David C. Richardson 2015-06-09 11:07:16
Hospitals may prioritize medical equipment, but can’t ignore their unique HVAC needs Hospitals use a lot of energy, “typically, twice as much as the equivalent size office building,” says Travis English, engineering manager for Kaiser Permanente’s nationwide network of health care facilities. While he says energy consumption for the typical office building might run about 90K BTU per square-foot annually, the average hospital in contrast, consumes 250K BTU per square foot yearly. Hospitals, overall, are the second-most energy-intensive commercial buildings in the US (topped only by supermarkets), and the health care industry is responsible for 8% of the country’s greenhouse gas emissions, according to Kathy Gerwig, Vice President of Employee Safety, Health, and Wellness at Kaiser Permanente. With around 600 medical facilities under Kaiser Permanente’s purview, it’s not difficult to see why English says from his perspective, “Every project is an energy project.” Stephanie Buckler, Esquire, an Outreach Specialist for Healthier Hospitals Initiative, says working toward energy efficiency is a chance for hospitals across the nation to save significantly and improve their bottom line. She wrote in a blog post, “Energy Star estimates that nationally, every $1 savings in annual energy costs is equivalent to an increase of $20 in annual revenue (based on a 5% net operating margin). When a hospital has a net margin of 1.5%, every $1 energy savings is worth $67 in increased revenue.” Most of us would not be surprised to see a hospital’s investments in helping people resolve health issues take precedence over energy management; hospitals are in business to save lives, not to haggle over BTU expenditures. Rightfully, they are not bashful about their caregiving mission goals, however some hospitals are taking a closer look at where energy efficiency can help fulfill obligations towards patients, while at the same time helping to bolster the bottom line. “Patient health and safety is the driving force behind everything hospitals do,” says Melissa Baker, Vice President of Technical Solutions with Practice Greenhealth—a nonprofit membership organization founded on the principles of positive environmental stewardship and best practices by organizations in the health care community. Nonetheless, she says, hospitals are also gradually moving towards adopting sustainable and less energy-intensive practices, with a number of them going after Leadership in Energy and Environmental Design (LEED) certification now that standards for LEED for Health Care were published in 2011. Baker, however, says that one of the main reasons hospitals may hesitate to take steps towards energy efficiency is the assumption that specifying investments in energy-efficient initiatives and products will be cost prohibitive. According to Practice Greenhealth’s online guide, Best Practices in Energy Efficiency, “Heating and cooling systems account for a significant portion of a building’s energy use—typically about a quarter,” and represent one place where hospitals are finding almost instantaneous gains in efficiency from new investments large and small. English, of Kaiser, amplifies the point. Although he concedes that hospitals use as much or more plug in equipment than a typical office building he says, “We have gigantic HVAC and most research shows that most of our energy use goes towards heating and cooling.” But there’s a lot more to meeting patient comfort and safety needs than temperature control. “There is a big emphasis on indoor air quality and a lot of science now developing on occupant comfort,” he adds. According to Tim Rice, Director of Sales for Desiccant Wheel Products at SEMCO, it’s not temperature that makes the biggest difference in patient care but air quality, and air-quality improvements can also lead to measurable results in energy efficiency. Adding Up Cool Points Tom Malloy, CEO of the Phoenix Design Group in Nashville, TN, that designed a new surgical suite for Floyd Medical Center, says consultants face a dilemma when trying to encourage health care facilities to integrate energy-efficient measures in their capital planning and design strategies. Although his firm performs 90% of its work for clients from the health care arena, he says rarely do projects come to the table with the primary goal of achieving energy efficiency. Hospitals are not simply looking for energy-efficient heating and cooling, but instead are seeking better patient results, and energy-efficient technology enters the picture when they realize it’s not just the heat, it’s the humidity. Rice explains that along with temperature control, indoor air quality is fast becoming a focal point for all kinds of building design projects and this is especially true for hospitals and health care environments. He says a key component providing indoor comfort is control of humidity, and, in hospitals, controlling humidity is of critical importance for health. According to Rice, with the evolving dynamic in the sphere of health care financing and insurance, “the number one thing hospitals began to look at was mortality rates, insurance costs, and the overall health of their buildings.” He says that research shows that mortality rates are lower in buildings with effective air quality control. But more specifically, Rice says the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (AHSRAE) 170 code Ventilation of Health Care Facilities specifies a temperature of 62°F, and relative humidity between 20% and 60% for such facilities. Rice says however, insurers of those facilities are generally more conservative than the code specifies, preferring their clients maintain less than 50% relative humidity under the premise that high humidity ranges promote the growth of microorganisms, some of which may be harmful to health. Within an economic climate that poses limitations on financing available across all business sectors, the health care industry is no exception. Malloy says there is always competition for funds. “Every hospital is competing for capital,” he says. “The question is: Where is the best use of capital? The place where we find difficulty is that hospitals are not so energized by the idea of the newest high-efficiency chiller as they are by the newest imaging systems.” In a head-to-head competition, the imaging systems frequently prevail. Nonetheless, Malloy says the economics of energy-efficient infrastructure are impressive when placed in the proper context. “We show them not just the upfront cost, but [also] the life cycle costs of the piece,” he says. From a business perspective, he says that energy-efficient enhancements can readily generate “a 25% rate of return over a life cycle.” In contrast, he adds, it is very rare that a hospital can show “anywhere near that kind of return for other types of capital investments.” The unyielding demands for accurate dew point, humidity, and temperature control in surgical suites creates a challenge for any engineer aspiring to deliver efficiency and optimum space conditions, but the Phoenix Design Group Inc. has become adept at meeting this challenge. An air-quality control enhancement designed by Phoenix Design Group increases the energy efficiency of Floyd Medical Center’s new Surgery Suite HVAC system, while making a vital contribution to patient comfort and safety. In hospitals, surgical suites demand strict control of temperature and dewpoint to maintain comfort and control perspiration, especially for surgical teams clad in the requisite infection control garments, Rice says. In addition, pinpoint control of air temperature and humidity parameters gives surgeons an additional tool to specify the precise environment required to optimize the outcomes for whatever type of surgical procedure the patient may need. According to John Wade, Senior Mechanical Engineer for the Phoenix Design Group, the low temperature and relative humidity needed in the surgical suite environment makes it difficult to rely on conventional refrigeration alone. The Phoenix Design Group consulted with surgical staff before setting the design parameters for the new suite. Based on the feedback they received, they set out to design a system that could maintain 62°F at a relative humidity of 45%. His firm opted for SEMCO’s Pinnacle primary ventilation system with integral energy recovery when designing the surgery center’s mechanical system. Rice says that in a critical environment like a health care facility, it is preferable to control humidity throughout the entire building and not just the individual targeted suites. “Without vapor barriers, moisture can move readily from areas with high temperature to areas with a lower temperature, making it difficult to maintain consistent adherence to specified air-quality standards throughout the facility,” says Rice. The optimal situation from a humidity control design standpoint, he says, “is when you can design the entire building to a common dew point of 50% relative humidity.” Rice says SEMCO Pinnacle allows designers to do this while increasing the efficiency of the HVAC system by removing the necessity to heat or cool unwanted water vapor in the air, reducing the demand and energy load on the HVAC system to reach the desired temperature set point. In addition, removing excessive moisture from the indoor air improves air quality and enhances health outcomes by discouraging microorganisms that require a moist environment in order to propagate. But Wade says the challenge remains of communicating the monetary benefits of energy efficient practices early in the design process. “With any project, it’s all about the first costs.” Often, he says, “By the time the engineers are brought on board, the customers have already overestimated the scope of the project and underestimated the budget.” Wade believes this mode of decision-making complicates the making of the tradeoffs that might be needed to pair energy efficiency along with the essential core goals of the health care institutions: patient safety and health. There is a solution, however. Wade says that if health care institutions “are really serious about getting the highest efficiency possible for the facility, those discussions need to happen before the budget is decided.” Comfort at a Discount Fred Rogers directed his Rush system design team in 2009 to plan for the John C. Stennis Memorial Hospital, focusing on two important elements. For this—his fourth critical access hospital—he emphasized patient comfort and energy savings, both of which centered on the facility’s HVAC system. Rogers is Rush Health Systems’ veteran vice president, chief resource officer, and facility manager. He says for three years at Rush’s hospital in downtown Meridian, energy costs had steadily risen at an adjusted $25,000 each year. When the institution added a Women’s Services facility on the third floor in two wings in 2008, he installed his first Mitsubishi Electric Cooling & Heating (Mitsubishi Electric) Variable Refrigerant Flow (VRF) system for the new construction. “With its unique, ductless, two-pipe, simultaneous cooling and heating capability taking the load off my chillers, I was able to realize a savings of $36,000 a year. That was very gratifying. With this outstanding track record, I ordered my team to install the very same system at Stennis.” Rather than expending vast sums of energy cooling and heating ventilation ductwork and pushing air back and forth all over the building, Mitsubishi’s two pipe VRF technology circulates chilled refrigerant directly to air handlers situated on the ceiling of each patient’s room. There, it can be used to either chill or warm the air in the room directly as the patient or caregiver desires. Stan Williamson, a senior project manager with McLain Plumbing & Electrical Services Inc., in Philadelphia, MS, explains the system: “The entire patient wing is a ductless installation. Every patient room has its own cooling system and controls in the form of a ceiling-recessed fan coil and remote controller. These intelligent indoor fan coils are connected to the six outdoor units through a series of electrical wires and piping for the refrigerant, all of which fits neatly into a three-inch space that runs concealed along the ceiling to the outdoor unit.” The Mitsubishi Electric Cooling & Heating VRF system can be equipped with a remote control capability to give the patient or caregiver on demand precision control of the temperature settings for each room. In addition to its efficacy, Williams says a ductless system simplifies installation, while individual controls for temperature and humidity enhance the patient experience. “Here in Mississippi, we have a very annoying wet heat,” says Williamson. “This wet heat clings to the body. For patient care and comfort, the importance of dehumidification cannot be overemphasized in a hospital environment. Mitsubishi Electric’s VRF dry mode is one tool that has helped remove humidity in the patient care rooms.” Opening a Door to Efficiency Even a well-designed air-conditioning and heating system can provide scant gains in efficiency if the entire investment in reconditioned air can simply escape through the front or back door any time a patient, visitor, or facility staff member enters or exits the hospital. While carefully planned and properly executed vestibules provide many hospitals with a first line of defense against paying twice for heating and cooling, Berner International’s Steve Benes says vestibules are unreliable and inefficient when they are needed most. Installing strategically placed air curtains can take the process a step further, retaining hard fought gains in efficiency by preventing intrusion from unwanted outdoor air. When the University of Pittsburgh Medical Center (UPMC) set out to make its $252 million Monroeville, PA, facility the most sustainable of its 30-hospital network, its design team delivered a building that’s saving an estimated $350,000 to $500,000 annually in energy. That design team for the 302,000-square-foot, 155-bed space included Joseph T. Badalich, corporate construction project director, UPMC; and architect Timothy Spence, principal, BBH Design, from Raleigh, NC. “Our HVAC system design exceeds ASHRAE 90.1-2004 requirements, and when combined with reduced electrical and lighting loads, it's saving an estimated 18% in energy, versus the standard minimum construction requirements of a standard HVAC system,” says Matthew J. Stevens, senior project manager, CJL Engineering, the project's mechanical, electrical, and plumbing (MEP) engineering firm. While some engineers rely only on major HVAC equipment to rack up LEED credits, CJL sees every green opportunity as critical to building performance. CJL specified 11 air curtains for energy conservation by protecting all entrances from outdoor air infiltration. Ten of the air curtains are in-ceiling models that appear as flush ceiling grilles and supplement BBH’s aesthetic lobby design. To protect air quality, the air curtains all draw clean air from the lobby through an integral diffuser, as opposed to models that need a supply duct or claim air from potentially contaminated, unconditioned air spaces above the ceiling. Besides energy savings, the air curtains all have electric heaters that are critical for lobby indoor air comfort. The heaters are efficiently controlled with a delay that continues spot heating at a lower air velocity until the doorway area’s set point temperatures are reached. The 11th air curtain is a conventional model mounted above the emergency room (ER) doorway that saves energy, but also prevents infiltration of any idling ER vehicle fumes, which is a common hospital industry indoor air-quality (IAQ) problem. According to a study funded by Berner International and performed by the independent validation firm Blue Ridge Numerics in Charlottesville, VA, air curtains use less supplemental heat than vestibule heaters, enhance employee comfort, reduce liability by maintaining drier entryway floors during inclement weather, keep traffic flow unhindered, and improve sanitation by reducing insect entry. According to Benes, air curtains provide energy savings year round, whether during the cooling or heating seasons, and customers can see a 1-year to 1-½-year payback on the initial investment. The UPMC design team’s green design is LEED Silver certified. It includes a combination chilled water loop and rooftop/variable air volume design. Three high-efficiency, 750-ton water-cooled chillers by Trane; three 9,900-Mbh boilers by Bryan Steam LLC; and one 6,000-Mbh domestic hot water boiler by Leslie Controls helped in capturing the LEED designation. The boilers operate ultra efficiently due to variable frequency drives. CJL also specified three 750-ton cooling towers by Baltimore Aircoil Co., five custom rooftop units ranging from 68,000 to 80,000-cfm each by TMI Climate Solutions, and pumps by Bell & Gossett. BBH’s unitized building envelope features low U-factor glass from PPG Industries, Pittsburgh. Reducing the heat load enabled CJL to use smaller mechanical equipment, but attain the same indoor air comfort efficacy. The UPMC project was awarded “Project of the Year” honors in the Commercial Category for 2013 from the Engineers’ Society of Western Pennsylvania, PA. “This is certainly one of the most, if not the most, sustainable hospital designs in the Mideast region,” says Badalich, who oversaw the project’s construction for UPMC. Air Quality in the Limelight Ultraviolet (UV) light comes in three varieties. UV-A is widely known as the black light that makes the once popular, but nonetheless tacky, velvet posters appear to glow in the dark. Then there is UV-B, which reaches the earth from the sun and contributes to the sunburn that affects avid worshippers; and finally there is UV-C, an invisible part of the electromagnetic spectrum, also generated by the sun. UV-C propagates at just the right electromagnetic frequency to disrupt DNA within the cells of living organisms. Fortunately, our planet’s dense and complex atmosphere topped with a protective ozone layer filters UV-C from sunlight completely before it can reach the Earth’s surface cause any damage to people. However, a company called Triatomic Environmental Incorporated has developed a product called Fresh-Aire UV that uses artificially generated UV-C to enhance indoor air quality and improve the operational efficiency of ventilation systems. Mike Walrath of Triatomic Environmental Inc., says the cooling surfaces of air-conditioning coils are especially susceptible to the accumulation of layers of biofilms, arising from colonies of organisms such as mold and bacteria that tend to cling for refuge to the cool dark recesses of air-conditioning grills and ductwork. These aggregations of biofilms can have a negative impact on both indoor air quality and energy efficiency, while adding to increased operating costs for maintenance and cleaning air-conditioning coils in a facility. Walrath explains that mold and slime of even a minimal thickness “can act as a sweater” insulating cooling coils, forcing the chilled water to struggle to maintain the proscribed room temperature set point. Walrath says Fresh-Aire solves the problem by eliminating microbial growth in treated areas. Broadly speaking, he says because in nature UVC light from the sun is filtered completely by the ozone layer of the atmosphere, living things—including bacteria—have never had to deal with UVC, and hence have developed no evolutionary defense mechanisms against it. Since no earth-bound organisms have any defense against UVC it can act as an ideal disinfectant when applied to surfaces that might otherwise represent safe haven for undesirable microorganisms. Shane Lutz, of Henderson Engineers, says over the past 10 years, UV germicidal irradiation (UVGI) technologies have been building a reputation as irreplaceable specifications for the health and safety of patients and staff. “We’ve seen the effects of no UV lights in older HVAC systems,” says Lutz, “and there’s a tendency for coil microorganism growth that you definitely wouldn’t want distributed throughout a critical environment such as an operating room, or any other health care environment.” In designing the ventilation system for Geary Hospital his firm specified Fresh-Aire UVGI units to help keep coils clean and ventilation optimal. When installed, UVGI alters an organism’s DNA and disables the reproductive capabilities of any microbe passing through its UV field in the air handler; the microbes later become entrapped in each unit’s High Efficiency Particulate Arrestor (HEPA) filters manufactured by Camfil Farr. Combined with each air handler’s 30% pre-filter and 65% filter, the HEPA filters’ 99.9% particle-free filtration helps prevent particles of microbes or mold from compromising patient care. The absence of particulate buildup also reduces the maintenance costs for shutting down and cleaning ventilation system coils and ductwork. Besides maintenance cost savings, UVGI also weighs heavily into each HVAC unit’s energy efficiency. Industry studies reveal that coils void of biological growth have unrestricted static pressure, reduced blower electric load, and optimum heat transfer. For example, a thin growth of biofilm on coil surfaces can reduce the free area and increase air velocity up to 9%. Cleaner coils also deliver up to a 30% increase in cooling capacity when compared to dirty coils, according to Michael Wixson, principal, Associated Air Products, a manufacturer’s representative that assisted with the UVGI specification. According to Walrath, the health care industry is beginning to see a “growing interaction between infection control and engineering departments to the benefit of both groups,” and he says a Fresh-Aire system installation could enable a return on investment in as few as 6–12 months. Permanent Improvement Even with the substantial gains that can be realized in return, energy efficiency is often not the direct objective of capital investments in hospital equipment; however, thoughtful investments in efficiency can also contribute to health efficacy and patient health and safety. One of the leaders in the industry making a push for sustainable practices in health care is Kaiser Permanente. The giant health care non-profit, has committed to LEED Gold Certification for all of its new construction. Melissa Baker of Practice Greenhealth says Kaiser Permanente’s health system has been phenomenally successful in moving towards its sustainability goal with the minimal cost of 1% net added to their projects. She adds that the United States Green Building Council (USGBC) is beginning to create incentives for more frequent discussions of sustainable and energy-efficient practices in the early stages of capital investment planning that can lead to fruitful energy efficiency projects in health care facilities. LEED version 4 contains a planning credit, which she says “encourages everyone to come to the table,” and the leadership in sustainable initiatives in hospitals can come from a variety of sources from engineering staff to line employees. “We know there is a payback from the energy efficiency savings that can really reinforce the desire to get there,” continues Baker. “One of the biggest ways to do that is to get into integrated design and integrated operations, where you have everybody at the table, so you know upfront people will be able to take advantage of those savings that you’re going to be seeing and that you’ll get the outcomes you want for staff and other people. We cared enough about that to make it a credit in LEED version 4 to bring people to the table to start the planning process early on. There is definitely a need to have everyone on board teach them how to use the space well and then to really see efficient operations.” Travis English of Kaiser Permanente says, “We’re trying to look at building energy consumption wherever we can. It’s always a multiple contingent strategy. “For us, energy conservation is a health issue; sustainability is a health issue; our carbon footprint is a health issue—a public health issue. We want to be good players in that field, and we’re looking at it from both a measure-by-measure level, and also at the strategic level. We’re involved in the day-to-day operating of the lighting system, all the way up to advocating where the future of codes and regulations needs to be.” With about 600 medical offices across the nation, English says, “Kaiser is a not-for-profit, so when we can make improvements in energy efficiency, it’s a direct contribution to lowering costs. We believe energy efficiency is aligned with better patient experience; we believe we can achieve both goals simultaneously.” Writer David C. Richardson is a frequent contributor to Forester publications.
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