by Craig Phillips, Commissioning Director at Bernhard

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In fall of 2020, The University of Alabama at Birmingham Healthcare (UAB) was faced with an increasing influx of COVID-19 patients and the question of how to best maintain medical staff safety as a top priority was at the forefront of UAB’s concerns. Changes in operation of heating, ventilation and air conditioning (HVAC) systems’ configuration to increase the systems effectiveness against the spread of COVID-19 was given careful consideration. Specifically, three questions were asked of the team.  Does an air change rate of six provide the quickest and most orderly removal of particles from the patient room?  Does maintaining a room differential pressure relationship of -0.01 inches water column relative to the adjacent corridor achieve near 100% particle containment?  Does the addition of a HEPA air scrubber have a positive effect on the time to remove particles from the room and does the location of the HEPA air scrubber play a vital role in containment of the particles? In order to better answer these questions, UAB organized a small team of healthcare engineers, an environmental health and safety manager, and the support of the hospitals C-Level stakeholders. At the inception of the efforts, UAB had just opened a new bone marrow transplant unit which provided the team with the unique opportunity of having an empty bone marrow transplant unit to utilize as a test site before the unit was to be transformed into a dedicated COVID unit.  And so began the task of creating the framework for a field testing lab to serve as the epicenter of the experiments.

The approach to achieving valid answers was to utilize one of the bone marrow transplant patient rooms with a high-supply, low-return diffuser configuration (referred to as patient room “A”) as one of the two test sites. Specifically, the configuration consisted of two perforated supply diffusers with an integrated HEPA filter, one floor-mounted return grille, and a typical ceiling exhaust in the adjacent dedicated restroom. The second test configuration (referred to as patient room “B”) consisted of a modified diffuser layout with high-supply high-return layout. Specifically, the configuration consisted of two smaller perforated supply diffusers without an integrated HEPA filter, one ceiling mounted return grille, and a typical ceiling exhaust in the adjacent dedicated restroom. The furniture layout was kept consistent and simple with a patient bed, an adjustable over-the-bed table and a chair in the corner of the room.

The method used to create measurable results started with procuring two BS 5295 rated fog generating machines that utilize pharmaceutical grade fog fluid producing the same Atomic Energy Authority (AEA) certified 0.2-micron particle sized fog. The size of the particles being generated was important because the particles should be in the same range of typical aerosolized COVID-19 particles (0.06-1.4 micron).  A high output machine, capable of 6,356 CFM, was chosen to be used in a “saturated” room test where the amount of time to completely fill the room with fog was precisely calculated. The smaller machine, capable of 100 CFM, was chose to be used in testing meant to simulate the amount of aerosolized COVID-19 particles generated from a typical infected adult male patient. To measure the effectiveness of the HVAC system to remove the fog from the room, a light intensity meter and ionization smoke detector were utilized.  The time was recorded for the smoke to visually clear, for the smoke detector to clear and for the light level to return to the same level as measured at the start of each test. In addition, other important parameters were monitored and recorded for each test such as the room pressure, the use or lack of an air scrubber, the air scrubber CFM and equivalent air change rate (fixed at 6 ACH) and the supply and return airflow (measured by the Building Automation System).

The team faced many challenges and barriers from the onset to the end of the endeavor. The first obstacle was developing a means to measure the effectiveness of the tests. The team reviewed plausible methods and ultimately settled on utilizing the ionization smoke detector and light meter combo to gauge the effectiveness of the HVAC system. The second major obstacle was selecting a fog machine(s) suitable for the testing. The team identified the machines must be pharmaceutical grade and generate particles between 0.06- and 1.4 micron.  After much research and debate, the team decided on two machines, one which had to be shipped from the United Kingdom, which presented the looming concerns of international shipping delays, which were rampant at the time and still linger today. Another obstacle was the testing site had a non-typical HVAC distribution layout with HEPA filters in the supply diffusers and a low return grille. The team decided to modify the HVAC distribution layout to better match the typical patient room with two supply diffusers and one high return grille. Furthermore, the inlet conditions to one of the terminal units was modified to obtain accurate airflow control. Perhaps the biggest obstacle was time itself. The same team that was dedicated to the experimentation was also being tasked with converting numerous patient floors into “COVID wings” and the location of the testing site was a prime location to convert into a COVID wing. As soon as the testing was completed, the HVAC system was slated to be retro-commissioned and turned over for immediate use.

The results of the study showed that six air changes provided subjectively better results (27.5 Minutes) when compared to CDC Guidelines (46 minutes at 99% efficiency) for Environmental Infection Control in Health-Care Facilities (2003). Typical COVID patient particle generation testing shows that the infectious risk posed by a patient infected with COVID-19 is relatively low because of the low viral load typical in infected patients unless that viral load is increased by severe acute coughing. For this scenario, with a neutral room pressure, a patient who is infected and is coughing 10 times per minute poses the least risk to medical staff with an air change rate of 6 air changes per hour with a HEPA scrubber in the room close to the patient bed between the supply and return grilles in the room. The chance of medical staff inhaling the viral particles is decreased the further the distance from the patient. Increasing the air change rate decreases the time to remove the virus particles from the room, but with increased air-change rate turbulence is created which causes the airborne particles to be distributed around the room. This phenomenon at eight and ten air changes increases the probability of the virus infecting medical staff compared to the tests conducted at air change rates of six. No visual difference was witnessed, related to undesired spread of aerosolized smoke, between four and six air changes per hour. However, at four air changes per hour, the time it took for the aerosolized smoke to clear was much greater than at six air changes per hour.

The smoke saturation room testing answered three important questions:

• The testing showed six air changes per hour provided comparable particle removal times compared to higher air changes rates of eight and ten air changes which are not feasible in most patient rooms due to existing HVAC infrastructure limitations.
• Scrubbing the air in the room with a HEPA scrubber significantly improves the particulate removal times.
• Orienting the scrubber so that the intake is at the door can better protect staff in the corridor areas by capturing the particles before they can exfiltrate the room.

Ideally, the scrubber would be pointed at a low return so the majority of particles are quickly removed from the room.  In addition, the testing proved that operating a room at negative 0.01 inches protects the staff in the corridor by not allowing the particles to escape the room. However, it is impractical to configure the majority of patient care spaces in such a manner due to the limitations of the existing HVAC infrastructure.  In such cases, where a patient exhibits severe coughing, it is advisable to configure a room to be at six supply air changes, ten return air changes and to install a HEPA scrubber at the door with the discharge directed at a return grille or restroom door with exhaust of ten air changes per hour.

Based on the data collected from the testing, UAB made strategic decisions to set all patient room air changes to six air changes and to include HEPA scrubbers in each COVID-19 patient room. At the height of the COVID pandemic, UAB Healthcare had 300 COVID patients admitted to the hospital. Despite the high COVID-19 patient census rates, UAB medical staff contraction rates were relatively low. Based on these promising results it is recommended healthcare institutions implement self-deployed air change compliancy verifications and when pandemic risks are great, implement additional filtration and air changes in the form of HEPA air scrubbers. If feasible, operate the patient room at a negative pressure equal to negative 0.01 in. w.c.

About the author

Craig Phillips has 16 years of industry experience and is the Director of Commissioning at Bernhard. He has extensive experience commissioning healthcare facilities and campus expansions around the country. He helped to build Bernhard’s commissioning services group, providing project management and commissioning services for projects including a 1-million-square-foot healthcare campus expansion, new data centers, commercial facility renovations, and more. Craig is a registered Professional Engineer, Certified Commissioning Authority, Certified Energy Manager, Healthcare Facility Design Professional, a NEBB Building Systems Commissioning Certified Professional, and LEED AP BD+C. Craig was the co-author of the US Military Health Care Commissioning Guidelines and co-author of Ascension Health’s Commissioning Guidelines. He holds a Bachelor of Science degree in Mechanical Engineering from Arkansas Tech University.

By: Ashley Downes, vice president

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Industry Snapshot

Rising energy costs often become an issue for hospitals as their facilities and equipment age. In such cases, retro-commissioning is a valuable solution. Retro-commissioning a building’s existing energy infrastructure can improve occupant comfort and environmental quality while also optimizing energy conservation and saving money. Whether the goal is to reduce energy costs or to allocate resources for staffing and facility improvements, evaluating and adjusting energy systems can enable a healthcare facility to focus on its mission: patient care.

As buildings and equipment age over time, a facility’s energy use may change as well. Without efficient operations and maintenance, these factors can cause the savings from a retro-commissioning project to dwindle. This is when facilities encounter degradation, and previous savings can fall by up to 10 percent after the first year. After five years, the savings found through retro-commissioning can vanish completely. So how do we make sure facilities continue to save on energy costs in the long term?

Long-Term Solutions

One option is to pay for a whole new retro-commissioning every few years, so that after the savings are lost, a new revamp takes place. However, I recommend facilities participate in constant commissioning, which costs less over the long-term than repeated full retro-commissionings and fights savings degradation. This process uses remote monitoring to help facility managers actively understand how their systems are changing daily, for better or worse, to prevent the loss of energy savings.

Remote monitoring helps operators verify sustained savings for the facility through the use of measurement and verification, automated fault detection, and continuous data collection and archival. The advanced measurement and verification system I utilize produces a scorecard on the facility’s performance that illustrates its current energy usage versus the usage before retro-commissioning to give a better understanding of the changes and their effects. Automated fault detection sends a real-time notification when a problem is identified in the energy system, allowing facility managers to immediately address it. Additionally, I would recommend the use of continuous data collection and archiving. This will give you the ability to track a facility’s energy trends over long periods of time, revealing insights that might not otherwise be obvious. All of these tools allow facility managers to make data-driven decisions to keep their energy systems optimized.

The Secret Sauce

In addition to these tools, there’s one other thing that’s equally as important in the fight against savings degradation: buy-in from the facility’s staff. In short, to maintain the savings, the staff has to understand how the new infrastructure works and why it matters.

During a retro-commissioning project, it’s important to comb through the building’s automation system to understand how things are operating in terms of air flow, outside air, and pressurization. With this baseline, it’s time to reprogram the system to create and maintain optimal levels, taking into account building codes, pressurization requirements, etc. This is where organizations find savings– by reducing factors like fan speeds and simultaneous heating and cooling, one of the biggest drivers of energy costs in a hospital. The end goal is to reach a point where everyone at the facility is comfortable and the energy use is at a minimum.

This is only the beginning. If the actual operations and maintenance staff at the hospital begin to operate this new system but don’t understand how the specific changes made in the retro-commissioning process work, they may be tempted to be reactionary in the day-to-day. Oftentimes, staff members override the changes in order to facilitate a specific request, rather than simply allowing the system to do its job. In some cases, we’ve even seen staff members remove or delete programming altogether. If these things happen, savings the hospital would have seen from retro-commissioning can go out the window.

For this reason, it’s very important to have staff members trained in not only how to utilize the new system but also why it matters. These trainings should be given by those who performed the retro-commissioning in order to maintain maximum savings. A general knowledge of how the facility’s energy systems work is not enough to ensure staff members understand why the system is operating the way it is after a retro-commissioning. Again, if they don’t understand why, they’ll often go right back to what they’re used to, and facility energy costs will go back to what they were as well.

Culture

To get staff members on board, there needs to be a top-down culture change. Upper management has to be on board with the retro-commissioning changes and be willing to challenge staff members who want to make overrides. This is not to say that overrides can never happen. Changes may be necessary at times to deal with hot or cold calls or other pressing issues. However, any overrides should be targeted and temporary, and it’s vital that staff members recognize this.

Meanwhile, feedback from those staff members, patients, and physicians, is also important. While outside retro-commissioning teams generally understand how hospitals operate, they also recognize each facility is different and some adjustments may be needed. That’s why constant commissioning works best. When there is a strong relationship between the facility and the people monitoring its systems, long-term success is attainable. Together, partners can ensure the hospital is operating efficiently (with its energy and its monetary resources) in a way that is truly optimized for its core mission: helping the community.

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About the author

For the last decade, Ashley Downes has spent her career helping establish Bernhard’s retro-commissioning service line and now spends countless hours traveling across the United States as a steward for healthcare facilities working to save them energy costs. She is currently a director in Bernhard’s engineering division. Her team focuses on hospitals and medical centers, which during the COVID-19 pandemic have been asked to do more and stretch their facility capabilities further. With Ashley’s guidance, they can make strategic systems improvements, shift use and utility, reconsider scheduled maintenance and see savings in utility spend.

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Nearly 27 years ago, one of Bernhard’s first HVAC service customers in Lafayette was the Lafayette Regional Airport. This week, they are both celebrating the grand opening of the facility’s new terminal.

“Lafayette and Bernhard have a long and storied relationship,” said Doug Dorsey, Vice President at Bernhard. “As the city grew, we grew, and that’s represented with this new terminal.”

After months of construction on the terminal and vital airport infrastructure components, Lafayette Regional Airport opened its new terminal Jan. 20th.

Bernhard’s role in the project saw their team tasked with performing all HVAC, plumbing, and electrical systems installation while transitioning the old terminal to the new structure with month-to-month HVAC services.

The new state-of-the-art LFT Terminal spans 120,000 square feet, which is double the size of the original where Bernhard has performed HVAC maintenance for almost three decades. Included in the expansion project is 966 parking spots, five departure and arrival gates with new jet bridges, a rotunda area with restaurant and bar, and two TSA security screening lines with the ability to add a third line if needed.

The previous terminal and all airport services remained open and in place while the new terminal was built adjacent.

“There were unique challenges with crews and utilizing equipment while staying out of the way of ongoing operations,” said Dorsey. “Our team takes a lot of pride in being able to solve those puzzles and deliver the best result for our customers.”

Louisiana’s history can be seen throughout the terminal design in subtle nuances. As visitors look up on arrival, they will notice panels of stained glass etched in the vibrant colors of the Acadian flag.

The New LFT Terminal project cost approximately $150 million and is 100% funded. The project was funded in part by $34 million in sales tax money approved in 2014 by Lafayette Parish voters.

“Seeing the ribbon cut on this project is a proud day for our team,” said Blake Greer, Lafayette Business Unit Manager at Bernhard. “Most of our crew members were born in Louisiana and still call this state home. Seeing an impact on our own local communities makes projects like this one special.”

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By: Jessi Bienert, Bernhard’s VP of Sustainable Solutions

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A 500-Year Storm

The North American winter storm (unofficially referred to as Winter Storm Uri) was a major winter and ice storm that had widespread impacts across the United States, Northern Mexico and parts of Canada from February 13 to 17, 2021. This once-in-500-years storm left 10 million people without power and Middle America was hit hard. Hospitals were among the most critical institutions impacted.

Hospitals in particular have unique interdependencies in their utility types. Power, water, heating, and more are intricately connected in healthcare facilities and any impact to one type of utility could mean disaster. Winter Storm Uri uncovered multiple vulnerabilities in the infrastructure serving hospitals and caused cascading effects. However, many of these issues can be mitigated by effective and efficient energy measures paired with good operations and maintenance practices.

The extreme cold affected gas markets from Texas to Minnesota leading to once-in-a-lifetime gas prices at extreme highs. Multiple electricity wholesale markets also spiked while its infrastructure reached emergency operating levels. In fact, wholesale electricity markets rose anywhere from 100x to 360x normal market prices.

The Brink

In this condition, both electricity and gas distributions were on the brink of shutting down. Hospitals, particularly in the southern states of North America, battled extreme market prices, the inability to receive additional diesel fuel for backup systems and frozen water infrastructure causing loss of water.

This storm affected all utilities because of the interconnection between natural gas, electricity and water. While some hospitals lost utilities for short periods of time, many experienced catastrophic impacts to utility budgets, which have only begun to be realized. In February alone, hospitals saw anywhere from a 65% to 5,000% increase in gas costs. Their inability to mitigate this price shock stemmed from a few key factors:

• Extreme cold weather forced peak natural gas consumption at peak prices.
• There was a lack of price signals from utilities.
• Freeze protection measures and pandemic operations increased peak energy consumption.

Short-Term Impacts

With these factors at play, the situation became dire. Short-term impacts were felt in extreme budget strains, water leaks, negative impacts from energy-saving measures and demand response obligations. One Bernhard client, the University of Arkansas of Medical Sciences (UAMS), purchases natural gas as part of a large pool in Arkansas. While we did explore opportunities to cut back on natural gas during the storm, this set-up enabled the hospital to stay out of the skyrocketing market. Unfortunately, our team at Bernhard saw other hospitals that were not in a pool arrangement incur costs that doubled their annual natural gas budget.

Pragmatically, many facilities in the southern United States were not created to survive such a freeze. That explains why leaks occurred and frozen pipes caused issues for facilities. Many were caught immediately, but underground pipes were not initially observed. Careful monitoring was necessary in the short-term, but is also a consideration for continued management.

During the storm, UAMS ran their facilities on diesel fuel on three occasions in order to reduce the peak load on the power grid serving central Arkansas. However, this actually increased natural gas usage in some ways. The facility’s two heat-pump chillers are unable to run while the facility was on generator power so the hospital still needed to run their natural gas boilers.

Since 2007, UAMS has implemented a strong energy conservation program, reducing its total utility cost by about 65% and cutting its carbon footprint by 30% with Bernhard’s help. But even the most prepared and energy-conscious organizations were greatly impacted by the weather crisis. Many of these occurred due to overcorrections that were never reverted post-crisis. With extensive, consistent monitoring using tools like automatic fault detection, facility operators can automatically identify energy concerns.

Long-Term Impacts

We are still discovering and experiencing the long-term impacts of Winter Storm Uri. Budget concerns will continue to impact future plans for many hospitals. From a legislative perspective (especially in Texas, but also in Oklahoma, Arkansas and other states), there are cascading impacts. Current legislation examines grid reliability and generation assessments, new weatherization requirements, changes to critical customer status, new bond programs and existing utility generation assessments.

On the electricity side, many hospitals take interruptible electricity. This gives them price breaks from their utilities, but means they can be required to cut back from or come off of the grid. On the gas side, most hospitals look for interruptible-type rates, but when that’s not possible, there are provisions and inclusions that actually make you curtailable. In this arrangement, it is imperative that you have a backup utility. All of these factors are important to pay attention to until we see how tariffs and utility rules are changed.

Increased utility rates are one of the many long-term concerns. During this storm, electricity saw high fuel costs as the market costs peaked. While the market stabilized in the short-term, fuel costs are rising again due to storage shortfalls brought about by Winter Storm Uri, those fuel costs will begin cascading down into your electricity costs as a fuel charge. Some states, like Oklahoma, approved new bond programs to allow utility companies to borrow money at a low interest rate so customers can pay over a longer period of time. As a result, the impact will be felt for 13-24 years with a 4-7% cost for electricity, just from those harrowing eleven days.

With so much storage withdrawn during the storm, commodity prices have not come back down to what we saw in 2020. We will continue to see sustained higher pricing in the long-term. Additionally, some utilities have filed to amend their integrative resource plan. This is a long-term plan for generation capacity and they want to amend it to move away from natural gas. This will impact how the cost gets passed down to customers as well and potentially reduce reliance on natural gas for electricity production.

Current Investigations

In the affected areas, most attorney general offices are investigating price gouging and general utility purchasing practices. In Arkansas, for example, the state commission has opened a docket examining how and if utilities are prepared to respond to a storm like this and how the fuel and purchase power is procured and allocated.

There are also federal investigations that look into wrongdoing in the natural gas market. It cost hospitals, customers and utilities billions of dollars, but there are people who made money. The North American Electric Reliability Corporation (NERC), which regulates the electric grid, is working alongside the Federal Energy Regulatory Commission (FERC) to understand the rolling blackouts, both in Texas and two regional transmission markets (covering the entire central United States).

Mitigating Future Risk

For hospitals, patients always come first. There are ways to mitigate future risk and it starts with communication. It’s vital to create a line of communication between commodity suppliers and facility personnel. Your local provider may be focused on keeping you online, but not concerned with the costs. Some of our customers hedged up to 90% of their natural gas and were still heavily impacted by the storm. It’s important to understand how you are purchasing natural gas and understand its impact in a situation like this storm. Review your commodity price risk mitigation plans and make a plan for possible emergency flow orders by keeping your nominations up to date.

Be aware your supplier often takes your monthly nominations and spreads them evenly throughout the month. That’s why it’s important to reduce consumption in non-critical areas and talk to those commodity managers to be sure you’re monitoring closely together. Very practically, you should ensure unoccupied areas are scheduled to minimum heating for freeze protection. We recommend checking this and the maintenance of your steam distribution year-round. One failed steam trap can increase your natural gas consumption by 20%.

Dual-fuel operations are vital, but in order for this to work properly, operators must be comfortable swapping to either fuel. Run each type regularly and check your diesel storage tanks to make sure you have enough fuel for an extended period of time.

Waste heat recovery technology, such as heat-pump chillers, will reduce consumption. Bernhard has clients that realize natural gas savings of more than 50% thanks to this equipment. Plate and frame heat exchangers are excellent tools for efficiency and they are even more important on the heels of this storm. Some of these measures can be time-consuming if you don’t have good control systems, so controls upgrades are a vital part of creating efficiencies.

Other key mitigation measures include:

• Maintaining override logs.
• Managing peak energy consumption.
• Investigating electricity programs that subsidize full back-up power during an NERC level 2 and 3 emergency
• Creating a historical reference guide of utilities failures including cause and detailed procedures to restore.
• Completing vulnerability and gap analysis for utility sources and distribution.

Lessons Learned

Interdependency between hospital utility types can have catastrophic effects on cost and availability during extreme weather. Now more than ever, we are aware that regulated utilities do not protect consumers from market price spikes; in fact, costs can simply be delayed. Most importantly, there are operational steps that can be taken to mitigate utility price impacts, such as energy efficiency measures. These measures can create resilient facilities against volatile commodity prices, especially when paired with good operations and maintenance practices.

About the Author:

Jessi Bienert has worked at Bernhard since 2009 and most recently served as a Director for the Logic group where she oversaw Bernhard’s measurement and verification, utility analysis, utility management, benchmarking, and O&M training service lines. She is an expert in utility management and specializes in utility rate analysis for large-scale campus energy conservation programs. Jessi is passionate about her work and often advocates on behalf of clients with utility providers to secure the best possible utility rate solutions.

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By: Craft Recruiting Team at Bernhard

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Anyone living in major cities across the United States is sure to have noticed the increasing amount of construction projects around them. Cranes and new high-rise buildings are filling city skylines and the construction industry as a whole is expected to see more than 12% growth (compared to 7% for all other occupations), according to Bureau of Labor Statistics. With heightened employment opportunities and industry growth expected on the horizon, why are recruiters expressing concern?

“We’re about to see a large chunk of the craft workforce entering that retirement age,” said Ralph Stingo, North Carolina Business Unit Manager. “There could be a mass exodus of the workforce and that includes mostly upper management and supervisors.”

In a 2017 report by the National Center for Construction Education and Research, it was projected that 41% of the construction workforce will enter retirement by 2031. An already expanding industry with nearly half of the workforce retiring will create an enormous job market for career-hungry job seekers. This level of opportunity for placement and promotion may not be seen again in the industry.

“This will be an once-in-a-lifetime opportunity for anyone entering the job market,” said Philip Garcia Jr., Executive Vice President at Bernhard. “Craft work is an incredibly quick track to a secure a career immediately after school or in some cases, you can enter your career and receive training while on the job.”

Bernhard believes training for craft employees will only add to the high quality standards the company has and as such, offers craft training and apprenticeship programs at several locations around the country.

2021 has seen a 46% increase in trade-based jobs since the same time last year and Bernhard is uniquely situated to offer a career for those seeking a start in the construction sector. Out of the estimated 1 million crewmember jobs in the United States, Bernhard has offices in 33% of the locations including the largest markets of Texas and Florida.

“Location versatility is a huge bonus for Bernhard,” said Richard Purcell, East Coast Labor Coordinator at Bernhard. “Someone interested in this career would have unparalleled flexibility on where they choose to work.”

Those new to a career in craft work can also expect a multitude of other quality of life and professional perks craft employees at Bernhard enjoy:

• Comprehensive benefit package including competitive pay rates, health benefits, PTO, Holiday pay, and 401k employer match.
• Paid, on the job, industry and trade specific training and testing, that not only supports continued skills development, but also career advancement within Bernhard.
• A safe and hazard-free work environment. Bernhard prides itself on creating and implementing the most current safety practices on all of its office and work-sites.

“Because we are in the industry every day, it’s easy for us to see the trends and project these huge moments that others may not be aware of,” said Patrick Sanders, General Superintendent in Florida at Bernhard. “I hope those in trade schools and apprenticeships right now realize the opportunity that’s in front of them.”

If you are interested in opportunities in the craft job market and would like to know more about the benefits of a career with Bernhard, visit bernhard.com/careers for more information.

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