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Backup services at health institutions - Can we make health services uninterruptible?
South African Federation of Hospital Engineering and Clinical Engineering Association of South Africa
SAFHE CONFERENCE 6-8 AUGUST 2019
Introduction
Why backup services? A health facility relies on water, sanitation, electrical, electronic and mechanical installations to provide health care and save lives.
Every effort is made to prevent breakdowns, through design, project implementation, ongoing upgrades, proper operation and regular maintenance.
The presentation explores challenges and solutions on various infrastructure facilities.
Presentation outline • The presentation provides
• an overview of the critical services that make a hospital different from a hotel;
• an understanding of the linkages between health service provision and infrastructure;
• how to get them working and keep them working.
• All facilities should have backup to the essential life-saving services including
• Engineering & bulk services at hospitals, • alternative backup electrical power at ideal clinics, • online generator monitoring system, • augmenting ESKOM power with solar thermal & solar pv
supplies for the laundry upgrading projects, • backup water • backup sanitation
• Issues are addressed during planning, implementation, operation and maintenance.
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Who’s this?
And now he’s in
theatre ….
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How did he get there? The referral system for health services
Tertiary hospital / Specialised
Regional hospital
District hospital
Community health centre
Clinic
Community health workers
Social determinants of health
Regional Hospitals provide level 2 health services to approx. 1.2 m population
District Hospitals provide level 1 health services to approx. 250,000 population
SOUTH AFRICA Population 57,725,600 (July 2018 estimate)
Growth rate 1.55% Annual growth 894,747
Patient referral to the
Regional hospital
Clinics provide services to up to 6000 population
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What’s needed
for success?
Clean utensils from
CSSD
Clean surfaces, hands, air
Staff
Medical gases,
vacuum
HVAC quality, air changes,
humidity, temperature
Lighting
Equipment and power
What’s needed for
success?
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1
0
5 4
4
3 2
What’s needed for
success?
Clean utensils from
CSSD
Clean surfaces, hands, air
Staff
Medical gases,
vacuum
HVAC quality, air changes,
humidity, temperature
Lighting
Equipment and power
CENTRALISED STEAM STERILISATION DEPARTMENT (CSSD)
THE PROCESS
• Sorting & sluicing
• Pre-washing
• Sonar
• Autoclaves using steam or hydrogen peroxide
• Sterile storage
ENGINEERING SERVICES REQUIRED
• Hot & cold water supply, waste water, backup water
• Electricity, backup electricity
• Steam (larger hospitals)
• HVAC
Clean utensils
from CSSD
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1
The steam system
Challenges and solutions • Installation costs are high – Do lifecycle cost comparisons
with electrical / alternatives at concept design stage
• Operational costs are high and include operator salaries, coal, water, repairs, parts, millwrights
• Scheduling repairs, getting parts, artisans
• Quality of coal and water
• Design changes over time can result in dead legs
• Where there are existing boilers its often more cost effective to keep them for the rest of their useful life
• High energy costs
How it works …
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Standby boiler
Low pressure (<80 degrees)
Low pressure (<80 degrees)
Hot water calorifier
Kitchen equipment Laundry equipment
CSSD equipment
Wards ? Nursing
school? Staff
accommodation?
Low pressure process (<80 degrees)
Condensate return pipes, valves, tanks, pumps, etc Feed hot
water into
the boiler
Steam pipes, valves, pumps, traps, etc Distribute
steam
around the
hospital
Hot water calorifier
How to reduce wastage to cut fuel & operational costs? • Quick wins:
• Service the boiler • Repair the coal feed screw and other labour saving devices • Treat the water, repair/replace the water softener • Quality of the coal • Service the steam equipment in laundry, kitchen, CSSD, calorifiers
& hot water circulating pumps • Repair steam reticulation leaks and repair/replace valves & traps
on the steam line and condensate return line • Repair/Replace condensate return tanks, pumps & leaks • Repair/Replace lagging (insulation) on steam pipes, condensate
pipes, boiler & boiler flue (chimney) • Remove/Cut-off “dead legs” • Laboratory analysis of coal and water • Continuous training of staff • Shortage of staff
• Projects: • Reducing the load on older boilers e.g autoclaves • Install heat pumps to manufacture domestic hot water using
reclaimed heat from chillers e.g. at theatre block. At Groote Schuur hospital in 2017 the cost was R1 500 000. Resulted in saving of coal, water and electricity. Return on Investment: 7 to 9 months
• Upgrade boiler house equipment e.g. replace the soot separators as well as the induced draft fans, install variable speed drives on the boiler stoker and force draft motors, upgrade the boiler house electrical system, sand blast the boiler tubes and flues
• Decentralise boilers to separate high and low pressure systems
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Standby boiler
Low pressure (<80 degrees)
Low pressure (<80 degrees)
Hot water calorifier
Kitchen equipment Laundry equipment
CSSD equipment
Wards ? Nursing
school? Staff
accommodation?
Low pressure process (<80 degrees)
Condensate return pipes, valves, tanks, pumps, etc Feed hot
water into
the boiler
Steam pipes, valves, pumps, traps, etc Distribute
steam
around the
hospital
Hot water calorifier
Example project:
Polokwane Hospital
What’s needed for
success?
Clean utensils from
CSSD
Clean surfaces, hands, air
Staff
Medical gases,
vacuum
HVAC quality, air changes,
humidity, temperature
Lighting
Equipment and power
HEATING, VENTILATION & AIR CONDITIONING (HVAC)
• Prevent infection transfer through air changes and filters
• Keep the patient and staff comfortable at the right temperature and humidity
HVAC quality, air changes, humidity,
temperature
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THEATRE HVAC
How it works …
• Operating departments • Obstetrics • High care, critical care and intensive care • Isolation units • Waiting areas
• Pathology labs • IVF Labs • Burns units • Neonatal units • Mortuary unit
Challenges and solutions
• High energy costs
• Maintenance of air handling units, etc
• Closing theatres for maintenance and repairs
• Costs of filters & HEPA filters
• Particle count tests to be done every year in ISO class 8,7,6 theatres, 6 monthly in class 5, when HEPA filters are replaced, when infections increase, if any alterations or construction was done in theatre
• Specialist HVAC applies in other areas …
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Breathing zone
Occupied zone
Example: Minor theatre full fresh air & exhausted
Example project: Letaba
Hospital
MEDICAL GASES
• Oxygen
• Nitrous oxide
• Anaesthetic gas-scavenging points
• Low-pressure medical air
• High-pressure medical air
• Medical vacuum points
What’s needed for
success?
Clean utensils from
CSSD
Clean surfaces, hands, air
Staff
Medical gases,
vaccuum
HVAC quality, air changes,
humidity, temperature
Lighting
Equipment and power
Medical gases,
vacuum
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3
Piped oxygen
MEDICAL GASES
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Anaesthetic gas scavenging
Vacuum system
& NNICU
& NNHC Example project: Letaba
Hospital
ELECTRICAL SUPPLY & BACKUP POWER AT HOSPITALS
• Mains electrical supply
• On-site reticulation
• Backup generators
• Life saving UPS
What’s needed for
success?
Clean utensils from
CSSD
Clean surfaces, hands, air
Staff
Medical gases,
vaccuum
HVAC quality, air changes,
humidity, temperature
Lighting
Equipment and power
Electrical supply & backup power
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4
ELECTRICAL SUPPLY & BACKUP POWER AT HOSPITALS – Distributed network How it works …
Ideal for Distributed Hospital
Challenges and solutions • Lack reliability from Eskom or municipal power
supply.
• Reliance on the diesel generators as back-up.
• Ring feed on the medium network – allow power to be supplied via each cable path.
• Remote monitoring of diesel generators is essential - fuel management (monitor fuel level on bulk and day tanks), feeder line performance (voltages and currents), warning of faults – in real time.
• In most cases, require retrofitting fuel level sensors on diesel tanks and installation of controller & gateway devices on each generator to access the information via web & to control the generator remotely. The system can also send notifications (via SMS or emails) to designated persons.
• More information on the monitoring covered in subsequent slides….
Letaba Hospital
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Generator 1
Transformer 1
Transformer 2
Generator 2
LV Panels
Eskom or municipal feeder
Essential loads
Non- essential loads
Essential loads
Non- essential loads
Main switchgearSwitchgear 2
Switchgear 3
MV cable
ELECTRICAL SUPPLY & BACKUP POWER AT HOSPITALS – Centralised network How it works …
Ideal for Compact Hospital
Generator 1
Transformer 1
Transformer 2
Generator 2
Main LV Panels
Eskom or municipal feeder 1
Essential loads
Non- essential loads
Essential loads
Non- essential loads
Main switchgear
Eskom or municipal feeder 2
Challenges and solutions
• Supply is more robust (supplied via two separate feeders).
• Transformers sized to carry the entire load of the hospital (same size)
• Generators may also be sized to carry entire load or all the essential loads of the hospital (also same sized).
• Network has N-1 redundancy. Faults and maintenance on one line or transformer does not affect supply to loads.
• Maybe be costly due to large sizes of the generators and transformers.
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ONLINE MONITORING OF GENERATORS How it works
• Each generator is fitted with its own controller, gateway device (which can connect more than 1 controller), GSM antennae and sim card (required on some controllers).
• Can monitor many generators via web or App in real time – depending on controller capability.
Challenges • Many controllers in the market – not compatible with
each other. E.g. DSEWebNet control and access deepsea control modules only
• Either retrofit new controller with preferred one (cost implications) or use more than one controller (no standardisation)
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ALTERNATIVE BACKUP POWER AT IDEAL CLINICS
• Ideal clinics need backup power to qualify as ideal
• The first phase of the programme provided backup generators supplying the whole clinic site
• Maintenance issues and fuel supply will require ongoing management by the districts & facilities
• Battery backup solutions are being investigated for future phases as the costs are reducing steadily (with or without solar)
• Solar panels require extra security so aren’t ideal for public facilities, but solar PV on the parking area is very cost effective
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USING SOLAR PV AND SOLAR THERMAL TO REDUCE PEAK LOADS & LIFETIME COSTS
The opportunity • Hospital laundries function during normal
working hours
• Thus the peak electricity usage is during the day
• Laundry buildings have large roof areas
Lifetime costing • Hospital laundry equipment is designed to
last 12-15 years
• Over the 12-15 year lifespan, costs were compared between • Mains electricity alone • Solar water pre-heating and solar PV electricity
alone • A mix of the 3 energy sources
• The life cycle costs of the mixed energy sources is lowest i.e. mains electricity covers the base electricity required, and solar thermal and solar PV cover the peak loads in the middle of the day when the laundry is busiest
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What’s needed for
success?
Clean utensils from
CSSD
Clean surfaces, hands, air
Staff
Medical gases,
vaccuum
HVAC quality, air changes,
humidity, temperature
Lighting
Equipment and power
BACKUP WATER AND SANITATION
• Potable water supplies, 72 hour backup
• Waste water
• Fire water
• Ablutions, backup
Water and sanitation
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MOVING WITH THE TIMES …. THE DIGITAL FUTURE
Digital future pursuits improve the performance of assets & reduce patient numbers & time in facilities:
• Capture asset data e.g. Facility condition assessments into the PMIS and use it with the existing project management data to produce the UAMP and IPMP documents
• Pharmacy stock control, Emergency medical services logistic support
• Remote monitoring of theatres with direct reporting to HOD, CEO, clinical & maintenance manager
• BMS on electro-mechanical installations at hospitals • Queue management systems to reduce patient waiting times
• Annual testing of medical equipment (e.g. incubators) using off the shelf test units
• A body suit full of equipment used by maintenance supervisor weekly to to trace the route, film and monitor air, temperature, lux, humidity, etc.
• Mobile testing of CO2 levels as a proxy for air changes to prevent TB & measles transmission
• Track medication through the distribution channels & cold chain (chronic meds and vaccines)
………………………….. • Community health workers use a mini vital signs kit (finger-prick) to
upload diagnostics to AI for the diagnosis (80% of patient visits result from 25% of medical conditions)
• Patients wear med trackers that dispense • Robots perform surgery in private & public hospitals • Explore integrating different data sets to improve community based
healthcare & match PHC facilities to patient load • ….
CAN WE MAKE HEALTH SERVICES UNINTERRUPTIBLE?
• Yes ….
• Change is constant - The population is growing, medicines and medical techniques improve, the burden of disease changes, non-communicable diseases are rising, patient numbers fluctuate so facilities and systems need to be flexible and need regular upgrading
• Design out risk and maintenance
• Quality of construction and installations matters
• Maintenance counts – need workshops, specialised staff, faster response times, monitoring/fault reporting & management systems
• Digital technologies can make it much easier
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