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ENERGY EFFICIENT ENVIRONMENTAL CONTROL FOR OPERATING ROOM Asfia Nishat GM (Mechanical) / Associate Fahim, Nanji & deSouza

Consulting Engineers

THE paper describes the possible air systems and options of getting an energy efficient environment

in operating room with proper infection control and life safety. Airborne particle count is inversely proportional to the effectiveness of the ventilation system. Besides precise temperature and humidity control; dilution ventilation, contaminant exhaust, directional air flow control, room pressurization control and air filtration are very essential factors to be considered while designing operating room air-conditioning system. Since operating room environmental control is a matter related to life safety, designer should be extremely conscious while considering energy conservation measures so that the applied cost effective measures are met without compromising infection control and life safety.
An operating room (OR) requires special planning for its prcised environmental control because life saving activities are being performed here. Reputation of a hospital is also dependent on the functional efficiency of its ORs. The intent of this paper is to discuss the energy efficient environmental control for a general surgery OR. For a good quality germ free environment in OR, following must be effectively controlled. To define the design limits for these parameters, one should establish the design guideline / code / standard to be followed, because the requirement for these parameters is not the same in different countries and different standards. In this paper we will mostly discuss the ASHRAE guideline for the design parameters. Unfortunately no Pakistani standards or codes are available yet to be followed and we all should seriously put our efforts from the Pakistan HVACR Society platform to establish certain guidelines and standards. 1. Dilution Ventilation This is probably the biggest debatable parameter in an economical and energy efficient OR design. Some standards and codes allow recirculation with a certain amount of make-up air whereas some standards ask for 100% fresh air for OR. Following chart shows the requirement for outdoor air in different standards.
Standard Minimum Air Change Rate of Outdoor Air per 4 20 10ACH 100% of supply air 3 5 3 Minimum Total Air Change per Hour

HVAC Application 2007 DIN-1947 British Medical Council UNE 1000&B: 2003 (A Spanish Standard) AIA HVAC Design Manual Hospitals CDC and HICPAC WHO OSHA

20 20 25ACH 15 25 15 20-25

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The purpose of dilution ventilation is: a) b) c) To maintain IAQ for occupants To provide germ free environment To remove anesthetic gases without exposure to OR staff.

Some experts say that 100% outside air with heat recovery device is the best solution for the administrators much concerned about infection control, however ASHRAE and many other standards and codes favor recirculation air system with proper make up air for dilution, as the best engineering practice. ASHRAE HVAC design manual for Hospitals & Clinics asks to recirculate no more than 80% of the supply air back through the air handling system. We recommend 30% fresh air with 70% return air for general surgery ORs. According to Modern Trends In Planning & Designing Of Hospital, during surgical operations the concentration of bacterially-contaminated air-borne particles in the operating theater averaged over any 5 minute period should not exceed 180 per m3 (5 per ft3), and special types of surgical operation, e.g. orthopedic and transplantation procedures, higher standards of air cleanliness must be ensured. It is also recommended in the same book that the OT should have less than 35 colony-forming units (CFU) of bacteria / m3 of air and less than 1 CFU of clostridium perfringens or Staphylococcus aureus per m3. The maximum germ concentration should not be more than 10 CFU/m3 in the room air in theaters used for transplantation of organs, heart and bone surgery. 2. Anesthetic Gases Removal Present practice with effective scavenging system and APL valve into the face of the anesthesia provider avoids the risk of work place exposure to waste anesthetic gases. OSHA guideline recommends minimum 3ACH fresh air with 15ACH minimum total air to minimize waste anesthetic gas concentrations in the operating room. For removal of waste anesthetic gases in a non-recirculation ventilation system the waste anesthetic gases are directed towards exhaust grill and from there it is exhausted to atmosphere. For recirculation ventilation system, a separate duct for venting these gases outside without mixing with the recirculated air is required. 3. External Design Conditions Normally 1% design conditions are followed however ASHRAE design manual for Hospital & Clinics recommend for 0.4% design condition for summer & winter temperatures and humidity for critical areas. Results of cooling load with 1% design condition should be checked for monsoon conditions. 4. Correctness of Internal Design Conditions Number of persons in OR is normally less than 8-10 for almost all surgeries except heart surgery where upto 20 people can be there at a time. Therefore one should know clearly whether OR will be used for heart operation or not. Electrical equipment normally operates in between 6-10 kW electrical power during surgery. General room lighting should be about 20-30 W/m2. Electronic ballasts are recommended to be used. Never conclude operating electrical load from the equipment name plate data. Ask the concerned persons to furnish accurate electrical load operating. 5. Temperature The ideal environment temperature in OR is a function of the type of surgery and the condition of patient. The temperature must be kept low enough to ensure that the growth of micro-organisms cannot take place. ASHRAE recommend design temperature to be 62F to 80F. however to prevent hypothermia in the patient and to provide a economical comfort condition for the surgeon and other staff, the temperature set point is normally kept between 68F72F with a provision of temperature and humidity control within OR by the OR staff. 6. Humidity Level ASHRAE recommends relative humidity to be 45% to 55%. These limits ensure that the micro-organisms growth does not take place without a feeling of dryness and skin imitation. However many other standards have this limit in between 30% to 60%. Very low humidity also increases the electrical conductivity of people. 7. Positive Pressure Pressure within OR should be positive with respect to the adjacent areas. Typical airborne contamination in OR and adjacent areas is shown in the below figure (Reference ASHRAE Application 2003). Research has shown that the air borne contamination in a properly air-conditioned surgery room is much lesser than its adjoining areas, therefore it is clear why it is advantageous to maintain positive pressure in OR. Ante Rooms can be provided in between the OR and adjoining space in exceptional cases of highly infectious patients e.g. patients in lungs surgery. Sealing of penetration openings and tight fitting doors are essential to ensure effective and economical room pressurization. None of the standard essentially requires automatic devices to control room pressure however in certain cases such as variable air volume supply, these should be installed. ASHRAE recommends some monitoring device to observe the OR pressure with respect to the adjacent areas. A differential pressure of 10Pa to 20Pa would be sufficient to ensure an effective positive pressure within OR.

8.

Supply & Return Air Terminals Research has shown that laminar air flow supply pattern above the operation table with low level exhaust / return grills on the opposite walls is probably the most effective air movement pattern for maintaining the germ count within control limits. Also for removal of both heavy & light anesthetic gases it is recommended to keep 2/3rd exhaust / return from floor level and 1/3rd from ceiling level. Supply air face velocity should be 25-35 fpm.

9.

Separate Air Handling System for each OR In case of recirculation air system, experts advise to design for separate AHU for each OR to avoid cross contamination. Even if it is a case of non-recirculating 100% fresh air system, use of separate AHU for each OR lead to maintain the ORs at different temperatures without wasting the energy in duct re-heaters. Also I have seen many people providing one AHU with 100% fresh air for a set of ORs and ancillary spaces, which is incorrect. Ancillary spaces have lesser fresh air requirement and filtration standards and can be easily kept at a bit higher temperatures than OR. Therefore it is advisable to provide separate AHU for ancillary spaces. The requirement of 100% stand-by AHU for OR is not justified in any standard or guide. Since the only moving part in AHU is the fan and motor which can fail, one may consider the followings: 1. 2. 3. Maintenance staffs to ensure before start of each operation that the AHU is in good running condition. Keep spare motor for each AHU. Design OR AHU with 2 parallel fans in operation so that failure of one fan does not cause complete stop of air supply till the time of motor belt replacement. However complications of parallel operation of fan need a careful design review.

10. Filtration Standards ASHRAE recommends filter bed No. 1 to be MERV-8 (30-35% dust spot efficiency). This filter bed should be upstream of the AHU. Filter bed No.2 (which should be down stream of supply fan) should be MERV-17 (HEPA filter of > 99.77% efficiency) for orthopedic operating rooms where as it should be MERV-14 (90-95% bag filter) for general procedure operating rooms. However it is to be noted that in case of recirculation air system, HEPA filter should be installed for all types of surgeries. For energy efficient filtration of recirculation air system, we recommend the following: Treated fresh air handling units = G4 panel filter + F-6 bag filter OR AHU = G4 panel filter + F-8 bag filter + HEPA filter within OR ceiling.

11. Heat Recovery Devices Run around coil, heat pipe, plate type heat exchanger and heat wheels are the 4 commonly used air to air heat recovery systems. The first 3 systems can only recover sensible heat where as heat wheel although much more expensive is

capable to remove sensible as well latent heat. For hot and humid climate in Pakistan the use of heat wheel is probably the only efficient way of heat recovery between the exhaust air and fresh air. 12. Variable Flow System For a 100% fresh air system it is essential to keep provisions for operation of AHU on recirculation mode during unoccupied periods. ASHRAE recommend that the number of air changes in the unoccupied mode may be reduced to 25% of the minimum values recommended for occupied mode. Therefore the air flow may be reduced. Also the room temperature may be kept at 75-78F in unoccupied mode. Room pressurization control is essential even in unoccupied mode. 13. Chilled Water Coil Vs. DX Coil For a large hospital with central chilled water plant (specially plants based on absorption chillers), chilled water supplied to OR AHU is normally 44F to 45F. With this chilled water supply temperature, possible coil apparatus dew point temperature (ADP) will be about 50F. The air flow rate increases with increased coil ADP leading to wastage of energy. One solution to this problem is to design the chilled water cooling coil sufficient to fulfill the following: 72F room temperature with 45% RH. 2.5% summer external design conditions 8 people in OR 20 w/m2 lighting 7 kW equipment load No design safety factor on space loads

Then install a DX coil in series with the chilled water coil to fulfill the cooling differential between peak cooling load and the average cooling load. Following table gives an idea of operational savings.

S. No. 1 2 3 4

Description Recirculation system OR at 62F Room Temp-CHW coil Recirculation system OR at 68F Room Temp-CHW coil Recirculation system OR at 72F Room Temp-CHW coil Recirculation system OR at 62F Room TempCHW+DX coil

Total Coil Load 8.3TR 7.9TR 7.6TR 7.0TR

Sensible Coil Load 6.1TR 6.0TR 5.9TR 5.2TR

Air Flow Rate (cfm) 4000 4000 4000 3000

Coil ADP(F) 47.9 53.8 57.6 45.5

Although the static pressure of AHU will increase due to 2 coils in series, one may get an operational saving of 0.75kW by reducing the air flow rate to 3000cfm instead of 4000cfm. 14. References a) b) c) d) e) f) ASHRAE Application 2007 ASHRAE HVAC Design Manual for Hospitals & Clinics Modern Trends in Planning and Designing of Hospitals by Shakit Kumar Gupta. Hygiene air-conditioning systems for highest clean room requirements in hospitals, Technical Information 18 by Weiss-Technik. Infection Control in Hospitals by Bill Drake OSHA guideline for work place exposure.

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