The HILLSIDE - User contributions [en-gb]

Infection Prevention and Control/Air Disinfection

2024-10-10T15:07:37Z

Tobyvan: /* Installation */

==Implementation of Upper Room UVGI==
===Introduction and context===
This guide is a compilation of current best practice and knowledge regarding the design, development and operation of indoor room air ultraviolet germicidal irradiation (UVGI) systems for reducing the rate of transmission of airborne diseases such as tuberculosis (TB).

This guidance document is not intended for the applications of water or surface disinfection.
===Effectiveness of UV===
The disinfection effectivity of UVGI and the susceptibility of airborne microorganisms including M. tuberculosis (TB) bacilli (peak sensitivity at around 265nm) have been scientifically proven.
===Safety===
UV-c has a lower skin penetration depth, thus does not easily cause skin irritation or cancers when compared to UV-a and UV-b found in sunlight. UV-c does cause eye irritation at high exposure levels.

Therefore, UVGI in occupied rooms should not exceed an exposure dose of 6 mJ/cm² (for mercury vapour lamps at 254 nm 15) and 3.8 mJ/cm² (at 265nm) per 8h.
The potential of high UV intensities being reflected from certain materials (e.g. reflectors of regular open luminaires, windows, exposed ducting and metallic or high gloss architectural finishes) into the occupied portion of the room must be considered by designers and users.

During any work in the upper room or with open UVGI devices, eye and skin protection should be worn.
===Applications and definitions===
The application of UVGI should not be seen as a substitute for, rather a component of, a comprehensive IPC policy.
====Upper room UVGI====
These devices irradiate air and inactivate pathogens in the unoccupied zone of the upper room. During normal air circulation, the air exchange between the upper and lower room reduces the concentration of viable airborne pathogens in the whole room.
====Air cleaners====
Room air cleaners consisting of enclosed UVGI lamps in housings, circulate air to achieve a measure of clean air delivery to the room. The advantages are related to safety aspects and lower maintenance costs.
====Whole room UVGI====
Whole room UVGI disinfection attempts to sterilise room surfaces by exposing the entire room volume to high UV fluence levels. This method is ineffective for reducing airborne transmission within occupied rooms.
===Planning and procurement===
The uncontrolled use of UVGI without a comprehensive management policy can result in fruitless expenditure and create a false sense of protection, thereby potentially exposing building occupants to increased risk. The management policy should align with the regional and national IPC policies and should include sourcing and procurement, maintenance, training, decommissioning and disposal of UVGI devices.
===Design and installation===
====Design lifecycle====
The UVGI design life cycle should include system planning, space evaluation, design and review, control of the design and commissioning documents. Risk prioritization and reverting to more conventional infection control strategies should be considered. Interference from obstructions (light fixtures, beams, ductwork, piping, furniture, equipment or non-prescribed lighting diffusers) to airflow around the device or radiation from the device must be taken into account.
Two design processes are briefly described. 

====Radiometric design process====
Two rational design methods are available. 

The first recommended rational design process follows the guidance of CIE 155:200315 and the design completion will need quantification and verification of:

*Selected UVGI device’s radiometric data
*Considered pathogen’s UV-c sensitivity (Z-value)
*Considered pathogen’s infectious dose
*Air exchange rates and ventilation efficiency parameters 

The design objective is a prescribed reduction in transmission of 80% or higher.

The second recommended rational design process is available through the application of design software targeting prescribed whole-room radiant flux levels. However, this method is only appropriate for open type UVGI devices.

{{Anchor|PrescriptiveDesign-UVGI}}
====Prescriptive design process====
The prescriptive design process aims to determine the required number of UVGI devices for the considered indoor space and the resultant occupancy limits in accordance with the WHO recommended minimum ventilation rate of 80 l/s per person. This design process is applicable for well-mixed room air, achieved through the installation of mixing fans. If the considered room has an existing and functional mechanical ventilation system, the outside air portion of that system’s ventilation rate should be included in the calculation to increase the occupancy limit determination. The design process assumes that UV-reflective surfaces do not affect eye safety. 

The following set of device and application data is required: 

*Total maintained UVGI radiant flux <math display="inline">\bigl(\Phi_T , mW \bigr)</math> of selected devices, measured in accordance with SATS 1706:2016 as amended and the UVGI measurement and instrumentation and calibration plan
*The selected device’s minimum equivalent clean air delivery rate <math display="inline">\bigl(CARD_e , L/s \bigr)</math>.
*Room volume <math display="inline">\bigl(V_r , m^3 \bigr)</math>, occupancy profile <math display="inline">\bigl(N_p , number of persons \bigr)</math> and effective mechanical ventilation rate (Qv, l/s) of considered room.

 

#<math>Number of devices_\phi=\frac{14\times V_r}{\phi_T}</math>
#<math>CADR_e=\frac{\bigl( 80\times N_p \bigr) -Q_v}{Number of devices_{CADR} }</math>

It is strongly recommended that the room be labelled with clear and informative signage to indicate the TB related occupancy limits with the UV system turned on and turned off. 

=====Acceptance criteria=====
Design requirements for effectiveness can be assessed through compliance with the following:

*Minimum required UV volumetric fluence rate (MRU) of 14mW/m³ or
*A UVGI equivalent ventilation rate of the product of 80 l/s per person and the typical peak number of room occupants. This CADRe rate determines the total required UV-c output.

Any shortfall between the required and the actual ventilation rate or MRU should be corrected for increasing by the number of UVGI devices installed, as determined using the formulae in section [[#PrescriptiveDesign-UVGI|§ Prescriptive Design Process]]. The number of devices required should not be less than the minimum number determined, or exceed this value by more than 1.

Alternatively, for rooms with unknown occupancy levels, the CADRe resulting from the number of devices determined by the prescribed MRU could be used to define the safe occupancy limit for that room
The UV dose should inactivate airborne infectious agents by at least 90% (D90) or a percentage equivalent of the ventilation rate of 80 l/s/per person as recommended by the WHO.

 

[[File:Upper Room UVGI Decision Tree.png|none|thumb|Design Decision Tree for Upper Room UVGI]]

====Lamp Ageing====
A 100-hour lamp burn-in is recommended prior to the device characterisation or system verification tests. The lamps of dimmable systems should be burnt-in at full output for the initial seasoning period.

====Factors affecting performance====
UVGI disinfection performance is dependent on good air movement rates either through natural convection or mechanically aided (e.g. paddle fan). The effectiveness may be reduced if the mechanical ventilation rates in a room are increased together with equivalent room air mixing. However, as ventilation is a primary environmental control against indoor airborne transmission, its maximum capacity within the considered area should be determined and targeted before implementing a UVGI solution.

====Installation====
The device must not be able to tilt or swing under normal operation.

The minimum installation height of the lower horizontal plane of any open UVGI device above the finished floor level is determined from the table below.

{| class="wikitable"
!Ceiling Height (m)
! colspan="3" |Recommended Mounting Height (m):
|-
| ||'''Corner type (90°)'''||'''Wall type (180°''')||'''Pendant type (360°)'''
|-
|2.4||2.2||2.2||2.4
|-
|2.7||2.3||2.3||2.4
|-
|3.0||2.4||2.4||2.4
|-
|}

In the typical application of 254 nm LPMV devices, occupant eye exposure shall not exceed and average of <math>0.10 \mu W\cdot cm^-2</math> for a period of time equivalent to 8 hours per day. The strategy for factoring equivalent acceptable exposure levels in the lower room in typical healthcare settings is represented in the table below.

{| class="wikitable"
!ZONE!!EYE LEVEL (m)!!ESTIMATED DAILY EXPOSURE TIME (h)!!IRRADIANCE LIMIT (uW/cm²)
|-
|Corridors (no waiting)||1.7||1||0.8
|-
|Indoor Waiting Areas||1.7
1.2
|3||0.3
|-
|ICU||1.7 1.0||4 6||0.2 0.15
|-
|Bedrooms/Offices||1.7 1.2||2 4||0.4 0.2
|-
|Wards/Dormitories||1.7 1.2||2 4||0.4 0.2
|-
|Isolation Rooms||1.7 1.2||2 4||0.4 0.2
|-
|Consultation Rooms||1.7||2||0.4
|-
|Bronchoscopy rooms||1.7||2||0.4
|-
|Autopsy Rooms||1.7||2||0.4
|-
|Dining Halls||1.7||2||0.4
|-
|Dormitories||2.1||8||0.1
|-
|Other areas||1.7||4||0.2
|-
|}

====Commissioning and start-up====
The system start-up should commence after the installation process is complete. Prior to start-up and the initial verification testing, lamps must be cleaned and seasoned according to the manufacturer’s instructions.
Device performance should be verified independently, by switching all devices off then measuring each device’s output individually. The output must concur with the initial specification stipulated in the procurement bid.
The 1m and 2m maximum irradiance (measured at 1m and 2m from the external front face of the device) for each device must comply with the manufacturer’s declared performance values. Using declared lifetime low performance values, each new or refurbished device will be independently accepted for service when it is proven to exceed the declared minimum or depreciated performance values by at least 43% (100/70).

Example:

<math>65 mW.cm^{-2} </math> -(declared 2m irradiance)

<math>65\times1.43=92.95 mW.cm^{-2} </math> -(acceptance measurement at 2m)

Eye safety measurements should only be conducted after performance verification tests are successfully completed.
====Documentation====
The following reports and records are required upon handover:

*User requirement specification
*Design report
*Performance verification report
*Operation and maintenance manual 

The operation and maintenance manual (O&M) should include the following information:

#Designer’s trade name, contact and professional or technical registration details.
#Room selection methodology; alternatively, where this selection was not made by the design consultant, a copy of the design brief.
#Electrical wiring drawings and compliance certificate covering all building electrical work relating to the UVGI installation.
#Plan and elevation drawings of considered rooms indicating device installation details, supporting structures and obstructions to radiation and airflow.
#Design data, including assumptions such as room occupancy and ventilation levels.
#Selected device performance criteria and datasheets.
#Selected lamp data sheets including rate lamp life and details of 3 alternate lamps and suppliers.
#Startup and shut down procedures.
#Maintenance and monitoring protocol, plan and log-book template.
#Initial performance and safety verification acceptance criteria.
#Performance verification reports
#Device cleaning instructions.
#Spare parts list with recommended stock levels.
#Decommissioning and disposal instructions

===Monitoring and maintenance===
In every workplace which may result in persons being exposed to hazardous biological agents (HBA) in the performance of their duties, the R1390 Government Gazette of 27 December 2001 No. 22956 is applicable. This legislation requires that the employer shall ensure that all control measures for transmission-based precautions are maintained in good working order; and that thorough examinations and tests of engineering control measures - such as UVGI - are carried out at intervals not exceeding 24 months by an approved inspection authority or their verified delegate.
Record of the examinations and tests carried out in terms of regulation and of any repairs resulting from these investigations and tests must be kept for at least three years.
If the maintenance and monitoring is done in-house it should be conducted by trained and competent personnel.
A maintenance plan shall be developed for each installation and include cleaning and component replacement as per manufacturer’s instructions. It is recommended that maintenance tags be put on all devices. A predictive maintenance model is recommended to determine frequency of maintenance interventions. System level maintenance and monitoring plans can initially be derived from generic templates but should be reviewed and updated regularly.

Irradiance measurements should be taken in the same location and orientation for repeatability between measurements. These locations can be physically marked in the room.

====Corrective actions====
If individual devices fail initial performance measurement upon lamp re-cleaning and ballast replacement, then the devices should be identified clearly with a red non-conformance sticker and scheduled for decommissioning and disposal. Any new ballasts and lamps installed in failed devices should be immediately salvaged for re-use. 

If the number of unserviceable devices within a considered space and system results in an insufficient number of functional devices; the entire system serving that space shall be declared as non-compliant. Individual devices declared functional within a non-functional system may be salvaged for re-use.

[[File:UVGI US TAG.png|none|thumb|Recommended Device Unserviceable Tag]]

===Training===
Competence and training of both system owners and service providers are critical to the successful and sustainable implementation of UVGI air disinfection systems. Professional service providers can be trained either by professional institutions or through tertiary or post graduate education. System owners can be trained by the service provider or can outsource training from a reputable and accredited training institution. An example of a responsibility matrix including the minimum training topics to be covered is presented in the complete guidance document.

===Acknowledgements===
Edward A. Nardell (Brigham and Women's’ Hospital), Richard L. Vincent (Mount Sinai Medical Center), Steve N. Rudnick (Harvard School of Public Health), Paul Jensen (US Centers for Disease Control), Lindiwe Mvusi (NDoH), FW Leuschner (University of Pretoria).
The development of the guidance document was supported by the Presidents Emergency Plan for Aids Relief (PEPFAR) grant together with the US-CDC. The content of this report does not necessarily reflect the opinion of the funders or those acknowledged or referenced in its development.

===Key References===

#IUVA Draft Guideline IUVA-G02A-2005 International Ultraviolet Association Guideline for Design and Installation of UVGI Air Disinfection Systems in New Building Construction Copyright 2005 International Ultraviolet Association
#Fundamental Factors Affecting Upper-Room Ultraviolet Germicidal Irradiation—Part II. Predicting Effectiveness
#World Health Organisation. WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Geneva, Switzerland; 2004.
#World Health Organisation. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Diseases in Health Care. Geneva, Switzerland, Switzerland; 2007.
#World Health Organisation. Natural Ventilation for Infection Control in Health-Care Settings. Geneva, Switzerland; 2009. http://www.who.int/entity/water_sanitation_health/publications/natural_ventilation.pdf. Accessed April 30, 2013.
#Downes A, Blunt T. Researches on the effect of light upon bacteria and other organisms. Proc R Soc London. 1877;26:179-184. http://rspl.royalsocietypublishing.org/content/26/179-184/488.full.pdf. Accessed May 28, 2014.
#Gates FL. A study of the bactericidal action of ultra violet light: III. The absorption of ultra violet light by bacteria. J Gen Physiol. 1930;14:31-42. http://jgp.rupress.org/content/14/1/31.full.pdf.
#Riley R. Guidelines for the Application of Upper-Room Ultraviolet Germicidal Irradiation for Preventing Transmission of Airborne Contagion — Part I : Basic Principles. 1999.
#Wells WF, Fair MG. Viability of B. coli exposed to ultra-violet radiation in air. Science (80- ). 1935;82:280-281.
#Riley RL, Permutt S. Room air disinfection by ultraviolet irradiation of upper air. Arch Environ Heal An Int J. 1971;22(2):208-219. http://www.tandfonline.com/doi/pdf/10.1080/00039896.1971.10665834#.U4Ym1fmSxyU.
#Riley RL, Permutt S. Convection, air mixing, and ultraviolet air disinfection in rooms. Arch Environ Heal An Int Journal1. 1971;22:200-207.
#Riley RL, Permutt S, Kaufman JE. Room air disinfection by ultraviolet irradiation of upper air: further analysis of convective air exchange. Arch Environ Heal An Int J. 1971;23(2):35-39.
#Escombe AR, Moore DAJ, Gilman RH, et al. Upper-room ultraviolet light and negative air ionization to prevent tuberculosis transmission. Wilson P, ed. PLoS Med. 2009;6(3):e43. doi:10.1371/journal.pmed.1000043.
#Nardell EA, Bucher SJ, Brickner PW, et al. Safety of upper-room ultraviolet germicidal air disinfection for room occupants: results from the Tuberculosis Ultraviolet Shelter Study. Public Health Rep. 2008;123(1):52-60. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2099326&tool=pmcentrez&rendertype=abstract.
#Nardell EA. Environmental control of tuberculosis. Med Clin North Am. 1993;77(6):1315-1334. http://europepmc.org/abstract/MED/8231415. Accessed June 9, 2014.
#NIOSH US Department of Health, Education and Welfare PHS. Criteria for a Recommended Standard Occupational Exposure to Ultraviolet Radiation.; 1972. doi:(HSM) 73-110009.
#CIE Technical Division 6. CIE 155: 2003 Ultraviolet Air Disinfection. Vienna, Austria; 2003. doi:ISBN 978 3 901906 25 1.
#The International Commission on Non-Ionizing Radiation Protection. Guidelines on Limits of Exposure to Ultraviolet Radiation of Wavelengths between 180 Nm and 400 Nm (Incoherent Optical Radiation). Vol 87.; 2004. doi:10.1097/00004032-200408000-00006.
#R.L. Riley, M K, G M. Ultraviolet susceptibility of BCG and virulent tubercle bacilli. Am Rev Respir Dis. 1976;113:413-18.
#Mundt E, Nielsen P V. Ventilation Effectiveness.; 2004.
#SATS 1706: 2015 SOUTH AFRICAN TECHNICAL STANDARD UVGI Luminaires - Safety and performance requirements.
#Beggs CB, Noakes CJ, Sleigh P a., Fletcher L a., Kerr KG. Methodology for determining the susceptibility of airborne microorganisms to irradiation by an upper-room UVGI system. J Aerosol Sci. 2006;37(7):885-902. doi:10.1016/j.jaerosci.2005.08.002.
#Illuminating Engineering Society of North America (IESNA) Testing Procedures Committee. Standard File Format for Electronic Transfer of Photometric Data and Related Information (ANSI/IESNA LM-63-02). New York; 2002.
#F.W. Leuschner. UVGI MEASUREMENTS, INSTRUMENTATION & FACILITIES PLAN. Pretoria; 2014.
#Zhang J, Levin R, Angelo R, et al. A radiometry protocol for UVGI fixtures using a moving-mirror type gonioradiometer. J Occup Environ Hyg. 2012;9(3):140-148. doi:10.1080/15459624.2011.648569.
#Illuminating Engineering Society of North America (IESNA) Testing Procedures Committee. IES Guide for Lamp Seasoning (LM-54-91). New York; 1991.
#First MW, Banahan KF, Dumyahn TS. Performance of ultraviolet germicidal irradiation and luminaries in long-term service. Leukos. 2007;3:181-188. doi:10.1582/LEUKOS.2007.03.03.005.
#South African Bureau of Standards. SANS 50285 : 2010 SOUTH AFRICAN NATIONAL STANDARD Energy Efficiency of Electric Lamps for Household Use Measurement Methods.; 2010.
#Vorlander FJ, Raddin EH. The effect of operating cycles on flourescent lamp performance. Illum Eng. 1950.
#Miller S.L., Hernandez M., Fennelly K, et al. Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation Guidelines for Healthcare Settings. Cincinnati, OH; 2009. http://www.cdc.gov/niosh/nas/rdrp/appendices/chapter6/a6-23.pdf.
#Xu P, Peccia J, Fabian P, et al. Efficacy of ultraviolet germicidal irradiation of upper-room air in inactivating airborne bacterial spores and mycobacteria in full-scale studies. Atmos Environ. 2003;37(3):405-419. doi:10.1016/S1352-2310(02)00825-7.
#Ko G, First MW, Burge H a. Influence of relative humidity on particle size and UV sensitivity of Serratia marcescens and Mycobacterium bovis BCG aerosols. Tuber Lung Dis. 2000;80(4-5):217-228. doi:10.1054/tuld.2000.0249.
#Miller S, Hernandez M, Fennelly K. Efficacy of ultraviolet irradiation in controlling the spread of tuberculosis. Atlanta Centers Dis …. 2002. http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Efficacy+of+ultraviolet+irradiation+in+controlling+the+spread+of+tuberculosis#0. Accessed August 15, 2014.
#Mphahlele M, Dharmadhikari AS, Jensen PA, et al. Institutional Tuberculosis Transmission: Controlled Trial of Upper Room Ultraviolet Air Disinfection - A Basis for New dosing Guidelines. Am J Respir Crit Care Med. 2015:150504122726005. doi:10.1164/rccm.201501-0060OC.
#Noakes CJ, Beggs CB, Sleigh PA, Kerr KG. Effect of Room Mixing and Ventilation Strategy on the Performance of Upper Room Ultraviolet Germicidal Irradiation Systems. In: Proceedings of ASHRAE IAQ 2004. ; 2004:1-13.
#First M, Rudnick SN, Banahan KF, Vincent RL, Brickner PW. Fundamental factors affecting upper-room ultraviolet germicidal irradiation - part I. Experimental. J Occup Environ Hyg. 2007;4(5):321-331. doi:10.1080/15459620701271693.
#ASHRAE. ASHRAE 55-2013; Thermal environmental conditions for human occupancy. Am Soc Heating, Refrig Air Cond. 2013.
#Coker I, Nardell E, Fourie B. Guidelines for the Utilisation of Ultraviolet Germicidal Irradiation (UVGI) Technology in Controlling the Transmission of Tuberculosis in Health Care Facilities in South.; 2001. http://www.sahealthinfo.com/tb/guidelines.pdf. Accessed June 30, 2014.
#Kowalski W, Bahnfleth W. Proposed standards and guidelines for UVGI air disinfection. IUVA News. 2004;6(1):20-25. http://www.aerobiologicalengineering.com/stds.pdf.
#Rudnick SN, First MW. Fundamental factors affecting upper-room ultraviolet germicidal irradiation - part II. Predicting effectiveness. J Occup Environ Hyg. 2007;4(5):352-362. doi:10.1080/15459620701298167 

[[Category: Infection Prevention and Control]]
[[Category: Decontamination]]
[[Category:Crosscutting Issues]]
[[Category:UVGI]]

Infection Prevention and Control/Air Disinfection

2024-10-10T15:04:39Z

Tobyvan: /* Installation */ Eye exposure limits adjusted to comply with recommendation of Sliney 2013

==Implementation of Upper Room UVGI==
===Introduction and context===
This guide is a compilation of current best practice and knowledge regarding the design, development and operation of indoor room air ultraviolet germicidal irradiation (UVGI) systems for reducing the rate of transmission of airborne diseases such as tuberculosis (TB).

This guidance document is not intended for the applications of water or surface disinfection.
===Effectiveness of UV===
The disinfection effectivity of UVGI and the susceptibility of airborne microorganisms including M. tuberculosis (TB) bacilli (peak sensitivity at around 265nm) have been scientifically proven.
===Safety===
UV-c has a lower skin penetration depth, thus does not easily cause skin irritation or cancers when compared to UV-a and UV-b found in sunlight. UV-c does cause eye irritation at high exposure levels.

Therefore, UVGI in occupied rooms should not exceed an exposure dose of 6 mJ/cm² (for mercury vapour lamps at 254 nm 15) and 3.8 mJ/cm² (at 265nm) per 8h.
The potential of high UV intensities being reflected from certain materials (e.g. reflectors of regular open luminaires, windows, exposed ducting and metallic or high gloss architectural finishes) into the occupied portion of the room must be considered by designers and users.

During any work in the upper room or with open UVGI devices, eye and skin protection should be worn.
===Applications and definitions===
The application of UVGI should not be seen as a substitute for, rather a component of, a comprehensive IPC policy.
====Upper room UVGI====
These devices irradiate air and inactivate pathogens in the unoccupied zone of the upper room. During normal air circulation, the air exchange between the upper and lower room reduces the concentration of viable airborne pathogens in the whole room.
====Air cleaners====
Room air cleaners consisting of enclosed UVGI lamps in housings, circulate air to achieve a measure of clean air delivery to the room. The advantages are related to safety aspects and lower maintenance costs.
====Whole room UVGI====
Whole room UVGI disinfection attempts to sterilise room surfaces by exposing the entire room volume to high UV fluence levels. This method is ineffective for reducing airborne transmission within occupied rooms.
===Planning and procurement===
The uncontrolled use of UVGI without a comprehensive management policy can result in fruitless expenditure and create a false sense of protection, thereby potentially exposing building occupants to increased risk. The management policy should align with the regional and national IPC policies and should include sourcing and procurement, maintenance, training, decommissioning and disposal of UVGI devices.
===Design and installation===
====Design lifecycle====
The UVGI design life cycle should include system planning, space evaluation, design and review, control of the design and commissioning documents. Risk prioritization and reverting to more conventional infection control strategies should be considered. Interference from obstructions (light fixtures, beams, ductwork, piping, furniture, equipment or non-prescribed lighting diffusers) to airflow around the device or radiation from the device must be taken into account.
Two design processes are briefly described. 

====Radiometric design process====
Two rational design methods are available. 

The first recommended rational design process follows the guidance of CIE 155:200315 and the design completion will need quantification and verification of:

*Selected UVGI device’s radiometric data
*Considered pathogen’s UV-c sensitivity (Z-value)
*Considered pathogen’s infectious dose
*Air exchange rates and ventilation efficiency parameters 

The design objective is a prescribed reduction in transmission of 80% or higher.

The second recommended rational design process is available through the application of design software targeting prescribed whole-room radiant flux levels. However, this method is only appropriate for open type UVGI devices.

{{Anchor|PrescriptiveDesign-UVGI}}
====Prescriptive design process====
The prescriptive design process aims to determine the required number of UVGI devices for the considered indoor space and the resultant occupancy limits in accordance with the WHO recommended minimum ventilation rate of 80 l/s per person. This design process is applicable for well-mixed room air, achieved through the installation of mixing fans. If the considered room has an existing and functional mechanical ventilation system, the outside air portion of that system’s ventilation rate should be included in the calculation to increase the occupancy limit determination. The design process assumes that UV-reflective surfaces do not affect eye safety. 

The following set of device and application data is required: 

*Total maintained UVGI radiant flux <math display="inline">\bigl(\Phi_T , mW \bigr)</math> of selected devices, measured in accordance with SATS 1706:2016 as amended and the UVGI measurement and instrumentation and calibration plan
*The selected device’s minimum equivalent clean air delivery rate <math display="inline">\bigl(CARD_e , L/s \bigr)</math>.
*Room volume <math display="inline">\bigl(V_r , m^3 \bigr)</math>, occupancy profile <math display="inline">\bigl(N_p , number of persons \bigr)</math> and effective mechanical ventilation rate (Qv, l/s) of considered room.

 

#<math>Number of devices_\phi=\frac{14\times V_r}{\phi_T}</math>
#<math>CADR_e=\frac{\bigl( 80\times N_p \bigr) -Q_v}{Number of devices_{CADR} }</math>

It is strongly recommended that the room be labelled with clear and informative signage to indicate the TB related occupancy limits with the UV system turned on and turned off. 

=====Acceptance criteria=====
Design requirements for effectiveness can be assessed through compliance with the following:

*Minimum required UV volumetric fluence rate (MRU) of 14mW/m³ or
*A UVGI equivalent ventilation rate of the product of 80 l/s per person and the typical peak number of room occupants. This CADRe rate determines the total required UV-c output.

Any shortfall between the required and the actual ventilation rate or MRU should be corrected for increasing by the number of UVGI devices installed, as determined using the formulae in section [[#PrescriptiveDesign-UVGI|§ Prescriptive Design Process]]. The number of devices required should not be less than the minimum number determined, or exceed this value by more than 1.

Alternatively, for rooms with unknown occupancy levels, the CADRe resulting from the number of devices determined by the prescribed MRU could be used to define the safe occupancy limit for that room
The UV dose should inactivate airborne infectious agents by at least 90% (D90) or a percentage equivalent of the ventilation rate of 80 l/s/per person as recommended by the WHO.

 

[[File:Upper Room UVGI Decision Tree.png|none|thumb|Design Decision Tree for Upper Room UVGI]]

====Lamp Ageing====
A 100-hour lamp burn-in is recommended prior to the device characterisation or system verification tests. The lamps of dimmable systems should be burnt-in at full output for the initial seasoning period.

====Factors affecting performance====
UVGI disinfection performance is dependent on good air movement rates either through natural convection or mechanically aided (e.g. paddle fan). The effectiveness may be reduced if the mechanical ventilation rates in a room are increased together with equivalent room air mixing. However, as ventilation is a primary environmental control against indoor airborne transmission, its maximum capacity within the considered area should be determined and targeted before implementing a UVGI solution.

====Installation====
The device must not be able to tilt or swing under normal operation.

The minimum installation height of the lower horizontal plane of any open UVGI device above the finished floor level is determined from the table below.

{| class="wikitable"
!Ceiling Height (m)
! colspan="3" |Recommended Mounting Height (m):
|-
| ||'''Corner type (90°)'''||'''Wall type (180°''')||'''Pendant type (360°)'''
|-
|2.4||2.2||2.2||2.4
|-
|2.7||2.3||2.3||2.4
|-
|3.0||2.4||2.4||2.4
|-
|}

In the typical application of 254 nm LPMV devices, occupant exposure shall not exceed and average of <math>0.10 \mu W\cdot cm^-2</math> for a period of time equivalent to 8 hours per day. The strategy for factoring equivalent acceptable exposure levels in the lower room in typical healthcare settings is represented in the table below.

{| class="wikitable"
!ZONE!!EYE LEVEL (m)!!ESTIMATED DAILY EXPOSURE TIME (h)!!IRRADIANCE LIMIT (uW/cm²)
|-
|Corridors (no waiting)||1.7||1||0.8
|-
|Indoor Waiting Areas||1.7
1.2
|3||0.3
|-
|ICU||1.7 1.0||4 6||0.2 0.15
|-
|Bedrooms/Offices||1.7 1.2||2 4||0.4 0.2
|-
|Wards/Dormitories||1.7 1.2||2 4||0.4 0.2
|-
|Isolation Rooms||1.7 1.2||2 4||0.4 0.2
|-
|Consultation Rooms||1.7||2||0.4
|-
|Bronchoscopy rooms||1.7||2||0.4
|-
|Autopsy Rooms||1.7||2||0.4
|-
|Dining Halls||1.7||2||0.4
|-
|Dormitories||2.1||8||0.1
|-
|Other areas||1.7||4||0.2
|-
|}

====Commissioning and start-up====
The system start-up should commence after the installation process is complete. Prior to start-up and the initial verification testing, lamps must be cleaned and seasoned according to the manufacturer’s instructions.
Device performance should be verified independently, by switching all devices off then measuring each device’s output individually. The output must concur with the initial specification stipulated in the procurement bid.
The 1m and 2m maximum irradiance (measured at 1m and 2m from the external front face of the device) for each device must comply with the manufacturer’s declared performance values. Using declared lifetime low performance values, each new or refurbished device will be independently accepted for service when it is proven to exceed the declared minimum or depreciated performance values by at least 43% (100/70).

Example:

<math>65 mW.cm^{-2} </math> -(declared 2m irradiance)

<math>65\times1.43=92.95 mW.cm^{-2} </math> -(acceptance measurement at 2m)

Eye safety measurements should only be conducted after performance verification tests are successfully completed.
====Documentation====
The following reports and records are required upon handover:

*User requirement specification
*Design report
*Performance verification report
*Operation and maintenance manual 

The operation and maintenance manual (O&M) should include the following information:

#Designer’s trade name, contact and professional or technical registration details.
#Room selection methodology; alternatively, where this selection was not made by the design consultant, a copy of the design brief.
#Electrical wiring drawings and compliance certificate covering all building electrical work relating to the UVGI installation.
#Plan and elevation drawings of considered rooms indicating device installation details, supporting structures and obstructions to radiation and airflow.
#Design data, including assumptions such as room occupancy and ventilation levels.
#Selected device performance criteria and datasheets.
#Selected lamp data sheets including rate lamp life and details of 3 alternate lamps and suppliers.
#Startup and shut down procedures.
#Maintenance and monitoring protocol, plan and log-book template.
#Initial performance and safety verification acceptance criteria.
#Performance verification reports
#Device cleaning instructions.
#Spare parts list with recommended stock levels.
#Decommissioning and disposal instructions

===Monitoring and maintenance===
In every workplace which may result in persons being exposed to hazardous biological agents (HBA) in the performance of their duties, the R1390 Government Gazette of 27 December 2001 No. 22956 is applicable. This legislation requires that the employer shall ensure that all control measures for transmission-based precautions are maintained in good working order; and that thorough examinations and tests of engineering control measures - such as UVGI - are carried out at intervals not exceeding 24 months by an approved inspection authority or their verified delegate.
Record of the examinations and tests carried out in terms of regulation and of any repairs resulting from these investigations and tests must be kept for at least three years.
If the maintenance and monitoring is done in-house it should be conducted by trained and competent personnel.
A maintenance plan shall be developed for each installation and include cleaning and component replacement as per manufacturer’s instructions. It is recommended that maintenance tags be put on all devices. A predictive maintenance model is recommended to determine frequency of maintenance interventions. System level maintenance and monitoring plans can initially be derived from generic templates but should be reviewed and updated regularly.

Irradiance measurements should be taken in the same location and orientation for repeatability between measurements. These locations can be physically marked in the room.

====Corrective actions====
If individual devices fail initial performance measurement upon lamp re-cleaning and ballast replacement, then the devices should be identified clearly with a red non-conformance sticker and scheduled for decommissioning and disposal. Any new ballasts and lamps installed in failed devices should be immediately salvaged for re-use. 

If the number of unserviceable devices within a considered space and system results in an insufficient number of functional devices; the entire system serving that space shall be declared as non-compliant. Individual devices declared functional within a non-functional system may be salvaged for re-use.

[[File:UVGI US TAG.png|none|thumb|Recommended Device Unserviceable Tag]]

===Training===
Competence and training of both system owners and service providers are critical to the successful and sustainable implementation of UVGI air disinfection systems. Professional service providers can be trained either by professional institutions or through tertiary or post graduate education. System owners can be trained by the service provider or can outsource training from a reputable and accredited training institution. An example of a responsibility matrix including the minimum training topics to be covered is presented in the complete guidance document.

===Acknowledgements===
Edward A. Nardell (Brigham and Women's’ Hospital), Richard L. Vincent (Mount Sinai Medical Center), Steve N. Rudnick (Harvard School of Public Health), Paul Jensen (US Centers for Disease Control), Lindiwe Mvusi (NDoH), FW Leuschner (University of Pretoria).
The development of the guidance document was supported by the Presidents Emergency Plan for Aids Relief (PEPFAR) grant together with the US-CDC. The content of this report does not necessarily reflect the opinion of the funders or those acknowledged or referenced in its development.

===Key References===

#IUVA Draft Guideline IUVA-G02A-2005 International Ultraviolet Association Guideline for Design and Installation of UVGI Air Disinfection Systems in New Building Construction Copyright 2005 International Ultraviolet Association
#Fundamental Factors Affecting Upper-Room Ultraviolet Germicidal Irradiation—Part II. Predicting Effectiveness
#World Health Organisation. WHO Policy on TB Infection Control in Health-Care Facilities, Congregate Settings and Households. Geneva, Switzerland; 2004.
#World Health Organisation. Infection Prevention and Control of Epidemic- and Pandemic-Prone Acute Respiratory Diseases in Health Care. Geneva, Switzerland, Switzerland; 2007.
#World Health Organisation. Natural Ventilation for Infection Control in Health-Care Settings. Geneva, Switzerland; 2009. http://www.who.int/entity/water_sanitation_health/publications/natural_ventilation.pdf. Accessed April 30, 2013.
#Downes A, Blunt T. Researches on the effect of light upon bacteria and other organisms. Proc R Soc London. 1877;26:179-184. http://rspl.royalsocietypublishing.org/content/26/179-184/488.full.pdf. Accessed May 28, 2014.
#Gates FL. A study of the bactericidal action of ultra violet light: III. The absorption of ultra violet light by bacteria. J Gen Physiol. 1930;14:31-42. http://jgp.rupress.org/content/14/1/31.full.pdf.
#Riley R. Guidelines for the Application of Upper-Room Ultraviolet Germicidal Irradiation for Preventing Transmission of Airborne Contagion — Part I : Basic Principles. 1999.
#Wells WF, Fair MG. Viability of B. coli exposed to ultra-violet radiation in air. Science (80- ). 1935;82:280-281.
#Riley RL, Permutt S. Room air disinfection by ultraviolet irradiation of upper air. Arch Environ Heal An Int J. 1971;22(2):208-219. http://www.tandfonline.com/doi/pdf/10.1080/00039896.1971.10665834#.U4Ym1fmSxyU.
#Riley RL, Permutt S. Convection, air mixing, and ultraviolet air disinfection in rooms. Arch Environ Heal An Int Journal1. 1971;22:200-207.
#Riley RL, Permutt S, Kaufman JE. Room air disinfection by ultraviolet irradiation of upper air: further analysis of convective air exchange. Arch Environ Heal An Int J. 1971;23(2):35-39.
#Escombe AR, Moore DAJ, Gilman RH, et al. Upper-room ultraviolet light and negative air ionization to prevent tuberculosis transmission. Wilson P, ed. PLoS Med. 2009;6(3):e43. doi:10.1371/journal.pmed.1000043.
#Nardell EA, Bucher SJ, Brickner PW, et al. Safety of upper-room ultraviolet germicidal air disinfection for room occupants: results from the Tuberculosis Ultraviolet Shelter Study. Public Health Rep. 2008;123(1):52-60. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2099326&tool=pmcentrez&rendertype=abstract.
#Nardell EA. Environmental control of tuberculosis. Med Clin North Am. 1993;77(6):1315-1334. http://europepmc.org/abstract/MED/8231415. Accessed June 9, 2014.
#NIOSH US Department of Health, Education and Welfare PHS. Criteria for a Recommended Standard Occupational Exposure to Ultraviolet Radiation.; 1972. doi:(HSM) 73-110009.
#CIE Technical Division 6. CIE 155: 2003 Ultraviolet Air Disinfection. Vienna, Austria; 2003. doi:ISBN 978 3 901906 25 1.
#The International Commission on Non-Ionizing Radiation Protection. Guidelines on Limits of Exposure to Ultraviolet Radiation of Wavelengths between 180 Nm and 400 Nm (Incoherent Optical Radiation). Vol 87.; 2004. doi:10.1097/00004032-200408000-00006.
#R.L. Riley, M K, G M. Ultraviolet susceptibility of BCG and virulent tubercle bacilli. Am Rev Respir Dis. 1976;113:413-18.
#Mundt E, Nielsen P V. Ventilation Effectiveness.; 2004.
#SATS 1706: 2015 SOUTH AFRICAN TECHNICAL STANDARD UVGI Luminaires - Safety and performance requirements.
#Beggs CB, Noakes CJ, Sleigh P a., Fletcher L a., Kerr KG. Methodology for determining the susceptibility of airborne microorganisms to irradiation by an upper-room UVGI system. J Aerosol Sci. 2006;37(7):885-902. doi:10.1016/j.jaerosci.2005.08.002.
#Illuminating Engineering Society of North America (IESNA) Testing Procedures Committee. Standard File Format for Electronic Transfer of Photometric Data and Related Information (ANSI/IESNA LM-63-02). New York; 2002.
#F.W. Leuschner. UVGI MEASUREMENTS, INSTRUMENTATION & FACILITIES PLAN. Pretoria; 2014.
#Zhang J, Levin R, Angelo R, et al. A radiometry protocol for UVGI fixtures using a moving-mirror type gonioradiometer. J Occup Environ Hyg. 2012;9(3):140-148. doi:10.1080/15459624.2011.648569.
#Illuminating Engineering Society of North America (IESNA) Testing Procedures Committee. IES Guide for Lamp Seasoning (LM-54-91). New York; 1991.
#First MW, Banahan KF, Dumyahn TS. Performance of ultraviolet germicidal irradiation and luminaries in long-term service. Leukos. 2007;3:181-188. doi:10.1582/LEUKOS.2007.03.03.005.
#South African Bureau of Standards. SANS 50285 : 2010 SOUTH AFRICAN NATIONAL STANDARD Energy Efficiency of Electric Lamps for Household Use Measurement Methods.; 2010.
#Vorlander FJ, Raddin EH. The effect of operating cycles on flourescent lamp performance. Illum Eng. 1950.
#Miller S.L., Hernandez M., Fennelly K, et al. Environmental Control for Tuberculosis: Basic Upper-Room Ultraviolet Germicidal Irradiation Guidelines for Healthcare Settings. Cincinnati, OH; 2009. http://www.cdc.gov/niosh/nas/rdrp/appendices/chapter6/a6-23.pdf.
#Xu P, Peccia J, Fabian P, et al. Efficacy of ultraviolet germicidal irradiation of upper-room air in inactivating airborne bacterial spores and mycobacteria in full-scale studies. Atmos Environ. 2003;37(3):405-419. doi:10.1016/S1352-2310(02)00825-7.
#Ko G, First MW, Burge H a. Influence of relative humidity on particle size and UV sensitivity of Serratia marcescens and Mycobacterium bovis BCG aerosols. Tuber Lung Dis. 2000;80(4-5):217-228. doi:10.1054/tuld.2000.0249.
#Miller S, Hernandez M, Fennelly K. Efficacy of ultraviolet irradiation in controlling the spread of tuberculosis. Atlanta Centers Dis …. 2002. http://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:Efficacy+of+ultraviolet+irradiation+in+controlling+the+spread+of+tuberculosis#0. Accessed August 15, 2014.
#Mphahlele M, Dharmadhikari AS, Jensen PA, et al. Institutional Tuberculosis Transmission: Controlled Trial of Upper Room Ultraviolet Air Disinfection - A Basis for New dosing Guidelines. Am J Respir Crit Care Med. 2015:150504122726005. doi:10.1164/rccm.201501-0060OC.
#Noakes CJ, Beggs CB, Sleigh PA, Kerr KG. Effect of Room Mixing and Ventilation Strategy on the Performance of Upper Room Ultraviolet Germicidal Irradiation Systems. In: Proceedings of ASHRAE IAQ 2004. ; 2004:1-13.
#First M, Rudnick SN, Banahan KF, Vincent RL, Brickner PW. Fundamental factors affecting upper-room ultraviolet germicidal irradiation - part I. Experimental. J Occup Environ Hyg. 2007;4(5):321-331. doi:10.1080/15459620701271693.
#ASHRAE. ASHRAE 55-2013; Thermal environmental conditions for human occupancy. Am Soc Heating, Refrig Air Cond. 2013.
#Coker I, Nardell E, Fourie B. Guidelines for the Utilisation of Ultraviolet Germicidal Irradiation (UVGI) Technology in Controlling the Transmission of Tuberculosis in Health Care Facilities in South.; 2001. http://www.sahealthinfo.com/tb/guidelines.pdf. Accessed June 30, 2014.
#Kowalski W, Bahnfleth W. Proposed standards and guidelines for UVGI air disinfection. IUVA News. 2004;6(1):20-25. http://www.aerobiologicalengineering.com/stds.pdf.
#Rudnick SN, First MW. Fundamental factors affecting upper-room ultraviolet germicidal irradiation - part II. Predicting effectiveness. J Occup Environ Hyg. 2007;4(5):352-362. doi:10.1080/15459620701298167 

[[Category: Infection Prevention and Control]]
[[Category: Decontamination]]
[[Category:Crosscutting Issues]]
[[Category:UVGI]]

Building Engineering Services

2024-05-08T13:03:26Z

Tobyvan: recirculation rules in theatres improved.

{{Cleanup}}{{Expand}}

=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===

==='''Context'''===
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.

==='''Design principles'''===
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.
{| class="wikitable"
|+Table 1: IUSS document
!Clinical services
!Essential
!Recommended
!Support Services
!Essential
!Recommended
!Healthcare environment/
Crosscutting issues
!Essential
!Recommended
!Procurement &
Operation
!Essential
!Recommended
|-
|Impatient services
|
|X
|Administration & related services
|
|
|Generic room data
|X
|
|Integrated infrastructure planning
|X
|
|-
|Laboratories
|
|X
|General hospital support services
|
|
|Hospital design principles
|X
|
|Project planning & briefing
|X
|
|-
|Mental Health Services
|
|
|Catering services
|
|
|Engineering design principles
|X
|
|Space guidelines
|
|
|-
|Critical care
|
|
|Laundry and Linen
|
|
|Environment and sustainability
|X
|
|Cost Guidelines
|X
|
|-
|Emergency centres
|
|
|Mortuary
|X
|
|Materials & finishes
|X
|
|Procurement liaison
|
|
|-
|Obstetrics & gynaecology
|
|
|Nursing colleges
|
|
|Future healthcare environments
|
|X
|Commissioning
|X
|
|-
|Oncology
|
|
|Health facility residential
|
|
|Healthcare technology
|
|
|Maintenance
|X
|
|-
|Outpatient services
|
|X
|Sterile supply
|X
|
|Inclusive environments
|
|X
|Decommissioning
|X
|
|-
|Paediatrics
|
|
|Clinical training
|
|
|Infection prevention & control
|X
|
|Capacity development
|
|X
|-
|Pharmacy
|
|
|Waste disposal
|
|X
|Health informatix
|
|
|
|
|
|-
|Primary health care
|
|
|
|
|
|Regulations
|X
|
|
|
|
|-
|Diagnostic radiology
|X
|
|
|
|
|
|
|
|
|
|
|-
|Rehabilitation services
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Surgery
|X
|
|
|
|
|
|
|
|
|
|
|-
|TB
|X
|
|
|
|
|
|
|
|
|
|
|}

Where this document lacks guidance on a topic or appears to contradict the requirements of the guidelines identified above, the guidance of those documents will take priority.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
#*Summaries of collated information
#*Reports on technical feasibility, benefits and risks
#*Reports on regulatory compliance issues
#*Reports on financial feasibility and risks
#*List of consents and approvals required
#*Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

==Design Questions==
6. In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

==Design considerations==

==='''7. Deep buildings'''===

#Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

==='''8. Plant and plant room size and location'''===

#Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.
#Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities. Plant rooms shall be located away from possible heat and contamination sources.
#Plant rooms shall be located in an accessible area which is secured from unauthorized entry
#Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

==Life cycle cost determination==
9. When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

10. Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

==Site-survey requirements==
11. In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

==Maintenance Considerations==
12. Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

13. The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

14. In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.

15. For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

==Planning for Retrofitting & Decommissioning==
16. While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

17. Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

18. When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

19. A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

20. Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

21. For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

==Sustainability & Environmental Measures==
===Design Life cycle===

Sustainability in designs for new health facilities can be addressed through the following steps:

'''22. Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.

'''23. Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.

'''24. Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.

'''25. Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.

'''26. Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.

'''27. Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

28. Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''PART - DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating Ventilation and Air-conditioning===
===Airborne-Precaution Risk Classification for Healthcare Zones===
South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for out-patients is common practice in South Africa.
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

An alternative exposure-based model can be considered where infection risk can be quantified in terms of the environmental reproductive number.

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo convective or buoyancy effects and wind pressure. Since the drivers of Natural ventilation are inherently variable, natural ventilation has a high variability in effectiveness.

2. In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space could have a negative impact on the variability of the ventilation system’s performance by opening and closing windows and doors. For this reason it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controllable ventilation openings be designed and created in the building

3. For additional design guidance on natural ventilation design, the CIBSE Applications Manual AM10 or similar can be consulted.

4. Peak and minimum internal temperatures should be calculated or modelled thermally for a space, for summer and wintertime respectively.

5. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

6. The following design interventions should be considered for implementation, singly or in combination, in the following hierarchy where the internal design condition cannot be met:

*Reducing solar and internal heat gains
*Using thermal mass to move room temperature extremes to outside of occupancy periods.
*Change occupancy schedules seasonally to improve indoor comfort conditions. (eg. Shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
*Introducing passive cooling or heating strategies
*Increasing ventilation rates
*Providing mechanical cooling or heating

7. Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed mode ventilation shall be considered as a solution preferred over full mechanical ventilation.

8. Mixed mode ventilation is considered as an assisted type of natural ventilation. Here fans are used in combination with damper controlled ventilation openings to ensure minimum ventilation rates are achieved.

9. Where mixed mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

[[File:NV-Decision Tree1.png|alt=NV-Decision Tree|border|frameless|800x800px]] 

===Mechanical ventilation and air-conditioning===
10. Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.

11. The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====12. Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====13. Zoning of a building=====
13.1. Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:

#Fire compartmentalization
#Air-handling unit (AHU) sizing
#Duct sizing
#Occupancy schedules
#Occupancy activity levels
#Building, environmental and equipment heat loads
#Airborne contamination control
#Tenancy, functional unit or utility metering

13.2. Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====14. Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.

=====15. Ventilation rates=====

#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant

=====16. Supply-only vs balanced ventilation systems=====

#Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

=====17. Airborne contamination-control concepts=====

#Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

#The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

#The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 
#The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 
#The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²).

17.4. Where ventilation rates and fresh air proportions are described within these guidance documents they are to serve as guidance values only. It is the responsibility of the designer to ensure that the ventilation rate selected is appropriate for the specific zone’s operational conditions, occupancy, contamination rates, pressurization, leakage rates, ventilation efficiency and external ambient conditions to achieve the desired airborne contamination and bio-burden levels. Ventilation rates higher or lower than the guidance values may achieve the desired conditions.

 

====='''18. AIR HANDLING UNITS AND FANS'''=====
18.1. GENERAL

#AHUs and fans shall be protected from adverse weather and wind sources which may upset their performance or reliability.
#A detailed name plate shall be included on the air handling units with manufacturer, design air volume, fan speed, cooling capacity, filter data and heating capacity.
#The air handling unit shall include individual differential pressure gauges over each installed filter bank. The gauges shall measure the pressure differential between upstream and downstream of the filter banks. The filter designation and design filter change pressure shall be neatly and clearly marked on each gauge.
#Air-handling units functioning in an airborne contamination control system, and demanding prescribed airflow rates, shall be provided with an electronic control system including variable frequency controllers with direct fan drives to automatically maintain design airflow for all filter conditions. The fans and drives will be selected to maintain design flow rates with all filters at maximum rated pressures.
#Where a ventilation system performs a critical role, air handling units shall have separate electrical distribution boards (Essential and Non-essential). The fan will be on essential power and heater elements may be on non-essential power.
#All compartment doors on the air handling unit shall be clearly labelled
#Where systems require duplicate standby fans or air-handling units these shall be installed with backdraught dampers, sufficiently air-tight for the application (eg EN1751 Cat 3 or 4). Special design and control consideration shall be given to limiting the build-up and dwelling of contaminants in the standby unit.
#AHU’s should be placed in easily accessible plant rooms with sufficient space for maintenance. Access stairs to the plant rooms should permit a technician to easily carry replacement parts or a toolbox into the plant.AHU’s located in ceiling voids are not appropriate or conducive to good operational management.
#AHUs should be designed for a working life of 20 - 25 years
#AHUs shall be designed and positioned such that the largest components, including heating and cooling coils, can be removed and replaced.
#AHUs greater than 1m wide should have hinged access doors large enough to provide full entry. Doors shall be unlockable and openable from the inside of the unit.
#Fan and filter plenums shall be provided with internal illumination and viewing portals such that internal components can be visually inspected without stopping or opening the unit.
#AHUs shall be designed such that dry steam humidification devices can be retrofitted into the systems with minimal disruption and without compromising its performance.
#Ventilation components shall have a drainage or condensate pumping system if they can produce moisture. Drip trays shall be of a corrosion resistant material and drainage systems shall have a 1:20 fall away from the unit in all directions. The unit shall have its own drain trap which shall be sized such that it can function at the fan's full static pressure. The first 3 meters of a dedicated condensate drainage line shall be insulated to prevent condensation within the plantroom. Where a condensate drain services a negative pressure plenum, clear air gaps of 15mm or anti-backflow devices are recommended at the trap discharge into the drainage system.
#Drop stop eliminators in stainless steel frames shall be employed, if fin spacing is less than 10 fins per inch, after the cooling coils in areas with high humidity levels. This includes all coastal areas for off coil temperatures of 10° and less
#In full fresh air systems, primary filters may be situated at the fresh air intake opening of the air-handling unit only if the climate does not require anti-fog or de-icing coils.
#Cooling or heating coils will be protected by a pleated primary filter, rated in accordance with SANS 1424, as minimum.
#In recirculation air systems, primary filters will be situated after the fresh/return air mixing plenum. This arrangement will ensure that blinding filters don’t inhibit the prescribed fresh air proportion.
#The final stage of filters on units serving operating theatres must be located after the supply fan chamber to filter any debris that might come from the fan chamber. HEPA filters should be protected from this potential dust and debris.

 

=====18.2. AIR EXTRACTION SYSTEMS=====

#The design of exhaust systems shall take special consideration of the potential for re-entrainment of contaminated exhaust air into air intakes through, inter alia, openable windows. Where this potential exists, precautionary measures such as aerosol or chemical filtration of exhaust should be applied, as appropriate.
#Single ablution facilities serving private wards or staff do not require extract ventilation, provided there are windows openable to outside.
#Extract ventilation shall be provided by either ceiling extract grilles connected to an in-line ducted fan with outside discharge air grilles by means of galvanized mild steel or PVC tubular ducting or odour extraction system.
#Extract grilles may be of the PVC type with adjustable disc valves, or powder coated or anodized aluminium type with adjustable dampers.
#All multiple toilets shall be provided with ventilation systems, which will serve as an extract ventilation system.
#Single toilet facilities serving private wards for staff do not require extract ventilation, provided there are windows openable to outside
#Where it is not considered safe to enter a space without respiratory protection, the air exhausted from that space should be rendered safe through filtration, decontamination or dilution before discharge.
#The design of exhaust system from airborne precaution areas should be such that all components can be safely maintained during normal service and safely disposed of at decommissioning.
#Planning for disposal of contaminated filters should be as for all biohazardous material.
#Filtration and decontamination components shall be installed upstream of fans, monitoring and control devices.

=====18.3. ENERGY RECOVERY SYSTEMS=====
1.3.1. Where full or partial exhaust is required for ventilation systems, energy recovery technologies should be considered. Enthalpy wheels offer a high level of efficiency but introduce a risk of cross infection as the wheel is exposed to both the exhaust and supply airstreams. An enthalpy or energy recovery wheel may only be used if pressure and filtration measures are taken to ensure it is not a potential source of cross infection or re-infection. Energy recovery wheels incorporating purge sections have a markedly reduced efficiency and are not considered to provide sufficient protection against biological cross contamination. Where cross infection is a considered risk, the following conditions shall be met.

#The exhaust airstream shall be consistently maintained at a lower static pressure than that of the supply airstream.
#The exhaust air shall be filtered with aerosol filters upstream of the energy recovery device.
#Levels of filtration, redundancy and safety shall meet the requirements of the biological pathogenicity class in consideration.

=====19. '''FILTRATION'''=====

#With the exception of the few specialist areas with aero-biological requirements, the primary purpose of filtration is to protect ventilated spaces and ventilation equipment from dust build-up.
#When designing filtration systems serving spaces with a high airborne cross contamination risk, consideration should be given to the safety of maintenance staff that may be required to handle contaminated filters. Where any safety risk is present, contaminated filters should be installed in safe-change or decontaminatable housings.
#All ventilation filter banks should be installed with a means of visually checking the filter pressure across them in Pascals (Pa)
#Filters are classified as being General Fine or Aerosol filters and are to be specified in accordance with the SANS 1424, EN779 or EN1822.
#General filters are selected to remove particles large enough to block cooling and heater fins and settle out of the airstream into the air distribution system. General filters are graded in terms of their “synthetic dust weight arrestance”. General filter grading ranges from G1 to G4. G3 and G4 filters are appropriate for primary air intake and tempered air supply respectively. General filters are not appropriate for combating airborne cross-contamination control.
#Fine filters are selected to keep a ventilated space visibly clean and for the protection of HEPA filters. Fine filters are graded in terms of their “Dust Spot Efficiency” from M5 to F9. F9 filters are capable of arresting particles with the approximate size of some bacteria and can be used for low level cleanrooms (ISO 14644-1 Class 8).
#Aerosol filters are selected for their efficiency in arresting sub-micron particles. They are graded in accordance with their “Most Penetrating Particle Size” (MPPS). Aerosol filters are subdivided into three categories: Efficient Particulate Air (EPA) and High Efficiency Particulate Air (HEPA) and Ultra high Particulate Air (ULPA) Filters in accordance with the EN1822:2009. The table below describes the classification of aerosol filters by integral and local values as defined in the EN1822. SULPA filters are not discussed within this document.

{| class="wikitable"
|+{{Anchor|Table_Filter_Classification}}'''Filtration Classification'''
| rowspan="2" |'''Group'''
| rowspan="2" |'''Filter Class'''

'''EN1822'''
|'''Integral Value'''
|'''Local Value'''
|-
|'''Efficiency %'''
|'''Efficiency %'''
|-
| rowspan="3" |'''EPA'''
|'''E10'''
|85%
|<nowiki>-</nowiki>
|-
|'''E11'''
|95%
|<nowiki>-</nowiki>
|-
|'''E12'''
|99.5%
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''HEPA'''
|'''H13'''
|99.95%
|99.75%
|-
|'''H14'''
|99.995%
|99.975%
|-
| rowspan="3" |'''ULPA'''
|'''U15'''
|99.9995%
|99.9975%
|-
|'''U16'''
|99.99995%
|99.99975%
|-
|'''U17'''
|99.999995%
|99.999975%
|}
8. HEPA filter installations shall include both an upstream challenge aerosol injection port and a downstream scan port to facilitate filter challenge testing. ULPA filter installations shall be designed such that an agreed upon test method can be accomplished.

9. All filters used for airborne precaution rooms, theatres or other areas with a high airborne contamination risk shall be selected with a construction suitable for incineration. These filters shall not contain PVC.

10. The installation and testing of HEPA filters shall only be conducted by suitably qualified technicians.

11. HEPA filters shall be specified to be compliant with the requirements of EN1822. Each HEPA filter is to be supplied with an individual factory test certificate displaying that filter's serial number, MPPS rating and DOP arrestance rating.

12. Type-test certificates are only acceptable for EPA and not HEPA filters.
 

=====20. '''HEAT REJECTION EQUIPMENT.'''=====
20.1. The location of heat rejection equipment shall be planned such that it does not adversely affect the performance, maintenance or reliability of any related or unrelated equipment, or pose an avoidable health risk.

20.2. The use of evaporative cooling towers shall only be considered where:

#Space, system capacity or efficiency demands their use.
#An effective plan for the [[Legionella Control|control of legionella]] must be developed and implemented.

 

=====21. '''AIR DISTRIBUTION SYSTEMS'''=====

#Discharge from extraction systems shall be located such that contaminated air does not get drawn into any system's air intake of get re-entrained though openable windows.
#The use of internally insulated ducting is not appropriate as internal linings will perish and slough off with aging. Particles from duct linings contaminate final filters and ducting components.
#Flexible ductwork is unsuitable for air distribution in healthcare applications. It should only be used for the final connection to an air terminal and then kept to less than 1.0m. Bends in flexible ductwork should be avoided.
#The use of dampers to throttle a deliberate oversupply of airflow should be avoided. Balance by design is preferable although this will not necessarily reduce the total fan pressure. Use of adjustable blade dampers should be kept to a minimum as these items may drift, can be tampered with and increase the complexity of commissioning. The use of constant volume dampers may improve stability of volume critical systems but may also mask inefficient design and be the source of increased system noise.
#Cleaning and access doors are to be installed in all air distribution ductwork to facilitate:

*Cleaning
*Inspection
*Measurement
*Maintenance

21.6. Ductwork installations shall be designed, built, installed and commissioned in accordance with SANS 1238: Air-conditioning ductwork and SANS 10173: The installation, testing and balancing of air-conditioning ductwork
 

=====22. '''ELECTRONIC CONTROLS'''=====

#Location of sensors in ventilation systems should ensure that the temperature and humidity measurement for monitoring control is representative of the occupied area
#The humidifier control will include humidity monitoring of the mixed airstream downstream of the humidifier lance and shall prevent this airstream from approaching dew point.
#The use of variable speed drives (VSD) can save energy in systems operating under varying motor loads. Reducing the fan speed when filters are new or clean can result in considerable energy savings over the life of a system. Reliability of smaller sized VSDs is a potential drawback, and for this reason VSDs must be selected and sized for high service life. VSDs should also be installed such they can be bypassed and the system can be run in manual control while failed VSDs are replaced or repaired. When designing with variable speed drives, cognisance should be taken of a motor’s minimum cooling requirements and the maximum restart rate. Caution should be exercised where variable speed drives are used in conjunction with constant volume dampers or volume flow controllers. This combination could drive up total system pressure where duct total pressure as opposed to velocity pressure is used as control feedback. Additional requirements for the selection of drives for variable air volume (VAV) fans is described in SAN204:2011
#Plant control systems should incorporate start-up and shut-down sequencing logic to prevent flow reversals and overheating.
#Set-back controls should be considered for spaces that have intermittent occupancy. This feature should be used with caution in specialist areas as poorly considered set-back conditions could compromise containment or contamination control.
#Where more than one ventilation system serves a department, system interlocks may be required to prevent unwanted airflow reversals during system shutdown or failure.
#Operational status indicators should be displayed locally in areas served by ventilation systems.
#"Low Air Flow" and "Plant Failure" alarms should also be installed in a location which can be manned by relevant and trained staff.
#Electronic control systems should be developed using recognised open protocols and standards such as BACnet DeviceNet, LonWorks, Modbus, SOAP and XML.

=====23. '''SPECIALIST VENTILATION SYSTEMS'''=====
23.1. The following areas will require specialist ventilation systems:
 
'''Table''' '''3 Specialist Ventilation Systems'''
{| class="wikitable"
|'''Department Name'''
|'''Ventilation system type'''
|-
|Operating departments
|Clean and Ultra clean ventilation systems: ISO8 to ISO5 & UDAF
|-
|Obstetrics
|Clean ventilation systems ISO8
|-
|High care, Critical Care and Intensive Care
|Fine filtered ventilation or Clean ventilation systems: Unclassified - ISO8
|-
|Isolation units
|Negative pressure ventilation, no recirculation
|-
|Pathology labs
|Biosafety ventilation: (BSL2 – BSL4)
|-
|IVF Labs
|Clean ventilation systems: VOC Filtration
|-
|Burns units
|Clean ventilation systems/ Negative pressure ventilation/ RH control
|-
|Neonatal Units
|Dedicated ventilation systems/ RH control
|-
|Mortuary unit
|Cold Rooms/ Extraction systems/ Odour Control
|}
23.2. Broad requirements for these systems are in this document. The engineering team shall consult each department’s specific design guidance document for detailed requirements.
 

=====23.3. '''AIRBORNE PRECAUTION ROOMS (INCLUDING TB)'''=====

#Where specific diseases are considered in the design of an airborne precaution room, the US CDC's "Select Agent List" may be consulted for design guidance until a South African list is compiled.
#Airborne precaution rooms shall be ventilated with a minimum of 12AC/h of fresh air or uncontaminated air. High risk areas such as sputum booths and airborne diseases wards shall have a nominal ventilation rate of 80 ℓ/s per person..
#Medium Risk areas such as congregate spaces such as waiting areas shall have a nominal ventilation rate of 60ℓ/s per person.
#Mechanical ventilation may be employed to achieve the minimum ventilation rates. It should be noted that very high ventilation rates can be achieved by employing a well-considered natural ventilation design. Consideration may also be given to mixed mode ventilation systems, which combine mechanical and passive ventilation and temperature control. An open window policy may therefore be adopted, with careful consideration of all the associated cross infection risks and management challenges.
#Airborne precaution rooms shall be designed so as to provide thermal comfort. Where occupants have freedom in location and dress code, an adaptive thermal comfort model should be adopted. Heating, cooling and energy recovery devices shall pose no risk of harbouring pathogens or increasing the cross-infection risk.
#Air from the airborne precaution rooms shall not flow into adjacent, uncontaminated rooms or adjacent airborne precaution rooms. Air shall not flow from a room with a higher airborne infection risk category to a room with a lower risk category.
#Ventilation ducting and pipe work shall not form a conduit by which pathogens can transfer from one zone to another whether the ventilation system is running or not. Filtration devices and anti-backflow devices may be employed provided these do not pose a risk of infection to maintenance staff.
#Filtration requirements for supply and exhaust air should follow the bio-containment requirements of that select agent being contained.
#The location of supply and air terminals should be such that the airflow patterns generated within the room serve to suppress and remove airborne particles.
#For general waiting areas or where the pathogens are known and unlikely to pose an environmental risk, exhaust air filtration may not be required provided exhausted air is directed 3m away from open-able windows and air intakes and there is no risk of re-entrainment of this air. See section 18.2.
#Commissioning and validation shall be well planned, diligently executed, fully documented and approved by suitably experienced professionals. It is advisable to have the validation process conducted or approved by a party independent of the designer and installer.
#Numerical or physical modelling may be of value in the design and validation process.

 

=====23.4. '''OPERATING THEATRE VENTILATION DESIGN'''=====
23.4.1. GENERAL REQUIREMENTS

#Constant volume systems shall be employed to maintain the correct pressure with respect to any adjoining rooms. The contamination control concept shall be developed in accordance with ISO14644-4
#Temperature range shall generally be 18°C to 24°C with a minimum relative humidity of 45% unless otherwise specified
#A pressure differential of 10-15Pa is to be maintained between the theatre and adjacent rooms when all doors are closed.
#Theatres may be maintained at a room pressure positive or negative to the adjacent rooms depending on the contamination control requirements.
#A theatre’s room pressure shall always be positive relative to technical spaces.
#Negative pressure theatres should not employ recirculation of room air.
#Minimum fresh air requirements are 5-7 Air Changes per hour to satisfy the occupancy requirements.
#Additional fresh air may be required for pressurisation and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurisation at the greatest possible energy efficiency. Rules of thumb rates of percentage fresh air as a function of the supply air rate are not acceptable methods for determining additional fresh air requirements for pressurization.
#Separate temperature controls in each theatre are to be provided.
#No manual on and off switching of air handling plant to be done from within the theatres.
#Automatic motion sensors / thermal sensors to ensure that the units are switched on when there is a presence in the theatre. Theatre ventilation switching may be linked to the theatre unit’s lights.
#Automatic switching of ventilation system to incorporate run-on timers to prevent overheating and accidental shutdown.
#An additional override to be used to switch the units on when the temperature in the theatre exceeds 25°C for the protection of stored medicine
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums.
#These validation tests shall be performed in accordance with SANS 14644Parts 1, 2 and 3 at the recommended intervals (SANS 14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#No internal ducting insulation is permitted.
#In multi theatre suites it is advisable to have dedicated AHUs per theatre. [[Building Engineering Services#%20msocom%201|[TR1]]]

23.4.2. UNIDIRECTIONAL AIRFLOW OR ULTRACLEAN THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 5 under protected zones (UDAF and Setup area) and ISO 14644-1 Class 6 in background and ancillary areas. These conditions are to be achieved under operational conditions.
#Temperature range shall generally be 18°C to 24°C and relative humidity 45% to 60% unless otherwise specified
#Ultra-clean theatre ventilation shall not be completely shut down when unoccupied unless required for maintenance interventions. Ventilation systems serving UDAF plenums shall instead switch to a minimum velocity set-back mode to prevent contaminants settling underneath the UDAF screens.
#Delivery of the conditioned air shall be by downward movement from the ceiling to four low level exhaust outlets located near the corners.
#All ductwork between HEPA filter housings and air terminals shall be high pressure rated and constructed of galvanised sheet metal. In the final connection to the terminal, where alignment necessitates, a maximum of 300mm of thermally insulated, high pressure flexible ducting may be used.
#The Air Conditioning system is to be complete with G4 primary, F9 secondary and H13 HEPA Filters.
#The ventilation systems shall be designed with a mean air velocity of between 0.35 & 0.45 m/sec measured below the UDAF screen and at the working height.
#Refer to ISO14644-4 for guideline ventilation rates for balance of areas.
#The mean velocities below the UDAF screen and at the working height shall not differ by more than ±10%
#A standard size of the UDAF screen is 2400 x 2400mm. The required size could vary dependent on the layout and function of the operating theatre.
#The protected zone below the UDAF plenum shall be clearly demarcated on the floor

23.4.3 CLEAN OR MAJOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 6 in all protected areas and Class 7 in background areas. These conditions are to be demonstrated as achievable under operational conditions.
#The ventilation system is to include G4 Primary, F9 Secondary and final H13 HEPA filters. No air tempering and conditioning equipment is permitted downstream of the HEPA filters
#The conditioned air is to be introduced into the theatre via suitable diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#Additional fresh air may be required for pressurization and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurization at the greatest possible energy efficiency.
#These validation tests shall be performed in accordance with SANS 14644 Parts 1, 2 and 3 at the recommended intervals (ISO14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high-pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#Recirculation from the theatre room to zones outside of the theatre room is not permitted and all recirculated air shall be filtered through the secondard and HEPA filters as a minimum. Recirculation from zones outside of any theatre room into that theatre room is not permitted.

23.4.4. MINOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 8 in all areas. These conditions are to be achieved under operational conditions.
#For recirculation systems the ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#For single pass systems the ventilation system is to include G4 Primary and F9 Secondary filters.
#The conditioned air is to be introduced into the theatre via suitably sized diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums. 

====='''VALIDATION OF SPECIALIST VENTILATION SYSTEMS'''=====

#Validation testing shall be completed in accordance with national standards for standardized tests (eg ISO14644 and ISO 14698 for cleanrooms) and shall be completed against mutually agreed protocols for non-standard tests.
#It essential that the validation testing of a ventilation system’s contamination control performance parameters is conducted against operational, and not only "at-rest", conditions. Validation against "as-built" conditions offers little insight into the ultimate performance of the system.
#Pre-Commissioning Checks shall cover the following aspects prior to the commencement of formal commissioning:
##Check whether the Design Specification satisfactorily addresses the demands of the User Requirement Specification.
##Check whether the ventilation systems have been provided and installed in accordance with the design specifications and drawings
##Check that the buildings either housing or served by the ventilation equipment is complete and finished such that testing can commence safely and effectively.
##Check that all AHUs, chillers, heat rejection equipment and filters are sufficiently accessible for inspection and maintenance.
##All components are connected and are functional
##Door gaps and openings are installed and sized as specified in specialised zones
##Airflow control devices are installed in the correct locations and in the correct orientation
##Duct and filter tests ports are installed and sealed satisfactorily
##Safety and control interlocks are established
##Fan and drive guards are in place
##Safety and warning signs are in place
##All major system components or sub-systems are clearly labelled with functional or controls identification in a neat and durable fashion.
##Fluid and air pressure monitoring gauges are labelled with identification and acceptable maximum and minimum operating conditions.
##All wiring, piping and ducting colour banding is complete in accordance with SANS-1091
#CLEANLINESS CHECKS:
##AHUs shall be checked for cleanliness on internal plenums with special attention being paid to fan and discharge plenums and condensate drip trays and drain lines.
##Ducting serving “clean” areas shall be cleaned prior to installation and the ends shall be sealed until installation. Open ends of duct runs shall similarly remain sealed during construction. Spot checks for compliance during the installation process are recommended.
#Recommended Filtration Levels and Ventilation Rates for Mechanically Ventilated Areas

This table serves as a quick reference guide and will be revised as and when detailed room data sheets are developed within each department’s guidance documents.
{| class="wikitable"
|+{{Anchor|Table_Room Ventilation Requirements}}'''Room Ventilation Requirements'''
| rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation'''[[Building Engineering Services#BESftn1|[1]]]

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range'''[[Building Engineering Services#BESftn2|[2]]]'''
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|Casualty/Minor Stitch Procedure room
|X
|
|X
|
|T
|
|
|7.5
|20
|
|-
|Theatres: Maternity/Caesarean
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: General Surgery
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Gynaecology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Ophthalmology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Urology
|X
|
|X
|'''X**'''
|T
|NA
|7
|10
|20
|
|-
|Theatres: Endoscopy
|X
|
|X
|'''X**'''
|T
|NA
|7
|80
|20
|
|-
|Theatres: Plastic Surgery
|X
|
|X
|X
|T
|6
|7
|7.5
|70***
|
|-
|Theatres: Bone Surgery/Orthopaedic
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Thoracic
|X
|
|X
|X
|M
|5
|7
|80
|70
|
|-
|Theatres: Vascular???
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Neuro Surgery
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Waiting and Congregate Areas
|X
|
|
|
|
|
|
|60
|8
|18-28
|-
|Auditoriums
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Mortuary
|X
|X
|
|
|
|
|
|
|12
|22-25
|-
|Bath Room
|
|
|
|
|
|
|
|25
|10
|N/A
|-
|Dirty Utility Room
|
|
|
|
|
|
|
|40
|10
|N/A
|-
|Blood Bank
|X
|
|
|
|
|
|
|
|4
|22-25
|-
|Casualty
|X
|X
|
|
|
|
|
|7.5
|12
|22-25
|-
|CSSD
|X
|X
|
|X
|
|
|
|7.5
|20
|22-25
|-
|Dark Room
|X
|
|
|
|
|
|
|
|10
|22-25
|-
|Dining Rooms/Canteens
|X
|
|
|
|
|
|
|7.5
|10
|18-28
|-
|General Stores
|X
|
|
|
|
|
|
|
|4
|N/A
|-
|Laboratories
|X
|X
|
|
|
|
|
|
|6
|22-24[<nowiki/>[[Building Engineering Services#BESftn3|3]]]<nowiki/>
|-
|Labour/Delivery Room
|X
|
|
|
|
|
|
|
|4
|22-24
|-
|Laundry – General
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Lecture Halls
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Outpatients Departments
|X
|
|
|
|
|
|
|60
|4
|18-28
|-
|Pharmacy Dispensing
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Pharmacy Store
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Specialist Clinics- ENT
|X
|X
|
|
|
|
|
|7.5
|4
|22-26
|-
|Sterilizer Equipment
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Toilet Room
|
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Units: Treatment Room
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|-
|Units: Burns
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|-
|Units: HCU / CCU
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU Neonatal
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|-
|Wards: General
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|-
|Wards: Airborne Precaution Rooms/Isolation'''[[Building Engineering Services#BESftn4|[4]]]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|-
|Wards: Maternity
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Medical
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Paediatric
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|-
|Wards: Psychiatric
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|-
|Wards: Orthopaedic
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: Surgical
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: TB
|X
|
|
|
|
|
|
|80
|12
|20-28
|-
|Radiology: General
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|-
|Radiology: Airborne Precaution
|X
|
|X
|
|
|
|
|60
|6
|22-24
|-
|Radiology: MR/CT

Scanner
|
|
|
|
|
|
|
|60
|6
|2-24
|}
{{Anchor|BESftn1}}[[Building Engineering Services#%20ftnref1|[1]]] These rates are considered for forced ventilation systems only. Average natural ventilation rates may be higher

{{Anchor|BESftn2}}[[Building Engineering Services#%20ftnref2|[2]]] Temperature range not to be exceeded for more than 50 hours per year.

{{Anchor|BESftn3}}[[Building Engineering Services#%20ftnref1|[3]]] Specialist cleanrooms and laboratories may require lower temperatures.

{{Anchor|BESftn4}}[[Building Engineering Services#%20ftnref1|[4]]] Levels of filtration are dependent on pathogenicity. Exhaust filtration may also be required.

======Commissioning tests shall include and record, but not be limited to:======
{| class="wikitable"
|'''System'''
|'''Commissioning Test'''
|'''Special Instructions'''
|-
|'''All'''
|Standard of installation
|Test to be authorised by client's representative.
|-
| rowspan="7" |'''Air Handling Units and Fans'''
|Fan motor drive speed and rotation.
|Cognisance should be taken of motor cooling requirements
|-
|Fan motor current draw.
|<nowiki>-</nowiki>
|-
|HEPA Filter challenge testing.
|In accordance with ISO DIS 14644-3
|-
|AHU heating and cooling coil performance
|Report on-coil and off-coil air conditions for full heating and full cooling with no air bypass.
|-
|AHU leakage tests
|<nowiki>-</nowiki>
|-
|Heating and Chilled Water circuits have been charged, dosed and pressure tested
|<nowiki>-</nowiki>
|-
|Flow rates and pressures across heat exchangers, pumps and compressors
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="2" |'''Room conditions'''
|Airflow and room pressure balancing in accordance with design tolerances.
|In accordance with ISO DIS 14644-3 Acceptance criteria Normally +10-0%
|-
|Room Temperature and humidity
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''Air Distribution systems'''
|Dampers and registers shall be locked and marked after balancing
|<nowiki>-</nowiki>
|-
|Duct leakage tests for medium and high pressure ducting in accordance with SANS 10173 or DW/143 requirements, as agreed upon
|<nowiki>-</nowiki>
|-
|'''Water Distribution Systems'''
|Pressure Drops and Flow Rates
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="4" |'''Control System'''
|Control system loop and function checks
|<nowiki>-</nowiki>
|-
|Alarm Checks
|<nowiki>-</nowiki>
|-
|System Start/Stop sequencing checks
|<nowiki>-</nowiki>
|-
|System Set-Back mode checks
|Include room condition and contiguous system impacts
|}

24.7. Select validation tests shall be conducted at intervals defined by the client:
 
{| class="wikitable"
|'''Tests'''
|'''Required/ Optional'''
|'''Recommended Frequency of testing'''
|'''At-Rest or In-Operation Testing'''
|-
|'''Airflow volume tests'''
|Required
|12 months
|At-Rest
|-
|'''Airflow visualization'''

'''(Airborne precaution rooms)'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Velocity Tests'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Airflow Visualisation'''
|Required
|6 Months
|At-Rest & In-Operation
|-
|'''Room pressure tests'''
|Optional
|3 Months
|At-Rest & In-Operation
|-
|'''Airflow direction tests'''
|Required
|1 Month
|At-Rest & In-Operation
|-
|'''Discreet practice counts'''
|Required
|12 Months
|In-Operation
|-
|'''Bio-burden testing'''
|Required
|1 Month
|At-Rest
|-
|'''Filter challenge testing'''
|Optional/Recommended
|24 Months
|At-Rest
|-
|'''Room Condition recovery'''
|Required
|24 Months
|In Operation
|}
24.8. Prescribed validation reports shall include:

*References to the test protocol
*Acceptance criteria
*Test results
*Test equipment identification and calibration status
*Name and signature of tester
*Name and signature of facility representative
*Dates of test and acceptance by client

===Medical gas installations===
25. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

26. All units of a health establishment, except sub-acute and hospice facilities, where patients are accommodated and treated, must have medial gases and vacuum provided by medical grade piped services, with indexed terminal connecter points. Bottle systems may be provided in sub-acute and outpatient facilities.

27. Mobile gas services must be available for crisis situations.

28. Sub-acute facilities must have one mobile oxygen cylinder per 10 patients and one suction machine for every 10 patients.

29. The minimum services to be supplied to all Acute Care areas are described in Table 11.1. Should the data in this table be in conflict be the table presented in the individual departmental design guidance documents, those individual guidance documents take precedence.
{| class="wikitable"
|+Table 5 Minimum gas services
!'''Description'''
!
!'''Oxygen'''
!'''HP Air'''
!'''LP Air'''
!'''N2O'''
!'''VAC'''
!'''Scavenging'''
|-
|'''Major Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Minor Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Cath Lab8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|1
|
|
|1
|1
|1
|-
|'''Post Op'''
|'''Bedhead'''
'''Trunking'''
|1
|
|1
|
|1
|
|-
|'''Procedure'''
'''Room'''
|'''Theatre Panel'''
|1
|
|1
|
|2
|
|-
|'''Resuscitation Bay'''
|
|1
|
|1
|
|2
|
|-
|'''Delivery Room'''
|
|2
|
|1
|
|2
|
|-
|'''High Care Unit, Per Bed'''
|
|1
|
|1
|
|2
|
|-
|'''Intensive Care Unit Per Bed'''
|
|2
|
|2
|
|2
|
|-
|'''Casualty Per Bed'''
|
|1
|
|1
|
|1
|
|-
|'''Wards'''
|
|'''1 per'''
'''2 beds'''
|
|
|
|'''1 per'''
'''2 beds'''
|
|}
30. A gas alarm system to monitor gases, excluding scavenging, must be installed in a location that is manned 24 hours per day. A slave panel must also be installed in the intensive care unit and in the theatre complex. This alarm system must be connected to UPS.

31. All piped vacuum and oxygen systems must have mobile back-up systems with adequately trained staff to handle them. . The back-up service shall be automatically activated if the line pressure drops below the set operating pressure. All back-up services and change-over valves shall be on UPS and diesel generator supplies.

32. Medical air (low pressure) for respiratory purposes must be provided at a fixed pipeline pressure of 400 kPa. Medical air (high pressure) for driving surgical power tools must be provided at a terminal usage pressure between 70 0kPa and 1000 kPa, depending on the tools/equipment to be used. ICU and operating rooms must be provided with a back-up system for both low and high pressure service. Air compressors must be fed off standby power supply.

33. Anaesthetic gas scavenging, which is a low-pressure suction system that removes exhaled anaesthetic gases from the patient circuit must be provided. Each outlet point must have its own balancing valve to allow the system to be balanced progressively from the furthest outlet point towards the suction fan or pump.

34. The vacuum installation shall comply with SANS 7396-1. Vacuum liquid bottle traps must be installed to collect any blood/fluid etc. that may be drawn into the pipeline. One bottle trap per operating room, ICU, ward block and other patient unit, must be supplied. Where possible the vacuum trap should be located in a sluice room. Emergency suction facilities must be provided in the ICU and High Care, operating rooms, recovery room, delivery room, emergency unit and nursery, and must be available to all patient rooms. Bacteria filters must be installed in the vacuum main before the vacuum reservoir and pumps. Used filters are considered a bio-hazard and must be handled accordingly when being changed and disposed. Care must be given to the location of the exhaust discharge of vacuum plants taking into account locations of windows and other air inlet points. Vacuum pumps must be fed off standby power supply.

35. Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.

36. Gas service outlets to be identified and colour-coded with 3mm lettering.

37. Should compressed air operated autoclaves be employed, High Pressure medical air may be taken to such equipment, provided the system possesses sufficient capacity.

38. Should pendants requiring compressed air for aid of movement be employed, High Pressure Medical Air may be taken to them, provided the system possesses sufficient capacity.

39. Should Health Technology Workshops require medical gas outlets for testing and servicing of medical equipment, the required service may be taken to them, provided the system possesses sufficient capacity.

40. SANS 7396-1, as amended, specifies the requirements from design to commissioning of medical gas and vacuum systems

41. Medical gas and vacuum pipelines shall be marked in accordance with SANS 7396-1 and ISO 5359 as applicable

42. SANS 7396-2, as amended, specifies the requirements from design to commissioning of anaesthetic gas scavenging disposal systems.

43. Colour coding of anaesthetic gas scavenging disposal system shall be red magenta or in accordance with the national standard. An example of red magenta is 3050-R40B, in accordance with SS 01 91 02.(Refer to SANS 73962-2).

44. Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.

45. SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.

46. Plain ended copper tubing for low pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.

47. Laboratory gas taps and valves shall be marked as described in SANS 10140-4

===Electrical installations===

====48. Lighting in Hospitals ====
48.1. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

48.2. Within the available scope presented in the National Building Regulations, the following lighting requirements should be interpreted with the aim of maximum energy and cost efficiency. The following innovations could be adopted to achieve this aim:

#Daylight harvesting with passive building elements and active systems response.
#Adoption of task lighting, where appropriate, within the scope of present and future planned activities.
#Considered selection of lighting elements and solutions.
#Considered selection of internal colours and materials.
#Accommodation for visually impaired occupants.

48.3. Where a requirement for natural light (daylight) is stated, this may be met if the room opens onto an atrium or courtyard, or if a roof light is incorporated, provided that privacy within the room or space is maintained. In addition, daylight may be borrowed from an adjacent room by means of glazing the wall in between, provided that the adjacent room or corridor is within the same unit.

48.4. Save where otherwise provided for in the requirements, health establishments must comply with the following: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table 6 Levels of Indoor Lighting (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings)'''
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''

'''/ lux'''
|'''Max. point illuminance/ lux'''

'''(not to be exceeded)'''
|'''Unified'''

'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''

'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Common areas'''

- changing room

- chapel

- classroom

- consulting room (general)

- care room (deep plan)

- day room

- disposal (clinical, domestic waste)

- doctor’s office

- domestic services room

- drug store (ITU/HDO)

- general office

- seminar room

- seminar room

- staff change

- staff rest room

- utility room (clean)

- utility room (dirty)
 
|

100-150

100-150

300

300

300

200

200

500

100

500

300

100-150

300

100

50/200

150

200
 
|

n/a

n/a

520

520

520

350

350

850

170

850

520

n/a

520

170

n/a

260

350
 
|

22

22

19

19

19

22

22

19

19

19

19

19

19

22

22

19

22
 
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

90

80

80
 
|

Floor

Pews

Desk

Work Surface

Work Surface

Work Surface

Floor

Desk

Floor

Desk

Desk

Floor

Work Surface

Floor

Work Surface

Work Surface

Work Surface
 
|

Normal

Normal

Normal

Normal

-

-

Normal

Normal

Normal

Normal

Normal

Normal

Selective

Normal

-

Normal

N
 
|

-

-

-

>30%

-

-

-

>30%

-

>30%

>30%

-

>30%

-

-

>30%

>30%
 
|-
|'''Corridors (screened from bed bays)'''

- by day

- by night
 
|

200

5-10
 
|

350

n/a
 
|

22

22
 
|

80

80
 
|

Floor

Floor
 
|

S

Normal
 
|

>30%

>30%
 
|-
|'''Circulation/communal areas'''

- corridors (general)

- day room

- entrance canopy

- entrance lobby

- hairdressing salon

- hospital street

- library

- lift car

- lift lobby

- loading bay

- reception area

- relatives overnight

- rest area

- shop/kiosk

- storage (general)

- toilets
|

200

200

n/a

n/a

300

200

300

150

200(min)

100

300

150

150

300

200

200
|

350

350

n/a

n/a

520

350

520

260

n/a

170

520

260

260

520

350

n/a
|

19

-

-

22

-

19

19

-

19

22

19

-

19

-

22

22
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80
|

Floor

Floor

Road surface

Floor

Chair

Floor

Desk

Floor

Floor

Platform or floor

Floor

Work Surface

Floor

Counter

Floor

Floor
|

Normal

S

Selective

Selective

Normal

N/EM

Normal

Sp

Selective

Normal

Normal

Normal

Normal

Normal

Normal

Normal
|

>30%

>30%

>30%

>30%

-

>30%

-

-

>30%

-

>30%

-

-

-

-

-
|-
|'''Restaurant/catering/breakout areas'''

- beverage bay

- counter

- general

- servery

- tables

- washing up
 
|

100

300

50

300

50/200

|

170

520

100

520

n/a

520
 
|

-

22

-

22

-

22
 
|

80

80

80

80

80

80
|

Floor

Counter

Floor

Counter

Tables

Sink
 
|

Normal

Normal

S

Normal

Normal

Normal
 
|

>30%

-

>30%

-

-

>30%
 
|-
|'''Wards and bedded areas'''

- children’s play area

- circulation space

- circulation space (night)

- examination/treatment

|

300

170

10

1000(local)

|

520

170

10

n/a

|

22

19

-

-

|

80

80

80

90

|

Desk

Floor

Floor

Bed level (usually provided by examination lamp
|

N/EM

Normal

Normal

Normal

|

>30%

>30%

>30%

>90%

|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Nursing'''

- general nursing care/examination

- night light

- nurses’ station (day)

- nurses’ station (night)

- observation/night watch

- observation/night

- mental illness care wards

- patient reading (adult)

- reading lights

- ward corridors (day)

- ward corridors (night)

|

300

5

300

30/200

20

1 to 5

200

300

300

200

50

|

520

10

520

250

40

n/a

350

520

520

350

75

|

19

-

19

22

-

-

19

19

19

19

19

|

80

80

80

80

80

80

80

80

80

80

80

|

Bed

Work Surface

Desk

Work Surface

Bed head

Bed head

Floor

Bed head

Patient activity area

Floor

Floor (50% uniformity required)
 
|

Selective

Normal

Variable

Normal

Normal

N/Sp

Normal

Normal

Selective

Normal

Normal

|

>30%

>90%

>30%

>90%

-

>30%

>30%

>30%

>30%

>90%

>30%

|-
|'''Orthopedic'''

- pacemaker

- treatment (general)

- venesection
 
|

500

300

300
 
|

850

520

520
 
|

19

19

19
 
|

80

80

80
 
|

Work Surface

Work Surface

Chair
 
|

Variable

Normal

Normal
 
|

>30%

>30%

>30%
 
|-
|'''Critical care'''

- intensive care (night)

- observation/night watch

- high dependency unit (HDU)

- intensive care unit (ICU)

- bed head (day)

- night light

- simple observation/examination

- examination

 
|

5(max)

20

100

100

30 to 50

5 to 10

300

1000 (local)

 
|

n/a

40

170

170

n/a

10

520

n/a

 
|

-

-

19

19

22

-

19

-

 
|

80

80

80

80

80

80

80

90

 
|

Circulation

Bed head

Circulation/general

Circulation/general

Bed head

Bed head

Bed

Bed level(to be provided by examination lamp)

|

N/Sp

N/Sp

Normal

Normal

Normal

Normal

Selective

Normal

 
|

>30%

>30%

>90%

>90%

>90%

>90%

>90%

>90%

 
|-
|'''Coronary care'''

- bed head (day)

- observation/night watch

- simple observation/examination

- examination

- staff base (day)

- staff base (night)
 
|

30 to 50

5 to 10

300

1000 (local)

300

30/200
 
|

n/a

n/a

520

n/a

520

250
 
|

19

-

19

-

19

19
 
|

80

80

80

90

80

80
 
|

Bed head

Bed head

Bed

Bed level (to be provided by examination lamp)

Desk

Desk
 
|

Normal

Normal

Selective

Normal

Selective

Variable
 
|

>90%

>90%

>90%

>90%

>90%

>90%
 
|-
|'''Nurse’s station/staff base'''

- day

- night

- interview
 
|

300

30/200

300
 
|

520

250

520
 
|

19

19

19
 
|

80

80

80
 
|

Desk

Desk

Desk
 
|

Selective

Variable

Normal
 
|

>90%

>90%

>30%
 
|-
|'''Operating theatres'''

- anesthesia (examination)

- anesthesia room (general)

- angiography room

- endoscopy

- operating room general

- operating table/cavity

- porter’s area

- post anaesthesia recovery

- preparation

- scrub up

- transfers

- utility rooms
 
|1000 (local)

500

500

300

300

1000

10000 to 100000

300

500

500

500

300

100 to 150
|

n/a

850

850

520

1500

n/a

520

850

860

860

520

n/a
|

-

19

19

19

19

-

19

19

19

19

19

19
|

80

80

80

80

90

90

80

90

801

80

80

80
|

Trolley head

Work Surface

Work Surface

Work Surface

Work Surface

Work Surface

Trolley/bed

Work Surface

Bench

Sink top

Work Surface

Floor
|

Normal

Selective

Variable

Variable

Variable

Variable

N/A

Selective

Normal

Normal

Normal

Normal
|

>90%

>90%

>90%

>30%

>90%

>90%

>90%

>90%

>30%

>30%

>30%

-
|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Accident and emergency'''

- Admissions. reception

- supplies stores

- minor treatment area

- minor operations

- couch (general area)

- couch (local)

- general examination areas

- procedure room

- resuscitation room
 
|

300

300

500

15000/30000

750

500

500

30000/60000

500
 
|

520

520

850

N/A

1000

850

850

N/A

860
 
|

22

22

19

-

19

19

19

-

19
 
|

80

80

80

90

90

80

80

90

80
|

Desk

Work Surface

Work Surface

Adjustable to suit treatment area

Over couch area

Couch level

Couch level

Task illumination provided by minor treatment lamp

Work Surface
 
|

Normal

Normal

Normal

Normal

Variable

Variable

Variable

Normal

Normal
 
|

>30%

>90%

>30%

>30%

>90%

>90%

>90%

>90%

>30%
 
|-
|'''Audiology'''

- audio testing

- consulting room

- ear examination

- vestibular testing (labyrinth)

|

300

300

1000 (local)

100

|

520

520

n/a

170

|

19

19

-

19

|

80

80

90

80

|

Work Surface

Work Surface

(examination lamp)

Couch head and instruments
 
|

Variable

Variable

-

Normal
 
|

>30%

>30%

-

>30%
 
|-
|'''Dentistry'''

- laboratories

- reception/administration areas

- surgeries/theatres

- treatment rooms

- white teeth matching

|

500

300

8000 to 20000

500

5000

|

850

520

n/a

850

n/a

|

19

19

-

19

-

|

80

80

90

90

90

|

Bench

Work Surface

Mouth

Bench work surface

Work Surface

(TCP ≤ 6000 K)
 
|

Normal

Selective

Variable

Normal

Normal

|

>30%

>30%

>90%

>30%

>30%

|-
|'''Diagnostics support'''

- aseptic laboratory

- blood bank

- colour inspection laboratory

- hot and cold rooms

- inspection

- laboratories

- laboratory (with computers)

- pathology laboratory

- relatives’ waiting room

- seminar room

- viewing/bier room
 
|

300

300

1000 (local)

200

500 (local)

500

300

500

300

300

30 to 150
 
|

520

520

n/a

350

n/a

850

520

850

520

520

n/a
 
|

19

19

-

19

-

19

19

19

19

19

19
 
|

80

80

90

80

80

80

80

80

80

80

80
 
|

Bench

Work Surface

Bench

(TCP ≤ 6500 K)

Work Surface

Bench

Bench/desk

Work Surface

Bench

Work Surface

Work Surface

Bier
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Variable

Normal

Variable
 
|

>30%

>90%

>90%

>30%

50-90%

50-90%

50-90%

50-90%

>30%

>30%

>30%
 
|-
|'''Women’s services (maternity)'''

- applying sutures

- circulation space (day)

- delivery

- day

- night

- neonatal

|

1000 (local)

100

500

50 to 100

5

1000 (local)

|

n/a

170

850

n/a

20

n/a

|

-

19

19

19

-

-

|

90

80

80

80

80

80

|

Couch, chair or bed (usually provided by examination lamp)

Floor

Work Surface

Cot

Cot

Cot

|

Normal

Normal

Selective

Normal

Normal

Normal
 
|

>90%

>30%

>90%

>90%

>90%

>90%

|-
|'''Mother and baby rooms'''

- circulation space (day)

- day

- night

- nurseries (day)

- nurseries (night)

- milk kitchen

- special care baby unit

- teaching areas
 
|

100

50 to 100

5

100

5

300

1000 (local)

300
 
|

170

n/a

20

170

20

520

n/a

520
 
|

22

19

-

19

-

22

19

19
 
|

80

80

80

80

80

80

80

80
 
|

Floor

Cot

Cot

Floor

Floor

Bench

Cot

Bench/Work Surface
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>30%

>90%

>90%

>30%

>30%

>30%

>90%

-
 
|} 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''General treatment areas'''

- autopsy (dissecting) table

- autopsy rooms and mortuaries

- dermatology

- dialysis

- dispensary

- minor surgery/treatment

- plaster room

- resuscitation (general)

- resuscitation/examination

- pharmacy
 
|

5000

500

(higher values could be required)

500

500

15000/30000

500

500

15000(local)

500
 
|

8600

850

n/a

850

860

 850

850

n/a

850
 
|

-

19

19

19

19

19

19

-

19
 
|

90

90

90

80

80

90

80

90

90

80
|

Table top

Work Surface

(Local operating lamp)

Work Surface (dimmable)

Bench

Work Surface

Work Surface

Head of trolley

Work Surface
 
|

-

-

-

-

Normal

Normal

Normal

Normal

Normal

Normal
 
|

-

-

-

-

>90%

>90%

>30%

>90%

>90%

50-90%
 
|-
|'''Mortuaries and animal houses'''

- autoclave

- body store

- general

- mortuary

- operation

- post mortem

- staff change

- store room

- viewing room

- waiting room
 
|

150/200

200

300

150

500 local

500

100 to 150

150

50/100

200 (min)
 
|

n/a

350

520

260

n/a

850

n/a

260

n/a

n/a
 
|

19

19

19

19

-

19

19

19

19

19
 
|

80

80

80

80

90

90

80

80

80

80
|

Work Surface

Work Surface

Work Surface

Bier room

Bench

Work Surface/table

Floor

Work Surface

Work Surface

Floor
 
|

Normal

Normal

Special

Variable

Normal

Normal

Normal

Normal

Variable

Selective
 
|

>30%

>30%

-

>30%

>30%

>30%

>30%

-

>30%

>30%
 
|-
|'''Engineering services'''

- ducts

- plant room

- roadways

- workshop
 
|

20 to 50

300

7

300/500
 
|

n/a

520

12

n/a
 
|

-

22

-

22
 
|

80

80

80

80
|

Floor

Floor

Road surface

Bench
 
|

Selective

Normal

-

Normal
 
|

-

>90%

-

>30%
 
|-
|'''Facilities support services'''

- laundry

- linen store (Linen Department)

- pack and dispatch

- pressing

- sewing room

- wash and dry
 
|

300

100

300

300

500 (local)

300
|

520

170

520

520

n/a

520
 
|

19

19

19

19

19

19
 
|

80

80

80

80

80

80
 
|

Bench

Floor

Bench

Equipment

Machine

Equipment

|

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>90%

-

>90%

>90%

>90%

>90%
 
|}
48.4.1. The lighting levels quoted above relate to the relevant task area. Levels of for the task areas and surrounding areas can be reduced where it can be justified by experienced staff or engineers. Lighting levels must, regardless, comply with the requirements of the National Building Regulations.

48.4.2. Lighting levels for external areas shall comply with the following table: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table''' '''7 Levels of Indoor Lighting'''
{| class="wikitable"
|Area
|Maintained average illuminance / lux
|Maintained minimum illuminance / lux
|Overall uniformity (not less than stated figure)
|Threshold increment
|Colour rendering (minimum)
|-
|

CCTV

- monochrome

- colour

Roads

General pedestrian areas

Information and display signs

Car Park

Vehicle drop-off points

Steps or stairways

General area lighting

Hazardous open storage areas
 
|

0

-

15

20

30

10

15

20

100(vertical)

15

10

100

20

50
 
|

5

15

6

8

12

4

6

12

6

5

40

12

20
|

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4
 
|

≥10%

≥10%

 
|

≥60%

≥60%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%
 
|}

49. Classification of Safety Services necessary for Medical Locations from SANS 10142-1
{| class="wikitable"
|'''Class'''
|'''Response Time'''
|-
|Class 0 (No break)
|Automatic supply available at no break

UPS backed up by Generator Required.
|-
|Class 0,15 (Very short break)
|Automatic supply available within 0,15 s

UPS backed up by Generator Required.
|-
|Class 0,5 (Short break)
|Automatic supply available within 0,5 s

UPS backed up by Generator Required.
|-
|Class 15 (Medium break)
|Automatic supply available within 15 s

Generator Required
|-
|Class > 15 (Long break)
|Automatic supply available in more than 15 s

Generator Required
|}
Note Safety Services in Medical locations are synonymous with Emergency Services.

50. '''Medical Location Classification'''

50.1. Group 0 location: where no applied part is intended to be used.

50.2. Group 1 location: Medical Location where applied parts are intended to be used.

#Externally, or
#To any part of the body, but not to the heart.

50.3. Group 2 location: Medical Location where applied parts are intended to be used in applications such as in an intracardiac procedure, in an operation (in an operating theatre) and in vital treatment where discontinuity (failure) of supply can cause danger to life.

Note: An intracardiac procedure is a procedure whereby an electrical conductor is placed within the cardiac zone of a patient or is likely to come into contact with the heart, such conductor being accessible outside the patient’s body. In this context, an electrical conductor includes insulated wires such as cardiac pacing electrodes or intracardiac ECG electrodes, or insulated tubes filled with conducting fluids.

50.4. For the allocation of medical location group and classification of safety service classes for medical locations see Table below as supplied in SANS 10142-1.
 
{| class="wikitable"
|
|
'''Medical Location'''
| colspan="3" |
'''Medical location group'''
| colspan="2" |
'''Safety service class'''
|-
|
|
|'''0'''
|'''1'''
|'''2'''
|'''≥ 0,5'''
|'''0,5'''

'''≤ 15'''
|-
|

1
|

Massage room
|

X
|

X
|
|
|

X
|-
|

2
|

Bedrooms
|

|

X
|
|
|

X
|-
|

3
|

Delivery room
|
|

X
|
|

X
|

X
|-
|

4
|

ECG, EEG, EHG room
|
|

X
|
|
|

X
|-
|

5
|

Endoscopic room
|
|

Xa
|
|
|

Xa
|-
|

6
|

Examination or treatment room
|
|

X
|
|
|

X
|-
|

7
|

Urology room
|
|

Xa
|
|
|

Xa
|-
|

8
|Radiology diagnostic and radio therapy room, other than mentioned under 21
|
|

X
|
|
|

X
|-
|

9
|

Hydrotherapy room
|
|

X
|
|
|

X
|-
|

10
|

Physiotherapy room
|
|

X
|
|
|

X
|-
|

11
|

Anaesthetic room
|
|
|

X
|

X
|

X
|-
|

12
|

Operating theatre
|
|
|

X
|

X
|

X
|-
|

13
|

Operating preparation room
|
|

X
|

X
|

X
|

X
|-
|

14
|

Operating plaster room
|
|

X
|

X
|

X
|

X
|-
|

15
|

Operating recovery room
|
|

X
|

X
|

X
|

X
|-
|

16
|

Heart catheterization room
|
|
|

X
|

X
|

X
|-
|

17
|

Intensive care room
|
|
|

X
|

X
|

X
|-
|

18
|

Angiographic examination room
|
|
|

X
|

X
|

X
|-
|

19
|

Haemodialysis room
|
|
|

X
|

|

X
|-
|

20
|

Magnetic resonance imaging (MRI)
|
|

X
|
|
|

X
|-
|

21
|

Nuclear medicine
|
|

X
|
|
|

X
|-
|

22
|

Premature baby room
|
|
|

X
|

X
|

X
|-
| colspan="3" |
a The room is not an operating theatre.
|
|
|
|
|}
50.5. In addition to the tables 0 and 50.4 above, generator supply is also required for:

#Night light in wards and ward corridors;
#All switched socket outlets used for patient life support anywhere in the facility;
#At least one patient lift or lift that can accommodate a bed for every 200 patients;
#Medical air compressor, vacuum pumps and gas alarm systems;
#Supply air fans serving theatres and uni-directional airflow systems;
#Isolation ward exhaust air fans.
#Mortuary Fridge Cabinets
#Nurse call System
#Fire detection system

51. General Requirements

51.1. Power supply to switched socket outlets in high care units, intensive care units and operating theatre units and recovery rooms must be on an earth monitoring system. Double pole isolators must be used for supply points in these areas and the power supply to these shall be fed from an isolation transformer.

51.2. Medical Location Group 1:

Switch Socket outlets in Medical Location 1 Shall have final Circuits for socket -outlets up to 16Amp shall be protected by earth leakage protection devices with a rated earth leakage tripping current ( rated residual current) not exceeding 30 Ma.

51.3. Medical Location Group 2:

Switch Socket outlets in Medical Location 2 the Medical Isolation Transformer (Medical IT) system shall be used for circuits that supply medical electrical equipment and systems intended for life support or surgical applications and other electrical Equipment located in the patient environment. In the case of each group 2 medical location, at least one separate medical IT system is necessary.

51.4. The Medical Isolation Transformer (MIT) shall be equipped with:

51.4.1. A 5 or 8 kVA Isolation Transformer complete with a 220 V Primary and 220 V / 110 V Secondary Winding with a centre Point Floating but bonded to the Earth monitor. The Secondary Side of the transformer shall provide 220 Volts between Line 1 and Line 2 (Note no Neutral with an Isolation Transformer) Line 1 and Line 2 will feed the Distribution Board for that particular Medical Group location, i.e. (Theatre No 1) or (ICU Bed 1-6) This local DB will then have a number of double pole Circuit Breakers feeding out to the outgoing Circuits feeding the Socket Outlets in the Medical Location 2 Area. Note that at least two circuits are required to each ICU Bed or Theatre Panel, and Theatre Pendant. Also note that all Switch Socket Outlets in a Medical Location 2 Area have to be double Pole Switched via a double pole Isolator (Provided two circuits provided) or a double pole Circuit Breaker.

51.4.2. The Transformer shall be installed either in a cabinet/DB or enclosure, to prevent unintentional contact with live parts. The Transformer / DB should be located close to the Group 2 Medical Location but consideration should be given to providing the DB outside the red line area of both the Theatres and ICU Areas, so maintenance can be carried out without the need to be gowned up. Line 1 & 2 and Earth should all be Insulated wires with the colour of Line 1 & 2 being different from red and black suggest Brown and Blue wire is used for Line 1 & 2 and green for Earth (Note this Earth wire should be connected to an insulated Earth bar dedicated to that particular Group two location and bonded to the centre point of the secondary winding.) Note a Separate Dirty earth (Equipotential bonding) should also be provided to the metal work of the Plugs, Theatre Panel, and Pendant this earth shall be connected to the Main Building Earth.

51.4.2. An insulation -monitoring device that:

#Has an internal impedance of at least 100 k Ohm;
#Has a test voltage not exceeding 25 V DC.
#Is of a current, even under fault conditions, not exceeding 1 mA DC. and
#Shall indicate, at least when the insulation resistance has decreased to 5 k Ohm.

A test device shall be provided to test this facility to ensure that the alarm (Audible and visual) operates when the insulation resistance reaches 5 k Ohm;

To test the System two male plugs should be used each with a resistor of 5 k Ohm. Plug No 1 should have a 5 k Ohm resistor bridged from the Earth Pin to the Right Hand live Pin. Plug No 2 should have a 5 k Ohm resistor bridged from the Earth Pin to the Left Hand live Pin.

51.4.4. Medical Isolation Transformer Alarm.

For each Medical IT system an audible and visual alarm shall be provided in the Theatre Area a alarm shall be provided on theatre Panel and repeated back to the main Nurse Station in Theatre Area .The Alarm shall consist of Green Light indicating Healthy, a red light indicating fault, a audible Alarm to also indicate fault and a local audible alarm mute button. The Visual signal shall revert to green and the audible alarm shall be automatically reset on the removal of the fault condition
 

Table 4 – Required for Medical Isolation Transformers (MIT) and Switch Socket Outlets (SSO)
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Office Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Laboratory Work Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Office
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Nurse Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward
|1
|1 x 16A Normal / Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point/ Bed(if required).
|
|3x 16A per bed
|
|
|
|
|-
|Ward Kitchen
|0
|2 x 16A Normal on Wall at 1200 mm over counter + 1 x 16 A next to Sink or Hydro Boil.
|
|1 x 16A supply for Fridge on generator supply
|
|
|
|
|-
|Ward Corridor
|0
|1 x 16A Normal / Every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Ward Staff Rest Room
|1
|I x 16 A on Wall for Cleaning, 1 x 16 A above counter for Electrical Appliances + 1 X 16 A next to sink for Hydro boil
|
|
|
|
|
|
|}
----[[Building Engineering Services#%20ftnref1|[1]]] Note: DPS is an abbreviation for double pole switch
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Theatre Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|-
|Theatre Post Op
|2
|
|
|
|6 x 16 A Dedicated SSO per Bed
|
|
|
|-
|Operating Theatre
|2
|
|
|
|
|8 x 16 A Dedicated SSO per Pendant
|8 x 16 A Dedicated SSO per pendant
|4 x 16 A Dedicated SSO
|-
|Cath Lab Operating Room
|2
|
|
|
|
|
|
|4 x 16 A Dedicated SSO
|-
|Cath Lab Control Room
|0
|1 x 16A Normal per Station
|1 x Red 16A Dedicated per Station
|
|
|
|
|
|-
|Cath Lab Equipment Room:

160 kva dedicated UPS Required to feed Dedicated DB and Equipment
|
|
|
|
|
|
|
|
|-
|Autoclave
|
|In autoclave plant room. 3-Phase 380V, 80A per autoclave
|
|
|
|
|
|
|-
|Instrument Washer
|
|In CSSD. Typically 3-Phase 380V, 15A per washer
|
|
|
|
|
|
|-
|Theatre Corridor
|1
|1 x 16A Normal for every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|}
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|ICU Circulation Space
|1
|1 x 16A Normal per 25m2 for cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Neo Natal ICU Cots Note: Care should be taken when sizing the Isolating Transformers to include the Heating Load
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care Nurse Station (per workstation)
|1
|1 x 16A Normal per Station
|2 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|-
|ICU and Ward Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|}
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Casualty Treatment Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point per Bed. 2 x 16A per Bed
|
|
|
|
|
|
|-
|Procedure Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning
|
|4 x 16A per Bed per two Circuits.
|
|
|
|
|-
|Casualty Ward Corridor 0
|0
|1 x 16A Normal per every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Radiology Procedure Crash Cart Position
|
|
|
|
|
|-
|Rooms Dedicated 125 Amp Supply to dedicated
|1
|1 x 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Radiology Control Room
|0
|1 x 16A Normal per Station
|1 x 16A Normal per Station
|
|
|
|
|
|-
|Maternity Delivery Rooms
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|
|
|}

{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Dialysis Treatment Beds.

Note that the Equipment can include Water Heating with high kw loading so care should be taken when sizing the Isolating Transformers
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|
|
|}
51.5. Uninterrupted Power System must be provided for operating theatre luminaries and all life support systems and computer systems where a break in electrical supply cannot be tolerated. The whole installation must conform to SANS 1474 of 1988.

51.6. Socket outlets for Dialysis units, in close proximity to water points or drains, shall be of the totally waterproof IP65 type, which also seal water-tight when the socket is removed.

51.7. Where more than one electrical transformer is used, they should preferably be located in separate structural enclosures. This is to prevent potential damage to an adjacent transformer if one is damaged.

51.8. All distribution boards fed from normal mains supply shall be painted Electric Orange, colour B26 to SABS 1091.

51.8. All distribution boards fed from standby emergency power supply shall be painted Signal Red, colour A11 to SABS 1091.

51.9. All distribution boards fed from UPS power supply shall be painted Blue colour F06 to SABS 1091.

51.10. All cable transition boxes shall be painted the appropriate colour corresponding to the source of the power supply.

51.11. All cables installed on surface mounted cable ladders shall be of the PVC/PVC/SWA/ECC/PVC type to SANS 101507 rated at 600/1000 Volt.

51.12. Electrical circuits to be engraved on base 3mm lettering indicating circuit number and DB.

51.13. Electrical Certificate of Compliance.
[[File:Picture 11.png|border|thumb|450x450px|alt=|center]]
 
===Electronic installations===
52. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

53. Nurse call system with emergency (nurse assistance) and TV control handsets (Interchangeable with LED PEAR PUSH).

The nurse system enables the patient to call a nurse for assistance from his bed or from a bath, shower and toilet. The system also enables the staff to call for assistance (EMERGENCY CALL) from any bed and treatment room etc.

#When a patient nurse call or staff emergency call is enabled the system must produce an intermittent AUDIBLE chimes or bleeper tone at the nurses’ station or/and duty room. Three different sounding tones must be produced for normal Patient call, Bathroom call and Emergency (nurse assistance) call.
#The system must also provide a VISUAL indication, at the nurse station (LED Mimic Panel and/ or Computer Monitor or LCD Display Panel), above the door to the passage of the activated unit, and at the actual activated unit (reassurance LED).
#The system must be so designed that any call may ONLY be RESET at the point of origin.
#The system must automatically activate a nurse call when the Hand Held Unit (Handset) or Pear Push unit is accidently pulled out from the Bed Head Unit.
#The Bed Head Unit must be compatible with Hand Held Unit (with TV Control), Rehab Hand Held Unit & Pear Push. (Inter-changeable)
#A Central Monitoring PC, or PC per duty station replacing Mimic Panel, must keep records of all events. (Optional)
#The system must be purpose made and aesthetically pleasing with components (call & reset units etc) manufactured from matching injection moulded ABS plastic. A system made up of push buttons etc mounted directly onto standard electrical plates will not be accepted.

54. Automatic fire detection in Hospitals

The Fire Detection System shall comply with SANS 10400 SANS 10139 & SANS 322. The Fire Detection System must be provided throughout the Facility and be a Addressable Fire Detection System, Note that Audible Fire Alarms which could panic the patients should not be provided instead Visual Strobe Lights should be provided at all Nurse stations, Reception and Security Office.

Audible alarms can be used in noisy areas such as plant rooms.

The wiring for the Automatic Fire Detection System shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area)
 55. Public Address and Evacuation in Hospital

The Public Address and Evacuation System shall comply with EN54 and provide voice message via fire retardant speakers throughout the hospital Circulation Areas, Staff Areas, Public Toilets. The wiring for the Evacuation Speakers shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area). As part of the Hospital Design the Hospital should be zoned to allow Evacuation of Individual zones in the event of a fire or other Emergency.

==Wet Services==
56. Plumbing services (Water supply and drainage) must comply as a minimum with the following Standard Specifications and Codes of Practice:

#SANS 10400: The Application of the National Building Regulations, including Part XA: Energy Use in Buildings
#SANS 10252 – Part 1 – Water Supply Installations for Buildings
#SANS 10252 – Part 2 – Drainage Installations for Buildings
#UK Department of Health Technical Memorandum 04-01: The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems: Part A: Design, Installation and Testing, and Part B: Operational Management or the equivalent SANS standard when available.

57. Where any apparent conflict between the functional requirements and the regulatory “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functional compliance.

58. Cold water storage, dedicated to the domestic water requirements of the facility, must be provided on the site. A minimum usable volume of 500 litres per bed must be provided.

59. If water storage is required for fire protection purposes (Sprinklers, Fire Hydrant supply) it must be stored separately from domestic water, unless adequate provision for the prevention of stagnation of the fire service reserve within the tank can be made.

60. Tanks must be accessible both on the outside as well as the inside, and provision for cleaning the tanks without interrupting water supply to the hospital must be made. Access manholes must be lockable, and a facility for draining the tank or individual compartments within it, must be made.

61. All openings to the tank (Overflows, vent pipes, etc) must be provided with screens.

62. Underground tanks, with their inherent risk of contamination must be avoided at all cost. If unavoidable, the tank should be constructed in a water tight bund allowing sufficient space all round for inspection and maintenance, and a sump for collecting drainage water

63. Cold water storage tanks must be located such that heat gain to the water is minimised. Cold water storage temperatures 20 C and lower will prevent the colonisation by or multiplication of Legionella

64. Site water reticulation must be designed using sound engineering principles, with adequate provision for isolating sections of the reticulation whilst keeping the remainder in operation being made.

65. Fire protection water reticulations must be kept totally separate from the domestic water reticulation

66. Water distribution may be gravity fed, or alternatively supplied via booster pumps. Pumps must be suited to handling potable water, and provision for built in redundancy must be made. Booster pumps must be supplied off standby power.

67. Hot water supply temperature to general patient care and staff areas must be controlled at 55 C, and must not exceed 60°C, except during a sanitation cycle as described hereunder.

68. Hot water generation systems must where possible use waste heat recovery from a central air conditioning system, if employed.

69. The facility for thermal disinfection of the hot water storage and circulation system must be provided in the system design. This can take the form of controlled heating of the storage vessel and circulating mains to 60°C during periods of low water and power demand. The use of shunt pumps to circulate hot water from the top level to the lowest level of the hot water tank during the sanitation cycle must be considered.

70. Hot water supply to paediatric wards, as well as to geriatric and to neonatal bathing facilities shall not exceed 42°C at the point of supply. If thermostatic mixing valves are employed to achieve this, they must be fitted with a safety feature such that the water flow is cut off within 2 seconds of the cold water supply to the valve being interrupted. The valve must also be able to control the set temperature with a pressure ratio of incoming hot to cold water supply pressure of up to 10 to 1.

71. Toilet flushing systems must be provided with easily identifiable dual flush mechanisms, one being for low flush water flow, the other for standard flush water flow.

72. All sanitary fittings must be piped such that the hot water control is on the left hand side, and the cold water supply is on the right hand side when facing the fitting.

73. Branch pipes (dead legs) between water heating equipment or hot water circulating mains and sanitary fittings must be sized and located such that the maximum waiting time for hot water to emerge from the fitting does not exceed 12 seconds.

74. Mixing taps in patient care areas must be elbow action type, installed such that the tap can be opened and shut by means of simple elbow action.

75. The discharge from kitchen floor drains and other kitchen drain points such as sinks, dishwashing washing, machines, and cooking equipment wash down, likely to contain grease, must be taken via a separate discharge system to a suitable grease interceptor, installed in a position to allow easy access for removal of intercepted grease and oil.

76. The drain pipes from equipment likely to produce high temperature discharge, such as autoclaves, sterilisers and cooking equipment must be from materials able to withstand such temperatures, installed such that distortion and/or expansion can be accommodated by the system.

77. Vertical pipe runs (Drainage stacks and water supply mains) in multi storey buildings must be housed in continuous vertical service ducts with easy access from non-patient areas at each level.

78. Condensate drains from air conditioning and refrigeration systems must discharge into piped drainage systems.

79. Anti-Backflow protection devices shall be fitted to faucets with hand-held shower heads to prevent back siphoning should the supply water pressure fail.

80. In areas housing patients at unusual risk of infection, faucets should not be fitted with low-flow or aerating devices which may increase the rate of aerosolisation of infectious droplets.

 

'''81. Legionella Control'''

#A facility-wide legionella control plan shall be in place which will inform operation, maintenance and design of water systems.
#This Plan must include a Legionella risk assessment document, listing all areas where the bacteria may occur. This must address specifically air conditioning condenser water systems, domestic hot and cold water installations, irrigation water storage and distribution systems, etc.
#The Plan must refer to as-built drawings identifying positions and layouts of plant and installations liable to cause a risk of Legionella being generated
#The facility’s Maintenance Procedures must describe all measures to be taken to minimise proliferation of Legionella. This is to include procedures and frequency of sanitation/disinfection, purging of dead legs on circulating systems, sample taking and testing at specific intervals, as well as a responsibility matrix of personnel

For additional information refer to the [[Legionella Control]] article.

==Lifts==
82. Standards and Regulations Pertaining to Lifts and Lifting Operations:

#SANS 50081 - SAFETY RULES FOR THE CONSTRUCTION AND INSTALLATION OF LIFTS - PARTICULAR APPLICATIONS FOR PASSENGER AND GOODS LIFTS
#SANS 10400 –SS3 FACILITIES FOR DISABLED PERSONS: LIFTS
#SANS 10400 –TT45 FIRE PROTECTION: LIFT SHAFTS
#SANS 10400 –TT46 FIRE PROTECTION: LIFT
#SANS 10400 –TT47 FIRE PROTECTION: FIREMAN’S LIFT
#SANS 10400 –TT48 FIRE PROTECTION: STRETCHER LIFT 

83. Planning for circulation, capacity and location of lifts

#A lift traffic plan should be developed. Detailed lift traffic planning is beyond the scope of this document. A specialist advisor should be consulted to assist in the planning of lifts within the general principles of lifts services for healthcare buildings.
#General Lift Planning Principles
#The operational details of the facility must be understood for effective lift planning. These include:

*Number of visitors and visiting hours
*Number of staff, shift hours and ward round schedules
*Numbers of day and overnight patients
*Increased provisions for reduced mobility persons
*Housekeeping schedule
*Evacuation plan for reduced mobility patients.

#Whenever possible, lifts should be provided in pairs to allow for continued operation during maintenance and breakdown.

 

===='''84. TYPES OF LIFTS:'''====
84.1. PASSENGER LIFTS

#These lifts shall be able to accommodate general passenger traffic including ambulatory and semi ambulatory passengers. It shall be able to accommodate reduced mobility passengers using mobility aids and wheelchairs. Refer to SANS 50081-70, Table 1
#The entrance to a passenger lift shall not be less than 1100 mm in width.
#The depth of a passenger lift shall not be less than 1400mm deep.
#Passenger lifts shall have a mirror on the top half of the rear wall equal to the width of the lift to enable wheelchair users to back out of the lift where the lift has internal dimensions less than 1,5 m in width and 2,0 m in depth
#At least on one side wall of the car a handrail shall be installed 

84.2. BED LIFTS

#Bed lifts shall have internal dimensions of 1 800 mm wide by 2 700 mm deep to accommodate most beds with staff and medical equipment.
#The entrance to a bed lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.3. STRETCHER LIFTS

#Stretcher lifts shall have internal dimensions of 1 400 mm wide by 2 400 mm deep to accommodate most trollies or stretchers.
#The entrance to a stretcher lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.4. GOODS LIFTS

#Goods lifts are for the movement of conventional goods and items that could not reasonably use passenger lifts without causing discomfort to passengers or damage and soiling of the lift car.
#Goods lifts can be designed to accommodate passengers.

84.5. SERVICE LIFTS

#Service lifts are not designed for accommodate passengers. They are typically of the “dumb waiter” style dispatched between service hatches.

84.6. HOUSEKEEPING LIFTS

#Housekeeping lifts are similar in function to goods lifts but are intended for the movement of cleaning supplies, medical supplies and equipment, linen etc.

{| class="wikitable"
|+Hospital Guide - Passenger
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''630 kg / 8 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|1800 x 1800

2000 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''800 kg / 10 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1350 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|2000 x 1800

2200 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1600 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2300 x 1800

2450 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1250 kg / 16 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|2000 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2700 x 2000

2700 x 2000
|1450
1500

1600
|4200
4300

4400
|}
 
{| class="wikitable"
|+Hospital guide - stretcher / Bed Lifts
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 2100
|CLD

TLD
|1000 x 2100

1000 x 2100
|200 x 2600

2000 x 2600
|1450
1500

1600
|4200
4300

4400
|-
|'''1600 kg / 21 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1400 x 2400
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 2800
2500 x 2900

2400 x 2900
|1450
1500

1600
|4200
4300

4400
|-
|'''2000 kg / 26 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1500 x 2700
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 3100
2600 x 3150

2450 x 3150
|1450
1500

1600
|4200
4300

4400
|-
|'''2500 kg / 33 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1800 x 2700
|CTLD

CTLD
|1400 x 2100

1600 x 2100
|2900 x 3150

3000 x 3150
|1450
1500

1600
|4200
4300

4400
|}
 
==PART D - COMMISSIONING AND HANDOVER==
===Deliverables===
1. This section is intended to detail the commissioning deliverables required before handover of building engineering services for operation. For further detail on commissioning and handover the '''IUSS Commissioning Health''' Facilities guidance document should be referred to.

2. Project Close-out deliverables include:

#Final Works completion lists
#Financial reports and final accounts
#Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
#Approved As-Built Drawings
#Electrical Certificates of Compliance

3. '''Maintenance manuals''' shall be timeously issued and shall include:

3.1. Designer and installer contact information

3.2. System information

#System description
#Suppliers list
#Equipment List
#Equipment data sheets
#Materials of construction data sheets
#Warranty information

3.3. Operational parameters

#Start up and shut down procedures
#Special instructions
#Security and access details
#Fault finding procedures
#Alarm management and data logging

3.4. Validation and commissioning

#Approved reports and data
#Relevant test protocols
#Relevant test plans
#Installed and test equipment calibration certificates
#Commissioning certificates
#Beneficial Occupation and Handover certificates

3.5. Spare parts list

3.6. Electronic Data Backup (Read only Media)

3.7. Approved “As-Built” Drawings

#Process diagrams
#Wiring Diagrams
#Control Diagrams
#System Plans
#Training records

3.8. Training Records

3.9. Training Materials

===Commissioning of ventilation systems===
4. Commissioning of ventilation and air conditioning systems shall comprise the following:

#Confirmation of accuracy of measurements.

Measurement accuracy depends on equipment accuracy and repeatability. Factors that would impact on the accuracy of measurement include:

*Operator error and competence
*Type and quality of measuring device
*Quality and adherence to measurement protocols.

4.2. Proof of competence of commissioning technician or engineer

4.3. Commissioning method statements or protocols shall be developed, recorded and adhered to, to ensure all technicians work to the same procedures and sequences. In some instances, such as healthcare units where the ventilation system is critical to that unit’s clinical outcomes or to the safety of occupants, the client or client’s representative may request that these method statements be issued for formal approval before commencement of commissioning.

4.4. As the operational parameters of variable air volume systems are more complex that constant volume systems, the designer is to provide details of all relevant aspects of these systems such that the commissioning specialist can sufficiently develop an appropriate plan the commissioning.

4.5. Preliminary inspections should be completed before the systems are started up for commissioning. Typically these inspections should include:

*The '''state of completion''' of the building and the condition of details such as openable windows, doors and ceilings.
*'''Building cleanliness''' as it pertains to the ventilated spaces as well as the equipment plant rooms.
*Ducting and ventilation components should be inspected internally and externally for '''system cleanliness.''' Prior to fitting filters the following components should be checked for completion, correctness and cleanliness:

#Air intakes screens and mixing plenums
#Heating components
#Cooling components
#Condensate and drip trays
#In duct UVGI systems
#Humidifiers
#Fan and equipment chambers including safeties and interlocks
#Sensors and gauges
#Airflow controllers and fire damper
#Filter frames and orientation thereof
#Insulation
#Ducting and air terminals

*Electrical Equipment should be inspected for completion, correctness, labelling and cleanliness. Prior to running any electrical rotating or control equipment the following check should be completed.

#Local isolators of motors, electric heaters and control circuits including labelling.
#Electrical safety
#Motor starters and frequency drives set correctly for overload and motor restart ratings.
#Direction of rotation of motors on motor shafts
#Motor starting current and sequencing

4.6. An initial running-in period should be conducted at low load before the installation of the filters. This running period is to ensure flushing of ducting, and allow checking of the system operation. During the this period the system should be shut down and restarted to ensure that the controls, fuses and switchgear function correctly; however, repeated rapid restarts should be avoided as this can over-stress the control gear and fuses.

4.7 After the initial running-in the filters can be installed by a suitably qualified technician and the system should then be run at normal load. New filters should be installed before the final proportional balancing commences.

4.8. The proportional balancing of the airflow should be delayed until the ventilation system has been run-in under normal load for a few days to ensure stability of the system. The airflow balancing should be conducted in accordance with good engineering principles such as those described in SANS 10173, the ASHRAE Fundamentals Handbook, CIBSE Commissioning Code A or BSRIA Application Guide 3/89.1 depending on the system requirements.

4.9. For variable air volume systems, the commissioning tests should demonstrate system performance across the design diversity.

4.10. A definitive total airflow measurement should be taken in either a section of the main duct, where duct length and turbulence allow, or in the branch ducts. This value shall be recorded, compared against the design values and tolerances and reported on in the commissioning reports including the percentage of the design flow rates.

4.11. The final airflow measurements shall be taken at all air terminals (supply, return and exhaust) using airflow capture hoods where the terminal generates turbulence and these values shall be recorded, compared to design values and tolerances and reported on in commissioning reports including the percentage of the design flow rates.

4.12. Direction, drop and throw of air terminals shall be assessed by the responsible engineer to confirm the correct air distribution within ventilated spaces.

4.13. The minimum outside air portion should be demonstrated and recorded across the system’s operational diversity.

4.14. A condition of system acceptance is that the commissioning tests be witnessed before signing off. This process could involve the repetition of only a selection of the tests under the observation of an authorised witness or responsible engineer. The following aspects should be demonstrated:

*Performance of the system according to the overall design requirements within specified limits
*Repeatability of performance and measurement results

==PART E - EXAMPLES==
===Mechanical system configurations===

===='''1. HOT WATER GENERATION SYSTEM'''====

[[File:Picture 1.png|thumb|570x570px|Hot water generation system|alt=|border|center]]

===='''2. THEATRE VENTILATION SYSTEMS'''====
The following examples indicate typical system configurations schematically.

2.1 UDAF Recirculation

 
[[File:Picture 2.png|border|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic|alt=|center]]

2.2. UDAF Full Fresh Air & Exhausted

[[File:Picture 3.png|center|thumb|410x410px|NOTE: Does not indicate sensors, interlocks or control logic]]
2.3. Major Theatre: Recirculation
 
[[File:Picture 4.png|center|thumb|410x410px]]

2.4. Major Theatre: Full Fresh Air Supply only
[[File:Picture 5.png|border|center|thumb|400x400px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

2.5. Minor Theatre: Recirculation
[[File:Picture 6.png|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.6. Minor Theatre: Full Fresh Air & Exhausted
[[File:Picture 7.png|border|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.7. Minor Theatre: Full Fresh Air Supply only
[[File:Picture 8.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

===='''3. AIRBORNE PRECAUTION ROOMS AND THEATRES'''====
3.1 Energy Recovery Systems for Airborne Precaution Rooms
 
[[File:Picture 9.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]
4. Energy Recovery Systems for Airborne Precaution Theatres
[[File:Picture 10.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks and control logic]]
 
==REFERENCES==
'''Applicable Regulations and Standards:'''

National Health Act 2004''.'' (61 2003). Cape Town South Africa: Government Gazette.

''Ammended Occupational Health and Safety Act 2004.'' (181 1993) South Africa: Department of Labour.

South African Bureau of Standards, 2009. ''SANS 10142-1:2008 The wiring of premises Part 1: Low-voltage installations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 10173:2003 The installation, testing and balancing of air-conditioning ductwork.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 10252-1:2012 Water supply and drainage for buildings Part 1: Water supply installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1993. ''SANS 10252-2:1993 Water supply and drainage for buildings Part 2: Drainage installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 10313: 1999 Protection of structures against lightning.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1990. ''SANS 10400-2: 1999 Code of Practice for The Application of the National Building Regulations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-1:2005 Copper-based fittings for copper tubes Part 1: Compression fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-2:2005 Copper-based fittings for copper tubes Part 2: Capillary solder fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 1091:2012 National colour standard''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1238:2005 Air-conditioning ductwork''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1409:2008 Outlet sockets and probes for medical (gas and vacuum) services used in hospitals.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1424:2008 Filters for use in air-conditioning and general ventilation.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2011. ''SANS 1453:2011 Copper Tubes for Medical Gas and Vacuum systems.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 14644-1:1999 Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-2:2003 Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-4:2003 Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1988. ''SANS 1474: 1988 Uninterruptible Power Supplies''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2009. ''SANS 7396-1:2009 Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 7396-2:2008 Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems.'' Pretoria South Africa: SABS Standards Division.

*All local Municipal laws and regulations,
*ISO 14644-3:, Cleanrooms and associated controlled environments - Part 3: Test Methods Australasian Health Infrastructure Alliance,2006. Australasian Health Facility guidelines [online] Available at: <nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> [Accesed ...].
*ISO/DIS 5359. Anaesthetic and respiratory equipment - Low-pressure hose assemblies for use with medical gases,
*National Health Act, 2004 (Act No. 61 of 2003).
*Occupational Health and Safety Act, of 1993
*Regulations of the Local Electricity Authority,
*SANS 10114: Lighting Requirements,
*SANS 10142-1: The wiring of premises Part 1: Low-voltage installations,
*SANS 10173: The installation, testing and balancing of air-conditioning ductwork,
*SANS 10224: Non-flammable medical gas pipeline,
*SANS 10252-1: Water supply and drainage for buildings Part 1: Water supply installations for buildings,
*SANS 10252-2: Water supply and drainage for buildings Part 2: Drainage installations for buildings,
*SANS 10313: 1999 Protection of structures against lightning,
*SANS 10400: Code of Practice for The Application of the National Building Regulations,
*SANS 1067: Copper-based fittings for copper tubes Part 1: Compression fittings,
*SANS 1067: Copper-based fittings for copper tubes Part 2: Capillary solder fittings,
*SANS 1091: Colour Coding of Services,
*SANS 1140: Identification colour marking Part 4: Contents of taps and valves in laboratories,
*SANS 1238: Air-conditioning ductwork,
*SANS 1409: Outlet sockets and probes for medical (gas and vacuum) services used in hospitals,
*SANS 1409: Part 3 Handling and storage of Medical Gas,
*SANS 1424: Filters for use in air-conditioning and general ventilation,
*SANS 1453: Copper Tubes for Medical Gas and Vacuum systems,
*SANS 14644-1, Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness,
*SANS 14644-2, Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1
*SANS 14644-4, Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up,
*SANS 1474: 1988 Uninterruptible Power Supplies,
*SANS 7396-1: Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum,
*SANS 7396-2: Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems,
*SANS 50081: Safety rules for the construction and installation of lifts — Particular applications for passenger and goods lifts,
*Any other applicable Laws or Regulations.

Chartered Institution of Building Services Engineers (CIBSE), 1999. Environmental design CIBSE Guide A. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2005. CIBSE Applications Manual AM10 Natural ventilation in non-domestic buildings. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2008. Lighting Guide 2: Hospitals and health care buildings. England: The Society of Light and Lighting.

 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009. ANSI/ASHRAE/ASHE Standard 170-2008 Ventilation of

Health Care Facilities. Atlanta USA:ASHRAE.

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2013. HVAC Design Manual for Hospitals and Clinics Second Edition. Atlanta USA:ASHRAE.

'''Further reading'''

*<nowiki>http://www.spaceforhealth.nhs.uk/</nowiki> (National Health Service NHS website for UK guidance) website closed now
*<nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> (Health Facility Guides website for Australasian Health Facility guidance)
*CIBSE Guide A – Environmental Design
*CIBSE Applications Manual for Natural Ventilation – AM10
*CIBSE Applications Manual for Mixed Mode Ventilation. – AM13

*CIBSE Lighting Guide 2: Hospitals and Health Care buildings
*ASHRAE 170:2008
*HVAC Design manual for Hospitals and Clinics Second Edition – ASHRAE TC 9.6, 2013
*CIBSE Commissioning Code A
*BSRIA Application Guide 3/89.1

 <references />

==LIST OF ABBREVIATIONS==
A & E- Accident and Emergency Department

AHU- Air Handling Unit

CSSD- Central Sterile Supply Department

EMS- Emergency Medical Services

HCW- High Care Ward

HEPA- High Efficiency Particulate Air (filter)

ICU- Intensive Care Unit

NBR- National Building Regulations SABS 0400

NICU- Neonatal Intensive Care Unit

OT- Operating Theatre

SABS- South African Bureau of Standards

SANS- South African National Standards

SSO- Switched Socket Outlet

UDAF- Uni-Directional Air Flow

UPS- Uninterrupted Power Supply

URS- User Requirement Specification

==LIST OF DEFINITIONS==
For the purposes of these regulations, unless the context otherwise indicates-

'''“barrier isolator”''' refers to a device comprising an physical film separating an operator or clinician from a work process. The work process is maintained within an isolated environment which may be held at a positive or negative pressure.

"'''Central Sterile Supply Department (CSSD)"''' means a facility for the receiving, decontamination, preparation, packing, sterilizing, storing and issuing of sterile and disinfected instruments and other reusable materials. This facility is also known as the "sterilisation and disinfection unit"(SDU);

"'''cleaners' room'''" means a room for the storage of cleaning equipment, the drawing of clean water and the disposal of dirty water, washing and drying of cleaning equipment. This room may be combined with the dirty utility room;

"'''clean air'''" means air that does not contain a considered contaminant;

"'''clean utility room'''" means a room for the storage of sterilized packs, dressings-, sterile equipment and pharmaceutical supplies respectively; This area may also be used for a set-up area for ward procedures;

"'''considered contaminant'''" means any actual contaminant, surface or airborne, which may have a certain impact which for which measures are taken to avoid;

'''"cross contamination"''' refers to the contamination of any zone or surface by fomites, considered particulates aerosols, biological agents, fumes or gasses originating from another zone or surface.

'''"cross infection"''' refers to the spreading of an infection from one organism to another by cross contamination.

'''"department"''' means a grouping of accommodation which has a specific function within a hospital. Its area includes the associated internal or departmental circulation space

'''"dirty utility room"''' means a room used for collection and temporary storage of used equipment and general ward material; it can combine the activities of the sluice room, the soiled linen and waste room and the cleaners' room;

'''"emergency trolley/crash cart"''' means a mobile cart used for the storage of all appropriate resuscitation equipment and pharmaceuticals;

"'''equipment store'''" means a room used for the storing of monkey chains, traction kits and other general equipment;

"'''fresh air'''" means air drawn from outside air of a building and contamination sources;

"'''high care ward'''" refers to a ward for the care and management of specific types of patients requiring a minimum of eight hours nursing care per patient day;

"'''holding area'''" means an area or room where pre-operative patients in transit to a procedure room/theatre are identified and continuously monitored by nursing personnel;

"'''induction room'''" means an area where patients are prepared for surgery/invasive procedures prior to being transferred to the operating theatre;

"'''intensive care unit'''" means a unit designed, staffed and equipped for the care and management of specific patients, (e.g. medical, cardiac or post-operative) requiring a minimum of twelve hours nursing care per patient day or for the care of a patient who requires ventilation, continuous invasive monitoring, invasive care, or who is clinically unstable and whose life is at risk;

"'''main kitchen'''" means a facility suitably finished and equipped for the receipt, storage and preparation of meals, special diets and beverages;

"'''maternity unit'''" means a unit where antenatal care is provided, babies are delivered and postnatal care is given to mothers and infants;

" '''midwife obstetric unit (MOU)'''" means a maternity unit usually attached to a clinic or a community health centre (CHC), which is staffed by nursing sisters or midwives;

“'''milk kitchen'''” means an area for the preparation of feeds for babies which must be separate from the hospital kitchen or ward kitchen. It must contain a clinical wash hand basin;

"'''mortuary'''" means a facility that receives, holds and allows for the identification of bodies of patients who died in the wards, theatre or casualty department, or who were dead on arrival at the facility; a facility which complies with the

"'''neonatal unit'''" means a facility for premature and new born babies requiring incubation, specific care and monitoring;

"'''nurse station'''" means the control point for all activities in the patient care areas;

"'''nursing unit or ward'''" means a unit with the facilities to accommodate patients as specified in this regulation;

"'''operating room'''” means a room within an operating theatre suite in which surgical or other invasive procedures are carried out;

"'''operating suite'''" refers to rooms within the demarcated area where surgical interventions are performed or support is provided to these surgical activities;

"'''patient room'''" means a room where the patient can be accommodated;

"'''procedure room'''" means a room in which certain restricted procedures generally taking less than one hour can be performed without making use of general anaesthetic, e.g. endoscopies, procedures under local anaesthetic such as suturing of lacerations, removal of skin lesions, biopsies, closed reductions and other similar procedures; May be situated outside the operating suite;

"'''recovery room/ area"''' means the section of the operating suite specially set aside for the immediate post-operative recovery, resuscitation, nursing and special care of patients, until such time as such patients are considered to have recovered sufficiently to be safely removed from the operating suite;

"'''sluice room'''” means a room used for the emptying, cleaning and storage of bedpans and urine bottles; It can be combined with the activities of the soiled linen and cleaners' rooms in the dirty utility room;

“'''specialised area'''” means any clinical area rendering specialised services such as intensive care, high care, or rehabilitation, for which additional space around the patient is required;

"'''soiled linen and waste room"''' means a room used for the collection and temporary storage of soiled linen and waste; May be combined with the dirty utility room

"'''treatment room'''" means a room used for treatment of patients in the wards, containing a clinical wash hand basin;

“'''ventilation”''' means “The process of supplying air to or removing air from a space for the purpose of controlling air contaminant levels, humidity or temperature within the space”. ASHRAE Standard 62.1-2007, Section 3

'''“validation”''' means the method of proving and documenting that an installed system or process performs reliably as intended and required.

'''“natural ventilation”''' means “Ventilation provided by thermal, wind, or diffusion effects through doors windows or other intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3

"'''ward kitchen'''” means the room that forms an integral part of a nursing unit or units, for the preparation of snacks and beverages; It also includes the area for the heating, storage and refrigeration of meals;

"'''uninterrupted power supply'''" means a battery system, which in the event of a normal mains supply failure will provide immediately the electrical supply for essential equipment and lighting.
[[Category:Crosscutting Issues]]
[[Category:Water Distributions Systems]]
[[Category:Legionella Control]]
[[Category:Ventilation]]

Building Engineering Services

2023-07-20T06:57:15Z

Tobyvan: /* 23.4. OPERATING THEATRE VENTILATION DESIGN */

{{Cleanup}}{{Expand}}

=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===

==='''Context'''===
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.

==='''Design principles'''===
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.
{| class="wikitable"
|+Table 1: IUSS document
!Clinical services
!Essential
!Recommended
!Support Services
!Essential
!Recommended
!Healthcare environment/
Crosscutting issues
!Essential
!Recommended
!Procurement &
Operation
!Essential
!Recommended
|-
|Impatient services
|
|X
|Administration & related services
|
|
|Generic room data
|X
|
|Integrated infrastructure planning
|X
|
|-
|Laboratories
|
|X
|General hospital support services
|
|
|Hospital design principles
|X
|
|Project planning & briefing
|X
|
|-
|Mental Health Services
|
|
|Catering services
|
|
|Engineering design principles
|X
|
|Space guidelines
|
|
|-
|Critical care
|
|
|Laundry and Linen
|
|
|Environment and sustainability
|X
|
|Cost Guidelines
|X
|
|-
|Emergency centres
|
|
|Mortuary
|X
|
|Materials & finishes
|X
|
|Procurement liaison
|
|
|-
|Obstetrics & gynaecology
|
|
|Nursing colleges
|
|
|Future healthcare environments
|
|X
|Commissioning
|X
|
|-
|Oncology
|
|
|Health facility residential
|
|
|Healthcare technology
|
|
|Maintenance
|X
|
|-
|Outpatient services
|
|X
|Sterile supply
|X
|
|Inclusive environments
|
|X
|Decommissioning
|X
|
|-
|Paediatrics
|
|
|Clinical training
|
|
|Infection prevention & control
|X
|
|Capacity development
|
|X
|-
|Pharmacy
|
|
|Waste disposal
|
|X
|Health informatix
|
|
|
|
|
|-
|Primary health care
|
|
|
|
|
|Regulations
|X
|
|
|
|
|-
|Diagnostic radiology
|X
|
|
|
|
|
|
|
|
|
|
|-
|Rehabilitation services
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Surgery
|X
|
|
|
|
|
|
|
|
|
|
|-
|TB
|X
|
|
|
|
|
|
|
|
|
|
|}

Where this document lacks guidance on a topic or appears to contradict the requirements of the guidelines identified above, the guidance of those documents will take priority.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
#*Summaries of collated information
#*Reports on technical feasibility, benefits and risks
#*Reports on regulatory compliance issues
#*Reports on financial feasibility and risks
#*List of consents and approvals required
#*Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

==Design Questions==
6. In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

==Design considerations==

==='''7. Deep buildings'''===

#Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

==='''8. Plant and plant room size and location'''===

#Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.
#Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities. Plant rooms shall be located away from possible heat and contamination sources.
#Plant rooms shall be located in an accessible area which is secured from unauthorized entry
#Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

==Life cycle cost determination==
9. When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

10. Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

==Site-survey requirements==
11. In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

==Maintenance Considerations==
12. Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

13. The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

14. In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.

15. For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

==Planning for Retrofitting & Decommissioning==
16. While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

17. Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

18. When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

19. A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

20. Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

21. For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

==Sustainability & Environmental Measures==
===Design Life cycle===

Sustainability in designs for new health facilities can be addressed through the following steps:

'''22. Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.

'''23. Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.

'''24. Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.

'''25. Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.

'''26. Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.

'''27. Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

28. Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''PART - DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating Ventilation and Air-conditioning===
===Airborne-Precaution Risk Classification for Healthcare Zones===
South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for out-patients is common practice in South Africa.
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo convective or buoyancy effects and wind pressure. Since the drivers of Natural ventilation are inherently variable, natural ventilation has a high variability in effectiveness.

2. In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space could have a negative impact on the variability of the ventilation system’s performance by opening and closing windows and doors. For this reason it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controllable ventilation openings be designed and created in the building

3. For additional design guidance on natural ventilation design, the CIBSE Applications Manual AM10 or similar can be consulted.

4. Peak and minimum internal temperatures should be calculated or modelled thermally for a space, for summer and wintertime respectively.

5. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

6. The following design interventions should be considered for implementation, singly or in combination, in the following hierarchy where the internal design condition cannot be met:

*Reducing solar and internal heat gains
*Using thermal mass to move room temperature extremes to outside of occupancy periods.
*Change occupancy schedules seasonally to improve indoor comfort conditions. (eg. Shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
*Introducing passive cooling or heating strategies
*Increasing ventilation rates
*Providing mechanical cooling or heating

7. Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed mode ventilation shall be considered as a solution preferred over full mechanical ventilation.

8. Mixed mode ventilation is considered as an assisted type of natural ventilation. Here fans are used in combination with damper controlled ventilation openings to ensure minimum ventilation rates are achieved.

9. Where mixed mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

[[File:NV-Decision Tree1.png|alt=NV-Decision Tree|border|frameless|800x800px]] 

===Mechanical ventilation and air-conditioning===
10. Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.

11. The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====12. Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====13. Zoning of a building=====
13.1. Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:

#Fire compartmentalization
#Air-handling unit (AHU) sizing
#Duct sizing
#Occupancy schedules
#Occupancy activity levels
#Building, environmental and equipment heat loads
#Airborne contamination control
#Tenancy, functional unit or utility metering

13.2. Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====14. Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.

=====15. Ventilation rates=====

#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant

=====16. Supply-only vs balanced ventilation systems=====

#Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

=====17. Airborne contamination-control concepts=====

#Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

#The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

#The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 
#The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 
#The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²).

17.4. Where ventilation rates and fresh air proportions are described within these guidance documents they are to serve as guidance values only. It is the responsibility of the designer to ensure that the ventilation rate selected is appropriate for the specific zone’s operational conditions, occupancy, contamination rates, pressurization, leakage rates, ventilation efficiency and external ambient conditions to achieve the desired airborne contamination and bio-burden levels. Ventilation rates higher or lower than the guidance values may achieve the desired conditions.

 

====='''18. AIR HANDLING UNITS AND FANS'''=====
18.1. GENERAL

#AHUs and fans shall be protected from adverse weather and wind sources which may upset their performance or reliability.
#A detailed name plate shall be included on the air handling units with manufacturer, design air volume, fan speed, cooling capacity, filter data and heating capacity.
#The air handling unit shall include individual differential pressure gauges over each installed filter bank. The gauges shall measure the pressure differential between upstream and downstream of the filter banks. The filter designation and design filter change pressure shall be neatly and clearly marked on each gauge.
#Air-handling units functioning in an airborne contamination control system, and demanding prescribed airflow rates, shall be provided with an electronic control system including variable frequency controllers with direct fan drives to automatically maintain design airflow for all filter conditions. The fans and drives will be selected to maintain design flow rates with all filters at maximum rated pressures.
#Where a ventilation system performs a critical role, air handling units shall have separate electrical distribution boards (Essential and Non-essential). The fan will be on essential power and heater elements may be on non-essential power.
#All compartment doors on the air handling unit shall be clearly labelled
#Where systems require duplicate standby fans or air-handling units these shall be installed with backdraught dampers, sufficiently air-tight for the application (eg EN1751 Cat 3 or 4). Special design and control consideration shall be given to limiting the build-up and dwelling of contaminants in the standby unit.
#AHU’s should be placed in easily accessible plant rooms with sufficient space for maintenance. Access stairs to the plant rooms should permit a technician to easily carry replacement parts or a toolbox into the plant.AHU’s located in ceiling voids are not appropriate or conducive to good operational management.
#AHUs should be designed for a working life of 20 - 25 years
#AHUs shall be designed and positioned such that the largest components, including heating and cooling coils, can be removed and replaced.
#AHUs greater than 1m wide should have hinged access doors large enough to provide full entry. Doors shall be unlockable and openable from the inside of the unit.
#Fan and filter plenums shall be provided with internal illumination and viewing portals such that internal components can be visually inspected without stopping or opening the unit.
#AHUs shall be designed such that dry steam humidification devices can be retrofitted into the systems with minimal disruption and without compromising its performance.
#Ventilation components shall have a drainage or condensate pumping system if they can produce moisture. Drip trays shall be of a corrosion resistant material and drainage systems shall have a 1:20 fall away from the unit in all directions. The unit shall have its own drain trap which shall be sized such that it can function at the fan's full static pressure. The first 3 meters of a dedicated condensate drainage line shall be insulated to prevent condensation within the plantroom. Where a condensate drain services a negative pressure plenum, clear air gaps of 15mm or anti-backflow devices are recommended at the trap discharge into the drainage system.
#Drop stop eliminators in stainless steel frames shall be employed, if fin spacing is less than 10 fins per inch, after the cooling coils in areas with high humidity levels. This includes all coastal areas for off coil temperatures of 10° and less
#In full fresh air systems, primary filters may be situated at the fresh air intake opening of the air-handling unit only if the climate does not require anti-fog or de-icing coils.
#Cooling or heating coils will be protected by a pleated primary filter, rated in accordance with SANS 1424, as minimum.
#In recirculation air systems, primary filters will be situated after the fresh/return air mixing plenum. This arrangement will ensure that blinding filters don’t inhibit the prescribed fresh air proportion.
#The final stage of filters on units serving operating theatres must be located after the supply fan chamber to filter any debris that might come from the fan chamber. HEPA filters should be protected from this potential dust and debris.

 

=====18.2. AIR EXTRACTION SYSTEMS=====

#The design of exhaust systems shall take special consideration of the potential for re-entrainment of contaminated exhaust air into air intakes through, inter alia, openable windows. Where this potential exists, precautionary measures such as aerosol or chemical filtration of exhaust should be applied, as appropriate.
#Single ablution facilities serving private wards or staff do not require extract ventilation, provided there are windows openable to outside.
#Extract ventilation shall be provided by either ceiling extract grilles connected to an in-line ducted fan with outside discharge air grilles by means of galvanized mild steel or PVC tubular ducting or odour extraction system.
#Extract grilles may be of the PVC type with adjustable disc valves, or powder coated or anodized aluminium type with adjustable dampers.
#All multiple toilets shall be provided with ventilation systems, which will serve as an extract ventilation system.
#Single toilet facilities serving private wards for staff do not require extract ventilation, provided there are windows openable to outside
#Where it is not considered safe to enter a space without respiratory protection, the air exhausted from that space should be rendered safe through filtration, decontamination or dilution before discharge.
#The design of exhaust system from airborne precaution areas should be such that all components can be safely maintained during normal service and safely disposed of at decommissioning.
#Planning for disposal of contaminated filters should be as for all biohazardous material.
#Filtration and decontamination components shall be installed upstream of fans, monitoring and control devices.

=====18.3. ENERGY RECOVERY SYSTEMS=====
1.3.1. Where full or partial exhaust is required for ventilation systems, energy recovery technologies should be considered. Enthalpy wheels offer a high level of efficiency but introduce a risk of cross infection as the wheel is exposed to both the exhaust and supply airstreams. An enthalpy or energy recovery wheel may only be used if pressure and filtration measures are taken to ensure it is not a potential source of cross infection or re-infection. Energy recovery wheels incorporating purge sections have a markedly reduced efficiency and are not considered to provide sufficient protection against biological cross contamination. Where cross infection is a considered risk, the following conditions shall be met.

#The exhaust airstream shall be consistently maintained at a lower static pressure than that of the supply airstream.
#The exhaust air shall be filtered with aerosol filters upstream of the energy recovery device.
#Levels of filtration, redundancy and safety shall meet the requirements of the biological pathogenicity class in consideration.

=====19. '''FILTRATION'''=====

#With the exception of the few specialist areas with aero-biological requirements, the primary purpose of filtration is to protect ventilated spaces and ventilation equipment from dust build-up.
#When designing filtration systems serving spaces with a high airborne cross contamination risk, consideration should be given to the safety of maintenance staff that may be required to handle contaminated filters. Where any safety risk is present, contaminated filters should be installed in safe-change or decontaminatable housings.
#All ventilation filter banks should be installed with a means of visually checking the filter pressure across them in Pascals (Pa)
#Filters are classified as being General Fine or Aerosol filters and are to be specified in accordance with the SANS 1424, EN779 or EN1822.
#General filters are selected to remove particles large enough to block cooling and heater fins and settle out of the airstream into the air distribution system. General filters are graded in terms of their “synthetic dust weight arrestance”. General filter grading ranges from G1 to G4. G3 and G4 filters are appropriate for primary air intake and tempered air supply respectively. General filters are not appropriate for combating airborne cross-contamination control.
#Fine filters are selected to keep a ventilated space visibly clean and for the protection of HEPA filters. Fine filters are graded in terms of their “Dust Spot Efficiency” from M5 to F9. F9 filters are capable of arresting particles with the approximate size of some bacteria and can be used for low level cleanrooms (ISO 14644-1 Class 8).
#Aerosol filters are selected for their efficiency in arresting sub-micron particles. They are graded in accordance with their “Most Penetrating Particle Size” (MPPS). Aerosol filters are subdivided into three categories: Efficient Particulate Air (EPA) and High Efficiency Particulate Air (HEPA) and Ultra high Particulate Air (ULPA) Filters in accordance with the EN1822:2009. The table below describes the classification of aerosol filters by integral and local values as defined in the EN1822. SULPA filters are not discussed within this document.

{| class="wikitable"
|+{{Anchor|Table_Filter_Classification}}'''Filtration Classification'''
| rowspan="2" |'''Group'''
| rowspan="2" |'''Filter Class'''

'''EN1822'''
|'''Integral Value'''
|'''Local Value'''
|-
|'''Efficiency %'''
|'''Efficiency %'''
|-
| rowspan="3" |'''EPA'''
|'''E10'''
|85%
|<nowiki>-</nowiki>
|-
|'''E11'''
|95%
|<nowiki>-</nowiki>
|-
|'''E12'''
|99.5%
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''HEPA'''
|'''H13'''
|99.95%
|99.75%
|-
|'''H14'''
|99.995%
|99.975%
|-
| rowspan="3" |'''ULPA'''
|'''U15'''
|99.9995%
|99.9975%
|-
|'''U16'''
|99.99995%
|99.99975%
|-
|'''U17'''
|99.999995%
|99.999975%
|}
8. HEPA filter installations shall include both an upstream challenge aerosol injection port and a downstream scan port to facilitate filter challenge testing. ULPA filter installations shall be designed such that an agreed upon test method can be accomplished.

9. All filters used for airborne precaution rooms, theatres or other areas with a high airborne contamination risk shall be selected with a construction suitable for incineration. These filters shall not contain PVC.

10. The installation and testing of HEPA filters shall only be conducted by suitably qualified technicians.

11. HEPA filters shall be specified to be compliant with the requirements of EN1822. Each HEPA filter is to be supplied with an individual factory test certificate displaying that filter's serial number, MPPS rating and DOP arrestance rating.

12. Type-test certificates are only acceptable for EPA and not HEPA filters.
 

=====20. '''HEAT REJECTION EQUIPMENT.'''=====
20.1. The location of heat rejection equipment shall be planned such that it does not adversely affect the performance, maintenance or reliability of any related or unrelated equipment, or pose an avoidable health risk.

20.2. The use of evaporative cooling towers shall only be considered where:

#Space, system capacity or efficiency demands their use.
#An effective plan for the [[Legionella Control|control of legionella]] must be developed and implemented.

 

=====21. '''AIR DISTRIBUTION SYSTEMS'''=====

#Discharge from extraction systems shall be located such that contaminated air does not get drawn into any system's air intake of get re-entrained though openable windows.
#The use of internally insulated ducting is not appropriate as internal linings will perish and slough off with aging. Particles from duct linings contaminate final filters and ducting components.
#Flexible ductwork is unsuitable for air distribution in healthcare applications. It should only be used for the final connection to an air terminal and then kept to less than 1.0m. Bends in flexible ductwork should be avoided.
#The use of dampers to throttle a deliberate oversupply of airflow should be avoided. Balance by design is preferable although this will not necessarily reduce the total fan pressure. Use of adjustable blade dampers should be kept to a minimum as these items may drift, can be tampered with and increase the complexity of commissioning. The use of constant volume dampers may improve stability of volume critical systems but may also mask inefficient design and be the source of increased system noise.
#Cleaning and access doors are to be installed in all air distribution ductwork to facilitate:

*Cleaning
*Inspection
*Measurement
*Maintenance

21.6. Ductwork installations shall be designed, built, installed and commissioned in accordance with SANS 1238: Air-conditioning ductwork and SANS 10173: The installation, testing and balancing of air-conditioning ductwork
 

=====22. '''ELECTRONIC CONTROLS'''=====

#Location of sensors in ventilation systems should ensure that the temperature and humidity measurement for monitoring control is representative of the occupied area
#The humidifier control will include humidity monitoring of the mixed airstream downstream of the humidifier lance and shall prevent this airstream from approaching dew point.
#The use of variable speed drives (VSD) can save energy in systems operating under varying motor loads. Reducing the fan speed when filters are new or clean can result in considerable energy savings over the life of a system. Reliability of smaller sized VSDs is a potential drawback, and for this reason VSDs must be selected and sized for high service life. VSDs should also be installed such they can be bypassed and the system can be run in manual control while failed VSDs are replaced or repaired. When designing with variable speed drives, cognisance should be taken of a motor’s minimum cooling requirements and the maximum restart rate. Caution should be exercised where variable speed drives are used in conjunction with constant volume dampers or volume flow controllers. This combination could drive up total system pressure where duct total pressure as opposed to velocity pressure is used as control feedback. Additional requirements for the selection of drives for variable air volume (VAV) fans is described in SAN204:2011
#Plant control systems should incorporate start-up and shut-down sequencing logic to prevent flow reversals and overheating.
#Set-back controls should be considered for spaces that have intermittent occupancy. This feature should be used with caution in specialist areas as poorly considered set-back conditions could compromise containment or contamination control.
#Where more than one ventilation system serves a department, system interlocks may be required to prevent unwanted airflow reversals during system shutdown or failure.
#Operational status indicators should be displayed locally in areas served by ventilation systems.
#"Low Air Flow" and "Plant Failure" alarms should also be installed in a location which can be manned by relevant and trained staff.
#Electronic control systems should be developed using recognised open protocols and standards such as BACnet DeviceNet, LonWorks, Modbus, SOAP and XML.

=====23. '''SPECIALIST VENTILATION SYSTEMS'''=====
23.1. The following areas will require specialist ventilation systems:
 
'''Table''' '''3 Specialist Ventilation Systems'''
{| class="wikitable"
|'''Department Name'''
|'''Ventilation system type'''
|-
|Operating departments
|Clean and Ultra clean ventilation systems: ISO8 to ISO5 & UDAF
|-
|Obstetrics
|Clean ventilation systems ISO8
|-
|High care, Critical Care and Intensive Care
|Fine filtered ventilation or Clean ventilation systems: Unclassified - ISO8
|-
|Isolation units
|Negative pressure ventilation, no recirculation
|-
|Pathology labs
|Biosafety ventilation: (BSL2 – BSL4)
|-
|IVF Labs
|Clean ventilation systems: VOC Filtration
|-
|Burns units
|Clean ventilation systems/ Negative pressure ventilation/ RH control
|-
|Neonatal Units
|Dedicated ventilation systems/ RH control
|-
|Mortuary unit
|Cold Rooms/ Extraction systems/ Odour Control
|}
23.2. Broad requirements for these systems are in this document. The engineering team shall consult each department’s specific design guidance document for detailed requirements.
 

=====23.3. '''AIRBORNE PRECAUTION ROOMS (INCLUDING TB)'''=====

#Where specific diseases are considered in the design of an airborne precaution room, the US CDC's "Select Agent List" may be consulted for design guidance until a South African list is compiled.
#Airborne precaution rooms shall be ventilated with a minimum of 12AC/h of fresh air or uncontaminated air. High risk areas such as sputum booths and airborne diseases wards shall have a nominal ventilation rate of 80 ℓ/s per person..
#Medium Risk areas such as congregate spaces such as waiting areas shall have a nominal ventilation rate of 60ℓ/s per person.
#Mechanical ventilation may be employed to achieve the minimum ventilation rates. It should be noted that very high ventilation rates can be achieved by employing a well-considered natural ventilation design. Consideration may also be given to mixed mode ventilation systems, which combine mechanical and passive ventilation and temperature control. An open window policy may therefore be adopted, with careful consideration of all the associated cross infection risks and management challenges.
#Airborne precaution rooms shall be designed so as to provide thermal comfort. Where occupants have freedom in location and dress code, an adaptive thermal comfort model should be adopted. Heating, cooling and energy recovery devices shall pose no risk of harbouring pathogens or increasing the cross infection risk.
#Air from the airborne precaution rooms shall not flow into adjacent, uncontaminated rooms or adjacent airborne precaution rooms. Air shall not flow from a room with a higher airborne infection risk category to a room with a lower risk category.
#Ventilation ducting and pipe work shall not form a conduit by which pathogens can transfer from one zone to another whether the ventilation system is running or not. Filtration devices and anti-backflow devices may be employed provided these do not pose a risk of infection to maintenance staff.
#Filtration requirements for supply and exhaust air should follow the bio-containment requirements of that select agent being contained.
#The location of supply and air terminals should be such that the airflow patterns generated within the room serve to suppress and remove airborne particles.
#For general waiting areas or where the pathogens are known and unlikely to pose an environmental risk, exhaust air filtration may not be required provided exhausted air is directed 3m away from open-able windows and air intakes and there is no risk of re-entrainment of this air. See section 18.2.
#Commissioning and validation shall be well planned, diligently executed, fully documented and approved by suitably experienced professionals. It is advisable to have the validation process conducted or approved by a party independent of the designer and installer.
#Numerical or physical modelling may be of value in the design and validation process.

 

=====23.4. '''OPERATING THEATRE VENTILATION DESIGN'''=====
23.4.1. GENERAL REQUIREMENTS

#Constant volume systems shall be employed to maintain the correct pressure with respect to any adjoining rooms. The contamination control concept shall be developed in accordance with ISO14644-4
#Temperature range shall generally be 18°C to 24°C with a minimum relative humidity of 45% unless otherwise specified
#A pressure differential of 10-15Pa is to be maintained between the theatre and adjacent rooms when all doors are closed.
#Theatres may be maintained at a room pressure positive or negative to the adjacent rooms depending on the contamination control requirements.
#A theatre’s room pressure shall always be positive relative to technical spaces.
#Negative pressure theatres should not employ recirculation of room air.
#Fresh air requirements are 5-7 Air Changes per hour to satisfy the occupancy requirements
#Additional fresh air may be required for pressurisation and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurisation at the greatest possible energy efficiency.
#Separate temperature controls in each theatre are to be provided.
#No manual on and off switching of air handling plant to be done from within the theatres.
#Automatic motion sensors / thermal sensors to ensure that the units are switched on when there is a presence in the theatre. Theatre ventilation switching may be linked to the theatre unit’s lights.
#Automatic switching of ventilation system to incorporate run-on timers to prevent overheating and accidental shutdown.
#An additional override to be used to switch the units on when the temperature in the theatre exceeds 25°C for the protection of stored medicine
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums.
#These validation tests shall be performed in accordance with SANS 14644Parts 1, 2 and 3 at the recommended intervals (SANS 14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#No internal ducting insulation is permitted.
#In multi theatre suites it is advisable to have dedicated AHUs per theatre. [[Building Engineering Services#%20msocom%201|[TR1]]]

23.4.2. UNIDIRECTIONAL AIRFLOW OR ULTRACLEAN THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 5 under protected zones (UDAF and Setup area) and ISO 14644-1 Class 6 in background and ancillary areas. These conditions are to be achieved under operational conditions.
#Temperature range shall generally be 18°C to 24°C and relative humidity 45% to 60% unless otherwise specified
#Ultra-clean theatre ventilation shall not be completely shut down when unoccupied unless required for maintenance interventions. Ventilation systems serving UDAF plenums shall instead switch to a minimum velocity set-back mode to prevent contaminants settling underneath the UDAF screens.
#Delivery of the conditioned air shall be by downward movement from the ceiling to four low level exhaust outlets located near the corners.
#All ductwork between HEPA filter housings and air terminals shall be high pressure rated and constructed of galvanised sheet metal. In the final connection to the terminal, where alignment necessitates, a maximum of 300mm of thermally insulated, high pressure flexible ducting may be used.
#The Air Conditioning system is to be complete with G4 primary, F9 secondary and H13 HEPA Filters.
#The ventilation systems shall be designed with a mean air velocity of between 0.35 & 0.45 m/sec measured below the UDAF screen and at the working height.
#Refer to ISO14644-4 for guideline ventilation rates for balance of areas.
#The mean velocities below the UDAF screen and at the working height shall not differ by more than ±10%
#A standard size of the UDAF screen is 2400 x 2400mm. The required size could vary dependent on the layout and function of the operating theatre.
#The protected zone below the UDAF plenum shall be clearly demarcated on the floor

23.4.3 CLEAN OR MAJOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 6 in all protected areas and Class 7 in backround areas. These conditions are to be demonstrated as achievable under operational conditions.
#The ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#The conditioned air is to be introduced into the theatre via suitable diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#Additional fresh air may be required for pressurization and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurization at the greatest possible energy efficiency.
#These validation tests shall be performed in accordance with SANS 14644 Parts 1, 2 and 3 at the recommended intervals (ISO14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.

23.4.4. MINOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 8 in all areas. These conditions are to be achieved under operational conditions.
#For recirculation systems the ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#For single pass systems the ventilation system is to include G4 Primary and F9 Secondary filters.
#The conditioned air is to be introduced into the theatre via suitably sized diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums. 

====='''VALIDATION OF SPECIALIST VENTILATION SYSTEMS'''=====

#Validation testing shall be completed in accordance with national standards for standardized tests (eg ISO14644 and ISO 14698 for cleanrooms) and shall be completed against mutually agreed protocols for non-standard tests.
#It essential that the validation testing of a ventilation system’s contamination control performance parameters is conducted against operational, and not only "at-rest", conditions. Validation against "as-built" conditions offers little insight into the ultimate performance of the system.
#Pre-Commissioning Checks shall cover the following aspects prior to the commencement of formal commissioning:
##Check whether the Design Specification satisfactorily addresses the demands of the User Requirement Specification.
##Check whether the ventilation systems have been provided and installed in accordance with the design specifications and drawings
##Check that the buildings either housing or served by the ventilation equipment is complete and finished such that testing can commence safely and effectively.
##Check that all AHUs, chillers, heat rejection equipment and filters are sufficiently accessible for inspection and maintenance.
##All components are connected and are functional
##Door gaps and openings are installed and sized as specified in specialised zones
##Airflow control devices are installed in the correct locations and in the correct orientation
##Duct and filter tests ports are installed and sealed satisfactorily
##Safety and control interlocks are established
##Fan and drive guards are in place
##Safety and warning signs are in place
##All major system components or sub-systems are clearly labelled with functional or controls identification in a neat and durable fashion.
##Fluid and air pressure monitoring gauges are labelled with identification and acceptable maximum and minimum operating conditions.
##All wiring, piping and ducting colour banding is complete in accordance with SANS-1091
#CLEANLINESS CHECKS:
##AHUs shall be checked for cleanliness on internal plenums with special attention being paid to fan and discharge plenums and condensate drip trays and drain lines.
##Ducting serving “clean” areas shall be cleaned prior to installation and the ends shall be sealed until installation. Open ends of duct runs shall similarly remain sealed during construction. Spot checks for compliance during the installation process are recommended.
#Recommended Filtration Levels and Ventilation Rates for Mechanically Ventilated Areas

This table serves as a quick reference guide and will be revised as and when detailed room data sheets are developed within each department’s guidance documents.
{| class="wikitable"
|+{{Anchor|Table_Room Ventilation Requirements}}'''Room Ventilation Requirements'''
| rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation'''[[Building Engineering Services#BESftn1|[1]]]

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range'''[[Building Engineering Services#BESftn2|[2]]]'''
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|Casualty/Minor Stitch Procedure room
|X
|
|X
|
|T
|
|
|7.5
|20
|
|-
|Theatres: Maternity/Caesarean
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: General Surgery
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Gynaecology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Ophthalmology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Urology
|X
|
|X
|'''X**'''
|T
|NA
|7
|10
|20
|
|-
|Theatres: Endoscopy
|X
|
|X
|'''X**'''
|T
|NA
|7
|80
|20
|
|-
|Theatres: Plastic Surgery
|X
|
|X
|X
|T
|6
|7
|7.5
|70***
|
|-
|Theatres: Bone Surgery/Orthopaedic
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Thoracic
|X
|
|X
|X
|M
|5
|7
|80
|70
|
|-
|Theatres: Vascular???
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Neuro Surgery
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Waiting and Congregate Areas
|X
|
|
|
|
|
|
|60
|8
|18-28
|-
|Auditoriums
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Mortuary
|X
|X
|
|
|
|
|
|
|12
|22-25
|-
|Bath Room
|
|
|
|
|
|
|
|25
|10
|N/A
|-
|Dirty Utility Room
|
|
|
|
|
|
|
|40
|10
|N/A
|-
|Blood Bank
|X
|
|
|
|
|
|
|
|4
|22-25
|-
|Casualty
|X
|X
|
|
|
|
|
|7.5
|12
|22-25
|-
|CSSD
|X
|X
|
|X
|
|
|
|7.5
|20
|22-25
|-
|Dark Room
|X
|
|
|
|
|
|
|
|10
|22-25
|-
|Dining Rooms/Canteens
|X
|
|
|
|
|
|
|7.5
|10
|18-28
|-
|General Stores
|X
|
|
|
|
|
|
|
|4
|N/A
|-
|Laboratories
|X
|X
|
|
|
|
|
|
|6
|22-24[<nowiki/>[[Building Engineering Services#BESftn3|3]]]<nowiki/>
|-
|Labour/Delivery Room
|X
|
|
|
|
|
|
|
|4
|22-24
|-
|Laundry – General
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Lecture Halls
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Outpatients Departments
|X
|
|
|
|
|
|
|60
|4
|18-28
|-
|Pharmacy Dispensing
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Pharmacy Store
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Specialist Clinics- ENT
|X
|X
|
|
|
|
|
|7.5
|4
|22-26
|-
|Sterilizer Equipment
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Toilet Room
|
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Units: Treatment Room
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|-
|Units: Burns
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|-
|Units: HCU / CCU
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU Neonatal
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|-
|Wards: General
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|-
|Wards: Airborne Precaution Rooms/Isolation'''[[Building Engineering Services#BESftn4|[4]]]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|-
|Wards: Maternity
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Medical
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Paediatric
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|-
|Wards: Psychiatric
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|-
|Wards: Orthopaedic
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: Surgical
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: TB
|X
|
|
|
|
|
|
|80
|12
|20-28
|-
|Radiology: General
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|-
|Radiology: Airborne Precaution
|X
|
|X
|
|
|
|
|60
|6
|22-24
|-
|Radiology: MR/CT

Scanner
|
|
|
|
|
|
|
|60
|6
|2-24
|}
{{Anchor|BESftn1}}[[Building Engineering Services#%20ftnref1|[1]]] These rates are considered for forced ventilation systems only. Average natural ventilation rates may be higher

{{Anchor|BESftn2}}[[Building Engineering Services#%20ftnref2|[2]]] Temperature range not to be exceeded for more than 50 hours per year.

{{Anchor|BESftn3}}[[Building Engineering Services#%20ftnref1|[3]]] Specialist cleanrooms and laboratories may require lower temperatures.

{{Anchor|BESftn4}}[[Building Engineering Services#%20ftnref1|[4]]] Levels of filtration are dependent on pathogenicity. Exhaust filtration may also be required.

======Commissioning tests shall include and record, but not be limited to:======
{| class="wikitable"
|'''System'''
|'''Commissioning Test'''
|'''Special Instructions'''
|-
|'''All'''
|Standard of installation
|Test to be authorised by client's representative.
|-
| rowspan="7" |'''Air Handling Units and Fans'''
|Fan motor drive speed and rotation.
|Cognisance should be taken of motor cooling requirements
|-
|Fan motor current draw.
|<nowiki>-</nowiki>
|-
|HEPA Filter challenge testing.
|In accordance with ISO DIS 14644-3
|-
|AHU heating and cooling coil performance
|Report on-coil and off-coil air conditions for full heating and full cooling with no air bypass.
|-
|AHU leakage tests
|<nowiki>-</nowiki>
|-
|Heating and Chilled Water circuits have been charged, dosed and pressure tested
|<nowiki>-</nowiki>
|-
|Flow rates and pressures across heat exchangers, pumps and compressors
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="2" |'''Room conditions'''
|Airflow and room pressure balancing in accordance with design tolerances.
|In accordance with ISO DIS 14644-3 Acceptance criteria Normally +10-0%
|-
|Room Temperature and humidity
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''Air Distribution systems'''
|Dampers and registers shall be locked and marked after balancing
|<nowiki>-</nowiki>
|-
|Duct leakage tests for medium and high pressure ducting in accordance with SANS 10173 or DW/143 requirements, as agreed upon
|<nowiki>-</nowiki>
|-
|'''Water Distribution Systems'''
|Pressure Drops and Flow Rates
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="4" |'''Control System'''
|Control system loop and function checks
|<nowiki>-</nowiki>
|-
|Alarm Checks
|<nowiki>-</nowiki>
|-
|System Start/Stop sequencing checks
|<nowiki>-</nowiki>
|-
|System Set-Back mode checks
|Include room condition and contiguous system impacts
|}

24.7. Select validation tests shall be conducted at intervals defined by the client:
 
{| class="wikitable"
|'''Tests'''
|'''Required/ Optional'''
|'''Recommended Frequency of testing'''
|'''At-Rest or In-Operation Testing'''
|-
|'''Airflow volume tests'''
|Required
|12 months
|At-Rest
|-
|'''Airflow visualization'''

'''(Airborne precaution rooms)'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Velocity Tests'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Airflow Visualisation'''
|Required
|6 Months
|At-Rest & In-Operation
|-
|'''Room pressure tests'''
|Optional
|3 Months
|At-Rest & In-Operation
|-
|'''Airflow direction tests'''
|Required
|1 Month
|At-Rest & In-Operation
|-
|'''Discreet practice counts'''
|Required
|12 Months
|In-Operation
|-
|'''Bio-burden testing'''
|Required
|1 Month
|At-Rest
|-
|'''Filter challenge testing'''
|Optional/Recommended
|24 Months
|At-Rest
|-
|'''Room Condition recovery'''
|Required
|24 Months
|In Operation
|}
24.8. Prescribed validation reports shall include:

*References to the test protocol
*Acceptance criteria
*Test results
*Test equipment identification and calibration status
*Name and signature of tester
*Name and signature of facility representative
*Dates of test and acceptance by client

===Medical gas installations===
25. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

26. All units of a health establishment, except sub-acute and hospice facilities, where patients are accommodated and treated, must have medial gases and vacuum provided by medical grade piped services, with indexed terminal connecter points. Bottle systems may be provided in sub-acute and outpatient facilities.

27. Mobile gas services must be available for crisis situations.

28. Sub-acute facilities must have one mobile oxygen cylinder per 10 patients and one suction machine for every 10 patients.

29. The minimum services to be supplied to all Acute Care areas are described in Table 11.1. Should the data in this table be in conflict be the table presented in the individual departmental design guidance documents, those individual guidance documents take precedence.
{| class="wikitable"
|+Table 5 Minimum gas services
!'''Description'''
!
!'''Oxygen'''
!'''HP Air'''
!'''LP Air'''
!'''N2O'''
!'''VAC'''
!'''Scavenging'''
|-
|'''Major Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Minor Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Cath Lab8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|1
|
|
|1
|1
|1
|-
|'''Post Op'''
|'''Bedhead'''
'''Trunking'''
|1
|
|1
|
|1
|
|-
|'''Procedure'''
'''Room'''
|'''Theatre Panel'''
|1
|
|1
|
|2
|
|-
|'''Resuscitation Bay'''
|
|1
|
|1
|
|2
|
|-
|'''Delivery Room'''
|
|2
|
|1
|
|2
|
|-
|'''High Care Unit, Per Bed'''
|
|1
|
|1
|
|2
|
|-
|'''Intensive Care Unit Per Bed'''
|
|2
|
|2
|
|2
|
|-
|'''Casualty Per Bed'''
|
|1
|
|1
|
|1
|
|-
|'''Wards'''
|
|'''1 per'''
'''2 beds'''
|
|
|
|'''1 per'''
'''2 beds'''
|
|}
30. A gas alarm system to monitor gases, excluding scavenging, must be installed in a location that is manned 24 hours per day. A slave panel must also be installed in the intensive care unit and in the theatre complex. This alarm system must be connected to UPS.

31. All piped vacuum and oxygen systems must have mobile back-up systems with adequately trained staff to handle them. . The back-up service shall be automatically activated if the line pressure drops below the set operating pressure. All back-up services and change-over valves shall be on UPS and diesel generator supplies.

32. Medical air (low pressure) for respiratory purposes must be provided at a fixed pipeline pressure of 400 kPa. Medical air (high pressure) for driving surgical power tools must be provided at a terminal usage pressure between 70 0kPa and 1000 kPa, depending on the tools/equipment to be used. ICU and operating rooms must be provided with a back-up system for both low and high pressure service. Air compressors must be fed off standby power supply.

33. Anaesthetic gas scavenging, which is a low-pressure suction system that removes exhaled anaesthetic gases from the patient circuit must be provided. Each outlet point must have its own balancing valve to allow the system to be balanced progressively from the furthest outlet point towards the suction fan or pump.

34. The vacuum installation shall comply with SANS 7396-1. Vacuum liquid bottle traps must be installed to collect any blood/fluid etc. that may be drawn into the pipeline. One bottle trap per operating room, ICU, ward block and other patient unit, must be supplied. Where possible the vacuum trap should be located in a sluice room. Emergency suction facilities must be provided in the ICU and High Care, operating rooms, recovery room, delivery room, emergency unit and nursery, and must be available to all patient rooms. Bacteria filters must be installed in the vacuum main before the vacuum reservoir and pumps. Used filters are considered a bio-hazard and must be handled accordingly when being changed and disposed. Care must be given to the location of the exhaust discharge of vacuum plants taking into account locations of windows and other air inlet points. Vacuum pumps must be fed off standby power supply.

35. Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.

36. Gas service outlets to be identified and colour-coded with 3mm lettering.

37. Should compressed air operated autoclaves be employed, High Pressure medical air may be taken to such equipment, provided the system possesses sufficient capacity.

38. Should pendants requiring compressed air for aid of movement be employed, High Pressure Medical Air may be taken to them, provided the system possesses sufficient capacity.

39. Should Health Technology Workshops require medical gas outlets for testing and servicing of medical equipment, the required service may be taken to them, provided the system possesses sufficient capacity.

40. SANS 7396-1, as amended, specifies the requirements from design to commissioning of medical gas and vacuum systems

41. Medical gas and vacuum pipelines shall be marked in accordance with SANS 7396-1 and ISO 5359 as applicable

42. SANS 7396-2, as amended, specifies the requirements from design to commissioning of anaesthetic gas scavenging disposal systems.

43. Colour coding of anaesthetic gas scavenging disposal system shall be red magenta or in accordance with the national standard. An example of red magenta is 3050-R40B, in accordance with SS 01 91 02.(Refer to SANS 73962-2).

44. Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.

45. SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.

46. Plain ended copper tubing for low pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.

47. Laboratory gas taps and valves shall be marked as described in SANS 10140-4

===Electrical installations===

====48. Lighting in Hospitals ====
48.1. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

48.2. Within the available scope presented in the National Building Regulations, the following lighting requirements should be interpreted with the aim of maximum energy and cost efficiency. The following innovations could be adopted to achieve this aim:

#Daylight harvesting with passive building elements and active systems response.
#Adoption of task lighting, where appropriate, within the scope of present and future planned activities.
#Considered selection of lighting elements and solutions.
#Considered selection of internal colours and materials.
#Accommodation for visually impaired occupants.

48.3. Where a requirement for natural light (daylight) is stated, this may be met if the room opens onto an atrium or courtyard, or if a roof light is incorporated, provided that privacy within the room or space is maintained. In addition, daylight may be borrowed from an adjacent room by means of glazing the wall in between, provided that the adjacent room or corridor is within the same unit.

48.4. Save where otherwise provided for in the requirements, health establishments must comply with the following: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table 6 Levels of Indoor Lighting (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings)'''
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''

'''/ lux'''
|'''Max. point illuminance/ lux'''

'''(not to be exceeded)'''
|'''Unified'''

'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''

'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Common areas'''

- changing room

- chapel

- classroom

- consulting room (general)

- care room (deep plan)

- day room

- disposal (clinical, domestic waste)

- doctor’s office

- domestic services room

- drug store (ITU/HDO)

- general office

- seminar room

- seminar room

- staff change

- staff rest room

- utility room (clean)

- utility room (dirty)
 
|

100-150

100-150

300

300

300

200

200

500

100

500

300

100-150

300

100

50/200

150

200
 
|

n/a

n/a

520

520

520

350

350

850

170

850

520

n/a

520

170

n/a

260

350
 
|

22

22

19

19

19

22

22

19

19

19

19

19

19

22

22

19

22
 
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

90

80

80
 
|

Floor

Pews

Desk

Work Surface

Work Surface

Work Surface

Floor

Desk

Floor

Desk

Desk

Floor

Work Surface

Floor

Work Surface

Work Surface

Work Surface
 
|

Normal

Normal

Normal

Normal

-

-

Normal

Normal

Normal

Normal

Normal

Normal

Selective

Normal

-

Normal

N
 
|

-

-

-

>30%

-

-

-

>30%

-

>30%

>30%

-

>30%

-

-

>30%

>30%
 
|-
|'''Corridors (screened from bed bays)'''

- by day

- by night
 
|

200

5-10
 
|

350

n/a
 
|

22

22
 
|

80

80
 
|

Floor

Floor
 
|

S

Normal
 
|

>30%

>30%
 
|-
|'''Circulation/communal areas'''

- corridors (general)

- day room

- entrance canopy

- entrance lobby

- hairdressing salon

- hospital street

- library

- lift car

- lift lobby

- loading bay

- reception area

- relatives overnight

- rest area

- shop/kiosk

- storage (general)

- toilets
|

200

200

n/a

n/a

300

200

300

150

200(min)

100

300

150

150

300

200

200
|

350

350

n/a

n/a

520

350

520

260

n/a

170

520

260

260

520

350

n/a
|

19

-

-

22

-

19

19

-

19

22

19

-

19

-

22

22
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80
|

Floor

Floor

Road surface

Floor

Chair

Floor

Desk

Floor

Floor

Platform or floor

Floor

Work Surface

Floor

Counter

Floor

Floor
|

Normal

S

Selective

Selective

Normal

N/EM

Normal

Sp

Selective

Normal

Normal

Normal

Normal

Normal

Normal

Normal
|

>30%

>30%

>30%

>30%

-

>30%

-

-

>30%

-

>30%

-

-

-

-

-
|-
|'''Restaurant/catering/breakout areas'''

- beverage bay

- counter

- general

- servery

- tables

- washing up
 
|

100

300

50

300

50/200

|

170

520

100

520

n/a

520
 
|

-

22

-

22

-

22
 
|

80

80

80

80

80

80
|

Floor

Counter

Floor

Counter

Tables

Sink
 
|

Normal

Normal

S

Normal

Normal

Normal
 
|

>30%

-

>30%

-

-

>30%
 
|-
|'''Wards and bedded areas'''

- children’s play area

- circulation space

- circulation space (night)

- examination/treatment

|

300

170

10

1000(local)

|

520

170

10

n/a

|

22

19

-

-

|

80

80

80

90

|

Desk

Floor

Floor

Bed level (usually provided by examination lamp
|

N/EM

Normal

Normal

Normal

|

>30%

>30%

>30%

>90%

|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Nursing'''

- general nursing care/examination

- night light

- nurses’ station (day)

- nurses’ station (night)

- observation/night watch

- observation/night

- mental illness care wards

- patient reading (adult)

- reading lights

- ward corridors (day)

- ward corridors (night)

|

300

5

300

30/200

20

1 to 5

200

300

300

200

50

|

520

10

520

250

40

n/a

350

520

520

350

75

|

19

-

19

22

-

-

19

19

19

19

19

|

80

80

80

80

80

80

80

80

80

80

80

|

Bed

Work Surface

Desk

Work Surface

Bed head

Bed head

Floor

Bed head

Patient activity area

Floor

Floor (50% uniformity required)
 
|

Selective

Normal

Variable

Normal

Normal

N/Sp

Normal

Normal

Selective

Normal

Normal

|

>30%

>90%

>30%

>90%

-

>30%

>30%

>30%

>30%

>90%

>30%

|-
|'''Orthopedic'''

- pacemaker

- treatment (general)

- venesection
 
|

500

300

300
 
|

850

520

520
 
|

19

19

19
 
|

80

80

80
 
|

Work Surface

Work Surface

Chair
 
|

Variable

Normal

Normal
 
|

>30%

>30%

>30%
 
|-
|'''Critical care'''

- intensive care (night)

- observation/night watch

- high dependency unit (HDU)

- intensive care unit (ICU)

- bed head (day)

- night light

- simple observation/examination

- examination

 
|

5(max)

20

100

100

30 to 50

5 to 10

300

1000 (local)

 
|

n/a

40

170

170

n/a

10

520

n/a

 
|

-

-

19

19

22

-

19

-

 
|

80

80

80

80

80

80

80

90

 
|

Circulation

Bed head

Circulation/general

Circulation/general

Bed head

Bed head

Bed

Bed level(to be provided by examination lamp)

|

N/Sp

N/Sp

Normal

Normal

Normal

Normal

Selective

Normal

 
|

>30%

>30%

>90%

>90%

>90%

>90%

>90%

>90%

 
|-
|'''Coronary care'''

- bed head (day)

- observation/night watch

- simple observation/examination

- examination

- staff base (day)

- staff base (night)
 
|

30 to 50

5 to 10

300

1000 (local)

300

30/200
 
|

n/a

n/a

520

n/a

520

250
 
|

19

-

19

-

19

19
 
|

80

80

80

90

80

80
 
|

Bed head

Bed head

Bed

Bed level (to be provided by examination lamp)

Desk

Desk
 
|

Normal

Normal

Selective

Normal

Selective

Variable
 
|

>90%

>90%

>90%

>90%

>90%

>90%
 
|-
|'''Nurse’s station/staff base'''

- day

- night

- interview
 
|

300

30/200

300
 
|

520

250

520
 
|

19

19

19
 
|

80

80

80
 
|

Desk

Desk

Desk
 
|

Selective

Variable

Normal
 
|

>90%

>90%

>30%
 
|-
|'''Operating theatres'''

- anesthesia (examination)

- anesthesia room (general)

- angiography room

- endoscopy

- operating room general

- operating table/cavity

- porter’s area

- post anaesthesia recovery

- preparation

- scrub up

- transfers

- utility rooms
 
|1000 (local)

500

500

300

300

1000

10000 to 100000

300

500

500

500

300

100 to 150
|

n/a

850

850

520

1500

n/a

520

850

860

860

520

n/a
|

-

19

19

19

19

-

19

19

19

19

19

19
|

80

80

80

80

90

90

80

90

801

80

80

80
|

Trolley head

Work Surface

Work Surface

Work Surface

Work Surface

Work Surface

Trolley/bed

Work Surface

Bench

Sink top

Work Surface

Floor
|

Normal

Selective

Variable

Variable

Variable

Variable

N/A

Selective

Normal

Normal

Normal

Normal
|

>90%

>90%

>90%

>30%

>90%

>90%

>90%

>90%

>30%

>30%

>30%

-
|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Accident and emergency'''

- Admissions. reception

- supplies stores

- minor treatment area

- minor operations

- couch (general area)

- couch (local)

- general examination areas

- procedure room

- resuscitation room
 
|

300

300

500

15000/30000

750

500

500

30000/60000

500
 
|

520

520

850

N/A

1000

850

850

N/A

860
 
|

22

22

19

-

19

19

19

-

19
 
|

80

80

80

90

90

80

80

90

80
|

Desk

Work Surface

Work Surface

Adjustable to suit treatment area

Over couch area

Couch level

Couch level

Task illumination provided by minor treatment lamp

Work Surface
 
|

Normal

Normal

Normal

Normal

Variable

Variable

Variable

Normal

Normal
 
|

>30%

>90%

>30%

>30%

>90%

>90%

>90%

>90%

>30%
 
|-
|'''Audiology'''

- audio testing

- consulting room

- ear examination

- vestibular testing (labyrinth)

|

300

300

1000 (local)

100

|

520

520

n/a

170

|

19

19

-

19

|

80

80

90

80

|

Work Surface

Work Surface

(examination lamp)

Couch head and instruments
 
|

Variable

Variable

-

Normal
 
|

>30%

>30%

-

>30%
 
|-
|'''Dentistry'''

- laboratories

- reception/administration areas

- surgeries/theatres

- treatment rooms

- white teeth matching

|

500

300

8000 to 20000

500

5000

|

850

520

n/a

850

n/a

|

19

19

-

19

-

|

80

80

90

90

90

|

Bench

Work Surface

Mouth

Bench work surface

Work Surface

(TCP ≤ 6000 K)
 
|

Normal

Selective

Variable

Normal

Normal

|

>30%

>30%

>90%

>30%

>30%

|-
|'''Diagnostics support'''

- aseptic laboratory

- blood bank

- colour inspection laboratory

- hot and cold rooms

- inspection

- laboratories

- laboratory (with computers)

- pathology laboratory

- relatives’ waiting room

- seminar room

- viewing/bier room
 
|

300

300

1000 (local)

200

500 (local)

500

300

500

300

300

30 to 150
 
|

520

520

n/a

350

n/a

850

520

850

520

520

n/a
 
|

19

19

-

19

-

19

19

19

19

19

19
 
|

80

80

90

80

80

80

80

80

80

80

80
 
|

Bench

Work Surface

Bench

(TCP ≤ 6500 K)

Work Surface

Bench

Bench/desk

Work Surface

Bench

Work Surface

Work Surface

Bier
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Variable

Normal

Variable
 
|

>30%

>90%

>90%

>30%

50-90%

50-90%

50-90%

50-90%

>30%

>30%

>30%
 
|-
|'''Women’s services (maternity)'''

- applying sutures

- circulation space (day)

- delivery

- day

- night

- neonatal

|

1000 (local)

100

500

50 to 100

5

1000 (local)

|

n/a

170

850

n/a

20

n/a

|

-

19

19

19

-

-

|

90

80

80

80

80

80

|

Couch, chair or bed (usually provided by examination lamp)

Floor

Work Surface

Cot

Cot

Cot

|

Normal

Normal

Selective

Normal

Normal

Normal
 
|

>90%

>30%

>90%

>90%

>90%

>90%

|-
|'''Mother and baby rooms'''

- circulation space (day)

- day

- night

- nurseries (day)

- nurseries (night)

- milk kitchen

- special care baby unit

- teaching areas
 
|

100

50 to 100

5

100

5

300

1000 (local)

300
 
|

170

n/a

20

170

20

520

n/a

520
 
|

22

19

-

19

-

22

19

19
 
|

80

80

80

80

80

80

80

80
 
|

Floor

Cot

Cot

Floor

Floor

Bench

Cot

Bench/Work Surface
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>30%

>90%

>90%

>30%

>30%

>30%

>90%

-
 
|} 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''General treatment areas'''

- autopsy (dissecting) table

- autopsy rooms and mortuaries

- dermatology

- dialysis

- dispensary

- minor surgery/treatment

- plaster room

- resuscitation (general)

- resuscitation/examination

- pharmacy
 
|

5000

500

(higher values could be required)

500

500

15000/30000

500

500

15000(local)

500
 
|

8600

850

n/a

850

860

 850

850

n/a

850
 
|

-

19

19

19

19

19

19

-

19
 
|

90

90

90

80

80

90

80

90

90

80
|

Table top

Work Surface

(Local operating lamp)

Work Surface (dimmable)

Bench

Work Surface

Work Surface

Head of trolley

Work Surface
 
|

-

-

-

-

Normal

Normal

Normal

Normal

Normal

Normal
 
|

-

-

-

-

>90%

>90%

>30%

>90%

>90%

50-90%
 
|-
|'''Mortuaries and animal houses'''

- autoclave

- body store

- general

- mortuary

- operation

- post mortem

- staff change

- store room

- viewing room

- waiting room
 
|

150/200

200

300

150

500 local

500

100 to 150

150

50/100

200 (min)
 
|

n/a

350

520

260

n/a

850

n/a

260

n/a

n/a
 
|

19

19

19

19

-

19

19

19

19

19
 
|

80

80

80

80

90

90

80

80

80

80
|

Work Surface

Work Surface

Work Surface

Bier room

Bench

Work Surface/table

Floor

Work Surface

Work Surface

Floor
 
|

Normal

Normal

Special

Variable

Normal

Normal

Normal

Normal

Variable

Selective
 
|

>30%

>30%

-

>30%

>30%

>30%

>30%

-

>30%

>30%
 
|-
|'''Engineering services'''

- ducts

- plant room

- roadways

- workshop
 
|

20 to 50

300

7

300/500
 
|

n/a

520

12

n/a
 
|

-

22

-

22
 
|

80

80

80

80
|

Floor

Floor

Road surface

Bench
 
|

Selective

Normal

-

Normal
 
|

-

>90%

-

>30%
 
|-
|'''Facilities support services'''

- laundry

- linen store (Linen Department)

- pack and dispatch

- pressing

- sewing room

- wash and dry
 
|

300

100

300

300

500 (local)

300
|

520

170

520

520

n/a

520
 
|

19

19

19

19

19

19
 
|

80

80

80

80

80

80
 
|

Bench

Floor

Bench

Equipment

Machine

Equipment

|

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>90%

-

>90%

>90%

>90%

>90%
 
|}
48.4.1. The lighting levels quoted above relate to the relevant task area. Levels of for the task areas and surrounding areas can be reduced where it can be justified by experienced staff or engineers. Lighting levels must, regardless, comply with the requirements of the National Building Regulations.

48.4.2. Lighting levels for external areas shall comply with the following table: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table''' '''7 Levels of Indoor Lighting'''
{| class="wikitable"
|Area
|Maintained average illuminance / lux
|Maintained minimum illuminance / lux
|Overall uniformity (not less than stated figure)
|Threshold increment
|Colour rendering (minimum)
|-
|

CCTV

- monochrome

- colour

Roads

General pedestrian areas

Information and display signs

Car Park

Vehicle drop-off points

Steps or stairways

General area lighting

Hazardous open storage areas
 
|

0

-

15

20

30

10

15

20

100(vertical)

15

10

100

20

50
 
|

5

15

6

8

12

4

6

12

6

5

40

12

20
|

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4
 
|

≥10%

≥10%

 
|

≥60%

≥60%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%
 
|}

49. Classification of Safety Services necessary for Medical Locations from SANS 10142-1
{| class="wikitable"
|'''Class'''
|'''Response Time'''
|-
|Class 0 (No break)
|Automatic supply available at no break

UPS backed up by Generator Required.
|-
|Class 0,15 (Very short break)
|Automatic supply available within 0,15 s

UPS backed up by Generator Required.
|-
|Class 0,5 (Short break)
|Automatic supply available within 0,5 s

UPS backed up by Generator Required.
|-
|Class 15 (Medium break)
|Automatic supply available within 15 s

Generator Required
|-
|Class > 15 (Long break)
|Automatic supply available in more than 15 s

Generator Required
|}
Note Safety Services in Medical locations are synonymous with Emergency Services.

50. '''Medical Location Classification'''

50.1. Group 0 location: where no applied part is intended to be used.

50.2. Group 1 location: Medical Location where applied parts are intended to be used.

#Externally, or
#To any part of the body, but not to the heart.

50.3. Group 2 location: Medical Location where applied parts are intended to be used in applications such as in an intracardiac procedure, in an operation (in an operating theatre) and in vital treatment where discontinuity (failure) of supply can cause danger to life.

Note: An intracardiac procedure is a procedure whereby an electrical conductor is placed within the cardiac zone of a patient or is likely to come into contact with the heart, such conductor being accessible outside the patient’s body. In this context, an electrical conductor includes insulated wires such as cardiac pacing electrodes or intracardiac ECG electrodes, or insulated tubes filled with conducting fluids.

50.4. For the allocation of medical location group and classification of safety service classes for medical locations see Table below as supplied in SANS 10142-1.
 
{| class="wikitable"
|
|
'''Medical Location'''
| colspan="3" |
'''Medical location group'''
| colspan="2" |
'''Safety service class'''
|-
|
|
|'''0'''
|'''1'''
|'''2'''
|'''≥ 0,5'''
|'''0,5'''

'''≤ 15'''
|-
|

1
|

Massage room
|

X
|

X
|
|
|

X
|-
|

2
|

Bedrooms
|

|

X
|
|
|

X
|-
|

3
|

Delivery room
|
|

X
|
|

X
|

X
|-
|

4
|

ECG, EEG, EHG room
|
|

X
|
|
|

X
|-
|

5
|

Endoscopic room
|
|

Xa
|
|
|

Xa
|-
|

6
|

Examination or treatment room
|
|

X
|
|
|

X
|-
|

7
|

Urology room
|
|

Xa
|
|
|

Xa
|-
|

8
|Radiology diagnostic and radio therapy room, other than mentioned under 21
|
|

X
|
|
|

X
|-
|

9
|

Hydrotherapy room
|
|

X
|
|
|

X
|-
|

10
|

Physiotherapy room
|
|

X
|
|
|

X
|-
|

11
|

Anaesthetic room
|
|
|

X
|

X
|

X
|-
|

12
|

Operating theatre
|
|
|

X
|

X
|

X
|-
|

13
|

Operating preparation room
|
|

X
|

X
|

X
|

X
|-
|

14
|

Operating plaster room
|
|

X
|

X
|

X
|

X
|-
|

15
|

Operating recovery room
|
|

X
|

X
|

X
|

X
|-
|

16
|

Heart catheterization room
|
|
|

X
|

X
|

X
|-
|

17
|

Intensive care room
|
|
|

X
|

X
|

X
|-
|

18
|

Angiographic examination room
|
|
|

X
|

X
|

X
|-
|

19
|

Haemodialysis room
|
|
|

X
|

|

X
|-
|

20
|

Magnetic resonance imaging (MRI)
|
|

X
|
|
|

X
|-
|

21
|

Nuclear medicine
|
|

X
|
|
|

X
|-
|

22
|

Premature baby room
|
|
|

X
|

X
|

X
|-
| colspan="3" |
a The room is not an operating theatre.
|
|
|
|
|}
50.5. In addition to the tables 0 and 50.4 above, generator supply is also required for:

#Night light in wards and ward corridors;
#All switched socket outlets used for patient life support anywhere in the facility;
#At least one patient lift or lift that can accommodate a bed for every 200 patients;
#Medical air compressor, vacuum pumps and gas alarm systems;
#Supply air fans serving theatres and uni-directional airflow systems;
#Isolation ward exhaust air fans.
#Mortuary Fridge Cabinets
#Nurse call System
#Fire detection system

51. General Requirements

51.1. Power supply to switched socket outlets in high care units, intensive care units and operating theatre units and recovery rooms must be on an earth monitoring system. Double pole isolators must be used for supply points in these areas and the power supply to these shall be fed from an isolation transformer.

51.2. Medical Location Group 1:

Switch Socket outlets in Medical Location 1 Shall have final Circuits for socket -outlets up to 16Amp shall be protected by earth leakage protection devices with a rated earth leakage tripping current ( rated residual current) not exceeding 30 Ma.

51.3. Medical Location Group 2:

Switch Socket outlets in Medical Location 2 the Medical Isolation Transformer (Medical IT) system shall be used for circuits that supply medical electrical equipment and systems intended for life support or surgical applications and other electrical Equipment located in the patient environment. In the case of each group 2 medical location, at least one separate medical IT system is necessary.

51.4. The Medical Isolation Transformer (MIT) shall be equipped with:

51.4.1. A 5 or 8 kVA Isolation Transformer complete with a 220 V Primary and 220 V / 110 V Secondary Winding with a centre Point Floating but bonded to the Earth monitor. The Secondary Side of the transformer shall provide 220 Volts between Line 1 and Line 2 (Note no Neutral with an Isolation Transformer) Line 1 and Line 2 will feed the Distribution Board for that particular Medical Group location, i.e. (Theatre No 1) or (ICU Bed 1-6) This local DB will then have a number of double pole Circuit Breakers feeding out to the outgoing Circuits feeding the Socket Outlets in the Medical Location 2 Area. Note that at least two circuits are required to each ICU Bed or Theatre Panel, and Theatre Pendant. Also note that all Switch Socket Outlets in a Medical Location 2 Area have to be double Pole Switched via a double pole Isolator (Provided two circuits provided) or a double pole Circuit Breaker.

51.4.2. The Transformer shall be installed either in a cabinet/DB or enclosure, to prevent unintentional contact with live parts. The Transformer / DB should be located close to the Group 2 Medical Location but consideration should be given to providing the DB outside the red line area of both the Theatres and ICU Areas, so maintenance can be carried out without the need to be gowned up. Line 1 & 2 and Earth should all be Insulated wires with the colour of Line 1 & 2 being different from red and black suggest Brown and Blue wire is used for Line 1 & 2 and green for Earth (Note this Earth wire should be connected to an insulated Earth bar dedicated to that particular Group two location and bonded to the centre point of the secondary winding.) Note a Separate Dirty earth (Equipotential bonding) should also be provided to the metal work of the Plugs, Theatre Panel, and Pendant this earth shall be connected to the Main Building Earth.

51.4.2. An insulation -monitoring device that:

#Has an internal impedance of at least 100 k Ohm;
#Has a test voltage not exceeding 25 V DC.
#Is of a current, even under fault conditions, not exceeding 1 mA DC. and
#Shall indicate, at least when the insulation resistance has decreased to 5 k Ohm.

A test device shall be provided to test this facility to ensure that the alarm (Audible and visual) operates when the insulation resistance reaches 5 k Ohm;

To test the System two male plugs should be used each with a resistor of 5 k Ohm. Plug No 1 should have a 5 k Ohm resistor bridged from the Earth Pin to the Right Hand live Pin. Plug No 2 should have a 5 k Ohm resistor bridged from the Earth Pin to the Left Hand live Pin.

51.4.4. Medical Isolation Transformer Alarm.

For each Medical IT system an audible and visual alarm shall be provided in the Theatre Area a alarm shall be provided on theatre Panel and repeated back to the main Nurse Station in Theatre Area .The Alarm shall consist of Green Light indicating Healthy, a red light indicating fault, a audible Alarm to also indicate fault and a local audible alarm mute button. The Visual signal shall revert to green and the audible alarm shall be automatically reset on the removal of the fault condition
 

Table 4 – Required for Medical Isolation Transformers (MIT) and Switch Socket Outlets (SSO)
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Office Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Laboratory Work Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Office
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Nurse Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward
|1
|1 x 16A Normal / Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point/ Bed(if required).
|
|3x 16A per bed
|
|
|
|
|-
|Ward Kitchen
|0
|2 x 16A Normal on Wall at 1200 mm over counter + 1 x 16 A next to Sink or Hydro Boil.
|
|1 x 16A supply for Fridge on generator supply
|
|
|
|
|-
|Ward Corridor
|0
|1 x 16A Normal / Every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Ward Staff Rest Room
|1
|I x 16 A on Wall for Cleaning, 1 x 16 A above counter for Electrical Appliances + 1 X 16 A next to sink for Hydro boil
|
|
|
|
|
|
|}
----[[Building Engineering Services#%20ftnref1|[1]]] Note: DPS is an abbreviation for double pole switch
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Theatre Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|-
|Theatre Post Op
|2
|
|
|
|6 x 16 A Dedicated SSO per Bed
|
|
|
|-
|Operating Theatre
|2
|
|
|
|
|8 x 16 A Dedicated SSO per Pendant
|8 x 16 A Dedicated SSO per pendant
|4 x 16 A Dedicated SSO
|-
|Cath Lab Operating Room
|2
|
|
|
|
|
|
|4 x 16 A Dedicated SSO
|-
|Cath Lab Control Room
|0
|1 x 16A Normal per Station
|1 x Red 16A Dedicated per Station
|
|
|
|
|
|-
|Cath Lab Equipment Room:

160 kva dedicated UPS Required to feed Dedicated DB and Equipment
|
|
|
|
|
|
|
|
|-
|Autoclave
|
|In autoclave plant room. 3-Phase 380V, 80A per autoclave
|
|
|
|
|
|
|-
|Instrument Washer
|
|In CSSD. Typically 3-Phase 380V, 15A per washer
|
|
|
|
|
|
|-
|Theatre Corridor
|1
|1 x 16A Normal for every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|}
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|ICU Circulation Space
|1
|1 x 16A Normal per 25m2 for cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Neo Natal ICU Cots Note: Care should be taken when sizing the Isolating Transformers to include the Heating Load
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care Nurse Station (per workstation)
|1
|1 x 16A Normal per Station
|2 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|-
|ICU and Ward Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|}
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Casualty Treatment Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point per Bed. 2 x 16A per Bed
|
|
|
|
|
|
|-
|Procedure Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning
|
|4 x 16A per Bed per two Circuits.
|
|
|
|
|-
|Casualty Ward Corridor 0
|0
|1 x 16A Normal per every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Radiology Procedure Crash Cart Position
|
|
|
|
|
|-
|Rooms Dedicated 125 Amp Supply to dedicated
|1
|1 x 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Radiology Control Room
|0
|1 x 16A Normal per Station
|1 x 16A Normal per Station
|
|
|
|
|
|-
|Maternity Delivery Rooms
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|
|
|}

{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Dialysis Treatment Beds.

Note that the Equipment can include Water Heating with high kw loading so care should be taken when sizing the Isolating Transformers
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|
|
|}
51.5. Uninterrupted Power System must be provided for operating theatre luminaries and all life support systems and computer systems where a break in electrical supply cannot be tolerated. The whole installation must conform to SANS 1474 of 1988.

51.6. Socket outlets for Dialysis units, in close proximity to water points or drains, shall be of the totally waterproof IP65 type, which also seal water-tight when the socket is removed.

51.7. Where more than one electrical transformer is used, they should preferably be located in separate structural enclosures. This is to prevent potential damage to an adjacent transformer if one is damaged.

51.8. All distribution boards fed from normal mains supply shall be painted Electric Orange, colour B26 to SABS 1091.

51.8. All distribution boards fed from standby emergency power supply shall be painted Signal Red, colour A11 to SABS 1091.

51.9. All distribution boards fed from UPS power supply shall be painted Blue colour F06 to SABS 1091.

51.10. All cable transition boxes shall be painted the appropriate colour corresponding to the source of the power supply.

51.11. All cables installed on surface mounted cable ladders shall be of the PVC/PVC/SWA/ECC/PVC type to SANS 101507 rated at 600/1000 Volt.

51.12. Electrical circuits to be engraved on base 3mm lettering indicating circuit number and DB.

51.13. Electrical Certificate of Compliance.
[[File:Picture 11.png|border|thumb|450x450px|alt=|center]]
 
===Electronic installations===
52. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

53. Nurse call system with emergency (nurse assistance) and TV control handsets (Interchangeable with LED PEAR PUSH).

The nurse system enables the patient to call a nurse for assistance from his bed or from a bath, shower and toilet. The system also enables the staff to call for assistance (EMERGENCY CALL) from any bed and treatment room etc.

#When a patient nurse call or staff emergency call is enabled the system must produce an intermittent AUDIBLE chimes or bleeper tone at the nurses’ station or/and duty room. Three different sounding tones must be produced for normal Patient call, Bathroom call and Emergency (nurse assistance) call.
#The system must also provide a VISUAL indication, at the nurse station (LED Mimic Panel and/ or Computer Monitor or LCD Display Panel), above the door to the passage of the activated unit, and at the actual activated unit (reassurance LED).
#The system must be so designed that any call may ONLY be RESET at the point of origin.
#The system must automatically activate a nurse call when the Hand Held Unit (Handset) or Pear Push unit is accidently pulled out from the Bed Head Unit.
#The Bed Head Unit must be compatible with Hand Held Unit (with TV Control), Rehab Hand Held Unit & Pear Push. (Inter-changeable)
#A Central Monitoring PC, or PC per duty station replacing Mimic Panel, must keep records of all events. (Optional)
#The system must be purpose made and aesthetically pleasing with components (call & reset units etc) manufactured from matching injection moulded ABS plastic. A system made up of push buttons etc mounted directly onto standard electrical plates will not be accepted.

54. Automatic fire detection in Hospitals

The Fire Detection System shall comply with SANS 10400 SANS 10139 & SANS 322. The Fire Detection System must be provided throughout the Facility and be a Addressable Fire Detection System, Note that Audible Fire Alarms which could panic the patients should not be provided instead Visual Strobe Lights should be provided at all Nurse stations, Reception and Security Office.

Audible alarms can be used in noisy areas such as plant rooms.

The wiring for the Automatic Fire Detection System shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area)
 55. Public Address and Evacuation in Hospital

The Public Address and Evacuation System shall comply with EN54 and provide voice message via fire retardant speakers throughout the hospital Circulation Areas, Staff Areas, Public Toilets. The wiring for the Evacuation Speakers shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area). As part of the Hospital Design the Hospital should be zoned to allow Evacuation of Individual zones in the event of a fire or other Emergency.

==Wet Services==
56. Plumbing services (Water supply and drainage) must comply as a minimum with the following Standard Specifications and Codes of Practice:

#SANS 10400: The Application of the National Building Regulations, including Part XA: Energy Use in Buildings
#SANS 10252 – Part 1 – Water Supply Installations for Buildings
#SANS 10252 – Part 2 – Drainage Installations for Buildings
#UK Department of Health Technical Memorandum 04-01: The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems: Part A: Design, Installation and Testing, and Part B: Operational Management or the equivalent SANS standard when available.

57. Where any apparent conflict between the functional requirements and the regulatory “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functional compliance.

58. Cold water storage, dedicated to the domestic water requirements of the facility, must be provided on the site. A minimum usable volume of 500 litres per bed must be provided.

59. If water storage is required for fire protection purposes (Sprinklers, Fire Hydrant supply) it must be stored separately from domestic water, unless adequate provision for the prevention of stagnation of the fire service reserve within the tank can be made.

60. Tanks must be accessible both on the outside as well as the inside, and provision for cleaning the tanks without interrupting water supply to the hospital must be made. Access manholes must be lockable, and a facility for draining the tank or individual compartments within it, must be made.

61. All openings to the tank (Overflows, vent pipes, etc) must be provided with screens.

62. Underground tanks, with their inherent risk of contamination must be avoided at all cost. If unavoidable, the tank should be constructed in a water tight bund allowing sufficient space all round for inspection and maintenance, and a sump for collecting drainage water

63. Cold water storage tanks must be located such that heat gain to the water is minimised. Cold water storage temperatures 20 C and lower will prevent the colonisation by or multiplication of Legionella

64. Site water reticulation must be designed using sound engineering principles, with adequate provision for isolating sections of the reticulation whilst keeping the remainder in operation being made.

65. Fire protection water reticulations must be kept totally separate from the domestic water reticulation

66. Water distribution may be gravity fed, or alternatively supplied via booster pumps. Pumps must be suited to handling potable water, and provision for built in redundancy must be made. Booster pumps must be supplied off standby power.

67. Hot water supply temperature to general patient care and staff areas must be controlled at 55 C, and must not exceed 60°C, except during a sanitation cycle as described hereunder.

68. Hot water generation systems must where possible use waste heat recovery from a central air conditioning system, if employed.

69. The facility for thermal disinfection of the hot water storage and circulation system must be provided in the system design. This can take the form of controlled heating of the storage vessel and circulating mains to 60°C during periods of low water and power demand. The use of shunt pumps to circulate hot water from the top level to the lowest level of the hot water tank during the sanitation cycle must be considered.

70. Hot water supply to paediatric wards, as well as to geriatric and to neonatal bathing facilities shall not exceed 42°C at the point of supply. If thermostatic mixing valves are employed to achieve this, they must be fitted with a safety feature such that the water flow is cut off within 2 seconds of the cold water supply to the valve being interrupted. The valve must also be able to control the set temperature with a pressure ratio of incoming hot to cold water supply pressure of up to 10 to 1.

71. Toilet flushing systems must be provided with easily identifiable dual flush mechanisms, one being for low flush water flow, the other for standard flush water flow.

72. All sanitary fittings must be piped such that the hot water control is on the left hand side, and the cold water supply is on the right hand side when facing the fitting.

73. Branch pipes (dead legs) between water heating equipment or hot water circulating mains and sanitary fittings must be sized and located such that the maximum waiting time for hot water to emerge from the fitting does not exceed 12 seconds.

74. Mixing taps in patient care areas must be elbow action type, installed such that the tap can be opened and shut by means of simple elbow action.

75. The discharge from kitchen floor drains and other kitchen drain points such as sinks, dishwashing washing, machines, and cooking equipment wash down, likely to contain grease, must be taken via a separate discharge system to a suitable grease interceptor, installed in a position to allow easy access for removal of intercepted grease and oil.

76. The drain pipes from equipment likely to produce high temperature discharge, such as autoclaves, sterilisers and cooking equipment must be from materials able to withstand such temperatures, installed such that distortion and/or expansion can be accommodated by the system.

77. Vertical pipe runs (Drainage stacks and water supply mains) in multi storey buildings must be housed in continuous vertical service ducts with easy access from non-patient areas at each level.

78. Condensate drains from air conditioning and refrigeration systems must discharge into piped drainage systems.

79. Anti-Backflow protection devices shall be fitted to faucets with hand-held shower heads to prevent back siphoning should the supply water pressure fail.

80. In areas housing patients at unusual risk of infection, faucets should not be fitted with low-flow or aerating devices which may increase the rate of aerosolisation of infectious droplets.

 

'''81. Legionella Control'''

#A facility-wide legionella control plan shall be in place which will inform operation, maintenance and design of water systems.
#This Plan must include a Legionella risk assessment document, listing all areas where the bacteria may occur. This must address specifically air conditioning condenser water systems, domestic hot and cold water installations, irrigation water storage and distribution systems, etc.
#The Plan must refer to as-built drawings identifying positions and layouts of plant and installations liable to cause a risk of Legionella being generated
#The facility’s Maintenance Procedures must describe all measures to be taken to minimise proliferation of Legionella. This is to include procedures and frequency of sanitation/disinfection, purging of dead legs on circulating systems, sample taking and testing at specific intervals, as well as a responsibility matrix of personnel

For additional information refer to the [[Legionella Control]] article.

==Lifts==
82. Standards and Regulations Pertaining to Lifts and Lifting Operations:

#SANS 50081 - SAFETY RULES FOR THE CONSTRUCTION AND INSTALLATION OF LIFTS - PARTICULAR APPLICATIONS FOR PASSENGER AND GOODS LIFTS
#SANS 10400 –SS3 FACILITIES FOR DISABLED PERSONS: LIFTS
#SANS 10400 –TT45 FIRE PROTECTION: LIFT SHAFTS
#SANS 10400 –TT46 FIRE PROTECTION: LIFT
#SANS 10400 –TT47 FIRE PROTECTION: FIREMAN’S LIFT
#SANS 10400 –TT48 FIRE PROTECTION: STRETCHER LIFT 

83. Planning for circulation, capacity and location of lifts

#A lift traffic plan should be developed. Detailed lift traffic planning is beyond the scope of this document. A specialist advisor should be consulted to assist in the planning of lifts within the general principles of lifts services for healthcare buildings.
#General Lift Planning Principles
#The operational details of the facility must be understood for effective lift planning. These include:

*Number of visitors and visiting hours
*Number of staff, shift hours and ward round schedules
*Numbers of day and overnight patients
*Increased provisions for reduced mobility persons
*Housekeeping schedule
*Evacuation plan for reduced mobility patients.

#Whenever possible, lifts should be provided in pairs to allow for continued operation during maintenance and breakdown.

 

===='''84. TYPES OF LIFTS:'''====
84.1. PASSENGER LIFTS

#These lifts shall be able to accommodate general passenger traffic including ambulatory and semi ambulatory passengers. It shall be able to accommodate reduced mobility passengers using mobility aids and wheelchairs. Refer to SANS 50081-70, Table 1
#The entrance to a passenger lift shall not be less than 1100 mm in width.
#The depth of a passenger lift shall not be less than 1400mm deep.
#Passenger lifts shall have a mirror on the top half of the rear wall equal to the width of the lift to enable wheelchair users to back out of the lift where the lift has internal dimensions less than 1,5 m in width and 2,0 m in depth
#At least on one side wall of the car a handrail shall be installed 

84.2. BED LIFTS

#Bed lifts shall have internal dimensions of 1 800 mm wide by 2 700 mm deep to accommodate most beds with staff and medical equipment.
#The entrance to a bed lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.3. STRETCHER LIFTS

#Stretcher lifts shall have internal dimensions of 1 400 mm wide by 2 400 mm deep to accommodate most trollies or stretchers.
#The entrance to a stretcher lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.4. GOODS LIFTS

#Goods lifts are for the movement of conventional goods and items that could not reasonably use passenger lifts without causing discomfort to passengers or damage and soiling of the lift car.
#Goods lifts can be designed to accommodate passengers.

84.5. SERVICE LIFTS

#Service lifts are not designed for accommodate passengers. They are typically of the “dumb waiter” style dispatched between service hatches.

84.6. HOUSEKEEPING LIFTS

#Housekeeping lifts are similar in function to goods lifts but are intended for the movement of cleaning supplies, medical supplies and equipment, linen etc.

{| class="wikitable"
|+Hospital Guide - Passenger
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''630 kg / 8 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|1800 x 1800

2000 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''800 kg / 10 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1350 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|2000 x 1800

2200 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1600 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2300 x 1800

2450 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1250 kg / 16 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|2000 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2700 x 2000

2700 x 2000
|1450
1500

1600
|4200
4300

4400
|}
 
{| class="wikitable"
|+Hospital guide - stretcher / Bed Lifts
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 2100
|CLD

TLD
|1000 x 2100

1000 x 2100
|200 x 2600

2000 x 2600
|1450
1500

1600
|4200
4300

4400
|-
|'''1600 kg / 21 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1400 x 2400
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 2800
2500 x 2900

2400 x 2900
|1450
1500

1600
|4200
4300

4400
|-
|'''2000 kg / 26 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1500 x 2700
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 3100
2600 x 3150

2450 x 3150
|1450
1500

1600
|4200
4300

4400
|-
|'''2500 kg / 33 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1800 x 2700
|CTLD

CTLD
|1400 x 2100

1600 x 2100
|2900 x 3150

3000 x 3150
|1450
1500

1600
|4200
4300

4400
|}
 
==PART D - COMMISSIONING AND HANDOVER==
===Deliverables===
1. This section is intended to detail the commissioning deliverables required before handover of building engineering services for operation. For further detail on commissioning and handover the '''IUSS Commissioning Health''' Facilities guidance document should be referred to.

2. Project Close-out deliverables include:

#Final Works completion lists
#Financial reports and final accounts
#Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
#Approved As-Built Drawings
#Electrical Certificates of Compliance

3. '''Maintenance manuals''' shall be timeously issued and shall include:

3.1. Designer and installer contact information

3.2. System information

#System description
#Suppliers list
#Equipment List
#Equipment data sheets
#Materials of construction data sheets
#Warranty information

3.3. Operational parameters

#Start up and shut down procedures
#Special instructions
#Security and access details
#Fault finding procedures
#Alarm management and data logging

3.4. Validation and commissioning

#Approved reports and data
#Relevant test protocols
#Relevant test plans
#Installed and test equipment calibration certificates
#Commissioning certificates
#Beneficial Occupation and Handover certificates

3.5. Spare parts list

3.6. Electronic Data Backup (Read only Media)

3.7. Approved “As-Built” Drawings

#Process diagrams
#Wiring Diagrams
#Control Diagrams
#System Plans
#Training records

3.8. Training Records

3.9. Training Materials

===Commissioning of ventilation systems===
4. Commissioning of ventilation and air conditioning systems shall comprise the following:

#Confirmation of accuracy of measurements.

Measurement accuracy depends on equipment accuracy and repeatability. Factors that would impact on the accuracy of measurement include:

*Operator error and competence
*Type and quality of measuring device
*Quality and adherence to measurement protocols.

4.2. Proof of competence of commissioning technician or engineer

4.3. Commissioning method statements or protocols shall be developed, recorded and adhered to, to ensure all technicians work to the same procedures and sequences. In some instances, such as healthcare units where the ventilation system is critical to that unit’s clinical outcomes or to the safety of occupants, the client or client’s representative may request that these method statements be issued for formal approval before commencement of commissioning.

4.4. As the operational parameters of variable air volume systems are more complex that constant volume systems, the designer is to provide details of all relevant aspects of these systems such that the commissioning specialist can sufficiently develop an appropriate plan the commissioning.

4.5. Preliminary inspections should be completed before the systems are started up for commissioning. Typically these inspections should include:

*The '''state of completion''' of the building and the condition of details such as openable windows, doors and ceilings.
*'''Building cleanliness''' as it pertains to the ventilated spaces as well as the equipment plant rooms.
*Ducting and ventilation components should be inspected internally and externally for '''system cleanliness.''' Prior to fitting filters the following components should be checked for completion, correctness and cleanliness:

#Air intakes screens and mixing plenums
#Heating components
#Cooling components
#Condensate and drip trays
#In duct UVGI systems
#Humidifiers
#Fan and equipment chambers including safeties and interlocks
#Sensors and gauges
#Airflow controllers and fire damper
#Filter frames and orientation thereof
#Insulation
#Ducting and air terminals

*Electrical Equipment should be inspected for completion, correctness, labelling and cleanliness. Prior to running any electrical rotating or control equipment the following check should be completed.

#Local isolators of motors, electric heaters and control circuits including labelling.
#Electrical safety
#Motor starters and frequency drives set correctly for overload and motor restart ratings.
#Direction of rotation of motors on motor shafts
#Motor starting current and sequencing

4.6. An initial running-in period should be conducted at low load before the installation of the filters. This running period is to ensure flushing of ducting, and allow checking of the system operation. During the this period the system should be shut down and restarted to ensure that the controls, fuses and switchgear function correctly; however, repeated rapid restarts should be avoided as this can over-stress the control gear and fuses.

4.7 After the initial running-in the filters can be installed by a suitably qualified technician and the system should then be run at normal load. New filters should be installed before the final proportional balancing commences.

4.8. The proportional balancing of the airflow should be delayed until the ventilation system has been run-in under normal load for a few days to ensure stability of the system. The airflow balancing should be conducted in accordance with good engineering principles such as those described in SANS 10173, the ASHRAE Fundamentals Handbook, CIBSE Commissioning Code A or BSRIA Application Guide 3/89.1 depending on the system requirements.

4.9. For variable air volume systems, the commissioning tests should demonstrate system performance across the design diversity.

4.10. A definitive total airflow measurement should be taken in either a section of the main duct, where duct length and turbulence allow, or in the branch ducts. This value shall be recorded, compared against the design values and tolerances and reported on in the commissioning reports including the percentage of the design flow rates.

4.11. The final airflow measurements shall be taken at all air terminals (supply, return and exhaust) using airflow capture hoods where the terminal generates turbulence and these values shall be recorded, compared to design values and tolerances and reported on in commissioning reports including the percentage of the design flow rates.

4.12. Direction, drop and throw of air terminals shall be assessed by the responsible engineer to confirm the correct air distribution within ventilated spaces.

4.13. The minimum outside air portion should be demonstrated and recorded across the system’s operational diversity.

4.14. A condition of system acceptance is that the commissioning tests be witnessed before signing off. This process could involve the repetition of only a selection of the tests under the observation of an authorised witness or responsible engineer. The following aspects should be demonstrated:

*Performance of the system according to the overall design requirements within specified limits
*Repeatability of performance and measurement results

==PART E - EXAMPLES==
===Mechanical system configurations===

===='''1. HOT WATER GENERATION SYSTEM'''====

[[File:Picture 1.png|thumb|570x570px|Hot water generation system|alt=|border|center]]

===='''2. THEATRE VENTILATION SYSTEMS'''====
The following examples indicate typical system configurations schematically.

2.1 UDAF Recirculation

 
[[File:Picture 2.png|border|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic|alt=|center]]

2.2. UDAF Full Fresh Air & Exhausted

[[File:Picture 3.png|center|thumb|410x410px|NOTE: Does not indicate sensors, interlocks or control logic]]
2.3. Major Theatre: Recirculation
 
[[File:Picture 4.png|center|thumb|410x410px]]

2.4. Major Theatre: Full Fresh Air Supply only
[[File:Picture 5.png|border|center|thumb|400x400px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

2.5. Minor Theatre: Recirculation
[[File:Picture 6.png|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.6. Minor Theatre: Full Fresh Air & Exhausted
[[File:Picture 7.png|border|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.7. Minor Theatre: Full Fresh Air Supply only
[[File:Picture 8.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

===='''3. AIRBORNE PRECAUTION ROOMS AND THEATRES'''====
3.1 Energy Recovery Systems for Airborne Precaution Rooms
 
[[File:Picture 9.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]
4. Energy Recovery Systems for Airborne Precaution Theatres
[[File:Picture 10.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks and control logic]]
 
==REFERENCES==
'''Applicable Regulations and Standards:'''

National Health Act 2004''.'' (61 2003). Cape Town South Africa: Government Gazette.

''Ammended Occupational Health and Safety Act 2004.'' (181 1993) South Africa: Department of Labour.

South African Bureau of Standards, 2009. ''SANS 10142-1:2008 The wiring of premises Part 1: Low-voltage installations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 10173:2003 The installation, testing and balancing of air-conditioning ductwork.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 10252-1:2012 Water supply and drainage for buildings Part 1: Water supply installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1993. ''SANS 10252-2:1993 Water supply and drainage for buildings Part 2: Drainage installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 10313: 1999 Protection of structures against lightning.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1990. ''SANS 10400-2: 1999 Code of Practice for The Application of the National Building Regulations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-1:2005 Copper-based fittings for copper tubes Part 1: Compression fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-2:2005 Copper-based fittings for copper tubes Part 2: Capillary solder fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 1091:2012 National colour standard''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1238:2005 Air-conditioning ductwork''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1409:2008 Outlet sockets and probes for medical (gas and vacuum) services used in hospitals.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1424:2008 Filters for use in air-conditioning and general ventilation.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2011. ''SANS 1453:2011 Copper Tubes for Medical Gas and Vacuum systems.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 14644-1:1999 Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-2:2003 Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-4:2003 Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1988. ''SANS 1474: 1988 Uninterruptible Power Supplies''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2009. ''SANS 7396-1:2009 Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 7396-2:2008 Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems.'' Pretoria South Africa: SABS Standards Division.

*All local Municipal laws and regulations,
*ISO 14644-3:, Cleanrooms and associated controlled environments - Part 3: Test Methods Australasian Health Infrastructure Alliance,2006. Australasian Health Facility guidelines [online] Available at: <nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> [Accesed ...].
*ISO/DIS 5359. Anaesthetic and respiratory equipment - Low-pressure hose assemblies for use with medical gases,
*National Health Act, 2004 (Act No. 61 of 2003).
*Occupational Health and Safety Act, of 1993
*Regulations of the Local Electricity Authority,
*SANS 10114: Lighting Requirements,
*SANS 10142-1: The wiring of premises Part 1: Low-voltage installations,
*SANS 10173: The installation, testing and balancing of air-conditioning ductwork,
*SANS 10224: Non-flammable medical gas pipeline,
*SANS 10252-1: Water supply and drainage for buildings Part 1: Water supply installations for buildings,
*SANS 10252-2: Water supply and drainage for buildings Part 2: Drainage installations for buildings,
*SANS 10313: 1999 Protection of structures against lightning,
*SANS 10400: Code of Practice for The Application of the National Building Regulations,
*SANS 1067: Copper-based fittings for copper tubes Part 1: Compression fittings,
*SANS 1067: Copper-based fittings for copper tubes Part 2: Capillary solder fittings,
*SANS 1091: Colour Coding of Services,
*SANS 1140: Identification colour marking Part 4: Contents of taps and valves in laboratories,
*SANS 1238: Air-conditioning ductwork,
*SANS 1409: Outlet sockets and probes for medical (gas and vacuum) services used in hospitals,
*SANS 1409: Part 3 Handling and storage of Medical Gas,
*SANS 1424: Filters for use in air-conditioning and general ventilation,
*SANS 1453: Copper Tubes for Medical Gas and Vacuum systems,
*SANS 14644-1, Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness,
*SANS 14644-2, Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1
*SANS 14644-4, Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up,
*SANS 1474: 1988 Uninterruptible Power Supplies,
*SANS 7396-1: Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum,
*SANS 7396-2: Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems,
*SANS 50081: Safety rules for the construction and installation of lifts — Particular applications for passenger and goods lifts,
*Any other applicable Laws or Regulations.

Chartered Institution of Building Services Engineers (CIBSE), 1999. Environmental design CIBSE Guide A. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2005. CIBSE Applications Manual AM10 Natural ventilation in non-domestic buildings. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2008. Lighting Guide 2: Hospitals and health care buildings. England: The Society of Light and Lighting.

 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009. ANSI/ASHRAE/ASHE Standard 170-2008 Ventilation of

Health Care Facilities. Atlanta USA:ASHRAE.

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2013. HVAC Design Manual for Hospitals and Clinics Second Edition. Atlanta USA:ASHRAE.

'''Further reading'''

*<nowiki>http://www.spaceforhealth.nhs.uk/</nowiki> (National Health Service NHS website for UK guidance) website closed now
*<nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> (Health Facility Guides website for Australasian Health Facility guidance)
*CIBSE Guide A – Environmental Design
*CIBSE Applications Manual for Natural Ventilation – AM10
*CIBSE Applications Manual for Mixed Mode Ventilation. – AM13

*CIBSE Lighting Guide 2: Hospitals and Health Care buildings
*ASHRAE 170:2008
*HVAC Design manual for Hospitals and Clinics Second Edition – ASHRAE TC 9.6, 2013
*CIBSE Commissioning Code A
*BSRIA Application Guide 3/89.1

 <references />

==LIST OF ABBREVIATIONS==
A & E- Accident and Emergency Department

AHU- Air Handling Unit

CSSD- Central Sterile Supply Department

EMS- Emergency Medical Services

HCW- High Care Ward

HEPA- High Efficiency Particulate Air (filter)

ICU- Intensive Care Unit

NBR- National Building Regulations SABS 0400

NICU- Neonatal Intensive Care Unit

OT- Operating Theatre

SABS- South African Bureau of Standards

SANS- South African National Standards

SSO- Switched Socket Outlet

UDAF- Uni-Directional Air Flow

UPS- Uninterrupted Power Supply

URS- User Requirement Specification

==LIST OF DEFINITIONS==
For the purposes of these regulations, unless the context otherwise indicates-

'''“barrier isolator”''' refers to a device comprising an physical film separating an operator or clinician from a work process. The work process is maintained within an isolated environment which may be held at a positive or negative pressure.

"'''Central Sterile Supply Department (CSSD)"''' means a facility for the receiving, decontamination, preparation, packing, sterilizing, storing and issuing of sterile and disinfected instruments and other reusable materials. This facility is also known as the "sterilisation and disinfection unit"(SDU);

"'''cleaners' room'''" means a room for the storage of cleaning equipment, the drawing of clean water and the disposal of dirty water, washing and drying of cleaning equipment. This room may be combined with the dirty utility room;

"'''clean air'''" means air that does not contain a considered contaminant;

"'''clean utility room'''" means a room for the storage of sterilized packs, dressings-, sterile equipment and pharmaceutical supplies respectively; This area may also be used for a set-up area for ward procedures;

"'''considered contaminant'''" means any actual contaminant, surface or airborne, which may have a certain impact which for which measures are taken to avoid;

'''"cross contamination"''' refers to the contamination of any zone or surface by fomites, considered particulates aerosols, biological agents, fumes or gasses originating from another zone or surface.

'''"cross infection"''' refers to the spreading of an infection from one organism to another by cross contamination.

'''"department"''' means a grouping of accommodation which has a specific function within a hospital. Its area includes the associated internal or departmental circulation space

'''"dirty utility room"''' means a room used for collection and temporary storage of used equipment and general ward material; it can combine the activities of the sluice room, the soiled linen and waste room and the cleaners' room;

'''"emergency trolley/crash cart"''' means a mobile cart used for the storage of all appropriate resuscitation equipment and pharmaceuticals;

"'''equipment store'''" means a room used for the storing of monkey chains, traction kits and other general equipment;

"'''fresh air'''" means air drawn from outside air of a building and contamination sources;

"'''high care ward'''" refers to a ward for the care and management of specific types of patients requiring a minimum of eight hours nursing care per patient day;

"'''holding area'''" means an area or room where pre-operative patients in transit to a procedure room/theatre are identified and continuously monitored by nursing personnel;

"'''induction room'''" means an area where patients are prepared for surgery/invasive procedures prior to being transferred to the operating theatre;

"'''intensive care unit'''" means a unit designed, staffed and equipped for the care and management of specific patients, (e.g. medical, cardiac or post-operative) requiring a minimum of twelve hours nursing care per patient day or for the care of a patient who requires ventilation, continuous invasive monitoring, invasive care, or who is clinically unstable and whose life is at risk;

"'''main kitchen'''" means a facility suitably finished and equipped for the receipt, storage and preparation of meals, special diets and beverages;

"'''maternity unit'''" means a unit where antenatal care is provided, babies are delivered and postnatal care is given to mothers and infants;

" '''midwife obstetric unit (MOU)'''" means a maternity unit usually attached to a clinic or a community health centre (CHC), which is staffed by nursing sisters or midwives;

“'''milk kitchen'''” means an area for the preparation of feeds for babies which must be separate from the hospital kitchen or ward kitchen. It must contain a clinical wash hand basin;

"'''mortuary'''" means a facility that receives, holds and allows for the identification of bodies of patients who died in the wards, theatre or casualty department, or who were dead on arrival at the facility; a facility which complies with the

"'''neonatal unit'''" means a facility for premature and new born babies requiring incubation, specific care and monitoring;

"'''nurse station'''" means the control point for all activities in the patient care areas;

"'''nursing unit or ward'''" means a unit with the facilities to accommodate patients as specified in this regulation;

"'''operating room'''” means a room within an operating theatre suite in which surgical or other invasive procedures are carried out;

"'''operating suite'''" refers to rooms within the demarcated area where surgical interventions are performed or support is provided to these surgical activities;

"'''patient room'''" means a room where the patient can be accommodated;

"'''procedure room'''" means a room in which certain restricted procedures generally taking less than one hour can be performed without making use of general anaesthetic, e.g. endoscopies, procedures under local anaesthetic such as suturing of lacerations, removal of skin lesions, biopsies, closed reductions and other similar procedures; May be situated outside the operating suite;

"'''recovery room/ area"''' means the section of the operating suite specially set aside for the immediate post-operative recovery, resuscitation, nursing and special care of patients, until such time as such patients are considered to have recovered sufficiently to be safely removed from the operating suite;

"'''sluice room'''” means a room used for the emptying, cleaning and storage of bedpans and urine bottles; It can be combined with the activities of the soiled linen and cleaners' rooms in the dirty utility room;

“'''specialised area'''” means any clinical area rendering specialised services such as intensive care, high care, or rehabilitation, for which additional space around the patient is required;

"'''soiled linen and waste room"''' means a room used for the collection and temporary storage of soiled linen and waste; May be combined with the dirty utility room

"'''treatment room'''" means a room used for treatment of patients in the wards, containing a clinical wash hand basin;

“'''ventilation”''' means “The process of supplying air to or removing air from a space for the purpose of controlling air contaminant levels, humidity or temperature within the space”. ASHRAE Standard 62.1-2007, Section 3

'''“validation”''' means the method of proving and documenting that an installed system or process performs reliably as intended and required.

'''“natural ventilation”''' means “Ventilation provided by thermal, wind, or diffusion effects through doors windows or other intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3

"'''ward kitchen'''” means the room that forms an integral part of a nursing unit or units, for the preparation of snacks and beverages; It also includes the area for the heating, storage and refrigeration of meals;

"'''uninterrupted power supply'''" means a battery system, which in the event of a normal mains supply failure will provide immediately the electrical supply for essential equipment and lighting.
[[Category:Crosscutting Issues]]
[[Category:Water Distributions Systems]]
[[Category:Legionella Control]]
[[Category:Ventilation]]

Building Engineering Services

2023-07-20T06:49:05Z

Tobyvan: /* 23.4. OPERATING THEATRE VENTILATION DESIGN */ Clarification that ISO 6 refers to protected ares only

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=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===

==='''Context'''===
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.

==='''Design principles'''===
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.
{| class="wikitable"
|+Table 1: IUSS document
!Clinical services
!Essential
!Recommended
!Support Services
!Essential
!Recommended
!Healthcare environment/
Crosscutting issues
!Essential
!Recommended
!Procurement &
Operation
!Essential
!Recommended
|-
|Impatient services
|
|X
|Administration & related services
|
|
|Generic room data
|X
|
|Integrated infrastructure planning
|X
|
|-
|Laboratories
|
|X
|General hospital support services
|
|
|Hospital design principles
|X
|
|Project planning & briefing
|X
|
|-
|Mental Health Services
|
|
|Catering services
|
|
|Engineering design principles
|X
|
|Space guidelines
|
|
|-
|Critical care
|
|
|Laundry and Linen
|
|
|Environment and sustainability
|X
|
|Cost Guidelines
|X
|
|-
|Emergency centres
|
|
|Mortuary
|X
|
|Materials & finishes
|X
|
|Procurement liaison
|
|
|-
|Obstetrics & gynaecology
|
|
|Nursing colleges
|
|
|Future healthcare environments
|
|X
|Commissioning
|X
|
|-
|Oncology
|
|
|Health facility residential
|
|
|Healthcare technology
|
|
|Maintenance
|X
|
|-
|Outpatient services
|
|X
|Sterile supply
|X
|
|Inclusive environments
|
|X
|Decommissioning
|X
|
|-
|Paediatrics
|
|
|Clinical training
|
|
|Infection prevention & control
|X
|
|Capacity development
|
|X
|-
|Pharmacy
|
|
|Waste disposal
|
|X
|Health informatix
|
|
|
|
|
|-
|Primary health care
|
|
|
|
|
|Regulations
|X
|
|
|
|
|-
|Diagnostic radiology
|X
|
|
|
|
|
|
|
|
|
|
|-
|Rehabilitation services
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Surgery
|X
|
|
|
|
|
|
|
|
|
|
|-
|TB
|X
|
|
|
|
|
|
|
|
|
|
|}

Where this document lacks guidance on a topic or appears to contradict the requirements of the guidelines identified above, the guidance of those documents will take priority.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
#*Summaries of collated information
#*Reports on technical feasibility, benefits and risks
#*Reports on regulatory compliance issues
#*Reports on financial feasibility and risks
#*List of consents and approvals required
#*Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

==Design Questions==
6. In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

==Design considerations==

==='''7. Deep buildings'''===

#Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

==='''8. Plant and plant room size and location'''===

#Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.
#Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities. Plant rooms shall be located away from possible heat and contamination sources.
#Plant rooms shall be located in an accessible area which is secured from unauthorized entry
#Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

==Life cycle cost determination==
9. When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

10. Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

==Site-survey requirements==
11. In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

==Maintenance Considerations==
12. Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

13. The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

14. In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.

15. For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

==Planning for Retrofitting & Decommissioning==
16. While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

17. Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

18. When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

19. A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

20. Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

21. For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

==Sustainability & Environmental Measures==
===Design Life cycle===

Sustainability in designs for new health facilities can be addressed through the following steps:

'''22. Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.

'''23. Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.

'''24. Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.

'''25. Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.

'''26. Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.

'''27. Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

28. Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''PART - DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating Ventilation and Air-conditioning===
===Airborne-Precaution Risk Classification for Healthcare Zones===
South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for out-patients is common practice in South Africa.
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo convective or buoyancy effects and wind pressure. Since the drivers of Natural ventilation are inherently variable, natural ventilation has a high variability in effectiveness.

2. In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space could have a negative impact on the variability of the ventilation system’s performance by opening and closing windows and doors. For this reason it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controllable ventilation openings be designed and created in the building

3. For additional design guidance on natural ventilation design, the CIBSE Applications Manual AM10 or similar can be consulted.

4. Peak and minimum internal temperatures should be calculated or modelled thermally for a space, for summer and wintertime respectively.

5. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

6. The following design interventions should be considered for implementation, singly or in combination, in the following hierarchy where the internal design condition cannot be met:

*Reducing solar and internal heat gains
*Using thermal mass to move room temperature extremes to outside of occupancy periods.
*Change occupancy schedules seasonally to improve indoor comfort conditions. (eg. Shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
*Introducing passive cooling or heating strategies
*Increasing ventilation rates
*Providing mechanical cooling or heating

7. Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed mode ventilation shall be considered as a solution preferred over full mechanical ventilation.

8. Mixed mode ventilation is considered as an assisted type of natural ventilation. Here fans are used in combination with damper controlled ventilation openings to ensure minimum ventilation rates are achieved.

9. Where mixed mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

[[File:NV-Decision Tree1.png|alt=NV-Decision Tree|border|frameless|800x800px]] 

===Mechanical ventilation and air-conditioning===
10. Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.

11. The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====12. Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====13. Zoning of a building=====
13.1. Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:

#Fire compartmentalization
#Air-handling unit (AHU) sizing
#Duct sizing
#Occupancy schedules
#Occupancy activity levels
#Building, environmental and equipment heat loads
#Airborne contamination control
#Tenancy, functional unit or utility metering

13.2. Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====14. Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.

=====15. Ventilation rates=====

#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant

=====16. Supply-only vs balanced ventilation systems=====

#Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

=====17. Airborne contamination-control concepts=====

#Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

#The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

#The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 
#The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 
#The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²).

17.4. Where ventilation rates and fresh air proportions are described within these guidance documents they are to serve as guidance values only. It is the responsibility of the designer to ensure that the ventilation rate selected is appropriate for the specific zone’s operational conditions, occupancy, contamination rates, pressurization, leakage rates, ventilation efficiency and external ambient conditions to achieve the desired airborne contamination and bio-burden levels. Ventilation rates higher or lower than the guidance values may achieve the desired conditions.

 

====='''18. AIR HANDLING UNITS AND FANS'''=====
18.1. GENERAL

#AHUs and fans shall be protected from adverse weather and wind sources which may upset their performance or reliability.
#A detailed name plate shall be included on the air handling units with manufacturer, design air volume, fan speed, cooling capacity, filter data and heating capacity.
#The air handling unit shall include individual differential pressure gauges over each installed filter bank. The gauges shall measure the pressure differential between upstream and downstream of the filter banks. The filter designation and design filter change pressure shall be neatly and clearly marked on each gauge.
#Air-handling units functioning in an airborne contamination control system, and demanding prescribed airflow rates, shall be provided with an electronic control system including variable frequency controllers with direct fan drives to automatically maintain design airflow for all filter conditions. The fans and drives will be selected to maintain design flow rates with all filters at maximum rated pressures.
#Where a ventilation system performs a critical role, air handling units shall have separate electrical distribution boards (Essential and Non-essential). The fan will be on essential power and heater elements may be on non-essential power.
#All compartment doors on the air handling unit shall be clearly labelled
#Where systems require duplicate standby fans or air-handling units these shall be installed with backdraught dampers, sufficiently air-tight for the application (eg EN1751 Cat 3 or 4). Special design and control consideration shall be given to limiting the build-up and dwelling of contaminants in the standby unit.
#AHU’s should be placed in easily accessible plant rooms with sufficient space for maintenance. Access stairs to the plant rooms should permit a technician to easily carry replacement parts or a toolbox into the plant.AHU’s located in ceiling voids are not appropriate or conducive to good operational management.
#AHUs should be designed for a working life of 20 - 25 years
#AHUs shall be designed and positioned such that the largest components, including heating and cooling coils, can be removed and replaced.
#AHUs greater than 1m wide should have hinged access doors large enough to provide full entry. Doors shall be unlockable and openable from the inside of the unit.
#Fan and filter plenums shall be provided with internal illumination and viewing portals such that internal components can be visually inspected without stopping or opening the unit.
#AHUs shall be designed such that dry steam humidification devices can be retrofitted into the systems with minimal disruption and without compromising its performance.
#Ventilation components shall have a drainage or condensate pumping system if they can produce moisture. Drip trays shall be of a corrosion resistant material and drainage systems shall have a 1:20 fall away from the unit in all directions. The unit shall have its own drain trap which shall be sized such that it can function at the fan's full static pressure. The first 3 meters of a dedicated condensate drainage line shall be insulated to prevent condensation within the plantroom. Where a condensate drain services a negative pressure plenum, clear air gaps of 15mm or anti-backflow devices are recommended at the trap discharge into the drainage system.
#Drop stop eliminators in stainless steel frames shall be employed, if fin spacing is less than 10 fins per inch, after the cooling coils in areas with high humidity levels. This includes all coastal areas for off coil temperatures of 10° and less
#In full fresh air systems, primary filters may be situated at the fresh air intake opening of the air-handling unit only if the climate does not require anti-fog or de-icing coils.
#Cooling or heating coils will be protected by a pleated primary filter, rated in accordance with SANS 1424, as minimum.
#In recirculation air systems, primary filters will be situated after the fresh/return air mixing plenum. This arrangement will ensure that blinding filters don’t inhibit the prescribed fresh air proportion.
#The final stage of filters on units serving operating theatres must be located after the supply fan chamber to filter any debris that might come from the fan chamber. HEPA filters should be protected from this potential dust and debris.

 

=====18.2. AIR EXTRACTION SYSTEMS=====

#The design of exhaust systems shall take special consideration of the potential for re-entrainment of contaminated exhaust air into air intakes through, inter alia, openable windows. Where this potential exists, precautionary measures such as aerosol or chemical filtration of exhaust should be applied, as appropriate.
#Single ablution facilities serving private wards or staff do not require extract ventilation, provided there are windows openable to outside.
#Extract ventilation shall be provided by either ceiling extract grilles connected to an in-line ducted fan with outside discharge air grilles by means of galvanized mild steel or PVC tubular ducting or odour extraction system.
#Extract grilles may be of the PVC type with adjustable disc valves, or powder coated or anodized aluminium type with adjustable dampers.
#All multiple toilets shall be provided with ventilation systems, which will serve as an extract ventilation system.
#Single toilet facilities serving private wards for staff do not require extract ventilation, provided there are windows openable to outside
#Where it is not considered safe to enter a space without respiratory protection, the air exhausted from that space should be rendered safe through filtration, decontamination or dilution before discharge.
#The design of exhaust system from airborne precaution areas should be such that all components can be safely maintained during normal service and safely disposed of at decommissioning.
#Planning for disposal of contaminated filters should be as for all biohazardous material.
#Filtration and decontamination components shall be installed upstream of fans, monitoring and control devices.

=====18.3. ENERGY RECOVERY SYSTEMS=====
1.3.1. Where full or partial exhaust is required for ventilation systems, energy recovery technologies should be considered. Enthalpy wheels offer a high level of efficiency but introduce a risk of cross infection as the wheel is exposed to both the exhaust and supply airstreams. An enthalpy or energy recovery wheel may only be used if pressure and filtration measures are taken to ensure it is not a potential source of cross infection or re-infection. Energy recovery wheels incorporating purge sections have a markedly reduced efficiency and are not considered to provide sufficient protection against biological cross contamination. Where cross infection is a considered risk, the following conditions shall be met.

#The exhaust airstream shall be consistently maintained at a lower static pressure than that of the supply airstream.
#The exhaust air shall be filtered with aerosol filters upstream of the energy recovery device.
#Levels of filtration, redundancy and safety shall meet the requirements of the biological pathogenicity class in consideration.

=====19. '''FILTRATION'''=====

#With the exception of the few specialist areas with aero-biological requirements, the primary purpose of filtration is to protect ventilated spaces and ventilation equipment from dust build-up.
#When designing filtration systems serving spaces with a high airborne cross contamination risk, consideration should be given to the safety of maintenance staff that may be required to handle contaminated filters. Where any safety risk is present, contaminated filters should be installed in safe-change or decontaminatable housings.
#All ventilation filter banks should be installed with a means of visually checking the filter pressure across them in Pascals (Pa)
#Filters are classified as being General Fine or Aerosol filters and are to be specified in accordance with the SANS 1424, EN779 or EN1822.
#General filters are selected to remove particles large enough to block cooling and heater fins and settle out of the airstream into the air distribution system. General filters are graded in terms of their “synthetic dust weight arrestance”. General filter grading ranges from G1 to G4. G3 and G4 filters are appropriate for primary air intake and tempered air supply respectively. General filters are not appropriate for combating airborne cross-contamination control.
#Fine filters are selected to keep a ventilated space visibly clean and for the protection of HEPA filters. Fine filters are graded in terms of their “Dust Spot Efficiency” from M5 to F9. F9 filters are capable of arresting particles with the approximate size of some bacteria and can be used for low level cleanrooms (ISO 14644-1 Class 8).
#Aerosol filters are selected for their efficiency in arresting sub-micron particles. They are graded in accordance with their “Most Penetrating Particle Size” (MPPS). Aerosol filters are subdivided into three categories: Efficient Particulate Air (EPA) and High Efficiency Particulate Air (HEPA) and Ultra high Particulate Air (ULPA) Filters in accordance with the EN1822:2009. The table below describes the classification of aerosol filters by integral and local values as defined in the EN1822. SULPA filters are not discussed within this document.

{| class="wikitable"
|+{{Anchor|Table_Filter_Classification}}'''Filtration Classification'''
| rowspan="2" |'''Group'''
| rowspan="2" |'''Filter Class'''

'''EN1822'''
|'''Integral Value'''
|'''Local Value'''
|-
|'''Efficiency %'''
|'''Efficiency %'''
|-
| rowspan="3" |'''EPA'''
|'''E10'''
|85%
|<nowiki>-</nowiki>
|-
|'''E11'''
|95%
|<nowiki>-</nowiki>
|-
|'''E12'''
|99.5%
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''HEPA'''
|'''H13'''
|99.95%
|99.75%
|-
|'''H14'''
|99.995%
|99.975%
|-
| rowspan="3" |'''ULPA'''
|'''U15'''
|99.9995%
|99.9975%
|-
|'''U16'''
|99.99995%
|99.99975%
|-
|'''U17'''
|99.999995%
|99.999975%
|}
8. HEPA filter installations shall include both an upstream challenge aerosol injection port and a downstream scan port to facilitate filter challenge testing. ULPA filter installations shall be designed such that an agreed upon test method can be accomplished.

9. All filters used for airborne precaution rooms, theatres or other areas with a high airborne contamination risk shall be selected with a construction suitable for incineration. These filters shall not contain PVC.

10. The installation and testing of HEPA filters shall only be conducted by suitably qualified technicians.

11. HEPA filters shall be specified to be compliant with the requirements of EN1822. Each HEPA filter is to be supplied with an individual factory test certificate displaying that filter's serial number, MPPS rating and DOP arrestance rating.

12. Type-test certificates are only acceptable for EPA and not HEPA filters.
 

=====20. '''HEAT REJECTION EQUIPMENT.'''=====
20.1. The location of heat rejection equipment shall be planned such that it does not adversely affect the performance, maintenance or reliability of any related or unrelated equipment, or pose an avoidable health risk.

20.2. The use of evaporative cooling towers shall only be considered where:

#Space, system capacity or efficiency demands their use.
#An effective plan for the [[Legionella Control|control of legionella]] must be developed and implemented.

 

=====21. '''AIR DISTRIBUTION SYSTEMS'''=====

#Discharge from extraction systems shall be located such that contaminated air does not get drawn into any system's air intake of get re-entrained though openable windows.
#The use of internally insulated ducting is not appropriate as internal linings will perish and slough off with aging. Particles from duct linings contaminate final filters and ducting components.
#Flexible ductwork is unsuitable for air distribution in healthcare applications. It should only be used for the final connection to an air terminal and then kept to less than 1.0m. Bends in flexible ductwork should be avoided.
#The use of dampers to throttle a deliberate oversupply of airflow should be avoided. Balance by design is preferable although this will not necessarily reduce the total fan pressure. Use of adjustable blade dampers should be kept to a minimum as these items may drift, can be tampered with and increase the complexity of commissioning. The use of constant volume dampers may improve stability of volume critical systems but may also mask inefficient design and be the source of increased system noise.
#Cleaning and access doors are to be installed in all air distribution ductwork to facilitate:

*Cleaning
*Inspection
*Measurement
*Maintenance

21.6. Ductwork installations shall be designed, built, installed and commissioned in accordance with SANS 1238: Air-conditioning ductwork and SANS 10173: The installation, testing and balancing of air-conditioning ductwork
 

=====22. '''ELECTRONIC CONTROLS'''=====

#Location of sensors in ventilation systems should ensure that the temperature and humidity measurement for monitoring control is representative of the occupied area
#The humidifier control will include humidity monitoring of the mixed airstream downstream of the humidifier lance and shall prevent this airstream from approaching dew point.
#The use of variable speed drives (VSD) can save energy in systems operating under varying motor loads. Reducing the fan speed when filters are new or clean can result in considerable energy savings over the life of a system. Reliability of smaller sized VSDs is a potential drawback, and for this reason VSDs must be selected and sized for high service life. VSDs should also be installed such they can be bypassed and the system can be run in manual control while failed VSDs are replaced or repaired. When designing with variable speed drives, cognisance should be taken of a motor’s minimum cooling requirements and the maximum restart rate. Caution should be exercised where variable speed drives are used in conjunction with constant volume dampers or volume flow controllers. This combination could drive up total system pressure where duct total pressure as opposed to velocity pressure is used as control feedback. Additional requirements for the selection of drives for variable air volume (VAV) fans is described in SAN204:2011
#Plant control systems should incorporate start-up and shut-down sequencing logic to prevent flow reversals and overheating.
#Set-back controls should be considered for spaces that have intermittent occupancy. This feature should be used with caution in specialist areas as poorly considered set-back conditions could compromise containment or contamination control.
#Where more than one ventilation system serves a department, system interlocks may be required to prevent unwanted airflow reversals during system shutdown or failure.
#Operational status indicators should be displayed locally in areas served by ventilation systems.
#"Low Air Flow" and "Plant Failure" alarms should also be installed in a location which can be manned by relevant and trained staff.
#Electronic control systems should be developed using recognised open protocols and standards such as BACnet DeviceNet, LonWorks, Modbus, SOAP and XML.

=====23. '''SPECIALIST VENTILATION SYSTEMS'''=====
23.1. The following areas will require specialist ventilation systems:
 
'''Table''' '''3 Specialist Ventilation Systems'''
{| class="wikitable"
|'''Department Name'''
|'''Ventilation system type'''
|-
|Operating departments
|Clean and Ultra clean ventilation systems: ISO8 to ISO5 & UDAF
|-
|Obstetrics
|Clean ventilation systems ISO8
|-
|High care, Critical Care and Intensive Care
|Fine filtered ventilation or Clean ventilation systems: Unclassified - ISO8
|-
|Isolation units
|Negative pressure ventilation, no recirculation
|-
|Pathology labs
|Biosafety ventilation: (BSL2 – BSL4)
|-
|IVF Labs
|Clean ventilation systems: VOC Filtration
|-
|Burns units
|Clean ventilation systems/ Negative pressure ventilation/ RH control
|-
|Neonatal Units
|Dedicated ventilation systems/ RH control
|-
|Mortuary unit
|Cold Rooms/ Extraction systems/ Odour Control
|}
23.2. Broad requirements for these systems are in this document. The engineering team shall consult each department’s specific design guidance document for detailed requirements.
 

=====23.3. '''AIRBORNE PRECAUTION ROOMS (INCLUDING TB)'''=====

#Where specific diseases are considered in the design of an airborne precaution room, the US CDC's "Select Agent List" may be consulted for design guidance until a South African list is compiled.
#Airborne precaution rooms shall be ventilated with a minimum of 12AC/h of fresh air or uncontaminated air. High risk areas such as sputum booths and airborne diseases wards shall have a nominal ventilation rate of 80 ℓ/s per person..
#Medium Risk areas such as congregate spaces such as waiting areas shall have a nominal ventilation rate of 60ℓ/s per person.
#Mechanical ventilation may be employed to achieve the minimum ventilation rates. It should be noted that very high ventilation rates can be achieved by employing a well-considered natural ventilation design. Consideration may also be given to mixed mode ventilation systems, which combine mechanical and passive ventilation and temperature control. An open window policy may therefore be adopted, with careful consideration of all the associated cross infection risks and management challenges.
#Airborne precaution rooms shall be designed so as to provide thermal comfort. Where occupants have freedom in location and dress code, an adaptive thermal comfort model should be adopted. Heating, cooling and energy recovery devices shall pose no risk of harbouring pathogens or increasing the cross infection risk.
#Air from the airborne precaution rooms shall not flow into adjacent, uncontaminated rooms or adjacent airborne precaution rooms. Air shall not flow from a room with a higher airborne infection risk category to a room with a lower risk category.
#Ventilation ducting and pipe work shall not form a conduit by which pathogens can transfer from one zone to another whether the ventilation system is running or not. Filtration devices and anti-backflow devices may be employed provided these do not pose a risk of infection to maintenance staff.
#Filtration requirements for supply and exhaust air should follow the bio-containment requirements of that select agent being contained.
#The location of supply and air terminals should be such that the airflow patterns generated within the room serve to suppress and remove airborne particles.
#For general waiting areas or where the pathogens are known and unlikely to pose an environmental risk, exhaust air filtration may not be required provided exhausted air is directed 3m away from open-able windows and air intakes and there is no risk of re-entrainment of this air. See section 18.2.
#Commissioning and validation shall be well planned, diligently executed, fully documented and approved by suitably experienced professionals. It is advisable to have the validation process conducted or approved by a party independent of the designer and installer.
#Numerical or physical modelling may be of value in the design and validation process.

 

=====23.4. '''OPERATING THEATRE VENTILATION DESIGN'''=====
23.4.1. GENERAL REQUIREMENTS

#Constant volume systems shall be employed to maintain the correct pressure with respect to any adjoining rooms. The contamination control concept shall be developed in accordance with ISO14644-4
#Temperature range shall generally be 18°C to 24°C with a minimum relative humidity of 45% unless otherwise specified
#A pressure differential of 10-15Pa is to be maintained between the theatre and adjacent rooms when all doors are closed.
#Theatres may be maintained at a room pressure positive or negative to the adjacent rooms depending on the contamination control requirements.
#A theatre’s room pressure shall always be positive relative to technical spaces.
#Negative pressure theatres should not employ recirculation of room air.
#Fresh air requirements are 5-7 Air Changes per hour to satisfy the occupancy requirements
#Additional fresh air may be required for pressurisation and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurisation at the greatest possible energy efficiency.
#Separate temperature controls in each theatre are to be provided.
#No manual on and off switching of air handling plant to be done from within the theatres.
#Automatic motion sensors / thermal sensors to ensure that the units are switched on when there is a presence in the theatre. Theatre ventilation switching may be linked to the theatre unit’s lights.
#Automatic switching of ventilation system to incorporate run-on timers to prevent overheating and accidental shutdown.
#An additional override to be used to switch the units on when the temperature in the theatre exceeds 25°C for the protection of stored medicine
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums.
#These validation tests shall be performed in accordance with SANS 14644Parts 1, 2 and 3 at the recommended intervals (SANS 14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#No internal ducting insulation is permitted.
#In multi theatre suites it is advisable to have dedicated AHUs per theatre. [[Building Engineering Services#%20msocom%201|[TR1]]]

23.4.2. UNIDIRECTIONAL AIRFLOW OR ULTRACLEAN THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 5 under protected zones (UDAF and Setup area) and ISO 14644-1 Class 6 in background and ancillary areas. These conditions are to be achieved under operational conditions.
#Temperature range shall generally be 18°C to 24°C and relative humidity 45% to 60% unless otherwise specified
#Ultra-clean theatre ventilation shall not be completely shut down when unoccupied unless required for maintenance interventions. Ventilation systems serving UDAF plenums shall instead switch to a minimum velocity set-back mode to prevent contaminants settling underneath the UDAF screens.
#Delivery of the conditioned air shall be by downward movement from the ceiling to four low level exhaust outlets located near the corners.
#All ductwork between HEPA filter housings and air terminals shall be high pressure rated and constructed of galvanised sheet metal. In the final connection to the terminal, where alignment necessitates, a maximum of 300mm of thermally insulated, high pressure flexible ducting may be used.
#The Air Conditioning system is to be complete with G4 primary, F9 secondary and H13 HEPA Filters.
#The ventilation systems shall be designed with a mean air velocity of between 0.35 & 0.45 m/sec measured below the UDAF screen and at the working height.
#Refer to ISO14644-4 for guideline ventilation rates for balance of areas.
#The mean velocities below the UDAF screen and at the working height shall not differ by more than ±10%
#A standard size of the UDAF screen is 2400 x 2400mm. The required size could vary dependent on the layout and function of the operating theatre.
#The protected zone below the UDAF plenum shall be clearly demarcated on the floor

23.4.3 CLEAN OR MAJOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 6 in all protected areas and Class 7 in backround areas. These conditions are to be achieved under operational conditions.
#The ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#The conditioned air is to be introduced into the theatre via suitable diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#Additional fresh air may be required for pressurization and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurization at the greatest possible energy efficiency.
#These validation tests shall be performed in accordance with SANS 14644 Parts 1, 2 and 3 at the recommended intervals (ISO14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.

23.4.4. MINOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 8 in all areas. These conditions are to be achieved under operational conditions.
#For recirculation systems the ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#For single pass systems the ventilation system is to include G4 Primary and F9 Secondary filters.
#The conditioned air is to be introduced into the theatre via suitably sized diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums. 

====='''VALIDATION OF SPECIALIST VENTILATION SYSTEMS'''=====

#Validation testing shall be completed in accordance with national standards for standardized tests (eg ISO14644 and ISO 14698 for cleanrooms) and shall be completed against mutually agreed protocols for non-standard tests.
#It essential that the validation testing of a ventilation system’s contamination control performance parameters is conducted against operational, and not only "at-rest", conditions. Validation against "as-built" conditions offers little insight into the ultimate performance of the system.
#Pre-Commissioning Checks shall cover the following aspects prior to the commencement of formal commissioning:
##Check whether the Design Specification satisfactorily addresses the demands of the User Requirement Specification.
##Check whether the ventilation systems have been provided and installed in accordance with the design specifications and drawings
##Check that the buildings either housing or served by the ventilation equipment is complete and finished such that testing can commence safely and effectively.
##Check that all AHUs, chillers, heat rejection equipment and filters are sufficiently accessible for inspection and maintenance.
##All components are connected and are functional
##Door gaps and openings are installed and sized as specified in specialised zones
##Airflow control devices are installed in the correct locations and in the correct orientation
##Duct and filter tests ports are installed and sealed satisfactorily
##Safety and control interlocks are established
##Fan and drive guards are in place
##Safety and warning signs are in place
##All major system components or sub-systems are clearly labelled with functional or controls identification in a neat and durable fashion.
##Fluid and air pressure monitoring gauges are labelled with identification and acceptable maximum and minimum operating conditions.
##All wiring, piping and ducting colour banding is complete in accordance with SANS-1091
#CLEANLINESS CHECKS:
##AHUs shall be checked for cleanliness on internal plenums with special attention being paid to fan and discharge plenums and condensate drip trays and drain lines.
##Ducting serving “clean” areas shall be cleaned prior to installation and the ends shall be sealed until installation. Open ends of duct runs shall similarly remain sealed during construction. Spot checks for compliance during the installation process are recommended.
#Recommended Filtration Levels and Ventilation Rates for Mechanically Ventilated Areas

This table serves as a quick reference guide and will be revised as and when detailed room data sheets are developed within each department’s guidance documents.
{| class="wikitable"
|+{{Anchor|Table_Room Ventilation Requirements}}'''Room Ventilation Requirements'''
| rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation'''[[Building Engineering Services#BESftn1|[1]]]

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range'''[[Building Engineering Services#BESftn2|[2]]]'''
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|Casualty/Minor Stitch Procedure room
|X
|
|X
|
|T
|
|
|7.5
|20
|
|-
|Theatres: Maternity/Caesarean
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: General Surgery
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Gynaecology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Ophthalmology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Urology
|X
|
|X
|'''X**'''
|T
|NA
|7
|10
|20
|
|-
|Theatres: Endoscopy
|X
|
|X
|'''X**'''
|T
|NA
|7
|80
|20
|
|-
|Theatres: Plastic Surgery
|X
|
|X
|X
|T
|6
|7
|7.5
|70***
|
|-
|Theatres: Bone Surgery/Orthopaedic
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Thoracic
|X
|
|X
|X
|M
|5
|7
|80
|70
|
|-
|Theatres: Vascular???
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Neuro Surgery
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Waiting and Congregate Areas
|X
|
|
|
|
|
|
|60
|8
|18-28
|-
|Auditoriums
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Mortuary
|X
|X
|
|
|
|
|
|
|12
|22-25
|-
|Bath Room
|
|
|
|
|
|
|
|25
|10
|N/A
|-
|Dirty Utility Room
|
|
|
|
|
|
|
|40
|10
|N/A
|-
|Blood Bank
|X
|
|
|
|
|
|
|
|4
|22-25
|-
|Casualty
|X
|X
|
|
|
|
|
|7.5
|12
|22-25
|-
|CSSD
|X
|X
|
|X
|
|
|
|7.5
|20
|22-25
|-
|Dark Room
|X
|
|
|
|
|
|
|
|10
|22-25
|-
|Dining Rooms/Canteens
|X
|
|
|
|
|
|
|7.5
|10
|18-28
|-
|General Stores
|X
|
|
|
|
|
|
|
|4
|N/A
|-
|Laboratories
|X
|X
|
|
|
|
|
|
|6
|22-24[<nowiki/>[[Building Engineering Services#BESftn3|3]]]<nowiki/>
|-
|Labour/Delivery Room
|X
|
|
|
|
|
|
|
|4
|22-24
|-
|Laundry – General
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Lecture Halls
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Outpatients Departments
|X
|
|
|
|
|
|
|60
|4
|18-28
|-
|Pharmacy Dispensing
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Pharmacy Store
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Specialist Clinics- ENT
|X
|X
|
|
|
|
|
|7.5
|4
|22-26
|-
|Sterilizer Equipment
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Toilet Room
|
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Units: Treatment Room
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|-
|Units: Burns
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|-
|Units: HCU / CCU
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU Neonatal
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|-
|Wards: General
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|-
|Wards: Airborne Precaution Rooms/Isolation'''[[Building Engineering Services#BESftn4|[4]]]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|-
|Wards: Maternity
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Medical
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Paediatric
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|-
|Wards: Psychiatric
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|-
|Wards: Orthopaedic
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: Surgical
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: TB
|X
|
|
|
|
|
|
|80
|12
|20-28
|-
|Radiology: General
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|-
|Radiology: Airborne Precaution
|X
|
|X
|
|
|
|
|60
|6
|22-24
|-
|Radiology: MR/CT

Scanner
|
|
|
|
|
|
|
|60
|6
|2-24
|}
{{Anchor|BESftn1}}[[Building Engineering Services#%20ftnref1|[1]]] These rates are considered for forced ventilation systems only. Average natural ventilation rates may be higher

{{Anchor|BESftn2}}[[Building Engineering Services#%20ftnref2|[2]]] Temperature range not to be exceeded for more than 50 hours per year.

{{Anchor|BESftn3}}[[Building Engineering Services#%20ftnref1|[3]]] Specialist cleanrooms and laboratories may require lower temperatures.

{{Anchor|BESftn4}}[[Building Engineering Services#%20ftnref1|[4]]] Levels of filtration are dependent on pathogenicity. Exhaust filtration may also be required.

======Commissioning tests shall include and record, but not be limited to:======
{| class="wikitable"
|'''System'''
|'''Commissioning Test'''
|'''Special Instructions'''
|-
|'''All'''
|Standard of installation
|Test to be authorised by client's representative.
|-
| rowspan="7" |'''Air Handling Units and Fans'''
|Fan motor drive speed and rotation.
|Cognisance should be taken of motor cooling requirements
|-
|Fan motor current draw.
|<nowiki>-</nowiki>
|-
|HEPA Filter challenge testing.
|In accordance with ISO DIS 14644-3
|-
|AHU heating and cooling coil performance
|Report on-coil and off-coil air conditions for full heating and full cooling with no air bypass.
|-
|AHU leakage tests
|<nowiki>-</nowiki>
|-
|Heating and Chilled Water circuits have been charged, dosed and pressure tested
|<nowiki>-</nowiki>
|-
|Flow rates and pressures across heat exchangers, pumps and compressors
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="2" |'''Room conditions'''
|Airflow and room pressure balancing in accordance with design tolerances.
|In accordance with ISO DIS 14644-3 Acceptance criteria Normally +10-0%
|-
|Room Temperature and humidity
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''Air Distribution systems'''
|Dampers and registers shall be locked and marked after balancing
|<nowiki>-</nowiki>
|-
|Duct leakage tests for medium and high pressure ducting in accordance with SANS 10173 or DW/143 requirements, as agreed upon
|<nowiki>-</nowiki>
|-
|'''Water Distribution Systems'''
|Pressure Drops and Flow Rates
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="4" |'''Control System'''
|Control system loop and function checks
|<nowiki>-</nowiki>
|-
|Alarm Checks
|<nowiki>-</nowiki>
|-
|System Start/Stop sequencing checks
|<nowiki>-</nowiki>
|-
|System Set-Back mode checks
|Include room condition and contiguous system impacts
|}

24.7. Select validation tests shall be conducted at intervals defined by the client:
 
{| class="wikitable"
|'''Tests'''
|'''Required/ Optional'''
|'''Recommended Frequency of testing'''
|'''At-Rest or In-Operation Testing'''
|-
|'''Airflow volume tests'''
|Required
|12 months
|At-Rest
|-
|'''Airflow visualization'''

'''(Airborne precaution rooms)'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Velocity Tests'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Airflow Visualisation'''
|Required
|6 Months
|At-Rest & In-Operation
|-
|'''Room pressure tests'''
|Optional
|3 Months
|At-Rest & In-Operation
|-
|'''Airflow direction tests'''
|Required
|1 Month
|At-Rest & In-Operation
|-
|'''Discreet practice counts'''
|Required
|12 Months
|In-Operation
|-
|'''Bio-burden testing'''
|Required
|1 Month
|At-Rest
|-
|'''Filter challenge testing'''
|Optional/Recommended
|24 Months
|At-Rest
|-
|'''Room Condition recovery'''
|Required
|24 Months
|In Operation
|}
24.8. Prescribed validation reports shall include:

*References to the test protocol
*Acceptance criteria
*Test results
*Test equipment identification and calibration status
*Name and signature of tester
*Name and signature of facility representative
*Dates of test and acceptance by client

===Medical gas installations===
25. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

26. All units of a health establishment, except sub-acute and hospice facilities, where patients are accommodated and treated, must have medial gases and vacuum provided by medical grade piped services, with indexed terminal connecter points. Bottle systems may be provided in sub-acute and outpatient facilities.

27. Mobile gas services must be available for crisis situations.

28. Sub-acute facilities must have one mobile oxygen cylinder per 10 patients and one suction machine for every 10 patients.

29. The minimum services to be supplied to all Acute Care areas are described in Table 11.1. Should the data in this table be in conflict be the table presented in the individual departmental design guidance documents, those individual guidance documents take precedence.
{| class="wikitable"
|+Table 5 Minimum gas services
!'''Description'''
!
!'''Oxygen'''
!'''HP Air'''
!'''LP Air'''
!'''N2O'''
!'''VAC'''
!'''Scavenging'''
|-
|'''Major Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Minor Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Cath Lab8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|1
|
|
|1
|1
|1
|-
|'''Post Op'''
|'''Bedhead'''
'''Trunking'''
|1
|
|1
|
|1
|
|-
|'''Procedure'''
'''Room'''
|'''Theatre Panel'''
|1
|
|1
|
|2
|
|-
|'''Resuscitation Bay'''
|
|1
|
|1
|
|2
|
|-
|'''Delivery Room'''
|
|2
|
|1
|
|2
|
|-
|'''High Care Unit, Per Bed'''
|
|1
|
|1
|
|2
|
|-
|'''Intensive Care Unit Per Bed'''
|
|2
|
|2
|
|2
|
|-
|'''Casualty Per Bed'''
|
|1
|
|1
|
|1
|
|-
|'''Wards'''
|
|'''1 per'''
'''2 beds'''
|
|
|
|'''1 per'''
'''2 beds'''
|
|}
30. A gas alarm system to monitor gases, excluding scavenging, must be installed in a location that is manned 24 hours per day. A slave panel must also be installed in the intensive care unit and in the theatre complex. This alarm system must be connected to UPS.

31. All piped vacuum and oxygen systems must have mobile back-up systems with adequately trained staff to handle them. . The back-up service shall be automatically activated if the line pressure drops below the set operating pressure. All back-up services and change-over valves shall be on UPS and diesel generator supplies.

32. Medical air (low pressure) for respiratory purposes must be provided at a fixed pipeline pressure of 400 kPa. Medical air (high pressure) for driving surgical power tools must be provided at a terminal usage pressure between 70 0kPa and 1000 kPa, depending on the tools/equipment to be used. ICU and operating rooms must be provided with a back-up system for both low and high pressure service. Air compressors must be fed off standby power supply.

33. Anaesthetic gas scavenging, which is a low-pressure suction system that removes exhaled anaesthetic gases from the patient circuit must be provided. Each outlet point must have its own balancing valve to allow the system to be balanced progressively from the furthest outlet point towards the suction fan or pump.

34. The vacuum installation shall comply with SANS 7396-1. Vacuum liquid bottle traps must be installed to collect any blood/fluid etc. that may be drawn into the pipeline. One bottle trap per operating room, ICU, ward block and other patient unit, must be supplied. Where possible the vacuum trap should be located in a sluice room. Emergency suction facilities must be provided in the ICU and High Care, operating rooms, recovery room, delivery room, emergency unit and nursery, and must be available to all patient rooms. Bacteria filters must be installed in the vacuum main before the vacuum reservoir and pumps. Used filters are considered a bio-hazard and must be handled accordingly when being changed and disposed. Care must be given to the location of the exhaust discharge of vacuum plants taking into account locations of windows and other air inlet points. Vacuum pumps must be fed off standby power supply.

35. Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.

36. Gas service outlets to be identified and colour-coded with 3mm lettering.

37. Should compressed air operated autoclaves be employed, High Pressure medical air may be taken to such equipment, provided the system possesses sufficient capacity.

38. Should pendants requiring compressed air for aid of movement be employed, High Pressure Medical Air may be taken to them, provided the system possesses sufficient capacity.

39. Should Health Technology Workshops require medical gas outlets for testing and servicing of medical equipment, the required service may be taken to them, provided the system possesses sufficient capacity.

40. SANS 7396-1, as amended, specifies the requirements from design to commissioning of medical gas and vacuum systems

41. Medical gas and vacuum pipelines shall be marked in accordance with SANS 7396-1 and ISO 5359 as applicable

42. SANS 7396-2, as amended, specifies the requirements from design to commissioning of anaesthetic gas scavenging disposal systems.

43. Colour coding of anaesthetic gas scavenging disposal system shall be red magenta or in accordance with the national standard. An example of red magenta is 3050-R40B, in accordance with SS 01 91 02.(Refer to SANS 73962-2).

44. Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.

45. SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.

46. Plain ended copper tubing for low pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.

47. Laboratory gas taps and valves shall be marked as described in SANS 10140-4

===Electrical installations===

====48. Lighting in Hospitals ====
48.1. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

48.2. Within the available scope presented in the National Building Regulations, the following lighting requirements should be interpreted with the aim of maximum energy and cost efficiency. The following innovations could be adopted to achieve this aim:

#Daylight harvesting with passive building elements and active systems response.
#Adoption of task lighting, where appropriate, within the scope of present and future planned activities.
#Considered selection of lighting elements and solutions.
#Considered selection of internal colours and materials.
#Accommodation for visually impaired occupants.

48.3. Where a requirement for natural light (daylight) is stated, this may be met if the room opens onto an atrium or courtyard, or if a roof light is incorporated, provided that privacy within the room or space is maintained. In addition, daylight may be borrowed from an adjacent room by means of glazing the wall in between, provided that the adjacent room or corridor is within the same unit.

48.4. Save where otherwise provided for in the requirements, health establishments must comply with the following: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table 6 Levels of Indoor Lighting (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings)'''
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''

'''/ lux'''
|'''Max. point illuminance/ lux'''

'''(not to be exceeded)'''
|'''Unified'''

'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''

'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Common areas'''

- changing room

- chapel

- classroom

- consulting room (general)

- care room (deep plan)

- day room

- disposal (clinical, domestic waste)

- doctor’s office

- domestic services room

- drug store (ITU/HDO)

- general office

- seminar room

- seminar room

- staff change

- staff rest room

- utility room (clean)

- utility room (dirty)
 
|

100-150

100-150

300

300

300

200

200

500

100

500

300

100-150

300

100

50/200

150

200
 
|

n/a

n/a

520

520

520

350

350

850

170

850

520

n/a

520

170

n/a

260

350
 
|

22

22

19

19

19

22

22

19

19

19

19

19

19

22

22

19

22
 
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

90

80

80
 
|

Floor

Pews

Desk

Work Surface

Work Surface

Work Surface

Floor

Desk

Floor

Desk

Desk

Floor

Work Surface

Floor

Work Surface

Work Surface

Work Surface
 
|

Normal

Normal

Normal

Normal

-

-

Normal

Normal

Normal

Normal

Normal

Normal

Selective

Normal

-

Normal

N
 
|

-

-

-

>30%

-

-

-

>30%

-

>30%

>30%

-

>30%

-

-

>30%

>30%
 
|-
|'''Corridors (screened from bed bays)'''

- by day

- by night
 
|

200

5-10
 
|

350

n/a
 
|

22

22
 
|

80

80
 
|

Floor

Floor
 
|

S

Normal
 
|

>30%

>30%
 
|-
|'''Circulation/communal areas'''

- corridors (general)

- day room

- entrance canopy

- entrance lobby

- hairdressing salon

- hospital street

- library

- lift car

- lift lobby

- loading bay

- reception area

- relatives overnight

- rest area

- shop/kiosk

- storage (general)

- toilets
|

200

200

n/a

n/a

300

200

300

150

200(min)

100

300

150

150

300

200

200
|

350

350

n/a

n/a

520

350

520

260

n/a

170

520

260

260

520

350

n/a
|

19

-

-

22

-

19

19

-

19

22

19

-

19

-

22

22
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80
|

Floor

Floor

Road surface

Floor

Chair

Floor

Desk

Floor

Floor

Platform or floor

Floor

Work Surface

Floor

Counter

Floor

Floor
|

Normal

S

Selective

Selective

Normal

N/EM

Normal

Sp

Selective

Normal

Normal

Normal

Normal

Normal

Normal

Normal
|

>30%

>30%

>30%

>30%

-

>30%

-

-

>30%

-

>30%

-

-

-

-

-
|-
|'''Restaurant/catering/breakout areas'''

- beverage bay

- counter

- general

- servery

- tables

- washing up
 
|

100

300

50

300

50/200

|

170

520

100

520

n/a

520
 
|

-

22

-

22

-

22
 
|

80

80

80

80

80

80
|

Floor

Counter

Floor

Counter

Tables

Sink
 
|

Normal

Normal

S

Normal

Normal

Normal
 
|

>30%

-

>30%

-

-

>30%
 
|-
|'''Wards and bedded areas'''

- children’s play area

- circulation space

- circulation space (night)

- examination/treatment

|

300

170

10

1000(local)

|

520

170

10

n/a

|

22

19

-

-

|

80

80

80

90

|

Desk

Floor

Floor

Bed level (usually provided by examination lamp
|

N/EM

Normal

Normal

Normal

|

>30%

>30%

>30%

>90%

|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Nursing'''

- general nursing care/examination

- night light

- nurses’ station (day)

- nurses’ station (night)

- observation/night watch

- observation/night

- mental illness care wards

- patient reading (adult)

- reading lights

- ward corridors (day)

- ward corridors (night)

|

300

5

300

30/200

20

1 to 5

200

300

300

200

50

|

520

10

520

250

40

n/a

350

520

520

350

75

|

19

-

19

22

-

-

19

19

19

19

19

|

80

80

80

80

80

80

80

80

80

80

80

|

Bed

Work Surface

Desk

Work Surface

Bed head

Bed head

Floor

Bed head

Patient activity area

Floor

Floor (50% uniformity required)
 
|

Selective

Normal

Variable

Normal

Normal

N/Sp

Normal

Normal

Selective

Normal

Normal

|

>30%

>90%

>30%

>90%

-

>30%

>30%

>30%

>30%

>90%

>30%

|-
|'''Orthopedic'''

- pacemaker

- treatment (general)

- venesection
 
|

500

300

300
 
|

850

520

520
 
|

19

19

19
 
|

80

80

80
 
|

Work Surface

Work Surface

Chair
 
|

Variable

Normal

Normal
 
|

>30%

>30%

>30%
 
|-
|'''Critical care'''

- intensive care (night)

- observation/night watch

- high dependency unit (HDU)

- intensive care unit (ICU)

- bed head (day)

- night light

- simple observation/examination

- examination

 
|

5(max)

20

100

100

30 to 50

5 to 10

300

1000 (local)

 
|

n/a

40

170

170

n/a

10

520

n/a

 
|

-

-

19

19

22

-

19

-

 
|

80

80

80

80

80

80

80

90

 
|

Circulation

Bed head

Circulation/general

Circulation/general

Bed head

Bed head

Bed

Bed level(to be provided by examination lamp)

|

N/Sp

N/Sp

Normal

Normal

Normal

Normal

Selective

Normal

 
|

>30%

>30%

>90%

>90%

>90%

>90%

>90%

>90%

 
|-
|'''Coronary care'''

- bed head (day)

- observation/night watch

- simple observation/examination

- examination

- staff base (day)

- staff base (night)
 
|

30 to 50

5 to 10

300

1000 (local)

300

30/200
 
|

n/a

n/a

520

n/a

520

250
 
|

19

-

19

-

19

19
 
|

80

80

80

90

80

80
 
|

Bed head

Bed head

Bed

Bed level (to be provided by examination lamp)

Desk

Desk
 
|

Normal

Normal

Selective

Normal

Selective

Variable
 
|

>90%

>90%

>90%

>90%

>90%

>90%
 
|-
|'''Nurse’s station/staff base'''

- day

- night

- interview
 
|

300

30/200

300
 
|

520

250

520
 
|

19

19

19
 
|

80

80

80
 
|

Desk

Desk

Desk
 
|

Selective

Variable

Normal
 
|

>90%

>90%

>30%
 
|-
|'''Operating theatres'''

- anesthesia (examination)

- anesthesia room (general)

- angiography room

- endoscopy

- operating room general

- operating table/cavity

- porter’s area

- post anaesthesia recovery

- preparation

- scrub up

- transfers

- utility rooms
 
|1000 (local)

500

500

300

300

1000

10000 to 100000

300

500

500

500

300

100 to 150
|

n/a

850

850

520

1500

n/a

520

850

860

860

520

n/a
|

-

19

19

19

19

-

19

19

19

19

19

19
|

80

80

80

80

90

90

80

90

801

80

80

80
|

Trolley head

Work Surface

Work Surface

Work Surface

Work Surface

Work Surface

Trolley/bed

Work Surface

Bench

Sink top

Work Surface

Floor
|

Normal

Selective

Variable

Variable

Variable

Variable

N/A

Selective

Normal

Normal

Normal

Normal
|

>90%

>90%

>90%

>30%

>90%

>90%

>90%

>90%

>30%

>30%

>30%

-
|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Accident and emergency'''

- Admissions. reception

- supplies stores

- minor treatment area

- minor operations

- couch (general area)

- couch (local)

- general examination areas

- procedure room

- resuscitation room
 
|

300

300

500

15000/30000

750

500

500

30000/60000

500
 
|

520

520

850

N/A

1000

850

850

N/A

860
 
|

22

22

19

-

19

19

19

-

19
 
|

80

80

80

90

90

80

80

90

80
|

Desk

Work Surface

Work Surface

Adjustable to suit treatment area

Over couch area

Couch level

Couch level

Task illumination provided by minor treatment lamp

Work Surface
 
|

Normal

Normal

Normal

Normal

Variable

Variable

Variable

Normal

Normal
 
|

>30%

>90%

>30%

>30%

>90%

>90%

>90%

>90%

>30%
 
|-
|'''Audiology'''

- audio testing

- consulting room

- ear examination

- vestibular testing (labyrinth)

|

300

300

1000 (local)

100

|

520

520

n/a

170

|

19

19

-

19

|

80

80

90

80

|

Work Surface

Work Surface

(examination lamp)

Couch head and instruments
 
|

Variable

Variable

-

Normal
 
|

>30%

>30%

-

>30%
 
|-
|'''Dentistry'''

- laboratories

- reception/administration areas

- surgeries/theatres

- treatment rooms

- white teeth matching

|

500

300

8000 to 20000

500

5000

|

850

520

n/a

850

n/a

|

19

19

-

19

-

|

80

80

90

90

90

|

Bench

Work Surface

Mouth

Bench work surface

Work Surface

(TCP ≤ 6000 K)
 
|

Normal

Selective

Variable

Normal

Normal

|

>30%

>30%

>90%

>30%

>30%

|-
|'''Diagnostics support'''

- aseptic laboratory

- blood bank

- colour inspection laboratory

- hot and cold rooms

- inspection

- laboratories

- laboratory (with computers)

- pathology laboratory

- relatives’ waiting room

- seminar room

- viewing/bier room
 
|

300

300

1000 (local)

200

500 (local)

500

300

500

300

300

30 to 150
 
|

520

520

n/a

350

n/a

850

520

850

520

520

n/a
 
|

19

19

-

19

-

19

19

19

19

19

19
 
|

80

80

90

80

80

80

80

80

80

80

80
 
|

Bench

Work Surface

Bench

(TCP ≤ 6500 K)

Work Surface

Bench

Bench/desk

Work Surface

Bench

Work Surface

Work Surface

Bier
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Variable

Normal

Variable
 
|

>30%

>90%

>90%

>30%

50-90%

50-90%

50-90%

50-90%

>30%

>30%

>30%
 
|-
|'''Women’s services (maternity)'''

- applying sutures

- circulation space (day)

- delivery

- day

- night

- neonatal

|

1000 (local)

100

500

50 to 100

5

1000 (local)

|

n/a

170

850

n/a

20

n/a

|

-

19

19

19

-

-

|

90

80

80

80

80

80

|

Couch, chair or bed (usually provided by examination lamp)

Floor

Work Surface

Cot

Cot

Cot

|

Normal

Normal

Selective

Normal

Normal

Normal
 
|

>90%

>30%

>90%

>90%

>90%

>90%

|-
|'''Mother and baby rooms'''

- circulation space (day)

- day

- night

- nurseries (day)

- nurseries (night)

- milk kitchen

- special care baby unit

- teaching areas
 
|

100

50 to 100

5

100

5

300

1000 (local)

300
 
|

170

n/a

20

170

20

520

n/a

520
 
|

22

19

-

19

-

22

19

19
 
|

80

80

80

80

80

80

80

80
 
|

Floor

Cot

Cot

Floor

Floor

Bench

Cot

Bench/Work Surface
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>30%

>90%

>90%

>30%

>30%

>30%

>90%

-
 
|} 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''General treatment areas'''

- autopsy (dissecting) table

- autopsy rooms and mortuaries

- dermatology

- dialysis

- dispensary

- minor surgery/treatment

- plaster room

- resuscitation (general)

- resuscitation/examination

- pharmacy
 
|

5000

500

(higher values could be required)

500

500

15000/30000

500

500

15000(local)

500
 
|

8600

850

n/a

850

860

 850

850

n/a

850
 
|

-

19

19

19

19

19

19

-

19
 
|

90

90

90

80

80

90

80

90

90

80
|

Table top

Work Surface

(Local operating lamp)

Work Surface (dimmable)

Bench

Work Surface

Work Surface

Head of trolley

Work Surface
 
|

-

-

-

-

Normal

Normal

Normal

Normal

Normal

Normal
 
|

-

-

-

-

>90%

>90%

>30%

>90%

>90%

50-90%
 
|-
|'''Mortuaries and animal houses'''

- autoclave

- body store

- general

- mortuary

- operation

- post mortem

- staff change

- store room

- viewing room

- waiting room
 
|

150/200

200

300

150

500 local

500

100 to 150

150

50/100

200 (min)
 
|

n/a

350

520

260

n/a

850

n/a

260

n/a

n/a
 
|

19

19

19

19

-

19

19

19

19

19
 
|

80

80

80

80

90

90

80

80

80

80
|

Work Surface

Work Surface

Work Surface

Bier room

Bench

Work Surface/table

Floor

Work Surface

Work Surface

Floor
 
|

Normal

Normal

Special

Variable

Normal

Normal

Normal

Normal

Variable

Selective
 
|

>30%

>30%

-

>30%

>30%

>30%

>30%

-

>30%

>30%
 
|-
|'''Engineering services'''

- ducts

- plant room

- roadways

- workshop
 
|

20 to 50

300

7

300/500
 
|

n/a

520

12

n/a
 
|

-

22

-

22
 
|

80

80

80

80
|

Floor

Floor

Road surface

Bench
 
|

Selective

Normal

-

Normal
 
|

-

>90%

-

>30%
 
|-
|'''Facilities support services'''

- laundry

- linen store (Linen Department)

- pack and dispatch

- pressing

- sewing room

- wash and dry
 
|

300

100

300

300

500 (local)

300
|

520

170

520

520

n/a

520
 
|

19

19

19

19

19

19
 
|

80

80

80

80

80

80
 
|

Bench

Floor

Bench

Equipment

Machine

Equipment

|

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>90%

-

>90%

>90%

>90%

>90%
 
|}
48.4.1. The lighting levels quoted above relate to the relevant task area. Levels of for the task areas and surrounding areas can be reduced where it can be justified by experienced staff or engineers. Lighting levels must, regardless, comply with the requirements of the National Building Regulations.

48.4.2. Lighting levels for external areas shall comply with the following table: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table''' '''7 Levels of Indoor Lighting'''
{| class="wikitable"
|Area
|Maintained average illuminance / lux
|Maintained minimum illuminance / lux
|Overall uniformity (not less than stated figure)
|Threshold increment
|Colour rendering (minimum)
|-
|

CCTV

- monochrome

- colour

Roads

General pedestrian areas

Information and display signs

Car Park

Vehicle drop-off points

Steps or stairways

General area lighting

Hazardous open storage areas
 
|

0

-

15

20

30

10

15

20

100(vertical)

15

10

100

20

50
 
|

5

15

6

8

12

4

6

12

6

5

40

12

20
|

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4
 
|

≥10%

≥10%

 
|

≥60%

≥60%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%
 
|}

49. Classification of Safety Services necessary for Medical Locations from SANS 10142-1
{| class="wikitable"
|'''Class'''
|'''Response Time'''
|-
|Class 0 (No break)
|Automatic supply available at no break

UPS backed up by Generator Required.
|-
|Class 0,15 (Very short break)
|Automatic supply available within 0,15 s

UPS backed up by Generator Required.
|-
|Class 0,5 (Short break)
|Automatic supply available within 0,5 s

UPS backed up by Generator Required.
|-
|Class 15 (Medium break)
|Automatic supply available within 15 s

Generator Required
|-
|Class > 15 (Long break)
|Automatic supply available in more than 15 s

Generator Required
|}
Note Safety Services in Medical locations are synonymous with Emergency Services.

50. '''Medical Location Classification'''

50.1. Group 0 location: where no applied part is intended to be used.

50.2. Group 1 location: Medical Location where applied parts are intended to be used.

#Externally, or
#To any part of the body, but not to the heart.

50.3. Group 2 location: Medical Location where applied parts are intended to be used in applications such as in an intracardiac procedure, in an operation (in an operating theatre) and in vital treatment where discontinuity (failure) of supply can cause danger to life.

Note: An intracardiac procedure is a procedure whereby an electrical conductor is placed within the cardiac zone of a patient or is likely to come into contact with the heart, such conductor being accessible outside the patient’s body. In this context, an electrical conductor includes insulated wires such as cardiac pacing electrodes or intracardiac ECG electrodes, or insulated tubes filled with conducting fluids.

50.4. For the allocation of medical location group and classification of safety service classes for medical locations see Table below as supplied in SANS 10142-1.
 
{| class="wikitable"
|
|
'''Medical Location'''
| colspan="3" |
'''Medical location group'''
| colspan="2" |
'''Safety service class'''
|-
|
|
|'''0'''
|'''1'''
|'''2'''
|'''≥ 0,5'''
|'''0,5'''

'''≤ 15'''
|-
|

1
|

Massage room
|

X
|

X
|
|
|

X
|-
|

2
|

Bedrooms
|

|

X
|
|
|

X
|-
|

3
|

Delivery room
|
|

X
|
|

X
|

X
|-
|

4
|

ECG, EEG, EHG room
|
|

X
|
|
|

X
|-
|

5
|

Endoscopic room
|
|

Xa
|
|
|

Xa
|-
|

6
|

Examination or treatment room
|
|

X
|
|
|

X
|-
|

7
|

Urology room
|
|

Xa
|
|
|

Xa
|-
|

8
|Radiology diagnostic and radio therapy room, other than mentioned under 21
|
|

X
|
|
|

X
|-
|

9
|

Hydrotherapy room
|
|

X
|
|
|

X
|-
|

10
|

Physiotherapy room
|
|

X
|
|
|

X
|-
|

11
|

Anaesthetic room
|
|
|

X
|

X
|

X
|-
|

12
|

Operating theatre
|
|
|

X
|

X
|

X
|-
|

13
|

Operating preparation room
|
|

X
|

X
|

X
|

X
|-
|

14
|

Operating plaster room
|
|

X
|

X
|

X
|

X
|-
|

15
|

Operating recovery room
|
|

X
|

X
|

X
|

X
|-
|

16
|

Heart catheterization room
|
|
|

X
|

X
|

X
|-
|

17
|

Intensive care room
|
|
|

X
|

X
|

X
|-
|

18
|

Angiographic examination room
|
|
|

X
|

X
|

X
|-
|

19
|

Haemodialysis room
|
|
|

X
|

|

X
|-
|

20
|

Magnetic resonance imaging (MRI)
|
|

X
|
|
|

X
|-
|

21
|

Nuclear medicine
|
|

X
|
|
|

X
|-
|

22
|

Premature baby room
|
|
|

X
|

X
|

X
|-
| colspan="3" |
a The room is not an operating theatre.
|
|
|
|
|}
50.5. In addition to the tables 0 and 50.4 above, generator supply is also required for:

#Night light in wards and ward corridors;
#All switched socket outlets used for patient life support anywhere in the facility;
#At least one patient lift or lift that can accommodate a bed for every 200 patients;
#Medical air compressor, vacuum pumps and gas alarm systems;
#Supply air fans serving theatres and uni-directional airflow systems;
#Isolation ward exhaust air fans.
#Mortuary Fridge Cabinets
#Nurse call System
#Fire detection system

51. General Requirements

51.1. Power supply to switched socket outlets in high care units, intensive care units and operating theatre units and recovery rooms must be on an earth monitoring system. Double pole isolators must be used for supply points in these areas and the power supply to these shall be fed from an isolation transformer.

51.2. Medical Location Group 1:

Switch Socket outlets in Medical Location 1 Shall have final Circuits for socket -outlets up to 16Amp shall be protected by earth leakage protection devices with a rated earth leakage tripping current ( rated residual current) not exceeding 30 Ma.

51.3. Medical Location Group 2:

Switch Socket outlets in Medical Location 2 the Medical Isolation Transformer (Medical IT) system shall be used for circuits that supply medical electrical equipment and systems intended for life support or surgical applications and other electrical Equipment located in the patient environment. In the case of each group 2 medical location, at least one separate medical IT system is necessary.

51.4. The Medical Isolation Transformer (MIT) shall be equipped with:

51.4.1. A 5 or 8 kVA Isolation Transformer complete with a 220 V Primary and 220 V / 110 V Secondary Winding with a centre Point Floating but bonded to the Earth monitor. The Secondary Side of the transformer shall provide 220 Volts between Line 1 and Line 2 (Note no Neutral with an Isolation Transformer) Line 1 and Line 2 will feed the Distribution Board for that particular Medical Group location, i.e. (Theatre No 1) or (ICU Bed 1-6) This local DB will then have a number of double pole Circuit Breakers feeding out to the outgoing Circuits feeding the Socket Outlets in the Medical Location 2 Area. Note that at least two circuits are required to each ICU Bed or Theatre Panel, and Theatre Pendant. Also note that all Switch Socket Outlets in a Medical Location 2 Area have to be double Pole Switched via a double pole Isolator (Provided two circuits provided) or a double pole Circuit Breaker.

51.4.2. The Transformer shall be installed either in a cabinet/DB or enclosure, to prevent unintentional contact with live parts. The Transformer / DB should be located close to the Group 2 Medical Location but consideration should be given to providing the DB outside the red line area of both the Theatres and ICU Areas, so maintenance can be carried out without the need to be gowned up. Line 1 & 2 and Earth should all be Insulated wires with the colour of Line 1 & 2 being different from red and black suggest Brown and Blue wire is used for Line 1 & 2 and green for Earth (Note this Earth wire should be connected to an insulated Earth bar dedicated to that particular Group two location and bonded to the centre point of the secondary winding.) Note a Separate Dirty earth (Equipotential bonding) should also be provided to the metal work of the Plugs, Theatre Panel, and Pendant this earth shall be connected to the Main Building Earth.

51.4.2. An insulation -monitoring device that:

#Has an internal impedance of at least 100 k Ohm;
#Has a test voltage not exceeding 25 V DC.
#Is of a current, even under fault conditions, not exceeding 1 mA DC. and
#Shall indicate, at least when the insulation resistance has decreased to 5 k Ohm.

A test device shall be provided to test this facility to ensure that the alarm (Audible and visual) operates when the insulation resistance reaches 5 k Ohm;

To test the System two male plugs should be used each with a resistor of 5 k Ohm. Plug No 1 should have a 5 k Ohm resistor bridged from the Earth Pin to the Right Hand live Pin. Plug No 2 should have a 5 k Ohm resistor bridged from the Earth Pin to the Left Hand live Pin.

51.4.4. Medical Isolation Transformer Alarm.

For each Medical IT system an audible and visual alarm shall be provided in the Theatre Area a alarm shall be provided on theatre Panel and repeated back to the main Nurse Station in Theatre Area .The Alarm shall consist of Green Light indicating Healthy, a red light indicating fault, a audible Alarm to also indicate fault and a local audible alarm mute button. The Visual signal shall revert to green and the audible alarm shall be automatically reset on the removal of the fault condition
 

Table 4 – Required for Medical Isolation Transformers (MIT) and Switch Socket Outlets (SSO)
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Office Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Laboratory Work Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Office
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Nurse Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward
|1
|1 x 16A Normal / Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point/ Bed(if required).
|
|3x 16A per bed
|
|
|
|
|-
|Ward Kitchen
|0
|2 x 16A Normal on Wall at 1200 mm over counter + 1 x 16 A next to Sink or Hydro Boil.
|
|1 x 16A supply for Fridge on generator supply
|
|
|
|
|-
|Ward Corridor
|0
|1 x 16A Normal / Every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Ward Staff Rest Room
|1
|I x 16 A on Wall for Cleaning, 1 x 16 A above counter for Electrical Appliances + 1 X 16 A next to sink for Hydro boil
|
|
|
|
|
|
|}
----[[Building Engineering Services#%20ftnref1|[1]]] Note: DPS is an abbreviation for double pole switch
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Theatre Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|-
|Theatre Post Op
|2
|
|
|
|6 x 16 A Dedicated SSO per Bed
|
|
|
|-
|Operating Theatre
|2
|
|
|
|
|8 x 16 A Dedicated SSO per Pendant
|8 x 16 A Dedicated SSO per pendant
|4 x 16 A Dedicated SSO
|-
|Cath Lab Operating Room
|2
|
|
|
|
|
|
|4 x 16 A Dedicated SSO
|-
|Cath Lab Control Room
|0
|1 x 16A Normal per Station
|1 x Red 16A Dedicated per Station
|
|
|
|
|
|-
|Cath Lab Equipment Room:

160 kva dedicated UPS Required to feed Dedicated DB and Equipment
|
|
|
|
|
|
|
|
|-
|Autoclave
|
|In autoclave plant room. 3-Phase 380V, 80A per autoclave
|
|
|
|
|
|
|-
|Instrument Washer
|
|In CSSD. Typically 3-Phase 380V, 15A per washer
|
|
|
|
|
|
|-
|Theatre Corridor
|1
|1 x 16A Normal for every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|}
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|ICU Circulation Space
|1
|1 x 16A Normal per 25m2 for cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Neo Natal ICU Cots Note: Care should be taken when sizing the Isolating Transformers to include the Heating Load
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care Nurse Station (per workstation)
|1
|1 x 16A Normal per Station
|2 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|-
|ICU and Ward Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|}
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Casualty Treatment Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point per Bed. 2 x 16A per Bed
|
|
|
|
|
|
|-
|Procedure Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning
|
|4 x 16A per Bed per two Circuits.
|
|
|
|
|-
|Casualty Ward Corridor 0
|0
|1 x 16A Normal per every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Radiology Procedure Crash Cart Position
|
|
|
|
|
|-
|Rooms Dedicated 125 Amp Supply to dedicated
|1
|1 x 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Radiology Control Room
|0
|1 x 16A Normal per Station
|1 x 16A Normal per Station
|
|
|
|
|
|-
|Maternity Delivery Rooms
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|
|
|}

{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Dialysis Treatment Beds.

Note that the Equipment can include Water Heating with high kw loading so care should be taken when sizing the Isolating Transformers
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|
|
|}
51.5. Uninterrupted Power System must be provided for operating theatre luminaries and all life support systems and computer systems where a break in electrical supply cannot be tolerated. The whole installation must conform to SANS 1474 of 1988.

51.6. Socket outlets for Dialysis units, in close proximity to water points or drains, shall be of the totally waterproof IP65 type, which also seal water-tight when the socket is removed.

51.7. Where more than one electrical transformer is used, they should preferably be located in separate structural enclosures. This is to prevent potential damage to an adjacent transformer if one is damaged.

51.8. All distribution boards fed from normal mains supply shall be painted Electric Orange, colour B26 to SABS 1091.

51.8. All distribution boards fed from standby emergency power supply shall be painted Signal Red, colour A11 to SABS 1091.

51.9. All distribution boards fed from UPS power supply shall be painted Blue colour F06 to SABS 1091.

51.10. All cable transition boxes shall be painted the appropriate colour corresponding to the source of the power supply.

51.11. All cables installed on surface mounted cable ladders shall be of the PVC/PVC/SWA/ECC/PVC type to SANS 101507 rated at 600/1000 Volt.

51.12. Electrical circuits to be engraved on base 3mm lettering indicating circuit number and DB.

51.13. Electrical Certificate of Compliance.
[[File:Picture 11.png|border|thumb|450x450px|alt=|center]]
 
===Electronic installations===
52. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

53. Nurse call system with emergency (nurse assistance) and TV control handsets (Interchangeable with LED PEAR PUSH).

The nurse system enables the patient to call a nurse for assistance from his bed or from a bath, shower and toilet. The system also enables the staff to call for assistance (EMERGENCY CALL) from any bed and treatment room etc.

#When a patient nurse call or staff emergency call is enabled the system must produce an intermittent AUDIBLE chimes or bleeper tone at the nurses’ station or/and duty room. Three different sounding tones must be produced for normal Patient call, Bathroom call and Emergency (nurse assistance) call.
#The system must also provide a VISUAL indication, at the nurse station (LED Mimic Panel and/ or Computer Monitor or LCD Display Panel), above the door to the passage of the activated unit, and at the actual activated unit (reassurance LED).
#The system must be so designed that any call may ONLY be RESET at the point of origin.
#The system must automatically activate a nurse call when the Hand Held Unit (Handset) or Pear Push unit is accidently pulled out from the Bed Head Unit.
#The Bed Head Unit must be compatible with Hand Held Unit (with TV Control), Rehab Hand Held Unit & Pear Push. (Inter-changeable)
#A Central Monitoring PC, or PC per duty station replacing Mimic Panel, must keep records of all events. (Optional)
#The system must be purpose made and aesthetically pleasing with components (call & reset units etc) manufactured from matching injection moulded ABS plastic. A system made up of push buttons etc mounted directly onto standard electrical plates will not be accepted.

54. Automatic fire detection in Hospitals

The Fire Detection System shall comply with SANS 10400 SANS 10139 & SANS 322. The Fire Detection System must be provided throughout the Facility and be a Addressable Fire Detection System, Note that Audible Fire Alarms which could panic the patients should not be provided instead Visual Strobe Lights should be provided at all Nurse stations, Reception and Security Office.

Audible alarms can be used in noisy areas such as plant rooms.

The wiring for the Automatic Fire Detection System shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area)
 55. Public Address and Evacuation in Hospital

The Public Address and Evacuation System shall comply with EN54 and provide voice message via fire retardant speakers throughout the hospital Circulation Areas, Staff Areas, Public Toilets. The wiring for the Evacuation Speakers shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area). As part of the Hospital Design the Hospital should be zoned to allow Evacuation of Individual zones in the event of a fire or other Emergency.

==Wet Services==
56. Plumbing services (Water supply and drainage) must comply as a minimum with the following Standard Specifications and Codes of Practice:

#SANS 10400: The Application of the National Building Regulations, including Part XA: Energy Use in Buildings
#SANS 10252 – Part 1 – Water Supply Installations for Buildings
#SANS 10252 – Part 2 – Drainage Installations for Buildings
#UK Department of Health Technical Memorandum 04-01: The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems: Part A: Design, Installation and Testing, and Part B: Operational Management or the equivalent SANS standard when available.

57. Where any apparent conflict between the functional requirements and the regulatory “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functional compliance.

58. Cold water storage, dedicated to the domestic water requirements of the facility, must be provided on the site. A minimum usable volume of 500 litres per bed must be provided.

59. If water storage is required for fire protection purposes (Sprinklers, Fire Hydrant supply) it must be stored separately from domestic water, unless adequate provision for the prevention of stagnation of the fire service reserve within the tank can be made.

60. Tanks must be accessible both on the outside as well as the inside, and provision for cleaning the tanks without interrupting water supply to the hospital must be made. Access manholes must be lockable, and a facility for draining the tank or individual compartments within it, must be made.

61. All openings to the tank (Overflows, vent pipes, etc) must be provided with screens.

62. Underground tanks, with their inherent risk of contamination must be avoided at all cost. If unavoidable, the tank should be constructed in a water tight bund allowing sufficient space all round for inspection and maintenance, and a sump for collecting drainage water

63. Cold water storage tanks must be located such that heat gain to the water is minimised. Cold water storage temperatures 20 C and lower will prevent the colonisation by or multiplication of Legionella

64. Site water reticulation must be designed using sound engineering principles, with adequate provision for isolating sections of the reticulation whilst keeping the remainder in operation being made.

65. Fire protection water reticulations must be kept totally separate from the domestic water reticulation

66. Water distribution may be gravity fed, or alternatively supplied via booster pumps. Pumps must be suited to handling potable water, and provision for built in redundancy must be made. Booster pumps must be supplied off standby power.

67. Hot water supply temperature to general patient care and staff areas must be controlled at 55 C, and must not exceed 60°C, except during a sanitation cycle as described hereunder.

68. Hot water generation systems must where possible use waste heat recovery from a central air conditioning system, if employed.

69. The facility for thermal disinfection of the hot water storage and circulation system must be provided in the system design. This can take the form of controlled heating of the storage vessel and circulating mains to 60°C during periods of low water and power demand. The use of shunt pumps to circulate hot water from the top level to the lowest level of the hot water tank during the sanitation cycle must be considered.

70. Hot water supply to paediatric wards, as well as to geriatric and to neonatal bathing facilities shall not exceed 42°C at the point of supply. If thermostatic mixing valves are employed to achieve this, they must be fitted with a safety feature such that the water flow is cut off within 2 seconds of the cold water supply to the valve being interrupted. The valve must also be able to control the set temperature with a pressure ratio of incoming hot to cold water supply pressure of up to 10 to 1.

71. Toilet flushing systems must be provided with easily identifiable dual flush mechanisms, one being for low flush water flow, the other for standard flush water flow.

72. All sanitary fittings must be piped such that the hot water control is on the left hand side, and the cold water supply is on the right hand side when facing the fitting.

73. Branch pipes (dead legs) between water heating equipment or hot water circulating mains and sanitary fittings must be sized and located such that the maximum waiting time for hot water to emerge from the fitting does not exceed 12 seconds.

74. Mixing taps in patient care areas must be elbow action type, installed such that the tap can be opened and shut by means of simple elbow action.

75. The discharge from kitchen floor drains and other kitchen drain points such as sinks, dishwashing washing, machines, and cooking equipment wash down, likely to contain grease, must be taken via a separate discharge system to a suitable grease interceptor, installed in a position to allow easy access for removal of intercepted grease and oil.

76. The drain pipes from equipment likely to produce high temperature discharge, such as autoclaves, sterilisers and cooking equipment must be from materials able to withstand such temperatures, installed such that distortion and/or expansion can be accommodated by the system.

77. Vertical pipe runs (Drainage stacks and water supply mains) in multi storey buildings must be housed in continuous vertical service ducts with easy access from non-patient areas at each level.

78. Condensate drains from air conditioning and refrigeration systems must discharge into piped drainage systems.

79. Anti-Backflow protection devices shall be fitted to faucets with hand-held shower heads to prevent back siphoning should the supply water pressure fail.

80. In areas housing patients at unusual risk of infection, faucets should not be fitted with low-flow or aerating devices which may increase the rate of aerosolisation of infectious droplets.

 

'''81. Legionella Control'''

#A facility-wide legionella control plan shall be in place which will inform operation, maintenance and design of water systems.
#This Plan must include a Legionella risk assessment document, listing all areas where the bacteria may occur. This must address specifically air conditioning condenser water systems, domestic hot and cold water installations, irrigation water storage and distribution systems, etc.
#The Plan must refer to as-built drawings identifying positions and layouts of plant and installations liable to cause a risk of Legionella being generated
#The facility’s Maintenance Procedures must describe all measures to be taken to minimise proliferation of Legionella. This is to include procedures and frequency of sanitation/disinfection, purging of dead legs on circulating systems, sample taking and testing at specific intervals, as well as a responsibility matrix of personnel

For additional information refer to the [[Legionella Control]] article.

==Lifts==
82. Standards and Regulations Pertaining to Lifts and Lifting Operations:

#SANS 50081 - SAFETY RULES FOR THE CONSTRUCTION AND INSTALLATION OF LIFTS - PARTICULAR APPLICATIONS FOR PASSENGER AND GOODS LIFTS
#SANS 10400 –SS3 FACILITIES FOR DISABLED PERSONS: LIFTS
#SANS 10400 –TT45 FIRE PROTECTION: LIFT SHAFTS
#SANS 10400 –TT46 FIRE PROTECTION: LIFT
#SANS 10400 –TT47 FIRE PROTECTION: FIREMAN’S LIFT
#SANS 10400 –TT48 FIRE PROTECTION: STRETCHER LIFT 

83. Planning for circulation, capacity and location of lifts

#A lift traffic plan should be developed. Detailed lift traffic planning is beyond the scope of this document. A specialist advisor should be consulted to assist in the planning of lifts within the general principles of lifts services for healthcare buildings.
#General Lift Planning Principles
#The operational details of the facility must be understood for effective lift planning. These include:

*Number of visitors and visiting hours
*Number of staff, shift hours and ward round schedules
*Numbers of day and overnight patients
*Increased provisions for reduced mobility persons
*Housekeeping schedule
*Evacuation plan for reduced mobility patients.

#Whenever possible, lifts should be provided in pairs to allow for continued operation during maintenance and breakdown.

 

===='''84. TYPES OF LIFTS:'''====
84.1. PASSENGER LIFTS

#These lifts shall be able to accommodate general passenger traffic including ambulatory and semi ambulatory passengers. It shall be able to accommodate reduced mobility passengers using mobility aids and wheelchairs. Refer to SANS 50081-70, Table 1
#The entrance to a passenger lift shall not be less than 1100 mm in width.
#The depth of a passenger lift shall not be less than 1400mm deep.
#Passenger lifts shall have a mirror on the top half of the rear wall equal to the width of the lift to enable wheelchair users to back out of the lift where the lift has internal dimensions less than 1,5 m in width and 2,0 m in depth
#At least on one side wall of the car a handrail shall be installed 

84.2. BED LIFTS

#Bed lifts shall have internal dimensions of 1 800 mm wide by 2 700 mm deep to accommodate most beds with staff and medical equipment.
#The entrance to a bed lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.3. STRETCHER LIFTS

#Stretcher lifts shall have internal dimensions of 1 400 mm wide by 2 400 mm deep to accommodate most trollies or stretchers.
#The entrance to a stretcher lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.4. GOODS LIFTS

#Goods lifts are for the movement of conventional goods and items that could not reasonably use passenger lifts without causing discomfort to passengers or damage and soiling of the lift car.
#Goods lifts can be designed to accommodate passengers.

84.5. SERVICE LIFTS

#Service lifts are not designed for accommodate passengers. They are typically of the “dumb waiter” style dispatched between service hatches.

84.6. HOUSEKEEPING LIFTS

#Housekeeping lifts are similar in function to goods lifts but are intended for the movement of cleaning supplies, medical supplies and equipment, linen etc.

{| class="wikitable"
|+Hospital Guide - Passenger
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''630 kg / 8 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|1800 x 1800

2000 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''800 kg / 10 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1350 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|2000 x 1800

2200 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1600 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2300 x 1800

2450 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1250 kg / 16 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|2000 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2700 x 2000

2700 x 2000
|1450
1500

1600
|4200
4300

4400
|}
 
{| class="wikitable"
|+Hospital guide - stretcher / Bed Lifts
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 2100
|CLD

TLD
|1000 x 2100

1000 x 2100
|200 x 2600

2000 x 2600
|1450
1500

1600
|4200
4300

4400
|-
|'''1600 kg / 21 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1400 x 2400
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 2800
2500 x 2900

2400 x 2900
|1450
1500

1600
|4200
4300

4400
|-
|'''2000 kg / 26 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1500 x 2700
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 3100
2600 x 3150

2450 x 3150
|1450
1500

1600
|4200
4300

4400
|-
|'''2500 kg / 33 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1800 x 2700
|CTLD

CTLD
|1400 x 2100

1600 x 2100
|2900 x 3150

3000 x 3150
|1450
1500

1600
|4200
4300

4400
|}
 
==PART D - COMMISSIONING AND HANDOVER==
===Deliverables===
1. This section is intended to detail the commissioning deliverables required before handover of building engineering services for operation. For further detail on commissioning and handover the '''IUSS Commissioning Health''' Facilities guidance document should be referred to.

2. Project Close-out deliverables include:

#Final Works completion lists
#Financial reports and final accounts
#Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
#Approved As-Built Drawings
#Electrical Certificates of Compliance

3. '''Maintenance manuals''' shall be timeously issued and shall include:

3.1. Designer and installer contact information

3.2. System information

#System description
#Suppliers list
#Equipment List
#Equipment data sheets
#Materials of construction data sheets
#Warranty information

3.3. Operational parameters

#Start up and shut down procedures
#Special instructions
#Security and access details
#Fault finding procedures
#Alarm management and data logging

3.4. Validation and commissioning

#Approved reports and data
#Relevant test protocols
#Relevant test plans
#Installed and test equipment calibration certificates
#Commissioning certificates
#Beneficial Occupation and Handover certificates

3.5. Spare parts list

3.6. Electronic Data Backup (Read only Media)

3.7. Approved “As-Built” Drawings

#Process diagrams
#Wiring Diagrams
#Control Diagrams
#System Plans
#Training records

3.8. Training Records

3.9. Training Materials

===Commissioning of ventilation systems===
4. Commissioning of ventilation and air conditioning systems shall comprise the following:

#Confirmation of accuracy of measurements.

Measurement accuracy depends on equipment accuracy and repeatability. Factors that would impact on the accuracy of measurement include:

*Operator error and competence
*Type and quality of measuring device
*Quality and adherence to measurement protocols.

4.2. Proof of competence of commissioning technician or engineer

4.3. Commissioning method statements or protocols shall be developed, recorded and adhered to, to ensure all technicians work to the same procedures and sequences. In some instances, such as healthcare units where the ventilation system is critical to that unit’s clinical outcomes or to the safety of occupants, the client or client’s representative may request that these method statements be issued for formal approval before commencement of commissioning.

4.4. As the operational parameters of variable air volume systems are more complex that constant volume systems, the designer is to provide details of all relevant aspects of these systems such that the commissioning specialist can sufficiently develop an appropriate plan the commissioning.

4.5. Preliminary inspections should be completed before the systems are started up for commissioning. Typically these inspections should include:

*The '''state of completion''' of the building and the condition of details such as openable windows, doors and ceilings.
*'''Building cleanliness''' as it pertains to the ventilated spaces as well as the equipment plant rooms.
*Ducting and ventilation components should be inspected internally and externally for '''system cleanliness.''' Prior to fitting filters the following components should be checked for completion, correctness and cleanliness:

#Air intakes screens and mixing plenums
#Heating components
#Cooling components
#Condensate and drip trays
#In duct UVGI systems
#Humidifiers
#Fan and equipment chambers including safeties and interlocks
#Sensors and gauges
#Airflow controllers and fire damper
#Filter frames and orientation thereof
#Insulation
#Ducting and air terminals

*Electrical Equipment should be inspected for completion, correctness, labelling and cleanliness. Prior to running any electrical rotating or control equipment the following check should be completed.

#Local isolators of motors, electric heaters and control circuits including labelling.
#Electrical safety
#Motor starters and frequency drives set correctly for overload and motor restart ratings.
#Direction of rotation of motors on motor shafts
#Motor starting current and sequencing

4.6. An initial running-in period should be conducted at low load before the installation of the filters. This running period is to ensure flushing of ducting, and allow checking of the system operation. During the this period the system should be shut down and restarted to ensure that the controls, fuses and switchgear function correctly; however, repeated rapid restarts should be avoided as this can over-stress the control gear and fuses.

4.7 After the initial running-in the filters can be installed by a suitably qualified technician and the system should then be run at normal load. New filters should be installed before the final proportional balancing commences.

4.8. The proportional balancing of the airflow should be delayed until the ventilation system has been run-in under normal load for a few days to ensure stability of the system. The airflow balancing should be conducted in accordance with good engineering principles such as those described in SANS 10173, the ASHRAE Fundamentals Handbook, CIBSE Commissioning Code A or BSRIA Application Guide 3/89.1 depending on the system requirements.

4.9. For variable air volume systems, the commissioning tests should demonstrate system performance across the design diversity.

4.10. A definitive total airflow measurement should be taken in either a section of the main duct, where duct length and turbulence allow, or in the branch ducts. This value shall be recorded, compared against the design values and tolerances and reported on in the commissioning reports including the percentage of the design flow rates.

4.11. The final airflow measurements shall be taken at all air terminals (supply, return and exhaust) using airflow capture hoods where the terminal generates turbulence and these values shall be recorded, compared to design values and tolerances and reported on in commissioning reports including the percentage of the design flow rates.

4.12. Direction, drop and throw of air terminals shall be assessed by the responsible engineer to confirm the correct air distribution within ventilated spaces.

4.13. The minimum outside air portion should be demonstrated and recorded across the system’s operational diversity.

4.14. A condition of system acceptance is that the commissioning tests be witnessed before signing off. This process could involve the repetition of only a selection of the tests under the observation of an authorised witness or responsible engineer. The following aspects should be demonstrated:

*Performance of the system according to the overall design requirements within specified limits
*Repeatability of performance and measurement results

==PART E - EXAMPLES==
===Mechanical system configurations===

===='''1. HOT WATER GENERATION SYSTEM'''====

[[File:Picture 1.png|thumb|570x570px|Hot water generation system|alt=|border|center]]

===='''2. THEATRE VENTILATION SYSTEMS'''====
The following examples indicate typical system configurations schematically.

2.1 UDAF Recirculation

 
[[File:Picture 2.png|border|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic|alt=|center]]

2.2. UDAF Full Fresh Air & Exhausted

[[File:Picture 3.png|center|thumb|410x410px|NOTE: Does not indicate sensors, interlocks or control logic]]
2.3. Major Theatre: Recirculation
 
[[File:Picture 4.png|center|thumb|410x410px]]

2.4. Major Theatre: Full Fresh Air Supply only
[[File:Picture 5.png|border|center|thumb|400x400px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

2.5. Minor Theatre: Recirculation
[[File:Picture 6.png|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.6. Minor Theatre: Full Fresh Air & Exhausted
[[File:Picture 7.png|border|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.7. Minor Theatre: Full Fresh Air Supply only
[[File:Picture 8.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

===='''3. AIRBORNE PRECAUTION ROOMS AND THEATRES'''====
3.1 Energy Recovery Systems for Airborne Precaution Rooms
 
[[File:Picture 9.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]
4. Energy Recovery Systems for Airborne Precaution Theatres
[[File:Picture 10.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks and control logic]]
 
==REFERENCES==
'''Applicable Regulations and Standards:'''

National Health Act 2004''.'' (61 2003). Cape Town South Africa: Government Gazette.

''Ammended Occupational Health and Safety Act 2004.'' (181 1993) South Africa: Department of Labour.

South African Bureau of Standards, 2009. ''SANS 10142-1:2008 The wiring of premises Part 1: Low-voltage installations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 10173:2003 The installation, testing and balancing of air-conditioning ductwork.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 10252-1:2012 Water supply and drainage for buildings Part 1: Water supply installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1993. ''SANS 10252-2:1993 Water supply and drainage for buildings Part 2: Drainage installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 10313: 1999 Protection of structures against lightning.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1990. ''SANS 10400-2: 1999 Code of Practice for The Application of the National Building Regulations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-1:2005 Copper-based fittings for copper tubes Part 1: Compression fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-2:2005 Copper-based fittings for copper tubes Part 2: Capillary solder fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 1091:2012 National colour standard''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1238:2005 Air-conditioning ductwork''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1409:2008 Outlet sockets and probes for medical (gas and vacuum) services used in hospitals.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1424:2008 Filters for use in air-conditioning and general ventilation.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2011. ''SANS 1453:2011 Copper Tubes for Medical Gas and Vacuum systems.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 14644-1:1999 Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-2:2003 Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-4:2003 Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1988. ''SANS 1474: 1988 Uninterruptible Power Supplies''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2009. ''SANS 7396-1:2009 Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 7396-2:2008 Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems.'' Pretoria South Africa: SABS Standards Division.

*All local Municipal laws and regulations,
*ISO 14644-3:, Cleanrooms and associated controlled environments - Part 3: Test Methods Australasian Health Infrastructure Alliance,2006. Australasian Health Facility guidelines [online] Available at: <nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> [Accesed ...].
*ISO/DIS 5359. Anaesthetic and respiratory equipment - Low-pressure hose assemblies for use with medical gases,
*National Health Act, 2004 (Act No. 61 of 2003).
*Occupational Health and Safety Act, of 1993
*Regulations of the Local Electricity Authority,
*SANS 10114: Lighting Requirements,
*SANS 10142-1: The wiring of premises Part 1: Low-voltage installations,
*SANS 10173: The installation, testing and balancing of air-conditioning ductwork,
*SANS 10224: Non-flammable medical gas pipeline,
*SANS 10252-1: Water supply and drainage for buildings Part 1: Water supply installations for buildings,
*SANS 10252-2: Water supply and drainage for buildings Part 2: Drainage installations for buildings,
*SANS 10313: 1999 Protection of structures against lightning,
*SANS 10400: Code of Practice for The Application of the National Building Regulations,
*SANS 1067: Copper-based fittings for copper tubes Part 1: Compression fittings,
*SANS 1067: Copper-based fittings for copper tubes Part 2: Capillary solder fittings,
*SANS 1091: Colour Coding of Services,
*SANS 1140: Identification colour marking Part 4: Contents of taps and valves in laboratories,
*SANS 1238: Air-conditioning ductwork,
*SANS 1409: Outlet sockets and probes for medical (gas and vacuum) services used in hospitals,
*SANS 1409: Part 3 Handling and storage of Medical Gas,
*SANS 1424: Filters for use in air-conditioning and general ventilation,
*SANS 1453: Copper Tubes for Medical Gas and Vacuum systems,
*SANS 14644-1, Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness,
*SANS 14644-2, Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1
*SANS 14644-4, Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up,
*SANS 1474: 1988 Uninterruptible Power Supplies,
*SANS 7396-1: Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum,
*SANS 7396-2: Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems,
*SANS 50081: Safety rules for the construction and installation of lifts — Particular applications for passenger and goods lifts,
*Any other applicable Laws or Regulations.

Chartered Institution of Building Services Engineers (CIBSE), 1999. Environmental design CIBSE Guide A. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2005. CIBSE Applications Manual AM10 Natural ventilation in non-domestic buildings. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2008. Lighting Guide 2: Hospitals and health care buildings. England: The Society of Light and Lighting.

 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009. ANSI/ASHRAE/ASHE Standard 170-2008 Ventilation of

Health Care Facilities. Atlanta USA:ASHRAE.

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2013. HVAC Design Manual for Hospitals and Clinics Second Edition. Atlanta USA:ASHRAE.

'''Further reading'''

*<nowiki>http://www.spaceforhealth.nhs.uk/</nowiki> (National Health Service NHS website for UK guidance) website closed now
*<nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> (Health Facility Guides website for Australasian Health Facility guidance)
*CIBSE Guide A – Environmental Design
*CIBSE Applications Manual for Natural Ventilation – AM10
*CIBSE Applications Manual for Mixed Mode Ventilation. – AM13

*CIBSE Lighting Guide 2: Hospitals and Health Care buildings
*ASHRAE 170:2008
*HVAC Design manual for Hospitals and Clinics Second Edition – ASHRAE TC 9.6, 2013
*CIBSE Commissioning Code A
*BSRIA Application Guide 3/89.1

 <references />

==LIST OF ABBREVIATIONS==
A & E- Accident and Emergency Department

AHU- Air Handling Unit

CSSD- Central Sterile Supply Department

EMS- Emergency Medical Services

HCW- High Care Ward

HEPA- High Efficiency Particulate Air (filter)

ICU- Intensive Care Unit

NBR- National Building Regulations SABS 0400

NICU- Neonatal Intensive Care Unit

OT- Operating Theatre

SABS- South African Bureau of Standards

SANS- South African National Standards

SSO- Switched Socket Outlet

UDAF- Uni-Directional Air Flow

UPS- Uninterrupted Power Supply

URS- User Requirement Specification

==LIST OF DEFINITIONS==
For the purposes of these regulations, unless the context otherwise indicates-

'''“barrier isolator”''' refers to a device comprising an physical film separating an operator or clinician from a work process. The work process is maintained within an isolated environment which may be held at a positive or negative pressure.

"'''Central Sterile Supply Department (CSSD)"''' means a facility for the receiving, decontamination, preparation, packing, sterilizing, storing and issuing of sterile and disinfected instruments and other reusable materials. This facility is also known as the "sterilisation and disinfection unit"(SDU);

"'''cleaners' room'''" means a room for the storage of cleaning equipment, the drawing of clean water and the disposal of dirty water, washing and drying of cleaning equipment. This room may be combined with the dirty utility room;

"'''clean air'''" means air that does not contain a considered contaminant;

"'''clean utility room'''" means a room for the storage of sterilized packs, dressings-, sterile equipment and pharmaceutical supplies respectively; This area may also be used for a set-up area for ward procedures;

"'''considered contaminant'''" means any actual contaminant, surface or airborne, which may have a certain impact which for which measures are taken to avoid;

'''"cross contamination"''' refers to the contamination of any zone or surface by fomites, considered particulates aerosols, biological agents, fumes or gasses originating from another zone or surface.

'''"cross infection"''' refers to the spreading of an infection from one organism to another by cross contamination.

'''"department"''' means a grouping of accommodation which has a specific function within a hospital. Its area includes the associated internal or departmental circulation space

'''"dirty utility room"''' means a room used for collection and temporary storage of used equipment and general ward material; it can combine the activities of the sluice room, the soiled linen and waste room and the cleaners' room;

'''"emergency trolley/crash cart"''' means a mobile cart used for the storage of all appropriate resuscitation equipment and pharmaceuticals;

"'''equipment store'''" means a room used for the storing of monkey chains, traction kits and other general equipment;

"'''fresh air'''" means air drawn from outside air of a building and contamination sources;

"'''high care ward'''" refers to a ward for the care and management of specific types of patients requiring a minimum of eight hours nursing care per patient day;

"'''holding area'''" means an area or room where pre-operative patients in transit to a procedure room/theatre are identified and continuously monitored by nursing personnel;

"'''induction room'''" means an area where patients are prepared for surgery/invasive procedures prior to being transferred to the operating theatre;

"'''intensive care unit'''" means a unit designed, staffed and equipped for the care and management of specific patients, (e.g. medical, cardiac or post-operative) requiring a minimum of twelve hours nursing care per patient day or for the care of a patient who requires ventilation, continuous invasive monitoring, invasive care, or who is clinically unstable and whose life is at risk;

"'''main kitchen'''" means a facility suitably finished and equipped for the receipt, storage and preparation of meals, special diets and beverages;

"'''maternity unit'''" means a unit where antenatal care is provided, babies are delivered and postnatal care is given to mothers and infants;

" '''midwife obstetric unit (MOU)'''" means a maternity unit usually attached to a clinic or a community health centre (CHC), which is staffed by nursing sisters or midwives;

“'''milk kitchen'''” means an area for the preparation of feeds for babies which must be separate from the hospital kitchen or ward kitchen. It must contain a clinical wash hand basin;

"'''mortuary'''" means a facility that receives, holds and allows for the identification of bodies of patients who died in the wards, theatre or casualty department, or who were dead on arrival at the facility; a facility which complies with the

"'''neonatal unit'''" means a facility for premature and new born babies requiring incubation, specific care and monitoring;

"'''nurse station'''" means the control point for all activities in the patient care areas;

"'''nursing unit or ward'''" means a unit with the facilities to accommodate patients as specified in this regulation;

"'''operating room'''” means a room within an operating theatre suite in which surgical or other invasive procedures are carried out;

"'''operating suite'''" refers to rooms within the demarcated area where surgical interventions are performed or support is provided to these surgical activities;

"'''patient room'''" means a room where the patient can be accommodated;

"'''procedure room'''" means a room in which certain restricted procedures generally taking less than one hour can be performed without making use of general anaesthetic, e.g. endoscopies, procedures under local anaesthetic such as suturing of lacerations, removal of skin lesions, biopsies, closed reductions and other similar procedures; May be situated outside the operating suite;

"'''recovery room/ area"''' means the section of the operating suite specially set aside for the immediate post-operative recovery, resuscitation, nursing and special care of patients, until such time as such patients are considered to have recovered sufficiently to be safely removed from the operating suite;

"'''sluice room'''” means a room used for the emptying, cleaning and storage of bedpans and urine bottles; It can be combined with the activities of the soiled linen and cleaners' rooms in the dirty utility room;

“'''specialised area'''” means any clinical area rendering specialised services such as intensive care, high care, or rehabilitation, for which additional space around the patient is required;

"'''soiled linen and waste room"''' means a room used for the collection and temporary storage of soiled linen and waste; May be combined with the dirty utility room

"'''treatment room'''" means a room used for treatment of patients in the wards, containing a clinical wash hand basin;

“'''ventilation”''' means “The process of supplying air to or removing air from a space for the purpose of controlling air contaminant levels, humidity or temperature within the space”. ASHRAE Standard 62.1-2007, Section 3

'''“validation”''' means the method of proving and documenting that an installed system or process performs reliably as intended and required.

'''“natural ventilation”''' means “Ventilation provided by thermal, wind, or diffusion effects through doors windows or other intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3

"'''ward kitchen'''” means the room that forms an integral part of a nursing unit or units, for the preparation of snacks and beverages; It also includes the area for the heating, storage and refrigeration of meals;

"'''uninterrupted power supply'''" means a battery system, which in the event of a normal mains supply failure will provide immediately the electrical supply for essential equipment and lighting.
[[Category:Crosscutting Issues]]
[[Category:Water Distributions Systems]]
[[Category:Legionella Control]]
[[Category:Ventilation]]

Ventilation and COVID-19

2021-08-19T12:56:21Z

Tobyvan: /* Transmission routes */ removed fomite from preferential route list

[[Category:COVID-19]]
[[Category:Crosscutting Issues]]

==Context==
This article aims to to contextualize COVID-19 related ventilation guidelines in a field of developing clinical evidence. This is done with the hope of empowering the reader to scrutinize proposed interventions within this context and employ appropriate and efficient solutions. The information and guidance in this article is the developing opinion of the author and does not represent any regulatory or institutional mandate or authority. The evidence supporting this opinion is evolving and therefore the opinion is similarly subject to change. The reader is encouraged to return to this article frequently to review any changes additions or updates highlighted in the history tab above.

Discussion and contributions are similarly welcomed in the discussion tab above.[https://thehillside.info/index.php?title=Talk:Ventilation_and_COVID-19#section1]

==Background==

===Transmission routes===
SARS-CoV-2 has caused many to revisit their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing, while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet spread''' with opportunistic airborne spread possible in specific conditions, although an extensive outbreak review revealed no indication of airborne spread as defined for TB or measles<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below.

====van Doremalen et al (NEMJ 2020)====
The van Doremalen SARS-CoV-2 survival study<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref> is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods. No evidence for long range airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> as it was not the study's intention to claim COVID-19 was airborne. A more recent pre-publication article has made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref> but this has significant problems with equipment standardization and repeatability. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains such as Ebola not considered to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref>.

====Guangzhou Restaurant Outbreak (2020)====
[[File:Guangzhou Restaurant COVID-19 2020.png|thumb|Plan of COVID-19 outbreak in Guangzhou Restaurant 2020<ref name=":0">Lu, J., Gu, J., Li, K., Xu, C., Su, W., Lai, Z....Yang, Z. (2020). COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2020. ''Emerging Infectious Diseases'', ''26''(7), 1628-1631. <nowiki>https://dx.doi.org/10.3201/eid2607.200764</nowiki>.[https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article]</ref>]]
The 2020 outbreak of COVID-19 in a restaurant in Guangzhou<ref name=":0" /> raises some important questions around the airborne spread of the disease. This study shows that the transmission range of COVID-19 may exceed the generally prescribed separation distance of 1m under certain conditions, but fails to do so convincingly. Confounding issues that are not addressed adequately in the articles conclusion include:

*the high probability of asymptomatic or pre-symptomatic spread of the virus from members of the index case's family<ref>How Coronavirus Infected Some, but Not All, in a Restaurant, Chang, K (2020) https://www.nytimes.com/2020/04/20/health/airflow-coronavirus-restaurants.html</ref>
*the possibility of onward transmission within family groups after the restaurant exposure is acknowledged but dismissed without discussion
*the difference in exposure times<ref>https://english.elpais.com/spanish_news/2020-06-17/an-analysis-of-three-covid-19-outbreaks-how-they-happened-and-how-they-can-be-avoided.html</ref> between tables (C-B )and (E-F) is not adequately addressed
*The overcrowded and under ventilated conditions in the restaurant.

This is a seminal event in the study of SARS-CoV-2 transmission, but we should be cautious to use it a clear evidence if airborne transmission where similar events are not widespread by now.

===='''South Korea Call Centre Outbreak 2020'''====
[[File:South Korea Call Centre Outbreak COVID-19 2020.png|thumb|Floor plan of South Korea Call Centre Outbreak COVID-19 2020]]
In this pre-publication report, the outbreak in a call-centre on the 11th story of a South Korean office block<ref>Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, et al. Coronavirus disease outbreak in call center, South Korea. Emerg Infect Dis. 2020 Aug [''date cited'']. <nowiki>https://doi.org/10.3201/eid2608.201274</nowiki></ref> offer some extraordinary insights but leaves many questions open. The distribution of the attacks is alarming in the call centre room, but is significantly reduced in adjacent room on the same floor.

The following is a summary of the findings:

*It appears as if the outbreak followed physical compartmentalization and not HVAC zoning although an HVAC plan of the building was not discussed.
*It is clear that COVID-19 is exceptionally contagious in crowded office settings.
*Lobbies and lifts contributed little to spread.
*Exposure time correlated with transmission risk.

Questions that remain:

*HVAC zoning or an HVAC plan of the building was not discussed.
*Ratios of male and female cases would have offered insight into the roles of bathrooms in COVID-19 spread.
*A review of vertical transport characteristics may have offered insight into the vertical distribution of case through the building.

===Aircraft Transmission Studies===
SARS and COVID-19 outbreaks on commercial aircraft have proven to be remarkedly rare. This may be due to the high ventilation rates<ref>Mangili, A., & Gendreau, M. A. (2005). Transmission of infectious diseases during commercial air travel. ''Lancet (London, England)'', ''365''(9463), 989–996. <nowiki>https://doi.org/10.1016/S0140-6736(05)71089-8</nowiki></ref>. Studies tracing contacts on flights seem to show multiple cases of very low to zero transmission rates with the transmission events raising disproportional alarm<ref name=":3">Olsen et al, N Engl J Med 2003; 349:2416-2422Transmission of the Severe Acute Respiratory Syndrome on Aircraft, DOI: 10.1056/NEJMoa031349 [https://www.nejm.org/doi/full/10.1056/nejmoa031349]</ref><ref>CMAJ 2020 April 14;192:E410. doi: 10.1503/cmaj.75015 [https://www.cmaj.ca/content/cmaj/192/15/E410.full.pdf]</ref>. The context of the scope of aircraft outbreak findings highlights the role ventilation has in creating safe environments, but similarly reveals the low risk levels associated with airborne transmission of SARS or COVID-19.

====Amoy Gardens SARS Outbreak (2003)<ref name=":1">McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route<ref name=":1" />, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart, the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system. Similar outbreaks have more recently been found<ref name=":2">Bhowmick, G.D., Dhar, D., Nath, D. et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water 3, 32 (2020). https://doi.org/10.1038/s41545-020-0079-1</ref>. The re-aerosolisation from sanitary systems should be directly compared with long range oral-airborne transmission. The Amoy-Gardens transmission mode was most likely closer to large droplet transmission from toilets and waste outlets.

====Other studies====
Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. Air sampling studies have failed to detect viable SARS-CoV-2<ref>Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. ''JAMA.'' 2020;323(16):1610–1612. doi:10.1001/jama.2020.3227</ref>.

It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.
====High Risk Settings (ICU)====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]] and [https://doi.org/10.1016/j.scitotenv.2020.139076 here]<ref>Kitajima et al,SARS-CoV-2 in wastewater: State of the knowledge and research needs,Science of The Total Environment,Volume 739,2020,139076,ISSN 0048-9697,<nowiki>https://doi.org/10.1016/j.scitotenv.2020.139076</nowiki></ref>. This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

==Institutional Guidance==
===WHO===
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.
===US-CDC===
The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to its guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

The US-CDC's recommendations regarding inpatient accommodation for SARS includes the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>
The CDC's guidance is consistent with the full context of hierarchical risk-based infection control and is suitably cognizant of variously resourced settings.
"Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)."<ref>Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated July 9, 2020)[https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]</ref>
This nuanced approach is difficult to tease out of the guidance from engineering societies.

{{Anchor|CDC COVID Airborne Precautions}}

====Airborne Transmission based precautions (US-CDC)====
The CDC has made the following recommendations for transmission based precautions. It is notable that this is only for "non-US settings".
Additionally, adequately ventilated single rooms or wards are suggested. For general ward rooms with natural ventilation, adequate ventilation for COVID-19 patients is considered to be 60 L/s per patient. When single rooms are not available, suspected COVID-19 patients should be grouped together with beds at least 1 meter apart based on WHO’s recommendation, although some member states have recommended maintaining greater distances whenever possible<ref name=":4">CDC 2019, COVID-19 Overview and Infection Prevention and Control Priorities in Non-US Healthcare Settings https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html </ref>
This guidance offers no reason or evidence for the suggestion of 60 L/s per patient. It may stem from the WHO's recommendations for 60 L/s per person for medium risk TB settings<ref>WHO 2009. WHO Policy on TB infection control in Health-care facilities, Congregate Settings and Households. [https://www.who.int/tb/publications/tb-facilities-policy/en/ https://apps.who.int/iris/bitstream/handle/10665/44148/9789241598323_eng.pdf?sequence=1]</ref> as it contradicts the CDC's own TB guidance <ref>CDC 2005, Guidelines for Environmental Infection Control in Health-Care Facilities (updated 2019)https://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf</ref>. It is of significance to note that the WHO has omitted this recommendation from its 2019 guidance <ref>WHO 2019, WHO Guidelines on tuberculosis infection prevention and control, 2019 update https://www.who.int/tb/publications/2019/guidelines-tuberculosis-infection-prevention-2019/en/</ref>. This guidance is not prescriptive, supported by evidence nor consistent with other CDC and WHO guidance. Additionally the guidance does not describe how the ventilation performance for naturally ventilated spaces should be verified. See [[#COVID-19 Engineering Response]] for recommended practice

===ASHRAE===
While the US-CDC and WHO maintains that the airborne transmission is possible but not common or of primary concern, ASHRAE (being an association dedicated to ventilation engineering) focuses on the airborne component.
"Transmission of SARS-CoV-2 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating, and air-conditioning systems, can reduce airborne exposures"<ref>Q: Does ASHRAE’s guidance agree with guidance from WHO and CDC? (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/does-ashrae-s-guidance-agree-with-guidance-from-who-and-cdc.pdf]</ref>
ASHRAE makes useful distinctions between guidance for healthcare<ref>ASHRAE healthcare C19 guidance (ASHRAE 2020) [https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-healthcare-c19-guidance.pdf]</ref>, residential <ref>ASHRAE residential c19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-residential-c19-guidance.pdf]</ref><ref>COVID 19 guidance for multifamily building owners-managers (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/covid-19-guidance-for-multifamily-building-owners_managers.pdf]</ref>, commercial <ref>ASHRAE commercial C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-commercial-c19-guidance.pdf]</ref> and schools<ref>ASHRAE Schools C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-schools-c19-guidance.pdf</ref>, but doesn't significantly address risk categories specifically in healthcare or resource limited settings.
===REHVA===
REHVA's temporary guidance is limited to commercial and public buildings<ref>REHVA COVID-19 guidance document, April 3, 2020[https://www.rehva.eu/fileadmin/user_upload/REHVA_COVID-19_guidance_document_ver2_20200403_1.pdf]</ref>. Similar to ASHRAE, REHVA focusses on engineering controls for airborne transmission. REHVA acknowledges importance of droplet precautions and the lack of quality evidence for airborne transmission, but draws the conclusion that SARS-CoV-2 RNA found in ventilation ducting implies airborne transmission, even though these real world studies have not yet proven viability of these particles. REHVA also draws the airborne conclusion from the van Doremalen study<ref name="van Doremalen" /> out of its intended comparative context.

===IUSS (2014)===
The [[Infrastructure_Unit_System_Support|IUSS]] Building Engineering Services Guidelines<ref>Building Engineering Services (2014)[https://iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-services]</ref>, which is mandated for new buildings by provincial departments of health by reference in Government Notice R116<ref>Government Notice R116 (17 Feb 2014)[https://iussonline.co.za/docman/gazettes/116-notice-37348/file]</ref>, describes risk based ventilation criteria which are broadly appropriate for COVID-19, if not excessive. This guideline was developed with control measures for the current TB epidemic in mind. These measures would be more than appropriate for most healthcare spaces. The guidance recommends no recirculation of air between theatres and adjacent spaces but does not prohibit cascading from surgeries to adjacent spaces. Therefore, confirmed COVID-19 patients should only be treated in negative pressure operating rooms that comply with the guidelines.

===SANS 10400-O (2011)===
The 2011 edition of the SANS 10400-O<ref>SABS. SANS 10400-O : 2011 SOUTH AFRICAN NATIONAL STANDARD The application of the National Building Regulations Part O : Lighting and Ventilation. (2011).</ref> is often criticized for over prescribing ventilation rates when compared with international best practice. The mechanical ventilation criteria of this standard, in it current form, prioritizes indoor air quality over energy efficiency and takes a heavy handed approach to ventilation in many spaces. 10 ACH and more is common for areas with any risk of airborne contamination. The standard gives inadequate performance guidance for naturally ventilated spaces.

While the SANS 10400-O:2011 demands unprecedently high ventilation rates and offers little supporting evidence with the criteria, it should be considered better than many international standards for use in general settings where airborne contamination is a risk.

Unfortunately, the SANS 10400-O:2011 does not permit the concurrent use of natural ventilation and air-conditioning and leads designers to incorrectly infer that windows in airconditioned spaces should not be opened/openable.

==Air-Conditioning, Ventilation and COVID-19==
It is important to differentiate between ventilation and air-conditioning when discussion indoor contamination. When the term ventilation is used, it describes any system that induces decontaminated, fresh or outdoor-air to enter a space by the application of supply or extraction systems. Diluting ventilation is the most commonly used regime. Other modes of contaminant removal include displacement and local exhaust ventilation systems, each of which requires its own nuanced discussion as they pertain to infection control.

Air-conditioning in contrast, refers to only the mechanical cooling or heating system, sometimes installed directly in a space (Spit-AC), to offer thermal comfort and sometimes humidity control. In-room air-conditioning systems that circulate air directly within a space with no dilution or extraction can directly offer no reduction in airborne contaminant levels. In some instances they can even assist in the distribution of contaminants.

Openable windows can be considered as ventilation apertures and, in most cases, offer highly effective ventilation. Unfortunately, this is sometimes at the expense of indoor comfort. Even though long range droplet transmission of SARS-CoV-2 is relatively low in comparison to short range transmission, encouraging occupants to open windows will reduce that risk. Allowing occupants to use air-conditioning to either heat or cool a space while windows are open can improve levels of open window compliance which is more important than limiting AC use for reducing long range transmission. An additional strategy to both improve open window compliance and reduce AC usage would be to relax strict corporate dress codes as this can improve thermal comfort levels seasonally.

{{Anchor|COVID-19 Engineering Response}}

==Engineering Response==
Ventilation society guidance understandably bears the risk of being biased toward over-prescribing solutions over which engineers have the greatest understanding and control. It is within this context that the valuable guidance published online by REHVA and ASHRAE should be considered. Revamping existing ventilation systems in resource-constrained healthcare settings to meet admittedly overly-cautious guidance should not be conducted without an informed investment case.
In these resource limited settings, it needs to be carefully considered whether resources are allocated to clinical capacity or to possibly unnecessary ventilation when the benefits of these criteria may be comparatively marginal.

Without good viability studies of the viral particles found in air or ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO, and these conditions should be avoided. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation. Engineers should not be tempted to assume or argue that all indoor spaces bear the same risk profile.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in negative pressure theatres only.
##No recirculation to adjacent spaces (for negative pressure theatres)
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}

===Airborne precautions for settings with uncertain or high residual risk===
Where the verification of engineering responses are uncertain or the residual risk remains high, the following approach is proposed.

Modelling ventilation rates for limiting transmission risk in the context of the proposed quantum generation rate<ref>Noakes, C. J. & Sleigh, P. A. Mathematical models for assessing the role of airflow on the risk of airborne infection in hospital wards. J. R. Soc. Interface 6, S791–S800 (2009). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843948/</ref> for airborne COVID-19 <ref>Zhao, Dai, preprint 2020, Association of infected probability of COVID-19 with ventilation rates in confined spaces: a Wells-Riley equation based investigation https://doi.org/10.1101/2020.04.21.20072397</ref> supports the conclusion that the COVID-19 ventilation rates should be not less that 59.7 L/s per person for an 8 hour exposure in a 100 seater waiting room, which (coincidentally) matches the WHO's previous recommendations for medium risk spaces and the CDC's adoption of that value for COVID-19 ([[Ventilation and COVID-19#CDC COVID Airborne Precautions|see above]]).
Reducing the exposure time would reduce the required ventilation rate. 8h is assumed to keep staff and patients equally "safe". Obviously additional precautions are recommended for health care staff to control for repeated daily exposure.
A significant problem with the WHO and CDC recommendation of 60 L/s per patient (person) is that an individual's risk increases from 1% to nearly 40% as this criteria is applied to room populations decreasing from 100 persons.

To maintain a personal risk below 1% the following correction is advised:
<math>Q/n = 60 \times \bigl(A/n) </math>
<math>\therefore Q = 60 \times \bigl(m^2 per person) </math>

Where '''Q''' is the ventilation rate <math>(L/s\cdot m^2)</math>, '''A''' is the floor area <math>(m^2)</math> and n is the maximum number of people in the space. Air changes per hour (ACH) can be estimated with <math>ACH = Q \times 3.6 \div h </math>, where <math>h</math> is the ceiling height.

Assuming face masks reduce transmission by 40%, ventilation rates of '''38''' <math>L/s\cdot person</math> would be required to control airborne transmission. This sounds like a lot until the social distancing and decongestion measures required for droplet precautions are applied. under these conditions this equates to only '''4.23''' <math>L/s\cdot m^2</math> or between 4 and 5 ACH (assuming a 3.2m ceiling height). This should be easily achievable for naturally ventilated spaces and could be verified by measuring average indoor CO2 concentrations no greater than '''170 PPM''' above outdoor.

==Conclusion==
Therefore, assuming ventilation systems in South Africa have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas and adjusting distancing rules.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
<references />
[[Category:ASHRAE]]
[[Category:REHVA]]
[[Category:IUSS]]
[[Category:Airborne Infection control]]
[[Category:Airborne Contamination Control]]

Main Page

2021-05-21T06:28:19Z

Tobyvan: changed blurb to give better result in google search result

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==Welcome to The HILLSIDE==
The '''Health Infrastructure's Living Library''' for Sustainable Innovation, Design and Engineering [HILLSIDE]

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COVID-19 specific infrastructure guidance can be accessed through the links below
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__NOTOC____NOEDITSECTION__

Legionella Control

2021-05-04T15:46:10Z

Tobyvan: /* HISTORY */

{{Stub}}
{{Anchor|Section1}}
==INTRODUCTION==

==HISTORY==
[[File:The first Legionnaires’ disease outbreak.png|thumb|The first Legionnaires’ disease outbreak]]Legionnaires’ disease was first described after a pneumonia outbreak at an American Legion Convention held in Philadelphia during 1976. In total, 182 delegates were affected and 29 died before workers at the Centers for Disease Control and Prevention (CDC) based in Atlanta, USA isolated the causative organism in January 1977. The organism was placed in the family Legionellaceae, genus Legionella to commemorate the first victims of the disease. The first species was named Legionella pneumophila (Greek for “lung loving”).

It soon became clear that legionellae were not really new; retrospective studies showed that an organism isolated for the first time in 1944 (called Tatlockia micdadei) actually belonged to the genus Legionella. The first strain of Lpneumophila was isolated already in 1947 from a guinea pig that had previously been inoculated with blood from a patient with what was called an “unknown febrile disease” at the time.

The two decades following the discovery of the family Legionellaceae was marked by rapid developments in Legionella detection and the identification of numerous new species. Twenty-eight new Legionella species and two “Legionella-like amoebal pathogens” (LLAPs) (LLAP-1 and LLAP-6) were isolated during the 1980s, mostly from sources in the USA. The 1990s were marked by an increase in Legionella isolation from countries in Europe and Australia with fifteen new Legionella species being described for the first time.
[[File:LegionellaPneumophila.jpg|alt=Intracellular Legionella organisms|thumb|Intracellular Legionella organisms]]
[[File:Gimenez stain- Legionella bacteria.png|thumb|Gimenez stain- Legionella bacteria]]More than half of the currently known Legionella species are potentially pathogenic to humans. L. pneumophila is still implicated in >80% of infections; however, as more species are isolated from environmental sources worldwide, even those species not yet associated with disease should be considered as potentially pathogenic until proven otherwise. For example, L. longbeacheae, often isolated from potting soil, is considered the most common cause of legionellosis in Australia.

Legionellae are faintly staining gram negative, rod-shaped, non acid fast bacteria that to not form spores or capsules. All species except L. oakridgensis are motile. Legionellae are typically between 0.3 and 0.9 µm wide and 1- 20 µm long. However, shorter forms measuring 1- 2 µm in length are often observed in clinical specimens or under conditions of iron deprivation.

The ability of legionellae to grow in water is influenced by several factors. They can grow at temperatures between 20°C and 60°C, with optimal growth occurring between 37°C and 45°C. They prefer a pH in the range of 5.0 9.5 and only grow in the presence of Lcysteine, HCl and iron salts. Legionella-like amoebal pathogens (LLAPs) are very similar to Legionella species in that they are gram negative, infect amoebae and can survive and multiply intracellularly. However, they cannot be cultured on laboratory media. The first LLAP was isolated<ref>Adeleke AA, Fields BS, Benson RF, Daneschvar MI, Pruckler JM, Ratcliff RM, Harrison TG, Weyant RS, Birtles RJ, Raoult D and Halablab MA (2001). Legionella drozanskii sp. nov., Legionella rowbothamii sp. nov. and Legionella fallonii sp. nov., three unusual Legionella species. Int. J. Sys. Evol. Microbiol. 51: 1151-1160</ref> from soil in Poland in 1954 and was named Sarcobium lyticum. The next isolation of an LLAP was in England more than 20 years later. Since then, LLAPs have been isolated from various sources, mostly associated with confirmed cases or outbreaks of <ref>De Gheldre Y, Maes N, Presti FL, Etienne J and Struelens M (2001). Rapid identification of clinically relevant Legionella species by analysis of transfer DNA intergenic spacer length polymorphism. ''J. Clin. Microbiol.'' '''39''': 162-169.</ref><ref>Adeleke AA (1996). Legionella-like amoebal pathogens phylogenetic status and possible role in respiratory disease. ''Emer. Infect. Dis.'' '''2''': 225-230.</ref> Legionnaires’ disease. Three of the LLAPs have since been reclassified as L. drozanskii, L. rowbothamii and L falloni. The currently known LLAPs are listed in the table below.

===INTERACTIONS WITH PROTOZOA===
Legionellae are slow-growing organisms that require a combination of nutrients for growth. Due to their fastidious nature and lack of antibiotic activity, they may be replaced by faster growing organisms if they do not have an alternative means of survival in aquatic environments. The fact that legionellae are ubiquitous in these environments suggests that protozoa, especially amoebae, play a supportive role in their survival and multiplication. In fact, their natural habitat, parasitic to protist hosts, has now been<ref>McCoy WF (2004). Legionella. In: Cloete TE, Rose J, Nel LH and Ford T (eds). Microbial waterborne pathogens. IWA Publishing, UK. <nowiki>ISBN 1 84339 055 8</nowiki>. Pp 100-131</ref> proven.
{| class="wikitable"
|+'''Legionella species'''
!ORGANISM
!SG
!YEAR
!SOURCE
!PATHOGEN
|-
|L adelaidensis
L anisa

L beliardensis

L birminghamensis

L bozemanii

L brunensis

L cherrii

L cincinnatiensis

L donaldsonii*

L drozanskii (LLAP-1)

L dumoffii

L erythra

L fairfieldensis

L fallonii (LLAP-10)

L feeleii

L geestiana

L gormanii

L gratiana

L gresilensis

L hackeliae

L israelensis

L jamestowniensis

L jordanis

L lansingensis

L londiniensis

L longbeacheae

L lytica

L maceachernii

L micdadei

L moravica

L nautarum

L oakridgensis

L parisiensis

L pittsburghensis

L pneumophila

L quateirensis

L quinlivanii

L rowbothamii (LLAP-6)

L rubrilucens

L sainthelensi

L santicrucis

L shakespeari

L spiritensis

L steigerwaltii

L taurinensis

L tusconensis

L wadsworthii

L waltersii

L worsleiensis
|1
1

1

1

2

1

1

1

*

1

1

2

1

1

2

1

1

1

1

2

1

1

1

1

1

2

1

1

1

1

1

1

1

1

15

1

2

1

1

2

1

1

1

1

1

1

1

1

1
|1991
1985

2001

1987

1980

1989

1985

1988

2002

2001

1980

1985

1991

2001

1993

1980

1991

2002

1985

1985

1985

1982

1994

1993

1982

1996

1985

1980

1989

1993

1983

1985

1980

1979

1993

1990

2001

1985

1984

1985

1992

1985

1985

1999

1990

1983

1996

1993

1993
|Cooling water (Adelaide Australia)

Faucet (Chicago), tap water (LA)

Water, France

Lung biopsy (Alabama)

Lung aspirate (Toronto)

Cooling tower water (Czechoslovakia)

Thermally altered water (Minnesota)

Lung tissue (Cincinnatti)

<nowiki>*</nowiki>

Tank of well water (Leeds 1981)

Lung tissue

Cooling tower water (Seattle)

Cooling tower water (Fairfield Australia)

Ship air conditioner (1994)

Grinding machine coolant fluid

Hot water tap, office building (London)

Bronchial wash of pneumonia patient

Thermal spa water (France)

Water, France

Bronchial biopsy (Ann Arbour)

Water (Israel)

Wet soil (New York)

Water and sewage (Israel)

Bronchial washing, hloramin patient

Office building cooling tower (London)

Human lung (Longbeach Australia)

Previously Sarcobium lyticum

Water (Phoenix)

Human blood via yolk sac

Cooling tower water (Czechoslovakia) Hot water tap (London)

Cooling tower water (Pennsylvania)

Cooling tower water (Paris)

Synonym for L micdadei, strain

TATLOCK

Water (Pennsylvania)

Shower in hotel bathroom (Portugal)

Water in bus airconditioner (Australia)

Water and sludge, industrial liquefier

Tap water (Los Angeles)

Spring water (Washington)

Tap water (Virgin Islands)

Cooling tower water (England)

Lake water (Washington)

Tap water (Virgin Islands)

Water, hospital humidifier (Italy)

Pleural fluid, transplant patient (Arizona)

Sputum

Potable water system (Australia)

Industrial cooling water (England)
|Unknown

Yes

Unknown

Yes

Yes

No

Yes

Yes

<nowiki>*</nowiki>

Yes

Yes

No

Unknown

Yes

Yes

Unknown

Yes

No

Unknown

Yes

No

No

Yes

Yes

Unknown

Yes

Yes

Yes

Yes

No

Unknown

Yes

Yes

Yes

Yes

Unknown

No

Yes

Yes

Yes

No

Unknown

No

No

Unknown

Yes

Yes

Unknown

Unknown
|}
{| class="wikitable"
|+'''Legionella-like amoebal pathogens (LLAPs)'''
|'''STRAIN'''
|'''HOSTS'''
|'''YEAR'''
|'''ORIGINAL SOURCE'''
|'''PATHOGENIC'''
|-
|Sarcobium lyticum
|A polyphaga

H vermiformis
|1954
|Soil
|Yes
|-
|LLAP-1
|A polyphaga
|1981
|Tank of portable water well
|Yes
|-
|LLAP-2
|A polyphaga

H vermiformis
|1986
|Garage steam cleaning pit
|Yes
|-
|LLAP-3
|A polyphaga
|1986
|Sputum from pneumonia patient
|Yes
|-
|LLAP-4
|A polyphaga
|1986
|Hospital whirlpool bath
|Yes
|-
|LLAP-5
|A polyphaga
|1988
|Nursing home plant spray
|Yes
|-
|LLAP-6
|A polyphaga

H vermiformis
|1988
|Factory liquefier tower
|Yes
|-
|LLAP-7
|A polyphaga

H vermiformis
|1991
|Hotel whirlpool spa
|Yes
|-
|LLAP-8
|H vermiformis
|1990
|Hospital shower
|Yes
|-
|LLAP-9
|A polyphaga

H vermiformis
|1992
|Factory cooling tower
|Yes
|-
|LLAP-10
|A polyphaga
|1994
|Ship air-conditioning system
|Yes
|-
|LLAP-11
|A polyphaga
|1993
|Furnace cooling system
|Yes
|-
|LLAP-12
|A polyphaga
|1994
|Furnace cooling system
|Yes
|}

Rowbotham<ref>Rowbotham TJ (1980). Preliminary report on the pathogenicity of ''Legionella pneumophila'' for freshwater and soil amoebae. ''J. Clin. Pathol.'' '''33''': 1179-1183</ref> was the first to demonstrate interactions between legionellae and protozoa. To date, protozoa of the genera Acanthamoeba, Tetrahymena, Naegleria, Echinamoeba and Vanella species have been implicated in these interactions. Not much is known about the metabolic and physiological status of legionellae after passage through protozoa, but in vitro studies have shown changes in their physiological status resulting in iron deprivation, possibly changing the susceptibility of the released bacteria to chemical inactivation. Although they can survive extracellularly, this phase is believed to be only temporary while they are searching for new hosts to<ref>McNealy T, Newsome A, Johnson R and Berk S (2000). Impact of amoebae, bacteria and tetrahymenae on ''Legionella pneumophila'' multiplication and distribution in an aquatic environment. In: Marre R, Abu Kwaik Y, Bartlett C, Cianciotto NP, Fields BS, Frosch M, Hacker </ref> infect. Furthermore, it was recently documented that very few Legionella bacteria are needed to start intracellular replication. Some workers have reported a 7000 times increase in Legionella colony forming units (CFU) after intracellular replication but there is no consensus yet as many believe that this intracellular replication cycle is not necessary for the proliferation of legionellae within mixed bacterial populations. From these studies it is clear that there is still extensive research to be done on this aspect of Legionella survival in the environment. Until more becomes known, it is unsafe to assume that the absence of protozoa within water samples prevents the survival of legionellae; as long as there are other bacterial species present, appropriate measures should be taken to prevent Legionella proliferation.

===HOW DOES THE INTERACTION WITH PROTOZOA BENEFIT LEGIONELLAE?===
Amoeba trophozoites feed and multiply in water and biofilm. When conditions become unfavourable, these trophozoites are transformed into cysts with hard, impermeable outer walls that provide protection for ingested Legionella organisms. When conditions become more favourable, the cysts change to trophozoites again and the bacteria are set free. Legionellae have been<ref>Kilvington S and Price J (1990). Survival of ''Legionella pneumophila'' within ''Acanthamoeba polyphaga'' cysts following chlorine exposure. ''J. Appl. Bacteriol.'' '''68''': 519-525</ref> recovered from cysts treated with 50 parts per million (ppm) chlorine suggesting a high level of protection by the cysts. This high resistance of amoebal cysts to biocides may be the mechanism for the apparent reseeding of water systems by legionellae often experienced in the water treatment industry. However, recontamination may also occur via transmission of airborne cysts acting as carriers for the legionellae.

===HOW IMPORTANTIS LEGIONELLA IN SOUTH AFRICA?===
Very little has been published on Legionella in South Africa. After the initial introduction of diagnostic laboratory tests in 1979, legionellosis cases were identified in Durban, Port Elizabeth and Johannesburg during the early 1980's. By 1982, antibodies to L.<ref>Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D and Klugman KP (1994). “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. '''84''': 678-682</ref><ref name=":1">Mauff AC and Koornhof HJ (1984). Legionellosis in South Africa. In: Thornsberry C, Balows A, Feeley JC and Jakubowski W (eds). Proceedings of the 2nd International Symposium on Legionella. American Society for Microbiology, Washington DC</ref> pneumophila had been demonstrated in 10% of hospitalised pneumonia patients, a figure that was confirmed in 1994. A high<ref name=":1" /><ref>Bartie C and Klugman KP (1997). Exposures to ''Legionella pneumophila'' and ''Chlamydia pneumoniae'' in South African mine workers. ''Int. J. Occup. Environ.'' ''Health'' '''3''': 120-127</ref><ref>Ratshikhopha ME, Klugman KP and Koornhof HJ (1990). An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires' disease in South Africa. ''South African Med. J.'' '''77''': 392-395</ref> prevalence of antibodies was also demonstrated in workers in the mining industry and the general public. Despite this high prevalence, only one Legionnaires' disease outbreak and less than 40 sporadic cases have been reported since legionellosis became notifiable in 1990. Similarly, very little is known about the prevalence of Legionella in the South African environment. Low concentrations of<ref>Grabouw NA, Pienaar EJ and Kfir R (1991). The occurrence of Legionella bacteria in cooling towers in South Africa. ''Wat. Sci. Tech.'' '''24''': 149152</ref> legionellae were reported in 77% of cooling towers in a large study reported in 1991. More recently, culturable legionellae were present in 82% of industrial water samples tested; 54% of these samples yielded legionellae in numbers equal to or in excess of 1000 11 CFU/ml3

===LEGIONELLA DETECTION===
Classical detection methods for Legionella species relied on the inoculation of susceptible guinea pig hosts. Although selective, these methods were expensive and time consuming and were soon replaced by isolation by culture on agar media. To improve the recovery of legionellae by culture, the use of certain selective media and steps were introduced to minimise contamination by nonlegionellae. In attempts to simplify Legionella identification, radioimmunoassays (RIAs), enzyme linked immunosorbent assays (ELISAs), agglutination tests and nucleic acid probes and polymerase chain reaction (PCR)-based assays have since been developed and tested.

Despite the relative success of these new methods for the detection of environmental legionellae, culture remains the method of choice. However, no single culture method has so far proven to be ideal for all samples in all given circumstances and environments. Even in the absence of contaminating bacteria or other inhibitory substances, the detection of small numbers of legionellae from environmental samples remains difficult. This, together with the lack of standardisation of methods, complicates the interpretation of culture results and comparisons of results from different laboratories. Variations in bacterial numbers in different areas within a water distribution system and the sampling method used often complicate the interpretation of culture results even further.

Previous studies have shown that the culture of Legionella species from environmental samples is complicated by the presence of <ref>Bartie C, Venter SN and Nel LH (2001). Identification methods for Legionella from environmental samples. ''Water Res.'' '''37''': 1362-1370</ref><ref>Bartie C, Venter SN and Nel LH (2003). Chapter 56. Legionella detection from South African cooling water systems. In: Marre R, Abu Kwaik Y, Bartlett C, Cianciotto NP, Fields BS, Frosch M, Hacker J and Lück PC (eds). Legionella. ASM Press, Washington DC. Pp 284-290. ISBN 1-55581-230-9</ref> faster growing bacteria due to inhibition of legionellae on culture media in the presence of heterotrophic bacteria. For example,<ref>Hussong D, Colwell RR, O'Brien M, Weiss E, Pearson AD, Reiner RM and Burge WD (1987). Viable ''Legionella pneumophila'' not detectable by culture on agar media. ''Biotechnology'' '''5''': 947-950</ref> Pseudomonas aeroginosa secrete bacterial substances into the surrounding media that dramatically inhibit Legionella growth. Although culture is still the gold standard, it remains time consuming and requires a certain level of technical skill. Legionellae may also enter a “viable but non-culturable (VBNC)” state under certain conditions which complicated culturing even further.)
{| class="wikitable"
|+'''Selected characteristics of Legionella species'''
|
|'''Lp'''
|'''Lm'''
|'''L boz'''
|'''L dum'''
|'''L gor'''
|'''L long'''
|'''L jor'''
|'''L oak'''
|-
|Growth on BCYE

Growth on TSB

Acid production

Gelatin hydrolysis

Urease

Primary growth on FG

Beta lactamase

Hippurate hydrolysis

Browning of tyrosine medium

Blue fluorescence on CYE
|<nowiki>+</nowiki>

-

-

+

-

+

+

+

+

-
|<nowiki>+</nowiki>

-

-

+

-

-

-

-

-

-
|<nowiki>+</nowiki>

-

-

+

-

- +/-

-

+

+
|<nowiki>+</nowiki>

-

-

+

-

-

+

-

+

+
|<nowiki>+</nowiki>

-

-

+

-

-

+

-

+

+
|<nowiki>+</nowiki>

-

-

+

-

-

+ or –

-

+

-
|<nowiki>+</nowiki>

-

-

+

-

-

+

-

+

-
|<nowiki>+</nowiki>

-

-

-

- nt

+/-

-

+

-
|-
| colspan="9" |''Nt: not tested, +/- weak positiv; L'' ''p L. pneumophila; Lm L. micdadei; Lboz L. bozemanii; Ldum L. dumoffii; Lgor L. gormanii; Llong L. longbeacheae; L jor L jordanis; Loak L. oakridgensis.''
|}
Recent developments in the molecular field opened doors for new detection assays of waterborne pathogens such as Legionella. These methods include:

* DNA probe hybridisation;<ref>Palmer CJ, Tsai YL, Paszko-Kolva C, Mayer C and Sangermano LR (1993). Detection of Legionella species in sewage and ocean water by the polymerase chain reaction, direct fluorescent staining and plate culture methods. ''Appl. Environ. Microbiol.'' '''59''': 3618-3624</ref>
* Restriction enzyme digestion;<ref>Bej AK, Mahbubani MH DiCesare JL and Atlas RM (1991). Polymerase chain reaction gene probe detection of microorganisms by using filter-concentrated samples. ''Appl. Environ. Microbiol''. '''57''': 3529-3534</ref>
* Polymerase chain reaction;<ref name=":2">Mahbubani MH, Bej AK, Miller R, Haff L, DiCesare J and Atlas RM (1990). Detection of Legionella pneumophila with polymerase chain reaction and gene probe methods. ''Mol. Cell. Probes'' '''4''': 175-187</ref><ref name=":3">Ferguson DA Jr. and Mayberry WR (1987). Differentiation of Legionella species by soluble protein patterns in polyacrylamide slab gels. ''Microbios.'' '''52''': 105-114.</ref>
* Soluble protein patterns;<ref>Lo Presti F, Riffard S, Meugnier H, Reyrolle M, Lasne Y, Grimont PA, Grimont F, Benson RF, Brenner DJ, Steigerwalt AG, Etienne J and Freney J (1998). ''Legionella gresiliensis'' sp. nov. and ''Legionella beliardensis'' sp. nov. isolated from water in France. ''J. Clin. Microbiol.'' '''36''': 193-197</ref>
* DNA restriction endonuclease profiles;<ref>Woods TC, McKinney RM, Plikaytis BD, Steigerwalt AG, Bibb WF and Brenner DJ (1988). Multilocus enzyme analysis of ''Legionella dumoffii''. ''J. Clin. Microbiol.'' '''26''': 799-803</ref>
* Multilocus enzyme analysis;<ref>Ehret W, Anding G, Tartakovski I and Ruckdeschel G (1993). Molecular epidemiology of outbreak-associated Serogroup 1 isolates. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225</ref>
* Orthogonal-field-alteration gel electrophoresis;<ref>Diogo A, Veríssimo A, Nobre MF and Da Costa MS (1999). Usefulness of fatty acid composition for differentiation of Legionella species. ''J. Clin. Microbiol.'' '''37''': 2248-2254</ref>
* Sodium dodecyl sulphate poly-acrylamide gel electrophoresis (SDS-PAGE).<ref>Ng DLK, Koh BB and Heng BH (1997). Comparison of polymerase chain reaction and conventional culture for the detection of legionellae in cooling tower waters in Singapore. ''Lett. Appl. Microbiol.'' '''24''': 214</ref><ref>De Klerck P, Vereist L, Duvivier L, Van Damme A and Olivier F (2003). A detection method for Legionella spp in (cooling) water: fluorescent ''in situ'' hybridisation (FISH) on whole bacteria. ''Wat. Sc. Tech.'' '''47''': 143-146</ref>

[[File:Legionella colonies on agar.png|alt=Legionella colonies on agar|thumb|Legionella colonies on agar]]

====Polymerase chain reaction (PCR)====
Although the sensitivity of most of these techniques is insufficient for direct detection of legionellae in environmental samples, <ref name=":2" /><ref name=":3" /> PCR has proven to be a sensitive and rapid alternative to culture. Many PCR assays have been described, but relatively few of them have been extensively studied on clinical as well as environmental samples and none are routinely used.

====Immunofluorescence====
Immunofluorescence is a technique whereby antigen and antibody is bound to a fluorochrome (fluorescent stain) and then allowed to react with the corresponding antigen or antibody on a microscope slide. The results are viewed under a fluorescent microscope. There are many variations of immunofluorescent techniques but only direct immunofluorescence (DFA) and indirect immunofluorescence (IFA) is of importance in the confirmation of environmental legionellae. Direct immunofluorescence (DFA) is most commonly used for confirmation of Legionella species from environmental samples. The test is simple to perform, but interpretation requires a fair amount of experience, especially in highly contaminated samples. Antigen from the sample is fixed to a microscope slide using heat or acetone and covered with fluorescein-isothiocyanate (FITC) labelled globulin. Antigens in the sample bind to the labelled globulin and the resulting antigen-antibody complexes are visible under ultraviolet light. Direct immunofluorescence (DFA) is useful to detect antigens in clinical samples when cultures cannot be obtained, but its value for environmental samples is controversial. Nevertheless, it is used as a screening test by some laboratories. Cross-reactions that may lead to false positive results have been documented.
[[File:Legionella immunofluorescence.png|alt=Legionella immunofluorescence|thumb|Legionella immunofluorescence]]

====Fluorescent in situ hybridization====
Fluorescent in situ hybridization (FISH) is a technique whereby a fluorescent labeled DNA probe is used to detect a particular chromosome or gene that can then be visualised by fluorescence microscopy. FISH tests are useful for the detection of legionellae in respiratory tract samples but has not been extensively tested in environmental samples. The method makes use of oligonucleotide probes targeting rRNA and offers a fast and specific alternative to direct immunofluorsecence, culture and urine antigen testing in clinical laboratories.

=== References ===
<references />
=='''THE CHAIN OF INFECTION'''==
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate. Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.'''10'''

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

*'''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

*'''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

*'''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

*'''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

*Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997 '''WHAT TO TAKE INTO ACCOUNT WHEN INTERPRETING LABORATORY RESULTS'''

*Both IgM and IgG should be measured simultaneously.
*Diagnostic IgM titres will provide an earlier diagnosis than IgG because they indicate a primary immune response.
*Results obtained by the IFA should always be interpreted in conjunction with the clinical presentation of the disease.
*Titres below the diagnostic level together with clinical manifestations may be useful for early provisional diagnosis of Legionnaires’ disease; but diagnosis by IFA is usually retrospective.
*The interpretation of the IFA should take into account the variation in the time of appearance of antibodies, the types of antibodies produced and the length of time the antibodies are detectable in sporadic cases, as well as the prevalence of antibodies in the population from which the patient comes.
*The type of reagents used for IFA tests may influence the results: ether-killed, formalin-killed or heat-killed antigens vary in sensitivity and specificity and this should be taken into account in the interpretation.
*False negative results may be reported because a long time is needed for seroconversion to occur and not all species and serogroups are detectable by this method.
*Seroconversion (a fourfold rise in titre to at least 1:128) is considered as a presumptive positive result.
*A single titre of 1:256 or higher is regarded as a presumptive positive result.
*Serological results should preferably be confirmed by culture.
*In communities with low antibody prevalence, a single titre of 1:128 may be diagnostic and where the prevalence is high, a single titre of 1:256 may still provide only presumptive evidence of infection.
*Low titres usually indicate past infections.
*When titres to multiple antigens are raised, the titre that is fourfold higher than the others is considered to be diagnostic.
*In epidemiological studies diagnostic titres are usually one twofold dilution higher than for sporadic cases.

===HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

 
[[File:FIGURE 3.3.jpg|center|thumb|500x500px|Figure 3.3 Histological section of lung of Legionnaires disease patient]]
 

===CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

*Initial involvement is unilateral, predominantly in the lower lobe
*Bilateral involvement has been described
*Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction
*Pulmonary densities enlarge during later stages of disease
*Pulmonary densities have a typical ground glass appearance or dense consolidation
*Total opacification of the lung may occur
*Pleural effusions are present in 24-63% of cases caused by L pneumophila
*Pleural effusions are uncommon in L micdadei infections
*Hilar adenopathy seldom occurs
*Cavitation may occur in immunocompromised patients
*Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called ''Acanthamoeba'' filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to ''L pneumophila, L feelei and L anisa''. Complete recovery usually occurs in 2 – 5 days without medical attention.

==CHAPTER 4==

===SURVEILLANCE FOR LEGIONELLA===
A major aspect of biosafety in the workplace is the assessment of hazards and risks of infection (environmental surveillance) and disease in workers (clinical surveillance). ENVIRONMENTALSURVEILLANCE Environmental surveillance is essential for the long term success of any water treatment program for Legionella to provide baseline environmental information to ensure the efficiency of disinfection and water treatment programmes and to control the risk of infection in events of mechanical failures and human error. The risk of contracting legionellosis can be summarised in terms of three factors, as summarised in Table 4.1. Table 4.1 Factors determining the risk of legionellosis Proliferation potential This potential exist in nearly all water systems and depends on many factors, including:  Presence of microbial biofilms  Diversity of microorganisms present  Availability of nutrients Exposure potential Certain industrial processes produce aerosols during their function. These aerosols can be aspirated (breathed deep into the lung) if the particle size is small enough (< 8 µm in diameter). Assessment of exposure potential thus focuses on the proximity of aerosol-generating systems to human populations. Population susceptibility The most susceptible individuals are elderly people (especially males), heavy smokers, alcoholics, patients with chronic pulmonary disease and immuno-suppressed people. 1 Source: McCoy 2004 4.1 RISK ASSESSMENTS A risk assessment is a scientifically based process used to estimate the likelihood of adverse effects occurring, taking into account the exposure (hazard), the level and nature of the risk and the target population. Risk assessments can be either quantitative or 1 qualitative. 4.1.1 Quantitative risk assessments Quantitative risk assessments involve the establishment of dose-effect and dose-response relationships in likely target individuals and populations. For a quantitative risk assessment to be successful, dose-response assessments, the extent and duration of human exposure and characterisation of the possible consequences resulting from exposure have to be determined 1 and quantified. Quantitative risk assessments are not possible for hazardous biological agents (including Legionella) for several reasons. Firstly, exposed people have varying degrees of susceptibility to infection. Secondly, water sources usually contain a diverse mixture of biological contaminants which may change rapidly over short periods of time. Thirdly, the contaminants present and the levels in which they are present are only applicable at the time and area sampled and the interactions among all these 1 biological agents present in the source and environment make exposure assessment extremely difficult. 4.1.2 Qualitative risk assessments Qualitative risk assessments on are done to “document site-specific conditions and recommendations for reducing the risk, if 1 necessary, and to establish assignments for actions, communications, training and management responsibilities”. Anumber of schemes have been developed to provide some form of risk ranking and risk scores to simplify these assessments 1 and to guide the water management plan. An example of a risk ranking for legionellosis is provided in Table 4.2. For example, if a system falls into Risk Category A, the frequency of testing, cleaning and disinfection and monitoring should be increased until the system falls into a lower Risk Category, when the rate of testing, cleaning and monitoring can be reduced again. 19 Table 4.2 Risk classification for legionellosis HIGHEST RISK LOWEST RISK RISK CLASSIFICATION A B C D CRITERIA MATCHES ANY OF THE RESPONSES BELOW MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A OR B MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A, B OR C Stagnant water  System idle more than once a month  Re-circulation pump not timed  Dead-legs present  A plus timed recirculation pump  Any single factor in A  System operates continuously  No dead-legs Nutrients and growth  Contaminated water  No corrosion control  Wet surfaces open to sunlight  Any two factors in A  Any one factor in A  No factors in A Water quality  No automated biocide dosing protocol  No water treatment program  No automated biocide dosing  No water treatment program in place  Automated biocide dosing  No water treatment program in place  Automated biocide dosing  Water treatment program in place Equipment design and operation  No system design review  No system operation and performance review  No drift eliminators  Drift eliminators for cooling towers in place  Same as B with at least one review lacking  System design review in place  System operation and performance review in place  Good drift eliminators Location and access  Located in healthcare or residential care facility  Large numbers of people exposed  Same as A but moderate numbers of people exposed  Same as B but few people exposed  Not located near susceptible people 1 Source: McCoy 2004 4.2 THE RISK ASSESSMENTPROCESS The four most important steps in the risk assessment process are to get an overview of the operation of the water distribution system, to conduct a walk-through investigation of the building or facility, to assess the results of the walk-through to determine an 2,3,4 appropriate course of action and to recommend appropriate control actions. These steps are explained in more detail below. STEP 1 GET AN OVERVIEW OF THE WATER DISTRIBUTION SYSTEM OPERATION Ask the facilities engineer or an experienced member of the building staff, who has knowledge of the design and current operation of the system to explain the system and to assist in the walk-through investigation. The overview should include inspection of: ! Plumbing systems, heating/ventilation/air-conditioning (HVAC) systems and other water reservoirs as summarised in Table 4.3 20 ! Maintenance records of all water systems, including records of temperature checks on potable water, details of visual and physical checks of cooling towers and reports of water quality assessments and chemical treatment that may have been performed ! Location of parts of the system where there may be stagnant water ! The presence of cross-connections between potable and non-potable water systems ! The condition and type of back flow prevention devices used at these connections ! Any recent major maintenance actions performed or major changes in the system ! Determine whether recent or frequent losses of water pressure have occurred from the incoming supply ! Keep in mind that the failure of a back flow prevention device under loss of pressure can result in contamination of the water system Table 4.3 Areas to include when doing an overview of a waterdistribution system Plumbing systems Hot and cold potable water systems Water heaters Water coolers Distribution piping Water treatment equipment (eg. water softeners, filters) Connections to process water systems (not protected by backflow preventers) Storage tanks Heating, ventilation and airconditioning (HVAC) systems Cooling towers Evaporative condensers Fluid coolers Direct and indirect evaporative cooling equipment Humidifiers Location of fresh air intakes relative to water sources Air washers for filtration Miscellaneous reservoirs Decorative fountains Plant misters Whirlpools and spas Tepid water eye washes Safety showers Cooling water for industrial processes 2 Source: <nowiki>http://www.nalco.com</nowiki> STEP 2 CONDUCT A WALK-THROUGH INVESTIGATION OF THE FACILITY Table 4.4 The walk-through investigation WHAT TO DO WHEN ! Check sample transport requirements and receiving times of laboratory before investigation ! Get as much information as possible from staff before investigation ! Go through checklist and make sure you are prepared before investigation ! Check water temperatures while sampling for Legionella ! Check hot water tanks and related piping during investigation ! Check cooling towers during investigation ! Check water quality during investigation ! ! ! ! ! WHO SHOULD BE PRESENT? The person who knows most about the building, particularly the domestic water system Aplumbing engineer if possible Aplumbing contractor who knows the building if possible Arepresentative from the company that services the HVAC system The water treatment specialist who services the cooling tower 21 EQUIPMENT NEEDED ! The floor plan (arrange in advance if possible) ! Drawings of plumbing if available (arrange in advance if possible) ! Inspection checklist ! Camera ! Knife ! Pliers or channel locks ! Measuring tape SAMPLING KITS AND EQUIPMENT TO TAKE WITH ! Thermometer ! Chlorine kit ! Iron kit ! pH meter ! Total dissolved solids (TDS) kit ! Hardness kit ! Calibration fluid ITEMS NEEDED FOR LEGIONELLA SAMPLING ! Sampling log (see example) ! Sodium thiosulfate ! Cooler bag and other materials needed for packaging of sample for transport ! Documentation from courier or transport agency ! Plastic bags for packaging of samples ! Sterile swabs ! Sampling bottles ! Labels for bottles ITEMS NEEDED FOR SAMPLING FOR THE TOTAL BACTERIAL COUNT (TBC) ! Sampling bottles ! Sampling log sheets ! Cooler bag and other materials needed for packaging of sample for shipping or transport ! Documentation from courier or transport agency ! ! REMEMBER The temperature may be below the gauge temperature of the heater due to heat stratification CHECKLIST FOR FAUCETS CONNECTED TO EACH WATER HEATER ! Maximum temperature of each location that is “close (C)”, “intermediate (I)” or “far (F)” from the heaters ............................................................................................................ REMEMBER You may have to run the water for several minutes before it reaches a maximum temperature at “far” locations CHECKLIST FOR COLD WATER STORAGE TANKS USED FOR RESERVE WATER OR FOR MAINTAINING HYDROSTATIC PRESSURE ! InitialTemperature (°C) .......................................................................................................................... ! Potential for stagnation: high (H), medium (M) or low (L)........................................................................ ! Temperature of cold water line at various locations Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Record both initial temperature and final equilibration temperature on cold water lines ...................... REMEMBER Tanks should be protected from temperature extremes and should be covered to prevent stagnation CHECKLIST FOR EACH STORAGE-TYPE HOT WATER HEATER Temperature of water drawn from it (°C) ................................................................................................. Presence of rust and scale ......................................................................................................................... 22 CHECKLIST FOR COOLING TOWERS, EVAPORATIVE CONDENSERS AND FLUID COOLERS ! Visual evidence of biofilm growth, scale build-up and turbidity ........................................................... ! The location of the tower relative to fresh air intakes ............................................................................ ! Proximity to sources such as kitchen exhausts, leaves, plant materials, or other sources of organic material that may contribute to Legionella growth .............................................................................................. CHECKLIST FOR COOLING TOWERS ! General physical and mechanical condition ........................................................................................... ! Presence and condition of drift eliminators ............................................................................................ ! Basin temperature of water (the tower is working) ................................................................................ REMEMBER Wear appropriate respiratory protection (half face-piece respirator and HEPA filter cartridge) during examination if cooling tower is operating SUMPS FOR COOLING TOWER, EVAPORATIVE CONDENSER AND FLUID COOLERS ! Location and condition ............................................................................................................................ ! Location of any cross-connections between potable and non-potable systems ......................................... REMEMBER Sumps are sometimes located indoors to prevent them from freezing. Cross-connections may be present to supply a back-up source of cool water to refrigeration condenser units or to supply secondary cooling units STEP 3 ASSESS THE RESULTS OF THE WALK-THROUGH TO DETERMINE AN APPROPRIATE COURSE OF ACTION Table 4.5 When is additional action necessary? NO FURTHER ACTION Operating temperatures measured in water heaters is 60°C Delivery temperature at distant faucets is ? 50°C No other potential problems observed TAKE FURTHER ACTION Poor maintenance Operating temperatures below minimums mentioned above STEP 4: RECOMMEND CONTROLACTIONS Remember! These actions may include disinfection of the potable water system as outlined in the section on disinfection 23 Table 4.6 Recommended control actions ACTION EXPLANATION Actions to limit the growth of organisms in water systems: Elimination of dead legs in the plumbing system Insulation of plumbing lines Installation of heat tracing to maintain proper system temperatures Elimination of rubber gaskets Removal or frequent cleaning of plumbing fixtures (eg aerators and shower heads) Water sampling to confirm the presence of Legionella: Not necessary at this stage BUT Customer may want to obtain background information, in which case sampling for Legionella will be helpful To ensure that corrective actions are successful: Sample water after corrective action BUT Customer may want to collect samples before corrective action to assess the extent of the problem but this is not normally done The customer should take the necessary corrective action, even if the pre-sampling tests are negative for the following reasons: Water sampling may produce false-negative results A contaminated portion of the system may have been missed The absence of legionellae at the time of sampling does NOT ensure that the system will remain negative at a later date Limited corrective actions that will not be sufficient: Raising water heater temperature without evaluation of system points of stagnation, heat loss and heat gain, cross-contamination and other factors that may contribute to the growth of Legionella bacteria. LEGIONELLA RISK ASSESSMENT DATA SHEET GENERAL INFORMATION Name of organisation Contact person 1 Contact person 2 Contact person 3 Site address Mailing address Building/area size Building age Type of building 24 RESULTS FROM PREVIOUS LEGIONELLA TESTING DATE RESULT Cooling towers Hot water tanks Outlet swabs Hot water outlets Cold water outlets Mixed outlets Incoming water 25 USEFUL QUESTIONS TO ASK ABOUT THE FACILITY WHEN DOING A RISK ASSESSMENT FOR LEGIONELLA(SOURCE: FREIJE 2001) Incoming mains Number Configuration Water source City - ground City - surface Utility: Private well Water usage Obtained from Water bills Fixture count Meter reading Other Deadlegs Present Policies Past construction Aerators Yes No Type Cold pipes location relative to hot Above Below Same level Pipe material Pipe insulation Cold Hot Both Type used Drinking fountains On chilled loop Individual 26 Fire sprinkler above ducts Yes No Water hammers arrestors or air chambers Water hammers Air chambers Both Sediment on water filters Yes No Other sediment gathering equipment Yes No Describe Connection control and/or backflow devices Yes No Faucets and showerheads Age Condition Water softened Cold water Yes No How Hot water Yes No How Water pressure shock Incidents Brown colour Building units closed off temporarily Yes No Major construction activities Yes No Dates Eye wash stations Mixed Cold Emergency showers Mixed Cold 27 Ice machines present Yes No Decorative fountains present Yes No Piped in coffee/tea/cooldrink centres present Yes No Rubber hoses present Yes No Misters for plants/food/comfort present Yes No Other equipment where water flow through that may produce a spray/mist Yes No Can windows be opened? Yes No HVAC systems +Condition of coils Overall condition Drainage of drip pans Humidifiers in duct? Hot water system Number of HW loops Number of CW loops HW recirculating? CW recirculating? Design temp at tank Design temp at taps Regulators Mixing valves Sensors to detect failures CW storage tanks present? Are they covered? Heaters or sunlight? 28 HOT WATER SYSTEM INSPECTION Model number Serial number Age Horizontal/vertical Condition Insulation Temp on gauge Temp from drain Temp of returning water Capacity/turnover Cleaning regimen Cleaning frequency All pumps used daily? Piping arrangement Draw diagram on separate sheet and attach 29 COOLING TOWER INSPECTION In-house identification Location Make and model Serial number Size Age Basin drainable? Cycling of each Months operating Water treatment company Contact details Cleaning frequency Who does the cleaning How is cleaning done? Is basin fully drained? Excessive foaming? Oily film on surfaces? Scum? Condition of drift eliminators Air bypassing: Around edges? Through holes in tower casing? Fill exposed to sunlight Basin exposed to sunlight Louvres/fill clogged? Louvres/fill damaged? Louvres/fill scale present? Louvres/fill algae present? Filters SAND BAG CARTRIDGE Pressure drop 30 Centrifugal separators Outlet strainers Pressure drop Corrosion/deterioration on Structural members? Safety rails? Ladders? Fasteners? Basin? Water leaks present? Air leaks present? Sump water level Cooling water temp Accessible to passers by? Distance from road Distance from parking Distance from sidewalks 31 COOLING TOWER INSPECTION CHECKLIST 5 Source: Freije 2001 BUILDING TOWER NAME/NUMBER INSPECTOR’S NAME DATE OF INSPECTION SAND FILTERS Water leaks? YES NO Suction air leaks? YES NO Pre-strainer clogged? YES NO Channeling in sand filter media (check quarterly) YES NO Operating pressure If YES, clean the media or replace it with filter sand designed specifically for cooling towers and evaporative condensers (not swimming pools). Clean the under-drain assembly while the media is removed. CENTRIFUGAL SEPARATORS Pressure drop Acceptable based on manufacturer’s chart? YES NO Flow rate Purge operation functional? YES NO UNUSUAL NOISE OR VIBRATION IN Pumps? YES NO Motors? YES NO Fans? YES NO Mounting hardware? YES NO OUTLET STRAINERS In place? YES NO Clogged? YES NO BAG AND CARTRIDGE FILTERS Pressure drop Acceptable based on manufacturer’s recommendations? YES NO If not, clean or replace TOWER STRUCTURE AND CASING Water leaks? YES NO Air leaks? YES NO 32 CORROSION OR OTHER DETERIORATION ON Structural members? YES NO Safety rails? YES NO Ladders? YES NO Fasteners? YES NO Basin? YES NO LOUVERS, FILL AND DRIFT ELIMINATORS Clogged? YES NO Damaged? YES NO Excessive scale or algae growth? YES NO If yes, clean with 6,895 – 10,343 kPa (1,000 – 1,500 psi) water, being careful not to damage fill and eliminator components WATER DISTRIBUTION Is the water distribution balanced? YES NO If not, unclog nozzles SEDIMENT BUILD-UP Sediment build-up around heater elements? YES NO FANS Do fans start and stop properly? YES NO VIBRATION Are the vibration switches operating properly? (check at least annually) YES NO SEASONAL OPERATION Are the seasonal systems working (check at least 3 months before winter) YES NO Are there any parts needed? YES NO If YES, what is needed? Are there any repairs necessary? YES NO If YES, what is needed? 2133 Describe action taken in response to above inspection (include dates): QUESTIONS FOR INFECTION CONTROL COORDINATOR (IF APPLICABLE) History of cases Cleaning of hydrotherapy baths and pools Practices for use and cleaning of portable humidifiers Practices for use and cleaning of nebulizers and other semi-critical respiratory equipment Water treatment for dialysis Contact details: Dental unit present? How is it treated? Contact details: Clinical tests for Legionella available? Policy for testing patients/workers for Legionella? 34 CHECKLIST FOR LEGIONELLA SAMPLING HW tank PRE-FLUSH POST-FLUSH Incoming water Faucets and showerheads Cooling make-up water Decorative fountains Cooling tower basins WATER QUALITY TESTS SAMPLE LOCATION pH Free chlorine Total chlorine Hardness TDS Iron TBC Coliforms WATER TEMPERATURES SAMPLE LOCATION HW after 1 minute (°C) CW after 1 minute (°C) 35 EXAMPLE OFSAMPLING LOG / REQUESTFORM REQUESTFOR TESTING OFWATER SAMPLES FOR LEGIONELLA COMPANYDETAILS .................................................................................................................................................................................................. CONTACTPERSON .................................................................................................................................................................................................. CONTACTDETAILS TEL........................................... FAX ............................................. E-MAIL................................................................ NAME OF PERSON WHO COLLECTED SAMPLES ............................................................................................................................... COLLECTION SITE .................................................................................................................................................................................................. SAMPLE NO LOCATION TYPE TIME COLLECTED COMMENTS Received by ……………………………..……….... Date ……………………….. Time ……………… HEALTH SURVEILLANCE Health surveillance can be defined as the “ongoing collection, comparison, analysis and dissemination of data relevant to public health issues”. The main objectives of health surveillance are to identify disease patterns in different population groups, to develop prevention strategies, to allocate resources for prevention and treatment and to educate health professionals and the general public. Health surveillance can take the form of: ! The notifiable disease reporting system (the first step in the surveillance cycle) ! Laboratory based surveillance (for diseases that can be monitored accurately through the laboratory data used for confirmation of the disease) 36 ! Hospital-based surveillance (where hospital discharge information and mortality data are used to monitor trends and disease burden in a particular area) ! Population-based surveillance (where data from a well-defined population are collected and analysed) DISEASE NOTIFICATION Disease notification serves as a means of collecting data on diseases that are considered to be of public health importance and is used world wide. Most countries (including South Africa) have a routine notification system requiring health professionals to report the occurrence of cases and deaths related to certain notifiable conditions. In South Africa, 39 medical conditions are currently 6 notifiable (Table 4.7). The notification system in South Africa is based on Health Act No. 63 of 1977 together with certain Regulations on the reporting of specific diseases to the Local, Provincial and National Health Departments. Table 4.7 Notifiable conditions in South Africa  Acute flaccid paralysis  Leprosy  TB (pulmonary) Any person (not necessarily a health care worker) may report a notifiable condition to a local authority via fax, mail or telephone. The relevant notification form is then completed by the local authority or district office, and submitted to the provincial office, which in turn summarises the cases and deaths for each notifiable condition (even if no cases or deaths occurred during that period) and sends the summary to the national office. WHO IS RESPONSIBLE FOR NOTIFICATION? The first health care professional or facility with whom a patient presenting with one of the notifiable medical conditions comes into contact is expected to notify the case (or death). This includes clinic personnel, infection control nurses, other hospital staff, and public and private medical practitioners. In cases where the patient had no contact with a health care professional, a member of the community is required to report the case. WHYIS NOTIFICATION SO IMPORTANT? Healthcare professionals have a legal obligation to report cases of notifiable conditions. The process of notification alerts outbreak response teams, resulting in appropriate and timely interventions, in turn assisting in the prevention of spread of communicable diseases. In addition, the notification system provides information on the status and trends of communicable diseases in the country. THE NOTIFICATION PROCESS There are certain forms to be filled in when reporting a case or death. These are available from the regional health office, the local Communicable Disease Coordinator or the provincial stores section. ! Form GW17/05: Initial diagnosis (to be completed immediately and containing finer details of the patient and the diagnosis) ! Form GW17/03: Line list of cases (to be completed weekly) ! Form GW17/04: Line list of deaths (to be completed weekly) Notifications are done using GW17/05 forms. The structure of the system, process of obtaining the forms and persons to which the forms are sent differ considerably between, and even within provinces. People at the provincial health information offices, however, are conversant with specific details of the system in their province, and nurses and doctors are encouraged to contact them for specific details about how to go about notifying cases and deaths of the diseases above. Alist of telephone numbers and addresses 7 of these contact people is included at the end of this article. Asemi-detailed overview of the process is described below. The GW17/05 forms are required to be completed as fully as possible, although information on patient's age, sex or race may be omitted only if it is not available. All other applicable information should be filled in, especially details relating to the place and date of infection, the disease being notified and whether a case or death is being notified. The contact people in the relevant provincial health information office will be able to furnish you with the details of the specific office to which the notification forms should be 37 sent. The steps to follow when reporting notifiable conditions are summarised in Table 4.8. Table 4.8 Steps in the notification process STEP 1 Diagnose and confirm that the patient is suffering/has died of a notifiable condition. STEP 2 Obtain the necessary documentation: Form GW 17/5  In the case of death the condition should be reported twice, first as a case and then as a death. STEP 3 Complete all the forms and send them to the relevant office:  Local Authority/Hospital/District responsible for disease containment (fill in Form GW 17/3);  Regional Office (the Health Information Unit);  Provincial Office (the Health Information Unit);  National Department (Directorate HSR and Epidemiology) 7 Source: The notification system in a nutshell. Remember! When workers complain of symptoms, the first question to be answered is not "How do we fix the building?", but rather: “Why to they have symptoms?". In other words, to address health complaints effectively, a health evaluation is absolutely essential. A systematic approach to legionellosis in the work environment is crucial.

==Acknowledgements==
Delene Bartie (CB Scientific)- 2023

==References Chapter 3==

#Dowling JN, McDaevitt DA, Pasculle AW. Isolation and preliminary characterization of erythromycin-resistant variants of Legionella micdadei and Legionella pneumophila. Agents Chemother. 1985, 27 (2): 272-274.
#MacFarlane JT, Miller AC, Smith WH, Morris AH, Rose DH. Comparative radiographic features of community acquired Legionnaires’ disease, pneumococcal pneumonia, Mycoplasma pneumonia and psittacosis. Thorax 1984, 39: 28-33.
#Boldur I, Beer S, Kazak R, Kahana H, Kannai Y. Predisposition of the asthmatic child to legionellosis? Isr. J. Med. Sci 1986, 22 (10): 733-736.
#Kurtz JB. Legionella pneumophila. Am. J. Occup. Hyg. 1988, 32 (1): 59-61.
#Shapiro M. Unusual epidemiologic and clinical manifestations of legionellosis: a review. Isr. J. Med. Sci. 1986, 22 (10): 724-727.
#Yu VL. Legionella pneumophila (Legionnaires’ disease). In: Mandell, Douglas and Bennet (eds). Principles and practice of infectious disease. 1990, Third Edition, Churchill Livingstone.
#Ratshikhopha ME, Klugman KP, Koornhof HJ. An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires’ disease in South Africa. South African Med. J. 1990, 77: 392-395.
#Bartie C and Klugman KP. Exposures to Legionella pneumophila and Chlamydia pneumoniae in South African mine workers. Int. J. Occup. Environ. Health 1997, 3: 120-127.
#Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D, Klugman KP. “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. 1994, 84: 678-682.
#Winn 1991
#Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles E, Manterola J, Morera J. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. CHEST 1991, 99: 344-350.
#Stout JE, Yu VL. Legionellosis. New Engl. J. Med. 1997, 682-687.
#Ruf B, Schürman D, Horbach I, Fehrenbach FJ, Pohle HD. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. J. Inf. Dis. 1990, 162: 1341-1348.
#Harrison TG, Dournon E, Taylor AG. Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1. J. Clin. Pathol. 1987, 40: 77-82.
#Pastoris MC, Ciarrochi S, Di Capula A, Temperanza AM. Comparison of phenol- and heat-killed antigens in the indirect immunofluorescence test for serodiagnosis of Legionella pneumophila serogroup 1 antigens. J. Clin. Microbiol. 1984, 20 (4): 780-783.
#Kaufmann AF, McDade JE, Patton CM, Bennett JV, Skalyi P, Feeley C, Anderson DC, Potter ME, Newhouse VF, Gregg MB, Brachman PS. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epid. 1981, 114 (3): 337-347.
#Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.
#Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.
#Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.
#Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397
#[[Legionella Control#cite%20ref-:0%205-0|Jump up to:5.0]] [[Legionella Control#cite%20ref-:0%205-1|5.1]] Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8
#MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270

[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]
<references />

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Legionella immunofluorescence

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Legionella colonies on agar

Legionella Control

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Tobyvan:

{{Stub}}
{{Anchor|Section1}}
==INTRODUCTION==

==HISTORY==
[[File:The first Legionnaires’ disease outbreak.png|thumb|The first Legionnaires’ disease outbreak]]

[[File:Gimenez stain- Legionella bacteria.png|thumb|Gimenez stain- Legionella bacteria]]
Legionnaires’ disease was first described after a pneumonia outbreak at an American Legion Convention held in Philadelphia during 1976. In total, 182 delegates were affected and 29 died before workers at the Centers for Disease Control and Prevention (CDC) based in Atlanta, USA isolated the causative organism in January 1977. The organism was placed in the family Legionellaceae, genus Legionella to commemorate the first victims of the disease. The first species was named Legionella pneumophila (Greek for “lung loving”).

It soon became clear that legionellae were not really new; retrospective studies showed that an organism isolated for the first time in 1944 (called Tatlockia micdadei) actually belonged to the genus Legionella. The first strain of Lpneumophila was isolated already in 1947 from a guinea pig that had previously been inoculated with blood from a patient with what was called an “unknown febrile disease” at the time.

The two decades following the discovery of the family Legionellaceae was marked by rapid developments in Legionella detection and the identification of numerous new species. Twenty-eight new Legionella species and two “Legionella-like amoebal pathogens” (LLAPs) (LLAP-1 and LLAP-6) were isolated during the 1980s, mostly from sources in the USA. The 1990s were marked by an increase in Legionella isolation from countries in Europe and Australia with fifteen new Legionella species being described for the first time.

More than half of the currently known Legionella species are potentially pathogenic to humans. L. pneumophila is still implicated in >80% of infections; however, as more species are isolated from environmental sources worldwide, even those species not yet associated with disease should be considered as potentially pathogenic until proven otherwise. For example, L. longbeacheae, often isolated from potting soil, is considered the most common cause of legionellosis in Australia.

Legionellae are faintly staining gram negative, rod-shaped, non acid fast bacteria that to not form spores or capsules. All species except L. oakridgensis are motile. Legionellae are typically between 0.3 and 0.9 µm wide and 1- 20 µm long. However, shorter forms measuring 1- 2 µm in length are often observed in clinical specimens or under conditions of iron deprivation.

Figure 1.3Gimenez stain: Legionella bacteria

The ability of legionellae to grow in water is influenced by several factors. They can grow at temperatures between 20°C and 60°C, with optimal growth occurring between 37°C and 45°C. They prefer a pH in the range of 5.0 9.5 and only grow in the presence of Lcysteine, HCl and iron salts. Legionella-like amoebal pathogens (LLAPs) are very similar to Legionella species in that they are gram negative, infect amoebae and can survive and multiply intracellularly. However, they cannot be cultured on laboratory media. The first LLAP was isolated 1 from soil in Poland in 1954 and was named Sarcobium lyticum. The next isolation of an LLAP was in England more than 20 years later. Since then, LLAPs have been isolated from various sources, mostly associated with confirmed cases or outbreaks of 2 3 Legionnaires’ disease. Three of the LLAPs have since been reclassified as L. drozanskii, L. rowbothamii and L falloni. The currently known LLAPs are listed in Table 1.2.

===INTERACTIONS WITH PROTOZOA===
Legionellae are slow-growing organisms that require a combination of nutrients for growth. Due to their fastidious nature and lack of antibiotic activity, they may be replaced by faster growing organisms if they do not have an alternative means of survival in aquatic environments. The fact that legionellae are ubiquitous in these environments suggests that protozoa, especially amoebae, play a supportive role in their survival and multiplication. In fact, their natural habitat, parasitic to protist hosts, has now been 4 proven.
{| class="wikitable"
|+'''Legionella species'''
!ORGANISM
!SG
!YEAR
!SOURCE
!PATHOGEN
|-
|L adelaidensis
L anisa

L beliardensis

L birminghamensis

L bozemanii

L brunensis

L cherrii

L cincinnatiensis

L donaldsonii*

L drozanskii (LLAP-1)

L dumoffii

L erythra

L fairfieldensis

L fallonii (LLAP-10)

L feeleii

L geestiana

L gormanii

L gratiana

L gresilensis

L hackeliae

L israelensis

L jamestowniensis

L jordanis

L lansingensis

L londiniensis

L longbeacheae

L lytica

L maceachernii

L micdadei

L moravica

L nautarum

L oakridgensis

L parisiensis

L pittsburghensis

L pneumophila

L quateirensis

L quinlivanii

L rowbothamii (LLAP-6)

L rubrilucens

L sainthelensi

L santicrucis

L shakespeari

L spiritensis

L steigerwaltii

L taurinensis

L tusconensis

L wadsworthii

L waltersii

L worsleiensis
|1
1

1

1

2

1

1

1

*

1

1

2

1

1

2

1

1

1

1

2

1

1

1

1

1

2

1

1

1

1

1

1

1

1

15

1

2

1

1

2

1

1

1

1

1

1

1

1

1
|1991
1985

2001

1987

1980

1989

1985

1988

2002

2001

1980

1985

1991

2001

1993

1980

1991

2002

1985

1985

1985

1982

1994

1993

1982

1996

1985

1980

1989

1993

1983

1985

1980

1979

1993

1990

2001

1985

1984

1985

1992

1985

1985

1999

1990

1983

1996

1993

1993
|Cooling water (Adelaide Australia)

Faucet (Chicago), tap water (LA)

Water, France

Lung biopsy (Alabama)

Lung aspirate (Toronto)

Cooling tower water (Czechoslovakia)

Thermally altered water (Minnesota)

Lung tissue (Cincinnatti)

<nowiki>*</nowiki>

Tank of well water (Leeds 1981)

Lung tissue

Cooling tower water (Seattle)

Cooling tower water (Fairfield Australia)

Ship air conditioner (1994)

Grinding machine coolant fluid

Hot water tap, office building (London)

Bronchial wash of pneumonia patient

Thermal spa water (France)

Water, France

Bronchial biopsy (Ann Arbour)

Water (Israel)

Wet soil (New York)

Water and sewage (Israel)

Bronchial washing, hloramin patient

Office building cooling tower (London)

Human lung (Longbeach Australia)

Previously Sarcobium lyticum

Water (Phoenix)

Human blood via yolk sac

Cooling tower water (Czechoslovakia) Hot water tap (London)

Cooling tower water (Pennsylvania)

Cooling tower water (Paris)

Synonym for L micdadei, strain

TATLOCK

Water (Pennsylvania)

Shower in hotel bathroom (Portugal)

Water in bus airconditioner (Australia)

Water and sludge, industrial liquefier

Tap water (Los Angeles)

Spring water (Washington)

Tap water (Virgin Islands)

Cooling tower water (England)

Lake water (Washington)

Tap water (Virgin Islands)

Water, hospital humidifier (Italy)

Pleural fluid, transplant patient (Arizona)

Sputum

Potable water system (Australia)

Industrial cooling water (England)
|Unknown

Yes

Unknown

Yes

Yes

No

Yes

Yes

<nowiki>*</nowiki>

Yes

Yes

No

Unknown

Yes

Yes

Unknown

Yes

No

Unknown

Yes

No

No

Yes

Yes

Unknown

Yes

Yes

Yes

Yes

No

Unknown

Yes

Yes

Yes

Yes

Unknown

No

Yes

Yes

Yes

No

Unknown

No

No

Unknown

Yes

Yes

Unknown

Unknown
|}

Table 1.1 Legionella species ORGANISM SGs YEAR SOURCE PATHOGEN L adelaidensis L anisa L beliardensis L birminghamensis L bozemanii L brunensis L cherrii L cincinnatiensis L donaldsonii* L drozanskii (LLAP-1) L dumoffii L erythra L fairfieldensis L fallonii (LLAP-10) L feeleii L geestiana L gormanii L gratiana L gresilensis L hackeliae L israelensis L jamestowniensis L jordanis L lansingensis L londiniensis L longbeacheae L lytica L maceachernii L micdadei L moravica L nautarum L oakridgensis L parisiensis L pittsburghensis L pneumophila L quateirensis L quinlivanii L rowbothamii (LLAP-6) L rubrilucens L sainthelensi L santicrucis L shakespeari L spiritensis L steigerwaltii L taurinensis L tusconensis L wadsworthii L waltersii L worsleiensis 1 1 1 1 2 1 1 1 * 1 1 2 1 1 2 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 15 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1991 1985 2001 1987 1980 1989 1985 1988 2002 2001 1980 1985 1991 2001 1993 1980 1991 2002 1985 1985 1985 1982 1994 1993 1982 1996 1985 1980 1989 1993 1983 1985 1980 1979 1993 1990 2001 1985 1984 1985 1992 1985 1985 1999 1990 1983 1996 1993 1993 Cooling water (Adelaide Australia) Faucet (Chicago), tap water (LA) Water, France Lung biopsy (Alabama) Lung aspirate (Toronto) Cooling tower water (Czechoslovakia) Thermally altered water (Minnesota) Lung tissue (Cincinnatti) * Tank of well water (Leeds 1981) Lung tissue Cooling tower water (Seattle) Cooling tower water (Fairfield Australia) Ship air conditioner (1994) Grinding machine coolant fluid Hot water tap, office building (London) Bronchial wash of pneumonia patient Thermal spa water (France) Water, France Bronchial biopsy (Ann Arbour) Water (Israel) Wet soil (New York) Water and sewage (Israel) Bronchial washing, hloramin patient Office building cooling tower (London) Human lung (Longbeach Australia) Previously Sarcobium lyticum Water (Phoenix) Human blood via yolk sac Cooling tower water (Czechoslovakia) Hot water tap (London) Cooling tower water (Pennsylvania) Cooling tower water (Paris) Synonym for L micdadei, strain TATLOCK Water (Pennsylvania) Shower in hotel bathroom (Portugal) Water in bus airconditioner (Australia) Water and sludge, industrial liquefier Tap water (Los Angeles) Spring water (Washington) Tap water (Virgin Islands) Cooling tower water (England) Lake water (Washington) Tap water (Virgin Islands) Water, hospital humidifier (Italy) Pleural fluid, transplant patient (Arizona) Sputum Potable water system (Australia) Industrial cooling water (England) Unknown Yes Unknown Yes Yes No Yes Yes * Yes Yes No Unknown Yes Yes Unknown Yes No Unknown Yes No No Yes Yes Unknown Yes Yes Yes Yes No Unknown Yes Yes Yes Yes Unknown No Yes Yes Yes No Unknown No No Unknown Yes Yes Unknown Unknown Sources: American Type Culture Collection; National Type Culture Collection. 2 Table 1.2 Legionella-like amoebal pathogens (LLAPs STRAIN HOSTS YEAR ORIGINAL SOURCE PATHOGENIC Sarcobium lyticum A polyphaga H vermiformis 1954 Soil Yes LLAP-1 A polyphaga 1981 Tank of portable water well Yes LLAP-2 A polyphaga H vermiformis 1986 Garage steam cleaning pit Yes LLAP-3 A polyphaga 1986 Sputum from pneumonia patient Yes LLAP-4 A polyphaga 1986 Hospital whirlpool bath Yes LLAP-5 A polyphaga 1988 Nursing home plant spray Yes LLAP-6 A polyphaga H vermiformis 1988 Factory liquefier tower Yes LLAP-7 A polyphaga H vermiformis 1991 Hotel whirlpool spa Yes LLAP-8 H vermiformis 1990 Hospital shower Yes LLAP-9 A polyphaga H vermiformis 1992 Factory cooling tower Yes LLAP-10 A polyphaga 1994 Ship air-conditioning system Yes LLAP-11 A polyphaga 1993 Furnace cooling system Yes LLAP-12 A polyphaga 1994 Furnace cooling system Yes 3 Adapted from Adeleke 1996 5

Rowbotham was the first to demonstrate interactions between legionellae and protozoa. To date, protozoa of the genera Acanthamoeba, Tetrahymena, Naegleria, Echinamoeba and Vanella species have been implicated in these interactions. Not much is known about the metabolic and physiological status of legionellae after passage through protozoa, but in vitro studies have shown changes in their physiological status resulting in iron deprivation, possibly changing the susceptibility of the released bacteria to chemical inactivation. Although they can survive extracellularly, this phase is believed to be only temporary while they are searching for new hosts to 6 infect. Furthermore, it was recently documented that very few Legionella bacteria are needed to start intracellular replication. Some workers have reported a 7000 times increase in Legionella colony forming units (CFU) after intracellular replication buth there is no consensus yet as many believe that this intracellular replication cycle is not necessary for the proliferation of legionellae within mixed bacterial populations. From these studies it is clear that there is still extensive research to be done on this aspect of Legionella survival in the environment. Until more becomes known, it is unsafe to assume that the absence of protozoa within water samples prevents the survival of legionellae; as long as there are other bacterial species present, appropriate measures should be taken to prevent Legionella proliferation.

===1.3 HOWDOES THE INTERACTION WITH PROTOZOABENEFITLEGIONELLAE?===
Amoeba trophozoites feed and multiply in water and biofilm. When conditions become unfavourable, these trophozoites are transformed into cysts with hard, impermeable outer walls that provide protection for ingested Legionella organisms. When conditions become more favourable, the cysts change to trophozoites again and the bacteria are set free. Legionellae have been 7 recovered from cysts treated with 50 parts per million (ppm) chlorine suggesting a high level of protection by the cysts. This high resistance of amoebal cysts to biocides may be the mechanism for the apparent reseeding of water systems by legionellae often experienced in the water treatment industry. However, recontamination may also occur via transmission of airborne cysts acting as carriers for the legionellae.

===1.4 HOWIMPORTANTIS LEGIONELLAIN SOUTH AFRICA?===
Very little has been published on Legionella in South Africa. After the initial introduction of diagnostic laboratory tests in 1979, legionellosis cases were identified in Durban, Port Elizabeth and Johannesburg during the early 1980's. By 1982, antibodies to L. 8,9 pneumophila had been demonstrated in 10% of hospitalised pneumonia patients, a figure that was confirmed in 1994. A high 9,10,11 prevalence of antibodies was also demonstrated in workers in the mining industry and the general public. Despite this high prevalence, only one Legionnaires' disease outbreak and less than 40 sporadic cases have been reported since legionellosis became notifiable in 1990. Similarly, very little is known about the prevalence of Legionella in the South African environment. Low concentrations of 12 legionellae were reported in 77% of cooling towers in a large study reported in 1991. More recently, culturable legionellae were present in 82% of industrial water samples tested; 54% of these samples yielded legionellae in numbers equal to or in excess of 1000 11 CFU/ml. 3

===1.5 LEGIONELLADETECTION===
Classical detection methods for Legionella species relied on the inoculation of susceptible guinea pig hosts. Although selective, these methods were expensive and time consuming and were soon replaced by isolation by culture on agar media. To improve the recovery of legionellae by culture, the use of certain selective media and steps were introduced to minimise contamination by nonlegionellae. In attempts to simplify Legionella identification, radioimmunoassays (RIAs), enzyme linked immunosorbent assays (ELISAs), agglutination tests and nucleic acid probes and polymerase chain reaction (PCR)-based assays have since been developed and tested.

Despite the relative success of these new methods for the detection of environmental legionellae, culture remains the method of choice. However, no single culture method has so far proven to be ideal for all samples in all given circumstances and environments. Even in the absence of contaminating bacteria or other inhibitory substances, the detection of small numbers of legionellae from environmental samples remains difficult. This, together with the lack of standardisation of methods, complicates the interpretation of culture results and comparisons of results from different laboratories. Variations in bacterial numbers in different areas within a water distribution system and the sampling method used often complicate the interpretation of culture results even further.

Previous studies have shown that the culture of Legionella species from environmental samples is complicated by the presence of 13,14 faster growing bacteria due to inhibition of legionellae on culture media in the presence of heterotrophic bacteria. For example, 15 Pseudomonas aeroginosa secrete bacterial substances into the surrounding media that dramatically inhibit Legionella growth. Although culture is still the gold standard, it remains time consuming and requires a certain level of technical skill. Legionellae may also enter a “viable but non-culturable (VBNC)” state under certain conditions which complicated culturing even further.)

Lp Lm L boz L dum L gor L long L jor L oak Growth on BCYE Growth on TSB Acid production Gelatin hydrolysis Urease Primary growth on FG Beta lactamase Hippurate hydrolysis Browning of tyrosine medium Blue fluorescence on CYE + - - + - + + + + - + - - + - - - - - - + - - + - - +/- - + + + - - + - - + - + + + - - + - - + - + + + - - + - - + or – - + - + - - + - - + - + - + - - - - nt +/- - + - Nt: not tested, +/- weak positiv; Lp L. pneumophila; Lm L. micdadei; Lboz L. bozemanii; Ldum L. dumoffii; Lgor L. gormanii; Llong L. longbeacheae; L jor L jordanis; L L. oakridgensis. oak Table 1.3 Selected characteristics of Legionella species Figure 1.4 Legionella colonies on agar (Sources: own laboratory pictures; Annual Report, American Water Technologies (2003) Recent developments in the molecular field opened doors for new detection assays of waterborne pathogens such as Legionella. These methods include: 16 ! DNA probe hybridisation; 4 ! ! ! ! ! ! !

====1.5.1 Polymerase chain reaction (PCR)====
Although the sensitivity of most of these techniques is insufficient for direct detection of legionellae in environmental samples, 18,19 PCR has proven to be a sensitive and rapid alternative to culture. Many PCR assays have been described, but relatively few of them have been extensively studied on clinical as well as environmental samples and none are routinely used.

====1.5.2 Immunofluorescence====
Immunofluorescence is a technique whereby antigen and antibody is bound to a fluorochrome (fluorescent stain) and then allowed to react with the corresponding antigen or antibody on a microscope slide. The results are viewed under a fluorescent microscope. There are many variations of immunofluorescent techniques but only direct immunofluorescence (DFA) and indirect immunofluorescence (IFA) is of importance in the confirmation of environmental legionellae. Direct immunofluorescence (DFA) is most commonly used for confirmation of Legionella species from environmental samples. The test is simple to perform, but interpretation requires a fair amount of experience, especially in highly contaminated samples. Antigen from the sample is fixed to a microscope slide using heat or acetone and covered with fluorescein-isothiocyanate (FITC) labelled globulin. Antigens in the sample bind to the labelled globulin and the resulting antigen-antibody complexes are visible under ultraviolet light. Direct immunofluorescence (DFA) is useful to detect antigens in clinical samples when cultures cannot be obtained, but its value for environmental samples is controversial. Nevertheless, it is used as a screening test by some laboratories. Cross-reactions that may lead to false positive results have been documented.

Figure 1.5 Legionella immunofluorescence/Fluorescent bacteria

17 Restriction enzyme digestion; 18,19 Polymerase chain reaction; 20 Soluble protein patterns; 21 DNA restriction endonuclease profiles; 22 Multilocus enzyme analysis; 23 Orthogonal-field-alteration gel electrophoresis; 24 Sodium dodecyl sulphate poly-acrylamide gel electrophoresis (SDS-PAGE).

====1.5.3 Fluorescent in situ hybridization====
Fluorescent in situ hybridization (FISH) is a technique whereby a fluorescent labeled DNA probe is used to detect a particular chromosome or gene that can then be visualised by fluorescence microscopy. FISH tests are useful for the detection of legionellae in respiratory tract samples but has not been extensively tested in environmental samples. The method makes use of oligonucleotide probes targeting rRNA and offers a fast and specific alternative to direct immunofluorsecence, culture and urine antigen testing in clinical laboratories. {{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate. Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.'''10'''

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

*'''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

*'''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

*'''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

*'''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

*Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997 '''WHAT TO TAKE INTO ACCOUNT WHEN INTERPRETING LABORATORY RESULTS'''

*Both IgM and IgG should be measured simultaneously.
*Diagnostic IgM titres will provide an earlier diagnosis than IgG because they indicate a primary immune response.
*Results obtained by the IFA should always be interpreted in conjunction with the clinical presentation of the disease.
*Titres below the diagnostic level together with clinical manifestations may be useful for early provisional diagnosis of Legionnaires’ disease; but diagnosis by IFA is usually retrospective.
*The interpretation of the IFA should take into account the variation in the time of appearance of antibodies, the types of antibodies produced and the length of time the antibodies are detectable in sporadic cases, as well as the prevalence of antibodies in the population from which the patient comes.
*The type of reagents used for IFA tests may influence the results: ether-killed, formalin-killed or heat-killed antigens vary in sensitivity and specificity and this should be taken into account in the interpretation.
*False negative results may be reported because a long time is needed for seroconversion to occur and not all species and serogroups are detectable by this method.
*Seroconversion (a fourfold rise in titre to at least 1:128) is considered as a presumptive positive result.
*A single titre of 1:256 or higher is regarded as a presumptive positive result.
*Serological results should preferably be confirmed by culture.
*In communities with low antibody prevalence, a single titre of 1:128 may be diagnostic and where the prevalence is high, a single titre of 1:256 may still provide only presumptive evidence of infection.
*Low titres usually indicate past infections.
*When titres to multiple antigens are raised, the titre that is fourfold higher than the others is considered to be diagnostic.
*In epidemiological studies diagnostic titres are usually one twofold dilution higher than for sporadic cases.

===HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

 
[[File:FIGURE 3.3.jpg|center|thumb|500x500px|Figure 3.3 Histological section of lung of Legionnaires disease patient]]
 

===CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

*Initial involvement is unilateral, predominantly in the lower lobe
*Bilateral involvement has been described
*Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction
*Pulmonary densities enlarge during later stages of disease
*Pulmonary densities have a typical ground glass appearance or dense consolidation
*Total opacification of the lung may occur
*Pleural effusions are present in 24-63% of cases caused by L pneumophila
*Pleural effusions are uncommon in L micdadei infections
*Hilar adenopathy seldom occurs
*Cavitation may occur in immunocompromised patients
*Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called ''Acanthamoeba'' filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to ''L pneumophila, L feelei and L anisa''. Complete recovery usually occurs in 2 – 5 days without medical attention.

==CHAPTER 4==

===SURVEILLANCE FOR LEGIONELLA===
A major aspect of biosafety in the workplace is the assessment of hazards and risks of infection (environmental surveillance) and disease in workers (clinical surveillance). ENVIRONMENTALSURVEILLANCE Environmental surveillance is essential for the long term success of any water treatment program for Legionella to provide baseline environmental information to ensure the efficiency of disinfection and water treatment programmes and to control the risk of infection in events of mechanical failures and human error. The risk of contracting legionellosis can be summarised in terms of three factors, as summarised in Table 4.1. Table 4.1 Factors determining the risk of legionellosis Proliferation potential This potential exist in nearly all water systems and depends on many factors, including:  Presence of microbial biofilms  Diversity of microorganisms present  Availability of nutrients Exposure potential Certain industrial processes produce aerosols during their function. These aerosols can be aspirated (breathed deep into the lung) if the particle size is small enough (< 8 µm in diameter). Assessment of exposure potential thus focuses on the proximity of aerosol-generating systems to human populations. Population susceptibility The most susceptible individuals are elderly people (especially males), heavy smokers, alcoholics, patients with chronic pulmonary disease and immuno-suppressed people. 1 Source: McCoy 2004 4.1 RISK ASSESSMENTS A risk assessment is a scientifically based process used to estimate the likelihood of adverse effects occurring, taking into account the exposure (hazard), the level and nature of the risk and the target population. Risk assessments can be either quantitative or 1 qualitative. 4.1.1 Quantitative risk assessments Quantitative risk assessments involve the establishment of dose-effect and dose-response relationships in likely target individuals and populations. For a quantitative risk assessment to be successful, dose-response assessments, the extent and duration of human exposure and characterisation of the possible consequences resulting from exposure have to be determined 1 and quantified. Quantitative risk assessments are not possible for hazardous biological agents (including Legionella) for several reasons. Firstly, exposed people have varying degrees of susceptibility to infection. Secondly, water sources usually contain a diverse mixture of biological contaminants which may change rapidly over short periods of time. Thirdly, the contaminants present and the levels in which they are present are only applicable at the time and area sampled and the interactions among all these 1 biological agents present in the source and environment make exposure assessment extremely difficult. 4.1.2 Qualitative risk assessments Qualitative risk assessments on are done to “document site-specific conditions and recommendations for reducing the risk, if 1 necessary, and to establish assignments for actions, communications, training and management responsibilities”. Anumber of schemes have been developed to provide some form of risk ranking and risk scores to simplify these assessments 1 and to guide the water management plan. An example of a risk ranking for legionellosis is provided in Table 4.2. For example, if a system falls into Risk Category A, the frequency of testing, cleaning and disinfection and monitoring should be increased until the system falls into a lower Risk Category, when the rate of testing, cleaning and monitoring can be reduced again. 19 Table 4.2 Risk classification for legionellosis HIGHEST RISK LOWEST RISK RISK CLASSIFICATION A B C D CRITERIA MATCHES ANY OF THE RESPONSES BELOW MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A OR B MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A, B OR C Stagnant water  System idle more than once a month  Re-circulation pump not timed  Dead-legs present  A plus timed recirculation pump  Any single factor in A  System operates continuously  No dead-legs Nutrients and growth  Contaminated water  No corrosion control  Wet surfaces open to sunlight  Any two factors in A  Any one factor in A  No factors in A Water quality  No automated biocide dosing protocol  No water treatment program  No automated biocide dosing  No water treatment program in place  Automated biocide dosing  No water treatment program in place  Automated biocide dosing  Water treatment program in place Equipment design and operation  No system design review  No system operation and performance review  No drift eliminators  Drift eliminators for cooling towers in place  Same as B with at least one review lacking  System design review in place  System operation and performance review in place  Good drift eliminators Location and access  Located in healthcare or residential care facility  Large numbers of people exposed  Same as A but moderate numbers of people exposed  Same as B but few people exposed  Not located near susceptible people 1 Source: McCoy 2004 4.2 THE RISK ASSESSMENTPROCESS The four most important steps in the risk assessment process are to get an overview of the operation of the water distribution system, to conduct a walk-through investigation of the building or facility, to assess the results of the walk-through to determine an 2,3,4 appropriate course of action and to recommend appropriate control actions. These steps are explained in more detail below. STEP 1 GET AN OVERVIEW OF THE WATER DISTRIBUTION SYSTEM OPERATION Ask the facilities engineer or an experienced member of the building staff, who has knowledge of the design and current operation of the system to explain the system and to assist in the walk-through investigation. The overview should include inspection of: ! Plumbing systems, heating/ventilation/air-conditioning (HVAC) systems and other water reservoirs as summarised in Table 4.3 20 ! Maintenance records of all water systems, including records of temperature checks on potable water, details of visual and physical checks of cooling towers and reports of water quality assessments and chemical treatment that may have been performed ! Location of parts of the system where there may be stagnant water ! The presence of cross-connections between potable and non-potable water systems ! The condition and type of back flow prevention devices used at these connections ! Any recent major maintenance actions performed or major changes in the system ! Determine whether recent or frequent losses of water pressure have occurred from the incoming supply ! Keep in mind that the failure of a back flow prevention device under loss of pressure can result in contamination of the water system Table 4.3 Areas to include when doing an overview of a waterdistribution system Plumbing systems Hot and cold potable water systems Water heaters Water coolers Distribution piping Water treatment equipment (eg. water softeners, filters) Connections to process water systems (not protected by backflow preventers) Storage tanks Heating, ventilation and airconditioning (HVAC) systems Cooling towers Evaporative condensers Fluid coolers Direct and indirect evaporative cooling equipment Humidifiers Location of fresh air intakes relative to water sources Air washers for filtration Miscellaneous reservoirs Decorative fountains Plant misters Whirlpools and spas Tepid water eye washes Safety showers Cooling water for industrial processes 2 Source: <nowiki>http://www.nalco.com</nowiki> STEP 2 CONDUCT A WALK-THROUGH INVESTIGATION OF THE FACILITY Table 4.4 The walk-through investigation WHAT TO DO WHEN ! Check sample transport requirements and receiving times of laboratory before investigation ! Get as much information as possible from staff before investigation ! Go through checklist and make sure you are prepared before investigation ! Check water temperatures while sampling for Legionella ! Check hot water tanks and related piping during investigation ! Check cooling towers during investigation ! Check water quality during investigation ! ! ! ! ! WHO SHOULD BE PRESENT? The person who knows most about the building, particularly the domestic water system Aplumbing engineer if possible Aplumbing contractor who knows the building if possible Arepresentative from the company that services the HVAC system The water treatment specialist who services the cooling tower 21 EQUIPMENT NEEDED ! The floor plan (arrange in advance if possible) ! Drawings of plumbing if available (arrange in advance if possible) ! Inspection checklist ! Camera ! Knife ! Pliers or channel locks ! Measuring tape SAMPLING KITS AND EQUIPMENT TO TAKE WITH ! Thermometer ! Chlorine kit ! Iron kit ! pH meter ! Total dissolved solids (TDS) kit ! Hardness kit ! Calibration fluid ITEMS NEEDED FOR LEGIONELLA SAMPLING ! Sampling log (see example) ! Sodium thiosulfate ! Cooler bag and other materials needed for packaging of sample for transport ! Documentation from courier or transport agency ! Plastic bags for packaging of samples ! Sterile swabs ! Sampling bottles ! Labels for bottles ITEMS NEEDED FOR SAMPLING FOR THE TOTAL BACTERIAL COUNT (TBC) ! Sampling bottles ! Sampling log sheets ! Cooler bag and other materials needed for packaging of sample for shipping or transport ! Documentation from courier or transport agency ! ! REMEMBER The temperature may be below the gauge temperature of the heater due to heat stratification CHECKLIST FOR FAUCETS CONNECTED TO EACH WATER HEATER ! Maximum temperature of each location that is “close (C)”, “intermediate (I)” or “far (F)” from the heaters ............................................................................................................ REMEMBER You may have to run the water for several minutes before it reaches a maximum temperature at “far” locations CHECKLIST FOR COLD WATER STORAGE TANKS USED FOR RESERVE WATER OR FOR MAINTAINING HYDROSTATIC PRESSURE ! InitialTemperature (°C) .......................................................................................................................... ! Potential for stagnation: high (H), medium (M) or low (L)........................................................................ ! Temperature of cold water line at various locations Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Record both initial temperature and final equilibration temperature on cold water lines ...................... REMEMBER Tanks should be protected from temperature extremes and should be covered to prevent stagnation CHECKLIST FOR EACH STORAGE-TYPE HOT WATER HEATER Temperature of water drawn from it (°C) ................................................................................................. Presence of rust and scale ......................................................................................................................... 22 CHECKLIST FOR COOLING TOWERS, EVAPORATIVE CONDENSERS AND FLUID COOLERS ! Visual evidence of biofilm growth, scale build-up and turbidity ........................................................... ! The location of the tower relative to fresh air intakes ............................................................................ ! Proximity to sources such as kitchen exhausts, leaves, plant materials, or other sources of organic material that may contribute to Legionella growth .............................................................................................. CHECKLIST FOR COOLING TOWERS ! General physical and mechanical condition ........................................................................................... ! Presence and condition of drift eliminators ............................................................................................ ! Basin temperature of water (the tower is working) ................................................................................ REMEMBER Wear appropriate respiratory protection (half face-piece respirator and HEPA filter cartridge) during examination if cooling tower is operating SUMPS FOR COOLING TOWER, EVAPORATIVE CONDENSER AND FLUID COOLERS ! Location and condition ............................................................................................................................ ! Location of any cross-connections between potable and non-potable systems ......................................... REMEMBER Sumps are sometimes located indoors to prevent them from freezing. Cross-connections may be present to supply a back-up source of cool water to refrigeration condenser units or to supply secondary cooling units STEP 3 ASSESS THE RESULTS OF THE WALK-THROUGH TO DETERMINE AN APPROPRIATE COURSE OF ACTION Table 4.5 When is additional action necessary? NO FURTHER ACTION Operating temperatures measured in water heaters is 60°C Delivery temperature at distant faucets is ? 50°C No other potential problems observed TAKE FURTHER ACTION Poor maintenance Operating temperatures below minimums mentioned above STEP 4: RECOMMEND CONTROLACTIONS Remember! These actions may include disinfection of the potable water system as outlined in the section on disinfection 23 Table 4.6 Recommended control actions ACTION EXPLANATION Actions to limit the growth of organisms in water systems: Elimination of dead legs in the plumbing system Insulation of plumbing lines Installation of heat tracing to maintain proper system temperatures Elimination of rubber gaskets Removal or frequent cleaning of plumbing fixtures (eg aerators and shower heads) Water sampling to confirm the presence of Legionella: Not necessary at this stage BUT Customer may want to obtain background information, in which case sampling for Legionella will be helpful To ensure that corrective actions are successful: Sample water after corrective action BUT Customer may want to collect samples before corrective action to assess the extent of the problem but this is not normally done The customer should take the necessary corrective action, even if the pre-sampling tests are negative for the following reasons: Water sampling may produce false-negative results A contaminated portion of the system may have been missed The absence of legionellae at the time of sampling does NOT ensure that the system will remain negative at a later date Limited corrective actions that will not be sufficient: Raising water heater temperature without evaluation of system points of stagnation, heat loss and heat gain, cross-contamination and other factors that may contribute to the growth of Legionella bacteria. LEGIONELLA RISK ASSESSMENT DATA SHEET GENERAL INFORMATION Name of organisation Contact person 1 Contact person 2 Contact person 3 Site address Mailing address Building/area size Building age Type of building 24 RESULTS FROM PREVIOUS LEGIONELLA TESTING DATE RESULT Cooling towers Hot water tanks Outlet swabs Hot water outlets Cold water outlets Mixed outlets Incoming water 25 USEFUL QUESTIONS TO ASK ABOUT THE FACILITY WHEN DOING A RISK ASSESSMENT FOR LEGIONELLA(SOURCE: FREIJE 2001) Incoming mains Number Configuration Water source City - ground City - surface Utility: Private well Water usage Obtained from Water bills Fixture count Meter reading Other Deadlegs Present Policies Past construction Aerators Yes No Type Cold pipes location relative to hot Above Below Same level Pipe material Pipe insulation Cold Hot Both Type used Drinking fountains On chilled loop Individual 26 Fire sprinkler above ducts Yes No Water hammers arrestors or air chambers Water hammers Air chambers Both Sediment on water filters Yes No Other sediment gathering equipment Yes No Describe Connection control and/or backflow devices Yes No Faucets and showerheads Age Condition Water softened Cold water Yes No How Hot water Yes No How Water pressure shock Incidents Brown colour Building units closed off temporarily Yes No Major construction activities Yes No Dates Eye wash stations Mixed Cold Emergency showers Mixed Cold 27 Ice machines present Yes No Decorative fountains present Yes No Piped in coffee/tea/cooldrink centres present Yes No Rubber hoses present Yes No Misters for plants/food/comfort present Yes No Other equipment where water flow through that may produce a spray/mist Yes No Can windows be opened? Yes No HVAC systems +Condition of coils Overall condition Drainage of drip pans Humidifiers in duct? Hot water system Number of HW loops Number of CW loops HW recirculating? CW recirculating? Design temp at tank Design temp at taps Regulators Mixing valves Sensors to detect failures CW storage tanks present? Are they covered? Heaters or sunlight? 28 HOT WATER SYSTEM INSPECTION Model number Serial number Age Horizontal/vertical Condition Insulation Temp on gauge Temp from drain Temp of returning water Capacity/turnover Cleaning regimen Cleaning frequency All pumps used daily? Piping arrangement Draw diagram on separate sheet and attach 29 COOLING TOWER INSPECTION In-house identification Location Make and model Serial number Size Age Basin drainable? Cycling of each Months operating Water treatment company Contact details Cleaning frequency Who does the cleaning How is cleaning done? Is basin fully drained? Excessive foaming? Oily film on surfaces? Scum? Condition of drift eliminators Air bypassing: Around edges? Through holes in tower casing? Fill exposed to sunlight Basin exposed to sunlight Louvres/fill clogged? Louvres/fill damaged? Louvres/fill scale present? Louvres/fill algae present? Filters SAND BAG CARTRIDGE Pressure drop 30 Centrifugal separators Outlet strainers Pressure drop Corrosion/deterioration on Structural members? Safety rails? Ladders? Fasteners? Basin? Water leaks present? Air leaks present? Sump water level Cooling water temp Accessible to passers by? Distance from road Distance from parking Distance from sidewalks 31 COOLING TOWER INSPECTION CHECKLIST 5 Source: Freije 2001 BUILDING TOWER NAME/NUMBER INSPECTOR’S NAME DATE OF INSPECTION SAND FILTERS Water leaks? YES NO Suction air leaks? YES NO Pre-strainer clogged? YES NO Channeling in sand filter media (check quarterly) YES NO Operating pressure If YES, clean the media or replace it with filter sand designed specifically for cooling towers and evaporative condensers (not swimming pools). Clean the under-drain assembly while the media is removed. CENTRIFUGAL SEPARATORS Pressure drop Acceptable based on manufacturer’s chart? YES NO Flow rate Purge operation functional? YES NO UNUSUAL NOISE OR VIBRATION IN Pumps? YES NO Motors? YES NO Fans? YES NO Mounting hardware? YES NO OUTLET STRAINERS In place? YES NO Clogged? YES NO BAG AND CARTRIDGE FILTERS Pressure drop Acceptable based on manufacturer’s recommendations? YES NO If not, clean or replace TOWER STRUCTURE AND CASING Water leaks? YES NO Air leaks? YES NO 32 CORROSION OR OTHER DETERIORATION ON Structural members? YES NO Safety rails? YES NO Ladders? YES NO Fasteners? YES NO Basin? YES NO LOUVERS, FILL AND DRIFT ELIMINATORS Clogged? YES NO Damaged? YES NO Excessive scale or algae growth? YES NO If yes, clean with 6,895 – 10,343 kPa (1,000 – 1,500 psi) water, being careful not to damage fill and eliminator components WATER DISTRIBUTION Is the water distribution balanced? YES NO If not, unclog nozzles SEDIMENT BUILD-UP Sediment build-up around heater elements? YES NO FANS Do fans start and stop properly? YES NO VIBRATION Are the vibration switches operating properly? (check at least annually) YES NO SEASONAL OPERATION Are the seasonal systems working (check at least 3 months before winter) YES NO Are there any parts needed? YES NO If YES, what is needed? Are there any repairs necessary? YES NO If YES, what is needed? 2133 Describe action taken in response to above inspection (include dates): QUESTIONS FOR INFECTION CONTROL COORDINATOR (IF APPLICABLE) History of cases Cleaning of hydrotherapy baths and pools Practices for use and cleaning of portable humidifiers Practices for use and cleaning of nebulizers and other semi-critical respiratory equipment Water treatment for dialysis Contact details: Dental unit present? How is it treated? Contact details: Clinical tests for Legionella available? Policy for testing patients/workers for Legionella? 34 CHECKLIST FOR LEGIONELLA SAMPLING HW tank PRE-FLUSH POST-FLUSH Incoming water Faucets and showerheads Cooling make-up water Decorative fountains Cooling tower basins WATER QUALITY TESTS SAMPLE LOCATION pH Free chlorine Total chlorine Hardness TDS Iron TBC Coliforms WATER TEMPERATURES SAMPLE LOCATION HW after 1 minute (°C) CW after 1 minute (°C) 35 EXAMPLE OFSAMPLING LOG / REQUESTFORM REQUESTFOR TESTING OFWATER SAMPLES FOR LEGIONELLA COMPANYDETAILS .................................................................................................................................................................................................. CONTACTPERSON .................................................................................................................................................................................................. CONTACTDETAILS TEL........................................... FAX ............................................. E-MAIL................................................................ NAME OF PERSON WHO COLLECTED SAMPLES ............................................................................................................................... COLLECTION SITE .................................................................................................................................................................................................. SAMPLE NO LOCATION TYPE TIME COLLECTED COMMENTS Received by ……………………………..……….... Date ……………………….. Time ……………… HEALTH SURVEILLANCE Health surveillance can be defined as the “ongoing collection, comparison, analysis and dissemination of data relevant to public health issues”. The main objectives of health surveillance are to identify disease patterns in different population groups, to develop prevention strategies, to allocate resources for prevention and treatment and to educate health professionals and the general public. Health surveillance can take the form of: ! The notifiable disease reporting system (the first step in the surveillance cycle) ! Laboratory based surveillance (for diseases that can be monitored accurately through the laboratory data used for confirmation of the disease) 36 ! Hospital-based surveillance (where hospital discharge information and mortality data are used to monitor trends and disease burden in a particular area) ! Population-based surveillance (where data from a well-defined population are collected and analysed) DISEASE NOTIFICATION Disease notification serves as a means of collecting data on diseases that are considered to be of public health importance and is used world wide. Most countries (including South Africa) have a routine notification system requiring health professionals to report the occurrence of cases and deaths related to certain notifiable conditions. In South Africa, 39 medical conditions are currently 6 notifiable (Table 4.7). The notification system in South Africa is based on Health Act No. 63 of 1977 together with certain Regulations on the reporting of specific diseases to the Local, Provincial and National Health Departments. Table 4.7 Notifiable conditions in South Africa  Acute flaccid paralysis  Leprosy  TB (pulmonary) Any person (not necessarily a health care worker) may report a notifiable condition to a local authority via fax, mail or telephone. The relevant notification form is then completed by the local authority or district office, and submitted to the provincial office, which in turn summarises the cases and deaths for each notifiable condition (even if no cases or deaths occurred during that period) and sends the summary to the national office. WHO IS RESPONSIBLE FOR NOTIFICATION? The first health care professional or facility with whom a patient presenting with one of the notifiable medical conditions comes into contact is expected to notify the case (or death). This includes clinic personnel, infection control nurses, other hospital staff, and public and private medical practitioners. In cases where the patient had no contact with a health care professional, a member of the community is required to report the case. WHYIS NOTIFICATION SO IMPORTANT? Healthcare professionals have a legal obligation to report cases of notifiable conditions. The process of notification alerts outbreak response teams, resulting in appropriate and timely interventions, in turn assisting in the prevention of spread of communicable diseases. In addition, the notification system provides information on the status and trends of communicable diseases in the country. THE NOTIFICATION PROCESS There are certain forms to be filled in when reporting a case or death. These are available from the regional health office, the local Communicable Disease Coordinator or the provincial stores section. ! Form GW17/05: Initial diagnosis (to be completed immediately and containing finer details of the patient and the diagnosis) ! Form GW17/03: Line list of cases (to be completed weekly) ! Form GW17/04: Line list of deaths (to be completed weekly) Notifications are done using GW17/05 forms. The structure of the system, process of obtaining the forms and persons to which the forms are sent differ considerably between, and even within provinces. People at the provincial health information offices, however, are conversant with specific details of the system in their province, and nurses and doctors are encouraged to contact them for specific details about how to go about notifying cases and deaths of the diseases above. Alist of telephone numbers and addresses 7 of these contact people is included at the end of this article. Asemi-detailed overview of the process is described below. The GW17/05 forms are required to be completed as fully as possible, although information on patient's age, sex or race may be omitted only if it is not available. All other applicable information should be filled in, especially details relating to the place and date of infection, the disease being notified and whether a case or death is being notified. The contact people in the relevant provincial health information office will be able to furnish you with the details of the specific office to which the notification forms should be 37 sent. The steps to follow when reporting notifiable conditions are summarised in Table 4.8. Table 4.8 Steps in the notification process STEP 1 Diagnose and confirm that the patient is suffering/has died of a notifiable condition. STEP 2 Obtain the necessary documentation: Form GW 17/5  In the case of death the condition should be reported twice, first as a case and then as a death. STEP 3 Complete all the forms and send them to the relevant office:  Local Authority/Hospital/District responsible for disease containment (fill in Form GW 17/3);  Regional Office (the Health Information Unit);  Provincial Office (the Health Information Unit);  National Department (Directorate HSR and Epidemiology) 7 Source: The notification system in a nutshell. Remember! When workers complain of symptoms, the first question to be answered is not "How do we fix the building?", but rather: “Why to they have symptoms?". In other words, to address health complaints effectively, a health evaluation is absolutely essential. A systematic approach to legionellosis in the work environment is crucial.

==Acknowledgements==
Delene Bartie (CB Scientific)- 2023

==References Chapter 3==

#Dowling JN, McDaevitt DA, Pasculle AW. Isolation and preliminary characterization of erythromycin-resistant variants of Legionella micdadei and Legionella pneumophila. Agents Chemother. 1985, 27 (2): 272-274.
#MacFarlane JT, Miller AC, Smith WH, Morris AH, Rose DH. Comparative radiographic features of community acquired Legionnaires’ disease, pneumococcal pneumonia, Mycoplasma pneumonia and psittacosis. Thorax 1984, 39: 28-33.
#Boldur I, Beer S, Kazak R, Kahana H, Kannai Y. Predisposition of the asthmatic child to legionellosis? Isr. J. Med. Sci 1986, 22 (10): 733-736.
#Kurtz JB. Legionella pneumophila. Am. J. Occup. Hyg. 1988, 32 (1): 59-61.
#Shapiro M. Unusual epidemiologic and clinical manifestations of legionellosis: a review. Isr. J. Med. Sci. 1986, 22 (10): 724-727.
#Yu VL. Legionella pneumophila (Legionnaires’ disease). In: Mandell, Douglas and Bennet (eds). Principles and practice of infectious disease. 1990, Third Edition, Churchill Livingstone.
#Ratshikhopha ME, Klugman KP, Koornhof HJ. An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires’ disease in South Africa. South African Med. J. 1990, 77: 392-395.
#Bartie C and Klugman KP. Exposures to Legionella pneumophila and Chlamydia pneumoniae in South African mine workers. Int. J. Occup. Environ. Health 1997, 3: 120-127.
#Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D, Klugman KP. “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. 1994, 84: 678-682.
#Winn 1991
#Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles E, Manterola J, Morera J. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. CHEST 1991, 99: 344-350.
#Stout JE, Yu VL. Legionellosis. New Engl. J. Med. 1997, 682-687.
#Ruf B, Schürman D, Horbach I, Fehrenbach FJ, Pohle HD. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. J. Inf. Dis. 1990, 162: 1341-1348.
#Harrison TG, Dournon E, Taylor AG. Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1. J. Clin. Pathol. 1987, 40: 77-82.
#Pastoris MC, Ciarrochi S, Di Capula A, Temperanza AM. Comparison of phenol- and heat-killed antigens in the indirect immunofluorescence test for serodiagnosis of Legionella pneumophila serogroup 1 antigens. J. Clin. Microbiol. 1984, 20 (4): 780-783.
#Kaufmann AF, McDade JE, Patton CM, Bennett JV, Skalyi P, Feeley C, Anderson DC, Potter ME, Newhouse VF, Gregg MB, Brachman PS. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epid. 1981, 114 (3): 337-347.
#Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.
#Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.
#Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.
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#[[Legionella Control#cite%20ref-:0%205-0|Jump up to:5.0]] [[Legionella Control#cite%20ref-:0%205-1|5.1]] Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8
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[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]
<references />

Legionella Control

2021-05-04T14:56:47Z

Tobyvan: /* 1.1 HISTORY */

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==INTRODUCTION==

==HISTORY==
Legionnaires’ disease was first described after a pneumonia outbreak at an American Legion Convention held in Philadelphia during 1976. In total, 182 delegates were affected and 29 died before workers at the Centers for Disease Control and Prevention (CDC) based in Atlanta, USA isolated the causative organism in January 1977. The organism was placed in the family Legionellaceae, genus Legionella to commemorate the first victims of the disease. The first species was named Legionella pneumophila (Greek for “lung loving”).

[[File:The first Legionnaires’ disease outbreak.png|thumb|The first Legionnaires’ disease outbreak]]

It soon became clear that legionellae were not really new; retrospective studies showed that an organism isolated for the first time in 1944 (called Tatlockia micdadei) actually belonged to the genus Legionella. The first strain of Lpneumophila was isolated already in 1947 from a guinea pig that had previously been inoculated with blood from a patient with what was called an “unknown febrile disease” at the time.

The two decades following the discovery of the family Legionellaceae was marked by rapid developments in Legionella detection and the identification of numerous new species. Twenty-eight new Legionella species and two “Legionella-like amoebal pathogens” (LLAPs) (LLAP-1 and LLAP-6) were isolated during the 1980s, mostly from sources in the USA. The 1990s were marked by an increase in Legionella isolation from countries in Europe and Australia with fifteen new Legionella species being described for the first time.

More than half of the currently known Legionella species are potentially pathogenic to humans. L. pneumophila is still implicated in >80% of infections; however, as more species are isolated from environmental sources worldwide, even those species not yet associated with disease should be considered as potentially pathogenic until proven otherwise. For example, L. longbeacheae, often isolated from potting soil, is considered the most common cause of legionellosis in Australia.

Legionellae are faintly staining gram negative, rod-shaped, non acid fast bacteria that to not form spores or capsules. All species except L. oakridgensis are motile. Legionellae are typically between 0.3 and 0.9 µm wide and 1- 20 µm long. However, shorter forms measuring 1- 2 µm in length are often observed in clinical specimens or under conditions of iron deprivation.

Figure 1.3Gimenez stain: Legionella bacteria

The ability of legionellae to grow in water is influenced by several factors. They can grow at temperatures between 20°C and 60°C, with optimal growth occurring between 37°C and 45°C. They prefer a pH in the range of 5.0 9.5 and only grow in the presence of Lcysteine, HCl and iron salts. Legionella-like amoebal pathogens (LLAPs) are very similar to Legionella species in that they are gram negative, infect amoebae and can survive and multiply intracellularly. However, they cannot be cultured on laboratory media. The first LLAP was isolated 1 from soil in Poland in 1954 and was named Sarcobium lyticum. The next isolation of an LLAP was in England more than 20 years later. Since then, LLAPs have been isolated from various sources, mostly associated with confirmed cases or outbreaks of 2 3 Legionnaires’ disease. Three of the LLAPs have since been reclassified as L. drozanskii, L. rowbothamii and L falloni. The currently known LLAPs are listed in Table 1.2.

===INTERACTIONS WITH PROTOZOA===
Legionellae are slow-growing organisms that require a combination of nutrients for growth. Due to their fastidious nature and lack of antibiotic activity, they may be replaced by faster growing organisms if they do not have an alternative means of survival in aquatic environments. The fact that legionellae are ubiquitous in these environments suggests that protozoa, especially amoebae, play a supportive role in their survival and multiplication. In fact, their natural habitat, parasitic to protist hosts, has now been 4 proven.
{| class="wikitable"
|+'''Legionella species'''
!ORGANISM
!SG
!YEAR
!SOURCE
!PATHOGEN
|-
|L adelaidensis
L anisa

L beliardensis

L birminghamensis

L bozemanii

L brunensis

L cherrii

L cincinnatiensis

L donaldsonii*

L drozanskii (LLAP-1)

L dumoffii

L erythra

L fairfieldensis

L fallonii (LLAP-10)

L feeleii

L geestiana

L gormanii

L gratiana

L gresilensis

L hackeliae

L israelensis

L jamestowniensis

L jordanis

L lansingensis

L londiniensis

L longbeacheae

L lytica

L maceachernii

L micdadei

L moravica

L nautarum

L oakridgensis

L parisiensis

L pittsburghensis

L pneumophila

L quateirensis

L quinlivanii

L rowbothamii (LLAP-6)

L rubrilucens

L sainthelensi

L santicrucis

L shakespeari

L spiritensis

L steigerwaltii

L taurinensis

L tusconensis

L wadsworthii

L waltersii

L worsleiensis
|1
1

1

1

2

1

1

1

*

1

1

2

1

1

2

1

1

1

1

2

1

1

1

1

1

2

1

1

1

1

1

1

1

1

15

1

2

1

1

2

1

1

1

1

1

1

1

1

1
|1991
1985

2001

1987

1980

1989

1985

1988

2002

2001

1980

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1991

2001

1993

1980

1991

2002

1985

1985

1985

1982

1994

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1985

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1989

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1985

1980

1979

1993

1990

2001

1985

1984

1985

1992

1985

1985

1999

1990

1983

1996

1993

1993
|Cooling water (Adelaide Australia)

Faucet (Chicago), tap water (LA)

Water, France

Lung biopsy (Alabama)

Lung aspirate (Toronto)

Cooling tower water (Czechoslovakia)

Thermally altered water (Minnesota)

Lung tissue (Cincinnatti)

<nowiki>*</nowiki>

Tank of well water (Leeds 1981)

Lung tissue

Cooling tower water (Seattle)

Cooling tower water (Fairfield Australia)

Ship air conditioner (1994)

Grinding machine coolant fluid

Hot water tap, office building (London)

Bronchial wash of pneumonia patient

Thermal spa water (France)

Water, France

Bronchial biopsy (Ann Arbour)

Water (Israel)

Wet soil (New York)

Water and sewage (Israel)

Bronchial washing, hloramin patient

Office building cooling tower (London)

Human lung (Longbeach Australia)

Previously Sarcobium lyticum

Water (Phoenix)

Human blood via yolk sac

Cooling tower water (Czechoslovakia) Hot water tap (London)

Cooling tower water (Pennsylvania)

Cooling tower water (Paris)

Synonym for L micdadei, strain

TATLOCK

Water (Pennsylvania)

Shower in hotel bathroom (Portugal)

Water in bus airconditioner (Australia)

Water and sludge, industrial liquefier

Tap water (Los Angeles)

Spring water (Washington)

Tap water (Virgin Islands)

Cooling tower water (England)

Lake water (Washington)

Tap water (Virgin Islands)

Water, hospital humidifier (Italy)

Pleural fluid, transplant patient (Arizona)

Sputum

Potable water system (Australia)

Industrial cooling water (England)
|Unknown

Yes

Unknown

Yes

Yes

No

Yes

Yes

<nowiki>*</nowiki>

Yes

Yes

No

Unknown

Yes

Yes

Unknown

Yes

No

Unknown

Yes

No

No

Yes

Yes

Unknown

Yes

Yes

Yes

Yes

No

Unknown

Yes

Yes

Yes

Yes

Unknown

No

Yes

Yes

Yes

No

Unknown

No

No

Unknown

Yes

Yes

Unknown

Unknown
|}

Table 1.1 Legionella species ORGANISM SGs YEAR SOURCE PATHOGEN L adelaidensis L anisa L beliardensis L birminghamensis L bozemanii L brunensis L cherrii L cincinnatiensis L donaldsonii* L drozanskii (LLAP-1) L dumoffii L erythra L fairfieldensis L fallonii (LLAP-10) L feeleii L geestiana L gormanii L gratiana L gresilensis L hackeliae L israelensis L jamestowniensis L jordanis L lansingensis L londiniensis L longbeacheae L lytica L maceachernii L micdadei L moravica L nautarum L oakridgensis L parisiensis L pittsburghensis L pneumophila L quateirensis L quinlivanii L rowbothamii (LLAP-6) L rubrilucens L sainthelensi L santicrucis L shakespeari L spiritensis L steigerwaltii L taurinensis L tusconensis L wadsworthii L waltersii L worsleiensis 1 1 1 1 2 1 1 1 * 1 1 2 1 1 2 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 15 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1991 1985 2001 1987 1980 1989 1985 1988 2002 2001 1980 1985 1991 2001 1993 1980 1991 2002 1985 1985 1985 1982 1994 1993 1982 1996 1985 1980 1989 1993 1983 1985 1980 1979 1993 1990 2001 1985 1984 1985 1992 1985 1985 1999 1990 1983 1996 1993 1993 Cooling water (Adelaide Australia) Faucet (Chicago), tap water (LA) Water, France Lung biopsy (Alabama) Lung aspirate (Toronto) Cooling tower water (Czechoslovakia) Thermally altered water (Minnesota) Lung tissue (Cincinnatti) * Tank of well water (Leeds 1981) Lung tissue Cooling tower water (Seattle) Cooling tower water (Fairfield Australia) Ship air conditioner (1994) Grinding machine coolant fluid Hot water tap, office building (London) Bronchial wash of pneumonia patient Thermal spa water (France) Water, France Bronchial biopsy (Ann Arbour) Water (Israel) Wet soil (New York) Water and sewage (Israel) Bronchial washing, hloramin patient Office building cooling tower (London) Human lung (Longbeach Australia) Previously Sarcobium lyticum Water (Phoenix) Human blood via yolk sac Cooling tower water (Czechoslovakia) Hot water tap (London) Cooling tower water (Pennsylvania) Cooling tower water (Paris) Synonym for L micdadei, strain TATLOCK Water (Pennsylvania) Shower in hotel bathroom (Portugal) Water in bus airconditioner (Australia) Water and sludge, industrial liquefier Tap water (Los Angeles) Spring water (Washington) Tap water (Virgin Islands) Cooling tower water (England) Lake water (Washington) Tap water (Virgin Islands) Water, hospital humidifier (Italy) Pleural fluid, transplant patient (Arizona) Sputum Potable water system (Australia) Industrial cooling water (England) Unknown Yes Unknown Yes Yes No Yes Yes * Yes Yes No Unknown Yes Yes Unknown Yes No Unknown Yes No No Yes Yes Unknown Yes Yes Yes Yes No Unknown Yes Yes Yes Yes Unknown No Yes Yes Yes No Unknown No No Unknown Yes Yes Unknown Unknown Sources: American Type Culture Collection; National Type Culture Collection. 2 Table 1.2 Legionella-like amoebal pathogens (LLAPs STRAIN HOSTS YEAR ORIGINAL SOURCE PATHOGENIC Sarcobium lyticum A polyphaga H vermiformis 1954 Soil Yes LLAP-1 A polyphaga 1981 Tank of portable water well Yes LLAP-2 A polyphaga H vermiformis 1986 Garage steam cleaning pit Yes LLAP-3 A polyphaga 1986 Sputum from pneumonia patient Yes LLAP-4 A polyphaga 1986 Hospital whirlpool bath Yes LLAP-5 A polyphaga 1988 Nursing home plant spray Yes LLAP-6 A polyphaga H vermiformis 1988 Factory liquefier tower Yes LLAP-7 A polyphaga H vermiformis 1991 Hotel whirlpool spa Yes LLAP-8 H vermiformis 1990 Hospital shower Yes LLAP-9 A polyphaga H vermiformis 1992 Factory cooling tower Yes LLAP-10 A polyphaga 1994 Ship air-conditioning system Yes LLAP-11 A polyphaga 1993 Furnace cooling system Yes LLAP-12 A polyphaga 1994 Furnace cooling system Yes 3 Adapted from Adeleke 1996 5

Rowbotham was the first to demonstrate interactions between legionellae and protozoa. To date, protozoa of the genera Acanthamoeba, Tetrahymena, Naegleria, Echinamoeba and Vanella species have been implicated in these interactions. Not much is known about the metabolic and physiological status of legionellae after passage through protozoa, but in vitro studies have shown changes in their physiological status resulting in iron deprivation, possibly changing the susceptibility of the released bacteria to chemical inactivation. Although they can survive extracellularly, this phase is believed to be only temporary while they are searching for new hosts to 6 infect. Furthermore, it was recently documented that very few Legionella bacteria are needed to start intracellular replication. Some workers have reported a 7000 times increase in Legionella colony forming units (CFU) after intracellular replication buth there is no consensus yet as many believe that this intracellular replication cycle is not necessary for the proliferation of legionellae within mixed bacterial populations. From these studies it is clear that there is still extensive research to be done on this aspect of Legionella survival in the environment. Until more becomes known, it is unsafe to assume that the absence of protozoa within water samples prevents the survival of legionellae; as long as there are other bacterial species present, appropriate measures should be taken to prevent Legionella proliferation.

===1.3 HOWDOES THE INTERACTION WITH PROTOZOABENEFITLEGIONELLAE?===
Amoeba trophozoites feed and multiply in water and biofilm. When conditions become unfavourable, these trophozoites are transformed into cysts with hard, impermeable outer walls that provide protection for ingested Legionella organisms. When conditions become more favourable, the cysts change to trophozoites again and the bacteria are set free. Legionellae have been 7 recovered from cysts treated with 50 parts per million (ppm) chlorine suggesting a high level of protection by the cysts. This high resistance of amoebal cysts to biocides may be the mechanism for the apparent reseeding of water systems by legionellae often experienced in the water treatment industry. However, recontamination may also occur via transmission of airborne cysts acting as carriers for the legionellae.

===1.4 HOWIMPORTANTIS LEGIONELLAIN SOUTH AFRICA?===
Very little has been published on Legionella in South Africa. After the initial introduction of diagnostic laboratory tests in 1979, legionellosis cases were identified in Durban, Port Elizabeth and Johannesburg during the early 1980's. By 1982, antibodies to L. 8,9 pneumophila had been demonstrated in 10% of hospitalised pneumonia patients, a figure that was confirmed in 1994. A high 9,10,11 prevalence of antibodies was also demonstrated in workers in the mining industry and the general public. Despite this high prevalence, only one Legionnaires' disease outbreak and less than 40 sporadic cases have been reported since legionellosis became notifiable in 1990. Similarly, very little is known about the prevalence of Legionella in the South African environment. Low concentrations of 12 legionellae were reported in 77% of cooling towers in a large study reported in 1991. More recently, culturable legionellae were present in 82% of industrial water samples tested; 54% of these samples yielded legionellae in numbers equal to or in excess of 1000 11 CFU/ml. 3

===1.5 LEGIONELLADETECTION===
Classical detection methods for Legionella species relied on the inoculation of susceptible guinea pig hosts. Although selective, these methods were expensive and time consuming and were soon replaced by isolation by culture on agar media. To improve the recovery of legionellae by culture, the use of certain selective media and steps were introduced to minimise contamination by nonlegionellae. In attempts to simplify Legionella identification, radioimmunoassays (RIAs), enzyme linked immunosorbent assays (ELISAs), agglutination tests and nucleic acid probes and polymerase chain reaction (PCR)-based assays have since been developed and tested.

Despite the relative success of these new methods for the detection of environmental legionellae, culture remains the method of choice. However, no single culture method has so far proven to be ideal for all samples in all given circumstances and environments. Even in the absence of contaminating bacteria or other inhibitory substances, the detection of small numbers of legionellae from environmental samples remains difficult. This, together with the lack of standardisation of methods, complicates the interpretation of culture results and comparisons of results from different laboratories. Variations in bacterial numbers in different areas within a water distribution system and the sampling method used often complicate the interpretation of culture results even further.

Previous studies have shown that the culture of Legionella species from environmental samples is complicated by the presence of 13,14 faster growing bacteria due to inhibition of legionellae on culture media in the presence of heterotrophic bacteria. For example, 15 Pseudomonas aeroginosa secrete bacterial substances into the surrounding media that dramatically inhibit Legionella growth. Although culture is still the gold standard, it remains time consuming and requires a certain level of technical skill. Legionellae may also enter a “viable but non-culturable (VBNC)” state under certain conditions which complicated culturing even further.)

Lp Lm L boz L dum L gor L long L jor L oak Growth on BCYE Growth on TSB Acid production Gelatin hydrolysis Urease Primary growth on FG Beta lactamase Hippurate hydrolysis Browning of tyrosine medium Blue fluorescence on CYE + - - + - + + + + - + - - + - - - - - - + - - + - - +/- - + + + - - + - - + - + + + - - + - - + - + + + - - + - - + or – - + - + - - + - - + - + - + - - - - nt +/- - + - Nt: not tested, +/- weak positiv; Lp L. pneumophila; Lm L. micdadei; Lboz L. bozemanii; Ldum L. dumoffii; Lgor L. gormanii; Llong L. longbeacheae; L jor L jordanis; L L. oakridgensis. oak Table 1.3 Selected characteristics of Legionella species Figure 1.4 Legionella colonies on agar (Sources: own laboratory pictures; Annual Report, American Water Technologies (2003) Recent developments in the molecular field opened doors for new detection assays of waterborne pathogens such as Legionella. These methods include: 16 ! DNA probe hybridisation; 4 ! ! ! ! ! ! !

====1.5.1 Polymerase chain reaction (PCR)====
Although the sensitivity of most of these techniques is insufficient for direct detection of legionellae in environmental samples, 18,19 PCR has proven to be a sensitive and rapid alternative to culture. Many PCR assays have been described, but relatively few of them have been extensively studied on clinical as well as environmental samples and none are routinely used.

====1.5.2 Immunofluorescence====
Immunofluorescence is a technique whereby antigen and antibody is bound to a fluorochrome (fluorescent stain) and then allowed to react with the corresponding antigen or antibody on a microscope slide. The results are viewed under a fluorescent microscope. There are many variations of immunofluorescent techniques but only direct immunofluorescence (DFA) and indirect immunofluorescence (IFA) is of importance in the confirmation of environmental legionellae. Direct immunofluorescence (DFA) is most commonly used for confirmation of Legionella species from environmental samples. The test is simple to perform, but interpretation requires a fair amount of experience, especially in highly contaminated samples. Antigen from the sample is fixed to a microscope slide using heat or acetone and covered with fluorescein-isothiocyanate (FITC) labelled globulin. Antigens in the sample bind to the labelled globulin and the resulting antigen-antibody complexes are visible under ultraviolet light. Direct immunofluorescence (DFA) is useful to detect antigens in clinical samples when cultures cannot be obtained, but its value for environmental samples is controversial. Nevertheless, it is used as a screening test by some laboratories. Cross-reactions that may lead to false positive results have been documented.

Figure 1.5 Legionella immunofluorescence/Fluorescent bacteria

17 Restriction enzyme digestion; 18,19 Polymerase chain reaction; 20 Soluble protein patterns; 21 DNA restriction endonuclease profiles; 22 Multilocus enzyme analysis; 23 Orthogonal-field-alteration gel electrophoresis; 24 Sodium dodecyl sulphate poly-acrylamide gel electrophoresis (SDS-PAGE).

====1.5.3 Fluorescent in situ hybridization====
Fluorescent in situ hybridization (FISH) is a technique whereby a fluorescent labeled DNA probe is used to detect a particular chromosome or gene that can then be visualised by fluorescence microscopy. FISH tests are useful for the detection of legionellae in respiratory tract samples but has not been extensively tested in environmental samples. The method makes use of oligonucleotide probes targeting rRNA and offers a fast and specific alternative to direct immunofluorsecence, culture and urine antigen testing in clinical laboratories. {{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate. Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.'''10'''

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

*'''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

*'''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

*'''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

*'''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

*Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997 '''WHAT TO TAKE INTO ACCOUNT WHEN INTERPRETING LABORATORY RESULTS'''

*Both IgM and IgG should be measured simultaneously.
*Diagnostic IgM titres will provide an earlier diagnosis than IgG because they indicate a primary immune response.
*Results obtained by the IFA should always be interpreted in conjunction with the clinical presentation of the disease.
*Titres below the diagnostic level together with clinical manifestations may be useful for early provisional diagnosis of Legionnaires’ disease; but diagnosis by IFA is usually retrospective.
*The interpretation of the IFA should take into account the variation in the time of appearance of antibodies, the types of antibodies produced and the length of time the antibodies are detectable in sporadic cases, as well as the prevalence of antibodies in the population from which the patient comes.
*The type of reagents used for IFA tests may influence the results: ether-killed, formalin-killed or heat-killed antigens vary in sensitivity and specificity and this should be taken into account in the interpretation.
*False negative results may be reported because a long time is needed for seroconversion to occur and not all species and serogroups are detectable by this method.
*Seroconversion (a fourfold rise in titre to at least 1:128) is considered as a presumptive positive result.
*A single titre of 1:256 or higher is regarded as a presumptive positive result.
*Serological results should preferably be confirmed by culture.
*In communities with low antibody prevalence, a single titre of 1:128 may be diagnostic and where the prevalence is high, a single titre of 1:256 may still provide only presumptive evidence of infection.
*Low titres usually indicate past infections.
*When titres to multiple antigens are raised, the titre that is fourfold higher than the others is considered to be diagnostic.
*In epidemiological studies diagnostic titres are usually one twofold dilution higher than for sporadic cases.

===HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

 
[[File:FIGURE 3.3.jpg|center|thumb|500x500px|Figure 3.3 Histological section of lung of Legionnaires disease patient]]
 

===CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

*Initial involvement is unilateral, predominantly in the lower lobe
*Bilateral involvement has been described
*Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction
*Pulmonary densities enlarge during later stages of disease
*Pulmonary densities have a typical ground glass appearance or dense consolidation
*Total opacification of the lung may occur
*Pleural effusions are present in 24-63% of cases caused by L pneumophila
*Pleural effusions are uncommon in L micdadei infections
*Hilar adenopathy seldom occurs
*Cavitation may occur in immunocompromised patients
*Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called ''Acanthamoeba'' filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to ''L pneumophila, L feelei and L anisa''. Complete recovery usually occurs in 2 – 5 days without medical attention.

==CHAPTER 4==

===SURVEILLANCE FOR LEGIONELLA===
A major aspect of biosafety in the workplace is the assessment of hazards and risks of infection (environmental surveillance) and disease in workers (clinical surveillance). ENVIRONMENTALSURVEILLANCE Environmental surveillance is essential for the long term success of any water treatment program for Legionella to provide baseline environmental information to ensure the efficiency of disinfection and water treatment programmes and to control the risk of infection in events of mechanical failures and human error. The risk of contracting legionellosis can be summarised in terms of three factors, as summarised in Table 4.1. Table 4.1 Factors determining the risk of legionellosis Proliferation potential This potential exist in nearly all water systems and depends on many factors, including:  Presence of microbial biofilms  Diversity of microorganisms present  Availability of nutrients Exposure potential Certain industrial processes produce aerosols during their function. These aerosols can be aspirated (breathed deep into the lung) if the particle size is small enough (< 8 µm in diameter). Assessment of exposure potential thus focuses on the proximity of aerosol-generating systems to human populations. Population susceptibility The most susceptible individuals are elderly people (especially males), heavy smokers, alcoholics, patients with chronic pulmonary disease and immuno-suppressed people. 1 Source: McCoy 2004 4.1 RISK ASSESSMENTS A risk assessment is a scientifically based process used to estimate the likelihood of adverse effects occurring, taking into account the exposure (hazard), the level and nature of the risk and the target population. Risk assessments can be either quantitative or 1 qualitative. 4.1.1 Quantitative risk assessments Quantitative risk assessments involve the establishment of dose-effect and dose-response relationships in likely target individuals and populations. For a quantitative risk assessment to be successful, dose-response assessments, the extent and duration of human exposure and characterisation of the possible consequences resulting from exposure have to be determined 1 and quantified. Quantitative risk assessments are not possible for hazardous biological agents (including Legionella) for several reasons. Firstly, exposed people have varying degrees of susceptibility to infection. Secondly, water sources usually contain a diverse mixture of biological contaminants which may change rapidly over short periods of time. Thirdly, the contaminants present and the levels in which they are present are only applicable at the time and area sampled and the interactions among all these 1 biological agents present in the source and environment make exposure assessment extremely difficult. 4.1.2 Qualitative risk assessments Qualitative risk assessments on are done to “document site-specific conditions and recommendations for reducing the risk, if 1 necessary, and to establish assignments for actions, communications, training and management responsibilities”. Anumber of schemes have been developed to provide some form of risk ranking and risk scores to simplify these assessments 1 and to guide the water management plan. An example of a risk ranking for legionellosis is provided in Table 4.2. For example, if a system falls into Risk Category A, the frequency of testing, cleaning and disinfection and monitoring should be increased until the system falls into a lower Risk Category, when the rate of testing, cleaning and monitoring can be reduced again. 19 Table 4.2 Risk classification for legionellosis HIGHEST RISK LOWEST RISK RISK CLASSIFICATION A B C D CRITERIA MATCHES ANY OF THE RESPONSES BELOW MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A OR B MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A, B OR C Stagnant water  System idle more than once a month  Re-circulation pump not timed  Dead-legs present  A plus timed recirculation pump  Any single factor in A  System operates continuously  No dead-legs Nutrients and growth  Contaminated water  No corrosion control  Wet surfaces open to sunlight  Any two factors in A  Any one factor in A  No factors in A Water quality  No automated biocide dosing protocol  No water treatment program  No automated biocide dosing  No water treatment program in place  Automated biocide dosing  No water treatment program in place  Automated biocide dosing  Water treatment program in place Equipment design and operation  No system design review  No system operation and performance review  No drift eliminators  Drift eliminators for cooling towers in place  Same as B with at least one review lacking  System design review in place  System operation and performance review in place  Good drift eliminators Location and access  Located in healthcare or residential care facility  Large numbers of people exposed  Same as A but moderate numbers of people exposed  Same as B but few people exposed  Not located near susceptible people 1 Source: McCoy 2004 4.2 THE RISK ASSESSMENTPROCESS The four most important steps in the risk assessment process are to get an overview of the operation of the water distribution system, to conduct a walk-through investigation of the building or facility, to assess the results of the walk-through to determine an 2,3,4 appropriate course of action and to recommend appropriate control actions. These steps are explained in more detail below. STEP 1 GET AN OVERVIEW OF THE WATER DISTRIBUTION SYSTEM OPERATION Ask the facilities engineer or an experienced member of the building staff, who has knowledge of the design and current operation of the system to explain the system and to assist in the walk-through investigation. The overview should include inspection of: ! Plumbing systems, heating/ventilation/air-conditioning (HVAC) systems and other water reservoirs as summarised in Table 4.3 20 ! Maintenance records of all water systems, including records of temperature checks on potable water, details of visual and physical checks of cooling towers and reports of water quality assessments and chemical treatment that may have been performed ! Location of parts of the system where there may be stagnant water ! The presence of cross-connections between potable and non-potable water systems ! The condition and type of back flow prevention devices used at these connections ! Any recent major maintenance actions performed or major changes in the system ! Determine whether recent or frequent losses of water pressure have occurred from the incoming supply ! Keep in mind that the failure of a back flow prevention device under loss of pressure can result in contamination of the water system Table 4.3 Areas to include when doing an overview of a waterdistribution system Plumbing systems Hot and cold potable water systems Water heaters Water coolers Distribution piping Water treatment equipment (eg. water softeners, filters) Connections to process water systems (not protected by backflow preventers) Storage tanks Heating, ventilation and airconditioning (HVAC) systems Cooling towers Evaporative condensers Fluid coolers Direct and indirect evaporative cooling equipment Humidifiers Location of fresh air intakes relative to water sources Air washers for filtration Miscellaneous reservoirs Decorative fountains Plant misters Whirlpools and spas Tepid water eye washes Safety showers Cooling water for industrial processes 2 Source: <nowiki>http://www.nalco.com</nowiki> STEP 2 CONDUCT A WALK-THROUGH INVESTIGATION OF THE FACILITY Table 4.4 The walk-through investigation WHAT TO DO WHEN ! Check sample transport requirements and receiving times of laboratory before investigation ! Get as much information as possible from staff before investigation ! Go through checklist and make sure you are prepared before investigation ! Check water temperatures while sampling for Legionella ! Check hot water tanks and related piping during investigation ! Check cooling towers during investigation ! Check water quality during investigation ! ! ! ! ! WHO SHOULD BE PRESENT? The person who knows most about the building, particularly the domestic water system Aplumbing engineer if possible Aplumbing contractor who knows the building if possible Arepresentative from the company that services the HVAC system The water treatment specialist who services the cooling tower 21 EQUIPMENT NEEDED ! The floor plan (arrange in advance if possible) ! Drawings of plumbing if available (arrange in advance if possible) ! Inspection checklist ! Camera ! Knife ! Pliers or channel locks ! Measuring tape SAMPLING KITS AND EQUIPMENT TO TAKE WITH ! Thermometer ! Chlorine kit ! Iron kit ! pH meter ! Total dissolved solids (TDS) kit ! Hardness kit ! Calibration fluid ITEMS NEEDED FOR LEGIONELLA SAMPLING ! Sampling log (see example) ! Sodium thiosulfate ! Cooler bag and other materials needed for packaging of sample for transport ! Documentation from courier or transport agency ! Plastic bags for packaging of samples ! Sterile swabs ! Sampling bottles ! Labels for bottles ITEMS NEEDED FOR SAMPLING FOR THE TOTAL BACTERIAL COUNT (TBC) ! Sampling bottles ! Sampling log sheets ! Cooler bag and other materials needed for packaging of sample for shipping or transport ! Documentation from courier or transport agency ! ! REMEMBER The temperature may be below the gauge temperature of the heater due to heat stratification CHECKLIST FOR FAUCETS CONNECTED TO EACH WATER HEATER ! Maximum temperature of each location that is “close (C)”, “intermediate (I)” or “far (F)” from the heaters ............................................................................................................ REMEMBER You may have to run the water for several minutes before it reaches a maximum temperature at “far” locations CHECKLIST FOR COLD WATER STORAGE TANKS USED FOR RESERVE WATER OR FOR MAINTAINING HYDROSTATIC PRESSURE ! InitialTemperature (°C) .......................................................................................................................... ! Potential for stagnation: high (H), medium (M) or low (L)........................................................................ ! Temperature of cold water line at various locations Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Record both initial temperature and final equilibration temperature on cold water lines ...................... REMEMBER Tanks should be protected from temperature extremes and should be covered to prevent stagnation CHECKLIST FOR EACH STORAGE-TYPE HOT WATER HEATER Temperature of water drawn from it (°C) ................................................................................................. Presence of rust and scale ......................................................................................................................... 22 CHECKLIST FOR COOLING TOWERS, EVAPORATIVE CONDENSERS AND FLUID COOLERS ! Visual evidence of biofilm growth, scale build-up and turbidity ........................................................... ! The location of the tower relative to fresh air intakes ............................................................................ ! Proximity to sources such as kitchen exhausts, leaves, plant materials, or other sources of organic material that may contribute to Legionella growth .............................................................................................. CHECKLIST FOR COOLING TOWERS ! General physical and mechanical condition ........................................................................................... ! Presence and condition of drift eliminators ............................................................................................ ! Basin temperature of water (the tower is working) ................................................................................ REMEMBER Wear appropriate respiratory protection (half face-piece respirator and HEPA filter cartridge) during examination if cooling tower is operating SUMPS FOR COOLING TOWER, EVAPORATIVE CONDENSER AND FLUID COOLERS ! Location and condition ............................................................................................................................ ! Location of any cross-connections between potable and non-potable systems ......................................... REMEMBER Sumps are sometimes located indoors to prevent them from freezing. Cross-connections may be present to supply a back-up source of cool water to refrigeration condenser units or to supply secondary cooling units STEP 3 ASSESS THE RESULTS OF THE WALK-THROUGH TO DETERMINE AN APPROPRIATE COURSE OF ACTION Table 4.5 When is additional action necessary? NO FURTHER ACTION Operating temperatures measured in water heaters is 60°C Delivery temperature at distant faucets is ? 50°C No other potential problems observed TAKE FURTHER ACTION Poor maintenance Operating temperatures below minimums mentioned above STEP 4: RECOMMEND CONTROLACTIONS Remember! These actions may include disinfection of the potable water system as outlined in the section on disinfection 23 Table 4.6 Recommended control actions ACTION EXPLANATION Actions to limit the growth of organisms in water systems: Elimination of dead legs in the plumbing system Insulation of plumbing lines Installation of heat tracing to maintain proper system temperatures Elimination of rubber gaskets Removal or frequent cleaning of plumbing fixtures (eg aerators and shower heads) Water sampling to confirm the presence of Legionella: Not necessary at this stage BUT Customer may want to obtain background information, in which case sampling for Legionella will be helpful To ensure that corrective actions are successful: Sample water after corrective action BUT Customer may want to collect samples before corrective action to assess the extent of the problem but this is not normally done The customer should take the necessary corrective action, even if the pre-sampling tests are negative for the following reasons: Water sampling may produce false-negative results A contaminated portion of the system may have been missed The absence of legionellae at the time of sampling does NOT ensure that the system will remain negative at a later date Limited corrective actions that will not be sufficient: Raising water heater temperature without evaluation of system points of stagnation, heat loss and heat gain, cross-contamination and other factors that may contribute to the growth of Legionella bacteria. LEGIONELLA RISK ASSESSMENT DATA SHEET GENERAL INFORMATION Name of organisation Contact person 1 Contact person 2 Contact person 3 Site address Mailing address Building/area size Building age Type of building 24 RESULTS FROM PREVIOUS LEGIONELLA TESTING DATE RESULT Cooling towers Hot water tanks Outlet swabs Hot water outlets Cold water outlets Mixed outlets Incoming water 25 USEFUL QUESTIONS TO ASK ABOUT THE FACILITY WHEN DOING A RISK ASSESSMENT FOR LEGIONELLA(SOURCE: FREIJE 2001) Incoming mains Number Configuration Water source City - ground City - surface Utility: Private well Water usage Obtained from Water bills Fixture count Meter reading Other Deadlegs Present Policies Past construction Aerators Yes No Type Cold pipes location relative to hot Above Below Same level Pipe material Pipe insulation Cold Hot Both Type used Drinking fountains On chilled loop Individual 26 Fire sprinkler above ducts Yes No Water hammers arrestors or air chambers Water hammers Air chambers Both Sediment on water filters Yes No Other sediment gathering equipment Yes No Describe Connection control and/or backflow devices Yes No Faucets and showerheads Age Condition Water softened Cold water Yes No How Hot water Yes No How Water pressure shock Incidents Brown colour Building units closed off temporarily Yes No Major construction activities Yes No Dates Eye wash stations Mixed Cold Emergency showers Mixed Cold 27 Ice machines present Yes No Decorative fountains present Yes No Piped in coffee/tea/cooldrink centres present Yes No Rubber hoses present Yes No Misters for plants/food/comfort present Yes No Other equipment where water flow through that may produce a spray/mist Yes No Can windows be opened? Yes No HVAC systems +Condition of coils Overall condition Drainage of drip pans Humidifiers in duct? Hot water system Number of HW loops Number of CW loops HW recirculating? CW recirculating? Design temp at tank Design temp at taps Regulators Mixing valves Sensors to detect failures CW storage tanks present? Are they covered? Heaters or sunlight? 28 HOT WATER SYSTEM INSPECTION Model number Serial number Age Horizontal/vertical Condition Insulation Temp on gauge Temp from drain Temp of returning water Capacity/turnover Cleaning regimen Cleaning frequency All pumps used daily? Piping arrangement Draw diagram on separate sheet and attach 29 COOLING TOWER INSPECTION In-house identification Location Make and model Serial number Size Age Basin drainable? Cycling of each Months operating Water treatment company Contact details Cleaning frequency Who does the cleaning How is cleaning done? Is basin fully drained? Excessive foaming? Oily film on surfaces? Scum? Condition of drift eliminators Air bypassing: Around edges? Through holes in tower casing? Fill exposed to sunlight Basin exposed to sunlight Louvres/fill clogged? Louvres/fill damaged? Louvres/fill scale present? Louvres/fill algae present? Filters SAND BAG CARTRIDGE Pressure drop 30 Centrifugal separators Outlet strainers Pressure drop Corrosion/deterioration on Structural members? Safety rails? Ladders? Fasteners? Basin? Water leaks present? Air leaks present? Sump water level Cooling water temp Accessible to passers by? Distance from road Distance from parking Distance from sidewalks 31 COOLING TOWER INSPECTION CHECKLIST 5 Source: Freije 2001 BUILDING TOWER NAME/NUMBER INSPECTOR’S NAME DATE OF INSPECTION SAND FILTERS Water leaks? YES NO Suction air leaks? YES NO Pre-strainer clogged? YES NO Channeling in sand filter media (check quarterly) YES NO Operating pressure If YES, clean the media or replace it with filter sand designed specifically for cooling towers and evaporative condensers (not swimming pools). Clean the under-drain assembly while the media is removed. CENTRIFUGAL SEPARATORS Pressure drop Acceptable based on manufacturer’s chart? YES NO Flow rate Purge operation functional? YES NO UNUSUAL NOISE OR VIBRATION IN Pumps? YES NO Motors? YES NO Fans? YES NO Mounting hardware? YES NO OUTLET STRAINERS In place? YES NO Clogged? YES NO BAG AND CARTRIDGE FILTERS Pressure drop Acceptable based on manufacturer’s recommendations? YES NO If not, clean or replace TOWER STRUCTURE AND CASING Water leaks? YES NO Air leaks? YES NO 32 CORROSION OR OTHER DETERIORATION ON Structural members? YES NO Safety rails? YES NO Ladders? YES NO Fasteners? YES NO Basin? YES NO LOUVERS, FILL AND DRIFT ELIMINATORS Clogged? YES NO Damaged? YES NO Excessive scale or algae growth? YES NO If yes, clean with 6,895 – 10,343 kPa (1,000 – 1,500 psi) water, being careful not to damage fill and eliminator components WATER DISTRIBUTION Is the water distribution balanced? YES NO If not, unclog nozzles SEDIMENT BUILD-UP Sediment build-up around heater elements? YES NO FANS Do fans start and stop properly? YES NO VIBRATION Are the vibration switches operating properly? (check at least annually) YES NO SEASONAL OPERATION Are the seasonal systems working (check at least 3 months before winter) YES NO Are there any parts needed? YES NO If YES, what is needed? Are there any repairs necessary? YES NO If YES, what is needed? 2133 Describe action taken in response to above inspection (include dates): QUESTIONS FOR INFECTION CONTROL COORDINATOR (IF APPLICABLE) History of cases Cleaning of hydrotherapy baths and pools Practices for use and cleaning of portable humidifiers Practices for use and cleaning of nebulizers and other semi-critical respiratory equipment Water treatment for dialysis Contact details: Dental unit present? How is it treated? Contact details: Clinical tests for Legionella available? Policy for testing patients/workers for Legionella? 34 CHECKLIST FOR LEGIONELLA SAMPLING HW tank PRE-FLUSH POST-FLUSH Incoming water Faucets and showerheads Cooling make-up water Decorative fountains Cooling tower basins WATER QUALITY TESTS SAMPLE LOCATION pH Free chlorine Total chlorine Hardness TDS Iron TBC Coliforms WATER TEMPERATURES SAMPLE LOCATION HW after 1 minute (°C) CW after 1 minute (°C) 35 EXAMPLE OFSAMPLING LOG / REQUESTFORM REQUESTFOR TESTING OFWATER SAMPLES FOR LEGIONELLA COMPANYDETAILS .................................................................................................................................................................................................. CONTACTPERSON .................................................................................................................................................................................................. CONTACTDETAILS TEL........................................... FAX ............................................. E-MAIL................................................................ NAME OF PERSON WHO COLLECTED SAMPLES ............................................................................................................................... COLLECTION SITE .................................................................................................................................................................................................. SAMPLE NO LOCATION TYPE TIME COLLECTED COMMENTS Received by ……………………………..……….... Date ……………………….. Time ……………… HEALTH SURVEILLANCE Health surveillance can be defined as the “ongoing collection, comparison, analysis and dissemination of data relevant to public health issues”. The main objectives of health surveillance are to identify disease patterns in different population groups, to develop prevention strategies, to allocate resources for prevention and treatment and to educate health professionals and the general public. Health surveillance can take the form of: ! The notifiable disease reporting system (the first step in the surveillance cycle) ! Laboratory based surveillance (for diseases that can be monitored accurately through the laboratory data used for confirmation of the disease) 36 ! Hospital-based surveillance (where hospital discharge information and mortality data are used to monitor trends and disease burden in a particular area) ! Population-based surveillance (where data from a well-defined population are collected and analysed) DISEASE NOTIFICATION Disease notification serves as a means of collecting data on diseases that are considered to be of public health importance and is used world wide. Most countries (including South Africa) have a routine notification system requiring health professionals to report the occurrence of cases and deaths related to certain notifiable conditions. In South Africa, 39 medical conditions are currently 6 notifiable (Table 4.7). The notification system in South Africa is based on Health Act No. 63 of 1977 together with certain Regulations on the reporting of specific diseases to the Local, Provincial and National Health Departments. Table 4.7 Notifiable conditions in South Africa  Acute flaccid paralysis  Leprosy  TB (pulmonary) Any person (not necessarily a health care worker) may report a notifiable condition to a local authority via fax, mail or telephone. The relevant notification form is then completed by the local authority or district office, and submitted to the provincial office, which in turn summarises the cases and deaths for each notifiable condition (even if no cases or deaths occurred during that period) and sends the summary to the national office. WHO IS RESPONSIBLE FOR NOTIFICATION? The first health care professional or facility with whom a patient presenting with one of the notifiable medical conditions comes into contact is expected to notify the case (or death). This includes clinic personnel, infection control nurses, other hospital staff, and public and private medical practitioners. In cases where the patient had no contact with a health care professional, a member of the community is required to report the case. WHYIS NOTIFICATION SO IMPORTANT? Healthcare professionals have a legal obligation to report cases of notifiable conditions. The process of notification alerts outbreak response teams, resulting in appropriate and timely interventions, in turn assisting in the prevention of spread of communicable diseases. In addition, the notification system provides information on the status and trends of communicable diseases in the country. THE NOTIFICATION PROCESS There are certain forms to be filled in when reporting a case or death. These are available from the regional health office, the local Communicable Disease Coordinator or the provincial stores section. ! Form GW17/05: Initial diagnosis (to be completed immediately and containing finer details of the patient and the diagnosis) ! Form GW17/03: Line list of cases (to be completed weekly) ! Form GW17/04: Line list of deaths (to be completed weekly) Notifications are done using GW17/05 forms. The structure of the system, process of obtaining the forms and persons to which the forms are sent differ considerably between, and even within provinces. People at the provincial health information offices, however, are conversant with specific details of the system in their province, and nurses and doctors are encouraged to contact them for specific details about how to go about notifying cases and deaths of the diseases above. Alist of telephone numbers and addresses 7 of these contact people is included at the end of this article. Asemi-detailed overview of the process is described below. The GW17/05 forms are required to be completed as fully as possible, although information on patient's age, sex or race may be omitted only if it is not available. All other applicable information should be filled in, especially details relating to the place and date of infection, the disease being notified and whether a case or death is being notified. The contact people in the relevant provincial health information office will be able to furnish you with the details of the specific office to which the notification forms should be 37 sent. The steps to follow when reporting notifiable conditions are summarised in Table 4.8. Table 4.8 Steps in the notification process STEP 1 Diagnose and confirm that the patient is suffering/has died of a notifiable condition. STEP 2 Obtain the necessary documentation: Form GW 17/5  In the case of death the condition should be reported twice, first as a case and then as a death. STEP 3 Complete all the forms and send them to the relevant office:  Local Authority/Hospital/District responsible for disease containment (fill in Form GW 17/3);  Regional Office (the Health Information Unit);  Provincial Office (the Health Information Unit);  National Department (Directorate HSR and Epidemiology) 7 Source: The notification system in a nutshell. Remember! When workers complain of symptoms, the first question to be answered is not "How do we fix the building?", but rather: “Why to they have symptoms?". In other words, to address health complaints effectively, a health evaluation is absolutely essential. A systematic approach to legionellosis in the work environment is crucial.

==Acknowledgements==
Delene Bartie (CB Scientific)- 2023

==References Chapter 3==

#Dowling JN, McDaevitt DA, Pasculle AW. Isolation and preliminary characterization of erythromycin-resistant variants of Legionella micdadei and Legionella pneumophila. Agents Chemother. 1985, 27 (2): 272-274.
#MacFarlane JT, Miller AC, Smith WH, Morris AH, Rose DH. Comparative radiographic features of community acquired Legionnaires’ disease, pneumococcal pneumonia, Mycoplasma pneumonia and psittacosis. Thorax 1984, 39: 28-33.
#Boldur I, Beer S, Kazak R, Kahana H, Kannai Y. Predisposition of the asthmatic child to legionellosis? Isr. J. Med. Sci 1986, 22 (10): 733-736.
#Kurtz JB. Legionella pneumophila. Am. J. Occup. Hyg. 1988, 32 (1): 59-61.
#Shapiro M. Unusual epidemiologic and clinical manifestations of legionellosis: a review. Isr. J. Med. Sci. 1986, 22 (10): 724-727.
#Yu VL. Legionella pneumophila (Legionnaires’ disease). In: Mandell, Douglas and Bennet (eds). Principles and practice of infectious disease. 1990, Third Edition, Churchill Livingstone.
#Ratshikhopha ME, Klugman KP, Koornhof HJ. An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires’ disease in South Africa. South African Med. J. 1990, 77: 392-395.
#Bartie C and Klugman KP. Exposures to Legionella pneumophila and Chlamydia pneumoniae in South African mine workers. Int. J. Occup. Environ. Health 1997, 3: 120-127.
#Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D, Klugman KP. “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. 1994, 84: 678-682.
#Winn 1991
#Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles E, Manterola J, Morera J. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. CHEST 1991, 99: 344-350.
#Stout JE, Yu VL. Legionellosis. New Engl. J. Med. 1997, 682-687.
#Ruf B, Schürman D, Horbach I, Fehrenbach FJ, Pohle HD. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. J. Inf. Dis. 1990, 162: 1341-1348.
#Harrison TG, Dournon E, Taylor AG. Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1. J. Clin. Pathol. 1987, 40: 77-82.
#Pastoris MC, Ciarrochi S, Di Capula A, Temperanza AM. Comparison of phenol- and heat-killed antigens in the indirect immunofluorescence test for serodiagnosis of Legionella pneumophila serogroup 1 antigens. J. Clin. Microbiol. 1984, 20 (4): 780-783.
#Kaufmann AF, McDade JE, Patton CM, Bennett JV, Skalyi P, Feeley C, Anderson DC, Potter ME, Newhouse VF, Gregg MB, Brachman PS. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epid. 1981, 114 (3): 337-347.
#Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.
#Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.
#Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.
#Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397
#[[Legionella Control#cite%20ref-:0%205-0|Jump up to:5.0]] [[Legionella Control#cite%20ref-:0%205-1|5.1]] Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8
#MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270

[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]
<references />

Legionella Control

2021-05-04T14:55:23Z

Tobyvan:

{{Stub}}
{{Anchor|Section1}}
==Section 1==

==1.1 HISTORY==
Legionnaires’ disease was first described after a pneumonia outbreak at an American Legion Convention held in Philadelphia during 1976. In total, 182 delegates were affected and 29 died before workers at the Centers for Disease Control and Prevention (CDC) based in Atlanta, USA isolated the causative organism in January 1977. The organism was placed in the family Legionellaceae, genus Legionella to commemorate the first victims of the disease. The first species was named Legionella pneumophila (Greek for “lung loving”).

It soon became clear that legionellae were not really new; retrospective studies showed that an organism isolated for the first time in 1944 (called Tatlockia micdadei) actually belonged to the genus Legionella. The first strain of Lpneumophila was isolated already in 1947 from a guinea pig that had previously been inoculated with blood from a patient with what was called an “unknown febrile disease” at the time.

[[File:The first Legionnaires’ disease outbreak.png|thumb|The first Legionnaires’ disease outbreak]]

The two decades following the discovery of the family Legionellaceae was marked by rapid developments in Legionella detection and the identification of numerous new species. Twenty-eight new Legionella species and two “Legionella-like amoebal pathogens” (LLAPs) (LLAP-1 and LLAP-6) were isolated during the 1980s, mostly from sources in the USA. The 1990s were marked by an increase in Legionella isolation from countries in Europe and Australia with fifteen new Legionella species being described for the first time.

Figure 1.2 Intracellular Legionella organisms

More than half of the currently known Legionella species are potentially pathogenic to humans. L. pneumophila is still implicated in >80% of infections; however, as more species are isolated from environmental sources worldwide, even those species not yet associated with disease should be considered as potentially pathogenic until proven otherwise. For example, L. longbeacheae, often isolated from potting soil, is considered the most common cause of legionellosis in Australia.

Legionellae are faintly staining gram negative, rod-shaped, non acid fast bacteria that to not form spores or capsules. All species except L. oakridgensis are motile. Legionellae are typically between 0.3 and 0.9 µm wide and 1- 20 µm long. However, shorter forms measuring 1- 2 µm in length are often observed in clinical specimens or under conditions of iron deprivation.

Figure 1.3Gimenez stain: Legionella bacteria

The ability of legionellae to grow in water is influenced by several factors. They can grow at temperatures between 20°C and 60°C, with optimal growth occurring between 37°C and 45°C. They prefer a pH in the range of 5.0 9.5 and only grow in the presence of Lcysteine, HCl and iron salts. Legionella-like amoebal pathogens (LLAPs) are very similar to Legionella species in that they are gram negative, infect amoebae and can survive and multiply intracellularly. However, they cannot be cultured on laboratory media. The first LLAP was isolated 1 from soil in Poland in 1954 and was named Sarcobium lyticum. The next isolation of an LLAP was in England more than 20 years later. Since then, LLAPs have been isolated from various sources, mostly associated with confirmed cases or outbreaks of 2 3 Legionnaires’ disease. Three of the LLAPs have since been reclassified as L. drozanskii, L. rowbothamii and L falloni. The currently known LLAPs are listed in Table 1.2.

===1.2 INTERACTIONS WITH PROTOZOA===
Legionellae are slow-growing organisms that require a combination of nutrients for growth. Due to their fastidious nature and lack of antibiotic activity, they may be replaced by faster growing organisms if they do not have an alternative means of survival in aquatic environments. The fact that legionellae are ubiquitous in these environments suggests that protozoa, especially amoebae, play a supportive role in their survival and multiplication. In fact, their natural habitat, parasitic to protist hosts, has now been 4 proven.
{| class="wikitable"
|+'''Legionella species'''
!ORGANISM
!SG
!YEAR
!SOURCE
!PATHOGEN
|-
|L adelaidensis
L anisa

L beliardensis

L birminghamensis

L bozemanii

L brunensis

L cherrii

L cincinnatiensis

L donaldsonii*

L drozanskii (LLAP-1)

L dumoffii

L erythra

L fairfieldensis

L fallonii (LLAP-10)

L feeleii

L geestiana

L gormanii

L gratiana

L gresilensis

L hackeliae

L israelensis

L jamestowniensis

L jordanis

L lansingensis

L londiniensis

L longbeacheae

L lytica

L maceachernii

L micdadei

L moravica

L nautarum

L oakridgensis

L parisiensis

L pittsburghensis

L pneumophila

L quateirensis

L quinlivanii

L rowbothamii (LLAP-6)

L rubrilucens

L sainthelensi

L santicrucis

L shakespeari

L spiritensis

L steigerwaltii

L taurinensis

L tusconensis

L wadsworthii

L waltersii

L worsleiensis
|1
1

1

1

2

1

1

1

*

1

1

2

1

1

2

1

1

1

1

2

1

1

1

1

1

2

1

1

1

1

1

1

1

1

15

1

2

1

1

2

1

1

1

1

1

1

1

1

1
|1991
1985

2001

1987

1980

1989

1985

1988

2002

2001

1980

1985

1991

2001

1993

1980

1991

2002

1985

1985

1985

1982

1994

1993

1982

1996

1985

1980

1989

1993

1983

1985

1980

1979

1993

1990

2001

1985

1984

1985

1992

1985

1985

1999

1990

1983

1996

1993

1993
|Cooling water (Adelaide Australia)

Faucet (Chicago), tap water (LA)

Water, France

Lung biopsy (Alabama)

Lung aspirate (Toronto)

Cooling tower water (Czechoslovakia)

Thermally altered water (Minnesota)

Lung tissue (Cincinnatti)

<nowiki>*</nowiki>

Tank of well water (Leeds 1981)

Lung tissue

Cooling tower water (Seattle)

Cooling tower water (Fairfield Australia)

Ship air conditioner (1994)

Grinding machine coolant fluid

Hot water tap, office building (London)

Bronchial wash of pneumonia patient

Thermal spa water (France)

Water, France

Bronchial biopsy (Ann Arbour)

Water (Israel)

Wet soil (New York)

Water and sewage (Israel)

Bronchial washing, hloramin patient

Office building cooling tower (London)

Human lung (Longbeach Australia)

Previously Sarcobium lyticum

Water (Phoenix)

Human blood via yolk sac

Cooling tower water (Czechoslovakia) Hot water tap (London)

Cooling tower water (Pennsylvania)

Cooling tower water (Paris)

Synonym for L micdadei, strain

TATLOCK

Water (Pennsylvania)

Shower in hotel bathroom (Portugal)

Water in bus airconditioner (Australia)

Water and sludge, industrial liquefier

Tap water (Los Angeles)

Spring water (Washington)

Tap water (Virgin Islands)

Cooling tower water (England)

Lake water (Washington)

Tap water (Virgin Islands)

Water, hospital humidifier (Italy)

Pleural fluid, transplant patient (Arizona)

Sputum

Potable water system (Australia)

Industrial cooling water (England)
|Unknown

Yes

Unknown

Yes

Yes

No

Yes

Yes

<nowiki>*</nowiki>

Yes

Yes

No

Unknown

Yes

Yes

Unknown

Yes

No

Unknown

Yes

No

No

Yes

Yes

Unknown

Yes

Yes

Yes

Yes

No

Unknown

Yes

Yes

Yes

Yes

Unknown

No

Yes

Yes

Yes

No

Unknown

No

No

Unknown

Yes

Yes

Unknown

Unknown
|}

Table 1.1 Legionella species ORGANISM SGs YEAR SOURCE PATHOGEN L adelaidensis L anisa L beliardensis L birminghamensis L bozemanii L brunensis L cherrii L cincinnatiensis L donaldsonii* L drozanskii (LLAP-1) L dumoffii L erythra L fairfieldensis L fallonii (LLAP-10) L feeleii L geestiana L gormanii L gratiana L gresilensis L hackeliae L israelensis L jamestowniensis L jordanis L lansingensis L londiniensis L longbeacheae L lytica L maceachernii L micdadei L moravica L nautarum L oakridgensis L parisiensis L pittsburghensis L pneumophila L quateirensis L quinlivanii L rowbothamii (LLAP-6) L rubrilucens L sainthelensi L santicrucis L shakespeari L spiritensis L steigerwaltii L taurinensis L tusconensis L wadsworthii L waltersii L worsleiensis 1 1 1 1 2 1 1 1 * 1 1 2 1 1 2 1 1 1 1 2 1 1 1 1 1 2 1 1 1 1 1 1 1 1 15 1 2 1 1 2 1 1 1 1 1 1 1 1 1 1991 1985 2001 1987 1980 1989 1985 1988 2002 2001 1980 1985 1991 2001 1993 1980 1991 2002 1985 1985 1985 1982 1994 1993 1982 1996 1985 1980 1989 1993 1983 1985 1980 1979 1993 1990 2001 1985 1984 1985 1992 1985 1985 1999 1990 1983 1996 1993 1993 Cooling water (Adelaide Australia) Faucet (Chicago), tap water (LA) Water, France Lung biopsy (Alabama) Lung aspirate (Toronto) Cooling tower water (Czechoslovakia) Thermally altered water (Minnesota) Lung tissue (Cincinnatti) * Tank of well water (Leeds 1981) Lung tissue Cooling tower water (Seattle) Cooling tower water (Fairfield Australia) Ship air conditioner (1994) Grinding machine coolant fluid Hot water tap, office building (London) Bronchial wash of pneumonia patient Thermal spa water (France) Water, France Bronchial biopsy (Ann Arbour) Water (Israel) Wet soil (New York) Water and sewage (Israel) Bronchial washing, hloramin patient Office building cooling tower (London) Human lung (Longbeach Australia) Previously Sarcobium lyticum Water (Phoenix) Human blood via yolk sac Cooling tower water (Czechoslovakia) Hot water tap (London) Cooling tower water (Pennsylvania) Cooling tower water (Paris) Synonym for L micdadei, strain TATLOCK Water (Pennsylvania) Shower in hotel bathroom (Portugal) Water in bus airconditioner (Australia) Water and sludge, industrial liquefier Tap water (Los Angeles) Spring water (Washington) Tap water (Virgin Islands) Cooling tower water (England) Lake water (Washington) Tap water (Virgin Islands) Water, hospital humidifier (Italy) Pleural fluid, transplant patient (Arizona) Sputum Potable water system (Australia) Industrial cooling water (England) Unknown Yes Unknown Yes Yes No Yes Yes * Yes Yes No Unknown Yes Yes Unknown Yes No Unknown Yes No No Yes Yes Unknown Yes Yes Yes Yes No Unknown Yes Yes Yes Yes Unknown No Yes Yes Yes No Unknown No No Unknown Yes Yes Unknown Unknown Sources: American Type Culture Collection; National Type Culture Collection. 2 Table 1.2 Legionella-like amoebal pathogens (LLAPs STRAIN HOSTS YEAR ORIGINAL SOURCE PATHOGENIC Sarcobium lyticum A polyphaga H vermiformis 1954 Soil Yes LLAP-1 A polyphaga 1981 Tank of portable water well Yes LLAP-2 A polyphaga H vermiformis 1986 Garage steam cleaning pit Yes LLAP-3 A polyphaga 1986 Sputum from pneumonia patient Yes LLAP-4 A polyphaga 1986 Hospital whirlpool bath Yes LLAP-5 A polyphaga 1988 Nursing home plant spray Yes LLAP-6 A polyphaga H vermiformis 1988 Factory liquefier tower Yes LLAP-7 A polyphaga H vermiformis 1991 Hotel whirlpool spa Yes LLAP-8 H vermiformis 1990 Hospital shower Yes LLAP-9 A polyphaga H vermiformis 1992 Factory cooling tower Yes LLAP-10 A polyphaga 1994 Ship air-conditioning system Yes LLAP-11 A polyphaga 1993 Furnace cooling system Yes LLAP-12 A polyphaga 1994 Furnace cooling system Yes 3 Adapted from Adeleke 1996 5

Rowbotham was the first to demonstrate interactions between legionellae and protozoa. To date, protozoa of the genera Acanthamoeba, Tetrahymena, Naegleria, Echinamoeba and Vanella species have been implicated in these interactions. Not much is known about the metabolic and physiological status of legionellae after passage through protozoa, but in vitro studies have shown changes in their physiological status resulting in iron deprivation, possibly changing the susceptibility of the released bacteria to chemical inactivation. Although they can survive extracellularly, this phase is believed to be only temporary while they are searching for new hosts to 6 infect. Furthermore, it was recently documented that very few Legionella bacteria are needed to start intracellular replication. Some workers have reported a 7000 times increase in Legionella colony forming units (CFU) after intracellular replication buth there is no consensus yet as many believe that this intracellular replication cycle is not necessary for the proliferation of legionellae within mixed bacterial populations. From these studies it is clear that there is still extensive research to be done on this aspect of Legionella survival in the environment. Until more becomes known, it is unsafe to assume that the absence of protozoa within water samples prevents the survival of legionellae; as long as there are other bacterial species present, appropriate measures should be taken to prevent Legionella proliferation.

===1.3 HOWDOES THE INTERACTION WITH PROTOZOABENEFITLEGIONELLAE?===
Amoeba trophozoites feed and multiply in water and biofilm. When conditions become unfavourable, these trophozoites are transformed into cysts with hard, impermeable outer walls that provide protection for ingested Legionella organisms. When conditions become more favourable, the cysts change to trophozoites again and the bacteria are set free. Legionellae have been 7 recovered from cysts treated with 50 parts per million (ppm) chlorine suggesting a high level of protection by the cysts. This high resistance of amoebal cysts to biocides may be the mechanism for the apparent reseeding of water systems by legionellae often experienced in the water treatment industry. However, recontamination may also occur via transmission of airborne cysts acting as carriers for the legionellae.

===1.4 HOWIMPORTANTIS LEGIONELLAIN SOUTH AFRICA?===
Very little has been published on Legionella in South Africa. After the initial introduction of diagnostic laboratory tests in 1979, legionellosis cases were identified in Durban, Port Elizabeth and Johannesburg during the early 1980's. By 1982, antibodies to L. 8,9 pneumophila had been demonstrated in 10% of hospitalised pneumonia patients, a figure that was confirmed in 1994. A high 9,10,11 prevalence of antibodies was also demonstrated in workers in the mining industry and the general public. Despite this high prevalence, only one Legionnaires' disease outbreak and less than 40 sporadic cases have been reported since legionellosis became notifiable in 1990. Similarly, very little is known about the prevalence of Legionella in the South African environment. Low concentrations of 12 legionellae were reported in 77% of cooling towers in a large study reported in 1991. More recently, culturable legionellae were present in 82% of industrial water samples tested; 54% of these samples yielded legionellae in numbers equal to or in excess of 1000 11 CFU/ml. 3

===1.5 LEGIONELLADETECTION===
Classical detection methods for Legionella species relied on the inoculation of susceptible guinea pig hosts. Although selective, these methods were expensive and time consuming and were soon replaced by isolation by culture on agar media. To improve the recovery of legionellae by culture, the use of certain selective media and steps were introduced to minimise contamination by nonlegionellae. In attempts to simplify Legionella identification, radioimmunoassays (RIAs), enzyme linked immunosorbent assays (ELISAs), agglutination tests and nucleic acid probes and polymerase chain reaction (PCR)-based assays have since been developed and tested.

Despite the relative success of these new methods for the detection of environmental legionellae, culture remains the method of choice. However, no single culture method has so far proven to be ideal for all samples in all given circumstances and environments. Even in the absence of contaminating bacteria or other inhibitory substances, the detection of small numbers of legionellae from environmental samples remains difficult. This, together with the lack of standardisation of methods, complicates the interpretation of culture results and comparisons of results from different laboratories. Variations in bacterial numbers in different areas within a water distribution system and the sampling method used often complicate the interpretation of culture results even further.

Previous studies have shown that the culture of Legionella species from environmental samples is complicated by the presence of 13,14 faster growing bacteria due to inhibition of legionellae on culture media in the presence of heterotrophic bacteria. For example, 15 Pseudomonas aeroginosa secrete bacterial substances into the surrounding media that dramatically inhibit Legionella growth. Although culture is still the gold standard, it remains time consuming and requires a certain level of technical skill. Legionellae may also enter a “viable but non-culturable (VBNC)” state under certain conditions which complicated culturing even further.)

Lp Lm L boz L dum L gor L long L jor L oak Growth on BCYE Growth on TSB Acid production Gelatin hydrolysis Urease Primary growth on FG Beta lactamase Hippurate hydrolysis Browning of tyrosine medium Blue fluorescence on CYE + - - + - + + + + - + - - + - - - - - - + - - + - - +/- - + + + - - + - - + - + + + - - + - - + - + + + - - + - - + or – - + - + - - + - - + - + - + - - - - nt +/- - + - Nt: not tested, +/- weak positiv; Lp L. pneumophila; Lm L. micdadei; Lboz L. bozemanii; Ldum L. dumoffii; Lgor L. gormanii; Llong L. longbeacheae; L jor L jordanis; L L. oakridgensis. oak Table 1.3 Selected characteristics of Legionella species Figure 1.4 Legionella colonies on agar (Sources: own laboratory pictures; Annual Report, American Water Technologies (2003) Recent developments in the molecular field opened doors for new detection assays of waterborne pathogens such as Legionella. These methods include: 16 ! DNA probe hybridisation; 4 ! ! ! ! ! ! !

====1.5.1 Polymerase chain reaction (PCR)====
Although the sensitivity of most of these techniques is insufficient for direct detection of legionellae in environmental samples, 18,19 PCR has proven to be a sensitive and rapid alternative to culture. Many PCR assays have been described, but relatively few of them have been extensively studied on clinical as well as environmental samples and none are routinely used.

====1.5.2 Immunofluorescence====
Immunofluorescence is a technique whereby antigen and antibody is bound to a fluorochrome (fluorescent stain) and then allowed to react with the corresponding antigen or antibody on a microscope slide. The results are viewed under a fluorescent microscope. There are many variations of immunofluorescent techniques but only direct immunofluorescence (DFA) and indirect immunofluorescence (IFA) is of importance in the confirmation of environmental legionellae. Direct immunofluorescence (DFA) is most commonly used for confirmation of Legionella species from environmental samples. The test is simple to perform, but interpretation requires a fair amount of experience, especially in highly contaminated samples. Antigen from the sample is fixed to a microscope slide using heat or acetone and covered with fluorescein-isothiocyanate (FITC) labelled globulin. Antigens in the sample bind to the labelled globulin and the resulting antigen-antibody complexes are visible under ultraviolet light. Direct immunofluorescence (DFA) is useful to detect antigens in clinical samples when cultures cannot be obtained, but its value for environmental samples is controversial. Nevertheless, it is used as a screening test by some laboratories. Cross-reactions that may lead to false positive results have been documented.

Figure 1.5 Legionella immunofluorescence/Fluorescent bacteria

17 Restriction enzyme digestion; 18,19 Polymerase chain reaction; 20 Soluble protein patterns; 21 DNA restriction endonuclease profiles; 22 Multilocus enzyme analysis; 23 Orthogonal-field-alteration gel electrophoresis; 24 Sodium dodecyl sulphate poly-acrylamide gel electrophoresis (SDS-PAGE).

====1.5.3 Fluorescent in situ hybridization====
Fluorescent in situ hybridization (FISH) is a technique whereby a fluorescent labeled DNA probe is used to detect a particular chromosome or gene that can then be visualised by fluorescence microscopy. FISH tests are useful for the detection of legionellae in respiratory tract samples but has not been extensively tested in environmental samples. The method makes use of oligonucleotide probes targeting rRNA and offers a fast and specific alternative to direct immunofluorsecence, culture and urine antigen testing in clinical laboratories. {{Expand}}

==Section 2==

==='''THE CHAIN OF INFECTION'''===
The mere presence of legionellae in a water distribution system does not necessarily imply a human health risk. For human infection to occur, certain conditions are necessary. These conditions are referred to as the “chain of infection” consisting of six links. All the links have to be present for disease to occur ([[#Legionella-Chain_of_Infection|Diagram: Chain of infection]] ). The first link, the pathogen, was discussed in [[#Section1|Section 1]].

{{Anchor|Legionella-Chain_of_Infection}}
[[File:Chain of infection.png|alt=Chain of infection|none|thumb|Chain of infection|450x450px]]

==='''SOURCES AND RESERVOIRS'''===
Legionellae are natural inhabitants of water, found a wide range of habitats. They are ubiquitous in streams, lakes and rivers. They also survive in dust, soil and mud. In fact, one of the species, ''Legionella longbeacheae'', is so often isolated from potting soil in Australia that soil has been suggested as the natural habitat of this particular species.

{{Anchor|Natural sources of Legionella}}
[[File:Natural sources of Legionella.png|alt=Natural sources of Legionella|none|thumb|Chain of infection|450x450px]]

Legionellae from these natural environments can be transmitted to man-made water systems by various means. For example, from raw water, during water treatment, as part of post-treatment after-growths within water distribution systems, during building and construction activities and during plumbing repair.

Once established, they can persist in the water supply for long periods of time and are difficult to eradicate. Therefore, their presence must be considered in all aspects of the design, operation and maintenance of buildings. For this to be effective, cooperation between engineers, occupational health practitioners and microbiologists is essential.

Figure 2.3 Man-made sources of Legionella

=====Water sources that provide optimal conditions for Legionella growth can be separated into those containing “non-potable” and those that contain “potable” water. '''Non-potable water distribution systems'''=====

Heat rejection devices like cooling towers, evaporative condensers and HVAC (heating, ventilation and air-conditioning) systems are often implicated as sources of legionellosis. They contain reservoirs filled with warm, recirculating water that makes them ideal for the growth, amplification and dissemination of micro organisms (including Legionella). In a typical water-cooled system air in induced through or blown over, packing material down which water, circulating from a pond under the packing, is allowed to fall by gravity, producing a large wetted surface that cools the falling water.

The constant fall of water through the tower, the large area of the basin, fill, pipes and heat exchanger, the warm temperature of the water, the high relative humidity and high organic content within these devices provide conditions that favour contamination by algae, protozoa, fungi and bacteria. The risk is increased further by the open nature of the systems, excessive aeration and the constant addition of fresh water to make up for water lost through evaporation.

In systems that are not regularly cleaned, sludge accumulates in the reservoir and slime adheres to water covered surfaces, resulting in the presence of large concentrations of micro-organisms, including legionellae, on these surfaces. In addition, water temperatures below 60°C, the age and configuration of the system, the pH of the water and the presence of certain metals may also increase the risk of contamination.

Water derived from municipal supplies but subsequently stored in cisterns, or conditioned prior to heating, is considered non-potable due to the deterioration in chemical and bacteriological quality during storage. Colonisation of such non-potable sources inside large buildings, such as hotels, factories or hospitals, may be a major cause of legionellosis.

====='''Potable (domestic) water distribution systems'''=====
Legionellae are often present in potable water supplies, especially in the hot water sections of these systems. The organisms may enter potable water supplies from the main source, even from municipal water, and survive standard treatment protocols because most municipal water systems are not routinely screened for the presence of legionellae and the organisms are chlorine tolerant. Once inside the system, they find a suitable environment to multiply and are usually very difficult to eradicate.

Legionella levels can rise from very low to very high within short periods of time. The factors that give rise to these fluctuations are not well understood and often very hard to determine. These factors include the age and configuration of the pipes, the degree of scaling and sediment and the potential for biofilm formation within the system increase the risk of contamination. Water temperatures of 25 – 42°C, stagnation and the presence of certain free-living amoebae capable of supporting the intracellular growth of legionellae are often mentioned as amplifying factors in published reports. The biofilm and scale that form on surfaces in water distribution systems provide nutrients for legionellae and protect them from hot water and disinfectants. Some materials used in these systems, for example neoprene washers, are more readily colonised than others (See [[Legionella Control#Materials used in the construction of potable water lines and fixtures|Table]]). Building location may also play a role in the colonisation of potable water with legionellae.

Hot water tanks are often colonised with legionellae, especially at the bottom where a warm zone may develop and scale and sediment accumulate. Hot water piping, especially dead-legs, presents an additional risk as legionellae thrive in stagnant water.

====='''Soil'''=====
Outdoors, the soil may be contaminated through contact with Legionella-polluted water and become a source of airborne bacteria during earth moving operations, such as construction work.
{| class="wikitable"
|+{{Anchor|Materials used in the construction of potable water lines and fixtures}}'''Materials used in the construction of potable water lines and fixtures'''
|
'''Very good'''
|
Copper
|-
|
'''Good'''
|

Neoprene

Other synthetic materials
|-
|
'''Reasonable'''
|
Steel
|-
|
'''Not recommended'''
|
Rubber

Plastics
|}

===='''Amplification'''====
Legionellae are usually present in low numbers in natural sources. However, certain factors present in man-made reservoirs can promote Legionella growth and amplification. To improve our understanding of Legionella, its potential to cause disease and how to better control the organisms in water systems, we must understand these conditions. The most important factors amplifying Legionella numbers in man-made reservoirs are listed in the table [[Legionella Control#Amplifying factors for Legionella in man-made sources and reservoirs.|Amplifying factors for Legionella in man-made sources and reservoirs.]]
'''Remember'''
Temperature data is usually based on laboratory studies and is not from actual system (piping) studies, which makes it even less reliable to use for Legionella control. System temperature on its own should therefore not be relied upon for Legionella control, because the so-called “system temperature” rarely indicates one uniform temperature throughout the entire system. Therefore, maintaining the system temperature does not guarantee Legionella control. Also, in plumbing systems, especially larger and/or more complex piping systems, legionellae have been shown to survive at even higher temperatures due to biofilm, dead-legs, and other complexities. It has been suggested that potable water systems be operated at temperatures as high as possible but take into account the risk of scalding injuries and energy conservation requirements.
{| class="wikitable"
|+{{Anchor|Amplifying factors for Legionella in man-made sources and reservoirs}}'''Amplifying factors for Legionella in man-made sources and reservoirs'''
|
'''TEMPERATURE'''
|

Legionellae can survive over a wide range of temperatures (20 – 60°C) with an optimum growth temperature of 37 – 45°C as illustrated in the figure [[Legionella Control#Natural sources of Legionella|Natural sources of Legionella]] 
|-
|
'''pH'''
|

Legionellae can survive and multiply at a pH of 5.0 – 8.5 
|-
|
'''STAGNATION'''
|

The presence of stagnant water in distribution systems increases the risk of Legionella contamination 
|-
|
'''WATER TREATMENT'''
|

The type of water treatment used may affect the numbers of legionellae present in a distribution system 
|-
|
'''DISINFECTANTS'''
|

The type, concentration and persistence of residual disinfectants in the system may affect the numbers and types of legionellae present 
|-
|
'''CHEMICAL PARAMETERS'''
|

The presence of organic carbon and certain metals like zinc and copper may influence the risk of Legionella contamination 
|-
|
'''RELATIVE HUMIDITY'''
|

Legionellae survive best at 65% relative humidity (RH) and are least stable below 55% RH
|-
|
'''SLIME, ALGAE AND PROTOZOA'''
|

Amoebae, cyanobacteria and flavobacteria have been associated with the growth of legionellae in water distribution systems
 
|-
|
'''CORROSION PRODUCTS'''
|

Legionellae numbers are usually highest in sections where corrosion products are present
 
|-
|
'''CONSTRUCTION'''
|

Major construction has been associated with outbreaks of legionellosis.

It is believed that legionellae are released from the soil during excavations from where they can enter the cooling tower of the building, air intakes or water pipes, or may be inhaled directly. Another possibility is that, during construction, nutrients already present in dust and dirt may become more readily available for the organisms. In new buildings, plumbing should be flushed before use. Renovated buildings may contain stagnant water, that should be flushed out before returning the building to normal use.
 
|-
|
'''WATER PRESSURE'''
|

An increase in water pressure may send dirt into a system, providing a food source for the bacteria or may dislodge scale and sediment containing legionellae from pipes.
 
|-
|
'''BIOFILM, SCALE AND SEDIMENT'''
|

In hot water systems the concentrations of legionellae are usually highest within biofilms and at the openings of water outlets. Biofilms are widespread in nature, and on most man-made surfaces when submerged in water.

Legionellae are not only able to survive in biofilms, but can proliferate and attach to susceptible hosts like protozoa, depending on the type of material on which the biofilm is formed. For example:

· Legionellae have been found in biofilms forming on plastic surfaces in water piping systems. At a temperature of 40° they were shown to account for approximately 50% of the total biofilm flora;

· Legionellae are less likely to be present on copper surfaces because copper generally do not support biofouling. If present, the bacteria are usually found in small numbers;

· Metal plumbing components and associated corrosion products provide iron and other metals needed for Legionella, thereby supporting their survival and growth.

Sediment and scale assists in the growth of supporting organisms and free-living protozoa, increasing the risk of contamination by legionellae. For this reason, its presence often indicates a possibility of Legionella contamination.

Algal slime also provides a stable habitat for their survival and multiplication.
 
|}
'''Disinfectants'''
After disinfection, municipal water supplies usually travel several kilometers before it reaches the point of use. During this course, disinfectant residuals diminish and there is increasing exposure to potentially biofilm-contaminated piping. Although municipal water systems are required to be disinfected at their points of distribution to conform to existing standards for bacterial disinfection, these standards are based upon the absence of coliform bacteria and do not include any specific testing requirements for Legionella.

====='''Transmission'''=====
After growth and amplification of legionellae to potentially infectious levels, the next requirement in the chain of infection is to achieve transmission of the bacteria to a susceptible host. Modern technology like cooling towers used to recirculate water for air-conditioning and humidifying purposes and other ventilation systems can cause the formation and distribution of aerosols through which the organisms can spread. Transmission can also occur through direct installation, aspiration or ingestion (Table [[Legionella Control#Dissemination of Legionella bacteria|Dissemination of Legionella bacteria]]).
{| class="wikitable"
|+'''Dissemination of Legionella bacteria'''
|
'''AEROSOLISATION'''
|

The most widely accepted theory for Legionella transmission is that the organism is aerosolised from a water distribution system and is inhaled as droplets of respirable size. Aerosolisation may affect persons outside as well as inside a building.
 
|-
|
'''DIRECT INSTALLATION'''
|

Respiratory therapy devices have the potential to disseminate legionellae by delivering gases at high temperatures and volumes, and by generating concentrated aerosols, enabling them to bypass the normal defence mechanisms of the respiratory system.
 
|-
|
'''INGESTION'''
|

The fact that diarrhoea is one of the symptoms of Legionnaires’ disease suggests the gastro-intestinal tract as the source in some cases. After infection via this route, the bacteria may spread to the respiratory tract, thereby causing Legionnaires’ disease.
 
|-
|
'''ASPIRATION'''
|

Another well documented mode of transmission that effectively gets bacteria into the lungs is aspiration (a “choking process” that often occur during drinking, swallowing or dlearing the throat, and during respiratory therapy). Evidence suggests that it may be a more common mode for Legionella dissemination than previously believed although it has not been widely described in the literature.<blockquote>

'''REMEMBER!'''

Never presume that you cannot get Legionnaires’ disease

from drinking water containing Legionella.</blockquote>

|}
[[File:Influence of temperature on Legionella growth (Freije 1996).png|alt=Influence of temperature on Legionella growth|none|thumb|604x604px|Influence of temperature on Legionella growth <ref name=":0" />]]

====='''INFECTION AND HOST SUSCEPTIBILITY'''=====
Infections caused by Legionella species are collectively known as ''legionellosis'' and include Legionnaires’ disease and Pontiac fever. Subclinical (asymptomatic) infections have been reported. Legionellosis occurs worldwide, in people of all ages and race groups, with no evidence of person-to-person spread of infection. It is most common in summer and autumn months. The incidence of legionellosis varies from country to country and from region to region. Recently, an increase in the worldwide incidence of reported legionellosis cases has become evident. This may be explained by the availability of improved diagnostic and testing methods, increased awareness of the symptoms and improved surveillance. However legionellosis, especially sporadic cases, is still not always reported to public health authorities, making it difficult to estimate its true incidence.

The mode of transmission, inoculum size, particle size and host susceptibility influence the severity of infection. Approximately half of the currently known Legionella species are implicated in disease, but ''pneumophila'' is still considered to be the causative agent in about 80% of diagnosed cases. However, this picture might change as the number of available diagnostic tests increases – it is thus important to regard all legionellae a potentially pathogenic until proven otherwise.

==Section 3==
===LEGIONELLA INFECTIONS===
Infections caused by Legionella species are collectively known as legionellosis and include Legionnaires’ disease and Pontiac fever.1,2 Subclinical infections have been reported. Legionella infections occur worldwide in people of all ages and race groups with no evidence of person-to-person spread of infection.3,4

===LEGIONNAIRES’ DISEASE===
Legionnaires’ disease (LD) is a severe multisystem disease with pneumonia as the most predominant clinical finding. Clinical features are similar to those of other pneumonias, making it difficult to diagnose.5,6 Symptoms range from a mild cough and slight fever to a coma with widespread pulmonary infiltrates and multisystem failure. Survivors usually recover completely although lung fibrosis and neurological abnormalities may persist in some cases. LD has a low attack rate but the mortality rate is high.

Legionnaires’ disease outbreaks occur frequently all over the world. In the United States, Legionnaires’ disease is considered to be fairly common and legionellae are among the top three causes of sporadic, community-acquired pneumonia. However, many cases are still not reported, as Legionnaires’ disease is difficult to distinguish from other forms of pneumonia. Although only approximately 1,000 cases are reported to the Centers for Disease Control and Prevention (CDC), it is estimated that over 25,000 cases occur every year, causing more than 4,000 deaths.

Despite this, only one outbreak has been reported in South Africa to date. However, previous South African studies indicated antibody levels to L pneumophila in 65% of healthy blood donors, 36% of healthy mineworkers, 10% of healthy factory workers and 16% of hospitalised pneumonia patients.7,8 One study reported seroconverion to L.

pneumophila in 9% of patients hospitalised between 1987 and 1988 with symptoms of community-acquired pneumonia.9

 
[[File:Hillside figure 3.1.jpg|thumb|420x420px|Figure 3.1 Legionella pathology|alt=|center]]

Figure 3.1 Legionella pathology
===RISK FACTORS===
In order for LD to occur, the host must be susceptible to infection. Older people (above 50 years of age) are more commonly infected. Men are more likely to be infected (ratio 3:1) but the racial distribution is usually consistent with that of the population involved.'''10'''

Table 3.1 lists the most common risk factors.
{| class="wikitable"
|+
!
!Table 3.1 Risk factors for development of Legionnaires’ disease
|-
|'''Patient demographics'''
|Smoking
Chronic pulmonary disease

Immunosuppression

Renal transplantation

Renal dialysis

Alcohol ingestion

Age > 50 years

Male
|-
|'''Environmental risks'''
|Exposure to construction activities
Exposure to air conditioning systems

Exposure to home air conditioning

Travelling and accommodation in hotels

Potable water

Hospitalization
|}
Source: Winn 1984 10

[[File:FIGURE 3.2 HISTOLOGY.jpg|center|thumb|500x500px|Figure 3.2 Risk Factors]]

===SYMPTOMS===
Legionnaires’ disease presents with a broad spectrum of symptoms, ranging from mild cough and low fever to stupor, respiratory and multi organ failure. Pneumonia is the predominant clinical finding. Early symptoms are mainly non-specific and include fever, malaise, myalgias, anorexia and headache.6,11 The temperature often exceeds 40°C and the patient may present with a slightly productive cough. Chest pain, occasionally pleuritic, can be prominent and when coupled with hemoptysis, may mistakenly suggest pulmonary emboli. Gastrointestinal symptoms (watery stools) are prominent, especially diarrhoea, which occurs in 20-40% of cases. Relative bradycardia has been over-emphasised as a diagnostic finding but is often seen in elderly patients with advanced pneumonia. Hyponatremia (serum sodium concentration ≥ 130 mmol/l) occurs more frequently in Legionnaires’ disease than in other pneumonias.

Extrapulmonary Legionnaires’ disease is rare but the clinical manifestations are often dramatic. These infections can easily be overlooked since the degree of suspicion is generally low in these cases. Legionella has been implicated in cases of sinusitis, cellulitis, pancreatitis, peritonitis and pyelonephritis. The most common extrapulmonary site of infection is the heart. There have been numerous reports of myocarditis, pericarditis, postcardiotomy syndrome and prosthetic valve endocarditis. In most cases there is no pneumonia symptoms present. Wound infections have also been reported.11

===INCUBATION PERIOD===
LD has an incubation period (the time it takes for symptoms to appear after exposure) of 2 – 10 days. The onset of symptoms may be sudden or gradual.

===DIAGNOSIS===
There are no reliable distinguishing clinical features to distinguish LD from pneumonia caused by other etiologic agents. However, there are some clinical clues to assist in the diagnosis (Table 3.2).6
{| class="wikitable"
|+
!Table 3.2 Clinical clues to Legionnaires’ disease
!
|-
|'''CLUE'''
|'''EXAMPLE'''
|-
|'''PATIENT HISTORY AND PHYSICAL EXAMINATION'''
|
|-
|Presence of an epidemic or documented source of infection
|Family, friends or associates with similar infection and exposure
|-
|Prominent neurologic or gastrointestinal symptoms
|Pneumonia with confusion, nausea and vomiting
|-
|Non-response to aminoglycosides or beta-lactam antibiotics
|Worsening condition after 5 days on antibiotics
|-
|'''LABORATORY RESULTS OF PATIENT'''
|
|-
|Gram stain of sputum with many neutrophils but no bacteria
|Laboratory reports showing many neutrophils and few normal flora or no bacteria
|-
|Nodular peripheral infiltrates in chest radiographs
|Progression of unilateral opacities to bilateral nodular infiltrates over several days
|}

It is important to remember that a clinical diagnosis of LD always has to be confirmed with specialised laboratory tests. As not all laboratories are equipped to perform these tests routinely, the tests have to be specifically requested by the physician. Table 3.3 highlights some of the most commonly used laboratory tests.12

*'''Culture''' of Legionella organisms from clinical samples is still the gold standard for diagnosing LD. The technique is highly specific, provided appropirate samples are used, and about 1.5 to 3 times more sensitive than immunofluorescence. Transtracheal aspirates are best for culture, but sputum, bronchial aspirates, pleural exudates, lung biopsies as well as wound swabs and even autopsy material have been used successfully.11 Disadvantages of the culturing of legionellae for diagnostic purposes include possible inhibition by non-legionellae organisms present in the sample, slow growth and difficulties in distinguishing legionellae from other organisms on solid media. These factors must be taken into account when choosing a laboratory to test clinical samples for LD.

*'''Immunofluorescence''' is useful to detect antigens (direct immunofluorescence) or antibodies (indirect immunofluorescence) in clinical samples in cases where culture is not possible. Cross reactions with organisms other than Legionella in the direct immunofluorescence (DFA) test may cause false positive results, making accurate interpretation of the results essential.11,13 Indirect immunofluorescence (IFA) is the most specific of the currently available serological tests for LD. It is reproducible, sensitive and specific for the diagnosis of especially L. pneumophila infections, but may be affected by several factors, including the method of antigen preparation, method of antigen fixation during preparation of the reagent, the class of immunoglobulin it is designed to detect and strain differences.14,15

*'''The Legionella Urinary Antigen test5''' is a relatively inexpensive and rapid diagnostic test, but only detects infections caused by L pneumophila Serogroup 1. The test is commercially available as a radioimmunoassay (RIA) or an enzyme linked immunosorbent assay (ELISA). An advantage of this test is the relative ease with which urine samples can be obtained, especially in patients with a non-productive cough. Legionella antigens may persist in the urine of some patients for as long as one year.

*'''Serological tests''' are useful for epidemiologic studies but less valuable for physicians. Diagnosis by serology is based on a fourfold rise in antibody titre to ≥ 1:128 in paired samples (from the acute and convalescent stage of disease).13,15 However, the antibody response may not be detectable until 1-3 months after onset of illness. Single titres of ≥1:256 during convalescence in pneumonia patients is suggestive of legionellosis. Antibody screening should include both IgG and IgM because some patients may only have an IgM response.5

*Assays based on the '''polymerase chain reaction (PCR)''' have been used to detect legionellae in urine, broncho-alveolar lavage fluid and sputum. These tests are highly specific but not more sensitive than culture and are much more expensive to perform. Limitations of PCR tests include the possible presence of certain “PCR inhibitors” in sputum and blood samples. The major advantage of PCR is the rapidity of the test and the ability to detect species other than L pneumophila. PCR is not used routinely for the clinical diagnosis of LD.

{| class="wikitable"
|+
!Table 3.3 Sensitivity and specificity of laboratory tests for the diagnosis of Legionnaires’ disease
!
!
|-
|'''TEST'''
|'''SENSITIVITY (%)'''
|'''SPECIFICITY (%)'''
|-
|Culture from clinical samples
|80
|100
|-
|Direct immunofluorescence (DFA)
|33-70
|96-99
|-
|Indirect immunofluorescence (IFA)
|40-60
|96-99
|-
|Urinary antigen detection
|70
|100
|}
Source: Stout and Yu, 1997 '''WHAT TO TAKE INTO ACCOUNT WHEN INTERPRETING LABORATORY RESULTS'''

*Both IgM and IgG should be measured simultaneously.
*Diagnostic IgM titres will provide an earlier diagnosis than IgG because they indicate a primary immune response.
*Results obtained by the IFA should always be interpreted in conjunction with the clinical presentation of the disease.
*Titres below the diagnostic level together with clinical manifestations may be useful for early provisional diagnosis of Legionnaires’ disease; but diagnosis by IFA is usually retrospective.
*The interpretation of the IFA should take into account the variation in the time of appearance of antibodies, the types of antibodies produced and the length of time the antibodies are detectable in sporadic cases, as well as the prevalence of antibodies in the population from which the patient comes.
*The type of reagents used for IFA tests may influence the results: ether-killed, formalin-killed or heat-killed antigens vary in sensitivity and specificity and this should be taken into account in the interpretation.
*False negative results may be reported because a long time is needed for seroconversion to occur and not all species and serogroups are detectable by this method.
*Seroconversion (a fourfold rise in titre to at least 1:128) is considered as a presumptive positive result.
*A single titre of 1:256 or higher is regarded as a presumptive positive result.
*Serological results should preferably be confirmed by culture.
*In communities with low antibody prevalence, a single titre of 1:128 may be diagnostic and where the prevalence is high, a single titre of 1:256 may still provide only presumptive evidence of infection.
*Low titres usually indicate past infections.
*When titres to multiple antigens are raised, the titre that is fourfold higher than the others is considered to be diagnostic.
*In epidemiological studies diagnostic titres are usually one twofold dilution higher than for sporadic cases.

===HISTOLOGY===
Pulmonary lesions usually consist of a mixture of neutrophils and macrophages, fibrin, proteinaceous material and red blood cells. Neutrophils and macrophages are often present in the centre of a lesion with mainly macrophages around the periphery.

Intracellular bacteria are present in both neutrophils and macrophages. Further away from the site of acute inflammation, bacteria are mainly seen inside the macrophages.10

 
[[File:FIGURE 3.3.jpg|center|thumb|500x500px|Figure 3.3 Histological section of lung of Legionnaires disease patient]]
 

===CHEST RADIOGRAPHS===
Radiographic features in Legionnaires’ disease are mostly non-specific, and absent in Pontiac fever. Abnormalities occur from the third day post infection in most Legionnaires’ disease patients and usually do not correlate well with the severity of illness.11 However, the abnormalities correlate with the presence of the Legionella bacterium in sputum. The time required to show clearing of infiltrates on radiographs is variable and may range from 1-4 months. Some patients show diffuse alveolar damage. In the majority of patients with Legionnaires’ disease:

*Initial involvement is unilateral, predominantly in the lower lobe
*Bilateral involvement has been described
*Initial densities are poorly marginated, homogenous, rounded, occur either on the periphery or in the centre of the lung and may be mistaken for pulmonary infarction
*Pulmonary densities enlarge during later stages of disease
*Pulmonary densities have a typical ground glass appearance or dense consolidation
*Total opacification of the lung may occur
*Pleural effusions are present in 24-63% of cases caused by L pneumophila
*Pleural effusions are uncommon in L micdadei infections
*Hilar adenopathy seldom occurs
*Cavitation may occur in immunocompromised patients
*Cavitation rarely occurs in L micdadei infections

Figure 3.4 Chest radiograph of Legionnaires’ disease patient

===TREATMENT===
Treatment of LD requires the use of antibiotics. However, many antibiotics effective against other bacterial pneumonias are ineffective against Legionella as these drugs do not penetrate the pulmonary cells (alveolar macrophages) where infectious Legionella bacteria thrive.

Erythromycin was historically the drug of choice for the treatment of Legionnaires’ disease, but the newer macrolides (azithromycin) and quinolones (ciprofloxacin, levofloxacin, moxifloxacin, gemifloxacin, trovofloxacin have superior in vitro activity and greater intracellular and lung-tissue penetration.12 Other agents that have been shown to be effective include tetracycline, doxycycline, minocycline, trimethoprim- sulfamethoxazole.12 Rifampin is recommended as part of combination therapy with a macrolide or a quinolone for patients who are severely ill. The total duration of therapy is usually 10-14 days; however a 21-day course may be needed for immuno-compromised patients or those with extensive evidence of disease on chest radiographs.12

When LD patients are treated with appropriate antibiotics near the onset of disease, the prognosis is usually very good, especially if there is no underlying illness compromising the immune system. For patients with compromised immune systems, including transplant patients, any delay of appropriate treatment may result in complications, prolonged hospitalisation and death. However after successful treatment and hospital discharge, many patients still experience fatigue, loss of energy and difficulty concentrating. These symptoms may persist for several months, but complete recovery usually occurs within one year.

===PONTIAC FEVER===
Pontiac fever is an acute, self-limiting, flu-like illness without symptoms of pneumonia. The first outbreak of Pontiac fever was reported in Pontiac, Michigan, in 1968.16

It is characterised by high fever, chills, myalgia and malaise but without the pneumonia or cough typical of Legionnaires’ disease. Some authors suggest that it is a hypersensitivity pneumonitis, caused either by infection with a free-living amoeba called ''Acanthamoeba'' filled with legionellae or as a result of a toxic reaction to the organism. The incubation period is short, ranging from 1 – 3 days, and the attack rate high, exceeding 90% in some cases. The fatality rate is low.

Pontiac fever symptoms usually resolve spontaneously within one week, only symptomatic treatment is needed and the chest radiograph is clear. There is no evidence of secondary spread of the infection in Pontiac fever. Diagnosis can only be made by seroconversion, which may be delayed for up to 6 weeks after onset of symptoms. Cases of PF have been linked to ''L pneumophila, L feelei and L anisa''. Complete recovery usually occurs in 2 – 5 days without medical attention.

==CHAPTER 4==

===SURVEILLANCE FOR LEGIONELLA===
A major aspect of biosafety in the workplace is the assessment of hazards and risks of infection (environmental surveillance) and disease in workers (clinical surveillance). ENVIRONMENTALSURVEILLANCE Environmental surveillance is essential for the long term success of any water treatment program for Legionella to provide baseline environmental information to ensure the efficiency of disinfection and water treatment programmes and to control the risk of infection in events of mechanical failures and human error. The risk of contracting legionellosis can be summarised in terms of three factors, as summarised in Table 4.1. Table 4.1 Factors determining the risk of legionellosis Proliferation potential This potential exist in nearly all water systems and depends on many factors, including:  Presence of microbial biofilms  Diversity of microorganisms present  Availability of nutrients Exposure potential Certain industrial processes produce aerosols during their function. These aerosols can be aspirated (breathed deep into the lung) if the particle size is small enough (< 8 µm in diameter). Assessment of exposure potential thus focuses on the proximity of aerosol-generating systems to human populations. Population susceptibility The most susceptible individuals are elderly people (especially males), heavy smokers, alcoholics, patients with chronic pulmonary disease and immuno-suppressed people. 1 Source: McCoy 2004 4.1 RISK ASSESSMENTS A risk assessment is a scientifically based process used to estimate the likelihood of adverse effects occurring, taking into account the exposure (hazard), the level and nature of the risk and the target population. Risk assessments can be either quantitative or 1 qualitative. 4.1.1 Quantitative risk assessments Quantitative risk assessments involve the establishment of dose-effect and dose-response relationships in likely target individuals and populations. For a quantitative risk assessment to be successful, dose-response assessments, the extent and duration of human exposure and characterisation of the possible consequences resulting from exposure have to be determined 1 and quantified. Quantitative risk assessments are not possible for hazardous biological agents (including Legionella) for several reasons. Firstly, exposed people have varying degrees of susceptibility to infection. Secondly, water sources usually contain a diverse mixture of biological contaminants which may change rapidly over short periods of time. Thirdly, the contaminants present and the levels in which they are present are only applicable at the time and area sampled and the interactions among all these 1 biological agents present in the source and environment make exposure assessment extremely difficult. 4.1.2 Qualitative risk assessments Qualitative risk assessments on are done to “document site-specific conditions and recommendations for reducing the risk, if 1 necessary, and to establish assignments for actions, communications, training and management responsibilities”. Anumber of schemes have been developed to provide some form of risk ranking and risk scores to simplify these assessments 1 and to guide the water management plan. An example of a risk ranking for legionellosis is provided in Table 4.2. For example, if a system falls into Risk Category A, the frequency of testing, cleaning and disinfection and monitoring should be increased until the system falls into a lower Risk Category, when the rate of testing, cleaning and monitoring can be reduced again. 19 Table 4.2 Risk classification for legionellosis HIGHEST RISK LOWEST RISK RISK CLASSIFICATION A B C D CRITERIA MATCHES ANY OF THE RESPONSES BELOW MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A OR B MATCHES ANY OF THE RESPONSES BELOW AND NONE IN A, B OR C Stagnant water  System idle more than once a month  Re-circulation pump not timed  Dead-legs present  A plus timed recirculation pump  Any single factor in A  System operates continuously  No dead-legs Nutrients and growth  Contaminated water  No corrosion control  Wet surfaces open to sunlight  Any two factors in A  Any one factor in A  No factors in A Water quality  No automated biocide dosing protocol  No water treatment program  No automated biocide dosing  No water treatment program in place  Automated biocide dosing  No water treatment program in place  Automated biocide dosing  Water treatment program in place Equipment design and operation  No system design review  No system operation and performance review  No drift eliminators  Drift eliminators for cooling towers in place  Same as B with at least one review lacking  System design review in place  System operation and performance review in place  Good drift eliminators Location and access  Located in healthcare or residential care facility  Large numbers of people exposed  Same as A but moderate numbers of people exposed  Same as B but few people exposed  Not located near susceptible people 1 Source: McCoy 2004 4.2 THE RISK ASSESSMENTPROCESS The four most important steps in the risk assessment process are to get an overview of the operation of the water distribution system, to conduct a walk-through investigation of the building or facility, to assess the results of the walk-through to determine an 2,3,4 appropriate course of action and to recommend appropriate control actions. These steps are explained in more detail below. STEP 1 GET AN OVERVIEW OF THE WATER DISTRIBUTION SYSTEM OPERATION Ask the facilities engineer or an experienced member of the building staff, who has knowledge of the design and current operation of the system to explain the system and to assist in the walk-through investigation. The overview should include inspection of: ! Plumbing systems, heating/ventilation/air-conditioning (HVAC) systems and other water reservoirs as summarised in Table 4.3 20 ! Maintenance records of all water systems, including records of temperature checks on potable water, details of visual and physical checks of cooling towers and reports of water quality assessments and chemical treatment that may have been performed ! Location of parts of the system where there may be stagnant water ! The presence of cross-connections between potable and non-potable water systems ! The condition and type of back flow prevention devices used at these connections ! Any recent major maintenance actions performed or major changes in the system ! Determine whether recent or frequent losses of water pressure have occurred from the incoming supply ! Keep in mind that the failure of a back flow prevention device under loss of pressure can result in contamination of the water system Table 4.3 Areas to include when doing an overview of a waterdistribution system Plumbing systems Hot and cold potable water systems Water heaters Water coolers Distribution piping Water treatment equipment (eg. water softeners, filters) Connections to process water systems (not protected by backflow preventers) Storage tanks Heating, ventilation and airconditioning (HVAC) systems Cooling towers Evaporative condensers Fluid coolers Direct and indirect evaporative cooling equipment Humidifiers Location of fresh air intakes relative to water sources Air washers for filtration Miscellaneous reservoirs Decorative fountains Plant misters Whirlpools and spas Tepid water eye washes Safety showers Cooling water for industrial processes 2 Source: <nowiki>http://www.nalco.com</nowiki> STEP 2 CONDUCT A WALK-THROUGH INVESTIGATION OF THE FACILITY Table 4.4 The walk-through investigation WHAT TO DO WHEN ! Check sample transport requirements and receiving times of laboratory before investigation ! Get as much information as possible from staff before investigation ! Go through checklist and make sure you are prepared before investigation ! Check water temperatures while sampling for Legionella ! Check hot water tanks and related piping during investigation ! Check cooling towers during investigation ! Check water quality during investigation ! ! ! ! ! WHO SHOULD BE PRESENT? The person who knows most about the building, particularly the domestic water system Aplumbing engineer if possible Aplumbing contractor who knows the building if possible Arepresentative from the company that services the HVAC system The water treatment specialist who services the cooling tower 21 EQUIPMENT NEEDED ! The floor plan (arrange in advance if possible) ! Drawings of plumbing if available (arrange in advance if possible) ! Inspection checklist ! Camera ! Knife ! Pliers or channel locks ! Measuring tape SAMPLING KITS AND EQUIPMENT TO TAKE WITH ! Thermometer ! Chlorine kit ! Iron kit ! pH meter ! Total dissolved solids (TDS) kit ! Hardness kit ! Calibration fluid ITEMS NEEDED FOR LEGIONELLA SAMPLING ! Sampling log (see example) ! Sodium thiosulfate ! Cooler bag and other materials needed for packaging of sample for transport ! Documentation from courier or transport agency ! Plastic bags for packaging of samples ! Sterile swabs ! Sampling bottles ! Labels for bottles ITEMS NEEDED FOR SAMPLING FOR THE TOTAL BACTERIAL COUNT (TBC) ! Sampling bottles ! Sampling log sheets ! Cooler bag and other materials needed for packaging of sample for shipping or transport ! Documentation from courier or transport agency ! ! REMEMBER The temperature may be below the gauge temperature of the heater due to heat stratification CHECKLIST FOR FAUCETS CONNECTED TO EACH WATER HEATER ! Maximum temperature of each location that is “close (C)”, “intermediate (I)” or “far (F)” from the heaters ............................................................................................................ REMEMBER You may have to run the water for several minutes before it reaches a maximum temperature at “far” locations CHECKLIST FOR COLD WATER STORAGE TANKS USED FOR RESERVE WATER OR FOR MAINTAINING HYDROSTATIC PRESSURE ! InitialTemperature (°C) .......................................................................................................................... ! Potential for stagnation: high (H), medium (M) or low (L)........................................................................ ! Temperature of cold water line at various locations Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Location ............................................................... Temperature (°C) ......................................... Record both initial temperature and final equilibration temperature on cold water lines ...................... REMEMBER Tanks should be protected from temperature extremes and should be covered to prevent stagnation CHECKLIST FOR EACH STORAGE-TYPE HOT WATER HEATER Temperature of water drawn from it (°C) ................................................................................................. Presence of rust and scale ......................................................................................................................... 22 CHECKLIST FOR COOLING TOWERS, EVAPORATIVE CONDENSERS AND FLUID COOLERS ! Visual evidence of biofilm growth, scale build-up and turbidity ........................................................... ! The location of the tower relative to fresh air intakes ............................................................................ ! Proximity to sources such as kitchen exhausts, leaves, plant materials, or other sources of organic material that may contribute to Legionella growth .............................................................................................. CHECKLIST FOR COOLING TOWERS ! General physical and mechanical condition ........................................................................................... ! Presence and condition of drift eliminators ............................................................................................ ! Basin temperature of water (the tower is working) ................................................................................ REMEMBER Wear appropriate respiratory protection (half face-piece respirator and HEPA filter cartridge) during examination if cooling tower is operating SUMPS FOR COOLING TOWER, EVAPORATIVE CONDENSER AND FLUID COOLERS ! Location and condition ............................................................................................................................ ! Location of any cross-connections between potable and non-potable systems ......................................... REMEMBER Sumps are sometimes located indoors to prevent them from freezing. Cross-connections may be present to supply a back-up source of cool water to refrigeration condenser units or to supply secondary cooling units STEP 3 ASSESS THE RESULTS OF THE WALK-THROUGH TO DETERMINE AN APPROPRIATE COURSE OF ACTION Table 4.5 When is additional action necessary? NO FURTHER ACTION Operating temperatures measured in water heaters is 60°C Delivery temperature at distant faucets is ? 50°C No other potential problems observed TAKE FURTHER ACTION Poor maintenance Operating temperatures below minimums mentioned above STEP 4: RECOMMEND CONTROLACTIONS Remember! These actions may include disinfection of the potable water system as outlined in the section on disinfection 23 Table 4.6 Recommended control actions ACTION EXPLANATION Actions to limit the growth of organisms in water systems: Elimination of dead legs in the plumbing system Insulation of plumbing lines Installation of heat tracing to maintain proper system temperatures Elimination of rubber gaskets Removal or frequent cleaning of plumbing fixtures (eg aerators and shower heads) Water sampling to confirm the presence of Legionella: Not necessary at this stage BUT Customer may want to obtain background information, in which case sampling for Legionella will be helpful To ensure that corrective actions are successful: Sample water after corrective action BUT Customer may want to collect samples before corrective action to assess the extent of the problem but this is not normally done The customer should take the necessary corrective action, even if the pre-sampling tests are negative for the following reasons: Water sampling may produce false-negative results A contaminated portion of the system may have been missed The absence of legionellae at the time of sampling does NOT ensure that the system will remain negative at a later date Limited corrective actions that will not be sufficient: Raising water heater temperature without evaluation of system points of stagnation, heat loss and heat gain, cross-contamination and other factors that may contribute to the growth of Legionella bacteria. LEGIONELLA RISK ASSESSMENT DATA SHEET GENERAL INFORMATION Name of organisation Contact person 1 Contact person 2 Contact person 3 Site address Mailing address Building/area size Building age Type of building 24 RESULTS FROM PREVIOUS LEGIONELLA TESTING DATE RESULT Cooling towers Hot water tanks Outlet swabs Hot water outlets Cold water outlets Mixed outlets Incoming water 25 USEFUL QUESTIONS TO ASK ABOUT THE FACILITY WHEN DOING A RISK ASSESSMENT FOR LEGIONELLA(SOURCE: FREIJE 2001) Incoming mains Number Configuration Water source City - ground City - surface Utility: Private well Water usage Obtained from Water bills Fixture count Meter reading Other Deadlegs Present Policies Past construction Aerators Yes No Type Cold pipes location relative to hot Above Below Same level Pipe material Pipe insulation Cold Hot Both Type used Drinking fountains On chilled loop Individual 26 Fire sprinkler above ducts Yes No Water hammers arrestors or air chambers Water hammers Air chambers Both Sediment on water filters Yes No Other sediment gathering equipment Yes No Describe Connection control and/or backflow devices Yes No Faucets and showerheads Age Condition Water softened Cold water Yes No How Hot water Yes No How Water pressure shock Incidents Brown colour Building units closed off temporarily Yes No Major construction activities Yes No Dates Eye wash stations Mixed Cold Emergency showers Mixed Cold 27 Ice machines present Yes No Decorative fountains present Yes No Piped in coffee/tea/cooldrink centres present Yes No Rubber hoses present Yes No Misters for plants/food/comfort present Yes No Other equipment where water flow through that may produce a spray/mist Yes No Can windows be opened? Yes No HVAC systems +Condition of coils Overall condition Drainage of drip pans Humidifiers in duct? Hot water system Number of HW loops Number of CW loops HW recirculating? CW recirculating? Design temp at tank Design temp at taps Regulators Mixing valves Sensors to detect failures CW storage tanks present? Are they covered? Heaters or sunlight? 28 HOT WATER SYSTEM INSPECTION Model number Serial number Age Horizontal/vertical Condition Insulation Temp on gauge Temp from drain Temp of returning water Capacity/turnover Cleaning regimen Cleaning frequency All pumps used daily? Piping arrangement Draw diagram on separate sheet and attach 29 COOLING TOWER INSPECTION In-house identification Location Make and model Serial number Size Age Basin drainable? Cycling of each Months operating Water treatment company Contact details Cleaning frequency Who does the cleaning How is cleaning done? Is basin fully drained? Excessive foaming? Oily film on surfaces? Scum? Condition of drift eliminators Air bypassing: Around edges? Through holes in tower casing? Fill exposed to sunlight Basin exposed to sunlight Louvres/fill clogged? Louvres/fill damaged? Louvres/fill scale present? Louvres/fill algae present? Filters SAND BAG CARTRIDGE Pressure drop 30 Centrifugal separators Outlet strainers Pressure drop Corrosion/deterioration on Structural members? Safety rails? Ladders? Fasteners? Basin? Water leaks present? Air leaks present? Sump water level Cooling water temp Accessible to passers by? Distance from road Distance from parking Distance from sidewalks 31 COOLING TOWER INSPECTION CHECKLIST 5 Source: Freije 2001 BUILDING TOWER NAME/NUMBER INSPECTOR’S NAME DATE OF INSPECTION SAND FILTERS Water leaks? YES NO Suction air leaks? YES NO Pre-strainer clogged? YES NO Channeling in sand filter media (check quarterly) YES NO Operating pressure If YES, clean the media or replace it with filter sand designed specifically for cooling towers and evaporative condensers (not swimming pools). Clean the under-drain assembly while the media is removed. CENTRIFUGAL SEPARATORS Pressure drop Acceptable based on manufacturer’s chart? YES NO Flow rate Purge operation functional? YES NO UNUSUAL NOISE OR VIBRATION IN Pumps? YES NO Motors? YES NO Fans? YES NO Mounting hardware? YES NO OUTLET STRAINERS In place? YES NO Clogged? YES NO BAG AND CARTRIDGE FILTERS Pressure drop Acceptable based on manufacturer’s recommendations? YES NO If not, clean or replace TOWER STRUCTURE AND CASING Water leaks? YES NO Air leaks? YES NO 32 CORROSION OR OTHER DETERIORATION ON Structural members? YES NO Safety rails? YES NO Ladders? YES NO Fasteners? YES NO Basin? YES NO LOUVERS, FILL AND DRIFT ELIMINATORS Clogged? YES NO Damaged? YES NO Excessive scale or algae growth? YES NO If yes, clean with 6,895 – 10,343 kPa (1,000 – 1,500 psi) water, being careful not to damage fill and eliminator components WATER DISTRIBUTION Is the water distribution balanced? YES NO If not, unclog nozzles SEDIMENT BUILD-UP Sediment build-up around heater elements? YES NO FANS Do fans start and stop properly? YES NO VIBRATION Are the vibration switches operating properly? (check at least annually) YES NO SEASONAL OPERATION Are the seasonal systems working (check at least 3 months before winter) YES NO Are there any parts needed? YES NO If YES, what is needed? Are there any repairs necessary? YES NO If YES, what is needed? 2133 Describe action taken in response to above inspection (include dates): QUESTIONS FOR INFECTION CONTROL COORDINATOR (IF APPLICABLE) History of cases Cleaning of hydrotherapy baths and pools Practices for use and cleaning of portable humidifiers Practices for use and cleaning of nebulizers and other semi-critical respiratory equipment Water treatment for dialysis Contact details: Dental unit present? How is it treated? Contact details: Clinical tests for Legionella available? Policy for testing patients/workers for Legionella? 34 CHECKLIST FOR LEGIONELLA SAMPLING HW tank PRE-FLUSH POST-FLUSH Incoming water Faucets and showerheads Cooling make-up water Decorative fountains Cooling tower basins WATER QUALITY TESTS SAMPLE LOCATION pH Free chlorine Total chlorine Hardness TDS Iron TBC Coliforms WATER TEMPERATURES SAMPLE LOCATION HW after 1 minute (°C) CW after 1 minute (°C) 35 EXAMPLE OFSAMPLING LOG / REQUESTFORM REQUESTFOR TESTING OFWATER SAMPLES FOR LEGIONELLA COMPANYDETAILS .................................................................................................................................................................................................. CONTACTPERSON .................................................................................................................................................................................................. CONTACTDETAILS TEL........................................... FAX ............................................. E-MAIL................................................................ NAME OF PERSON WHO COLLECTED SAMPLES ............................................................................................................................... COLLECTION SITE .................................................................................................................................................................................................. SAMPLE NO LOCATION TYPE TIME COLLECTED COMMENTS Received by ……………………………..……….... Date ……………………….. Time ……………… HEALTH SURVEILLANCE Health surveillance can be defined as the “ongoing collection, comparison, analysis and dissemination of data relevant to public health issues”. The main objectives of health surveillance are to identify disease patterns in different population groups, to develop prevention strategies, to allocate resources for prevention and treatment and to educate health professionals and the general public. Health surveillance can take the form of: ! The notifiable disease reporting system (the first step in the surveillance cycle) ! Laboratory based surveillance (for diseases that can be monitored accurately through the laboratory data used for confirmation of the disease) 36 ! Hospital-based surveillance (where hospital discharge information and mortality data are used to monitor trends and disease burden in a particular area) ! Population-based surveillance (where data from a well-defined population are collected and analysed) DISEASE NOTIFICATION Disease notification serves as a means of collecting data on diseases that are considered to be of public health importance and is used world wide. Most countries (including South Africa) have a routine notification system requiring health professionals to report the occurrence of cases and deaths related to certain notifiable conditions. In South Africa, 39 medical conditions are currently 6 notifiable (Table 4.7). The notification system in South Africa is based on Health Act No. 63 of 1977 together with certain Regulations on the reporting of specific diseases to the Local, Provincial and National Health Departments. Table 4.7 Notifiable conditions in South Africa  Acute flaccid paralysis  Leprosy  TB (pulmonary) Any person (not necessarily a health care worker) may report a notifiable condition to a local authority via fax, mail or telephone. The relevant notification form is then completed by the local authority or district office, and submitted to the provincial office, which in turn summarises the cases and deaths for each notifiable condition (even if no cases or deaths occurred during that period) and sends the summary to the national office. WHO IS RESPONSIBLE FOR NOTIFICATION? The first health care professional or facility with whom a patient presenting with one of the notifiable medical conditions comes into contact is expected to notify the case (or death). This includes clinic personnel, infection control nurses, other hospital staff, and public and private medical practitioners. In cases where the patient had no contact with a health care professional, a member of the community is required to report the case. WHYIS NOTIFICATION SO IMPORTANT? Healthcare professionals have a legal obligation to report cases of notifiable conditions. The process of notification alerts outbreak response teams, resulting in appropriate and timely interventions, in turn assisting in the prevention of spread of communicable diseases. In addition, the notification system provides information on the status and trends of communicable diseases in the country. THE NOTIFICATION PROCESS There are certain forms to be filled in when reporting a case or death. These are available from the regional health office, the local Communicable Disease Coordinator or the provincial stores section. ! Form GW17/05: Initial diagnosis (to be completed immediately and containing finer details of the patient and the diagnosis) ! Form GW17/03: Line list of cases (to be completed weekly) ! Form GW17/04: Line list of deaths (to be completed weekly) Notifications are done using GW17/05 forms. The structure of the system, process of obtaining the forms and persons to which the forms are sent differ considerably between, and even within provinces. People at the provincial health information offices, however, are conversant with specific details of the system in their province, and nurses and doctors are encouraged to contact them for specific details about how to go about notifying cases and deaths of the diseases above. Alist of telephone numbers and addresses 7 of these contact people is included at the end of this article. Asemi-detailed overview of the process is described below. The GW17/05 forms are required to be completed as fully as possible, although information on patient's age, sex or race may be omitted only if it is not available. All other applicable information should be filled in, especially details relating to the place and date of infection, the disease being notified and whether a case or death is being notified. The contact people in the relevant provincial health information office will be able to furnish you with the details of the specific office to which the notification forms should be 37 sent. The steps to follow when reporting notifiable conditions are summarised in Table 4.8. Table 4.8 Steps in the notification process STEP 1 Diagnose and confirm that the patient is suffering/has died of a notifiable condition. STEP 2 Obtain the necessary documentation: Form GW 17/5  In the case of death the condition should be reported twice, first as a case and then as a death. STEP 3 Complete all the forms and send them to the relevant office:  Local Authority/Hospital/District responsible for disease containment (fill in Form GW 17/3);  Regional Office (the Health Information Unit);  Provincial Office (the Health Information Unit);  National Department (Directorate HSR and Epidemiology) 7 Source: The notification system in a nutshell. Remember! When workers complain of symptoms, the first question to be answered is not "How do we fix the building?", but rather: “Why to they have symptoms?". In other words, to address health complaints effectively, a health evaluation is absolutely essential. A systematic approach to legionellosis in the work environment is crucial.

==Acknowledgements==
Delene Bartie (CB Scientific)- 2023

==References Chapter 3==

#Dowling JN, McDaevitt DA, Pasculle AW. Isolation and preliminary characterization of erythromycin-resistant variants of Legionella micdadei and Legionella pneumophila. Agents Chemother. 1985, 27 (2): 272-274.
#MacFarlane JT, Miller AC, Smith WH, Morris AH, Rose DH. Comparative radiographic features of community acquired Legionnaires’ disease, pneumococcal pneumonia, Mycoplasma pneumonia and psittacosis. Thorax 1984, 39: 28-33.
#Boldur I, Beer S, Kazak R, Kahana H, Kannai Y. Predisposition of the asthmatic child to legionellosis? Isr. J. Med. Sci 1986, 22 (10): 733-736.
#Kurtz JB. Legionella pneumophila. Am. J. Occup. Hyg. 1988, 32 (1): 59-61.
#Shapiro M. Unusual epidemiologic and clinical manifestations of legionellosis: a review. Isr. J. Med. Sci. 1986, 22 (10): 724-727.
#Yu VL. Legionella pneumophila (Legionnaires’ disease). In: Mandell, Douglas and Bennet (eds). Principles and practice of infectious disease. 1990, Third Edition, Churchill Livingstone.
#Ratshikhopha ME, Klugman KP, Koornhof HJ. An evaluation of two indirect fluorescent antibody tests for the diagnosis of Legionnaires’ disease in South Africa. South African Med. J. 1990, 77: 392-395.
#Bartie C and Klugman KP. Exposures to Legionella pneumophila and Chlamydia pneumoniae in South African mine workers. Int. J. Occup. Environ. Health 1997, 3: 120-127.
#Maartens G, Lewis SJ, de Goveia C, Bartie C, Roditi D, Klugman KP. “Atypical” bacteria are a common cause of community acquired pneumonia in hospitalised adults. South African Med. J. 1994, 84: 678-682.
#Winn 1991
#Roig J, Aguilar X, Ruiz J, Domingo C, Mesalles E, Manterola J, Morera J. Comparative study of Legionella pneumophila and other nosocomial-acquired pneumonias. CHEST 1991, 99: 344-350.
#Stout JE, Yu VL. Legionellosis. New Engl. J. Med. 1997, 682-687.
#Ruf B, Schürman D, Horbach I, Fehrenbach FJ, Pohle HD. Prevalence and diagnosis of Legionella pneumonia: a 3-year prospective study with emphasis on application of urinary antigen detection. J. Inf. Dis. 1990, 162: 1341-1348.
#Harrison TG, Dournon E, Taylor AG. Evaluation of sensitivity of two serological tests for diagnosing pneumonia caused by Legionella pneumophila serogroup 1. J. Clin. Pathol. 1987, 40: 77-82.
#Pastoris MC, Ciarrochi S, Di Capula A, Temperanza AM. Comparison of phenol- and heat-killed antigens in the indirect immunofluorescence test for serodiagnosis of Legionella pneumophila serogroup 1 antigens. J. Clin. Microbiol. 1984, 20 (4): 780-783.
#Kaufmann AF, McDade JE, Patton CM, Bennett JV, Skalyi P, Feeley C, Anderson DC, Potter ME, Newhouse VF, Gregg MB, Brachman PS. Pontiac fever: isolation of the etiologic agent (Legionella pneumophila) and demonstration of its mode of transmission. Am. J. Epid. 1981, 114 (3): 337-347.
#Dennis PJ (1993). Potable water systems: insights into control. In: Barbaree JM, Breiman RF and Dufour AP (eds). Legionella: Current status and emerging perspectives. American Society for Microbiology, Washington DC. Pp 223-225.
#Colbourne JS and Dennis PJ (1985). Distribution and persistence of Legionella in water systems. ''Microbiol. Sc.'' '''2''': 40-43.
#Muraca PW, Stout JE, Yu VL and Yee YC (1988). Mode of transmission of ''Legionella pneumophila''. A critical review. ''Am. J. Hyg. Assoc.'' '''49''': 584-590.
#Yamamoto H, Sugiura M, Kusunoki S, Ezaki T, Ikedo M and Yabuuchi E (1992). Factors stimulating propagation of legionellae in cooling tower water. ''Appl. Environ. Microbiol.'' '''58''': 1394-1397
#[[Legionella Control#cite%20ref-:0%205-0|Jump up to:5.0]] [[Legionella Control#cite%20ref-:0%205-1|5.1]] Freije MR (1996). Legionella control in healthcare facilities: A guide for minimising risk. HC Information Resources, Inc. United States of America. P 8
#MarrieTJ, Haldane D, Bezanson G and Peppard R (1992). Each water outlet is a unique ecological niche for ''Legionella pneumophila''. ''Epid. Infect.'' '''108''': 264-270

[[Category:Legionella Control]]
[[Category:Infection Prevention and Control]]
[[Category:Water Distributions Systems]]
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Sustainability

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==INTRODUCTION==

==Purpose==
This document has been developed for the Department of Health to ensure that sustainable development is integrated into to planning and design of health facilities. The document defines sustainable development and outlines the implications of this for the built environment. It provides objectives and criteria that can be used in the development health facilities in South Africa.

==Background==
The Department of Health wish to support sustainable development in South Africa and ensure that there is an appropriate balance between economic development, social integration and protection of the environment.
Global Warming and South African legislation and policy now make it imperative that built environment projects address sustainability. However, there is limited South African guidance on how sustainable development can be integrated with built environment projects. There is also the perception that addressing sustainability in facilities will be expensive and complicated.
This document provides guidance and checklists that can be used to support the integration of sustainability into health facilities. It shows that by addressing sustainability early in projects, additional costs can be minimised and innovative, high-performance solutions that benefit society, the economy and the environment can be achieved. It also shows that achieving more sustainable facilities need not be complex but can be based on robust, sensible and simple measures.

==How to use this document==

This document provides a framework that can be used to inform the development of health facilities. It can be used in the following ways:

*'''Awareness''': This document can be used to increase awareness about sustainable development and the need to address this in built environment projects. This will lead to more rigorous debate on development options and support more innovative and sustainable solutions.

*'''Setting sustainable development targets''': This framework can be used by a development team to set explicit and challenging sustainable development targets for projects. This is done by setting quantified targets against criteria in the document and putting in place systems to ensure that these are achieved.

*'''Self-assessments''': This framework can also be used for self-assessment and to ascertain the performance of development proposals. To carry this out refer to the Facility Recommended Compliance sheet and Compliance Checklist at the end of the document. This enables different health facility development proposals to be evaluated in terms of recommended compliance. Assessment using the criteria can also inform the design process by being used to evaluate different development options. This enables optimal solutions to be developed in an iterative and efficient way.

*'''Coordinated development''': Some criteria in the document may appear not to be in the remit of, or possible in, a single development. These criteria however can be achieved through partnerships and local collaboration. This framework can be used bring together the key role players in order to develop integrated plans that enable key sustainable development objectives to be achieved.

==Structure of the guideline==
The document has the following structure:

*'''Implementing Sustainable Development''': This section provides a description of sustainable development and translates this into specific sustainable development objectives for the built environment.

*'''Built Environment Sustainable Development Objectives''': In this section more detailed guidance and checklists are provided for each of sustainable development objectives listed in the section above.

*'''Sustainability Integration Plans''': This provides guidance on plans and a structure that can be used to integrated sustainability in design and operational processes.

==IMPLEMENTING SUSTAINABLE DEVELOPMENT==

===Introduction===
South Africa faces a range of social, economic and environmental challenges. HIV/AIDs has resulted in a life expectancy dropping from 67 years in 1998 years to around 47 years currently. Unemployment is estimated to be 27% and climate change is likely to lead to increasing water stress, reduced food security and loss of species and ecosystems (DEAT 2009).
Sustainable development, which aims to achieve social and economic improvements while reducing negative environmental impacts, can be used to address these challenges. Sustainable development however can be difficult to achieve. This is because a holistic and integrated approach is required and the development sector and in particular, the construction industry, operates in a highly fragmented way. In addition, the concept of sustainable development is still new and has not been adequately translated into practical actions that can be readily implemented.
This section defines sustainable development and translates this into key built environment objectives. It also describes the role of the built environment in creating environmental and other problems and shows how integrating sustainable development considerations into construction and the built environment can make a substantial contribution to improving the social, economic and environmental performance of the built environment.

===The environmental context===
Increasing carbon emissions from human activities and a reduction in the ability of the natural environment to absorb carbon dioxide is leading to an accumulation of greenhouse gases in the upper atmosphere. These gases trap more heat in the upper atmosphere leading to global warming and temperatures are predicted to increase by 2 - 6°C OC by the end of the century (IPCC, 2007). Estimates carried out for the City of Joburg indicate that temperatures in the next 50 years may increase between 2 and 3.5°C (Hewitson, Engelbrecht, Tadross, Jack, 2005).

Within Africa, South Africa produces the highest CO2 emissions and has one of the highest CO2 emissions per GDP in the world. In 2002, carbon emissions per capita in South Africa were 8.4tonnes/capita - higher than Western European averages of 7.9tonnes/capita (SEA 2006).
Global warming is likely to impact Africa particularly negatively. The National Climate Change Response Policy Developed by the Department of Environment and Tourism outlines the following impacts (DEAT 2009a):

*Agricultural production and food security in many African countries are likely to be severely compromised by climate change and variability. Projected yields in some countries may be reduced by as much as 50% in some countries by 2020 and as much as 100% by 2100. Small scale farmers will be most severely affected.

*Existing water stresses will be aggravated. About 25% o Africa’s population (about 200million people) currently experience high water stress. This is projected to increase to between 75-250 million by 2020 and 350-600 million by 2050.

*Changes in ecosystems are already being detected and the proportion of arid and semi-arid lands in Africa is likely to increase by 5-8% by 2080. It is projected that between 25 and 40% of mammal species in national parks in sub-Saharan Africa will become endangered.

*Projected sea-level rises will have implications for human health and the physical vulnerability of coastal cities. The cost of adaptation to sea level rise could amount to 5-10% of gross domestic product.

*Human health will be negatively affected by climate change and vulnerability and incidences of Malaria, Dengue fever, Meningitis and Cholera may increase.

===The contribution of the built environment===
Construction and the built environment make a substantial contribution to global warming and play a significant role most economies. Environmental, social and economic impacts attributed to the built environment at a global scale are outlined below.

*Consumes 40% of energy use,

*Consumes 17% of fresh water use,

*Consumes 25% of wood harvested,

*Consumes 40% of material use,
*Employs 10% of the world’s work force,

*Construction is the largest employer of micro-firms (less than 10 people),

*Facilities are typically located on the most productive land (Estimated to be 250 million hectares world wide, mostly on primary agricultural land).

In South Africa the built environment is directly responsible, through electricity consumption, for over 23% of South Africa’s carbon emissions (see table below). Vehicle-based infrastructure and transport planning has resulted in transport contributing to 16% of South Africa’s CO2 emissions and an additional 18mtCO2 per year, or about 4% of South Africa’s CO2 emissions, come from the manufacture of building materials (CIDB 2009).

Sector C02 Emissions

Commercial 10%

Residential 13%

Transport 16%

Industry 40%

Mining 11%

Other 10%

Total 100%

''Figure 1: South African carbon emissions per sector''

===Defining sustainability===
Recent work by the World Wildlife Fund contributes substantially to defining sustainable development by providing quantified minimum criteria for sustainability. In the 2006 Living Planet Report, sustainability is defined as achieving an Ecological Footprint (EF) of less than 1.8 global hectares per person and an Human Development Index (HDI) value of above 0.8 (WWF 2006).

===Ecological Footprint===
An Ecological Footprint is an estimate of the amount of biologically productive land and sea required to provide the resources a human population consumes and absorb the corresponding waste. These estimates are based on the consumption of resources and production of waste and emissions in the following areas:

*Food, measured in type and amount of food consumed,

*Shelter, measured in size, utilization and energy consumption,

*Mobility, measured in type of transport used and distances travelled,

*Goods, measured in type and quantity consumed.

*Services, measured in type and quantity consumed The area of biologically productive land and sea for each of these areas is calculated in global hectares (gha) and then added together to provide an overall ecological footprint. This measure is particularly useful as it enables the impact of infrastructure and lifestyles to be measured in relation to the earth’s carrying capacity of 1.8 global hectares (gha) per person.

===The Human Development Index===
The Human Development Index was developed as an alternative to economic progress indicators and aimed to provide a broader measure that defined human development as a process of enlarging people’s choices and enhancing human capabilities (United Nations Development Programme 2007). The measure is based on:

*A long healthy life, measured by life expectancy at birth,

*Knowledge, measured by the adult literacy rate and combined primary, secondary, and tertiary gross enrolment ratio,

*A decent standard of living, as measure by the GDP per capita in purchasing power parity (PPP) in terms of US dollars.

===South African EF and HDI figures===
The figures below show that South Africa has an ecological footprint of 2.1, above the maximum required of 1.8 gha and a human development index measure of 0.66, below the minimum of 0.8 required for sustainability.

Measure South Africa Sustainability Target
Ecological Footprint (gha) 2.1 1.8
Human Development Index 0.658 0.8
{| class="wikitable"
|+
!Measure
!South Africa
!Sustainability Target
|-
|Ecological Footprint (gha)
|2.1
|1.8
|-
|Human Development Index
|0.658
|0.8
|}

For South Africa to move towards sustainability there must therefore be an improvement in both the Ecological Footprint and Human Development Index performance. The built environment has a key role in supporting this improvement.

===The legislative and policy context===
South Africa has a range of legislation and policy that aims to protect the environment and support sustainable development. Key legislation supporting sustainable development includes the South African Constitution and the National Environmental Management. These are discussed briefly below.

===South African Constitution===
The South African Constitution contains a Bill of Rights that enshrines the rights of all people in South African and affirms the democratic values of human dignity, equality and freedom. The Bill has sections covering equality, human dignity, privacy, freedom of religious belief and opinion, environment, property, housing, healthcare, food, water and social security, children, education, language and culture. Through a section on equality, the Bill requires that all people have full and equal enjoyment of these rights and freedoms:

''Everyone is equal before the law and has the right to equal protection and benefit of the law.''

Equality includes the full and equal enjoyment of all rights and freedoms. To promote the achievement of equality, legislative and other measures designed to protect or advance persons or categories of persons, disadvantaged by unfair discrimination, may be taken.
Environmental rights in the Bill of Rights include the right to an environment that supports health and wellbeing. It also requires legislation to be developed to ensure that the environment is protected and that development that does occur is both sustainable, and justifiable:

===Environment===
Everyone has the right

a). to an environment that is not harmful to their health or well-being; and

b). to have the environment protected, for the benefit of present and future generations, through reasonable legislative and other measures that ¬

#prevent pollution and ecological degradation;
#promote conservation; and
#secure ecologically sustainable development and use of natural resources while promoting justifiable economic and social development.

Sustainable development and the protection of the environment is, therefore, a constitutional obligation and there is a requirement for ‘reasonable legislative and other measures’ to be put in place to ensure that this achieved. '''This document represents a measure taken by the Department of Health to achieve sustainable development.'''

===Carbon emission mitigation strategies===
South Africa is a signatory to both the United Nations Framework Convention on Climate Change (UNFCC) and the Kyoto Protocol. In order to address UNFCC commitments, the Long Term Mitigation Scenarios (LTMS) process was initiated in 2006 and completed in 2008. This formulated strategies to ensure that South Africa would reduce carbon emissions. Many of the mitigation strategies identified have implications on the built environment and these are outlined below (DEAT 2009b):

*Limits on less efficient vehicles

*Passenger modal shift
*Solar water heater subsidy

*Commercial efficiency
*Residential efficiency

*Renewables with learning

*Waste management

*Land use: afforestation

*Escalating CO2 tax

Following the LTMS process, key policy approaches were agreed on by the South African cabinet. These strengthen current energy efficiency and demand-side management initiatives such as environmental fiscal reform and carbon taxation which will penalize energy inefficient technology and provide for additional tax allowances of up to 15% for energy-efficient equipment.
The LTMS process however also showed that although significant emission reductions could be achieved through technology-based actions, these were not sufficient for the scale of change required and that adaptations in social behaviour would be required. (DEAT 2009c).The LTMS, therefore, proposed a number of people and building orientated measures that offered low-cost large scale mitigation impacts including:

*Social adaptation and changes in human habitation, urban planning and the built environmental

*Studies on the distance between work, home and other life functions

*Modal shifts to public transport and moves away from individual car owners towards the operation of shared vehicles

*Food production and consumption, as well as the localization of these activities

==Built environment sustainable development objectives==
The environmental context, legislation and potential future measures to reduce carbon measures make it clear that the built environment must change to support sustainable development. It also makes it clear that many of the conventional practices in the planning, design, construction and management of building must be substituted with improved more sustainable approaches.
In order to develop practical measures that can be integrated into the built environment, it is useful to set out built environment or development objectives that, together, would support sustainable development. These objectives are outlined below and form the starting point for the next sections of this document where more detailed criteria are provided.

===Environmental objectives===

*Energy: The building is energy efficient and uses renewable energy

*Water: The building minimises the consumption of mains potable water.

*Waste: The building minimizes emissions and waste directed to landfill

*Materials: Construction impacts of building are minimized
*Biodiversity: The building supports biodiversity

===Economic objectives===

*Transport: The building supports energy efficient transportation
*Resource Use: The building makes efficient use of resources
*Management: The building is managed to support sustainability
*Local Economy: The building supports the local economy
*Products and Services: The building supports use of more sustainable products and services

===Social objectives===

*Access: The building supports access to facilities

*Health: The building supports a healthy and productive environment

*Education: The building supports education
*Inclusion: The building is inclusive of diversity in population

*Social Cohesion: The building supports social cohesion

===Integrating sustainable development objectives into health facilities===
Integrating sustainable development objectives requires structured processes. These are described below in terms of design and operational processes.

===Design processes===
Addressing sustainability in designs for new health facilities can be achieved through the following steps:

'''Target setting:''' Challenging sustainability targets should be set for the building and agreed with all of the key stakeholders of the project including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies as well as local and international best practice.

2. '''Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through analysis of best practice examples and precedents.

3. '''Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires the different disciplines to work closely together.

4. '''Testing:''' Throughout the design process, checks should be carried out to ensure that targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets a re-evaluation of the design should be carried out and in an iterative and integrated way, improved, to ensure that performance achieves, or surpasses, targets set.

5. '''Detailed design and implementation:''' It is important to ensure that the principles set out in 2 above, are carried out in to detail otherwise this may affect operational performance. This includes, for instance, details such as appropriate locations for switches, labels and instructions.

6. '''Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers required to ensure effective management of the building.

===Operational performance===
Addressing sustainability in existing or newly developed health facilities can be achieved through the following steps:

#'''Data''': Obtain operational performance data on your building for at least a full year. For energy, this can be obtained in the form of utility statements that indicate energy consumption in kWh.
#'''Benchmark''': The above data should be normalised so that it can be compared to benchmarks. This will indicate whether your facility is below or above benchmark performance. If performance is well over benchmark, further investigation should be carried out, as this indicates there is room for improvement.
#'''Walkthrough assessment''': A walkthrough energy assessment can be used to identify where obvious improvements can be made. Checklists are used as a basis for these assessment and they can be carried out by health facilities personnel with training or experience of the respective areas such as water and energy.
#'''Audit''': Where walkthrough assessments and benchmarking exercise indicate that a full audit is warranted this can be carried out. These audits provide detailed reports on interventions that can be carried out to improve sustainability performance in a facility.
#'''On-going operational performance''': A key component of improving sustainability operational performance, in combination with the steps above, is an on-going programme that improves performance. This includes detailed sustainability monitoring and reporting as well as day-to-day management processes required to optimise performance. Operational performance should be allocated to an individual who is required to report on this to senior management. Identified responsible persons should be provided with appropriate training, resources and incentives to achieve excellent energy performance.

==='''Sustainability integration plans'''===
The above processes can be supported through sustainability integration plans which present targets, strategies and monitoring process for each sustainability performance areas. The simplest form of this is illustrated in the table below and can be used for both design and operational processes.

Area Targets Strategy Monitoring
Sustainability performance area Sustainability targets and requirements Proposed strategy and processes Progress on achievement of targets
{| class="wikitable"
|+
!Area
!Targets
!Strategy
!Monitoring
|-
|Sustainability performance area
|Sustainability targets and requirements
|Proposed strategy and processes
|Progress on achievement of targets
|-
|
|
|
|
|-
|
|
|
|
|}



==ENERGY==

===Objective===
The building is energy efficient and uses renewable energy

===Introduction===
Energy is used in health facilities to operate equipment, heat water, and to ensure that required minimum lighting, ventilation and thermal comfort standards are met. In most existing South African building it is estimated that savings of up to 30% of energy consumption can be achieved at no or low cost. These savings can be considerably higher in new facilities were passive strategies, energy efficient equipment and renewable energy systems can be used.

Ensuring that health facilities are more energy efficient use renewable energy has a wide range of benefits including:

*Reduced carbon emissions and therefore global warming impacts

*Reduced impact of mains power outages

*Reduced negative health impacts of pollution from coal-fired power stations

*Reduced operational costs

*Improved internal environment where passive strategies such as day lighting and natural ventilation lead to improved internal conditions relative to mechanical ventilation and artificial lighting.

===Energy consumption in health facilities===
Energy in South African health facilities is largely sourced from electricity, however gas and coal may also be used in larger hospitals and some rural clinics rely on local renewable energy systems such as photovoltaic panels and solar water heaters. The proportions of energy use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of energy consumption in a typical South African hospital
|Proportions of energy consumption in a typical South African clinic
|}

Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Energy benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Energy consumption (kWh/m2.a)
|1
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|-
|Hospitals
|
|
|-
|Energy consumption (kWh/m2.a)
|395 2
|1
|-
|Maximum demand (VA/m2)
|1
|
|-
|Renewable energy (kWh/m2.a)
|0
|
|}
 
===Design Criteria===
Highly energy efficient facilities are optimized and integrated solutions that respond closely to the local site, climate and required internal functions. It is therefore difficult to prescribe this in a set of specific design criteria; however a series of questions are outlined below which can be used to check that key energy considerations have been addressed.

===Design and operation===
Improving energy performance in health facilities requires plans, procedures and processes that ensure that sustainability is integrated effectively into design and operations of a health facility. This can be achieved through setting challenging targets and effective monitoring processes.

#Have challenging sustainability targets been set for energy?
#Have effective procedures been established to model and test performance throughout the design process to ensure that these targets are achieved?
#Have the effective monitoring and evaluation systems, including regular reporting to the client, been put in place to ensure targets are achieved?
#Have capacity and systems in the form of staffing, training, manuals, commissioning and monitoring processes been planned for and put in place to ensure that design targets are achieved in operation.

===Orientation===
Orienting facilities so that the long facades face North – South helps to reduce unwanted heat gains from low angle sunlight early in the morning and late in afternoon. Where there is no alternative but to have facades face East and West, appropriate solar shading should be provided to avoid glare and control solar heat gain.

1. Are the long facades of facilities orientated to face within 15 degrees of a North – South orientation?

2. Is glazing on West and East facades minimized?

===Building shape===
While building shape and form may generally be determined by the functions accommodated, building form can also be shaped to minimise energy consumption. Shaping built form to limit building depth (see below) ensures that interior spaces can be naturally ventilated and day lit. Built form can also direct prevailing breezes through the facilities, supporting cooling and ventilation. It can also be used to create comfortable external spaces.

#Does the form of the building respond to local climate and topography?
#Does the building shape support reduced energy consumption and help create comfortable internal and external spaces?

===Building depth===
Limiting building depth enables internal space to be day lit and naturally ventilated. This ensures that internal space may not need artificial lighting or mechanical ventilation for much of the day, reducing energy consumption.

#Are building depths less than 15m?

==='''Insulation'''===
Insulation, especially when combined with thermal mass can be used to maintain comfortable indoor conditions without significant use of mechanical equipment. Insulation can ensure that valuable heat gains from people, equipment and the sun can be retained in the building to support comfort during winter. It can also reduce unwanted heat gains from ambient conditions in summer.

#Do the building envelope U-values achieve or surpass minimum values outlined in SANS 204 (SABS 2008)?

==='''Solar shading and glazing'''===
Glazing is usually the most vulnerable area of a building envelope and high heat losses and gains can be experienced through this component. It is therefore important to design glazing and devices which enable light and heat flow to be controlled.

#Is the glazing to wall ratio compliant with SANS 204 (SABS 2008)?
#Is solar shading compliant with SANS 204 (SABS 2008)?
#Has glazing with appropriate U-values, visual transmittance and solar heat gain coefficients been selected?

===Opening areas===
Opening areas within the building envelope such as doors and windows can be used to naturally ventilate the building. In general, it is advisable to provide for openings even in facilities that are mechanically ventilated and cooled as this enables them to be occupied and used in the event of a power cut.

#Are opening areas located to support effective natural ventilation?
#Is the area of openings provided compliant with SANS 10400 XA:2011?

Air tightness

Uncontrolled infiltration and airflow through the building envelope can affect comfort and increase heating and cooling loads in the building.

#Has careful detailing and specification been used to minimise infiltration in the building.
#Has a plan for rigorous construction supervision been put in place to ensure that building envelopes are air tight?

===Mechanical systems===
As far as possible mechanical cooling, heating and ventilation should be avoided. If this is not possible, a mixed mode operation should be selected. Mixed mode operation use mechanical system when ambient and internal conditions require this, but otherwise rely on passive systems to maintain thermal comfort and meet ventilation rate requirements. In particular circumstances mechanical cooling, heating and ventilation may be required for much of the year.

#Can the building or most of the spaces be passively cooled, heated and ventilated without the requirement for mechanical systems?
#If the application of passive systems will not achieve an acceptable number of annual comfort hours, can complementary mechanical systems be introduced to meet the comfort and ventilation requirements?
#Where zones exist within a facility that are not tolerant of passive ventilation and comfort systems, can a zoned mixed mode ventilation strategy be adopted?
#Where mechanical systems have been used has a rigorous exercise been undertaken to identify the most appropriate and energy efficient system?
#Where mechanical systems have been used do these include features that help reduce energy consumption such as:

a. An economy cycle

b. Controls that enable easy systems adjustments in order to benefit for seasonal and occupancy changes.

===Equipment===
As equipment used in building can consume large amounts of energy, the energy efficiency of equipment and energy ratings should be a key consideration. In addition, controls that ensure equipment is switched off when not in use should be specified.

#Is energy efficiency a key consideration in the selection of equipment?
#Is benchmarking energy consumption or energy rating used to support the selection of equipment?
#Are the controls provided for equipment easy to use and do they ensure that equipment is off when not required?

===Internal lighting===
Ensuring adequate lighting levels may be a key consideration in many spaces within health building. This should however be achieved in the most energy efficient way. Lighting is rapidly becoming more energy efficient and there are increasingly sophisticated controls.

#Is energy efficiency a key consideration in the selection of lighting?
#Has a rigorous evaluation process, including lighting power density calculations, been undertaken to ensure that the selected lighting system is highly energy efficient?
#Have appropriately sized lighting zones (ie under 100m2) been designed to avoid lighting being on where it is not required.
#Are lighting switching arrangements easy to use and encourage users to switch off lighting when not required?
#Are motion sensors used to switch lighting off in areas such as store rooms and meeting rooms when these are not used?
#Are daylight sensors used to switch lighting off in areas where these is adequate daylight? Areas with good daylight are usually found within a zone of about 6 m from external windows.
#Can light harvesting techniques and systems be incorporated in the design solution?

===External lighting===
Concerns about security often result in highly lit external areas. While security and building access requirements must be met, external lighting should be designed to be as energy efficient as possible.

#Are only areas that specifically require external lighting included?
#Has external lighting been provided as close to the area that requires lighting as possible and directed in order to avoid losses and light pollution?
#Are photo sensors, motion sensors or timers used to ensure that lighting is only on when required?

===BMS system===
Building Management Systems (BMS) should be used in complex building with complex equipment and systems. A BMS enables different systems to integrated and controlled and can support energy efficiency

#Has a BMS been used to coordinate and integrate systems, where complex systems are used in a large building?
#Is the BMS easy to use and understand?
#Is there local training and support for the BMS>
#Is the BMS system developed to open protocols and standards?
#Does the BMS include features that support energy efficiency such as:

a. Easy access to equipment schedules so that these can easily be changed to suite occupancy patterns.

b. Reminders to ensure that BMS operator tune building systems for greatest energy efficiency. For instance the system may provide a reminder to change air conditioning set points to match seasonal changes.

c. Reporting on water and energy sub metering and related equipment schedules.

===Sub metering===
An appropriate sub-metering system enables effective energy management. A facilities manager can see how much energy is used in different areas or uses in the facility. Sub-meters also show when and how energy is used through for instance energy profiles which show energy consumption and demand over time.

#Has an energy sub metering design been developed that will monitor all of the main energy uses in the facility?
#Is energy management data provided in formats and reports that can be easily understood and analyzed to support improved energy management?
#Does the system provide energy management report that can be used by both facilities managers and senior managers to improve energy efficiency in the facility?

===Renewable energy===
Increasingly renewable energy is becoming a competitive alterative to ESKOM supplied power. It also has the advantage that it increases the energy autonomy and independence of facilities, allowing these to operate even when there are mains power cuts.

#Are solar water heaters used to heat water in the facility?
#In areas with high quality, reliable sunlight, are photovoltaic systems used to reduce the reliance on ESKOM power?
#In areas with high quality, reliable wind, are wind turbines used to supplement to reduce the reliance on ESKOM power?

==WATER==

===Objective===
The building minimises the consumption of mains potable water.

===Introduction===
Water is used in health facilities for cleaning equipment, utensils and facilities, laundry, irrigation, food preparation and for drinking. In most existing South African health facility it is possible to reduce mains potable water consumption at no or low cost. These savings can be considerably higher in new facilities where water efficient technologies, grey water and rainwater systems can be used.

Ensuring that health facilities are more water efficient has a wide range of benefits including:

*Reduced water consumption and associated negative environmental impacts
*Reduced impact of mains water shortages or outages
*Reduced operational costs

===Water consumption in health facilities===
Water in South African health facilities is largely sourced from municipal potable water supply, however in some areas water may come from a rain water tanks or a borehole. The proportions of water use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of water consumption in a typical South African hospital
|Proportions of water consumption in a typical South African clinic
|}



Data on energy consumption and demand in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Water benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Water consumption (kl/m2.a)
|1
|1
|-
|Hospitals
|
|
|-
|Water consumption (kl/m2.a)
|70 2
|1
|}
 

===Criteria===
The consumption of mains potable water in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective performance requirements within the health facility; however a series of questions can be used to check that key water considerations have been addressed. These are outlined below.

===Wash Hand Basin Taps===
Controlling and reducing water flows in wash hand basin taps can be used to reduce water consumption.

#Are wash-hand basin tap flow rates should not exceed 6L/minutes?
#Are passive infra-red (PIRs) or push-button controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Toilets===
Reducing flush rates in water-borne sanitation can be used to reduce water consumption.

#Have WC flush rates been specified that do not exceed 6L/flush?
#Have dual flush controls can be used to ensure that reduced flush rates can be used when full flushes are not required?

===Showerheads===
Controlling and reducing water flows in showers can be used to reduce water consumption. The following measures can be considered:

#Have shower head flow rates been specified to not exceed 10L/minute?
#Are push-button type controls used to limit the duration of flows?
#Has legionella control been considered when designing for low flow and systems and where existing system are made redundant?

===Irrigation===
Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are locally indigenous species (species found in the local area) used to minimise irrigation requirements?
#If irrigation is required, are highly efficient water delivery systems, such as a drip irrigation linked to soil moisture probes, used to minimise irrigation requirements.
#Has grey water been used to avoid the use of potable water for irrigation?

===Grey water systems===
Grey water systems reduce mains potable water consumption by reusing lower quality water within the facility. Examples of this are where waste water from showers and wash hand basins is captured and reused to flush toilets. Other sources of grey water include waste water from laundries and HVAC systems. Grey water systems however are potentially hazardous to human health, particularly in health facility environments. In particular, grey water which is left to stand for over 36 hours or is contaminated by food or similar waste is considered as blackwater and requires the same treatment as sewage. Therefore, grey water systems should only be designed, implemented and operated by appropriately competent people. Potential grey water applications in health facility environments are described below:

*Wash hand basin and shower waste water: Waste water from wash hand basins and showers can be directed to a grey water system and then used to flush toilets or for landscape irrigation.
*Vehicle wash: Waste water from vehicle waste can be reused to wash vehicles for up to 3 or 4 times. After this it can be disposed of or used for irrigation.
*HVAC plant: It may be possible to use waste water from HVAC systems for irrigation or to flush toilets. To ascertain if this is possible investigations should be carried out with the HVAC manufacturer and grey water specialists.

The following considerations in relation to grey water systems should be made:

*Have significant sources of grey water from, for instance, showers and wash-hand basins, been captured in a grey water system?
*Are grey water usage points appropriately labelled to prevent unsafe consumption.
*Will this grey water be used for irrigation or to flush toilets in order to significantly reduce portable water consumption?
*Is the proposed grey water system easy and cost effective to maintain?
*Have as many of the potential health hazards associated with the system been eliminated?

===Rain water systems===
Rain water systems store water captured from roofs or hard landscape surfaces. This water is then available for irrigation, to flush toilets or for cleaning. In large facilities very substantial amounts of water can be captured and used to reduce mains potable water consumption. A number of different types of systems are described below:

*Roof rainwater harvesting: Rainwater from roofs is directed to tanks and stores. Usually a proportion of initial run-off is directed to waste as it may have picked up dust and other debris. This system is the most common and generally has the lowest cost as rainwater tanks can be installed above ground surface.
*Hard surface rain water: This system captures storm water run-off from hard surfaces such as game pitches, paths and car parking. This type of system generally requires some form of filtration to remove debris, and in the case of car parking, oil wastes. Tanks are usually sub-surface.
*Landscape surface run-off capture: Surface run-off from soft landscaping can be captured and reused. This is sometimes used as part of an onsite storm water retention strategy. The disadvantage of this system is that the resulting water quality can be poor as debris and silt may be picked up. The filtration and maintenance requirements are therefore more stringent.

The following considerations in relation to rain water systems should be made:

#Have significant sources of rain water from roof and hard surfaces been captured in a rainwater harvesting system?
#Will this rain water be used in functions such as irrigation or to flush toilets in order to significantly reduce portable water consumption?
#Is the proposed rainwater harvesting system easy and cost effective to maintain? Have as many of the potential health hazards associated with the system been eliminated?

==WASTE==

===Objective===
The building minimizes waste directed to landfills.

===Introduction===
Waste in South African health facilities is largely directed to landfill sites. Not only does this use up valuable land, but can also lead to air, soil and water pollution if not waste is not disposed of correctly. In addition, this waste also consists of valuable resources that could be easily reused and recycled. Recycling and reusing materials not only reduces energy and resource consumption but can also create jobs and additional revenue streams.

Ensuring that health facilities minimise waste and reuse and recycle waste products are as follows:

#Reduced loss of land area to landfill
#Reduced energy and resource consumption
#Potential to create jobs and small enterprises

===Waste production in health facilities===
Waste in South African health facilities is largely directed to landfill sites. However in some area waste may be disposed of by local recyclers. The proportions of waste generated use in a conventional South African hospital and clinic are shown in the pie charts below:
{| class="wikitable"
|+
!
!
|-
|Proportions of waste in a typical South African hospital
|Proportions of waste in a typical South African clinic
|}

Data on waste in South African facilities is not readily available. However the following table provides a number of benchmarks 1
{| class="wikitable"
|+
!Waste benchmark type
!Typical
!Good practice
|-
|Clinics
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|-
|Hospitals
|
|
|-
|Waste production (kg/m2.a)
|1
|1
|-
|Proportion of waste recycled or reused
|10%
|
|}

===Criteria===
Waste in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Provision for recycling===
Recycling can be encouraged by developing systems that make this easy. This includes providing easy-to-use receptacles for different types of waste and providing space in the right locations so that waste can be stockpiled into worthwhile quantities for a recycler to collect.

#Are there appropriate waste receptacles at the waste source to enable waste to be disposed of easily?
#Are there adequate number and type of waste receptacles at source to ensure that the value of waste is not reduced as a result of wastage or mixing of waste? For instance, clean waste paper can be spoilt if mixed with food waste.
#Has adequate storage space been provided in an appropriate location for the different recycling waste streams so that this waste can be stockpiled and easily accessed recycling contractors?

===Engagement with local recyclers===
Engaging with local recyclers earlier in the development of a new or refurbished facility can be used to understand the recycling process and the key requirements to make this effective.

#Have all the potential waste streams been identified? These include paper, cardboard, tin, glass, plastic, timber, electrical appliances etc?
#Have appropriate associations and local recyclers related to each of these waste streams been engaged with a view to ensuring that appropriate provision and systems are put in place to maximised recycling.

===Engagement with suppliers===
Engaging with suppliers can be used to reduce waste and transportation impacts. Waste and transportation impacts can be reduced through reduced use of packaging, use of reusable containers and optimized logistic supply chains.

#Have all suppliers of substantial goods and services to the health facilities been identified? Have these been engaged in relation to transportation and packaging with a view to minimising impacts in these areas?
#Has provision been made to reduce packaging waste and transport impacts through aspects such as increased space allowances for releasable containers and storage of products?

===Construction waste===
Construction is a major source of landfill waste. Waste from construction however can usually be easily reduced through explicit planning and monitoring processes.

#Has was construction waste minimization and recycling been included as specific requirement within tender and contract documents?
#Has the contractor been asked to develop a construction waste management plan in order to minimise waste? Does this plan include specific construction waste management targets ie 50% of all waste on site will be recycled? Have the parties responsible for implementing the plan been identified clearly and have they been given the mandate and resources to implement the plan? Has an appropriate monitoring and evaluation systems been put in place to ensure targets are achieved?

==MATERIALS==

===Objective===
Construction impacts of building are minimized

===Introduction===
Materials used in new facilities and the refurbishment of facilities can have significant impacts. Materials may be mined, processed, manufactured and transported before being incorporated in facilities. The extent and nature of the impacts of these stages varies widely depending on the material. The selection of materials and products to be used in facilities therefore is important in reducing negative environmental impacts.

Careful selection of construction materials used in health facilities has the following benefits:

*Reduced land and mining impacts
*Reduced environmental and health impacts from manufacturing processes
*Reduced transportation impacts
*Reduced material use
*Increased use of local sustainable materials

===Material use in health facilities===
Materials are used to construct South African health facilities and largely found in the building structure and envelope. More specialist materials and products such as refrigerants are found in equipment and systems within the building. The source and processes associated with construction materials and products have a wide range of impacts. It is therefore important to understand and confirm these with respective suppliers in order to select and specify materials and components with the least negative impacts.

===Criteria===
Material and component selection in health facilities can be addressed developing criteria list, communicating this to suppliers, and using this as a basis for specification and design. The nature of these criteria will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key material and component considerations have been addressed. These are outlined below.

===Building reuse===
Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Can the existing facilities continue to be used? If necessary, can these be refurbished and expanded rather than building a new facility?
#Are there other existing facilities that can be used? Can these be readily adapted for health use rather than constructing new facilities?

===Contribution to Global Warming===
Construction materials can contribute to global warming through carbon emissions associated with large amounts of energy used in their extraction, processing and transportation. This is referred to as embodied energy. Other materials such as refrigerant can contribute directly to global warming if they are released or leak into the atmosphere. Using existing facilities instead of building new avoids or reduces the requirements for construction materials and therefore the impacts associated with extracting, manufacturing and transporting these. In addition, existing facilities are usually part of the urban fabric and already serviced with electricity, water, roads and public transport. Increasing the intensity of use of this fabric increases its efficiency and avoids the requirement to replicate this elsewhere. Therefore, in most circumstances it is preferable to reuse and refurbish existing facilities rather than build new facilities.

#Refrigerants: Where refrigerants are being used in HVAC systems, cold rooms or in fire suppressions sytems have refrigerants with the lowest Global Warming Potential (GWP) and Ozone Depleting Potential (ODP) impacts been selected?
#High embodied energy materials: As far as possible, have construction materials with low embodied energy such as timber been selected? Where it is not possible to use these type of materials and high embodied energy materials such as cement and aluminium have to be use have the quantities of these materials been minimised?

===Reused materials or materials with recycled content===
Construction materials that are reused or have recycled content have less energy associated with their manufacture than equivalent new materials. Where possible, it is therefore preferable to reuse materials that may have already been used in another building or to select materials with recycled content.

#Are there materials from another building that is being demolished that could be reused? Aspects that can be reused include structure steel elements, facades, demountable structures such as carports, and building components such as windows and doors. Crushed concrete from demolished structures can also be used as aggregate in new construction.
#Have materials with recycled content been specified in preference to materials without any recycled content? Can the supplier / manufacture confirm the reduced environmental impacts of their recycled content product relative to new products?

===Reduced material use===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Material source===
The quantity of construction materials used in facilities can be reduced through avoiding material use, using materials more intelligently and using materials for more than one use.

#Avoided material use: Have materials been avoided where these are not required? For instance, can ceilings and plastering be avoided through better concrete finishes? Can improved floor finishes be used to avoid the requirement for carpets and tiling? Can the use of passive systems reduce the requirement for ducting and plant?
#Intelligent material use: Can quantities of materials be reduced through different designs and specifications? For instance, can structural strategies such as pre-tensioning concrete slabs and waffle slabs be used to reduce concrete requirements? Can material use and wastage be reduced through use of precast elements?
#Dual plus use: Can materials be used for more than one purpose? For instance, can photovoltaic panels be used as a roofing material as well as to generate material?

===Sustainable sources===
Materials can be defined in terms of whether they are from sustainable or non-sustainable sources. Materials from sustainable sources include timber, cork, wool that are grown and therefore can be harvested on an on-going materials. Other materials such as plastics and metals are mined and therefore once these sources are depleted will not be available.

#Where possible, have materials from sustainable sources been specified? For example, have timber, and plant-based products been used in preference to materials that have to be mined and processed?
#Are materials from sustainable sources actually being grown and harvested on a sustainable on-going basis? For instance, has timber specified been certified by the Forest Stewardship Council (FSC) as being from a sustainable source? It is important to note that there are still timber products available, in particular hardwoods, that are harvested from tropical rainforests which are not being replanted and therefore are not considered sustainable sources.

===BIODIVERSITY===

===Objective===
The building supports biodiversity

===Introduction===
Biodiversity plays a very important role for man through providing ecosystem services. Ecosystem services include the production of food and water, the control of climate and disease, supporting nutrient cycles and crop pollination and spiritual and recreational benefits.

Ensuring that health facilities take into account biodiversity has a wide range of benefits including:

*Maintaining local ecosystem services
*Providing an natural amenity such as gardens which would could support recuperation.

===Biodiversity in health facilities===
Health facilities affect biodiversity through their location and in the way that site planning and landscaping is carried out. New facilities can minimise negative impacts on biodiversity by avoiding green field sites and building outside municipal boundaries. Biodiversity within health facility sites can be supported through considered site planning and landscaping strategies.

===Criteria===
Biodiversity in health facilities can be addressed in a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key biodiversity considerations have been addressed. These are outlined below.

===Site location===
Biodiversity is being lost at a rapid rate through urban sprawl. Preserving existing biodiversity can therefore be achieved by avoiding green field site and building only within urban boundaries.

#Has the health facility been planned for a brown field (already built-on) sites?
#Has the health facility been planned for a location within an urban boundary so that this does not take up land that supports agriculture and or biodiversity.

===Design for biodiversity===
Biodiversity can be supported through site layouts and landscaping that retains existing biodiversity and enhances this.

#Has planning of the health facility ensured that existing valuable biodiversity on site is preserved?
#Have valuable links and wildlife corridors between biodiversity on the health facility and adjacent sites been preserved?
#Has the landscaping strategy enhanced existing biodiversity? Does this include the introduction of appropriate loc

==TRANSPORT==

===Objective===
The building supports energy efficient transportation

===Introduction===
Ensuring that health facilities support energy efficient transportation has a wide range of benefits including:

*Reduced air pollution and noise from vehicles
*Health benefits from increased opportunities for exercise
*More affordable transport for health facility users
*Reduced space requirements as a result of reduced parking and road requirements.

===Transportation in health facilities===
Transportation is important in health facilities as large numbers of people and goods need access to these facilities everyday. This includes health facilities staff who commute and health facilities users. The right location and provision of facilities help ensure that the transport impacts associated with this access is minimized and potential health benefits such as exercise are supported.

===Criteria===
The transportation in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that transportation considerations have been addressed. These are outlined below.

===Access to public transport===
Locating health facilities near public transport facilities and enabling good access to these encourage people to use these in preference to personal vehicles. The use of public transport can be encouraged by ensuring that health facilities are located near well used public transport nodes and that there are good walking routes between these and key locations within the health facility.

#Is the health facilities located near good public transport nodes such as minibuses, buses, trains and bus rapid transport systems?
#Are there safe, direct and easy-to-use routes between public transport nodes and key locations within the health facility? (see also provision for walking criteria)

===Provision for walking===
Making provision that encourages walking helps to ensure that people walk to health facilities instead of using vehicles. Walking can be encouraged through safe, direct and easy-to-use routes.

#Are there safe direct pedestrian routes to and around the health facilities site from neighboring areas and public transport nodes? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 for detail)
#Are there safe direct pedestrian routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does pedestrian provision include safe road crossings such as bridges, underpasses and zebra crossings? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by people with disabilities and by predicted pedestrian numbers? Are routes safe and benefit from visual supervision by surrounding facilities and other pedestrians? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

===Provision for cycling===
Making provision that encourages cycling helps to ensure that people cycle to health facilities instead of using motorized vehicles. Cycling can be encouraged by providing secure cycle storage, changing or showering facilities and safe, easy-to-use local routes.

#Are there safe direct cycle routes to and around the health facilities site from neighboring areas? (see also criteria 4 for detail)
#Are there safe direct cycle routes from neighboring areas to key locations within the health facility such as the main reception? (see also criteria 4 below for detail)
#Are there safe direct cycle routes within the health facilities between all locations within the health facility? (see also criteria 4 for detail)
#Does this cycle provision include designated, separate routes and safe road crossings and junctions? Are routes wide enough and have appropriate finishes and other required characteristics to enable them to be easily used by predicted numbers of cyclists? Are routes safe and benefit from visual supervision by surrounding facilities and other cyclists? Have lighting and appropriate security safety mechanisms been put in place if routes will be used at night?

==RESOURCE USE==

===Objective===
The building makes efficient use of resources

===Introduction===
There are limited resources in the form of land, finance and raw materials to construct and maintain facilities. It is therefore important to use these resourced carefully. Benefits associated with careful resource use include:

*Avoiding waste
*Ensuring effective and efficient use of resources
*Ensuring that resources are available for other uses where these are not required

===Resource use in health facilities===
Health facilities use financial resources to enable construction and maintenance. They also consume materials and energy in their construction. Finally health facilities use land. Careful use of these resources enables waste to be avoided and these resources to be available for other uses where this is required.

===Criteria===
Resource in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health facility; however a series of questions can be used to check that key resource considerations have been addressed. These are outlined below.

===Site density===
Detailed long term strategic plans for health facilities should be developed that take into account future projections. These should ensure that expansion or changes that are envisaged can be accommodated. However care should be taken that unnecessarily large areas are allocated for health facilities to avoid land being unused.

#Has a long term strategic site plan been developed for the health facility that addresses changes that may occur in the future, such as expansion or contraction?
#Has the over allocation of space for health facility sites been avoided?

===Occupancy density===
Robust sustainable facilities accommodate change through flexible and adaptable allocation and configuration of space. While this is important over provision of space should be avoided as this space will need to be serviced and maintained even if it is not used. Health facilities should therefore be designed to support spatial efficiency and effective use.

#Is the overall space allowance in the health facility in line or below health facilities norms, for instance, in terms of gross area per bed?
#Are the proportions of spaces use in the health facility in line with good practice health facilities design? For instance is the space allocated for circulation, support and ancillary services as a proportion of the total area in line with best practice norms?

===Food production===
Food production in the form of orchards or vegetable gardens are a productive way of using land that leads to both environmental and health benefits. Where land is available in health facility sites and there is water and appropriate capacity, food production should be encouraged and produce made available to be consumed within the health facility or by local communities.

#Has available land within the health facility site been developed for local food production?
#Has appropriate provision in the form of irrigation, fencing, organizational and capacity requirements been made to ensure that food production will be effective and sustained?

==MANAGEMENT==

===Objective===
The building is managed to support sustainability

===Introduction===
Facilities can be designed to support effective management. Systems can also be developed to ensure that facilities are effectively and efficiently used and maintained. In health facilities this is particularly important because of the stringent environmental requirements for health care and the high operating costs of the facility.

Ensuring that health facilities are effectively managed has a wide range of benefits including:

*Ensuring that operating costs are controlled and reduced
*Minimising disruption to health care as result of maintained and repairs
*Ensuring that maintenance is planned for and effective carried out

===Building management in health facilities===
Building management aims to ensure that health facilities are effectively operated and maintained in order to support healthcare services that they accommodate. Personnel with appropriate capacity, mandate and resources should be allocated to this function.

===Criteria===
Building management in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that building management considerations have been addressed. These are outlined below.

===Energy and water sub metering===
Energy and water sub metering enables the manager of a health facility to manage the consumption of energy and water and reduce costs associated with these services.

#Has energy sub metering been installed which enables energy consumption in all areas with substantial loads to be measured and monitored? Do energy meters support assessment of energy consumption trends, profiles and comparison with benchmarks?
#Has water sub metering been installed which enables water consumption in all areas with substantial consumption to be measured and monitored? Do water meters support assessment of water consumption trends, profiles and comparison with benchmarks?
#Is water and energy consumption monitored and reported to senior management on a regular basis?

===Facilities management manual===
A facilities management manual provides technical detail on all aspects of the building and how they should be maintained and managed. It is useful because it provides a repository of knowledge and information that can be used by facilities managers and their staff to ensure that health facilities are effectively managed and maintained.

#Has a detailed facilities management manual been developed for the health facilities? Does this include a detailed schedule for maintenance and other checks on equipment such as lighting, pluming fittings and HVAC
#Does the facilities management manual refer to a full set of as-built drawings and equipment manuals? Have a full set of hard copy and electronic copy as-built drawings and manuals been provided?
#Have facilities managers in the building had a full induction on the building’s systems and the facilities management manual?
#Does the facilities management manual get regularly reviewed and updated to reflect upgrade and renovations details.

===Senior management commitment===
Effective management of facilities can be supported by senior management commitment. Regular reporting on facilities performance such as energy and water consumption serve to ensure that management is aware of these issues and are likely to ensure that the appropriate mandate and resources are in place to improve this.

#Have facilities management policies in relation to sustainability been developed? For instance, are there policies or guidance on how energy and water consumption will monitored and managed?
#Have facilities management policies or guidelines been endorsed by senior management? Is there are requirement for facilities management to report on facilities performance on a regular basis to senior management?

==LOCAL ECONOMY==

===Objective===
The building supports the local economy

===Introduction===
The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the local economy has a wide range of benefits including:

*Increased local employment
*Increased local capacity for new construction and maintenance of facilities

===Local economy in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the local economy in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

===Small enterprise support===
The waste and emissions in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key waste considerations have been addressed. These are outlined below.

Minimizing irrigation water requirements can be used to reduce water consumption. The following measures can be considered:

#Are small enterprises provided with opportunities to tender for relevant construction and maintenance contracts? Can local, small enterprises be given preference in the awarding of work?
#Where local small enterprises have limited capacity and experience, can they be supported by encouraging partnerships with more established and larger enterprises?

===Material and component procurement===
The specification of local materials and components in the construction of health facilities can provide a significant incentive to local suppliers and manufacturer to develop appropriate products and capacity. This in turn provides local employment and can ensure that maintenance and repairs at the facilities can be carried out more quickly and cost effectively.

#Has a review of local materials and components been carried out?
#Have local materials and components been specified?

===Construction employment===
The construction industry can employ significant numbers of people. This can be supported through designs, specifications and labour intensive construction techniques which can be used to construct facilities without significant cost or time implications. Local construction employment improves the local economic impact of projects and ensures that there is local capacity to undertake repairs and maintenance of facilities.

#Is construction employment a key consideration in the design, specification and construction of the facility?
#Have opportunities to create local employment been sought and developed through the project?

==PRODUCTS AND SERVICES==

===Objective===
The building supports use of more sustainable products and services

===Introduction===
Products and services used in health facilities have a range of impacts and planning can be used to maximise beneficial impacts and avoid negative impacts. The construction and maintenance health facilities are a significant investment by government. This investment, if considered carefully, can be used to support the local economy and employment. This is done by specifying local products and services from the local area.

Ensuring that health facilities support the more sustainable products and services has a wide range of benefits including:

*Reduced waste
*Increased support for sustainable choices and options for health facility users

===Products and services in health facilities===
Supporting the local economy can be achieved in new facilities by understanding the nature and type of local building product suppliers and where appropriate specifying these in the building. Similarly understanding the capacity and skills of local contractors can be used to ensure that these are developed and enhanced by being engaged in the construction and maintenance of health facilities.

===Criteria===
Supporting the more sustainable products and services in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key product and service considerations have been addressed. These are outlined below.

===Local produce===
Impacts associated with transport and storage / refrigeration mean that produce imported from some distance away generally has significantly higher ecological footprints than local produce. Health facilities can therefore reduce ecological footprints associated with food through using local produce as far as possible.

#Is local produce used in preference to produce imported some distance away?
#Has the use of local produce been made a requirement in outsourced catering contracts?

===Vegetarian options===
Meat-based meals generally have significantly higher ecological food print requirements relative to vegetarian meals. Providing vegetarian options can therefore support reduced food impacts within health facilities.

#Are vegetarian options provided in catering establishments within the health facility?
#Has the provision of vegetarian options been made a requirement for outsourced catering contracts?

===Drinking water===
Waste streams can be reduced by providing alternatives to bottled drinking water. Drinking water can be provided through strategically located drinking fountains, as well as being supplied in reusable containers. A ready supply of drinking water also has health benefits.

#Is non-bottled drinking water readily and freely available throughout the health facility?

===Reuseable vessels===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Have reusable vessels been specified in preference to disposable containers, for services such as catering?
#Has adequate provision been made for reusable vessels in the form of storage and washing facilities?

==ACCESS==

===Objective===
The building supports access to facilities

===Introduction===
Current work patterns and lifestyles mean that many people have to access facilities such as banking, retail, childcare and communications on a regular basis. Ensuring that these facilities are within the health facility or within easy walking distance helps to avoid or reduce associated time and transport impacts.

Ensuring that health facilities support access to facilities has a wide range of benefits including:

*Reduced transport impacts
*Reduced time spent travelling to and from facilities

===Access to facilities in health facilities===
Supporting access to local facilities can be achieved through incorporating these into the health facility. Alternatively the health facility can be located near where these exist. It may also be possible to work with relevant service providers in order to provide these locally.

===Criteria===
Supporting access to facilities in health facilities can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key access considerations have been addressed. These are outlined below.

===Banking===
Access to banking can be provided through formal banking facilities or through bank ATMs. This can be provided within the health facility or within easy walking distance of this.

#Are banking facilities available within the health facilities or within the local area?

===Grocery retail===
Grocery retail can be provided through local shops, supermarkets and markets. This can be provided within the health facility or within easy walking distance of this.

#Are grocery retail facilities available within the health facility or within the local area?

===Communication===
Access to telephone and internet can be provided through internet cafes or at stand alone kiosks. This can be provided within the health facility or within easy walking distance of this.

#Are internet and telephone facilities available within the health facility or in the local area?

===Café===
Access to catering facilities can be provided through cafes, restaurants or canteens. Refreshments should be affordable and accessible to both staff and health facility users. This can be provided within the health facility or within easy walking distance of this.
1. Is there an accessible, affordable café, restaurant or canteen within the health facility or in the local area?

===Childcare===
Significant waste streams can be avoided through the use of reusable vessels. In particular disposable food and drink vessels can be avoided by providing reusable vessels. This option can be supported through provision of required storage and washing and facilities.

#Is there a childcare facility within the health facility or in the local area?

==HEALTH==

===Objective===
The building supports a healthy and productive environment

===Introduction===
Health facilities by their definition aim to support health and well being in their users. In addition to medical care health can be promoted through beneficial environmental conditions including a plentiful supply of fresh air, views and optimum thermal comfort conditions. It is particularly important to avoid conditions and situations that may be harmful to human health.
Ensuring that health facilities support the health in facility users and construction workers services has a wide range of benefits including:

*Improved recovery rates for patients
*Reduced absenteeism associated with environmental conditions by health facility staff
*Reduce injury and absenteeism rates associated with dangerous or harmful working construction environments

===Criteria===
Ensuring construction and health facilities promote health can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that health promotion considerations have been addressed. These are outlined below.

===External views===
Views and a connection to the external environment improve internal environmental conditions and can help improve recovery rates and reduce employee absenteeism.

#Do health facility staff working areas have views to the external environment
#Do patient areas have views of the external environment?

===Daylight===
Day lighting can help reduce energy consumption associated with artificial lighting. It also improves internal environmental conditions for patients and health facility employees.

#Are health facility staff working areas well day lit?
#Are patient areas well day lit?

===Ventilation===
High levels of fresh air are important for human health and productivity. This can be provided through natural or mechanical ventilation. Where mechanical ventilation is used sufficiently high levels of external, fresh air should be provided and recirculated air should be avoided or minimized.

#If the condition of outside air makes it unfit for direct ventilation use, is it appropriately pre-treated and filtered by the ventilation system?
#Are health facility staff working areas well supplied with good quality outside air?
#Are patient areas well supplied with good quality outside air?

===Building materials===
Building materials can have negative impacts for human health associated with their extraction and manufacture. They may affect health in facilities, through for instance offgassing hazardous chemicals. Construction materials should therefore be screened to avoid products being used in health facilities that have negative impacts on human health.

#Has criteria been developed and applied for the selection and screening of building materials?
#Have all building materials that may off gas substances such as formaldehyde and volatiles organic components that may be harmful to human health been avoided?

===Contractor health and safety===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

==EDUCATION==

===Objective===
The building supports education

===Introduction===
Education and on-going learning is increasingly been seen as an essential component of sustainable development and a competitive economy. This is recognised in health care through the requirement for health care professionals to under continued professional development (CPD). Education and on-going learning can be supported through technology and spaces within facilities that support this. Examples of this include training rooms and access to ICT and reading material. In addition well packaged
Ensuring that health facilities support the education has a wide range of benefits including:

*Improve ability by health facilities staff to keep up-to-date with new developments in health care
*Ability to attract and retain staff

===Criteria===
Ensuring construction and health facilities promote education and on-going learning can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that education and on-going learning considerations have been addressed. These are outlined below.

===Contractor education===
There are considerable health and safety risks in the construction industry. Considering health and safety in the design of health facilities can be used to reduce health and safety risks associated with construction and maintenance. Making provision for safe access to glass facades or to high level lighting helps to ensure that this can be installed, cleaned and maintained without undue health and safety risks. In addition, addressing health and safety comprehensively in contract and construction planning, procedures and processes can be used to eliminate many construction health and safety risks.

#Has contractor health and safety been considered as a key issue in the design of the building? Have construction risks been minimised through appropriate design risk assessments and mitigation?
#Have detailed construction plans, procedures and processes been developed to minimise risks where these may occur during construction?
#Has appropriate health and safety procedures been put in place to ensure that plans are implemented and monitored?

===Notice boards===
Notices are very easy and cost effective way of communicating information. They can be used to support education and awareness by drawing attention to new or important education. For instance, awareness and reminders about new health care policy, procedures and processes can be communicated. Notice boards have the benefit that they can be located where they will be seen by all personnel on a regular basis and are not reliant on a particular technology, such as email. This helps to ensure information can be communicated to all levels of staff within a health facility.

#Have notice boards been located in key locations in the health facility where they can be used to communicate key information to facility staff and users?
#Have communication and education plans been developed that will ensure that notice boards will be updated throughout the year with relevant notices and information?

===Space for learning===
Formal training can be supported through access to training rooms. More informal on-going learning can be provided through access to resource centres where learning material, computers and the internet can be accessed.

#Are there appropriately sized and equipped facilities to accommodate formal training?
#Are there appropriately sized and equipped facilities to support informal on-going learning by staff?

===Employee induction===
Employee induction refers to awareness training provided to new employees. This can be used to support sustainability by developing awareness in health facility staff about sustainable building systems and how they should be used. This may include aspects such as lighting and HVAC operation as well as recycling procedures.

*Have employee induction processes been developed?
*Do these include detailed information on systems in the building that aim to support sustainability?

===Building user manual===
Building user manuals aim to complement employee induction processes by providing easily accessible and understanding information related to a facility in order to support user behaviour that support sustainability.

#Has a building user manual been developed?
#Is this readily accessible and easy to use?

==INCLUSION==

===Objective===
The building is inclusive of diversity in population

===Introduction===
Design for inclusion helps to ensure that facilities can be used by all users including older people, sick people, people with children and people with disabilities. Inclusive design also often means that facilities are safer and easier to use. In health facilities both of these aspects are particularly important.

Ensuring that health facilities are inclusive has a wide range of benefits including:

*Less requirement to replicate facilities
*Facilities that are easier and safer to use

===Criteria===
Ensuring health facilities are inclusive can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key inclusion considerations have been addressed. These are outlined below.

===Accessible transport===
Inclusive access to health facilities is an important consideration. This means ensuring that people who may be ill, infirm, old or have disabilities are able to access health facilities easily. This requires accessible routes from places for work and accommodation to the facilities and often requires easily accessible local public transport systems. This can be p

Ensuring that health facilities support the education has a wide range of benefits including:

#Are there regular, affordable and efficient local transport systems?
#Can these be accessed readily from health facility users’ accommodation and places of work?
#Can the health facility be accessed readily from public transport?
#Is public transport provision inclusive?

===Environmental access===
Facility design and management for environmental access can be used to ensure that health facilities are inclusive. This requires a comprehensive approach that ensures that access consideration are effectively integrated into all aspects of health facility design. Guidance on this aspect is provided in the IUSS d

#Does the facility design fully comply with the IUSS environmental access requirements?
#Are systems and management in place to ensure that environmental access standards are maintained during operation?

===Access to affordable accommodation===
There is an increasing shortage of affordable accommodation in many South African cities. This can have a range of negative impacts including the requirement for long distance commuting, disrupted family life, and reduced family budgets for non-transport related costs such as education and health. Increasing local affordable accommodation can be achieved through partnership agreements with local developers and social housing organizations.

#Is there affordable local accommodation for health facility staff?
#If this does not exist, have initiative been taken to develop this with developers and or social housing institutions?

==SOCIAL COHESION==

===Objective===
The building supports social cohesion

===Introduction===
Social cohesion refers to the extent to which individuals within a community understand, collaborate, trust and work together. It is valuable because it enables collective knowledge and resources to be used more effectively and efficiently to support common goals. Within a health facility improved social cohesion can support improved healthcare with fewer resources by sharing and using these more effectively. It can also support improved communication and cooperation within health teams and therefore improving levels of service and reducing wastage and mistakes.

Ensuring that health facilities support social cohesion has a wide range of benefits including:

*More efficient and effective use of resources
*Improved communication and coordination
*Reduced wastage

===Criteria===
Ensuring health facilities support social cohesion can be addressed through a variety of ways. The applicability of each measure will depend on local circumstances and the respective requirements of the health building; however a series of questions can be used to check that key social cohesion considerations have been addressed. These are outlined below.

===Shared used of facilities===
Shared use of facilities helps to ensure that valuable facilities are well used and beneficial impacts are experienced across a wider range of people. Capital and operating costs of the facility may also be reduced as these are shared between a larger number of organizations or individuals. This concept can be applied to health facilities in a range of different ways. For instance, sharing arrangements with a local sport club or fitness center can be used to enable a health facility to use swimming pools and other facilities for rehabilitation without having the ongoing costs and management of this facility.

#Have shared use, and possibly development, of facilities been explored with local organizations?
#Have appropriate design considerations been put in place to ensure effective shared use of facilities?
#Have appropriate management considerations been put in place to ensure effective shared use of facilities?

===Social spaces===
Social spaces, such as canteens, cafes and common rooms can play an important role in the life of organization. They not only provide a respite from work environments they also provide a space for relaxed social interaction. This interaction and the relationships and communication networks created can may a significant impact in improving organizational effectiveness and responsiveness. In health care facilities this is a valuable resource which helps to motivate individuals and build strong teams that are able to provide effective and responsive health care.

#Have an appropriate number and type of social spaces been provided within the health facility?
#Will these facilities support easy social interaction within and between health teams, as well as cross health facility staff structures?

===Stakeholder involvement===
Involving people in decisions on issues will have an impact on them is a useful way of helping ensure that there is support for an initiative or a process. Structured involvement of stakeholder helps to ensure a shared understanding can be developed, joint decisions made and there is efficient and effective implementation. For instance, within a health facility, effective involvement of key stakeholders can help goals such as improved energy efficiency through ensuring that managers, building technical staff and health services staff understand the goal, the means that this will be achieved and can see their role in supporting this.

#Has there been appropriate stakeholder involvement in the design of health facilities?
#Has there been appropriate stakeholder involvement in the management of health facilities?

==REFERENCES==

#CIDB, 2009. South African Report on Greenhouse Gas Emission Reduction, Potentials from Facilities, A Discussion Document. Construction Industry Development Board. Page 22.
#. DEAT, 1995. Urban Open Space: Guidelines for effective management. Discussion document based on Agenda 21 and the RDP
#DEAT, 1998. National Environmental Management Act. Department of Environment and Tourism, Pretoria. Chapter 1.
#DEAT 2009, State of the Environment Report Accessible from http://soer.deat.gov.za/themes.aspx?m=387
#DEAT, 2009a, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 8.
#DEAT, 2009b, The National Climate Change Response Policy. Department of Environment and Tourism, Pretoria. Page 14
#DEAT, 2009c, The National Climate Change Response Policy. Policy Department of Environment and Tourism, Pretoria. Page 20.
#EMM and GDACE, 2007. Environmental Management Framework for Ekurhuleni. Ekurhuleni Metropolitan Municipality and Gauteng Department of Agriculture, Conservation and the Environment
#Hewitson, B. Engelbrecht, F Tadross, M. and Jack, C., 2005. General conclusions on development of plausible climate change scenarios for southern Africa, in: R. E. Schulze (ed.), Climate Change and Water Resources in Southern Africa: Studies on Scenarios, Impacts, Vulnerabilities and Adaptation, Water Research Commission, WRC Report 1430/1/05, Pretoria, South Africa.
#IPCC, 2007. Climate Change 2007, Synthesis Report. Inter Governmental Panel on Climate Change. 2007.Page 7
#SEA 2006, State of Energy in South African Cities. Sustainable Energy Africa. Cape Town.
#South African Bureau of Standards. 2007. SANS 204 Energy Efficiency in Facilities
#WWF 2006. Living Planet Report 2006.World Wildlife Fund. Accessed from www.panda.org.

==APPENDIX A: SUSTAINABILITY INTEGRATION PLANS==
 
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[[Category:Crosscutting Issues]]

Building Engineering Services

2021-04-22T07:45:29Z

Tobyvan: /* Natural ventilation */

{{Cleanup}}{{Expand}}

=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===

==='''Context'''===
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.

==='''Design principles'''===
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.
{| class="wikitable"
|+Table 1: IUSS document
!Clinical services
!Essential
!Recommended
!Support Services
!Essential
!Recommended
!Healthcare environment/
Crosscutting issues
!Essential
!Recommended
!Procurement &
Operation
!Essential
!Recommended
|-
|Impatient services
|
|X
|Administration & related services
|
|
|Generic room data
|X
|
|Integrated infrastructure planning
|X
|
|-
|Laboratories
|
|X
|General hospital support services
|
|
|Hospital design principles
|X
|
|Project planning & briefing
|X
|
|-
|Mental Health Services
|
|
|Catering services
|
|
|Engineering design principles
|X
|
|Space guidelines
|
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|-
|Critical care
|
|
|Laundry and Linen
|
|
|Environment and sustainability
|X
|
|Cost Guidelines
|X
|
|-
|Emergency centres
|
|
|Mortuary
|X
|
|Materials & finishes
|X
|
|Procurement liaison
|
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|-
|Obstetrics & gynaecology
|
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|Nursing colleges
|
|
|Future healthcare environments
|
|X
|Commissioning
|X
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|-
|Oncology
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|Health facility residential
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|Healthcare technology
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|Maintenance
|X
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|-
|Outpatient services
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|X
|Sterile supply
|X
|
|Inclusive environments
|
|X
|Decommissioning
|X
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|-
|Paediatrics
|
|
|Clinical training
|
|
|Infection prevention & control
|X
|
|Capacity development
|
|X
|-
|Pharmacy
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|
|Waste disposal
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|X
|Health informatix
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|Primary health care
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|Regulations
|X
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|Diagnostic radiology
|X
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|X
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|TB
|X
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Where this document lacks guidance on a topic or appears to contradict the requirements of the guidelines identified above, the guidance of those documents will take priority.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
#*Summaries of collated information
#*Reports on technical feasibility, benefits and risks
#*Reports on regulatory compliance issues
#*Reports on financial feasibility and risks
#*List of consents and approvals required
#*Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

==Design Questions==
6. In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

==Design considerations==

==='''7. Deep buildings'''===

#Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

==='''8. Plant and plant room size and location'''===

#Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.
#Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities. Plant rooms shall be located away from possible heat and contamination sources.
#Plant rooms shall be located in an accessible area which is secured from unauthorized entry
#Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

==Life cycle cost determination==
9. When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

10. Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

==Site-survey requirements==
11. In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

==Maintenance Considerations==
12. Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

13. The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

14. In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.

15. For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

==Planning for Retrofitting & Decommissioning==
16. While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

17. Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

18. When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

19. A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

20. Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

21. For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

==Sustainability & Environmental Measures==
===Design Life cycle===

Sustainability in designs for new health facilities can be addressed through the following steps:

'''22. Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.

'''23. Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.

'''24. Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.

'''25. Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.

'''26. Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.

'''27. Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

28. Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''PART - DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating Ventilation and Air-conditioning===
===Airborne-Precaution Risk Classification for Healthcare Zones===
South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for out-patients is common practice in South Africa.
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo convective or buoyancy effects and wind pressure. Since the drivers of Natural ventilation are inherently variable, natural ventilation has a high variability in effectiveness.

2. In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space could have a negative impact on the variability of the ventilation system’s performance by opening and closing windows and doors. For this reason it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controllable ventilation openings be designed and created in the building

3. For additional design guidance on natural ventilation design, the CIBSE Applications Manual AM10 or similar can be consulted.

4. Peak and minimum internal temperatures should be calculated or modelled thermally for a space, for summer and wintertime respectively.

5. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

6. The following design interventions should be considered for implementation, singly or in combination, in the following hierarchy where the internal design condition cannot be met:

*Reducing solar and internal heat gains
*Using thermal mass to move room temperature extremes to outside of occupancy periods.
*Change occupancy schedules seasonally to improve indoor comfort conditions. (eg. Shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
*Introducing passive cooling or heating strategies
*Increasing ventilation rates
*Providing mechanical cooling or heating

7. Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed mode ventilation shall be considered as a solution preferred over full mechanical ventilation.

8. Mixed mode ventilation is considered as an assisted type of natural ventilation. Here fans are used in combination with damper controlled ventilation openings to ensure minimum ventilation rates are achieved.

9. Where mixed mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

[[File:NV-Decision Tree1.png|alt=NV-Decision Tree|border|frameless|800x800px]] 

===Mechanical ventilation and air-conditioning===
10. Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.

11. The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====12. Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====13. Zoning of a building=====
13.1. Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:

#Fire compartmentalization
#Air-handling unit (AHU) sizing
#Duct sizing
#Occupancy schedules
#Occupancy activity levels
#Building, environmental and equipment heat loads
#Airborne contamination control
#Tenancy, functional unit or utility metering

13.2. Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====14. Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.

=====15. Ventilation rates=====

#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant

=====16. Supply-only vs balanced ventilation systems=====

#Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

=====17. Airborne contamination-control concepts=====

#Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

#The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

#The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 
#The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 
#The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²).

17.4. Where ventilation rates and fresh air proportions are described within these guidance documents they are to serve as guidance values only. It is the responsibility of the designer to ensure that the ventilation rate selected is appropriate for the specific zone’s operational conditions, occupancy, contamination rates, pressurization, leakage rates, ventilation efficiency and external ambient conditions to achieve the desired airborne contamination and bio-burden levels. Ventilation rates higher or lower than the guidance values may achieve the desired conditions.

 

====='''18. AIR HANDLING UNITS AND FANS'''=====
18.1. GENERAL

#AHUs and fans shall be protected from adverse weather and wind sources which may upset their performance or reliability.
#A detailed name plate shall be included on the air handling units with manufacturer, design air volume, fan speed, cooling capacity, filter data and heating capacity.
#The air handling unit shall include individual differential pressure gauges over each installed filter bank. The gauges shall measure the pressure differential between upstream and downstream of the filter banks. The filter designation and design filter change pressure shall be neatly and clearly marked on each gauge.
#Air-handling units functioning in an airborne contamination control system, and demanding prescribed airflow rates, shall be provided with an electronic control system including variable frequency controllers with direct fan drives to automatically maintain design airflow for all filter conditions. The fans and drives will be selected to maintain design flow rates with all filters at maximum rated pressures.
#Where a ventilation system performs a critical role, air handling units shall have separate electrical distribution boards (Essential and Non-essential). The fan will be on essential power and heater elements may be on non-essential power.
#All compartment doors on the air handling unit shall be clearly labelled
#Where systems require duplicate standby fans or air-handling units these shall be installed with backdraught dampers, sufficiently air-tight for the application (eg EN1751 Cat 3 or 4). Special design and control consideration shall be given to limiting the build-up and dwelling of contaminants in the standby unit.
#AHU’s should be placed in easily accessible plant rooms with sufficient space for maintenance. Access stairs to the plant rooms should permit a technician to easily carry replacement parts or a toolbox into the plant.AHU’s located in ceiling voids are not appropriate or conducive to good operational management.
#AHUs should be designed for a working life of 20 - 25 years
#AHUs shall be designed and positioned such that the largest components, including heating and cooling coils, can be removed and replaced.
#AHUs greater than 1m wide should have hinged access doors large enough to provide full entry. Doors shall be unlockable and openable from the inside of the unit.
#Fan and filter plenums shall be provided with internal illumination and viewing portals such that internal components can be visually inspected without stopping or opening the unit.
#AHUs shall be designed such that dry steam humidification devices can be retrofitted into the systems with minimal disruption and without compromising its performance.
#Ventilation components shall have a drainage or condensate pumping system if they can produce moisture. Drip trays shall be of a corrosion resistant material and drainage systems shall have a 1:20 fall away from the unit in all directions. The unit shall have its own drain trap which shall be sized such that it can function at the fan's full static pressure. The first 3 meters of a dedicated condensate drainage line shall be insulated to prevent condensation within the plantroom. Where a condensate drain services a negative pressure plenum, clear air gaps of 15mm or anti-backflow devices are recommended at the trap discharge into the drainage system.
#Drop stop eliminators in stainless steel frames shall be employed, if fin spacing is less than 10 fins per inch, after the cooling coils in areas with high humidity levels. This includes all coastal areas for off coil temperatures of 10° and less
#In full fresh air systems, primary filters may be situated at the fresh air intake opening of the air-handling unit only if the climate does not require anti-fog or de-icing coils.
#Cooling or heating coils will be protected by a pleated primary filter, rated in accordance with SANS 1424, as minimum.
#In recirculation air systems, primary filters will be situated after the fresh/return air mixing plenum. This arrangement will ensure that blinding filters don’t inhibit the prescribed fresh air proportion.
#The final stage of filters on units serving operating theatres must be located after the supply fan chamber to filter any debris that might come from the fan chamber. HEPA filters should be protected from this potential dust and debris.

 

=====18.2. AIR EXTRACTION SYSTEMS=====

#The design of exhaust systems shall take special consideration of the potential for re-entrainment of contaminated exhaust air into air intakes through, inter alia, openable windows. Where this potential exists, precautionary measures such as aerosol or chemical filtration of exhaust should be applied, as appropriate.
#Single ablution facilities serving private wards or staff do not require extract ventilation, provided there are windows openable to outside.
#Extract ventilation shall be provided by either ceiling extract grilles connected to an in-line ducted fan with outside discharge air grilles by means of galvanized mild steel or PVC tubular ducting or odour extraction system.
#Extract grilles may be of the PVC type with adjustable disc valves, or powder coated or anodized aluminium type with adjustable dampers.
#All multiple toilets shall be provided with ventilation systems, which will serve as an extract ventilation system.
#Single toilet facilities serving private wards for staff do not require extract ventilation, provided there are windows openable to outside
#Where it is not considered safe to enter a space without respiratory protection, the air exhausted from that space should be rendered safe through filtration, decontamination or dilution before discharge.
#The design of exhaust system from airborne precaution areas should be such that all components can be safely maintained during normal service and safely disposed of at decommissioning.
#Planning for disposal of contaminated filters should be as for all biohazardous material.
#Filtration and decontamination components shall be installed upstream of fans, monitoring and control devices.

=====18.3. ENERGY RECOVERY SYSTEMS=====
1.3.1. Where full or partial exhaust is required for ventilation systems, energy recovery technologies should be considered. Enthalpy wheels offer a high level of efficiency but introduce a risk of cross infection as the wheel is exposed to both the exhaust and supply airstreams. An enthalpy or energy recovery wheel may only be used if pressure and filtration measures are taken to ensure it is not a potential source of cross infection or re-infection. Energy recovery wheels incorporating purge sections have a markedly reduced efficiency and are not considered to provide sufficient protection against biological cross contamination. Where cross infection is a considered risk, the following conditions shall be met.

#The exhaust airstream shall be consistently maintained at a lower static pressure than that of the supply airstream.
#The exhaust air shall be filtered with aerosol filters upstream of the energy recovery device.
#Levels of filtration, redundancy and safety shall meet the requirements of the biological pathogenicity class in consideration.

=====19. '''FILTRATION'''=====

#With the exception of the few specialist areas with aero-biological requirements, the primary purpose of filtration is to protect ventilated spaces and ventilation equipment from dust build-up.
#When designing filtration systems serving spaces with a high airborne cross contamination risk, consideration should be given to the safety of maintenance staff that may be required to handle contaminated filters. Where any safety risk is present, contaminated filters should be installed in safe-change or decontaminatable housings.
#All ventilation filter banks should be installed with a means of visually checking the filter pressure across them in Pascals (Pa)
#Filters are classified as being General Fine or Aerosol filters and are to be specified in accordance with the SANS 1424, EN779 or EN1822.
#General filters are selected to remove particles large enough to block cooling and heater fins and settle out of the airstream into the air distribution system. General filters are graded in terms of their “synthetic dust weight arrestance”. General filter grading ranges from G1 to G4. G3 and G4 filters are appropriate for primary air intake and tempered air supply respectively. General filters are not appropriate for combating airborne cross-contamination control.
#Fine filters are selected to keep a ventilated space visibly clean and for the protection of HEPA filters. Fine filters are graded in terms of their “Dust Spot Efficiency” from M5 to F9. F9 filters are capable of arresting particles with the approximate size of some bacteria and can be used for low level cleanrooms (ISO 14644-1 Class 8).
#Aerosol filters are selected for their efficiency in arresting sub-micron particles. They are graded in accordance with their “Most Penetrating Particle Size” (MPPS). Aerosol filters are subdivided into three categories: Efficient Particulate Air (EPA) and High Efficiency Particulate Air (HEPA) and Ultra high Particulate Air (ULPA) Filters in accordance with the EN1822:2009. The table below describes the classification of aerosol filters by integral and local values as defined in the EN1822. SULPA filters are not discussed within this document.

{| class="wikitable"
|+{{Anchor|Table_Filter_Classification}}'''Filtration Classification'''
| rowspan="2" |'''Group'''
| rowspan="2" |'''Filter Class'''

'''EN1822'''
|'''Integral Value'''
|'''Local Value'''
|-
|'''Efficiency %'''
|'''Efficiency %'''
|-
| rowspan="3" |'''EPA'''
|'''E10'''
|85%
|<nowiki>-</nowiki>
|-
|'''E11'''
|95%
|<nowiki>-</nowiki>
|-
|'''E12'''
|99.5%
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''HEPA'''
|'''H13'''
|99.95%
|99.75%
|-
|'''H14'''
|99.995%
|99.975%
|-
| rowspan="3" |'''ULPA'''
|'''U15'''
|99.9995%
|99.9975%
|-
|'''U16'''
|99.99995%
|99.99975%
|-
|'''U17'''
|99.999995%
|99.999975%
|}
8. HEPA filter installations shall include both an upstream challenge aerosol injection port and a downstream scan port to facilitate filter challenge testing. ULPA filter installations shall be designed such that an agreed upon test method can be accomplished.

9. All filters used for airborne precaution rooms, theatres or other areas with a high airborne contamination risk shall be selected with a construction suitable for incineration. These filters shall not contain PVC.

10. The installation and testing of HEPA filters shall only be conducted by suitably qualified technicians.

11. HEPA filters shall be specified to be compliant with the requirements of EN1822. Each HEPA filter is to be supplied with an individual factory test certificate displaying that filter's serial number, MPPS rating and DOP arrestance rating.

12. Type-test certificates are only acceptable for EPA and not HEPA filters.
 

=====20. '''HEAT REJECTION EQUIPMENT.'''=====
20.1. The location of heat rejection equipment shall be planned such that it does not adversely affect the performance, maintenance or reliability of any related or unrelated equipment, or pose an avoidable health risk.

20.2. The use of evaporative cooling towers shall only be considered where:

#Space, system capacity or efficiency demands their use.
#An effective plan for the [[Legionella Control|control of legionella]] must be developed and implemented.

 

=====21. '''AIR DISTRIBUTION SYSTEMS'''=====

#Discharge from extraction systems shall be located such that contaminated air does not get drawn into any system's air intake of get re-entrained though openable windows.
#The use of internally insulated ducting is not appropriate as internal linings will perish and slough off with aging. Particles from duct linings contaminate final filters and ducting components.
#Flexible ductwork is unsuitable for air distribution in healthcare applications. It should only be used for the final connection to an air terminal and then kept to less than 1.0m. Bends in flexible ductwork should be avoided.
#The use of dampers to throttle a deliberate oversupply of airflow should be avoided. Balance by design is preferable although this will not necessarily reduce the total fan pressure. Use of adjustable blade dampers should be kept to a minimum as these items may drift, can be tampered with and increase the complexity of commissioning. The use of constant volume dampers may improve stability of volume critical systems but may also mask inefficient design and be the source of increased system noise.
#Cleaning and access doors are to be installed in all air distribution ductwork to facilitate:

*Cleaning
*Inspection
*Measurement
*Maintenance

21.6. Ductwork installations shall be designed, built, installed and commissioned in accordance with SANS 1238: Air-conditioning ductwork and SANS 10173: The installation, testing and balancing of air-conditioning ductwork
 

=====22. '''ELECTRONIC CONTROLS'''=====

#Location of sensors in ventilation systems should ensure that the temperature and humidity measurement for monitoring control is representative of the occupied area
#The humidifier control will include humidity monitoring of the mixed airstream downstream of the humidifier lance and shall prevent this airstream from approaching dew point.
#The use of variable speed drives (VSD) can save energy in systems operating under varying motor loads. Reducing the fan speed when filters are new or clean can result in considerable energy savings over the life of a system. Reliability of smaller sized VSDs is a potential drawback, and for this reason VSDs must be selected and sized for high service life. VSDs should also be installed such they can be bypassed and the system can be run in manual control while failed VSDs are replaced or repaired. When designing with variable speed drives, cognisance should be taken of a motor’s minimum cooling requirements and the maximum restart rate. Caution should be exercised where variable speed drives are used in conjunction with constant volume dampers or volume flow controllers. This combination could drive up total system pressure where duct total pressure as opposed to velocity pressure is used as control feedback. Additional requirements for the selection of drives for variable air volume (VAV) fans is described in SAN204:2011
#Plant control systems should incorporate start-up and shut-down sequencing logic to prevent flow reversals and overheating.
#Set-back controls should be considered for spaces that have intermittent occupancy. This feature should be used with caution in specialist areas as poorly considered set-back conditions could compromise containment or contamination control.
#Where more than one ventilation system serves a department, system interlocks may be required to prevent unwanted airflow reversals during system shutdown or failure.
#Operational status indicators should be displayed locally in areas served by ventilation systems.
#"Low Air Flow" and "Plant Failure" alarms should also be installed in a location which can be manned by relevant and trained staff.
#Electronic control systems should be developed using recognised open protocols and standards such as BACnet DeviceNet, LonWorks, Modbus, SOAP and XML.

=====23. '''SPECIALIST VENTILATION SYSTEMS'''=====
23.1. The following areas will require specialist ventilation systems:
 
'''Table''' '''3 Specialist Ventilation Systems'''
{| class="wikitable"
|'''Department Name'''
|'''Ventilation system type'''
|-
|Operating departments
|Clean and Ultra clean ventilation systems: ISO8 to ISO5 & UDAF
|-
|Obstetrics
|Clean ventilation systems ISO8
|-
|High care, Critical Care and Intensive Care
|Fine filtered ventilation or Clean ventilation systems: Unclassified - ISO8
|-
|Isolation units
|Negative pressure ventilation, no recirculation
|-
|Pathology labs
|Biosafety ventilation: (BSL2 – BSL4)
|-
|IVF Labs
|Clean ventilation systems: VOC Filtration
|-
|Burns units
|Clean ventilation systems/ Negative pressure ventilation/ RH control
|-
|Neonatal Units
|Dedicated ventilation systems/ RH control
|-
|Mortuary unit
|Cold Rooms/ Extraction systems/ Odour Control
|}
23.2. Broad requirements for these systems are in this document. The engineering team shall consult each department’s specific design guidance document for detailed requirements.
 

=====23.3. '''AIRBORNE PRECAUTION ROOMS (INCLUDING TB)'''=====

#Where specific diseases are considered in the design of an airborne precaution room, the US CDC's "Select Agent List" may be consulted for design guidance until a South African list is compiled.
#Airborne precaution rooms shall be ventilated with a minimum of 12AC/h of fresh air or uncontaminated air. High risk areas such as sputum booths and airborne diseases wards shall have a nominal ventilation rate of 80 ℓ/s per person..
#Medium Risk areas such as congregate spaces such as waiting areas shall have a nominal ventilation rate of 60ℓ/s per person.
#Mechanical ventilation may be employed to achieve the minimum ventilation rates. It should be noted that very high ventilation rates can be achieved by employing a well-considered natural ventilation design. Consideration may also be given to mixed mode ventilation systems, which combine mechanical and passive ventilation and temperature control. An open window policy may therefore be adopted, with careful consideration of all the associated cross infection risks and management challenges.
#Airborne precaution rooms shall be designed so as to provide thermal comfort. Where occupants have freedom in location and dress code, an adaptive thermal comfort model should be adopted. Heating, cooling and energy recovery devices shall pose no risk of harbouring pathogens or increasing the cross infection risk.
#Air from the airborne precaution rooms shall not flow into adjacent, uncontaminated rooms or adjacent airborne precaution rooms. Air shall not flow from a room with a higher airborne infection risk category to a room with a lower risk category.
#Ventilation ducting and pipe work shall not form a conduit by which pathogens can transfer from one zone to another whether the ventilation system is running or not. Filtration devices and anti-backflow devices may be employed provided these do not pose a risk of infection to maintenance staff.
#Filtration requirements for supply and exhaust air should follow the bio-containment requirements of that select agent being contained.
#The location of supply and air terminals should be such that the airflow patterns generated within the room serve to suppress and remove airborne particles.
#For general waiting areas or where the pathogens are known and unlikely to pose an environmental risk, exhaust air filtration may not be required provided exhausted air is directed 3m away from open-able windows and air intakes and there is no risk of re-entrainment of this air. See section 18.2.
#Commissioning and validation shall be well planned, diligently executed, fully documented and approved by suitably experienced professionals. It is advisable to have the validation process conducted or approved by a party independent of the designer and installer.
#Numerical or physical modelling may be of value in the design and validation process.

 

=====23.4. '''OPERATING THEATRE VENTILATION DESIGN'''=====
23.4.1. GENERAL REQUIREMENTS

#Constant volume systems shall be employed to maintain the correct pressure with respect to any adjoining rooms. The contamination control concept shall be developed in accordance with ISO14644-4
#Temperature range shall generally be 18°C to 24°C with a minimum relative humidity of 45% unless otherwise specified
#A pressure differential of 10-15Pa is to be maintained between the theatre and adjacent rooms when all doors are closed.
#Theatres may be maintained at a room pressure positive or negative to the adjacent rooms depending on the contamination control requirements.
#A theatre’s room pressure shall always be positive relative to technical spaces.
#Negative pressure theatres should not employ recirculation of room air.
#Fresh air requirements are 5-7 Air Changes per hour to satisfy the occupancy requirements
#Additional fresh air may be required for pressurisation and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurisation at the greatest possible energy efficiency.
#Separate temperature controls in each theatre are to be provided.
#No manual on and off switching of air handling plant to be done from within the theatres.
#Automatic motion sensors / thermal sensors to ensure that the units are switched on when there is a presence in the theatre. Theatre ventilation switching may be linked to the theatre unit’s lights.
#Automatic switching of ventilation system to incorporate run-on timers to prevent overheating and accidental shutdown.
#An additional override to be used to switch the units on when the temperature in the theatre exceeds 25°C for the protection of stored medicine
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums.
#These validation tests shall be performed in accordance with SANS 14644Parts 1, 2 and 3 at the recommended intervals (SANS 14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#No internal ducting insulation is permitted.
#In multi theatre suites it is advisable to have dedicated AHUs per theatre. [[Building Engineering Services#%20msocom%201|[TR1]]]

23.4.2. UNIDIRECTIONAL AIRFLOW OR ULTRACLEAN THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 5 under protected zones (UDAF and Setup area) and ISO 14644-1 Class 6 in background and ancillary areas. These conditions are to be achieved under operational conditions.
#Temperature range shall generally be 18°C to 24°C and relative humidity 45% to 60% unless otherwise specified
#Ultra-clean theatre ventilation shall not be completely shut down when unoccupied unless required for maintenance interventions. Ventilation systems serving UDAF plenums shall instead switch to a minimum velocity set-back mode to prevent contaminants settling underneath the UDAF screens.
#Delivery of the conditioned air shall be by downward movement from the ceiling to four low level exhaust outlets located near the corners.
#All ductwork between HEPA filter housings and air terminals shall be high pressure rated and constructed of galvanised sheet metal. In the final connection to the terminal, where alignment necessitates, a maximum of 300mm of thermally insulated, high pressure flexible ducting may be used.
#The Air Conditioning system is to be complete with G4 primary, F9 secondary and H13 HEPA Filters.
#The ventilation systems shall be designed with a mean air velocity of between 0.35 & 0.45 m/sec measured below the UDAF screen and at the working height.
#Refer to ISO14644-4 for guideline ventilation rates for balance of areas.
#The mean velocities below the UDAF screen and at the working height shall not differ by more than ±10%
#A standard size of the UDAF screen is 2400 x 2400mm. The required size could vary dependent on the layout and function of the operating theatre.
#The protected zone below the UDAF plenum shall be clearly demarcated on the floor

23.4.3 CLEAN OR MAJOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 6 in all areas. These conditions are to be achieved under operational conditions.
#The ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#The conditioned air is to be introduced into the theatre via suitable diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#Additional fresh air may be required for pressurization and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurization at the greatest possible energy efficiency.
#These validation tests shall be performed in accordance with SANS 14644 Parts 1, 2 and 3 at the recommended intervals (ISO14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.

23.4.4. MINOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 8 in all areas. These conditions are to be achieved under operational conditions.
#For recirculation systems the ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#For single pass systems the ventilation system is to include G4 Primary and F9 Secondary filters.
#The conditioned air is to be introduced into the theatre via suitably sized diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums. 

====='''VALIDATION OF SPECIALIST VENTILATION SYSTEMS'''=====

#Validation testing shall be completed in accordance with national standards for standardized tests (eg ISO14644 and ISO 14698 for cleanrooms) and shall be completed against mutually agreed protocols for non-standard tests.
#It essential that the validation testing of a ventilation system’s contamination control performance parameters is conducted against operational, and not only "at-rest", conditions. Validation against "as-built" conditions offers little insight into the ultimate performance of the system.
#Pre-Commissioning Checks shall cover the following aspects prior to the commencement of formal commissioning:
##Check whether the Design Specification satisfactorily addresses the demands of the User Requirement Specification.
##Check whether the ventilation systems have been provided and installed in accordance with the design specifications and drawings
##Check that the buildings either housing or served by the ventilation equipment is complete and finished such that testing can commence safely and effectively.
##Check that all AHUs, chillers, heat rejection equipment and filters are sufficiently accessible for inspection and maintenance.
##All components are connected and are functional
##Door gaps and openings are installed and sized as specified in specialised zones
##Airflow control devices are installed in the correct locations and in the correct orientation
##Duct and filter tests ports are installed and sealed satisfactorily
##Safety and control interlocks are established
##Fan and drive guards are in place
##Safety and warning signs are in place
##All major system components or sub-systems are clearly labelled with functional or controls identification in a neat and durable fashion.
##Fluid and air pressure monitoring gauges are labelled with identification and acceptable maximum and minimum operating conditions.
##All wiring, piping and ducting colour banding is complete in accordance with SANS-1091
#CLEANLINESS CHECKS:
##AHUs shall be checked for cleanliness on internal plenums with special attention being paid to fan and discharge plenums and condensate drip trays and drain lines.
##Ducting serving “clean” areas shall be cleaned prior to installation and the ends shall be sealed until installation. Open ends of duct runs shall similarly remain sealed during construction. Spot checks for compliance during the installation process are recommended.
#Recommended Filtration Levels and Ventilation Rates for Mechanically Ventilated Areas

This table serves as a quick reference guide and will be revised as and when detailed room data sheets are developed within each department’s guidance documents.
{| class="wikitable"
|+{{Anchor|Table_Room Ventilation Requirements}}'''Room Ventilation Requirements'''
| rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation'''[[Building Engineering Services#BESftn1|[1]]]

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range'''[[Building Engineering Services#BESftn2|[2]]]'''
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|Casualty/Minor Stitch Procedure room
|X
|
|X
|
|T
|
|
|7.5
|20
|
|-
|Theatres: Maternity/Caesarean
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: General Surgery
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Gynaecology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Ophthalmology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Urology
|X
|
|X
|'''X**'''
|T
|NA
|7
|10
|20
|
|-
|Theatres: Endoscopy
|X
|
|X
|'''X**'''
|T
|NA
|7
|80
|20
|
|-
|Theatres: Plastic Surgery
|X
|
|X
|X
|T
|6
|7
|7.5
|70***
|
|-
|Theatres: Bone Surgery/Orthopaedic
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Thoracic
|X
|
|X
|X
|M
|5
|7
|80
|70
|
|-
|Theatres: Vascular???
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Neuro Surgery
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Waiting and Congregate Areas
|X
|
|
|
|
|
|
|60
|8
|18-28
|-
|Auditoriums
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Mortuary
|X
|X
|
|
|
|
|
|
|12
|22-25
|-
|Bath Room
|
|
|
|
|
|
|
|25
|10
|N/A
|-
|Dirty Utility Room
|
|
|
|
|
|
|
|40
|10
|N/A
|-
|Blood Bank
|X
|
|
|
|
|
|
|
|4
|22-25
|-
|Casualty
|X
|X
|
|
|
|
|
|7.5
|12
|22-25
|-
|CSSD
|X
|X
|
|X
|
|
|
|7.5
|20
|22-25
|-
|Dark Room
|X
|
|
|
|
|
|
|
|10
|22-25
|-
|Dining Rooms/Canteens
|X
|
|
|
|
|
|
|7.5
|10
|18-28
|-
|General Stores
|X
|
|
|
|
|
|
|
|4
|N/A
|-
|Laboratories
|X
|X
|
|
|
|
|
|
|6
|22-24[<nowiki/>[[Building Engineering Services#BESftn3|3]]]<nowiki/>
|-
|Labour/Delivery Room
|X
|
|
|
|
|
|
|
|4
|22-24
|-
|Laundry – General
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Lecture Halls
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Outpatients Departments
|X
|
|
|
|
|
|
|60
|4
|18-28
|-
|Pharmacy Dispensing
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Pharmacy Store
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Specialist Clinics- ENT
|X
|X
|
|
|
|
|
|7.5
|4
|22-26
|-
|Sterilizer Equipment
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Toilet Room
|
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Units: Treatment Room
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|-
|Units: Burns
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|-
|Units: HCU / CCU
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU Neonatal
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|-
|Wards: General
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|-
|Wards: Airborne Precaution Rooms/Isolation'''[[Building Engineering Services#BESftn4|[4]]]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|-
|Wards: Maternity
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Medical
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Paediatric
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|-
|Wards: Psychiatric
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|-
|Wards: Orthopaedic
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: Surgical
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: TB
|X
|
|
|
|
|
|
|80
|12
|20-28
|-
|Radiology: General
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|-
|Radiology: Airborne Precaution
|X
|
|X
|
|
|
|
|60
|6
|22-24
|-
|Radiology: MR/CT

Scanner
|
|
|
|
|
|
|
|60
|6
|2-24
|}
{{Anchor|BESftn1}}[[Building Engineering Services#%20ftnref1|[1]]] These rates are considered for forced ventilation systems only. Average natural ventilation rates may be higher

{{Anchor|BESftn2}}[[Building Engineering Services#%20ftnref2|[2]]] Temperature range not to be exceeded for more than 50 hours per year.

{{Anchor|BESftn3}}[[Building Engineering Services#%20ftnref1|[3]]] Specialist cleanrooms and laboratories may require lower temperatures.

{{Anchor|BESftn4}}[[Building Engineering Services#%20ftnref1|[4]]] Levels of filtration are dependent on pathogenicity. Exhaust filtration may also be required.

======Commissioning tests shall include and record, but not be limited to:======
{| class="wikitable"
|'''System'''
|'''Commissioning Test'''
|'''Special Instructions'''
|-
|'''All'''
|Standard of installation
|Test to be authorised by client's representative.
|-
| rowspan="7" |'''Air Handling Units and Fans'''
|Fan motor drive speed and rotation.
|Cognisance should be taken of motor cooling requirements
|-
|Fan motor current draw.
|<nowiki>-</nowiki>
|-
|HEPA Filter challenge testing.
|In accordance with ISO DIS 14644-3
|-
|AHU heating and cooling coil performance
|Report on-coil and off-coil air conditions for full heating and full cooling with no air bypass.
|-
|AHU leakage tests
|<nowiki>-</nowiki>
|-
|Heating and Chilled Water circuits have been charged, dosed and pressure tested
|<nowiki>-</nowiki>
|-
|Flow rates and pressures across heat exchangers, pumps and compressors
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="2" |'''Room conditions'''
|Airflow and room pressure balancing in accordance with design tolerances.
|In accordance with ISO DIS 14644-3 Acceptance criteria Normally +10-0%
|-
|Room Temperature and humidity
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''Air Distribution systems'''
|Dampers and registers shall be locked and marked after balancing
|<nowiki>-</nowiki>
|-
|Duct leakage tests for medium and high pressure ducting in accordance with SANS 10173 or DW/143 requirements, as agreed upon
|<nowiki>-</nowiki>
|-
|'''Water Distribution Systems'''
|Pressure Drops and Flow Rates
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="4" |'''Control System'''
|Control system loop and function checks
|<nowiki>-</nowiki>
|-
|Alarm Checks
|<nowiki>-</nowiki>
|-
|System Start/Stop sequencing checks
|<nowiki>-</nowiki>
|-
|System Set-Back mode checks
|Include room condition and contiguous system impacts
|}

24.7. Select validation tests shall be conducted at intervals defined by the client:
 
{| class="wikitable"
|'''Tests'''
|'''Required/ Optional'''
|'''Recommended Frequency of testing'''
|'''At-Rest or In-Operation Testing'''
|-
|'''Airflow volume tests'''
|Required
|12 months
|At-Rest
|-
|'''Airflow visualization'''

'''(Airborne precaution rooms)'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Velocity Tests'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Airflow Visualisation'''
|Required
|6 Months
|At-Rest & In-Operation
|-
|'''Room pressure tests'''
|Optional
|3 Months
|At-Rest & In-Operation
|-
|'''Airflow direction tests'''
|Required
|1 Month
|At-Rest & In-Operation
|-
|'''Discreet practice counts'''
|Required
|12 Months
|In-Operation
|-
|'''Bio-burden testing'''
|Required
|1 Month
|At-Rest
|-
|'''Filter challenge testing'''
|Optional/Recommended
|24 Months
|At-Rest
|-
|'''Room Condition recovery'''
|Required
|24 Months
|In Operation
|}
24.8. Prescribed validation reports shall include:

*References to the test protocol
*Acceptance criteria
*Test results
*Test equipment identification and calibration status
*Name and signature of tester
*Name and signature of facility representative
*Dates of test and acceptance by client

===Medical gas installations===
25. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

26. All units of a health establishment, except sub-acute and hospice facilities, where patients are accommodated and treated, must have medial gases and vacuum provided by medical grade piped services, with indexed terminal connecter points. Bottle systems may be provided in sub-acute and outpatient facilities.

27. Mobile gas services must be available for crisis situations.

28. Sub-acute facilities must have one mobile oxygen cylinder per 10 patients and one suction machine for every 10 patients.

29. The minimum services to be supplied to all Acute Care areas are described in Table 11.1. Should the data in this table be in conflict be the table presented in the individual departmental design guidance documents, those individual guidance documents take precedence.
{| class="wikitable"
|+Table 5 Minimum gas services
!'''Description'''
!
!'''Oxygen'''
!'''HP Air'''
!'''LP Air'''
!'''N2O'''
!'''VAC'''
!'''Scavenging'''
|-
|'''Major Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Minor Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Cath Lab8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|1
|
|
|1
|1
|1
|-
|'''Post Op'''
|'''Bedhead'''
'''Trunking'''
|1
|
|1
|
|1
|
|-
|'''Procedure'''
'''Room'''
|'''Theatre Panel'''
|1
|
|1
|
|2
|
|-
|'''Resuscitation Bay'''
|
|1
|
|1
|
|2
|
|-
|'''Delivery Room'''
|
|2
|
|1
|
|2
|
|-
|'''High Care Unit, Per Bed'''
|
|1
|
|1
|
|2
|
|-
|'''Intensive Care Unit Per Bed'''
|
|2
|
|2
|
|2
|
|-
|'''Casualty Per Bed'''
|
|1
|
|1
|
|1
|
|-
|'''Wards'''
|
|'''1 per'''
'''2 beds'''
|
|
|
|'''1 per'''
'''2 beds'''
|
|}
30. A gas alarm system to monitor gases, excluding scavenging, must be installed in a location that is manned 24 hours per day. A slave panel must also be installed in the intensive care unit and in the theatre complex. This alarm system must be connected to UPS.

31. All piped vacuum and oxygen systems must have mobile back-up systems with adequately trained staff to handle them. . The back-up service shall be automatically activated if the line pressure drops below the set operating pressure. All back-up services and change-over valves shall be on UPS and diesel generator supplies.

32. Medical air (low pressure) for respiratory purposes must be provided at a fixed pipeline pressure of 400 kPa. Medical air (high pressure) for driving surgical power tools must be provided at a terminal usage pressure between 70 0kPa and 1000 kPa, depending on the tools/equipment to be used. ICU and operating rooms must be provided with a back-up system for both low and high pressure service. Air compressors must be fed off standby power supply.

33. Anaesthetic gas scavenging, which is a low-pressure suction system that removes exhaled anaesthetic gases from the patient circuit must be provided. Each outlet point must have its own balancing valve to allow the system to be balanced progressively from the furthest outlet point towards the suction fan or pump.

34. The vacuum installation shall comply with SANS 7396-1. Vacuum liquid bottle traps must be installed to collect any blood/fluid etc. that may be drawn into the pipeline. One bottle trap per operating room, ICU, ward block and other patient unit, must be supplied. Where possible the vacuum trap should be located in a sluice room. Emergency suction facilities must be provided in the ICU and High Care, operating rooms, recovery room, delivery room, emergency unit and nursery, and must be available to all patient rooms. Bacteria filters must be installed in the vacuum main before the vacuum reservoir and pumps. Used filters are considered a bio-hazard and must be handled accordingly when being changed and disposed. Care must be given to the location of the exhaust discharge of vacuum plants taking into account locations of windows and other air inlet points. Vacuum pumps must be fed off standby power supply.

35. Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.

36. Gas service outlets to be identified and colour-coded with 3mm lettering.

37. Should compressed air operated autoclaves be employed, High Pressure medical air may be taken to such equipment, provided the system possesses sufficient capacity.

38. Should pendants requiring compressed air for aid of movement be employed, High Pressure Medical Air may be taken to them, provided the system possesses sufficient capacity.

39. Should Health Technology Workshops require medical gas outlets for testing and servicing of medical equipment, the required service may be taken to them, provided the system possesses sufficient capacity.

40. SANS 7396-1, as amended, specifies the requirements from design to commissioning of medical gas and vacuum systems

41. Medical gas and vacuum pipelines shall be marked in accordance with SANS 7396-1 and ISO 5359 as applicable

42. SANS 7396-2, as amended, specifies the requirements from design to commissioning of anaesthetic gas scavenging disposal systems.

43. Colour coding of anaesthetic gas scavenging disposal system shall be red magenta or in accordance with the national standard. An example of red magenta is 3050-R40B, in accordance with SS 01 91 02.(Refer to SANS 73962-2).

44. Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.

45. SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.

46. Plain ended copper tubing for low pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.

47. Laboratory gas taps and valves shall be marked as described in SANS 10140-4

===Electrical installations===

====48. Lighting in Hospitals ====
48.1. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

48.2. Within the available scope presented in the National Building Regulations, the following lighting requirements should be interpreted with the aim of maximum energy and cost efficiency. The following innovations could be adopted to achieve this aim:

#Daylight harvesting with passive building elements and active systems response.
#Adoption of task lighting, where appropriate, within the scope of present and future planned activities.
#Considered selection of lighting elements and solutions.
#Considered selection of internal colours and materials.
#Accommodation for visually impaired occupants.

48.3. Where a requirement for natural light (daylight) is stated, this may be met if the room opens onto an atrium or courtyard, or if a roof light is incorporated, provided that privacy within the room or space is maintained. In addition, daylight may be borrowed from an adjacent room by means of glazing the wall in between, provided that the adjacent room or corridor is within the same unit.

48.4. Save where otherwise provided for in the requirements, health establishments must comply with the following: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table 6 Levels of Indoor Lighting (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings)'''
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''

'''/ lux'''
|'''Max. point illuminance/ lux'''

'''(not to be exceeded)'''
|'''Unified'''

'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''

'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Common areas'''

- changing room

- chapel

- classroom

- consulting room (general)

- care room (deep plan)

- day room

- disposal (clinical, domestic waste)

- doctor’s office

- domestic services room

- drug store (ITU/HDO)

- general office

- seminar room

- seminar room

- staff change

- staff rest room

- utility room (clean)

- utility room (dirty)
 
|

100-150

100-150

300

300

300

200

200

500

100

500

300

100-150

300

100

50/200

150

200
 
|

n/a

n/a

520

520

520

350

350

850

170

850

520

n/a

520

170

n/a

260

350
 
|

22

22

19

19

19

22

22

19

19

19

19

19

19

22

22

19

22
 
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

90

80

80
 
|

Floor

Pews

Desk

Work Surface

Work Surface

Work Surface

Floor

Desk

Floor

Desk

Desk

Floor

Work Surface

Floor

Work Surface

Work Surface

Work Surface
 
|

Normal

Normal

Normal

Normal

-

-

Normal

Normal

Normal

Normal

Normal

Normal

Selective

Normal

-

Normal

N
 
|

-

-

-

>30%

-

-

-

>30%

-

>30%

>30%

-

>30%

-

-

>30%

>30%
 
|-
|'''Corridors (screened from bed bays)'''

- by day

- by night
 
|

200

5-10
 
|

350

n/a
 
|

22

22
 
|

80

80
 
|

Floor

Floor
 
|

S

Normal
 
|

>30%

>30%
 
|-
|'''Circulation/communal areas'''

- corridors (general)

- day room

- entrance canopy

- entrance lobby

- hairdressing salon

- hospital street

- library

- lift car

- lift lobby

- loading bay

- reception area

- relatives overnight

- rest area

- shop/kiosk

- storage (general)

- toilets
|

200

200

n/a

n/a

300

200

300

150

200(min)

100

300

150

150

300

200

200
|

350

350

n/a

n/a

520

350

520

260

n/a

170

520

260

260

520

350

n/a
|

19

-

-

22

-

19

19

-

19

22

19

-

19

-

22

22
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80
|

Floor

Floor

Road surface

Floor

Chair

Floor

Desk

Floor

Floor

Platform or floor

Floor

Work Surface

Floor

Counter

Floor

Floor
|

Normal

S

Selective

Selective

Normal

N/EM

Normal

Sp

Selective

Normal

Normal

Normal

Normal

Normal

Normal

Normal
|

>30%

>30%

>30%

>30%

-

>30%

-

-

>30%

-

>30%

-

-

-

-

-
|-
|'''Restaurant/catering/breakout areas'''

- beverage bay

- counter

- general

- servery

- tables

- washing up
 
|

100

300

50

300

50/200

|

170

520

100

520

n/a

520
 
|

-

22

-

22

-

22
 
|

80

80

80

80

80

80
|

Floor

Counter

Floor

Counter

Tables

Sink
 
|

Normal

Normal

S

Normal

Normal

Normal
 
|

>30%

-

>30%

-

-

>30%
 
|-
|'''Wards and bedded areas'''

- children’s play area

- circulation space

- circulation space (night)

- examination/treatment

|

300

170

10

1000(local)

|

520

170

10

n/a

|

22

19

-

-

|

80

80

80

90

|

Desk

Floor

Floor

Bed level (usually provided by examination lamp
|

N/EM

Normal

Normal

Normal

|

>30%

>30%

>30%

>90%

|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Nursing'''

- general nursing care/examination

- night light

- nurses’ station (day)

- nurses’ station (night)

- observation/night watch

- observation/night

- mental illness care wards

- patient reading (adult)

- reading lights

- ward corridors (day)

- ward corridors (night)

|

300

5

300

30/200

20

1 to 5

200

300

300

200

50

|

520

10

520

250

40

n/a

350

520

520

350

75

|

19

-

19

22

-

-

19

19

19

19

19

|

80

80

80

80

80

80

80

80

80

80

80

|

Bed

Work Surface

Desk

Work Surface

Bed head

Bed head

Floor

Bed head

Patient activity area

Floor

Floor (50% uniformity required)
 
|

Selective

Normal

Variable

Normal

Normal

N/Sp

Normal

Normal

Selective

Normal

Normal

|

>30%

>90%

>30%

>90%

-

>30%

>30%

>30%

>30%

>90%

>30%

|-
|'''Orthopedic'''

- pacemaker

- treatment (general)

- venesection
 
|

500

300

300
 
|

850

520

520
 
|

19

19

19
 
|

80

80

80
 
|

Work Surface

Work Surface

Chair
 
|

Variable

Normal

Normal
 
|

>30%

>30%

>30%
 
|-
|'''Critical care'''

- intensive care (night)

- observation/night watch

- high dependency unit (HDU)

- intensive care unit (ICU)

- bed head (day)

- night light

- simple observation/examination

- examination

 
|

5(max)

20

100

100

30 to 50

5 to 10

300

1000 (local)

 
|

n/a

40

170

170

n/a

10

520

n/a

 
|

-

-

19

19

22

-

19

-

 
|

80

80

80

80

80

80

80

90

 
|

Circulation

Bed head

Circulation/general

Circulation/general

Bed head

Bed head

Bed

Bed level(to be provided by examination lamp)

|

N/Sp

N/Sp

Normal

Normal

Normal

Normal

Selective

Normal

 
|

>30%

>30%

>90%

>90%

>90%

>90%

>90%

>90%

 
|-
|'''Coronary care'''

- bed head (day)

- observation/night watch

- simple observation/examination

- examination

- staff base (day)

- staff base (night)
 
|

30 to 50

5 to 10

300

1000 (local)

300

30/200
 
|

n/a

n/a

520

n/a

520

250
 
|

19

-

19

-

19

19
 
|

80

80

80

90

80

80
 
|

Bed head

Bed head

Bed

Bed level (to be provided by examination lamp)

Desk

Desk
 
|

Normal

Normal

Selective

Normal

Selective

Variable
 
|

>90%

>90%

>90%

>90%

>90%

>90%
 
|-
|'''Nurse’s station/staff base'''

- day

- night

- interview
 
|

300

30/200

300
 
|

520

250

520
 
|

19

19

19
 
|

80

80

80
 
|

Desk

Desk

Desk
 
|

Selective

Variable

Normal
 
|

>90%

>90%

>30%
 
|-
|'''Operating theatres'''

- anesthesia (examination)

- anesthesia room (general)

- angiography room

- endoscopy

- operating room general

- operating table/cavity

- porter’s area

- post anaesthesia recovery

- preparation

- scrub up

- transfers

- utility rooms
 
|1000 (local)

500

500

300

300

1000

10000 to 100000

300

500

500

500

300

100 to 150
|

n/a

850

850

520

1500

n/a

520

850

860

860

520

n/a
|

-

19

19

19

19

-

19

19

19

19

19

19
|

80

80

80

80

90

90

80

90

801

80

80

80
|

Trolley head

Work Surface

Work Surface

Work Surface

Work Surface

Work Surface

Trolley/bed

Work Surface

Bench

Sink top

Work Surface

Floor
|

Normal

Selective

Variable

Variable

Variable

Variable

N/A

Selective

Normal

Normal

Normal

Normal
|

>90%

>90%

>90%

>30%

>90%

>90%

>90%

>90%

>30%

>30%

>30%

-
|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Accident and emergency'''

- Admissions. reception

- supplies stores

- minor treatment area

- minor operations

- couch (general area)

- couch (local)

- general examination areas

- procedure room

- resuscitation room
 
|

300

300

500

15000/30000

750

500

500

30000/60000

500
 
|

520

520

850

N/A

1000

850

850

N/A

860
 
|

22

22

19

-

19

19

19

-

19
 
|

80

80

80

90

90

80

80

90

80
|

Desk

Work Surface

Work Surface

Adjustable to suit treatment area

Over couch area

Couch level

Couch level

Task illumination provided by minor treatment lamp

Work Surface
 
|

Normal

Normal

Normal

Normal

Variable

Variable

Variable

Normal

Normal
 
|

>30%

>90%

>30%

>30%

>90%

>90%

>90%

>90%

>30%
 
|-
|'''Audiology'''

- audio testing

- consulting room

- ear examination

- vestibular testing (labyrinth)

|

300

300

1000 (local)

100

|

520

520

n/a

170

|

19

19

-

19

|

80

80

90

80

|

Work Surface

Work Surface

(examination lamp)

Couch head and instruments
 
|

Variable

Variable

-

Normal
 
|

>30%

>30%

-

>30%
 
|-
|'''Dentistry'''

- laboratories

- reception/administration areas

- surgeries/theatres

- treatment rooms

- white teeth matching

|

500

300

8000 to 20000

500

5000

|

850

520

n/a

850

n/a

|

19

19

-

19

-

|

80

80

90

90

90

|

Bench

Work Surface

Mouth

Bench work surface

Work Surface

(TCP ≤ 6000 K)
 
|

Normal

Selective

Variable

Normal

Normal

|

>30%

>30%

>90%

>30%

>30%

|-
|'''Diagnostics support'''

- aseptic laboratory

- blood bank

- colour inspection laboratory

- hot and cold rooms

- inspection

- laboratories

- laboratory (with computers)

- pathology laboratory

- relatives’ waiting room

- seminar room

- viewing/bier room
 
|

300

300

1000 (local)

200

500 (local)

500

300

500

300

300

30 to 150
 
|

520

520

n/a

350

n/a

850

520

850

520

520

n/a
 
|

19

19

-

19

-

19

19

19

19

19

19
 
|

80

80

90

80

80

80

80

80

80

80

80
 
|

Bench

Work Surface

Bench

(TCP ≤ 6500 K)

Work Surface

Bench

Bench/desk

Work Surface

Bench

Work Surface

Work Surface

Bier
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Variable

Normal

Variable
 
|

>30%

>90%

>90%

>30%

50-90%

50-90%

50-90%

50-90%

>30%

>30%

>30%
 
|-
|'''Women’s services (maternity)'''

- applying sutures

- circulation space (day)

- delivery

- day

- night

- neonatal

|

1000 (local)

100

500

50 to 100

5

1000 (local)

|

n/a

170

850

n/a

20

n/a

|

-

19

19

19

-

-

|

90

80

80

80

80

80

|

Couch, chair or bed (usually provided by examination lamp)

Floor

Work Surface

Cot

Cot

Cot

|

Normal

Normal

Selective

Normal

Normal

Normal
 
|

>90%

>30%

>90%

>90%

>90%

>90%

|-
|'''Mother and baby rooms'''

- circulation space (day)

- day

- night

- nurseries (day)

- nurseries (night)

- milk kitchen

- special care baby unit

- teaching areas
 
|

100

50 to 100

5

100

5

300

1000 (local)

300
 
|

170

n/a

20

170

20

520

n/a

520
 
|

22

19

-

19

-

22

19

19
 
|

80

80

80

80

80

80

80

80
 
|

Floor

Cot

Cot

Floor

Floor

Bench

Cot

Bench/Work Surface
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>30%

>90%

>90%

>30%

>30%

>30%

>90%

-
 
|} 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''General treatment areas'''

- autopsy (dissecting) table

- autopsy rooms and mortuaries

- dermatology

- dialysis

- dispensary

- minor surgery/treatment

- plaster room

- resuscitation (general)

- resuscitation/examination

- pharmacy
 
|

5000

500

(higher values could be required)

500

500

15000/30000

500

500

15000(local)

500
 
|

8600

850

n/a

850

860

 850

850

n/a

850
 
|

-

19

19

19

19

19

19

-

19
 
|

90

90

90

80

80

90

80

90

90

80
|

Table top

Work Surface

(Local operating lamp)

Work Surface (dimmable)

Bench

Work Surface

Work Surface

Head of trolley

Work Surface
 
|

-

-

-

-

Normal

Normal

Normal

Normal

Normal

Normal
 
|

-

-

-

-

>90%

>90%

>30%

>90%

>90%

50-90%
 
|-
|'''Mortuaries and animal houses'''

- autoclave

- body store

- general

- mortuary

- operation

- post mortem

- staff change

- store room

- viewing room

- waiting room
 
|

150/200

200

300

150

500 local

500

100 to 150

150

50/100

200 (min)
 
|

n/a

350

520

260

n/a

850

n/a

260

n/a

n/a
 
|

19

19

19

19

-

19

19

19

19

19
 
|

80

80

80

80

90

90

80

80

80

80
|

Work Surface

Work Surface

Work Surface

Bier room

Bench

Work Surface/table

Floor

Work Surface

Work Surface

Floor
 
|

Normal

Normal

Special

Variable

Normal

Normal

Normal

Normal

Variable

Selective
 
|

>30%

>30%

-

>30%

>30%

>30%

>30%

-

>30%

>30%
 
|-
|'''Engineering services'''

- ducts

- plant room

- roadways

- workshop
 
|

20 to 50

300

7

300/500
 
|

n/a

520

12

n/a
 
|

-

22

-

22
 
|

80

80

80

80
|

Floor

Floor

Road surface

Bench
 
|

Selective

Normal

-

Normal
 
|

-

>90%

-

>30%
 
|-
|'''Facilities support services'''

- laundry

- linen store (Linen Department)

- pack and dispatch

- pressing

- sewing room

- wash and dry
 
|

300

100

300

300

500 (local)

300
|

520

170

520

520

n/a

520
 
|

19

19

19

19

19

19
 
|

80

80

80

80

80

80
 
|

Bench

Floor

Bench

Equipment

Machine

Equipment

|

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>90%

-

>90%

>90%

>90%

>90%
 
|}
48.4.1. The lighting levels quoted above relate to the relevant task area. Levels of for the task areas and surrounding areas can be reduced where it can be justified by experienced staff or engineers. Lighting levels must, regardless, comply with the requirements of the National Building Regulations.

48.4.2. Lighting levels for external areas shall comply with the following table: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table''' '''7 Levels of Indoor Lighting'''
{| class="wikitable"
|Area
|Maintained average illuminance / lux
|Maintained minimum illuminance / lux
|Overall uniformity (not less than stated figure)
|Threshold increment
|Colour rendering (minimum)
|-
|

CCTV

- monochrome

- colour

Roads

General pedestrian areas

Information and display signs

Car Park

Vehicle drop-off points

Steps or stairways

General area lighting

Hazardous open storage areas
 
|

0

-

15

20

30

10

15

20

100(vertical)

15

10

100

20

50
 
|

5

15

6

8

12

4

6

12

6

5

40

12

20
|

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4
 
|

≥10%

≥10%

 
|

≥60%

≥60%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%
 
|}

49. Classification of Safety Services necessary for Medical Locations from SANS 10142-1
{| class="wikitable"
|'''Class'''
|'''Response Time'''
|-
|Class 0 (No break)
|Automatic supply available at no break

UPS backed up by Generator Required.
|-
|Class 0,15 (Very short break)
|Automatic supply available within 0,15 s

UPS backed up by Generator Required.
|-
|Class 0,5 (Short break)
|Automatic supply available within 0,5 s

UPS backed up by Generator Required.
|-
|Class 15 (Medium break)
|Automatic supply available within 15 s

Generator Required
|-
|Class > 15 (Long break)
|Automatic supply available in more than 15 s

Generator Required
|}
Note Safety Services in Medical locations are synonymous with Emergency Services.

50. '''Medical Location Classification'''

50.1. Group 0 location: where no applied part is intended to be used.

50.2. Group 1 location: Medical Location where applied parts are intended to be used.

#Externally, or
#To any part of the body, but not to the heart.

50.3. Group 2 location: Medical Location where applied parts are intended to be used in applications such as in an intracardiac procedure, in an operation (in an operating theatre) and in vital treatment where discontinuity (failure) of supply can cause danger to life.

Note: An intracardiac procedure is a procedure whereby an electrical conductor is placed within the cardiac zone of a patient or is likely to come into contact with the heart, such conductor being accessible outside the patient’s body. In this context, an electrical conductor includes insulated wires such as cardiac pacing electrodes or intracardiac ECG electrodes, or insulated tubes filled with conducting fluids.

50.4. For the allocation of medical location group and classification of safety service classes for medical locations see Table below as supplied in SANS 10142-1.
 
{| class="wikitable"
|
|
'''Medical Location'''
| colspan="3" |
'''Medical location group'''
| colspan="2" |
'''Safety service class'''
|-
|
|
|'''0'''
|'''1'''
|'''2'''
|'''≥ 0,5'''
|'''0,5'''

'''≤ 15'''
|-
|

1
|

Massage room
|

X
|

X
|
|
|

X
|-
|

2
|

Bedrooms
|

|

X
|
|
|

X
|-
|

3
|

Delivery room
|
|

X
|
|

X
|

X
|-
|

4
|

ECG, EEG, EHG room
|
|

X
|
|
|

X
|-
|

5
|

Endoscopic room
|
|

Xa
|
|
|

Xa
|-
|

6
|

Examination or treatment room
|
|

X
|
|
|

X
|-
|

7
|

Urology room
|
|

Xa
|
|
|

Xa
|-
|

8
|Radiology diagnostic and radio therapy room, other than mentioned under 21
|
|

X
|
|
|

X
|-
|

9
|

Hydrotherapy room
|
|

X
|
|
|

X
|-
|

10
|

Physiotherapy room
|
|

X
|
|
|

X
|-
|

11
|

Anaesthetic room
|
|
|

X
|

X
|

X
|-
|

12
|

Operating theatre
|
|
|

X
|

X
|

X
|-
|

13
|

Operating preparation room
|
|

X
|

X
|

X
|

X
|-
|

14
|

Operating plaster room
|
|

X
|

X
|

X
|

X
|-
|

15
|

Operating recovery room
|
|

X
|

X
|

X
|

X
|-
|

16
|

Heart catheterization room
|
|
|

X
|

X
|

X
|-
|

17
|

Intensive care room
|
|
|

X
|

X
|

X
|-
|

18
|

Angiographic examination room
|
|
|

X
|

X
|

X
|-
|

19
|

Haemodialysis room
|
|
|

X
|

|

X
|-
|

20
|

Magnetic resonance imaging (MRI)
|
|

X
|
|
|

X
|-
|

21
|

Nuclear medicine
|
|

X
|
|
|

X
|-
|

22
|

Premature baby room
|
|
|

X
|

X
|

X
|-
| colspan="3" |
a The room is not an operating theatre.
|
|
|
|
|}
50.5. In addition to the tables 0 and 50.4 above, generator supply is also required for:

#Night light in wards and ward corridors;
#All switched socket outlets used for patient life support anywhere in the facility;
#At least one patient lift or lift that can accommodate a bed for every 200 patients;
#Medical air compressor, vacuum pumps and gas alarm systems;
#Supply air fans serving theatres and uni-directional airflow systems;
#Isolation ward exhaust air fans.
#Mortuary Fridge Cabinets
#Nurse call System
#Fire detection system

51. General Requirements

51.1. Power supply to switched socket outlets in high care units, intensive care units and operating theatre units and recovery rooms must be on an earth monitoring system. Double pole isolators must be used for supply points in these areas and the power supply to these shall be fed from an isolation transformer.

51.2. Medical Location Group 1:

Switch Socket outlets in Medical Location 1 Shall have final Circuits for socket -outlets up to 16Amp shall be protected by earth leakage protection devices with a rated earth leakage tripping current ( rated residual current) not exceeding 30 Ma.

51.3. Medical Location Group 2:

Switch Socket outlets in Medical Location 2 the Medical Isolation Transformer (Medical IT) system shall be used for circuits that supply medical electrical equipment and systems intended for life support or surgical applications and other electrical Equipment located in the patient environment. In the case of each group 2 medical location, at least one separate medical IT system is necessary.

51.4. The Medical Isolation Transformer (MIT) shall be equipped with:

51.4.1. A 5 or 8 kVA Isolation Transformer complete with a 220 V Primary and 220 V / 110 V Secondary Winding with a centre Point Floating but bonded to the Earth monitor. The Secondary Side of the transformer shall provide 220 Volts between Line 1 and Line 2 (Note no Neutral with an Isolation Transformer) Line 1 and Line 2 will feed the Distribution Board for that particular Medical Group location, i.e. (Theatre No 1) or (ICU Bed 1-6) This local DB will then have a number of double pole Circuit Breakers feeding out to the outgoing Circuits feeding the Socket Outlets in the Medical Location 2 Area. Note that at least two circuits are required to each ICU Bed or Theatre Panel, and Theatre Pendant. Also note that all Switch Socket Outlets in a Medical Location 2 Area have to be double Pole Switched via a double pole Isolator (Provided two circuits provided) or a double pole Circuit Breaker.

51.4.2. The Transformer shall be installed either in a cabinet/DB or enclosure, to prevent unintentional contact with live parts. The Transformer / DB should be located close to the Group 2 Medical Location but consideration should be given to providing the DB outside the red line area of both the Theatres and ICU Areas, so maintenance can be carried out without the need to be gowned up. Line 1 & 2 and Earth should all be Insulated wires with the colour of Line 1 & 2 being different from red and black suggest Brown and Blue wire is used for Line 1 & 2 and green for Earth (Note this Earth wire should be connected to an insulated Earth bar dedicated to that particular Group two location and bonded to the centre point of the secondary winding.) Note a Separate Dirty earth (Equipotential bonding) should also be provided to the metal work of the Plugs, Theatre Panel, and Pendant this earth shall be connected to the Main Building Earth.

51.4.2. An insulation -monitoring device that:

#Has an internal impedance of at least 100 k Ohm;
#Has a test voltage not exceeding 25 V DC.
#Is of a current, even under fault conditions, not exceeding 1 mA DC. and
#Shall indicate, at least when the insulation resistance has decreased to 5 k Ohm.

A test device shall be provided to test this facility to ensure that the alarm (Audible and visual) operates when the insulation resistance reaches 5 k Ohm;

To test the System two male plugs should be used each with a resistor of 5 k Ohm. Plug No 1 should have a 5 k Ohm resistor bridged from the Earth Pin to the Right Hand live Pin. Plug No 2 should have a 5 k Ohm resistor bridged from the Earth Pin to the Left Hand live Pin.

51.4.4. Medical Isolation Transformer Alarm.

For each Medical IT system an audible and visual alarm shall be provided in the Theatre Area a alarm shall be provided on theatre Panel and repeated back to the main Nurse Station in Theatre Area .The Alarm shall consist of Green Light indicating Healthy, a red light indicating fault, a audible Alarm to also indicate fault and a local audible alarm mute button. The Visual signal shall revert to green and the audible alarm shall be automatically reset on the removal of the fault condition
 

Table 4 – Required for Medical Isolation Transformers (MIT) and Switch Socket Outlets (SSO)
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Office Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Laboratory Work Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Office
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Nurse Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward
|1
|1 x 16A Normal / Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point/ Bed(if required).
|
|3x 16A per bed
|
|
|
|
|-
|Ward Kitchen
|0
|2 x 16A Normal on Wall at 1200 mm over counter + 1 x 16 A next to Sink or Hydro Boil.
|
|1 x 16A supply for Fridge on generator supply
|
|
|
|
|-
|Ward Corridor
|0
|1 x 16A Normal / Every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Ward Staff Rest Room
|1
|I x 16 A on Wall for Cleaning, 1 x 16 A above counter for Electrical Appliances + 1 X 16 A next to sink for Hydro boil
|
|
|
|
|
|
|}
----[[Building Engineering Services#%20ftnref1|[1]]] Note: DPS is an abbreviation for double pole switch
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Theatre Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|-
|Theatre Post Op
|2
|
|
|
|6 x 16 A Dedicated SSO per Bed
|
|
|
|-
|Operating Theatre
|2
|
|
|
|
|8 x 16 A Dedicated SSO per Pendant
|8 x 16 A Dedicated SSO per pendant
|4 x 16 A Dedicated SSO
|-
|Cath Lab Operating Room
|2
|
|
|
|
|
|
|4 x 16 A Dedicated SSO
|-
|Cath Lab Control Room
|0
|1 x 16A Normal per Station
|1 x Red 16A Dedicated per Station
|
|
|
|
|
|-
|Cath Lab Equipment Room:

160 kva dedicated UPS Required to feed Dedicated DB and Equipment
|
|
|
|
|
|
|
|
|-
|Autoclave
|
|In autoclave plant room. 3-Phase 380V, 80A per autoclave
|
|
|
|
|
|
|-
|Instrument Washer
|
|In CSSD. Typically 3-Phase 380V, 15A per washer
|
|
|
|
|
|
|-
|Theatre Corridor
|1
|1 x 16A Normal for every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|}
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|ICU Circulation Space
|1
|1 x 16A Normal per 25m2 for cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Neo Natal ICU Cots Note: Care should be taken when sizing the Isolating Transformers to include the Heating Load
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care Nurse Station (per workstation)
|1
|1 x 16A Normal per Station
|2 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|-
|ICU and Ward Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|}
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Casualty Treatment Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point per Bed. 2 x 16A per Bed
|
|
|
|
|
|
|-
|Procedure Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning
|
|4 x 16A per Bed per two Circuits.
|
|
|
|
|-
|Casualty Ward Corridor 0
|0
|1 x 16A Normal per every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Radiology Procedure Crash Cart Position
|
|
|
|
|
|-
|Rooms Dedicated 125 Amp Supply to dedicated
|1
|1 x 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Radiology Control Room
|0
|1 x 16A Normal per Station
|1 x 16A Normal per Station
|
|
|
|
|
|-
|Maternity Delivery Rooms
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|
|
|}

{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Dialysis Treatment Beds.

Note that the Equipment can include Water Heating with high kw loading so care should be taken when sizing the Isolating Transformers
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|
|
|}
51.5. Uninterrupted Power System must be provided for operating theatre luminaries and all life support systems and computer systems where a break in electrical supply cannot be tolerated. The whole installation must conform to SANS 1474 of 1988.

51.6. Socket outlets for Dialysis units, in close proximity to water points or drains, shall be of the totally waterproof IP65 type, which also seal water-tight when the socket is removed.

51.7. Where more than one electrical transformer is used, they should preferably be located in separate structural enclosures. This is to prevent potential damage to an adjacent transformer if one is damaged.

51.8. All distribution boards fed from normal mains supply shall be painted Electric Orange, colour B26 to SABS 1091.

51.8. All distribution boards fed from standby emergency power supply shall be painted Signal Red, colour A11 to SABS 1091.

51.9. All distribution boards fed from UPS power supply shall be painted Blue colour F06 to SABS 1091.

51.10. All cable transition boxes shall be painted the appropriate colour corresponding to the source of the power supply.

51.11. All cables installed on surface mounted cable ladders shall be of the PVC/PVC/SWA/ECC/PVC type to SANS 101507 rated at 600/1000 Volt.

51.12. Electrical circuits to be engraved on base 3mm lettering indicating circuit number and DB.

51.13. Electrical Certificate of Compliance.
[[File:Picture 11.png|border|thumb|450x450px|alt=|center]]
 
===Electronic installations===
52. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

53. Nurse call system with emergency (nurse assistance) and TV control handsets (Interchangeable with LED PEAR PUSH).

The nurse system enables the patient to call a nurse for assistance from his bed or from a bath, shower and toilet. The system also enables the staff to call for assistance (EMERGENCY CALL) from any bed and treatment room etc.

#When a patient nurse call or staff emergency call is enabled the system must produce an intermittent AUDIBLE chimes or bleeper tone at the nurses’ station or/and duty room. Three different sounding tones must be produced for normal Patient call, Bathroom call and Emergency (nurse assistance) call.
#The system must also provide a VISUAL indication, at the nurse station (LED Mimic Panel and/ or Computer Monitor or LCD Display Panel), above the door to the passage of the activated unit, and at the actual activated unit (reassurance LED).
#The system must be so designed that any call may ONLY be RESET at the point of origin.
#The system must automatically activate a nurse call when the Hand Held Unit (Handset) or Pear Push unit is accidently pulled out from the Bed Head Unit.
#The Bed Head Unit must be compatible with Hand Held Unit (with TV Control), Rehab Hand Held Unit & Pear Push. (Inter-changeable)
#A Central Monitoring PC, or PC per duty station replacing Mimic Panel, must keep records of all events. (Optional)
#The system must be purpose made and aesthetically pleasing with components (call & reset units etc) manufactured from matching injection moulded ABS plastic. A system made up of push buttons etc mounted directly onto standard electrical plates will not be accepted.

54. Automatic fire detection in Hospitals

The Fire Detection System shall comply with SANS 10400 SANS 10139 & SANS 322. The Fire Detection System must be provided throughout the Facility and be a Addressable Fire Detection System, Note that Audible Fire Alarms which could panic the patients should not be provided instead Visual Strobe Lights should be provided at all Nurse stations, Reception and Security Office.

Audible alarms can be used in noisy areas such as plant rooms.

The wiring for the Automatic Fire Detection System shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area)
 55. Public Address and Evacuation in Hospital

The Public Address and Evacuation System shall comply with EN54 and provide voice message via fire retardant speakers throughout the hospital Circulation Areas, Staff Areas, Public Toilets. The wiring for the Evacuation Speakers shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area). As part of the Hospital Design the Hospital should be zoned to allow Evacuation of Individual zones in the event of a fire or other Emergency.

==Wet Services==
56. Plumbing services (Water supply and drainage) must comply as a minimum with the following Standard Specifications and Codes of Practice:

#SANS 10400: The Application of the National Building Regulations, including Part XA: Energy Use in Buildings
#SANS 10252 – Part 1 – Water Supply Installations for Buildings
#SANS 10252 – Part 2 – Drainage Installations for Buildings
#UK Department of Health Technical Memorandum 04-01: The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems: Part A: Design, Installation and Testing, and Part B: Operational Management or the equivalent SANS standard when available.

57. Where any apparent conflict between the functional requirements and the regulatory “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functional compliance.

58. Cold water storage, dedicated to the domestic water requirements of the facility, must be provided on the site. A minimum usable volume of 500 litres per bed must be provided.

59. If water storage is required for fire protection purposes (Sprinklers, Fire Hydrant supply) it must be stored separately from domestic water, unless adequate provision for the prevention of stagnation of the fire service reserve within the tank can be made.

60. Tanks must be accessible both on the outside as well as the inside, and provision for cleaning the tanks without interrupting water supply to the hospital must be made. Access manholes must be lockable, and a facility for draining the tank or individual compartments within it, must be made.

61. All openings to the tank (Overflows, vent pipes, etc) must be provided with screens.

62. Underground tanks, with their inherent risk of contamination must be avoided at all cost. If unavoidable, the tank should be constructed in a water tight bund allowing sufficient space all round for inspection and maintenance, and a sump for collecting drainage water

63. Cold water storage tanks must be located such that heat gain to the water is minimised. Cold water storage temperatures 20 C and lower will prevent the colonisation by or multiplication of Legionella

64. Site water reticulation must be designed using sound engineering principles, with adequate provision for isolating sections of the reticulation whilst keeping the remainder in operation being made.

65. Fire protection water reticulations must be kept totally separate from the domestic water reticulation

66. Water distribution may be gravity fed, or alternatively supplied via booster pumps. Pumps must be suited to handling potable water, and provision for built in redundancy must be made. Booster pumps must be supplied off standby power.

67. Hot water supply temperature to general patient care and staff areas must be controlled at 55 C, and must not exceed 60°C, except during a sanitation cycle as described hereunder.

68. Hot water generation systems must where possible use waste heat recovery from a central air conditioning system, if employed.

69. The facility for thermal disinfection of the hot water storage and circulation system must be provided in the system design. This can take the form of controlled heating of the storage vessel and circulating mains to 60°C during periods of low water and power demand. The use of shunt pumps to circulate hot water from the top level to the lowest level of the hot water tank during the sanitation cycle must be considered.

70. Hot water supply to paediatric wards, as well as to geriatric and to neonatal bathing facilities shall not exceed 42°C at the point of supply. If thermostatic mixing valves are employed to achieve this, they must be fitted with a safety feature such that the water flow is cut off within 2 seconds of the cold water supply to the valve being interrupted. The valve must also be able to control the set temperature with a pressure ratio of incoming hot to cold water supply pressure of up to 10 to 1.

71. Toilet flushing systems must be provided with easily identifiable dual flush mechanisms, one being for low flush water flow, the other for standard flush water flow.

72. All sanitary fittings must be piped such that the hot water control is on the left hand side, and the cold water supply is on the right hand side when facing the fitting.

73. Branch pipes (dead legs) between water heating equipment or hot water circulating mains and sanitary fittings must be sized and located such that the maximum waiting time for hot water to emerge from the fitting does not exceed 12 seconds.

74. Mixing taps in patient care areas must be elbow action type, installed such that the tap can be opened and shut by means of simple elbow action.

75. The discharge from kitchen floor drains and other kitchen drain points such as sinks, dishwashing washing, machines, and cooking equipment wash down, likely to contain grease, must be taken via a separate discharge system to a suitable grease interceptor, installed in a position to allow easy access for removal of intercepted grease and oil.

76. The drain pipes from equipment likely to produce high temperature discharge, such as autoclaves, sterilisers and cooking equipment must be from materials able to withstand such temperatures, installed such that distortion and/or expansion can be accommodated by the system.

77. Vertical pipe runs (Drainage stacks and water supply mains) in multi storey buildings must be housed in continuous vertical service ducts with easy access from non-patient areas at each level.

78. Condensate drains from air conditioning and refrigeration systems must discharge into piped drainage systems.

79. Anti-Backflow protection devices shall be fitted to faucets with hand-held shower heads to prevent back siphoning should the supply water pressure fail.

80. In areas housing patients at unusual risk of infection, faucets should not be fitted with low-flow or aerating devices which may increase the rate of aerosolisation of infectious droplets.

 

'''81. Legionella Control'''

#A facility-wide legionella control plan shall be in place which will inform operation, maintenance and design of water systems.
#This Plan must include a Legionella risk assessment document, listing all areas where the bacteria may occur. This must address specifically air conditioning condenser water systems, domestic hot and cold water installations, irrigation water storage and distribution systems, etc.
#The Plan must refer to as-built drawings identifying positions and layouts of plant and installations liable to cause a risk of Legionella being generated
#The facility’s Maintenance Procedures must describe all measures to be taken to minimise proliferation of Legionella. This is to include procedures and frequency of sanitation/disinfection, purging of dead legs on circulating systems, sample taking and testing at specific intervals, as well as a responsibility matrix of personnel

For additional information refer to the [[Legionella Control]] article.

==Lifts==
82. Standards and Regulations Pertaining to Lifts and Lifting Operations:

#SANS 50081 - SAFETY RULES FOR THE CONSTRUCTION AND INSTALLATION OF LIFTS - PARTICULAR APPLICATIONS FOR PASSENGER AND GOODS LIFTS
#SANS 10400 –SS3 FACILITIES FOR DISABLED PERSONS: LIFTS
#SANS 10400 –TT45 FIRE PROTECTION: LIFT SHAFTS
#SANS 10400 –TT46 FIRE PROTECTION: LIFT
#SANS 10400 –TT47 FIRE PROTECTION: FIREMAN’S LIFT
#SANS 10400 –TT48 FIRE PROTECTION: STRETCHER LIFT 

83. Planning for circulation, capacity and location of lifts

#A lift traffic plan should be developed. Detailed lift traffic planning is beyond the scope of this document. A specialist advisor should be consulted to assist in the planning of lifts within the general principles of lifts services for healthcare buildings.
#General Lift Planning Principles
#The operational details of the facility must be understood for effective lift planning. These include:

*Number of visitors and visiting hours
*Number of staff, shift hours and ward round schedules
*Numbers of day and overnight patients
*Increased provisions for reduced mobility persons
*Housekeeping schedule
*Evacuation plan for reduced mobility patients.

#Whenever possible, lifts should be provided in pairs to allow for continued operation during maintenance and breakdown.

 

===='''84. TYPES OF LIFTS:'''====
84.1. PASSENGER LIFTS

#These lifts shall be able to accommodate general passenger traffic including ambulatory and semi ambulatory passengers. It shall be able to accommodate reduced mobility passengers using mobility aids and wheelchairs. Refer to SANS 50081-70, Table 1
#The entrance to a passenger lift shall not be less than 1100 mm in width.
#The depth of a passenger lift shall not be less than 1400mm deep.
#Passenger lifts shall have a mirror on the top half of the rear wall equal to the width of the lift to enable wheelchair users to back out of the lift where the lift has internal dimensions less than 1,5 m in width and 2,0 m in depth
#At least on one side wall of the car a handrail shall be installed 

84.2. BED LIFTS

#Bed lifts shall have internal dimensions of 1 800 mm wide by 2 700 mm deep to accommodate most beds with staff and medical equipment.
#The entrance to a bed lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.3. STRETCHER LIFTS

#Stretcher lifts shall have internal dimensions of 1 400 mm wide by 2 400 mm deep to accommodate most trollies or stretchers.
#The entrance to a stretcher lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.4. GOODS LIFTS

#Goods lifts are for the movement of conventional goods and items that could not reasonably use passenger lifts without causing discomfort to passengers or damage and soiling of the lift car.
#Goods lifts can be designed to accommodate passengers.

84.5. SERVICE LIFTS

#Service lifts are not designed for accommodate passengers. They are typically of the “dumb waiter” style dispatched between service hatches.

84.6. HOUSEKEEPING LIFTS

#Housekeeping lifts are similar in function to goods lifts but are intended for the movement of cleaning supplies, medical supplies and equipment, linen etc.

{| class="wikitable"
|+Hospital Guide - Passenger
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''630 kg / 8 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|1800 x 1800

2000 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''800 kg / 10 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1350 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|2000 x 1800

2200 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1600 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2300 x 1800

2450 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1250 kg / 16 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|2000 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2700 x 2000

2700 x 2000
|1450
1500

1600
|4200
4300

4400
|}
 
{| class="wikitable"
|+Hospital guide - stretcher / Bed Lifts
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 2100
|CLD

TLD
|1000 x 2100

1000 x 2100
|200 x 2600

2000 x 2600
|1450
1500

1600
|4200
4300

4400
|-
|'''1600 kg / 21 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1400 x 2400
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 2800
2500 x 2900

2400 x 2900
|1450
1500

1600
|4200
4300

4400
|-
|'''2000 kg / 26 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1500 x 2700
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 3100
2600 x 3150

2450 x 3150
|1450
1500

1600
|4200
4300

4400
|-
|'''2500 kg / 33 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1800 x 2700
|CTLD

CTLD
|1400 x 2100

1600 x 2100
|2900 x 3150

3000 x 3150
|1450
1500

1600
|4200
4300

4400
|}
 
==PART D - COMMISSIONING AND HANDOVER==
===Deliverables===
1. This section is intended to detail the commissioning deliverables required before handover of building engineering services for operation. For further detail on commissioning and handover the '''IUSS Commissioning Health''' Facilities guidance document should be referred to.

2. Project Close-out deliverables include:

#Final Works completion lists
#Financial reports and final accounts
#Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
#Approved As-Built Drawings
#Electrical Certificates of Compliance

3. '''Maintenance manuals''' shall be timeously issued and shall include:

3.1. Designer and installer contact information

3.2. System information

#System description
#Suppliers list
#Equipment List
#Equipment data sheets
#Materials of construction data sheets
#Warranty information

3.3. Operational parameters

#Start up and shut down procedures
#Special instructions
#Security and access details
#Fault finding procedures
#Alarm management and data logging

3.4. Validation and commissioning

#Approved reports and data
#Relevant test protocols
#Relevant test plans
#Installed and test equipment calibration certificates
#Commissioning certificates
#Beneficial Occupation and Handover certificates

3.5. Spare parts list

3.6. Electronic Data Backup (Read only Media)

3.7. Approved “As-Built” Drawings

#Process diagrams
#Wiring Diagrams
#Control Diagrams
#System Plans
#Training records

3.8. Training Records

3.9. Training Materials

===Commissioning of ventilation systems===
4. Commissioning of ventilation and air conditioning systems shall comprise the following:

#Confirmation of accuracy of measurements.

Measurement accuracy depends on equipment accuracy and repeatability. Factors that would impact on the accuracy of measurement include:

*Operator error and competence
*Type and quality of measuring device
*Quality and adherence to measurement protocols.

4.2. Proof of competence of commissioning technician or engineer

4.3. Commissioning method statements or protocols shall be developed, recorded and adhered to, to ensure all technicians work to the same procedures and sequences. In some instances, such as healthcare units where the ventilation system is critical to that unit’s clinical outcomes or to the safety of occupants, the client or client’s representative may request that these method statements be issued for formal approval before commencement of commissioning.

4.4. As the operational parameters of variable air volume systems are more complex that constant volume systems, the designer is to provide details of all relevant aspects of these systems such that the commissioning specialist can sufficiently develop an appropriate plan the commissioning.

4.5. Preliminary inspections should be completed before the systems are started up for commissioning. Typically these inspections should include:

*The '''state of completion''' of the building and the condition of details such as openable windows, doors and ceilings.
*'''Building cleanliness''' as it pertains to the ventilated spaces as well as the equipment plant rooms.
*Ducting and ventilation components should be inspected internally and externally for '''system cleanliness.''' Prior to fitting filters the following components should be checked for completion, correctness and cleanliness:

#Air intakes screens and mixing plenums
#Heating components
#Cooling components
#Condensate and drip trays
#In duct UVGI systems
#Humidifiers
#Fan and equipment chambers including safeties and interlocks
#Sensors and gauges
#Airflow controllers and fire damper
#Filter frames and orientation thereof
#Insulation
#Ducting and air terminals

*Electrical Equipment should be inspected for completion, correctness, labelling and cleanliness. Prior to running any electrical rotating or control equipment the following check should be completed.

#Local isolators of motors, electric heaters and control circuits including labelling.
#Electrical safety
#Motor starters and frequency drives set correctly for overload and motor restart ratings.
#Direction of rotation of motors on motor shafts
#Motor starting current and sequencing

4.6. An initial running-in period should be conducted at low load before the installation of the filters. This running period is to ensure flushing of ducting, and allow checking of the system operation. During the this period the system should be shut down and restarted to ensure that the controls, fuses and switchgear function correctly; however, repeated rapid restarts should be avoided as this can over-stress the control gear and fuses.

4.7 After the initial running-in the filters can be installed by a suitably qualified technician and the system should then be run at normal load. New filters should be installed before the final proportional balancing commences.

4.8. The proportional balancing of the airflow should be delayed until the ventilation system has been run-in under normal load for a few days to ensure stability of the system. The airflow balancing should be conducted in accordance with good engineering principles such as those described in SANS 10173, the ASHRAE Fundamentals Handbook, CIBSE Commissioning Code A or BSRIA Application Guide 3/89.1 depending on the system requirements.

4.9. For variable air volume systems, the commissioning tests should demonstrate system performance across the design diversity.

4.10. A definitive total airflow measurement should be taken in either a section of the main duct, where duct length and turbulence allow, or in the branch ducts. This value shall be recorded, compared against the design values and tolerances and reported on in the commissioning reports including the percentage of the design flow rates.

4.11. The final airflow measurements shall be taken at all air terminals (supply, return and exhaust) using airflow capture hoods where the terminal generates turbulence and these values shall be recorded, compared to design values and tolerances and reported on in commissioning reports including the percentage of the design flow rates.

4.12. Direction, drop and throw of air terminals shall be assessed by the responsible engineer to confirm the correct air distribution within ventilated spaces.

4.13. The minimum outside air portion should be demonstrated and recorded across the system’s operational diversity.

4.14. A condition of system acceptance is that the commissioning tests be witnessed before signing off. This process could involve the repetition of only a selection of the tests under the observation of an authorised witness or responsible engineer. The following aspects should be demonstrated:

*Performance of the system according to the overall design requirements within specified limits
*Repeatability of performance and measurement results

==PART E - EXAMPLES==
===Mechanical system configurations===

===='''1. HOT WATER GENERATION SYSTEM'''====

[[File:Picture 1.png|thumb|570x570px|Hot water generation system|alt=|border|center]]

===='''2. THEATRE VENTILATION SYSTEMS'''====
The following examples indicate typical system configurations schematically.

2.1 UDAF Recirculation

 
[[File:Picture 2.png|border|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic|alt=|center]]

2.2. UDAF Full Fresh Air & Exhausted

[[File:Picture 3.png|center|thumb|410x410px|NOTE: Does not indicate sensors, interlocks or control logic]]
2.3. Major Theatre: Recirculation
 
[[File:Picture 4.png|center|thumb|410x410px]]

2.4. Major Theatre: Full Fresh Air Supply only
[[File:Picture 5.png|border|center|thumb|400x400px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

2.5. Minor Theatre: Recirculation
[[File:Picture 6.png|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.6. Minor Theatre: Full Fresh Air & Exhausted
[[File:Picture 7.png|border|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.7. Minor Theatre: Full Fresh Air Supply only
[[File:Picture 8.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

===='''3. AIRBORNE PRECAUTION ROOMS AND THEATRES'''====
3.1 Energy Recovery Systems for Airborne Precaution Rooms
 
[[File:Picture 9.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]
4. Energy Recovery Systems for Airborne Precaution Theatres
[[File:Picture 10.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks and control logic]]
 
==REFERENCES==
'''Applicable Regulations and Standards:'''

National Health Act 2004''.'' (61 2003). Cape Town South Africa: Government Gazette.

''Ammended Occupational Health and Safety Act 2004.'' (181 1993) South Africa: Department of Labour.

South African Bureau of Standards, 2009. ''SANS 10142-1:2008 The wiring of premises Part 1: Low-voltage installations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 10173:2003 The installation, testing and balancing of air-conditioning ductwork.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 10252-1:2012 Water supply and drainage for buildings Part 1: Water supply installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1993. ''SANS 10252-2:1993 Water supply and drainage for buildings Part 2: Drainage installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 10313: 1999 Protection of structures against lightning.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1990. ''SANS 10400-2: 1999 Code of Practice for The Application of the National Building Regulations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-1:2005 Copper-based fittings for copper tubes Part 1: Compression fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-2:2005 Copper-based fittings for copper tubes Part 2: Capillary solder fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 1091:2012 National colour standard''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1238:2005 Air-conditioning ductwork''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1409:2008 Outlet sockets and probes for medical (gas and vacuum) services used in hospitals.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1424:2008 Filters for use in air-conditioning and general ventilation.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2011. ''SANS 1453:2011 Copper Tubes for Medical Gas and Vacuum systems.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 14644-1:1999 Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-2:2003 Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-4:2003 Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1988. ''SANS 1474: 1988 Uninterruptible Power Supplies''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2009. ''SANS 7396-1:2009 Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 7396-2:2008 Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems.'' Pretoria South Africa: SABS Standards Division.

*All local Municipal laws and regulations,
*ISO 14644-3:, Cleanrooms and associated controlled environments - Part 3: Test Methods Australasian Health Infrastructure Alliance,2006. Australasian Health Facility guidelines [online] Available at: <nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> [Accesed ...].
*ISO/DIS 5359. Anaesthetic and respiratory equipment - Low-pressure hose assemblies for use with medical gases,
*National Health Act, 2004 (Act No. 61 of 2003).
*Occupational Health and Safety Act, of 1993
*Regulations of the Local Electricity Authority,
*SANS 10114: Lighting Requirements,
*SANS 10142-1: The wiring of premises Part 1: Low-voltage installations,
*SANS 10173: The installation, testing and balancing of air-conditioning ductwork,
*SANS 10224: Non-flammable medical gas pipeline,
*SANS 10252-1: Water supply and drainage for buildings Part 1: Water supply installations for buildings,
*SANS 10252-2: Water supply and drainage for buildings Part 2: Drainage installations for buildings,
*SANS 10313: 1999 Protection of structures against lightning,
*SANS 10400: Code of Practice for The Application of the National Building Regulations,
*SANS 1067: Copper-based fittings for copper tubes Part 1: Compression fittings,
*SANS 1067: Copper-based fittings for copper tubes Part 2: Capillary solder fittings,
*SANS 1091: Colour Coding of Services,
*SANS 1140: Identification colour marking Part 4: Contents of taps and valves in laboratories,
*SANS 1238: Air-conditioning ductwork,
*SANS 1409: Outlet sockets and probes for medical (gas and vacuum) services used in hospitals,
*SANS 1409: Part 3 Handling and storage of Medical Gas,
*SANS 1424: Filters for use in air-conditioning and general ventilation,
*SANS 1453: Copper Tubes for Medical Gas and Vacuum systems,
*SANS 14644-1, Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness,
*SANS 14644-2, Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1
*SANS 14644-4, Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up,
*SANS 1474: 1988 Uninterruptible Power Supplies,
*SANS 7396-1: Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum,
*SANS 7396-2: Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems,
*SANS 50081: Safety rules for the construction and installation of lifts — Particular applications for passenger and goods lifts,
*Any other applicable Laws or Regulations.

Chartered Institution of Building Services Engineers (CIBSE), 1999. Environmental design CIBSE Guide A. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2005. CIBSE Applications Manual AM10 Natural ventilation in non-domestic buildings. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2008. Lighting Guide 2: Hospitals and health care buildings. England: The Society of Light and Lighting.

 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009. ANSI/ASHRAE/ASHE Standard 170-2008 Ventilation of

Health Care Facilities. Atlanta USA:ASHRAE.

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2013. HVAC Design Manual for Hospitals and Clinics Second Edition. Atlanta USA:ASHRAE.

'''Further reading'''

*<nowiki>http://www.spaceforhealth.nhs.uk/</nowiki> (National Health Service NHS website for UK guidance) website closed now
*<nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> (Health Facility Guides website for Australasian Health Facility guidance)
*CIBSE Guide A – Environmental Design
*CIBSE Applications Manual for Natural Ventilation – AM10
*CIBSE Applications Manual for Mixed Mode Ventilation. – AM13

*CIBSE Lighting Guide 2: Hospitals and Health Care buildings
*ASHRAE 170:2008
*HVAC Design manual for Hospitals and Clinics Second Edition – ASHRAE TC 9.6, 2013
*CIBSE Commissioning Code A
*BSRIA Application Guide 3/89.1

 <references />

==LIST OF ABBREVIATIONS==
A & E- Accident and Emergency Department

AHU- Air Handling Unit

CSSD- Central Sterile Supply Department

EMS- Emergency Medical Services

HCW- High Care Ward

HEPA- High Efficiency Particulate Air (filter)

ICU- Intensive Care Unit

NBR- National Building Regulations SABS 0400

NICU- Neonatal Intensive Care Unit

OT- Operating Theatre

SABS- South African Bureau of Standards

SANS- South African National Standards

SSO- Switched Socket Outlet

UDAF- Uni-Directional Air Flow

UPS- Uninterrupted Power Supply

URS- User Requirement Specification

==LIST OF DEFINITIONS==
For the purposes of these regulations, unless the context otherwise indicates-

'''“barrier isolator”''' refers to a device comprising an physical film separating an operator or clinician from a work process. The work process is maintained within an isolated environment which may be held at a positive or negative pressure.

"'''Central Sterile Supply Department (CSSD)"''' means a facility for the receiving, decontamination, preparation, packing, sterilizing, storing and issuing of sterile and disinfected instruments and other reusable materials. This facility is also known as the "sterilisation and disinfection unit"(SDU);

"'''cleaners' room'''" means a room for the storage of cleaning equipment, the drawing of clean water and the disposal of dirty water, washing and drying of cleaning equipment. This room may be combined with the dirty utility room;

"'''clean air'''" means air that does not contain a considered contaminant;

"'''clean utility room'''" means a room for the storage of sterilized packs, dressings-, sterile equipment and pharmaceutical supplies respectively; This area may also be used for a set-up area for ward procedures;

"'''considered contaminant'''" means any actual contaminant, surface or airborne, which may have a certain impact which for which measures are taken to avoid;

'''"cross contamination"''' refers to the contamination of any zone or surface by fomites, considered particulates aerosols, biological agents, fumes or gasses originating from another zone or surface.

'''"cross infection"''' refers to the spreading of an infection from one organism to another by cross contamination.

'''"department"''' means a grouping of accommodation which has a specific function within a hospital. Its area includes the associated internal or departmental circulation space

'''"dirty utility room"''' means a room used for collection and temporary storage of used equipment and general ward material; it can combine the activities of the sluice room, the soiled linen and waste room and the cleaners' room;

'''"emergency trolley/crash cart"''' means a mobile cart used for the storage of all appropriate resuscitation equipment and pharmaceuticals;

"'''equipment store'''" means a room used for the storing of monkey chains, traction kits and other general equipment;

"'''fresh air'''" means air drawn from outside air of a building and contamination sources;

"'''high care ward'''" refers to a ward for the care and management of specific types of patients requiring a minimum of eight hours nursing care per patient day;

"'''holding area'''" means an area or room where pre-operative patients in transit to a procedure room/theatre are identified and continuously monitored by nursing personnel;

"'''induction room'''" means an area where patients are prepared for surgery/invasive procedures prior to being transferred to the operating theatre;

"'''intensive care unit'''" means a unit designed, staffed and equipped for the care and management of specific patients, (e.g. medical, cardiac or post-operative) requiring a minimum of twelve hours nursing care per patient day or for the care of a patient who requires ventilation, continuous invasive monitoring, invasive care, or who is clinically unstable and whose life is at risk;

"'''main kitchen'''" means a facility suitably finished and equipped for the receipt, storage and preparation of meals, special diets and beverages;

"'''maternity unit'''" means a unit where antenatal care is provided, babies are delivered and postnatal care is given to mothers and infants;

" '''midwife obstetric unit (MOU)'''" means a maternity unit usually attached to a clinic or a community health centre (CHC), which is staffed by nursing sisters or midwives;

“'''milk kitchen'''” means an area for the preparation of feeds for babies which must be separate from the hospital kitchen or ward kitchen. It must contain a clinical wash hand basin;

"'''mortuary'''" means a facility that receives, holds and allows for the identification of bodies of patients who died in the wards, theatre or casualty department, or who were dead on arrival at the facility; a facility which complies with the

"'''neonatal unit'''" means a facility for premature and new born babies requiring incubation, specific care and monitoring;

"'''nurse station'''" means the control point for all activities in the patient care areas;

"'''nursing unit or ward'''" means a unit with the facilities to accommodate patients as specified in this regulation;

"'''operating room'''” means a room within an operating theatre suite in which surgical or other invasive procedures are carried out;

"'''operating suite'''" refers to rooms within the demarcated area where surgical interventions are performed or support is provided to these surgical activities;

"'''patient room'''" means a room where the patient can be accommodated;

"'''procedure room'''" means a room in which certain restricted procedures generally taking less than one hour can be performed without making use of general anaesthetic, e.g. endoscopies, procedures under local anaesthetic such as suturing of lacerations, removal of skin lesions, biopsies, closed reductions and other similar procedures; May be situated outside the operating suite;

"'''recovery room/ area"''' means the section of the operating suite specially set aside for the immediate post-operative recovery, resuscitation, nursing and special care of patients, until such time as such patients are considered to have recovered sufficiently to be safely removed from the operating suite;

"'''sluice room'''” means a room used for the emptying, cleaning and storage of bedpans and urine bottles; It can be combined with the activities of the soiled linen and cleaners' rooms in the dirty utility room;

“'''specialised area'''” means any clinical area rendering specialised services such as intensive care, high care, or rehabilitation, for which additional space around the patient is required;

"'''soiled linen and waste room"''' means a room used for the collection and temporary storage of soiled linen and waste; May be combined with the dirty utility room

"'''treatment room'''" means a room used for treatment of patients in the wards, containing a clinical wash hand basin;

“'''ventilation”''' means “The process of supplying air to or removing air from a space for the purpose of controlling air contaminant levels, humidity or temperature within the space”. ASHRAE Standard 62.1-2007, Section 3

'''“validation”''' means the method of proving and documenting that an installed system or process performs reliably as intended and required.

'''“natural ventilation”''' means “Ventilation provided by thermal, wind, or diffusion effects through doors windows or other intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3

"'''ward kitchen'''” means the room that forms an integral part of a nursing unit or units, for the preparation of snacks and beverages; It also includes the area for the heating, storage and refrigeration of meals;

"'''uninterrupted power supply'''" means a battery system, which in the event of a normal mains supply failure will provide immediately the electrical supply for essential equipment and lighting.
[[Category:Crosscutting Issues]]
[[Category:Water Distributions Systems]]
[[Category:Legionella Control]]
[[Category:Ventilation]]

File:NV-Decision Tree1.png

2021-04-22T07:31:45Z

Tobyvan:

NV-Decision Tree1

File:NV-Decision Tree.png

2021-04-22T07:28:23Z

Tobyvan:

NV Decision Tree

Infection Prevention and Control/Surface Decontamination

2021-02-22T09:40:11Z

Tobyvan: /* Sampling and Validation */ This sections requires expansion

[[Infection Prevention and Control/Air Disinfection| Return to Air Disinfection]]

==Decontamination==
Decontamination is the process of making an area safe by removing, neutralising or destroying any harmful substances. Decontamination can be achieved by applying physical agents, chemical agents or mechanical removal through any combination of cleaning, disinfection or sterilisation. Physical agents could include heat, radiation and chemical agents include a myriad gasses and liquids.
===Cleaning===
Cleaning is the process of achieving a state where an area is visually free of contaminating debris. Cleaning is generally achieved by the application of mechanical removal and liquid chemical agents. Cleaning is often an initial decontamination process which removes organic matter from an area. Such organic matter can promote microbial growth and protect microorganisms during further decontamination stages such as disinfection or sterilisation. Cleaning is also frequently applied as the final decontamination stage during which inactivated microorganisms or residual toxins are removed from an area.
===Disinfection===
Disinfection is the decontamination process of reducing the number of infectious agents to the level where they no longer cause disease. Disinfection typically does not remove bacterial spores.
===Sterilisation===
Sterilisation is any decontamination process which removes or kills all forms of life in an area. This includes viruses, bacteria, funguses and spores forming organisms.

==Surface Decontamination by Cleaning==
Before cleaning, a strategy must be available which identifies target organisms, areas, processes, tools and chemical agents appropriate to the area. A review of the high touch areas in the space will inform the strategy. The selection of chemical agents should be based on their intended function (rates of cleaning or disinfection) and the resistance of the target surfaces to potentially corrosive agents. A final cleaning should be done with chemical agents and tools that remove residues from other processes leave no additional unwanted residues.
==Surface Decontamination by Heat==
Decontamination by heat is typically a sterilisation process with some measure of cleaning beforehand. Surface decontamination by heat is not a common practice and the temperature/time dose function typically requires long exposure times due to the low heat tolerance of surfaces. 
Two heat sterilisation processes are available, wet and dry heat. 
'''Wet heat''' is considered the most dependable method of sterilisation. Steam sterilisers or autoclaves apply heat and humidity under pressure (using saturated steam at 121 °C and 104 kPa) to sterilise laboratory and medical equipment. The application of steam allows for better penetration of heat through permeable insulating layers on any surface than dry heat alone. Autoclaves are occasionally used to sterilise infectious waste. 
'''Dry heat''' sterilisation is less dependable than wet heat as layers of debris on a surface can insulate organic materials from the process. Dry heat sterilisation is appropriate for impermeable surfaces like glass, but higher temperatures and exposure times are required (160 – 170 °C for periods of 120 to 240 minutes).

==Surface Decontamination by Chemicals==
{{stub}}

==Surface Decontamination by Irradiation==
Ionising and non-ionising irradiation are both able to decontaminate surfaces. Ionising radiation is not considered generally safe and practical for surface decontamination in a clinical or laboratory setting. Non-ionising radiation such as ultraviolet light in the UV-C band effectively inactivates most microorganisms on surfaces and in the air.

===Surface Decontamination by Ultraviolet Germicidal Irradiation===
The disinfection effect of ultraviolet light has been described for over 100 years<ref> Downes, Arthur; Blunt, Thomas P. (19 December 1878). https://royalsocietypublishing.org/doi/pdf/10.1098/rspl.1878.0109</ref>. It is effective against a variety of microorganisms and has been successfully deployed for the purpose of disinfection of water, air and surfaces. Effectiveness depends on a range of variables related to the microorganism of interest, environment and application. Ultraviolet radiation in the UV-C range has been used for its germicidal properties specifically for infection prevention and control - have been demonstrated to work at laboratory scale, in ducts, as upper room irradiation and as portable devices. Safety guidelines have been established (ACGIH)<ref name="cite">Citation Needed</ref>. 

UVGI surface disinfection has advantages over chemical disinfection because:

*There is no off-gassing of chemicals or residual chemical contamination frequently associated with chemical-based disinfection methods. Therefore, vehicles or spaces can be occupied immediately after UVGI disinfection<ref name="Kowalski 2009">Wladyslaw Kowalski, 2009. Ultraviolet Germicidal Irradiation Handbook: UVGI for Air and Surface Disinfection. New York. Springer. [https://www.springer.com/gp/book/9783642019982]</ref>;
*It has high pathogen reduction rates when compared to chemical cleaning; and
*Chemical disinfection methods are time-consuming <ref name="Kostyuchenko 2009">Sergey Kostyuchenko, Anna Khan, Sergey Volkov, Henk Giller, 2009. UV Disinfection in Moscow Metro Public Transport Systems. IUVA News / Vol. 11 No. 1 [https://iuvanews.com/stories/pdf/archives/110101KostyuchenkoEtAl_Article.pdf]</ref>.

A guideline on hospital infection control <ref name="Brown 1996">Brown IW Jr et al (1996) Toward further reducing wound infections in cardiac operations. Ann Thorac Surg 62(6):1783–1789.[https://www.ncbi.nlm.nih.gov/pubmed/8957387]</ref><ref name="Shamim 2017">Shamim, I. A. ed., 2017. Ultraviolet Light in Human Health, Diseases and Environment. Cham, Switzerland: Springer International Publishing AG.[https://www.springer.com/gp/book/9783319560168]</ref> recommends the use of both UVGI and chemical disinfection since UVGI has no penetrating power on dust, dirt and grease, which may harbour microbial contamination. Exposure to UV-C may degrade some materials. 

For UVGI surface disinfection for SARC-CoV-2, refer to [[Infrastructure_Guidance_for_COVID-19/COVID-19_Infection_Prevention_and_Control#Ultraviolet_Surface_Disinfection_for_SARS-CoV-2|COVID-19 infection control guidance]]
The effective band of germicidal ultraviolet (GUV) radiation is between wavelengths of 250-270 nm with 265 nm the optimum efficiency. Ultraviolet Germicidal Irradiation effectively destroys most microorganisms on surfaces. Dirt, dust, and shadows can shield organisms which must be directly exposed to the GUV light. This and safety concerns are limiting factors for its general application. 

The application of UVGI for surface disinfection usually involves the use of bare UVGI lamps. Two main approaches to surface disinfection systems are via permanently installed disinfection systems and portable disinfection systems. Permanently installed systems generally consist of bare UVGI lamp fixtures mounted on ceilings or walls. Portable UVGI systems are moved into a place temporarily to decontaminate surfaces <ref name="Kowalski 2009" />.
Efficacy is dependent on the intensity of irradiation emitted from the device, proximity of the device to the surface being disinfected and exposure time. The reflectivity of the materials in the vicinity of exposure can increase or decrease efficacy. Shaded items not directly exposed to UV-C irradiation may not effectively be disinfected
----
====UVGI Efficacy====

:'''UVGI dose'''

The UV-C dose required to achieve a particular pathogen reduction rate is calculated from the single-stage decay equation:
S=e-kD
where: 

;*S is the Survival fractional [%] 
;*k is the UVGI rate constant [m2/J] 
;*D is the UVGI exposure dose [J/m2] 

The required UVGI dose for a 4 log reduction (99.99% pathogen reduction rate) is calculated by expressing the single-stage decay equation as follows:
ln(''⁡S'')=-''k''·''D''·ln(⁡''e'')
∴''D'' = (ln (⁡0.0001))/(-k) '' mJ/cm2'' ''(J/cm2)''
----
====UVGI Validation====
Validation testing for UVGI surface disinfecting systems is required to ensure that the UV dose for ≥99.99% level of pathogen inactivation is achieved. As the dose rate is a function of the UV sources output and its distance to the target, the manufacturer for non-static UVGI surface disinfecting systems should specify the design minimum distance away from a surface, the UVGI intensity on the surface and the time required to achieve ≥99.99% pathogen reduction. 
For disinfection that has either dynamic source or target components, repeatability and confidence studies are required to ensure that the range of variability expected does not exceed acceptable limits for efficacy and safety

====UVGI Safety====
Studies of personnel practising proper UVGI exposure control measures have shown no harmful effects<ref name="Brown 1996" />, <ref name="Shamim 2017" /> . Noncompliance with safety precautions can lead to injuries <ref name="Shamim 2017" />. The following safety issues are associated with the handling of UV equipment. 
UV radiation exposure present hazards to the skin and the eyes <ref name="Kowalski 2009" /> <ref name="Myung 2005">Myung C. J., 2005. Ultraviolet (UV) Radiation Safety. Environmental Health and Safety University of Nevada Reno. [https://www.unr.edu/ehs/program-areas/radiation-safety/ultraviolet]</ref>.

=====UVGI Exposure Guidelines=====
The ability of UV radiation to penetrate the eyes and skin depends on the wavelength, therefore the UV radiation exposure Threshold Limit Values (TLV) for the eyes and skin published by the American Conference of Governmental Industrial Hygienists (ACGIH) <ref name="ACGIH" /> also varies according to the UV wavelength. For UVGI at 254 nm, a cumulative exposure dose greater than 6mJ/cm2 <ref name="ACGIH" /> is considered harmful to eyes and skin. Since UVGI surface disinfection systems use bare lamps with dose requirements exceeding 6 mJ/cm2, adherence to PPE is highly recommended to avoid harm.

=====Eye Safety=====
The UV wavelength is the determining factor as to which part(s) of the eye may absorb the radiation and suffer biological effects. 
The table below shows the absorption of different UV wavelengths by the human eye. 
{| class="wikitable"
|+Absorption of UV wavelengths in the Human Eye <ref name="Myung 2005" />
!Wavelength {nm}!!Cornea!!Aqueous!!Lens!!Vitreous
|-
|100-280||100%||0%||0%||0%
|-
|300||92%||6%||2%||0%
|-
|320||45%||16%||36%||1%
|-
|340||37%||14%||48%||1%
|-
|360||34%||12%||52%||2%
|}

UVGI (UV wavelengths 200 to 280nm) cumulative exposure dose greater than 6mJ/cm2 <ref name="ACGIH">American Conference of Governmental Industrial Hygienists (ACGIH), 2019. Threshold Limit Values for Chemical Substances and Physical Agents and Biological Exposure Indices. ACGIH: USA [https://www.acgih.org/forms/store/ProductFormPublic/2019-tlvs-and-beis-with-7th-edition-documentation-cd-rom-single-user-version]</ref> can cause temporary corneal injuries (photokeratitis and conjunctivitis <ref name="Kowalski 2009" />). Symptoms of corneal injuries (extreme pain in the eyes) present after 6 -12 hours of exposure and lasts for a few days during which corneal cells will recuperate <ref name="Kowalski 2009" /><ref name="Shamim 2017" />.

=====Skin Safety=====
Because of poor penetration and absorption capability <ref name="Brown 1996" />, UVGI cannot penetrate or cause permanent harm to human skin <ref name="Myung 2005" />. Some skin irritation or [https://en.wikipedia.org/wiki/Erythema erythema] may be experienced but this will generally clear up with proper care.

====UV control measures====
=====Administrative controls=====
Prevent unauthorized personnel from entering the UV radiation area.
=====Personal protective equipment (PPE)=====
Personal protective equipment (PPE) protects the wearer from harm due to UV radiation exposure. The following PPE should be worn when operating UVGI surface disinfection systems:

:#Plastic goggles with side shields;
:#Head, neck and face covering opaque to UV radiation;
:#Soft cotton gloves and.
:#Long-sleeved, tightly woven fabrics with SPF 15 or greater.

====Burn safety====
UV lamps, depending on the lamp technology, may operate at up to 900°C. The UV lamps and sleeves should be allowed to properly cool down before maintenance to minimize the risk of burns. The electrical equipment (e.g., ballasts) may also become hot during operation and should be evaluated prior to maintenance <ref name="Bolton 2008">Bolton, J.R., Cotton, C.A., 2008. The Ultraviolet Disinfection Handbook. Springer 2008. [https://link.springer.com/book/10.1007%2F978-3-642-01999-9]</ref>.

====Lamp breakage issues and mercury exposure====
UV lamps pose two safety hazards if broken; the lamps and sleeves are constructed of quartz that, when broken, can pose a risk of serious cuts, and UV lamps contain mercury that can create an inhalation or contact hazard <ref name="Bolton 2008" />.

====UV-C effects on materials====
UV radiation that is incident upon a surface can be transmitted, reflected or absorbed <ref name="Shamim 2017" />. Absorption of UV causes photodegradation that result in an alteration to the colour, texture or mechanical properties of the materials <ref name="Shamim 2017" />. Materials with high UV absorption indicate greater potential for photodegradation while those with high reflectivity indicate protective effects <ref name="Kowalski 2009" />. All metals do not experience damage under UV exposure <ref name="Kowalski 2009" />. Some of the materials that experience photodegradation are wood, plastic, Polyvinyl chloride (PVC), fabrics, paint and glass <ref name="Kowalski 2009" />.

Because UV-C is absorbed in the ozone layer in the atmosphere and is material exposure is uncommon, published data on degradation by UV-C is minimal<ref name="UV Solutions"> https://uvsolutionsmag.com/articles/2019/uv-degradation-effects-in-materials-an-elementary-overview/ (Accessed 2020 May 12)</ref>. Nonetheless, UV light is linked with possible material degradation; degrade paint, yellow plastics, and destroy air filters.
Metals are almost entirely unaffected by UV, ceramics are completely unaffected by UV exposure but most polymers are susceptible to degradation by UV-C exposure<ref name="UV Solutions" />. The degradation of polymers can in-turn deteriorate the aesthetic properties such as colour and texture and release by-products into the surrounding environment (outgassing) which may raise additional concern on human health.

===Maintenance and monitoring===
Proper maintenance and monitoring of UVGI surface disinfection systems ensure continued efficacy. Maintenance tasks and their frequencies are shown in the table below.

{| class="wikitable"
|+Maintenance tasks for UVGI surface disinfection system
|-
!Task!!Frequency!!Action
|-
|Check lamp run time values||Monthly||Change lamps if operating hours exceeded design life of 9–10 thousand hours <ref name="Kowalski 2009" />
|-
|Check intensity of UV lamps||Bimonthly||Replace lamps when UVGI dose is equal to or less than the validated UVGI dose after verifying that this condition is caused by low lamp output.
|-
|Visually inspect bulbs to ensure all bulbs are operational.||Weekly||If the bulbs show visual dust accumulation, they should be cleaned. Lamps can be wiped clean with a cloth dampened with water or a cleaning agent like dilute alcohol <ref name="Kowalski 2009" />
|}

The surface UVGI system should be equipped with sensors that automatically monitor UV intensity, validated UV dose and lamps status. A decision chart for UVGI surface disinfection system monitoring is shown below.
[[File:Decision chart for UVGI surface disinfection system monitoring.png|600px|thumb|none|Decision chart for UVGI surface disinfection system monitoring]]

===UVGI lamps disposal===
LPMV lamp contains mercury which is a toxic heavy metal which cycles through the soil, water and atmosphere in the environment.
Send spent lamps to a mercury recycling facility or back to the manufacturer to prevent personal or environmental exposure.

===Training===
Operators designated to care for the UVGI systems should receive adequate training in both UV system theory, operation, maintenance and safety.
----

===Case Studies===
====Moscow trains====
In Moscow, Russia, Kostyuchenko, et. al., <ref name="Kostyuchenko 2009" />, investigated the potential of UVGI disinfection on internal surfaces of train carriages and on escalator handrails. They found that the required UV doses for effective disinfection are higher than the theoretically calculated doses. 

====Ambulance decontamination <ref name="cite" />====

====Respiratory Protective Equipment decontamination <ref name="cite" />====

===Elements of a successful UVGI Disinfection Program===
====Messaging====
It is important for messaging around a UVGI Disinfection Program to detail that UVGI can be safe and effective when applied according to a defined and validated protocol 

The messaging program should include the following safety aspects:

*UVGI is a form of actinic radiation which does not cause skin cancer
*UVGI/UVC is not the same as UV found in outdoor sunlight
*UVGI can cause reversible skin and eye irritation
*Skin and eye protection should be worn when the possibility of irradiation is present 
*UV Lamps should not be used for skin or hand sterilisation

The messaging program should include the following efficacy aspects:

*UVGI is a supplemental surface disinfection technology
*UVGI can be used to kill the new coronavirus as well as a number of other common pathogens

==Sampling and Validation==
{{Expand}}

==Notes and References==
<references />

[[Category: Infection Prevention and Control]]
[[Category: Decontamination]]
[[Category:Crosscutting Issues]]

Ventilation and COVID-19

2021-02-16T11:43:34Z

Tobyvan: /* Transmission routes */

[[Category:COVID-19]]
[[Category:Crosscutting Issues]]

==Context==
This article aims to to contextualize COVID-19 related ventilation guidelines in a field of developing clinical evidence. This is done with the hope of empowering the reader to scrutinize proposed interventions within this context and employ appropriate and efficient solutions. The information and guidance in this article is the developing opinion of the author and does not represent any regulatory or institutional mandate or authority. The evidence supporting this opinion is evolving and therefore the opinion is similarly subject to change. The reader is encouraged to return to this article frequently to review any changes additions or updates highlighted in the history tab above.

Discussion and contributions are similarly welcomed in the discussion tab above.[https://thehillside.info/index.php?title=Talk:Ventilation_and_COVID-19#section1]

==Background==

===Transmission routes===
SARS-CoV-2 has caused many to revisit their understanding of droplet and airborne transmission. These two transmission mechanisms form a continuum, but the following is generally accepted:

*''Infectious'' particles <5μm in size can remain suspended and viable for many hours and these contribute to the risk of '''airborne transmission'''.
*'''Droplet transmission''' involves larger particles which can also spread through the air for some distance, but the range of transmission is generally considered to be less than 2 meters where after particles fall out of the breathing zone. It is important to remember that within this 2 m distance these larger droplets are essentially 'airborne' and diluting ventilation systems have little effect on reducing the risk of near-range droplet transmission<ref>Liu, L., Li, Y., Nielsen, P. V., Wei, J. & Jensen, R. L. Short-range airborne transmission of expiratory droplets between two people. Indoor Air 1–11 (2016) doi:10.1111/ina.12314.</ref>.

Droplet precautions, therefore, include standard precautions like PPE, hand washing and distancing, while airborne precautions include negative pressure isolation, respiratory protection, special exhaust or filtration regimes, etc.

Diseases seldom obey only one mode of transmission (obligatory transmission) but often have preferences (preferential transmission) while occasionally exploiting circumstances which provide rare opportunities for transmission (opportunistic routes). SARS-COV-2 is understood to be '''preferentially droplet and contact spread''' (a form of droplet spread where droplets can settle on fomites) with opportunistic airborne spread possible in specific conditions, although an extensive outbreak review revealed no indication of airborne spread as defined for TB or measles<ref>https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>.

===Airborne Transmission===
There is still little strong evidence of common long-range airborne transmission in the sense of droplet nucleation, as with TB and measles<ref>World Health Organization. Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 16-24 February 2020 [Internet]. Geneva: World Health Organization; 2020 Available from: [https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-covid-19-final-report.pdf]</ref>. Where evidence of airborne transmission has been reported, this can be seen in the context of opportunistic long-range droplet spread<ref> Wenzhao Chen, Nan Zhang, Jianjian Wei, Hui-LingYen, and Yuguo Li, “Short-range airborne route dominates exposure of respiratory infection during close contact,” medRxiv preprint, https://doi.org/10.1101/2020.03.16.20037291</ref>. A discussion contextualizing the reported cases of airborne transmission is discussed below.

====van Doremalen et al (NEMJ 2020)====
The van Doremalen SARS-CoV-2 survival study<ref name="van Doremalen">Neeltje van Doremalen, Trenton Bushmaker, Dylan H. Morris, Myndi G. Holbrook, Amandine Gamble, Brandi N. Williamson, Azaibi Tamin, Jennifer L. Harcourt, Natalie J. Thornburg, Susan I. Gerber, James O. LloydSmith, Emmie de Wit, and Vincent J. Munster, “Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1,” The New England Journal of Medicine (2020), DOI: 10.1056/NEJMc2004973 [https://www.nejm.org/doi/pdf/10.1056/NEJMc2004973?articleTools=true]</ref> is often incorrectly reported to have shown that SARS-CoV-2 can remain viable in air for extended periods. No evidence for long range airborne viability has yet been found outside of lab settings. SARS-CoV-2 virus found dispersed at long range has not been cultured to prove viability and many studies have failed to detect it directly in air in quantities substantial enough to culture<ref>Faridi, S. et al. A field indoor air measurement of SARS-CoV-2 in the patient rooms of the largest hospital in Iran. Sci. Total Environ. 725, 1–5 (2020).</ref><ref>Liu, Y. et al. Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals. Nature (2020) doi:10.1038/s41586-020-2271-3.</ref>. Correlations between culture viability, particle size and the real world infectious quantum were not described in this study<ref name="van Doremalen" /> as it was not the study's intention to claim COVID-19 was airborne. A more recent pre-publication article has made similar findings<ref>Fears SC, Klimstra WB, Duprex P, Hartman A, Weaver SC, Plante KS, et al. Persistence of severe acute respiratory syndrome coronavirus 2 in aerosol suspensions. Emerg Infect Dis. 2020 Sep [''date cited'']. <nowiki>https://doi.org/10.3201/eid2609.201806</nowiki></ref> but this has significant problems with equipment standardization and repeatability. More importantly, similar lab studies have also demonstrated a 3h airborne survival for viral strains such as Ebola not considered to be airborne<ref>Robert Comparison of the Aerosol Stability of 2 Strains of Zaire ebolavirus From the 1976 and 2013 Outbreaks Robert J. Fischer, Trenton Bushmaker, Seth Judson, Vincent J. Munster
J Infect Dis. 2016 Oct 15; 214(Suppl 3): S290–S293. Published online 2016 Oct 4. doi: 10.1093/infdis/jiw193 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5050463/</ref>. This makes the direct application of this lab study in real-world settings problematic. Therefore, the understanding of the mechanisms of COVID-19 transmission is still largely reliant on what is understood of SARS (SARS-CoV-1)<ref>Isao Arita, Kazunobu Kojima, and Miyuki Nakane, “Transmission of severe acute respiratory syndrome,” Emerging. Infectious Diseases 9 No. 9 (2003):1183-84, [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016764/].</ref>.

====Guangzhou Restaurant Outbreak (2020)====
[[File:Guangzhou Restaurant COVID-19 2020.png|thumb|Plan of COVID-19 outbreak in Guangzhou Restaurant 2020<ref name=":0">Lu, J., Gu, J., Li, K., Xu, C., Su, W., Lai, Z....Yang, Z. (2020). COVID-19 Outbreak Associated with Air Conditioning in Restaurant, Guangzhou, China, 2020. ''Emerging Infectious Diseases'', ''26''(7), 1628-1631. <nowiki>https://dx.doi.org/10.3201/eid2607.200764</nowiki>.[https://wwwnc.cdc.gov/eid/article/26/7/20-0764_article]</ref>]]
The 2020 outbreak of COVID-19 in a restaurant in Guangzhou<ref name=":0" /> raises some important questions around the airborne spread of the disease. This study shows that the transmission range of COVID-19 may exceed the generally prescribed separation distance of 1m under certain conditions, but fails to do so convincingly. Confounding issues that are not addressed adequately in the articles conclusion include:

*the high probability of asymptomatic or pre-symptomatic spread of the virus from members of the index case's family<ref>How Coronavirus Infected Some, but Not All, in a Restaurant, Chang, K (2020) https://www.nytimes.com/2020/04/20/health/airflow-coronavirus-restaurants.html</ref>
*the possibility of onward transmission within family groups after the restaurant exposure is acknowledged but dismissed without discussion
*the difference in exposure times<ref>https://english.elpais.com/spanish_news/2020-06-17/an-analysis-of-three-covid-19-outbreaks-how-they-happened-and-how-they-can-be-avoided.html</ref> between tables (C-B )and (E-F) is not adequately addressed
*The overcrowded and under ventilated conditions in the restaurant.

This is a seminal event in the study of SARS-CoV-2 transmission, but we should be cautious to use it a clear evidence if airborne transmission where similar events are not widespread by now.

===='''South Korea Call Centre Outbreak 2020'''====
[[File:South Korea Call Centre Outbreak COVID-19 2020.png|thumb|Floor plan of South Korea Call Centre Outbreak COVID-19 2020]]
In this pre-publication report, the outbreak in a call-centre on the 11th story of a South Korean office block<ref>Park SY, Kim YM, Yi S, Lee S, Na BJ, Kim CB, et al. Coronavirus disease outbreak in call center, South Korea. Emerg Infect Dis. 2020 Aug [''date cited'']. <nowiki>https://doi.org/10.3201/eid2608.201274</nowiki></ref> offer some extraordinary insights but leaves many questions open. The distribution of the attacks is alarming in the call centre room, but is significantly reduced in adjacent room on the same floor.

The following is a summary of the findings:

*It appears as if the outbreak followed physical compartmentalization and not HVAC zoning although an HVAC plan of the building was not discussed.
*It is clear that COVID-19 is exceptionally contagious in crowded office settings.
*Lobbies and lifts contributed little to spread.
*Exposure time correlated with transmission risk.

Questions that remain:

*HVAC zoning or an HVAC plan of the building was not discussed.
*Ratios of male and female cases would have offered insight into the roles of bathrooms in COVID-19 spread.
*A review of vertical transport characteristics may have offered insight into the vertical distribution of case through the building.

===Aircraft Transmission Studies===
SARS and COVID-19 outbreaks on commercial aircraft have proven to be remarkedly rare. This may be due to the high ventilation rates<ref>Mangili, A., & Gendreau, M. A. (2005). Transmission of infectious diseases during commercial air travel. ''Lancet (London, England)'', ''365''(9463), 989–996. <nowiki>https://doi.org/10.1016/S0140-6736(05)71089-8</nowiki></ref>. Studies tracing contacts on flights seem to show multiple cases of very low to zero transmission rates with the transmission events raising disproportional alarm<ref name=":3">Olsen et al, N Engl J Med 2003; 349:2416-2422Transmission of the Severe Acute Respiratory Syndrome on Aircraft, DOI: 10.1056/NEJMoa031349 [https://www.nejm.org/doi/full/10.1056/nejmoa031349]</ref><ref>CMAJ 2020 April 14;192:E410. doi: 10.1503/cmaj.75015 [https://www.cmaj.ca/content/cmaj/192/15/E410.full.pdf]</ref>. The context of the scope of aircraft outbreak findings highlights the role ventilation has in creating safe environments, but similarly reveals the low risk levels associated with airborne transmission of SARS or COVID-19.

====Amoy Gardens SARS Outbreak (2003)<ref name=":1">McKinney KR, Gong YY, Lewis TG. Environmental transmission of SARS at Amoy Gardens. ''J Environ Health''. 2006;68(9):26-52.</ref>====
Studies, which indicate the Amoy Gardens building's SARS outbreaks' transmission was via the airborne route<ref name=":1" />, commonly reference the prevailing wind between buildings. It should be noted that, since these buildings are about 60m apart, the environmental dilution and concentration decay effects are so strong it is not feasible that an infectious dose persists at that range. Similarly, the possibility that air can commute out of one window and into another needs to account for these dilution effects before assumptions of transmission can be drawn. These studies do not sufficiently account for dilution, infectious doses and pathogen survival rates. A more feasible hypothesis is that the Amoy Gardens intra-building spread was through re-aerosolisation of contaminated waste water coming from the faulty plumbing system. Similar outbreaks have more recently been found<ref name=":2">Bhowmick, G.D., Dhar, D., Nath, D. et al. Coronavirus disease 2019 (COVID-19) outbreak: some serious consequences with urban and rural water cycle. npj Clean Water 3, 32 (2020). https://doi.org/10.1038/s41545-020-0079-1</ref>. The re-aerosolisation from sanitary systems should be directly compared with long range oral-airborne transmission. The Amoy-Gardens transmission mode was most likely closer to large droplet transmission from toilets and waste outlets.

====Other studies====
Studies which have found real-world SARS-CoV-2 in air, ducting and on extraction fans have so far failed to prove that the virus found was still viable<ref>Santarpia et al, “Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center,. medRxiv preprint (2020), [https://doi.org/10.1101/2020.03.23.20039446]</ref><ref>Po Ying Chia et al, 2020 (Preprint) “Detection of Air and Surface Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) in Hospital Rooms of Infective Patients,” medRxiv preprint (2020), https://doi.org/10.1101/2020.03.29.20046557 [https://www.medrxiv.org/content/10.1101/2020.03.29.20046557v2.full.pdf]</ref>. Air sampling studies have failed to detect viable SARS-CoV-2<ref>Ong SWX, Tan YK, Chia PY, et al. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. ''JAMA.'' 2020;323(16):1610–1612. doi:10.1001/jama.2020.3227</ref>.

It has been suggested that high temperature and humidity would reduce the spread of the virus<ref>Chin, A. W. H. et al. Stability of SARS-CoV-2 in different environmental conditions. The Lancet Microbe 0–4 (2020) doi:10.1016/s2666-5247(20)30003-3.</ref><ref>Pyankov, O. V., Bodnev, S. A., Pyankova, O. G. & Agranovski, I. E. Survival of aerosolized coronavirus in the ambient air. J. Aerosol Sci. 115, (2018).</ref>. The temperature ranges suggested (>50°C) are beyond what anyone could endure in an ICU but the humidity ranges of between 40-60% are achievable. The high humidity slows the nucleation of the viral droplet and increases its settling speed, thereby reducing its range.
====High Risk Settings (ICU)====
Much of the work being done to understand the transmission mechanism of COVID-19 is focused on community transmission. It is important to remember that transmission risk in an ICU will not be the same as in homes and workplaces. The conditions and procedures in ICUs could promote transmission - see WHO 2020 below<ref name="WHO 2020">WHO 2020, Modes of transmission of virus causing COVID-19: implications for IPC precaution recommendations https://www.who.int/news-room/commentaries/detail/modes-of-transmission-of-virus-causing-covid-19-implications-for-ipc-precaution-recommendations</ref>. Firstly, in a COVID ICU unit, the contamination source strength is much higher than other spaces since infected patients are congregated there. These are presumably ill patients with high viral shedding. Secondly, procedures like intubation are understood to release high quantities of aerosolized particles, unlike with general talking or coughing. Additionally, viral shedding through talking and coughing can be more readily mitigated than from intubation.

===Fecal-Oral Transmission===
Fecal oral route of transmission is acknowledged for COVID-19<ref>Pan Y, Zhang D, Yang P, Poon LLM, Wang Q. Viral load of SARS-CoV-2 in clinical samples. Lancet Infect Dis. 2020;20(4):411-2.</ref> and considerations for waste water management are discussed [[SARS-CoV-2 is found in faecal matter|here]] and [https://doi.org/10.1016/j.scitotenv.2020.139076 here]<ref>Kitajima et al,SARS-CoV-2 in wastewater: State of the knowledge and research needs,Science of The Total Environment,Volume 739,2020,139076,ISSN 0048-9697,<nowiki>https://doi.org/10.1016/j.scitotenv.2020.139076</nowiki></ref>. This transmission route indirectly affects ventilation system design as special consideration should be given to common scenarios where the aerosolisation of contaminated wastewater is a possibility such as in bathrooms, sluice rooms and slurry pumping. These spaces should be well-ventilated and kept under negative pressure relative to adjacent spaces.

==Institutional Guidance==
===WHO===
The WHO's advice regarding SARS-CoV-2 transmission during clinical interventions is as follows:
''"In the context of COVID-19, airborne transmission may be possible in specific circumstances and settings in which procedures or support treatments that generate aerosols are performed; i.e., endotracheal intubation, bronchoscopy, open suctioning, administration of nebulized treatment, manual ventilation before intubation, turning the patient to the prone position, disconnecting the patient from the ventilator, non-invasive positive-pressure ventilation, tracheostomy, and cardiopulmonary resuscitation."'' - WHO 2020<ref name="WHO 2020" /> 

While the WHO's position acknowledges the increased risk of transmission in overcrowded and under-ventilated spaces, the appropriate response is not to increase prescribed general ventilation rates, but rather to avoid overcrowding and maintain ventilation systems correctly.
===US-CDC===
The CDC's advice regarding SARS-CoV-2 transmission is still nearly identical to its guidance for SARS-CoV-1:
''"The primary transmission of COVID-19 is from person-to-person through respiratory droplets. These droplets are released when someone with COVID-19 sneezes or coughs. COVID-19 can also be spread when you are in close contact with someone who is sick (e.g., shaking hands or talking). A physical distance of at least 1 meter (3ft) between persons is suggested by the World Health Organization (WHO) to avoid infection, although some WHO member states have recommended maintaining greater distances whenever possible. Respiratory droplets can land on objects or surfaces around the person when they cough or talk, and people can then become infected with COVID-19 from touching these objects or surfaces and then touching their eyes, nose or mouth. Recent data suggests that there can be transmission of COVID-19 through droplets of those with mild symptoms or those who do not feel ill"'' <ref>https://www.cdc.gov/sars/about/faq.html</ref><ref>https://www.cdc.gov/sars/about/faq.html</ref>

The US-CDC's recommendations regarding inpatient accommodation for SARS includes the comment,
"Experience in some settings in Taiwan and Toronto demonstrated that cohorting SARS patients, without use of AIIRs, effectively interrupted transmission"<ref>US-CDC,2005, https://www.cdc.gov/sars/guidance/i-infection/healthcare.html</ref>
The CDC's guidance is consistent with the full context of hierarchical risk-based infection control and is suitably cognizant of variously resourced settings.
"Airborne Infection Isolation Rooms (AIIRs) (See definition of AIIR in appendix) should be reserved for patients who will be undergoing aerosol generating procedures (See Aerosol Generating Procedures Section)."<ref>Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic (updated July 9, 2020)[https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html]</ref>
This nuanced approach is difficult to tease out of the guidance from engineering societies.

{{Anchor|CDC COVID Airborne Precautions}}

====Airborne Transmission based precautions (US-CDC)====
The CDC has made the following recommendations for transmission based precautions. It is notable that this is only for "non-US settings".
Additionally, adequately ventilated single rooms or wards are suggested. For general ward rooms with natural ventilation, adequate ventilation for COVID-19 patients is considered to be 60 L/s per patient. When single rooms are not available, suspected COVID-19 patients should be grouped together with beds at least 1 meter apart based on WHO’s recommendation, although some member states have recommended maintaining greater distances whenever possible<ref name=":4">CDC 2019, COVID-19 Overview and Infection Prevention and Control Priorities in Non-US Healthcare Settings https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html </ref>
This guidance offers no reason or evidence for the suggestion of 60 L/s per patient. It may stem from the WHO's recommendations for 60 L/s per person for medium risk TB settings<ref>WHO 2009. WHO Policy on TB infection control in Health-care facilities, Congregate Settings and Households. [https://www.who.int/tb/publications/tb-facilities-policy/en/ https://apps.who.int/iris/bitstream/handle/10665/44148/9789241598323_eng.pdf?sequence=1]</ref> as it contradicts the CDC's own TB guidance <ref>CDC 2005, Guidelines for Environmental Infection Control in Health-Care Facilities (updated 2019)https://www.cdc.gov/mmwr/pdf/rr/rr5417.pdf</ref>. It is of significance to note that the WHO has omitted this recommendation from its 2019 guidance <ref>WHO 2019, WHO Guidelines on tuberculosis infection prevention and control, 2019 update https://www.who.int/tb/publications/2019/guidelines-tuberculosis-infection-prevention-2019/en/</ref>. This guidance is not prescriptive, supported by evidence nor consistent with other CDC and WHO guidance. Additionally the guidance does not describe how the ventilation performance for naturally ventilated spaces should be verified. See [[#COVID-19 Engineering Response]] for recommended practice

===ASHRAE===
While the US-CDC and WHO maintains that the airborne transmission is possible but not common or of primary concern, ASHRAE (being an association dedicated to ventilation engineering) focuses on the airborne component.
"Transmission of SARS-CoV-2 through the air is sufficiently likely that airborne exposure to the virus should be controlled. Changes to building operations, including the operation of heating, ventilating, and air-conditioning systems, can reduce airborne exposures"<ref>Q: Does ASHRAE’s guidance agree with guidance from WHO and CDC? (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/does-ashrae-s-guidance-agree-with-guidance-from-who-and-cdc.pdf]</ref>
ASHRAE makes useful distinctions between guidance for healthcare<ref>ASHRAE healthcare C19 guidance (ASHRAE 2020) [https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-healthcare-c19-guidance.pdf]</ref>, residential <ref>ASHRAE residential c19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-residential-c19-guidance.pdf]</ref><ref>COVID 19 guidance for multifamily building owners-managers (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/covid-19-guidance-for-multifamily-building-owners_managers.pdf]</ref>, commercial <ref>ASHRAE commercial C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-commercial-c19-guidance.pdf]</ref> and schools<ref>ASHRAE Schools C19 guidance (ASHRAE 2020)[https://www.ashrae.org/file%20library/technical%20resources/covid-19/ashrae-schools-c19-guidance.pdf</ref>, but doesn't significantly address risk categories specifically in healthcare or resource limited settings.
===REHVA===
REHVA's temporary guidance is limited to commercial and public buildings<ref>REHVA COVID-19 guidance document, April 3, 2020[https://www.rehva.eu/fileadmin/user_upload/REHVA_COVID-19_guidance_document_ver2_20200403_1.pdf]</ref>. Similar to ASHRAE, REHVA focusses on engineering controls for airborne transmission. REHVA acknowledges importance of droplet precautions and the lack of quality evidence for airborne transmission, but draws the conclusion that SARS-CoV-2 RNA found in ventilation ducting implies airborne transmission, even though these real world studies have not yet proven viability of these particles. REHVA also draws the airborne conclusion from the van Doremalen study<ref name="van Doremalen" /> out of its intended comparative context.

===IUSS (2014)===
The [[Infrastructure_Unit_System_Support|IUSS]] Building Engineering Services Guidelines<ref>Building Engineering Services (2014)[https://iussonline.co.za/norms-standards/healthcare-environment/60-building-engineering-services]</ref>, which is mandated for new buildings by provincial departments of health by reference in Government Notice R116<ref>Government Notice R116 (17 Feb 2014)[https://iussonline.co.za/docman/gazettes/116-notice-37348/file]</ref>, describes risk based ventilation criteria which are broadly appropriate for COVID-19, if not excessive. This guideline was developed with control measures for the current TB epidemic in mind. These measures would be more than appropriate for most healthcare spaces. The guidance recommends no recirculation of air between theatres and adjacent spaces but does not prohibit cascading from surgeries to adjacent spaces. Therefore, confirmed COVID-19 patients should only be treated in negative pressure operating rooms that comply with the guidelines.

===SANS 10400-O (2011)===
The 2011 edition of the SANS 10400-O<ref>SABS. SANS 10400-O : 2011 SOUTH AFRICAN NATIONAL STANDARD The application of the National Building Regulations Part O : Lighting and Ventilation. (2011).</ref> is often criticized for over prescribing ventilation rates when compared with international best practice. The mechanical ventilation criteria of this standard, in it current form, prioritizes indoor air quality over energy efficiency and takes a heavy handed approach to ventilation in many spaces. 10 ACH and more is common for areas with any risk of airborne contamination. The standard gives inadequate performance guidance for naturally ventilated spaces.

While the SANS 10400-O:2011 demands unprecedently high ventilation rates and offers little supporting evidence with the criteria, it should be considered better than many international standards for use in general settings where airborne contamination is a risk.

Unfortunately, the SANS 10400-O:2011 does not permit the concurrent use of natural ventilation and air-conditioning and leads designers to incorrectly infer that windows in airconditioned spaces should not be opened/openable.

==Air-Conditioning, Ventilation and COVID-19==
It is important to differentiate between ventilation and air-conditioning when discussion indoor contamination. When the term ventilation is used, it describes any system that induces decontaminated, fresh or outdoor-air to enter a space by the application of supply or extraction systems. Diluting ventilation is the most commonly used regime. Other modes of contaminant removal include displacement and local exhaust ventilation systems, each of which requires its own nuanced discussion as they pertain to infection control.

Air-conditioning in contrast, refers to only the mechanical cooling or heating system, sometimes installed directly in a space (Spit-AC), to offer thermal comfort and sometimes humidity control. In-room air-conditioning systems that circulate air directly within a space with no dilution or extraction can directly offer no reduction in airborne contaminant levels. In some instances they can even assist in the distribution of contaminants.

Openable windows can be considered as ventilation apertures and, in most cases, offer highly effective ventilation. Unfortunately, this is sometimes at the expense of indoor comfort. Even though long range droplet transmission of SARS-CoV-2 is relatively low in comparison to short range transmission, encouraging occupants to open windows will reduce that risk. Allowing occupants to use air-conditioning to either heat or cool a space while windows are open can improve levels of open window compliance which is more important than limiting AC use for reducing long range transmission. An additional strategy to both improve open window compliance and reduce AC usage would be to relax strict corporate dress codes as this can improve thermal comfort levels seasonally.

{{Anchor|COVID-19 Engineering Response}}

==Engineering Response==
Ventilation society guidance understandably bears the risk of being biased toward over-prescribing solutions over which engineers have the greatest understanding and control. It is within this context that the valuable guidance published online by REHVA and ASHRAE should be considered. Revamping existing ventilation systems in resource-constrained healthcare settings to meet admittedly overly-cautious guidance should not be conducted without an informed investment case.
In these resource limited settings, it needs to be carefully considered whether resources are allocated to clinical capacity or to possibly unnecessary ventilation when the benefits of these criteria may be comparatively marginal.

Without good viability studies of the viral particles found in air or ventilation systems, no firm guidance can be offered regarding the rate of reduction for SARS-CoV-2 viability with time and distance. Until that time it would be prudent to assume that the virus should only be considered as airborne under special and rare conditions, based on the guidance of the WHO, and these conditions should be avoided. This would determine that we have different filtration and ventilation approaches between COVID-ICUs, general indoor public spaces and spaces with a potential for high density occupation. Engineers should not be tempted to assume or argue that all indoor spaces bear the same risk profile.

For high-risk spaces it may be prudent to implement temporary measures to limit transmission risk to the minimum possible. In order of priorities, engineering interventions include:

#decongest indoor spaces to the minimum possible occupancy levels
#open windows to outside when occupational health, safety and security are not compromised
#increase HVAC fresh air rates to maximum possible levels
#reduce HVAC recirculation levels to minimum possible levels
#flush buildings with fresh air before and after daily occupancy

The following matrix is intended to guide our design responses for a sample of space types
{| class="wikitable"
|+Risk Response Matrix
!Space Type
!Risk
!Initial Risk
!Engineering Response
!Residual Risk
|-
| rowspan="2" |ICU
|Transmission in ICU
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Low
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Where high risks are associated with adjacent spaces, ventilate ICU in accordance with IUSS Guidelines for Airborne Precaution Rooms
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |Surgeries
|Transmission in Theatre
|Severe
|
#Ventilate in accordance with IUSS Guidelines for ICUs,
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
|Low
|-
|Transmission to Adjacent spaces
|Moderate
|
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rates
##Surgeries on identified COVID-19 patients in negative pressure theatres only.
##No recirculation to adjacent spaces (for negative pressure theatres)
##Ensure compliance with contact, droplet and airborne precautions for staff
##Where high risks are associated with adjacent spaces, ventilate the operating room in accordance with IUSS Guidelines for Airborne Precaution Rooms or sepsis theatres
##Extraction systems to discharge safely at high-level
##Exhaust air decontamination only prescribed for unsafe exhaust locations
|Low
|-
| rowspan="2" |COVID Wards
|Transmission within COVID-19 Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for general wards
#Keep available windows open when safe and secure
#Ensure compliance with contact, droplet and airborne precautions
|Low
|-
|Transmission to Adjacent spaces
|High
| 

#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
##Increase ventilation rates in adjacent areas (passages)
##Positive pressure relative to COVID wards
##Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
##Extraction systems to discharge safely at high-level
|Low
|-
|General wards
|Transmission within and from Ward
|Low
|
#Ventilate in accordance with IUSS Guidelines for General Wards
|Low
|-
|Emergency centre
|Transmission within EC
|High
|
#Reduce number of occupants to only essential staff and caregivers
#Screen and fast-track patients with respiratory illness symptoms
#Isolate persons under investigation for COVID-19
##Isolation rooms ventilated in accordance with IUSS guidance for airborne precaution rooms
|Moderate
|-
|Hospital Waiting Areas
|Transmission within waiting room
|High
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with IUSS Guidelines for Waiting Areas
|Moderate
|-
|Other public waiting spaces
|Transmission within waiting room
|Moderate
|
#Ensure compliance with contact, droplet and airborne precautions for staff and suspected cases
#Reduce waiting time and occupancy densities
#Introduce appointment and automated queueing systems
#Screen and fast-track patients with respiratory illness symptoms
#Relocate waiting areas to outdoors when possible
#Based on a risk assessment of adjacent spaces' occupancy and susceptibility rate
#Keep available windows open when safe and secure
#Ventilate in accordance with Building Regulations
|Moderate
|}

===Airborne precautions for settings with uncertain or high residual risk===
Where the verification of engineering responses are uncertain or the residual risk remains high, the following approach is proposed.

Modelling ventilation rates for limiting transmission risk in the context of the proposed quantum generation rate<ref>Noakes, C. J. & Sleigh, P. A. Mathematical models for assessing the role of airflow on the risk of airborne infection in hospital wards. J. R. Soc. Interface 6, S791–S800 (2009). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843948/</ref> for airborne COVID-19 <ref>Zhao, Dai, preprint 2020, Association of infected probability of COVID-19 with ventilation rates in confined spaces: a Wells-Riley equation based investigation https://doi.org/10.1101/2020.04.21.20072397</ref> supports the conclusion that the COVID-19 ventilation rates should be not less that 59.7 L/s per person for an 8 hour exposure in a 100 seater waiting room, which (coincidentally) matches the WHO's previous recommendations for medium risk spaces and the CDC's adoption of that value for COVID-19 ([[Ventilation and COVID-19#CDC COVID Airborne Precautions|see above]]).
Reducing the exposure time would reduce the required ventilation rate. 8h is assumed to keep staff and patients equally "safe". Obviously additional precautions are recommended for health care staff to control for repeated daily exposure.
A significant problem with the WHO and CDC recommendation of 60 L/s per patient (person) is that an individual's risk increases from 1% to nearly 40% as this criteria is applied to room populations decreasing from 100 persons.

To maintain a personal risk below 1% the following correction is advised:
<math>Q/n = 60 \times \bigl(A/n) </math>
<math>\therefore Q = 60 \times \bigl(m^2 per person) </math>

Where '''Q''' is the ventilation rate <math>(L/s\cdot m^2)</math>, '''A''' is the floor area <math>(m^2)</math> and n is the maximum number of people in the space. Air changes per hour (ACH) can be estimated with <math>ACH = Q \times 3.6 \div h </math>, where <math>h</math> is the ceiling height.

Assuming face masks reduce transmission by 40%, ventilation rates of '''38''' <math>L/s\cdot person</math> would be required to control airborne transmission. This sounds like a lot until the social distancing and decongestion measures required for droplet precautions are applied. under these conditions this equates to only '''4.23''' <math>L/s\cdot m^2</math> or between 4 and 5 ACH (assuming a 3.2m ceiling height). This should be easily achievable for naturally ventilated spaces and could be verified by measuring average indoor CO2 concentrations no greater than '''170 PPM''' above outdoor.

==Conclusion==
Therefore, assuming ventilation systems in South Africa have been designed in accordance with the IUSS guidance, there should be little reason to change their configuration or pressurization unless general areas are repurposed as airborne precaution rooms. Risk assessments should be conducted for ICUs and COVID-19 wards immediately adjacent to public waiting areas or other high traffic areas, with corrective actions including but not limited to reducing occupancy times and rates for these areas and adjusting distancing rules.

 
----

==Notes and References==
[[Category:Reference Desk]]
[[Category:COVID-19]]
[[Category:ICU]]
<references />
[[Category:ASHRAE]]
[[Category:REHVA]]
[[Category:IUSS]]
[[Category:Airborne Infection control]]
[[Category:Airborne Contamination Control]]

Building Engineering Services

2020-12-15T09:19:05Z

Tobyvan: /* 24. VALIDATION OF SPECIALIST VENTILATION SYSTEMS */ Cleaning up of Table 4 (Ventilation)

{{Cleanup}}{{Expand}}

=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===

==='''Context'''===
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.

==='''Design principles'''===
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.
{| class="wikitable"
|+Table 1: IUSS document
!Clinical services
!Essential
!Recommended
!Support Services
!Essential
!Recommended
!Healthcare environment/
Crosscutting issues
!Essential
!Recommended
!Procurement &
Operation
!Essential
!Recommended
|-
|Impatient services
|
|X
|Administration & related services
|
|
|Generic room data
|X
|
|Integrated infrastructure planning
|X
|
|-
|Laboratories
|
|X
|General hospital support services
|
|
|Hospital design principles
|X
|
|Project planning & briefing
|X
|
|-
|Mental Health Services
|
|
|Catering services
|
|
|Engineering design principles
|X
|
|Space guidelines
|
|
|-
|Critical care
|
|
|Laundry and Linen
|
|
|Environment and sustainability
|X
|
|Cost Guidelines
|X
|
|-
|Emergency centres
|
|
|Mortuary
|X
|
|Materials & finishes
|X
|
|Procurement liaison
|
|
|-
|Obstetrics & gynaecology
|
|
|Nursing colleges
|
|
|Future healthcare environments
|
|X
|Commissioning
|X
|
|-
|Oncology
|
|
|Health facility residential
|
|
|Healthcare technology
|
|
|Maintenance
|X
|
|-
|Outpatient services
|
|X
|Sterile supply
|X
|
|Inclusive environments
|
|X
|Decommissioning
|X
|
|-
|Paediatrics
|
|
|Clinical training
|
|
|Infection prevention & control
|X
|
|Capacity development
|
|X
|-
|Pharmacy
|
|
|Waste disposal
|
|X
|Health informatix
|
|
|
|
|
|-
|Primary health care
|
|
|
|
|
|Regulations
|X
|
|
|
|
|-
|Diagnostic radiology
|X
|
|
|
|
|
|
|
|
|
|
|-
|Rehabilitation services
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Surgery
|X
|
|
|
|
|
|
|
|
|
|
|-
|TB
|X
|
|
|
|
|
|
|
|
|
|
|}

Where this document lacks guidance on a topic or appears to contradict the requirements of the guidelines identified above, the guidance of those documents will take priority.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
#*Summaries of collated information
#*Reports on technical feasibility, benefits and risks
#*Reports on regulatory compliance issues
#*Reports on financial feasibility and risks
#*List of consents and approvals required
#*Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

==Design Questions==
6. In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

==Design considerations==

==='''7. Deep buildings'''===

#Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

==='''8. Plant and plant room size and location'''===

#Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.
#Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities. Plant rooms shall be located away from possible heat and contamination sources.
#Plant rooms shall be located in an accessible area which is secured from unauthorized entry
#Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

==Life cycle cost determination==
9. When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

10. Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

==Site-survey requirements==
11. In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

==Maintenance Considerations==
12. Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

13. The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

14. In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.

15. For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

==Planning for Retrofitting & Decommissioning==
16. While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

17. Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

18. When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

19. A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

20. Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

21. For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

==Sustainability & Environmental Measures==
===Design Life cycle===

Sustainability in designs for new health facilities can be addressed through the following steps:

'''22. Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.

'''23. Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.

'''24. Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.

'''25. Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.

'''26. Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.

'''27. Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

28. Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''PART - DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating Ventilation and Air-conditioning===
===Airborne-Precaution Risk Classification for Healthcare Zones===
South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for out-patients is common practice in South Africa.
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo convective or buoyancy effects and wind pressure. Since the drivers of Natural ventilation are inherently variable, natural ventilation has a high variability in effectiveness.

2. In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space could have a negative impact on the variability of the ventilation system’s performance by opening and closing windows and doors. For this reason it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controllable ventilation openings be designed and created in the building

3. For additional design guidance on natural ventilation design, the CIBSE Applications Manual AM10 or similar can be consulted.

4. Peak and minimum internal temperatures should be calculated or modelled thermally for a space, for summer and wintertime respectively.

5. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

6. The following design interventions should be considered for implementation, singly or in combination, in the following hierarchy where the internal design condition cannot be met:

*Reducing solar and internal heat gains
*Using thermal mass to move room temperature extremes to outside of occupancy periods.
*Change occupancy schedules seasonally to improve indoor comfort conditions. (eg. Shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
*Introducing passive cooling or heating strategies
*Increasing ventilation rates
*Providing mechanical cooling or heating

7. Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed mode ventilation shall be considered as a solution preferred over full mechanical ventilation.

8. Mixed mode ventilation is considered as an assisted type of natural ventilation. Here fans are used in combination with damper controlled ventilation openings to ensure minimum ventilation rates are achieved.

9. Where mixed mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

===Mechanical ventilation and air-conditioning===
10. Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.

11. The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====12. Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====13. Zoning of a building=====
13.1. Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:

#Fire compartmentalization
#Air-handling unit (AHU) sizing
#Duct sizing
#Occupancy schedules
#Occupancy activity levels
#Building, environmental and equipment heat loads
#Airborne contamination control
#Tenancy, functional unit or utility metering

13.2. Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====14. Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.

=====15. Ventilation rates=====

#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant

=====16. Supply-only vs balanced ventilation systems=====

#Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

=====17. Airborne contamination-control concepts=====

#Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

#The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

#The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 
#The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 
#The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²).

17.4. Where ventilation rates and fresh air proportions are described within these guidance documents they are to serve as guidance values only. It is the responsibility of the designer to ensure that the ventilation rate selected is appropriate for the specific zone’s operational conditions, occupancy, contamination rates, pressurization, leakage rates, ventilation efficiency and external ambient conditions to achieve the desired airborne contamination and bio-burden levels. Ventilation rates higher or lower than the guidance values may achieve the desired conditions.

 

====='''18. AIR HANDLING UNITS AND FANS'''=====
18.1. GENERAL

#AHUs and fans shall be protected from adverse weather and wind sources which may upset their performance or reliability.
#A detailed name plate shall be included on the air handling units with manufacturer, design air volume, fan speed, cooling capacity, filter data and heating capacity.
#The air handling unit shall include individual differential pressure gauges over each installed filter bank. The gauges shall measure the pressure differential between upstream and downstream of the filter banks. The filter designation and design filter change pressure shall be neatly and clearly marked on each gauge.
#Air-handling units functioning in an airborne contamination control system, and demanding prescribed airflow rates, shall be provided with an electronic control system including variable frequency controllers with direct fan drives to automatically maintain design airflow for all filter conditions. The fans and drives will be selected to maintain design flow rates with all filters at maximum rated pressures.
#Where a ventilation system performs a critical role, air handling units shall have separate electrical distribution boards (Essential and Non-essential). The fan will be on essential power and heater elements may be on non-essential power.
#All compartment doors on the air handling unit shall be clearly labelled
#Where systems require duplicate standby fans or air-handling units these shall be installed with backdraught dampers, sufficiently air-tight for the application (eg EN1751 Cat 3 or 4). Special design and control consideration shall be given to limiting the build-up and dwelling of contaminants in the standby unit.
#AHU’s should be placed in easily accessible plant rooms with sufficient space for maintenance. Access stairs to the plant rooms should permit a technician to easily carry replacement parts or a toolbox into the plant.AHU’s located in ceiling voids are not appropriate or conducive to good operational management.
#AHUs should be designed for a working life of 20 - 25 years
#AHUs shall be designed and positioned such that the largest components, including heating and cooling coils, can be removed and replaced.
#AHUs greater than 1m wide should have hinged access doors large enough to provide full entry. Doors shall be unlockable and openable from the inside of the unit.
#Fan and filter plenums shall be provided with internal illumination and viewing portals such that internal components can be visually inspected without stopping or opening the unit.
#AHUs shall be designed such that dry steam humidification devices can be retrofitted into the systems with minimal disruption and without compromising its performance.
#Ventilation components shall have a drainage or condensate pumping system if they can produce moisture. Drip trays shall be of a corrosion resistant material and drainage systems shall have a 1:20 fall away from the unit in all directions. The unit shall have its own drain trap which shall be sized such that it can function at the fan's full static pressure. The first 3 meters of a dedicated condensate drainage line shall be insulated to prevent condensation within the plantroom. Where a condensate drain services a negative pressure plenum, clear air gaps of 15mm or anti-backflow devices are recommended at the trap discharge into the drainage system.
#Drop stop eliminators in stainless steel frames shall be employed, if fin spacing is less than 10 fins per inch, after the cooling coils in areas with high humidity levels. This includes all coastal areas for off coil temperatures of 10° and less
#In full fresh air systems, primary filters may be situated at the fresh air intake opening of the air-handling unit only if the climate does not require anti-fog or de-icing coils.
#Cooling or heating coils will be protected by a pleated primary filter, rated in accordance with SANS 1424, as minimum.
#In recirculation air systems, primary filters will be situated after the fresh/return air mixing plenum. This arrangement will ensure that blinding filters don’t inhibit the prescribed fresh air proportion.
#The final stage of filters on units serving operating theatres must be located after the supply fan chamber to filter any debris that might come from the fan chamber. HEPA filters should be protected from this potential dust and debris.

 

=====18.2. AIR EXTRACTION SYSTEMS=====

#The design of exhaust systems shall take special consideration of the potential for re-entrainment of contaminated exhaust air into air intakes through, inter alia, openable windows. Where this potential exists, precautionary measures such as aerosol or chemical filtration of exhaust should be applied, as appropriate.
#Single ablution facilities serving private wards or staff do not require extract ventilation, provided there are windows openable to outside.
#Extract ventilation shall be provided by either ceiling extract grilles connected to an in-line ducted fan with outside discharge air grilles by means of galvanized mild steel or PVC tubular ducting or odour extraction system.
#Extract grilles may be of the PVC type with adjustable disc valves, or powder coated or anodized aluminium type with adjustable dampers.
#All multiple toilets shall be provided with ventilation systems, which will serve as an extract ventilation system.
#Single toilet facilities serving private wards for staff do not require extract ventilation, provided there are windows openable to outside
#Where it is not considered safe to enter a space without respiratory protection, the air exhausted from that space should be rendered safe through filtration, decontamination or dilution before discharge.
#The design of exhaust system from airborne precaution areas should be such that all components can be safely maintained during normal service and safely disposed of at decommissioning.
#Planning for disposal of contaminated filters should be as for all biohazardous material.
#Filtration and decontamination components shall be installed upstream of fans, monitoring and control devices.

=====18.3. ENERGY RECOVERY SYSTEMS=====
1.3.1. Where full or partial exhaust is required for ventilation systems, energy recovery technologies should be considered. Enthalpy wheels offer a high level of efficiency but introduce a risk of cross infection as the wheel is exposed to both the exhaust and supply airstreams. An enthalpy or energy recovery wheel may only be used if pressure and filtration measures are taken to ensure it is not a potential source of cross infection or re-infection. Energy recovery wheels incorporating purge sections have a markedly reduced efficiency and are not considered to provide sufficient protection against biological cross contamination. Where cross infection is a considered risk, the following conditions shall be met.

#The exhaust airstream shall be consistently maintained at a lower static pressure than that of the supply airstream.
#The exhaust air shall be filtered with aerosol filters upstream of the energy recovery device.
#Levels of filtration, redundancy and safety shall meet the requirements of the biological pathogenicity class in consideration.

=====19. '''FILTRATION'''=====

#With the exception of the few specialist areas with aero-biological requirements, the primary purpose of filtration is to protect ventilated spaces and ventilation equipment from dust build-up.
#When designing filtration systems serving spaces with a high airborne cross contamination risk, consideration should be given to the safety of maintenance staff that may be required to handle contaminated filters. Where any safety risk is present, contaminated filters should be installed in safe-change or decontaminatable housings.
#All ventilation filter banks should be installed with a means of visually checking the filter pressure across them in Pascals (Pa)
#Filters are classified as being General Fine or Aerosol filters and are to be specified in accordance with the SANS 1424, EN779 or EN1822.
#General filters are selected to remove particles large enough to block cooling and heater fins and settle out of the airstream into the air distribution system. General filters are graded in terms of their “synthetic dust weight arrestance”. General filter grading ranges from G1 to G4. G3 and G4 filters are appropriate for primary air intake and tempered air supply respectively. General filters are not appropriate for combating airborne cross-contamination control.
#Fine filters are selected to keep a ventilated space visibly clean and for the protection of HEPA filters. Fine filters are graded in terms of their “Dust Spot Efficiency” from M5 to F9. F9 filters are capable of arresting particles with the approximate size of some bacteria and can be used for low level cleanrooms (ISO 14644-1 Class 8).
#Aerosol filters are selected for their efficiency in arresting sub-micron particles. They are graded in accordance with their “Most Penetrating Particle Size” (MPPS). Aerosol filters are subdivided into three categories: Efficient Particulate Air (EPA) and High Efficiency Particulate Air (HEPA) and Ultra high Particulate Air (ULPA) Filters in accordance with the EN1822:2009. The table below describes the classification of aerosol filters by integral and local values as defined in the EN1822. SULPA filters are not discussed within this document.

{| class="wikitable"
|+{{Anchor|Table_Filter_Classification}}'''Filtration Classification'''
| rowspan="2" |'''Group'''
| rowspan="2" |'''Filter Class'''

'''EN1822'''
|'''Integral Value'''
|'''Local Value'''
|-
|'''Efficiency %'''
|'''Efficiency %'''
|-
| rowspan="3" |'''EPA'''
|'''E10'''
|85%
|<nowiki>-</nowiki>
|-
|'''E11'''
|95%
|<nowiki>-</nowiki>
|-
|'''E12'''
|99.5%
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''HEPA'''
|'''H13'''
|99.95%
|99.75%
|-
|'''H14'''
|99.995%
|99.975%
|-
| rowspan="3" |'''ULPA'''
|'''U15'''
|99.9995%
|99.9975%
|-
|'''U16'''
|99.99995%
|99.99975%
|-
|'''U17'''
|99.999995%
|99.999975%
|}
8. HEPA filter installations shall include both an upstream challenge aerosol injection port and a downstream scan port to facilitate filter challenge testing. ULPA filter installations shall be designed such that an agreed upon test method can be accomplished.

9. All filters used for airborne precaution rooms, theatres or other areas with a high airborne contamination risk shall be selected with a construction suitable for incineration. These filters shall not contain PVC.

10. The installation and testing of HEPA filters shall only be conducted by suitably qualified technicians.

11. HEPA filters shall be specified to be compliant with the requirements of EN1822. Each HEPA filter is to be supplied with an individual factory test certificate displaying that filter's serial number, MPPS rating and DOP arrestance rating.

12. Type-test certificates are only acceptable for EPA and not HEPA filters.
 

=====20. '''HEAT REJECTION EQUIPMENT.'''=====
20.1. The location of heat rejection equipment shall be planned such that it does not adversely affect the performance, maintenance or reliability of any related or unrelated equipment, or pose an avoidable health risk.

20.2. The use of evaporative cooling towers shall only be considered where:

#Space, system capacity or efficiency demands their use.
#An effective plan for the [[Legionella Control|control of legionella]] must be developed and implemented.

 

=====21. '''AIR DISTRIBUTION SYSTEMS'''=====

#Discharge from extraction systems shall be located such that contaminated air does not get drawn into any system's air intake of get re-entrained though openable windows.
#The use of internally insulated ducting is not appropriate as internal linings will perish and slough off with aging. Particles from duct linings contaminate final filters and ducting components.
#Flexible ductwork is unsuitable for air distribution in healthcare applications. It should only be used for the final connection to an air terminal and then kept to less than 1.0m. Bends in flexible ductwork should be avoided.
#The use of dampers to throttle a deliberate oversupply of airflow should be avoided. Balance by design is preferable although this will not necessarily reduce the total fan pressure. Use of adjustable blade dampers should be kept to a minimum as these items may drift, can be tampered with and increase the complexity of commissioning. The use of constant volume dampers may improve stability of volume critical systems but may also mask inefficient design and be the source of increased system noise.
#Cleaning and access doors are to be installed in all air distribution ductwork to facilitate:

*Cleaning
*Inspection
*Measurement
*Maintenance

21.6. Ductwork installations shall be designed, built, installed and commissioned in accordance with SANS 1238: Air-conditioning ductwork and SANS 10173: The installation, testing and balancing of air-conditioning ductwork
 

=====22. '''ELECTRONIC CONTROLS'''=====

#Location of sensors in ventilation systems should ensure that the temperature and humidity measurement for monitoring control is representative of the occupied area
#The humidifier control will include humidity monitoring of the mixed airstream downstream of the humidifier lance and shall prevent this airstream from approaching dew point.
#The use of variable speed drives (VSD) can save energy in systems operating under varying motor loads. Reducing the fan speed when filters are new or clean can result in considerable energy savings over the life of a system. Reliability of smaller sized VSDs is a potential drawback, and for this reason VSDs must be selected and sized for high service life. VSDs should also be installed such they can be bypassed and the system can be run in manual control while failed VSDs are replaced or repaired. When designing with variable speed drives, cognisance should be taken of a motor’s minimum cooling requirements and the maximum restart rate. Caution should be exercised where variable speed drives are used in conjunction with constant volume dampers or volume flow controllers. This combination could drive up total system pressure where duct total pressure as opposed to velocity pressure is used as control feedback. Additional requirements for the selection of drives for variable air volume (VAV) fans is described in SAN204:2011
#Plant control systems should incorporate start-up and shut-down sequencing logic to prevent flow reversals and overheating.
#Set-back controls should be considered for spaces that have intermittent occupancy. This feature should be used with caution in specialist areas as poorly considered set-back conditions could compromise containment or contamination control.
#Where more than one ventilation system serves a department, system interlocks may be required to prevent unwanted airflow reversals during system shutdown or failure.
#Operational status indicators should be displayed locally in areas served by ventilation systems.
#"Low Air Flow" and "Plant Failure" alarms should also be installed in a location which can be manned by relevant and trained staff.
#Electronic control systems should be developed using recognised open protocols and standards such as BACnet DeviceNet, LonWorks, Modbus, SOAP and XML.

=====23. '''SPECIALIST VENTILATION SYSTEMS'''=====
23.1. The following areas will require specialist ventilation systems:
 
'''Table''' '''3 Specialist Ventilation Systems'''
{| class="wikitable"
|'''Department Name'''
|'''Ventilation system type'''
|-
|Operating departments
|Clean and Ultra clean ventilation systems: ISO8 to ISO5 & UDAF
|-
|Obstetrics
|Clean ventilation systems ISO8
|-
|High care, Critical Care and Intensive Care
|Fine filtered ventilation or Clean ventilation systems: Unclassified - ISO8
|-
|Isolation units
|Negative pressure ventilation, no recirculation
|-
|Pathology labs
|Biosafety ventilation: (BSL2 – BSL4)
|-
|IVF Labs
|Clean ventilation systems: VOC Filtration
|-
|Burns units
|Clean ventilation systems/ Negative pressure ventilation/ RH control
|-
|Neonatal Units
|Dedicated ventilation systems/ RH control
|-
|Mortuary unit
|Cold Rooms/ Extraction systems/ Odour Control
|}
23.2. Broad requirements for these systems are in this document. The engineering team shall consult each department’s specific design guidance document for detailed requirements.
 

=====23.3. '''AIRBORNE PRECAUTION ROOMS (INCLUDING TB)'''=====

#Where specific diseases are considered in the design of an airborne precaution room, the US CDC's "Select Agent List" may be consulted for design guidance until a South African list is compiled.
#Airborne precaution rooms shall be ventilated with a minimum of 12AC/h of fresh air or uncontaminated air. High risk areas such as sputum booths and airborne diseases wards shall have a nominal ventilation rate of 80 ℓ/s per person..
#Medium Risk areas such as congregate spaces such as waiting areas shall have a nominal ventilation rate of 60ℓ/s per person.
#Mechanical ventilation may be employed to achieve the minimum ventilation rates. It should be noted that very high ventilation rates can be achieved by employing a well-considered natural ventilation design. Consideration may also be given to mixed mode ventilation systems, which combine mechanical and passive ventilation and temperature control. An open window policy may therefore be adopted, with careful consideration of all the associated cross infection risks and management challenges.
#Airborne precaution rooms shall be designed so as to provide thermal comfort. Where occupants have freedom in location and dress code, an adaptive thermal comfort model should be adopted. Heating, cooling and energy recovery devices shall pose no risk of harbouring pathogens or increasing the cross infection risk.
#Air from the airborne precaution rooms shall not flow into adjacent, uncontaminated rooms or adjacent airborne precaution rooms. Air shall not flow from a room with a higher airborne infection risk category to a room with a lower risk category.
#Ventilation ducting and pipe work shall not form a conduit by which pathogens can transfer from one zone to another whether the ventilation system is running or not. Filtration devices and anti-backflow devices may be employed provided these do not pose a risk of infection to maintenance staff.
#Filtration requirements for supply and exhaust air should follow the bio-containment requirements of that select agent being contained.
#The location of supply and air terminals should be such that the airflow patterns generated within the room serve to suppress and remove airborne particles.
#For general waiting areas or where the pathogens are known and unlikely to pose an environmental risk, exhaust air filtration may not be required provided exhausted air is directed 3m away from open-able windows and air intakes and there is no risk of re-entrainment of this air. See section 18.2.
#Commissioning and validation shall be well planned, diligently executed, fully documented and approved by suitably experienced professionals. It is advisable to have the validation process conducted or approved by a party independent of the designer and installer.
#Numerical or physical modelling may be of value in the design and validation process.

 

=====23.4. '''OPERATING THEATRE VENTILATION DESIGN'''=====
23.4.1. GENERAL REQUIREMENTS

#Constant volume systems shall be employed to maintain the correct pressure with respect to any adjoining rooms. The contamination control concept shall be developed in accordance with ISO14644-4
#Temperature range shall generally be 18°C to 24°C with a minimum relative humidity of 45% unless otherwise specified
#A pressure differential of 10-15Pa is to be maintained between the theatre and adjacent rooms when all doors are closed.
#Theatres may be maintained at a room pressure positive or negative to the adjacent rooms depending on the contamination control requirements.
#A theatre’s room pressure shall always be positive relative to technical spaces.
#Negative pressure theatres should not employ recirculation of room air.
#Fresh air requirements are 5-7 Air Changes per hour to satisfy the occupancy requirements
#Additional fresh air may be required for pressurisation and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurisation at the greatest possible energy efficiency.
#Separate temperature controls in each theatre are to be provided.
#No manual on and off switching of air handling plant to be done from within the theatres.
#Automatic motion sensors / thermal sensors to ensure that the units are switched on when there is a presence in the theatre. Theatre ventilation switching may be linked to the theatre unit’s lights.
#Automatic switching of ventilation system to incorporate run-on timers to prevent overheating and accidental shutdown.
#An additional override to be used to switch the units on when the temperature in the theatre exceeds 25°C for the protection of stored medicine
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums.
#These validation tests shall be performed in accordance with SANS 14644Parts 1, 2 and 3 at the recommended intervals (SANS 14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#No internal ducting insulation is permitted.
#In multi theatre suites it is advisable to have dedicated AHUs per theatre. [[Building Engineering Services#%20msocom%201|[TR1]]]

23.4.2. UNIDIRECTIONAL AIRFLOW OR ULTRACLEAN THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 5 under protected zones (UDAF and Setup area) and ISO 14644-1 Class 6 in background and ancillary areas. These conditions are to be achieved under operational conditions.
#Temperature range shall generally be 18°C to 24°C and relative humidity 45% to 60% unless otherwise specified
#Ultra-clean theatre ventilation shall not be completely shut down when unoccupied unless required for maintenance interventions. Ventilation systems serving UDAF plenums shall instead switch to a minimum velocity set-back mode to prevent contaminants settling underneath the UDAF screens.
#Delivery of the conditioned air shall be by downward movement from the ceiling to four low level exhaust outlets located near the corners.
#All ductwork between HEPA filter housings and air terminals shall be high pressure rated and constructed of galvanised sheet metal. In the final connection to the terminal, where alignment necessitates, a maximum of 300mm of thermally insulated, high pressure flexible ducting may be used.
#The Air Conditioning system is to be complete with G4 primary, F9 secondary and H13 HEPA Filters.
#The ventilation systems shall be designed with a mean air velocity of between 0.35 & 0.45 m/sec measured below the UDAF screen and at the working height.
#Refer to ISO14644-4 for guideline ventilation rates for balance of areas.
#The mean velocities below the UDAF screen and at the working height shall not differ by more than ±10%
#A standard size of the UDAF screen is 2400 x 2400mm. The required size could vary dependent on the layout and function of the operating theatre.
#The protected zone below the UDAF plenum shall be clearly demarcated on the floor

23.4.3 CLEAN OR MAJOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 6 in all areas. These conditions are to be achieved under operational conditions.
#The ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#The conditioned air is to be introduced into the theatre via suitable diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#Additional fresh air may be required for pressurization and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurization at the greatest possible energy efficiency.
#These validation tests shall be performed in accordance with SANS 14644 Parts 1, 2 and 3 at the recommended intervals (ISO14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.

23.4.4. MINOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 8 in all areas. These conditions are to be achieved under operational conditions.
#For recirculation systems the ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#For single pass systems the ventilation system is to include G4 Primary and F9 Secondary filters.
#The conditioned air is to be introduced into the theatre via suitably sized diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums. 

====='''VALIDATION OF SPECIALIST VENTILATION SYSTEMS'''=====

# Validation testing shall be completed in accordance with national standards for standardized tests (eg ISO14644 and ISO 14698 for cleanrooms) and shall be completed against mutually agreed protocols for non-standard tests.
# It essential that the validation testing of a ventilation system’s contamination control performance parameters is conducted against operational, and not only "at-rest", conditions. Validation against "as-built" conditions offers little insight into the ultimate performance of the system.
# Pre-Commissioning Checks shall cover the following aspects prior to the commencement of formal commissioning:
## Check whether the Design Specification satisfactorily addresses the demands of the User Requirement Specification.
## Check whether the ventilation systems have been provided and installed in accordance with the design specifications and drawings
## Check that the buildings either housing or served by the ventilation equipment is complete and finished such that testing can commence safely and effectively.
## Check that all AHUs, chillers, heat rejection equipment and filters are sufficiently accessible for inspection and maintenance.
## All components are connected and are functional
## Door gaps and openings are installed and sized as specified in specialised zones
## Airflow control devices are installed in the correct locations and in the correct orientation
## Duct and filter tests ports are installed and sealed satisfactorily
## Safety and control interlocks are established
## Fan and drive guards are in place
## Safety and warning signs are in place
## All major system components or sub-systems are clearly labelled with functional or controls identification in a neat and durable fashion.
## Fluid and air pressure monitoring gauges are labelled with identification and acceptable maximum and minimum operating conditions.
## All wiring, piping and ducting colour banding is complete in accordance with SANS-1091
# CLEANLINESS CHECKS:
## AHUs shall be checked for cleanliness on internal plenums with special attention being paid to fan and discharge plenums and condensate drip trays and drain lines.
## Ducting serving “clean” areas shall be cleaned prior to installation and the ends shall be sealed until installation. Open ends of duct runs shall similarly remain sealed during construction. Spot checks for compliance during the installation process are recommended.
# Recommended Filtration Levels and Ventilation Rates for Mechanically Ventilated Areas

This table serves as a quick reference guide and will be revised as and when detailed room data sheets are developed within each department’s guidance documents.
{| class="wikitable"
|+{{Anchor|Table_Room Ventilation Requirements}}'''Room Ventilation Requirements'''
| rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation'''[[Building Engineering Services#BESftn1|[1]]]''''''

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range'''[[Building Engineering Services#BESftn2|[2]]]'''
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|Casualty/Minor Stitch Procedure room
|X
|
|X
|
|T
|
|
|7.5
|20
|
|-
|Theatres: Maternity/Caesarean
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: General Surgery
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Gynaecology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Ophthalmology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Urology
|X
|
|X
|'''X**'''
|T
|NA
|7
|10
|20
|
|-
|Theatres: Endoscopy
|X
|
|X
|'''X**'''
|T
|NA
|7
|80
|20
|
|-
|Theatres: Plastic Surgery
|X
|
|X
|X
|T
|6
|7
|7.5
|70***
|
|-
|Theatres: Bone Surgery/Orthopaedic
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Thoracic
|X
|
|X
|X
|M
|5
|7
|80
|70
|
|-
|Theatres: Vascular???
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Neuro Surgery
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Waiting and Congregate Areas
|X
|
|
|
|
|
|
|60
|8
|18-28
|-
|Auditoriums
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Mortuary
|X
|X
|
|
|
|
|
|
|12
|22-25
|-
|Bath Room
|
|
|
|
|
|
|
|25
|10
|N/A
|-
|Dirty Utility Room
|
|
|
|
|
|
|
|40
|10
|N/A
|-
|Blood Bank
|X
|
|
|
|
|
|
|
|4
|22-25
|-
|Casualty
|X
|X
|
|
|
|
|
|7.5
|12
|22-25
|-
|CSSD
|X
|X
|
|X
|
|
|
|7.5
|20
|22-25
|-
|Dark Room
|X
|
|
|
|
|
|
|
|10
|22-25
|-
|Dining Rooms/Canteens
|X
|
|
|
|
|
|
|7.5
|10
|18-28
|-
|General Stores
|X
|
|
|
|
|
|
|
|4
|N/A
|-
|Laboratories
|X
|X
|
|
|
|
|
|
|6
|22-24[<nowiki/>[[Building Engineering Services#BESftn3|3]]]<nowiki/>
|-
|Labour/Delivery Room
|X
|
|
|
|
|
|
|
|4
|22-24
|-
|Laundry – General
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Lecture Halls
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Outpatients Departments
|X
|
|
|
|
|
|
|60
|4
|18-28
|-
|Pharmacy Dispensing
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Pharmacy Store
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Specialist Clinics- ENT
|X
|X
|
|
|
|
|
|7.5
|4
|22-26
|-
|Sterilizer Equipment
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Toilet Room
|
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Units: Treatment Room
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|-
|Units: Burns
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|-
|Units: HCU / CCU
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU Neonatal
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|-
|Wards: General
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|-
|Wards: Airborne Precaution Rooms/Isolation'''[[Building Engineering Services#BESftn4|[4]]]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|-
|Wards: Maternity
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Medical
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Paediatric
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|-
|Wards: Psychiatric
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|-
|Wards: Orthopaedic
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: Surgical
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: TB
|X
|
|
|
|
|
|
|80
|12
|20-28
|-
|Radiology: General
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|-
|Radiology: Airborne Precaution
|X
|
|X
|
|
|
|
|60
|6
|22-24
|-
|Radiology: MR/CT

Scanner
|
|
|
|
|
|
|
|60
|6
|2-24
|}
{{Anchor|BESftn1}}[[Building Engineering Services#%20ftnref1|[1]]] These rates are considered for forced ventilation systems only. Average natural ventilation rates may be higher

{{Anchor|BESftn2}}[[Building Engineering Services#%20ftnref2|[2]]] Temperature range not to be exceeded for more than 50 hours per year.

{{Anchor|BESftn3}}[[Building Engineering Services#%20ftnref1|[3]]] Specialist cleanrooms and laboratories may require lower temperatures.

{{Anchor|BESftn4}}[[Building Engineering Services#%20ftnref1|[4]]] Levels of filtration are dependent on pathogenicity. Exhaust filtration may also be required.

====== Commissioning tests shall include and record, but not be limited to: ======
{| class="wikitable"
|'''System'''
|'''Commissioning Test'''
|'''Special Instructions'''
|-
|'''All'''
|Standard of installation
|Test to be authorised by client's representative.
|-
| rowspan="7" |'''Air Handling Units and Fans'''
|Fan motor drive speed and rotation.
|Cognisance should be taken of motor cooling requirements
|-
|Fan motor current draw.
|<nowiki>-</nowiki>
|-
|HEPA Filter challenge testing.
|In accordance with ISO DIS 14644-3
|-
|AHU heating and cooling coil performance
|Report on-coil and off-coil air conditions for full heating and full cooling with no air bypass.
|-
|AHU leakage tests
|<nowiki>-</nowiki>
|-
|Heating and Chilled Water circuits have been charged, dosed and pressure tested
|<nowiki>-</nowiki>
|-
|Flow rates and pressures across heat exchangers, pumps and compressors
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="2" |'''Room conditions'''
|Airflow and room pressure balancing in accordance with design tolerances.
|In accordance with ISO DIS 14644-3 Acceptance criteria Normally +10-0%
|-
|Room Temperature and humidity
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''Air Distribution systems'''
|Dampers and registers shall be locked and marked after balancing
|<nowiki>-</nowiki>
|-
|Duct leakage tests for medium and high pressure ducting in accordance with SANS 10173 or DW/143 requirements, as agreed upon
|<nowiki>-</nowiki>
|-
|'''Water Distribution Systems'''
|Pressure Drops and Flow Rates
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="4" |'''Control System'''
|Control system loop and function checks
|<nowiki>-</nowiki>
|-
|Alarm Checks
|<nowiki>-</nowiki>
|-
|System Start/Stop sequencing checks
|<nowiki>-</nowiki>
|-
|System Set-Back mode checks
|Include room condition and contiguous system impacts
|}

24.7. Select validation tests shall be conducted at intervals defined by the client:
 
{| class="wikitable"
|'''Tests'''
|'''Required/ Optional'''
|'''Recommended Frequency of testing'''
|'''At-Rest or In-Operation Testing'''
|-
|'''Airflow volume tests'''
|Required
|12 months
|At-Rest
|-
|'''Airflow visualization'''

'''(Airborne precaution rooms)'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Velocity Tests'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Airflow Visualisation'''
|Required
|6 Months
|At-Rest & In-Operation
|-
|'''Room pressure tests'''
|Optional
|3 Months
|At-Rest & In-Operation
|-
|'''Airflow direction tests'''
|Required
|1 Month
|At-Rest & In-Operation
|-
|'''Discreet practice counts'''
|Required
|12 Months
|In-Operation
|-
|'''Bio-burden testing'''
|Required
|1 Month
|At-Rest
|-
|'''Filter challenge testing'''
|Optional/Recommended
|24 Months
|At-Rest
|-
|'''Room Condition recovery'''
|Required
|24 Months
|In Operation
|}
24.8. Prescribed validation reports shall include:

*References to the test protocol
*Acceptance criteria
*Test results
*Test equipment identification and calibration status
*Name and signature of tester
*Name and signature of facility representative
*Dates of test and acceptance by client

===Medical gas installations===
25. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

26. All units of a health establishment, except sub-acute and hospice facilities, where patients are accommodated and treated, must have medial gases and vacuum provided by medical grade piped services, with indexed terminal connecter points. Bottle systems may be provided in sub-acute and outpatient facilities.

27. Mobile gas services must be available for crisis situations.

28. Sub-acute facilities must have one mobile oxygen cylinder per 10 patients and one suction machine for every 10 patients.

29. The minimum services to be supplied to all Acute Care areas are described in Table 11.1. Should the data in this table be in conflict be the table presented in the individual departmental design guidance documents, those individual guidance documents take precedence.
{| class="wikitable"
|+Table 5 Minimum gas services
!'''Description'''
!
!'''Oxygen'''
!'''HP Air'''
!'''LP Air'''
!'''N2O'''
!'''VAC'''
!'''Scavenging'''
|-
|'''Major Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Minor Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Cath Lab8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|1
|
|
|1
|1
|1
|-
|'''Post Op'''
|'''Bedhead'''
'''Trunking'''
|1
|
|1
|
|1
|
|-
|'''Procedure'''
'''Room'''
|'''Theatre Panel'''
|1
|
|1
|
|2
|
|-
|'''Resuscitation Bay'''
|
|1
|
|1
|
|2
|
|-
|'''Delivery Room'''
|
|2
|
|1
|
|2
|
|-
|'''High Care Unit, Per Bed'''
|
|1
|
|1
|
|2
|
|-
|'''Intensive Care Unit Per Bed'''
|
|2
|
|2
|
|2
|
|-
|'''Casualty Per Bed'''
|
|1
|
|1
|
|1
|
|-
|'''Wards'''
|
|'''1 per'''
'''2 beds'''
|
|
|
|'''1 per'''
'''2 beds'''
|
|}
30. A gas alarm system to monitor gases, excluding scavenging, must be installed in a location that is manned 24 hours per day. A slave panel must also be installed in the intensive care unit and in the theatre complex. This alarm system must be connected to UPS.

31. All piped vacuum and oxygen systems must have mobile back-up systems with adequately trained staff to handle them. . The back-up service shall be automatically activated if the line pressure drops below the set operating pressure. All back-up services and change-over valves shall be on UPS and diesel generator supplies.

32. Medical air (low pressure) for respiratory purposes must be provided at a fixed pipeline pressure of 400 kPa. Medical air (high pressure) for driving surgical power tools must be provided at a terminal usage pressure between 70 0kPa and 1000 kPa, depending on the tools/equipment to be used. ICU and operating rooms must be provided with a back-up system for both low and high pressure service. Air compressors must be fed off standby power supply.

33. Anaesthetic gas scavenging, which is a low-pressure suction system that removes exhaled anaesthetic gases from the patient circuit must be provided. Each outlet point must have its own balancing valve to allow the system to be balanced progressively from the furthest outlet point towards the suction fan or pump.

34. The vacuum installation shall comply with SANS 7396-1. Vacuum liquid bottle traps must be installed to collect any blood/fluid etc. that may be drawn into the pipeline. One bottle trap per operating room, ICU, ward block and other patient unit, must be supplied. Where possible the vacuum trap should be located in a sluice room. Emergency suction facilities must be provided in the ICU and High Care, operating rooms, recovery room, delivery room, emergency unit and nursery, and must be available to all patient rooms. Bacteria filters must be installed in the vacuum main before the vacuum reservoir and pumps. Used filters are considered a bio-hazard and must be handled accordingly when being changed and disposed. Care must be given to the location of the exhaust discharge of vacuum plants taking into account locations of windows and other air inlet points. Vacuum pumps must be fed off standby power supply.

35. Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.

36. Gas service outlets to be identified and colour-coded with 3mm lettering.

37. Should compressed air operated autoclaves be employed, High Pressure medical air may be taken to such equipment, provided the system possesses sufficient capacity.

38. Should pendants requiring compressed air for aid of movement be employed, High Pressure Medical Air may be taken to them, provided the system possesses sufficient capacity.

39. Should Health Technology Workshops require medical gas outlets for testing and servicing of medical equipment, the required service may be taken to them, provided the system possesses sufficient capacity.

40. SANS 7396-1, as amended, specifies the requirements from design to commissioning of medical gas and vacuum systems

41. Medical gas and vacuum pipelines shall be marked in accordance with SANS 7396-1 and ISO 5359 as applicable

42. SANS 7396-2, as amended, specifies the requirements from design to commissioning of anaesthetic gas scavenging disposal systems.

43. Colour coding of anaesthetic gas scavenging disposal system shall be red magenta or in accordance with the national standard. An example of red magenta is 3050-R40B, in accordance with SS 01 91 02.(Refer to SANS 73962-2).

44. Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.

45. SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.

46. Plain ended copper tubing for low pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.

47. Laboratory gas taps and valves shall be marked as described in SANS 10140-4

===Electrical installations===

====48. Lighting in Hospitals ====
48.1. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

48.2. Within the available scope presented in the National Building Regulations, the following lighting requirements should be interpreted with the aim of maximum energy and cost efficiency. The following innovations could be adopted to achieve this aim:

#Daylight harvesting with passive building elements and active systems response.
#Adoption of task lighting, where appropriate, within the scope of present and future planned activities.
#Considered selection of lighting elements and solutions.
#Considered selection of internal colours and materials.
#Accommodation for visually impaired occupants.

48.3. Where a requirement for natural light (daylight) is stated, this may be met if the room opens onto an atrium or courtyard, or if a roof light is incorporated, provided that privacy within the room or space is maintained. In addition, daylight may be borrowed from an adjacent room by means of glazing the wall in between, provided that the adjacent room or corridor is within the same unit.

48.4. Save where otherwise provided for in the requirements, health establishments must comply with the following: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table 6 Levels of Indoor Lighting (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings)'''
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''

'''/ lux'''
|'''Max. point illuminance/ lux'''

'''(not to be exceeded)'''
|'''Unified'''

'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''

'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Common areas'''

- changing room

- chapel

- classroom

- consulting room (general)

- care room (deep plan)

- day room

- disposal (clinical, domestic waste)

- doctor’s office

- domestic services room

- drug store (ITU/HDO)

- general office

- seminar room

- seminar room

- staff change

- staff rest room

- utility room (clean)

- utility room (dirty)
 
|

100-150

100-150

300

300

300

200

200

500

100

500

300

100-150

300

100

50/200

150

200
 
|

n/a

n/a

520

520

520

350

350

850

170

850

520

n/a

520

170

n/a

260

350
 
|

22

22

19

19

19

22

22

19

19

19

19

19

19

22

22

19

22
 
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

90

80

80
 
|

Floor

Pews

Desk

Work Surface

Work Surface

Work Surface

Floor

Desk

Floor

Desk

Desk

Floor

Work Surface

Floor

Work Surface

Work Surface

Work Surface
 
|

Normal

Normal

Normal

Normal

-

-

Normal

Normal

Normal

Normal

Normal

Normal

Selective

Normal

-

Normal

N
 
|

-

-

-

>30%

-

-

-

>30%

-

>30%

>30%

-

>30%

-

-

>30%

>30%
 
|-
|'''Corridors (screened from bed bays)'''

- by day

- by night
 
|

200

5-10
 
|

350

n/a
 
|

22

22
 
|

80

80
 
|

Floor

Floor
 
|

S

Normal
 
|

>30%

>30%
 
|-
|'''Circulation/communal areas'''

- corridors (general)

- day room

- entrance canopy

- entrance lobby

- hairdressing salon

- hospital street

- library

- lift car

- lift lobby

- loading bay

- reception area

- relatives overnight

- rest area

- shop/kiosk

- storage (general)

- toilets
|

200

200

n/a

n/a

300

200

300

150

200(min)

100

300

150

150

300

200

200
|

350

350

n/a

n/a

520

350

520

260

n/a

170

520

260

260

520

350

n/a
|

19

-

-

22

-

19

19

-

19

22

19

-

19

-

22

22
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80
|

Floor

Floor

Road surface

Floor

Chair

Floor

Desk

Floor

Floor

Platform or floor

Floor

Work Surface

Floor

Counter

Floor

Floor
|

Normal

S

Selective

Selective

Normal

N/EM

Normal

Sp

Selective

Normal

Normal

Normal

Normal

Normal

Normal

Normal
|

>30%

>30%

>30%

>30%

-

>30%

-

-

>30%

-

>30%

-

-

-

-

-
|-
|'''Restaurant/catering/breakout areas'''

- beverage bay

- counter

- general

- servery

- tables

- washing up
 
|

100

300

50

300

50/200

|

170

520

100

520

n/a

520
 
|

-

22

-

22

-

22
 
|

80

80

80

80

80

80
|

Floor

Counter

Floor

Counter

Tables

Sink
 
|

Normal

Normal

S

Normal

Normal

Normal
 
|

>30%

-

>30%

-

-

>30%
 
|-
|'''Wards and bedded areas'''

- children’s play area

- circulation space

- circulation space (night)

- examination/treatment

|

300

170

10

1000(local)

|

520

170

10

n/a

|

22

19

-

-

|

80

80

80

90

|

Desk

Floor

Floor

Bed level (usually provided by examination lamp
|

N/EM

Normal

Normal

Normal

|

>30%

>30%

>30%

>90%

|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Nursing'''

- general nursing care/examination

- night light

- nurses’ station (day)

- nurses’ station (night)

- observation/night watch

- observation/night

- mental illness care wards

- patient reading (adult)

- reading lights

- ward corridors (day)

- ward corridors (night)

|

300

5

300

30/200

20

1 to 5

200

300

300

200

50

|

520

10

520

250

40

n/a

350

520

520

350

75

|

19

-

19

22

-

-

19

19

19

19

19

|

80

80

80

80

80

80

80

80

80

80

80

|

Bed

Work Surface

Desk

Work Surface

Bed head

Bed head

Floor

Bed head

Patient activity area

Floor

Floor (50% uniformity required)
 
|

Selective

Normal

Variable

Normal

Normal

N/Sp

Normal

Normal

Selective

Normal

Normal

|

>30%

>90%

>30%

>90%

-

>30%

>30%

>30%

>30%

>90%

>30%

|-
|'''Orthopedic'''

- pacemaker

- treatment (general)

- venesection
 
|

500

300

300
 
|

850

520

520
 
|

19

19

19
 
|

80

80

80
 
|

Work Surface

Work Surface

Chair
 
|

Variable

Normal

Normal
 
|

>30%

>30%

>30%
 
|-
|'''Critical care'''

- intensive care (night)

- observation/night watch

- high dependency unit (HDU)

- intensive care unit (ICU)

- bed head (day)

- night light

- simple observation/examination

- examination

 
|

5(max)

20

100

100

30 to 50

5 to 10

300

1000 (local)

 
|

n/a

40

170

170

n/a

10

520

n/a

 
|

-

-

19

19

22

-

19

-

 
|

80

80

80

80

80

80

80

90

 
|

Circulation

Bed head

Circulation/general

Circulation/general

Bed head

Bed head

Bed

Bed level(to be provided by examination lamp)

|

N/Sp

N/Sp

Normal

Normal

Normal

Normal

Selective

Normal

 
|

>30%

>30%

>90%

>90%

>90%

>90%

>90%

>90%

 
|-
|'''Coronary care'''

- bed head (day)

- observation/night watch

- simple observation/examination

- examination

- staff base (day)

- staff base (night)
 
|

30 to 50

5 to 10

300

1000 (local)

300

30/200
 
|

n/a

n/a

520

n/a

520

250
 
|

19

-

19

-

19

19
 
|

80

80

80

90

80

80
 
|

Bed head

Bed head

Bed

Bed level (to be provided by examination lamp)

Desk

Desk
 
|

Normal

Normal

Selective

Normal

Selective

Variable
 
|

>90%

>90%

>90%

>90%

>90%

>90%
 
|-
|'''Nurse’s station/staff base'''

- day

- night

- interview
 
|

300

30/200

300
 
|

520

250

520
 
|

19

19

19
 
|

80

80

80
 
|

Desk

Desk

Desk
 
|

Selective

Variable

Normal
 
|

>90%

>90%

>30%
 
|-
|'''Operating theatres'''

- anesthesia (examination)

- anesthesia room (general)

- angiography room

- endoscopy

- operating room general

- operating table/cavity

- porter’s area

- post anaesthesia recovery

- preparation

- scrub up

- transfers

- utility rooms
 
|1000 (local)

500

500

300

300

1000

10000 to 100000

300

500

500

500

300

100 to 150
|

n/a

850

850

520

1500

n/a

520

850

860

860

520

n/a
|

-

19

19

19

19

-

19

19

19

19

19

19
|

80

80

80

80

90

90

80

90

801

80

80

80
|

Trolley head

Work Surface

Work Surface

Work Surface

Work Surface

Work Surface

Trolley/bed

Work Surface

Bench

Sink top

Work Surface

Floor
|

Normal

Selective

Variable

Variable

Variable

Variable

N/A

Selective

Normal

Normal

Normal

Normal
|

>90%

>90%

>90%

>30%

>90%

>90%

>90%

>90%

>30%

>30%

>30%

-
|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Accident and emergency'''

- Admissions. reception

- supplies stores

- minor treatment area

- minor operations

- couch (general area)

- couch (local)

- general examination areas

- procedure room

- resuscitation room
 
|

300

300

500

15000/30000

750

500

500

30000/60000

500
 
|

520

520

850

N/A

1000

850

850

N/A

860
 
|

22

22

19

-

19

19

19

-

19
 
|

80

80

80

90

90

80

80

90

80
|

Desk

Work Surface

Work Surface

Adjustable to suit treatment area

Over couch area

Couch level

Couch level

Task illumination provided by minor treatment lamp

Work Surface
 
|

Normal

Normal

Normal

Normal

Variable

Variable

Variable

Normal

Normal
 
|

>30%

>90%

>30%

>30%

>90%

>90%

>90%

>90%

>30%
 
|-
|'''Audiology'''

- audio testing

- consulting room

- ear examination

- vestibular testing (labyrinth)

|

300

300

1000 (local)

100

|

520

520

n/a

170

|

19

19

-

19

|

80

80

90

80

|

Work Surface

Work Surface

(examination lamp)

Couch head and instruments
 
|

Variable

Variable

-

Normal
 
|

>30%

>30%

-

>30%
 
|-
|'''Dentistry'''

- laboratories

- reception/administration areas

- surgeries/theatres

- treatment rooms

- white teeth matching

|

500

300

8000 to 20000

500

5000

|

850

520

n/a

850

n/a

|

19

19

-

19

-

|

80

80

90

90

90

|

Bench

Work Surface

Mouth

Bench work surface

Work Surface

(TCP ≤ 6000 K)
 
|

Normal

Selective

Variable

Normal

Normal

|

>30%

>30%

>90%

>30%

>30%

|-
|'''Diagnostics support'''

- aseptic laboratory

- blood bank

- colour inspection laboratory

- hot and cold rooms

- inspection

- laboratories

- laboratory (with computers)

- pathology laboratory

- relatives’ waiting room

- seminar room

- viewing/bier room
 
|

300

300

1000 (local)

200

500 (local)

500

300

500

300

300

30 to 150
 
|

520

520

n/a

350

n/a

850

520

850

520

520

n/a
 
|

19

19

-

19

-

19

19

19

19

19

19
 
|

80

80

90

80

80

80

80

80

80

80

80
 
|

Bench

Work Surface

Bench

(TCP ≤ 6500 K)

Work Surface

Bench

Bench/desk

Work Surface

Bench

Work Surface

Work Surface

Bier
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Variable

Normal

Variable
 
|

>30%

>90%

>90%

>30%

50-90%

50-90%

50-90%

50-90%

>30%

>30%

>30%
 
|-
|'''Women’s services (maternity)'''

- applying sutures

- circulation space (day)

- delivery

- day

- night

- neonatal

|

1000 (local)

100

500

50 to 100

5

1000 (local)

|

n/a

170

850

n/a

20

n/a

|

-

19

19

19

-

-

|

90

80

80

80

80

80

|

Couch, chair or bed (usually provided by examination lamp)

Floor

Work Surface

Cot

Cot

Cot

|

Normal

Normal

Selective

Normal

Normal

Normal
 
|

>90%

>30%

>90%

>90%

>90%

>90%

|-
|'''Mother and baby rooms'''

- circulation space (day)

- day

- night

- nurseries (day)

- nurseries (night)

- milk kitchen

- special care baby unit

- teaching areas
 
|

100

50 to 100

5

100

5

300

1000 (local)

300
 
|

170

n/a

20

170

20

520

n/a

520
 
|

22

19

-

19

-

22

19

19
 
|

80

80

80

80

80

80

80

80
 
|

Floor

Cot

Cot

Floor

Floor

Bench

Cot

Bench/Work Surface
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>30%

>90%

>90%

>30%

>30%

>30%

>90%

-
 
|} 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''General treatment areas'''

- autopsy (dissecting) table

- autopsy rooms and mortuaries

- dermatology

- dialysis

- dispensary

- minor surgery/treatment

- plaster room

- resuscitation (general)

- resuscitation/examination

- pharmacy
 
|

5000

500

(higher values could be required)

500

500

15000/30000

500

500

15000(local)

500
 
|

8600

850

n/a

850

860

 850

850

n/a

850
 
|

-

19

19

19

19

19

19

-

19
 
|

90

90

90

80

80

90

80

90

90

80
|

Table top

Work Surface

(Local operating lamp)

Work Surface (dimmable)

Bench

Work Surface

Work Surface

Head of trolley

Work Surface
 
|

-

-

-

-

Normal

Normal

Normal

Normal

Normal

Normal
 
|

-

-

-

-

>90%

>90%

>30%

>90%

>90%

50-90%
 
|-
|'''Mortuaries and animal houses'''

- autoclave

- body store

- general

- mortuary

- operation

- post mortem

- staff change

- store room

- viewing room

- waiting room
 
|

150/200

200

300

150

500 local

500

100 to 150

150

50/100

200 (min)
 
|

n/a

350

520

260

n/a

850

n/a

260

n/a

n/a
 
|

19

19

19

19

-

19

19

19

19

19
 
|

80

80

80

80

90

90

80

80

80

80
|

Work Surface

Work Surface

Work Surface

Bier room

Bench

Work Surface/table

Floor

Work Surface

Work Surface

Floor
 
|

Normal

Normal

Special

Variable

Normal

Normal

Normal

Normal

Variable

Selective
 
|

>30%

>30%

-

>30%

>30%

>30%

>30%

-

>30%

>30%
 
|-
|'''Engineering services'''

- ducts

- plant room

- roadways

- workshop
 
|

20 to 50

300

7

300/500
 
|

n/a

520

12

n/a
 
|

-

22

-

22
 
|

80

80

80

80
|

Floor

Floor

Road surface

Bench
 
|

Selective

Normal

-

Normal
 
|

-

>90%

-

>30%
 
|-
|'''Facilities support services'''

- laundry

- linen store (Linen Department)

- pack and dispatch

- pressing

- sewing room

- wash and dry
 
|

300

100

300

300

500 (local)

300
|

520

170

520

520

n/a

520
 
|

19

19

19

19

19

19
 
|

80

80

80

80

80

80
 
|

Bench

Floor

Bench

Equipment

Machine

Equipment

|

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>90%

-

>90%

>90%

>90%

>90%
 
|}
48.4.1. The lighting levels quoted above relate to the relevant task area. Levels of for the task areas and surrounding areas can be reduced where it can be justified by experienced staff or engineers. Lighting levels must, regardless, comply with the requirements of the National Building Regulations.

48.4.2. Lighting levels for external areas shall comply with the following table: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table''' '''7 Levels of Indoor Lighting'''
{| class="wikitable"
|Area
|Maintained average illuminance / lux
|Maintained minimum illuminance / lux
|Overall uniformity (not less than stated figure)
|Threshold increment
|Colour rendering (minimum)
|-
|

CCTV

- monochrome

- colour

Roads

General pedestrian areas

Information and display signs

Car Park

Vehicle drop-off points

Steps or stairways

General area lighting

Hazardous open storage areas
 
|

0

-

15

20

30

10

15

20

100(vertical)

15

10

100

20

50
 
|

5

15

6

8

12

4

6

12

6

5

40

12

20
|

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4
 
|

≥10%

≥10%

 
|

≥60%

≥60%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%
 
|}

49. Classification of Safety Services necessary for Medical Locations from SANS 10142-1
{| class="wikitable"
|'''Class'''
|'''Response Time'''
|-
|Class 0 (No break)
|Automatic supply available at no break

UPS backed up by Generator Required.
|-
|Class 0,15 (Very short break)
|Automatic supply available within 0,15 s

UPS backed up by Generator Required.
|-
|Class 0,5 (Short break)
|Automatic supply available within 0,5 s

UPS backed up by Generator Required.
|-
|Class 15 (Medium break)
|Automatic supply available within 15 s

Generator Required
|-
|Class > 15 (Long break)
|Automatic supply available in more than 15 s

Generator Required
|}
Note Safety Services in Medical locations are synonymous with Emergency Services.

50. '''Medical Location Classification'''

50.1. Group 0 location: where no applied part is intended to be used.

50.2. Group 1 location: Medical Location where applied parts are intended to be used.

#Externally, or
#To any part of the body, but not to the heart.

50.3. Group 2 location: Medical Location where applied parts are intended to be used in applications such as in an intracardiac procedure, in an operation (in an operating theatre) and in vital treatment where discontinuity (failure) of supply can cause danger to life.

Note: An intracardiac procedure is a procedure whereby an electrical conductor is placed within the cardiac zone of a patient or is likely to come into contact with the heart, such conductor being accessible outside the patient’s body. In this context, an electrical conductor includes insulated wires such as cardiac pacing electrodes or intracardiac ECG electrodes, or insulated tubes filled with conducting fluids.

50.4. For the allocation of medical location group and classification of safety service classes for medical locations see Table below as supplied in SANS 10142-1.
 
{| class="wikitable"
|
|
'''Medical Location'''
| colspan="3" |
'''Medical location group'''
| colspan="2" |
'''Safety service class'''
|-
|
|
|'''0'''
|'''1'''
|'''2'''
|'''≥ 0,5'''
|'''0,5'''

'''≤ 15'''
|-
|

1
|

Massage room
|

X
|

X
|
|
|

X
|-
|

2
|

Bedrooms
|

|

X
|
|
|

X
|-
|

3
|

Delivery room
|
|

X
|
|

X
|

X
|-
|

4
|

ECG, EEG, EHG room
|
|

X
|
|
|

X
|-
|

5
|

Endoscopic room
|
|

Xa
|
|
|

Xa
|-
|

6
|

Examination or treatment room
|
|

X
|
|
|

X
|-
|

7
|

Urology room
|
|

Xa
|
|
|

Xa
|-
|

8
|Radiology diagnostic and radio therapy room, other than mentioned under 21
|
|

X
|
|
|

X
|-
|

9
|

Hydrotherapy room
|
|

X
|
|
|

X
|-
|

10
|

Physiotherapy room
|
|

X
|
|
|

X
|-
|

11
|

Anaesthetic room
|
|
|

X
|

X
|

X
|-
|

12
|

Operating theatre
|
|
|

X
|

X
|

X
|-
|

13
|

Operating preparation room
|
|

X
|

X
|

X
|

X
|-
|

14
|

Operating plaster room
|
|

X
|

X
|

X
|

X
|-
|

15
|

Operating recovery room
|
|

X
|

X
|

X
|

X
|-
|

16
|

Heart catheterization room
|
|
|

X
|

X
|

X
|-
|

17
|

Intensive care room
|
|
|

X
|

X
|

X
|-
|

18
|

Angiographic examination room
|
|
|

X
|

X
|

X
|-
|

19
|

Haemodialysis room
|
|
|

X
|

|

X
|-
|

20
|

Magnetic resonance imaging (MRI)
|
|

X
|
|
|

X
|-
|

21
|

Nuclear medicine
|
|

X
|
|
|

X
|-
|

22
|

Premature baby room
|
|
|

X
|

X
|

X
|-
| colspan="3" |
a The room is not an operating theatre.
|
|
|
|
|}
50.5. In addition to the tables 0 and 50.4 above, generator supply is also required for:

#Night light in wards and ward corridors;
#All switched socket outlets used for patient life support anywhere in the facility;
#At least one patient lift or lift that can accommodate a bed for every 200 patients;
#Medical air compressor, vacuum pumps and gas alarm systems;
#Supply air fans serving theatres and uni-directional airflow systems;
#Isolation ward exhaust air fans.
#Mortuary Fridge Cabinets
#Nurse call System
#Fire detection system

51. General Requirements

51.1. Power supply to switched socket outlets in high care units, intensive care units and operating theatre units and recovery rooms must be on an earth monitoring system. Double pole isolators must be used for supply points in these areas and the power supply to these shall be fed from an isolation transformer.

51.2. Medical Location Group 1:

Switch Socket outlets in Medical Location 1 Shall have final Circuits for socket -outlets up to 16Amp shall be protected by earth leakage protection devices with a rated earth leakage tripping current ( rated residual current) not exceeding 30 Ma.

51.3. Medical Location Group 2:

Switch Socket outlets in Medical Location 2 the Medical Isolation Transformer (Medical IT) system shall be used for circuits that supply medical electrical equipment and systems intended for life support or surgical applications and other electrical Equipment located in the patient environment. In the case of each group 2 medical location, at least one separate medical IT system is necessary.

51.4. The Medical Isolation Transformer (MIT) shall be equipped with:

51.4.1. A 5 or 8 kVA Isolation Transformer complete with a 220 V Primary and 220 V / 110 V Secondary Winding with a centre Point Floating but bonded to the Earth monitor. The Secondary Side of the transformer shall provide 220 Volts between Line 1 and Line 2 (Note no Neutral with an Isolation Transformer) Line 1 and Line 2 will feed the Distribution Board for that particular Medical Group location, i.e. (Theatre No 1) or (ICU Bed 1-6) This local DB will then have a number of double pole Circuit Breakers feeding out to the outgoing Circuits feeding the Socket Outlets in the Medical Location 2 Area. Note that at least two circuits are required to each ICU Bed or Theatre Panel, and Theatre Pendant. Also note that all Switch Socket Outlets in a Medical Location 2 Area have to be double Pole Switched via a double pole Isolator (Provided two circuits provided) or a double pole Circuit Breaker.

51.4.2. The Transformer shall be installed either in a cabinet/DB or enclosure, to prevent unintentional contact with live parts. The Transformer / DB should be located close to the Group 2 Medical Location but consideration should be given to providing the DB outside the red line area of both the Theatres and ICU Areas, so maintenance can be carried out without the need to be gowned up. Line 1 & 2 and Earth should all be Insulated wires with the colour of Line 1 & 2 being different from red and black suggest Brown and Blue wire is used for Line 1 & 2 and green for Earth (Note this Earth wire should be connected to an insulated Earth bar dedicated to that particular Group two location and bonded to the centre point of the secondary winding.) Note a Separate Dirty earth (Equipotential bonding) should also be provided to the metal work of the Plugs, Theatre Panel, and Pendant this earth shall be connected to the Main Building Earth.

51.4.2. An insulation -monitoring device that:

#Has an internal impedance of at least 100 k Ohm;
#Has a test voltage not exceeding 25 V DC.
#Is of a current, even under fault conditions, not exceeding 1 mA DC. and
#Shall indicate, at least when the insulation resistance has decreased to 5 k Ohm.

A test device shall be provided to test this facility to ensure that the alarm (Audible and visual) operates when the insulation resistance reaches 5 k Ohm;

To test the System two male plugs should be used each with a resistor of 5 k Ohm. Plug No 1 should have a 5 k Ohm resistor bridged from the Earth Pin to the Right Hand live Pin. Plug No 2 should have a 5 k Ohm resistor bridged from the Earth Pin to the Left Hand live Pin.

51.4.4. Medical Isolation Transformer Alarm.

For each Medical IT system an audible and visual alarm shall be provided in the Theatre Area a alarm shall be provided on theatre Panel and repeated back to the main Nurse Station in Theatre Area .The Alarm shall consist of Green Light indicating Healthy, a red light indicating fault, a audible Alarm to also indicate fault and a local audible alarm mute button. The Visual signal shall revert to green and the audible alarm shall be automatically reset on the removal of the fault condition
 

Table 4 – Required for Medical Isolation Transformers (MIT) and Switch Socket Outlets (SSO)
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Office Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Laboratory Work Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Office
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Nurse Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward
|1
|1 x 16A Normal / Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point/ Bed(if required).
|
|3x 16A per bed
|
|
|
|
|-
|Ward Kitchen
|0
|2 x 16A Normal on Wall at 1200 mm over counter + 1 x 16 A next to Sink or Hydro Boil.
|
|1 x 16A supply for Fridge on generator supply
|
|
|
|
|-
|Ward Corridor
|0
|1 x 16A Normal / Every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Ward Staff Rest Room
|1
|I x 16 A on Wall for Cleaning, 1 x 16 A above counter for Electrical Appliances + 1 X 16 A next to sink for Hydro boil
|
|
|
|
|
|
|}
----[[Building Engineering Services#%20ftnref1|[1]]] Note: DPS is an abbreviation for double pole switch
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Theatre Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|-
|Theatre Post Op
|2
|
|
|
|6 x 16 A Dedicated SSO per Bed
|
|
|
|-
|Operating Theatre
|2
|
|
|
|
|8 x 16 A Dedicated SSO per Pendant
|8 x 16 A Dedicated SSO per pendant
|4 x 16 A Dedicated SSO
|-
|Cath Lab Operating Room
|2
|
|
|
|
|
|
|4 x 16 A Dedicated SSO
|-
|Cath Lab Control Room
|0
|1 x 16A Normal per Station
|1 x Red 16A Dedicated per Station
|
|
|
|
|
|-
|Cath Lab Equipment Room:

160 kva dedicated UPS Required to feed Dedicated DB and Equipment
|
|
|
|
|
|
|
|
|-
|Autoclave
|
|In autoclave plant room. 3-Phase 380V, 80A per autoclave
|
|
|
|
|
|
|-
|Instrument Washer
|
|In CSSD. Typically 3-Phase 380V, 15A per washer
|
|
|
|
|
|
|-
|Theatre Corridor
|1
|1 x 16A Normal for every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|}
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|ICU Circulation Space
|1
|1 x 16A Normal per 25m2 for cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Neo Natal ICU Cots Note: Care should be taken when sizing the Isolating Transformers to include the Heating Load
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care Nurse Station (per workstation)
|1
|1 x 16A Normal per Station
|2 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|-
|ICU and Ward Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|}
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Casualty Treatment Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point per Bed. 2 x 16A per Bed
|
|
|
|
|
|
|-
|Procedure Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning
|
|4 x 16A per Bed per two Circuits.
|
|
|
|
|-
|Casualty Ward Corridor 0
|0
|1 x 16A Normal per every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Radiology Procedure Crash Cart Position
|
|
|
|
|
|-
|Rooms Dedicated 125 Amp Supply to dedicated
|1
|1 x 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Radiology Control Room
|0
|1 x 16A Normal per Station
|1 x 16A Normal per Station
|
|
|
|
|
|-
|Maternity Delivery Rooms
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|
|
|}

{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Dialysis Treatment Beds.

Note that the Equipment can include Water Heating with high kw loading so care should be taken when sizing the Isolating Transformers
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|
|
|}
51.5. Uninterrupted Power System must be provided for operating theatre luminaries and all life support systems and computer systems where a break in electrical supply cannot be tolerated. The whole installation must conform to SANS 1474 of 1988.

51.6. Socket outlets for Dialysis units, in close proximity to water points or drains, shall be of the totally waterproof IP65 type, which also seal water-tight when the socket is removed.

51.7. Where more than one electrical transformer is used, they should preferably be located in separate structural enclosures. This is to prevent potential damage to an adjacent transformer if one is damaged.

51.8. All distribution boards fed from normal mains supply shall be painted Electric Orange, colour B26 to SABS 1091.

51.8. All distribution boards fed from standby emergency power supply shall be painted Signal Red, colour A11 to SABS 1091.

51.9. All distribution boards fed from UPS power supply shall be painted Blue colour F06 to SABS 1091.

51.10. All cable transition boxes shall be painted the appropriate colour corresponding to the source of the power supply.

51.11. All cables installed on surface mounted cable ladders shall be of the PVC/PVC/SWA/ECC/PVC type to SANS 101507 rated at 600/1000 Volt.

51.12. Electrical circuits to be engraved on base 3mm lettering indicating circuit number and DB.

51.13. Electrical Certificate of Compliance.
[[File:Picture 11.png|border|thumb|450x450px|alt=|center]]
 
===Electronic installations===
52. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

53. Nurse call system with emergency (nurse assistance) and TV control handsets (Interchangeable with LED PEAR PUSH).

The nurse system enables the patient to call a nurse for assistance from his bed or from a bath, shower and toilet. The system also enables the staff to call for assistance (EMERGENCY CALL) from any bed and treatment room etc.

#When a patient nurse call or staff emergency call is enabled the system must produce an intermittent AUDIBLE chimes or bleeper tone at the nurses’ station or/and duty room. Three different sounding tones must be produced for normal Patient call, Bathroom call and Emergency (nurse assistance) call.
#The system must also provide a VISUAL indication, at the nurse station (LED Mimic Panel and/ or Computer Monitor or LCD Display Panel), above the door to the passage of the activated unit, and at the actual activated unit (reassurance LED).
#The system must be so designed that any call may ONLY be RESET at the point of origin.
#The system must automatically activate a nurse call when the Hand Held Unit (Handset) or Pear Push unit is accidently pulled out from the Bed Head Unit.
#The Bed Head Unit must be compatible with Hand Held Unit (with TV Control), Rehab Hand Held Unit & Pear Push. (Inter-changeable)
#A Central Monitoring PC, or PC per duty station replacing Mimic Panel, must keep records of all events. (Optional)
#The system must be purpose made and aesthetically pleasing with components (call & reset units etc) manufactured from matching injection moulded ABS plastic. A system made up of push buttons etc mounted directly onto standard electrical plates will not be accepted.

54. Automatic fire detection in Hospitals

The Fire Detection System shall comply with SANS 10400 SANS 10139 & SANS 322. The Fire Detection System must be provided throughout the Facility and be a Addressable Fire Detection System, Note that Audible Fire Alarms which could panic the patients should not be provided instead Visual Strobe Lights should be provided at all Nurse stations, Reception and Security Office.

Audible alarms can be used in noisy areas such as plant rooms.

The wiring for the Automatic Fire Detection System shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area)
 55. Public Address and Evacuation in Hospital

The Public Address and Evacuation System shall comply with EN54 and provide voice message via fire retardant speakers throughout the hospital Circulation Areas, Staff Areas, Public Toilets. The wiring for the Evacuation Speakers shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area). As part of the Hospital Design the Hospital should be zoned to allow Evacuation of Individual zones in the event of a fire or other Emergency.

==Wet Services==
56. Plumbing services (Water supply and drainage) must comply as a minimum with the following Standard Specifications and Codes of Practice:

#SANS 10400: The Application of the National Building Regulations, including Part XA: Energy Use in Buildings
#SANS 10252 – Part 1 – Water Supply Installations for Buildings
#SANS 10252 – Part 2 – Drainage Installations for Buildings
#UK Department of Health Technical Memorandum 04-01: The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems: Part A: Design, Installation and Testing, and Part B: Operational Management or the equivalent SANS standard when available.

57. Where any apparent conflict between the functional requirements and the regulatory “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functional compliance.

58. Cold water storage, dedicated to the domestic water requirements of the facility, must be provided on the site. A minimum usable volume of 500 litres per bed must be provided.

59. If water storage is required for fire protection purposes (Sprinklers, Fire Hydrant supply) it must be stored separately from domestic water, unless adequate provision for the prevention of stagnation of the fire service reserve within the tank can be made.

60. Tanks must be accessible both on the outside as well as the inside, and provision for cleaning the tanks without interrupting water supply to the hospital must be made. Access manholes must be lockable, and a facility for draining the tank or individual compartments within it, must be made.

61. All openings to the tank (Overflows, vent pipes, etc) must be provided with screens.

62. Underground tanks, with their inherent risk of contamination must be avoided at all cost. If unavoidable, the tank should be constructed in a water tight bund allowing sufficient space all round for inspection and maintenance, and a sump for collecting drainage water

63. Cold water storage tanks must be located such that heat gain to the water is minimised. Cold water storage temperatures 20 C and lower will prevent the colonisation by or multiplication of Legionella

64. Site water reticulation must be designed using sound engineering principles, with adequate provision for isolating sections of the reticulation whilst keeping the remainder in operation being made.

65. Fire protection water reticulations must be kept totally separate from the domestic water reticulation

66. Water distribution may be gravity fed, or alternatively supplied via booster pumps. Pumps must be suited to handling potable water, and provision for built in redundancy must be made. Booster pumps must be supplied off standby power.

67. Hot water supply temperature to general patient care and staff areas must be controlled at 55 C, and must not exceed 60°C, except during a sanitation cycle as described hereunder.

68. Hot water generation systems must where possible use waste heat recovery from a central air conditioning system, if employed.

69. The facility for thermal disinfection of the hot water storage and circulation system must be provided in the system design. This can take the form of controlled heating of the storage vessel and circulating mains to 60°C during periods of low water and power demand. The use of shunt pumps to circulate hot water from the top level to the lowest level of the hot water tank during the sanitation cycle must be considered.

70. Hot water supply to paediatric wards, as well as to geriatric and to neonatal bathing facilities shall not exceed 42°C at the point of supply. If thermostatic mixing valves are employed to achieve this, they must be fitted with a safety feature such that the water flow is cut off within 2 seconds of the cold water supply to the valve being interrupted. The valve must also be able to control the set temperature with a pressure ratio of incoming hot to cold water supply pressure of up to 10 to 1.

71. Toilet flushing systems must be provided with easily identifiable dual flush mechanisms, one being for low flush water flow, the other for standard flush water flow.

72. All sanitary fittings must be piped such that the hot water control is on the left hand side, and the cold water supply is on the right hand side when facing the fitting.

73. Branch pipes (dead legs) between water heating equipment or hot water circulating mains and sanitary fittings must be sized and located such that the maximum waiting time for hot water to emerge from the fitting does not exceed 12 seconds.

74. Mixing taps in patient care areas must be elbow action type, installed such that the tap can be opened and shut by means of simple elbow action.

75. The discharge from kitchen floor drains and other kitchen drain points such as sinks, dishwashing washing, machines, and cooking equipment wash down, likely to contain grease, must be taken via a separate discharge system to a suitable grease interceptor, installed in a position to allow easy access for removal of intercepted grease and oil.

76. The drain pipes from equipment likely to produce high temperature discharge, such as autoclaves, sterilisers and cooking equipment must be from materials able to withstand such temperatures, installed such that distortion and/or expansion can be accommodated by the system.

77. Vertical pipe runs (Drainage stacks and water supply mains) in multi storey buildings must be housed in continuous vertical service ducts with easy access from non-patient areas at each level.

78. Condensate drains from air conditioning and refrigeration systems must discharge into piped drainage systems.

79. Anti-Backflow protection devices shall be fitted to faucets with hand-held shower heads to prevent back siphoning should the supply water pressure fail.

80. In areas housing patients at unusual risk of infection, faucets should not be fitted with low-flow or aerating devices which may increase the rate of aerosolisation of infectious droplets.

 

'''81. Legionella Control'''

#A facility-wide legionella control plan shall be in place which will inform operation, maintenance and design of water systems.
#This Plan must include a Legionella risk assessment document, listing all areas where the bacteria may occur. This must address specifically air conditioning condenser water systems, domestic hot and cold water installations, irrigation water storage and distribution systems, etc.
#The Plan must refer to as-built drawings identifying positions and layouts of plant and installations liable to cause a risk of Legionella being generated
#The facility’s Maintenance Procedures must describe all measures to be taken to minimise proliferation of Legionella. This is to include procedures and frequency of sanitation/disinfection, purging of dead legs on circulating systems, sample taking and testing at specific intervals, as well as a responsibility matrix of personnel

For additional information refer to the [[Legionella Control]] article.

==Lifts==
82. Standards and Regulations Pertaining to Lifts and Lifting Operations:

#SANS 50081 - SAFETY RULES FOR THE CONSTRUCTION AND INSTALLATION OF LIFTS - PARTICULAR APPLICATIONS FOR PASSENGER AND GOODS LIFTS
#SANS 10400 –SS3 FACILITIES FOR DISABLED PERSONS: LIFTS
#SANS 10400 –TT45 FIRE PROTECTION: LIFT SHAFTS
#SANS 10400 –TT46 FIRE PROTECTION: LIFT
#SANS 10400 –TT47 FIRE PROTECTION: FIREMAN’S LIFT
#SANS 10400 –TT48 FIRE PROTECTION: STRETCHER LIFT 

83. Planning for circulation, capacity and location of lifts

#A lift traffic plan should be developed. Detailed lift traffic planning is beyond the scope of this document. A specialist advisor should be consulted to assist in the planning of lifts within the general principles of lifts services for healthcare buildings.
#General Lift Planning Principles
#The operational details of the facility must be understood for effective lift planning. These include:

*Number of visitors and visiting hours
*Number of staff, shift hours and ward round schedules
*Numbers of day and overnight patients
*Increased provisions for reduced mobility persons
*Housekeeping schedule
*Evacuation plan for reduced mobility patients.

#Whenever possible, lifts should be provided in pairs to allow for continued operation during maintenance and breakdown.

 

===='''84. TYPES OF LIFTS:'''====
84.1. PASSENGER LIFTS

#These lifts shall be able to accommodate general passenger traffic including ambulatory and semi ambulatory passengers. It shall be able to accommodate reduced mobility passengers using mobility aids and wheelchairs. Refer to SANS 50081-70, Table 1
#The entrance to a passenger lift shall not be less than 1100 mm in width.
#The depth of a passenger lift shall not be less than 1400mm deep.
#Passenger lifts shall have a mirror on the top half of the rear wall equal to the width of the lift to enable wheelchair users to back out of the lift where the lift has internal dimensions less than 1,5 m in width and 2,0 m in depth
#At least on one side wall of the car a handrail shall be installed 

84.2. BED LIFTS

#Bed lifts shall have internal dimensions of 1 800 mm wide by 2 700 mm deep to accommodate most beds with staff and medical equipment.
#The entrance to a bed lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.3. STRETCHER LIFTS

#Stretcher lifts shall have internal dimensions of 1 400 mm wide by 2 400 mm deep to accommodate most trollies or stretchers.
#The entrance to a stretcher lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.4. GOODS LIFTS

#Goods lifts are for the movement of conventional goods and items that could not reasonably use passenger lifts without causing discomfort to passengers or damage and soiling of the lift car.
#Goods lifts can be designed to accommodate passengers.

84.5. SERVICE LIFTS

#Service lifts are not designed for accommodate passengers. They are typically of the “dumb waiter” style dispatched between service hatches.

84.6. HOUSEKEEPING LIFTS

#Housekeeping lifts are similar in function to goods lifts but are intended for the movement of cleaning supplies, medical supplies and equipment, linen etc.

{| class="wikitable"
|+Hospital Guide - Passenger
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''630 kg / 8 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|1800 x 1800

2000 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''800 kg / 10 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1350 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|2000 x 1800

2200 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1600 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2300 x 1800

2450 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1250 kg / 16 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|2000 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2700 x 2000

2700 x 2000
|1450
1500

1600
|4200
4300

4400
|}
 
{| class="wikitable"
|+Hospital guide - stretcher / Bed Lifts
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 2100
|CLD

TLD
|1000 x 2100

1000 x 2100
|200 x 2600

2000 x 2600
|1450
1500

1600
|4200
4300

4400
|-
|'''1600 kg / 21 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1400 x 2400
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 2800
2500 x 2900

2400 x 2900
|1450
1500

1600
|4200
4300

4400
|-
|'''2000 kg / 26 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1500 x 2700
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 3100
2600 x 3150

2450 x 3150
|1450
1500

1600
|4200
4300

4400
|-
|'''2500 kg / 33 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1800 x 2700
|CTLD

CTLD
|1400 x 2100

1600 x 2100
|2900 x 3150

3000 x 3150
|1450
1500

1600
|4200
4300

4400
|}
 
==PART D - COMMISSIONING AND HANDOVER==
===Deliverables===
1. This section is intended to detail the commissioning deliverables required before handover of building engineering services for operation. For further detail on commissioning and handover the '''IUSS Commissioning Health''' Facilities guidance document should be referred to.

2. Project Close-out deliverables include:

#Final Works completion lists
#Financial reports and final accounts
#Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
#Approved As-Built Drawings
#Electrical Certificates of Compliance

3. '''Maintenance manuals''' shall be timeously issued and shall include:

3.1. Designer and installer contact information

3.2. System information

#System description
#Suppliers list
#Equipment List
#Equipment data sheets
#Materials of construction data sheets
#Warranty information

3.3. Operational parameters

#Start up and shut down procedures
#Special instructions
#Security and access details
#Fault finding procedures
#Alarm management and data logging

3.4. Validation and commissioning

#Approved reports and data
#Relevant test protocols
#Relevant test plans
#Installed and test equipment calibration certificates
#Commissioning certificates
#Beneficial Occupation and Handover certificates

3.5. Spare parts list

3.6. Electronic Data Backup (Read only Media)

3.7. Approved “As-Built” Drawings

#Process diagrams
#Wiring Diagrams
#Control Diagrams
#System Plans
#Training records

3.8. Training Records

3.9. Training Materials

===Commissioning of ventilation systems===
4. Commissioning of ventilation and air conditioning systems shall comprise the following:

#Confirmation of accuracy of measurements.

Measurement accuracy depends on equipment accuracy and repeatability. Factors that would impact on the accuracy of measurement include:

*Operator error and competence
*Type and quality of measuring device
*Quality and adherence to measurement protocols.

4.2. Proof of competence of commissioning technician or engineer

4.3. Commissioning method statements or protocols shall be developed, recorded and adhered to, to ensure all technicians work to the same procedures and sequences. In some instances, such as healthcare units where the ventilation system is critical to that unit’s clinical outcomes or to the safety of occupants, the client or client’s representative may request that these method statements be issued for formal approval before commencement of commissioning.

4.4. As the operational parameters of variable air volume systems are more complex that constant volume systems, the designer is to provide details of all relevant aspects of these systems such that the commissioning specialist can sufficiently develop an appropriate plan the commissioning.

4.5. Preliminary inspections should be completed before the systems are started up for commissioning. Typically these inspections should include:

*The '''state of completion''' of the building and the condition of details such as openable windows, doors and ceilings.
*'''Building cleanliness''' as it pertains to the ventilated spaces as well as the equipment plant rooms.
*Ducting and ventilation components should be inspected internally and externally for '''system cleanliness.''' Prior to fitting filters the following components should be checked for completion, correctness and cleanliness:

#Air intakes screens and mixing plenums
#Heating components
#Cooling components
#Condensate and drip trays
#In duct UVGI systems
#Humidifiers
#Fan and equipment chambers including safeties and interlocks
#Sensors and gauges
#Airflow controllers and fire damper
#Filter frames and orientation thereof
#Insulation
#Ducting and air terminals

*Electrical Equipment should be inspected for completion, correctness, labelling and cleanliness. Prior to running any electrical rotating or control equipment the following check should be completed.

#Local isolators of motors, electric heaters and control circuits including labelling.
#Electrical safety
#Motor starters and frequency drives set correctly for overload and motor restart ratings.
#Direction of rotation of motors on motor shafts
#Motor starting current and sequencing

4.6. An initial running-in period should be conducted at low load before the installation of the filters. This running period is to ensure flushing of ducting, and allow checking of the system operation. During the this period the system should be shut down and restarted to ensure that the controls, fuses and switchgear function correctly; however, repeated rapid restarts should be avoided as this can over-stress the control gear and fuses.

4.7 After the initial running-in the filters can be installed by a suitably qualified technician and the system should then be run at normal load. New filters should be installed before the final proportional balancing commences.

4.8. The proportional balancing of the airflow should be delayed until the ventilation system has been run-in under normal load for a few days to ensure stability of the system. The airflow balancing should be conducted in accordance with good engineering principles such as those described in SANS 10173, the ASHRAE Fundamentals Handbook, CIBSE Commissioning Code A or BSRIA Application Guide 3/89.1 depending on the system requirements.

4.9. For variable air volume systems, the commissioning tests should demonstrate system performance across the design diversity.

4.10. A definitive total airflow measurement should be taken in either a section of the main duct, where duct length and turbulence allow, or in the branch ducts. This value shall be recorded, compared against the design values and tolerances and reported on in the commissioning reports including the percentage of the design flow rates.

4.11. The final airflow measurements shall be taken at all air terminals (supply, return and exhaust) using airflow capture hoods where the terminal generates turbulence and these values shall be recorded, compared to design values and tolerances and reported on in commissioning reports including the percentage of the design flow rates.

4.12. Direction, drop and throw of air terminals shall be assessed by the responsible engineer to confirm the correct air distribution within ventilated spaces.

4.13. The minimum outside air portion should be demonstrated and recorded across the system’s operational diversity.

4.14. A condition of system acceptance is that the commissioning tests be witnessed before signing off. This process could involve the repetition of only a selection of the tests under the observation of an authorised witness or responsible engineer. The following aspects should be demonstrated:

*Performance of the system according to the overall design requirements within specified limits
*Repeatability of performance and measurement results

==PART E - EXAMPLES==
===Mechanical system configurations===

===='''1. HOT WATER GENERATION SYSTEM'''====

[[File:Picture 1.png|thumb|570x570px|Hot water generation system|alt=|border|center]]

===='''2. THEATRE VENTILATION SYSTEMS'''====
The following examples indicate typical system configurations schematically.

2.1 UDAF Recirculation

 
[[File:Picture 2.png|border|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic|alt=|center]]

2.2. UDAF Full Fresh Air & Exhausted

[[File:Picture 3.png|center|thumb|410x410px|NOTE: Does not indicate sensors, interlocks or control logic]]
2.3. Major Theatre: Recirculation
 
[[File:Picture 4.png|center|thumb|410x410px]]

2.4. Major Theatre: Full Fresh Air Supply only
[[File:Picture 5.png|border|center|thumb|400x400px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

2.5. Minor Theatre: Recirculation
[[File:Picture 6.png|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.6. Minor Theatre: Full Fresh Air & Exhausted
[[File:Picture 7.png|border|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.7. Minor Theatre: Full Fresh Air Supply only
[[File:Picture 8.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

===='''3. AIRBORNE PRECAUTION ROOMS AND THEATRES'''====
3.1 Energy Recovery Systems for Airborne Precaution Rooms
 
[[File:Picture 9.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]
4. Energy Recovery Systems for Airborne Precaution Theatres
[[File:Picture 10.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks and control logic]]
 
==REFERENCES==
'''Applicable Regulations and Standards:'''

National Health Act 2004''.'' (61 2003). Cape Town South Africa: Government Gazette.

''Ammended Occupational Health and Safety Act 2004.'' (181 1993) South Africa: Department of Labour.

South African Bureau of Standards, 2009. ''SANS 10142-1:2008 The wiring of premises Part 1: Low-voltage installations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 10173:2003 The installation, testing and balancing of air-conditioning ductwork.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 10252-1:2012 Water supply and drainage for buildings Part 1: Water supply installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1993. ''SANS 10252-2:1993 Water supply and drainage for buildings Part 2: Drainage installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 10313: 1999 Protection of structures against lightning.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1990. ''SANS 10400-2: 1999 Code of Practice for The Application of the National Building Regulations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-1:2005 Copper-based fittings for copper tubes Part 1: Compression fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-2:2005 Copper-based fittings for copper tubes Part 2: Capillary solder fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 1091:2012 National colour standard''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1238:2005 Air-conditioning ductwork''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1409:2008 Outlet sockets and probes for medical (gas and vacuum) services used in hospitals.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1424:2008 Filters for use in air-conditioning and general ventilation.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2011. ''SANS 1453:2011 Copper Tubes for Medical Gas and Vacuum systems.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 14644-1:1999 Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-2:2003 Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-4:2003 Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1988. ''SANS 1474: 1988 Uninterruptible Power Supplies''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2009. ''SANS 7396-1:2009 Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 7396-2:2008 Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems.'' Pretoria South Africa: SABS Standards Division.

*All local Municipal laws and regulations,
*ISO 14644-3:, Cleanrooms and associated controlled environments - Part 3: Test Methods Australasian Health Infrastructure Alliance,2006. Australasian Health Facility guidelines [online] Available at: <nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> [Accesed ...].
*ISO/DIS 5359. Anaesthetic and respiratory equipment - Low-pressure hose assemblies for use with medical gases,
*National Health Act, 2004 (Act No. 61 of 2003).
*Occupational Health and Safety Act, of 1993
*Regulations of the Local Electricity Authority,
*SANS 10114: Lighting Requirements,
*SANS 10142-1: The wiring of premises Part 1: Low-voltage installations,
*SANS 10173: The installation, testing and balancing of air-conditioning ductwork,
*SANS 10224: Non-flammable medical gas pipeline,
*SANS 10252-1: Water supply and drainage for buildings Part 1: Water supply installations for buildings,
*SANS 10252-2: Water supply and drainage for buildings Part 2: Drainage installations for buildings,
*SANS 10313: 1999 Protection of structures against lightning,
*SANS 10400: Code of Practice for The Application of the National Building Regulations,
*SANS 1067: Copper-based fittings for copper tubes Part 1: Compression fittings,
*SANS 1067: Copper-based fittings for copper tubes Part 2: Capillary solder fittings,
*SANS 1091: Colour Coding of Services,
*SANS 1140: Identification colour marking Part 4: Contents of taps and valves in laboratories,
*SANS 1238: Air-conditioning ductwork,
*SANS 1409: Outlet sockets and probes for medical (gas and vacuum) services used in hospitals,
*SANS 1409: Part 3 Handling and storage of Medical Gas,
*SANS 1424: Filters for use in air-conditioning and general ventilation,
*SANS 1453: Copper Tubes for Medical Gas and Vacuum systems,
*SANS 14644-1, Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness,
*SANS 14644-2, Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1
*SANS 14644-4, Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up,
*SANS 1474: 1988 Uninterruptible Power Supplies,
*SANS 7396-1: Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum,
*SANS 7396-2: Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems,
*SANS 50081: Safety rules for the construction and installation of lifts — Particular applications for passenger and goods lifts,
*Any other applicable Laws or Regulations.

Chartered Institution of Building Services Engineers (CIBSE), 1999. Environmental design CIBSE Guide A. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2005. CIBSE Applications Manual AM10 Natural ventilation in non-domestic buildings. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2008. Lighting Guide 2: Hospitals and health care buildings. England: The Society of Light and Lighting.

 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009. ANSI/ASHRAE/ASHE Standard 170-2008 Ventilation of

Health Care Facilities. Atlanta USA:ASHRAE.

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2013. HVAC Design Manual for Hospitals and Clinics Second Edition. Atlanta USA:ASHRAE.

'''Further reading'''

*<nowiki>http://www.spaceforhealth.nhs.uk/</nowiki> (National Health Service NHS website for UK guidance) website closed now
*<nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> (Health Facility Guides website for Australasian Health Facility guidance)
*CIBSE Guide A – Environmental Design
*CIBSE Applications Manual for Natural Ventilation – AM10
*CIBSE Applications Manual for Mixed Mode Ventilation. – AM13

*CIBSE Lighting Guide 2: Hospitals and Health Care buildings
*ASHRAE 170:2008
*HVAC Design manual for Hospitals and Clinics Second Edition – ASHRAE TC 9.6, 2013
*CIBSE Commissioning Code A
*BSRIA Application Guide 3/89.1

 <references />

==LIST OF ABBREVIATIONS==
A & E- Accident and Emergency Department

AHU- Air Handling Unit

CSSD- Central Sterile Supply Department

EMS- Emergency Medical Services

HCW- High Care Ward

HEPA- High Efficiency Particulate Air (filter)

ICU- Intensive Care Unit

NBR- National Building Regulations SABS 0400

NICU- Neonatal Intensive Care Unit

OT- Operating Theatre

SABS- South African Bureau of Standards

SANS- South African National Standards

SSO- Switched Socket Outlet

UDAF- Uni-Directional Air Flow

UPS- Uninterrupted Power Supply

URS- User Requirement Specification

==LIST OF DEFINITIONS==
For the purposes of these regulations, unless the context otherwise indicates-

'''“barrier isolator”''' refers to a device comprising an physical film separating an operator or clinician from a work process. The work process is maintained within an isolated environment which may be held at a positive or negative pressure.

"'''Central Sterile Supply Department (CSSD)"''' means a facility for the receiving, decontamination, preparation, packing, sterilizing, storing and issuing of sterile and disinfected instruments and other reusable materials. This facility is also known as the "sterilisation and disinfection unit"(SDU);

"'''cleaners' room'''" means a room for the storage of cleaning equipment, the drawing of clean water and the disposal of dirty water, washing and drying of cleaning equipment. This room may be combined with the dirty utility room;

"'''clean air'''" means air that does not contain a considered contaminant;

"'''clean utility room'''" means a room for the storage of sterilized packs, dressings-, sterile equipment and pharmaceutical supplies respectively; This area may also be used for a set-up area for ward procedures;

"'''considered contaminant'''" means any actual contaminant, surface or airborne, which may have a certain impact which for which measures are taken to avoid;

'''"cross contamination"''' refers to the contamination of any zone or surface by fomites, considered particulates aerosols, biological agents, fumes or gasses originating from another zone or surface.

'''"cross infection"''' refers to the spreading of an infection from one organism to another by cross contamination.

'''"department"''' means a grouping of accommodation which has a specific function within a hospital. Its area includes the associated internal or departmental circulation space

'''"dirty utility room"''' means a room used for collection and temporary storage of used equipment and general ward material; it can combine the activities of the sluice room, the soiled linen and waste room and the cleaners' room;

'''"emergency trolley/crash cart"''' means a mobile cart used for the storage of all appropriate resuscitation equipment and pharmaceuticals;

"'''equipment store'''" means a room used for the storing of monkey chains, traction kits and other general equipment;

"'''fresh air'''" means air drawn from outside air of a building and contamination sources;

"'''high care ward'''" refers to a ward for the care and management of specific types of patients requiring a minimum of eight hours nursing care per patient day;

"'''holding area'''" means an area or room where pre-operative patients in transit to a procedure room/theatre are identified and continuously monitored by nursing personnel;

"'''induction room'''" means an area where patients are prepared for surgery/invasive procedures prior to being transferred to the operating theatre;

"'''intensive care unit'''" means a unit designed, staffed and equipped for the care and management of specific patients, (e.g. medical, cardiac or post-operative) requiring a minimum of twelve hours nursing care per patient day or for the care of a patient who requires ventilation, continuous invasive monitoring, invasive care, or who is clinically unstable and whose life is at risk;

"'''main kitchen'''" means a facility suitably finished and equipped for the receipt, storage and preparation of meals, special diets and beverages;

"'''maternity unit'''" means a unit where antenatal care is provided, babies are delivered and postnatal care is given to mothers and infants;

" '''midwife obstetric unit (MOU)'''" means a maternity unit usually attached to a clinic or a community health centre (CHC), which is staffed by nursing sisters or midwives;

“'''milk kitchen'''” means an area for the preparation of feeds for babies which must be separate from the hospital kitchen or ward kitchen. It must contain a clinical wash hand basin;

"'''mortuary'''" means a facility that receives, holds and allows for the identification of bodies of patients who died in the wards, theatre or casualty department, or who were dead on arrival at the facility; a facility which complies with the

"'''neonatal unit'''" means a facility for premature and new born babies requiring incubation, specific care and monitoring;

"'''nurse station'''" means the control point for all activities in the patient care areas;

"'''nursing unit or ward'''" means a unit with the facilities to accommodate patients as specified in this regulation;

"'''operating room'''” means a room within an operating theatre suite in which surgical or other invasive procedures are carried out;

"'''operating suite'''" refers to rooms within the demarcated area where surgical interventions are performed or support is provided to these surgical activities;

"'''patient room'''" means a room where the patient can be accommodated;

"'''procedure room'''" means a room in which certain restricted procedures generally taking less than one hour can be performed without making use of general anaesthetic, e.g. endoscopies, procedures under local anaesthetic such as suturing of lacerations, removal of skin lesions, biopsies, closed reductions and other similar procedures; May be situated outside the operating suite;

"'''recovery room/ area"''' means the section of the operating suite specially set aside for the immediate post-operative recovery, resuscitation, nursing and special care of patients, until such time as such patients are considered to have recovered sufficiently to be safely removed from the operating suite;

"'''sluice room'''” means a room used for the emptying, cleaning and storage of bedpans and urine bottles; It can be combined with the activities of the soiled linen and cleaners' rooms in the dirty utility room;

“'''specialised area'''” means any clinical area rendering specialised services such as intensive care, high care, or rehabilitation, for which additional space around the patient is required;

"'''soiled linen and waste room"''' means a room used for the collection and temporary storage of soiled linen and waste; May be combined with the dirty utility room

"'''treatment room'''" means a room used for treatment of patients in the wards, containing a clinical wash hand basin;

“'''ventilation”''' means “The process of supplying air to or removing air from a space for the purpose of controlling air contaminant levels, humidity or temperature within the space”. ASHRAE Standard 62.1-2007, Section 3

'''“validation”''' means the method of proving and documenting that an installed system or process performs reliably as intended and required.

'''“natural ventilation”''' means “Ventilation provided by thermal, wind, or diffusion effects through doors windows or other intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3

"'''ward kitchen'''” means the room that forms an integral part of a nursing unit or units, for the preparation of snacks and beverages; It also includes the area for the heating, storage and refrigeration of meals;

"'''uninterrupted power supply'''" means a battery system, which in the event of a normal mains supply failure will provide immediately the electrical supply for essential equipment and lighting.
[[Category:Crosscutting Issues]]
[[Category:Water Distributions Systems]]
[[Category:Legionella Control]]
[[Category:Ventilation]]

Building Engineering Services

2020-12-15T09:07:02Z

Tobyvan: /* 24. VALIDATION OF SPECIALIST VENTILATION SYSTEMS */

{{Cleanup}}{{Expand}}

=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===

==='''Context'''===
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.

==='''Design principles'''===
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.
{| class="wikitable"
|+Table 1: IUSS document
!Clinical services
!Essential
!Recommended
!Support Services
!Essential
!Recommended
!Healthcare environment/
Crosscutting issues
!Essential
!Recommended
!Procurement &
Operation
!Essential
!Recommended
|-
|Impatient services
|
|X
|Administration & related services
|
|
|Generic room data
|X
|
|Integrated infrastructure planning
|X
|
|-
|Laboratories
|
|X
|General hospital support services
|
|
|Hospital design principles
|X
|
|Project planning & briefing
|X
|
|-
|Mental Health Services
|
|
|Catering services
|
|
|Engineering design principles
|X
|
|Space guidelines
|
|
|-
|Critical care
|
|
|Laundry and Linen
|
|
|Environment and sustainability
|X
|
|Cost Guidelines
|X
|
|-
|Emergency centres
|
|
|Mortuary
|X
|
|Materials & finishes
|X
|
|Procurement liaison
|
|
|-
|Obstetrics & gynaecology
|
|
|Nursing colleges
|
|
|Future healthcare environments
|
|X
|Commissioning
|X
|
|-
|Oncology
|
|
|Health facility residential
|
|
|Healthcare technology
|
|
|Maintenance
|X
|
|-
|Outpatient services
|
|X
|Sterile supply
|X
|
|Inclusive environments
|
|X
|Decommissioning
|X
|
|-
|Paediatrics
|
|
|Clinical training
|
|
|Infection prevention & control
|X
|
|Capacity development
|
|X
|-
|Pharmacy
|
|
|Waste disposal
|
|X
|Health informatix
|
|
|
|
|
|-
|Primary health care
|
|
|
|
|
|Regulations
|X
|
|
|
|
|-
|Diagnostic radiology
|X
|
|
|
|
|
|
|
|
|
|
|-
|Rehabilitation services
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Surgery
|X
|
|
|
|
|
|
|
|
|
|
|-
|TB
|X
|
|
|
|
|
|
|
|
|
|
|}

Where this document lacks guidance on a topic or appears to contradict the requirements of the guidelines identified above, the guidance of those documents will take priority.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
#*Summaries of collated information
#*Reports on technical feasibility, benefits and risks
#*Reports on regulatory compliance issues
#*Reports on financial feasibility and risks
#*List of consents and approvals required
#*Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

==Design Questions==
6. In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

==Design considerations==

==='''7. Deep buildings'''===

#Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

==='''8. Plant and plant room size and location'''===

#Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.
#Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities. Plant rooms shall be located away from possible heat and contamination sources.
#Plant rooms shall be located in an accessible area which is secured from unauthorized entry
#Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

==Life cycle cost determination==
9. When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

10. Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

==Site-survey requirements==
11. In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

==Maintenance Considerations==
12. Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

13. The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

14. In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.

15. For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

==Planning for Retrofitting & Decommissioning==
16. While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

17. Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

18. When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

19. A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

20. Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

21. For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

==Sustainability & Environmental Measures==
===Design Life cycle===

Sustainability in designs for new health facilities can be addressed through the following steps:

'''22. Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.

'''23. Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.

'''24. Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.

'''25. Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.

'''26. Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.

'''27. Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

28. Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''PART - DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating Ventilation and Air-conditioning===
===Airborne-Precaution Risk Classification for Healthcare Zones===
South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for out-patients is common practice in South Africa.
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo convective or buoyancy effects and wind pressure. Since the drivers of Natural ventilation are inherently variable, natural ventilation has a high variability in effectiveness.

2. In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space could have a negative impact on the variability of the ventilation system’s performance by opening and closing windows and doors. For this reason it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controllable ventilation openings be designed and created in the building

3. For additional design guidance on natural ventilation design, the CIBSE Applications Manual AM10 or similar can be consulted.

4. Peak and minimum internal temperatures should be calculated or modelled thermally for a space, for summer and wintertime respectively.

5. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

6. The following design interventions should be considered for implementation, singly or in combination, in the following hierarchy where the internal design condition cannot be met:

*Reducing solar and internal heat gains
*Using thermal mass to move room temperature extremes to outside of occupancy periods.
*Change occupancy schedules seasonally to improve indoor comfort conditions. (eg. Shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
*Introducing passive cooling or heating strategies
*Increasing ventilation rates
*Providing mechanical cooling or heating

7. Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed mode ventilation shall be considered as a solution preferred over full mechanical ventilation.

8. Mixed mode ventilation is considered as an assisted type of natural ventilation. Here fans are used in combination with damper controlled ventilation openings to ensure minimum ventilation rates are achieved.

9. Where mixed mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

===Mechanical ventilation and air-conditioning===
10. Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.

11. The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====12. Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====13. Zoning of a building=====
13.1. Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:

#Fire compartmentalization
#Air-handling unit (AHU) sizing
#Duct sizing
#Occupancy schedules
#Occupancy activity levels
#Building, environmental and equipment heat loads
#Airborne contamination control
#Tenancy, functional unit or utility metering

13.2. Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====14. Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.

=====15. Ventilation rates=====

#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant

=====16. Supply-only vs balanced ventilation systems=====

#Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

=====17. Airborne contamination-control concepts=====

#Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

#The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

#The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 
#The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 
#The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²).

17.4. Where ventilation rates and fresh air proportions are described within these guidance documents they are to serve as guidance values only. It is the responsibility of the designer to ensure that the ventilation rate selected is appropriate for the specific zone’s operational conditions, occupancy, contamination rates, pressurization, leakage rates, ventilation efficiency and external ambient conditions to achieve the desired airborne contamination and bio-burden levels. Ventilation rates higher or lower than the guidance values may achieve the desired conditions.

 

====='''18. AIR HANDLING UNITS AND FANS'''=====
18.1. GENERAL

#AHUs and fans shall be protected from adverse weather and wind sources which may upset their performance or reliability.
#A detailed name plate shall be included on the air handling units with manufacturer, design air volume, fan speed, cooling capacity, filter data and heating capacity.
#The air handling unit shall include individual differential pressure gauges over each installed filter bank. The gauges shall measure the pressure differential between upstream and downstream of the filter banks. The filter designation and design filter change pressure shall be neatly and clearly marked on each gauge.
#Air-handling units functioning in an airborne contamination control system, and demanding prescribed airflow rates, shall be provided with an electronic control system including variable frequency controllers with direct fan drives to automatically maintain design airflow for all filter conditions. The fans and drives will be selected to maintain design flow rates with all filters at maximum rated pressures.
#Where a ventilation system performs a critical role, air handling units shall have separate electrical distribution boards (Essential and Non-essential). The fan will be on essential power and heater elements may be on non-essential power.
#All compartment doors on the air handling unit shall be clearly labelled
#Where systems require duplicate standby fans or air-handling units these shall be installed with backdraught dampers, sufficiently air-tight for the application (eg EN1751 Cat 3 or 4). Special design and control consideration shall be given to limiting the build-up and dwelling of contaminants in the standby unit.
#AHU’s should be placed in easily accessible plant rooms with sufficient space for maintenance. Access stairs to the plant rooms should permit a technician to easily carry replacement parts or a toolbox into the plant.AHU’s located in ceiling voids are not appropriate or conducive to good operational management.
#AHUs should be designed for a working life of 20 - 25 years
#AHUs shall be designed and positioned such that the largest components, including heating and cooling coils, can be removed and replaced.
#AHUs greater than 1m wide should have hinged access doors large enough to provide full entry. Doors shall be unlockable and openable from the inside of the unit.
#Fan and filter plenums shall be provided with internal illumination and viewing portals such that internal components can be visually inspected without stopping or opening the unit.
#AHUs shall be designed such that dry steam humidification devices can be retrofitted into the systems with minimal disruption and without compromising its performance.
#Ventilation components shall have a drainage or condensate pumping system if they can produce moisture. Drip trays shall be of a corrosion resistant material and drainage systems shall have a 1:20 fall away from the unit in all directions. The unit shall have its own drain trap which shall be sized such that it can function at the fan's full static pressure. The first 3 meters of a dedicated condensate drainage line shall be insulated to prevent condensation within the plantroom. Where a condensate drain services a negative pressure plenum, clear air gaps of 15mm or anti-backflow devices are recommended at the trap discharge into the drainage system.
#Drop stop eliminators in stainless steel frames shall be employed, if fin spacing is less than 10 fins per inch, after the cooling coils in areas with high humidity levels. This includes all coastal areas for off coil temperatures of 10° and less
#In full fresh air systems, primary filters may be situated at the fresh air intake opening of the air-handling unit only if the climate does not require anti-fog or de-icing coils.
#Cooling or heating coils will be protected by a pleated primary filter, rated in accordance with SANS 1424, as minimum.
#In recirculation air systems, primary filters will be situated after the fresh/return air mixing plenum. This arrangement will ensure that blinding filters don’t inhibit the prescribed fresh air proportion.
#The final stage of filters on units serving operating theatres must be located after the supply fan chamber to filter any debris that might come from the fan chamber. HEPA filters should be protected from this potential dust and debris.

 

=====18.2. AIR EXTRACTION SYSTEMS=====

#The design of exhaust systems shall take special consideration of the potential for re-entrainment of contaminated exhaust air into air intakes through, inter alia, openable windows. Where this potential exists, precautionary measures such as aerosol or chemical filtration of exhaust should be applied, as appropriate.
#Single ablution facilities serving private wards or staff do not require extract ventilation, provided there are windows openable to outside.
#Extract ventilation shall be provided by either ceiling extract grilles connected to an in-line ducted fan with outside discharge air grilles by means of galvanized mild steel or PVC tubular ducting or odour extraction system.
#Extract grilles may be of the PVC type with adjustable disc valves, or powder coated or anodized aluminium type with adjustable dampers.
#All multiple toilets shall be provided with ventilation systems, which will serve as an extract ventilation system.
#Single toilet facilities serving private wards for staff do not require extract ventilation, provided there are windows openable to outside
#Where it is not considered safe to enter a space without respiratory protection, the air exhausted from that space should be rendered safe through filtration, decontamination or dilution before discharge.
#The design of exhaust system from airborne precaution areas should be such that all components can be safely maintained during normal service and safely disposed of at decommissioning.
#Planning for disposal of contaminated filters should be as for all biohazardous material.
#Filtration and decontamination components shall be installed upstream of fans, monitoring and control devices.

=====18.3. ENERGY RECOVERY SYSTEMS=====
1.3.1. Where full or partial exhaust is required for ventilation systems, energy recovery technologies should be considered. Enthalpy wheels offer a high level of efficiency but introduce a risk of cross infection as the wheel is exposed to both the exhaust and supply airstreams. An enthalpy or energy recovery wheel may only be used if pressure and filtration measures are taken to ensure it is not a potential source of cross infection or re-infection. Energy recovery wheels incorporating purge sections have a markedly reduced efficiency and are not considered to provide sufficient protection against biological cross contamination. Where cross infection is a considered risk, the following conditions shall be met.

#The exhaust airstream shall be consistently maintained at a lower static pressure than that of the supply airstream.
#The exhaust air shall be filtered with aerosol filters upstream of the energy recovery device.
#Levels of filtration, redundancy and safety shall meet the requirements of the biological pathogenicity class in consideration.

=====19. '''FILTRATION'''=====

#With the exception of the few specialist areas with aero-biological requirements, the primary purpose of filtration is to protect ventilated spaces and ventilation equipment from dust build-up.
#When designing filtration systems serving spaces with a high airborne cross contamination risk, consideration should be given to the safety of maintenance staff that may be required to handle contaminated filters. Where any safety risk is present, contaminated filters should be installed in safe-change or decontaminatable housings.
#All ventilation filter banks should be installed with a means of visually checking the filter pressure across them in Pascals (Pa)
#Filters are classified as being General Fine or Aerosol filters and are to be specified in accordance with the SANS 1424, EN779 or EN1822.
#General filters are selected to remove particles large enough to block cooling and heater fins and settle out of the airstream into the air distribution system. General filters are graded in terms of their “synthetic dust weight arrestance”. General filter grading ranges from G1 to G4. G3 and G4 filters are appropriate for primary air intake and tempered air supply respectively. General filters are not appropriate for combating airborne cross-contamination control.
#Fine filters are selected to keep a ventilated space visibly clean and for the protection of HEPA filters. Fine filters are graded in terms of their “Dust Spot Efficiency” from M5 to F9. F9 filters are capable of arresting particles with the approximate size of some bacteria and can be used for low level cleanrooms (ISO 14644-1 Class 8).
#Aerosol filters are selected for their efficiency in arresting sub-micron particles. They are graded in accordance with their “Most Penetrating Particle Size” (MPPS). Aerosol filters are subdivided into three categories: Efficient Particulate Air (EPA) and High Efficiency Particulate Air (HEPA) and Ultra high Particulate Air (ULPA) Filters in accordance with the EN1822:2009. The table below describes the classification of aerosol filters by integral and local values as defined in the EN1822. SULPA filters are not discussed within this document.

'''Table 2 Filtration Classification'''
{| class="wikitable"
| rowspan="2" |'''Group'''
| rowspan="2" |'''Filter Class'''

'''EN1822'''
|'''Integral Value'''
|'''Local Value'''
|-
|'''Efficiency %'''
|'''Efficiency %'''
|-
| rowspan="3" |'''EPA'''
|'''E10'''
|85%
|<nowiki>-</nowiki>
|-
|'''E11'''
|95%
|<nowiki>-</nowiki>
|-
|'''E12'''
|99.5%
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''HEPA'''
|'''H13'''
|99.95%
|99.75%
|-
|'''H14'''
|99.995%
|99.975%
|-
| rowspan="3" |'''ULPA'''
|'''U15'''
|99.9995%
|99.9975%
|-
|'''U16'''
|99.99995%
|99.99975%
|-
|'''U17'''
|99.999995%
|99.999975%
|}
8. HEPA filter installations shall include both an upstream challenge aerosol injection port and a downstream scan port to facilitate filter challenge testing. ULPA filter installations shall be designed such that an agreed upon test method can be accomplished.

9. All filters used for airborne precaution rooms, theatres or other areas with a high airborne contamination risk shall be selected with a construction suitable for incineration. These filters shall not contain PVC.

10. The installation and testing of HEPA filters shall only be conducted by suitably qualified technicians.

11. HEPA filters shall be specified to be compliant with the requirements of EN1822. Each HEPA filter is to be supplied with an individual factory test certificate displaying that filter's serial number, MPPS rating and DOP arrestance rating.

12. Type-test certificates are only acceptable for EPA and not HEPA filters.
 

=====20. '''HEAT REJECTION EQUIPMENT.'''=====
20.1. The location of heat rejection equipment shall be planned such that it does not adversely affect the performance, maintenance or reliability of any related or unrelated equipment, or pose an avoidable health risk.

20.2. The use of evaporative cooling towers shall only be considered where:

#Space, system capacity or efficiency demands their use.
#An effective plan for the [[Legionella Control|control of legionella]] must be developed and implemented.

 

=====21. '''AIR DISTRIBUTION SYSTEMS'''=====

#Discharge from extraction systems shall be located such that contaminated air does not get drawn into any system's air intake of get re-entrained though openable windows.
#The use of internally insulated ducting is not appropriate as internal linings will perish and slough off with aging. Particles from duct linings contaminate final filters and ducting components.
#Flexible ductwork is unsuitable for air distribution in healthcare applications. It should only be used for the final connection to an air terminal and then kept to less than 1.0m. Bends in flexible ductwork should be avoided.
#The use of dampers to throttle a deliberate oversupply of airflow should be avoided. Balance by design is preferable although this will not necessarily reduce the total fan pressure. Use of adjustable blade dampers should be kept to a minimum as these items may drift, can be tampered with and increase the complexity of commissioning. The use of constant volume dampers may improve stability of volume critical systems but may also mask inefficient design and be the source of increased system noise.
#Cleaning and access doors are to be installed in all air distribution ductwork to facilitate:

*Cleaning
*Inspection
*Measurement
*Maintenance

21.6. Ductwork installations shall be designed, built, installed and commissioned in accordance with SANS 1238: Air-conditioning ductwork and SANS 10173: The installation, testing and balancing of air-conditioning ductwork
 

=====22. '''ELECTRONIC CONTROLS'''=====

#Location of sensors in ventilation systems should ensure that the temperature and humidity measurement for monitoring control is representative of the occupied area
#The humidifier control will include humidity monitoring of the mixed airstream downstream of the humidifier lance and shall prevent this airstream from approaching dew point.
#The use of variable speed drives (VSD) can save energy in systems operating under varying motor loads. Reducing the fan speed when filters are new or clean can result in considerable energy savings over the life of a system. Reliability of smaller sized VSDs is a potential drawback, and for this reason VSDs must be selected and sized for high service life. VSDs should also be installed such they can be bypassed and the system can be run in manual control while failed VSDs are replaced or repaired. When designing with variable speed drives, cognisance should be taken of a motor’s minimum cooling requirements and the maximum restart rate. Caution should be exercised where variable speed drives are used in conjunction with constant volume dampers or volume flow controllers. This combination could drive up total system pressure where duct total pressure as opposed to velocity pressure is used as control feedback. Additional requirements for the selection of drives for variable air volume (VAV) fans is described in SAN204:2011
#Plant control systems should incorporate start-up and shut-down sequencing logic to prevent flow reversals and overheating.
#Set-back controls should be considered for spaces that have intermittent occupancy. This feature should be used with caution in specialist areas as poorly considered set-back conditions could compromise containment or contamination control.
#Where more than one ventilation system serves a department, system interlocks may be required to prevent unwanted airflow reversals during system shutdown or failure.
#Operational status indicators should be displayed locally in areas served by ventilation systems.
#"Low Air Flow" and "Plant Failure" alarms should also be installed in a location which can be manned by relevant and trained staff.
#Electronic control systems should be developed using recognised open protocols and standards such as BACnet DeviceNet, LonWorks, Modbus, SOAP and XML.

=====23. '''SPECIALIST VENTILATION SYSTEMS'''=====
23.1. The following areas will require specialist ventilation systems:
 
'''Table''' '''3 Specialist Ventilation Systems'''
{| class="wikitable"
|'''Department Name'''
|'''Ventilation system type'''
|-
|Operating departments
|Clean and Ultra clean ventilation systems: ISO8 to ISO5 & UDAF
|-
|Obstetrics
|Clean ventilation systems ISO8
|-
|High care, Critical Care and Intensive Care
|Fine filtered ventilation or Clean ventilation systems: Unclassified - ISO8
|-
|Isolation units
|Negative pressure ventilation, no recirculation
|-
|Pathology labs
|Biosafety ventilation: (BSL2 – BSL4)
|-
|IVF Labs
|Clean ventilation systems: VOC Filtration
|-
|Burns units
|Clean ventilation systems/ Negative pressure ventilation/ RH control
|-
|Neonatal Units
|Dedicated ventilation systems/ RH control
|-
|Mortuary unit
|Cold Rooms/ Extraction systems/ Odour Control
|}
23.2. Broad requirements for these systems are in this document. The engineering team shall consult each department’s specific design guidance document for detailed requirements.
 

=====23.3. '''AIRBORNE PRECAUTION ROOMS (INCLUDING TB)'''=====

#Where specific diseases are considered in the design of an airborne precaution room, the US CDC's "Select Agent List" may be consulted for design guidance until a South African list is compiled.
#Airborne precaution rooms shall be ventilated with a minimum of 12AC/h of fresh air or uncontaminated air. High risk areas such as sputum booths and airborne diseases wards shall have a nominal ventilation rate of 80 ℓ/s per person..
#Medium Risk areas such as congregate spaces such as waiting areas shall have a nominal ventilation rate of 60ℓ/s per person.
#Mechanical ventilation may be employed to achieve the minimum ventilation rates. It should be noted that very high ventilation rates can be achieved by employing a well-considered natural ventilation design. Consideration may also be given to mixed mode ventilation systems, which combine mechanical and passive ventilation and temperature control. An open window policy may therefore be adopted, with careful consideration of all the associated cross infection risks and management challenges.
#Airborne precaution rooms shall be designed so as to provide thermal comfort. Where occupants have freedom in location and dress code, an adaptive thermal comfort model should be adopted. Heating, cooling and energy recovery devices shall pose no risk of harbouring pathogens or increasing the cross infection risk.
#Air from the airborne precaution rooms shall not flow into adjacent, uncontaminated rooms or adjacent airborne precaution rooms. Air shall not flow from a room with a higher airborne infection risk category to a room with a lower risk category.
#Ventilation ducting and pipe work shall not form a conduit by which pathogens can transfer from one zone to another whether the ventilation system is running or not. Filtration devices and anti-backflow devices may be employed provided these do not pose a risk of infection to maintenance staff.
#Filtration requirements for supply and exhaust air should follow the bio-containment requirements of that select agent being contained.
#The location of supply and air terminals should be such that the airflow patterns generated within the room serve to suppress and remove airborne particles.
#For general waiting areas or where the pathogens are known and unlikely to pose an environmental risk, exhaust air filtration may not be required provided exhausted air is directed 3m away from open-able windows and air intakes and there is no risk of re-entrainment of this air. See section 18.2.
#Commissioning and validation shall be well planned, diligently executed, fully documented and approved by suitably experienced professionals. It is advisable to have the validation process conducted or approved by a party independent of the designer and installer.
#Numerical or physical modelling may be of value in the design and validation process.

 

=====23.4. '''OPERATING THEATRE VENTILATION DESIGN'''=====
23.4.1. GENERAL REQUIREMENTS

#Constant volume systems shall be employed to maintain the correct pressure with respect to any adjoining rooms. The contamination control concept shall be developed in accordance with ISO14644-4
#Temperature range shall generally be 18°C to 24°C with a minimum relative humidity of 45% unless otherwise specified
#A pressure differential of 10-15Pa is to be maintained between the theatre and adjacent rooms when all doors are closed.
#Theatres may be maintained at a room pressure positive or negative to the adjacent rooms depending on the contamination control requirements.
#A theatre’s room pressure shall always be positive relative to technical spaces.
#Negative pressure theatres should not employ recirculation of room air.
#Fresh air requirements are 5-7 Air Changes per hour to satisfy the occupancy requirements
#Additional fresh air may be required for pressurisation and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurisation at the greatest possible energy efficiency.
#Separate temperature controls in each theatre are to be provided.
#No manual on and off switching of air handling plant to be done from within the theatres.
#Automatic motion sensors / thermal sensors to ensure that the units are switched on when there is a presence in the theatre. Theatre ventilation switching may be linked to the theatre unit’s lights.
#Automatic switching of ventilation system to incorporate run-on timers to prevent overheating and accidental shutdown.
#An additional override to be used to switch the units on when the temperature in the theatre exceeds 25°C for the protection of stored medicine
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums.
#These validation tests shall be performed in accordance with SANS 14644Parts 1, 2 and 3 at the recommended intervals (SANS 14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#No internal ducting insulation is permitted.
#In multi theatre suites it is advisable to have dedicated AHUs per theatre. [[Building Engineering Services#%20msocom%201|[TR1]]]

23.4.2. UNIDIRECTIONAL AIRFLOW OR ULTRACLEAN THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 5 under protected zones (UDAF and Setup area) and ISO 14644-1 Class 6 in background and ancillary areas. These conditions are to be achieved under operational conditions.
#Temperature range shall generally be 18°C to 24°C and relative humidity 45% to 60% unless otherwise specified
#Ultra-clean theatre ventilation shall not be completely shut down when unoccupied unless required for maintenance interventions. Ventilation systems serving UDAF plenums shall instead switch to a minimum velocity set-back mode to prevent contaminants settling underneath the UDAF screens.
#Delivery of the conditioned air shall be by downward movement from the ceiling to four low level exhaust outlets located near the corners.
#All ductwork between HEPA filter housings and air terminals shall be high pressure rated and constructed of galvanised sheet metal. In the final connection to the terminal, where alignment necessitates, a maximum of 300mm of thermally insulated, high pressure flexible ducting may be used.
#The Air Conditioning system is to be complete with G4 primary, F9 secondary and H13 HEPA Filters.
#The ventilation systems shall be designed with a mean air velocity of between 0.35 & 0.45 m/sec measured below the UDAF screen and at the working height.
#Refer to ISO14644-4 for guideline ventilation rates for balance of areas.
#The mean velocities below the UDAF screen and at the working height shall not differ by more than ±10%
#A standard size of the UDAF screen is 2400 x 2400mm. The required size could vary dependent on the layout and function of the operating theatre.
#The protected zone below the UDAF plenum shall be clearly demarcated on the floor

23.4.3 CLEAN OR MAJOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 6 in all areas. These conditions are to be achieved under operational conditions.
#The ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#The conditioned air is to be introduced into the theatre via suitable diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#Additional fresh air may be required for pressurization and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurization at the greatest possible energy efficiency.
#These validation tests shall be performed in accordance with SANS 14644 Parts 1, 2 and 3 at the recommended intervals (ISO14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.

23.4.4. MINOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 8 in all areas. These conditions are to be achieved under operational conditions.
#For recirculation systems the ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#For single pass systems the ventilation system is to include G4 Primary and F9 Secondary filters.
#The conditioned air is to be introduced into the theatre via suitably sized diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums. 

====='''24. VALIDATION OF SPECIALIST VENTILATION SYSTEMS'''=====
24.1. Validation testing shall be completed in accordance with national standards for standardized tests (eg ISO14644 and ISO 14698 for cleanrooms) and shall be completed against mutually agreed protocols for non-standard tests.

24.2. It essential that the validation testing of a ventilation system’s contamination control performance parameters is conducted against operational, and not only "at-rest", conditions. Validation against "as-built" conditions offers little insight into the ultimate performance of the system.

23.3. Pre-Commissioning Checks shall cover the following aspects prior to the commencement of formal commissioning:

#Check whether the Design Specification satisfactorily addresses the demands of the User Requirement Specification.
#Check whether the ventilation systems have been provided and installed in accordance with the design specifications and drawings.
#Check that the buildings either housing or served by the ventilation equipment is complete and finished such that testing can commence safely and effectively.
#Check that all AHUs, chillers, heat rejection equipment and filters are sufficiently accessible for inspection and maintenance.
#All components are connected and are functional
#Door gaps and openings are installed and sized as specified in specialised zones
#Airflow control devices are installed in the correct locations and in the correct orientation
#Duct and filter tests ports are installed and sealed satisfactorily
#Safety and control interlocks are established
#Fan and drive guards are in place
#Safety and warning signs are in place
#All major system components or sub-systems are clearly labelled with functional or controls identification in a neat and durable fashion.
#Fluid and air pressure monitoring gauges are labelled with identification and acceptable maximum and minimum operating conditions.
#All wiring, piping and ducting colour banding is complete in accordance with SANS-1091

24.4. CLEANLINESS CHECKS:

#AHUs shall be checked for cleanliness on internal plenums with special attention being paid to fan and discharge plenums and condensate drip trays and drain lines.
#Ducting serving “clean” areas shall be cleaned prior to installation and the ends shall be sealed until installation. Open ends of duct runs shall similarly remain sealed during construction. Spot checks for compliance during the installation process are recommended.

24.5. Recommended Filtration Levels and Ventilation Rates for Mechanically Ventilated Areas

This table serves as a quick reference guide and will be revised as and when detailed room data sheets are developed within each department’s guidance documents.
{| class="wikitable"
|+'''Room Ventilation Requirements'''
| rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation[[Building Engineering Services#%20ftn1|'''[1]''']]'''

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range[[Building Engineering Services#%20ftn2|'''[2]''']]
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|Casualty/Minor Stitch Procedure room
|X
|
|X
|
|T
|
|
|7.5
|20
|
|-
|Theatres: Maternity/Caesarean
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: General Surgery
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Gynaecology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Ophthalmology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Urology
|X
|
|X
|'''X**'''
|T
|NA
|7
|10
|20
|
|-
|Theatres: Endoscopy
|X
|
|X
|'''X**'''
|T
|NA
|7
|80
|20
|
|-
|Theatres: Plastic Surgery
|X
|
|X
|X
|T
|6
|7
|7.5
|70***
|
|-
|Theatres: Bone Surgery/Orthopaedic
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Thoracic
|X
|
|X
|X
|M
|5
|7
|80
|70
|
|-
|Theatres: Vascular???
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Neuro Surgery
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Waiting and Congregate Areas
|X
|
|
|
|
|
|
|60
|8
|18-28
|-
|Auditoriums
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Mortuary
|X
|X
|
|
|
|
|
|
|12
|22-25
|-
|Bath Room
|
|
|
|
|
|
|
|25
|10
|N/A
|-
|Dirty Utility Room
|
|
|
|
|
|
|
|40
|10
|N/A
|-
|Blood Bank
|X
|
|
|
|
|
|
|
|4
|22-25
|-
|Casualty
|X
|X
|
|
|
|
|
|7.5
|12
|22-25
|-
|CSSD
|X
|X
|
|X
|
|
|
|7.5
|20
|22-25
|-
|Dark Room
|X
|
|
|
|
|
|
|
|10
|22-25
|-
|Dining Rooms/Canteens
|X
|
|
|
|
|
|
|7.5
|10
|18-28
|-
|General Stores
|X
|
|
|
|
|
|
|
|4
|N/A
|-
|Laboratories
|X
|X
|
|
|
|
|
|
|6
|22-24[<nowiki/>[[Building Engineering Services#BESftn3|3]]]
|-
|Labour/Delivery Room
|X
|
|
|
|
|
|
|
|4
|22-24
|-
|Laundry – General
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Lecture Halls
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Outpatients Departments
|X
|
|
|
|
|
|
|60
|4
|18-28
|-
|Pharmacy Dispensing
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Pharmacy Store
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Specialist Clinics- ENT
|X
|X
|
|
|
|
|
|7.5
|4
|22-26
|-
|Sterilizer Equipment
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Toilet Room
|
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Units: Treatment Room
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|-
|Units: Burns
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|-
|Units: HCU / CCU
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU Neonatal
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|-
|Wards: General
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|-
|Wards: Airborne Precaution Rooms/Isolation'''[[Building Engineering Services#%20ftn1|[1]]]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|-
|Wards: Maternity
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Medical
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Paediatric
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|-
|Wards: Psychiatric
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|-
|Wards: Orthopaedic
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: Surgical
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: TB
|X
|
|
|
|
|
|
|80
|12
|20-28
|-
|Radiology: General
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|-
|Radiology: Airborne Precaution
|X
|
|X
|
|
|
|
|60
|6
|22-24
|-
|Radiology: MR/CT

Scanner
|
|
|
|
|
|
|
|60
|6
|2-24
|-
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|}
[[Building Engineering Services#%20ftnref1|[1]]] These rates are considered for forced ventilation systems only. Average natural ventilation rates may be higher

[[Building Engineering Services#%20ftnref2|[2]]] Temperature range not to be exceeded for more than 50 hours per year.

{{Anchor|BESftn3}}[[Building Engineering Services#%20ftnref1|[1]]] Specialist cleanrooms and laboratories may require lower temperatures.

[[Building Engineering Services#%20ftnref1|[1]]] Levels of filtration are dependent on pathogenicity. Exhaust filtration may also be required.
{| class="wikitable"
| colspan="2" rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation[[Building Engineering Services#%20ftn1|'''[1]''']]'''

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range[[Building Engineering Services#%20ftn2|'''[2]''']]
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|}
 
{| class="wikitable"
| colspan="2" rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation[[Building Engineering Services#%20ftn1|'''[1]''']]'''

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range[[Building Engineering Services#%20ftn2|'''[2]''']]
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|'''Pharmacy Dispensing'''
|'''X'''
|'''X'''
|
|
|
|
|
|7.5
|4
|22-24
|
|-
|'''Pharmacy Store'''
|'''X'''
|'''X'''
|
|
|
|
|
|7.5
|4
|22-24
|
|-
|'''Specialist Clinics- ENT'''
|'''X'''
|'''X'''
|
|
|
|
|
|7.5
|4
|22-26
|
|-
|'''Sterilizer Equipment'''
|'''X'''
|
|
|
|
|
|
|7.5
|10
|N/A
|
|-
|'''Toilet Room'''
|
|
|
|
|
|
|
|7.5
|10
|N/A
|
|-
|'''Units: Treatment Room'''
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|
|-
|'''Units: Burns'''
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|
|-
|'''Units: HCU / CCU'''
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|
|-
|'''Units: ICU'''
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|
|-
|'''Units: ICU Neonatal'''
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|
|-
|'''Wards: General'''
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|
|-
|'''Wards: Airborne Precaution Rooms/Isolation[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|
|-
|'''Wards: Maternity'''
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|
|-
|'''Wards: Medical'''
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|
|-
|'''Wards: Paediatric'''
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|
|-
|'''Wards: Psychiatric'''
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|
|-
|'''Wards: Orthopaedic'''
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|
|-
|'''Wards: Surgical'''
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|
|-
|'''Wards: TB'''
|X
|
|
|
|
|
|
|80
|12
|20-28
|
|-
|'''Radiology: General'''
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|
|-
|'''Radiology: Airborne Precaution'''
|X
|
|X
|
|
|
|
|60
|6
|22-24
|
|-
|'''Radiology: MR/CT'''

'''Scanner'''
|
|
|
|
|
|
|
|60
|6
|2-24
|
|}

24.6. Commissioning tests shall include and record, but not be limited to:
{| class="wikitable"
|'''System'''
|'''Commissioning Test'''
|'''Special Instructions'''
|-
|'''All'''
|Standard of installation
|Test to be authorised by client's representative.
|-
| rowspan="7" |'''Air Handling Units and Fans'''
|Fan motor drive speed and rotation.
|Cognisance should be taken of motor cooling requirements
|-
|Fan motor current draw.
|<nowiki>-</nowiki>
|-
|HEPA Filter challenge testing.
|In accordance with ISO DIS 14644-3
|-
|AHU heating and cooling coil performance
|Report on-coil and off-coil air conditions for full heating and full cooling with no air bypass.
|-
|AHU leakage tests
|<nowiki>-</nowiki>
|-
|Heating and Chilled Water circuits have been charged, dosed and pressure tested
|<nowiki>-</nowiki>
|-
|Flow rates and pressures across heat exchangers, pumps and compressors
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="2" |'''Room conditions'''
|Airflow and room pressure balancing in accordance with design tolerances.
|In accordance with ISO DIS 14644-3 Acceptance criteria Normally +10-0%
|-
|Room Temperature and humidity
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''Air Distribution systems'''
|Dampers and registers shall be locked and marked after balancing
|<nowiki>-</nowiki>
|-
|Duct leakage tests for medium and high pressure ducting in accordance with SANS 10173 or DW/143 requirements, as agreed upon
|<nowiki>-</nowiki>
|-
|'''Water Distribution Systems'''
|Pressure Drops and Flow Rates
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="4" |'''Control System'''
|Control system loop and function checks
|<nowiki>-</nowiki>
|-
|Alarm Checks
|<nowiki>-</nowiki>
|-
|System Start/Stop sequencing checks
|<nowiki>-</nowiki>
|-
|System Set-Back mode checks
|Include room condition and contiguous system impacts
|}

24.7. Select validation tests shall be conducted at intervals defined by the client:
 
{| class="wikitable"
|'''Tests'''
|'''Required/ Optional'''
|'''Recommended Frequency of testing'''
|'''At-Rest or In-Operation Testing'''
|-
|'''Airflow volume tests'''
|Required
|12 months
|At-Rest
|-
|'''Airflow visualization'''

'''(Airborne precaution rooms)'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Velocity Tests'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Airflow Visualisation'''
|Required
|6 Months
|At-Rest & In-Operation
|-
|'''Room pressure tests'''
|Optional
|3 Months
|At-Rest & In-Operation
|-
|'''Airflow direction tests'''
|Required
|1 Month
|At-Rest & In-Operation
|-
|'''Discreet practice counts'''
|Required
|12 Months
|In-Operation
|-
|'''Bio-burden testing'''
|Required
|1 Month
|At-Rest
|-
|'''Filter challenge testing'''
|Optional/Recommended
|24 Months
|At-Rest
|-
|'''Room Condition recovery'''
|Required
|24 Months
|In Operation
|}
24.8. Prescribed validation reports shall include:

*References to the test protocol
*Acceptance criteria
*Test results
*Test equipment identification and calibration status
*Name and signature of tester
*Name and signature of facility representative
*Dates of test and acceptance by client

===Medical gas installations===
25. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

26. All units of a health establishment, except sub-acute and hospice facilities, where patients are accommodated and treated, must have medial gases and vacuum provided by medical grade piped services, with indexed terminal connecter points. Bottle systems may be provided in sub-acute and outpatient facilities.

27. Mobile gas services must be available for crisis situations.

28. Sub-acute facilities must have one mobile oxygen cylinder per 10 patients and one suction machine for every 10 patients.

29. The minimum services to be supplied to all Acute Care areas are described in Table 11.1. Should the data in this table be in conflict be the table presented in the individual departmental design guidance documents, those individual guidance documents take precedence.
{| class="wikitable"
|+Table 5 Minimum gas services
!'''Description'''
!
!'''Oxygen'''
!'''HP Air'''
!'''LP Air'''
!'''N2O'''
!'''VAC'''
!'''Scavenging'''
|-
|'''Major Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Minor Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Cath Lab8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|1
|
|
|1
|1
|1
|-
|'''Post Op'''
|'''Bedhead'''
'''Trunking'''
|1
|
|1
|
|1
|
|-
|'''Procedure'''
'''Room'''
|'''Theatre Panel'''
|1
|
|1
|
|2
|
|-
|'''Resuscitation Bay'''
|
|1
|
|1
|
|2
|
|-
|'''Delivery Room'''
|
|2
|
|1
|
|2
|
|-
|'''High Care Unit, Per Bed'''
|
|1
|
|1
|
|2
|
|-
|'''Intensive Care Unit Per Bed'''
|
|2
|
|2
|
|2
|
|-
|'''Casualty Per Bed'''
|
|1
|
|1
|
|1
|
|-
|'''Wards'''
|
|'''1 per'''
'''2 beds'''
|
|
|
|'''1 per'''
'''2 beds'''
|
|}
30. A gas alarm system to monitor gases, excluding scavenging, must be installed in a location that is manned 24 hours per day. A slave panel must also be installed in the intensive care unit and in the theatre complex. This alarm system must be connected to UPS.

31. All piped vacuum and oxygen systems must have mobile back-up systems with adequately trained staff to handle them. . The back-up service shall be automatically activated if the line pressure drops below the set operating pressure. All back-up services and change-over valves shall be on UPS and diesel generator supplies.

32. Medical air (low pressure) for respiratory purposes must be provided at a fixed pipeline pressure of 400 kPa. Medical air (high pressure) for driving surgical power tools must be provided at a terminal usage pressure between 70 0kPa and 1000 kPa, depending on the tools/equipment to be used. ICU and operating rooms must be provided with a back-up system for both low and high pressure service. Air compressors must be fed off standby power supply.

33. Anaesthetic gas scavenging, which is a low-pressure suction system that removes exhaled anaesthetic gases from the patient circuit must be provided. Each outlet point must have its own balancing valve to allow the system to be balanced progressively from the furthest outlet point towards the suction fan or pump.

34. The vacuum installation shall comply with SANS 7396-1. Vacuum liquid bottle traps must be installed to collect any blood/fluid etc. that may be drawn into the pipeline. One bottle trap per operating room, ICU, ward block and other patient unit, must be supplied. Where possible the vacuum trap should be located in a sluice room. Emergency suction facilities must be provided in the ICU and High Care, operating rooms, recovery room, delivery room, emergency unit and nursery, and must be available to all patient rooms. Bacteria filters must be installed in the vacuum main before the vacuum reservoir and pumps. Used filters are considered a bio-hazard and must be handled accordingly when being changed and disposed. Care must be given to the location of the exhaust discharge of vacuum plants taking into account locations of windows and other air inlet points. Vacuum pumps must be fed off standby power supply.

35. Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.

36. Gas service outlets to be identified and colour-coded with 3mm lettering.

37. Should compressed air operated autoclaves be employed, High Pressure medical air may be taken to such equipment, provided the system possesses sufficient capacity.

38. Should pendants requiring compressed air for aid of movement be employed, High Pressure Medical Air may be taken to them, provided the system possesses sufficient capacity.

39. Should Health Technology Workshops require medical gas outlets for testing and servicing of medical equipment, the required service may be taken to them, provided the system possesses sufficient capacity.

40. SANS 7396-1, as amended, specifies the requirements from design to commissioning of medical gas and vacuum systems

41. Medical gas and vacuum pipelines shall be marked in accordance with SANS 7396-1 and ISO 5359 as applicable

42. SANS 7396-2, as amended, specifies the requirements from design to commissioning of anaesthetic gas scavenging disposal systems.

43. Colour coding of anaesthetic gas scavenging disposal system shall be red magenta or in accordance with the national standard. An example of red magenta is 3050-R40B, in accordance with SS 01 91 02.(Refer to SANS 73962-2).

44. Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.

45. SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.

46. Plain ended copper tubing for low pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.

47. Laboratory gas taps and valves shall be marked as described in SANS 10140-4

===Electrical installations===

====48. Lighting in Hospitals ====
48.1. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

48.2. Within the available scope presented in the National Building Regulations, the following lighting requirements should be interpreted with the aim of maximum energy and cost efficiency. The following innovations could be adopted to achieve this aim:

#Daylight harvesting with passive building elements and active systems response.
#Adoption of task lighting, where appropriate, within the scope of present and future planned activities.
#Considered selection of lighting elements and solutions.
#Considered selection of internal colours and materials.
#Accommodation for visually impaired occupants.

48.3. Where a requirement for natural light (daylight) is stated, this may be met if the room opens onto an atrium or courtyard, or if a roof light is incorporated, provided that privacy within the room or space is maintained. In addition, daylight may be borrowed from an adjacent room by means of glazing the wall in between, provided that the adjacent room or corridor is within the same unit.

48.4. Save where otherwise provided for in the requirements, health establishments must comply with the following: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table 6 Levels of Indoor Lighting (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings)'''
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''

'''/ lux'''
|'''Max. point illuminance/ lux'''

'''(not to be exceeded)'''
|'''Unified'''

'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''

'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Common areas'''

- changing room

- chapel

- classroom

- consulting room (general)

- care room (deep plan)

- day room

- disposal (clinical, domestic waste)

- doctor’s office

- domestic services room

- drug store (ITU/HDO)

- general office

- seminar room

- seminar room

- staff change

- staff rest room

- utility room (clean)

- utility room (dirty)
 
|

100-150

100-150

300

300

300

200

200

500

100

500

300

100-150

300

100

50/200

150

200
 
|

n/a

n/a

520

520

520

350

350

850

170

850

520

n/a

520

170

n/a

260

350
 
|

22

22

19

19

19

22

22

19

19

19

19

19

19

22

22

19

22
 
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

90

80

80
 
|

Floor

Pews

Desk

Work Surface

Work Surface

Work Surface

Floor

Desk

Floor

Desk

Desk

Floor

Work Surface

Floor

Work Surface

Work Surface

Work Surface
 
|

Normal

Normal

Normal

Normal

-

-

Normal

Normal

Normal

Normal

Normal

Normal

Selective

Normal

-

Normal

N
 
|

-

-

-

>30%

-

-

-

>30%

-

>30%

>30%

-

>30%

-

-

>30%

>30%
 
|-
|'''Corridors (screened from bed bays)'''

- by day

- by night
 
|

200

5-10
 
|

350

n/a
 
|

22

22
 
|

80

80
 
|

Floor

Floor
 
|

S

Normal
 
|

>30%

>30%
 
|-
|'''Circulation/communal areas'''

- corridors (general)

- day room

- entrance canopy

- entrance lobby

- hairdressing salon

- hospital street

- library

- lift car

- lift lobby

- loading bay

- reception area

- relatives overnight

- rest area

- shop/kiosk

- storage (general)

- toilets
|

200

200

n/a

n/a

300

200

300

150

200(min)

100

300

150

150

300

200

200
|

350

350

n/a

n/a

520

350

520

260

n/a

170

520

260

260

520

350

n/a
|

19

-

-

22

-

19

19

-

19

22

19

-

19

-

22

22
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80
|

Floor

Floor

Road surface

Floor

Chair

Floor

Desk

Floor

Floor

Platform or floor

Floor

Work Surface

Floor

Counter

Floor

Floor
|

Normal

S

Selective

Selective

Normal

N/EM

Normal

Sp

Selective

Normal

Normal

Normal

Normal

Normal

Normal

Normal
|

>30%

>30%

>30%

>30%

-

>30%

-

-

>30%

-

>30%

-

-

-

-

-
|-
|'''Restaurant/catering/breakout areas'''

- beverage bay

- counter

- general

- servery

- tables

- washing up
 
|

100

300

50

300

50/200

|

170

520

100

520

n/a

520
 
|

-

22

-

22

-

22
 
|

80

80

80

80

80

80
|

Floor

Counter

Floor

Counter

Tables

Sink
 
|

Normal

Normal

S

Normal

Normal

Normal
 
|

>30%

-

>30%

-

-

>30%
 
|-
|'''Wards and bedded areas'''

- children’s play area

- circulation space

- circulation space (night)

- examination/treatment

|

300

170

10

1000(local)

|

520

170

10

n/a

|

22

19

-

-

|

80

80

80

90

|

Desk

Floor

Floor

Bed level (usually provided by examination lamp
|

N/EM

Normal

Normal

Normal

|

>30%

>30%

>30%

>90%

|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Nursing'''

- general nursing care/examination

- night light

- nurses’ station (day)

- nurses’ station (night)

- observation/night watch

- observation/night

- mental illness care wards

- patient reading (adult)

- reading lights

- ward corridors (day)

- ward corridors (night)

|

300

5

300

30/200

20

1 to 5

200

300

300

200

50

|

520

10

520

250

40

n/a

350

520

520

350

75

|

19

-

19

22

-

-

19

19

19

19

19

|

80

80

80

80

80

80

80

80

80

80

80

|

Bed

Work Surface

Desk

Work Surface

Bed head

Bed head

Floor

Bed head

Patient activity area

Floor

Floor (50% uniformity required)
 
|

Selective

Normal

Variable

Normal

Normal

N/Sp

Normal

Normal

Selective

Normal

Normal

|

>30%

>90%

>30%

>90%

-

>30%

>30%

>30%

>30%

>90%

>30%

|-
|'''Orthopedic'''

- pacemaker

- treatment (general)

- venesection
 
|

500

300

300
 
|

850

520

520
 
|

19

19

19
 
|

80

80

80
 
|

Work Surface

Work Surface

Chair
 
|

Variable

Normal

Normal
 
|

>30%

>30%

>30%
 
|-
|'''Critical care'''

- intensive care (night)

- observation/night watch

- high dependency unit (HDU)

- intensive care unit (ICU)

- bed head (day)

- night light

- simple observation/examination

- examination

 
|

5(max)

20

100

100

30 to 50

5 to 10

300

1000 (local)

 
|

n/a

40

170

170

n/a

10

520

n/a

 
|

-

-

19

19

22

-

19

-

 
|

80

80

80

80

80

80

80

90

 
|

Circulation

Bed head

Circulation/general

Circulation/general

Bed head

Bed head

Bed

Bed level(to be provided by examination lamp)

|

N/Sp

N/Sp

Normal

Normal

Normal

Normal

Selective

Normal

 
|

>30%

>30%

>90%

>90%

>90%

>90%

>90%

>90%

 
|-
|'''Coronary care'''

- bed head (day)

- observation/night watch

- simple observation/examination

- examination

- staff base (day)

- staff base (night)
 
|

30 to 50

5 to 10

300

1000 (local)

300

30/200
 
|

n/a

n/a

520

n/a

520

250
 
|

19

-

19

-

19

19
 
|

80

80

80

90

80

80
 
|

Bed head

Bed head

Bed

Bed level (to be provided by examination lamp)

Desk

Desk
 
|

Normal

Normal

Selective

Normal

Selective

Variable
 
|

>90%

>90%

>90%

>90%

>90%

>90%
 
|-
|'''Nurse’s station/staff base'''

- day

- night

- interview
 
|

300

30/200

300
 
|

520

250

520
 
|

19

19

19
 
|

80

80

80
 
|

Desk

Desk

Desk
 
|

Selective

Variable

Normal
 
|

>90%

>90%

>30%
 
|-
|'''Operating theatres'''

- anesthesia (examination)

- anesthesia room (general)

- angiography room

- endoscopy

- operating room general

- operating table/cavity

- porter’s area

- post anaesthesia recovery

- preparation

- scrub up

- transfers

- utility rooms
 
|1000 (local)

500

500

300

300

1000

10000 to 100000

300

500

500

500

300

100 to 150
|

n/a

850

850

520

1500

n/a

520

850

860

860

520

n/a
|

-

19

19

19

19

-

19

19

19

19

19

19
|

80

80

80

80

90

90

80

90

801

80

80

80
|

Trolley head

Work Surface

Work Surface

Work Surface

Work Surface

Work Surface

Trolley/bed

Work Surface

Bench

Sink top

Work Surface

Floor
|

Normal

Selective

Variable

Variable

Variable

Variable

N/A

Selective

Normal

Normal

Normal

Normal
|

>90%

>90%

>90%

>30%

>90%

>90%

>90%

>90%

>30%

>30%

>30%

-
|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Accident and emergency'''

- Admissions. reception

- supplies stores

- minor treatment area

- minor operations

- couch (general area)

- couch (local)

- general examination areas

- procedure room

- resuscitation room
 
|

300

300

500

15000/30000

750

500

500

30000/60000

500
 
|

520

520

850

N/A

1000

850

850

N/A

860
 
|

22

22

19

-

19

19

19

-

19
 
|

80

80

80

90

90

80

80

90

80
|

Desk

Work Surface

Work Surface

Adjustable to suit treatment area

Over couch area

Couch level

Couch level

Task illumination provided by minor treatment lamp

Work Surface
 
|

Normal

Normal

Normal

Normal

Variable

Variable

Variable

Normal

Normal
 
|

>30%

>90%

>30%

>30%

>90%

>90%

>90%

>90%

>30%
 
|-
|'''Audiology'''

- audio testing

- consulting room

- ear examination

- vestibular testing (labyrinth)

|

300

300

1000 (local)

100

|

520

520

n/a

170

|

19

19

-

19

|

80

80

90

80

|

Work Surface

Work Surface

(examination lamp)

Couch head and instruments
 
|

Variable

Variable

-

Normal
 
|

>30%

>30%

-

>30%
 
|-
|'''Dentistry'''

- laboratories

- reception/administration areas

- surgeries/theatres

- treatment rooms

- white teeth matching

|

500

300

8000 to 20000

500

5000

|

850

520

n/a

850

n/a

|

19

19

-

19

-

|

80

80

90

90

90

|

Bench

Work Surface

Mouth

Bench work surface

Work Surface

(TCP ≤ 6000 K)
 
|

Normal

Selective

Variable

Normal

Normal

|

>30%

>30%

>90%

>30%

>30%

|-
|'''Diagnostics support'''

- aseptic laboratory

- blood bank

- colour inspection laboratory

- hot and cold rooms

- inspection

- laboratories

- laboratory (with computers)

- pathology laboratory

- relatives’ waiting room

- seminar room

- viewing/bier room
 
|

300

300

1000 (local)

200

500 (local)

500

300

500

300

300

30 to 150
 
|

520

520

n/a

350

n/a

850

520

850

520

520

n/a
 
|

19

19

-

19

-

19

19

19

19

19

19
 
|

80

80

90

80

80

80

80

80

80

80

80
 
|

Bench

Work Surface

Bench

(TCP ≤ 6500 K)

Work Surface

Bench

Bench/desk

Work Surface

Bench

Work Surface

Work Surface

Bier
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Variable

Normal

Variable
 
|

>30%

>90%

>90%

>30%

50-90%

50-90%

50-90%

50-90%

>30%

>30%

>30%
 
|-
|'''Women’s services (maternity)'''

- applying sutures

- circulation space (day)

- delivery

- day

- night

- neonatal

|

1000 (local)

100

500

50 to 100

5

1000 (local)

|

n/a

170

850

n/a

20

n/a

|

-

19

19

19

-

-

|

90

80

80

80

80

80

|

Couch, chair or bed (usually provided by examination lamp)

Floor

Work Surface

Cot

Cot

Cot

|

Normal

Normal

Selective

Normal

Normal

Normal
 
|

>90%

>30%

>90%

>90%

>90%

>90%

|-
|'''Mother and baby rooms'''

- circulation space (day)

- day

- night

- nurseries (day)

- nurseries (night)

- milk kitchen

- special care baby unit

- teaching areas
 
|

100

50 to 100

5

100

5

300

1000 (local)

300
 
|

170

n/a

20

170

20

520

n/a

520
 
|

22

19

-

19

-

22

19

19
 
|

80

80

80

80

80

80

80

80
 
|

Floor

Cot

Cot

Floor

Floor

Bench

Cot

Bench/Work Surface
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>30%

>90%

>90%

>30%

>30%

>30%

>90%

-
 
|} 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''General treatment areas'''

- autopsy (dissecting) table

- autopsy rooms and mortuaries

- dermatology

- dialysis

- dispensary

- minor surgery/treatment

- plaster room

- resuscitation (general)

- resuscitation/examination

- pharmacy
 
|

5000

500

(higher values could be required)

500

500

15000/30000

500

500

15000(local)

500
 
|

8600

850

n/a

850

860

 850

850

n/a

850
 
|

-

19

19

19

19

19

19

-

19
 
|

90

90

90

80

80

90

80

90

90

80
|

Table top

Work Surface

(Local operating lamp)

Work Surface (dimmable)

Bench

Work Surface

Work Surface

Head of trolley

Work Surface
 
|

-

-

-

-

Normal

Normal

Normal

Normal

Normal

Normal
 
|

-

-

-

-

>90%

>90%

>30%

>90%

>90%

50-90%
 
|-
|'''Mortuaries and animal houses'''

- autoclave

- body store

- general

- mortuary

- operation

- post mortem

- staff change

- store room

- viewing room

- waiting room
 
|

150/200

200

300

150

500 local

500

100 to 150

150

50/100

200 (min)
 
|

n/a

350

520

260

n/a

850

n/a

260

n/a

n/a
 
|

19

19

19

19

-

19

19

19

19

19
 
|

80

80

80

80

90

90

80

80

80

80
|

Work Surface

Work Surface

Work Surface

Bier room

Bench

Work Surface/table

Floor

Work Surface

Work Surface

Floor
 
|

Normal

Normal

Special

Variable

Normal

Normal

Normal

Normal

Variable

Selective
 
|

>30%

>30%

-

>30%

>30%

>30%

>30%

-

>30%

>30%
 
|-
|'''Engineering services'''

- ducts

- plant room

- roadways

- workshop
 
|

20 to 50

300

7

300/500
 
|

n/a

520

12

n/a
 
|

-

22

-

22
 
|

80

80

80

80
|

Floor

Floor

Road surface

Bench
 
|

Selective

Normal

-

Normal
 
|

-

>90%

-

>30%
 
|-
|'''Facilities support services'''

- laundry

- linen store (Linen Department)

- pack and dispatch

- pressing

- sewing room

- wash and dry
 
|

300

100

300

300

500 (local)

300
|

520

170

520

520

n/a

520
 
|

19

19

19

19

19

19
 
|

80

80

80

80

80

80
 
|

Bench

Floor

Bench

Equipment

Machine

Equipment

|

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>90%

-

>90%

>90%

>90%

>90%
 
|}
48.4.1. The lighting levels quoted above relate to the relevant task area. Levels of for the task areas and surrounding areas can be reduced where it can be justified by experienced staff or engineers. Lighting levels must, regardless, comply with the requirements of the National Building Regulations.

48.4.2. Lighting levels for external areas shall comply with the following table: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table''' '''7 Levels of Indoor Lighting'''
{| class="wikitable"
|Area
|Maintained average illuminance / lux
|Maintained minimum illuminance / lux
|Overall uniformity (not less than stated figure)
|Threshold increment
|Colour rendering (minimum)
|-
|

CCTV

- monochrome

- colour

Roads

General pedestrian areas

Information and display signs

Car Park

Vehicle drop-off points

Steps or stairways

General area lighting

Hazardous open storage areas
 
|

0

-

15

20

30

10

15

20

100(vertical)

15

10

100

20

50
 
|

5

15

6

8

12

4

6

12

6

5

40

12

20
|

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4
 
|

≥10%

≥10%

 
|

≥60%

≥60%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%
 
|}

49. Classification of Safety Services necessary for Medical Locations from SANS 10142-1
{| class="wikitable"
|'''Class'''
|'''Response Time'''
|-
|Class 0 (No break)
|Automatic supply available at no break

UPS backed up by Generator Required.
|-
|Class 0,15 (Very short break)
|Automatic supply available within 0,15 s

UPS backed up by Generator Required.
|-
|Class 0,5 (Short break)
|Automatic supply available within 0,5 s

UPS backed up by Generator Required.
|-
|Class 15 (Medium break)
|Automatic supply available within 15 s

Generator Required
|-
|Class > 15 (Long break)
|Automatic supply available in more than 15 s

Generator Required
|}
Note Safety Services in Medical locations are synonymous with Emergency Services.

50. '''Medical Location Classification'''

50.1. Group 0 location: where no applied part is intended to be used.

50.2. Group 1 location: Medical Location where applied parts are intended to be used.

#Externally, or
#To any part of the body, but not to the heart.

50.3. Group 2 location: Medical Location where applied parts are intended to be used in applications such as in an intracardiac procedure, in an operation (in an operating theatre) and in vital treatment where discontinuity (failure) of supply can cause danger to life.

Note: An intracardiac procedure is a procedure whereby an electrical conductor is placed within the cardiac zone of a patient or is likely to come into contact with the heart, such conductor being accessible outside the patient’s body. In this context, an electrical conductor includes insulated wires such as cardiac pacing electrodes or intracardiac ECG electrodes, or insulated tubes filled with conducting fluids.

50.4. For the allocation of medical location group and classification of safety service classes for medical locations see Table below as supplied in SANS 10142-1.
 
{| class="wikitable"
|
|
'''Medical Location'''
| colspan="3" |
'''Medical location group'''
| colspan="2" |
'''Safety service class'''
|-
|
|
|'''0'''
|'''1'''
|'''2'''
|'''≥ 0,5'''
|'''0,5'''

'''≤ 15'''
|-
|

1
|

Massage room
|

X
|

X
|
|
|

X
|-
|

2
|

Bedrooms
|

|

X
|
|
|

X
|-
|

3
|

Delivery room
|
|

X
|
|

X
|

X
|-
|

4
|

ECG, EEG, EHG room
|
|

X
|
|
|

X
|-
|

5
|

Endoscopic room
|
|

Xa
|
|
|

Xa
|-
|

6
|

Examination or treatment room
|
|

X
|
|
|

X
|-
|

7
|

Urology room
|
|

Xa
|
|
|

Xa
|-
|

8
|Radiology diagnostic and radio therapy room, other than mentioned under 21
|
|

X
|
|
|

X
|-
|

9
|

Hydrotherapy room
|
|

X
|
|
|

X
|-
|

10
|

Physiotherapy room
|
|

X
|
|
|

X
|-
|

11
|

Anaesthetic room
|
|
|

X
|

X
|

X
|-
|

12
|

Operating theatre
|
|
|

X
|

X
|

X
|-
|

13
|

Operating preparation room
|
|

X
|

X
|

X
|

X
|-
|

14
|

Operating plaster room
|
|

X
|

X
|

X
|

X
|-
|

15
|

Operating recovery room
|
|

X
|

X
|

X
|

X
|-
|

16
|

Heart catheterization room
|
|
|

X
|

X
|

X
|-
|

17
|

Intensive care room
|
|
|

X
|

X
|

X
|-
|

18
|

Angiographic examination room
|
|
|

X
|

X
|

X
|-
|

19
|

Haemodialysis room
|
|
|

X
|

|

X
|-
|

20
|

Magnetic resonance imaging (MRI)
|
|

X
|
|
|

X
|-
|

21
|

Nuclear medicine
|
|

X
|
|
|

X
|-
|

22
|

Premature baby room
|
|
|

X
|

X
|

X
|-
| colspan="3" |
a The room is not an operating theatre.
|
|
|
|
|}
50.5. In addition to the tables 0 and 50.4 above, generator supply is also required for:

#Night light in wards and ward corridors;
#All switched socket outlets used for patient life support anywhere in the facility;
#At least one patient lift or lift that can accommodate a bed for every 200 patients;
#Medical air compressor, vacuum pumps and gas alarm systems;
#Supply air fans serving theatres and uni-directional airflow systems;
#Isolation ward exhaust air fans.
#Mortuary Fridge Cabinets
#Nurse call System
#Fire detection system

51. General Requirements

51.1. Power supply to switched socket outlets in high care units, intensive care units and operating theatre units and recovery rooms must be on an earth monitoring system. Double pole isolators must be used for supply points in these areas and the power supply to these shall be fed from an isolation transformer.

51.2. Medical Location Group 1:

Switch Socket outlets in Medical Location 1 Shall have final Circuits for socket -outlets up to 16Amp shall be protected by earth leakage protection devices with a rated earth leakage tripping current ( rated residual current) not exceeding 30 Ma.

51.3. Medical Location Group 2:

Switch Socket outlets in Medical Location 2 the Medical Isolation Transformer (Medical IT) system shall be used for circuits that supply medical electrical equipment and systems intended for life support or surgical applications and other electrical Equipment located in the patient environment. In the case of each group 2 medical location, at least one separate medical IT system is necessary.

51.4. The Medical Isolation Transformer (MIT) shall be equipped with:

51.4.1. A 5 or 8 kVA Isolation Transformer complete with a 220 V Primary and 220 V / 110 V Secondary Winding with a centre Point Floating but bonded to the Earth monitor. The Secondary Side of the transformer shall provide 220 Volts between Line 1 and Line 2 (Note no Neutral with an Isolation Transformer) Line 1 and Line 2 will feed the Distribution Board for that particular Medical Group location, i.e. (Theatre No 1) or (ICU Bed 1-6) This local DB will then have a number of double pole Circuit Breakers feeding out to the outgoing Circuits feeding the Socket Outlets in the Medical Location 2 Area. Note that at least two circuits are required to each ICU Bed or Theatre Panel, and Theatre Pendant. Also note that all Switch Socket Outlets in a Medical Location 2 Area have to be double Pole Switched via a double pole Isolator (Provided two circuits provided) or a double pole Circuit Breaker.

51.4.2. The Transformer shall be installed either in a cabinet/DB or enclosure, to prevent unintentional contact with live parts. The Transformer / DB should be located close to the Group 2 Medical Location but consideration should be given to providing the DB outside the red line area of both the Theatres and ICU Areas, so maintenance can be carried out without the need to be gowned up. Line 1 & 2 and Earth should all be Insulated wires with the colour of Line 1 & 2 being different from red and black suggest Brown and Blue wire is used for Line 1 & 2 and green for Earth (Note this Earth wire should be connected to an insulated Earth bar dedicated to that particular Group two location and bonded to the centre point of the secondary winding.) Note a Separate Dirty earth (Equipotential bonding) should also be provided to the metal work of the Plugs, Theatre Panel, and Pendant this earth shall be connected to the Main Building Earth.

51.4.2. An insulation -monitoring device that:

#Has an internal impedance of at least 100 k Ohm;
#Has a test voltage not exceeding 25 V DC.
#Is of a current, even under fault conditions, not exceeding 1 mA DC. and
#Shall indicate, at least when the insulation resistance has decreased to 5 k Ohm.

A test device shall be provided to test this facility to ensure that the alarm (Audible and visual) operates when the insulation resistance reaches 5 k Ohm;

To test the System two male plugs should be used each with a resistor of 5 k Ohm. Plug No 1 should have a 5 k Ohm resistor bridged from the Earth Pin to the Right Hand live Pin. Plug No 2 should have a 5 k Ohm resistor bridged from the Earth Pin to the Left Hand live Pin.

51.4.4. Medical Isolation Transformer Alarm.

For each Medical IT system an audible and visual alarm shall be provided in the Theatre Area a alarm shall be provided on theatre Panel and repeated back to the main Nurse Station in Theatre Area .The Alarm shall consist of Green Light indicating Healthy, a red light indicating fault, a audible Alarm to also indicate fault and a local audible alarm mute button. The Visual signal shall revert to green and the audible alarm shall be automatically reset on the removal of the fault condition
 

Table 4 – Required for Medical Isolation Transformers (MIT) and Switch Socket Outlets (SSO)
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Office Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Laboratory Work Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Office
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Nurse Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward
|1
|1 x 16A Normal / Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point/ Bed(if required).
|
|3x 16A per bed
|
|
|
|
|-
|Ward Kitchen
|0
|2 x 16A Normal on Wall at 1200 mm over counter + 1 x 16 A next to Sink or Hydro Boil.
|
|1 x 16A supply for Fridge on generator supply
|
|
|
|
|-
|Ward Corridor
|0
|1 x 16A Normal / Every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Ward Staff Rest Room
|1
|I x 16 A on Wall for Cleaning, 1 x 16 A above counter for Electrical Appliances + 1 X 16 A next to sink for Hydro boil
|
|
|
|
|
|
|}
----[[Building Engineering Services#%20ftnref1|[1]]] Note: DPS is an abbreviation for double pole switch
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Theatre Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|-
|Theatre Post Op
|2
|
|
|
|6 x 16 A Dedicated SSO per Bed
|
|
|
|-
|Operating Theatre
|2
|
|
|
|
|8 x 16 A Dedicated SSO per Pendant
|8 x 16 A Dedicated SSO per pendant
|4 x 16 A Dedicated SSO
|-
|Cath Lab Operating Room
|2
|
|
|
|
|
|
|4 x 16 A Dedicated SSO
|-
|Cath Lab Control Room
|0
|1 x 16A Normal per Station
|1 x Red 16A Dedicated per Station
|
|
|
|
|
|-
|Cath Lab Equipment Room:

160 kva dedicated UPS Required to feed Dedicated DB and Equipment
|
|
|
|
|
|
|
|
|-
|Autoclave
|
|In autoclave plant room. 3-Phase 380V, 80A per autoclave
|
|
|
|
|
|
|-
|Instrument Washer
|
|In CSSD. Typically 3-Phase 380V, 15A per washer
|
|
|
|
|
|
|-
|Theatre Corridor
|1
|1 x 16A Normal for every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|}
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|ICU Circulation Space
|1
|1 x 16A Normal per 25m2 for cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Neo Natal ICU Cots Note: Care should be taken when sizing the Isolating Transformers to include the Heating Load
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care Nurse Station (per workstation)
|1
|1 x 16A Normal per Station
|2 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|-
|ICU and Ward Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|}
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Casualty Treatment Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point per Bed. 2 x 16A per Bed
|
|
|
|
|
|
|-
|Procedure Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning
|
|4 x 16A per Bed per two Circuits.
|
|
|
|
|-
|Casualty Ward Corridor 0
|0
|1 x 16A Normal per every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Radiology Procedure Crash Cart Position
|
|
|
|
|
|-
|Rooms Dedicated 125 Amp Supply to dedicated
|1
|1 x 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Radiology Control Room
|0
|1 x 16A Normal per Station
|1 x 16A Normal per Station
|
|
|
|
|
|-
|Maternity Delivery Rooms
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|
|
|}

{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Dialysis Treatment Beds.

Note that the Equipment can include Water Heating with high kw loading so care should be taken when sizing the Isolating Transformers
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|
|
|}
51.5. Uninterrupted Power System must be provided for operating theatre luminaries and all life support systems and computer systems where a break in electrical supply cannot be tolerated. The whole installation must conform to SANS 1474 of 1988.

51.6. Socket outlets for Dialysis units, in close proximity to water points or drains, shall be of the totally waterproof IP65 type, which also seal water-tight when the socket is removed.

51.7. Where more than one electrical transformer is used, they should preferably be located in separate structural enclosures. This is to prevent potential damage to an adjacent transformer if one is damaged.

51.8. All distribution boards fed from normal mains supply shall be painted Electric Orange, colour B26 to SABS 1091.

51.8. All distribution boards fed from standby emergency power supply shall be painted Signal Red, colour A11 to SABS 1091.

51.9. All distribution boards fed from UPS power supply shall be painted Blue colour F06 to SABS 1091.

51.10. All cable transition boxes shall be painted the appropriate colour corresponding to the source of the power supply.

51.11. All cables installed on surface mounted cable ladders shall be of the PVC/PVC/SWA/ECC/PVC type to SANS 101507 rated at 600/1000 Volt.

51.12. Electrical circuits to be engraved on base 3mm lettering indicating circuit number and DB.

51.13. Electrical Certificate of Compliance.
[[File:Picture 11.png|border|thumb|450x450px|alt=|center]]
 
===Electronic installations===
52. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

53. Nurse call system with emergency (nurse assistance) and TV control handsets (Interchangeable with LED PEAR PUSH).

The nurse system enables the patient to call a nurse for assistance from his bed or from a bath, shower and toilet. The system also enables the staff to call for assistance (EMERGENCY CALL) from any bed and treatment room etc.

#When a patient nurse call or staff emergency call is enabled the system must produce an intermittent AUDIBLE chimes or bleeper tone at the nurses’ station or/and duty room. Three different sounding tones must be produced for normal Patient call, Bathroom call and Emergency (nurse assistance) call.
#The system must also provide a VISUAL indication, at the nurse station (LED Mimic Panel and/ or Computer Monitor or LCD Display Panel), above the door to the passage of the activated unit, and at the actual activated unit (reassurance LED).
#The system must be so designed that any call may ONLY be RESET at the point of origin.
#The system must automatically activate a nurse call when the Hand Held Unit (Handset) or Pear Push unit is accidently pulled out from the Bed Head Unit.
#The Bed Head Unit must be compatible with Hand Held Unit (with TV Control), Rehab Hand Held Unit & Pear Push. (Inter-changeable)
#A Central Monitoring PC, or PC per duty station replacing Mimic Panel, must keep records of all events. (Optional)
#The system must be purpose made and aesthetically pleasing with components (call & reset units etc) manufactured from matching injection moulded ABS plastic. A system made up of push buttons etc mounted directly onto standard electrical plates will not be accepted.

54. Automatic fire detection in Hospitals

The Fire Detection System shall comply with SANS 10400 SANS 10139 & SANS 322. The Fire Detection System must be provided throughout the Facility and be a Addressable Fire Detection System, Note that Audible Fire Alarms which could panic the patients should not be provided instead Visual Strobe Lights should be provided at all Nurse stations, Reception and Security Office.

Audible alarms can be used in noisy areas such as plant rooms.

The wiring for the Automatic Fire Detection System shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area)
 55. Public Address and Evacuation in Hospital

The Public Address and Evacuation System shall comply with EN54 and provide voice message via fire retardant speakers throughout the hospital Circulation Areas, Staff Areas, Public Toilets. The wiring for the Evacuation Speakers shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area). As part of the Hospital Design the Hospital should be zoned to allow Evacuation of Individual zones in the event of a fire or other Emergency.

==Wet Services==
56. Plumbing services (Water supply and drainage) must comply as a minimum with the following Standard Specifications and Codes of Practice:

#SANS 10400: The Application of the National Building Regulations, including Part XA: Energy Use in Buildings
#SANS 10252 – Part 1 – Water Supply Installations for Buildings
#SANS 10252 – Part 2 – Drainage Installations for Buildings
#UK Department of Health Technical Memorandum 04-01: The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems: Part A: Design, Installation and Testing, and Part B: Operational Management or the equivalent SANS standard when available.

57. Where any apparent conflict between the functional requirements and the regulatory “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functional compliance.

58. Cold water storage, dedicated to the domestic water requirements of the facility, must be provided on the site. A minimum usable volume of 500 litres per bed must be provided.

59. If water storage is required for fire protection purposes (Sprinklers, Fire Hydrant supply) it must be stored separately from domestic water, unless adequate provision for the prevention of stagnation of the fire service reserve within the tank can be made.

60. Tanks must be accessible both on the outside as well as the inside, and provision for cleaning the tanks without interrupting water supply to the hospital must be made. Access manholes must be lockable, and a facility for draining the tank or individual compartments within it, must be made.

61. All openings to the tank (Overflows, vent pipes, etc) must be provided with screens.

62. Underground tanks, with their inherent risk of contamination must be avoided at all cost. If unavoidable, the tank should be constructed in a water tight bund allowing sufficient space all round for inspection and maintenance, and a sump for collecting drainage water

63. Cold water storage tanks must be located such that heat gain to the water is minimised. Cold water storage temperatures 20 C and lower will prevent the colonisation by or multiplication of Legionella

64. Site water reticulation must be designed using sound engineering principles, with adequate provision for isolating sections of the reticulation whilst keeping the remainder in operation being made.

65. Fire protection water reticulations must be kept totally separate from the domestic water reticulation

66. Water distribution may be gravity fed, or alternatively supplied via booster pumps. Pumps must be suited to handling potable water, and provision for built in redundancy must be made. Booster pumps must be supplied off standby power.

67. Hot water supply temperature to general patient care and staff areas must be controlled at 55 C, and must not exceed 60°C, except during a sanitation cycle as described hereunder.

68. Hot water generation systems must where possible use waste heat recovery from a central air conditioning system, if employed.

69. The facility for thermal disinfection of the hot water storage and circulation system must be provided in the system design. This can take the form of controlled heating of the storage vessel and circulating mains to 60°C during periods of low water and power demand. The use of shunt pumps to circulate hot water from the top level to the lowest level of the hot water tank during the sanitation cycle must be considered.

70. Hot water supply to paediatric wards, as well as to geriatric and to neonatal bathing facilities shall not exceed 42°C at the point of supply. If thermostatic mixing valves are employed to achieve this, they must be fitted with a safety feature such that the water flow is cut off within 2 seconds of the cold water supply to the valve being interrupted. The valve must also be able to control the set temperature with a pressure ratio of incoming hot to cold water supply pressure of up to 10 to 1.

71. Toilet flushing systems must be provided with easily identifiable dual flush mechanisms, one being for low flush water flow, the other for standard flush water flow.

72. All sanitary fittings must be piped such that the hot water control is on the left hand side, and the cold water supply is on the right hand side when facing the fitting.

73. Branch pipes (dead legs) between water heating equipment or hot water circulating mains and sanitary fittings must be sized and located such that the maximum waiting time for hot water to emerge from the fitting does not exceed 12 seconds.

74. Mixing taps in patient care areas must be elbow action type, installed such that the tap can be opened and shut by means of simple elbow action.

75. The discharge from kitchen floor drains and other kitchen drain points such as sinks, dishwashing washing, machines, and cooking equipment wash down, likely to contain grease, must be taken via a separate discharge system to a suitable grease interceptor, installed in a position to allow easy access for removal of intercepted grease and oil.

76. The drain pipes from equipment likely to produce high temperature discharge, such as autoclaves, sterilisers and cooking equipment must be from materials able to withstand such temperatures, installed such that distortion and/or expansion can be accommodated by the system.

77. Vertical pipe runs (Drainage stacks and water supply mains) in multi storey buildings must be housed in continuous vertical service ducts with easy access from non-patient areas at each level.

78. Condensate drains from air conditioning and refrigeration systems must discharge into piped drainage systems.

79. Anti-Backflow protection devices shall be fitted to faucets with hand-held shower heads to prevent back siphoning should the supply water pressure fail.

80. In areas housing patients at unusual risk of infection, faucets should not be fitted with low-flow or aerating devices which may increase the rate of aerosolisation of infectious droplets.

 

'''81. Legionella Control'''

#A facility-wide legionella control plan shall be in place which will inform operation, maintenance and design of water systems.
#This Plan must include a Legionella risk assessment document, listing all areas where the bacteria may occur. This must address specifically air conditioning condenser water systems, domestic hot and cold water installations, irrigation water storage and distribution systems, etc.
#The Plan must refer to as-built drawings identifying positions and layouts of plant and installations liable to cause a risk of Legionella being generated
#The facility’s Maintenance Procedures must describe all measures to be taken to minimise proliferation of Legionella. This is to include procedures and frequency of sanitation/disinfection, purging of dead legs on circulating systems, sample taking and testing at specific intervals, as well as a responsibility matrix of personnel

For additional information refer to the [[Legionella Control]] article.

==Lifts==
82. Standards and Regulations Pertaining to Lifts and Lifting Operations:

#SANS 50081 - SAFETY RULES FOR THE CONSTRUCTION AND INSTALLATION OF LIFTS - PARTICULAR APPLICATIONS FOR PASSENGER AND GOODS LIFTS
#SANS 10400 –SS3 FACILITIES FOR DISABLED PERSONS: LIFTS
#SANS 10400 –TT45 FIRE PROTECTION: LIFT SHAFTS
#SANS 10400 –TT46 FIRE PROTECTION: LIFT
#SANS 10400 –TT47 FIRE PROTECTION: FIREMAN’S LIFT
#SANS 10400 –TT48 FIRE PROTECTION: STRETCHER LIFT 

83. Planning for circulation, capacity and location of lifts

#A lift traffic plan should be developed. Detailed lift traffic planning is beyond the scope of this document. A specialist advisor should be consulted to assist in the planning of lifts within the general principles of lifts services for healthcare buildings.
#General Lift Planning Principles
#The operational details of the facility must be understood for effective lift planning. These include:

*Number of visitors and visiting hours
*Number of staff, shift hours and ward round schedules
*Numbers of day and overnight patients
*Increased provisions for reduced mobility persons
*Housekeeping schedule
*Evacuation plan for reduced mobility patients.

#Whenever possible, lifts should be provided in pairs to allow for continued operation during maintenance and breakdown.

 

===='''84. TYPES OF LIFTS:'''====
84.1. PASSENGER LIFTS

#These lifts shall be able to accommodate general passenger traffic including ambulatory and semi ambulatory passengers. It shall be able to accommodate reduced mobility passengers using mobility aids and wheelchairs. Refer to SANS 50081-70, Table 1
#The entrance to a passenger lift shall not be less than 1100 mm in width.
#The depth of a passenger lift shall not be less than 1400mm deep.
#Passenger lifts shall have a mirror on the top half of the rear wall equal to the width of the lift to enable wheelchair users to back out of the lift where the lift has internal dimensions less than 1,5 m in width and 2,0 m in depth
#At least on one side wall of the car a handrail shall be installed 

84.2. BED LIFTS

#Bed lifts shall have internal dimensions of 1 800 mm wide by 2 700 mm deep to accommodate most beds with staff and medical equipment.
#The entrance to a bed lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.3. STRETCHER LIFTS

#Stretcher lifts shall have internal dimensions of 1 400 mm wide by 2 400 mm deep to accommodate most trollies or stretchers.
#The entrance to a stretcher lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.4. GOODS LIFTS

#Goods lifts are for the movement of conventional goods and items that could not reasonably use passenger lifts without causing discomfort to passengers or damage and soiling of the lift car.
#Goods lifts can be designed to accommodate passengers.

84.5. SERVICE LIFTS

#Service lifts are not designed for accommodate passengers. They are typically of the “dumb waiter” style dispatched between service hatches.

84.6. HOUSEKEEPING LIFTS

#Housekeeping lifts are similar in function to goods lifts but are intended for the movement of cleaning supplies, medical supplies and equipment, linen etc.

{| class="wikitable"
|+Hospital Guide - Passenger
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''630 kg / 8 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|1800 x 1800

2000 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''800 kg / 10 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1350 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|2000 x 1800

2200 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1600 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2300 x 1800

2450 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1250 kg / 16 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|2000 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2700 x 2000

2700 x 2000
|1450
1500

1600
|4200
4300

4400
|}
 
{| class="wikitable"
|+Hospital guide - stretcher / Bed Lifts
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 2100
|CLD

TLD
|1000 x 2100

1000 x 2100
|200 x 2600

2000 x 2600
|1450
1500

1600
|4200
4300

4400
|-
|'''1600 kg / 21 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1400 x 2400
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 2800
2500 x 2900

2400 x 2900
|1450
1500

1600
|4200
4300

4400
|-
|'''2000 kg / 26 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1500 x 2700
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 3100
2600 x 3150

2450 x 3150
|1450
1500

1600
|4200
4300

4400
|-
|'''2500 kg / 33 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1800 x 2700
|CTLD

CTLD
|1400 x 2100

1600 x 2100
|2900 x 3150

3000 x 3150
|1450
1500

1600
|4200
4300

4400
|}
 
==PART D - COMMISSIONING AND HANDOVER==
===Deliverables===
1. This section is intended to detail the commissioning deliverables required before handover of building engineering services for operation. For further detail on commissioning and handover the '''IUSS Commissioning Health''' Facilities guidance document should be referred to.

2. Project Close-out deliverables include:

#Final Works completion lists
#Financial reports and final accounts
#Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
#Approved As-Built Drawings
#Electrical Certificates of Compliance

3. '''Maintenance manuals''' shall be timeously issued and shall include:

3.1. Designer and installer contact information

3.2. System information

#System description
#Suppliers list
#Equipment List
#Equipment data sheets
#Materials of construction data sheets
#Warranty information

3.3. Operational parameters

#Start up and shut down procedures
#Special instructions
#Security and access details
#Fault finding procedures
#Alarm management and data logging

3.4. Validation and commissioning

#Approved reports and data
#Relevant test protocols
#Relevant test plans
#Installed and test equipment calibration certificates
#Commissioning certificates
#Beneficial Occupation and Handover certificates

3.5. Spare parts list

3.6. Electronic Data Backup (Read only Media)

3.7. Approved “As-Built” Drawings

#Process diagrams
#Wiring Diagrams
#Control Diagrams
#System Plans
#Training records

3.8. Training Records

3.9. Training Materials

===Commissioning of ventilation systems===
4. Commissioning of ventilation and air conditioning systems shall comprise the following:

#Confirmation of accuracy of measurements.

Measurement accuracy depends on equipment accuracy and repeatability. Factors that would impact on the accuracy of measurement include:

*Operator error and competence
*Type and quality of measuring device
*Quality and adherence to measurement protocols.

4.2. Proof of competence of commissioning technician or engineer

4.3. Commissioning method statements or protocols shall be developed, recorded and adhered to, to ensure all technicians work to the same procedures and sequences. In some instances, such as healthcare units where the ventilation system is critical to that unit’s clinical outcomes or to the safety of occupants, the client or client’s representative may request that these method statements be issued for formal approval before commencement of commissioning.

4.4. As the operational parameters of variable air volume systems are more complex that constant volume systems, the designer is to provide details of all relevant aspects of these systems such that the commissioning specialist can sufficiently develop an appropriate plan the commissioning.

4.5. Preliminary inspections should be completed before the systems are started up for commissioning. Typically these inspections should include:

*The '''state of completion''' of the building and the condition of details such as openable windows, doors and ceilings.
*'''Building cleanliness''' as it pertains to the ventilated spaces as well as the equipment plant rooms.
*Ducting and ventilation components should be inspected internally and externally for '''system cleanliness.''' Prior to fitting filters the following components should be checked for completion, correctness and cleanliness:

#Air intakes screens and mixing plenums
#Heating components
#Cooling components
#Condensate and drip trays
#In duct UVGI systems
#Humidifiers
#Fan and equipment chambers including safeties and interlocks
#Sensors and gauges
#Airflow controllers and fire damper
#Filter frames and orientation thereof
#Insulation
#Ducting and air terminals

*Electrical Equipment should be inspected for completion, correctness, labelling and cleanliness. Prior to running any electrical rotating or control equipment the following check should be completed.

#Local isolators of motors, electric heaters and control circuits including labelling.
#Electrical safety
#Motor starters and frequency drives set correctly for overload and motor restart ratings.
#Direction of rotation of motors on motor shafts
#Motor starting current and sequencing

4.6. An initial running-in period should be conducted at low load before the installation of the filters. This running period is to ensure flushing of ducting, and allow checking of the system operation. During the this period the system should be shut down and restarted to ensure that the controls, fuses and switchgear function correctly; however, repeated rapid restarts should be avoided as this can over-stress the control gear and fuses.

4.7 After the initial running-in the filters can be installed by a suitably qualified technician and the system should then be run at normal load. New filters should be installed before the final proportional balancing commences.

4.8. The proportional balancing of the airflow should be delayed until the ventilation system has been run-in under normal load for a few days to ensure stability of the system. The airflow balancing should be conducted in accordance with good engineering principles such as those described in SANS 10173, the ASHRAE Fundamentals Handbook, CIBSE Commissioning Code A or BSRIA Application Guide 3/89.1 depending on the system requirements.

4.9. For variable air volume systems, the commissioning tests should demonstrate system performance across the design diversity.

4.10. A definitive total airflow measurement should be taken in either a section of the main duct, where duct length and turbulence allow, or in the branch ducts. This value shall be recorded, compared against the design values and tolerances and reported on in the commissioning reports including the percentage of the design flow rates.

4.11. The final airflow measurements shall be taken at all air terminals (supply, return and exhaust) using airflow capture hoods where the terminal generates turbulence and these values shall be recorded, compared to design values and tolerances and reported on in commissioning reports including the percentage of the design flow rates.

4.12. Direction, drop and throw of air terminals shall be assessed by the responsible engineer to confirm the correct air distribution within ventilated spaces.

4.13. The minimum outside air portion should be demonstrated and recorded across the system’s operational diversity.

4.14. A condition of system acceptance is that the commissioning tests be witnessed before signing off. This process could involve the repetition of only a selection of the tests under the observation of an authorised witness or responsible engineer. The following aspects should be demonstrated:

*Performance of the system according to the overall design requirements within specified limits
*Repeatability of performance and measurement results

==PART E - EXAMPLES==
===Mechanical system configurations===

===='''1. HOT WATER GENERATION SYSTEM'''====

[[File:Picture 1.png|thumb|570x570px|Hot water generation system|alt=|border|center]]

===='''2. THEATRE VENTILATION SYSTEMS'''====
The following examples indicate typical system configurations schematically.

2.1 UDAF Recirculation

 
[[File:Picture 2.png|border|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic|alt=|center]]

2.2. UDAF Full Fresh Air & Exhausted

[[File:Picture 3.png|center|thumb|410x410px|NOTE: Does not indicate sensors, interlocks or control logic]]
2.3. Major Theatre: Recirculation
 
[[File:Picture 4.png|center|thumb|410x410px]]

2.4. Major Theatre: Full Fresh Air Supply only
[[File:Picture 5.png|border|center|thumb|400x400px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

2.5. Minor Theatre: Recirculation
[[File:Picture 6.png|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.6. Minor Theatre: Full Fresh Air & Exhausted
[[File:Picture 7.png|border|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.7. Minor Theatre: Full Fresh Air Supply only
[[File:Picture 8.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

===='''3. AIRBORNE PRECAUTION ROOMS AND THEATRES'''====
3.1 Energy Recovery Systems for Airborne Precaution Rooms
 
[[File:Picture 9.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]
4. Energy Recovery Systems for Airborne Precaution Theatres
[[File:Picture 10.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks and control logic]]
 
==REFERENCES==
'''Applicable Regulations and Standards:'''

National Health Act 2004''.'' (61 2003). Cape Town South Africa: Government Gazette.

''Ammended Occupational Health and Safety Act 2004.'' (181 1993) South Africa: Department of Labour.

South African Bureau of Standards, 2009. ''SANS 10142-1:2008 The wiring of premises Part 1: Low-voltage installations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 10173:2003 The installation, testing and balancing of air-conditioning ductwork.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 10252-1:2012 Water supply and drainage for buildings Part 1: Water supply installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1993. ''SANS 10252-2:1993 Water supply and drainage for buildings Part 2: Drainage installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 10313: 1999 Protection of structures against lightning.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1990. ''SANS 10400-2: 1999 Code of Practice for The Application of the National Building Regulations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-1:2005 Copper-based fittings for copper tubes Part 1: Compression fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-2:2005 Copper-based fittings for copper tubes Part 2: Capillary solder fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 1091:2012 National colour standard''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1238:2005 Air-conditioning ductwork''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1409:2008 Outlet sockets and probes for medical (gas and vacuum) services used in hospitals.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1424:2008 Filters for use in air-conditioning and general ventilation.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2011. ''SANS 1453:2011 Copper Tubes for Medical Gas and Vacuum systems.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 14644-1:1999 Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-2:2003 Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-4:2003 Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1988. ''SANS 1474: 1988 Uninterruptible Power Supplies''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2009. ''SANS 7396-1:2009 Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 7396-2:2008 Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems.'' Pretoria South Africa: SABS Standards Division.

*All local Municipal laws and regulations,
*ISO 14644-3:, Cleanrooms and associated controlled environments - Part 3: Test Methods Australasian Health Infrastructure Alliance,2006. Australasian Health Facility guidelines [online] Available at: <nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> [Accesed ...].
*ISO/DIS 5359. Anaesthetic and respiratory equipment - Low-pressure hose assemblies for use with medical gases,
*National Health Act, 2004 (Act No. 61 of 2003).
*Occupational Health and Safety Act, of 1993
*Regulations of the Local Electricity Authority,
*SANS 10114: Lighting Requirements,
*SANS 10142-1: The wiring of premises Part 1: Low-voltage installations,
*SANS 10173: The installation, testing and balancing of air-conditioning ductwork,
*SANS 10224: Non-flammable medical gas pipeline,
*SANS 10252-1: Water supply and drainage for buildings Part 1: Water supply installations for buildings,
*SANS 10252-2: Water supply and drainage for buildings Part 2: Drainage installations for buildings,
*SANS 10313: 1999 Protection of structures against lightning,
*SANS 10400: Code of Practice for The Application of the National Building Regulations,
*SANS 1067: Copper-based fittings for copper tubes Part 1: Compression fittings,
*SANS 1067: Copper-based fittings for copper tubes Part 2: Capillary solder fittings,
*SANS 1091: Colour Coding of Services,
*SANS 1140: Identification colour marking Part 4: Contents of taps and valves in laboratories,
*SANS 1238: Air-conditioning ductwork,
*SANS 1409: Outlet sockets and probes for medical (gas and vacuum) services used in hospitals,
*SANS 1409: Part 3 Handling and storage of Medical Gas,
*SANS 1424: Filters for use in air-conditioning and general ventilation,
*SANS 1453: Copper Tubes for Medical Gas and Vacuum systems,
*SANS 14644-1, Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness,
*SANS 14644-2, Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1
*SANS 14644-4, Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up,
*SANS 1474: 1988 Uninterruptible Power Supplies,
*SANS 7396-1: Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum,
*SANS 7396-2: Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems,
*SANS 50081: Safety rules for the construction and installation of lifts — Particular applications for passenger and goods lifts,
*Any other applicable Laws or Regulations.

Chartered Institution of Building Services Engineers (CIBSE), 1999. Environmental design CIBSE Guide A. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2005. CIBSE Applications Manual AM10 Natural ventilation in non-domestic buildings. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2008. Lighting Guide 2: Hospitals and health care buildings. England: The Society of Light and Lighting.

 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009. ANSI/ASHRAE/ASHE Standard 170-2008 Ventilation of

Health Care Facilities. Atlanta USA:ASHRAE.

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2013. HVAC Design Manual for Hospitals and Clinics Second Edition. Atlanta USA:ASHRAE.

'''Further reading'''

*<nowiki>http://www.spaceforhealth.nhs.uk/</nowiki> (National Health Service NHS website for UK guidance) website closed now
*<nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> (Health Facility Guides website for Australasian Health Facility guidance)
*CIBSE Guide A – Environmental Design
*CIBSE Applications Manual for Natural Ventilation – AM10
*CIBSE Applications Manual for Mixed Mode Ventilation. – AM13

*CIBSE Lighting Guide 2: Hospitals and Health Care buildings
*ASHRAE 170:2008
*HVAC Design manual for Hospitals and Clinics Second Edition – ASHRAE TC 9.6, 2013
*CIBSE Commissioning Code A
*BSRIA Application Guide 3/89.1

 <references />

==LIST OF ABBREVIATIONS==
A & E- Accident and Emergency Department

AHU- Air Handling Unit

CSSD- Central Sterile Supply Department

EMS- Emergency Medical Services

HCW- High Care Ward

HEPA- High Efficiency Particulate Air (filter)

ICU- Intensive Care Unit

NBR- National Building Regulations SABS 0400

NICU- Neonatal Intensive Care Unit

OT- Operating Theatre

SABS- South African Bureau of Standards

SANS- South African National Standards

SSO- Switched Socket Outlet

UDAF- Uni-Directional Air Flow

UPS- Uninterrupted Power Supply

URS- User Requirement Specification

==LIST OF DEFINITIONS==
For the purposes of these regulations, unless the context otherwise indicates-

'''“barrier isolator”''' refers to a device comprising an physical film separating an operator or clinician from a work process. The work process is maintained within an isolated environment which may be held at a positive or negative pressure.

"'''Central Sterile Supply Department (CSSD)"''' means a facility for the receiving, decontamination, preparation, packing, sterilizing, storing and issuing of sterile and disinfected instruments and other reusable materials. This facility is also known as the "sterilisation and disinfection unit"(SDU);

"'''cleaners' room'''" means a room for the storage of cleaning equipment, the drawing of clean water and the disposal of dirty water, washing and drying of cleaning equipment. This room may be combined with the dirty utility room;

"'''clean air'''" means air that does not contain a considered contaminant;

"'''clean utility room'''" means a room for the storage of sterilized packs, dressings-, sterile equipment and pharmaceutical supplies respectively; This area may also be used for a set-up area for ward procedures;

"'''considered contaminant'''" means any actual contaminant, surface or airborne, which may have a certain impact which for which measures are taken to avoid;

'''"cross contamination"''' refers to the contamination of any zone or surface by fomites, considered particulates aerosols, biological agents, fumes or gasses originating from another zone or surface.

'''"cross infection"''' refers to the spreading of an infection from one organism to another by cross contamination.

'''"department"''' means a grouping of accommodation which has a specific function within a hospital. Its area includes the associated internal or departmental circulation space

'''"dirty utility room"''' means a room used for collection and temporary storage of used equipment and general ward material; it can combine the activities of the sluice room, the soiled linen and waste room and the cleaners' room;

'''"emergency trolley/crash cart"''' means a mobile cart used for the storage of all appropriate resuscitation equipment and pharmaceuticals;

"'''equipment store'''" means a room used for the storing of monkey chains, traction kits and other general equipment;

"'''fresh air'''" means air drawn from outside air of a building and contamination sources;

"'''high care ward'''" refers to a ward for the care and management of specific types of patients requiring a minimum of eight hours nursing care per patient day;

"'''holding area'''" means an area or room where pre-operative patients in transit to a procedure room/theatre are identified and continuously monitored by nursing personnel;

"'''induction room'''" means an area where patients are prepared for surgery/invasive procedures prior to being transferred to the operating theatre;

"'''intensive care unit'''" means a unit designed, staffed and equipped for the care and management of specific patients, (e.g. medical, cardiac or post-operative) requiring a minimum of twelve hours nursing care per patient day or for the care of a patient who requires ventilation, continuous invasive monitoring, invasive care, or who is clinically unstable and whose life is at risk;

"'''main kitchen'''" means a facility suitably finished and equipped for the receipt, storage and preparation of meals, special diets and beverages;

"'''maternity unit'''" means a unit where antenatal care is provided, babies are delivered and postnatal care is given to mothers and infants;

" '''midwife obstetric unit (MOU)'''" means a maternity unit usually attached to a clinic or a community health centre (CHC), which is staffed by nursing sisters or midwives;

“'''milk kitchen'''” means an area for the preparation of feeds for babies which must be separate from the hospital kitchen or ward kitchen. It must contain a clinical wash hand basin;

"'''mortuary'''" means a facility that receives, holds and allows for the identification of bodies of patients who died in the wards, theatre or casualty department, or who were dead on arrival at the facility; a facility which complies with the

"'''neonatal unit'''" means a facility for premature and new born babies requiring incubation, specific care and monitoring;

"'''nurse station'''" means the control point for all activities in the patient care areas;

"'''nursing unit or ward'''" means a unit with the facilities to accommodate patients as specified in this regulation;

"'''operating room'''” means a room within an operating theatre suite in which surgical or other invasive procedures are carried out;

"'''operating suite'''" refers to rooms within the demarcated area where surgical interventions are performed or support is provided to these surgical activities;

"'''patient room'''" means a room where the patient can be accommodated;

"'''procedure room'''" means a room in which certain restricted procedures generally taking less than one hour can be performed without making use of general anaesthetic, e.g. endoscopies, procedures under local anaesthetic such as suturing of lacerations, removal of skin lesions, biopsies, closed reductions and other similar procedures; May be situated outside the operating suite;

"'''recovery room/ area"''' means the section of the operating suite specially set aside for the immediate post-operative recovery, resuscitation, nursing and special care of patients, until such time as such patients are considered to have recovered sufficiently to be safely removed from the operating suite;

"'''sluice room'''” means a room used for the emptying, cleaning and storage of bedpans and urine bottles; It can be combined with the activities of the soiled linen and cleaners' rooms in the dirty utility room;

“'''specialised area'''” means any clinical area rendering specialised services such as intensive care, high care, or rehabilitation, for which additional space around the patient is required;

"'''soiled linen and waste room"''' means a room used for the collection and temporary storage of soiled linen and waste; May be combined with the dirty utility room

"'''treatment room'''" means a room used for treatment of patients in the wards, containing a clinical wash hand basin;

“'''ventilation”''' means “The process of supplying air to or removing air from a space for the purpose of controlling air contaminant levels, humidity or temperature within the space”. ASHRAE Standard 62.1-2007, Section 3

'''“validation”''' means the method of proving and documenting that an installed system or process performs reliably as intended and required.

'''“natural ventilation”''' means “Ventilation provided by thermal, wind, or diffusion effects through doors windows or other intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3

"'''ward kitchen'''” means the room that forms an integral part of a nursing unit or units, for the preparation of snacks and beverages; It also includes the area for the heating, storage and refrigeration of meals;

"'''uninterrupted power supply'''" means a battery system, which in the event of a normal mains supply failure will provide immediately the electrical supply for essential equipment and lighting.
[[Category:Crosscutting Issues]]
[[Category:Water Distributions Systems]]
[[Category:Legionella Control]]
[[Category:Ventilation]]

Building Engineering Services

2020-12-15T09:03:54Z

Tobyvan: /* 24. VALIDATION OF SPECIALIST VENTILATION SYSTEMS */

{{Cleanup}}{{Expand}}

=='''POLICY AND SERVICE CONTEXT'''==
===Overview===
Many of the Building Engineering Services of a health facility have specialised needs within the context of healthcare provision and infection prevention and control. Specialist needs may include a combination of hygiene, redundancy and contamination-control requirements over and above the normal best engineering practice.

The Building Engineering Services dealt with in this document include: ventilation systems, wet services, gas and vacuum services, electrical services and electronic services.
The primary function of this document is to provide terms of reference to designers who are contacted to develop building engineering services systems. This document does not serve as a principal facility planning guide but as a best-practice guide within any planned level of healthcare service.
“This document describes engineering design, installation and commissioning principles in terms of current specialist clinical, contamination control and maintenance requirements“

===Policy and Service Context===

==='''Context'''===
This document serves as guidance in the development of all levels of the healthcare facility. Certain sections may not be applicable to all considered levels of facility although, where a certain engineering service is supplied, that service shall be developed in accordance with the guiding principles contained herein.

==='''Design principles'''===
This document will detail design principles within the scope of services described in the Engineering Council of South Africa’s gazetted Guideline scope of services and tariff of fees in terms of the Engineering Professions Act (46 of 200). This document will also describe design, installation and commissioning principles in terms of current specialist clinical, contamination-control and maintenance requirements.
While this document details design requirements and acceptance criteria which have an impact on clinical services, these requirements are prescribed within the framework of the entire IUSS set of guidance documents, and cannot be viewed in isolation. The following documents should be complied with, together with this document:
Within the South African healthcare context, many clinical and administrative zones may be subject to infection prevention and control measures with particular consideration for airborne contamination control.
{| class="wikitable"
|+Table 1: IUSS document
!Clinical services
!Essential
!Recommended
!Support Services
!Essential
!Recommended
!Healthcare environment/
Crosscutting issues
!Essential
!Recommended
!Procurement &
Operation
!Essential
!Recommended
|-
|Impatient services
|
|X
|Administration & related services
|
|
|Generic room data
|X
|
|Integrated infrastructure planning
|X
|
|-
|Laboratories
|
|X
|General hospital support services
|
|
|Hospital design principles
|X
|
|Project planning & briefing
|X
|
|-
|Mental Health Services
|
|
|Catering services
|
|
|Engineering design principles
|X
|
|Space guidelines
|
|
|-
|Critical care
|
|
|Laundry and Linen
|
|
|Environment and sustainability
|X
|
|Cost Guidelines
|X
|
|-
|Emergency centres
|
|
|Mortuary
|X
|
|Materials & finishes
|X
|
|Procurement liaison
|
|
|-
|Obstetrics & gynaecology
|
|
|Nursing colleges
|
|
|Future healthcare environments
|
|X
|Commissioning
|X
|
|-
|Oncology
|
|
|Health facility residential
|
|
|Healthcare technology
|
|
|Maintenance
|X
|
|-
|Outpatient services
|
|X
|Sterile supply
|X
|
|Inclusive environments
|
|X
|Decommissioning
|X
|
|-
|Paediatrics
|
|
|Clinical training
|
|
|Infection prevention & control
|X
|
|Capacity development
|
|X
|-
|Pharmacy
|
|
|Waste disposal
|
|X
|Health informatix
|
|
|
|
|
|-
|Primary health care
|
|
|
|
|
|Regulations
|X
|
|
|
|
|-
|Diagnostic radiology
|X
|
|
|
|
|
|
|
|
|
|
|-
|Rehabilitation services
|
|
|
|
|
|
|
|
|
|
|
|-
|Sub-acute services
|
|
|
|
|
|
|
|
|
|
|
|-
|Surgery
|X
|
|
|
|
|
|
|
|
|
|
|-
|TB
|X
|
|
|
|
|
|
|
|
|
|
|}

Where this document lacks guidance on a topic or appears to contradict the requirements of the guidelines identified above, the guidance of those documents will take priority.

===Service Context===
'''Levels of care'''

#“Levels of Care” is discussed in detail in the Project Planning and Briefing document. The Building Engineering Services document does not prescribe levels of care within the healthcare system and does not delineate the application of technology within these levels. It intends only to describe the building engineering services and technical aspects that should be considered from the concept development to the closeout and handover stages of the project. It is not incumbent on the engineer to prescribe appropriate levels of care and this subject is therefore not addressed herein. The allocation of appropriate technologies and services within the prescribed levels of care is a function of the engineer during the facility-planning stage as described by this document.
#In this document, where three distinct options are made describing system quantities or capacities, these are to be interpreted as the minimum acceptable standard, recommended best practice, and maximum practical limit respectively. Where only two options are given, these are to be interpreted as the minimum standard and best practice respectively. Where only one option is given, this is to be interpreted as the minimum acceptable standard. The reader is cautioned not to interpret these capacity standards as levels of care.
<gallery mode="packed" heights="600">
File:King George V (KZN 2013).jpg|King George V (KZN 2013)
</gallery>

=='''PLANNING AND DESIGN'''==
===Overview===
The national and provincial service and policy context should be the basic determinant of planning and design principles in the public sector
The national and provincial service and policy context (Part A of this document) is the basic determinant of planning and design principles in the public sector. In the private sector, planning and design will have determinants as defined by the service provider, within certain minimum prescribed limits. Part B describes the scope of planning and design guidance, design considerations and functional relationships between engineering systems. These principles are subsequently developed into a series of Design Specifications (Part C), Commissioning, Handover and Decommissioning (Part D) including some case studies (Part E). Parts C, D and E are intended to demonstrate how the principles prescribed in Part B should be applied. Parts C and D, if used directly, are deemed to satisfy the principles developed in Part B, but are not the only acceptable solutions. Case studies (Part E) are for illustrative purposes, to demonstrate worked solutions and should not be adopted without appropriate contextual adaptation
===Stages of design and implementation===

#It is critical that building engineering services professionals involve themselves in the early stages of a project’s initial planning, studies, investigations and assessments. Exclusion or late inclusion of an engineering team from the planning stages of a multi-disciplinary construction project presents a considerable risk of resulting, not in savings, but fruitless expenditure, design delays and ultimately compromises in the functional and build quality of the product.
#The scoping and broad coordination of services is invaluable during concept development, and the value-added through the early inclusion of building services professionals is frequently underestimated.
#Briefing authorities or developers are therefore encouraged to ensure that the client’s representative consults with a team of engineering professionals during the earliest project-planning stages. The deliverables of the concept and viability study stages should, therefore, include the following:
#*Summaries of collated information
#*Reports on technical feasibility, benefits and risks
#*Reports on regulatory compliance issues
#*Reports on financial feasibility and risks
#*List of consents and approvals required
#*Schedule of additional surveys, tests, analyses, studies and investigations.
#'''The Guideline Scope of Services and Tariff of Fees''' for Persons Registered in Terms of the Engineering Profession Act 46 of 2000 (2012) defines the following as within the [http://www.ecsa.co.za/documents/EngProfAct46_2000.pdf Normal Scope of Professional Services].
##'''INCEPTION'''
###At the inception stage, the client’s requirements and needs are established. The project brief is established and the professional team is appointed. The professional team should contribute towards developing the project brief and concluding the terms of its appointment. Here the professional team should advise on criteria that could significantly impact on the project life cycle cost.
##'''CONCEPT AND VIABILITY STUDY'''
###At the Concept and Viability study stage, the preliminary design details and cost estimates should be finalised. This should be concluded in accordance with the project brief.
###A Preliminary design report would include the:
####Concept design
####Process design
####Schedule of design assumptions, required surveys, tests, reports and investigations
####Preliminary design details
####Installation and life cycle cost estimates
##'''DESIGN DEVELOPMENT / DETAIL DESIGN'''
###During design development the design team will further develop the concept to realise the following:
####Finalised design
####Detail specification outline
####Financial plan
####Project programme.
##DOCUMENTATION AND PROCUREMENT
###This stage is often combined with the design development stage.
###Its deliverables include:
####Procurement and construction documentation and specifications
####Application of timeous procurement strategies appropriate for the project
####Assisting in the tender evaluation of detailed services and samples for compliance with the design intent.
##'''CONTRACT ADMINISTRATION AND INSPECTION'''
###This stage includes the management and administration of the construction contracts and works to facilitate practical completion in accordance with the design intent.
##'''CLOSEOUT'''
###Closeout deliverables include:
####Final works-completion lists
####Financial reports and final accounts
####Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
####As-built drawings

==Design Questions==
6. In order for the engineer to satisfactorily fulfil the user’s requirements, the following list of questions should be asked, answered and understood by the professional services team.
“Engineers responsible for the design of environmental control systems require guidelines and standards, in order to derive at and to specify appropriate solutions to the problem of building related illness (BRI) in occupied spaces.” -Dr S. A Parsons 2002

#Is the building service required, and why?
#What options are available?
#What is the service’s required performance?
#What is the service’s expected lifespan?
#What is needed in terms of energy management?
#What are the expected service consumption rates?
#What are the expected occupancy profiles per planning unit, considering:
##Patient and staff numbers?
##Peak occupancy times?
##Airborne infection risk profile?
##Seasonal occupancy profiles?
#What are service distribution constraints, considering:
##Location
##Space?
##Fire protection and regulations?
##Services coordination?
##Access for maintenance and operations?
##Repair replacement and refurbishment?
#What are the minimum component/system requirements?
#What are the specific requirements regarding functional controls?
#What are validation and testing requirements
#What are the Maintenance and operational requirements?
#Commissioning and handover requirements
#Special requirements for test and balance documents and certificates

==Design considerations==

==='''7. Deep buildings'''===

#Deep buildings inevitably result in some measure of ventilation being required within the core areas. Where deep buildings cannot be avoided, the extent of building ventilation can be minimised by planning the deep-core areas as those that require specialist ventilation systems and which could not be served by natural ventilation.

==='''8. Plant and plant room size and location'''===

#Noisy and vibrating equipment shall not be placed near, above or below sensitive areas such as operating rooms and ICUs. They shall be designed and located so as to give sufficient reduction in noise and vibration.
#Plant rooms shall be designed such that there is safe access to equipment for maintenance and repair activities. Plant rooms shall be located away from possible heat and contamination sources.
#Plant rooms shall be located in an accessible area which is secured from unauthorized entry
#Where plant room equipment presents a potential source of airborne contamination (e.g. Legionella and vacuum exhaust) the location of the plant room shall be such that contaminated air is not carried into occupied spaces and air inlets.

==Life cycle cost determination==
9. When planning and designing building engineering services, the engineer shall take cognisance of the service context within which the facility is placed. As part of the financial plan, outlined in the concept and viability study stage, the engineer will assist in developing the facility’s life cycle cost by giving input into the life cycle cost estimates for the services within the engineer’s responsibility. This financial plan shall be finalised as a deliverable of the detail design stage.

10. Environmental life cycle planning is a critical element of the life cycle planning but should be considered as a service additional to the scope of the normal prescribed services.

==Site-survey requirements==
11. In order for the engineer to plan adequately, a detailed site survey will need to be conducted to present essential planning information. These factors need to be weighed against the level of service to be provided.

The National Department of Public Works has developed a comprehensive site-survey model for the completion of this task (Citation needed). The following list summarises the information that needs to be developed.

#Geotechnical considerations
#Availability, quantity and quality of mobile phone reception
#Availability, quantity and quality of services such as:
##Electricity
##Water supply
##Drainage conditions
##Gas
##Land and air transport
##Outsourced laundry and catering services
##Proximity to additional social services

==Maintenance Considerations==
12. Maintenance failures within the building services of the healthcare environment have the potential for severe consequences. Services should be designed with this in mind.

13. The design should consider the financial and environmental impact of disposable and reusable components within the planned maintenance regime. Reporting on the financial aspects of the life cycle plan is required within the normal scope of services of the planning and design project stages.

14. In the development of healthcare building engineering services the designer should consider the following maintenance challenges when designing systems and planning maintenance regimes:

#Where highly specialised services are installed in remote areas, it becomes difficult to source the requisite level of technical skills and, as a result, either maintenance costs rise or the serviceable life of these systems is decreased.
#The availability of spares and contracted technical services becomes problematic in remote locations and this leads to difficulties with unscheduled maintenance and extended callout response times.
#Routine and unscheduled maintenance may need to be performed with a system in operation, with minimal down-time. This should be considered when planning levels of redundancy.
#Routine and unscheduled maintenance should not have a negative impact of the service levels of healthcare. Where IPC and cross-infection risks are high, systems should be designed such that the maintenance staff can complete their work without affecting staff or patient safety.

15. For further guidance on health-facility maintenance, the IUSS Health Facilities Maintenance guidance document should be referred to.

==Planning for Retrofitting & Decommissioning==
16. While engineering systems may have a functional life of 20 to 25 years, healthcare buildings could have a life of 50 years. It is therefore likely that engineering services would need to be decommissioned, retrofitted, and replaced at least once during the life of a building, and these interventions should be planned for.

17. Projects with a retrofitting element shall include for the formal decommissioning of equipment or services which become redundant or obsolete as a result of the retrofitting project or can be conveniently decommissioned within the project. Decommissioning of any assets shall be undertaken in accordance with the Public Finance Management Act 1 of 1999, the Generally Accepted Accounting Practice, the Companies Act of 2006 and principles of good corporate governance. 

18. When planning for retrofitting and decommissioning, consideration should be given to the following aspects:

#Development and implementation of a risk assessment and hazard control plan.
#Identification of clinician and IPC manager with authority to approve or halt construction activities under defined conditions.
#Power requirements for future expansions and installations.
#Emerging healthcare technologies.
#Space for removal and refitting of equipment.
#Materials of construction for recycling potential and disposal.
#Toxicity and environmental impact of gases, paints and polymers.
#Specific healthcare services risks (IPC, etc).
#Occupational Health and Safety Regulations and requirements. 

19. A risk assessment shall consider the following aspects:

#Identification of occupancy groups which are susceptible to risks.
#Identification of building services, such as ventilation, in the proximity of the construction activity and the potential impact on function. Specific consideration should be given to specialist ventilation systems.
#Need for supplementary protection or support systems for building services.
#Impact on fire-protection and -response systems, and action plans.
#Impact of noise and vibration on occupants and equipment. 

20. Opportunistic environmental or airborne microorganisms and allergens, which are liberated or distributed during retrofitting and decommissioning activities, can present a significant hazard to patients and employees unusually at risk. Where the environmental and risk assessments identify the need for intervention or mitigating controls, the following shall be considered:

#Establishment of rigid non-permeable barriers between patients or staff and construction activities during construction, with the inclusion of appropriate “airlocks” where traffic between occupied and construction areas is required.
#Increased ventilation rates and ventilation efficiency to areas at risk.
#Extraction and filtration systems serving the construction area. Where there is a chance of re-entrainment of diluted exhausted air, a minimum of an EN779-F9 filter should be installed as the final filtration stage. Where air is actively re-circulated it should be filtered with at least an EN1822-H13 final filter.
#Establishment of a protective pressure cascade or airflow direction between zones. 

21. For further guidance on the decommissioning of health facilities, the [[Decommissioning and Disposal of Health Facilities and Health Technology|Health Decommissioning and Disposal of Health Facilities and Health Technology]] guidance document should be referred to.

==Sustainability & Environmental Measures==
===Design Life cycle===

Sustainability in designs for new health facilities can be addressed through the following steps:

'''22. Target setting:''' Challenging but realistic sustainability targets should be set for the building and agreed with all of the key stakeholders of the project, including the design team, the facilities manager and the funder or owner of the building. Targets should take into account government policy and strategies, as well as local and international best practice.

'''23. Design principles:''' Strategies and design principles required to achieve these sustainability objectives should be understood and established from the outset. For instance, energy targets may require passive environmental control strategies to be well understood and established from the outset. These strategies and their implications can be understood through an analysis of best-practice examples and precedents.

'''24. Integrated design:''' Once targets and design principles have been established, an integrated design process should be used to ensure that all aspects of the building work together to achieve the required performance. This requires different disciplines to work closely together.

'''25. Testing:''' Throughout the design process, checks should be carried out to ensure that the targets set will be achieved. This can be done through calculations, modelling and analysis which assesses performance against targets set. Where aspects of the design are found not to meet targets, a re-evaluation of the design should be carried out and, in an iterative and integrated way, improved to ensure that the performance achieves, or surpasses, targets set.

'''26. Detailed design and implementation:''' It is important to ensure that the design principles set out are carried out in detail, or this may affect operational performance. This includes, for instance, seemingly insignificant details such as appropriate locations for switches, labels and instructions.

'''27. Handover:''' On completion, effective processes should be followed to ensure that design intentions are carried through into building operation. This includes effective commissioning, handover and training processes which ensure that designers, subcontractors and suppliers transfer knowledge and skills to facilities managers to ensure effective management of the building.

28. Refer to [[Sustainability|Sustainability Guide]] for further information on sustainability.

=='''PART - DESIGN SPECIFICATIONS'''==
===Design considerations===
Best engineering practices for the design, specification, testing and management of wet services, vacuum, medical gases, building electrical, electronic, and lighting and ventilation systems are contained in this guide. This guide also defines applicable local and international informative standards and describes regulatory aspects for consideration.

===Heating Ventilation and Air-conditioning===
===Airborne-Precaution Risk Classification for Healthcare Zones===
South Africa does not have a uniform formal policy regarding the classification and design of infection prevention and control zones. Provision of multi-bed patient accommodation and internal waiting areas for out-patients is common practice in South Africa.
{| class="wikitable"
|+{{APR Ventilation Risk Matrix}}'''Building Ventilation for Airborne IPC'''
|-

| colspan="2" rowspan="2" style="background-color:#c2d69b " |
! colspan="3" style="background-color:#c2d69b " |'''Patient/Staff Susceptibility to Infection'''**
|-
| style="background-color:#c2d69b " |'''Low'''
| style="background-color:#c2d69b " |'''Moderate'''
| style="background-color:#c2d69b " |'''High'''
|-

| rowspan="3" style="background-color:#c2d69b " |'''Potential for cross infection'''*
| style="background-color:#c2d69b " |'''High'''
||
*Administrative controls
*Controlled access
*Negative pressure
*Fresh air (FA) supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure
*FA supply >80L/s per person
||
*Administrative controls
*Controlled access
*Negative pressure room with overpressure airlocks
*Clean air supply >20AC/h and 80L/s per person
|-

| style="background-color:#c2d69b " |'''Moderate'''
||
*Administrative controls
*Fresh air supply >60L/s per person
||
*Administrative controls
*Controlled access
*FA supply >60L/s per person
||
*Administrative controls
*Clean air supply >60L/s per person and 20 AC/h
*Overpressure airlocks
|-

| style="background-color:#c2d69b " |'''Low'''
||
*No additional requirements
||
*Administrative controls
*FA supply >60L/s per person

||
*Administrative

controls

*Clean air supply >20 AC/h
*Overpressure rooms
|-
|}

For this reason, a burden is placed on the building services design to ensure that the utilities and services provided do not hinder efforts to manage airborne-infection control

The [[Building Engineering Services#APR Ventilation Risk Matrix|matrix presented above]] is proposed for consideration when planning mechanical building ventilation for airborne IPC.

'''Table 24.5''' gives further guidance on ventilation rates for specific areas.

For further information regarding the requirements for airborne-infection precaution rooms, refer to Part C, Section 23.3 of this document and the [[Infection Prevention and Control]].

===Ventilation requirements===
====Natural ventilation====
Due to the high capital outlay required, medical facilities in countries defined as developing, such as South Africa, are generally not provided with “traditional” engineering control measures, such as ventilation, to achieve acceptable environmental management.
-Dr S A Parsons, 2002

#Natural ventilation is driven by a combination of thermo convective or buoyancy effects and wind pressure. Since the drivers of Natural ventilation are inherently variable, natural ventilation has a high variability in effectiveness.

2. In addition to the variability of the drivers of natural ventilation, the responses of the occupants of a space could have a negative impact on the variability of the ventilation system’s performance by opening and closing windows and doors. For this reason it is recommended that, where natural ventilation is considered as the primary ventilation mode, dedicated and controllable ventilation openings be designed and created in the building

3. For additional design guidance on natural ventilation design, the CIBSE Applications Manual AM10 or similar can be consulted.

4. Peak and minimum internal temperatures should be calculated or modelled thermally for a space, for summer and wintertime respectively.

5. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

6. The following design interventions should be considered for implementation, singly or in combination, in the following hierarchy where the internal design condition cannot be met:

*Reducing solar and internal heat gains
*Using thermal mass to move room temperature extremes to outside of occupancy periods.
*Change occupancy schedules seasonally to improve indoor comfort conditions. (eg. Shift consultation hours from or towards the warmest daytime hours during summer or winter respectively)
*Introducing passive cooling or heating strategies
*Increasing ventilation rates
*Providing mechanical cooling or heating

7. Where natural ventilation alone cannot achieve the required air quality, quantity and consistency, mixed mode ventilation shall be considered as a solution preferred over full mechanical ventilation.

8. Mixed mode ventilation is considered as an assisted type of natural ventilation. Here fans are used in combination with damper controlled ventilation openings to ensure minimum ventilation rates are achieved.

9. Where mixed mode ventilation cannot achieve the required air quality, quantity or consistency, mechanical ventilation may be considered as a solution.

===Mechanical ventilation and air-conditioning===
10. Where the quantity and quality of air within a space can be maintained to a satisfactory degree of consistency, natural ventilation should always be the preferred solution.

11. The design parameters for internal spaces should be found in the detailed room-requirement sheets published in the individual IUSS guidance documents of the various functional units.Where these room-requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

=====12. Temperature, Relative Humidity (RH) and fresh air requirements=====

#The [[wikipedia:Thermal_comfort#:~:text=The%20adaptive%20model%20is%20based,different%20times%20of%20the%20year.|adaptive approach to thermal comfort]] will result in designs with broader acceptable temperature ranges and thereby greater energy efficiency<ref>de Dear, Richard; Brager, Gail (1998). "Developing an adaptive model of thermal comfort and preference". ''ASHRAE Transactions''. '''104''' (1): 145–67.</ref>. The following aspects have been found to influence the perception of thermal comfort in a space
##Climate and social custom
##Rate of temperature drift >1°C daily and 3°C weekly
##Exponentially time-weighted mean outdoor temperatures
#For the majority of occupied spaces, unless otherwise indicated, a temperature range of 18-28°C is acceptable, although the level of gowning of the patients and staff needs to be considered in the design
#Clinical practices seldom use explosive anaesthetic gases and the requirement for humidity control from this perspective is generally outdated. Direct humidity control is only required in a select few specialised areas. In general, humidity control is indirect, but the designer should consider the resultant humidity levels and the impact on comfort levels in the space.

Table 3: Specialist ventilation systems, provides a list of spaces that have particular temperature and humidity requirements that are critical to the effective provision of healthcare.
{{Cleanup}}

=====13. Zoning of a building=====
13.1. Where the choice between a central and a local ventilation plant needs to be made, the following points should be considered:

#Fire compartmentalization
#Air-handling unit (AHU) sizing
#Duct sizing
#Occupancy schedules
#Occupancy activity levels
#Building, environmental and equipment heat loads
#Airborne contamination control
#Tenancy, functional unit or utility metering

13.2. Zoning of ventilation systems has a large impact on ventilation efficiency and effectiveness.

=====14. Minimum fresh air requirements=====

#For minimum fresh air requirements refer to the National Building Regulations and relevant IUSS Infrastructure Guidance Document. Where any apparent conflict between the functional requirements and the “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functionality.
#Where odour control is a consideration, a ventilation rate of 10 litres per second per person may be used.
#Where airborne cross infection is controlled primarily through dilution and natural ventilation, medium and high risk areas require 60 or 160 litres per second per person respectively.
#Where airborne cross infection is controlled primarily through dilution and forced ventilation, medium and high risk areas require 60 or 80 litres per second per person respectively.

=====15. Ventilation rates=====

#Air change rates per hour (AC/h) are specified in this document for a room with ceiling height of 3m. Where ceiling heights are increased these rates can be reduced, and vice versa.
#Minimum ventilation rates quoted as air changes per hour should be complied with together with the recommended rate of fresh air per occupant

=====16. Supply-only vs balanced ventilation systems=====

#Supply-only ventilation systems do not supply air to all spaces individually, but instead supply air to only the least contaminated or most critical space. Air is then allowed to cascade from the “clean” core to adjacent and auxiliary spaces. Where this type of system is employed, it is critical to be aware of and control the risk of contamination generated in the clean core and permeating through the entire system. This type of system is not appropriate for thoracic and sepsis theatres or areas where unpleasant or noxious odours, fumes and vapours may be generated. It is also important to ensure and prove that the statutory conditions for ventilation and fresh air rates are met for all spaces. 

=====17. Airborne contamination-control concepts=====

#Airborne contamination control often requires the application of one or more of the concepts described below since airborne contaminants can be generated both internally and external to the controlled zone. 

17.2. Barrier concept 

#The barrier concept relies on airtight enclosures to isolate the contamination source. Typical examples are glove boxes or barrier isolators. 

17.3. Aerodynamic effects 

#The displacement concept relies on flushing contaminants away with high volumes of air at relatively low velocity. 
#The dilution concept involves reducing contamination levels in a space by diluting them with quantities of "clean" air. The ventilation rate required is a function of the required contamination level, the rate of generation of contaminants in the space, and the ventilation efficiency. 
#The pressure-differential concept relies on the pressure differential developed between spaces when "clean" air cascades through small orifices, such as door gaps and pressure-control dampers. The pressure differential, and resulting airflow developed, prevents contaminants from moving into higher pressure “clean” areas from lower pressure "dirty" areas. The following diagram gives indicative values for infiltration and exfiltration rates associated with varying pressure differentials (Pa) and opening sizes (m²).

17.4. Where ventilation rates and fresh air proportions are described within these guidance documents they are to serve as guidance values only. It is the responsibility of the designer to ensure that the ventilation rate selected is appropriate for the specific zone’s operational conditions, occupancy, contamination rates, pressurization, leakage rates, ventilation efficiency and external ambient conditions to achieve the desired airborne contamination and bio-burden levels. Ventilation rates higher or lower than the guidance values may achieve the desired conditions.

 

====='''18. AIR HANDLING UNITS AND FANS'''=====
18.1. GENERAL

#AHUs and fans shall be protected from adverse weather and wind sources which may upset their performance or reliability.
#A detailed name plate shall be included on the air handling units with manufacturer, design air volume, fan speed, cooling capacity, filter data and heating capacity.
#The air handling unit shall include individual differential pressure gauges over each installed filter bank. The gauges shall measure the pressure differential between upstream and downstream of the filter banks. The filter designation and design filter change pressure shall be neatly and clearly marked on each gauge.
#Air-handling units functioning in an airborne contamination control system, and demanding prescribed airflow rates, shall be provided with an electronic control system including variable frequency controllers with direct fan drives to automatically maintain design airflow for all filter conditions. The fans and drives will be selected to maintain design flow rates with all filters at maximum rated pressures.
#Where a ventilation system performs a critical role, air handling units shall have separate electrical distribution boards (Essential and Non-essential). The fan will be on essential power and heater elements may be on non-essential power.
#All compartment doors on the air handling unit shall be clearly labelled
#Where systems require duplicate standby fans or air-handling units these shall be installed with backdraught dampers, sufficiently air-tight for the application (eg EN1751 Cat 3 or 4). Special design and control consideration shall be given to limiting the build-up and dwelling of contaminants in the standby unit.
#AHU’s should be placed in easily accessible plant rooms with sufficient space for maintenance. Access stairs to the plant rooms should permit a technician to easily carry replacement parts or a toolbox into the plant.AHU’s located in ceiling voids are not appropriate or conducive to good operational management.
#AHUs should be designed for a working life of 20 - 25 years
#AHUs shall be designed and positioned such that the largest components, including heating and cooling coils, can be removed and replaced.
#AHUs greater than 1m wide should have hinged access doors large enough to provide full entry. Doors shall be unlockable and openable from the inside of the unit.
#Fan and filter plenums shall be provided with internal illumination and viewing portals such that internal components can be visually inspected without stopping or opening the unit.
#AHUs shall be designed such that dry steam humidification devices can be retrofitted into the systems with minimal disruption and without compromising its performance.
#Ventilation components shall have a drainage or condensate pumping system if they can produce moisture. Drip trays shall be of a corrosion resistant material and drainage systems shall have a 1:20 fall away from the unit in all directions. The unit shall have its own drain trap which shall be sized such that it can function at the fan's full static pressure. The first 3 meters of a dedicated condensate drainage line shall be insulated to prevent condensation within the plantroom. Where a condensate drain services a negative pressure plenum, clear air gaps of 15mm or anti-backflow devices are recommended at the trap discharge into the drainage system.
#Drop stop eliminators in stainless steel frames shall be employed, if fin spacing is less than 10 fins per inch, after the cooling coils in areas with high humidity levels. This includes all coastal areas for off coil temperatures of 10° and less
#In full fresh air systems, primary filters may be situated at the fresh air intake opening of the air-handling unit only if the climate does not require anti-fog or de-icing coils.
#Cooling or heating coils will be protected by a pleated primary filter, rated in accordance with SANS 1424, as minimum.
#In recirculation air systems, primary filters will be situated after the fresh/return air mixing plenum. This arrangement will ensure that blinding filters don’t inhibit the prescribed fresh air proportion.
#The final stage of filters on units serving operating theatres must be located after the supply fan chamber to filter any debris that might come from the fan chamber. HEPA filters should be protected from this potential dust and debris.

 

=====18.2. AIR EXTRACTION SYSTEMS=====

#The design of exhaust systems shall take special consideration of the potential for re-entrainment of contaminated exhaust air into air intakes through, inter alia, openable windows. Where this potential exists, precautionary measures such as aerosol or chemical filtration of exhaust should be applied, as appropriate.
#Single ablution facilities serving private wards or staff do not require extract ventilation, provided there are windows openable to outside.
#Extract ventilation shall be provided by either ceiling extract grilles connected to an in-line ducted fan with outside discharge air grilles by means of galvanized mild steel or PVC tubular ducting or odour extraction system.
#Extract grilles may be of the PVC type with adjustable disc valves, or powder coated or anodized aluminium type with adjustable dampers.
#All multiple toilets shall be provided with ventilation systems, which will serve as an extract ventilation system.
#Single toilet facilities serving private wards for staff do not require extract ventilation, provided there are windows openable to outside
#Where it is not considered safe to enter a space without respiratory protection, the air exhausted from that space should be rendered safe through filtration, decontamination or dilution before discharge.
#The design of exhaust system from airborne precaution areas should be such that all components can be safely maintained during normal service and safely disposed of at decommissioning.
#Planning for disposal of contaminated filters should be as for all biohazardous material.
#Filtration and decontamination components shall be installed upstream of fans, monitoring and control devices.

=====18.3. ENERGY RECOVERY SYSTEMS=====
1.3.1. Where full or partial exhaust is required for ventilation systems, energy recovery technologies should be considered. Enthalpy wheels offer a high level of efficiency but introduce a risk of cross infection as the wheel is exposed to both the exhaust and supply airstreams. An enthalpy or energy recovery wheel may only be used if pressure and filtration measures are taken to ensure it is not a potential source of cross infection or re-infection. Energy recovery wheels incorporating purge sections have a markedly reduced efficiency and are not considered to provide sufficient protection against biological cross contamination. Where cross infection is a considered risk, the following conditions shall be met.

#The exhaust airstream shall be consistently maintained at a lower static pressure than that of the supply airstream.
#The exhaust air shall be filtered with aerosol filters upstream of the energy recovery device.
#Levels of filtration, redundancy and safety shall meet the requirements of the biological pathogenicity class in consideration.

=====19. '''FILTRATION'''=====

#With the exception of the few specialist areas with aero-biological requirements, the primary purpose of filtration is to protect ventilated spaces and ventilation equipment from dust build-up.
#When designing filtration systems serving spaces with a high airborne cross contamination risk, consideration should be given to the safety of maintenance staff that may be required to handle contaminated filters. Where any safety risk is present, contaminated filters should be installed in safe-change or decontaminatable housings.
#All ventilation filter banks should be installed with a means of visually checking the filter pressure across them in Pascals (Pa)
#Filters are classified as being General Fine or Aerosol filters and are to be specified in accordance with the SANS 1424, EN779 or EN1822.
#General filters are selected to remove particles large enough to block cooling and heater fins and settle out of the airstream into the air distribution system. General filters are graded in terms of their “synthetic dust weight arrestance”. General filter grading ranges from G1 to G4. G3 and G4 filters are appropriate for primary air intake and tempered air supply respectively. General filters are not appropriate for combating airborne cross-contamination control.
#Fine filters are selected to keep a ventilated space visibly clean and for the protection of HEPA filters. Fine filters are graded in terms of their “Dust Spot Efficiency” from M5 to F9. F9 filters are capable of arresting particles with the approximate size of some bacteria and can be used for low level cleanrooms (ISO 14644-1 Class 8).
#Aerosol filters are selected for their efficiency in arresting sub-micron particles. They are graded in accordance with their “Most Penetrating Particle Size” (MPPS). Aerosol filters are subdivided into three categories: Efficient Particulate Air (EPA) and High Efficiency Particulate Air (HEPA) and Ultra high Particulate Air (ULPA) Filters in accordance with the EN1822:2009. The table below describes the classification of aerosol filters by integral and local values as defined in the EN1822. SULPA filters are not discussed within this document.

'''Table 2 Filtration Classification'''
{| class="wikitable"
| rowspan="2" |'''Group'''
| rowspan="2" |'''Filter Class'''

'''EN1822'''
|'''Integral Value'''
|'''Local Value'''
|-
|'''Efficiency %'''
|'''Efficiency %'''
|-
| rowspan="3" |'''EPA'''
|'''E10'''
|85%
|<nowiki>-</nowiki>
|-
|'''E11'''
|95%
|<nowiki>-</nowiki>
|-
|'''E12'''
|99.5%
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''HEPA'''
|'''H13'''
|99.95%
|99.75%
|-
|'''H14'''
|99.995%
|99.975%
|-
| rowspan="3" |'''ULPA'''
|'''U15'''
|99.9995%
|99.9975%
|-
|'''U16'''
|99.99995%
|99.99975%
|-
|'''U17'''
|99.999995%
|99.999975%
|}
8. HEPA filter installations shall include both an upstream challenge aerosol injection port and a downstream scan port to facilitate filter challenge testing. ULPA filter installations shall be designed such that an agreed upon test method can be accomplished.

9. All filters used for airborne precaution rooms, theatres or other areas with a high airborne contamination risk shall be selected with a construction suitable for incineration. These filters shall not contain PVC.

10. The installation and testing of HEPA filters shall only be conducted by suitably qualified technicians.

11. HEPA filters shall be specified to be compliant with the requirements of EN1822. Each HEPA filter is to be supplied with an individual factory test certificate displaying that filter's serial number, MPPS rating and DOP arrestance rating.

12. Type-test certificates are only acceptable for EPA and not HEPA filters.
 

=====20. '''HEAT REJECTION EQUIPMENT.'''=====
20.1. The location of heat rejection equipment shall be planned such that it does not adversely affect the performance, maintenance or reliability of any related or unrelated equipment, or pose an avoidable health risk.

20.2. The use of evaporative cooling towers shall only be considered where:

#Space, system capacity or efficiency demands their use.
#An effective plan for the [[Legionella Control|control of legionella]] must be developed and implemented.

 

=====21. '''AIR DISTRIBUTION SYSTEMS'''=====

#Discharge from extraction systems shall be located such that contaminated air does not get drawn into any system's air intake of get re-entrained though openable windows.
#The use of internally insulated ducting is not appropriate as internal linings will perish and slough off with aging. Particles from duct linings contaminate final filters and ducting components.
#Flexible ductwork is unsuitable for air distribution in healthcare applications. It should only be used for the final connection to an air terminal and then kept to less than 1.0m. Bends in flexible ductwork should be avoided.
#The use of dampers to throttle a deliberate oversupply of airflow should be avoided. Balance by design is preferable although this will not necessarily reduce the total fan pressure. Use of adjustable blade dampers should be kept to a minimum as these items may drift, can be tampered with and increase the complexity of commissioning. The use of constant volume dampers may improve stability of volume critical systems but may also mask inefficient design and be the source of increased system noise.
#Cleaning and access doors are to be installed in all air distribution ductwork to facilitate:

*Cleaning
*Inspection
*Measurement
*Maintenance

21.6. Ductwork installations shall be designed, built, installed and commissioned in accordance with SANS 1238: Air-conditioning ductwork and SANS 10173: The installation, testing and balancing of air-conditioning ductwork
 

=====22. '''ELECTRONIC CONTROLS'''=====

#Location of sensors in ventilation systems should ensure that the temperature and humidity measurement for monitoring control is representative of the occupied area
#The humidifier control will include humidity monitoring of the mixed airstream downstream of the humidifier lance and shall prevent this airstream from approaching dew point.
#The use of variable speed drives (VSD) can save energy in systems operating under varying motor loads. Reducing the fan speed when filters are new or clean can result in considerable energy savings over the life of a system. Reliability of smaller sized VSDs is a potential drawback, and for this reason VSDs must be selected and sized for high service life. VSDs should also be installed such they can be bypassed and the system can be run in manual control while failed VSDs are replaced or repaired. When designing with variable speed drives, cognisance should be taken of a motor’s minimum cooling requirements and the maximum restart rate. Caution should be exercised where variable speed drives are used in conjunction with constant volume dampers or volume flow controllers. This combination could drive up total system pressure where duct total pressure as opposed to velocity pressure is used as control feedback. Additional requirements for the selection of drives for variable air volume (VAV) fans is described in SAN204:2011
#Plant control systems should incorporate start-up and shut-down sequencing logic to prevent flow reversals and overheating.
#Set-back controls should be considered for spaces that have intermittent occupancy. This feature should be used with caution in specialist areas as poorly considered set-back conditions could compromise containment or contamination control.
#Where more than one ventilation system serves a department, system interlocks may be required to prevent unwanted airflow reversals during system shutdown or failure.
#Operational status indicators should be displayed locally in areas served by ventilation systems.
#"Low Air Flow" and "Plant Failure" alarms should also be installed in a location which can be manned by relevant and trained staff.
#Electronic control systems should be developed using recognised open protocols and standards such as BACnet DeviceNet, LonWorks, Modbus, SOAP and XML.

=====23. '''SPECIALIST VENTILATION SYSTEMS'''=====
23.1. The following areas will require specialist ventilation systems:
 
'''Table''' '''3 Specialist Ventilation Systems'''
{| class="wikitable"
|'''Department Name'''
|'''Ventilation system type'''
|-
|Operating departments
|Clean and Ultra clean ventilation systems: ISO8 to ISO5 & UDAF
|-
|Obstetrics
|Clean ventilation systems ISO8
|-
|High care, Critical Care and Intensive Care
|Fine filtered ventilation or Clean ventilation systems: Unclassified - ISO8
|-
|Isolation units
|Negative pressure ventilation, no recirculation
|-
|Pathology labs
|Biosafety ventilation: (BSL2 – BSL4)
|-
|IVF Labs
|Clean ventilation systems: VOC Filtration
|-
|Burns units
|Clean ventilation systems/ Negative pressure ventilation/ RH control
|-
|Neonatal Units
|Dedicated ventilation systems/ RH control
|-
|Mortuary unit
|Cold Rooms/ Extraction systems/ Odour Control
|}
23.2. Broad requirements for these systems are in this document. The engineering team shall consult each department’s specific design guidance document for detailed requirements.
 

=====23.3. '''AIRBORNE PRECAUTION ROOMS (INCLUDING TB)'''=====

#Where specific diseases are considered in the design of an airborne precaution room, the US CDC's "Select Agent List" may be consulted for design guidance until a South African list is compiled.
#Airborne precaution rooms shall be ventilated with a minimum of 12AC/h of fresh air or uncontaminated air. High risk areas such as sputum booths and airborne diseases wards shall have a nominal ventilation rate of 80 ℓ/s per person..
#Medium Risk areas such as congregate spaces such as waiting areas shall have a nominal ventilation rate of 60ℓ/s per person.
#Mechanical ventilation may be employed to achieve the minimum ventilation rates. It should be noted that very high ventilation rates can be achieved by employing a well-considered natural ventilation design. Consideration may also be given to mixed mode ventilation systems, which combine mechanical and passive ventilation and temperature control. An open window policy may therefore be adopted, with careful consideration of all the associated cross infection risks and management challenges.
#Airborne precaution rooms shall be designed so as to provide thermal comfort. Where occupants have freedom in location and dress code, an adaptive thermal comfort model should be adopted. Heating, cooling and energy recovery devices shall pose no risk of harbouring pathogens or increasing the cross infection risk.
#Air from the airborne precaution rooms shall not flow into adjacent, uncontaminated rooms or adjacent airborne precaution rooms. Air shall not flow from a room with a higher airborne infection risk category to a room with a lower risk category.
#Ventilation ducting and pipe work shall not form a conduit by which pathogens can transfer from one zone to another whether the ventilation system is running or not. Filtration devices and anti-backflow devices may be employed provided these do not pose a risk of infection to maintenance staff.
#Filtration requirements for supply and exhaust air should follow the bio-containment requirements of that select agent being contained.
#The location of supply and air terminals should be such that the airflow patterns generated within the room serve to suppress and remove airborne particles.
#For general waiting areas or where the pathogens are known and unlikely to pose an environmental risk, exhaust air filtration may not be required provided exhausted air is directed 3m away from open-able windows and air intakes and there is no risk of re-entrainment of this air. See section 18.2.
#Commissioning and validation shall be well planned, diligently executed, fully documented and approved by suitably experienced professionals. It is advisable to have the validation process conducted or approved by a party independent of the designer and installer.
#Numerical or physical modelling may be of value in the design and validation process.

 

=====23.4. '''OPERATING THEATRE VENTILATION DESIGN'''=====
23.4.1. GENERAL REQUIREMENTS

#Constant volume systems shall be employed to maintain the correct pressure with respect to any adjoining rooms. The contamination control concept shall be developed in accordance with ISO14644-4
#Temperature range shall generally be 18°C to 24°C with a minimum relative humidity of 45% unless otherwise specified
#A pressure differential of 10-15Pa is to be maintained between the theatre and adjacent rooms when all doors are closed.
#Theatres may be maintained at a room pressure positive or negative to the adjacent rooms depending on the contamination control requirements.
#A theatre’s room pressure shall always be positive relative to technical spaces.
#Negative pressure theatres should not employ recirculation of room air.
#Fresh air requirements are 5-7 Air Changes per hour to satisfy the occupancy requirements
#Additional fresh air may be required for pressurisation and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurisation at the greatest possible energy efficiency.
#Separate temperature controls in each theatre are to be provided.
#No manual on and off switching of air handling plant to be done from within the theatres.
#Automatic motion sensors / thermal sensors to ensure that the units are switched on when there is a presence in the theatre. Theatre ventilation switching may be linked to the theatre unit’s lights.
#Automatic switching of ventilation system to incorporate run-on timers to prevent overheating and accidental shutdown.
#An additional override to be used to switch the units on when the temperature in the theatre exceeds 25°C for the protection of stored medicine
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums.
#These validation tests shall be performed in accordance with SANS 14644Parts 1, 2 and 3 at the recommended intervals (SANS 14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#No internal ducting insulation is permitted.
#In multi theatre suites it is advisable to have dedicated AHUs per theatre. [[Building Engineering Services#%20msocom%201|[TR1]]]

23.4.2. UNIDIRECTIONAL AIRFLOW OR ULTRACLEAN THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 5 under protected zones (UDAF and Setup area) and ISO 14644-1 Class 6 in background and ancillary areas. These conditions are to be achieved under operational conditions.
#Temperature range shall generally be 18°C to 24°C and relative humidity 45% to 60% unless otherwise specified
#Ultra-clean theatre ventilation shall not be completely shut down when unoccupied unless required for maintenance interventions. Ventilation systems serving UDAF plenums shall instead switch to a minimum velocity set-back mode to prevent contaminants settling underneath the UDAF screens.
#Delivery of the conditioned air shall be by downward movement from the ceiling to four low level exhaust outlets located near the corners.
#All ductwork between HEPA filter housings and air terminals shall be high pressure rated and constructed of galvanised sheet metal. In the final connection to the terminal, where alignment necessitates, a maximum of 300mm of thermally insulated, high pressure flexible ducting may be used.
#The Air Conditioning system is to be complete with G4 primary, F9 secondary and H13 HEPA Filters.
#The ventilation systems shall be designed with a mean air velocity of between 0.35 & 0.45 m/sec measured below the UDAF screen and at the working height.
#Refer to ISO14644-4 for guideline ventilation rates for balance of areas.
#The mean velocities below the UDAF screen and at the working height shall not differ by more than ±10%
#A standard size of the UDAF screen is 2400 x 2400mm. The required size could vary dependent on the layout and function of the operating theatre.
#The protected zone below the UDAF plenum shall be clearly demarcated on the floor

23.4.3 CLEAN OR MAJOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 6 in all areas. These conditions are to be achieved under operational conditions.
#The ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#The conditioned air is to be introduced into the theatre via suitable diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#Additional fresh air may be required for pressurization and shall be designed to maintain the required pressure differential between the theatre, the ancillary rooms and the corridors. The fresh air rate shall be selected to offer the required pressurization at the greatest possible energy efficiency.
#These validation tests shall be performed in accordance with SANS 14644 Parts 1, 2 and 3 at the recommended intervals (ISO14644-2) or after any system or building intervention has been completed. Detail records are to be kept and be presented upon demand.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.

23.4.4. MINOR THEATRES

#Airborne particulate contamination levels are not to exceed ISO 14644-1 Class 8 in all areas. These conditions are to be achieved under operational conditions.
#For recirculation systems the ventilation system is to include G4 Primary, F9 Secondary and H13 HEPA filters.
#For single pass systems the ventilation system is to include G4 Primary and F9 Secondary filters.
#The conditioned air is to be introduced into the theatre via suitably sized diffusers.
#Refer to ISO14644-4 for guideline ventilation rates.
#All ductwork between the HEPA filter housing and the air terminal shall be of rigid medium pressure ducting (SANS 10173) construction. All ductwork upstream of the HEPA filter housing shall be rigid high pressure ducting. Where alignment necessitates, the final connection to the terminal shall have a maximum of 300mm of thermally insulated flexible ducting.
#For ISO7 and cleaner areas, HEPA filters shall be mounted within the supply air terminals and UDAF plenums. 

====='''24. VALIDATION OF SPECIALIST VENTILATION SYSTEMS'''=====
24.1. Validation testing shall be completed in accordance with national standards for standardized tests (eg ISO14644 and ISO 14698 for cleanrooms) and shall be completed against mutually agreed protocols for non-standard tests.

24.2. It essential that the validation testing of a ventilation system’s contamination control performance parameters is conducted against operational, and not only "at-rest", conditions. Validation against "as-built" conditions offers little insight into the ultimate performance of the system.

23.3. Pre-Commissioning Checks shall cover the following aspects prior to the commencement of formal commissioning:

#Check whether the Design Specification satisfactorily addresses the demands of the User Requirement Specification.
#Check whether the ventilation systems have been provided and installed in accordance with the design specifications and drawings.
#Check that the buildings either housing or served by the ventilation equipment is complete and finished such that testing can commence safely and effectively.
#Check that all AHUs, chillers, heat rejection equipment and filters are sufficiently accessible for inspection and maintenance.
#All components are connected and are functional
#Door gaps and openings are installed and sized as specified in specialised zones
#Airflow control devices are installed in the correct locations and in the correct orientation
#Duct and filter tests ports are installed and sealed satisfactorily
#Safety and control interlocks are established
#Fan and drive guards are in place
#Safety and warning signs are in place
#All major system components or sub-systems are clearly labelled with functional or controls identification in a neat and durable fashion.
#Fluid and air pressure monitoring gauges are labelled with identification and acceptable maximum and minimum operating conditions.
#All wiring, piping and ducting colour banding is complete in accordance with SANS-1091

24.4. CLEANLINESS CHECKS:

#AHUs shall be checked for cleanliness on internal plenums with special attention being paid to fan and discharge plenums and condensate drip trays and drain lines.
#Ducting serving “clean” areas shall be cleaned prior to installation and the ends shall be sealed until installation. Open ends of duct runs shall similarly remain sealed during construction. Spot checks for compliance during the installation process are recommended.

24.5. Recommended Filtration Levels and Ventilation Rates for Mechanically Ventilated Areas

This table serves as a quick reference guide and will be revised as and when detailed room data sheets are developed within each department’s guidance documents.
{| class="wikitable"
|+'''Room Ventilation Requirements'''
| rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation[[Building Engineering Services#%20ftn1|'''[1]''']]'''

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range[[Building Engineering Services#%20ftn2|'''[2]''']]
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|Casualty/Minor Stitch Procedure room
|X
|
|X
|
|T
|
|
|7.5
|20
|
|-
|Theatres: Maternity/Caesarean
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: General Surgery
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Gynaecology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Ophthalmology
|X
|
|X
|'''X**'''
|T
|NA
|7
|7.5
|20
|
|-
|Theatres: Urology
|X
|
|X
|'''X**'''
|T
|NA
|7
|10
|20
|
|-
|Theatres: Endoscopy
|X
|
|X
|'''X**'''
|T
|NA
|7
|80
|20
|
|-
|Theatres: Plastic Surgery
|X
|
|X
|X
|T
|6
|7
|7.5
|70***
|
|-
|Theatres: Bone Surgery/Orthopaedic
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Thoracic
|X
|
|X
|X
|M
|5
|7
|80
|70
|
|-
|Theatres: Vascular???
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Theatres: Neuro Surgery
|X
|
|X
|X
|M
|5
|7
|7.5
|70
|
|-
|Waiting and Congregate Areas
|X
|
|
|
|
|
|
|60
|8
|18-28
|-
|Auditoriums
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Mortuary
|X
|X
|
|
|
|
|
|
|12
|22-25
|-
|Bath Room
|
|
|
|
|
|
|
|25
|10
|N/A
|-
|Dirty Utility Room
|
|
|
|
|
|
|
|40
|10
|N/A
|-
|Blood Bank
|X
|
|
|
|
|
|
|
|4
|22-25
|-
|Casualty
|X
|X
|
|
|
|
|
|7.5
|12
|22-25
|-
|CSSD
|X
|X
|
|X
|
|
|
|7.5
|20
|22-25
|-
|Dark Room
|X
|
|
|
|
|
|
|
|10
|22-25
|-
|Dining Rooms/Canteens
|X
|
|
|
|
|
|
|7.5
|10
|18-28
|-
|General Stores
|X
|
|
|
|
|
|
|
|4
|N/A
|-
|Laboratories
|X
|X
|
|
|
|
|
|
|6
|22-24[<nowiki/>[[Building Engineering Services#BESftn3|3]]]
|-
|Labour/Delivery Room
|X
|
|
|
|
|
|
|
|4
|22-24
|-
|Laundry – General
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Lecture Halls
|X
|
|
|
|
|
|
|7.5
|4
|22-26
|-
|Outpatients Departments
|X
|
|
|
|
|
|
|60
|4
|18-28
|-
|Pharmacy Dispensing
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Pharmacy Store
|X
|X
|
|
|
|
|
|7.5
|4
|22-24
|-
|Specialist Clinics- ENT
|X
|X
|
|
|
|
|
|7.5
|4
|22-26
|-
|Sterilizer Equipment
|X
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Toilet Room
|
|
|
|
|
|
|
|7.5
|10
|N/A
|-
|Units: Treatment Room
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|-
|Units: Burns
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|-
|Units: HCU / CCU
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|-
|Units: ICU Neonatal
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|-
|Wards: General
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|-
|Wards: Airborne Precaution Rooms/Isolation'''[[Building Engineering Services#%20ftn1|[1]]]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|-
|Wards: Maternity
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Medical
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|-
|Wards: Paediatric
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|-
|Wards: Psychiatric
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|-
|Wards: Orthopaedic
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: Surgical
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|-
|Wards: TB
|X
|
|
|
|
|
|
|80
|12
|20-28
|-
|Radiology: General
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|-
|Radiology: Airborne Precaution
|X
|
|X
|
|
|
|
|60
|6
|22-24
|-
|Radiology: MR/CT

Scanner
|
|
|
|
|
|
|
|60
|6
|2-24
|-
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|}
[[Building Engineering Services#%20ftnref1|[1]]] These rates are considered for forced ventilation systems only. Average natural ventilation rates may be higher

[[Building Engineering Services#%20ftnref2|[2]]] Temperature range not to be exceeded for more than 50 hours per year.

{{Anchor|ftn3}}[[Building Engineering Services#%20ftnref1|[1]]] Specialist cleanrooms and laboratories may require lower temperatures.

[[Building Engineering Services#%20ftnref1|[1]]] Levels of filtration are dependent on pathogenicity. Exhaust filtration may also be required.
{| class="wikitable"
| colspan="2" rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation[[Building Engineering Services#%20ftn1|'''[1]''']]'''

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range[[Building Engineering Services#%20ftn2|'''[2]''']]
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|-
|
|
|
|
|
|
|
|
|
|
|
|
|}
 
{| class="wikitable"
| colspan="2" rowspan="3" |'''Systems Serving'''[[Building Engineering Services#%20msocom%201|[TvR1]]] ''':'''
|'''Primary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Secondary'''

'''Filters'''
|'''Tertiary'''

'''Filters'''
|'''Airflow Type'''
| colspan="2" |'''Airborne Particle Count'''
| colspan="2" |'''Ventilation[[Building Engineering Services#%20ftn1|'''[1]''']]'''

'''(Considering Forced)'''
|'''Temperature'''
|-
|Pleated Panel
|Pleated Panel/ Bag
|High Capacity

Rigid Minipleat
|High Capacity

Rigid Minipleat
|Unidirectional/

Turbulent/

Mixed
|Protected zone
|Background area
|Minimum

Outdoor Air
|Min. Air changes

per Hour
|Design Range[[Building Engineering Services#%20ftn2|'''[2]''']]
|-
|EN779 Classification

G4
|EN779 Classification

F6
|EN779 Classification

F9
|EN1822 Classification

H13-H14
|U/T/M
|SANS14644-1

Class
|SANS14644-1

Class
|ℓ/s per person
|(Assuming 3m ceiling height)
|°C
|-
|'''Pharmacy Dispensing'''
|'''X'''
|'''X'''
|
|
|
|
|
|7.5
|4
|22-24
|
|-
|'''Pharmacy Store'''
|'''X'''
|'''X'''
|
|
|
|
|
|7.5
|4
|22-24
|
|-
|'''Specialist Clinics- ENT'''
|'''X'''
|'''X'''
|
|
|
|
|
|7.5
|4
|22-26
|
|-
|'''Sterilizer Equipment'''
|'''X'''
|
|
|
|
|
|
|7.5
|10
|N/A
|
|-
|'''Toilet Room'''
|
|
|
|
|
|
|
|7.5
|10
|N/A
|
|-
|'''Units: Treatment Room'''
|X
|
|
|
|
|
|
|7.5
|6
|24-26
|
|-
|'''Units: Burns'''
|X
|
|X
|X
|T
|8
|8
|7.5
|20
|26-28

(50-60%RH)
|
|-
|'''Units: HCU / CCU'''
|X
|X
|
|
|
|
|
|7.5
|30
|22-24
|
|-
|'''Units: ICU'''
|X
|
|X
|
|
|
|
|7.5
|30
|22-24
|
|-
|'''Units: ICU Neonatal'''
|X
|
|X
|
|
|
|
|7.5
|6
|26-28
|
|-
|'''Wards: General'''
|X
|
|
|
|
|
|
|7.5
|4
|18-28
|
|-
|'''Wards: Airborne Precaution Rooms/Isolation[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|X
|
|X
|
|
|
|
|80
|12
|22-24
|
|-
|'''Wards: Maternity'''
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|
|-
|'''Wards: Medical'''
|X
|
|
|
|
|
|
|7.5
|4
|24-26
|
|-
|'''Wards: Paediatric'''
|X
|
|
|
|
|
|
|7.5
|4
|22-25
|
|-
|'''Wards: Psychiatric'''
|'''X'''
|
|
|
|
|
|
|'''7.5'''
|'''4'''
|'''20-28'''
|
|-
|'''Wards: Orthopaedic'''
|X
|
|
|
|
|
|
|7.5
|4
|20-28
|
|-
|'''Wards: Surgical'''
|X
|X
|
|
|
|
|
|7.5
|4
|20-28
|
|-
|'''Wards: TB'''
|X
|
|
|
|
|
|
|80
|12
|20-28
|
|-
|'''Radiology: General'''
|X
|
|X
|
|
|
|
|7.5
|6
|22-24
|
|-
|'''Radiology: Airborne Precaution'''
|X
|
|X
|
|
|
|
|60
|6
|22-24
|
|-
|'''Radiology: MR/CT'''

'''Scanner'''
|
|
|
|
|
|
|
|60
|6
|2-24
|
|}

24.6. Commissioning tests shall include and record, but not be limited to:
{| class="wikitable"
|'''System'''
|'''Commissioning Test'''
|'''Special Instructions'''
|-
|'''All'''
|Standard of installation
|Test to be authorised by client's representative.
|-
| rowspan="7" |'''Air Handling Units and Fans'''
|Fan motor drive speed and rotation.
|Cognisance should be taken of motor cooling requirements
|-
|Fan motor current draw.
|<nowiki>-</nowiki>
|-
|HEPA Filter challenge testing.
|In accordance with ISO DIS 14644-3
|-
|AHU heating and cooling coil performance
|Report on-coil and off-coil air conditions for full heating and full cooling with no air bypass.
|-
|AHU leakage tests
|<nowiki>-</nowiki>
|-
|Heating and Chilled Water circuits have been charged, dosed and pressure tested
|<nowiki>-</nowiki>
|-
|Flow rates and pressures across heat exchangers, pumps and compressors
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="2" |'''Room conditions'''
|Airflow and room pressure balancing in accordance with design tolerances.
|In accordance with ISO DIS 14644-3 Acceptance criteria Normally +10-0%
|-
|Room Temperature and humidity
|<nowiki>-</nowiki>
|-
| rowspan="2" |'''Air Distribution systems'''
|Dampers and registers shall be locked and marked after balancing
|<nowiki>-</nowiki>
|-
|Duct leakage tests for medium and high pressure ducting in accordance with SANS 10173 or DW/143 requirements, as agreed upon
|<nowiki>-</nowiki>
|-
|'''Water Distribution Systems'''
|Pressure Drops and Flow Rates
|Pressure drops and flow rates should be measured, recorded and confirmed to be in accordance with design specifications.
|-
| rowspan="4" |'''Control System'''
|Control system loop and function checks
|<nowiki>-</nowiki>
|-
|Alarm Checks
|<nowiki>-</nowiki>
|-
|System Start/Stop sequencing checks
|<nowiki>-</nowiki>
|-
|System Set-Back mode checks
|Include room condition and contiguous system impacts
|}

24.7. Select validation tests shall be conducted at intervals defined by the client:
 
{| class="wikitable"
|'''Tests'''
|'''Required/ Optional'''
|'''Recommended Frequency of testing'''
|'''At-Rest or In-Operation Testing'''
|-
|'''Airflow volume tests'''
|Required
|12 months
|At-Rest
|-
|'''Airflow visualization'''

'''(Airborne precaution rooms)'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Velocity Tests'''
|Required
|12 Months
|At-Rest & In-Operation
|-
|'''UDAF Airflow Visualisation'''
|Required
|6 Months
|At-Rest & In-Operation
|-
|'''Room pressure tests'''
|Optional
|3 Months
|At-Rest & In-Operation
|-
|'''Airflow direction tests'''
|Required
|1 Month
|At-Rest & In-Operation
|-
|'''Discreet practice counts'''
|Required
|12 Months
|In-Operation
|-
|'''Bio-burden testing'''
|Required
|1 Month
|At-Rest
|-
|'''Filter challenge testing'''
|Optional/Recommended
|24 Months
|At-Rest
|-
|'''Room Condition recovery'''
|Required
|24 Months
|In Operation
|}
24.8. Prescribed validation reports shall include:

*References to the test protocol
*Acceptance criteria
*Test results
*Test equipment identification and calibration status
*Name and signature of tester
*Name and signature of facility representative
*Dates of test and acceptance by client

===Medical gas installations===
25. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

26. All units of a health establishment, except sub-acute and hospice facilities, where patients are accommodated and treated, must have medial gases and vacuum provided by medical grade piped services, with indexed terminal connecter points. Bottle systems may be provided in sub-acute and outpatient facilities.

27. Mobile gas services must be available for crisis situations.

28. Sub-acute facilities must have one mobile oxygen cylinder per 10 patients and one suction machine for every 10 patients.

29. The minimum services to be supplied to all Acute Care areas are described in Table 11.1. Should the data in this table be in conflict be the table presented in the individual departmental design guidance documents, those individual guidance documents take precedence.
{| class="wikitable"
|+Table 5 Minimum gas services
!'''Description'''
!
!'''Oxygen'''
!'''HP Air'''
!'''LP Air'''
!'''N2O'''
!'''VAC'''
!'''Scavenging'''
|-
|'''Major Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Minor Theatre8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|2
|2
|2
|1
|2
|1
|-
|'''Cath Lab8'''
|'''Theatre Panel'''
|1
|1
|1
|1
|2
|
|-
|
|'''Per Pendant'''
|1
|
|
|1
|1
|1
|-
|'''Post Op'''
|'''Bedhead'''
'''Trunking'''
|1
|
|1
|
|1
|
|-
|'''Procedure'''
'''Room'''
|'''Theatre Panel'''
|1
|
|1
|
|2
|
|-
|'''Resuscitation Bay'''
|
|1
|
|1
|
|2
|
|-
|'''Delivery Room'''
|
|2
|
|1
|
|2
|
|-
|'''High Care Unit, Per Bed'''
|
|1
|
|1
|
|2
|
|-
|'''Intensive Care Unit Per Bed'''
|
|2
|
|2
|
|2
|
|-
|'''Casualty Per Bed'''
|
|1
|
|1
|
|1
|
|-
|'''Wards'''
|
|'''1 per'''
'''2 beds'''
|
|
|
|'''1 per'''
'''2 beds'''
|
|}
30. A gas alarm system to monitor gases, excluding scavenging, must be installed in a location that is manned 24 hours per day. A slave panel must also be installed in the intensive care unit and in the theatre complex. This alarm system must be connected to UPS.

31. All piped vacuum and oxygen systems must have mobile back-up systems with adequately trained staff to handle them. . The back-up service shall be automatically activated if the line pressure drops below the set operating pressure. All back-up services and change-over valves shall be on UPS and diesel generator supplies.

32. Medical air (low pressure) for respiratory purposes must be provided at a fixed pipeline pressure of 400 kPa. Medical air (high pressure) for driving surgical power tools must be provided at a terminal usage pressure between 70 0kPa and 1000 kPa, depending on the tools/equipment to be used. ICU and operating rooms must be provided with a back-up system for both low and high pressure service. Air compressors must be fed off standby power supply.

33. Anaesthetic gas scavenging, which is a low-pressure suction system that removes exhaled anaesthetic gases from the patient circuit must be provided. Each outlet point must have its own balancing valve to allow the system to be balanced progressively from the furthest outlet point towards the suction fan or pump.

34. The vacuum installation shall comply with SANS 7396-1. Vacuum liquid bottle traps must be installed to collect any blood/fluid etc. that may be drawn into the pipeline. One bottle trap per operating room, ICU, ward block and other patient unit, must be supplied. Where possible the vacuum trap should be located in a sluice room. Emergency suction facilities must be provided in the ICU and High Care, operating rooms, recovery room, delivery room, emergency unit and nursery, and must be available to all patient rooms. Bacteria filters must be installed in the vacuum main before the vacuum reservoir and pumps. Used filters are considered a bio-hazard and must be handled accordingly when being changed and disposed. Care must be given to the location of the exhaust discharge of vacuum plants taking into account locations of windows and other air inlet points. Vacuum pumps must be fed off standby power supply.

35. Gas service isolation valves should be carefully positioned for each clinical unit to avoid shutdowns of major sections.

36. Gas service outlets to be identified and colour-coded with 3mm lettering.

37. Should compressed air operated autoclaves be employed, High Pressure medical air may be taken to such equipment, provided the system possesses sufficient capacity.

38. Should pendants requiring compressed air for aid of movement be employed, High Pressure Medical Air may be taken to them, provided the system possesses sufficient capacity.

39. Should Health Technology Workshops require medical gas outlets for testing and servicing of medical equipment, the required service may be taken to them, provided the system possesses sufficient capacity.

40. SANS 7396-1, as amended, specifies the requirements from design to commissioning of medical gas and vacuum systems

41. Medical gas and vacuum pipelines shall be marked in accordance with SANS 7396-1 and ISO 5359 as applicable

42. SANS 7396-2, as amended, specifies the requirements from design to commissioning of anaesthetic gas scavenging disposal systems.

43. Colour coding of anaesthetic gas scavenging disposal system shall be red magenta or in accordance with the national standard. An example of red magenta is 3050-R40B, in accordance with SS 01 91 02.(Refer to SANS 73962-2).

44. Colour coding of non-medical gas piping must be as per SANS 10140-3:2003.

45. SANS 1409, as amended, specifies the requirements for non-interchangeable outlet sockets and probes for specific medical (gas and vacuum) services used in hospitals.

46. Plain ended copper tubing for low pressure medical gas and vacuum shall comply with the requirements of SANS 1453 and SANS 1067-1 or SANS 1067-2, as deemed suitable.

47. Laboratory gas taps and valves shall be marked as described in SANS 10140-4

===Electrical installations===

====48. Lighting in Hospitals ====
48.1. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

48.2. Within the available scope presented in the National Building Regulations, the following lighting requirements should be interpreted with the aim of maximum energy and cost efficiency. The following innovations could be adopted to achieve this aim:

#Daylight harvesting with passive building elements and active systems response.
#Adoption of task lighting, where appropriate, within the scope of present and future planned activities.
#Considered selection of lighting elements and solutions.
#Considered selection of internal colours and materials.
#Accommodation for visually impaired occupants.

48.3. Where a requirement for natural light (daylight) is stated, this may be met if the room opens onto an atrium or courtyard, or if a roof light is incorporated, provided that privacy within the room or space is maintained. In addition, daylight may be borrowed from an adjacent room by means of glazing the wall in between, provided that the adjacent room or corridor is within the same unit.

48.4. Save where otherwise provided for in the requirements, health establishments must comply with the following: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table 6 Levels of Indoor Lighting (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings)'''
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''

'''/ lux'''
|'''Max. point illuminance/ lux'''

'''(not to be exceeded)'''
|'''Unified'''

'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''

'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Common areas'''

- changing room

- chapel

- classroom

- consulting room (general)

- care room (deep plan)

- day room

- disposal (clinical, domestic waste)

- doctor’s office

- domestic services room

- drug store (ITU/HDO)

- general office

- seminar room

- seminar room

- staff change

- staff rest room

- utility room (clean)

- utility room (dirty)
 
|

100-150

100-150

300

300

300

200

200

500

100

500

300

100-150

300

100

50/200

150

200
 
|

n/a

n/a

520

520

520

350

350

850

170

850

520

n/a

520

170

n/a

260

350
 
|

22

22

19

19

19

22

22

19

19

19

19

19

19

22

22

19

22
 
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

90

80

80
 
|

Floor

Pews

Desk

Work Surface

Work Surface

Work Surface

Floor

Desk

Floor

Desk

Desk

Floor

Work Surface

Floor

Work Surface

Work Surface

Work Surface
 
|

Normal

Normal

Normal

Normal

-

-

Normal

Normal

Normal

Normal

Normal

Normal

Selective

Normal

-

Normal

N
 
|

-

-

-

>30%

-

-

-

>30%

-

>30%

>30%

-

>30%

-

-

>30%

>30%
 
|-
|'''Corridors (screened from bed bays)'''

- by day

- by night
 
|

200

5-10
 
|

350

n/a
 
|

22

22
 
|

80

80
 
|

Floor

Floor
 
|

S

Normal
 
|

>30%

>30%
 
|-
|'''Circulation/communal areas'''

- corridors (general)

- day room

- entrance canopy

- entrance lobby

- hairdressing salon

- hospital street

- library

- lift car

- lift lobby

- loading bay

- reception area

- relatives overnight

- rest area

- shop/kiosk

- storage (general)

- toilets
|

200

200

n/a

n/a

300

200

300

150

200(min)

100

300

150

150

300

200

200
|

350

350

n/a

n/a

520

350

520

260

n/a

170

520

260

260

520

350

n/a
|

19

-

-

22

-

19

19

-

19

22

19

-

19

-

22

22
|

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80

80
|

Floor

Floor

Road surface

Floor

Chair

Floor

Desk

Floor

Floor

Platform or floor

Floor

Work Surface

Floor

Counter

Floor

Floor
|

Normal

S

Selective

Selective

Normal

N/EM

Normal

Sp

Selective

Normal

Normal

Normal

Normal

Normal

Normal

Normal
|

>30%

>30%

>30%

>30%

-

>30%

-

-

>30%

-

>30%

-

-

-

-

-
|-
|'''Restaurant/catering/breakout areas'''

- beverage bay

- counter

- general

- servery

- tables

- washing up
 
|

100

300

50

300

50/200

|

170

520

100

520

n/a

520
 
|

-

22

-

22

-

22
 
|

80

80

80

80

80

80
|

Floor

Counter

Floor

Counter

Tables

Sink
 
|

Normal

Normal

S

Normal

Normal

Normal
 
|

>30%

-

>30%

-

-

>30%
 
|-
|'''Wards and bedded areas'''

- children’s play area

- circulation space

- circulation space (night)

- examination/treatment

|

300

170

10

1000(local)

|

520

170

10

n/a

|

22

19

-

-

|

80

80

80

90

|

Desk

Floor

Floor

Bed level (usually provided by examination lamp
|

N/EM

Normal

Normal

Normal

|

>30%

>30%

>30%

>90%

|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Nursing'''

- general nursing care/examination

- night light

- nurses’ station (day)

- nurses’ station (night)

- observation/night watch

- observation/night

- mental illness care wards

- patient reading (adult)

- reading lights

- ward corridors (day)

- ward corridors (night)

|

300

5

300

30/200

20

1 to 5

200

300

300

200

50

|

520

10

520

250

40

n/a

350

520

520

350

75

|

19

-

19

22

-

-

19

19

19

19

19

|

80

80

80

80

80

80

80

80

80

80

80

|

Bed

Work Surface

Desk

Work Surface

Bed head

Bed head

Floor

Bed head

Patient activity area

Floor

Floor (50% uniformity required)
 
|

Selective

Normal

Variable

Normal

Normal

N/Sp

Normal

Normal

Selective

Normal

Normal

|

>30%

>90%

>30%

>90%

-

>30%

>30%

>30%

>30%

>90%

>30%

|-
|'''Orthopedic'''

- pacemaker

- treatment (general)

- venesection
 
|

500

300

300
 
|

850

520

520
 
|

19

19

19
 
|

80

80

80
 
|

Work Surface

Work Surface

Chair
 
|

Variable

Normal

Normal
 
|

>30%

>30%

>30%
 
|-
|'''Critical care'''

- intensive care (night)

- observation/night watch

- high dependency unit (HDU)

- intensive care unit (ICU)

- bed head (day)

- night light

- simple observation/examination

- examination

 
|

5(max)

20

100

100

30 to 50

5 to 10

300

1000 (local)

 
|

n/a

40

170

170

n/a

10

520

n/a

 
|

-

-

19

19

22

-

19

-

 
|

80

80

80

80

80

80

80

90

 
|

Circulation

Bed head

Circulation/general

Circulation/general

Bed head

Bed head

Bed

Bed level(to be provided by examination lamp)

|

N/Sp

N/Sp

Normal

Normal

Normal

Normal

Selective

Normal

 
|

>30%

>30%

>90%

>90%

>90%

>90%

>90%

>90%

 
|-
|'''Coronary care'''

- bed head (day)

- observation/night watch

- simple observation/examination

- examination

- staff base (day)

- staff base (night)
 
|

30 to 50

5 to 10

300

1000 (local)

300

30/200
 
|

n/a

n/a

520

n/a

520

250
 
|

19

-

19

-

19

19
 
|

80

80

80

90

80

80
 
|

Bed head

Bed head

Bed

Bed level (to be provided by examination lamp)

Desk

Desk
 
|

Normal

Normal

Selective

Normal

Selective

Variable
 
|

>90%

>90%

>90%

>90%

>90%

>90%
 
|-
|'''Nurse’s station/staff base'''

- day

- night

- interview
 
|

300

30/200

300
 
|

520

250

520
 
|

19

19

19
 
|

80

80

80
 
|

Desk

Desk

Desk
 
|

Selective

Variable

Normal
 
|

>90%

>90%

>30%
 
|-
|'''Operating theatres'''

- anesthesia (examination)

- anesthesia room (general)

- angiography room

- endoscopy

- operating room general

- operating table/cavity

- porter’s area

- post anaesthesia recovery

- preparation

- scrub up

- transfers

- utility rooms
 
|1000 (local)

500

500

300

300

1000

10000 to 100000

300

500

500

500

300

100 to 150
|

n/a

850

850

520

1500

n/a

520

850

860

860

520

n/a
|

-

19

19

19

19

-

19

19

19

19

19

19
|

80

80

80

80

90

90

80

90

801

80

80

80
|

Trolley head

Work Surface

Work Surface

Work Surface

Work Surface

Work Surface

Trolley/bed

Work Surface

Bench

Sink top

Work Surface

Floor
|

Normal

Selective

Variable

Variable

Variable

Variable

N/A

Selective

Normal

Normal

Normal

Normal
|

>90%

>90%

>90%

>30%

>90%

>90%

>90%

>90%

>30%

>30%

>30%

-
|}
 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''Accident and emergency'''

- Admissions. reception

- supplies stores

- minor treatment area

- minor operations

- couch (general area)

- couch (local)

- general examination areas

- procedure room

- resuscitation room
 
|

300

300

500

15000/30000

750

500

500

30000/60000

500
 
|

520

520

850

N/A

1000

850

850

N/A

860
 
|

22

22

19

-

19

19

19

-

19
 
|

80

80

80

90

90

80

80

90

80
|

Desk

Work Surface

Work Surface

Adjustable to suit treatment area

Over couch area

Couch level

Couch level

Task illumination provided by minor treatment lamp

Work Surface
 
|

Normal

Normal

Normal

Normal

Variable

Variable

Variable

Normal

Normal
 
|

>30%

>90%

>30%

>30%

>90%

>90%

>90%

>90%

>30%
 
|-
|'''Audiology'''

- audio testing

- consulting room

- ear examination

- vestibular testing (labyrinth)

|

300

300

1000 (local)

100

|

520

520

n/a

170

|

19

19

-

19

|

80

80

90

80

|

Work Surface

Work Surface

(examination lamp)

Couch head and instruments
 
|

Variable

Variable

-

Normal
 
|

>30%

>30%

-

>30%
 
|-
|'''Dentistry'''

- laboratories

- reception/administration areas

- surgeries/theatres

- treatment rooms

- white teeth matching

|

500

300

8000 to 20000

500

5000

|

850

520

n/a

850

n/a

|

19

19

-

19

-

|

80

80

90

90

90

|

Bench

Work Surface

Mouth

Bench work surface

Work Surface

(TCP ≤ 6000 K)
 
|

Normal

Selective

Variable

Normal

Normal

|

>30%

>30%

>90%

>30%

>30%

|-
|'''Diagnostics support'''

- aseptic laboratory

- blood bank

- colour inspection laboratory

- hot and cold rooms

- inspection

- laboratories

- laboratory (with computers)

- pathology laboratory

- relatives’ waiting room

- seminar room

- viewing/bier room
 
|

300

300

1000 (local)

200

500 (local)

500

300

500

300

300

30 to 150
 
|

520

520

n/a

350

n/a

850

520

850

520

520

n/a
 
|

19

19

-

19

-

19

19

19

19

19

19
 
|

80

80

90

80

80

80

80

80

80

80

80
 
|

Bench

Work Surface

Bench

(TCP ≤ 6500 K)

Work Surface

Bench

Bench/desk

Work Surface

Bench

Work Surface

Work Surface

Bier
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Variable

Normal

Variable
 
|

>30%

>90%

>90%

>30%

50-90%

50-90%

50-90%

50-90%

>30%

>30%

>30%
 
|-
|'''Women’s services (maternity)'''

- applying sutures

- circulation space (day)

- delivery

- day

- night

- neonatal

|

1000 (local)

100

500

50 to 100

5

1000 (local)

|

n/a

170

850

n/a

20

n/a

|

-

19

19

19

-

-

|

90

80

80

80

80

80

|

Couch, chair or bed (usually provided by examination lamp)

Floor

Work Surface

Cot

Cot

Cot

|

Normal

Normal

Selective

Normal

Normal

Normal
 
|

>90%

>30%

>90%

>90%

>90%

>90%

|-
|'''Mother and baby rooms'''

- circulation space (day)

- day

- night

- nurseries (day)

- nurseries (night)

- milk kitchen

- special care baby unit

- teaching areas
 
|

100

50 to 100

5

100

5

300

1000 (local)

300
 
|

170

n/a

20

170

20

520

n/a

520
 
|

22

19

-

19

-

22

19

19
 
|

80

80

80

80

80

80

80

80
 
|

Floor

Cot

Cot

Floor

Floor

Bench

Cot

Bench/Work Surface
 
|

Normal

Normal

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>30%

>90%

>90%

>30%

>30%

>30%

>90%

-
 
|} 
{| class="wikitable"
|'''Area, unit or department'''
|'''Service illuminance '''
'''/ lux'''
|'''Max. point illuminance/ lux'''
'''(not to be exceeded)'''
|'''Unified'''
'''Glare'''

'''Rating'''

'''(UGR)'''
|'''Min.Ra'''
|'''Measurement'''
'''Point'''
|'''Type of control'''
|'''Standby lighting level (%)'''
|-
|'''General treatment areas'''

- autopsy (dissecting) table

- autopsy rooms and mortuaries

- dermatology

- dialysis

- dispensary

- minor surgery/treatment

- plaster room

- resuscitation (general)

- resuscitation/examination

- pharmacy
 
|

5000

500

(higher values could be required)

500

500

15000/30000

500

500

15000(local)

500
 
|

8600

850

n/a

850

860

 850

850

n/a

850
 
|

-

19

19

19

19

19

19

-

19
 
|

90

90

90

80

80

90

80

90

90

80
|

Table top

Work Surface

(Local operating lamp)

Work Surface (dimmable)

Bench

Work Surface

Work Surface

Head of trolley

Work Surface
 
|

-

-

-

-

Normal

Normal

Normal

Normal

Normal

Normal
 
|

-

-

-

-

>90%

>90%

>30%

>90%

>90%

50-90%
 
|-
|'''Mortuaries and animal houses'''

- autoclave

- body store

- general

- mortuary

- operation

- post mortem

- staff change

- store room

- viewing room

- waiting room
 
|

150/200

200

300

150

500 local

500

100 to 150

150

50/100

200 (min)
 
|

n/a

350

520

260

n/a

850

n/a

260

n/a

n/a
 
|

19

19

19

19

-

19

19

19

19

19
 
|

80

80

80

80

90

90

80

80

80

80
|

Work Surface

Work Surface

Work Surface

Bier room

Bench

Work Surface/table

Floor

Work Surface

Work Surface

Floor
 
|

Normal

Normal

Special

Variable

Normal

Normal

Normal

Normal

Variable

Selective
 
|

>30%

>30%

-

>30%

>30%

>30%

>30%

-

>30%

>30%
 
|-
|'''Engineering services'''

- ducts

- plant room

- roadways

- workshop
 
|

20 to 50

300

7

300/500
 
|

n/a

520

12

n/a
 
|

-

22

-

22
 
|

80

80

80

80
|

Floor

Floor

Road surface

Bench
 
|

Selective

Normal

-

Normal
 
|

-

>90%

-

>30%
 
|-
|'''Facilities support services'''

- laundry

- linen store (Linen Department)

- pack and dispatch

- pressing

- sewing room

- wash and dry
 
|

300

100

300

300

500 (local)

300
|

520

170

520

520

n/a

520
 
|

19

19

19

19

19

19
 
|

80

80

80

80

80

80
 
|

Bench

Floor

Bench

Equipment

Machine

Equipment

|

Normal

Normal

Normal

Normal

Normal

Normal
 
|

>90%

-

>90%

>90%

>90%

>90%
 
|}
48.4.1. The lighting levels quoted above relate to the relevant task area. Levels of for the task areas and surrounding areas can be reduced where it can be justified by experienced staff or engineers. Lighting levels must, regardless, comply with the requirements of the National Building Regulations.

48.4.2. Lighting levels for external areas shall comply with the following table: (Adapted from CIBSE Lighting Guide 2: Hospitals and Healthcare settings).

'''Table''' '''7 Levels of Indoor Lighting'''
{| class="wikitable"
|Area
|Maintained average illuminance / lux
|Maintained minimum illuminance / lux
|Overall uniformity (not less than stated figure)
|Threshold increment
|Colour rendering (minimum)
|-
|

CCTV

- monochrome

- colour

Roads

General pedestrian areas

Information and display signs

Car Park

Vehicle drop-off points

Steps or stairways

General area lighting

Hazardous open storage areas
 
|

0

-

15

20

30

10

15

20

100(vertical)

15

10

100

20

50
 
|

5

15

6

8

12

4

6

12

6

5

40

12

20
|

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4

0.4
 
|

≥10%

≥10%

 
|

≥60%

≥60%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%

≥20%
 
|}

49. Classification of Safety Services necessary for Medical Locations from SANS 10142-1
{| class="wikitable"
|'''Class'''
|'''Response Time'''
|-
|Class 0 (No break)
|Automatic supply available at no break

UPS backed up by Generator Required.
|-
|Class 0,15 (Very short break)
|Automatic supply available within 0,15 s

UPS backed up by Generator Required.
|-
|Class 0,5 (Short break)
|Automatic supply available within 0,5 s

UPS backed up by Generator Required.
|-
|Class 15 (Medium break)
|Automatic supply available within 15 s

Generator Required
|-
|Class > 15 (Long break)
|Automatic supply available in more than 15 s

Generator Required
|}
Note Safety Services in Medical locations are synonymous with Emergency Services.

50. '''Medical Location Classification'''

50.1. Group 0 location: where no applied part is intended to be used.

50.2. Group 1 location: Medical Location where applied parts are intended to be used.

#Externally, or
#To any part of the body, but not to the heart.

50.3. Group 2 location: Medical Location where applied parts are intended to be used in applications such as in an intracardiac procedure, in an operation (in an operating theatre) and in vital treatment where discontinuity (failure) of supply can cause danger to life.

Note: An intracardiac procedure is a procedure whereby an electrical conductor is placed within the cardiac zone of a patient or is likely to come into contact with the heart, such conductor being accessible outside the patient’s body. In this context, an electrical conductor includes insulated wires such as cardiac pacing electrodes or intracardiac ECG electrodes, or insulated tubes filled with conducting fluids.

50.4. For the allocation of medical location group and classification of safety service classes for medical locations see Table below as supplied in SANS 10142-1.
 
{| class="wikitable"
|
|
'''Medical Location'''
| colspan="3" |
'''Medical location group'''
| colspan="2" |
'''Safety service class'''
|-
|
|
|'''0'''
|'''1'''
|'''2'''
|'''≥ 0,5'''
|'''0,5'''

'''≤ 15'''
|-
|

1
|

Massage room
|

X
|

X
|
|
|

X
|-
|

2
|

Bedrooms
|

|

X
|
|
|

X
|-
|

3
|

Delivery room
|
|

X
|
|

X
|

X
|-
|

4
|

ECG, EEG, EHG room
|
|

X
|
|
|

X
|-
|

5
|

Endoscopic room
|
|

Xa
|
|
|

Xa
|-
|

6
|

Examination or treatment room
|
|

X
|
|
|

X
|-
|

7
|

Urology room
|
|

Xa
|
|
|

Xa
|-
|

8
|Radiology diagnostic and radio therapy room, other than mentioned under 21
|
|

X
|
|
|

X
|-
|

9
|

Hydrotherapy room
|
|

X
|
|
|

X
|-
|

10
|

Physiotherapy room
|
|

X
|
|
|

X
|-
|

11
|

Anaesthetic room
|
|
|

X
|

X
|

X
|-
|

12
|

Operating theatre
|
|
|

X
|

X
|

X
|-
|

13
|

Operating preparation room
|
|

X
|

X
|

X
|

X
|-
|

14
|

Operating plaster room
|
|

X
|

X
|

X
|

X
|-
|

15
|

Operating recovery room
|
|

X
|

X
|

X
|

X
|-
|

16
|

Heart catheterization room
|
|
|

X
|

X
|

X
|-
|

17
|

Intensive care room
|
|
|

X
|

X
|

X
|-
|

18
|

Angiographic examination room
|
|
|

X
|

X
|

X
|-
|

19
|

Haemodialysis room
|
|
|

X
|

|

X
|-
|

20
|

Magnetic resonance imaging (MRI)
|
|

X
|
|
|

X
|-
|

21
|

Nuclear medicine
|
|

X
|
|
|

X
|-
|

22
|

Premature baby room
|
|
|

X
|

X
|

X
|-
| colspan="3" |
a The room is not an operating theatre.
|
|
|
|
|}
50.5. In addition to the tables 0 and 50.4 above, generator supply is also required for:

#Night light in wards and ward corridors;
#All switched socket outlets used for patient life support anywhere in the facility;
#At least one patient lift or lift that can accommodate a bed for every 200 patients;
#Medical air compressor, vacuum pumps and gas alarm systems;
#Supply air fans serving theatres and uni-directional airflow systems;
#Isolation ward exhaust air fans.
#Mortuary Fridge Cabinets
#Nurse call System
#Fire detection system

51. General Requirements

51.1. Power supply to switched socket outlets in high care units, intensive care units and operating theatre units and recovery rooms must be on an earth monitoring system. Double pole isolators must be used for supply points in these areas and the power supply to these shall be fed from an isolation transformer.

51.2. Medical Location Group 1:

Switch Socket outlets in Medical Location 1 Shall have final Circuits for socket -outlets up to 16Amp shall be protected by earth leakage protection devices with a rated earth leakage tripping current ( rated residual current) not exceeding 30 Ma.

51.3. Medical Location Group 2:

Switch Socket outlets in Medical Location 2 the Medical Isolation Transformer (Medical IT) system shall be used for circuits that supply medical electrical equipment and systems intended for life support or surgical applications and other electrical Equipment located in the patient environment. In the case of each group 2 medical location, at least one separate medical IT system is necessary.

51.4. The Medical Isolation Transformer (MIT) shall be equipped with:

51.4.1. A 5 or 8 kVA Isolation Transformer complete with a 220 V Primary and 220 V / 110 V Secondary Winding with a centre Point Floating but bonded to the Earth monitor. The Secondary Side of the transformer shall provide 220 Volts between Line 1 and Line 2 (Note no Neutral with an Isolation Transformer) Line 1 and Line 2 will feed the Distribution Board for that particular Medical Group location, i.e. (Theatre No 1) or (ICU Bed 1-6) This local DB will then have a number of double pole Circuit Breakers feeding out to the outgoing Circuits feeding the Socket Outlets in the Medical Location 2 Area. Note that at least two circuits are required to each ICU Bed or Theatre Panel, and Theatre Pendant. Also note that all Switch Socket Outlets in a Medical Location 2 Area have to be double Pole Switched via a double pole Isolator (Provided two circuits provided) or a double pole Circuit Breaker.

51.4.2. The Transformer shall be installed either in a cabinet/DB or enclosure, to prevent unintentional contact with live parts. The Transformer / DB should be located close to the Group 2 Medical Location but consideration should be given to providing the DB outside the red line area of both the Theatres and ICU Areas, so maintenance can be carried out without the need to be gowned up. Line 1 & 2 and Earth should all be Insulated wires with the colour of Line 1 & 2 being different from red and black suggest Brown and Blue wire is used for Line 1 & 2 and green for Earth (Note this Earth wire should be connected to an insulated Earth bar dedicated to that particular Group two location and bonded to the centre point of the secondary winding.) Note a Separate Dirty earth (Equipotential bonding) should also be provided to the metal work of the Plugs, Theatre Panel, and Pendant this earth shall be connected to the Main Building Earth.

51.4.2. An insulation -monitoring device that:

#Has an internal impedance of at least 100 k Ohm;
#Has a test voltage not exceeding 25 V DC.
#Is of a current, even under fault conditions, not exceeding 1 mA DC. and
#Shall indicate, at least when the insulation resistance has decreased to 5 k Ohm.

A test device shall be provided to test this facility to ensure that the alarm (Audible and visual) operates when the insulation resistance reaches 5 k Ohm;

To test the System two male plugs should be used each with a resistor of 5 k Ohm. Plug No 1 should have a 5 k Ohm resistor bridged from the Earth Pin to the Right Hand live Pin. Plug No 2 should have a 5 k Ohm resistor bridged from the Earth Pin to the Left Hand live Pin.

51.4.4. Medical Isolation Transformer Alarm.

For each Medical IT system an audible and visual alarm shall be provided in the Theatre Area a alarm shall be provided on theatre Panel and repeated back to the main Nurse Station in Theatre Area .The Alarm shall consist of Green Light indicating Healthy, a red light indicating fault, a audible Alarm to also indicate fault and a local audible alarm mute button. The Visual signal shall revert to green and the audible alarm shall be automatically reset on the removal of the fault condition
 

Table 4 – Required for Medical Isolation Transformers (MIT) and Switch Socket Outlets (SSO)
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Office Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Laboratory Work Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Office
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward Nurse Station
|0
|1 x Red 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Ward
|1
|1 x 16A Normal / Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point/ Bed(if required).
|
|3x 16A per bed
|
|
|
|
|-
|Ward Kitchen
|0
|2 x 16A Normal on Wall at 1200 mm over counter + 1 x 16 A next to Sink or Hydro Boil.
|
|1 x 16A supply for Fridge on generator supply
|
|
|
|
|-
|Ward Corridor
|0
|1 x 16A Normal / Every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Ward Staff Rest Room
|1
|I x 16 A on Wall for Cleaning, 1 x 16 A above counter for Electrical Appliances + 1 X 16 A next to sink for Hydro boil
|
|
|
|
|
|
|}
----[[Building Engineering Services#%20ftnref1|[1]]] Note: DPS is an abbreviation for double pole switch
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Theatre Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|-
|Theatre Post Op
|2
|
|
|
|6 x 16 A Dedicated SSO per Bed
|
|
|
|-
|Operating Theatre
|2
|
|
|
|
|8 x 16 A Dedicated SSO per Pendant
|8 x 16 A Dedicated SSO per pendant
|4 x 16 A Dedicated SSO
|-
|Cath Lab Operating Room
|2
|
|
|
|
|
|
|4 x 16 A Dedicated SSO
|-
|Cath Lab Control Room
|0
|1 x 16A Normal per Station
|1 x Red 16A Dedicated per Station
|
|
|
|
|
|-
|Cath Lab Equipment Room:

160 kva dedicated UPS Required to feed Dedicated DB and Equipment
|
|
|
|
|
|
|
|
|-
|Autoclave
|
|In autoclave plant room. 3-Phase 380V, 80A per autoclave
|
|
|
|
|
|
|-
|Instrument Washer
|
|In CSSD. Typically 3-Phase 380V, 15A per washer
|
|
|
|
|
|
|-
|Theatre Corridor
|1
|1 x 16A Normal for every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|}
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|ICU Circulation Space
|1
|1 x 16A Normal per 25m2 for cleaning
|1 x Red 16A Dedicated for Crash Cart Position.
|
|
|
|
|
|-
|Neo Natal ICU Cots Note: Care should be taken when sizing the Isolating Transformers to include the Heating Load
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care
|2
|
|
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|15 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|-
|High Care Nurse Station (per workstation)
|1
|1 x 16A Normal per Station
|2 x Red 16A Dedicated for Crash Cart Position
|
|
|
|
|
|-
|ICU and Ward Equipment Room
|0
|15 x 16A Normal on Wall at 1200 mm over shelf
|
|
|
|
|
|
|}
 
{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Casualty Treatment Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning + 1 x 16 Amp in ceiling for TV Point per Bed. 2 x 16A per Bed
|
|
|
|
|
|
|-
|Procedure Rooms 1
|1
|1 x 16A Normal per Ward for Cleaning
|
|4 x 16A per Bed per two Circuits.
|
|
|
|
|-
|Casualty Ward Corridor 0
|0
|1 x 16A Normal per every 15 m of corridor for Cleaning
|1 x Red 16A Dedicated for Radiology Procedure Crash Cart Position
|
|
|
|
|
|-
|Rooms Dedicated 125 Amp Supply to dedicated
|1
|1 x 16A Normal
|1 x Red 16A Dedicated
|
|
|
|
|
|-
|Radiology Control Room
|0
|1 x 16A Normal per Station
|1 x 16A Normal per Station
|
|
|
|
|
|-
|Maternity Delivery Rooms
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits (Note if you are using a 8 kva Isolating Transformer you can put 6 Beds on one Transformer)
|
|
|
|}

{| class="wikitable"
| rowspan="3" |'''Description'''
| rowspan="3" |'''Medical Location Group'''
| colspan="7" |'''Number and type of Switch Socket Outlets (SSO)'''
|-
| rowspan="2" |'''Location on wall or from UPS on wall or Power Skirting'''
| rowspan="2" |'''Dedicated Red SSO fed from UPS on wall or Power Skirting'''
| colspan="5" |'''Hospital Service Panel'''
|-
|'''Bed Head Trunking Backed up by Standby'''
|'''Bed Head Trunking Fed from MIT and UPS. 16 A Red Dedicated SSO with Blue DPS[[Building Engineering Services#%20ftn1|'''[1]''']]'''
|'''Theatre Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''Pendant Panel Fed from MIT and UPS Red Dedicated SSO w Blue DPS'''
|'''On Wall Fed from MIT and UPS Red Dedicated SSO with Blue DPS'''
|-
|Dialysis Treatment Beds.

Note that the Equipment can include Water Heating with high kw loading so care should be taken when sizing the Isolating Transformers
|2
|
|
|
|4 x 16A Dedicated per Bed on the same Isolating Transformer but two separate Circuits
|
|
|
|}
51.5. Uninterrupted Power System must be provided for operating theatre luminaries and all life support systems and computer systems where a break in electrical supply cannot be tolerated. The whole installation must conform to SANS 1474 of 1988.

51.6. Socket outlets for Dialysis units, in close proximity to water points or drains, shall be of the totally waterproof IP65 type, which also seal water-tight when the socket is removed.

51.7. Where more than one electrical transformer is used, they should preferably be located in separate structural enclosures. This is to prevent potential damage to an adjacent transformer if one is damaged.

51.8. All distribution boards fed from normal mains supply shall be painted Electric Orange, colour B26 to SABS 1091.

51.8. All distribution boards fed from standby emergency power supply shall be painted Signal Red, colour A11 to SABS 1091.

51.9. All distribution boards fed from UPS power supply shall be painted Blue colour F06 to SABS 1091.

51.10. All cable transition boxes shall be painted the appropriate colour corresponding to the source of the power supply.

51.11. All cables installed on surface mounted cable ladders shall be of the PVC/PVC/SWA/ECC/PVC type to SANS 101507 rated at 600/1000 Volt.

51.12. Electrical circuits to be engraved on base 3mm lettering indicating circuit number and DB.

51.13. Electrical Certificate of Compliance.
[[File:Picture 11.png|border|thumb|450x450px|alt=|center]]
 
===Electronic installations===
52. The design parameters for internal spaces should be found in the detailed room requirement sheets published in the individual IUSS guidance documents of the various functional units. Where these room requirement sheets are absent or lacking adequate information, the data contained in this document may be used.

53. Nurse call system with emergency (nurse assistance) and TV control handsets (Interchangeable with LED PEAR PUSH).

The nurse system enables the patient to call a nurse for assistance from his bed or from a bath, shower and toilet. The system also enables the staff to call for assistance (EMERGENCY CALL) from any bed and treatment room etc.

#When a patient nurse call or staff emergency call is enabled the system must produce an intermittent AUDIBLE chimes or bleeper tone at the nurses’ station or/and duty room. Three different sounding tones must be produced for normal Patient call, Bathroom call and Emergency (nurse assistance) call.
#The system must also provide a VISUAL indication, at the nurse station (LED Mimic Panel and/ or Computer Monitor or LCD Display Panel), above the door to the passage of the activated unit, and at the actual activated unit (reassurance LED).
#The system must be so designed that any call may ONLY be RESET at the point of origin.
#The system must automatically activate a nurse call when the Hand Held Unit (Handset) or Pear Push unit is accidently pulled out from the Bed Head Unit.
#The Bed Head Unit must be compatible with Hand Held Unit (with TV Control), Rehab Hand Held Unit & Pear Push. (Inter-changeable)
#A Central Monitoring PC, or PC per duty station replacing Mimic Panel, must keep records of all events. (Optional)
#The system must be purpose made and aesthetically pleasing with components (call & reset units etc) manufactured from matching injection moulded ABS plastic. A system made up of push buttons etc mounted directly onto standard electrical plates will not be accepted.

54. Automatic fire detection in Hospitals

The Fire Detection System shall comply with SANS 10400 SANS 10139 & SANS 322. The Fire Detection System must be provided throughout the Facility and be a Addressable Fire Detection System, Note that Audible Fire Alarms which could panic the patients should not be provided instead Visual Strobe Lights should be provided at all Nurse stations, Reception and Security Office.

Audible alarms can be used in noisy areas such as plant rooms.

The wiring for the Automatic Fire Detection System shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area)
 55. Public Address and Evacuation in Hospital

The Public Address and Evacuation System shall comply with EN54 and provide voice message via fire retardant speakers throughout the hospital Circulation Areas, Staff Areas, Public Toilets. The wiring for the Evacuation Speakers shall be KAL21B Fire Alarm cable, or equivalent 2 hour rated cable (1,5mm² minimum cross Sectional area). As part of the Hospital Design the Hospital should be zoned to allow Evacuation of Individual zones in the event of a fire or other Emergency.

==Wet Services==
56. Plumbing services (Water supply and drainage) must comply as a minimum with the following Standard Specifications and Codes of Practice:

#SANS 10400: The Application of the National Building Regulations, including Part XA: Energy Use in Buildings
#SANS 10252 – Part 1 – Water Supply Installations for Buildings
#SANS 10252 – Part 2 – Drainage Installations for Buildings
#UK Department of Health Technical Memorandum 04-01: The Control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems: Part A: Design, Installation and Testing, and Part B: Operational Management or the equivalent SANS standard when available.

57. Where any apparent conflict between the functional requirements and the regulatory “deemed to satisfy” guidance emerges, the rational design route to regulatory compliance would need to be followed so as not to compromise any system’s functional compliance.

58. Cold water storage, dedicated to the domestic water requirements of the facility, must be provided on the site. A minimum usable volume of 500 litres per bed must be provided.

59. If water storage is required for fire protection purposes (Sprinklers, Fire Hydrant supply) it must be stored separately from domestic water, unless adequate provision for the prevention of stagnation of the fire service reserve within the tank can be made.

60. Tanks must be accessible both on the outside as well as the inside, and provision for cleaning the tanks without interrupting water supply to the hospital must be made. Access manholes must be lockable, and a facility for draining the tank or individual compartments within it, must be made.

61. All openings to the tank (Overflows, vent pipes, etc) must be provided with screens.

62. Underground tanks, with their inherent risk of contamination must be avoided at all cost. If unavoidable, the tank should be constructed in a water tight bund allowing sufficient space all round for inspection and maintenance, and a sump for collecting drainage water

63. Cold water storage tanks must be located such that heat gain to the water is minimised. Cold water storage temperatures 20 C and lower will prevent the colonisation by or multiplication of Legionella

64. Site water reticulation must be designed using sound engineering principles, with adequate provision for isolating sections of the reticulation whilst keeping the remainder in operation being made.

65. Fire protection water reticulations must be kept totally separate from the domestic water reticulation

66. Water distribution may be gravity fed, or alternatively supplied via booster pumps. Pumps must be suited to handling potable water, and provision for built in redundancy must be made. Booster pumps must be supplied off standby power.

67. Hot water supply temperature to general patient care and staff areas must be controlled at 55 C, and must not exceed 60°C, except during a sanitation cycle as described hereunder.

68. Hot water generation systems must where possible use waste heat recovery from a central air conditioning system, if employed.

69. The facility for thermal disinfection of the hot water storage and circulation system must be provided in the system design. This can take the form of controlled heating of the storage vessel and circulating mains to 60°C during periods of low water and power demand. The use of shunt pumps to circulate hot water from the top level to the lowest level of the hot water tank during the sanitation cycle must be considered.

70. Hot water supply to paediatric wards, as well as to geriatric and to neonatal bathing facilities shall not exceed 42°C at the point of supply. If thermostatic mixing valves are employed to achieve this, they must be fitted with a safety feature such that the water flow is cut off within 2 seconds of the cold water supply to the valve being interrupted. The valve must also be able to control the set temperature with a pressure ratio of incoming hot to cold water supply pressure of up to 10 to 1.

71. Toilet flushing systems must be provided with easily identifiable dual flush mechanisms, one being for low flush water flow, the other for standard flush water flow.

72. All sanitary fittings must be piped such that the hot water control is on the left hand side, and the cold water supply is on the right hand side when facing the fitting.

73. Branch pipes (dead legs) between water heating equipment or hot water circulating mains and sanitary fittings must be sized and located such that the maximum waiting time for hot water to emerge from the fitting does not exceed 12 seconds.

74. Mixing taps in patient care areas must be elbow action type, installed such that the tap can be opened and shut by means of simple elbow action.

75. The discharge from kitchen floor drains and other kitchen drain points such as sinks, dishwashing washing, machines, and cooking equipment wash down, likely to contain grease, must be taken via a separate discharge system to a suitable grease interceptor, installed in a position to allow easy access for removal of intercepted grease and oil.

76. The drain pipes from equipment likely to produce high temperature discharge, such as autoclaves, sterilisers and cooking equipment must be from materials able to withstand such temperatures, installed such that distortion and/or expansion can be accommodated by the system.

77. Vertical pipe runs (Drainage stacks and water supply mains) in multi storey buildings must be housed in continuous vertical service ducts with easy access from non-patient areas at each level.

78. Condensate drains from air conditioning and refrigeration systems must discharge into piped drainage systems.

79. Anti-Backflow protection devices shall be fitted to faucets with hand-held shower heads to prevent back siphoning should the supply water pressure fail.

80. In areas housing patients at unusual risk of infection, faucets should not be fitted with low-flow or aerating devices which may increase the rate of aerosolisation of infectious droplets.

 

'''81. Legionella Control'''

#A facility-wide legionella control plan shall be in place which will inform operation, maintenance and design of water systems.
#This Plan must include a Legionella risk assessment document, listing all areas where the bacteria may occur. This must address specifically air conditioning condenser water systems, domestic hot and cold water installations, irrigation water storage and distribution systems, etc.
#The Plan must refer to as-built drawings identifying positions and layouts of plant and installations liable to cause a risk of Legionella being generated
#The facility’s Maintenance Procedures must describe all measures to be taken to minimise proliferation of Legionella. This is to include procedures and frequency of sanitation/disinfection, purging of dead legs on circulating systems, sample taking and testing at specific intervals, as well as a responsibility matrix of personnel

For additional information refer to the [[Legionella Control]] article.

==Lifts==
82. Standards and Regulations Pertaining to Lifts and Lifting Operations:

#SANS 50081 - SAFETY RULES FOR THE CONSTRUCTION AND INSTALLATION OF LIFTS - PARTICULAR APPLICATIONS FOR PASSENGER AND GOODS LIFTS
#SANS 10400 –SS3 FACILITIES FOR DISABLED PERSONS: LIFTS
#SANS 10400 –TT45 FIRE PROTECTION: LIFT SHAFTS
#SANS 10400 –TT46 FIRE PROTECTION: LIFT
#SANS 10400 –TT47 FIRE PROTECTION: FIREMAN’S LIFT
#SANS 10400 –TT48 FIRE PROTECTION: STRETCHER LIFT 

83. Planning for circulation, capacity and location of lifts

#A lift traffic plan should be developed. Detailed lift traffic planning is beyond the scope of this document. A specialist advisor should be consulted to assist in the planning of lifts within the general principles of lifts services for healthcare buildings.
#General Lift Planning Principles
#The operational details of the facility must be understood for effective lift planning. These include:

*Number of visitors and visiting hours
*Number of staff, shift hours and ward round schedules
*Numbers of day and overnight patients
*Increased provisions for reduced mobility persons
*Housekeeping schedule
*Evacuation plan for reduced mobility patients.

#Whenever possible, lifts should be provided in pairs to allow for continued operation during maintenance and breakdown.

 

===='''84. TYPES OF LIFTS:'''====
84.1. PASSENGER LIFTS

#These lifts shall be able to accommodate general passenger traffic including ambulatory and semi ambulatory passengers. It shall be able to accommodate reduced mobility passengers using mobility aids and wheelchairs. Refer to SANS 50081-70, Table 1
#The entrance to a passenger lift shall not be less than 1100 mm in width.
#The depth of a passenger lift shall not be less than 1400mm deep.
#Passenger lifts shall have a mirror on the top half of the rear wall equal to the width of the lift to enable wheelchair users to back out of the lift where the lift has internal dimensions less than 1,5 m in width and 2,0 m in depth
#At least on one side wall of the car a handrail shall be installed 

84.2. BED LIFTS

#Bed lifts shall have internal dimensions of 1 800 mm wide by 2 700 mm deep to accommodate most beds with staff and medical equipment.
#The entrance to a bed lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.3. STRETCHER LIFTS

#Stretcher lifts shall have internal dimensions of 1 400 mm wide by 2 400 mm deep to accommodate most trollies or stretchers.
#The entrance to a stretcher lift shall not be less than 1370 mm in width.
#The power supply to the motor operating such a lift shall be able to withstand fire for at least 120 min.

84.4. GOODS LIFTS

#Goods lifts are for the movement of conventional goods and items that could not reasonably use passenger lifts without causing discomfort to passengers or damage and soiling of the lift car.
#Goods lifts can be designed to accommodate passengers.

84.5. SERVICE LIFTS

#Service lifts are not designed for accommodate passengers. They are typically of the “dumb waiter” style dispatched between service hatches.

84.6. HOUSEKEEPING LIFTS

#Housekeeping lifts are similar in function to goods lifts but are intended for the movement of cleaning supplies, medical supplies and equipment, linen etc.

{| class="wikitable"
|+Hospital Guide - Passenger
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''630 kg / 8 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|1800 x 1800

2000 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''800 kg / 10 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1350 x 1400
|CLD

CLD
|800 x 2100

900 x 2100
|2000 x 1800

2200 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1600 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2300 x 1800

2450 x 1800
|1450
1500

1600
|4200
4300

4400
|-
|'''1250 kg / 16 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|2000 x 1400
|CLD

CLD
|1000 x 2100

1100 x 2100
|2700 x 2000

2700 x 2000
|1450
1500

1600
|4200
4300

4400
|}
 
{| class="wikitable"
|+Hospital guide - stretcher / Bed Lifts
!'''Load:'''
!'''Speed:'''
!'''Car size:'''
'''W mm x D mm'''
!'''Door type:'''
!'''Door opening:'''
'''W mm x H mm'''
!'''Shaft size: minimum'''
'''W mm x D mm'''
!'''Pit depth:'''
'''mm'''
!'''Headroom: mm'''
|-
|'''1000 kg / 13 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1100 x 2100
|CLD

TLD
|1000 x 2100

1000 x 2100
|200 x 2600

2000 x 2600
|1450
1500

1600
|4200
4300

4400
|-
|'''1600 kg / 21 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1400 x 2400
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 2800
2500 x 2900

2400 x 2900
|1450
1500

1600
|4200
4300

4400
|-
|'''2000 kg / 26 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1500 x 2700
|CLD
TLD

CTLD
|1300 x 2100
1300 x 2100

1400 x 2100
|2800 x 3100
2600 x 3150

2450 x 3150
|1450
1500

1600
|4200
4300

4400
|-
|'''2500 kg / 33 persons'''
|1.0 m/s
1.0 m/s

1.75 m/s
|1800 x 2700
|CTLD

CTLD
|1400 x 2100

1600 x 2100
|2900 x 3150

3000 x 3150
|1450
1500

1600
|4200
4300

4400
|}
 
==PART D - COMMISSIONING AND HANDOVER==
===Deliverables===
1. This section is intended to detail the commissioning deliverables required before handover of building engineering services for operation. For further detail on commissioning and handover the '''IUSS Commissioning Health''' Facilities guidance document should be referred to.

2. Project Close-out deliverables include:

#Final Works completion lists
#Financial reports and final accounts
#Facilitation in development of Operation and Maintenance Manuals (O&Ms), warranties and guarantees.
#Approved As-Built Drawings
#Electrical Certificates of Compliance

3. '''Maintenance manuals''' shall be timeously issued and shall include:

3.1. Designer and installer contact information

3.2. System information

#System description
#Suppliers list
#Equipment List
#Equipment data sheets
#Materials of construction data sheets
#Warranty information

3.3. Operational parameters

#Start up and shut down procedures
#Special instructions
#Security and access details
#Fault finding procedures
#Alarm management and data logging

3.4. Validation and commissioning

#Approved reports and data
#Relevant test protocols
#Relevant test plans
#Installed and test equipment calibration certificates
#Commissioning certificates
#Beneficial Occupation and Handover certificates

3.5. Spare parts list

3.6. Electronic Data Backup (Read only Media)

3.7. Approved “As-Built” Drawings

#Process diagrams
#Wiring Diagrams
#Control Diagrams
#System Plans
#Training records

3.8. Training Records

3.9. Training Materials

===Commissioning of ventilation systems===
4. Commissioning of ventilation and air conditioning systems shall comprise the following:

#Confirmation of accuracy of measurements.

Measurement accuracy depends on equipment accuracy and repeatability. Factors that would impact on the accuracy of measurement include:

*Operator error and competence
*Type and quality of measuring device
*Quality and adherence to measurement protocols.

4.2. Proof of competence of commissioning technician or engineer

4.3. Commissioning method statements or protocols shall be developed, recorded and adhered to, to ensure all technicians work to the same procedures and sequences. In some instances, such as healthcare units where the ventilation system is critical to that unit’s clinical outcomes or to the safety of occupants, the client or client’s representative may request that these method statements be issued for formal approval before commencement of commissioning.

4.4. As the operational parameters of variable air volume systems are more complex that constant volume systems, the designer is to provide details of all relevant aspects of these systems such that the commissioning specialist can sufficiently develop an appropriate plan the commissioning.

4.5. Preliminary inspections should be completed before the systems are started up for commissioning. Typically these inspections should include:

*The '''state of completion''' of the building and the condition of details such as openable windows, doors and ceilings.
*'''Building cleanliness''' as it pertains to the ventilated spaces as well as the equipment plant rooms.
*Ducting and ventilation components should be inspected internally and externally for '''system cleanliness.''' Prior to fitting filters the following components should be checked for completion, correctness and cleanliness:

#Air intakes screens and mixing plenums
#Heating components
#Cooling components
#Condensate and drip trays
#In duct UVGI systems
#Humidifiers
#Fan and equipment chambers including safeties and interlocks
#Sensors and gauges
#Airflow controllers and fire damper
#Filter frames and orientation thereof
#Insulation
#Ducting and air terminals

*Electrical Equipment should be inspected for completion, correctness, labelling and cleanliness. Prior to running any electrical rotating or control equipment the following check should be completed.

#Local isolators of motors, electric heaters and control circuits including labelling.
#Electrical safety
#Motor starters and frequency drives set correctly for overload and motor restart ratings.
#Direction of rotation of motors on motor shafts
#Motor starting current and sequencing

4.6. An initial running-in period should be conducted at low load before the installation of the filters. This running period is to ensure flushing of ducting, and allow checking of the system operation. During the this period the system should be shut down and restarted to ensure that the controls, fuses and switchgear function correctly; however, repeated rapid restarts should be avoided as this can over-stress the control gear and fuses.

4.7 After the initial running-in the filters can be installed by a suitably qualified technician and the system should then be run at normal load. New filters should be installed before the final proportional balancing commences.

4.8. The proportional balancing of the airflow should be delayed until the ventilation system has been run-in under normal load for a few days to ensure stability of the system. The airflow balancing should be conducted in accordance with good engineering principles such as those described in SANS 10173, the ASHRAE Fundamentals Handbook, CIBSE Commissioning Code A or BSRIA Application Guide 3/89.1 depending on the system requirements.

4.9. For variable air volume systems, the commissioning tests should demonstrate system performance across the design diversity.

4.10. A definitive total airflow measurement should be taken in either a section of the main duct, where duct length and turbulence allow, or in the branch ducts. This value shall be recorded, compared against the design values and tolerances and reported on in the commissioning reports including the percentage of the design flow rates.

4.11. The final airflow measurements shall be taken at all air terminals (supply, return and exhaust) using airflow capture hoods where the terminal generates turbulence and these values shall be recorded, compared to design values and tolerances and reported on in commissioning reports including the percentage of the design flow rates.

4.12. Direction, drop and throw of air terminals shall be assessed by the responsible engineer to confirm the correct air distribution within ventilated spaces.

4.13. The minimum outside air portion should be demonstrated and recorded across the system’s operational diversity.

4.14. A condition of system acceptance is that the commissioning tests be witnessed before signing off. This process could involve the repetition of only a selection of the tests under the observation of an authorised witness or responsible engineer. The following aspects should be demonstrated:

*Performance of the system according to the overall design requirements within specified limits
*Repeatability of performance and measurement results

==PART E - EXAMPLES==
===Mechanical system configurations===

===='''1. HOT WATER GENERATION SYSTEM'''====

[[File:Picture 1.png|thumb|570x570px|Hot water generation system|alt=|border|center]]

===='''2. THEATRE VENTILATION SYSTEMS'''====
The following examples indicate typical system configurations schematically.

2.1 UDAF Recirculation

 
[[File:Picture 2.png|border|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic|alt=|center]]

2.2. UDAF Full Fresh Air & Exhausted

[[File:Picture 3.png|center|thumb|410x410px|NOTE: Does not indicate sensors, interlocks or control logic]]
2.3. Major Theatre: Recirculation
 
[[File:Picture 4.png|center|thumb|410x410px]]

2.4. Major Theatre: Full Fresh Air Supply only
[[File:Picture 5.png|border|center|thumb|400x400px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

2.5. Minor Theatre: Recirculation
[[File:Picture 6.png|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.6. Minor Theatre: Full Fresh Air & Exhausted
[[File:Picture 7.png|border|center|thumb|410x410px|Note: Diagram does not indicate sensors, interlocks or control logic]]

2.7. Minor Theatre: Full Fresh Air Supply only
[[File:Picture 8.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]

===='''3. AIRBORNE PRECAUTION ROOMS AND THEATRES'''====
3.1 Energy Recovery Systems for Airborne Precaution Rooms
 
[[File:Picture 9.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks or control logic]]
4. Energy Recovery Systems for Airborne Precaution Theatres
[[File:Picture 10.png|border|center|thumb|410x410px|NOTE: Diagram does not indicate sensors, interlocks and control logic]]
 
==REFERENCES==
'''Applicable Regulations and Standards:'''

National Health Act 2004''.'' (61 2003). Cape Town South Africa: Government Gazette.

''Ammended Occupational Health and Safety Act 2004.'' (181 1993) South Africa: Department of Labour.

South African Bureau of Standards, 2009. ''SANS 10142-1:2008 The wiring of premises Part 1: Low-voltage installations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 10173:2003 The installation, testing and balancing of air-conditioning ductwork.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 10252-1:2012 Water supply and drainage for buildings Part 1: Water supply installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1993. ''SANS 10252-2:1993 Water supply and drainage for buildings Part 2: Drainage installations for buildings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 10313: 1999 Protection of structures against lightning.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1990. ''SANS 10400-2: 1999 Code of Practice for The Application of the National Building Regulations.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-1:2005 Copper-based fittings for copper tubes Part 1: Compression fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1067-2:2005 Copper-based fittings for copper tubes Part 2: Capillary solder fittings.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2012. ''SANS 1091:2012 National colour standard''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2005. ''SANS 1238:2005 Air-conditioning ductwork''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1409:2008 Outlet sockets and probes for medical (gas and vacuum) services used in hospitals.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 1424:2008 Filters for use in air-conditioning and general ventilation.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2011. ''SANS 1453:2011 Copper Tubes for Medical Gas and Vacuum systems.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1999. ''SANS 14644-1:1999 Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-2:2003 Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2003. ''SANS 14644-4:2003 Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 1988. ''SANS 1474: 1988 Uninterruptible Power Supplies''. Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2009. ''SANS 7396-1:2009 Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum.'' Pretoria South Africa: SABS Standards Division.

South African Bureau of Standards, 2008. ''SANS 7396-2:2008 Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems.'' Pretoria South Africa: SABS Standards Division.

*All local Municipal laws and regulations,
*ISO 14644-3:, Cleanrooms and associated controlled environments - Part 3: Test Methods Australasian Health Infrastructure Alliance,2006. Australasian Health Facility guidelines [online] Available at: <nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> [Accesed ...].
*ISO/DIS 5359. Anaesthetic and respiratory equipment - Low-pressure hose assemblies for use with medical gases,
*National Health Act, 2004 (Act No. 61 of 2003).
*Occupational Health and Safety Act, of 1993
*Regulations of the Local Electricity Authority,
*SANS 10114: Lighting Requirements,
*SANS 10142-1: The wiring of premises Part 1: Low-voltage installations,
*SANS 10173: The installation, testing and balancing of air-conditioning ductwork,
*SANS 10224: Non-flammable medical gas pipeline,
*SANS 10252-1: Water supply and drainage for buildings Part 1: Water supply installations for buildings,
*SANS 10252-2: Water supply and drainage for buildings Part 2: Drainage installations for buildings,
*SANS 10313: 1999 Protection of structures against lightning,
*SANS 10400: Code of Practice for The Application of the National Building Regulations,
*SANS 1067: Copper-based fittings for copper tubes Part 1: Compression fittings,
*SANS 1067: Copper-based fittings for copper tubes Part 2: Capillary solder fittings,
*SANS 1091: Colour Coding of Services,
*SANS 1140: Identification colour marking Part 4: Contents of taps and valves in laboratories,
*SANS 1238: Air-conditioning ductwork,
*SANS 1409: Outlet sockets and probes for medical (gas and vacuum) services used in hospitals,
*SANS 1409: Part 3 Handling and storage of Medical Gas,
*SANS 1424: Filters for use in air-conditioning and general ventilation,
*SANS 1453: Copper Tubes for Medical Gas and Vacuum systems,
*SANS 14644-1, Cleanrooms and associated controlled environments - Part 1: Classification of air cleanliness,
*SANS 14644-2, Cleanrooms and associated controlled environments - Part 2: Specifications for testing and monitoring to prove continued compliance with ISO 14644-1
*SANS 14644-4, Cleanrooms and associated controlled environments - Part 4: Design, construction and start-up,
*SANS 1474: 1988 Uninterruptible Power Supplies,
*SANS 7396-1: Medical gas pipeline systems Part 1: Pipeline systems for compressed medical gases and vacuum,
*SANS 7396-2: Medical gas pipeline systems Part 2: Part 2: Anaesthetic gas scavenging disposal systems,
*SANS 50081: Safety rules for the construction and installation of lifts — Particular applications for passenger and goods lifts,
*Any other applicable Laws or Regulations.

Chartered Institution of Building Services Engineers (CIBSE), 1999. Environmental design CIBSE Guide A. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2005. CIBSE Applications Manual AM10 Natural ventilation in non-domestic buildings. London: CIBSE.

Chartered Institution of Building Services Engineers (CIBSE), 2008. Lighting Guide 2: Hospitals and health care buildings. England: The Society of Light and Lighting.

 American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2009. ANSI/ASHRAE/ASHE Standard 170-2008 Ventilation of

Health Care Facilities. Atlanta USA:ASHRAE.

American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), 2013. HVAC Design Manual for Hospitals and Clinics Second Edition. Atlanta USA:ASHRAE.

'''Further reading'''

*<nowiki>http://www.spaceforhealth.nhs.uk/</nowiki> (National Health Service NHS website for UK guidance) website closed now
*<nowiki>http://healthfacilityguidelines.com/guidelines.htm</nowiki> (Health Facility Guides website for Australasian Health Facility guidance)
*CIBSE Guide A – Environmental Design
*CIBSE Applications Manual for Natural Ventilation – AM10
*CIBSE Applications Manual for Mixed Mode Ventilation. – AM13

*CIBSE Lighting Guide 2: Hospitals and Health Care buildings
*ASHRAE 170:2008
*HVAC Design manual for Hospitals and Clinics Second Edition – ASHRAE TC 9.6, 2013
*CIBSE Commissioning Code A
*BSRIA Application Guide 3/89.1

 <references />

==LIST OF ABBREVIATIONS==
A & E- Accident and Emergency Department

AHU- Air Handling Unit

CSSD- Central Sterile Supply Department

EMS- Emergency Medical Services

HCW- High Care Ward

HEPA- High Efficiency Particulate Air (filter)

ICU- Intensive Care Unit

NBR- National Building Regulations SABS 0400

NICU- Neonatal Intensive Care Unit

OT- Operating Theatre

SABS- South African Bureau of Standards

SANS- South African National Standards

SSO- Switched Socket Outlet

UDAF- Uni-Directional Air Flow

UPS- Uninterrupted Power Supply

URS- User Requirement Specification

==LIST OF DEFINITIONS==
For the purposes of these regulations, unless the context otherwise indicates-

'''“barrier isolator”''' refers to a device comprising an physical film separating an operator or clinician from a work process. The work process is maintained within an isolated environment which may be held at a positive or negative pressure.

"'''Central Sterile Supply Department (CSSD)"''' means a facility for the receiving, decontamination, preparation, packing, sterilizing, storing and issuing of sterile and disinfected instruments and other reusable materials. This facility is also known as the "sterilisation and disinfection unit"(SDU);

"'''cleaners' room'''" means a room for the storage of cleaning equipment, the drawing of clean water and the disposal of dirty water, washing and drying of cleaning equipment. This room may be combined with the dirty utility room;

"'''clean air'''" means air that does not contain a considered contaminant;

"'''clean utility room'''" means a room for the storage of sterilized packs, dressings-, sterile equipment and pharmaceutical supplies respectively; This area may also be used for a set-up area for ward procedures;

"'''considered contaminant'''" means any actual contaminant, surface or airborne, which may have a certain impact which for which measures are taken to avoid;

'''"cross contamination"''' refers to the contamination of any zone or surface by fomites, considered particulates aerosols, biological agents, fumes or gasses originating from another zone or surface.

'''"cross infection"''' refers to the spreading of an infection from one organism to another by cross contamination.

'''"department"''' means a grouping of accommodation which has a specific function within a hospital. Its area includes the associated internal or departmental circulation space

'''"dirty utility room"''' means a room used for collection and temporary storage of used equipment and general ward material; it can combine the activities of the sluice room, the soiled linen and waste room and the cleaners' room;

'''"emergency trolley/crash cart"''' means a mobile cart used for the storage of all appropriate resuscitation equipment and pharmaceuticals;

"'''equipment store'''" means a room used for the storing of monkey chains, traction kits and other general equipment;

"'''fresh air'''" means air drawn from outside air of a building and contamination sources;

"'''high care ward'''" refers to a ward for the care and management of specific types of patients requiring a minimum of eight hours nursing care per patient day;

"'''holding area'''" means an area or room where pre-operative patients in transit to a procedure room/theatre are identified and continuously monitored by nursing personnel;

"'''induction room'''" means an area where patients are prepared for surgery/invasive procedures prior to being transferred to the operating theatre;

"'''intensive care unit'''" means a unit designed, staffed and equipped for the care and management of specific patients, (e.g. medical, cardiac or post-operative) requiring a minimum of twelve hours nursing care per patient day or for the care of a patient who requires ventilation, continuous invasive monitoring, invasive care, or who is clinically unstable and whose life is at risk;

"'''main kitchen'''" means a facility suitably finished and equipped for the receipt, storage and preparation of meals, special diets and beverages;

"'''maternity unit'''" means a unit where antenatal care is provided, babies are delivered and postnatal care is given to mothers and infants;

" '''midwife obstetric unit (MOU)'''" means a maternity unit usually attached to a clinic or a community health centre (CHC), which is staffed by nursing sisters or midwives;

“'''milk kitchen'''” means an area for the preparation of feeds for babies which must be separate from the hospital kitchen or ward kitchen. It must contain a clinical wash hand basin;

"'''mortuary'''" means a facility that receives, holds and allows for the identification of bodies of patients who died in the wards, theatre or casualty department, or who were dead on arrival at the facility; a facility which complies with the

"'''neonatal unit'''" means a facility for premature and new born babies requiring incubation, specific care and monitoring;

"'''nurse station'''" means the control point for all activities in the patient care areas;

"'''nursing unit or ward'''" means a unit with the facilities to accommodate patients as specified in this regulation;

"'''operating room'''” means a room within an operating theatre suite in which surgical or other invasive procedures are carried out;

"'''operating suite'''" refers to rooms within the demarcated area where surgical interventions are performed or support is provided to these surgical activities;

"'''patient room'''" means a room where the patient can be accommodated;

"'''procedure room'''" means a room in which certain restricted procedures generally taking less than one hour can be performed without making use of general anaesthetic, e.g. endoscopies, procedures under local anaesthetic such as suturing of lacerations, removal of skin lesions, biopsies, closed reductions and other similar procedures; May be situated outside the operating suite;

"'''recovery room/ area"''' means the section of the operating suite specially set aside for the immediate post-operative recovery, resuscitation, nursing and special care of patients, until such time as such patients are considered to have recovered sufficiently to be safely removed from the operating suite;

"'''sluice room'''” means a room used for the emptying, cleaning and storage of bedpans and urine bottles; It can be combined with the activities of the soiled linen and cleaners' rooms in the dirty utility room;

“'''specialised area'''” means any clinical area rendering specialised services such as intensive care, high care, or rehabilitation, for which additional space around the patient is required;

"'''soiled linen and waste room"''' means a room used for the collection and temporary storage of soiled linen and waste; May be combined with the dirty utility room

"'''treatment room'''" means a room used for treatment of patients in the wards, containing a clinical wash hand basin;

“'''ventilation”''' means “The process of supplying air to or removing air from a space for the purpose of controlling air contaminant levels, humidity or temperature within the space”. ASHRAE Standard 62.1-2007, Section 3

'''“validation”''' means the method of proving and documenting that an installed system or process performs reliably as intended and required.

'''“natural ventilation”''' means “Ventilation provided by thermal, wind, or diffusion effects through doors windows or other intentional openings in the building." ASHRAE Standard 62.1-2007, Section 3

"'''ward kitchen'''” means the room that forms an integral part of a nursing unit or units, for the preparation of snacks and beverages; It also includes the area for the heating, storage and refrigeration of meals;

"'''uninterrupted power supply'''" means a battery system, which in the event of a normal mains supply failure will provide immediately the electrical supply for essential equipment and lighting.
[[Category:Crosscutting Issues]]
[[Category:Water Distributions Systems]]
[[Category:Legionella Control]]
[[Category:Ventilation]]