Code Green:

June 21st, 2010

New Hospitals Blend Healing and Conservation

By Diane Rogers — Stanford Medicine,

In an alcove a few feet away from an operating room, the surgeon covers his hair with a surgical cap and pulls a surgical mask over his nose and mouth. He uses a pick to clean under his closely trimmed nails, though they look clean already.

Then the washing begins. He gets the water flowing just right — gentle enough to avoid splashing, but hard enough to sweep away microbes and debris. He’s careful to keep his hands above elbow level so the dirty water runs away from his fingertips throughout the washing. He wets his hands and forearms with a sponge and antiseptic, 30 seconds per arm. He brushes his nails, 30 seconds per hand. Then he washes both arms for two minutes each, scrubs between his fingers and scrubs his palms with his fingertips. He rinses his arms and hands, turns off the tap using his elbows, and allows his hands and arms to drip dry, keeping his hands above his elbows. With drying and gowning still to come, he’s only halfway through scrubbing in — a routine that hasn’t changed in its essentials for over a century.

Meanwhile in a conference room on another floor, hospital administrators are in the midst of their own version of scrubbing in. They’re scrutinizing every aspect of the construction and operation of a new facility so they can build and run it as cleanly as possible. Electricity demands and carbon emissions will be reduced by maximizing natural light and adjusting ventilation and temperature throughout the day; air quality will be high because of new nontoxic carpeting and upholstery; wastewater will be treated to arrive at the sewage plant free of drugs and other chemicals. The administrators aim to reduce the hospital’s waste, shrink its carbon footprint, cut resource consumption and eliminate pollution. In effect, they’re scrubbing the whole hospital.

As similar scenarios play out in hospitals throughout the country, it’s clear that the $40 billion health-care construction industry is not only booming today — it’s going green. Like Stanford Hospital & Clinics, which opened in 1959, hundreds of hospitals built after World War II have come to the end of their 50-year life spans. Like Stanford and the adjacent Lucile Packard Children’s Hospital, they’re being rebuilt in a far more environmentally conscious era.

Their leaders are learning that factoring in protections for the environment is complicated and expensive — but can save money in the long run. And the communities surrounding them won’t stand for anything less.

“What is different from 10 years ago is that the general public and local governments are now aware of and tuned into environmental impact,” says George Tingwald, MD, director of medical planning for the Stanford Hospital renewal project. The new building, designed by Rafael Viñoly Architects, is projected to open before the end of the decade.

“Going green is not only the right thing to do, or the fashionable thing to do today — sometimes it’s the law,” says Tingwald. “Costs for certain green technologies have decreased, so it’s easier to go green, but more important, governments are mandating green design.”

In Palo Alto, for example, a city ordinance requires that new construction projects of greater than 5,000 square feet meet LEED “silver” requirements. LEED is the Leadership in Energy and Environmental Design rating program of the U.S. Green Building Council, and silver is its third-ranked category. Stanford has set LEED silver equivalence as its goal, Tingwald adds.

Hospitals are different
Compared with other industries, health care has been slow to climb aboard the green-building bandwagon, says Robin Guenther, lead architect for the Packard Children’s Hospital expansion project. That’s because hospitals operate in “a restrictive, highly regulated, risk-averse environment,” says Guenther, a nationally recognized sustainable-hospital design expert and a principal at the design firm Perkins+Will.

Even two or three years ago, says Walter Vernon, president of the San Francisco engineering design firm Mazzetti & Associates, “you had to work pretty hard to convince health-care owners that they needed to think about green-building issues.”

But today? “Going green has gone mainstream,” says Vernon, whose company is engineering both the Stanford Hospital and Packard projects.

While the greenness of most commercial buildings is determined by their impact on the outdoor environment, hospitals are held to a higher standard: They are expected to tread lightly outdoors and to promote a healing environment indoors. “A green hospital includes everything from siting and design to the construction and operations of buildings. It’s about everything that occurs in and around the buildings,” notes Anna Gilmore Hall, executive director of Practice Greenhealth, a nonprofit membership organization representing more than 1,000 hospitals in North America.

It’s a big job for hospitals. The energy costs of keeping lights and computers on 24/7, maintaining the humidity and temperature in operating suites, running negative-air pressure rooms for patients who need to be isolated, cooling ginormous specimen fridges — you get the picture. Not to mention toxic waste, like the lead in radiation shielding, disposal of pharmaceuticals, as well as the challenge of keeping clean without caustic chemicals in cleaners and pesticides. (In 2007, Stanford Hospital switched to cleaning chemicals certified by the ecolabeling organization Green Seal.)

The U.S. health-care industry consumes $6.5 billion worth of energy each year, making it the second most energy-intensive building sector (food service is No. 1). Hospitals are often communities’ largest users of water and are major generators of waste. All of this activity contributes to the production of climate-changing greenhouse gases.

Sustainability in practice
Guenther has been in the business of “green health care” since its inception, in the mid-1990s, when she was asked to design a bone marrow transplant unit for Mount Sinai Medical Center in New York. “The laminar air-flow manufacturer rejected every material I wanted to use on the basis of unwanted particulate off-gassing,” she recalls. “I thought, ‘Wow! If these materials are really bad for patients whose immune systems are compromised, they can’t be good for other patients, either.’ And that led me on this whole investigation into the materials that we surround ourselves with.” Ultimately she wrote, with co-author Gail Vittori, the key reference text for the field, Sustainable Healthcare Architecture (John Wiley & Sons Inc., 2008).

With Guenther as lead architect for the Packard renewal and Vernon as head engineer for both the Packard and Stanford Hospital projects, it would be difficult to find a more committed green-building team. Together with Vittori, they helped develop the Green Guide for Health Care, a best-practices guide for improving energy and water efficiency and using safer materials, and they oversee the guide’s online forum. They know the key elements that have to be addressed in every successful sustainable project: site planning, energy, water, materials and indoor environmental quality. And they could teach The Greening of Health Care 101.

Starting about 10 years ago, Guenther notes, community hospitals in environmentally progressive communities, like Boulder Community Hospital in Boulder, Colo., and religious-based health-care organizations, like St. Mary’s/Duluth Clinics in Duluth, Minn., began to take the lead in the greening of health-care facilities. By installing a new high-efficiency, low-emission boiler, the Boulder hospital reduced nitrogen oxide emissions by 70 percent, carbon monoxide emissions by 50 percent and fuel consumption by 20 percent over standard boilers.

In many projects, hospital administrators with environmental commitments initiated pollution prevention and green building efforts, for instance low-VOC (volatile organic compounds) paints, recycled denim for insulation and PVC-free carpeting. CEOs often cited a personal reason or a cathartic experience for their interest. “For example, Kaiser Permanente, an early adopter, traces its interest to a talk Rachel Carson, author of Silent Spring, gave executives just before she died from breast cancer,” Guenther says.

Designers and architects also started asking broad questions that prompted hospital administrators to consider greening not only construction but also overall operations. Could new urban buildings be sited near mass transit systems so that patients, family members and staff could get to the hospital more easily? What could be done to reduce the volume and toxicity of medical wastes? What could be done to lower hospital staff exposures to cleaners and pesticides? Could hospitals use locally grown food? Could cafeteria managers purchase beef that is antibiotic-free, as well as milk and yogurt without synthetic growth hormones?

The American Medical Association has long advocated the elimination of antibiotics in meat production, largely because of developing antibiotic resistance. But hospitals — not the AMA — buy meat. And when they make “green” purchases, the market responds. “Why do green hospitals matter?” Guenther asks. “Because the health-care sector is the largest service sector of the U.S. economy, a huge employer and touches most Americans’ lives. When health care models green building or healthier food choices, or advocates for public transit, patients and staff notice.”

Models of green health-care facilities include Brigham and Women’s Hospital’s Shapiro Cardiovascular Center. Opened in 2008, it is the first hospital building in New England to achieve silver LEED certification. The Shapiro design team set out to emphasize indoor air quality and energy efficiency. State-of-the-art air filtration helps reduce the incidence of hospital-acquired infections. New floor cleaners are resulting in fewer respiratory problems among staff — an important change since health-care workers account for more than 40 percent of occupationally related, adult-onset asthma. Latex gloves have been eliminated, more efficient landscaping has reduced water use by 50 percent and more than 90 percent of construction debris was recycled. More than 75 percent of the center’s interior is exposed to natural light, which some studies indicate accelerates healing and reduces need for pain medication.

Healing influence
Numerous studies over the past decade have shown that sunlight in patient rooms is associated with reduced pain, stress and depression. Views of nature similarly strengthen patient recovery, shorten hospital stays and reduce levels of pain and stress. For example, a study in Psychosomatic Medicine of 89 spinal surgery patients concluded that exposure to sunlight led to recovery with less stress, pain and need for pain medication (Jeffrey Walch et al., Jan./Feb. 2005).

Another green model, Dell Children’s Medical Center of Central Texas, has earned the top-ranked platinum LEED certification. In addition to using local materials for construction, the Dell design team built an onsite power-generation facility, recycled 92 percent of construction debris, reclaimed an environmentally damaged site, or “brown field,” significantly reduced potable water use and planted only native grasses. Spotlighting the intimate link between outdoor environment and indoor, healing environment, the hospital has seven courtyards for patients, family members and staff to meander through. The designers refer to them as “the lungs of the building.”

Guenther is particularly pleased with the way the new building in the Packard Children’s Hospital project will connect to the outside environment. The proposed design features a two-story glass lobby that faces one of many gardens. The current site, dominated by asphalt parking surfaces, would be converted into almost four additional acres of landscaped green space. “Recovering what is termed in the industry a ‘gray field,’ or a previously developed site that has been stripped of its capacity to support ecosystems, and turning it back into a ‘green field’ is a huge achievement,” Guenther says. “It can handle storm water better, and it’s just going to function better, supporting life on every level.” Plans also call for using condensate water — the liquid that is formed by dehumidifying indoor air — to irrigate all of the landscaping, along with rainwater that is collected in an underground 90,000-gallon cistern.

“Having green buildings doesn’t mean that suddenly the operating rooms are going to be warm because we’re saving energy, or that there won’t be enough light to see,” Guenther adds. “Sustainability does not equal deprivation. It’s actually about being smarter in resource use.”

Ask Walter Vernon about the coolest new green technologies that are going into the two hospital projects, and he’s liable to slip into geek speak about IAQ, or indoor air quality. According to the Environmental Protection Agency, indoor air pollution is one of the top five environmental risks to public health. Hospitals traditionally have relied on ventilation systems that cool down air, then warm it back up, and finally mix it up to dilute the amount of airborne, transmissible organisms. Vernon’s displacement system eliminates the need to cool and reheat air. “We basically introduce air at the floor level, at a low velocity, and as it rises up, it displaces warmer room air and carries out any bugs with it.” If Vernon’s new system meets expectations, the potential energy savings could be dramatic.

Vernon’s firm has also completed a greenhouse-gas inventory for Stanford Hospital, measuring and recording all the emissions for the hospital and its related buildings. “It’s not a required procedure, so Stanford is very progressive in the sense that they even did this,” he says. “What we found was that Stanford’s current greenhouse-gas footprint is already far less than that of competing hospitals, because the Palo Alto Municipal Utility District has been so progressive in its use of renewable generation sources.”

In the current design phase for the two hospital projects, hundreds of decisions about operating systems and materials are still to be made. For example, floors in most hospitals of the past were made of VCT, vinyl composition tile, which contains toxic chemicals, and which required chemical-laden cleaners, waxes and strippers filled with heavy metals. “Everyone in the hospital likes those clean, shiny floors, but VCT is not sustainable,” Tingwald says. “We’ve looked at rubber floors, which you can’t polish, and at linoleum, which is not as durable over time. These are the kinds of challenges we’re facing, where there’s no replacement product on the market at the moment that’s as good and durable. We may either have to compromise, or delay our selection until better products become available.”

Guenther takes a slightly different position. “Hospitals are finding that more sustainable materials and systems can be introduced with surprising results. For example, rubber floors may not be shiny, but clinicians prefer their softness underfoot, and appreciate the noise reduction,” she says. “Kaiser Permanente reports less planter fasciitis among nursing staff since substituting for VCT. With their introduction of permeable paving — which allows rainwater to pass through it, into the ground — there have been fewer slips and falls in the Kaiser Modesto Hospital lobby as less water is tracked through the entrance.”

Vernon ticks off more of the technologies the hospital is planning to incorporate: solar panels on the rooftop to provide energy; fuel cells that consume stinky landfill gas to produce electricity with almost no emissions; and LED light fixtures, which produce more light per watt than other lights, last 10 times longer and, unlike most energy-efficient fluorescent bulbs, contain no mercury — a toxin that persists in the environment and accumulates in food chains.

The architects and engineers continue to consult regularly with teams of physicians, nurses, housekeeping staffers, food service workers and others. “This is our visionary opportunity, when we can say, ‘Let’s build and operate the greenest building we can,’” says Krisanne Hanson, a project manager for Stanford Hospital’s general services division who is widely known as “the garbage gal” for her mastery of waste handling.

Hanson and a dozen other employees meet regularly as a “green team,” to “see if there’s anything else we can ‘green up,’ as time goes by and technologies improve.” She may explain new composting proposals for the hospitals’ cafeterias. Or share the results of members’ work — like the team of nurses who found they could save an extra 7 tons of waste per year by using slightly smaller IV bags without an exterior liner.

For those who may question the breadth of support for greener, more environmentally responsible hospitals, Hanson likes to share a brief anecdote about a friend who recently gave birth at Packard. The new mom had a great experience, with one exception: She was surprised that there weren’t any recycling containers in her room.

“We health-care practitioners may sometimes feel that environmental stuff is difficult to do in a hospital setting,” Hanson adds. “But the public is saying, ‘Why not?’”