CHF Spring 2016 by MediaEdge

Canadian

HealthcareFacilities JOURNAL OF CANADIAN HEALTHCARE ENGINEERING SOCIETY

Volume 36 Issue 2

BREAKTHROUGH PERFORMANCE

PM#40063056

Nanaimo Regional General Hospital's new emergency department designed to deliver sustainable care

Spring/Printemps 2016

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CONTENTS

CANADIAN HEALTHCARE FACILITIES Volume 36

Issue 2

Kevin Brown kevinb@mediaedge.ca PUBLISHER/ÉDITEUR

ASSOCIATE PUBLISHER/ Stephanie Philbin ÉDITRICE ASSOCIÉE stephaniep@mediaedge.ca EDITOR/RÉDACTRICE Clare Tattersall claret@mediaedge.ca SENIOR DESIGNER/ CONCEPTEUR GRAPHIQUE SENIOR

Annette Carlucci annettec@mediaedge.ca

PRODUCTION MANAGER/ Rachel Selbie DIRECTEUR DE rachels@mediaedge.ca PRODUCTION

12 DEPARTMENTS

TECHNOLOGY

6 8

20 Robots in Disguise Hospital automated guided carts increase efficiency, reduce operating costs

Editor's Note President's Message

10 Chapter Reports

CIRCULATION MANAGER/ Maria Siassini DIRECTEUR DE LA marias@mediaedge.ca DIFFUSION CANADIAN HEALTHCARE FACILITIES IS PUBLISHED BY UNDER THE PATRONAGE OF THE CANADIAN HEALTHCARE ENGINEERING SOCIETY. SCISS JOURNAL TRIMESTRIEL PUBLIE PAR SOUS LE PATRONAGE DE LA SOCIETE CANADIENNE D'INGENIERIE DES SERVICES DE SANTE.

CHES Canadian Healthcare Engineering Society

26 A Winnable Battle Canadian invention wages war on superbugs like never before

SCISS

Société canadienne d'ingénierie des services de santé

PRESIDENT VICE-PRESIDENT PAST PRESIDENT TREASURER SECRETARY EXECUTIVE DIRECTOR

Mitch Weimer Preston Kostura Peter Whiteman Craig. B Doerksen Sarah Thorn Donna Dennison

CHAPTER CHAIRS

INNOVATION

REGULATORY UPDATE

12 Where Sustainability Supports Care Inside Nanaimo Regional General Hospital’s new emergency department

28 Raising the Bar Revised CSA standards provide updated guidance to healthcare facilities

16 Extending the Hospital Walls New approach to critical care knocks down distance barriers for patients in northeastern Ontario

Newfoundland & Labrador: Brian Kinden Maritimes: Robert Barss Ontario: Roger Holliss Manitoba: Craig B. Doerksen Saskatchewan: Al F. Krieger Alberta: Tom Howard British Columbia: Steve McEwan FOUNDING MEMBERS

H. Callan, G.S. Corbeil, J. Cyr, S.T. Morawski CHES

4 Cataraqui St., Suite 310, Kingston, Ont. K7K 1Z7 Telephone: (613) 531-2661 Fax: (866) 303-0626 E-mail: ches@eventsmgt.com www.ches.org Canada Post Sales Product Agreement No. 40063056 ISSN # 1486-2530

Committed to service excellence

Structural Restoration Structural Engineering Building Science Parking Facility Design

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EDITOR'S NOTE

INNOVATION NATION IT SEEMS LIKE EVERY OTHER week Canada’s healthcare infrastructure is in the news. Stories run the gamut from the cancellation of a week’s worth of surgeries at Eastern Health due to contaminated equipment, to the recent flooding and subsequent shutdown of St. Michael’s Hospital’s emergency department in Toronto, to the ‘long list of ills’ — Legionella, heating failures and bedbugs, to name a few — at Halifax’s Victoria General Hospital. But not all news is bad; it just happens to dominate mainstream media headlines. From east to west, health authorities across the country are embarking on ambitious multi-million dollar revitalization projects. They’re investing in their communities, creating innovative and sustainable places that will provide quality patient care well into the future. Many projects are currently in the early stages of development, while others are well underway and a number are already complete. One such project is Nanaimo Regional General Hospital’s new emergency department, which is our lead story this issue. Located on Vancouver Island, the 35,000-square-foot hospital addition is triple the size of the old emergency wing. But its size isn’t what makes this project truly remarkable. The LEED (Leadership in Energy and Environmental Design) gold building is designed to improve the health, healthcare and quality of life of its users. You can read all about the ‘generative space’ beginning on pg. 12. From here we move east to Ontario, where we continue our innovation journey. At Health Sciences North, video conferencing technology connects a team of intensive care physicians, specially trained nurses and respiratory therapists with smaller hospital critical care units and emergency departments across northeastern Ontario. Extending the Hospital Walls delves into this virtual critical care model, which enhances the diagnosis and treatment of patients. Ontario is also the birthplace of Asepticsure (pg. 26). Developed by Dr. Dick Zoutman, chief of staff at Quinte Health Care, and Dr. Michael Shannon, former deputy surgeon general of Canada, the hospital room disinfection system is virtually 100 per cent effective and safe. Rounding out this issue, we look at the rise of robots in hospitals and provide a regulatory update on two CSA standards, Z317.1 and Z317.2. Clare Tattersall claret@mediaedge.ca

Reproduction or adoption of articles appearing in Canadian Healthcare Facilities is authorized subject to acknowledgement of the source. Opinions expressed in articles are those of the authors and are not necessarily those of the Canadian Healthcare Engineering Society. For information or permission to quote, reprint or translate articles contained in this publication, please write or contact the editor. Canadian Healthcare Facilities Magazine Rate Extra Copies (members only) $25 per issue Canadian Healthcare Facilities (non members) $30 per issue Canadian Healthcare Facilities (non members) $80 for 4 issues A subscription to Canadian Healthcare Facilities is included in yearly CHES membership fees.

6 CANADIAN HEALTHCARE FACILITIES

La reproduction ou l’adaptation d’articles parus dans le Journal trimestriel de la Société canadienne d’ingénierie des services de santé est autorisée à la condition que la source soit indiquée. Les opinions exprimées dans les articles sont celles des auteurs, qui ne sont pas nécessairement celles de la Société canadienne d’ingénierie des services de santé. Pour information ou permission de citer, réimprimer ou traduire des articles contenus dans la présente publication, veuillez vous adresser à la rédactrice. Prix d’achat du Journal trimestriel Exemplaires additionnels (membres seulement) 25 $ par numéro Journal trimestriel (non-membres) 30 $ par numéro Journal trimestriel (non-membres) 80 $ pour quatre numéros L’abonnement au Journal trimestriel est inclus dans la cotisation annuelle de la SCISS.

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PRESIDENT'S MESSAGE

SPRING INTO LEARNING AS I WRITE THIS MESSAGE the days are getting longer and the nights shorter, signalling the coming of spring. The season is a time of growth and most chapters are working diligently to bring their spring conferences and education days to fruition. Planning and running these events requires hundreds of volunteer hours. When you attend your local chapter event this year, please take a few moments to thank the hardworking people who made it a reality. As we move further into 2016, the pace of work for most of us in the healthcare sector will not diminish, leaving little “free” time. Most organizations emphasize the importance of continuing education but formal programs require a significant commitment. Selfdirected learning is a key component of professional development, and it provides an alternative for those who are time-strapped. Reading Canadian Healthcare Facilities will help you keep pace with changes in the healthcare industry. The CHES website and, in particular, our webinar series are also valuable resources. The professional development committee has put together a series of informative webinars for 2016, with webinars scheduled for March, April, October and November. They are great group events, where you can educate an entire team for the price of just one registration. The two-day Canadian Healthcare Construction Course (CanHCC) is also being offered by CHES several times this year. CHES is ramping up the Canadian Certified Healthcare Facility Manager (CCHFM) program. The certification program was established to help set a national workplace standard for those responsible for the operations and maintenance of Canada’s healthcare facilities. I would like to congratulate Manitoba Chapter chair, Craig Doerksen, as the first person to complete the program and earn the CCHFM designation. CSA Group is publishing several new standards this year, including Z317.1 (Special Requirements for Plumbing Installations in Health Care Facilities) and Z317.2 (Special Requirements for HVAC Systems in Health Care Facilities). Familiarizing yourself with them will help you stay current. As well, CSA is currently looking for a CHES representative for its Special Requirements for Illumination in Health Care Facilities standard. The partnership and advocacy subcommittee will run a process to select a volunteer to serve as the CHES representative on that committee. As always, CHES membership provides free access to the “top 10” CSA standards. 2016 marks a return of the CHES National Conference to the West Coast. The British Columbia chapter last hosted the conference in the shadow of the 2010 Winter Olympics in Whistler. This year, I am honoured to welcome all CHES members to my hometown of Vancouver, to experience all that the world-class city has to offer. Conference chair Norbert Fischer and B.C. Chapter chair Steve McEwan have been whipping the conference team into action. This year’s conference, to be held at the spectacular Vancouver Convention Centre Sept. 11-13, is shaping up to be a fantastic event. Following the conference, on Sept. 14-15, there will be a two-day session of the CanHCC. As you read this edition of Canadian Healthcare Facilities, please remember the journal relies heavily on information and articles submitted by our membership. I encourage you to take some time to submit your editorial pitches to the MediaEdge team. Mitch Weimer President, CHES National

8 CANADIAN HEALTHCARE FACILITIES

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CHAPTER REPORTS

ONTARIO CHAPTER

NEWFOUNDLAND & LABRADOR CHAPTER

Even though we’re still in the thick of winter, the days are getting longer — a good indication spring isn’t too far off. With it comes warmer weather and a fresh set of exciting challenges and opportunities. Our CSA Z8002 Education Day was held March 2. The all-day training session guided attendees through this nationally recognized baseline for the operation and maintenance of healthcare facilities. Since the standard contains numerous discipline-specific training modules, the Ontario Chapter is assessing the success of the education day to determine if and how future CSA Z8002 sessions should be facilitated. The Ontario Chapter’s annual conference and trade show is coming together nicely. To be held May 29-31, in Kitchener, Ont., it will have an interesting blend of high-tech, leading edge sessions. The companion program includes a Mennonite horse-drawn wagon ride tour to the mini Oktoberfest keg opening at the gala. Conference particulars should be finalized shortly, after which chapter members will receive a notification package. Ontario Chapter secretary John Marshman and I have received positive feedback about the seminar we hosted Dec. 2, 2015, at PM Expo. Our presentation addressed the unique aspects of designing, tendering and undertaking hospital renovation and construction projects in Ontario. Topics covered included: recent new guidelines for procurement in the broader public sector, which includes schools, universities and hospitals, among others; the pace of medical advancement and its impact on hospital infrastructure; and CSA Group’s standards on infection control. It has been almost a year since I became chapter chair and I’d like to thank everyone I’ve crossed paths with during this time. I’ve been conscious of trying to balance the demands on people to contribute to the chapter and the demands of their regular jobs. But to date, I’ve had nothing but full support by all, which has been greatly appreciated. —Roger Holliss, Ontario Chapter chair

The chapter recently called for nominations for the secretary position. Four names were put forward and Randy Cull was chosen by acclamation. I would like to thank all nominees for their continued support of the chapter and congratulate Randy in particular. Planning has been ongoing for the 2016 Newfoundland & Labrador Professional Development Day. It will be held May 15-16, at Capital Hotel in St. John’s, Nfld. — not May 29-30, as indicated in the last chapter report. We are in the final stage of booking speakers for the event. It is shaping up to be a very informative couple of days. Those interested in taking the Canadian Certified Healthcare Facility Manager (CCHFM) exam can do so now at one of 14 testing centres located across the country. College of the North Atlantic was selected as the testing centre for our region. The exam can be written at various campuses throughout the province. Upon successful completion of the program, the chapter will provide a $150 bursary to the paid member. Information on the program can be found on the CHES website. Should you have any questions, please feel free to e-mail me directly at chesnl@outlook.com. —Brian Kinden, Newfoundland & Labrador Chapter chair

SASK ATCHEWAN CHAPTER Planning is well underway for this year’s conference. It will be held in Saskatoon at TCU Place, Oct. 23-25. Invitations will be sent out soon and registration forms will be posted to the website in due course. The conference theme is “Technological Change in Healthcare.” The focus isn’t just on facilities but also includes the clinical side, and the infrastructure that is required to support such change. Location scouting has begun for the 2019 CHES National Conference. The dates have been set and a venue should be finalized within the next couple months. The chapter hosted the Canadian HealthCare Construction Course (CanHCC) Jan. 26-27, at the newly built Courtyard by Marriott at the Saskatoon airport. More than 20 people attended the course. Participants included contractors, consultants and senior administration from healthcare organizations. Presenting faculty included Mike Hickey, Gordon Burrill and Jeff Smith. Feedback has been positive. —Alan F. Krieger, Saskatchewan Chapter chair 10 CANADIAN HEALTHCARE FACILITIES

MANITOBA CHAPTER Two events in Manitoba will shape the future of healthcare in the province. Late last year, the Manitoba government committed to introducing a cap-and-trade system to reduce greenhouse gas emissions. The program will impact many healthcare facilities, resulting in cost penalties or spurring energy and environmental improvements. In less than two months, the fixed-date provincial election (April 19) will either extend the current government’s 17-year term in office or bring change. By the time the Manitoba 2016 Education Day arrives, one of these matters will be settled. This year’s education day will take place April 28, at the Canad Inns Destination Centre Polo Park in Winnipeg. The theme is “Energy Savings: Building on Past Success.” Session topics include: the Winnipeg Health Region’s energy measurement and benchmarking system; Manitoba Hydro’s measurement tools; energy awareness programs; energy-saving maintenance practices for air-handling systems; lighting improvements; and water savings in healthcare. The University of Manitoba will also report on its long history of energy management practices. Calls for nominations to the chapter board went out in December and January, as we will be electing new officers at the annual meeting (held in conjunction with the education day). The more involved members are in the chapter, the better the chapter can serve its membership. There are proposed revisions to chapter bylaws to reflect current management practices. These have been shared via e-mail for member review. They can also be found at www.ches.org/chapters/manitoba.html. Members will have the opportunity to vote on the proposed revisions at the annual meeting on the education day. —Craig B. Doerksen, Manitoba Chapter chair

CHAPTER REPORTS

BRITISH COLUMBIA CHAPTER

MARITIME CHAPTER

Planning continues for the 2016 CHES National Conference in Vancouver. Sponsorship has exceeded expectations and more than 75 per cent of the trade show booths have been booked. The chapter held its third quarter executive meeting at the Vancouver Convention Centre to review the site and layout. We are excited to host this year’s event in an amazing facility and to have the opportunity to showcase this world-class city. In lieu of our provincial conference, the education committee is reviewing the possibility of each health authority hosting an education day in spring. The chapter will support the events once details are finalized. As well, the B.C. Chapter has agreed to cover the costs for three applicants from each health authority to take the CHES online medical gas piping course. —Steve McEwan, British Columbia Chapter chair

The 2016 CHES Maritime Chapter Spring Conference & Trade Show planning committee is working diligently to produce another successful event. The conference will be held May 15-17, in Moncton, N.B., at the Delta Beausejour. This year’s theme is “Challenges and Opportunities in Healthcare Facilities.” Gordon Burrill, president of Teegor Consulting Inc., has accepted an invitation to provide the keynote address. The trade show will promote the latest advancements in healthcare facilities technology. This year it will be open to front line maintenance staff from across the Maritimes. For more information on the upcoming event, please go to www.ches.org/chapters/maritime.html. Following the conference, the chapter will host the Canadian Healthcare Construction Course (CanHCC) May 18-19. Members are encouraged to speak to their contractors about attending the two-day course and sending staff that require orientation in healthcare facilities. The Maritime Chapter continues to balance its books while offering several financial incentives to its members. The present bank balance is approximately $42,000. The chapter’s associate chair, Kerry Fraser, has been busy reviewing the work of the CHES National corporate/associate member advisory council, which has great potential to improve and promote the associate membership within the organization. We are the only chapter with a corporate/associate member on its executive team. The hope is that this will eventually result in a liaison with the National board. —Robert Barss, Maritime Chapter chair

ALBERTA CHAPTER Spring hasn’t quite made it to Alberta yet but it is trying. The chapter executive is scheduled to meet to make a final decision on the next Clarence White Conference & Trade Show, including the possibility of moving the conference from fall to spring. At this time, we will also discuss hosting some training sessions or seminars this year. As well, the national board has offered the services of a logo designer for the CHES webpage. The chapter executive will review and consider making some changes. —Tom Howard, Alberta Chapter chair

CALL FOR NOMINATIONS FOR AWARDS

CHES Canadian Healthcare Engineering Society

2016

SCISS

Société canadienne d'ingénierie des services de santé

2016

Hans Burgers Award Wayne McLellanFOR Award of Excellence CALL FOR NOMINATIONS AWARDS For Outstanding Contribution to In Healthcare Facilities Management Healthcare Engineering

2016 Wayne 2016 Hans Burgers Award DEADLINE: AprilMcLellan 30, 2016Award of Excellence DEADLINE: April 30, 2016 in Healthcare Facilities Management for Outstanding Contribution to Healthcare Engineering To nominate: To nominate: DEADLINE: April 30, 2016 DEADLINE: April 30, 2016  Please use the nomination form posted on  Please use the nomination form posted on the CHES website and refer to the Terms of the CHESPlease website and to the Terms of To nominate: Please use the nomination form posted on the To nominate: use therefer nomination form posted on the Reference. Reference. CHES website and refer to the Terms of Reference. CHES website and refer to the Terms of Reference. Purpose Purpose  To Purpose:To recognize hospitals long-term care recognizeorhospitals or long-term care facilities that Purpose: Theshall award be presented to a resident of Canada The award beshall presented to a resident of that have demonstrated outstanding a mark of recognition of outstanding have demonstrated outstanding success in completion of a major asCanada a mark as of recognition of outstanding achievement in the field facilities success in completion of a major capital achievement in the field of healthcare capital project, energy efficiency program, environmental of healthcare engineering. project, energy efficiency program, engineering. stewardship program, or teamorbuilding exercise. Award sponsored by environmental stewardship program, Award sponsored by team building exercise. Award sponsored by Award sponsored by

For nomination forms, Terms of Reference, criteria and past winners: www.ches.org / About CHES / Awards For Nomination Forms, Terms of Reference, and past winners Fax: 613-531-0626 Send nominations to: CHES National Office criteria, ches@eventsmgt.com www.ches.org / About CHES / Awards Send nominations to; CHES National Office

SPRING/PRINTEMPS 2016 11

INNOVATION

WHERE SUSTAINABILITY SUPPORTS CARE Inside Nanaimo Regional General Hospital’s new emergency department By Ray Pradinuk

anaimo Regional General Hospital’s new emergency department has transformed the way staff and patients experience urgent care. The 35,000-square-foot facility has been designed for functionality, indoor environmental quality and sustainability. The ambulance and walk-in entries as well as all clinical functions are on the second floor, matching existing grade and the hospital’s main level. The new addition is set apart from the original structure to preserve existing windows and provide daylight to staff work areas along the inside of the L-shaped wing on both floors. COURTING CALM

The hospital’s four values underlie the project’s design principles — timely, respectful, quality care and a place people would want to come to work. The well-being of patients, their families and staff was carefully weighted with the well-functioning of care processes. A spirit of innovation developed around the project, inspired by the early decision to focus each of the five patient care zones around plan-enclosed landscaped courtyards. The goal was to reduce caregiver and patient stress by 12 CANADIAN HEALTHCARE FACILITIES

providing views of nature in all public and clinical areas. Extra ceiling height around the courtyards improves daylighting and the efficacy of the displacement ventilation system. Staged daylighting controls maximize the calming benefit of the natural light in treatment areas. Operable glazed walls in the psychiatric emergency and intensive care patient lounges fold open to courtyard gardens. The three medical zone upper level courtyards extend down to the lower level, increasing daylight to future workspaces. A staff respite courtyard lies between the existing hospital and emergency department addition. The project’s small courtyards are landscaped with indigenous vegetation, transforming the phenomenology of the interior experience from ‘nature available from inside’ to that of ‘nature infusing inside.’ Studies concluded that with overall productivity gains conservatively estimated at between one and three per cent of the costs of staffing only the additional daylit area, the daylighting/nature view benefits would pay for the courtyards within three to nine years.

LEEDING THE WAY

Symbiotic sustainability strategies, p a r t i c u l a rl y t h o s e t h a t s u p p o r t improved indoor environmental quality, were prioritized in achieving the LEED (Leadership in Energy and Environmental Design) gold rating provincially mandated for all healthcare projects in British Columbia, including seven of the 10 energy credits without use of renewables. The daylit building configuration and other systems integration strategies implemented on the project were supported by Stantec’s ongoing research program into low energy healthcare building design. The displacement ventilation and radiant heating and cooling system was used for the first time on an emergency department project, but only after years of research in collaboration with consulting and engineering firm, Mazzetti, and project specific CFD (computational fluid dynamics) modelling of occupant comfort in a 118-square-foot treatment room with 12 air changes per hour. The displacement system is enhanced by 12-foot ceilings around the courtyards and 10-foot ceilings elsewhere. Both air quality and thermal comfort

INNOVATION

Opening wall between psychiatric emergency services day lounge and dedicated courtyard.

s LEFT: Treatment room sliding glass doors with electronic glazing arranged around urgent/emergent pod courtyard and charting stations. RIGHT: Staff respite courtyard on lower level between existing hospital and the new addition.

received high marks on post-occupancy evaluations. Materially, a ‘wood first’ policy introduced mid-project by the provincial government supported the use of beautiful perforated wood acoustic panels for the higher ceilings around the courtyards within each care zone. IMPROVING THE INDOOR CLIMATE

The emergency department’s lower level below-grade perimeter is lined with building service rooms and a thermal labyrinth that provides significant pre-cooling of supply air

in summer and the shoulder seasons, and pre-warming in winter. The labyrinth can be operated in three modes: active, storage and flushing. A wind tower with grills in all directions feeds air to the labyrinth during active mode. In summer flushing mode, cool night air pooled above the building’s high albedo roof is drawn down through one of the courtyards and then backwards through the labyrinth and out of the tower, usually using only stack effect and wind. In the Nanaimo climatic context, the labyrinth delivers the higher supply temperature required for displacement

ventilation, virtually eliminating the need for mechanical cooling. Displacement ventilation necessitated the use of automatic exterior solar shading to avoid excessive solar gains. The exterior solar shades also control glare without the need for cleaning, which indoor blinds require. Natural ventilation is provided for mental health, emergency and intensive care treatment spaces, staff offices, lounges and education spaces. SOOTHING THE SENSES

The courtyards have had by far the greatest impact of any of the project’s innovations on SPRING/PRINTEMPS 2016 13

INNOVATION the quality of space throughout the facility. Their affect on ongoing emergency care delivery was more difficult to discern. With visibility and quick access to patient treatment rooms from team care stations in urgent/emergent care a high priority for users, rectangular pods with approximately 15 treatment rooms were inevitable. The amount of support space available inside the eight-foot wide treatment room access corridors was a geometrical byproduct of the capacity of the number of treatment

rooms in the pods and the desire for visibility of the full front of each treatment room. After placing open team workspaces at each end of the s u p p o r t s p a c e bl o c k , t h e o n l y programmed spaces that could fill the rest were the high-walled support spaces usually found in the core of emergency department pods that visually and acoustically separate the team, and cramp and clutter what can often be a very busy care environment.

Infection Control Sink Designed specifically to minimize splashing and reduce the spread of infectious disease.

DAYLIGHTING THE ED

It is unusual for a healthcare facility program not to encourage the design team to “provide daylight wherever possible.” The hospital’s emergency department challenges the notion that there are areas within hospitals where daylight and nature views are not possible — not even where safety and efficiency matter most, as in the heart of a busy emergency department. The urgent/emergent care pods of the emergency department could be adapted for use in other group treatment areas of the hospital, including the intensive care unit, post-anesthetic recovery in the interventional suite, as well as dialysis and infusion areas. The central courtyard provides connection to the day for patients and clinicians, and patient visibility from the care station.

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Admittedly, the project did benefit from having its budget established at the peak of a provincewide building boom and its tender released in the trough of a worldwide recession. The Nanaimo Regional General Hospital’s emergency department is an intrinsically habitable building that will deliver benefits to patients and caregivers over its lifetime, and is an example of the kind of facility that should consistently be built for healthcare delivery, with budgets set and adjusted appropriately to support procurement by whatever means.

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The extraordinary daylighting, the spaciousness generated by the additional ceiling height around the courtyards and the ceiling’s wood finish lend serenity to a care area usually associated with high stress and controlled chaos. The use of plan-enclosed courtyards was inspired by the growing body of research linking daylight to building occupant well-being and hospital patient outcomes; years benchmarking day-lit European hospitals; extensive analysis over a number of projects of the virtual non-impact of daylight planning on travel distance; the user’s desire for a day-lit environment; and fortuitously, a visit to the Herzog & de Meuron-designed Rehab Basel in Switzerland, with its five smallest courtyards placed within care areas rather than between them.

Vancouver architect Ray Pradinuk leads healthcare research and innovation for Stantec. He uses evidencebased design research and innovation in striving for the best architectural solutions for healthcare facilities. Ray can be reached at ray.pradinuk@stantec.com.

INNOVATION

EXTENDING THE HOSPITAL WALLS

New approach to critical care knocks down distance barriers for patients in northeastern Ontario By Renée Fillier

overing nearly 266,000 square kilometres, there is no denying that northeastern Ontario is vast. Couple the region’s geography with its beautiful yet hilly terrain, hot summers and long cold winters, and it is inevitable that medical transport is ripe with challenges; significant transportation delays of unstable, critically ill patients is one of them. This along with variations in available multidisciplinary healthcare resources across northeastern Ontario led to the creation of a Virtual Critical Care (VCC) unit. Based at Health Sciences North (HSN), the VCC unit began as a pilot project in 2009, between HSN’s tertiary care centre and three small rural hospitals. The program, which received start-up funding through the North East Local Health Integration Network (North East LHIN) and uses a special software program created by the Ontario Telemedicine Network (OTN), has since expanded to include a total of 22 healthcare facilities, garnering recognition from the

16 CANADIAN HEALTHCARE FACILITIES

province’s Ministry of Health and LongTerm Care. Last year, the VCC unit team was presented with the Minister’s Medal Honouring Excellence in Health Quality and Safety for putting patients in the centre of the circle of care. DISTANCE MED PROGRAM

The VCC unit is the first critical care model of its kind in Canada; however, it’s no longer the only one. Since its launch in May 2014, the North West LHIN has instituted a similar program based on the pioneering initiative. The HSN program uses state-of-the-art video conferencing technology and electronic medical records sharing to connect the VCC unit team with smaller critical care units and emergency departments at participating hospitals across northeastern Ontario. The team is led by an intensivist who works with a group of specially trained nurses and respiratory therapists to provide a 24-7 emergency consultation service for critically ill patients. Video conference consultations

bring the HSN team to the bedside of patients and their primary care providers, allowing for improved assessments and treatment recommendations. Both teams collaborate to establish a plan of care — the patient is admitted to the VCC unit and therefore remains in their home hospital, or is transferred to a higher level of care facility. If a patient is admitted to the VCC unit, multidisciplinary follow-up rounds are conducted daily with the primary care team, patient and/or their family. The VCC unit team is also available around-the-clock to answer questions or address concerns about the patient, and can facilitate access to other allied health team members, such as a respiratory therapist, pharmacist and dietitian. VIRTUAL BEDSIDE BUY-IN

HSN undertook a campaign of engagement with partner hospitals to communicate the VCC unit mission, the need for a VCC program in the North

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Ontario region. Labour Canada has fully “acknowledged” scopefully of Labour Canadathehas work provided inthethescope semi“acknowledged” of annual inspection program. work provided in the semiIn addition, the program. written annual inspection documentation contributes In addition, the written greatly to thecontributes hospital documentation accreditation greatly to programs. the hospital accreditation programs. Further we are always pooling the knowledge resources Further we are always poolingof Infection Control and Engineering the knowledge resources of Groups like CHES, the ventilation Infection Control and Engineering inspection is in a constant Groups likeprogram CHES, the ventilation evolution meet future needs for inspectiontoprogram is healthcare in a constant patients evolutionand to staff. meet future healthcare needs for patients and staff.

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CONSULTATIONS PROVIDED THROUGH THE VCC PROGRAM HAVE PREVENTED 97 PATIENT TRANSFERS BY AIR AMBULANCE. East LHIN, and how it benefits patients and the healthcare facilities that take part. Not only does the program enhance the diagnosis and treatment of patients, with a goal of improving patient outcomes, but it also provides timely second opinions, potentially expediting the transfer of patients from their local hospital to a larger healthcare facility or avoiding unnecessary transfers altogether. Caring for patients within their community maintains contact with family and local support networks, leading to improved patient satisfaction. Involving all potential stakeholders early on was key to successful buy-in. An introductory video conference was held for medical directors, administrators, privacy officers, infor mation technologists, diagnostic imaging consultants, and emergency department and intensive care unit/medical step

down unit managers, with telemedicine coordinators in attendance. This meeting created an open forum where questions and/or concerns could be addressed. It also presented an opportunity for partner hospitals to identify any potential barriers early on in the process. To help prepare the remote sites for implementation, the VCC program coordinator met with management teams every two weeks for a three-month period. Training sessions were provided and a one-stop shop VCC program resource guide was developed to support the remote site managers. Once installed, video conferencing equipment was made available to both day and night shift workers for educational training. A ‘super-user’ training session was recorded for manager use to train new hires and sustain education with refresher sessions. Periodic practice calls

are ongoing with low call volume sites to ensure staff remain comfortable using the equipment and activating a VCC unit consultation. To ensure transference of information, communication pathways were established at both the senior level and front line. The VCC program newsletter also creates a forum where processes and outcome metrics may be shared. To date, the VCC unit has been used to treat 310 patients. It has recorded 455 follow-up visits, for a total of 24,875 video conferencing minutes. Consultations provided through the VCC program have prevented 97 patient transfers by air ambulance, resulting in an estimated savings of $1.65 million to the healthcare system and 420 hours of real-time education. Renée Fillier is a registered nurse with more than 23 years of experience in the intensive care unit. She is currently the nurse clinician for the virtual critical care unit and the critical care response team at Health Sciences North in Sudbury, Ont. Renée can be reached at 1-705-523-7100 ext. 1579 or rfillier@hsnsudbury.ca.

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This promises to be an exciting and jam-packed program. Please check the website www.ches.org in the coming This promises to education be an exciting and jam-packed program. the website www.ches.org in the coming weeks as the full program will be posted and thePlease onlinecheck registration will open soon! weeks as the full education program will be posted and the online registration will open soon! Some of the EXCITING topics: Some of the EXCITING topics: · Designing green & sustainable buildings · IAHSS Guidelines Designing green & sustainable buildings IAHSS Guidelines · LEAN Methodology · Healthcare Emergencies – Best practice solutions LEAN Methodology Healthcare – Best practice solutions · High Rise Hospital Design · Hybrid LEANEmergencies Process High Rise Hospital Design& Energy renewal Hybrid Process · Infrastructure upgrades · Owner LEAN project Requirements (Commissioning) · Infrastructure upgrades & Energy renewal · Owner project Requirements Decision risks – A Scientific Model Air Quality & Reliability is vital(Commissioning) · Decision risks – A Scientific Model · Air Quality & Reliability is vital And Much More! And Much More! The 2016 Program will kick off with Keynote Speaker Tony Dagnone. He has more than 38 years’ The 2016 Program will kick off sector, with Keynote Speaker Tonyas Dagnone. He has more than 38 years’ experience in the Health Care 25 of which have been Chief Executive Officer of academic experienceHis in the Health Care sector, 25 of the which have been as Chief Officer of of over academic hospitals. career achievements include visioning, planning andExecutive redevelopment $500 hospitals. His career achievements million of new healthcare facilities. include the visioning, planning and redevelopment of over $500 million of new healthcare facilities.

Other Conference Highlights Include: • • • •

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TECHNOLOGY

ROBOTS IN DISGUISE Hospital automated guided carts increase efficiency, reduce operating costs By Garry A. Koff

anual cart transportation is not only wasteful and inefficient but also completely avoidable today thanks to mobile robots. These batterypowered machines, commonly referred to as automatic guided vehicles (AGVs), are capable of performing a wide variety of tasks within healthcare facilities. AGVs drive under carts, automatically taking them to specified destinations. They safely traverse hospital corridors and interface with elevators to move patient meals, linens, medical supplies, trash and other materials as needed. AGVs have an operational speed of approximately 200 feet per minute, w h i ch i s t h e s p e e d o f w a l k i n g pedestrians. They can slowdown automatically in areas as desired, and are equipped with audible devices and flashing lights. Most units are outfitted with a laser bumper sensor to detect objects in their path. Typically, the sensor can be programmed for range and width of coverage. Anything detected in the path of the AGV will 20 CANADIAN HEALTHCARE FACILITIES

slow and stop the unit. The AGV will only resume its travel when the object is clear of the detection range. AGVs communicate with a central system controller, which provides their ‘missions’ — for example, where to pick up and deliver a cart — and keeps track of their locations so logistics management know where the units are and what they are doing at all times. The units can be readily removed or rerouted since no physical ‘tracks’ are required for pathways. AGVs have a virtual set of coordinates stored in their computer memories, allowing routes and station locations to be changed by simply modifying the CAD (computer-aided design) path drawing. This ‘virtual’ path navigation means they can be easily installed in both new and existing facilities. PLIGHT OF THE NAVIGATOR

Several types of navigation technologies are used to guide AGVs in a facility. Some of the most popular forms of

AGV guidance are proximity sensor, laser and inertial navigation. Proximity sensor navigation uses multiple sensors (sonic, infrared and laser, for example) to determine the vehicle’s position relative to walls and other physical objects in order to guide it through an area. Laser target navigation makes use of fixed reflective targets mounted on walls and columns in the AGV operating area. Equipped with a rotating laser transmitter/ receiver, the AGV emits a laser beam that is reflected back by multiple targets along its path. The unit then calculates the beam’s angle and distance in relation to the targets to triangulate its position and guide it on its way. Inertial navigation utilizes an electronic chip, called an inertial sensor, in the AGV. The sensor detects the slightest change in the left-right movement of the vehicle as it travels. With the aid of small reference markers, this information is used to correct the vehicle’s position and keep it on the right path. Both laser and inertial navigation systems are accurate within plus or minus one inch.

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TECHNOLOGY

CALL OF DUTY

AGV systems typically employ some type of ‘call and remote dispatch’ operation. Staff can call for an AGV by pressing a button or using a touchscreen, for example, when a cart is ready to be picked up. The central controller stores these calls and then assigns an available AGV to perform the pickup and associated delivery mission. Systems with this capability do not require an operator to be present when the AGV arrives, allowing staff to place a cart for pickup and then resume their regular responsibilities. Idle AGVs will go to automatic battery charging stations periodically, eliminating the need to change batteries. The vehicles even ‘go to sleep’ during off shifts or low volume periods to conserve the charge level in their batteries. There are various ways to alert maintenance when there is a problem or notify staff when a cart is delivered to their area. The central controller can send text messages to designated personnel, for example. Graphic displays of the system path, vehicle locations and system status are also available on monitors networked with the system. HANDLE WITH CARE

AGVs require periodic maintenance. This typically involves a simple inspection, cleaning, and mechanical and electronic adjustments. Preventive maintenance is generally performed quarterly and requires one to two hours per vehicle. The skill level required to maintain an AGV is similar to that of an electrician/mechanical facility engineer. AGV uptime is quite high. With proper maintenance vehicles sustain 97 to 99 per cent uptime. Fleet sizing for larger systems includes spare AGVs to allow for planned maintenance and unplanned vehicle downtime. System-wide failure is extremely 22 CANADIAN HEALTHCARE FACILITIES

s Automatic guided vehicles drive under carts, automatically taking them to specified destinations. They safely traverse hospital corridors to move trash and other materials as needed.

rare because the central controller normally includes a backup controller. INVESTING IN THE FUTURE

While AGVs have been widely used in the industrial sector for more than 40 years (where company survival is tightly coupled with operating costs), they have been mostly overlooked in the healthcare industry; that is, until now. Tightening budgets and rising healthcare costs have prompted hospitals to look at new ways to reduce non-value added labour. AGVs not only increase productivity, improve cart delivery response times, eliminate lost/delayed cart deliveries and help cut operating costs, but newer technologies have greatly lowered the investment cost of these systems, making them a viable option for nearly all facilities. Today, the payback period for vehicle automation can often be less than two years. Hospitals that employ AGV cart transportation systems have seen a positive return on investment of 1.25 to 1.5 full-time equivalents (FTEs) per AGV per shift. Even a system with just a few AGVs can reduce labour by three to five people per shift.

The price of an AGV system can vary widely, depending on its size and vendor. A small system with three vehicles will cost between $300,000 and $400,000 US, while a larger system with approximately 15 vehicles will range from $1.5 million to $2.5 million US. The cost includes the AGVs, system controls, system engineering services, and system installation and startup. If the initial cost of a small system of three AGVs is approximately $350,000 US, for example, it provides a FTE reduction of three per shift, two shifts per day and a FTE cost of $45,000 per year. A hospital could see a reduction in its operating budget of $270,000 per year. This would result in an investment payback of less than 18 months. More importantly, the savings per year continues every year the system is in operation. Garry A. Koff is president of Savant Automation Inc. He has more than 35 years’ experience in the automatic guided vehicle system business. Garry can be reached at 616-485-6300 or garry.koff@savantautomation.com.

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Infection Prevention & Control: Underscoring its Importance for Healthcare Engineers Speaker: Kim Allain, BScN RN MHS CIC, Nova Scotia Health & Wellness Speaker: Suzanne Rhodenizer Rose RN BScN MHS CIC, Nova Scotia Health & Wellness Wednesday October 26, 2016

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TECHNOLOGY

A WINNABLE BATTLE Canadian invention wages war on superbugs like never before By Dick Zoutman

eople expect hospitals to be places where they can go to receive treatment and recover from an illness. Certainly a hospital is the last place anyone would expect to pick up a serious infection that could delay recovery, or worse, cause serious complications and even death. Unfortunately, moder n healthcare facilities are associated with just such outcomes as a result of hospitalacquired infections (HAIs). While there is no national surveillance system that comprehensively measures the frequency of HAIs, best estimates indicate that up to 10 per cent of persons that go to hospital acquire an infection. According to Canada’s Public Health Agency, more than 200,000 patients get infections every year while receiving healthcare. Of these cases, more than 8,000 die as a result. Research has shown that the hospital environment plays an important role in the transmission of HAIs. Telephones, washrooms, bedrails, bedside tables, c o m m o d e c h a i r s, I V p o l e s a n d wheelchairs, among other surfaces and medical equipment, are a reservoir of bacteria capable of infecting patients, visitors and staff. 26 CANADIAN HEALTHCARE FACILITIES

Hospitals can spend up to five per cent of their operating budget trying to clean away nasty pathogens. Those costs increase substantially d u r i n g an infection outbreak. The challenges associated with using current hospital cleaning methods are the costliness of the products, the amount of time and effort it takes to apply them properly, and the required contact time to achieve an appropriate level o f disinfection in a healthcare setting where time pressures are significant. A recently published Canada-wide study has revealed that when short staffed and pressed for time, environmental services teams struggle to achieve the level of cleanliness that is necessary to keep a hospital safe. TECHNOLOGY AT WORK

In recent years, a number of automated technologies have been developed to complement traditional cleaning methods. Among the latest advancements are no-touch room disinfection systems, which use moderate (five to six per cent) to high (35 per cent) concentrations of hydrogen peroxide. The systems release the hydrogen peroxide into the air as a vapour or dry mist. High concentrations of hydrogen peroxide vapour does produce a high-level of disinfection but clinical studies indicate it can take as long as between two-anda-half and five hours of treatment to achieve. In addition, the Environmental

Protection Agency (EPA) recommends surfaces treated with 35 per cent hydrogen peroxide be thoroughly rinsed following disinfection. The duration to process a single patient room may not be nearly fast enough given the demands for rapid turnover to meet patient flow requirements in a busy hospital. Then there are ultraviolet (UV) light systems, which use mercury-vapour or pulse xenon lamps, with the theoretical potential to disinfect patient rooms possibly more quickly. However, published evaluation using careful microbiological methods to assess the effectiveness of the UV lights in a hospital setting have demonstrated a disappointingly low level of bacteria and spore kill. SQUEAKY CLEAN

The ideal automated room disinfection system would be fast enough to work within the workflow requirements of a busy hospital, and be able to achieve a high-level of bacterial and spore kill using a methodology that is both reliable and safe. Tw o r e s e a r c h e r s a t Q u e e n’s Univer sity’s Innovation Park in Kingston, Ont., created such a system. The Canadian invention, known as AsepticSure, uses a combination of ozone gas and hydrogen peroxide vapour to produce trioxidane gas, which is lethal to bacteria, spores and viruses, among other pathogens. Extensive testing has demonstrated that AsepticSure has a very high efficacy and effectiveness rate. It can kill 99.9999 per cent (or 6 log) of bacteria, bacterial spores and viral pathogens. The system was deployed during Methicillin-resistant

TECHNOLOGY Staphylococcus aureus (MRSA) and C. difficile outbreaks at Quinte Health Care in 2013 and 2014, respectively. Each outbreak was rapidly terminated within a day with no subsequent cases — a response not previously seen when manual cleaning procedures were used. BRINGING HOME THE BENEFITS

AsepticSure stands to benefit patients, healthcare workers and the organizations that employ the disinfection and decontamination technology. The use of low levels of ozone (80 parts per million) derived from the room air and hydrogen peroxide (one to two per cent) makes AsepticSure economical to operate. It also means the system does not cause damage to the healthcare environment or medical devices/ instruments in the treated rooms. The system itself is both portable and easily operable. It can be brought into patient care areas in any healthcare setting and deployed to achieve a high-level of disinfectionClass1_CHF_Spring_2016_FINAL.pdf of the room and all its contents. 1 This includes mobile patient care equipment

(such as wheelchairs and IV poles) that is notoriously hard to clean by hand, and privacy curtains, which can be left in place as long as they are not grossly soiled. Run wirelessly, AsepticSure signals a base computer when it is turned on, which then records all of the data throughout the cycle process. This provides a level of quality assurance and risk management support that has never before been available in the environmental services industry. Until now, hospitals have had to rely upon visual checks of room cleanliness. Furthermore, if a healthcare facility so desires, paper strips inoculated with spores of Bacillus stearothermophilus (indicators routinely used to monitor the effectiveness of steam sterilization) can be placed in the room to provide unequivocal evidence that high-level disinfection has been achieved. AsepticSure is much faster and more efficient than manual cleaning. Terminal cleaning four rooms contaminated with C. difficile for 90 minutes per room requires six hours of continuous labour. Two AsepticSure machines operated by one environmental 2016-02-11 3:31 PM services worker can complete the task in 40

per cent less time (three hours and 40 minutes), using only 25 per cent of the labour effort of manual cleaning. The labour effort is greatly reduced because once the room has been pre-cleaned (with a neutral cleaner to remove any dirt) and the machine has been placed in the room, the environmental services worker is free to prepare other areas for disinfection or perform other tasks. Once disinfection is complete, carbon filters remove all the ozone and hydrogen peroxide gas in the room. It may then be immediately returned to service, as it is a completely safe environment in which to provide care. In fact, at that moment, it will be the safest room in the hospital, absolutely free of pathogens on both soft and hard surfaces. Dick Zoutman, MD, is chief of staff at Quinte Health Care in Belleville, Ont. He is professor emeritus at Queen’s University, an infectious disease specialist and, along with his colleague Dr. Michael Shannon, co-inventor of Medizone International’s disinfection technology, AsepticSure.

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REGULATORY UPDATE

RAISING THE BAR

Revised CSA standards provide updated guidance to healthcare facilities

tandards provide people and organizations with better, safer and more sustainable work environments. But they must remain current and be technically valid to be truly useful. Canada’s largest standards development organization, the CSA Group, systematically reviews its standards at least every five years. The choices at that point are to reaffirm, replace or withdraw the standard. Here, CSA’s Jeffrey Kraegel discusses the new editions of two standards — one that was recently published and the other that is to be released later this year. What are the core principles of Z317.1?

Z317.1, Special Requirements for Plumbing Installations in Health Care Facilities, sets out essential requirements for plumbing systems in hospitals, clinics and long-term care facilities. These are in addition to what is already provided in plumbing codes and regulations. The need for additional precautions is driven by the higher risk of 28 CANADIAN HEALTHCARE FACILITIES

infection, vulnerability of patients (especially those who are infirm or immunocompromised) and the potential health impacts of the wastes generated by these technology-intensive facilities. The standard addresses the design, construction, operation and maintenance of plumbing systems. Specifically, it focuses on: water supply systems, including domestic cold and hot water systems; plumbing fixtures and fittings; drainage systems; monitoring and maintenance of water systems; infection control; catastrophic event planning; specialized water systems, such as reverse osmosis, deionized and distilled systems; and hydraulic fire protection systems. Why is the standard being revised?

A new edition of the standard is needed to address advances in technology and increased concerns about legionella and other infectious organisms in water systems. There is also a need to align the standard with Z8000, Canadian Health Care

Facilities: Planning, Design and Construction, which was released in 2011. When will the new edition be published?

Work on the new edition is ongoing; however, it is due to be released this fall. Public review of the draft closed Feb. 16. The CSA subcommittee on plumbing in healthcare facilities is cur rently considering the comments. It will make any necessary changes to the draft before it is finalized for formal approval by the parent technical committee. What do the revisions entail?

There will be upgraded requirements and recommendations aimed at preventing the spread of legionella and other infectious organisms through the plumbing system. To do this, the standard will use an integrated approach, covering system design, initial system treatment and ongoing maintenance measures. Z317.1 will also have updated requirements on plumbing fixtures and

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REGULATORY UPDATE fittings, including hand hygiene sinks. The design and location requirements for hand hygiene sinks were first developed in Z8000. The new edition of the standard will adopt the design requirements for these sinks and any future changes will be included. There will also be a new clause on catastrophic event management. Requirements for catastrophic event preparation are being expanded in most of the new CSA editions for healthcare facilities, in response to an increasing incidence of these events, such as natural disasters and infectious disease outbreaks. What are the core principles of Z317.2?

Z317.2, Special Requirements for Heating, Ventilation and Air Conditioning Systems in Health Care Facilities, defines the essential requirements for HVAC systems, supplementing what is already specified in building codes and regulations. Temperature, humidity, air exchange and backup requirements are important in any building but they can have life or death significance when it comes to healthcare facilities and vulnerable patient populations.

The standard addresses the planning, design, construction, commissioning, operation and maintenance of HVAC systems. A key objective is to reduce the risk of transmission of infection among building occupants, including patients, staff and visitors. Why was the standard revised?

A fourth edition of the standard was needed to address advances in technology, increased concerns about airborne infection and catastrophic event planning. There was also a need to align Z317.2 with new CSA standards that had come out since the last edition was published in 2010, including Z8000, Z8001, Commissioning of Health Care Facilities, and Z8002, Operation and Maintenance of Health Care Facilities. The new edition of Z317.2 was formally approved by the technical committee in 2015, and published in January 2016. What’s new in the fourth edition of the standard?

The most significant addition is the introduction of a new subclass in the definition of “healthcare facility.” In earlier

editions, there was one classification — Class C — for doctors’ offices, clinics and any other types of outpatient facilities. With the increased incidence of higher risk medical and surgical procedures taking place out-of-hospital, there was an urgent need to delineate between office settings and higher risk clinics. Class C was divided into C-1 and C-2, with C-1 being a place where patients might not be capable of selfpreservation in an emergency. Additional changes to the standard include: replacement of prescriptive design specifications with performance requirements, particularly with respect to system redundancy; updated values for temperature, humidity and relative pressurization; new provisions for reduced operation of HVAC systems during unoccupied periods; revisions to requirements for system upgrades when renovations or additions are being done; revised requirements for system design capacities to respond to catastrophic events; updated requirements for energy ef ficiency; and revised acoustic requirements for HVAC equipment and systems.

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