In 2020 We Got Ready. Will We Stay Ready?

Tip #21

By Angie Stokes, Christy Festch and Jon Lehr

Some of the best memes are the ones that blame every unfortunate accident on the year 2020. Your holiday tree falls over, chalk it up to 2020. You arrive late to an appointment,it’s2020. No doubt, it's been a strange year, but it has also presented opportunities for reflection and for challenging the status quo.

From the onset of the pandemic in March, our health care teams began fighting a hostile enemy. While many of us quarantined, the people that keep our hospitals running had to continue to beat back the beast with only the tools they’ve had in their belts for years. Until 2020, existing numbers of isolation rooms and air change requirements worked well. A need for negative and positive pressure areas that align with our day-to-daycare environment typically met demand. But today, teams of hospital engineers have had to make continuous and varied changes to systems that previously provided a safe and quality patient and staff environment. Today, we are learning new meanings of the word flexibility.

New strategies of varying capability were implemented across health care systems. Energy consumption was impacted as systems had to rise to this new challenge. The need to be flexible to ensure stewardship of financial resources has been more evident than ever. Because we have seen a year driving so much instability, it’s important to understand that maintenance, infrastructure and operational challenges can be reimagined and financed.

At the dawn of the pandemic, our health care systems were in reactive mode. Changes were made to ensure enough spaces to isolate sick patients beyond the traditional ICU and negative pressure rooms.

And what if a sick patient required a procedure? The following initiatives represent a sample of decisions made by health care systems as they strived to follow the Centers for Disease Control and Prevention (CDC) and American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE) guidelines:

1. Dilute:
   Most of the air-handling units in a health care facility are designed to operate using a minimum amount of outside air, which aligns with Facility Guidelines Institute (FGI)requirements. As such, outside air dampers need to maintain a minimum position. With the risk of indoor contaminant build-up, quick decisions had to be made. Certain air-handling units were identified and converted to 100% outside air operation, which eliminated the use of return air from the hospital spaces. These changes were made possible through a series of building automation system (BAS) modifications and/or physical modifications to infrastructure.
2. Exhaust:
   In a traditional ICU space, there are dedicated exhaust systems designed to maintain a negative pressure relationship to adjacent spaces. Health care systems quickly realized that the need for isolation rooms would far exceed the spaces available. Converting patient rooms to isolation rooms was a common practice, primarily achieved with negative pressure machines that were rented, purchased or built in-house. By using such equipment, room-side contaminants were continuously exhausted and negative pressure relationships were maintained.
3. Contain:
   Health care systems quickly reacted by making changes to maintain indoor air quality, but this did not come without recourse. Depending on climatic region, operating in 100% outside mode complicated the existing challenge of maintaining indoor relative humidity levels as it relates to compliance, occupant comfort and risk of microbial growth. Short of major infrastructure upgrades, humidity control relied on modifications to BAS sequencing. Adaptingto100% outside air usage meant that BAS systems commanded higher output of mechanical heating and cooling, exposing systems and infrastructure that were already in a deteriorated state.
4. Clean:
   Health care engineers employed a variety of strategies to reduce particles in the air stream and to keep surfaces clean. HEPA filtration is by far the best option to reduce particles in the airstream. Unfortunately, most of the hospitals’ air-handling units were not designed to leverage HEPA filtration. In lieu of HEPA filtration, it was best practice to ensure that the highest MERV-rated filters were used. UV lighting was leveraged to clean surfaces, such as the surfaces inside the air-handling unit cabinets and at the coil face. The best practice for reducing contaminants is through bipolar ionization, which reduces coronavirus by 90% and all other viruses up to 98%.

As facilities professionals learn to adapt their building operations to CDC and ASHRAE recommendations, their focus lies on increasing indoor environment quality(IEQ). Simply put, creating healthy indoor environments is mandatory. Energy usage and utility spend are casualties of these necessary operational changes. In 2020, many health care systems experienced lost revenue and extreme budget pressures, which may become exaggerated if the resulting increased energy usage is overlooked, especially in the demand-heavy summer and winter months. Changing space usages and installing temporary HEPA negative air machines are additional examples of unaccounted-for energy increases. To combat the unpredicted energy expenditures, proactive measures should be taken. Consider areas where support staff once worked in person: Is this staff working remotely? Is the area able to be scheduled to reduce the HVAC strain?

Budgets, space usages and PPE innovations need to be considered more than ever. In the spirit of adapting, facilities are focusing efforts on facility spaces that may not have had 100% outside air or exhaust, which are now required to operate with that functionality. Limits to existing systems must be investigated and creative solutions must be examined.

Now is a great time to consider creative financing. Most health care facilities have other concerns to address beyond the changes needed to be ready and stay ready for COVID-19 or similar challenges. This may not feel like good news, but there are benefits: the marketplace is flush with investors and lenders that are looking to support sustainable efforts. Infrastructure problems in hospital scan be solved with sustainable solutions that reduce the environmental impact and have financial upsides that can be used in Energy as a Service contracts, Commercial PACE lending and other non-capital sources of money.

It is time to get ready and stay ready. It is time to be ready for now and resilient for tomorrow. How will you adapt and respond?