Munini Hospital Tour - Can a building system be robust, resilient, and simple to operate?

Previous post (Day?#3)

International "Benefit" Tour - Africa Day #4

Today, we visited the second of the hospitals our team designed with the MASS Design Group.??

This hospital serves the District of Munini, in the extreme Southern part of the country, near the border with Burundi.??

Touring this facility was especially interesting — Brian, our Chief Plumbing Engineer, designed the water and medical gas systems for the Builidng. While there, he shared his stories about how he designed the building, and how the owner “value-engineered” certain needed solutions out of the design. He remembered this because it turned out that. after the building was built, the owner had retrofitted most of these elements back into the building.?

This hospital is similar to Nyarugenge, which we visited yesterday. However, it appeared to be in much better shape, likely due to lower usage. Elements of the medical planning and fa?ade were somewhat different. (I am no architecture critic, but I really liked the design for this building.) One prominent element was the way interior spaces relied on the exterior for circulation, and a series of large open areas for people to gather in different ways. (The latter reminds me of the spaces that my friend Robin Guenther created at Stanford Children’s Hospital.)?

This hospital used the same ventilation design as Nyarugenge – a set of low openings to draw air in, a set of high louvers for exhaust, fans to move the air, and UV lights to destroy circulating pathogens. This design was based upon WHO Guidance for natural ventilation. In this case, the system has been almost completely disabled. First, the owner value-engineered out the large fans we specified, and used fans that were too small. In all spaces, the low vents have been blocked closed, due to patients complaining about the cold. (The area is at a high elevation, and it does get cold. January is the hot season, so we did not experience that; but, even now, it is a very pleasant temperature). The fans were all turned off, due to high electrical costs. And, the facility had believed that the UV lights were to kill mosquitos, and they have removed all of the bulbs, since the area has few mosquitos. As a result, the ventilation today consists of open doors into the wards and the high-mounted exhaust louvers – a scenario we did NOT model when we designed the building! The hospital is looking for solutions to the temperature control problem in these spaces, is planning to restore the UV lighting, and is working towards opening up the low-mounted ventilation wall openings.

This building illustrates the vulnerabilities of natural ventilation to changing conditions and the inability to respond to needs for thermal comfort, even in such a benign climate. It also shows, given the misunderstanding of the UV purpose, the need in all designs for knowledge and thinking transfer from design teams to operating teams — an intractable problem everywhere.?

One thing we discussed was the possibility of collecting data with respect to hospital acquired infections (HAI) at the facility. Given the controversy over the clinical efficacy of the U.S. healthcare ventilation standards, it would be interesting to compare the HAI rate in these wards to the performance of U.S. healthcare buildings.

The only spaces in the building with mechanical ventilation are a block of 10 isolation rooms for patients with identified infectious diseases and the operating rooms. Each OR has a dedicated return-air unit, with MERV-14 filters, four supply diffusers, and four low-mounted return diffusers.?

The electrical system consisted of a reliable utility service backed up by two emergency generators. The original design included a smaller generator serving only critical loads, in order to save both capital and operating expense. However, during construction, the owner elected to add a larger generator, designed to serve the entire hospital in the event of a utility outage. Thus, the system has two levels of redundancy, but at a MUCH higher cost than if the original design concept had been executed.??

The fuel oil system for the generators consist of tanks in the sub-bases of the two generators, supported by a large external tank. However, due to problems of cost, and the need to maintain fuel quality, the large tank has been left empty. The sub-base tanks contain enough fuel for approximately 12 hours of operation, plenty of time for re-fueling in the event of an extended outage.??

Again, this entire hospital is all-electric. Data on the fuel mix for the country show that approximately 50% of the country’s electricity comes from renewable sources, mostly hydroelectric, so an all-electric building makes sense.?

The water supplied to the facility is pumped to a number of tanks located on the roof, which serve the various fixtures via gravity. The water in one wing, serving maternity and pediatrics, is heated using a solar thermal system. Effluent runs through a sewage treatment plant, and then to a municipal sewage system consisting of open sewers.?The hospital has not had the kind of “explosive” toilets that Nyarugenge suffered from.?

?This building has no kitchen; families must bring food for the patients. The hospital contains a number of alcohol dispensers throughout. None of them contained any alcohol. Soap dispensers at the handwashing sinks (where they occurred) contained no soap.?

The medical gas systems for the hospital consist of an oxygen generation system and a pair of medical air pumps.?The medical air pumps serve both medical air and surgical air systems (e.g. different air pressures). They only operate the pumps when surgeries are in progress. When we were there, the pumps were off, and the system showed NO pressure in the pipes, implying that the piped system is leaking somewhere. Nobody at the hospital has paid attention to this issue. The oxygen generation system was another "value engineering" item. We had originally specified an on-site generation system. To save money, the owner opted for a room full of bottled oxygen. After the building was open, and when the Covid crisis struck, the government chose to go back to our original design, and they retrofitted the oxygen generation system back into the building.?

In general, this hospital was, I think, well-designed. The architecture was splendid. The engineering systems were appropriate to the need, and, in general effective. BUT, as always, chronic problems of lack of operating staff and maintenance made them less than optimal, over time. Poor communication and training of facility staff from the design team resulted in sub-optimal performance. And, critically, the issue of natural ventilation’s inability to respond to challenges of temperature control, coupled with electricity costs, resulted in shutting down the system in its entirety.?

Engineering systems for this kind of installation must be robust, resilient, and simple. They must be able to operate for extended numbers of years without intervention, without energy, and without a need for replacement parts.?

. . . . the impossible dream.?