ABSTRACT

HOW OPERATION AND MAINTENANCE CAN AFFECT THE ENERGY CONSUMPTION OF A HEALTHCARE FACILITY

A healthcare facility, be it a hospital, a clinic or an outpatient clinic, in our imagination is dedicated exclusively to patient care, diagnostics or surgery.

In order to be able to carry out activities consistently with the needs of operators, patients and visitors, it consists of several areas, which are essential for operation.

Electrical installations, special electrical installations, air conditioning installations, water installations, thermal installations, refrigeration installations are some examples of these areas.

In essence, the hospital consists of a hidden world that makes it very similar to an industrial plant.

In the structure we can distinguish different areas to be managed:

1. Building from a civil point of view

2. Electrical installations

3. Special electrical installations

4. Mechanical installations

5. Pollutant treatment plants

6. Plumbing

7. Air conditioning systems

8. Thermal installations

9. Substance storage

10. Fire-fighting systems

11. Emergency power supply systems

12. Irrigation systems

13. Elevator systems

14. Doors

15. Cogeneration/trigeneration

The technician who manages, leads and maintains these disciplines is the Building Manager.

In addition to these disciplines, there are others that are non-core, but essential to the practice of the activity:

1. Cleaning and sanitising

2. Securitiy service

3. Furniture

4. Pest control

5. Waste Management

6. Laundry and cloakroom

7. Reception

8. Guardian

9. Gardening

10. Document archiving

11. Printer and fax management

12. Internal and external transport

13. Transport management

14. Food administration, canteen, bar and vending

15. Fitness centre

16. Parking spaces

17. Nursery

The figure who manages all these ancillary, non-core, but indispensable services is the General Services Manager.

The Facility Manager is the fusion of the two figures, who is responsible both for the management of the civil and technical part of the facility, and for all those activities that support and are indispensable for the company's operations.

In Italy, every health facility is subject to compliance with certain regulatory parameters, relating to microclimate and lighting parameters, in order to be granted health authorisation to operate. These parameters are to be maintained over time and are subject to periodic verification of their existence, through the Presidential Decree 14/01/1997 'Minimum structural, technological and organizational requirements for the operation of healthcare activities by public and private facilities.

Depending on the health department, the following parameters must be met

Outpatient clinics: summer and winter temperature must be between 20°C and 28°C, relative humidity between 40 and 60%, the number of air changes must be at least 2 v/h, lighting must be at least 200 lx in common areas and 300-750 lx in examination areas

Imaging: summer and winter temperature must be between 20°C and 28°C; relative humidity between 40 and 60%; number of air changes per hour at least 5 v/h, air speed between 0.05 and 0.15 m/s; lighting must be between 200-300-500 lx in general and between 30-150 lx in control rooms

MRI: summer and winter temperature must be between 20°C and 24°C, relative humidity between 40 and 60%, number of air changes per our between 6v/h and 10 in normal operation and at least 18v/h in emergency operations (if Helium leakeage could be observed)

Emergency room: winter temperature must be no lower than 20°C; summer internal temperature no higher than 28°C, relative humidity between 40 and 60%; number of air changes per hour at least 2 v/h, air speed between 0.05 and 0.15 m/s; lighting must be between 200-300 lx general lighting, 500-750 lx lighting for examinations, inspections, 750-1000-1500 lx lighting for minor interventions. Medium efficiency filtration

Inpatient: winter internal temperature must be no lower than 20°C, no lower than 22°C for the medical and paediatric wards; summer internal temperature must be no higher than 28°C. The relative humidity must be between 40% - 60%. The number of air changes per hour must be at least 2 v/h for normal inpatient rooms, 3 v/h for paediatric inpatient rooms, 2 v/h for the medical and examination rooms (also non-forced for existing facilities) and 12 v/h for the toilets. Air velocity must be between 0.05 - 0.15 m/s; positive or neutral pressure for rooms. The operating illuminance must be at least 200 lx; general illuminance between 300-750 lx for the dressing room and examination room;

Operating Department: In the Operating Room the internal winter and summer temperature must be between 20 and 24°C; summer and winter relative humidity (obtained with steam) between 40-60%; air changes per hour (outside air without recirculation) must be at least 15 v/h; air speed between 0.05 - 0.15 m/s. The pressure must be positive with a gradient of at least 10 Pascal with respect to neighbouring rooms, 15 Pascal with respect to outside rooms: air filtration must be at least 99.97%.

Annexed rooms must have an internal winter and summer temperature of between 20 and 28°C, summer and winter relative humidity (obtained with steam) between 40-60%; air changes per hour (outside air without recirculation) between 6-10 v/h; air speed between 0.05-0.15 m/s; pressure must be positive with respect to the outside environment and negative with respect to the operating theatre; air filtration between 60-95%. Operating illuminance and general illumination must be between 500-750-1000 lx, illumination of the operating field between 10,000-30,000-100,000 lx, and illumination of the area surrounding the operating field must be at least 10,000 lx.

Intensive care: winter and summer internal temperature must be between 20-24°C; summer and winter relative humidity between 40-60%; air changes per hour (outside air without recirculation) must be at least 6 v/h; air speed between 0.05 - 0.15 m/s; pressure must be positive with a minimum gradient of 10 Pascal (neighbouring rooms) and 15 Pascal (outside environment) air filtration by absolute filtration with filters having an efficiency range of 99.99%.

Sterilisation: the internal winter and summer temperature must be between 20-27°C; summer and winter relative humidity between 40-60%; external air exchange rate between 6-10 v/h; air speed between 0.05 - 0.15 m/s; the pressure must be negative in the dirty area with respect to the clean area, negative in the clean area with respect to the sterile area; the purity class of the filtration in the clean area must be high-efficiency with filters having an efficiency range of 60-95%, in the sterile area absolute filtration with filters having an efficiency range of 99.9 - 99.99%.

The parameters are very stringent and can only be maintained through deep and constant management and maintenance.

Types of maintenance in hospitals

Maintenance within a healthcare facility must take into account the particular reality in which the priority is to safeguard the safety and health of the people who occupy it (workers and patients), which derives from the reliability of the systems and equipment and continuity of service.

- Plant and civil system master data

- Presence on site of design documentation, as built, declarations of conformity, initial verifications and periodic verifications

- Presence of authorisation documentation on site

Maintenance in healthcare contributes to improving the efficiency of facilities, the continuous improvement of facilities, bearing in mind that any policy adopted influences the quality and safety of the care provided, as well as significantly affecting operating costs.

The main mission of maintenance is to ensure the availability of utilities, installations, buildings, so that they can perform their function safely and qualitatively and can be operated under the best technical/economic conditions.

The performance of maintenance also tends to have a major influence on the performance of plants, their life cycle cost and energy consumption.

Healthcare facilities can implement maintenance policies that can be very different from one another. We can distinguish the following types:

1. Maintenance at fault: action is taken once the fault/failure has occurred

a. Pros:

i. zero maintenance costs until failure

b. Cons:

i. Loss of revenue due to sudden plant downtime

ii. Unpredictability of downtime

iii. Emergency maintenance with higher costs

iv. Possible further failures induced by the first

2. Preventive maintenance: maintenance work at fixed intervals to avoid failure, involving replacement of system parts

a. Pros:

i. It is programmable in a manner consistent with the activity

b. Cons:

i. It represents a fixed cost and it sometimes happens that parts of the system that could still function are replaced

3. Condition-based maintenance: this is scheduled maintenance, but preceded by inspections to check the actual condition of the part to be replaced

4. Predictive maintenance: this is the analysis and interpretation of premonitory signals of faults, allowing action to be taken in the correct time before the fault occurs, minimizing the fixed costs of preventive maintenance and the costs of sudden plant downtime, being able to schedule it at a time most consistent with production needs

In order to ensure safe operation, the healthcare facility must, in addition to the statutory inspections, carry out various periodic maintenance and checks:

1. Monthly replacement of AHU flat filters

2. Quarterly replacement of AHU bag filters

3. Annual replacement of absolute filters in operating rooms

4. Quarterly fancoil maintenance

5. Annual testing of differentials

6. Annual test of isolating transformers

7. Biennial testing of equipotential bonding conductors

8. Quarterly verifications of uninterruptible power supplies

9. Quarterly discharge tests of uninterruptible power supply batteries

10. Quarterly generators inspections

11. Quarterly load tests of generators

12. Quarterly checks of water circuits

Delays in maintenance, in addition to affecting the safety level of the entire system, can result in increased energy consumption, for example:

1. Differential pressure decreased in order increasing inverter frequency

2. Air changes decreasing

3. Heat exchangers clogging

All this translates into electricity and heat energy consumed and often not efficiently.

How is energy consumed in a hospital?

The hospital needs electricity the whole day 365 days/year, thermal energy the whole day 365 days/year, cooling energy the whole day 365 days/year, medical gas the whole day 365 days/year, water the whole day 365 days/year.

The hospital is an ever-living creature, needing heat and cooling energy in both summer and winter

Why do you need thermal energy even in summer?

Thermal energy is needed during the hot period, because rooms with a controlled humidity range, such as operating theatres (40-60%), MRI (40-60%), ICUs (40-60%) need to cool the air inside the AHU below the dew point, for the physical process of dehumidification, and then postheat the air to reach the desired temperature.

Why do you need cooling energy even in winter?

You need refrigeration energy during the cold period, because for example the MRI room has the magnet circuit that must always be refrigerated H24, 365 days/year.

The energy consumption characteristic of a hospital can have different aspects, depending on the intended use of the premises. For example, we can identify 3 types of facilities:

1. the characteristic of a purely in-patient or out-patient facility has a typical day/night ratio of more than 2/1, i.e. daytime consumption is on average more than twice as high as night-time consumption

2. the characteristic of a facility with daytime, in-patient and out-patient operating theatres or diagnostics has a typical 2/1 day/night ratio, i.e. daytime consumption is on average twice as high as night-time consumption

3. the characteristic of a facility with both day and night operating theatres, emergency room, intensive care, inpatient, outpatient and diagnostic facilities has a different, more squashed consumption curve, as night consumption never goes to a minimum.

The typical consumption of a health facility is not, contrary to what one might think, exclusively due to the health sector, but can indicatively be broken down into:

1. Air conditioning, heating and installations: 50-55%.

2. Sanitary: 20-25%.

3. Diagnostics: 10-15%.

4. Lighting: 5%.

5. Other 5%

It follows from this that the most important interventions on energy containment in a healthcare facility should converge in the plant/conditioning/heating area.

What are the strategies for consumption analysis and energy efficiency in a hospital?

Maintenance area

1. Filtration stages: the correct maintenance of air conditioning systems allows operating conditions to be maintained within the design parameters. Dirty filters force ventilation systems to increase their operating speed to allow the set pressure set point to be maintained

2. Heat exchange coils: Correctly maintaining the cleanliness of the fins of the heat exchange coils, located within the air conditioning systems, enables the efficient maintenance of heat exchange parameters, avoiding forcing the three-way valves to work at 100%.

3. Heat circuits: periodic purging and cleaning of the closed heat circuits optimises heat exchange

4. Cold circuits: periodic purging and cleaning of closed cold circuits allows optimisation of heat exchange

5. Colling towers: periodic maintenance of exchange packs not only reduces the risk of Legionella, but also optimises evaporative exchange

6. Hot distribution circuits: maintaining networks by decommissioning old lines

7. Chiller unit plate heat exchangers: periodic cleaning enables the working pressure of refrigerants to be lowered

8. Chilled water production plants: the fine-tuning of chilled water production plants, the source of the largest electricity consumption in a hospital, allows substantial savings

9. Automatic regulation dampers: motorised dampers maintained in efficiency prevent their operation in manual mode

10. Control systems (building management system): continuous maintenance avoids sensor failures that force the systems to work in manual mode to allow for smooth operation

11. Medical compressed air circuits: continuous monitoring and maintenance of terminals limits sources of leakage

12. Lighting: the installation and maintenance of lighting control systems enables the efficient operation of lighting

13. Thermal plant insulation: maintaining efficient insulation affects gas consumption

14. Refrigeration plant insulation: maintaining efficient insulation affects electricity consumption

15. Refrigeration unit exchange batteries: periodic cleaning of the batteries allows the working pressure of the refrigerants to be lowered

Management area

1. Electric and thermal consumption monitoring: the first step in analysing consumption is to monitor it. Know what it consumes, how much it consumes and when it consumes, otherwise any adjustment, maintenance cannot be verified.

2. Equipment scheduling: creation of operating schedules perfectly suited to the needs of the areas being served. For example, changing operation from 'comfort' to 'reduced' for AHUs serving the operating theatres during non-activity, or changing operation from 'comfort' to 'off' for AHUs serving meeting rooms during non-occupancy hours.

3. Extraordinary maintenance of chilled water generation plants

a. Cleaning exchangers

b. Pipe cleaning

c. Made-to-measure insulation

4. Extraordinary maintenance of hot water generation systems

a. Extraordinary maintenance of pumping systems

b. Revamping or replacement of installations

c. Dismantling of dead branches

d. Descaling and sanitising of storage tanks

e. Optimising Legionella risk management

5. Plant climate compensation curves

a. Creation of climate compensation curves, depending on outside temperature,

resulting in a dynamic SP

6. Inverter installation

7. Creation of variable control set points according to 'comfort', 'reduced', 'night' operating

modes. Very useful in chilled water circuits when demand for chilled water decreases

8. Extraordinary lighting maintenance

a. Replacement of lighting sources with LED lighting in common areas, corridors,

connectivity

9. Extraordinary maintenance of thermal installations

a. Periodic cleaning of plate heat exchangers

b. Careful management of water treatment plants thermal plants

10. Replacement of windows and doors

11. Strategies for comparing consumption over different years to assess the goodness of

solutions

Consumption analysis

Energy consumption in the health sector can have a very wide variability in consideration of:

- Building typology

- Geographical position and exposure

- Daytime, daytime and night, weekday, weekday and holiday operation

- Type of structure if

a. outpatient,

b. outpatient and inpatient,

c. outpatient, inpatient and surgical,

d. outpatient, inpatient, surgical and intensive care

- presence or absence of forced ventilation

- site climate

comparing energy consumption, even on the same structure, is therefore a difficult task.

First it is necessary to purify consumption of the climate factor by calculating a normalisation index that takes into account both heating degree days and cooling degree days.

The climate parameter is calculated by taking into account heating degree days and cooling degree days. It is necessary to calculate a sample of at least 20 years in order to average the annual result over more than 20 years and obtain a dimensioned number that allows the calculation of the specific energy consumption, adjusted for the climate variable. From this calculation, a dimensioned parameter is obtained with which to divide the monthly consumption and obtain the consumption adjusted for the climate parameter. If the facility is still the same and has not changed the complexity of the care provided, the climate parameter is sufficient to provide a specific consumption value that makes it comparable between different years. If the objective is to compare different structures, it is necessary to calculate other parameters. Secondly, it is necessary to classify the facility according to the complexity of care.

A coefficient is calculated to identify areas according to the complexity of care:

a. High-tech area: 3

b. Diagnostic imaging area: 1.5

c. Degrees: 1

d. Outpatient clinics: 0.65

e. Offices, services: 0.5

Lastly, a humanisation coefficient is calculated, i.e. in how many areas there is a ventilation and/or air conditioning system, based on technical-hygrometric comfort:

f. Areas with mechanical ventilation and summer climate: 2

g. Areas not served by mechanical ventilation: 1

h. Areas with recent coat and windows: 0.5

At this point, the equivalent surface area can be calculated by multiplying the actual surface area.

Calculating the equivalent surface area to obtain kWh/m2

Equivalent surface area: (Surface area) x (coefficient 1) x (coefficient 2)

After calculating the equivalent surface area and obtaining the climatic coefficient, the monthly consumption can be multiplied with the parameter obtained and the result is a specific consumption (both electricity and natural gas), which makes it possible to compare the consumption of different healthcare facilities

Average consumption in northern Italy:

19Mwh/pl

1850Sm3/pl

So at about 200 bed an Energy Manager has to be named