HEALTHCARE PLUMBIING
Providing Maximum Hygiene and Water Efficiency

The healthcare industry touches the life of every person in the United States, either as a healthcare worker or as a patient. While healthcare facilities have many needs in common with commercial buildings, healthcare plumbing systems are more complex than those of commercial buildings. Plumbing in healthcare facilities plays an important supporting role in assisting the care givers in maximizing the quality of life for the patients and assisting in the safe delivery of various treatments. The services provided in healthcare demand an absolute need for functional and hygienic restrooms throughout the facility to ensure the highest level of patient care.

Although most healthcare facilities are exempt from water and energy conservation regulations, there are plumbing systems for healthcare facilities that foster wellness for patients and are environmentally- friendly.

Healthcare facilities epitomize “mission critical”, operating 365 days a year and consume vast quantities of water. Down the line, that water becomes sewage and then returns to municipal water treatment plants to make the circuit again. But plumbing systems can ease the environmental burden by dramatically reducing water consumption and ultimately operating costs-by incorporating fixtures that promote sustainability while maintaining hygiene standards required in healthcare settings.

The American Society of Healthcare Engineers’ guidance statement on protecting the health of the surrounding community is a holistic approach on sustainability: “Local air and water quality is also significantly affected by building design choices...Water management on the grounds and water conservation efforts within the building will influence the amount of toxic emissions released to the water and air throughout the life of the building.”

Consequently, plumbing is not just a “building” issue, but a holistic building issue. As such, a systematic look should be taken to identify sources of potential water savings and how technologies can be used to reduce consumption and discharges.

The American Institute of Architects’ (AIA) 2006 Guidelines for Design and Construction of Hospital and Healthcare Facilities, the AIA’s current healthcare standard, which became available in July 2006, contains distinct, new requirements for the design of healthcare facilities. The AIA healthcare guideline states that potable water consumption reductions may be achieved through the use of “low- consumption fixtures and controls” (1.2 Environment of Care, Appendix 3.1.3, Water Quality and Conservation).

Many of the changes affect patient rooms with the goal to improve hygiene and privacy. Most notably, single-bed rooms should now be specified as the minimum standard in new construction unless a functional program demonstrates the necessity for a two-bed arrangement. For renovated space, capacity may not increase from previous levels, with a maximum of four patients per room (2.1 General Hospitals, 3.1.1.1 Typical Patient Rooms, Capacity). Patients are also required to have access to a toilet room, which may serve no more than two patient rooms and no more than four beds, without entering a general corridor (2.1 General Hospitals, 2.2 Patient Rooms or Care Areas). The toilet room must contain both a water  closet and a handwashing station (2.1 General Hospitals, 2.2.1.2 Toilet Rooms).

Another handwashing station must be provided in the patient room in addition to that in the toilet room for both new construction and renovation (2.1 General Hospitals, 3.3.2.6 Handwashing stations). The handwashing station should be convenient to staff entering and leaving the room and located outside the patient’s cubicle curtain. To bolster hygiene, the specifications call for hands-free operation of handwashing stations (1.6 Common Requirements, 2.1.3.2 Plumbing Fixtures). The AIA’s healthcare standard also states, with the exception of scrub sinks, that provisions for hand drying must be provided at all handwashing stations. Electronic, hot-air dryers installed to preclude possible contamination by recirculation of air are included in the guidelines (2.1 General Hospitals, 8.2.2.8 Handwashing stations).

To provide proper accessibility, the AIA’s guidelines identify the Americans with Disabilities Act Accessibility Guidelines and the Uniform Federal Accessibility Standards as criteria to follow, but with built-in flexibility to meet the specific needs for healthcare facilities (1.1 Introduction, 4 Design Standards for the Disabled). While the new healthcare guidelines are comprehensive to ensure facility compliance, the AIA urges professionals to refer to local code standards for all projects.

Hygienic Measures
Nosocomial infection-which means infection acquired in a hospital- is the fourth-leading cause of mortality for Americans. According to the Centers for Disease Control and Prevention (CDC), nearly two million patients in the United States are affected by nosocomial infections, and about 90,000 of those die as a result of their infection each year.

Approximately one-third of hospital-acquired infections are preventable. In fact, transfer of a pathogen to a patient via the hands of healthcare workers is thought to be the most likely mechanism of exposure to patients. Hand hygiene is imperative when it comes to providing the best healing environment for patients by minimizing cross contamination.

The CDC cites handwashing as the single most effective method to reduce illness and cross-contamination. In agreement, the Association for Professionals in Infection Control and Epidemiology (APIC) states “handwashing causes a significant reduction in the carriage of potential pathogens on the hands and,” [in healthcare settings it] “can result in reductions in patient morbidity and mortality from nosocomial infection.”

Yet, according to the “APIC Guideline for Handwashing and Hand Antisepsis in Health Care Settings,” proper handwashing occurs in approximately half of the instances when appropriate and usually for a shorter duration than recommended. A recent study at a teaching hospital found just 48 percent compliance with handwashing procedures. The study found that one of the biggest obstacles to handwashing was the placement of sinks. The APIC suggests convenient placement of sinks and handwashing products to encourage proper hygiene.

The APIC also recommends that faucets can be turned off by means other than the hands to help healthcare personnel avoid immediate recontamination after washing. Recontamination is quite easy considering that handwashing stations are where people shed bacteria from their skin. This was confirmed by University of Arizona research that identifies handwashing stations as the dirtiest area in a hospital restroom. Specifically, sink drain surfaces resulted in positive samples of coliforms, which are aerobic bacteria found in the colon or feces, 80% of the time. The rim of the sink followed with 20% of the samples being positive and the area under the soap dispenser followed with 10%. Overall, the same study found that coliforms were present on 17.3% of the 248 surface samples taken from hospitals.

Water Conservation
The AIA also refers to the growing body of knowledge for sustainable construction- namely the U.S. Green Building Council’s LEED® Green Building Rating System and Green Guidelines for Healthcare Constructionavailable to assist building professionals and healthcare organizations in understanding how structures affect human health and the environment, and how these effects can be mitigated through a variety of strategies.

One of the most cost-effective ways to pursue LEED criteria is by surpassing the standards for the Water Efficiency section. That means reducing water consumption 20 or more percent below the baseline fixture performance requirements set by the Energy Policy Act of 1992. For example, a baseline toilet fixture uses 1.6 gallons per flush (gpf) and a baseline urinal consumes 1 gpf. Consider then the fiscal and environmental impact of a strategy that uses 0.5 gpf urinals, or even non-water-supplied urinals. For water-closet applications, new dual-flush flushometers allow the user to select a full flush (1.6 gpf) or reduced flush (average 0.8-1.1 gpf).

Representing the largest source of savings in the restroom, sensor- operated faucets with 0.5 gallon-per-minute aerators reduce consumption because water flows only when a person’s hands are in the “active area”, which means water is not flowing continuously. With an estimated 56 minutes spent washing hands during a typical eight-hour nursing shift, healthcare water consumption can be shown to be cut dramatically with touchless faucets.

Other Initiatives
Similar to LEED, Green Guide for Health Care™ is the first quantifiable sustainable design tool that integrates enhanced environmental and health principles and practices into the planning, design, construction, operations and maintenance of healthcare facilities to achieve high performance healing environments. This voluntary program is a joint project of the Center for Maximum Potential Building Systems and Health Care without Harm. It follows the same basic structure of LEED, but is more focused to healthcare building issues by providing a comprehensive portrait of the healthcare industry’s approach to green building and operations. The program stresses the importance of using safer, non-toxic building materials on health care projects and the availability of cost-effective energy and water efficiency strategies.

Another developing program is the Environmental Protection Agency’s WaterSense program. This program has recently established voluntary specification criteria for a High Efficiency Toilet (HET). The specification includes a performance standard in addition to maximum consumption levels based on uniform North American requirements, which includes the soybean mixed media extraction test. Fixtures that meet the guidelines will need to comply with the new labeling program, which is intended to help educate consumers.

As defined by WaterSense, an HET fixture has an effective flush volume that does not exceed 1.28 gpf/4.8 Lpf. As for the minimum performance requirement, the specification requires a minimum extraction of 350 grams of soybean media. To earn HET designation, the fixtures must also meet applicable sections of ASME A112.19.2- 2003, A112.19.5-2005, and A112.19.14-2001.

New Technologies
Operating costs and water consumption at healthcare facilities can be greatly reduced with immediate-impact technologies. Examples of low-consumption technology currently available include waterfree urinals, 0.125- gpf/0.5 Lpf urinals, 1-gpf/3.8 Lpf pressure- assist toilets and dual-flush technology for both tank and flushometer applications are additional engineered solutions that can make a significant local impact. This generation of water saving fixtures has years of field evaluations that will prove valuable in earning industry acceptance and assure customer satisfaction providing confidence in today’s advancing technological solutions for water conservation.

For example, waterfree urinals have been in use for the past 12 years. Halfgallon urinals have been used for the last 10 years. Fractional flush urinals, also called High Efficiency Urinals (HEU), have been around for years as well; one manufacturer has been making this type of product for naval applications for 50+ years.

Dual-flush technology for water closets, which has been available for residential installations for more than 10 years, is now available for flushometer applications. Dual-flushing technology represents a ratio of 1:2, that is, one flush of 1.6 gpf/6.0 Lpf for solids to every two flushes of 1.1 gpf/4.2 Lpf for liquids, the result of which is a combined effective flush volume. Essentially, this means a 20% drop in water consumption.

The new demands for conservation are driving more wide spread use of this technology. These plumbing systems can go a long way in providing a healing environment.

Peter Jahrling is a director of engineering for Sloan Valve Co. His email is: sloanengineer@sloanvalve.com.

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