Perhaps the most complicated and confusing regulations that impinge on hospitals are the codes and standards associated with the design, construction, and maintenance of facilities - those for which the facility manager is responsible. Often, this same facility manager is responsible for energy management (demand side) and with energy deregulation, management of the procurement of energy, and utilities (supply side).

As much as deregulation has made an impact on energy management, environmental control needs, to remove contaminated air and to protect susceptible patients from airborne pathogens, have dramatically increased the complexity of hospital design, construction, and maintenance. This complexity directly translates into increased energy costs.

The Regulation and Enforcement Labyrinth

Government and hospitals have shared the responsibility for regulation of construction through national standards implemented at the state level. State agencies responsible for hospital licensure (e.g., public health department) adopt and enforce one of the "model" building codes (BOCA - National Building Code, ICBO - Uniform Building Code, or SBCCI - Standard Building Code). Adoption, in total or with modification, varies from state to state.

Besides these building codes, states will adopt additional standards for mechanical and electrical building systems to ensure an adequate environment for health care occupancy. These standards set specific requirements for hvac and air changing systems. Often states directly adopt the Guidelines for Design and Construction of Hospitals and Health Care Facilities, published by the American Institute of Architects (AIA) (see sidebar).

Besides state licensure, most hospitals receive reimbursement from the Centers for Medicare and Medicaid Services (CMS). In order for a health care organization to participate in and receive payment from the Medicare or Medicaid programs, it must be certified as complying with the Conditions of Participation (COP) set forth in federal regulations. This certification is based on a survey conducted by a state agency on behalf of the CMS.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) enforces standards that meet the federal COP, therefore a hospital receiving JCAHO accreditation receives "deemed status" and is not subject to the Medicare survey and certification process.

Keeping Up (with) the Standards

The Environment of Care (EC) chapter of the JCAHO hospital accreditation manual contains standards on design and construction of health care facilities. These standards require that organizations utilize the 2001 edition of Guidelines for Design and Construction of Hospitals and Health Care Facilities, published by the American Institute of Architects (AIA) or equivalent construction standards.

Originally published in the Federal Register as part of the Hill-Burton program, the AIA Guidelines are revised every three years and referenced by Health and Human Services and most state licensing agencies. Section 2.1 states that "The importance of energy conservation shall be considered in all phases of facility development or renovation" but "Design for energy conservation shall not adversely affect patient health, safety, or accepted personal comfort levels."

The AIA Guidelines provides clear hvac guidance including air filter efficiencies, area temperature and humidity, space pressurization, ach, and allowance of air recirculation. In addition to the AIA Guidelines, JCAHO requires compliance to the National Fire Protection Association (NFPA) 101 Life Safety Code that addresses issues of egress corridors, smoke barriers, building compartmentalization, and other safety-to-life issues.

In addition to these state and federal regulations, the hospital facility manager is also faced with a number of codes and standards that define the expectation of care and services within the health care environment. These include additional NFPA codes, American Society of Heating, Refrigeration, and Air-Conditioning Engineers (ASHRAE), and Centers for Disease Control and Prevention (CDC). Each of these standards further defines operating expectations that cumulatively have a large impact on hospital energy usage.

The NFPA standards that impact energy usage include Standard 90A, "Standard for the Installation of Air-Conditioning and Ventilating Systems;" Standard 99, "Health Care Facilities;" and Standard 110, "Standard for Emergency and Standby Power Systems."

ASHRAE standards include Standard 62, "Indoor Air Quality," Standard 90.1, "Energy Standard for Buildings," and the ASHRAE Applications Handbook.

The CDC is set to publish the Guideline for Environmental Infection Control in Healthcare Facilities in late 2002. Highlights of this document include details on specific recommendations for hvac operational performance including filter efficiency, air pressure relationships, ach, and procedures for construction, demolition, and system shutdown.

Besides this overarching document, the CDC has also has previously published the Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities and the Interim Smallpox Response Plan & Guidelines is currently under review.

In response to growing threats of terrorism, Health and Human Services (HHS) recently released Guidance for Protecting Building Environments from Airborne Chemical, Biological, or Radiological Attacks.

A Balancing Act

These codes, standards, regulations, and guidelines all combine to make hospitals one of the most tightly regulated environments possible. With these high demands, the potential for inefficient energy usage is great, but the potential for compromising the performance of a building system in the hopes of decreasing energy usage is even greater.

The challenge is to find the areas where energy is truly wasted and where a reduction in energy cost does not result in a loss of operational performance. That is the daily challenge of a health care facility manager. And it is a challenge that can only be met through full knowledge of the regulatory environment, design/operational characteristics of the facility, and knowledge of the patient population served by the hospital. ES

Guidelines Update - Environmental Infection Control

Control of infection (e.g., post-surgical wound infection) and containment of infectious disease have tasked hospital systems and practices since the first hospitals were founded. But in recent years, the challenge of controlling infection has dramatically increased. As a result of advances in medical technology and therapies, a greater number of patients are becoming increasingly immunocompromised (weakened immune system) in the course of their treatment.

As such, they are at increased risk of acquiring healthcare-associated opportunistic infections. At the same time, in response to declining reimbursement for services, the length of stay for patients in hospitals has steadily decreased - primarily for patients without compromised immune systems.

Those patients remaining in acute care facilities for longer stays are likely to be those who require extensive medical interventions and are therefore at high risk for opportunistic infection.

This growing population of severely immunocompromised patients is at odds with demands on the health care industry to remain viable in the marketplace, and is taxing to the equipment, diagnostic procedures, treatments, and facilities. These factors have led to national estimates of more than 2 million hospital-acquired infections/year leading to 88,000 deaths annually.

The foundation of all infection control programs is identification, isolation, and treatment. For airborne infections, the isolation is accomplished through engineering controls involving the following areas:

  • Local exhaust ventilation to remove airborne contaminants at or near their source;
  • General ventilation to dilute and remove contaminants generated in the space, measured in ach;
  • Directional airflow to provide continuous flow from the cleaner to the dirtier parts of the facility, isolating an entire area of a building from the rest of the facility;
  • Negative room pressure. Like directional airflow, this technique protects clean areas from isolation rooms or other areas by establishing a pressure differential between the spaces and forcing air to flow from the protected space to the area being isolated; and
  • Air cleaning via HEPA filtration.

The AIA Guidelines identifies the degree to which these practices should be used for specific areas of the hospital. In response to the increasing numbers of immunocompromised patients, the 2001 revision of the Guidelines contain the most stringent ventilation requirements to date including:

  • General patient rooms (increase from 2 ach to 6 ach and first filter bed from 25% to 30%);
  • Orthopedic operating rooms to 40 ach with 99.97% at 0.3-micron final filter (Cardiology OR at 25 ach with 99.97% filter and general OR at 20 ach with 90% dust spot filter);
  • Operating rooms are required to maintain positive pressure 24/7 to prevent infiltration of contaminants (no shutdown of supply air during off hours);
  • Emergency department and radiology waiting areas require negative pressure with 12 ach and 90% dust spot filter;
  • Airborne infectious isolation room(s) in emergency departments and on patient floors with 12 ach, 90% dust spot filter for supply air, 99.97% at 0.3 micron final filter for return air, 125 cfm offset (exhaust greater then supply), 0.01 in. wg pressure differential (negative room pressure); and
  • Protective environment (PE) rooms for severely immunocompromised patients require 99.97% at 0.3-micron final filter for supply air, 125 cfm offset (supply greater then exhaust), and 0.01-inch in. wg pressure differential (positive room pressure).

These ventilation requirements are to be met for new construction and renovation of areas determined to be sensitive to airborne contaminants. However, the increased focus on building ventilation systems as a means of distributing chemical, biological, or nuclear agents resulting from a terrorist action potentially makes much larger areas of the hospital sensitive to airborne contaminants. As a result, the demands on ventilation systems, and the energy needs to meet these demands, will continue to increase. ES