May 12, 2015

Chris Rousseau Chairman, ASHRAE SSPC-170 NEWCOMB & BOYD 303 Peachtree Center Avenue, NE, Suite 525 Atlanta, GA 3030

Subject:

Indoor Air Quality and Energy Use in Health Care Facilities

Dear Chris: I write representing the engineering planning group at Kaiser Permanente (KP), a US health care provider and building owner, managing over 70 million square feet of space, and caring for nearly 10 million members. As a result of ongoing research regarding ASHRAE Standard 170 (S170), which we summarize below, we ask SSPC-170 and its support resources to investigate indoor air quality (IAQ) needs and energy use in health care spaces. Specifically, we ask if SSPC-170 can designate resources for the following actions: 1.

Work with SSPC-90.1, and seek recommendations regarding S170’s use of the so-called "health/safety exemption", ASHRAE Standard 90.1 (S90.1) §6.5.2.1 Exception 1.d or 2.a.4, to S901’s §6.5.2.1's reheat prohibition; and 2. Work with SSPC-90.1 to develop guidelines for the intended use of the “health/safety exemption” by another ANSI/ASHRAE Standard; and 3. Work with SSPC-62.1 to determine outdoor air (OA) ventilation rates for IAQ in health care spaces; and 4. Work with SSPC-62.1 to coordinate S170’s integration with the Standard 62.1 (S62.1) ventilation rate procedure (VRP); and 5. Review with SSPC-62.1 a re-instatement of S62.1’s occupant-based ventilation rates, or addition of Ra and Rp rates into either S62.1 or S170; and 6. Review, with SSPC-62.1, which IAQ standards in S62.1 Appendix B (Tables B1, B2, and B3) are applicable to staff and visitors in health care facilities. Consider adding, where appropriate, similar references to S170; and 7. Seek input from SSPC-62.1 on what IAQ considerations, if any, S62.1 gives spaces such daycare sickrooms or correctional cells occupied by unhealthy or sick persons; and 8. Review, with SSPC-62.1, the conference paper “Comparison of Indoor Air Quality Standards in Health Care Settings” [1], and jointly assess its recommendations; and 9. Work with SSPC-90.1 and SSPC-62.1 on whether and how Ventilation Controls for High-Occupancy Areas (90.1 §6.4.3.8) should be used in health care spaces; and 10. Work with SSPC-62.1 to determine how S62.1’s Rationale for Minimum Physiological Requirements for Respiration Air Based on CO2 Concentration could be applied in health care spaces.

These requests stem from our deep interest as a stakeholder in S170, including its impacts on patient healing, staff and visitor well-being, facility capital and operating costs, greenhouse gas emissions, and public health. In many jurisdictions, we have a legal obligation to comply with past or present versions of S170. KP led a multi-year inquiry into S170. We conducted a survey of practicing engineers [2], evaluated the energy impacts of its various measures [3], and benchmarked it against other US and international standards [4] [5] [1] [6]. As a result, and with regret, KP decided not to adopt S170 where we are not obliged to do so by law.

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We regret declining using one of the most influential standards in our industry. However, we made this decision based on a number of important technical issues. Though assuredly unintended, there appear to be fundamental conflicts between ANSI standards, S170, S90.1, and S62.1. Potential conflicts include the following: a) S90.1 discourages reheat energy; S170 seemingly does not. We do not believe any party in ASHRAE has validated the reheat energy cost /benefit of S170’s Total Air Change per Hour (TACH) rates. SSPC90.1 stated they had not validated the TACH rates in health care spaces, but assumed they were required for comfort [7]. SSPC-170 also indicated you had not validated the TACH in regards to reheat energy [8]. SSPC-170 also confirmed the standard does not provide “thermal comfort for human occupancy” [9]. Benchmarking showed conflicts in ASHRAE’s comfort requirements for health care spaces [5]. We understand SSPC-55 is currently engaged with SSPC-170 to review these differences. b) ASHRAE standards may not directly contain OA ventilation rates for IAQ in health care spaces. SSPC-62.1 has indicated that S170’s OA rates must be used [10]. However, SSPC-170 states “acceptable IAQ” is excluded from S170 [11]. SSPC-170 has also indicated that many IAQ methods, used in S62.1, are not currently allowed [12]. c) S170's ACH methodology appears incompatible with S62.1’s VRP. There are no apparent considerations of occupancy, space process contamination, space ventilation effectiveness, occupant diversity, or system ventilation effectiveness in S170. The multiple-space system OA methodologies of S62.1 and S170 vary. d) ASHRAE standards address public health with unequal methodologies. S62.1 covers spaces where sick individuals are known of occupy. However, none of those spaces use the ACH methodology, or have Total ACH requirements. Total ACH rates may need to be added to certain educational or institutional spaces in S62.1. e) A number of scope overlaps exist between S170 and S62.1. There are technical overlaps and variances between the requirements of the standards in several categories. These are detailed in the conference paper “Comparison of Indoor Air Quality Standards in Health Care Settings”, which will be presented at the June 2015 conference. f) S90.1 encourages demand-controlled ventilation (DCV) in high-occupancy spaces; S62.1 provides a rationale for it. S170 does not enable it. S90.1 requires DCV in high-occupancy spaces over 50m2. In health care facilities, this includes nursing dining rooms, and group occupational therapy or physical therapy spaces. We asked SSPC-170 if occupant-based ventilation methods were acceptable. SSPC-170 replied that all such methods are not included [12]. We note that S90.1 is often not required for hospitals. Many states exempt acute-care or I-occupancy facilities from S90.1-type energy codes. There, coordination between S90.1 and S170 is less important. Some owners adopt S90.1 as a standard beyond code. Any owner seeking, for example, a greenbuilding certification (e.g. LEED) would likely use S90.1 By contrast, in ambulatory care medical office buildings (MOBs), building codes may either permit or even require 30% VAV and S62.1-type ventilation designs. In California, for example, MOBs are often Boccupancy. They are designed to meet the state energy code (CCR T24 p6) which limits reheat in a manner similar to S90.1. Most of KP’s MOBs nationally are so designed and built. They often employ 30% VAV systems, return plenums, etc. Our review indicates S170’s methods may benefit from dialogue and cross-coordination with S62.1 and S90.1. Please consider include the following:

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a) S170’s TACH ventilation rates appear to use a method which dates back to the 1960s [13] and reflects common practices prior to 1975’s Standard 90 [14]. A research group investigated these methods in 1978, and found the TACH rates were unnecessary in many cases [15]. An ASHRAE research project (RP-312) in 1983 similarly found the TACH rates were unjustified in many cases [16]. b) While it may seem a minor point, the "health/safety exemption" in 90.1 substantially affects hospital energy. Inclusion of minimum TACHs in a baseline energy cost budget (ECB) establishes a high baseline energy use. Hospital variable air volume (VAV) systems don’t use the so-called “30% VAV” practice. Minimum flows are often 70% to 80% of peak. Studies show much hospital energy goes to reheat [17]. It is the single largest end use in hospitals’ energy signatures, even in warm climates. ASHRAE advises, as a primary energy strategy for hospitals, “aggressive reduction of reheat” [18].

Figure 1: Energy, Carbon Dioxide (CO2), and PM2.5 of VAV with Varying Minimum Air Settings Source: [3], as presented

c) Lower room air minimums are a significant opportunity for energy conservation [3]. The size of this opportunity varies across US health care facilities. Hospitals designed since the 1990s often include VAV systems, heat recovery, or other energy technologies. For those, the potential is likely 15%-20% of total energy. Older hospitals more often have baseline CV systems, limited heat recovery, and fewer energy technologies. For those, the potential could be 30%-40%, or much higher. d) From 1968-2002, the TACH rates were published by agencies other than ASHRAE [19], and were not ANSI standards. These agencies did not always resolve conflicts with ANSI standards. ASHRAE published IAQ ventilation rates for health care spaces from 1975-2002. They were occupant-based rates, and did not include the TACH component. In 2008, ASHRAE adapted the industry standard into S170. Based on SSPC-170’s statement [8], development of S170 didn’t include an analysis of the TACH rates’ energy implications. e) Operating rooms and isolation room spaces have bona-fide, clinically-based imperatives to maintain air cleanliness and prevent cross-contamination [20] [21] [22]. These spaces seem to

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logically fall under the “health/safety” exemption to reheat limits. However, such clinical imperatives apply to only a few of the spaces covered by S170. f) Many practicing HVAC engineers believe TACH rates are related to preventing infections [2]. This popular hypothesis originated in the 1960s [23]. However, the claim that overall levels of general infections are reduced by high ventilation rates or ventilation system measures has been repeatedly investigated [15] [16] [24] [25] [26] [27] [28]. To date, the scientific evidence does not support such a claim (outside of operating and isolation spaces). g) S170 uses 2 ACH OA for most spaces. (Operating spaces use 4 ACH OA). These OA ACHs appear to come from volume considerations, popular in the 1860s-1870s [13]. The ACH OA method may not provide a modern, nuanced, energy-conscious approach to IAQ. ASHRAE funded research into hospital ventilation some years ago (RP-312). It concluded most spaces in hospitals could use S62.1-type methods [16]. For many years, ASHRAE published OA rates for health care spaces (e.g. 15-25 cfm per person). These still appear in state building codes (e.g. [29]). But, they are not in the current S62.1 or S170. h) S170 neither states nor implies a relationship to contaminant thresholds in OSHA, NIOSH, ACGIH or other agency standards. S62.1 includes these as appendices. It implies, via inclusion of the IAQ procedure (IAQP), they are targeted outcomes of the standard. There is a popular assertion health care spaces should meet very stringent IAQ standards, based on susceptibility of occupants. However, S170 does not describe any such standards. This leaves hygienists no way to determine successful outcomes. In other countries, active monitoring of particles and aero-biological levels has been used [30] [31]. There is some history of this in the US [32] [33]. i) DCV savings is not available in health care spaces. The DCV rationale detailed in S62.1 and S90.1 uses occupancy as a foundation. This rationale has been used since the late-1990s. It was recently validated by ASHRAE RP-1547 [34]. Spaces that would require DCV under S90.1 §6.4.3.8 are limited. But, DCV and active IAQ monitoring have a broad potential in health care spaces. In many health care spaces, there are long, quiet hours where activities are minimal. We believe sharing expertise among ASHRAE standards will add significant value to S170. We are thereby asking SSPC-170 to coordinate with the knowledge base within ASHRAE to aide in enhancing health care ventilation practices. Though time will be needed to develop and coordinate, we do not see a need for new research of the literature review, laboratory, or field-testing varieties. Much of that research has been done over the years [13]. As such, much of the technical know-how to develop a more contemporary health care ventilation method exists in ASHRAE today. The following actions should be immediately feasible: 1. SSPC-170 and SSPC-90.1 could review TACH rates which use reheat under the “heath/safety exemption”, and collaboratively determine which rates meet the intent of the “health/safety exemption”. 2. SSPC-90.1 could establish guidelines for the future use of the “heath/safety exemption” by other ANSI/ASHRAE Standards (including, but not limited to, S170). Preliminarily, we propose use of the exemption be limited to spaces where: a. A clinical need for air volume exists, substantiated by a reasonable body of clinical literature; or b. A bona-fide health or safety need exists, substantiated by a reasonable body of evidence, and where the air volume effectively mitigates a demonstrable risk or particular contaminant; or c. An air volume need can be validated by IAQ or comfort requirements, demonstrated in alignment with the procedures of ANSI IAQ or comfort standards (S62.1 or S55).

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3. SSPC-170 and SSPC-62.1 could jointly determine minimum OA ventilation rates for acceptable IAQ in health care spaces. 4. SSPC-170 and SSPC-62.1 could review S170’s integration with the Standard 62.1 (S62.1) VRP, such that a common air system serving both space types (e.g. Nurses’ station per S62.1 and Patient Room per S170) use a coordinated methodology. 5. SSPC-170 and SSPC-62.1 could re-instate ASHRAE’s per-person ventilation rates for health care spaces. Alternately, SSPC-170 and SSPC-62.1 could assign Ra and Rp rates for health care spaces, using normal criteria [35]. These could be used as either a primary or an alternate compliance method. 6. SSPC-170 and SSPC-62.1 could review and determine which IAQ standards in S62.1 Appendix B (Tables B1, B2, and B3) are applicable to staff and healthy visitors in health care facilities. Similar references, where appropriate, could be added to S170. 7. SSPC-170 and SSPC-62.1 could review and determine which IAQ standards, in S62.1 Appendix B (Tables B1, B2, and B3) and beyond, are applicable to spaces such daycare sickrooms or correctional cells occupied by unhealthy or sick persons. 8. SSPC-170 and SSPC-62.1 could review "Comparison of Indoor Air Quality Standards in Health Care Settings" and collaborate on resolving its recommendations. 9. SSPC-170, SSPC-62.1, and SSPC-90.1 could advise if high-occupancy health care spaces (e.g. nursing dining rooms, group occupational therapy, group physical therapy spaces ) should use DCV controls, when complying to S90.1 §6.4.3.8. We propose DCV should be used. 10. SSPC-170 and SSPC-62.1 could develop a rationale for DCV in health care spaces, similar to S62.1’s Rationale for Minimum Physiological Requirements for Respiration Air Based on CO2 Concentration. While this is not a formal change proposal, please consider it a formal request for action by SSPC-170. We’d ask SSPC 170 to address each of the ten items above, and issue findings in a public forum (where KP and other stakeholders can reference). Please let us know as soon as possible what a timeline might be. Given our financial stake, we’re anxious for progress. We will also gladly offer support which may be helpful. KP’s in-house engineering group may be used to supplement sub-committee or task group efforts. To date, we’ve amassed a good deal of reference material, which we can share. Thank you for your consideration. assistance.

Please let me know if you have questions and/or I can be of

Sincerely,

Travis R. English, PE KAISER PERMANENTE Chief Design Engineer Facilities Planning & Design National Facilities Services 714-469-9553 Mobile

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CC: Roger Hendrick, SSPC 62.1 Steve Skalko, SSPC-90.1 Mark Webber & Stephanie C. Reiniche, ASHRAE Standards Doug Erickson & Walter Vernon, Facilities Guidelines Institute Chad Beebe & Jonathan Flannery, American Society of Healthcare Engineers Paul Lipke, Health Care Without Harm, Brendan Owens & Corey Enck, United States Green Building Council Don Ordoff, John Kouletsis & H Rame Hemstreet, KP National Facilities Services

Cited Works [1] T. English, A. Darwich, E. Stewart and H. Platt, "Comparison of Indoor Air Quality Standards in Health Care Settings," in ASHRAE Annual Conference 2015 Atlanta, 2015. [2] T. English, "Engineers’ Perspectives on Hospital Ventilation," HPAC Engineering, 2014. [3] T. English, "A Simoultaneous Consideration of Energy and Ventilation in Health Care," in ASHRAE Papers CD: 2014 ASHRAE Annual Conference, Seattle, WA, 2014. [4] English et al., "Benchmarking the US Healthcare Ventilation Standard with the UK Healthcare Ventilation Standard," in 2015 ASHRAE Winter Conference, Chicago, IL, 2015. [5] T. English, "Comparison of Standard Comfort Ranges in Health Care Settings (CH-15-C019)," in 2015 ASHRAE Winter Conference, January 24–28., Chicago, IL, 2015. [6] Betz et al, "Benchmarking the US Healthcare Ventilation Standard with the German Healthcare Ventilation Standard," in 2015 Annual Confernce, Atlanta, GA, 2015. [7] ASHRAE SSPC90.1, "Interpretation IC90.1-2010-19 of ANSI/ASHRAE/IES Standard 90.1-2010 Energy Standard for Buildings Except Low-Rise Residential Buildings," American Society of Heating, Refrigeration and Air Conditioning Engineers, [Online]. Available: https://www.ashrae.org/File%20Library/docLib/StdsInterpretations/IC-90-1-2010-19.pdf. [Accessed 15 2 2015]. [8] ASHRAE SSPC170, "Interpretation IC 170-2008-9 of ANSI/ASHRAE Standard 170-2008 Ventilation of Health Care Facilities," American Society of Heating, Refrigeration and Air Conditioning Engineers, [Online]. Available: https://www.ashrae.org/File%20Library/docLib/StdsInterpretations/IC-170-2008-9.pdf. [Accessed 15 2 2015]. [9] ASHRAE SSPC170, "Interpretation IC 170-2013-2 of ANSI/ASHRAE Standard 170-2008 Ventilation of Health Care Facilities," American Society of Heating, Refrigeration and Air Conditioning Engineers, [Online]. Available: https://www.ashrae.org/File%20Library/docLib/StdsInterpretations/IC-170-2013-2.pdf. [Accessed 15 2 2015]. [10] ASHRAE SSPC-62.1, "Interpretation IC 62.1-2013-1 of ASNI/ASHRAE Standard 62.1-2013 Ventilation for Acceptable Indoor Air Quality," American Society of Heating Refrigeration and Air Conditioning Engineers, [Online]. Available: https://www.ashrae.org/File%20Library/docLib/StdsInterpretations/IC_62.1-2013-1.pdf. [11] ASHRAE SSPC-170, "Interpretation IC 170-2013-3 of ANSI/ASHRAE Standard 170-2008 Ventilation of Health Care Facilities," American Society of Heating, Refrigeration and Air Conditioning Engineers, 2015. [Online]. Available: https://www.ashrae.org/File%20Library/docLib/StdsInterpretations/IC170-2013-3.pdf. [12] ASHRAE SSPC-170, "Interpretation IC 170-2013-5 of ANSI/ASHRAE Standard 170-2008 Ventilation of Health Care Facilities," American Society of Heating, Refrigeration and Air Conditioning Engineers, 2015. [Online]. Available: https://www.ashrae.org/File%20Library/docLib/StdsInterpretations/IC170-2013-5.pdf. [13] T. English and D. Koenigshofer, "A History of the Changing Concepts on Health Care Ventilation," ASHRAE Transactions, 2015 (July). [14] R. Kirkwood, "The Genesis of Standard 90: ASHRAE Takes on Energy Standard," ASHRAE Journal, 2010. [15] DeRoos and Banks, "Hospital Ventilation Standards and Energy Conservation: A Summary Of the Literature With Concusions and Recommendations, FY 78 Final report," LBNL paper LBL-8316, 1978. [16] J. Chaddock, "Ventilation and Exhaust Requirements for Hospitals," American Society of Heating Refirigeration and Air Conditioning Engineers (ASHRAE RP-312), Atlanta, GA, 1983. [17] Hatten M et. al, "Targeting 100!: Energy Use and Model Calibration Study: Legacy Salmon Creek Medical Center Vancouver, Washington," University of Washington’s Integrated Design Lab, 2011. [18] ASHRAE, Advanced energy design guide for large hospitals : achieving 50% energy savings toward a net zero

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energy building, Atlanta, GA: American Society of Heating, Refrigeration and Air Conditioning Engineers, 2012. [19] FGI, "About: History of the FGI," 2012. [Online]. Available: http://www.fgiguidelines.org/about.php. [Accessed 15 8 2014]. [20] Lidwell et al, "Airborne contamination of wounds in joint replacement operation: the relationship to sepsis rate," Journal of Hospital Infection, 4:111-31, 1983. [21] Lidwell et al., "Infection and sepsis after operations for total hip or knee-joint replacement: influence of ultraclean air, prophylactic antibiotics and other factors," J. Hyg., Camb., 93, pp. 505-529, 1984. [22] CDC, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings," MMWR 2005;54(No. RR-17), 2005. [23] Galson and Goddard, "Hospital air conditioning and sepsis control," ASHRAE Journal, 1968. [24] Li, Y et al, "Role of ventilation in airborne transmission of infectious agents in the built environment - a multidisciplinary systematic review.," Indoor Air. Feb, pp. 2-18, 2007. [25] Atkinson, J et al, "Natural Ventilation for Infection Control in Health-Care Settings," WHO Publication/Guidelines, 2009. [26] C. A. Short and S. Al-Maiyah, "Design strategy for low energy ventilation and cooling of hospitals," Building Research & Information, 37(3), 2009. [27] F. Memarzedeh, "Literature Review: Room Ventialtion and Airborne Disease Transmission," American Society for Healthcare Engineering, Chicago, IL, 2013. [28] Jacob, J et al, "The Role of the Hospital Environment in Preventing Healthcare-Associated Infections Caused by Pathogens Transmitted Through the Air," Health Environments Research & Design Journal, vol. 7, no. Supplement, 2013. [29] ICC, 2012 International Mechanical Code, International Code Council, Inc, 2011. [30] M. El-Sharkawy and M. Noweir, "Indoor air quality levels in a University Hospital in the Eastern Province of Saudi Arabia," Journal of Family and Community Medicine 21.1, 2014. [31] C.-T. e. a. Yang, "Construction and Application of an Intelligent Air Quality Monitoring System for Healthcare Environment," Journal of Medical Systems 38.2, 2014. [32] T. e. a. Mayatt, "Aspergillus Surveillance in a pediatric oncology unit during hospital renovation," Proceedings of IAQ 2004. American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc., 2004. [33] A. Streifel and F. Rhamme, "Hospital Building Design for Particle Management.," in Healthy Buildings, 1995. [34] X. Lin, J. Lau and K. Y. Greenville, "Evaluation of the Validity of the Assumptions Underlying Co2-Based Demand-Controlled Ventialtion by a Literature review," ASHRAE Transactions NY-14-007 (RP-1547), 2012. [35] D. Stanke, "Explaining Science Behind Standard 62.1-200," ASHRAE IAQ Applications, V7, Summer 2006, 2006.

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