New AIA guidelines for healthcare facility construction offer direction on how to design and install plumbing systems that focus on patient wellness, as well as protect the environment.

The Latin phrase “primum non nocere” gives clear instruction to a physician: “First, do no harm.”

Plumbing professionals would do well to follow the same dictum for both the human population and planet Earth by designing plumbing systems for healthcare facilities that foster wellness for patients, while being environmentally friendly.

Specifications to accomplish this lofty goal can be found in the American Institute of Architects' new 2006 Guidelines for Design and Construction of Hospital and Healthcare Facilities. The AIA's current healthcare standard, which became available in July 2006, contains distinct, new requirements for the design of healthcare facilities.

Many of the changes affect patient rooms with the goal to improve hygiene and privacy. Most notably, single-bed rooms should now be specified as the minimum standard in new construction unless a functional program demonstrates necessity of a two-bed arrangement. For renovated space, capacity may not increase from previous levels, with a maximum of four patients per room (2.1 General Hospitals, Typical Patient Rooms, Capacity). Patients are also required to have access to a toilet room, which may serve no more than two patient rooms and no more than four beds without entering a general corridor (2.1 General Hospitals, 2.2 Patient Rooms or Care Areas). The toilet room must contain both a water closet and a hand-washing station (2.1 General Hospitals, Toilet Rooms).

Another hand-washing station must be provided in the patient room in addition to that in the toilet room for both new construction and renovations (2.1 General Hospitals, Hand-washing Stations). The hand-washing station should be convenient to staff entering and leaving the room, as well as located outside the patient's cubicle curtain. To bolster hygiene, the specifications call for hands-free operation of hand-washing stations (1.6 Common Requirements, Plumbing Fixtures). The AIA's healthcare standard also states, with the exception of scrub sinks, that provisions for hand drying must be provided at all hand-washing stations. Electronic, hot-air dryers installed to preclude possible contamination by recirculation of air are included in the guidelines (2.1 General Hospitals, Hand-washing stations).

To provide proper accessibility, the AIA's guidelines identify the Americans with Disabilities Act Accessibility Guidelines and the Uniform Federal Accessibility Standards as criteria to follow, but with built-in flexibility to meet the specific needs for healthcare facilities (1.1 Introduction, 4 Design Standards for the Disabled).

While the new healthcare guidelines are comprehensive, to ensure facility compliance, the AIA urges building professionals to refer to local code standards for all projects.

New dual-flush Flushometers allow the user to select a full flush (1.6 gpf) or reduced flush (average 0.8-1.1 gpf).

Patient Wellness

Nosocomial infection - which means infection acquired in a hospital - is the fourth-leading cause of mortality for Americans. According to the Centers for Disease Control and Prevention, nearly 2 million patients in the United States are affected by nosocomial infections, and about 90,000 of these patients die as a result of the infection each year.

Approximately one-third of hospital-acquired infections are preventable. In fact, transfer of a pathogen to a patient via the hands of healthcare workers is thought to be the most likely mechanism of exposure to patients (see “The Path of Nosocomial Infection,” on right).

The CDC cites hand-washing as the single most effective method to reduce illness and cross-contamination. In agreement, the Association for Professionals in Infection Control and Epidemiology (APIC) states that “hand-washing causes a significant reduction in the carriage of potential pathogens on the hands,” and “[in healthcare settings, it] can result in reductions in patient morbidity and mortality from nosocomial infection.”

Yet, according to the APIC Guideline for Hand-washing and Hand Antisepsis in Health Care Settings, proper hand-washing occurs in approximately half of the instances when appropriate, and usually for a shorter duration than recommended. A recent study at a teaching hospital found just 48 percent compliance with hand-washing procedures. The study found that one of the biggest obstacles to hand-washing was the placement of sinks. APIC suggests convenient placement of sinks and hand-washing products to encourage proper hygiene.

APIC also recommends that faucets can be turned off by means other than the hands to help healthcare personnel avoid immediate recontamination after washing. Recontamination is quite easy, considering that hand-washing stations are where people shed bacteria from their skin. This was confirmed by University of Arizona research that identifies hand-washing stations as the dirtiest area in a hospital restroom. Specifically, sink drain surface tests resulted in positive samples of coliforms (aerobic bacteria found in the colon or feces) 80 percent of the time. The rim of the sink followed, with 20 percent of the samples being positive, and the area under the soap dispenser followed, with 10 percent. Overall, the same study found that coliforms were present on 17.3 percent of the 248 surface samples taken from hospitals.

Water Conservation

Healthcare facilities epitomize “mission critical,” operating 365 days a year and consuming vast quantities of water. Down the line, that water becomes sewage and then returns to municipal water treatment plants to make the circuit again. But plumbing professionals can ease the environmental burden by dramatically reducing water consumption - and ultimately operating costs - by incorporating fixtures that promote sustainability, while maintaining hygiene standards required in healthcare settings.

The American Society of Healthcare Engineers' guidance statement on protecting the health of the surrounding community is a holistic take on sustainability: “Local air and water quality is also significantly affected by building design choices … Water management on the grounds and water conservation efforts within the building will influence the amount of toxic emissions released to the water and air throughout the life of the building.”

Consequently, plumbing isn't just a “building” decision, but a community issue. As such, a systematic look should be taken to identify sources of potential water savings and how technologies can be used to reduce consumption and discharges. The AIA healthcare guideline states that potable water consumption reductions may be achieved through the use of “low-consumption fixtures and controls” (1.2 Environment of Care, Appendix 3.1.3, Water Quality and Conservation). The AIA also refers to the growing body of knowledge for sustainable construction - namely the U.S. Green Building Council's LEED® Green Building Rating System and Green Guidelines for Healthcare Construction - available to assist building professionals and healthcare organizations in understanding how structures affect human health and the environment, and how these effects can be mitigated through a variety of strategies.

One of the most cost-effective ways to earn LEED credits is by surpassing the standards for the Water Efficiency section. That means reducing water consumption 20 percent below the baseline fixture performance requirements set by the Energy Policy Act of 1992 for one point, or reducing consumption by 30 percent in comparison with the baseline for two points. For example, a baseline toilet fixture uses 1.6 gallons per flush (gpf) and a baseline urinal consumes 1 gpf. Consider then the fiscal and environmental impact of a strategy that uses 0.5 gpf urinals, or even nonwater-supplied urinals. For water closet applications, new dual-flush flushometers allow the user to select a full flush (1.6 gpf) or reduced flush (average 0.8-1.1 gpf).

Representing the largest source of savings in the restroom, sensor-operated faucets with 0.5 gpm aerators reduce consumption because water flows only when a person's hands are in the “active area,” which means water is not flowing continuously. With an estimated 56 minutes spent washing hands during a typical eight-hour nursing shift, healthcare water consumption is cut dramatically with touchless faucets.

Other Initiatives

The Environmental Protection Agency's WaterSense program, which is comparable to the successful Energy Star® program for major household appliances, has recently established voluntary specification criteria for high-efficiency toilets. The specification includes a performance standard in addition to maximum consumption levels based on Uniform North American Requirements, which includes the soybean mixed-media extraction test. Fixtures that meet the guidelines of the EPA will need to comply with the new labeling program, which is intended to help educate consumers.

As defined by WaterSense, an HET fixture has an effective flush volume that does not exceed 1.28 gpf/4.8 lpf. As for the minimum performance requirement, the specification requires a minimum extraction of 350 grams of soybean media. To earn HET designation, the fixtures must also meet applicable sections of ASME A112.19.2-2003, A112.19.5-2005, and A112.19.14-2001.

On the state level, Texas lawmakers passed Senate Bill 1094 that was signed on May 20, 2003, by the governor to create the Water Conservation Implementation Task Force (WCITF). In September 2004, the task force members submitted the “Best Management Practices Guide” to the legislature (downloadable at

The report specifies optimal levels of water use and gives recommendations to achieve water efficiency in the state. The WCITF recommends implementing Toilet Performance Standards to ensure that toilets “cannot be retrofitted so that they waste water.”

Effectively, this would outlaw products that allow adjustment to plumbing fixtures' flush volume.

The draft form of legislation published in the report addresses the concerns of the task force by stating, “Due to the design of many current gravity toilets, some of these toilets will use significantly more than 1.6 gallons per flush. Toilet standards should ensure good performance.” The proposed language clearly specifies that performance is a factor by requiring all toilets to be able to clear 250-plus grams of media using the MaP testing protocol or equivalent ASME standard, if such a standard is adopted.

New Technologies

Operating costs and water consumption at healthcare facilities can be greatly reduced with immediate-impact technologies. Examples of low-consumption technology currently available include waterfree urinals, 0.125 gpf/0.5 lpf urinals, 1 gpf/3.8 lpf pressure-assist toilets and dual-flush technology for both tank and flushometer applications are additional engineered solutions that can make a significant local impact. Unlike previous low-consumption products that were brought to market quickly, this generation has years of field evaluations that will prove valuable in earning industry acceptance, reduce fear of unfounded manufacturer claims, assure customer satisfaction, and provide a feeling of confidence in today's advancing technological solutions for water conservation.

For example, waterfree urinals have been in use for the past 12 years. Half-gallon urinals have been used for the last 10 years. Fractional flush urinals, also called high-efficiency urinals, have been around for years as well; one manufacturer has been making this type of product for naval applications for 50-plus years.

Dual-flush technology for water closets, which has been available for residential installations for more than 10 years, is now available for flushometer applications. Dual-flushing technology represents a ratio of 1:2, that is, one flush of 1.6 gpf/6.0 lpf for solids to every two flushes of 1.1 gpf/4.2 lpf for liquids, the result of which is a combined effective flush volume. Essentially, this means a 20 percent drop in toilet flushing, and a 50 percent drop in urinal flushing.

Gravity and 1.0-gpf pressure-assist toilets have been available for more than six years. In addition to the field studies related to consumption, performance, and drainline carry, the industry has begun to embrace the mixed-media test developed by a firm outside the industry. This test is further substantiated by media research to validate minimum performance requirements.

The new demands for conservation are driving more widespread use of this technology. Whether your interest is meeting local codes, reducing construction costs and impact fees, or LEED initiatives, the industry is meeting these needs for the “now” generation of water-consuming products.

Pathogen = micro-organism that causes infection; Reservoir = where micro-organisms live; Means of exit = how the micro-organism leaves reservoir; Method of transmission = how the pathogen moves; Means of entry = how the micro-organism enters host; Susceptible host = the person who may become infected.

The Path of Nosocomial Infection

The chain of nosocomial infection, according to the CDC, begins when pathogenic organisms transfer to an individual by physical contact. In other words, a person is admitted to the hospital and later develops an infection, possibly resulting from cross-contamination from a contaminated surface, which can include patient-to-surface contamination and hand-to-hand contact by visitors, medical personnel or any number of people involved in the care of a patient.

Approximately one-third of hospital-acquired infections are preventable, with the most effective method to reduce nosocomial infections being hand-washing. In fact, transfer of a pathogen to a patient via the hands of healthcare workers is thought to be the most likely mechanism of exposure to patients.

It's a proven fact that a person who touches a contaminated surface can pass on the germs and bacteria just as easily. Clinical testing shows that cross-contamination can occur even up to 24 hours after original contamination. Research shows that the rate of cross-contamination from a faucet to clean hands is as high as 72.4 percent.

Additional research on cross-contamination concludes that the bacterial transfer rates of hand-to-hard surface are similar to the transfer rate of fingertips-to-the-lips, which is the final link in the chain - a portal of entry into a new host. Organisms will continue to transfer via touch until they are shed from the skin of the host or have been killed by antimicrobial agents.

The “Chain of Infection” is a basic component of understanding the prevention and control of infection that most healthcare workers recall from their early days of training. It is a critical concept in infection control that is worth reviewing.