S. Roostaie¹, N. Nawari, Ph.D., P.E.²

¹Ph.D. student, UF School of Architecture, College of Design, Construction & Planning, University of Florida, P.O. Box 115702, 1480 Inner Road, Gainesville, FL 32611-5702; email: sroostaie@ufl.edu

² UF School of Architecture, College of Design, Construction & Planning, University of Florida, P.O. Box 115702, 1480 Inner Road, Gainesville, FL 32611-5702; email: nnawari@ufl.edu

Declarations of interest: none.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

ABSTRACT

Every year, the United States experiences a large number of deaths and billions of dollars in damage due to the growing trend of climate hazards such as hurricanes and floods. The disruptive nature of such events challenges the functionality of the built environment and communities. The resilience of critical structures such as hospitals is the key to achieve resilient communities. This is due to the fact that they provide lifeline services that need to be maintained during and after the disaster. This paper aims at studying the resilience of healthcare facilities as an essential step towards achieving community resilience. The United States has an interconnected utility model which includes electricity, gas supply, water supply, landline telecommunication, mobile phone, etc. Failure of one has a cascading effect on the others. This paper focuses on electricity disruption in the face of disasters which frequently leads to failures in other systems. The results demonstrate the impact of utility interruption on the operation of healthcare facilities as one of the most challenging issues in the face of natural hazards. Shortcomings in the performance of alternative sources such as performance lag of backup generators and short term service of Uninterruptible Power Supply (UPS) systems exist. This requires using new technologies in the field of service restoration such as Combined Heat and Power (CHP) and microgrids. The primary sources of information used in developing this paper are research publications, policy papers, reports and tool guidelines as well as case studies. The paper proposes solutions to address these shortcomings and improve the resilience of healthcare facilities to cope with future natural disasters.

KEYWORDS

healthcare facility, resilience, resilient Community, utility resilience, natural hazards, CHP system, microgrid

Introduction

The United States has experienced significant losses in terms of life, property and economic activity due to natural disasters over the past 10 years. The National Oceanic and Atmospheric Administration (NOAA, 2019) reported fourteen weather and climate disasters –including Hurricanes Michael, and Florence– in 2018 across the US with losses exceeding $1 billion each (Figure 1). This was the fourth highest total number of events, only behind 2017, 2011, and 2016. “These events resulted in the deaths of 247 people and had significant economic effects [over 91 billion dollars only behind the years 2017, 2005 and 2012] on the areas impacted”(NOAA, 2019)(see Figure 2). In regard to this concomitant escalation in numbers of large-scale emergencies and natural disasters, the role of healthcare facilities has significantly increased over the last twenty years (Cristian, 2018). Hospitals play a key role in community resilience by providing “lifeline” services which minimize the impact of disasters on the community and help to achieve higher community resilience (Braun et al., 2006; Paturas et al., 2010). Resilience is defined by the Resilient Design Institute (2018) as “a fundamental function of buildings, landscapes, communities, and regions to respond to natural and manmade disasters and disturbances—as well as long-term changes resulting from climate change—including sea level rise, increased frequency of heat waves, and regional drought”.

Figure 1. This map denotes the approximate location for each of the 14 separate billion-dollar weather and climate disasters that impacted the United States during 2018. Source: (NOAA, 2019a)

Figure 2. a) 1980-2018 Year-to-Date United States Billion-Dollar Disaster Event Frequency. b) 1980-2018 Year-to-Date United States Billion-Dollar Disaster Event Cost. Source: (NOAA, 2019a) https://www.ncdc.noaa.gov/billions/

Healthcare facilities fall into the category of critical infrastructures. The United States PATRIOT Act of 2001, defines critical infrastructure as “systems and assets, whether physical or virtual, so vital to the United States that the incapacity or destruction of such systems and assets would have a debilitating impact on security, national economic security, national public health or safety, or any combination of those matters” (Cook et al., 2018). The importance of hospitals in the aftermath of crises, to not only remain standing but also functional extends beyond the necessity to sustain uninterrupted medical services for the community. They are where affected individual seek shelter, food, water and psychosocial support (Paturas et al., 2010). There has been a substantial research on healthcare resilience with more focus on structural and functional aspects and post-crisis upgrading strategies (Mehani et al. , 2011; Wilkinson et al., 2012) or developing a framework of key indicators of hospital resilience (Zhong et al., 2015), and evaluating and measuring hospital resilience ( Zhong et al., 2014; Cimellaro et al., 2018).

One of the key factors in maintaining a hospital functional is the availability of utility services. In recent years, the frequency of utility resilience publications seems to be increasing. For example, in recent publications, Arboleda et al. (2006) studied the impact of infrastructures and their interdependencies on healthcare facilities, and Achour, et al., (2014) investigated the impact of utility performance on hospital resilience. This shows an increasing interest in focusing on the resilience of hospital utility system. Additionally, disasters such as Hurricane Katrina in 2005 and Superstorm Sandy in 2012 demonstrated the fragility of healthcare facilities in the United States. They highlighted the interdependence of individual infrastructure systems and proved that failures cascade from one subsystem to another and from one system to the next (Arboleda et al., 2006). In this regard, the literature indicates the need for more research on the impact of utility services on the resilience of healthcare facilities, and to identify the possible implications of utility interruption on the continuity of healthcare services (Achour et al., 2014; Balbus & Guenther, 2014).

Goals and Objectives:

The main goal of this research is to improve the resilience of healthcare facilities to cope with natural disasters. It focuses on the issues related to utility interruption on the operation of healthcare facilities in the face of natural hazards such as hurricane and sea level rise. The primary objectives of this study include (1) exploring the resilience of healthcare facilities regarding utility supplies and specifically power outage. (2) identifying the challenges of using alternative sources such as backup generators; and (3) proposing solutions to improve the resilience of healthcare facilities.

Methodology:

The primary sources of information used to develop this paper are peer-reviewed journal articles, policy papers, reports and, grey literature which were found through searching Web of Science and ProQuest databases. Additional references were identified through examination of the references from most recent publications. Two sets of search terms were used, namely, (1) “resilience and healthcare facilities or hospitals” or (2) “hospitals or hospital resilience and utility or utility resilience” and (3) “hospital or healthcare resilience and CHP and microgrid”. The language was set to English and the publication year was set to 2005 (Hurricane Katrina to 2019. The titles and abstracts of records were examined for relevance and significance and irrelevant publications were removed if focused on performance or staff resilience, structural resilience of hospitals, supply change management, etc. Records were selected for the full assessment if included resilience of healthcare facilities, the impact of utility interruption on hospital resilience, and alternative sources of power such as CHP and microgrid systems. Full-text records were then analyzed for their contribution to the definition of hospital resilience, the impact of utility outage on the resilience of healthcare facilities, alternative sources of power and their potential shortcomings, as well as the application of microgrid system. Figure 3 outlines the method and searching strategy of this study.

Figure 3. The study approach, search process, and evaluation strategy.

Results:

The concept of resilience is gaining momentum in academia and practice in response to “the damage caused by the overexploitation of resources” (Lizarralde et al., 2015) which causes the earth’s climate to change and deviate from historical climate data (Champagne & Aktas, 2016). The Intergovernmental Panel on Climate Change (IPCC) ( 2018) identifies a series of five key Reasons For Concern (CFR) with regard to effects of climate change which includes RCF2 and RCF3 as extreme weather events and large scale singular events respectively (see Figure 4).

Figure 4. Five Reasons For Concern (RFCs) illustrate the impact and risks of different levels of global warming for people, economics and ecosystems across sectors and regions. Source: (IPCC, 2018).

During Hurricane Harvey which hit the Houston, TX area in August 2017, 20 of the roughly 120 hospitals in the area had to close or evacuate (Cavanaugh & Farbstein, 2017). As Mcdaniels et al. (2008) point out, resilient infrastructure systems, particularly ‘‘lifeline’’ services such as electric power, water, and health care, play a crucial role in minimizing the impact of extreme events including earthquakes, storms, floods, or terrorism. In this regard, and as part of the global resilience movement to avoid continued environmental degradation in the past decade, the resilience of healthcare facilities has become one of the fundamental pillars of community resilience. The resilience of a healthcare facility is defined as its “ability to resist, absorb, and respond to the shock of disasters while maintaining its critical health care functions, and then recover to its original state or adapt to a new one” (Zhong et al., 2014).

In addition to the structural stability of healthcare facilities, maintaining their functionality, or business continuity, depends, to a great extent, on the resilience of utility and energy distribution systems. According to the U.S. Department of Energy (2009), resilience against major disasters is the most essential characteristic of the future smart distribution systems. There is a substantial number of case studies showing the impact of utility failure on the resilience of healthcare facilities (Cocanour et al., 2002; Gray & Hebert, 2007). Some examples of hospitals’ failure include Southeastern Regional Medical Center in North Carolina which lost municipal water during Hurricane Matthew in 2016, and Myrtle Beach Gulf Coast Regional Medical Center in Florida Panhandle which suspended all services on October 11 2018, and evacuated all patients due to the impact of Hurricane Michael(Morgan, 2018). These problems have resulted in producing guiding documents such as Climate Resilient Healthcare Facilities Initiative and its corresponding report Primary Protection: Enhancing Health Care Resiliency For A Changing Climate by the U.S. Department of Health and Human Services in 2014 (Balbus & Guenther, 2014). Therefore, it is important to better understand the utility services and their role in sustaining the continuity of medical services during and after a crisis.

The utility system includes electricity, gas supply, water supply, landline telecommunication, mobile phone, etc. It also covers all systems, equipment, and fixtures, including mechanical, electrical, plumbing, heating, ventilating, and air conditioning (Balbus & Guenther, 2014). The United States has an interconnected utility model. In such a model the failure of one system has a cascading effect on the others and gives rise to numerous challenges that do not exist in single infrastructure models (Arboleda et al., 2006). This paper focuses on electricity which is frequently affected by extreme events, and quite often leads to failures in other systems.

4.1. Challenges of Using backup Systems:

Hospitals are required to comply with ‎NFPA 110 (Standard for Emergency and Standby Power Systems) in conjunction with NFPA 70 (National Electrical Code) to include emergency power generation that activates within 10-sec­onds of loss of grid power, with sufficient fuel for 96 hours of operation. The emergency power generators are usually fueled by diesel oil to provide required electrical power in case of the municipal grid failure. If undamaged and given uninterrupted fuel supply, these generators can remain operational through the municipal electrical grid (Balbus & Guenther, 2014). In reality, however, there have been issues with the performance of power generators. There is usually a lag time between grid failure and generator startup. This interruption, no matter how brief, can be detrimental to patients undergoing surgery or under critical care at an ICU (Johnson, 2016). Also, because backup generators are not used on a regular basis, they can encounter problems in an actual emergency or if used at full loads for an extended period of time (ICF International, 2013). Uninterruptible Power Supply (UPS) is another alternative source for healthcare facilities. Unlike backup generators, UPS Systems provide immediate, short term electricity as a backup in the event of an electrical power outage (CC&N, 2019). During the superstorm Sandy in 2012, the failure of both grid power and emergency generators forced hospitals to evacuate. Because, although backup generators were located above flood elevations, the critical infrastructure components such as fuel pumps, fuel tanks, electrical switchgear, were not (Balbus & Guenther, 2014). While the region was affected by an extended power outage for days, some critical infrastructure and industrial facilities, including Greenwich Hospital and South Oaks Hospital remained functional due to their onsite combined heat and power (CHP) system (ICF International, 2013).

What is a CHP system?

Combined heat and power (CHP) is a form of the distributed generation which produces both electricity and thermal energy(Figure 5). The captured heat is a byproduct of electricity production that provides hot water or steam which can be used for space heating, cooling, domestic hot water, and industrial processes. Capturing and using the waste heat allows CHP systems to reach an overall efficiency of 65–85%, compared with 45-55% for conventional separate heat and power systems (US Department of Energy, 2017). Figure 6 indicates the main advantages of CHP systems over backup generators.

Figure 5. CHP System with Backup Responsibility for Critical Loads. Modified from (ICF International, 2013; SWCOGEN, 2018)

Thanks to the CHP technology, Greenwich Hospital in Greenwich, Connecticut maintained its services during hurricane Sandy. Greenwich Hospital, a 175 bed, 5000,000 sq ft medical center experienced only 7 seconds of a power outage during Superstorm Sandy while the surrounding area lost power for almost 7 days. The hospital’s CHP system consists of two 1,250 kW natural gas-fired reciprocating engines. The whole transition from using grid power to operating solely on the CHP system takes approximately 5 minutes. It requires the CHP system to shut down and restart in island mode, while power is being supplied to the hospital by a 2,000 kW backup generator (ICF International, 2013).

Figure 6. Comparison between CHP and backup generators. Information from (ICF International, 2013).

CHP systems despite showing significant success during recent events can only offer a partial solution to the problem of healthcare resilience. As the resiliency discussion evolves there is a convergence in research and industry around the merits of microgrids to deliver more resilient energy for cities, communities, and campuses, especially those clusters that value business continuity and enhanced life-safety, such as hospitals, against a clear trend of more frequent, severe weather events. (Utility Dive, 2018).

Microgrid, the Solution to Enhance Resilience of Healthcare Facilities:

According to the U.S. Department of Energy (DOE), a microgrid is “a group of interconnected loads and distributed energy resources within clearly defined electrical boundaries that acts as a single controllable entity with respect to the grid. A microgrid can connect and disconnect from the grid to enable it to operate in both grid-connected or island mode” (Ton & Smith, 2012). This self-sufficient energy system can serve a discrete geographic footprint such as a university campus or a hospital (Figure 7). The microgrid relies on a different kind of distributed energy to produce its power, including solar panels, wind turbines, combined heat and power (CHP) system, and generators (Wood, 2017).

Figure 7. Microgrid Technology.

The resilience of a microgrid emanates from its ability to island itself from the main grid. It also creates energy for nearby customers. This local energy generation offers an answer to the problem of 8-15% transition loss of central grids (Wood, 2017). Additionally, in the case of predictable problems, such as a forecasted massive storm, the microgrid can adopt a precautionary strategy by reducing non-vital loads, preparing a local generation for dispatch, and charging batteries to increase the future resilience of the system (Wild et al., 2016). Successful examples of microgrid projects such as the district energy/CHP microgrids at Princeton University, New York University and Co-Op City in the Bronx during Superstorm Sandy proved the value and resilience of community-scale microgrids anchored by district energy and combined heat & power (CHP) systems, even while emergency generator sets sputtered, failed or exhausted fuel supplies (Utility Dive, 2018).

Microgrids typically rely on fossil fuel sources including distributed generators running on natural gas or diesel, but renewable energy has increased significantly from about 4 MW in 2008 to 164 MW in 2016. Photovoltaics (PV) account for 73% of this renewable capacity. (Cook et al., 2018). Figure 8 shows different capacity growth scenarios for the U.S. microgrid system.

Figure 8. U.S. Microgrid Capacity Growth Under Different Forecast Cases. Source: (GTM, 2016).

DISCUSSION:

Given the large number of environmental and geophysical natural hazards and the threat they pose to lives and livelihoods, the role of the healthcare system in the face of a crisis becomes more and more important. The resilience of healthcare facilities is a key factor in achieving community resilience. Recent events have proved that “when struck by large-scale natural disasters, hospital services are interrupted temporarily or permanently, mainly due to damage to their infrastructure”(PAHO, 2004). Healthcare facilities depend on different internal and external systems to deliver their services. Increased technological capability such as increased use of monitors, HVAC, and artificial lighting systems has resulted in many power-depended systems (Achour, 2015). Hospitals also have some critical energy loads to run the operating rooms, ventilators, radiology devices, etc. In this regard increasing the resilience of healthcare facilities to ensure their business continuity is of utmost importance. One way to improve resilience and reduce this dependence is to maintain a high number of potential responses to change (Kibert et al., 2011) or to provide multiple independent and redundant ways of supplying necessary services. For example, facilities that incorporate renewable power on-site have a third option to operate critical ventilation systems when grid infrastructure is unavailable and backup generators fail. (Balbus & Guenther, 2014). Consequently, health care facilities should have alternative power supplies to achieve a certain level of independence from the energy grid, especially in emergency situations. The traditional approach uses power generators to produce electricity when the main supply is interrupted. This approach, however, proved not to always be reliable due to the functional issues associated with the use of power generators. This includes, their unexpected malfunction during an actual emergency when they must be used at full loads for an extended period of time, their limited fuel supply, performance lag, and their shortcoming in providing thermal energy including heating and cooling.

To secure the continuity of utility supplies, the literature suggests three major solutions as follows: “(1) improv[ing] the resilience of utility infrastructure to natural hazards; (2)[ to] ensure that healthcare utility supplies are well covered by resilience codes and legislation; and (3) improv[ing] performance of alternative sources” (Achour et al., 2014). Enhancing the resilience of utility infrastructure requires an effort at a national level to establish a long-sighted energy policy. In terms of resilience codes and regulations, there are several codes and standards that govern emergency power requirements for the hospitals, including NFPA 110, 101, 99, 70 (Davoudi, 2015). These codes, however, cover the mandatory back up generation requirements which even if functional are useful only for short term outages. Because they assume “all necessary services would be restored within 96 hours”(Balbus & Guenther, 2014). This brings us to the third suggestion which calls for improving the performance of alternative sources. This requires deploying resilient solutions which share a few key components such as onsite electricity generation, islanding controls, black start capability, and energy storage solutions (Cook et al., 2018). “Island” operation is one of the most essential features of a resilient healthcare facility. Using the microgrid technology, the islanded hospital campus maintains its operational capability even in the absence of municipal electricity and thermal energy for extended periods of time.

Conclusion:

Healthcare facilities are one of the most critical facilities in any country. These complex systems host many interconnective systems and subsystems which are heavily dependent on infrastructure schemes. The importance of health care facilities lies in their critical role in community resilience especially during and after large-scale disasters. Recent events such as hurricane Sandy and Harvey demonstrated the fragility of the U.S. healthcare system. Setting the structural integrity of these facilities aside, this vulnerability emerges from their dependency on external sources and utility services. One way to increase the resilience of health care facilities is to reduce their reliance on utility and power distribution systems. This study proposes a framework based on microgrid systems to address this problem. A microgrid system generates and stores power onsite and can perform in both grid-connected and islanded mode. The strength of this approach relies on its independence from the grid during an outage to effectively function and provide all required energy loads. Given the importance of hospitals in delivering effective services when confronted with disasters, there is an urgent need for improving healthcare utility resilience. Future research will focus on developing a comprehensive framework and strategy to achieve this goal.

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