Resilience of ‘Nightingale’ hospital wards in a changing climate:

TL;DR: The National Health Service (NHS) Estate in England comprises more than 30mm2 with 18.83m2 acute hospital accommodation on 330 sites as discussed by the authors, and there is concern about the resilience of these buildings.

Abstract: The National Health Service (NHS) Estate in England comprises more than 30 Mm2 with 18.83 Mm2 of acute hospital accommodation on 330 sites. There is concern about the resilience of these buildings ...

Summary

1 Introduction

• In England, 22% of National Health Service (NHS) acute hospital buildings pre-date 1948,1 and on some sites the majority of wards are of this type.
• In the post-2008 economic climate, however, the possibility of wholesale replacement is much diminished.
• 9,11 Thus although the NHS Heatwave Plan advocates a ‘passive approach’ to coping with heatwaves, it also suggests that the NHS should ‘target vulnerable areas (patients, medications, IT) with air conditioning’.8.

2 The Nightingale ward as a recurrent hospital building type

• The first use of the ‘Nightingale’ ward in British hospital design dates from the 1860s, although its roots are found in 18th-century French hospitals.
• It was advocated by various figures, not least Florence Nightingale, nurse, reformer and writer.
• Wards arranged as long, rectangular single-storey blocks, cross- and stack-ventilated by tall opposing windows, seemed to yield the most benign environments.
• Recent computational fluid dynamic modelling work has indeed demonstrated that significant rates of air change can be achieved.
• There was until the 1960s no national design guidance for hospitals, but some common patterns are recorded in Table 1.

3 Bradford Royal Infirmary

• Bradford Royal Infirmary moved to new buildings on the city’s western outskirts between 1927 and 1937.16.
• The hoppers had a double folding hinge enabling almost all free area to be realised .
• Orientation and layout Typically north/south pavilions, with separate ‘sanitary tower’ to one side, accessed via ventilated lobby.
• The below-window ventilators have been blocked; the convectors are modern replacements of the original ‘hospital’ radiators.

4.1 Internal temperatures

• The internal temperatures in four distinctly different spaces are currently being recorded at hourly intervals using Hobo U12, Hobo pendant and Tiny Tag loggers.a.
• During the monitoring period, the ambient temperature was not especially warm, reaching a maximum value of just 24.18C (see sections 4.2 & 5).
• Overall therefore it is evident that the temperatures in all the spaces were rather well controlled and well within the wide range recommended for wards by Health Technical Memorandum HTM03-01 of 188C to 288C,10 despite reduced ventilation capacity.
• The temperatures measured by each sensor are plotted against the running mean of ambient temperature, with the category envelopes overlaid, in Figures 8 to 11.

4.2 Energy use and CO2 emissions

• To predict the annual energy demands and resulting CO2 emissions of the Nightingale bHere and elsewhere comfort is as defined by the BSEN15251 categories and not by patient, staff or visitor perceptions.
• Further, predicted maximum, mean daytime and mean night-time operative temperatures were 28.28C, 23.68C and 22.98C, respectively, very similar to the monitored maximum, mean daytime and mean night-time operative temperatures were 28.28C, 23.48C and 22.78C.
• The model predicted 179 annual hours above the BSEN15251 Cat I upper temperature threshold.
• Across all UK hospitals these other elements would be about 44% of total energy demand.
• Notwithstanding this uplift, the adjusted energy demandc of about 25GJ/100m3 is well below the NHS target of 55–65GJ/ 100m3 for refurbished buildings and, indeed, below the target of 35–55GJ/100m3 for new buildings.

5 The refurbishment options and performance in current climate

• Current economic circumstances place a particular premium on light-touch refurbishment of NHS sites; similarly, a wholly reasonable concern to improve the patient experience also means that cosmetic changes can be favoured over more substantial interventions.
• The results were assessed using the CIBSE overheating criterion for night-time and the HTM03 criterion for all hours, except the option with the fan (Option 2), which is not amenable to analysis using HTM03.
• Rather importantly, however, the refurbishment reduces the impact of higher ambient temperatures and solar gain, resulting in a reduction in the peak temperatures (Table 4).
• Option 3 has the same insulation standards and shading as the other options, but seals all the windows.
• Primary heating and cooling is delivered through the installation of radiant ceiling panels (Table 3).

6 Performance in a future climate

• The standard temperature files for the current weather in Bradford, the Test Reference Year (called 2005TRY) and the Design Summer Year (called 2005DSY), were developed by the University of Exeter using the customary CIBSE methods as described by Levermore and Parkinson.
• Thus, as the years go by, the difference between the temperatures in typical and extreme years is accentuated.
• This approach is consistent with that taken previously by the authors.
• The results clearly indicate that neither the existing or refurbished building will overheat in typical years, as judged by the HTM03 and BSEN15251 criteria but in the 2050s warmer night-time temperatures may be experienced (although these might be ameliorated easily with a refined window opening regimen).

7 Conclusions

• What might be regarded as an archaic and redundant hospital building type, problematic in its plan geometry, reveals a degree of resilience to summertime overheating in gThis is the adjacent 5 km grid to the one containing the Bingley meteorological station.
• The narrow sections, high floor to ceiling heights, and the potential for cross ventilation, plus the mass inherent in the masonry and concrete construction, deliver the basic resilience.
• The addition of a slow fan (Option 2) further reduces the hours outside the Cat I envelope.
• The anxieties expressed relate to the facilities management issue of cleaning and infection control.

Figures

Figure 2 Typical Nightingale pavilion, Bradford Royal Infirmary, as designed/built 1927 and as currently. 1: Solid masonry wall, c.500mm thick inner brick, c.75mm rubble infill, 150mm coursed ashlar; 2: Airbricks to vents behind HW radiators; 3: Hot water ‘hospital’ radiator; 4: ‘Crittal’ type steel windows: Type ‘A’ with upper light comprising outward-opening hopper and lower side-hung casements, 3.025m2 max free area; 5: ‘Crittal’ type steel windows: Type ‘B’ with three stacked hopper windows providing 2.48m2 max free area; 6: Intermediate floors have unusually thin slab; facilities staff report embedded timber beams and that loading capacity is at maximum); 7: 75mm extruded polystyrene insulation; 8: 3-light aluminium-framed thermal break windows installed 1990s, centre light opening restricted to 100mm; 9: Ventilators blocked; 10: Hospital radiators replaced by convector heaters.

Figure 8 Comparison of measured temperatures with BSEN15251 comfort envelopes: Ward 8.

Figure 9 Comparison of measured temperatures with BSEN15251 comfort envelopes: Ward 9.

Figure 13 Predicted energy consumption pattern of the existing building and proposed refurbishment options during the year 2010.

Figure 4 Measured temperatures in Ward 8 and ambient conditions.

Figure 3 The Nightingale Wards showing temperature measurement locations: (a) Ward 8; (b) Ward 9.

Figure 7 Measured temperatures in Ward 9 administration office and ambient conditions.

Table 4 Summary of predicted internal operative and air temperatures for May to September, 2010 Bradford weather.

Figure 12 Percentage of all measured values in each BSEN15251 category.

Table 2 Summary of monitored internal temperatures.

Figure 5 Measured temperatures in Ward 9 and ambient conditions.

Figure 16 Frequency of occurrence of outdoor temperature above 208C.

Figure 15 Predicted carbon dioxide release pattern for different options during the year 2010.

Figure 11 Comparison of measured temperatures with BSEN15251 comfort envelopes: Ward 9 administration office.

Figure 10 Comparison of measured temperatures with BSEN15251 comfort envelopes: Ward 8 twin bed room.

Figure 6 Measured temperatures in Ward 8 twin bed space and ambient conditions.

Figure 1 Bradford Royal Infirmary, site plan in 2011 with key building dates.

Figure 14 Section showing existing configuration and refurbishment options. 1: Remove stone, insulate (125mm), replace stone, add insulation to roof to 300mm o/a; 2: High level 100mm air inlet ducts through solid wall with radiant panel to ceiling; 3: Radiant panel for hot and cold water; 4: Opening lights in existing window openings with guards as needed externally; 5: Introduce slow wide-span fans above beds; 6: Shading and lightshelves of perforated white powder-coated aluminium to suppress glare and achieve more even daylight distribution; 7: Seal vents and remove radiators/ convectors to counter cleaning problem; 8: Perimeter heating is retained below the windows.

Full text

Edinburgh Research Explorer
Resilience of 'Nightingale' hospital wards in a changing climate
Citation for published version:
Lomas, KJ, Giridharan, R, Short, CA & Fair, A 2012, 'Resilience of 'Nightingale' hospital wards in a
changing climate', Building Services Engineering Research and Technology, vol. 33, no. 1, pp. 81-103.
https://doi.org/10.1177/0143624411432012
Digital Object Identifier (DOI):
10.1177/0143624411432012
Link:
Link to publication record in Edinburgh Research Explorer
Document Version:
Publisher's PDF, also known as Version of record
Published In:
Building Services Engineering Research and Technology
Publisher Rights Statement:
© Lomas, KJ, Giridharan, R, Short, CA & Fair, A 2012, 'Resilience of 'Nightingale' hospital wards in achanging
climate' Building Services Engineering Research & Technology, vol 33, no. 1, pp. 81-103.,
10.1177/0143624411432012
General rights
Copyright for the publications made accessible via the Edinburgh Research Explorer is retained by the author(s)
and / or other copyright owners and it is a condition of accessing these publications that users recognise and
abide by the legal requirements associated with these rights.
Take down policy
The University of Edinburgh has made every reasonable effort to ensure that Edinburgh Research Explorer
content complies with UK legislation. If you believe that the public display of this file breaches copyright please
contact openaccess@ed.ac.uk providing details, and we will remove access to the work immediately and
investigate your claim.
Download date: 10. Aug. 2022

Resilience of ‘Nightingale’ hospital wards in a
changing climate
KJ Lomas
a
CEng BSc PhD FCIBSE MEI, R Giridharan
a
BArch MUrbDgn PhD AIA (SL), CA Short
b
MA (Cantab)
DipArch RIBA and AJ Fair
b
BA (Hons) MA PhD
a
Department of Civil and Building Engineering, University of Loughborough, Leicestershire, UK
b
Department of Architecture, University of Cambridge, Cambridge, UK
The National Health Service (NHS) Estate in England comprises more than 30 Mm
2
with
18.83 Mm
2
of acute hospital accommodation on 330 sites. There is concern about the
resilience of these buildings in a changing climate, informed by the experience of recent
heatwaves. However, the widespread installation of air conditioning would disrupt the
achievement of ambitious energy reduction targets. The research project ‘Design and
Delivery of Robust Hospital Environments in a Changing Climate’ is attempting to estimate
the resilience of the NHS Estate on the basis of current and projected performance, using
an adaptive comfort model. This paper presents results relating to a 1920s traditionally built
block with open ‘Nightingale’ wards, a representative type. The paper demonstrates the
relative resilience of the type, and illustrates a series of light-touch measures that may
increase resilience while saving energy.
Practical application: The results presented in this paper will be of value to NHS Trusts:
Estates staff charged with operating buildings as well as Boards and others involved in
decision-making. It will also find an audience with policymakers in central government and
the Department of Health, as well as those who own, operate or are tasked with working on
non-domestic buildings with heavy traditional construction.
1 Introduction
‘Nightingale’ hospital wards are open-plan
dormitories for 24–30 patients. They were the
dominant form of UK hospital ward before
1948, and a significant number remain in use.
In England, 22% of National Health Service
(NHS) acute hospital buildings pre-date
1948,
1
and on some sites the majority of
wards are of this type. However, Nightingale
wards are now considered undesirable by the
Department of Health (DH), which reports
that they offer ‘very little personal privacy or
peace’.
2
The DH called in 2001 for
Nightingale wards to be subdivided into
bays.
3
A growing call for single en-suite
rooms on the grounds of privacy and infec-
tion control has added to the debate, as the
dimensions of Nightingale wards often do not
support efficient conversion into single
rooms. There is thus pressure to replace
them. In the post-2008 economic climate,
however, the possibility of wholesale replace-
ment is much diminished. Many of these
wards will therefore remain in use for the
foreseeable future.
4
Address for correspondence: CA Short, Department of
Architecture, University of Cambridge, 1-5 Scroope Terrace,
Trumpington Street, Cambridge CB2 1PX, UK
E-mail: cas64@cam.ac.uk
Figures 3–13, 15 and 16 appear in color online:
http://bse.sagepub.com
Building Serv. Eng. Res. Technol. 33,1 (2012) pp. 81–103
ß The Chartered Institution of Building Services Engineers 2012 10.1177/0143624411432012

This paper presents the findings of an
investigation into a particular and previously
unexplored property of this building type, its
inherent resilience to high external tempera-
tures, which are predicted to be more prevalent
in the future. It takes as working examples
two Nightingale wards at Bradford Royal
Infirmary, considering their resilience and
proposing adaptive strategies to enhance it.
The work was carried out as part of the
research project ‘Design and Delivery of
Robust Hospital Environments in a
Changing Climate’, funded by the UK
Engineering and Physical Sciences Research
Council and the Department of Health. The
project is investigating the resilience of the
NHS Retained Estate and proposing econom-
ical and resilient strategies for its adaptation in
a changing climate to maintain what current
guidance considers acceptable thermal condi-
tions. The NHS faces a challenge: how to
deliver safe environments in a changing cli-
mate whilst meeting ambitious carbon reduc-
tion targets. The perhaps obvious strategy of
fully air conditioning more NHS buildings is
unlikely to deliver both results. Within the
total NHS Estate in England of more than
30 Mm
2
(million square metres), there are 330
acute hospital sites with a gross floor area of
18.83 Mm
2
of which at least 8.3 Mm
2
is occu-
pied by patients.
1
The NHS reports that it
generates 18% of the carbon emissions of the
UK non-domestic stock, 25% of UK public
sector emissions, and 3% of total UK emis-
sions.
5
In a typical UK hospital, 44% of the
energy used can be attributed to air and space
heating.
6
NHS organisations have ambitious
targets for delivered energy of 35–55 GJ/
100 m
3
in new buildings and 55–65 GJ/100 m
3
when refurbishing existing facilities for all
building uses (including space heating, hot
water, lights, appliances, catering).
6
However,
the energy use of the majority of NHS Trusts
in England is significantly higher, being in the
range of 44.8–98.0 GJ/100 m
3
for 2004/2005
peaking at 125 GJ/100m
3
.
7
The health implications of a changing
climate add to the challenge. UK heatwaves
in 2003 and 2006 saw elevated levels of
mortality
8
principally among the elderly and
chronically ill. Such people are likely to be
present in hospitals, alongside others unable
to take action in the face of high temperatures
including young children, the bed-bound, and
those with mental illnesses.
9
The NHS has a
fundamental duty of care and must provide a
safe and comfortable environment for
patients and visitors and staff (1.3 million
employees, 5% of the UK workforce). It has
acquired the role of offering a ‘safe haven’ for
the vulnerable. High temperatures can affect
certain pharmaceutical products as well as the
functioning of computers and medical diag-
nostic equipment. Guidance suggests that
naturally conditioned wards should not
exceed 288C for more than 50 occupied
hours per year.
10
The Department of Health advocates nat-
ural ventilation for non-critical spaces includ-
ing wards and offices,
10
but concerns about
infection control, worries about security and
safety at operable windows, and a risk-averse
procurement environment all act as barriers
to its implementation.
11
There are few exam-
ples of the application of innovative passive
cooling strategies in hospitals, even theoreti-
cally.
9,11
Thus although the NHS Heatwave
Plan advocates a ‘passive approach’ to coping
with heatwaves, it also suggests that the NHS
should ‘target vulnerable areas (patients,
medications, IT) with air conditioning’.
8
This paper is about patient spaces.
2 The Nightingale ward as a recurrent
hospital building type
The first use of the ‘Nightingale’ ward in
British hospital design dates from the 1860s,
although its roots are found in 18th-century
French hospitals.
12
It was advocated by
various figures, not least Florence
Nightingale, nurse, reformer and writer.
82 Resilience of ‘Nightingale’ hospital wards in a changing climate

Nightingale’s experience during the Crimean
War of 1853–1856 suggested that hospital
planning could significantly affect the inci-
dence of cross-infection, believed to be at least
partly the result of bad ventilation. Wards
arranged as long, rectangular single-storey
blocks, cross- and stack-ventilated by tall
opposing windows, seemed to yield the most
benign environments. Recent computational
fluid dynamic modelling work has indeed
demonstrated that significant rates of air
change can be achieved.
13,14
As developed in
the UK in the late 19th century, pavilions
typically comprised several storeys, hence the
reliance on cross-ventilation, as in the exam-
ple of St Thomas’, London (1868). A more
sophisticated single-storey version, top-lit and
mechanically ventilated, was developed in the
Royal Victoria Hospital, Belfast (1899).
15
There was until the 1960s no national design
guidance for hospitals, but some common
patterns are recorded in Table 1.
3 Bradford Royal Infirmary
Bradford Royal Infirmary moved to new
buildings on the city’s western outskirts
between 1927 and 1937.
16
The new hospital
was a typical ‘Nightingale’ example with
parallel four-storey ward blocks projecting
south from a long east/west spine corridor;
two wards on adjacent floors in one of these
pavilions are the focus of this paper
(Figure 1). Walls were load-bearing, of
stone, c.500 mm thick, comprising 150 mm
stone outer skin and 350–400 mm inner skin
with some rubble infill; roofs were flat. Each
pavilion, as originally designed, accommo-
dated on each floor 25–28 patients in the main
part of the ward in a space 33.8 metres long
by 8.2 m wide by 4.2 m floor to underside of
structural soffit (110 ft  22 ft  13 ft 9 in.),
with a small number of single and double
bedrooms and other ancillary spaces located
at the northern end of the pavilion. Sanitary
facilities were set to the east. The design
provided 20 m
2
per bed.
17
Windows were
‘Crittal’ type steel units of two types, with
opening casements below a high-level hopper
or with three top-hung ‘hopper’ windows
opening in and out below a fixed lower
casement. The hoppers had a double folding
hinge enabling almost all free area to be
realised (Figure 2). Ventilators below the
windows ducted air behind the radiators.
The wards being studied have, like many
others on the site, been subdivided within
recent years to create three separate bedded
areas, allowing gender segregation and reduc-
ing their ‘institutional’ quality, and beds now
can be curtained off. Suspended ceilings have
been installed, reportedly to reduce the heated
volume. Windows have been replaced with
thermally broken aluminium-framed double-
glazed units with significantly reduced open-
ing area with only the middle section being
operable; as is recommended by guidance
18
it
is limited to 100 mm. The result is a signifi-
cant reduction in the ability to provide
natural ventilation, although, interestingly,
the guidance suggests that larger openings
could be provided for use in very hot periods.
The originally open balconies at the ends of
the wards have been glazed in to provide
Table 1 Nightingale ward, key characteristics.
Orientation and layout Typically north/south pavilions, with separate ‘sanitary tower’ to one side, accessed via
ventilated lobby. From 1920s, many had south-facing open balcony.
Typical dimensions 23.7 m long  7.9 m wide  3.6 m tall; 38–58 m
3
per patient
(75 feet long  26 feet wide  12 feet tall; 1000–1500 cu.ft per patient)
Ventilation Type evolved to deliver natural cross-ventilation; up to 30 ach
1
via windows and openings
13
Heating Stoves and fires supplemented by low-pressure hot water systems in early 20th century.
Temperatures locally set but literature suggested temperature of at least 608F (15.58C)
26
KJ Lomas et al. 83

dayrooms. An ongoing programme of work is
adding 120 mm of insulation to the roof to
achieve a U-value of 0.24 W/m
2
.K; the roofs
already had 75 mm insulation during the
period being reported here (U-value of
0.3 W/m
2
.K). The below-window ventilators
have been blocked; the convectors are modern
replacements of the original ‘hospital’ radia-
tors. There is no mechanical ventilation.
4 Performance of existing wards
4.1 Internal temperatures
The internal temperatures in four distinctly
different spaces are currently being recorded
at hourly intervals using Hobo U12, Hobo
pendant and Tiny Tag loggers.
a
In addition to
the Nightingale wards, a number of other
ward types have been monitored on the site.
Although different loggers were used, they
were all calibrated prior to monitoring. The
difference between them for the same space
temperature is less than 0.28C. There are two
monitored spaces in Ward 8 on the 2nd floor
(Figure 3(a)); one has two beds and one has
24 beds. There are two spaces in Ward 9 on
the 3 rd floor (Figure 3(b)), i.e. one
Administration room and a 24-bed ward.
There were two recorded temperatures in the
twin bed room and the Administration room
and eight in each ward. Ward 9 was internally
partitioned but with openings between each
zone. Ward 8 was partitioned in late October
2010.
The internal temperatures reported here are
for a 69-day period from 1 June to 11 August
2010. The study uses weather data from the
Bingley station which is the closest
Meteorological Office site to the Infirmary,
being approximately 4 miles to the Northwest.
During the monitoring period, the ambient
temperature was not especially warm, reaching
a maximum value of just 24.18C(seesections
4.2 & 5). In mid-June, night-time lows of just
over 58C were recorded. The peak global solar
radiation intensity, which was predicted from
the recorded cloud cover at the Bingley, was
around 750 W/m
2
.
Despite the partitions the internal temper-
atures were rather similar throughout Ward 8
pre-1927
1927-36
1945-67
1960s
1970-95
Post 1995
The case
study ward
50m 100m 200m
Figure 1 Bradford Royal Infirmary, site plan in 2011 with key building dates.
a
The temperature recorded approximates to air temperature,
but must include an unknown radiant component.
84 Resilience of ‘Nightingale’ hospital wards in a changing climate

Frequently asked questions

Q1. What are the contributions in "Resilience of ‘nightingale’ hospital wards in a changing climate" ?

Short et al. this paper investigated the resilience of the NHS Retained Estate and proposed economical and resilient strategies for its adaptation in a changing climate to maintain what current guidance considers acceptable thermal conditions. 

Q2. What future works have the authors mentioned in the paper "Resilience of ‘nightingale’ hospital wards in a changing climate" ?

The future weather years were created from the UKCP09 future climate projections assuming an A1B global emissions development scenariof using the method evolved by the University of Exeter for the ‘ Prometheus ’ research project. It can be seen that the occurrence of higher temperatures increases gradually in the TRYs but quite rapidly in the DSYs. The results clearly indicate that neither the existing or refurbished building will overheat in typical years, as judged by the HTM03 and BSEN15251 criteria but in the 2050s warmer night-time temperatures may be experienced ( although these might be ameliorated easily with a refined window opening regimen ). The BSEN15251 approach, which accommodates human adaptation to the prevailing ambient conditions and thus their preference for warmer conditions in free-running buildings as the ambient conditions become warmer, indicates that the refurbishment options that do not incorporate cooling will remain comfortable in both typical and extreme years right up to 2080s.