healthcare ventilation, “high consequence spaces”...healthcare ventilation, “high consequence...

Healthcare Ventilation, “High Consequence Spaces”

Healthcare EnvironmentsMiSHE Chapter

Don MacDonald, Phoenix ControlsSeptember 28, 2017


I. Industry ChallengesII. Standards and Guidelines

I. USP 800 update

III. ApplicationsIV. Energy Management TrendsV. Optimizer Simulation Analysis

Software VI. Case StudiesVII. Summary

Presentation Outline

Presented by:

Don MacDonaldNorthern Regional ManagerPhoenix ControlsCell: 519‐212‐[email protected]

INDUSTRY CHALLENGES

Presentation and Discussion

Energy Challenges

• Escalating Demand– HVAC 44 % of cost– 43% charged higher rates– $1.5 M per hospital per year– $25 Electricity / bed / day– 28% pay $3 to $4 per ft2– 21% pay $5 to $6 per ft2– Cost to double in 20 years

2011 Hospital Energy Management Survey, HFM Magazine

Energy Challenges

• HVAC Requirements– Outside Air Demands – Spaces with high ACH demand– HEPA filtered Ventilation Systems – Emergency Power– Temperature/Humidity– Reluctance to setback ACH

CSAZ317.2‐10

Space ACH Requirements

Operating Rooms 20Caesarean delivery 20Fracture Room 12Cardiac Cath 20AI Isolation Rms 12Diagnostic Imaging CT, MRI, X-Ray, Ultrasound

9-20

Burn unit 15Laboratory 12Pharmacies See USP

Sustainable Opportunities

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HVAC VENTILATION DESIGN CHALLENGES


Ventilation Design Challenges

• Air Terminal Units – VAV Boxes– Commercial application engineering– Component performance variances– Low flow accuracy restrictions– Extra duct length for accuracy– Maintenance requirements– Re‐calibration necessities– Commissioning inconsistencies– Energy waste

Sizing VAV Boxes, Steven T. Taylor, PE, Fellow ASHRAE and Jeff Stein, PE, Member ASRAEVAV Box Controllers Have Limitations, Sutton Page Austin Air Balancing Corporation, 1106 West 6th Street, Suite 206, Austin, Texas 78703 (512) 447‐7247 fax (512) 477‐8152

ESL‐TR‐04/10‐01 Point‐to‐Point Verification of Monitored Sensors at Reynolds Army Clinic and Hospital Final ReportTurndown And Transducer Accuracy Chart: Paragon Controls, Tech Talk, August 16, 2002

VAV Sensors & Ductwork: Placement and Pitfalls Engineered Systems (Feb 2006)ASHRAE Research Project 1137The problems with specifying VAV Boxes, Daniel – Int Hout, The Construction Specifyer, July 2004

Ventilation Design Challenges

• Evidence: Energy Waste– Reynolds Army Hospital Final Report

• Pitot tube assemblies clogged• Blockage causing averaging sensor to send skewed signal to transducer

• Energy waste due to false signals causing supply and return fans to operate at maximum conditions

• Recommend ongoing maintenance and re‐calibration

• Current standards require that maintenance area be enclosed.

ESL-TR-04/10-01 Point-to-Point Verification

of Monitored Sensors

STANDARDS & GUIDELINESPresentation and Discussion

Codes and GuidelinesEnergy Efficiency

• Set energy efficiency goals‐strategies• Consider total Life Cycle Cost• Mechanical control systems should

optimize consumption to the minimum needs of the building

• Use energy‐saving mechanisms such as variable‐air‐volume (VAV) systems and programmed controls for spaces in unoccupied periods

FGI 2014


• Energy Standard: Buildings Except Low‐Rise Residential Buildings– Minimum requirements– Energy efficient design and construction

• Mechanical equipment efficiencies • Occupant‐sensing controls • Expanded modeling requirements

– Energy demand efficiency.• Reduces consumption 30% over 2004

FGI 2010ASHRAE 90.1 , 2013

ASHRAE90.1reducesenergyconsumption.JeffMcClain,CEM,LEEDAP,GregorySifferlen,andWayneH.StoppelmoorJr.,CEM,CFE MediaLLC,01/29/2011KeepingupwithStandard90.1,CarolMarriott,PE,LEEDAP,CarolMarriottConsulting,MapleGrove,Minn.CFEMedia,01/18/2011

Overview of the currently adopted commercial energy code in each state as of September 2016

https://www.energycodes.gov/status-state-energy-code-adoption


• ASHRAE Table 7‐1– Pressurized rooms: Air changes may be

reduced when room is unoccupied. – Number of air changes indicated must be

re‐established when occupied.– Pressure relationship must be maintained.– Areas requiring no continuous directional

control, ventilation systems may be shut down when unoccupied

– If any form of VAV system is used for energy conservation it shall not compromise the pressure relationships or the minimum air changes required by the table

FGI 2010ASHRAE Standard 90.1, 2013 ASHRAE Standard 170 , 2013


• Night setback or Unoccupied setback– OR’s have high ACH rates (20‐30)– ACH may be reduced if pressure held– OR’s may be unoccupied 40%– Staff usage profile– Temperature setback?

• Moderate Cost and Control strategy– Airflow control:

• pressure independent air valves• Supply and exhaust pair• Controlled to set‐point to maintain offset• Volumetric control to maintain pressure

differential or direct pressure control• Requires minimal maintenance

ASHE Operating Room HVAC Setback Strategies

• HD Protection Overview– Stored in negative pressure room.– Ante rooms; one room to two room design.– Sterile storage areas should have a positive pressure relationship to

all adjacent areas except ORs.

USP 800 – Hazardous Drugs

https://www.usp.org/sites/default/files/usp_pdf/EN/m7808_pre-post.pdf

• Continue to Implement USP 797 Criteria– All compounded sterile preparations (CSP) to be in a Primary

Engineering Controls (PEC) Device-Environment.– Containment by HD Type.

• C-PECs: Containment Primary Engineering Control.• C-SECs: Containment Secondary Engineering Control.

– ISO Class 5 enviro.– ISO 7 buffer/ISO 8 ante areas must be separate rooms divided by walls and

doors.

– Environmental Performance Verification• Certification of primary engineering controls performance.• Testing the air quality of compounding area every six months.

USP 800 – Sterile Compounding

USP <797> Comparison to <800>USP <797>

Pharmaceutical Compounding ‐Sterile Preparations

USP <800>Hazardous Drugs

‐Handling in Healthcare Settings

Applies to sterile compounding only Applies to sterile and nonsterile compounding

Applies from receipt of inventory up to drug administration

Wider continuum of time;Applies from receipt of inventory through drug

administration

All HDs must be stored separatelyin area with 12 ACPH and

0.01” w.c. negative to adjacent space

Antineoplastic HDs must be stored separately from non‐HDs in an area with 12 ACPH and 0.01” negative to adjacent

space unless coated, final‐manufactured dosage forms are clearly labeled as HDs and safety strategies are detailed in

SOPs

Exemption for low volume compounding No low volume exemption

Copyright © 2013-2017 CriticalPoint’s Sterile Compounding Boot Camp®- All rights reserved

USP <797> Comparison to <800>

USP <797>Pharmaceutical Compounding

‐Sterile Preparations

USP <800>Hazardous Drugs

‐Handling in Healthcare Settings

CSTD use is a “should”CSTD use is a “shall” during administration

as long as dosage form permits and “should” for compounding

Defines PECs for HDsterile compounding

Defines PECs for nonsterile & sterile HD compounding; allows manipulation of HDs that do not produce aerosols

(e.g., coated tablets or capsules) outside of C‐PEC

Prohibits SCA for HD compounding; Requires BSC to be housed in ISO class 7 room air that

is 0.01” w.c. negative

Permits C‐SCA for HDs provided CACI/BSC in area that has 12 ACPH and 0.01” w.c. negative; maximum BUD 12 hours

Does not require environmental and medical surveillance Recommends environmental and medical surveillance

Copyright © 2013-2017 CriticalPoint’s Sterile Compounding Boot Camp®- All rights reserved

USP 800 – Storage and Compounding• Iso 5, 6 and 7 Environment Examples

https://www.terrauniversal.com/cleanrooms/usp-800-cleanrooms.php

USP 800 – Storage and Compounding• Iso 5, 7 and 8 Environment Examples

Airflow ControlCode Requirements Operation Maintenance Planning

• Operating Rooms (OR)– Tested for positive pressure semi‐annually– Preventative maintenance schedule

• Protective Environment Rooms (PE) – Remain positive to adjacent space

whenever an immuno‐compromised patient is present

– Tested daily when occupied

• Airborne Infection Isolation Room (AII) – Remain negative to adjacent space

whenever an infected patient is present– Tested daily when occupied

ASHRAE 170 Maintenance, Informative Appendix A O&M in Health Care Facilities

VENTILATION APPLICATIONSPresentation and Discussion

Operating Rooms• .01” wc positively pressurized space• 20 ACH when in use• 4 ACH minimum outside air• typically runs at constant volume• during surgery temperature range 68‒75°F• humidity 20‒60%• operates 24 hours a day• Supply diffusers unidirectional downward and average velocity

25‐35 cfm/sqft• Area of diffusers shall extend a minimum of 12" beyond the

surgical table• Exhaust grills, at least 2 low level approx 8" above floor as far

apart as possible

Operating Room (OR) Ventilation Design

ASHRAE 170-2013

Operating‐Surgery Rooms

Supply / Exhaust Tracking Pairs

Room Pressure Monitor

• VAV or 2‐Position • Occupancy modes • Temperature• Humidity• Pressure monitor• Remote monitoring• Duct temp sensor• Decontamination

Operating‐SurgeryClean / Dirty CorridorSupply / Exhaust Tracking Pairs

CleanCorridor

DirtyCorridor

AII Airborne Infections Isolation room– maintain continuous air pressure negative .01” wc– ensure rooms well‐sealed/no leakage– 70‐75 Deg F design temperature– 12 ACH, 2 ACH of minimum outdoor air– Calculate ACH based on exhaust flow– If not occupied pressure relationship is maintained

and min ACH 6– Switching controls for reversible airflow (pressure

relationship) shall not be permitted (note t)– self‐closing devices on exit doors– direct exhaust air outside, away from intake

Isolation Room Ventilation Design

ASHRAE 170-2013

AII Airborne Infections Isolation room– Retrofit can use HEPA filtration recirc system for ACH– When AII room has an ante room: AII room negative

to ante room, ante room negative to corridor– Monitoring device between room and the corridor

alarm when pressurization not maintained– Exhaust grills located in ceiling or wall at the head of

the patient bed.


ASHRAE 170-2013

Isolation Rooms w anteroom


• CV, VAV or 2‐Position • High turndown• APM2 pressure monitor• Remote monitoring• Occupancy modes • Temperature control• Duct temperature sensor

AII Airborne Infectious Isolation room

- .01” wc

PE Protective Environment Isolation room– Pressure positive .01 " wc. 2.5 pa– 12 ACH, 2 ACH of minimum outdoor air– ACH for positive room calc on supply airflow– Switching controls for reversible airflow (pressure

relationship) shall not be permitted (note t)– 70‐75 Deg F design temperature– maintain continuous positive air pressure– Ensure rooms well‐sealed/no leakage– When PE room has an ante room: PE room positive to

ante room, ante room positive to corridor– Monitoring device between room and the corridor alarm

when pressurization not maintained– Supply diffusers located at the head of the patient bed.– Exhaust grills located near the patient room door.


ASHRAE 170-2013



PE Protective Environment Isolation room

+ .01” wc

Combination AII/PE Isolation room– 12 ACH, 2 ACH of minimum outdoor air– maintain continuous positive air pressure– ensure rooms well‐sealed/no leakage– self‐closing devices on exit doors– 70‐75 Deg F design temperature– Monitoring device(s) between AII/PE room and the

ante room and ante room to corridor alarm when pressurization not maintained

– Supply diffusers located at the head of the patient bed.

– Exhaust grills located near the patient room doorAII/PE room has an ante room:– Ante room shall be positive to both patient room and

the corridor OR…..– Ante room shall be negative to both patient room

and the corridor


ASHRAE 170-2013



• CV, VAV or 2‐Position • High turndown• APM2 pressure monitor• Remote monitoring• Occupancy modes • Temperature control• Duct temperature sensor

Combination AII/PE Isolation room

Compounded Sterile Preparation rooms– 30 ACH, 15 ACH of minimum HEPA filtered outdoor air. Non

hazardous, non radioactive CSPs ** 15 ACH if meet criteria– 70‐75 Deg F design temperature– Sterile prep, maintain positive air pressure– Compounding rm: maintain .01” wc negative air pressure– Hazardous drugs prep in a ISO Class 5 BSC and placed in a

ISO Class 7 area– ISO Class 7 ante room next to prep room– The BSC should be 100% vented to the outside via HEPA

filtration– rooms well‐sealed/no leakage– A pressure indicator shall be installed that can be readily

monitored for correct room pressurization– Pressure differential between the Class 7 prep and general

pharmacy area shall not be less than .02” wc– Hand motion door activation

Pharmacy Ventilation Design – CSPsCompounded Sterile PreparationsASHRAE 170-2013 w reference USP 797 - 2012

Phoenix Hospital Pharmacy PressurizationUPS 797/800

Compound Sterile Prep Rooms

Supply / Exhaust Tracking with BSC shutdown

• VAV or 2‐Position • High turndown • Temp/Humidity Sensor • Pressure monitor• Remote monitoring• Duct Temp Sensor • Occupancy Modes • BSC driven to shut‐off when

not in use• General Exhaust required in

the event of BSC failure or shutdown.

PharmacyShut‐Off Containment

Typical patient room– Approximately 70‒80% of hospital

space – Neutral to slightly positive– Supply unit, ducted exhaust– 6 ACH with 2 ACH OSA– Typically CV, but shifting

towards VAV– Temperature range 70‒75°F– Humidity 30‒60%– Bathroom 100% exhaust

Patient Room Ventilation Design

Patient Rooms

Supply / Exhaust Tracking Pairs option for Pandemic ready

• VAV or 2‐Position • Temp control• Occupancy modes • Pandemic sequences

Patient Room

• VAV or 2‐Position • Occupancy modes • Pandemic sequences• Room pressure monitors• Remote monitoring• Dampers to control

sequence and to close for decontamination

Surge Capacity Zones


Normal Mode

• VAV or 2‐Position • Occupancy modes • Pandemic sequences• Room pressure monitors• Remote monitoring• Dampers to control

sequence and to close for decontamination

Surge Capacity Zones


Surge Mode

Diagnostic Laboratories

Laboratory Rooms

PROJECT CASE STUDIES


HealthcareVenturi Airflow Valves Project Histories

Phase II– 530K ft2– Green– 300 VVs, EO (Exhaust Only)– ORs, ICUs, Patient, PACUs– No Flow Sensors, No Maintenance,

Feedback– Install 2009, Open 2011– NBBJ, Turner, APA

Massachusetts General Hospital Boston, MABuilding for the Third Century (B3C)Boston, MA

“Will offer a number of sustainable architectural design elements intended topromote healing, conserve energy and enhance the interior areas.”

HealthcareVenturi Airflow ValvesProject Histories

Procedure Room– Reduce air changes during unoccupied

periods– 20 Procedure Rooms– Difference in Air Flow: 2,352 cfm– Temp of Conditioned Air (AHU): 55°F– Annual Savings $147,700


Occupied25 ACH2,800 cfm65 hr/wk

Unoccupied4 ACH448 cfm103 hr/wk

http://www.massgeneral.org/about/newsarticle.aspx?id=1281,MassGeneral‐PhoenixControlsPresentationonSustainabilitypresentedatHCD2010.LasVegas


Isolation Room– Reduce air changes when not needed as

an Isolation Room and utilize as a Patient Room

– 25 Isolation Rooms – Difference in Air Flow: 508 cfm– Temp of Conditioned Air (AHU): 55°F– Annual Savings $46,604 per


AII Occupied12 ACH1,015 cfm42 hr/wk (25%)

Patient Room6 ACH508 cfm126 hr/wk (75%)

http://www.massgeneral.org/about/newsarticle.aspx?id=1281,MassGeneral‐PhoenixControlsPresentationonSustainabilitypresentedatHCD2010.LasVegas

Conditioned Air Cooling 2,035 kWh $305Conditioned Air Heating 5.4 Mbtu $81Reheat Energy 53.9 Mbtu $808Fan Energy 4,465 kWh $670

6,499 kWh59.3 Mbtu

$1,864Total:


Patient Tower– 12 Stories, 680K ft2, 368 Beds– TP, BACnet– Patient Rooms, Isolation– Energy Conservation, Airborne Infection

Control , Room Pressurization, Emergency Surge Capacity

– ZGF Architects , CDi, Mortenson Construction, Hermanson Mechanical, ATS Seattle

Providence Health & Services Renton, WAProvidence EverettEverett, WA

Healthcare Project Histories

Providence Health & Services Renton, WAProvidence EverettEverett, WA

Engineering study Changing from CV (11.6 ACH) to VAV would provide significant savings Fan energy and re‐heat demand

VAV design Energy savings

Venturi Valve Technology Airborne infection control Enables hospital to respond to pandemic incidents by creating isolation rooms on‐demand

OPTIMIZER SOFTWARE


Optimizer Software

Airflow energy and lifecycle software– Wizard Style User Interface– Accurate VAV modeling – Alignment with various commercial building types – Flexibility for quick simple or more detailed energy analysis – What if scenarios – Utilizes TMY3 and WMO weather data – Flexible Reporting on Energy, Sustainability, and ROI – Built in room types for quicker modeling

• https://www.phoenixcontrols.com/resource‐pc‐optimizer.htm

Optimizer SoftwareAirborne Infectious Isolation (AII) Rooms Example

•10 Rooms• AII 25% of the time at 12 ACH• Patient Room 75% at 6 ACHCV VAV Box

VAV Boxes

VAV Venturi Valves

CV VAV Box

VAV Boxes

VAV VV

CV VAV Box

VAV Boxes

VAV Venturi Valves CV

VAV BoxVAV Boxes

VAV Venturi Valves

SUMMARYPresentation and Discussion

• Healing environment for patient– More effective comfort control for faster patient recovery

• Hospital‐acquired infections– Better airborne infection control

• Energy efficiency– Ability to implement setback strategies during unoccupied periods without compromising environmental integrity.

• Operational efficiency– Flexibility of switching from a normal patient room to a negative surge capacity room.

Why Improve Ventilation in the Hospital Environment?

USP800 Summary Document


Healthcare EnvironmentsMiSHE Chapter

Don MacDonald, Phoenix ControlsSeptember 28, 2017

Thank you!

healthcare ventilation, “high consequence spaces”...healthcare ventilation, “high consequence...

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