By Eamonn Ryan
Healthcare is without a doubt one of the cornerstones of modern society. While healthcare has seen dramatic evolution through the last couple of decades, the sector is currently faced with a conundrum in terms of changing technology, clinical modalities and the ever-increasing requirements to save on the excessive consumption of energy and other natural resources.
Doctor Carlo Urbani was at his desk in 2003 at the World Health Organisation (WHO) office in Hanoi, Vietnam, when he got a desperate call from the city’s French Hospital. There, a Chinese-American businessman named Johnny Chen was critically ill with an aggressive flu-like disease.
It rapidly spread through wards, causing panic among doctors who had never witnessed anything like it. Urbani lead the race against time to contain the outbreak, but a month later was himself dead. His killer: SARS, the disease that 16 years ago arrived on the medical scene to take lives in cities as far flung as the Far East to Canada.
A WHO investigation into the outbreak later pinned the blame on inadequate plumbing at the hotel. This demonstrates how important plumbing is to health, and especially hospitals.
Today that shouldn’t happen. For instance, Harscan Distributors has a waterless waste valve that forms a trap and never dries out. Harscan owner Malcolm Harris says, “We sell these into hospitals and laboratories because it keeps the odours out even in tough windy conditions which otherwise might create a condition that compromises the trap. It’s recognised all over the world, but sadly the standards in South Africa have not been updated.”
This means that something like SARS could still happen in South Africa, whose standards are in desperate need of being updated, precisely for reasons such as this.
Most of today’s healthcare systems worldwide suffer from ageing buildings that are unable to cope with the new demands and legislation pertaining to resource usage. The process of wellness that is promoted in healthcare facilities is neither only a result of the medical staff and procedures, nor is it by the nature of the design of the facility, but intrinsically it is reliant on the environment that the MEP (mechanical, electrical and plumbing) design facilitates in the modern healthcare facility.
Adriaan Vorster, Architecture Business Line Director: Buildings & Places, Africa; Healthcare Sector Lead, Africa and Middle East at AECOM, says in terms of infection control: “The modern health system was created to effectively fight and cure disease, infections and contagious viruses in addition to the various surgical procedures undertaken on a regular basis. It is critical to create the environment to effectively drive this agenda.
“It is therefore critical to take the above-mentioned into account when designing not only the fabric of the building to fight disease, but to include the MEP design in these considerations.
“In terms of infection control it is critical to design the MEP system to optimise air changes in operating rooms, safely increase air temperatures in operation theatres, and co-locating certain critical functions like isolation rooms, operating theatres and hospital wards in a coherent manner. By getting the layout of the facilities right, the design of the MEP system will be enhanced, and an initial level of optimisation will be achieved in terms of cost efficiency and energy consumption,” says Vorster.
“One of the key aspects of a hospital is the fact that most of the facilities are operational 24 hours a day, seven days a week. If any system fails, it can have a disastrous effect on the operation of the facility and also directly may affect the well-being of patients. Facilities where isolation rooms or other enhanced environments exist need careful consideration and fail-safe systems to avoid environmental breakdown. Systems also need to be designed to give extended service life with acceptable service and maintenance windows that match the operation of the facility.”
Performance is critical: “Close inspection at every stage of the installation is required, from the design through to installation. The installations can then be fine-tuned in the latter stages of commissioning. Key aspects like inspection hatches need careful consideration. Certain areas like operating theatres should not have services in the ceiling void as good practice. In corridors, valves and other service points should be grouped in corridors to lessen the impact when servicing is required.
“Air-conditioning has also received attention through the years with the environment being suited for microbial growth that can in turn be spread in the facility. By strategically placing exit and intake points, cross contamination can be avoided. Also, air handling systems for different environments should not be in proximity in terms of exhaust points.”
Vorster says that typical failures in healthcare buildings can be classified as design or mechanical failure. “The design failure in turn can be either insufficient capacity based, such as adequate cooling or heating. In terms of mechanical failure, the consequences can vary in terms of severity. Minor leaks can, over time, create areas suitable for the growth of microbes and could in turn be detrimental to the air quality for instance. A major failure of services could close a department down for an extended time and could as a result affect a number of allied departments. Ill-conceived design could also have an effect as maintenance crews could be required to enter.
“The single-most challenging aspect for the plumber is gaining access to the services. Hospitals are by their very nature highly sanitised and most of the internal areas are particularly sensitive in terms of noise vibration or any other aspect like chemical odours emanating from any maintenance.”
The plumbing design
Vollie Brink, a veteran design engineer of 65 years, says that the cost of health institutions is high and therefore the cost of the design of a hospital and its services require cost-effective solutions. “Some developers or owners have their own design parameters and I have heard of some who are now busy with developing their own at this moment. However, we need to address the contamination of hospitals due to the sanitary drainage system and access inside the building.
“The NBR (National Building Regulations) is based on three important elements namely, health, safety and economy and if you read SANS10400-P, P2 you will see it describes the performance of the sanitary drainage system and how it relates to health, safety and economy. The design of the sanitary drainage system of a hospital can easily be ‘rationalised’ by an experienced and competent engineer to comply with the performance specifications as per SANS10400-P, P2. This engineer must also know how a hospital functions and how to operate the systems and importantly, how to carry out maintenance. It is also critically important that this design engineer knows what the risks are and how to prevent and mitigate potential problems.
“The sanitary drainage system is the system that poses the greatest danger of contamination of the hospital interior from the wards to the Intensive Care Unit. The greatest risk is contamination from the drainage system when there is a blockage in the piping inside and outside the building. This also happens when the access lids are opened inside the building to clear a blockage and the air in the piping escapes out of the piping into the room and contaminates the environment in the building,”says Brink.
He explains that in the past, all fixtures had to be provided with an anti-symphonic vent pipe, which had to discharge above the roof. This system had the advantage that even if you open the access lid, the air in the piping moves up in the vent pipe and even sucks the air into it to discharge it upwards and out of the building. The hospital drainage system must have these ventilation pipes to prevent contamination of
the building.
“This is just one solution, but there are a number of other solutions such as special designed pipe ducts which are ventilated. There are institutions that have done extensive research and have found proof of the contamination of the internal and external environment of hospitals.
“To just wash hands is no longer a solution – we have to go further,” he adds.
Vollie’s research
“I have been busy with research on hospital water services such as the sanitary drainage system and the hot- and cold-water systems. I always feel that it is important to link any technical discussion to the institutional situation and therefore if we talk about the hospital water services, then we must link it to the NBR, the Act, and what follows.”
The NBR is relevant for all buildings and therefore the design drawings of all buildings must be submitted for approval by the local Building Control Office (BCO). The NBR, SANS10400, only contains a Part for Sanitary Drainage and not a Part for Domestic Water.
The Sanitary Drainage Part, SANS10400-P, contains seven regulations, namely P1 to P7 and these regulations are compulsory. This part also contains a number of ‘deem to satisfy’ rules, which are not compulsory unless the owner wants to apply it to comply with the seven regulations. There is no requirement under the NBR to submit water drawings for approval except for the fire water drawings and therefore the BCO doesn’t accept building water services drawings for approval.
“However, lately SANS10400-XA, which is a standard on energy conservation, but has also been promulgated as a regulation, requires the design and installation of the hot water system to comply with it,” says Brink.
He says his research on sanitary drainage of hospitals has revealed interesting information and also potentially dangerous situations in the existing ‘deem to satisfy’ rules design method. “There are a number of new challenges in the design of hot water generation and reticulation and I have found that many designers are not aware of it and therefore their design is not compliant.
“I have found that important new information does not get communicated to engineers. Saice (the South African institute of Civil Engineers) has now established a new Saice/SABS forum in an effort to get important information to the engineers. These challenges relate to the disease Legionella and the minimum temperatures to combat Legionella. But there are also other new requirements which relate to water conservation which have not yet been promulgated which pose new design challenges when promulgated,” says Brink.
“The present situation is that there is no specific National Building Regulations for the design and installation of hospital drainage and water systems. The only solution is to have a ‘rational design’ for both services and even use an international standard.”
SANS10252-1 is a Water Design Code of Practice which was promulgated under the Water Act as a regulation, but not applied by the BCO. This document also does not contain a specific Hospital Water Design section. There is a document, R158, which is used for the design of hospitals but it only states that the water services must be designed by an ‘experienced engineer’.
“From my 65 years working, and mostly with design of hospital services and also for a time involved with the operation and maintenance of hospitals which included all the services including steam, I fully agree that hospital services must be designed by an ‘experienced’ engineer who is a professional registered engineer.
“I am also of the opinion that in future, the facilities management (FM) operator must also become part of the design team, but this is difficult as the FM is usually not yet appointed during the design. I have also found that when the FM is replaced the new FM has other preferences.
“I have found on many projects that when one FM company is replaced with another FM company that in many cases the information such as drawings and critical manuals with critical information gets lost. The design engineers only have to keep drawings and operation manuals for a certain period.
“I have always propagated, and have applied, what I call a ‘Works Information Document’ which contains all the design information and specifications including standard details and a pro forma for quality assurance for the installation, which is the responsibility of the contractor but also guides him with regard to what is required in terms of quality assurance,” says Brink.
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