from aged care facilities

Chart 2. Legionella detections in facilities with no disinfection and continuous disinfection.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

No Regular Dosing

15 10

TECHNICAL PAPERS 8

5 0

Positive Sites

water systems. Other jurisdictions do not require disinfections unless positive culture results are returned.

Distribition of Legionella culture results (cfu/mL) from aged care facilities 6% 39%

26%

10-50 51-100 101-500

29%

>501

TAKE HOME MESSAGES

757 Water samples taken over 124 sites

Positives n=114

Chart 3. Distribution of Legionella culture results (cfu/mL) from aged care facilities Percentages of total positive Legionella isolations from different outlets

Percentages of total positive Legionella isolations from different outlets 15% 41%

15%

18%

Shower

41%

Basin Shower Sink Basin Bath Sink

18% 26%

26%

Bath

Chart 4. Percentages of total positive Legionella isolations from different outletsâ&#x20AC;&#x192;

Distribition of Legionella Detections in Hot, Warm and Cold Water Systems

Distribition of Legionella Detections in Hot, Warm and Cold Water Systems 10% 23%

Warm Outlet

10%

Cold Outlet Warm Outlet Hot Outlet Cold Outlet

67%

23%

67%

Hot Outlet 757 Water samples taken over 124 sites

Positives n=114

757 Water samples taken over 124 sites

Positives n=114

Legionella cfu/mL test results from facilities receiving 6 Chartmonthly 5. Distribution of positive Legionella cultures(chlorination) from Hot, warm and cold water systems or annual disinfection

Legionella cfu/mL test results from facilities receiving 6 monthly or annual disinfection 4% 1% 4% (chlorination) 6%

Although the majority of positive Legionella culture results came from warm water4%system a significant proportion 4% outlets 1% 6% of positive results (33%) were from hot and cold water outlets 85% (Chart 5). 85% Interestingly, six monthly or annual disinfection markedly affected the ratio of positive to negative test culture results, but maintained a Poisson distribution (see chart 6). Annual disinfection requirement for warm water <10 is a statutory 10-50 51-100 101-500 >501systems in South Australia but is not, as yet, required for hot or cold <10

10-50

Speciation of the test results revealed 26% of samples were Legionella pneumophila SG1, 9% Legionella pneumophila other serogroups and other Legionella species were 65% of the data set. (Chart 7). Only non-pneumophila species were isolated from hot water systems, but L.pneumophila SG1, SG2-16 and other species were isolated from cold systems linked to hot water systems.

51-100

101-500

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

>501

Roughly one third of 124 aged care facilities showed contamination by Legionella species over the past 2 years. Common features of positive test results were failure to routinely flush infrequently used outlets, infrequent maintenance and cleaning of fittings and lack of disinfection. In building water systems the test results do not actually reflect sampling of the water in most instances â&#x20AC;&#x201C; rather the outlet and attached biofilm the water flows through. Reducing surface areas for biofilm aggregation will reduce Legionella populations. This was highlighted by the greater percentages of positive results from showers and basins fitted with diffusers. Well managed and maintained outlets are arguably more critical to Legionella control than the quality of the water supply. Contamination was found in hot, warm and cold water supplies. It is a fallacy that either hot or cold water systems will not harbour Legionella contamination and that only warm water systems are problematic. We demonstrated colonisation in all types of systems. In some facilities measured cold water temperatures were above 25ÂşC, well inside the multiplication for Legionella. Disinfection and decontamination procedures should therefore address both hot and cold water storages and distributions to be effective. Culture positive results were predominantly non-pneumophila Legionella species. Although L.pneumophila infections dominate the notified cases of disease from water globally other Legionella species also cause infection. Particularly in health and aged care premises where there are concentrations of immune-compromised individuals. From the perspective of the precautionary principle of public health any Legionella detection in a facility should be treated with concern and demonstrate to facility operators that conditions in the system are suitable for the survival and multiplication of other more virulent species and strains. Annual disinfection and continuous dosing of low concentrations of chlorine were both effective in reducing the number Legionella detections and Legionella concentrations in positive test results. Continuous dosing may be less disruptive and cost comparable alternative to annual of 6 monthly disinfection events. Implementation of the enHealth Guidelines and preparation of comprehensive risk management plans is likely to further improve on these results. This data set was collected

Cold Outlet

67%

Hot Outlet

TECHNICAL PAPERS

757 Water samples taken over 124 sites

TECHNICAL PAPERS

Positives n=114

Legionella cfu/mL test results from facilities receiving 6 monthly or annual disinfection (chlorination) 4%

4% 1%

85%

<10

10-50

51-100

101-500

>501

Chart 6. Legionella cfu/mL test results from facilities receiving 6 monthly or annual disinfection (chlorination).

Legionella speciation of positive samples for L.pneumophila SG1 (SG1),L.pneumophila SG2-14 (SG2) and other Legionella (Non PN) 9% 25%

Non PN 66%

SG1 SG2

757 Water samples taken over 124 sites Chart 7. Legionella speciation of positive samples for L. pneumophila SG1 (SG1), L. pneumophila SG2-14 (SG2) and other Legionella species (Non PN).

predominantly from systems where risk management plans had not yet been implemented. A comprehensive water safety and risk management plan will also minimise risk from other microbial, chemical and physical hazards that are present in aged and health care facilities.

ABOUT THE AUTHORS Ross Jones, Manager at Hindmarsh Water Treatment. He has extensive knowledge in all areas of plumbing and water treatment and multiple direct experiences of successful remediation of Legionella contaminated premises. Lyn Pope, Risk Management Administrator. She has extensive data-processing and programming skills. Dr Richard Bentham, Risk Management Specialist. He has 25+ experience in Legionella ecology and control. He contributed to four chapters in the WHO ‘Legionella and the control of Legionellosis’ book, as well as publishing more than 20 scientific journal articles and book chapters relating to Legionella ecology and control.

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TECHNICAL PAPERS

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TECHNICAL PAPERS

The complexities of waste management WALTER VERNON, JESSICA HAMANN, KAYLYNN ROTHLEDER, MIKE RINKEN

The hazards created by healthcare waste are complex, and its management much more so. Waste varies in type and quantity, risk profile, public perception, regulatory complexity, and available management methods.

aws and regulations across the globe require certain types of waste be treated in specific ways to render it into less-hazardous materials. These treatment options for can be expensive, resource consumptive, and environmentally damaging; in fact, every method of waste management creates consequences for the natural world. Most problematic is the treatment of infectious, pathological and pharmaceutical wastes. Although accounting for only a small proportion of the total volume of waste coming out of a hospital, they do pose particular complications. Pathological and infectious wastes carry with them the risk of disease transmission. Emerging health threats such as Ebola underscore the hazardous nature of these waste streams. Pharmaceutical wastes are chemicals that pose exposure risks to humans and wildlife. Many countries require these parts of the healthcare waste stream to be incinerated. With no real alternative, the WHO agrees that, in the short run, incineration is a preferable strategy, though aspiring to better methods that produce no or few dioxins and furans in the future.1 Many parts of the world have no regulation, or at least no effective regulation of medical waste disposal. Even where regulation exists, the infrastructure needed to implement this may be seriously lacking, leaving a local facility with few options.

Older incineration technology created a variety of environmental and health problems. These technologies were often coupled with energy recovery systems, and advertised as ‘Waste to Energy’ systems. Newer incineration technologies allow incineration to be employed with fewer impacts and some European countries now have large plants dedicated to this strategy. Other new waste conversion technologies are similar to but scientifically different from incineration, allow waste to be converted to char and heat energy with even smaller footprints. As noted above, no disposal method is without harm, and so, at least for the time being, we need to be able to choose systems that do the least harm. However, comprehensive data is hard to come by today, and is often obscured by emotion. The global healthcare sector can benefit from rigorous analysis of the environmental footprint of various waste management strategies for various potential waste streams. These analyses should also include the related impacts from offsetting benefits such as emissions avoided due to energy generation or prevention of waste transportation. The proximity of hazard is more difficult to measure, but can be equally as real. Clearly, industry needs to focus on waste reduction and segregation to minimise environmental impact. Tools are also needed to help minimise the health and environmental impacts of waste management, based on ‘real’ data including that for newer

technologies. Shared expertise can help healthcare organisations stay on top of new technologies, make timely decisions and ultimately do better than opting for apparently preferable solutions whose impacts may actually be more significant. In the early 1980’s, medical waste washed up on the east coast beaches of the US, causing many to be closed to the public.2 A community and political uproar ensued that resulted in the Medical Waste Tracking Act of 1988 that required medical facilities to treat and track their waste.3 In response, hospitals began to install on-site incinerators to dispose of waste. In some cases, incinerators also served as a source of thermal energy for the facility. These on-site incinerators not only burned medical waste, but also burned all the solid waste from the facility. Once these devices appeared on a campus, they created an appetite for fuel, so there was no incentive to reduce or recycle waste. Even more problematic was that because these systems were unregulated, they often had little in the way of emission abatement systems, and hospitals often operated them poorly. As a result their airborne emissions became a serious threat to environmental and human health, particularly within contiguous areas. In 1994, The Mercury Report to Congress4 and the Dioxin Reports5 identified healthcare as a leading source of both mercury and dioxin

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

THE DESIGNER PAPERS TECHNICAL Helen Kelleher graduated as an Occupational Therapist from Sydney in 1965. Her first appointment as an OT was at the Mount Wilga Commonwealth Rehabilitation Centre, Hornsby, in Sydney. Due to family commitments and living overseas, Helen’s career path was put on hold for several years. Upon returning to Canberra, after several years living overseas, Helen joined the Mobile Unit of The Rehabilitation Team at the Canberra Hospital in 1973. In the two years with the unit she made home assessments and arranged the supply of equipment for clients. This gave Helen a more thorough understanding the needs and difficulties faced by clients with the equipment that they had at this time. After eight years running a day care program for the aged and disabled, Helen moved back into the hospital environment working at Queanbeyan Hospital. Her duties included Home Modifications as well as working with patients on the wards and in the Day Care Centre.

THRONE ACCESSORIES It was while working in the Home Modification area that Helen identified a deficit in the design of some of the equipment. She saw that the safety aspects in accessing the toilet for many of her clients were not being adequately met by any of the equipment available. The most obvious challenge Helen identified was that other rails required patients to pull themselves up, a very difficult task for the frail, aged and those with back injuries. The Throne rails are positioned much closer to the body allowing patients to push up more like they do when sitting on a chair. Having exhausted enquiries in her search for suitable equipment, Helen set about developing her own ideas with safety and comfort high on the agenda. She was encouraged to learn that existing porcelain bowls had the strength to hold a rigid fixture that she knew was the answer for people with disabilities and physical restraints. Helen commenced designing a prototype Rail and continued to develop the Rails until the highest safety aspects were met as well as ease of transportation. The initial design was so well received that Helen set about refining the model to accommodate people with a full range of disabilities including sports injuries as well as rails and steps especially for children.

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THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

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TECHNICAL PAPERS

emissions due to incineration. Emissions testing determined that 98% of the medical waste incinerators (MWI) could not meet the clean air standards set forth in Maximum Achievable Control Technology (MACT) Act of 1992.6 This resulted in hospitals disbanding the use of incineration, and so, by the early 2000s, most of these MWI’s (medical waste incinerators) were shut down permanently. Today there are only 60 or so commercial incinerators in operation in the US.7 As a result, the relatively small quantity of pathological and pharmaceutical waste is often hauled long distances to be incinerated. In most cases, the MWIs used have no energy generation features. This hauling and incineration results in a significant, and seemingly unavoidable environmental impact. Improved incineration and emission abatement technologies are now available, often with energy recovery, particularly at large, municipal scales. However, such facilities are unavailable in much of the world, often they are also not permitted to handle medical waste, and it would still require significant transportation. Emerging technologies, called ‘Conversion Technologies’ (CT), offer an opportunity to replace traditional incineration, and it can be achieved on site eliminating the need for transportation. CTs refer to a wide range of biological, chemical, thermal (excluding incineration), and mechanical technologies that are capable of converting solid waste into residue, fuels, biodiesel, and clean

energy.8 These technologies have been slow to gain any traction in healthcare. Some label CTs as ‘incinerators in disguise,’ and given the history with incinerators, few hospitals are anxious to repeat that perceived mistake.

TECHNOLOGY BENEFITS AND LIMITATIONS Autoclaving, which is not a CT, but is the most widely used non-incineration form of treatment system, sterilises medical waste using steam and high pressure. These systems are limited to the treatment of pathogens (live infectious agents) and do little to render chemicals non-hazardous. Further, autoclaving does not render waste unrecognisable and in the US many states require that before waste is landfilled, it must be unrecognisable, adding the need to shred treated waste. Autoclaving was used in many base scenario-planning cases.

WHO agrees that, in the short run, incineration is a preferable strategy, though aspiring to better methods that produce no or few dioxins and furans in the future. Pyrolysis is an oxygen-free thermal treatment process that processes waste at temperatures between

400°C (750ºF) and 815°C (1500ºF) in the absence of air.9 The lack of oxygenation is a critical difference between pyrolysis and combustion. The fuel used to initiate the ‘baking’ of the waste can be natural gas, propane, or the gas generated by the pyrolysis process itself. This process first uses a pyrolytic chamber that reduces the waste to ashes and gases, and uses a ‘post-combustion’ chamber to burn the produced gases at very high temperatures. The resulting synthetic gaseous product of this and other conversion technologies is often referred to as syngas, and consists of hydrogen, carbon monoxide, and methane. Both off-site and onsite facilities, as well as small-scale and large-scale pyrolytic systems are available. Today, pyrolysis is the most likely technology to be used for healthcare applications because of unit sizing more appropriate to in-house or smaller uses, and because, while still a costly technology, it is relatively less so than other CTs such as gasification or plasma arc. Gasification is a process in which organic waste is partially oxidised to form chemical reactions to produce carbon dioxide, carbon monoxide, and methane gases that create extreme high temperatures in the gasifier. The syngas that is generated from the three primary gases can be utilised for industrial and commercial process and products, including photographic film, coal, and petroleum, while the solid residue (slag), made non-hazardous by cooling, can be used for a variety of manufacturing products. Some versions of this technology use the gas to fuel the process, and extract heat energy from the system for use as an energy source. Plasma arc is another form of CT that uses extremely high temperatures, and is also very expensive. It may be a good solution for the chemical or ammunitions industry, but it is it probably too much for on-site healthcare solutions. Waste-to-energy (WTE) systems can be integrated into CT systems rather easily, and because these systems can generate a large amount of syngas, the

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS Base scenario. This includes information relating to waste generation types and weights, where and how the waste if being managed. Then to further understand the assumptions of the scenarios to be analysed, like the onsite and off-site, CT treatment systems need to be compared via CT systems and information and assumptions, summarised in Figure 1.

Figure 1: Inputs and outputs of the Waste Treatment Calculator.

opportunity to generate energy is used in both the economic and environmental countermeasures. CT systems are applicable for waste treatment for infectious, pathological, sharps, and (if applicable) municipal solid waste (MSW).10 However Regulated Medical Waste (RMW) must be pre-treated and MSW must be shredded prior to the CT process, which is yet another complicating factor.

considerations, and environmental emission factors from different types of waste treatment options. The calculator references various emissions factors from landfilling, transportation (e.g., distance, fuels consumed, truck type), mass and energy balances, etc. wherever they are used so that can be changed when new data is available, or if there is simply a disagreement factor used.

WHERE DO WE GO FROM HERE?

The intent of the calculator is to be a free, open-source tool for the measurement of waste management scenarios. We intend for the tool to be available to all; we believe that ‘opensourcing’ its development can help us bring collective best thinking to bear to ensure its accuracy, and to help it help the industry. At the end of the day, we all have a vested interest in working on the medical waste management issue.

The volume and toxicity of waste is not getting any smaller. Existing systems are aging. New technologies are available and health facilities need a plan. In order to develop a plan, they need data on the health impacts of transporting waste long distances, on the real emissions of one technology over another, on the benefits, and impacts, of waste-to-energy compared to the impacts of energy from other sources. Is it more environmentally and health friendly to recycle waste that is transported hundreds of miles, and perhaps shipped overseas, or used in a local WTE/CT unit? The healthcare sector could greatly benefit from asking these tough questions so that, together, we might be able to make evidencedbased informed on the benefits and impacts of one technology over the other. In 2012, Mazzetti set out to answer some of the questions and developed a rudimentary Waste Treatment Calculator to offer a way to compare and assess the different treatment scenarios. The Calculator compiles performance data, transportation

The calculator user needs to understand and compile all of the information on what is happening today to create the

Analysing WTE systems adds a certain complexity, but a necessary one which addresses the impacts of energy produced, and displaced. Material input specifications include waste, water, and oxygen consumption. Material output specifications include syngas, water, and solid residue generation; recoverable residue generation (if applicable). Energy input specifications include energy from internal waste processing; natural gas and electricity consumption, and output includes net electricity export; internal plant ‘parasitic’ consumption; energy losses from system, and of course, emissions from all sources, and of all types (including mercury, dioxins, and furans).

CALCULATOR ASSESSMENT To determine the validity of the Calculator, treatment scenarios were formulated that reflected real-world scenarios. The base model assumed that waste is treated using typically available treatment methods and actual distances for a 100-bed hospital in Southern California. Table 1 summarises the general assumptions for the scenarios. A critical assumption

Item

Assumptions

Waste generation

Total generation rate: 1.15 Tons/day DW (5% of total) RMW (10% of total) MSW (45% of total)

Hospital size and location

100 beds in Southern California

Treatment facility locations

Incineration: Chambers, TX Off-site treatment (CT & autoclave): Vernon, CA Landfill: Lancaster, CA

Cost considerations

Electricity, Water, Wastewater, Diesel fuel, Labour, Landfill disposal, Hauling, Off-site treatment

Hauling schedule

Based on EPA requirements Three days for all types of untreated waste 90 days for residuals from on-site CT treatment

Table 1: General assumptions for assessment scenarios.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

Scenario name

Waste commingled?

Treatment system

System location

Waste disposed in landfill

Base model

Incineration for DW

All off-site

MSW

Autoclave for RMW

Residuals from treatment

Landfill for MSW Pyrolysis

Yes

Pyrolysis – small

On-site

Residuals from treatment

Table 2: Specified assumptions for assessment scenarios.

was that the total waste management operation included a progressive waste minimisation and recycling program to minimise the total amount of waste of any kind that requires treatment, creating a recycling rate of 40%, while the other 60% of the waste requires treatment. As per the calculator requirements and assumptions, the total amount of waste in each scenario remains constant. It was assumed that 60% of the total waste quantity would require treatment and include:

1. Dangerous Waste (DW – pathological and pharmaceutical waste that is required to be incinerated by regulations), 2. RMW, and 3. MSW. All of the analysed scenarios are shown in Table 2 with their specified assumptions that were included when analysed within the calculator. In the Base Model, the three waste streams are treated in different locations using different technologies. In the scenarios using CT’s, the waste is ‘commingled’

Airborne emissions became a serious threat to environmental and human health, particularly within contiguous areas. (only in the sense that they are going to the same location, but stored and managed according to regulations). One important waste management question that was considered was whether it is better to landfill MSW or include it in the total waste sent to the CT system, even though it is not required to be treated? For the specified scenarios, emissions were found to be greater for landfilling MSW than through a treatment system. A factor of four was reported for carbon dioxide emissions and a factor of two was reported for

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS dioxin emissions for landfilling versus treatment. It was also beneficial to include MSW for adequate moisture content preservation during treatment and to reduce expenses.

Control Technology (MACT) Standards, as cited at http://www.epa.gov/epawaste/hazard/ tsd/td/combust/finalmact/index.htm

9 California Integrated Waste Management Board. 2007. New and Emerging Conversion Technologies: Repot to the Legislature.

7 N TangriNeil. 2003. Waste Incineration: A Dying Technology.

CONCLUSION

8 Los Angeles County Department of Public Works. 2007. Los Angeles County Conversion Technology Evaluation Report, Phase II report.

10 Los Angeles County Department of Public Works. 2007. Los Angeles County Conversion Technology Evaluation Report, Phase II report.

This article probably raises more questions than it answers. However, the healthcare sector does need solutions to address a waste dilemma that is not going away. Are conversion technologies really just incinerators in disguise? What are the emissions from a life-cycle analysis? For a hospital that is committed to human health and environmental protection and thinks they are making the right decision to ship waste to faraway places instead of treating waste closer to home, is that really the ‘right’ decision? Mazzetti invites to global community to review the Waste Treatment Calculator so we can all benefit from a viable, reliable decision making open-source tool. The emissions calculator can be found at: http://coolthings.mazzetti.com/wasteto-energy-calculator/

The healthcare sector does need solutions to address a waste dilemma that is not going away. REFERENCES 1 World Health Organization. Safe management of wastes from health-care activities. 2nd edition, 2012. 2 Eric Schmitt. On the Jersey Shore, a Summer to Forget. New Jersey; Atlantic Ocean, The New York Times, September 09, 1988. 3 United States Environmental Protection Agency. Medical Waste Tracking Act of 1988. 4 United States Environmental Protection Agency. 1997. Mercury Study Report to Congress. 5 United States Environmental Protection Agency. 1994. Estimating Exposure to Dioxinlike Compounds.

This article first appeared in IFHE Digest 2016.

WALTER VERNON Walter Vernon is CEO for Mazzetti, an international program management, strategic advisory services, consulting and engineering firm headquartered in San Francisco, USA. He still serves on, and is the former chair for, the NFPA99 Electrical Systems Technical Committee. He is the former Electrical Engineer for the California Hospital Building Safety Board. He also served as a coordinator for the Green Guide for Healthcare, the nation’s first Green Healthcare rating system. He co-authored the IEEE/ANSI White Book, the international standard for Electrical Systems in Healthcare Facilities. He also co-chairs the ASHRAE 189.3 committee, and chairs the Research and Development Committee for the Facilities Guideline Institute (FGI), the body that writes the Guidelines for Healthcare Construction, which is the model licensing code for most states in the US. He represents the US to the International Federation of Healthcare Engineering. He also served as principal author for the World Health Organization’s (WHO) Health in the Green Economy.

JESSICA HAMANN Jessica Hamann is the Content and Communications Manager at Mazzetti. She extracts and shares stories of our work in each of the company foursight lenses ¬– Research & Policy, Planning, Finance, and Project Delivery.

KAYLYNN ROTHLEDER Kaylynn Rothleder is an electrical engineering undergraduate at California Polytechnic State University in San Luis Obispo. She also works as an electrical designer for sustainable healthcare projects. She is actively involved with Engineers Without Borders, which provides sustainable engineering projects to communities in need.

MIKE RINKEN Mike Rinken has 20 years of industry experience and is a member of Mazzetti’s leadership team focused on Information Technology. Most recently, he has served as Vice President of Technology for FRCH in Cincinnati. Prior to that, he was an Associate and IT Manager for Fentress Bradburn Architects and an IT consultant at Zweig White. He is also past President and board member for the AEC/IT Leaders Organization.

6 United States Environmental Protection Agency. NESHAPS – Maximum Achievable THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

3D surgery and remote surgical viewing for St. John of God Ballarat Hospital Remote monitoring of activities in all the hospital’s operating theatres allows senior clinicians to give guidance or diagnostic observations to medical staff, and for resource managers to allocate patients to the most appropriate theatre to maximise efficient use of staff and equipment.

s part of a major upgrade to the surgical imaging suite at St John of God Ballarat Hospital, management and clinical staff looked for a state-of-the-art system that would support the most efficient use of medical staff and equipment resources associated with all the hospital’s operating theatres. After an extensive search for a new surgical management system—mainly associated with its laproscopic imaging work—the hospital selected ENDOALPHA through Olympus Australia. Troy Tregilles, Peri-Operative Services Manager at St John of God Ballarat Hospital, said “The Olympus solution stood well and truly above all other systems considered.” ENDOALPHA facilitates image and video management within the OR and procedure room as well as making it available anywhere and at any time through a hospital’s network. The system has the ability to route video feeds to multiple locations such as a lecture room or doctor’s office. According to Tregilles, extensive consultations took place reviewing the various options available to the hospital. “During the planning process for the renovation we sat down with the project staff at Olympus to decide what we really needed,” he said.

St John of God Ballarat Hospital surgeon David Deutscher (L), with Daniel Hinch from Olympus, demonstrating the 3D view of a procedure in the new operating suite at the hospital.

“While the project timeframes were tight,” said Wilson Arango, National Projects Consultant – Systems Integration with Olympus’ Medical Instruments Division, “we were still able to supply and install the medical equipment control system, video management software and monitor pendants for four operating rooms.” In addition, Olympus also provided

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

a documentation solution for the endoscopy suite. St John of God Ballarat Hospital (SJGBH) is one of the largest not-forprofit regional hospitals in Australia. Opened in 1915 the hospital has 196 beds and provides an extensive range of health care providing city services to residents living in Ballarat and Western

TECHNICAL PAPERS beneficial ‘knock on’ effect of reducing the preparation and sterilisation time for an operation.” Tregilles is wary to use the term “fully integrated” for the operating suite management system he now has. “During the 1990s, every supplier was claiming that they could integrate all systems which seemed to only mean they could put in the infrastructure required for every system they supplied no matter what the customer bought.”

A recent Olympus ENDOALPHA 3D operating room installation similar to that at St John of God Ballarat Hospital.

Victoria. The hospital is part of St John of God Health Care which is a leading health care provider, with private hospitals along with home nursing, pathology and social outreach services.

of a single button in either the sterile and non-sterile areas of the theatre. This helps to standardise procedures, enhance quality standards, decrease turn-around time and improve workflow.

ENDOALPHA features centralised control of all medical and peripheral equipment via a touch screen panel designed to maximise operating room efficiency. The panel provides intuitive control of devices such as electrosurgical generators, insufflator, camera systems, surgical lights and operating table, in addition to music and ambient lighting in the operating theatre and pre-op rooms.

Once a surgeon has been trained, the opportunities for continuing professional development are diminished. “We are able to sell the idea that a junior surgeon can show a senior colleague what is occurring during an operation and seek guidance.” The senior surgeon could be on hand to advise several junior doctors performing a number of procedures.”

“Reducing the amount of equipment where a surgeon is working is vital to minimising infection risks,” said Arango. “The capability to create doctor specific configurations that allow the set up of multiple pieces equipment with a single touch of a button enables equipment control from outside the sterile field.” Automation has been enhanced with the development of ‘scene selection’ which allows settings for pre-, intra-, and post-operative procedure steps to be set up and instigated at the touch

It is important for the hospital to make the most efficient use of all its resources,” Tregilles stated. “The streamlining that has taken place has drastically cut down the amount of downtime.” The St John of God Ballarat Hospital project is still in its implementation phase but the Olympus solution has already reduced the number of extra instruments in the sterile surgical field by two thirds. “The equipment is an all-in-one unit whereas we usually need three separate pieces all with their own cabling,” said Tregilles. “This has the

SJGBH receives many patients from outside its official catchment area. “We regularly have people come in from virtually any part of western Victoria and even over the border into South Australia. In addition to its own private patients, the hospital works closely in conjunction with Ballarat’s public hospital and regularly accepts overflow patients for the general wards as well as emergency cases that might require the particular expertise of a surgeon working in one of SJGBH’s theatres. The operating suites at the hospital have also been refitted with LED lights to reduce running costs and stronger, articulated monitor arms for mounting larger screens. “There are new highdefinition display screens being developed which we will be able to accommodate when they become available,” said Tregilles. SJGBH has also reduced the number of types of cabling from eight to two. “We found we no longer needed to have almost obsolete types such as VGA and sVideo,” Tregilles added. SJGBH wanted to “future proof” its systems as much as possible. The basic infrastructure should be suitable for the next seven to ten years but also allows for potential upgrades and expansion with minimal interruption to the work of the medical staff at the hospital. “The ORs have been enabled with the latest technology in medical control, which will last for long time to come and one theatre also has our latest 3D Imaging platform bringing 3D surgical visualisation to the hospital for the first time,” Arango stated. “They have also

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

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TECHNICAL PAPERS been equipped with 4K connectivity should SJGBH decide to upgrade their platform to Olympus 4K imaging.” “Plans are in place to increase the size of the hospital in the coming years,” Tregilles said. “We want a system in place where we know that all our staff are trained on the new equipment and comfortable working with their particular part of the surgical management system. We were confident that Olympus would provide the ongoing assistance required to meet our needs.” Employing more than 10,500 staff, St John of God Health Care is Australia’s largest not-for-profit private health care group. In addition, it is the third largest private hospital system in the country and operates the fourth largest pathology service. The group returns all funds to the communities it serves by updating and expanding facilities and technology as well as expanding, developing and acquiring new services. With more than 120 years of experience in health care, the St John of God Health Care group has earned an excellent reputation for providing quality health services to metropolitan and regional communities across Australia and New Zealand. Control column for an Olympus ENDOALPHA 3D operating suite.

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Fire safety: preparing staff for emergencies FRANCOIS BESTER I ENVIRONMENTAL SYSTEMS MANAGER, MEDICLINIC SOUTHERN AFRICA

How many patients are going to die if there is a fire in your hospital? It may be a harsh question, but it is a reality that we need consider, and live with every day.

e design buildings that include all the necessary safety features and equipment. Then we think we are fineâ&#x20AC;Ś we can handle a fire. Wrong! Safety precautions and equipment do not safeguard your hospital against fire and deaths. People do! People do the design, people do the installation, people do the maintenance and most importantly people do the evacuation. Of all these elements evacuation is the most critical. Not even the most modern, advanced systems and the best maintenance teams can ensure that you will have no fatalities during a fire. Evacuation is the most neglected element of fire safety and it is also the most difficult element to implement and maintain.

THE STARTING POINT Mediclinic International was founded in 1983 and is a private healthcare group with operations in South Africa, Namibia, Switzerland and the United Arab Emirates. Mediclinic Southern Africa currently operates 50 hospitals throughout South Africa and three hospitals in Namibia. Around 80% of its operational beds are located in Mediclinic Southern Africa. In 2002 the Mediclinic Group started implementing the ISO 14001 Environmental Management System (EMS) which encourages good business practices to limit the environmental impacts the business has on its

A Quick Reference Emergency Folder on display.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS in the auditing of compliance of the hospitals are the local authority fire chief and the Department of Health Inspectorate.

Best practice emergency escape route.

surroundings. One of the clauses in the ISO 14001 International Standard is ‘Emergency Preparedness’. The requirement of this clause is that businesses shall establish, implement and maintain a procedure to identify potential emergency situations and potential accidents that can have an impact on the environment and how it will respond to them. It says: • The business shall respond to actual emergency situations and accidents and prevent or mitigate associated adverse environmental impacts. • The business shall periodically review and, where necessary, revise its emergency preparedness and response procedures, in particular, after the occurrence of accidents or emergency situations. • The business shall also periodically test such procedures where practicable. ISO14001 is an Environmental Management System (EMS) that encourages good business practices to limit the environmental impact the business has on its surroundings. Well managed companies do this every day as environmental (resources and waste) management and it is integrated in their day to day operations. Many businesses already do most of what is required in an EMS without realising it. In November 2002, eight hospitals within the Mediclinic Group have

decided to lead the way to a better and more sustainable environment in the healthcare industry and were awarded an ISO14001 international certification. Since 2008 an additional 32 hospitals have been added to the international certificate of the Mediclinic Group. ISO14001 Environmental Management System (EMS) can actively assist in emergency preparedness and disaster management in hospitals. Under the ISO 14001 Environmental Management System (EMS), a corporate procedure for emergency preparedness was created. The procedure describes the identification and response to emergency situations which have, or could have, an impact on the environment. The procedure ensures that all employees are capable of reacting effectively to emergencies in order to mitigate or control the resulting impacts. This procedure also assesses how incidents can be prevented. The hospital manager is ultimately responsible for safety, health and environment at hospital level. Heads of departments, including unit managers, are responsible for the implementation of this procedure in their dedicated areas.

THE LEGAL REQUIREMENTS In South Africa is various legislation to control and manage the evacuation of buildings. The two biggest players

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

Hospitals are seen in the same category as hotels and, as such, the same inspection protocol is followed by the fire chief of the local authority. The major difference between a hospital and a hotel is that in a hotel clients are alone in their rooms and are themselves responsible for ensuring their own safe evacuation if an alarms sounds. In a hospital patients are in dedicated wards with hospital staff. These hospital staff members are on the premises 24/7 and it is their responsibility to ensure the safe evacuation of patients, doctors and members of the public when an alarm is sounded. This has caused conflict in the past with fire chief of the local authority, but since implementation of the ISO 14001 Environmental Management System (EMS), most of these conflicts have been resolved. Another legal requirement, which has caused various conflicts in the past, was the requirement for the six-monthly evacuation of the hospital in its entirety. A hospital is not an ordinary building, but is a complex systems building. To evacuate a hospital in its entirety is not operationally always practicable and when the element of medico legal risks for the patients are included this is seen as a very high risk scenario for patient wellbeing. In the last eight years a system of compliance has been developed to ensure reasonable practicable compliance with the legal requirements. Six-monthly mock drills are undertaken by all dedicated areas. These mock drills are done by dedicated area and not by the hospital in its entirety. A mock drill can include: • Physical evacuation with staff. • Table top exercises. • Training session. • Examination/tests. • Scenario playing. • Walkthrough of evacuation plans with staff.

TECHNICAL PAPERS CURRENT PRACTICES In the Mediclinic hospitals there is a clear drive to educate all staff members that emergency preparedness has a direct connection with patient safety. Mediclinic staff members are responsible for the safe evacuation of all patients, doctors and members of the public. This is not considered to be the responsibility of the local emergency services. When starting to develop a functional emergency plan it is important to ask the following questions: • How is your emergency preparedness? • Do you have scheduled mock drills? • Where are your observation reports? ISO 14001 Environmental Management System (EMS) Internal Audit Schedule system is used for the planning and documentation of these various mock drills.

Physical evacuation with staff is undertaken for each dedicated area at least once every two years. Staff members of other areas are used as patients, only half of the available staff per dedicated area is used in the physical evacuation,with the other half of the available staff per dedicated area being used to care for the patients in the dedicated area while the physical evacuation drill is in progress. The heads of these dedicated areas are responsible for compliance to this procedure This more reasonable practicable application for the evacuation of hospitals was accepted by the various authorities. Since implementation of this new version of the corporate procedure for emergency preparedness was implemented under the ISO 14001 Environmental Management System (EMS), various actual incidents of fire, flooding and bomb threats have been experienced, which resulted in hospitals being evacuated with no patients, doctors, members of the public or staff members being injured or killed. This is a testimony that this new procedure developed in conjunction with the hospitals worked.

COMMON MISTAKES Mediclinic hospitals in Southern Africa started the process eight years ago. There were evacuation plans in place,

but these plans were not practical or user-friendly. The plans were complicated, not regularly audited and no detailed documented proof was kept of evacuations drills. This situation changed with the implementation of the new version of the corporate procedure for emergency preparedness under the ISO 14001 Environmental Management System (EMS). The most common mistakes made were: • Development of the emergency plan by a perfectionist; • The basic questions not being asked and answered in the development phase of the emergency plan; • Not focusing on people as the most important component of your emergency plan; • The development of a complex system consisting of various folders and; • Compliance to corporate office requirements by window dressing. What are the basic questions? • How are you going to get out of this building? • Have you checked for escape routes? • What is the likelihood of something happening? • What is the exposure? • What is the severity?

• Where are your corrective action requests?

STAY CALM The most important component of a functional emergency plan is to stay calm. This component outweighs any other component that we will take in the present or future. A recent ferry disaster in the Adriatic Sea clearly demonstrated the various aspects of a disastrous evacuation plan. There are various similarities between a hospital and the ferry disaster. Comments from the disaster included “Despite their cabins filling with smoke, no alarm had sounded” – a well-maintained fire detection system and fire equipment is critical in buying time to facilitate an evacuation. “Order to abandon ship was not given until four hours after the fire had started.” – visible and clear command must be taken by top management. “The crew of the ship gave passengers little assistance.” – staff members must have clear instructions accompanied with the necessary training to facilitate an orderly evacuation. “People started to panic.” – clear control, necessary training and management will ensure that people stay calm. Without the necessary control, training or management people will panic, which will lead to chaos and potentially to deaths. Panic = Chaos = Deaths.

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Water penetration solutions.

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TECHNICAL PAPERS LESS IS BETTER

• Fire

Complicated documentation consisting of many folders is not user-friendly. Out-ofexperience with various incidents of fires and other emergency incidents in the past these folders has not been used in the emergency time period. One detailed master folder for the hospital describing all of the necessary procedures maybe beneficial for record keeping and possible legal actions after an incident. However, such folders are impractical in an emergency at unit level. At Mediclinic hospitals a ‘Quick Reference Emergency Folder’ guide has been developed. This consists only of the priority emergency incidents with a high likelihood of happening at ward level. Each priority emergency incident is limited to just two pages with minimum wording to ease usage during emergency incident. An action card system is also attached to the guide for empowering staff members in the vicinity of the incident to assist. The following emergency incidents were classified as high priority:

root cause; description of the remedial actions taken and documented evidence of the closed out of the non-compliance.

• Flooding • Bomb Threat • Bomb Blast • Hostage Situation • Medical Emergency

PRACTICE MAKES PERFECT Training sessions are conducted by the people responsible for the various incident procedures/emergency plans. Evacuation mock drills are planned twice a year and sessions are scheduled in advance with opportunities utilised as available. The ISO 14001 Environmental Management System (EMS) Internal Audit Schedule system is used for the planning and documentation of these various mock drills. The results are recorded via an observer in an observation report. Non-compliance to corporate emergency evacuation procedures are addressed via the issuing of Corrective Action Request (CAR) to the relevant unit for the necessary actions to be taken. In the Corrective Action Request (CAR) there is a clear description of the non-compliance; identification of the

Emergency preparedness = Patient safety. Under the ISO 14001 Environmental Management System (EMS) Training and Awareness; a focus drive is implemented and documented to educate all staff members that emergency preparedness has a direct connection with patient safety. Well maintained equipment buys time. Mediclinic’s definition of maintenance is to ensure that all equipment, plant, building and services remain functional at all times to their original state in the most cost-effective manner. We follow a structured stepped approach to the planned maintenance programme. Fires can cause total destruction of property, equipment and lives. Fire fighting equipment and alarm systems form an essential part of managing the risks to lives and property. Life support maintenance policy is applicable.

CONCLUSION Whatever happens, stay calm! This article first appeared in IFHE Digest 2016.

Emergency preparedness internal audit guideline questions.

Wards

Guideline questions for internal audit Emergency preparedness

Emergency procedures Emergency preparedness training Mock drills observation reports – annually

Emergency preparedness

Escape route plans User-friendly Escape route plan orientation Escape route plans: Date/revision/signature

Emergency preparedness

Escape route Escape route unobstructed

Emergency preparedness

Exit door Exit door clearly marked Exit door in working condition

Emergency preparedness

Exit door Exit door clearly marked

FRANCOIS BESTER Francois Bester has 25 years experience in safety, health, and environment legislation in South Africa and provides specialist safety health environment support to all 53 hospitals within the Mediclinc group. He joined the group in 2001 and his responsibilities include legal compliance, implementation of the ISO 14001:2004 system, developing planned maintenance procedures, advising and monitoring new and amended legislation and influencing the hospital environment. He has a National Higher Diploma in Mechanical Engineering from the Central University of Technology (SA) and is a national council member of the South African Federation of Hospital Engineering (SAFHE).

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Water scarcity – mitigating the risk PAUL ANGUS I HYDRAULIC ENGINEERING DISCIPLINE LEADER, ERBAS & ASSOCIATES, SYDNEY

Paul Angus, Hydraulic Engineering Discipline Leader at Erbas & Associates in Sydney, discusses the importance of water conservation and the merits of creating a water strategy to mitigate the risks of water scarcity and take advantage of the vast opportunities.

nder AS/NZS 4360:2004 — risk management, the likelihood and consequences of the water supply impacts of climate change can be classed as extreme. The changes will occur over the same time frame that engineering assets are designed for (i.e. a design life of 80-150 years). As climate change intensifies, water supply constraints, either through scarcity of supply interruptions from extreme events, will lead to increasing pressure for businesses to implement water efficiency measures. How does this risk translate to a healthcare building or a facility? Water is often not seen as a high business risk based on its relatively low cost, but risk lies in the security of its supply, which is paramount to the continuity of a facility. In a building, if water supply is cut for any given reason, for a period of time the building becomes uninhabitable, unproductive and, as such, a loss of earnings will be incurred, whatever the nature of the business. For example, within a healthcare establishment the amenities or onsite cooking facilities is one of the major onsite services that a building requires to operate. Because water is used as part of the building’s amenities/Commercial Kitchens facilities, any water supply issues will impact upon productivity and profitability. From a risk perspective, it makes good business sense to mitigate, where possible, against the risks associated with scarcity of water and interruptions to water supply. In order to build confidence with facility and investors alike, it is paramount to ensure a water strategy is in place. It can be applied to any healthcare sector facility where, in the event of water failure, any water-reliant systems, for example fire protection systems, are fully considered. Firstly, a building’s water footprint needs to be understood. How much water is being used productively, or wasted unnecessarily, where is it being used and for what purpose? Water audits and water metering programs play pivotal roles

in understanding a water footprint. They will draw attention to areas of unusually high consumption or aging infrastructure that is soon to become a problem. Various studies undertaken globally indicate that by connecting water meters (and sub meters in tenanted areas) to a Building Management System (BMS), water usage can be reduced through the provision of data changing water use behaviours. Once the building’s water footprint is understood, an informed plan of action can be developed to mitigate risk. Such plans should include the detection of leaks and upgrades to aging water infrastructure. On average, approximately 10% of a buildings water usage is from undetected leaks. The majority of new buildings have systems incorporated to detect water leakage as they occur, saving vast amounts of time, labour, expense and water related damages. When retrofitting a building, these systems should be considered. Issues associated with aging infrastructure, such as hydraulic plant, pipework and sanitary fixtures often escalate and can require immediate action. When undertaking these upgrades, reactive or quick fix practises should be avoided, as they will inevitably cause more financial burden than relief. Taking a proactive approach to upgrades is beneficial. For example, replacing out of date, inefficient plumbing fixtures with low-flow outlets, or alternatively providing fixtures with aerators to reduce water consumption are effective methods of addressing water efficiency issues that can be significant savings associated within a complex building with multiple fixtures and fittings. However, the full extent of other consequences should be considered. For example, installing low flow fixtures and in conjunction within existing extensive horizontal high level sanitary drainage runs can cause blockages. Retrofitting waterless urinals may seem an effective solution; however existing waste pipework requires to be fully assessed, as the pH content of urine can quickly corrode existing copper THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS waste pipework, making a quick solution an expensive high priority issue to replace the pipework. These situations are rarely budgeted for, straining an already limited budget, and causing frustrations for building operations staff and tenants. Any water strategy needs to look at mitigating risks and maximising opportunities. Such opportunities may include the payback and lifecycle analysis of system upgrades and assessment of water reuse and recycling opportunities. For example, Erbas and Associates are currently providing an environmentally sustainable hydraulic design on the refurbishment of the Gorman House facility at St. Vincent’s Hospital, Sydney. This refurbishment aims to be on the forefront of providing environmental sustainability initiatives, not only within the St. Vincent’s Hospital campus, but as well as within Australia. At a very early stage, following an audit of the hydraulic system, a matrix was introduced scoring each system to evaluate the most effective solution to suit the buildings needs and requirements. The water usage overall, including hot water and fire hydrants and sprinkler system, were recognised early in the project as a primary consuming element, which will be minimised and integrated with recycled water, as well as plate heat exchangers integrated with the new mechanical heating and cooling system, an opportunity that will assist in reducing energy consumption, as a result. It should be noted that opportunities can also present unaccounted for costs or risks. For example, when considering the opportunity to implement and retrofit systems, such as rainwater harvesting or grey water recycling systems, the full life-cycle cost needs to be considered, and water is

just one cost. The energy required to pump the water from the basement to all WC fixtures within a complex hospital facility building can have a significant impact on electrical loads and costs. Energy efficient pumps may help, however the full impact should be assessed, with consideration to the location of the water systems in retrofit applications. The robust water strategy should focus on operational measures, as well as engineering solutions. It needs to avoid reactive measures, identifying both short and long term solutions that can be staged. It must also be integrated with other strategies, for example energy management, for a building is a complex web of interconnected systems that cannot operate in isolation of one another. A strategy can be aligned with a range of industry benchmarking tools such as LEED, GreenStar and NABERS. These tools can help a healthcare building’s performance to be publicly recognised and as such, increase its overall asset value. A forward thinking water strategy is an important aspect to a building to not only mitigate the risk of business continuity, but also take advantage of opportunities, be they environmental, cost or reputation related opportunities. Paul Angus leads the Hydraulic and Fire Protection Engineering team at Erbas & Associates. Paul has strong commercial and technical capability in developing and delivering hydraulic design strategies and solutions. He specialises in providing a sustainable approach to system design, including water conservation, recycling and generating innovative engineering solutions. For more information contact: www.erbacs.com.au

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Considerations for Kitchen Exhaust Design and Specification in Hospital Environments JONATHAN BUNGE (M.ENG CHEMICAL), SHANNON ROGER (B.ED) AND DR ALLAN HECKENBERG (PHD) I AIREPURE AUSTRALIA 2016

Considering the vast number of hospital and commercial kitchens in Australia, one would expect that exhaust treatment solutions for these applications would be routine. However, whilst the aims of good kitchen design and the effective treatment and exhaust of cooking fumes, are easy to express – the diverse range of sites and environments, create a remarkably complex situation.

ifferent cuisine types produce varying amounts of moisture, grease, smoke and odour and the resulting cooking fumes comprise a combination of solid particles, liquid droplets and vapour/gaseous phase contaminants. Various kitchen exhaust treatment technologies are available to choose from – each with pros and cons affecting the cost versus performance scale. This article seeks to set out the broad aims and parameters of commercial kitchen exhaust design within hospital environments to ensure exhausted cooking fume matter complies with relevant standards to reduce fire risk and will appease sensitive receptors to the exhaust odours.

Effective treatment of kitchen exhaust requires air temperature in the duct to be under 50°C and at low contaminant concentrations; which are both functions of adequate dilution air from the hood. AS1668.2 prescribes a minimum exhaust airflow rate through kitchen hoods depending on the size of the hood, the type of hood and the appliances under the hood (process cooking type). Excerpt of AS1668.2: 3.4.2.2 Hood Type Nomenclature2

RELEVANT STANDARDS AND GUIDELINES Within Australia, there are standards that govern kitchen ventilation including council and state regulations, local, state and federal fire codes and most significantly AS/NZS 1668.11 and AS 1668.22 – all of which are referred to by the BCA (Building Code of Australia).

MINIMUM EXHAUST AIRFLOWS Kitchen exhaust hoods have three (3) major functions; the first and most obvious one is to ensure all of the cooking fumes generated by cooking processes are captured by the hood. The second and third is to ensure enough dilution air is captured by the hood to reduce the temperature of the exhaust air and the contaminant concentration of the exhaust air.

Note the hood type 7 (proprietary hoods) are calculated using alternate proven and tested standards. They will generally have a flow rate of 30-40% less than AS1668.2 suggests for a regular hood, as vendors maintain that the jet flow technology enables the capture of contaminants with a lower amount of air. However the reduction of dilution air which will affect temperature and contaminate concentration

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS may decrease the efficiency of downstream treatment systems. Whilst it is recommended to use the kitchen hood exhaust airflow rate specified by AS 1668.2 as a minimum, designing for a higher airflow rate than required will provide your system more chance of success and decrease the possibility of such issues arising in the future.

DETERMINING EXHAUST TREATMENT REQUIREMENTS The Australian Standards 1668.2 has clear guidelines to determine if treatment is needed, and the extent of treatment (if required). Some key elements are:

A combination of kitchen exhaust treatment technologies is often employed to achieve the most cost effective, high performing results. These technologies target particulates (P) and/or odour (O) and include hood filters (P), ultra violet light (UV-C) (PO), ozone (O), electrostatic precipitators (ESP) (P), multi-staged filter packs (P), activated carbon (O), wet scrubbers (PO) and dilution/dispersion (O). Wet scrubbers are tailored for solid fuel applications – this is not relevant to hospitals and therefore will not be covered in this article.

PARTICULATE (OIL, GREASE AND SMOKE) CONTROL Diagram of recommended kitchen exhaust treatment systems by flow rate and contaminant level

• Horizontal exhaust generally needs treatment, and must be treated above 1000L/s. • Vertical exhausts are less likely to demand treatment. • The better the efficiency of the treatment system, the closer “sensitive odour receptors” may be. These receptors include air intakes, boundaries or natural ventilation devices. (Table 1) Minimum Separation Distances from Discharges to Intakes, Boundary or Natural Ventilation Device3

Airflow rate within the minimum distance (L/s)

Minimum Distance (m)

<200 <400 <600 <800 <1000 ≥1000

1 2 3 4 5 6

Additionally, in any treatment system, an odour control stage relies on particles being removed – before the odour control section. It is difficult to quantify odour removal, but the starting point is always to remove particles and measure the success of particle removal at the 0.3 micron level. It should be remembered that even when the standards have been followed, additional treatment may be enforced by local councils if odour complaints are received. This applies to both horizontal and vertical exhaust systems, and can become very costly for the system owner to rectify.

KITCHEN EXHAUST TREATMENT TECHNOLOGIES Whilst the end goal for any kitchen exhaust system is to ensure that no smoke, grease or odour is exhausted into sensitive locations, the type of treatment system selected is dependent on the contamination level and the airflow rate.

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Kitchens operating within hospital environments often have lower flow rates and lower contaminant levels than most commercial kitchens, making the multi-staged filter pack a viable and cost effective selection for particulate filtration. This system can easily be paired up with other technologies such as a high efficiency hood filters and UV to increase effectiveness and reduce maintenance costs. Kitchens operating with high particulate contaminations levels should consider using ESP’s, which are effective at treating large volumes of highly contaminated air with relatively low operating costs. This is typically due to a maintenance regime consisting of cleaning instead of replacement. Technologies such as high efficiency hood filters and UV-C may be effective in reducing particulate loads on other treatment systems but are not seen as a complete solution and come with some risks that must be controlled. Many UV systems introduce Ozone into the system, which has been found to be injurious to health at levels consistently above 50 ppb.4

ODOUR CONTROL Ideally, a kitchen exhaust treatment system should be designed to remove particulates (such as grease, oil and smoke) to a high level before removing the odour. Effective odour removal technologies such as activated carbon will provide greater performance and endurance when protected from grease, oil and smoke particulates. These contaminations will overload, impede and reduce the

TECHNICAL PAPERS efficiency of activated carbon, rendering its odour removal properties as ineffective.

Typical Multi-Stage Filter Pack Configuration

To ensure effective odour removal and to save on unnecessary replacement costs, a treatment system that incorporates adequate protection of activated carbon filters or media from grease, oil and smoke particulates is recommended. This protection may be in the form of prefilters, often referred to as “safety filters”. The grade of these filters may vary from simple G4 to HEPAs depending on the nature of the primary contamination. Whilst activated carbon is the preferred method of odour abatement, this is often paired with UV-C lamps and ozone to reduce load. UV-C lamps reduce grease and odour through a mechanism known as photolysis as well as generating ozone along with other ozonolysis methods such as corona discharge. Ozone should be used with care, as it is harmful to human health and Safe Work Australia TWA exposure standard limits are 0.1 ppm (0.2 mg/m35). To meet AS 1668.2 requirements that no residual ozone remains in the final exhaust air, one must provide control systems that detect and alter ozone generation as the amount required varies with cooking load. Alternatively, activated carbon can be placed downstream to adsorb residual ozone. UV-C and by extension ozone should only be seen as a viable solution for odour control if one of these control mechanism are in place and there is at least 2-5 seconds of residence time in the duct work before exhaustion/carbon filtration to allow sufficient oxidation to occur. Excerpt of AS1668.2: 3.4.2.2 Cooking Process Type Nomenclature

These systems are typically designed with four (4) stages of filtration consisting of three (3) sequential stages of particulate filtration and one (1) final stage of odour control. • Pre-filter – 45% of total of grease and smoke contaminants are captured here; typically a sacrificial G4 filter, which has the shortest lifespan in the system and requires replacement often. • Bag filter – 45% of total of grease and smoke contaminants are captured here; typically a F6-F8 capacity filter with a medium lifespan. • Final filter – remaining 10% of total of grease and smoke contaminants are captured here; typically a H11 efficiency mini pleat filter or HEPA 95% DOP at 0.3 micron rating with a longer lifespan. • Activated carbon – Protected by the particle filters, activated carbon media or filters are in place to effectively remove odour. It is possible for these systems to handle kitchen exhaust with a higher contaminant loading, however this will increase the change out frequency required.

ESP’S ESP’s are ideal for kitchens with a higher contaminant loading, namely cooking process types 4, 5 and 6 according to AS 1668.2.

MULTI-STAGED FILTER PACK Multi-stage filter pack systems are ideal for kitchens with a low to moderate contaminant loading, namely cooking process types 1, 2, 3 and 7 according to AS1668.2. These systems typically offer a low capital cost solution with higher operating costs from the static and filter change outs. Change out cycles can be reduced by pairing this system with an efficient hood filter or appropriately designed UV-C lamps prior to the filter pack.

ESP’s use electrostatic charges to ionise particles initially before collection on plates of the opposition charge. If the ESP is doing its job – there will be extensive contamination trapped on the plates of the ESP. These plates must be cleaned/regenerated periodically to remove grease and smoke particles. An ESP is able to clean air of all contaminant levels, however the required frequency of cell cleaning directly relates to the contaminant load; a higher contaminant load means more frequent washing of the cells to maintain performance of the system. Manual washes of ESP cells may need to take place anywhere from daily to monthly depending on load; and a short wash cycle will add significant maintenance costs, THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

Kaire Unit: Multi-Staged Filtration Systems for the Treatment of Hospital Kitchen Exhaust The Kaire Unit by Airepure is a multi-staged filtration system designed to control the light to moderate kitchen exhaust emissions* typified by hospital based commercial kitchens. This system incorporates four stages of filtration to control light to moderate smoke, grease and cooking odours. The first three stages utilise industry standard filters to deliver high performance particulate filtration at minimal cost: • Stage 1 : Pre filtration stage, utilising Airepure G4 Pure-V pleated panel filter or Honeycomb grease filter • Stage 2 : Intermediate filtration stage, utilising Airepure AirePak F6-F8 multi-pocket filter • Stage 3 : Final particulate filtration stage, utilising Airepure H11 95% DOP AireFlow-V rigid mini pleat filter

AIRFLOW

Odour Control Purafil PM18

Final Filter H11 AireFlow-V

Intermediate Filter F7 AirePak

PreFilter G4 Pure-V

The final stage (four) uses tailored activated carbon to remove cooking odours: • Stage 4 : Custom odour control stage, utilising Purafil PM18/ PK18 mediaPAK modules, Purafil PuraGrid filters or Airepure Aireflow-CC activated carbon rigid mini pleat filters.

* Cooking process types 1, 2, 3 & 7 as outlined in AS1668:2012. Note: Cooking types 4-6 are suitable if a high efficiency hood filter (coil type) is used in conjunction with the Kaire Unit, or if the owner is prepared to change filters regularly.

Airepure Australia

Servicing Health Service and Health Science Industries

Airepure Australia is a leading 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 have office, warehouse and technical support facilities in all major cities, including Melbourne, Canberra, Sydney, Brisbane, Townsville, Adelaide, Perth, and Hobart. Our in-house engineering, estimation and service departments ensure we can support our clients through the entire process from system design to installation as well as after sales service and maintenance.

ph:1300 886 353 48

Airepure offer a range product for health service and health science applications; including multi-staged filtration packs and large-scale, self washing ESP systems for kitchen exhaust, Focus UCV systems for operating theatres, HEPA filters and terminal HEPA housings, air showers, pass through cabinets and custom laminar air booths or ceilings, Flanders CSC airborne containment air filtration systems, AS/NZS 2243.8:2014 compliant manifolded process fume exhaust and odour dilution systems, Purafil gas-phase air filtration systems for hazardous, corrosive, toxic or odourous gas, general AHU filters and pre-filters.

www.airepure.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

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TECHNICAL PAPERS particularly if the treatment system is placed in a hard to access location.

to compare apples to apples, always compare system efficiency at a particle size of 0.3 microns.

More capital intensive ESP systems will have programmed wash systems to ensure the system is automatically maintained for optimum performance, this ensures lower operation costs over time. An automatic wash system for the ESP can be programmed to run daily, weekly, fortnightly etc. This can extend the frequency required for a manual clean from 1-5 years depending on the contaminant load.

Most Penetrating Particle Size – Fractional Efficiency by Particle Size

Typical Large Scale Self-Washing ESP System Configuration

The particle size of smoke (an easily visualised pollutant) ranges between 0.3 to 1.0 microns. To ensure an adequate amount of smoke particles are captured, you would require high efficiency filtration at this particle size – 95% efficiency at 0.3 microns. Large scale, self-washing ESP systems may include the following options: • Pre-filter – typically a mesh filter to capture large particles which may short circuit the ESP cell. • ESP Cell – removes smoke and grease particulates, and requires regular cleaning to maintain performance. • Auto-wash function – typically a programmable automatic wash and fan dry function that sprays the ESP cell with a water and detergent mix to keep it running effectively and extend manual cleaning intervals. • Safety bag filter – typically a F6-8 bag filter used to protect the odour removal function of the activated carbon from poorly maintained ESPs. • Activated carbon – for effective odour removal.

AIR VELOCITY Kitchen exhaust systems are typically designed to operate at 1.8m/s (650L/s per 600 x 600mm area) to allow enough residence time for the technologies to effectively remove the smoke, grease, particulates and odours. Do not be tempted to raise the air velocity above 1.8m/s to reduce the size of the treatment system, as this will reduce the efficiency of the system and directly increase energy and maintenance costs. For example; a multi-staged filter pack system* running at 1.8m/s will clean the exhaust air more effectively and cost up to $1.5K less in energy costs annually compared to a system running at 2.5m/s. (*2,500L/s system, hospital hours of operation).

SYSTEM EFFICIENCY The particle size of 0.3 micron is typically selected as the test point for rating filtration efficiency because particles above and below this size are generally easier to capture – and these are the most “elusive”. This principle applies to all technologies (filters, ESPs, UV, ozone), so if you want

It seems surprising, but a system which is rated as 95% efficient at 0.01 microns is actually inferior to a system that is rated as 95% efficient at 0.3 microns. This is due Brownian motion (diffusion) which describes the motion of extremely small particles and how it differs from bulk flow. It demonstrates why smaller 0.01 micron particles are easier to trap than the 0.3 micron particles. In fact, particles of 0.01 microns are as easy to catch as particles of 10 microns. The wise buyer and specifier will always judge system performance with ratings at 0.3 micron – the most challenging particles to capture. Additionally, air velocity directly impacts system efficiency. For example; an ESP operating at 3.5m/s air velocity would only be 40% efficient at 0.3 microns – even though it rates at 95% efficiency at 0.01 microns. This same ESP operating at a lower velocity – 1.8m/s would rate at 95% efficiency at 0.3 microns – thus be comparatively effective. Therefore, look for ratings at the hardest particle size (0.3 micron) and at a sensible air flow velocity (around 1.8m/sec). Despite operating at the desired velocity, the efficiency of a system can be severely impacted by its location. If the treatment system is placed directly after or before duct bends with short transitions; the flow of air will not be evenly distributed through the treatment system, rendering a portion of the system useless. It is recommended to use industry standard transition sizes and allow 2-4 duct diameters of straight run either side of the treatment system.

SERVICE AND MAINTENANCE Every effort to design a successful commercial kitchen exhaust can be defeated by an inadequate service program. The various filter sections, ducts and fans will become coated by contamination over time. If these are not serviced, the chance of fire and other issues is amplified considerably. Ducts must be cleaned by regulations (AS/NZS 1668.1:2015), so in the building phase it is essential that THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS duct cleaning ports are inserted in compliance with design standards. It is also important that they be practically accessed, which is often a tricky thing to achieve. It is a requirement of AS1668.2 to maintain the performance of a kitchen exhaust treatment system. There is significant cost involved in the maintenance of any kitchen exhaust system, and the users, facility managers and owners must be made aware of these costs and resist the tendency to “shortchange” budgets in this area – as responsibilities to; safety, public health and council compliance are important. Similarly, regular maintenance of fans, electrical systems and the hood filters is essential to have the system operational at the intended flow rates over time. In the design phase – attention should be given to some of the potential cost savings that can be achieved for “longterm-operation” with larger capital investments at the building stage, e.g. auto-washing filter systems vs manually changed filter systems.

relevant standards and local council regulations, as well as your specific objectives for performance and cost. Key considerations include: • Use the kitchen hood exhaust airflow rate specified by AS 1668.2 as a minimum and design for a higher airflow rate than required to provide your system with a greater chance of success. • An effective and efficient kitchen exhaust treatment system should remove particles before odour. • Kitchen exhaust systems are typically designed to operate at 1.8m/s (650L/s per 600 x 600mm area). Operating above this velocity will directly reduce efficiency and increase energy and maintenance costs. • Always judge particulate removal system performance with ratings at 0.3 micron – the most challenging particles to capture – and be wary of specifications of performance at 0.01 microns.

FINAL THOUGHTS

• Every kitchen exhaust technology has its own pros and cons affecting the cost versus performance scale – and this should be investigated with due diligence.

Whilst there are many factors affecting the design, implementation and maintenance of a successful kitchen exhaust treatment system; there are guidelines and sound recommendations available to assist with your compliance to

• A singular kitchen exhaust treatment technology may not provide a complete solution. Selective pairing of compatible technologies may increase effectiveness and reduce maintenance costs. • Strict guidelines regarding UV-C and ozone technologies are provided to ensure workplace safety for your staff and patients. • Always budget for maintenance – it is a requirement of AS1668.2 and a functional kitchen exhaust. Airepure Australia offer a range of products, services and consulting expertise that can assist you with your compliance to AS/NZS 1668.1 and AS 1668.2, as well as ACHS, DHS VIC Guidelines (and equivalent for QLD, WA and NSW), ISO/IEC 17025:2005 Requirements, AS/ NZS 2243.3:2010 and AS/NZS 2243.8:2014. Airepure is a leading 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 1. Australia S. The use of ventilation and air conditioning in buildings. Part 1: Fire and smoke control in buildings: SAI Global 2015 2. Australia S. The use of ventilation and air conditioning in buildings. Part 2: Mechanical ventilation in buildings: SAI Global Limited 2012 3. Yeung L, To W. Size distributions of the aerosols emitted from commercial cooking processes – indoor and built environment. 2008;17(3):220-9. 4. Stedman JR, Anderson HR, Atkinson RW, Maynard RL. Emergency hospital admissions for respiratory disorders attributable to summer time ozone episodes in Great Britain. Thorax. 1997 Nov;52(11):958-63. 5. Based on TWA (time weighted average) over 8 hour day, 5 days per week.

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TOTAL SOLUTIONS FOR EVERY BUILDING DESIGN APPLICATION Slot diffusers

Variable volume control

Ceiling & swirl diffusers

Constant volume control

Jet nozzles

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Floor & displacement diffusers

Chilled beams & chilled ceilings

Fire dampers & tunnel dampers

Hepa filters & casings

TROX Australia Pty Ltd Level 2, Building 3 35-41 Waterloo Road Macquarie Park NSW 2113 Tel: Sydney + 61 (02) 8923 2551 www.troxaustralia.com THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

LAF Technologies Pty Ltd

Testing, Monitoring & Laboratory Products

Laboratory Equipment

Indoor Air Quality Monitoring

Cleanroom & Facility Monitoring

Ventilation Test Instruments

• • • • • • • • • • • •

Vacuum Equipment Baths & Circulators Ovens & Furnaces Forensic Equipment Incubators & Chambers Chemical & Powder Safe Handling Handheld Particle Counters Portable Particle Counters Fixed / Remote Particle Counters Liquid Particle Counters Gas Particle Counting Complete Facility EMS Monitoring Systems

Contamination Control Products • • • • • •

Biological Safety Cabinets Cytotoxic Cabinets Laminar Flow Cabinets Professional PCR Cabinets Isolator Technologies Fume Cabinets

• • • • • • • • • • •

Multi-Function IAQ Monitors Dust Monitors, Particle Counters & Sizers Ultrafine Particle Counters Microbial Air Sampling Filters & Filter Testing Equipment Portable Odour Monitors Air Balancing Hoods Vane Anemometers Duct Leakage Testers Sound & Vibration Meters Digital Micro Manometers

Particle & Dust Monitoring • • • • • •

Personal Dust Monitors Portable Dust Monitors Tripod Based Dust Monitors Fixed Dust Monitoring Stations Ultrafine Particle Counters Particle Research Instruments

Testing and Certification Services Fume Cupboards

Cytotoxic Drug Cabinets

Fume Cabinets

Class 1 Biological Safety Cabinets

Laminar Air Flow Cabinets

Class 2 Biological Safety Cabinets

Class 3 Safety Cabinets & Isolators

Particles in Gas / Compressed Air

Decontamination Services

Particulate Cleanliness

Cleanrooms & Workstations

HEPA Filtration Testing

Professional testing and certification of fume cupboards in accordance with AS/NZS 2243.8 Australian standards Professional testing & certification of fume cabinets (luminance, smoke & velocity) to AS/NZS 2243.9 Australian standards Professional testing and certification of laminar air flow cabinets in accordance with AS 2252.6-2011 Australian standards Professional testing and certification of class 3 biological safety cabinets and isolators to the highest standards Decontamination of cabinets, incubators and rooms utilizing the latest iHP technology to achieve a 6 log kill Cleanroom and workstation testing & certification in accordance with ISO 14644-3

State-of-the-art Calibration Laboratories

Education & Training Services

Professional testing and certification of cytotoxic drug cabinets in accordance with AS2567 Australian standards Professional testing & certification of class 1 biological safety cabinets in accordance with AS 2252.1 Australian standards Professional testing & certification of class 2 biological safety cabinets in accordance with AS 2252.2 Australian standards Accurate and reliable particulate testing in compressed air and gas in accordance with ISO8573-4 standards Particulate cleanliness testing in accordance with AS/NZS and ISO14644.1 international standards Professional testing & certification of HEPA filters to AS1807.6, AS1807.7 or ISO14644-3 standards

Professional Servicing & Support

NATA Accredited Test and Certification Services

LAF Technologies Pty Ltd Head Office: 12 Royan Place, Bayswater North, VIC 3153 Australia

Call: 1300 306 002 www.laftech.com.au THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

The modern approach to managing indoor air quality in health care facilities MARK GRAHAM, B.SC. (HONS), BUILDING BIOLOGY CERT IV QED ENVIRONMENTAL SERVICES

INTRODUCTION

ir is all around us and despite being so crucial for human health and life, is often taken for granted and misunderstood as a cause for adverse human health conditions. Indoor Air Quality (IAQ) is a complex issue, much more so than any single environmental issue. There are hundreds of pollutants that affect IAQ and thousands of sources. Worldwide research shows that more than 900 different contaminants are present in the indoor environment, a problem which is exacerbated by the interaction of complex set of factors that are constantly changing. When we discuss Indoor Air it is generally in reference to the health impact of the air to building occupants and is defined by the National Health and Medical Research Centre (NHMRC) as air within a building occupied for at least one hour by people of various states of health. In extending that concept air quality is the totality of attributes of indoor air that affects the health, comfort and performance of occupants. Through established research and the development of Indoor Air Quality management systems there are general common indoor air quality parameters that are tested to assess the indoor air quality of a building compared to guidelines and other buildings of a similar type. It is not feasible to test every known indoor air quality parameter. The following indoor air quality parameters are typically

assessed to provide effective risk management strategies; • Moulds and other allergens • Particles – Varying sizes • Gases – Carbon Monoxide, Carbon Dioxide, Ozone, Nitrogen Oxides, Sulfur oxides • Volatile Organic Compounds – Formaldehyde, Benzene etc • Legionella • Asbestos Fibres With the many potential contaminates in the air we breathe it is essential that all managers of buildings are aware of the hazards that these contaminates can cause to human health and the various controls to minimise risk. The latest research indicates many pollutants at low levels exacerbate existing health conditions and have the highest impact to immune sensitive people. This is particularly relevant to the typical building occupants in a health care facility. The owner and/or building manager may be liable for personal injuries if they knew or should have known about an indoor air quality problem and failed to disclose the problem. Building owners, operators and managers may also be liable for failing to adequately maintain the buildings heating, ventilation and air conditioning (HVAC) system. In addition, Building Insurance may also include the requirement for Indoor Air Quality testing, and as such owners/managers would not be covered in such an event.

There are various standards that specify minimum requirements in terms of ventilation and air quality. These standards may be used in legal proceedings to show the minimum acceptable level of compliance. Some of the standards that apply to Australian buildings include; • Australian Standards AS1668.2 (2012) The use of ventilation and airconditioning in buildings • Australian Standards AS 3666 (2012) Air handling and water systems of buildings. • Australian Standard SAA/SNZ HB 32 “Control of microbial growth in air-handling and water systems in buildings” • Building Code of Australia (BCA) (1996). Clearly there is a requirement for building managers to provide assurance to the occupants of a building that the air quality is not causing adverse health effects, especially when the air is completely supplied by the base building HVAC system. The following are examples of guidelines that should be followed in the provision of indoor air by the owner or building management. • Particulates – Workplace Exposure Standards for Airborne Contaminants (2011), National Environmental Protection Measure (NEPM) for ambient airborne PM10 particulates, World Health Organisation Air

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS Quality Guidelines (Global Update 2005) • Carbon Monoxide – Workplace Exposure Standards for Airborne Contaminants (2011) of 30 ppm, the World Health Organisation Air Quality Guidelines (Global Update 2005). • Ozone – National Occupational Health & Safety Commission exposure standard 1003 (1995). • Formaldehyde – Workplace Exposure Standards for Airborne Contaminants (2011), World Health Organisation Air Quality Guidelines (Global Update 2005) • Humidity – (Managing Indoor Environment Quality, Property Council of Australia 2009), ASHRAE 552013 guidelines, ISO 7730 (2005) • Temperature – (Managing Indoor Environment Quality, Property Council of Australia 2009). PCA, ASHRAE and ISO standards for recommended values of thermal comfort parameters.

• Carbon Dioxide – Workplace Exposure Standards for Airborne Contaminants (2011), AS1668 (2012), industry accepted limit for comfort (Brown (CSIRO) 1997, Health & Welfare Canada 1989). The typical air quality programmes that are in place for health care facilities are generally reactive based and don’t provide an ongoing compliance programme that ensures an effective risk management approach to the hazards associated with indoor air quality. QED have developed programmes in conjunction with Western Australian based hospitals that ensure hazards associated with indoor air quality are identified and all parties are protected.

MAIN BODY In order to determine compliance with guidelines, an assessment of indoor air quality is required. QED have developed an inspection and testing

based methodology to determine compliance. An Inspection regime is summarised as follows; • HVAC hygiene assessment, conformance with Australian Standard 3666 – Air-handling and water systems of buildings – Microbial Control. o I ntakes, HVAC rooms, filters, plant, condensate and drainage systems, distribution systems • Microbiological assessment of HVAC components • Visual assessment of HVAC components of insulation condition (synthetic mineral fibres) • Subjective assessment of other environmental parameters that may be affecting air quality or its perception (e.g. asbestos, odours, environmental tobacco smoke)

It’s what you can’t see that matters most. QED manages the risks to indoor air and water quality, such as mould or legionella.

Uniquely, we integrate HVAC hygiene and indoor air

quality monitoring, ensuring compliance with legislation, Australian Standards and infection control guidelines. As the only NATA accredited indoor air quality

inspectors with 25 years’ experience we work with health care facilities to create performance/risk

programmes tailored to their maintenance priorities.

P: +61 8 9201 0998

E: info@qed.net.au

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www.qed.net.au

TECHNICAL PAPERS An Indoor air sampling regime typically focuses on a combination of the following indoor air influencing factors; • Carbon Dioxide (CO2) – as an indicator of ventilation • Particulates (PM10) – Particulates of less than 10 micron in size (respirable) • Air Temperature (plus subjective assessment on other factors affecting thermal comfort) • Relative Humidity • Carbon Monoxide (CO) • Ozone • Airborne sampling for formaldehyde • Airborne sampling for volatile organic compounds • Airborne sampling for micro-organisms The implementation of both inspection and sampling provides assessment of influencing factors that are most likely to: • Cause potential health concerns, • Impact the productivity of the space and • Impact the general comfort and well-being of the building occupants. The integrative approach inspection and testing provides an “as far as practicable” approach.

from preventable deaths each year that is attributed to air pollution. The increasing amount of research on air pollutants has resulted in an improved understanding of just how dangerous certain pollutants can be to people with pre-existing conditions and/or with lower immune function. This is particularly relevant to hospitals where a large proportion of the patients are in this state of health. Two pollutants that have been the focus of much research includes the particles less than 2.5 microns in aerodynamic diameter (PM2.5) and ground based ozone. The sources for these pollutants include vehicle exhaust, construction sites, industrial processes and mining activities. The particles less than 2.5 microns (PM2.5) penetrate deep into the lungs and can enter directly into the bloodstream which have been found to aggravate chronic respiratory and cardiac disease, damage the lungs and increase the risk of premature death. Ozone is the by-product of volatile organic compounds mixing with nitrogen oxides on hot days which affects even healthy lungs, causing inflammation, reduced lung function and increased respiratory symptoms.

The advancement of population growth, increasing ambient pollution and placement of hospitals in areas close to main roads increases the need to the level of pollutants present in the outside air.

Due to the known health effects of fine particles and Ozone ASHRAE have recently introduced ANSI/ ASHRAE Standard 62.1-2013 which recommends filtration to be implemented when outside air levels of PM2.5 and Ozone consistently exceed local guidelines.

According to the state of the Environment report (2011), three thousand Australians die

A summary of this is provided below;

Air Toxic

Filtration System

Ozone

1. Virgin activated carbon in granular form (GAC). A 25 mm (1”) bed of carbon – applied as modules, trays, or “V-bank” configurations in either side access housings or front/rear access frames. 2. Pleated filters employing a carbon-loaded non-woven fibre matrix or panel filters employing an extruded carbon composite can be used as alternative to packed-beds of GAC. These provide much more flexibility in their application because they are available in all standard filter sizes.

PM10 PM2.5

Particulate matter filters or air cleaners shall have a Minimum Efficiency Reporting Value (MERV) of 6 or higher when rated in accordance with ANSI/ASHRAE Standard 52.2. Particulate matter filters or air cleaners shall have a Minimum Efficiency Reporting Value (MERV) of 11 or higher when rated in accordance with ANSI/ASHRAE Standard 52.2.

With the increasing knowledge and guidelines applicable to indoor air quality it is crucial that health care facility managers have pro-active strategies in place to assess not only internal sources of poor air quality but also external sources. The external sources of air can be assessed by measuring the conditions at close proximity to the outside air intakes using weather stations. Weather stations are small enclosures that are mounted outside with instruments and equipment for measuring atmospheric conditions. Weather stations can monitor not only wind and wind speed but pollutants like ozone and particles at the outside air intake to provide the ultimate data for facility managers to adopt real time strategies to alter the level of outside air being introduced and to understand if the level of filtration is sufficient to protect building occupants. The addition of outside air monitoring to complement an internal inspection and testing regime is a pro-active approach to manage the hazards associated with indoor air and ensuring patients and staff in health care facilities are protected. This also protects the building owner and manager for the liability of not managing a risk effectively. While health care facilities are required to use HEPA filtration and the implementation of design standards to protect indoor air quality for higher sensitive areas such as operating theatres and isolation wards there can be gaps in knowledge of the actual air throughout the whole building that still have highly sensitive patients and/or staff constantly exposed. This is why a thorough internal testing and inspection regime is required to fully assess the health care facility. The internal assessment methodology required for health care facilities requires a high level of quality assurance. The QED health care facilities indoor air quality management programme has been developed from the Western Australia Department of

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

PM1 – FINE DUST HAZARD TO HEALTH

PM1 WHAT IS HAPPENING INSIDE THE BODY EVERY DAY WE EAT 1 KG FOOD, DRINK 2 KG BEVERAGE AND BREATHE 25 KG AIR!

COARSE DUST Particles 10 μm in diameter and larger. The human body is able to “filter” these particles in the nose via the nose hairs and mucous membranes. Limited health impact.

PM10 Particles 10 μm in diameter or smaller that can reach the respiratory ducts and potentially cause decreased lung function.

PM2.5 Particles 2.5 μm in diameter or smaller that can penetrate the lungs and cause decreased lung function, skin and eye problems, etc.

PM1 PARTICLES – INTO THE BLOOD VIA THE ALVEOLI CO 2 OUT

AIR

BEVERAGE

O2 IN

FOOD

PM1 Particles 1 μm in diameter or smaller. A significant part of these particles are tiny enough to enter the blood stream and lead to tumours, cardiovascular diseases, dementia, etc.

PM1 PARTICLES

CA P

ILL A

These very small particles can reach the lungs and pass through the cell membranes of the alveoli, the tiny sacs in our lungs where oxygen and carbon dioxide are exchanged, and continue out into the blood stream.

RY ALVEOLI

www.camfil.com

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

CLEAN AIR SOLUTIONS

TECHNICAL PAPERS Health Infection Control Guidelines (2005), Queensland Department of Health Guidelines (2013), QED NATA accredited procedures compliant with ISO/IEC 17025, SafeWork Australia Workplace Exposure Standards for Airborne Contaminants (2011) and Australian Standards AS3666.4 (2011). The air handlers in health care facilities are a common source of indoor air pollution due to non-conformance with standards and/or the presence of moisture that encourages microbial contamination. Air-handling hygiene assessments are recommended to be conducted annually for areas with Group 1 & 2 Functional Area Sensitivity Status (lowest and medium risk) and biannually for Group 3 & 4 Functional Area Sensitivity Status (high and highest risk). The following is an example of the systematic approach which is implemented in major Perth based hospitals for the reporting on the action level required in relation to HVAC hygiene risk and the sensitivity of patients. The actions and recommendations can then be related from a low risk that has a low priority routine maintenance action (1) up to an issue that is a high risk and requires urgent and immediate attention (6).

sound data and the action priority ranking that recognises the potential for risk. In addition to identifying how indoor air influencing factors and HVAC plant condition affects building occupants there are other important stages to have in place to ensure all stake holders are involved. This includes effective internal policies and procedures and a review process with a continuous improvement plan for IAQ management.

CONCLUSION As the understanding of indoor air quality and level of contaminates increases so too does the requirements for building managers to ensure the most appropriate and effective programme is in place to provide an environment that doesn’t contradict the aim of a health care facility. By implementing a programme that captures outdoor ambient air conditions, with a thorough internal HVAC inspection and indoor air testing regime. The risks that arise from air quality can then be identified and solutions incorporated into the operation and maintenance management and budgets. The frequent reporting of this programme ensures that compliance and best practice is achieved and health care facility managers not only provide effective risk management but contribute to the best possible indoor environment for their facility and the building occupants.

The indoor air quality testing also requires strategic placement of relevant parameters where there is recognised guidelines for comparison and sound reasoning of why these parameters should be tested. When measurements are made and the inspection of HVAC hygiene understood the following practices can be assessed on their effectiveness to protecting the indoor air quality for building occupants. • HVAC Control Strategies • HVAC Maintenance Regime • General Cleaning and Material Use • Sterilisation and Specialised Cleaning • Air Quality Management during Construction and Refit Works • Contractor Quality Management The balancing act as engineers is to ensure any investment into the improvement of the indoor air quality is met with

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

ADVERTORIAL

Living & Working in Clean Air as nature intended Nature has its own method of cleaning air of odours, bacteria and virus besides simple dispersion.

hey are known as Hydroxyls or Hydroxyl Clusters and are found mostly at average mountain top heights especially on sunny days. Ozone is also nature’s odour and pathogen killer, but is also poisonous to all forms of life at the concentrations required to be effective, whilst Hydroxyls are not. Nature has seen it fit to make our bodies immune to hydroxyls whilst leaving them extremely effective in killing single celled organisms such as bacteria, virus, mould and fungus spores. Hydroxyls can be easily reproduced by today’s technology from compact devices and is employed already in Hospitals, Food Manufacturing, Nursing Homes, Office blocks and a wide range of other applications to improve air quality and rid the air of airborne pathogens such as respiratory diseases and other bacteria that may contaminate and spread in food products or by surface contact with humans etc. Hydroxyls are also effective against a range of odours. They will eliminate ammonia based odours in roughly half the time it takes by natural dispersion. Hydroxyls are effective against Ethylene gas as well which is the gas given off by fruit and vegetables to promote ripening – bananas can be retarded from browning up to an extra four days by being stored in an area being controlled by a hydroxyl generator. Waste and decomposition gases can also be reduced by the presence of hydroxyls, and testing is currently

underway for controlling obnoxious odours for Veterinarians and Pet accommodations – particularly Catteries. Hydroxyls have proven results in deodorising smoking smells. Hydroxyls have been known about and researched for some 100 years since Louis Pasteur first discovered them whilst researching why people living at high altitudes in sunny conditions were generally healthier than people living at sea level. Since then such organisations as the British Army have researched Hydroxyls as a method of combating germ warfare in the late 60’s and all papers and studies have confirmed the benefits of using Hydroxyls, but not been able to reproduce them by compact means. It’s only in the last decade that technology has caught up with science and it’s been made possible to produce hydroxyls from a compact generator. What is a hydroxyl? It’s a water molecule (H²O) missing one of its Hydrogen atoms and because it’s in an unbalanced state, it seeks to replace its missing Hydrogen atom.

This is a very simple mechanical action. Bacteria & virus cannot become immune to it. Further, the Hydroxyl is indiscriminate on what Bacteria & Virus it chooses and thus they work on every and all strains. Several companies have hydroxyl generators on the market using different methods – all but one requiring consumables or servicing or both. By far the most successful method passes air through a small cold plasma field to produce hydroxyls which then are distributed throughout the space by a strong fan. They do not require any maintenance or consumables other than electricity, and so they can be mounted high on a wall or from a ceiling to get maximum coverage across the space concerned. They use the natural water molecules in the air all around us and do not require topping up or chemicals or any other medium to perform their function in generating Hydroxyls.

REFERENCES: “Science Summit. Ozone Olefins and environmental contamination” by Prof DC Ellwood B.Sc., Ph.D

These hydroxyl (OH-) molecules are attracted to single celled organisms in the air and on surfaces, attach to them and forcibly rip a Hydrogen atom from the cell wall.

“The impact of air quality on productivity and health in the workplace” by Jukes Jenkins and Laws (workplace environmental science and research association 1998)

They are now H²O again – harmless water molecules.

“Air Ions and Human Performance” LH Hawkins and T Barker (Ergonomics 1978 Vol 21 Xo 273-278)

In the meantime, the cell wall of the organism has been ruptured and like a popped balloon, it dies.

Hydroxyl and Air Purification, by Howard D. Lash The Journal of Microbiology, June 2006

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

Water Hygiene Workshop The Alfred Hospital, Melbourne, Victoria, Australia. November 2015 ELISE MAYNARD

This workshop delivered essential advice and guidance on in-premise water systems and water hygiene for Hospital and Healthcare Facilities. Recognised experts with international knowledge were invited to speak at the event which was made freely available by an educational grant from Pall Medical. Please note: This summary was written by Elise Maynard, and reviewed with the individual speakers prior to publication

he event was chaired by Dr David Cunliffe, Principal Water Quality Advisor, South Australian Department of Health. He is a member of the WHO Drinking Water Quality Committee and the Small Community Water Supply Network. David also chairs the Australian National Water Quality Advisory Committee. The presentations commenced with “What’s Lurking in Your Water?” Elise Maynard, Chair of the Water Management Society, UK, reviewed the microbial hazards that may be present within an in-premise potable water supply. Municipal water is not sterile (nor does it have to be) and microorganisms including opportunistic pathogens are able to multiply within water distribution systems and buildings, such as healthcare premises, unless adequate controls are in place. Their pathogenicity depends on • Patient susceptibility (e.g. immunocompromised); • Route of acquisition (e.g. inhalation, aspiration, ingestion, contact or immersion); • Source (e.g. endoscopy rinse water or potable water); • Concentration (e.g. infective dose quantity)

There are many stringent guidelines and regulations at national and international level for the management of Legionella spp., but there are also a number of other organisms which are also ubiquitous in water and which may also have serious public health connotations particularly in the healthcare environment. Nontuberculous Mycobacteria (NTM) are slow-growing in the laboratory, but within water systems can be highly resistant to systemic disinfectants. Pseudomonas spp. and other similar organisms such as Stenotrophomonas maltophilia and Ralstonia picketti are known to be waterborne and typically reside closer to the point of use, such as at tap or shower outlets. Parasites such as Cryptosporidum spp. are also highly resistant to chemical disinfection and are typically removed through coagulation and filtering. There is also evidence that fungi, such as Fusarium and Aspergillus, are waterborne. These are very difficult to treat and result in high mortality in bone-marrow transplant patients. Dr David Cunliffe opened his presentation by commenting that globally most waterborne diseases occur due to ingestion of pathogens, we do not live in a sterile environment and so exposure to bacteria is inevitable. He followed this with

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

some examples pertinent to Australia, where outbreaks of Legionella have been associated with inhalation of aerosols. The most well-known was the Melbourne aquarium outbreak in 2000, where 125 people were diagnosed with Legionnaires’ disease and 4 died. This outbreak was linked to the cooling towers of the aquarium. Global Outbreaks: • Evaporative Cooling Towers > 40 outbreaks (with between 2-approx. 800 cases reported) • Hot/warm water > 30 outbreaks (with between 2-approx. 180 cases reported) • Spa pools > 10 outbreaks (with between 3-approx. 188 cases reported) He also noted that an ice machine in an Adelaide hospital had caused problems due to aspiration of Legionella from ice made with contaminated water in an immunocompromised patient. Typically there are approximately 300 cases of Legionnaires’ Disease reported in Australia per annum, which is similar to that of the UK and growing. There is approximately 5% mortality in the general population (higher in the healthcare population), but a number of studies have also identified

TECHNICAL PAPERS antibodies in asymptomatic volunteers, which suggests a wider exposure. Outbreaks from Pseudomonas aeruginosa included ventilatorassociated pneumonia which caused temporary closure of a ward at the Queen Elizabeth Hospital in Adelaide. Contaminated water is known to be a major source of P. aeruginosa infections (approx. 40%). Ralstonia infections were noted in nine Queensland hospital patients which were linked to one particular supply of bottled water. He concluded that the only way to control such events in piped water supplies would be to raise the hot water temperature or to use point-of-use water filters at taps and showers. Dr Cunliffe explained non-tuberculous mycobacteria (NTM) have been found in approximately 40% of water samples in a Queensland study, and identified by polymerase chain reaction (PCR) in 2 of South Australia’s water supplies. The Queensland study found a potential link between water and infection. NTM have also been found in spa water. It is therefore essential that immunocompromised patients are provided with boiled and cooled, or filtered water as drinking water quality in healthcare is often overlooked. Although current Australian guidelines recommend thermostatic mixing valves (TMVs), it is important to risk assess where to place them as there is a balance between scalding and disease. In summary Dr Cunliffe concluded: • Drinking water quality in healthcare facilities is often overlooked as a source of microbial risk • Opportunistic pathogens are common inhabitants of drinking water supplies • Risks are higher at the ends of the distribution systems, including within buildings • Legionella, Pseudomonas aeruginosa and NTM represent the highest risks but other organisms in the water supply can cause disease • Unlike most waterborne disease, transmission of opportunistic pathogens within in-premise water systems is rarely by ingestion.

Inhalation, contact and aspiration are more significant • Hospital and healthcare facilities provide services to people at much higher risk of infection i.e. with factors that increase risks and consequences of infection • Not all patients are at higher risk, but water, chilled water and ice should be considered a potential hazard where other precautions are taken to reduce risk of infection (e.g. filtered air, modified diets etc.). • Drinking water/ice used for high risk patients should receive additional treatment:o Boiling before use or use of sterile water for preparation of ice o Point of use filtration • Bottled water is generally not a safer alternative to tap water Dr Catherine Whapham, Global Healthcare Water Manager for Pall Medical and Fellow of the Royal Society for Public Health, presented on the use and effectiveness of in-premise water filtration from the point of building entry to the point of use. Considerations for filtration at the point of entry into a building usually focus on improving the influent water quality with relation to particulates and/or microbial contamination, to reduce maintenance of fittings and equipment installed downstream, and to improve subsequent multi-barrier water treatment(s) – such as chemical and thermal systemic treatment – efficiency. Methods to determine water quality for particulates, including silt density index testing and spectrophotometry, plus large volume water sampling for more accurate microbial content analysis were presented and interpretation of results to select appropriate filtration options were also discussed. An overview addressed biofilm formation within pipework systems, components and equipment. Often fittings and equipment are leak tested with water at the manufacturing site prior to release and, although well drained, may contain large volumes of water which then stagnates and readily

forms a biofilm prior to installation. Once established, biofilm is virtually impossible to remove unless the pipework or fittings are replaced. Even when robust filtration, or other technologies, are applied at the point of building entry, the multiple kilometres of pipework downstream, subsequent additional and remedial plumbing works, handling of fittings and the fact that water outlets are not sterile, provide an ideal opportunity for biofilms to form post-filtration. The audience were reminded that in-premise plumbing represents only approximately 1% of the water distribution distance, but 25% of the surface area due to the small diameter pipework – coupled with warmer temperatures, plentiful available nutrients from plumbing materials and pockets of stagnancy, represents the optimal conditions for biofilm establishment and growth. Use of systemic chemical or thermal disinfectants can be effective in controlling bacteria in the water phase (planktonic bacteria), but often have little or no effect on the biofilm due to limitations on the concentrations used and flow dynamics/low penetration of the biofilm layers. Consequently biofilm regrowth, reseeding and return of microbial counts in water samples shortly after disinfection, within 4-7 days, is common. Additionally, systemic disinfection can alter the microbiome and select for resistant microbial strains and/or create viable but non-culturable cells which rejuvenate once the source of stress is removed. Specialist filtration can be very effective for protection of specific and critical equipment and machines such as those within endoscopy, renal, central sterilising & disinfection departments, dental units, ice making machines and chilled drinking water dispensers. Water quality aims are with regard to low or no bacteria, endotoxin, particulate levels and/or to ensure there are no chemical residuals or byproducts. Reverse Osmosis waters may become contaminated and can have high bacterial and endotoxin levels downstream. Robust, positively charged filtration membranes can remove

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

ARE YOU SURE YOUR HYDROTHERAPY POOL WATER IS HYGIENIC?

“in 60 seconds, I can accurately do 9 different tests.” The only way you really can be sure is to test the water properly. And the best way to do that is with WaterLINK Spin, an innovative new technology that makes water testing faster, easier and much more accurate. Gone are the days of photometers that require you to crush tablets, wash test tubes and time chemical reactions. Not only were these tasks tedious and slow, but they were also sources of user error. You simply couldn’t be sure if your tests were accurate or not. Now, with WaterLINK Spin, all users have to do is inject a little water into a disc. From there on the testing process is automatic. There is almost no chance of user error. And accuracy is assured. But accuracy and ease-of-use are not the only benefits of WaterLINK Spin. The system is also very fast. It takes just 60 seconds to analyse 9 different parameters of water quality. For people needing to test pool water frequently the saving in labour time and cost can be enormous.

If you would like to know more about WaterLINK Spin please call (02) 9450-0466 or email info@vendart.com.au.

Distributed exclusively by Vendart Pty Ltd Phone: (02) 9450-0466 Fax: (02) 9450-0755 www.vendart.com.au

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS endotoxins whilst withstanding the very high temperatures sometimes used in renal plumbing loops. Even with pre- and in-line filtration, where there is pipework or tubing downstream of a filter, there is opportunity for biofilms to form and for pathogens to be present. For tap and shower outlets point of use (POU) water filters, the final barrier before the water reaches the user, can be deployed. These are typically used in the short term where critical levels of contamination have been detected within a building and protection of users is required whilst confirmatory sampling, the root cause established and remedial engineering actions are completed. POU filters are often commonly used when renovation and plumbing works are being undertaken in order to protect high risk patients. In some areas POU water filtration may be in longer term use or become a standard of care such as in wound care, oncology, neonatal or burns units, and are mainly used for drinking, cleansing and washing applications where considerations are for low/no bacteria, fungi, particulates. When selecting filtration, particularly POU filtration, it is important to consider the environment in which the filter is being placed, and that it is handled appropriately in-situ to avoid retrograde contamination from touch or back splash. The space between user and outlet, the activity space, should be adequate to avoid inadvertent contamination of the filter housing and outlet. Consideration should be given to the materials of filter construction to avoid adding nutrient source (avoid glues and resins), and international and national approvals may be appropriate such as Watermark, TGA, CE marked medical device, Food Contact compliance etc. Checking independent references regarding reduction of patient colonisation and infection with the particular technology is also important, alongside the manufacturer’s data, plus any on-site performance data that may be required by the Water Safety Group. In conclusion, Dr Whapham summarised the clinical and cost effectiveness of POU water filters from two publications (Trautmann, 2008; Loveday, 2014) confirming their efficacy as part of a Water Safety Plan in reducing the risk of waterborne pathogens. Dr Susanne Lee, Director of Legionella Ltd, an independent water system hygiene consultancy, discussed the Water Safety Plan (WSP) approach to water safety concentrating on healthcare premises. According to the WHO 2011 guidelines, all healthcare facilities should have specific WSPs which include water quality assessments and water treatment options; not just for the water in distribution but also specialised equipment. For the development of a fully documented WSP, the appointment of the water safety team is critical and requires a fully engaged cross-functional team, to include engineers, clinical staff, infection control and budget holders as a bare minimum but may also need input from external experts. A risk assessment based on HACCP principles, which covers all potential sources from source through distribution to the point of use, and which identifies all significant risks to health, hazards, hazardous events, increased susceptibility of users etc. prioritises risks

TECHNICAL PAPERS and ensures the application of effective controls and barriers as far as reasonably practicable. To ensure water safety is maintained there is a monitoring programme to ensure operational controls are effective and backed up by internal and external audit. Importantly the WSP relies on more operational monitoring to ensure controls and barriers are working, and less reliance on microbiological monitoring at POU. Whereas HACCP is confined to managing identified hazards; the WSP is about preventing and managing risks from the point of design, through construction and commissioning of water systems and equipment to the end of lifecycle. A WSP also includes supporting programmes to ensure there is effective surveillance, good communication and training of all those involved in water safety. Water quality entering the building is the first place where interventions may be needed to protect the water quality within the building. An inherent risk in Australia is the temperature of the incoming water, but there may also be additional risk factors such as an intermittent supply or where there is a risk of contamination from animals, insects and sewage, where the maintenance of effective biocide levels at point of entry is a critical control. ALL potential routes of infection including direct and indirect ingestion, contact (swimming, bathing, wound management etc.); inhalation of aerosols, aspiration and all potential water sources need to be considered, and Dr Lee listed a wide variety of equipment, including water used for diagnosis and treatment, but also those which may not have been considered such as floor washers and steam cleaners which have a water tank and which often contain contaminated, stagnant water if not managed effectively. The temperature regime of both hot and cold water is important in controlling growth but regardless of the choice of control, the presence of biofilm has the potential to increase the number of pathogens. Dr Lee explained that biofilms which are inherently resistant to biocides are found throughout the system and are impossible to remove from all parts of the system particularly from within complicated components, such as sensor taps and thermostatic mixing valves where there is a large surface area to low water volume ratio and this will inevitably result in a higher risk of waterborne pathogens. The development of a comprehensive WSP can help mitigate high costs by careful review and allocation of resource to the highest priority issues. A combination of both engineering expertise and clinical surveillance will help target the highest-risk scenarios and the most effective areas to allocate budgets. Building design at all stages of the project is another critical component which needs careful review by the water safety team. Litigation has proven to be a very costly exercise in the majority of cases where good quality water safety plans have not been in place or implemented effectively. Dr Lee also noted that according to the US EPA 0.85% of the U.S.A. population is estimated to be immunocompromised this is an increasing trend and enhanced protection for high risk patients will need to be extended to domestic properties

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THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS in future to avoid waterborne complications in the home setting. Noel Cleaves, Manager, Environmental Health Regulation and Compliance from the Victoria Department of Health & Human Services, explained that the Australian Guidelines for Legionella control are currently in advanced draft form, with the expectation that they will be endorsed by the States and Territories by the end of 2015. Please note the Guidelines for Legionella Control in the Operation and Maintenance of Water Distribution Systems in Health and Aged Care Facilities subsequently have been endorsed by the Australian Health Protection Principal Committee and are now published. Electronic copies of the Guidelines and risk management plan template are available for download and can be accessed from the SA Health website. The scope is operation and maintenance of water distribution systems in Health and Aged Care facilities, but excluding cooling water systems.

to be checked. Disinfection may include both chemical and physical treatments (including point-of-use microfiltration). Maintenance and monitoring should include water storage tanks, water temperature, disinfection system, cleaning of TMVs, outlets and/or shower heads and at least weekly flushing of underused outlets. Flushing, however, is a potential problem for Australia with restricted water supply. Exposure controls could include removing aerators from the taps and minimising aerosols. Operational monitoring is different to verification monitoring and is based on risk assessment. The latter would include microbial assays at sentinel points, for example. Sampling for outbreaks would be more intense than for routine monitoring. Response needs to be established to positive cases in advance and this requires skilled people and established protocols. Some of the Department’s observations so far include examples such as: • A failure to plan for urgent disinfection

Establishing a Legionella risk management system involves:

• Sampling without consideration on what happens if the result is positive

• Analysing risk

• Relying on temperature control with no back-up plan

• Managing risk

• Poor commissioning

• Responding to detection or cases

• Poorly targeted water sampling

• Reviewing the risk management plan

• Poorly managed water treatment

Responsibility needs to be shared by facilities management, clinical staff, infection control, health and safety and the executive team – with a documented plan. The guidelines discuss water system risk and health risk. System analysis is required such as:

• Dead-legs • Insufficient knowledge about built design Mr Cleaves concluded with his top tips: • Team approach

• Physical inspections

• Documented risk assessment plan can save angst

• Evaluation of the source and quality of incoming water (especially in remote areas)

• Understand your system as best you can • Identify end use/users of water that pose most risks

• “As built” schematic diagrams

• Plan for urgent disinfection following detection of Legionella

• Situations where water may be unintentionally warmed

• Have a back-up treatment plan in place

• Components

• Keep up maintenance standards, including monitoring

• Final use – water features, birthing pools, spa’s, ice machines, dental chairs and clinical care equipment

• Remove dead legs

• Previous testing history

• Check commissioning

• Case histories At risk patients include neonates, older people and the immunocompromised. Risk assessments of the plumbing should consider dead legs, condition and materials of pipework and deficiencies in commissioning. Both hot and cold water requires assessment as well as the final use, as described above. Implementing controls needs to be proactive and not reactive and a multi-barrier approach is best. Commissioning needs

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

• Target sampling Pall Medical organises and supports educational events relevant to in-premise water hygiene, typically selecting speakers with backgrounds and experience relevant to supporting a Water Safety Plan/Water Safety Team approach. We are confident that educational events, delivered in a neutral and professional manner by Subject Matter Experts, enable the audience to access information on current scientific thinking and experience, and raise the overall awareness of in-premise water hygiene. We look forward to seeing you at the IHEA Healthcare Facilities Management Conference in Adelaide, 19-21 October 2016.

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THE INTEGRATED ACCESS CONTROL SOLUTION KeyWatcher is designed for complete interactivity with your other business systems. For example, by integrating your KeyWatcher system with your access control system, your access control system will know which users have keys and which do not. A user who has taken a specific key from KeyWatcher can be denied egress from the facility until the key is returned – and selected management can be alerted via email if a key has not been returned on time.

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TECHNICAL PAPERS

Hospital Engineers & Emergency Planning Committee Liabilities

DEREK HENDRY I THE HENDRY GROUP

Hospital Engineers should be aware AS 3745-2010 Panning for emergencies in facilities dictates that Facility Owners, Managers and Occupiers must be familiar with their responsibilities and requirements of the standard.

his standard nominates ‘facility owners, managers (hospital engineers), occupiers and employers’ in 12 separate parts within the body of the standard. The clauses listing the facility owner in AS 3745 Planning for emergencies in facilities are as follows:

• Preface • Page 12 2.1 General • 2.2 Responsibilities • 2.5 Indemnity • 3.1 General • 5.4 Authority Notes 1 and 2 • 5.5 Indemnity • 5.7.4 Post Emergency Note • 7.1 General • 7.2 Initial Testing and Implementation and Note 3

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AS 3745-2010 contains legal obligations that concern people involved in emergency preparedness (as members of the Emergency Planning Committee and Emergency Control Organisation) and involves the statement regarding legal liability.

INDEMNIFIED BY EMPLOYER Clause 2.1.3 in AS 3745-2002 states the following: “Both the Emergency Planning Committee and the Emergency Control Organisation personnel shall be indemnified by their employer against civil liability resulting from workplace emergency assessment, education, fire safety training sessions, periodic exercises or fire evacuation of a building, where the personnel act in good faith and in the course of their emergency control duties.” These words have been deleted from the 2010 version of AS 3745 and new wording in Clauses 2.5 and 5.5 has been inserted:

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“Facility owners, managers, occupiers and employers should obtain professional advice on the level of indemnity provided to Emergency Planning Committee members. The Emergency Planning Committee members should be advised of the level of indemnity provided.”

TECHNICAL PAPERS Clause 5.5 – AS 3745 specifies that:

SUMMARY

“Facility owners, managers, occupiers and employers should obtain professional advice on the level of indemnity provided to Emergency Control Organisation members. The Emergency Control Organisation members should be advised of the level of indemnity provided.”

AS 3745-2010 has not really changed the status of liability of individuals involved in emergency prevention.

UNDERSTAND THE INDEMNITY ISSUE This apparent lessening of the indemnity provided in the amended AS 3745 to the Emergency Planning Committee and Emergency Control Organisation needs to be considered in the following light: • The Emergency Planning Committee issues the Emergency Plan and is responsible for outcomes from its implementation • The responsibility of safety in facilities comes from both State and Federal legislation for Occupational Health and Safety and Work Health Safety (for employers to their employees) and common law (from those in control of facilities, to those who obtain access) • The indemnity of members of the Emergency Planning Committee and Emergency Control Organisation will generally fall into two categories: o Those who are acting as employees, whose liability will almost certainly be covered by their employers under the respondent superior doctrine, for negligent acts or omissions by their employees in the course of employment. o Those, perhaps property owners, who are not employees, whose liability will be determined by the nature of the negligent act or omission in preparing the emergency plan. • The liability or indemnity of members of the Emergency Control Organisation, who follow the emergency plan, will be determined in the same way.

Employers and property managers should obtain legal advice regarding the emergency plan required by AS 3745 or use a respected contractor as they would for any specialised work with legal liability. The unique mix of membership of the Emergency Planning Committee (typically building owners, agents, occupiers, lessors, employers) may mean it contains individuals who are not employees and so should ensure their liability is not increased by using the same measures. However, the majority of Emergency Planning Committee and Emergency Control Organisation members will be employees who will be indemnified by their employer. Hendry can assist your Emergency Planning Committee and Emergency Control Organisation in upgrading the emergency management plan of your facility to AS 37452010, while limiting the legal liability of owners, employers and occupants.

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• Indemnity does not flow from AS 3745. AS 3745 is not law, but a guide to best practice. • Any past statements made by the Emergency Response Procedures under the AS 3745-2002 Standard would have had the same weight as statements made under the current AS 3745-2010 standard, with liability or indemnity of an individual determined by their status as an employee, and then the nature of the negligent act or omission. Employers who provide indemnity to their employees or property owners who retain liability should ensure that the emergency plan does not expose them to liability. They can do this by: • Seeking legal advice (as suggested by AS 3745-2010); and • Using a respected Emergency Plan contractor who has a responsibility to provide documentation that addresses the liability in a professional manner

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TECHNICAL PAPERS

The Building Information Modelling solution TODD WILKENING I DIRECTOR OF FACILITY SERVICES, RIDGEVIEW MEDICAL CENTRE, CANADA

Building Information Modelling (BIM) can help close the gap between design, construction and operation and can simplify building management of new premises.

oday, at the end of construction projects an organisation will quickly open for business as it is important to start to generate revenue immediately upon occupancy to start to gain value from the cost of construction. However, often the organisation is not ready for occupancy, which can lead to patient risk and added costs. Reasons why include: Compliance failure: During project close out, the Facilities Manager (FM) is left with the task of making the building operational. Documents need to be collected and disseminated into numerous silos in order to support the vast amount of information needed by the many service providers and building of the organisation. Static state: The information provided dictates a point in time of construction. Known as ‘as-built’ or ‘as-constructed.’ This information has historically been deemed to be the most reliable and accurate information about the project. Fragmentation: Over time, service departments working from the original as-constructed information will have migrated to their own level of information. Also known as the ‘as-maintained’ model. Although not all the original information is needed to maintain the building assets it can lead to building assets being maintained with fragmented information. As organisational needs change and future projects are planned, planners, designers, and constructors may require the original constructed documentation and it is then service departments will need to look closely at what has changed. Certainly we do not wish for owners to plan their future needs on bad information… but this does often happen. Ready, set, go: Health care systems are now closing the gaps between design, construction, and operation. This leading approach to the life cycle management of building assets is effectively transforming the supporting world of facilities management.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

GETTING STARTED Exponential advances in computing technology over the past 10 years has presented the opportunity to move design, construction, and operation of the built environment into a data driven process. This has resulted in a paradigm shift in the practice of architecture and engineering, construction, and facility management offering significants for those involved. The foundation of this shift in process is based on the use of Building Information Modelling (BIM). The creation and operation of hospital buildings has historically consisted of three primary silos of knowledge – that of the designer, contractor and owner. The design and construction process has been rigidly linear with a formal handoff of a portion of the total work effort of a designer to the contractor, then from the contractor to the owner. With each handoff there has been a significant loss of information that would be beneficial for the subsequent phase of a building project. The result is wasted time, effort, and money due to issues such as poor coordination of disciplines

TECHNICAL PAPERS and subcontractors, construction delays, order changes, redundant documentation of intent and fabrication and failed opportunities for facility management and operations of these assets. The introduction of BIM is transformative to the traditional way of delivering a construction project to an owner, and also to the way an owner can manage the building after construction. Design and construction professions have recognised the benefit and functionality of this emerging technology and have made strides to adopt it, primarily in their respective silos, limited to their own benefit. Integration would make better sense. Owners are now beginning to recognise the potential of BIM and the real savings it can provide to construction, operating and maintenance costs. Owners have also recognised its potential and are making a commitment to the implementation of a data driven design and construction process, and for the management of its facilities.

WRITING THE OWNER RULE BOOK The utilisation of BIM technology for design, construction and operation of new building and major renovation projects has been recognised as a valuable asset for owners. The ability to create a digital model of a building and preserve the data developed during design and construction can aid design team collaboration, construction methodology and

facility management, collaboratively. A significant long-term benefit to owners will be realised through the creation and preservation of building information for use in the ownerâ&#x20AC;&#x2122;s Integrated Workplace Management System (IWMS) platform,

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

TECHNICAL PAPERS

21-04 10 80 10 21-04 10 80 20 21-04 10 80 30 21-04 10 80 40 21-04 10 80 50 21-04 20 21-04 20 10 21-04 20 10 10 21-04 20 10 20 21-04 20 10 40 21-04 20 10 60 21-04 20 10 90 21-04 20 20 21-04 20 20 10 21-04 20 20 30 21-04 20 20 90 21-04 20 30 21-04 20 30 10 21-04 20 30 20 21-04 20 30 30 21-04 20 30 60 21-04 20 30 90 21-04 20 50 21-04 20 60 21-04 20 60 10 21-04 20 60 20 21-04 20 60 30 21-04 20 60 40 21-04 20 60 50 21-04 20 60 90 21-04 30

LOD MEA Notes LOD MEA Notes LOD

Suspended Scaffolding Rope Climbers Elevating Platforms Powered Scaffolding Building Envelope Access Plumbing Domestic Water Distribution Facility Potable-Water Storage Tanks Domestic Water Equipment Domestic Water Piping Plumbing Fixtures Domestic Water Distribution Supplementary Components Sanitary Drainage Sanitary Sewerage Equipment Sanitary Sewerage Piping Sanitary Drainage Supplementary Components Building Support Plumbing Systems Stormwater Drainage Equipment Stormwater Drainage Piping Facility Stormwater Drains Gray Water Systems Building Support Plumbing System Supplementary Components General Service Compressed-Air Process Support Plumbing Systems Compressed-Air Systems Vacuum Systems Gas Systems Chemical-Waste Systems Processed Water Systems Process Support Plumbing System Supplementary Components Heating, Ventilation, and Air Conditioning (HVAC)

MEA Notes LOD MEA Notes LOD

MEA Notes LOD MEA Notes

200 200 200 200

A,M A,M A,M A,M

100 100 100 100

A,M A,M A,M A,M

200 200 200 200

M M M M

300 300 300 300 100

M M M M M

300 300 300 300 100

M M M M M

300 400 350 400 100

M M M M M

200 200

A,M A,M

100 100

A,M A,M

200 200

M M

300 300 100

M M M

300 300 100

M M M

500 350 400

M M M

200 200 200 200

A,M A,M A,M A,M

100 100 100

A,M A,M A,M

200 200 200

M M M

300 300 300 100

M M M M

300 300 300 100

M M M M

400 350 350 200

M M M M

100 100 100 100 100

A,M A,M A,M A,M A,M

200 200 200 200 200

M M M M M

300 300 300 300 300

M M M M M

300 300 300 300 300

M M M M M

350 350 350 350 350

M M M M M

100

300

100

A,M

200

A,M

200 200 200 200 200

A,M A,M A,M A,M A,M

Note Number (See Sec. 3.4)

AS MAINTAINED

AS-CONSTRUCTED

Insert abbreviations for each MEA identified in the table below, such as “A— Architect,” or “C—Contractor.”

CONSTRUCTION DOCUMETS

Identify (1) the LOD required for each Model Element at each Project milestone, (2) the Model Element Author (MEA), and (3) references to any applicable notes found in Section 3.4.

DESIGN DEVELOPMENT

EXISTING AS-CONSTRUCTED

§ 3.3 Model Element Table – Minimum Requirements

Model Elements utilizing OmniClass™

SCHEMATIC DESIGN

AS MAINTAINED

AIA Document G202™ – 2013. Copyright © 2013 by The American Institute of Architects. All rights reserved. WARNING: This AIA® Document is protected by U.S. Copyright Law and International Treaties. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This draft was produced by AIA software at 12:11:13 on 10/14/2014 under Order No.7657227259_1 which expires on 10/14/2015, and is not for resale. User Notes: (1383745075)

the powerhouse which connects all the disciplines. Owners need to understand that technology is useful for projects and consistent standards need to be defined for projects that are selected for utilisation of BIM. Owners need to establish minimum BIM requirements for design and construction services and to establish a formal process that results in complete and consistent deliverables from project to project. This is needed for existing buildings, renovations,

as well as new constructions. The BIM standards offer established results offering a higher degree of informed decision, coordination and preservation of data. These standards also support a more collaborative process among project team members, which support the design and construction team’s effort to meet expectations set by the owner’s real estate, construction, and facilities management departments.

Advances in computing technology over the past 10 years has presented the opportunity to move design, construction, and operation of the built environment into a data driven process.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

Included within the owner’s BIM standard must be a process for establishing a project specific digital practice execution plan that will be used by all design and construction partners to collectively identify unique project characteristics, expectations, completeness, and required work effort for the successful delivery of projects. All project participants must participate in defining the project specific digital practice protocols at the outset of the project using the framework established by these documents. As project participants are added to the project new participants will also be bound to those protocols. The utilisation of BIM for design and construction will become the owner’s standard for new construction and all

TECHNICAL PAPERS renovation projects. Not to mention incidental changes from operations. BIM must also be utilised for management of existing facilities. The development of BIM Standards provides benefits to all parties involved in the process and will support successful delivery of data beneficial for functional facility management of its assets.

Certainly we do not wish for owners to plan their future needs on bad information… but this does often happen. AS CONSTRUCTED DOCUMENTATION The design team must continuously maintain and update the design intent model(s) with changes made from official construction change directives and as-built mark-ups maintained on site by the contractor(s) during construction. At an interval that is decided within the BIM execution plan or at minimum once a month during construction the updated design intent model will be presented for review and comment by the project participants. As-constructed models: These could include fabrication models, coordination models, or shop drawing models. These models will be referred to as the as-constructed models and should reflect the exact geometric properties of the materials and/or systems being submitted. These should also reflect the exact material properties and performance data. Deliverables: The contractor shall require subcontractors, fabricators, suppliers and manufacturers to submit all models to the contractor in both a format and 2D and/or 3D DWF formats as agreed upon. These models should be updated after each project coordination meeting or as changes occur in the field during construction.

The following are some of benefits that owners can expect from the implementation of its own BIM standards: • A clearly defined owner process for design & construction partners working with the owner. • Standardisation of requirements for owner projects utilising BIM. • A platform for information exchange between the designers, vendors, constructors, and operators. • Design and construction model reviews that provide consistent quality on the owner’s projects. • A recognisable level of anticipated model development and coordination for models developed for the owner. • The ability to evaluate the to-be-built environment in two and/or three dimensions and better understand the design. • The ability to make changes through the design process based on end-user operability. • Visual tools for end-user approval and acceptance among stakeholders. • Marketing tools through renderings of designed spaces for fund raising, and occupant evaluation including tenants. • More reliable cost estimates earlier in the design phase. • Reduced design schedules and increased design coordination through model reviews. • Development of model based schedules and quantities for early proactive management of building assets. • The ability to evaluate the building components and develop an efficient plan for the construction of the project eliminating the potential for rework. • Early and periodic analysis of design impact on operational and energy use. • Cost-savings by supporting prefabricated building components, thus reducing waste and inefficiencies.

• The ability to utilise prefabricated components that are produced in a controlled environment reducing installation time and field labour, while increasing quality of work. • Efficient construction sequencing for a quality installation and project flow. • The ability to communicate with subcontractors using a visual tool. • Building system coordination that reduces conflicts in the field, saving time lost with Request for Information (RFI’s) and cost incurred through change orders. • Model based safety reviews that assure safety measures are in place throughout the construction schedule reducing project risk while assuring the construction schedule. • Established standards for document turnover, model turnover, and data organisation. • The ability to collect project data in a consistent manner with which the Owner can begin to plan for the future use of models for support of facilities maintenance and management. • Enhanced operational efficiency due to readily access to facility data ahead of project completion. • Vastly improved uptime of compliance by regulatory agencies. • Greater customer service by facilities management to its constituents. • More accurate facility assessment and future capital improvement planning. • The ability to greatly improve upon the life cycle value of buildings and assets. • Provide cohesive coordination of building information into a single source of truth. • Aid in the development of ‘as-maintained’ documentation in real time with disciplined coordination.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

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TECHNICAL PAPERS Files should be created at all critical coordination milestones. This record format will document a coordinated section of the model, either by area of the building or between specific critical trades.

AS MAINTAINED DOCUMENTATION Owners need to provide the architect, engineer, and constructor with a list of required elements to be used as ‘as-maintained’ documentation for the seamless insertion of data into the integrated IWMS system for day-to-day management of the owners buildings and assets. The data shall be provided in a format consistent with the IWMS system requirements. The contractor should submit a plan to the owner for review, prior to the start of construction which outlines the process for concurrent as-maintained documentation. As-maintained level of detail must be mandated. Methods for recording as-maintained information need to be left to the discretion of owner and the contractor. Potential options could include traditional methods, and/ or periodic laser scanning of completed or partially completed primary systems coordinated with the sequence of construction. Primary systems can include, but may not be limited to structural detail, primary HVAC duct runs, lighting fixtures, plumbing, primary fire protection main runs, primary electrical conduits, ceiling grid layouts, finishes, major fixed equipment, and alike. Commissioning data including but not limited to design intent, performance criteria and operations data shall be recorded and/or linked to the model as commissioning occurs throughout the project. Commissioning requirements need to be coordinated with the owner. It should be the contractor’s responsibility to coordinate the information sources and provide this information to the owner for addition into the model prior to completion of the project. The savvy owner will realise that the information described in this article can be readily accessible at strategic points during the project and well ahead of project close out. There is no longer a need to wait for post project proceedings to make this happen. This means that the facility manager can now begin to plan how to operationalise the building asset well head of turn over. Additionally, providing education to building operators on how to maintain the building ahead of occupancy will greatly reduces costs and risk to patients. It is also compliant with regulatory agencies such as DNVISO, The Joint Commission, department of health, and others. Upon final review and acceptance, the owner shall release the architect, engineer, and constructor from the as maintained documentation during the construction close out process.

PROJECT CLOSE OUT The design team shall update their respective model(s) with contractor recorded changes. Documents should be recorded

Providing education to building operators on how to maintain the building ahead of occupancy will greatly reduces costs and risk to patients. either on paper, rvt, dwg, pdf, or other formats required by the owner and their IWMS system. The design team also needs to submit full model(s) with all needed objects and reference drawings, in the original authored software. The design and construction team must comply with the owner’s written agreement for as-constructed and asmaintained requirements. The design and construction team shall submit the following information to the owner – one or two paper copies in binders of the O&M manual and also in the models electronic requirements including manufacturer cut sheets, installation instructions, recommended maintenance tasks, and required testing reports. As maintained documents shall be reviewed, accepted, and uploaded into the concurrent as-maintained models under the ownership of the Owner through the coordination of the architect, engineer, and constructor. Completion of the close out process should result in a simple quality assurance check list that all the required information needed to fully operationalise the building asset have been achieved and are successfully implemented.

OWNER AND RIGHTS OF DATA Owners need to retain ownership of all files, BIM models, and facility data developed for the project. The owner will make use of this data following any deliverable for any purpose. Any copyrights will remain with the author of the work they have provided. This article first appeared in IFHE Digest 2016.

TODD WILKENING Todd Wilkening CHFM, CHST is Director of Facility Services at Ridgeview Medical Center in Canada. He has 25 years of experience in health care facilities management and has led the way for his employer, in obtaining many national awards in facilities management and sustainability. He has served as the Vice President of Research for the International Facility Managers Association’s Health Care Institute (IFMA-HCI).

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

PRODUCT NEWS THE WORLD LEADER IN CLEAN AIR SOLUTIONS

Gas-Phase Solutions for Medical Centre Helipad Fumes Introduction

In the fall of 2008, one of the busiest public hospitals in the western United States opened a new medical centre complex. Shortly after its opening, employees began complaining about poor indoor air quality. Exhaust fumes from the rooftop helipad landings set off fire alarms, and caused odours within in the hospital. The medical centre’s air handling units (AHUs), with outdoor air intakes, are located in the vicinity of the helipad. The air intake vents circulate air throughout the medical centre’s diagnostic and treatment tower, which houses emergency and operating rooms. A standard gas-phase filtration system was in place to remove odorous chemical contaminants, such as helicopter exhaust, but failed to provide sufficient protection for the facility’s patients and staff. After several months of working with the filter manufacturer to find a solution for the failing filtration system, the medical centre closed the helipad in early February, 2009. Within a few weeks, the State’s Division of Occupational Safety and Health (DOSH) fined the medical centre after validating employees’ claims of poor air quality. The problem became so prominent that a local newspaper reported the issue and followed it until the helipad was reopened.

The AAF Solution

AAF® International was contacted to provided an on-site assessment of the affected rooftop AHUs to obtain a viable solution for the medical centre. Our gas-phase experts quickly identified an inferior gas-phase filtration product, and recommended a custom sized cassette to hold AAF proprietary SAAFBlend™ GP media as a solution. This project involved the selection of a unique metal cassette size, successfully provided by AAF, to replace the inferior system. The cassettes filled with SAAFBlend GP media, consisting of a blend of activated carbon and a propriety oxidant formulation, offer the most effective gaseous contaminant removal solution for helicopter exhaust.

Testing Confirms Superior Product

The medical centre retained a third party environmental consultant who conducted monitoring and sampling for gaseous contaminants associated with helicopter exhaust. The contaminants include sulphur dioxide (S02), nitrogen dioxide (N02), and volatile organic compounds (total and speciated) during a helicopter landing event. The medical centre reviewed the results of the tests, and concluded that our SAAF Cassettes with SAAFBlend GP media were superior.

THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016

As a result, the medical centre decided to use SAAF gas-phase filtration systems within all seventeen AHUs with outdoor air intakes in the vicinity of the helipad.

Helipad Reopens

AAF’s gas-phase filtration system was installed in July 2009 and the helipad reopened. It has since remained operational. AAF continues to support the medical centre with replacement filtration products as well as media life analysis services, to best estimate when the media needs to be changed to ensure the hospital is providing a safe, odour free indoor environment. For more information contact: www.aafintl.com 02 9725 5443 info@aafaus.com

Tente Castors & Wheels TENTE IS PROUD TO OFFER THE E-DRIVE 5TH WHEEL OPTION, THE WHEEL IS ABLE TO FIT TO MOST EXISTING TROLLEYS WHICH ADDS THE ABILITY TO MAKE YOUR TROLLEY MOTORISED AND EASES EFFORT FOR STAFF TO MOVE GOODS FROM POINT A TO POINT B. THE TENTE 5TH WHEEL OPTION IS UNIQUE IN THE FACT THAT IT RETRACTS AUTOMATICALLY WHEN NOT IN DRIVE MODE, THEREFORE ALLOWING THE TROLLEY TO FUNCTION AS NORMAL WHEN MANOEUVRING INTO TIGHT AREAS WITHOUT AFFECTING THE OPERATION OF THE ORIGINAL SWIVEL CASTORS. The E Drive 5th can be fitted to Platform Trolleys, Food Trolleys, Medical record Trolleys, Laundry Trolleys etc. where heavy trolley loads are encountered, which may cause the operator to strain in the initial start-up, manoeuvring and stopping of heavy trolley loads. The E Drive is maintenance free and very user friendly to operate. Contact Tente Castors & Wheels 1300 836 831 or sales@tente.com.au for a demonstration.

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THE AUSTRALIAN HOSPITAL ENGINEER I JUNE 2016