Medical facilities are a priority when we look at implementing cross-connection control standards and installing backflow protection. From hospitals to dialysis centers, to dentist and doctor offices, to walk-in medical clinics, each presents different challenges and hazards. The size and complexity of these facilities can be a challenge to surveyors and inspectors looking for issues. Ongoing expansion and updates to these types of locations can also be a significant challenge to ensuring the proper protection is installed and maintained.
Looking at full-service hospitals as an example, it is possible to see hundreds — if not thousands — of cross-connections within the facility. Ensuring that each cross-connection is eliminated or protected, and that the required protection is maintained — and in the case of backflow assemblies tested annually — is critically important. Starting with the water service to the facility you can see that the need for continuous water is addressed with the installation of containment protection in parallel (photo 1). Many medical centers have multiple water services feeding the facility from different parts of the public distribution system. The International Plumbing Code (IPC) in Section 609.2 (Water Service) states: “Hospitals shall have two water services pipes installed in such a manner so as to minimize the potential for an interruption of the supply of water in the event of a water main or water service pipe failure.”
When we look at the facility itself, hazards exist everywhere. As a plumber there are certain facilities that we love to build — I refer to them as the big three. Hotels, prisons and hospitals stand out as places where water closets, lavatory sinks, and related plumbing exist in almost every room. Hospitals, however, are number one. In the mechanical areas you will find high-pressure steam boilers with chemical treatment systems, as well as medical gas and vacuum equipment. Chillers and cooling towers create additional hazards. Operating rooms, sterilizers, autoclaves, bedpan washers, large commercial washers, and food service areas pose further risks. Morgue tables, MRI cooling systems, dialysis suites, and fire protection piping all add to list of potential crossconnections. This is just the tip of the iceberg of issues that exist within the facility.
The plumbing code addresses health care plumbing with some particular requirements just for these locations. The Uniform Plumbing Code (UPC®) in Section 603.5.15 (Health Care or Laboratory Areas), states: “Vacuum breakers for washer hose bedpans shall be located not less than 5 feet above the floor. Hose connections in health care or laboratory areas shall not be less than 6 feet above the floor.” (photo 2) The code also addresses other equipment. Section 603.5.16 (Special Equipment) states: “Portable cleaning equipment and dental vacuum pumps shall be protected from backflow by an air gap, an atmospheric vacuum breaker, a spill-resistant vacuum breaker, or a reduced pressure principle backflow preventer.” Because of changes in technology and remodeling or expansion of many hospitals, cross-connection control must be constantly addressed, and facility maintenance personnel must be well trained to understand the problems that can and will occur.
Correctly identifying systems piping within a large facility is also vital, and the plumbing code addresses the issue. The UPC states in Section 601.3 (Identification of a Potable and Nonpotable Water System): “In buildings where potable water and non-potable water systems are installed, each system shall be clearly identified.” The code goes further, stating in Section 601.3.2 (Color and Information): “Each system shall be identified with a colored pipe or band and coded with paints, wraps, and material compatible with the piping.” The UPC uses ANSI colors to achieve conformity and be recognizable (photo 3).
With the popularity of off-site dialysis centers for treatment, it is important to recognize we are dealing with a high hazard issue in what may simply look like a storefront in a shopping mall. The location is not a factor in the cross-connection protection required on these systems. Whether in a remote location or within a hospital, the containment assembly should be a reduced pressure principle assembly. The UPC addresses the protection required for the dialysis process in two sections. Section 603.5.18 (Pure Water Process Systems) states: “The water supply to a pure water process system, such as a dialysis water system, semiconductor washing system, and similar process piping systems, shall be protected from backpressure and backsiphonage by a reduced pressure principle backflow preventer.”
Section 603.5.18.1 (Dialysis Water Systems) states: “The individual connections of the dialysis related equipment to the dialysis pure water system shall not require additional backflow protection.” Testing requirements for these assemblies may be more frequent. For example, the state of New Jersey requires containment assemblies at dialysis centers to be tested on a quarterly basis.
Cleaning equipment in a medical center can also be problematic. A surveyor or inspector must be concerned about chemical dispensers attached to the building’s water systems. In some cases, these are installed after the inspection process is complete and may be installed incorrectly, creating backflow issues. The most common issue is using a service sink faucet as the water supply for the dispenser (photo 4). The ASSE 1055 chemical dispenser includes integral backflow protection, so no additional protection is needed if it is installed with a dedicated water supply to the dispenser. Problems arise when the faucet is used incorrectly. The UPC addresses the issue in Section 603.5.22 (1) (Chemical Dispensers): “The chemical dispenser shall comply with ANSI/CAN/ASSE/IAPMO 1055. Where an installation involves a water source coming from a faucet with an integrated vacuum breaker device, a pressure bleed device confirming to IAPMO PS 104 shall be used to protect the vacuum breaker device” (photo 5). This bleed device will prevent the vacuum breaker from being subjected to backpressure of continuous pressure and will ensure that the faucet handles are turned off when not in use. It also allows the faucet to supply water to the fixture. It is a low-cost, simple solution to the problem.
The truth is, some cross-connection problems in medical settings no longer exist because of changes to the technology we are now using. Water-cooled X-ray machines have been replaced by digital imaging. Most modern dental chairs no longer require a water supply; instead, a water tank is filled and connected to the chair each day, effectively air gapping the fixture from the system.
We do have challenges to address to minimize the potential for issues. We need to remain proactive and work to eliminate problems before they occur. Low-flow fixtures, dead legs in the piping systems, Legionella, and many other things can affect water quality and safety. Training for employees is another vital component in our overall system protection. We need to get things right each and every day. This is work that will never be finished. Every day is a new adventure, but it is what we do. We protect the water supply and we protect the health of the world.
