Since the dawn of modern medicine, technology has been a driving force, constantly reshaping the way healthcare providers treat patients, whether in an outpatient clinic or a hospital ICU. As cathode ray tube monitors gave way to plasma, LCD, and DLP, patients now move freely around the hospital floor with their families while having their vital signs wirelessly monitored. These significant evolutions in patient-care technology create coordination issues for the teams that design these environments. The design complexities of a technologically advanced healthcare facility require the combined talents and shared knowledge of architects, MEP engineers, interior designers, equipment consultants, hospital staff, systems manufacturers, etc., and also require an understanding of these systems by the entire construction team.

It's a massive coordination effort that is par for the course for traditional engineered systems like power and plumbing—technologies that haven't changed much in past years—but due to the ever-changing nature of healthcare technology, there usually isn't a standardized procedure for how to deal with low-voltage communications systems.

At HEALTHCARE DESIGN.08 in Washington, D.C., a group of architects, engineers, healthcare owners, and systems vendors joined X-nth, Inc., in a roundtable discussion concerning how today's technologies affect the design and construction of healthcare facilities, and what can be done to prepare for tomorrow's advancements. It quickly became clear that this is a very complicated topic.

Case study: Access control and security

As a concept alone, access-control doors are simple. Imagine a lockable door. The lock is controlled either through a pin pad, a card, or biometrics and therefore only allows an authorized user to pass. This provides several benefits over traditional lock-and-key doors, such as the ability to give access to new users with relative speed, logging who enters and when this happens, and controlling the security criteria and access rights of an array of doors from a centralized point. The tricky part is the installation—the challenge arises from all the different personnel involved in this door's installation.

First, the general contractor (person #1) frames the door. Next, the hardware contractor (person #2) installs the vertical latch and electric strikes or magnetic locks used to secure the door—but he does not wire these parts yet. Next, if it's an automatic door, the door manufacturer (person #3) installs the door opening motor or auto operator, but again, does not wire it up yet. The fire alarm vendor (person #4) then installs the relays to unlock the door during a fire alarm. Assuming this door serves labor/delivery suite, the infant protection vendor (person #5) connects door controllers and tag exciters. Next the general contractor (remember person #1?) returns to install the door, and finally the access control vendor (person #6) installs the readers and connects the control wiring to the auto door motor, the electric strike or lock, and the access control equipment. At this point, of course, power hasn't even been connected to the door yet by the electrical contractor (person #7). All this happens for a “simple” door.

The key to unlocking this complexity occurs at the design stage and requires in-depth discussions between the architect, door hardware consultant, and the low-voltage systems designer (the American Society of Healthcare Engineers [ASHE] is one place to turn for a list of these designers). Door by door, every detail affecting patient, staff, and public movements is considered. The ability to control access must also be balanced against the life safety codes ensuring that emergency egress is maintained; this must be properly designed and detailed on the drawings. Even then, it takes on-site coordination to successfully install this simple door.

Communications rooms: Size (and location) matters

When a healthcare facility plans on creating a technology infrastructure that will carry them into the future, the worst thing that can happen is to disable the systems before the first shovel is turned during construction by skimping on the communications rooms. The term “closet” should never be used in this context, today. This name stemmed from telephone punch blocks occupying nothing more than mere inches of space on a single wall in a very confined space. With the advent of voice-over-IP (VoIP) systems, gigabit Ethernet networks delivering medical imaging files, and security systems keeping an eye on patient safety, “closet” space doesn't cut it anymore.

Coordination between the low-voltage designer and the architect during the schematic design phase of a project should define adequate space for the planned and future needs of the facility. A good rule of thumb is to make an intermediate distribution frame (IDF) room no smaller than 9′ x 12′, and, if the facility is multifloor, that these rooms be stacked. The designer and architect also need to make sure that these rooms are located throughout the building footprint so that every data termination point is within 295 feet (beyond which there is risk of data loss). In subsequent phases of the design, it is the responsibility of the low-voltage designer to coordinate the power-consuming and heat-dispensing equipment with the electrical and mechanical designers to ensure an adequate amount of power and cooling is provided to each room.

Cabling infrastructure: Seeing the future

We all understand that the bottom line must be met for our projects. If the cost of technology outweighs its potential benefits, be they monetary or in regards to patient care, sacrifices to the robustness of the systems are likely necessary. Unfortunately, these sacrifices can significantly reduce the future expansion of these systems. For example, category cables have been the standard information distribution medium for years, with each iteration (Cat5, Cat5e, Cat6, etc.) being more or less compatible with the others (each successive iteration, though, having greater bandwidth capabilities). What happens when a facility with a Cat5 infrastructure (not the most robust wiring) wants to transmit gigantic images from their new PACS equipment over their network? Logjams, return error messages, and general slow functioning of the system, that's what. While not all newly adopted standards for cables are immediately necessary (e.g., Cat6A), discussions with a low-voltage designer regarding the current needs and future plans of a facility's technology plans will help make the transition easier (and usually more cost-effective).

Ownership: Documenting responsibility

Proper documentation is the key to any successful design project in any discipline. When different trades take on a single set of documents, fingers can start pointing at others before the first backbox is installed. Common problems occur, for example, when data cabling is used for newer versions of systems that traditionally do not use this medium. Thus, if the surveillance camera installer is using fiber for a camera installed in a parking lot, he may assume that the fiber from the headend equipment to the camera belongs to the structured cabling vendor. Likewise, the structured cabling vendor may look at the drawings, see that fiber is being used for the cameras but not the data network, and conclude that this work is part of the surveillance system, not the structured cabling system. Whenever disciplines cross, it is important for the designer to designate who will be responsible for each part of the installation.

Planning for the future: How?

Claims of clairvoyance and the ability to magically predict future events make for entertaining television, but it doesn't make for acceptable budgeting practices. So, what justifies the cost of the expensive cable, or the high-tech nurse call system, or the pricey wireless network? Who's to say what this technology should cost?

Low-voltage designers must keep close ties with the manufacturers whose equipment they specify, as well as with the vendors who install these systems. Understanding the trends of one company isn't enough to predict the entire industry's direction. Keeping up to date on the advancements and new offerings from dozens of companies and technologies will enable the designer to inform the owner of the right technologies at the right time. Owners may want to be on the “cutting edge” but they don't want to be on the “bleeding edge.”

For example, an internet protocol closed circuit TV system (IP CCTV) would have been risky two years ago (when the technology was untested), whereas today this system can be more readily installed and maintained.

Another good indicator for the future of many systems is the regular updating of codes and standards. New standards often aren't adopted immediately, giving the entire design team time to prepare their clients for the future of technology. It is a good idea, for example, to stay in touch with the ANSI TIA/EIA standard, as well as with relevant municipal codes. This can involve dull reading, but it can also save a client a fortune in the long run.

The commissioning engineer is a valuable asset to low-voltage design. This on-site field representative is responsible for ensuring that the transition between the contract documents and “plug-in” is as smooth and effective as possible. A primary responsibility is to ensure that the owner gets what the owner paid for in the contract documents. This is not to say that a systems installer will cheat an owner at every turn, but rather than what is on paper and what is installed can differ when time and budgets are at risk. The low-voltage commissioning engineer's job is to record and report all changes to the owner to prevent future incompatibility issues. Another important responsibility is to test all installed systems prior to any inspection. If a malfunctioning nurse call dome light is caught in time, it can be repaired quickly and cheaply before it threatens to set the whole project back due to a failed inspection.

In the end, what becomes the bottom line in designing today's technology for healthcare is the need of each individual facility. It is ultimately up to the facility staff to decide what is needed and what is not. The designers must then properly design technology to fill those needs, and make sure it will work as planned when construction is complete. HD

Grant Ramsay is Principal and Director of Special Building Systems for X-nth, Inc., Maitland, Florida. Neal Boothe, PE, is Vice-President of X-nth, Inc.

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Healthcare Design 2009 January;9(1):36-39