To your health!

With India running short of hospital beds, developers are pulling out all the stops to bridge the gap. But constructing a first-class hospital comes with its own unique set of challenges, finds out Shriyal Sethumadhavan.Ancient Indian physician Sushruta, known as the ‘Father of Surgery’, was so ahead of his time that he reportedly performed the world’s first nose job (circa 600 BC) and laid out guidelines for procedures that are still undertaken. Yet, even he could not have predicted the complexity of modern-day hospitals – or the dire need for them in his country. Consider this: a recent report estimates that India needs 100,000 beds each year for the next 20 years, at over US$ 10 billion per year.Different strokesThis is easier said than done, as planning, designing and building a hospital is far more complex than any other project. “More than 35 different consultancies and design services are required in a hospital project,” says Dikshu C Kukreja, Architect – Urban Designer, CP Kukreja Associates, “right from architecture, structural and electrical work to nursing call systems, operation theatres (OTs), waste treatment, affluent treatment and medical gases.” To this Varun Khanna, Regional Director, Fortis Healthcare (India) Ltd, adds, “As these are service-oriented buildings, apart from aesthetics and architecture, special emphasis is given to service engineering.”For starters, floor-to-floor height is normally much higher owing to the services laid underground. “Apart from the ward floors, which are generally located on top, the functional requirement of OTs, intensive therapy units, and various diagnostic equipment dictate the floor height that varies from 3.45 m to 4.2 m,” says SN Subrahmanyan, Member of the Board and Senior Executive Vice-President (Construction), Larsen & Toubro Ltd. Shekhar Patki, Principal Design and Proprietor, PG Patki Architects Pvt Ltd, agrees, “This height is ideally required to provide a clearance of about 2.7 m. For specialised areas such as CT, MRI and OTs, the height will be 4.5 m to 6 m, creating space for essential services and structural requirements.A corridor with a clear width of at least 2.5 m to 3.0 m is essential to accommodate the free and easy movement of stretchers and equipment. Staircases must have a clear flight and landing width of 2 m, such that a stretcher too can be accommodated. All dimensions should be suitable for the physically challenged, and ramps should be made available for changes in levels of a floor plate.”Today, many superspeciality hospitals require air ambulance systems at the terrace level, informs Subrahmanyan. “We design and construct helipads in structural steel, and the whole structure has anti-vibration pads at the terrace level to avoid vibrations to the floors below. Further, to fulfil the oncology department’s requirement of a linear accelerator in the basement of the building, as per stringent Atomic Energy Regulatory Board (AERB) guidelines, we need a minimum of 1.5 m thick RC walls all around and a 2.4 m thick RC slab at the top. Pouring and supporting concrete for this thickness requires a special formwork system.”Codes and specificationsThe National Building Code (NBC) clearly spells out the specifications for designing a hospital. “This includes earthquake design and fire safety and emergency evacuation,” says Kukreja. The code stipulates parameters ranging from the requirement of water for each bed and car parking facility to the width of the staircase flight and building height. “But in India,” points out Subrahmanyan, “there are no major codes for designing hospitals except for Medical Council of India norms for teaching hospitals. One can construct a 300-bed hospital at a meagre 500 sq ft per bed to 1,200 sq ft per bed. This compromises on safety and patients’ comfort level. Hence, space planning norms are important. Apart from this, nuclear medicine should be designed as per AERB guidelines and the blood bank with FDA guidelines.” He adds that if a hospital is aiming to get patients from abroad, in keeping with the ‘medical tourism’ trend, it needs to get accreditation from JCAHO (Joint Commission on the Accreditation of Healthcare Organizations)/ JCI (Joint Commission International). And designers must have complete knowledge of AIA (Academy of Architecture for Health)/NHS (National Health Service) guidelines.Focusing on the NBC guidelines, S Sukumar, CEO, Apollo Global Project Consultancy, says, “The height of a hospital building must not cross 30 m because it becomes difficult to reach a higher building from a 2 m ramp in an emergency. The code also factors in the pressurisation of internal staircases, and lift shafts and lobbies, so that in case of fire, the positive pressure prevents ingress of smoke. You also need smoke exhaust systems in all areas.” On the required height, Subrahmanyan comments, “Today, when land is scarce and high FSI permissible, this is a major hurdle for the promoter. With fire departments in most metros equipped to handle high-rise buildings, this age-old norm needs to be modified.”Khanna affirms, “Most of these norms actually percolate down to the local corporation, and they enforce their guidelines as per NBC.” On special permissions, he says, “There are two parts to this, pre and post-construction. Pre-construction involves approvals of building plans, commencement certificates and subsequently various NOCs from the fire department, pollution control board, waste and water management systems, etc. Multiple government agencies come into play and unfortunately there is no single window, which leads to delays sometimes.”Safety firstThe key lies in implementing and upgrading systems with regard to fire safety norms, avers Manoj Phatak, Head-Civil Construction, Kokilaben Dhirubai Ambani (KDA) Hospital, Mumbai, “There are specifications for fire doors, sprinklers, smoke detectors, number of staircases, open areas, passages, and much more. So, where you have a complete team to operate a system, you also require one to maintain it.” To this, Subrahmanyan adds, “A large hospital will have to be designed and constructed for five-tier fire safety norms that include smoke detector and fire alarm systems, sprinkler systems, wet rise and hose reel systems, fire escape exit routes with signage and fire extinguishers.”Talking of Fortis, Khanna says, “First, the entry and exit are planned so that other than the fire exit, people movement is synchronised. Second, cameras keep a tab of what is happening.” Sukumar adds, “For safety, critical areas like the ICU, OTs and radiology units have to be zoned to ensure minimal travel distance. At Apollo, we also provide a DG set as backup; sufficient redundancy is also created in air-conditioner, boiler or any medicinal equipment, ensuring backup during power failure.”There’s more to keeping a hospital secure though. As Khanna says, “Ensuring that hospitals are infection-free is the biggest security.” Sukumar further elaborates, “Guidelines are followed for ventilation to avoid airborne infections and water used is also reverse-osmosis (RO) treated. A certain wall thickness for radiology equipment is maintained to contain radiation. Safety grills are installed in all windows, and OTs are clad in vinyl floors. Fire-retardant materials are used, and anti-skid flooring is provided in public areas and patient washrooms, which are also equipped with grab bars for easy functioning.”Provisions for instant evacuation are also essential. “Lift shafts and lobbies must be pressurised to prevent the spread of fire. If the hospital has a glass façade, an effective smoke seal detail must be prepared and executed,” highlights Patki. “Refuge floors need to be oriented facing a road. There must be designated fireman lifts and signage should be easily visible.” To this, Subrahmanyan adds, “The entire floor must be divided into different zones and each zone’s peripheral walls must have two hours’ fire rating and taken up to the soffit of the ceiling. AHU ducts should have fire dampers at these points. This system, widely followed abroad, must be made mandatory in India.” While fire escape staircases with glass panelled doors are already mandatory at every 45 m intervals, he believes mock fire drills at regular intervals are essential.Going greenIn keeping with today’s sustainability mantra, ultra-efficient and ‘deep green’ hospitals are the buzzwords today. “Integrated building design is very difficult to implement in reality,” says Dr Satish Kumar, Energy Efficient Ambassador, Vice-President, Schneider Electric India Pvt Ltd. “Here, hospital owners, designers and consultants must learn from best practices of Scandinavian countries, which have created hospital facilities that can be 30-50 per cent more efficient with a better layout, energy-efficient design, and advanced controls and automation equipment.” The running cost is one area green hospitals focus on. Locally available elements are harnessed to ensure low operation cost. Also, daylight is of utmost importance. “Maximum daylight is proven to help patients heal faster,” says Ashish Rakheja, COO, Spectral Services Consultants Pvt Ltd. “Modern hospitals have gone to the extent of designing big windows in the ICU for natural light.” For instance, in Medanta Medi City large glazing areas flood the hospital with natural light. Also, Apollo’s Kolkata and Delhi hospitals have been Silver LEED-certified. “We maintain low plot coverage of about 30 per cent and focus on vertical planning,” says Sukumar. “Terrace gardens dot the building in the ward floors. Focusing on natural light, technologies depend on the materials used. For power loads, we use EFD motors that work according to the load requirement. With generally automated services, we mostly use recycled and reused materials.”Today, many contractors and builders have dedicated teams for green building design solutions. “Most private customers want at least a Silver-rated green hospital,” says Subrahmanyan. “But, in many government projects, officials do not allow the use of locally available flyash bricks. ‘GRIHA’ norms, made mandatory by the government, still remain on paper. The government must ensure they are implemented.”Green measures include ensuring indoor air quality; installation of LED lights and highly efficient chillers; solar heaters; STPs and rainwater harvesting systems; well-insulated and low-e DGUs; and local materials for construction and high recyclable content in const­ruction materials.HVAC designIn HVAC design, there are two aspects: air conditioning and ventilation. “Central air-conditioning is important for moderate to large system sizes, which consist of high and low sides,” says Ajaj Kazi, Regional Manager-Projects, Voltas Ltd. Designing the high side basically depends on the size of the hospital (the air-conditioning load), availability of water and the space for keeping equipment like chillers and pumping systems. If the water source is available and there is sufficient space in the building, water-cooled chillers can also be used. These are energy-efficient with low kW/tonne ratios and result in low operational costs. For large hospitals, water-cooled centrifugal chillers are recommended to cater to large air-conditioning requirements with better efficiency.The use of air conditioning depends on the requirement. “At KDA Hospital, we have a standard ventilation system with water chillers and air handling and fan coil units,” says Phatak. “The only difference is that the air quality differs for different zones.” To this, HVAC expert Kazi suggests, “There are various new systems that basically focus on energy consumption, filtration and automation of the system. Air terminals like Thermafusers help maintain the right temperature in areas like the ICU and reduce energy in conjunction with Variable Frequency Drives (VFD).” Designing air-conditioning systems can also involve segregating critical areas like OTs and ICUs and providing the dedicated system with standby equipment.“The low side consists of field equipment, which treats air circulation,” explains Kazi. “This design is based on a number of air changes and use of high-efficiency filtering media. The classification of the pressure levels between different areas is also critical. For instance, areas with patients suffering from contagious diseases are kept under negative pressure with respect to adjoining areas, while wards with burn cases are kept under positive pressure. In the case of OTs, dedicated air handling units for each OT is recommended. To maintain humidity, heaters or hot water are used. Also, there are three stages of filtration; using normal prefilters, microvee filters and HEPA filters. The process of fumigation and defumigation can be done with the help of air handling units.”Ventilation also caters to areas like the car park, toilet exhaust and staircases. “At Apollo, our ventilation system has a laminar flow where air moves in a circular motion; a scavenging system expels ventilated air out of the terrace. Most filters used are hepatised with total bacterial control,” says Sukumar. The handling of air, particularly from sterile areas and the laundry is important, and this can be done by discharging the air into the atmosphere. Hence, designing the fans is very critical.Waste-n-water managementIs it right to discharge hospital wastewater directly into the municipal sewer and mix it with domestic sewage and wastewater, or should there be a pre-treatment at the hospital before discharging into municipal sewers for co-treatment? The STP at Fortis is defined by the pollution control board, and KDA efficiently recycles 100 per cent of sewage water (about 500,000 litre per day).Highlighting the need for purified water in hospitals, Ankur Parikh, Director, Alfaa UV, says, “There are primarily two main areas; first is the water used for washing hands, etc, in surgical areas and second is for haemodialysis.” As he tells us, for the first part, most hospitals install UV disinfection systems in the main water line to destroy microbial contamination. Also, an online monitoring validation system is essential. Also, for dialysis patients, you need a high-end and multi-stage water treatment system.Unfortunately, there is not enough data highlighting the possible impact of hospital wastewater discharges. Harshad Bastikar, Founder and CEO, Jaldhara Technologies, strongly suggests that some sort of a policy framework should be developed considering various treatment scenarios for hospital wastewater. “At Jaldhara Technologies, we specialise in water, wastewater and effluent treatment spaces,” he says. These systems re­spond to flow and load variations automatically, so they can be easily expanded and scaled up, as required. Treatment processes, including liquid/solid separation, are done automatically and continuously in a single tank.Materials and systemsA hospital building can be protected against dirt and contamination by selecting the right materials and systems. “In India,” Subrahmanyan states, “the secondary level of infection to patients owing to poor maintenance and wrong selection of materials stands at 65 per cent compared to only 15 per cent in developed countries.”Paints: The mandate is low VOC paints. In OTs, it is recommended to go for 2-3 mm of self-levelling epoxy paints that are washable and possess anti-fungal properties. In general areas, plastic emulsion and acrylic paints can be used. In green hospitals, use of non-alcoholic and water-based paints (like those from Nippon) can be propagated.Fire-retardant materials: For this, metal is best. From an environmental perspective, both the flooring material and adhesives used in flooring or paints should be fire-retardant, as must the wood used in the doors, which should be sprayed with fire-retardant paint. A normal 9 inch brick wall must enclose the fire staircases; they must be at least two-hour fire rated.Elevators: The elevator hoist weight must be larger to accommodate stretchers and hospital beds. The average size of these is 1,600 mm x 2,400 mm load carrying capacity, with the weight at 1,768 kg. Companies like Otis offer green ‘regenerative’ elevators – on going up, the elevator consumes power and while coming down, power is generated. The body design should be able to resist fire and help in emergency evacuation. Apart from bed elevators, you need service lifts for moving linen and food items and dumb waiters to connect the OT in the upper floor to the CSSD in the basement. Bed lifts and service elevators would have crash guards on the sides. (For more details, please refer to the Feature on Elevators and Escalators on Page 110)BIM systems: These are essential to monitor hospital services at every corner of the building for 24 hours and are being promoted by the Indian Green Building Council.Lighting: Lighting requirements depend on the function of the space. For example, lighting in a corridor is very different from that in an in-patient room, or an OT. The light load in public areas is about 4 kN/m as against the 2 kN/m required otherwise. LED and CFL lamps can be provided in common areas.Acoustics: Silence is an important part of healing. To reduce sound, the structural glazing can be double-glazed.Floors: They need high resistance owing to high footfalls. Seamless soft floors like vinyl flooring are best for patients’ rooms, the ICU and OT; vitrified tiles for OPD, labs and staff areas; and granite floors for lobby and public areas. Preferred hard flooring includes scratch-free and germ-free tiles with an anti-microbial glaze. H&R Johnson offers both, as Vijay Aggarwal, Managing Director and CEO, tells us.Going pan IndiaThe past few years have witnessed a major consolidation in the healthcare service sector in India, with major players like Fortis, Apollo, Max and Medanta making their mark. Now, it’s the turn of Tier-II and Tier-III cities.“Indian healthcare is annually growing at the rate of 15 per cent, faster than most other service sectors,” Patki affirms. However, urban and rural India is witnessing an uneven distribution of medical facilities.” For his part, Akshay Bhalla, Managing Director, Protiviti Consulting Pvt Ltd, witnesses signifying gaps in the Tier-I cities itself. “New Delhi – NCR has a population of about 20-odd million people, and Apollo Hospitals has been sanctioned some 800-odd beds, which is nothing,” he says.As for Apollo Hospital, Subrahmanyan says, “We are currently constructing Apollo’s Reach Hospital in Chennai, and the strategy is very clear: to target the rural population and plan around 200-bedded hospitals without spending too much on elevation features.” To this, Sukumar adds, “Our plan, ‘Rocket 14’ aims to increase our total bed count of 9,000 beds to 14,000 by 2014. We also plan to introduce a telemedicine satellite for remote areas. At the moment, we have 53 hospitals with seven currently under construction.”In western and eastern India, Fortis plans to expand to cities like Nashik, Indore, Ahmedabad and Vadodara. Bhalla is looking at Ludhiana, Mohali, Chandigarh, Bhopal, Gwalior and Patna attracting investments in northern India and Kochi and Madurai in the south. L&T has its own point of view. “We are con­structing two AIIMS-type hospitals in Bhubaneswar and Jodhpur,” says Subrahmanyan. “Two of our ESIC hospitals are coming up in Coimbatore and Thiruvananthapuram. Ahmedabad, Patna, Lucknow, Jaipur, Bhubaneswar and Visakhapatnam are some major Tier-II cities that will benefit immensely with new healthcare facilities.”Revamp timeAnother route is to refurbish old hospitals, which can be challenging when it is a running facility. “Without changing the basic layout of the hospital, a plan has to be put in place to optimise it, and then to further implement the plan over a period of time without inconveniencing patients,” says Khanna. Meanwhile, Sukumar observes, “Little has to be done to upgrade an existing facility to the latest technology. However, some old buildings do not cater to existing rules. Heights go beyond 30 m, there is low ceiling space, and most old hospitals have no air-conditioning. Also, poor space utilisation makes it difficult to accommodate heavy-duty medical equipment.”L&T and Kukreja Associates have been engaged in refurbishing old hospitals into new healthcare facilities. In JIPMER, Puducherry, L&T upgraded many departments in the existing building; at present, the company is upgrading the ESIC Hospital in Joka in Kolkata. Similarly, Kukreja Associates redesigned the 50 year-old Sir Ganga Ram Hospital and included super-speciality blocks with 20 OTs. “Working in a functional hospital demands extra care to ensure that dust and sound do not trouble occupants,” ex­presses Subrahmanyan. “And if it is a vertical expansion, reaching upper levels needs proper planning. We cannot access them through the inside and have to provide our own transportation system for the movement of men and material. Similarly, the approach road is challenging. Material, labour and construction vehicles all require separate access.”The cost factorWhether building new or undertaking a revamp, hospital construction is expensive. “The average cost of building a hospital is Rs 3,800 per sq ft, excluding the cost of medical equipment and land,” Sukumar estimates. Khanna offers his own take based on the ‘per bed’ cost. “The space utilised per bed varies from 450 sq ft to 1,200 sq ft,” he says. “If we further calculate this, 200,000 sq ft can have about 250 beds. And per bed in a metro could cost about Rs 1 crore.”A daunting figure, no doubt. “The government should consider selling land at a concession,” recommends Sukumar. “Second, low-interest loans will help combat construction costs.” Going green is also a step towards cost-effectiveness – less energy consumption leads to lower operational costs. As Rakheja says, “Through the BIM systems, the owner can predict his additional investment and will accordingly know the payback period.”The road aheadApart from costs, hospital chains are also concerned about speedy development, which would be aided by a single-window clearance system and public-private partnerships (PPP) in the sector. “If land comes from the government, many private corporations like us will be keen to develop the property and work with the government on a 30 to 60-year basis,” suggests Khanna.Despite the challenges, the movers and shakers in the sector – from architects to developers and hospital chains – remain positive about the future, with state governments setting up new facilities and many private players establishing medical colleges.For his part, Kukreja is certain that, going ahead, hospitals will be more research-oriented, rather than just treatment-oriented. Fortis, too, is looking ahead with optimism. “We were a single hospital in 2001 and today we have 67 in India,” says Khanna. “Some are operational and others under construction. That is the speed at which we have grown, and the same will hold true in the next 10 years as well.Contractors see the opportunity as well. “There will be a good demand for hospital development as the population increases, especially for quality treatment in tier-II and -III cities,” predicts MN Balasubramanian, Senior General Manager, Brigade Group. “And we will certainly be interested in this sector for development as part of our future plans.”Meanwhile, we need to consider certain ground realities: recession in the Indian market and delays aplenty in projects. Hopefully, this is just a passing cloud, and the sunshine sector lives up to its promise. After all, there are lives – millions of them – banking on it.“Energy-efficient infrastructure should be planned without compromising on reliability and safety.”- Satish Kumar, Energy Efficient Ambassador, Vice-President, Schneider Electric India Pvt LtdThe hospital boom has a flipside: high energy consumption. Here are some solutions to reduce this:Point of focus: During design, load can be reduced through proper orientation, fenestration, location and sizing to optimise daylight while reducing solar heat gain. Other strategies include use of high-performance glazing, high-efficiency condensing boilers and water heaters, high-efficiency variable speed chillers and reducing fan power requirements. Always choose appliances labelled four or five stars by the Bureau of Energy Efficiency (BEE). In existing facilities, one must raise awareness among users of the hospital; and focus on tech solutions like automation and control of processes, measurement and verification of energy consumption, and integration of different systems in a facility.Technology in use: Energy-efficient infrastructure must be planned without compromising on reliability and safety factors. For lighting, a T-5 lamp with electronic ballasts is very efficient. LED lighting can be deployed in select areas depending on the budget. Implementing heat recovery strategies can lead to substantial savings. Other strategies include daylight integration, dimming, occupancy-based lighting and ventilation controls, and meeting partial space conditioning loads through the installation of variable speed drives.Electric systems: Suitable for new and existing hospitals, our exclusive EcoStruxure solution for healthcare is an open architecture approach that creates intelligent buildings through integration of systems like HVAC, access control, security management, power distribution and monitoring, IT management, and lighting control.According to Brigade Group and PG Patki Architects, some salient features of the National Building Code include:• Part 3 Section-5: Development control rules and general building requirement links – preferences of open spaces and amenities vs number of beds.• Part 4 Section-3: Fire safety – details hospitals into different typologies and segregates them into various fire zones, recommending construction and usage of materials. • Part 4 Section-6: Fire safety – details staircase widths (1.5-2 m), refuge requirements, etc. Guidelines to achieve maximum safety. • Part 5: Building materials that can be used.• Part 7: Constructional practices and safety.• Part 8 Section-1: Light ventilation – details lux levels or illumination levels for various rooms and spaces in the hospital.• Part 8 Section-5: Installation of lifts – details no. of attendants and preferred dimensions for various capacities in patient elevators. • Part 8 Section-4: Acoustics and noise reduction – Depending on common sources of noise, identifies material types, sound absorption, etc. • Part 9 Section-1 – Water supply, drainage, toilet requirements and administration.Give us your feedback on this article at feedback@ASAPPmedia.com