Nursing homes may be defined as follows: extended care facilities for hospital patient recuperation. Clientele may be of any age, usually stay from 35 to 40 days, and usually have only one diagnostic problem. They no longer require hospital facilities but do require care by skilled nurses who administer therapeutic and rehabilitative services. These facilities are usually a direct hospital adjunct or they may be a separate facility with close hospital ties.
Skilled Nursing Homes
Generally care for elderly (average age of 80) people who require assistance in daily activities. Many of the patients are incontinent and non-ambulatory; some are disoriented. The patients typically come directly from independent living environments or residential care homes, stay an average of 47 months, and frequently have multiple diagnostic problems.
Residential Care Homes
Also known as congregated or assisted living facilities, residential care homes are usually for elderly people who are unable to do or have difficulty doing regular housekeeping chores, but have no acute ailments. The residents are able to care for all their personal needs, lead normal lives, and move freely in and out of the facility and the community.
In Assisted Living homes, nurse's aide-type personnel assist the residents with bathing, dressing, taking medication, and moving to and from dining rooms and recreation areas. In many respects, they resemble apartment buildings designed or modified to include extensive handicap amenities. These homes may or may not offer skilled nursing care. The average length of a stay is four (4) years or more.
Unlike Extended Care Units and Skilled Nursing Homes, Residential Care Homes frequently require tenants to supply their own task lighting and other amenities. However, general utilities may be allocated and even metered for each individual space. These arrangements will have a direct impact on the justification of improvements or modifications, especially those regarding energy usage.
Functionally, these buildings have five types of areas that may be of concern:
1) administrative and supportive areas inhabited by the staff
2) patient areas that provide direct normal daily services
3) treatment areas that provide special medical services
4) workrooms for storage and distribution of clean supplies
5) workrooms for collection of soiled and contaminated supplies and for sanitization of non-laundry items
Skilled nursing home and extended care facility occupants are usually frail, many are incontinent, some may be ambulatory, and some are bedridden with illnesses in advanced stages. Therefore, the selected HVAC system must dilute and control odors and should not cause drafts. Local climactic conditions, costs, and preferences usually determine the extent and degree of air conditioning and humidification. Odor control may deal with large volumes of outside air and some form of heat recovery. To conserve energy, odor control with activated carbon or potassium permanganate-impregnated, activated alumina filters may be used.
Temperature control should be on an individual room basis. However, there is the necessity for odor control, filtration, and airflow control between certain areas, especially common areas and hallways. Recommended filter efficiencies for air systems, minimum ventilation rates, and desired pressure relationships for specific areas in nursing homes can be found in the ASHRAE Applications Handbook.
The recommended interior design temperature in winter is 75°F for areas occupied by patients and 70°F for other areas. Provisions for maintenance of minimum humidity levels in winter depend on the severity of the climate. Where air conditioning is provided, the recommended interior design temperature and humidity in summer is 75°F and 50% relative humidity (RH).
For individual room control, closed-loop, water-loop, or geothermal heat pumps systems are often selected. Larger facilities with central chilled/hot water systems may use room fan-coil units; quality installations consider 4-pipe or similar systems so heating or cooling can always be selected. Low-rise buildings usually use roof-top gas/electric or heat pump packages for the public spaces and for ventilation air. In climates with severe winters, patients' rooms should have supplementary heat along exposed walls and under-window hot water or electric baseboard units to counter any cold down drafts. In climates where outside winter conditions are 30°F or above, overhead heating may be used instead.
Residential care homes may use HVAC designs similar to that of apartment buildings, which they closely resemble in many aspects.
Energy Saving Recommendations
Nursing homes are often looking at ways to cut costs. Some ways to do that in the energy department include high efficiency lighting, energy management systems, heat pipes, run-around loops, economizer cycles, "free cooling", and other forms of heat recovery and energy conservation. Energy costs can also be reduced in areas that use 100% outside air by utilizing run-around coils, VAV systems, load shedding, and systems to minimize ventilation in unoccupied areas. Other opportunities to minimze costs include:
- Investigating older, potentially inefficient systems to see if they need upgrading or replacement, particularly if CFC refrigerants are used
- Where demand and/or on-peak energy costs are high, investigate thermal storage
- Where through-the-wall PTAC heating and air conditioning is used, a conversion to a central two-pipe heat pump systems should be considered
- Energy conservation concepts discussed above that are not curently implemented, and antiquated, or inappropriate, control systems all represent energy saving opportunities
Hot water is required for bathtubs, showers, sinks, kitchen equipment, laundry equipment, and general cleaning. When other equipment, such as that necessary for hydrotherapy, is to be used, its additional hot water requirement must be factored in as well. The domestic hot water temperatures are usually restricted to as low as 105 ºF.
Most water heating is done separately from the building heating system and uses direct resistance or gas heaters; in some cases, point-of-use heaters. Some high-quality buildings use central distribution systems with storage and constant recirculation to wherever it is desirable to have hot water available continuously at the fixtures. Rural locations may use fuel oil or propane fired water heaters. Most residential care homes use individual heaters to meter use.
Energy Saving Recommendations
- Replace inefficient water heaters
- Improve heater insulation and/or controls (such as off-peak timers)
- Where excess/waste heat is available, consider water-to-water heat pumps for temperature needs up to 140°F or a water-to-air heat-pump water heater that will economically produce hot water and provide inexpensive cooling to the kitchen/corridors/etc.
- Where low cost off-peak or time-of-use rates exist, look into adding high temperature thermal storage.
- Consider installing a waste incinerator
Many nursing homes contain cafeterias or full-service dining operations. The cooking needs of each nursing home should be handled on an individual basis.
Because they are occupied by many people with poor vision, elderly care facilities such as nursing homes have special lighting requirements. Indirect lighting should be used as much as possible to reduce glare, and evenly illuminated floors are a must.
It is recommended that nursing homes use lamp sources such as incandescents and fluorescents with a 3000k to 3500k color temperature and a CRI of at least 80. Adjustable task fixtures, such as three-way table lamps, shoud be provided wherever possible. Follow the IES-recommended illumination requirements to ensure the appropriate task lighting for those over 50 years old.
Energy Saving Recommendations
When residents supply their own task lighting - usually with lamps - the facility should promote high efficiency replacements such as compact fluorescents. This can be accomplished by providing purchasing and even replacement services. If the facility provides lighting - exit lights, common area lights and fixed fixtures in occupant spaces - high efficiency lighting such as T-8 and LED exit signs can usually be justified for an overall energy conservation program.