Philip Harris Utilities and Services Essay 2 Foundation Degree Building Services and Sustainability

Water Services
Availability, collection, treatment and storage methods
The water supply to healthcare premises is usually via one or more connections to the mains of the local water authority. Provision should be made for alternative supply in an emergency situation. Alternative arrangements would include a second supply from the water authority or a private supply. Water treatment systems should meet the requirements of the Water Supply (Water Quality) Regulations 2000. The water supplied by the local authority will usually be of a high standard, but it is highly unlikely it will be completely free of all biological matter that would be undesirable in a healthcare environment. One method of treating against micro organisms in the water supply is via the chlorination of the storage tanks and the distribution pipework. However the continual chlorination of hot and cold water systems after the initial commissioning is not recommended as chlorine has a limited ability to penetrate bio-film and inactivate sessile micro-organisms (National Health Services, 2009). Another method of water treatment that could be employed is ionisation. Ionisation as a water treatment method has been shown to be effective against planktonic Legionella in hot and cold water systems. Ionisation systems release copper and silver ions into the water stream by means of electrolyte action. If the healthcare facility should be designed to include sustainable water collection methods such as rainwater or grey water then appropriate levels of treatment must be included before these systems can be used. The Scottish Health Technical Memorandum 04 (HTM04) identifies four distinct departments within a hospital style facility that would require specially treated water: renal departments; pharmacies, laboratories and hydrotherapy departments (National Health Services, 2009). Water storage on healthcare premises is done for several practical reasons and has a variety of uses: (a) To provide a supply of cold water should the mains distribution fail. (b) The provision of a treated supply of water for laundries and heating in soft water areas is beneficial. (c) Storage in the form of break tanks that serve areas where backflow is likely to be harmful due to a substance representing a serious hazard, such as pathology laboratories. (d) Storage for the sprinkler systems to help with fire fighting (National Health Services, 2009). The above list is not exhaustive and the extent of storage will depend upon the requirements of each individual project.

Distribution within the Building

HTM04 provides guidance on the distribution systems within healthcare premises and the design of the cold water distribution system should comply with the Water Byelaws (Scotland) 2000 and the relevant parts of BS6700:1997 and BS EN 806-2:2005(National Health Services, 2009). Cibse Guide G

Philip Harris Utilities and Services Essay 2 Foundation Degree Building Services and Sustainability

Public Health Engineering and the WRAS Water Regulations Guide are also good reference material for designers to use. The main guidance for the installation of the building s water distribution is that it should be designed to avoid waste, undue consumption, misuse and contamination. Section 8.25 of HTM04 focuses on the distribution system for medical procedures. It states that where water is required for specialist operations within a healthcare establishment then it will be necessary to consult with the hospital infection control team and the water authority to clarify any special precautions that may be necessary (National Health Services, 2009). Measures that can be taken to minimise consumption and thus tie the distribution in with sustainable guidelines include: (a) The installation of water meters to closely monitor the onsite consumption of various areas/equipment. (b) The use of automatic flush controls such as Cistermisers to control flushing of urinals. (c) WC pans and cisterns that use no more than 6 litres per flush. Dual flush technology should be considered. (d) Fitting water flow restrictors at hot and cold water taps. (e) Installing percussion taps in appropriate circumstances (National Health Services, 2009). Although it is not included in the HTM04 recommendations, the use of infra red, non-touch technology on wc s, urinals and taps should be given consideration, particularly in surgical areas. Not only does this type of technology help with the sustainable agenda by matching usageto occupancy and preventing wastage, but it also limits the chance of germ transfer as skin contact with point of use facilities can be avoided.

Prevention of Water Borne Diseases

All cold water installations should be fitted with adequate protection against backflow. In healthcare facilities there should be a high degree of protection to the installation to protect the patients and the staff. The dangers of backflow in healthcare facilities are amplified by the presence of category 5 fluids. Category 5 fluids are defined as those likely to involve fluids contaminated with human waste. As water usage in healthcare facilities covers such a wide range of applications, from domestic use by patients and staff to specialised use in operating departments and pathology laboratories, they can be high risk (National Health Services, 2009). One of the most common forms of water borne disease in a water system is legionella. The bacterium grows in water distribution systems and is known to replicate between 20 and 45 . There is guidance in place to prevent this. The Health and Safety Commission s Approved Code of Practice L8 insist that all cold water should be stored at a temperature below 20 , and all hot water should be stored above 60 . ACoP L8 also requires that hot water should reach the outlet at a temperature of 50 after one minute and cold water should reach the outlet at 20 after two minutes. The distribution pipe work should not be unnecessarily long and there should be no dead legs.

Preliminary Size of the Storage Tanks

Philip Harris Utilities and Services Essay 2 Foundation Degree Building Services and Sustainability

Sizing of cold water storage tanks is usually done to ensure that there is enough water to last 24 hours should there be an interruption in mains supply. However ACoP L8 recommends storage is only for 12 hours to maximise turnover and avoid stagnation. Water consumption in hospitals is extremely varied, depending on the condition of the hospital and the extent of outpatient, casualty and clinic provision. Consumption has been shown to vary, for different conditions in hospitals, from 180 litre/bed per day to over 1800 litre/bed per day (National Health Services, 2009). Cibse Guide G offers a formula that allows the calculation of the required cold water storage for medical facilities. This formula is based upon an investigation into the water consumption of ward units carried out in the Hospital Engineering Research Unit of the University of Glasgow. The investigation contained a series of equations; the one below is for the storage of cold water:


Where:
             

The table that the figure for is taken from has been reproduced below:

Type of Ward
Surgical and gynaecological Medical Obstetric Geriatric and chronic Thoracic Paediatric and infectious Orthopaedic

Value for Constant 

+518 -750 +1691 -786 -1277 +868 -368

Once the type of ward has been designated and the bed numbers are chosen the above calculation can be used to work out the required stored water for that ward (CIBSE, 2004).

Refuse disposal (clinical and none clinical wastes)

Waste Identification and Assessment Framework
Health Technical Memorandum 07 (HTM07), section 4.3 states that waste regulation requires the classification of waste on the basis of hazardous characteristics and point of production (Department of Health, 2006). Appendix E of HTM07 provides the assessment procedures for the medicinal, chemical, infectious, and offensive properties produced by healthcare facilities.

Philip Harris Utilities and Services Essay 2 Foundation Degree Building Services and Sustainability

The assessment framework considers: the definition of an infectious clinical waste; the definition of a hazardous waste; the structure of the EWC and the classification of the waste; the general principles of the Carriage Regulations. To determine their classification, all healthcare waste items must be clinically and specifically assessed by the producer, at the time of production, for: medicinal properties; chemical properties; and infectious properties. Staff segregating waste should be provided with clear instructions on the segregation process and should be provided with appropriate training. Colour-coded waste receptacles should be supplied for each waste stream.

Waste segregation and storage

Waste should be segregated at the point of production into suitable colour-coded packaging. Unfortunately colour coded segregation is not mandatory and is not specified in regulations. Recommendations are made in HTM04 for a colour coding system that is hoped will lead to standardisation across the UK. It is likely that healthcare waste will have to be stored on site prior to its disposal. This waste must not be allowed to accumulate in areas accessible to the public or unauthorised personnel. Healthcare waste needs to be stored securely, away from public areas, and in sufficient space to allow the segregation of different classes of waste. There needs to be separate storage provided within for sharps receptacles and waste medicines Healthcare waste storage needs to be separated from normal waste storage, well lit and ventilated. If there is on-site incineration or disposal then the healthcare waste needs to be close to this. It also needs to be separate from areas where food is prepared and other goods are stored, and form public access routes.

Methods employed for treatment and disposal

The treatment and disposal for healthcare waste is required to render safe the waste. To do this depends upon the type of waste treated and the nature of the contaminants present. The systems employed to achieve this can be segregated into two broad types: (a) Incineration/combustion (b) Non-burn/low temperature technologies (Department of Health, 2006). There are a large number of systems that are used to treat healthcare waste. They all use heat, chemicals, irradiation or combinations of these methods. There are five criteria to help in choosing the correct disposal method: (a) (b) (c) (d) (e) The composition of the waste The volume of the waste to be treated Support capabilities of the supplier Staffing requirements Initial and continuing operating costs (Department of Health, 2006).

Environmental Considerations
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Philip Harris Utilities and Services Essay 2 Foundation Degree Building Services and Sustainability

EU policy on waste management is that member states should promote waste reduction and prevention. Cleaner technologies should be utilised and products should be reusable and recyclable.

Medical Gas Services

According to Health Technical Memorandum 2022 Medical Gas Pipeline Systems: Operational Management a medical gas pipeline system (MGPS) is made up of a source of supply, pipeline distribution system, terminal units (to which a user connects and disconnects medical equipment) (NHS Estates, 1997)

Availability and Storage Methods

For oxygen systems the source of supply can usually be bulk liquid oxygen in a vacuum insulated evaporator (VIE), liquid or gaseous cylinders, or an oxygen concentrator system. The use of a cylinder supply system will mean that the cylinders will need to be grouped into banks; a primary and a secondary, with an automatic changeover function to ensure continuity of supply. Other medical gases are usually supplied from a gas manifold system, in two banks. It is a requirement that reserve manifolds are provided for all gases and medical air. Gas cylinders should be stored in either a specially-constructed building, or a store room which is part of the health care building. These areas should be used solely for the storage of medical gas cylinders and must have adequate ventilation. Section 8 of HTM2022 lists a number of criteria that the cylinder store has to meet to achieve the expected standard (NHS Estates, 1997).

Distribution within the Building

The distribution of gases throughout a healthcare facility is done via either localised cylinders or pipeline. If done by cylinder it is normally mobile and can be manoeuvred to where is needed. The other method is a series of specific pipelines that deliver gases to terminal units that are carefully located within rooms and theatres according to the use and type. Pipelines should be identified in accordance with BS1710 and colour banding for the pipelines should be use outside of the plantroom.

Figure 1: Colour code identification for medical gas terminal outlets and pipe installations (NHS Estates, 1997)

Above is an example of the identification banding. The first image shows the colours used to identify oxygen. The second image is the identification colours for Nitrous oxide Medical gas outlets are normally wall-mounted in single or multiple panels. Each outlet is identified with colour and with engraved lettering.

System Design

Philip Harris Utilities and Services Essay 2 Foundation Degree Building Services and Sustainability

Section 2.16 of Medical Gas Pipeline Systems: Design, Installation, Validation and Verification states that the system design requires four considerations: (a) (b) (c) (d) Schedule of provision of terminal units Design flow rates and pressure requirements at each terminal unit Diversified flows for each section of the pipeline system Total flow (NHS Estates, 1997)

A diagram demonstrating a pipeline distribution system from the point of use terminal to the gas source is available in Medical Gas Pipeline Systems: Operational Management . To determine how many terminal units are required the use of the room will need to be known. For example operating theatres will require more varied gases and therefore more terminals than a recovery ward. To work out design flow rates the designer needs to consider the flow required at each terminal; the flow required in each branch; and the total flow. As the system needs to be designed to work should all the terminals be operating at the same time (although this is likely to be a rare occurrence) it is necessary to employ a diversity factor to the branch design. The diversity factor is available in Medical Gas Pipeline Systems: Design, Installation, Validation and Verification and is based upon surveys of actual gas usage in typical hospitals (NHS Estates, 1997).

Environmental and Safe Working Considerations

The Health and Safety at Work Act 1974 is the most important statutory requirement for anybody working with MGPS. At the heart of this act is the idea that the employer AND the individual are responsible for making a systematic assessment of the hazards and risks associated with any task. COSHH applies to MGPS as the gases used can be asphyxiating if not properly controlled. It is the manager s responsibility to ensure that a proper system of assessment, protection and monitoring is implemented. The Pressure Systems and Transportable Gas Containers Regulations 1989apply to all systems in which gas pressure exceeds 0.5 bar; therefore they apply to MGPS (NHS Estates, 1997).

Bibliography
CIBSE. (2004). Guide G: Public Health engineering. Norwich: CIBSE. Department of Health. (2006). Health Technical Memorandum 07-01: Safe Management of Healthcare Waste. London: The Stationery Office. National Health Services. (2009). Scottish Health Technical Memorandum 04-01: The Control of Legionella,'Safe' Hot Water, Cold Water, and Drinking Water Systems. Part A: Design, Installation and Testing. Health Facilities Scotland. NHS Estates. (1997). Health Technical Memorandum 2022: Medical Gas Pipeline Systems: Design, Installation, Validation and Verification. London: NHS Estates. NHS Estates. (1997). Health Technical Memorandum 2022: Medical Gas Pipeline Systems: Operational Management. London: NHS Estates.