BY JEREMY CRESSMAN, LEED AP

Transcription

1 SMART PLUMBING BY JEREMY CRESSMAN, LEED AP 26 Plumbing Systems & Design SEPTEMBER

2 CHOICES FOR HEAL+HCARE FACILITIES Despite the down economy, public and private entities continue to invest in healthcare construction, with an emphasis on special facilities such as long-term care, rehabilitation, oncology, and urgent care facilities. The American Recovery and Reinvestment Act, for example, will provide more than $1 billion for the Veterans Health Administration s Non- Recurring Maintenance Program and energy initiatives. As institutional design and specifying engineers look toward new healthcare projects, evidence shows that improved design can reduce healthcare-associated infections (HAIs), promote safe, accessible use for all ages and abilities, and reduce water use. The role of plumbing products is evolving, as are design considerations for patient rooms and restrooms. INFeCTIoN CoNTRoL One of the most important considerations in choosing plumbing fixtures for the healthcare environment is sanitation. The Centers for Disease Control and Prevention estimates that 1.7 million people each year become infected while staying in a healthcare facility, and of those, nearly 100,000 deaths occur annually. One reason is that people in hospitals often have suppressed immune systems and are more easily infected than healthy individuals. Secondly, many existing hospitals unknowingly have spaces that are ideal for infectious bacterial growth. According to the CDC, HAIs add more than $5 billion to the nation s annual healthcare bill. The CDC also notes that hygienic handwashing is the most-effective measure for preventing the spread of pathogens to food, water, other people, and inanimate objects, such as hand railings and other surfaces. According to Guidelines for Design and Construction of Health Care Facilities by the Facility Guidelines Institute (FGI), sinks in handwashing stations need deep basins to prevent splashing and should be constructed from nonporous materials to limit bacteria growth. That means sinks can be vitreous china or stainless steel or made from solid surface materials. To help minimize splashing and the resulting spread of infectious pathogens, faucet spouts should not flow directly into the drain, and water pressure rates should be decreased. Figure 1 Hands-free faucets help minimize the spread of infection by reducing the number of surfaces that patients, doctors, nurses, visitors, and other staff have to touch while interacting with a patient. SEPTEMBER 2011 Plumbing Systems & Design 27

3 Barriers should be placed between the sink and prep areas, and patient care supplies should be moved more than 3 feet (the distance that splashed water can travel) from the sink. Based on the FGI guidelines, an effective handwash sink might feature a deep basin, a high-arch gooseneck motionsensor faucet, and an offset drain. The rim, and backsplash if applicable, should be sloped to direct water into the bowl and to eliminate the likelihood of users placing objects on the sink, as this provides a vehicle for HAIs. Other desirable features for a sink in a healthcare facility include splash guards, smooth corners, antimicrobial finishes, and hands-free faucets. Guidelines prohibit spouts that have aerators, modulators, or spray modifiers, all of which can contribute to bacterial establishment. Standard Surface 52 Days of flushing 74,000 cycles Iron stains & biofilm Antimicrobial Surface 65 Days of flushing 91,000 cycles No iron stains or biofilm Figure 2 Toilet with antimicrobial surface versus standard toilet HANDS-FRee TeCHNoLoGY FGI guidelines also require healthcare facilities to have faucets with hands-free sensors (see Figure 1) or foot pedals. While the use of hands-free faucets helps minimize the spread of infection by reducing the number of surfaces contacted, recent research from Johns Hopkins Hospital in Baltimore discovered that water samples from some electronic faucets in the hospital had higher rates of bacteria and Legionella present than their manual counterparts. This counter-intuitive finding refutes more than 20 years of studies that suggest electronic faucets offer stronger infection control safeguards than manual faucets and requires further study. It also affirms at least one earlier study suggesting that persistent contamination of electronic faucets despite hyperchlorination and aerator replacement should lead to prompt replacement of electronic faucets by conventional faucets. In the end, research points to significant risks of bacterial cross-contamination from surface contact in restroom environments. 1 Touch-free faucets alleviate the need for any hand-surface contact. If electronic controls are used, FGI specifies that they must be Figure 3 Sample ADA-compliant fixtures hand-motion activated, rather than body-motion activated. This stipulation helps conserve water, as the faucet will operate only when hands are in the sink, rather than when someone is standing in front of the sink. Another best practice is to provide a mechanical manual override for all electronic sensor-operated urinal and toilet flush valves. Likewise, sensor faucet metering times should be coordinated with the hospital s infection control guidelines and provide handwashing for 60 seconds or the appropriate duration. In surgical prep areas, including anesthesia, pre-operative services, surgery, and post-anesthesia care, two rooms typically are immediately adjacent to the operating room where faucet selection is very important. The FGI guidelines require freestanding scrub sinks and lavatories to feature foot, knee, or ultrasonic controls. Single-lever wrist blade controls used for scrubbing-in procedures are not permitted. Finally, fixtures with a permanent antimicrobial glaze (see Figure 2) are available. Unlike surface protectants, a permanent antimicrobial is incorporated as part of the manufacturing process and therefore works continuously and never wears away. These permanent surfaces inhibit the growth of stain- and odor-causing bacteria, mold, and mildew on the fixture s surface. ACCeSSIBLe AND BARIATRIC DeSIGN Another consideration for specifiers of healthcare plumbing systems is universal access. The 1990 Americans with Disabilities Act (ADA) requires healthcare providers to follow specific accessibility standards when constructing new facilities or renovating existing spaces that could affect access to or use of the facility by people with disabilities. 28 Plumbing Systems & Design SEPTEMBER

4 Common upgrades include ramps, barrier-free thresholds, roll-in showers, walk-in tubs, barrier-free sinks, and accessible toilet stalls (see Figure 3). Rising rates of obesity require special bathroom design consideration as well, particularly related to the toilet. Almost all toilets are made of vitreous china, an extremely strong material, especially when downward or compression forces are applied. In new facilities, floor-mounted toilets are recommended, as most can withstand extreme loads. Most existing healthcare facilities, however, utilize wallmounted toilets, which typically can withstand a 500-pound static load. Problems arise when excess force is applied to a wall-mounted fixture, creating a powerful shearing force, especially when someone plops down on a toilet. Thus, for areas of a hospital specializing in bariatric surgery, gastric bypass, or other medical conditions related to weight, it is recommended that toilets always be floor mounted. Engineers encountering wall-outlet plumbing should consider retrofitting older toilets with floor-mounted wall-outlet toilet models. These fixtures mount on the floor and connect to the plumbing system through the wall, similar to a wall-mounted fixture. Extended-width bowls, sometimes called right-width, also are suggested for these applications. Some more recommended bariatric design and installation guidelines follow. Ensure that all toilets are installed by qualified plumbers. Occasionally inspect toilets for cracks or other signs of damage and replace them if damage or weakness is evident. Ensure that the nuts on the carrier studs show no signs of damage and are not loose. If they are loose, do not attempt to tighten them, as this must be done to manufacturer specifications. Call a licensed plumber to inspect the installation. Use of a floor-outlet plumbing system is strongly recommended. If floor-outlet toilets cannot be used, floor-mounted back-outlet designs are the next best option. Comfort-width seats and oversized bowls can be used for overweight patients. WATER CONSERVATION Since healthcare facilities (particularly hospitals) use large amounts of water, the plumbing design offers many opportunities for significant water-conservation savings. On average, hospitals use nearly 125,000 gallons of water per day, based on facilities with bed capacities between 130 and 550. In most cases, healthcare facilities are 24/7 operations, requiring a lot of water and energy. According to U.S. Environmental Protection Agency (EPA) ENERGY STAR statistics, more than 40 percent of hospital water use is for bathrooms and sanitary facilities. Green building programs such as LEED for Healthcare and the Green Guide for Health Care identify ways to reduce water consumption while maintaining a healthy environment for patients, visitors, physicians, nurses, and staff. For example, water-efficiency guidelines established for LEED recommend calculating water usage for metering or autocontrol faucets according to gallons per cycle (gpc) instead of gallons per minute (gpm) (see Equation 1). The baseline flow rate for a metering faucet is 0.25 gpc. Since the flow rate is measured in gallons per cycle, the duration of the faucet cycle is necessary to calculate the water savings. Equation 1 Installed flow rate (gpc) = Flow rate (gpm) x Duration (seconds per cycle) 60 seconds SEPTEMBER 2011 Plumbing Systems & Design 29

5 + Water Conservation and Green Building for Hospitals LEED for Healthcare (LEED HC) was developed in partnership with Green Guide for Health Care to address specifics in healthcare facility design and operation. The water-efficiency category of LEED for Healthcare is substantially modified from the LEED for New Construction rating system. WE Credit 3 is where faucets, sinks, toilets, urinals, and showers may help achieve points directly. Water consumption must be calculated to show a 20 percent reduction over the baseline prediction, based on occupant number and frequency of use. This means a 20 percent (or greater) reduction in potable water use for process water needs, which includes washing machines, dishwashers, ice machines, food steamers, and combination ovens. For example, the installed flow rate of a 0.5- To achieve the 20 percent required reduction, gpm faucet at a 10-second consider specifying WaterSense-certified fixtures and handwashing cycle would fittings, using high-efficiency fixtures, and installing be 0.5 x (10/60) = a graywater capture system to reduce potable water gpc. (Note: The above data use for nonpotable water needs. is based on the U.S. Green Building Council s Water Keep in mind that many of the water-efficiency Use Reduction Additional credits depend on the overall design goal of the Guidance, updated on water and plumbing systems. That is, sinks may August 16, 2010.) not directly contribute, but if the water from For toilet flush valves, handwashing sinks is captured and reused for hands-free sensor landscaping needs or equipment cooling, then the operation is ideal for both sinks indirectly contribute. Reclamation systems conserving water and often have on-site purification systems to clean the limiting the transmission water to tertiary standards. of bacteria. A best practice for this area is to specify an automatic flush valve with a manual mechanical override that operates the fixture when battery or hardwire power is not available. For applications that require handwashing, WaterSensecertified sensor faucets are ideally suited to both conserve water and limit infections. As noted earlier, sensors will operate only when the sensor is triggered, providing a two-fold benefit: They offer greater water savings by being both low flow and hand-motion activated, and they also prevent the unnecessary transmission of bacteria by being hands-free. While battery-operated or hard-wired sensor faucets are preferred, manual models should be considered for applications with no redundant power source. Note that sensor-operated faucets that are powered by solar collectors or turbines still depend on batteries and therefore require redundant power. Figure 4 Having a fully integrated BIM model properly implemented can streamline design, approvals, construction, and operations/maintenance for the healthcare sector s massive projects. Many healthcare facilities are now requiring the inclusion of BIM as part of the preconstruction bid process. THE FUTURE The way we use healthcare facilities is changing, which will have a signification impact on the design and redesign of healthcare facilities. With sink design and placement such an important consideration in patient rooms, nursing stations, scrub rooms, and other patient-care areas, building information modeling (BIM) is an excellent tool to see what your design will look like in three dimensions before construction is complete (see Figure 4). Some manufacturers offer combined nested families so the entire fixture tag is kept around 500 kilobytes. Recent advances to Revit file formats combine a base fixture with the faucet or fitting, drain, p-trap, supplies, carrier, connection points, and relevant specifications and parameters into one nested family, saving designers time and money while eliminating potential conflicts. Hospitals provide a wide array of services to the community, including inpatient and outpatient care, emergency and trauma care, laboratories, pathology, and more. Hospitals also provide food service, maintenance, and staff washrooms in addition to the specific plumbing needs of patients and families. All of these services must be considered when selecting fixtures for the different hospital environments. REFERENCES 1. Kennedy, D., Enriquez, C. and Gerba, C., Enteric Bacterial Contamination of Public Restrooms, University of Arizona, Tucson, Arizona, December (Read the article here: Jeremy Cressman, LEED AP, is vice president of commercial trade for American Standard. For more information or to comment on this article, articles@psdmagazine.org. 30 Plumbing Systems & Design SEPTEMBER