ANSI/BICSI 004-2018

Information Communication
Technology Systems Design and
Implementation Best Practices for
Healthcare Institutions and Facilities

Committee Approval: March 2018

ANSI Final Action: April 5, 2018
First Published: April 2018
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 ANSI/BICSI 004-2018

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BICSI standards and publications are designed to serve the public interest by offering information communication and
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TABLE OF CONTENTS

PREFACE ........................................................................................................................................ xi

1 Introduction ..................................................................................................................................... 1
1.1 General ............................................................................................................................................................ 1
1.2 Purpose ............................................................................................................................................................ 1
1.3 Categories of Criteria..................................................................................................................................... 1

2 Scope ........................................................................................................................................... 1

3 Required Standards and Documents ............................................................................................ 3

4 Definitions, Acronyms, Abbreviations, and Units of Measurement .......................................... 5

4.1 Definitions ....................................................................................................................................................... 5
4.2 Acronyms and Abbreviations ........................................................................................................................ 6
4.3 Units of Measurement .................................................................................................................................... 7

5 Regulatory Bodies and Regulations ............................................................................................. 9

5.1 Authorities Having Jurisdiction (AHJ’s) ..................................................................................................... 9
5.1.1 Centers for Medicare & Medicaid Services (CMS) .................................................................................... 9
5.1.2 Department Of Health, Ministry Of Health ................................................................................................ 9
5.1.3 Accrediting Organizations .......................................................................................................................... 9
5.2 Patient Information Privacy ........................................................................................................................ 10
5.2.1 Health Insurance Portability and Accountability Act (HIPAA) ............................................................... 10
5.3 Disability Access ........................................................................................................................................... 10
5.3.1 Americans with Disabilities Act (ADA) ................................................................................................... 10
5.3.2 Disability Discrimination Act [Australia]................................................................................................. 10
5.4 Other Organizations..................................................................................................................................... 11

6 Communications Infrastructure .................................................................................................. 13

6.1 Overview ....................................................................................................................................................... 13
6.2 OSP Pathways and Spaces ........................................................................................................................... 13
6.2.1 Requirements ............................................................................................................................................ 13
6.2.2 Recommendations .................................................................................................................................... 13
6.3 Entrance Facilities ........................................................................................................................................ 13
6.3.1 Location .................................................................................................................................................... 13
6.3.2 Cabling Entrance ...................................................................................................................................... 14
6.3.3 Design Requirements ................................................................................................................................ 14
6.4 Equipment Rooms ........................................................................................................................................ 14
6.4.1 Requirements ............................................................................................................................................ 14
6.4.2 Recommendations .................................................................................................................................... 14
6.4.3 Additional Information ............................................................................................................................. 15
6.5 Telecommunications Rooms ........................................................................................................................ 15
6.5.1 Requirements ............................................................................................................................................ 15
6.5.2 Recommendations .................................................................................................................................... 15
6.5.3 Additional Information ............................................................................................................................. 16
6.6 Cabling Pathways ......................................................................................................................................... 18
6.6.1 Requirements ............................................................................................................................................ 18
6.6.2 Recommendations .................................................................................................................................... 18

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6.7 Work Areas ................................................................................................................................................... 19

6.7.1 Telecommunication Outlets ...................................................................................................................... 19
6.7.2 Patient Care Areas .................................................................................................................................... 19
6.7.3 Water and Wet Areas ................................................................................................................................ 19
6.8 Cabling .......................................................................................................................................................... 19
6.8.1 Requirements ............................................................................................................................................ 19
6.8.2 Recommendations ..................................................................................................................................... 19
6.9 Transmission Performance Field Testing ................................................................................................... 19
6.9.1 Introduction ............................................................................................................................................... 19
6.9.2 Requirements ............................................................................................................................................ 19
6.9.3 Recommendations ..................................................................................................................................... 19
6.10 Wireless Networks ........................................................................................................................................ 20
6.10.1 Overview................................................................................................................................................... 20
6.10.2 General Design Considerations ................................................................................................................. 20
6.10.3 Distributed Antenna Systems .................................................................................................................... 21
6.10.4 Discrete Antenna Systems ........................................................................................................................ 22
6.10.5 Wireless System Grades of Service .......................................................................................................... 23
6.11 Passive Optical Networks ............................................................................................................................. 24
7 General Design Considerations ...................................................................................................25
7.1 Architectural ................................................................................................................................................. 25
7.1.1 Overview................................................................................................................................................... 25
7.1.2 NFPA 99, Healthcare Facilities Code ....................................................................................................... 25
7.1.3 FGI Guidelines .......................................................................................................................................... 25
7.1.4 Ceilings ..................................................................................................................................................... 25
7.1.5 Patient Rooms ........................................................................................................................................... 25
7.1.6 Controlled and Sterile Environments ........................................................................................................ 26
7.2 Redundancy................................................................................................................................................... 27
7.2.1 Space Redundancy .................................................................................................................................... 27
7.2.2 Network and System Redundancy ............................................................................................................ 29
7.3 Electrical Power ............................................................................................................................................ 29
7.3.1 Overview................................................................................................................................................... 29
7.3.2 Power Supply Units .................................................................................................................................. 29
7.3.3 Uninterruptible Power Supplies ................................................................................................................ 29
7.4 Security Control Frameworks .................................................................................................................... 30
7.4.1 Introduction .............................................................................................................................................. 30
7.4.2 HIPAA Security Rule ............................................................................................................................... 30
7.4.3 National Institute of Standards and Technology (NIST) Cybersecurity Framework ................................. 31
7.4.4 NIST Special Publication (SP) 800-53 ...................................................................................................... 31
7.4.5 ISO/IEC 27001:2013 and 27002:2015 ...................................................................................................... 32
7.4.6 Center for Internet Security (CIS) Critical Security Controls (aka “Top Twenty”) ................................... 32
8 Healthcare Systems .......................................................................................................................33
8.1 Nurse and Code Call Systems ...................................................................................................................... 33
8.1.1 Overview................................................................................................................................................... 33
8.1.2 System Architecture .................................................................................................................................. 33
8.1.3 Devices ..................................................................................................................................................... 34
8.1.4 Communications Interface ........................................................................................................................ 36
8.1.5 Wireless Nurse Call Systems .................................................................................................................... 36
8.1.6 Code Call Systems .................................................................................................................................... 36
8.2 Connected Medical Imaging ........................................................................................................................ 37
8.2.1 Overview................................................................................................................................................... 37
8.2.2 Imaging Modalities ................................................................................................................................... 37
8.2.3 Imaging Infrastructure and Communication Systems ............................................................................... 37
8.2.4 Network Bandwidth and Service Level Agreement Considerations ......................................................... 39

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8.3 Patient Monitoring (Telemetry) .................................................................................................................. 41

8.3.1 Overview .................................................................................................................................................. 41
8.3.2 System Connections ................................................................................................................................. 41
8.3.3 Cabling ..................................................................................................................................................... 42
8.3.4 Power Recommendations ......................................................................................................................... 43
8.3.5 Monitors ................................................................................................................................................... 43
8.3.6 Additional Information ............................................................................................................................. 43
8.3.7 Wireless Medical Telemetry System (WMTS)......................................................................................... 44
8.4 Physician Dictation ....................................................................................................................................... 44
8.4.1 Overview .................................................................................................................................................. 44
8.5 At-Risk Human Perimeter Systems ............................................................................................................ 44
8.5.1 Overview .................................................................................................................................................. 44
8.5.2 Infant Abduction Prevention..................................................................................................................... 44
8.5.3 Supervised Care Elopement Prevention ................................................................................................... 45
8.6 Interactive Patient Television System ......................................................................................................... 46
8.6.1 Overview .................................................................................................................................................. 46
8.6.2 System Description ................................................................................................................................... 46
8.6.3 Design with Coaxial Cabling Systems...................................................................................................... 47
8.6.4 Design with Balanced Twisted-Pair Cabling Systems .............................................................................. 48
8.7 Alarm Management ..................................................................................................................................... 49
8.7.1 Overview .................................................................................................................................................. 49
8.7.2 Devices ..................................................................................................................................................... 49
8.7.3 Design Overview ...................................................................................................................................... 49
8.7.4 Building Automation and Management Systems ..................................................................................... 50
8.7.5 Medical Systems ....................................................................................................................................... 50
8.7.6 Electronic Safety and Security (ESS) Systems ......................................................................................... 50
8.8 Emergency Medical Services Radio ............................................................................................................ 50
8.8.1 Overview .................................................................................................................................................. 50
8.8.2 Requirements ............................................................................................................................................ 50
8.8.3 Recommendations .................................................................................................................................... 50
8.9 Telemedicine, Communication and Notification Suites ............................................................................ 51
8.9.1 Telemedicine ............................................................................................................................................ 51
8.9.2 Communication and Notification Suites ................................................................................................... 51

9 Other Information Communication Technology Systems ........................................................ 52

9.1 Notification Systems ..................................................................................................................................... 52
9.1.1 Overview .................................................................................................................................................. 52
9.1.2 System Types............................................................................................................................................ 52
9.1.3 Notification System Inputs ....................................................................................................................... 53
9.1.4 Connectivity Arrangements ...................................................................................................................... 53
9.1.5 Design Considerations .............................................................................................................................. 53
9.1.6 Integration................................................................................................................................................. 54
9.2 Intercom Systems ......................................................................................................................................... 54
9.2.1 Overview .................................................................................................................................................. 54
9.2.2 Components .............................................................................................................................................. 54
9.2.3 System Types............................................................................................................................................ 55
9.2.4 Healthcare Applications ........................................................................................................................... 56
9.2.5 Operation .................................................................................................................................................. 56
9.2.6 Integration................................................................................................................................................. 57
9.2.7 Wireless Intercoms ................................................................................................................................... 57

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9.3 Sound and Acoustical Systems .................................................................................................................... 57

9.3.1 Purposes of Sound Systems: ..................................................................................................................... 57
9.3.2 Sound Systems .......................................................................................................................................... 57
9.3.3 Sound System Design Conditions: ............................................................................................................ 58
9.3.4 Integration ................................................................................................................................................. 58
9.3.5 Code and AHJ Requirements .................................................................................................................... 58
9.4 Sound Masking/Privacy Systems ................................................................................................................. 58
9.4.1 Overview................................................................................................................................................... 58
9.4.2 Requirements ............................................................................................................................................ 59
9.4.3 Recommendations ..................................................................................................................................... 59
9.5 Emergency Communication Telephone ...................................................................................................... 59
9.5.1 Overview................................................................................................................................................... 59
9.5.2 Components .............................................................................................................................................. 59
9.5.3 Location .................................................................................................................................................... 59
9.6 Digital Signage and Wayfinding .................................................................................................................. 59
9.6.1 Overview................................................................................................................................................... 59
9.6.2 Digital Displays ........................................................................................................................................ 60
9.6.3 Usage Conditions ...................................................................................................................................... 60
9.6.4 Design Considerations .............................................................................................................................. 61
9.6.5 Wayfinding Recommendations ................................................................................................................. 61
9.7 Clock and Time Systems .............................................................................................................................. 61
9.7.1 Master Clock System ................................................................................................................................ 61
9.7.2 Elapsed Time Clock .................................................................................................................................. 62
9.7.3 Time and Attendance System ................................................................................................................... 62
9.8 Electronic Safety and Security Systems ...................................................................................................... 63
9.8.1 Overview................................................................................................................................................... 63
9.8.2 Requirements ............................................................................................................................................ 63
9.9 Radio Frequency Identification (RFID)-Based Systems ........................................................................... 63
9.9.1 Overview................................................................................................................................................... 63
9.9.2 Retail/Asset Management ......................................................................................................................... 63
9.10 Real Time Locations System (RTLS) .......................................................................................................... 63
9.10.1 Overview................................................................................................................................................... 63
9.10.2 Active vs Passive Systems ........................................................................................................................ 63
9.10.3 Common Methods of Transmission .......................................................................................................... 64

10 Integration of Systems ..................................................................................................................65

10.1 Overview ........................................................................................................................................................ 65
10.2 Integrated Operating Rooms ....................................................................................................................... 65
10.2.1 Overview................................................................................................................................................... 65
10.2.2 Devices ..................................................................................................................................................... 65
10.2.3 Design Considerations .............................................................................................................................. 66
10.3 Procedure Rooms .......................................................................................................................................... 68
10.3.1 Overview................................................................................................................................................... 68
10.3.2 Operational Requirements ........................................................................................................................ 68
10.3.3 Devices ..................................................................................................................................................... 69
10.3.4 Coordination ............................................................................................................................................. 70
10.3.5 Procedure Room Integration ..................................................................................................................... 70
10.3.6 Procedure Room Pathways ....................................................................................................................... 70
10.3.7 Grounding ................................................................................................................................................. 71
10.3.8 Commissioning ......................................................................................................................................... 71
10.3.9 System Training ........................................................................................................................................ 71

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Appendix A Infectious Control Risk Assessment (ICRA) (Informative) ....................................... 73

A.1 Overview ....................................................................................................................................................... 73
A.2 Background ................................................................................................................................................... 73
A.3 Policy ............................................................................................................................................................. 73
A.4 Products ........................................................................................................................................................ 74
A.5 Infection Control Training .......................................................................................................................... 74
A.6 Contractor Work Schedule.......................................................................................................................... 74
A.7 Storage of Building Materials...................................................................................................................... 75
A.8 Protective Clothing for Contractors ........................................................................................................... 75
A.9 Contractor’s Access to Occupied Areas ..................................................................................................... 75
A.10 Construction of Short Duration Barriers ................................................................................................... 75
A.11 Construction of Long Duration Barriers.................................................................................................... 75
A.12 Negative Pressurization of Work Zone ....................................................................................................... 75
A.13 HEPA-Filtered Fan Units and HEPA-Filtered Vacuums ......................................................................... 76
A.14 Construction in Occupied Areas ................................................................................................................. 76
A.15 Enforcement .................................................................................................................................................. 76

Appendix B Network Security (Informative) .................................................................................... 77

B.1 Overview ....................................................................................................................................................... 77
B.2 Risks .............................................................................................................................................................. 78
B.3 Control Measures ......................................................................................................................................... 79
B.4 General Security Recommendations........................................................................................................... 85
B.5 Trends............................................................................................................................................................ 87
B.6 Network Security for Facility and IT Networks ........................................................................................ 87

Appendix C Network Design Principles (Informative) .................................................................... 89

C.1 Overview ....................................................................................................................................................... 89
C.2 Systems Integration and Interfacing ........................................................................................................... 89
C.3 Scalability ...................................................................................................................................................... 89
C.4 Resource Sharing.......................................................................................................................................... 89
C.5 Reliability ...................................................................................................................................................... 90
C.6 Resiliency ...................................................................................................................................................... 90
C.7 Standardization ............................................................................................................................................ 91
C.8 Network Management and Administration ............................................................................................... 91
C.9 Bandwidth and Quality of Service (QoS) ................................................................................................... 91
C.10 Intelligence to the Edge Devices .................................................................................................................. 92

Appendix D Related Documents (Informative) ................................................................................ 93

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INDEX OF FIGURES

Section 6 Communications Infrastructure

Figure 6-1 Typical TR Layout ..........................................................................................................................17
Figure 6-2 Typical Healthcare TR ....................................................................................................................17
Figure 6-3 Typical Healthcare TR (Split Rooms) .............................................................................................18

Section 7 General Design Considerations

Figure 7-1 Redundancy Examples for ICT Spaces and Cabling Backbone ......................................................28

Section 8 Healthcare Systems

Figure 8-1 Main PACS Functions.....................................................................................................................38
Figure 8-2 Example of a Stand-Alone Patient Monitoring Station ...................................................................42
Figure 8-3 Example Interactive Patient Television System Infrastructure .......................................................47
Figure 8-4 Broadband Video Distribution Over Balanced Twisted-Pair Cabling.............................................48

Appendix B Network Security (Informative)

Figure B-1 Stand-Alone Network ......................................................................................................................80
Figure B-2 Enterprise Network .........................................................................................................................81
Figure B-3 Example of Security Zones..............................................................................................................82
Figure B-4 Example of Facility & IT Network Topology .................................................................................88

INDEX OF TABLES

Section 6 Communications Infrastructure

Table 6-1 Example of Applied Service Grades ...............................................................................................23
Table 6-2 Service Assurance Requirements ....................................................................................................24

Section 8 Healthcare Systems

Table 8-1 Typical Study Size for Differing Image Modalities ........................................................................40
Table 8-2 Example Transmission Times of Image Modalities for Differing Transmission Technologies ......40
Table 8-3 Example of Study Size and Expected Annual Load ........................................................................41

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PREFACE

Revision History

December 4, 2012 First publication of this standard, titled BICSI 004-2012, Information Technology Systems
Design and Implementation Best Practices for Healthcare Institutions and Facilities

April 12, 2013 Published as an American National Standard, with the designation of ANSI/BICSI 004-2012

April 25, 2018 Revision of ANSI/BICSI 004-2012, retitled and published as ANSI/BICSI 004-2018,
Information Communication Technology Systems Design and Implementation Best Practices
for Healthcare Institutions and Facilities

Major revisions include:

• Expansion of Section 5, Regulatory Bodies and Regulations
• Expansion of content for communication and ICT infrastructure
• Expansion of content for wireless systems
• Addition of passive optical networks
• Expansion of content for architectural aspects of healthcare facilities
• Addition of content for telemedicine and communication suites
• Content revision for notification and intercom systems
• Addition of content for emergency medical services radio, sound and acoustical systems, sound masking, and
digital signage and wayfinding
• Addition of Appendix B, Network Security
• Addition of Appendix C, Network Design Principles

Minor revisions include:

• Restructure of former Sections 1-8 with relevant content relocated into the new structure
• Added content for electrical power
• Added content for security control frameworks
• Minor revisions of healthcare systems
• Revision of real time location systems
• Other content updates and editorial corrections

Document Format (Usability Features)

This standard has the following usability features as aids to the user:
• Additions and changes, other than those for editorial purposes, are indicated with a vertical rule within the left
page margin.
• Deletion of one or more paragraphs within unrevised content is indicated with a bullet (•).

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Translation Notice

This standard may have one or more translations available for the convenience of its readers. As translated text may
contain inconsistencies when compared to the original text, if differences between the translation and the published
English version exist, the English text shall be used as the official and authoritative version.

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1 Introduction

1.1 General
Today’s healthcare facilities are encountering many issues because of:
• Rapid changes in medical technologies
• Rapid changes in information technologies
• An aging nursing workforce and patient demographics
Industry initiatives are also a key factor in the need to upgrade or replace the built electronic infrastructure, such as:
• Electronic health records
• Patient portable (personal) health records
• Electronic security
• Clinical and information technology convergence
Today’s modern hospital’s technology infrastructure supports the following:
• Medical procedures and clinical processes
• Business and enterprise operations
• Building and facilities requirements
A hospital’s main function is to treat the injured, sick and infirmed and its infrastructure must be capable of supporting
that mission.
This standard is intended primarily for, but not limited to, healthcare facilities, such as:
• Hospitals
• Skilled nursing facilities (nursing homes)
• Rehabilitation centers
• Psychiatric facilities
• Ambulatory clinics and surgical centers
• Outpatient clinics
• Acute care facilities
1.2 Purpose
This standard is written for use in the design and implementation of information technology systems used within
healthcare facilities. This standard provides a reference of common technology and design practices and is not intended
to be used by architects and engineers as their sole reference or as a step-by-step design guide. This standard may also
be used to determine design requirements in conjunction with the system owner, occupant, or safety and security
consultant.
1.3 Categories of Criteria
Two categories of criteria are specified: mandatory and advisory.
• Mandatory criteria generally apply to protection, performance, administration, and compatibility; they specify
the absolute minimum acceptable requirements.
• Advisory or desirable criteria are presented when their attainment will enhance the general performance of the
building system infrastructure in all its contemplated applications.
Mandatory requirements are designated by the word shall; advisory recommendations are designated by the words
should, may, or desirable, which are used interchangeably in this standard. When possible, recommendations and
requirements were separated to aid in clarity.

2 Scope
This standard provides requirements and recommendations for best practices for the design and implementation of
information communication technology systems infrastructure for healthcare institutions and facilities.

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3 Required Standards and Documents

The following standards and documents contain provisions that constitute requirements listed within this standard.
Unless otherwise indicated, all standards and documents listed are the latest published version prior to the initial
publication of this standard. Parties to agreement based on this standard are encouraged to investigate the possibility of
applying a more recent version as applicable.
Where equivalent local codes and standards exist, requirements from these local specifications shall apply. Where
reference is made to a requirement that exceeds minimum code requirements, the specification requirement shall take
precedence over any apparent conflict with applicable codes.

BICSI
• ANSI/BICSI 002, Data Center Design and Implementation Best Practices
• ANSI/BICSI 005, Electronic Safety and Security (ESS) System Design and Implementation Best Practices
• ANSI/BICSI 006, Distributed Antenna System (DAS) Design and Implementation Best Practices
• ANSI/BICSI 007, Information Communication Technology Design and Implementation Practices for
Intelligent Buildings and Premises
• ANSI/BICSI 008, Wireless Local Area Network (WLAN) Systems Design and Implementation Best Practices

European Committee for Electrotechnical Standardization (CENELEC)

• EN 50173-1, Information technology—Generic cabling systems—Part 1: General requirements

International Organization for Standardization (ISO)

• ISO/IEC 11801-1, Generic cabling for customer premises – Part 1: General requirements
• ISO/IEC 11801-6, Generic cabling for customer premises – Part 6: Distributed building services
• ISO/IEC 14763-2, Information technology – Implementation and operation of customer premises cabling –
Part 2: Planning and installation

National Fire Protection Association (NFPA)

• NFPA 70®, National Electrical Code®
• NFPA 99, Health Care Facilities Code

Telecommunication Industry Association (TIA)

• ANSI/TIA-526-7-A, Measurement of Optical Power Loss of Installed Single-Mode Fiber Cable Plant,
Adoption of IEC 61280-4-2 edition 2: Fibre-Optic Communications Subsystem Test Procedures – Part 4-2:
Installed Cable Plant – Single-Mode Attenuation and Optical Return Loss Measurement
• ANSI/TIA-526-14-C, Optical Power Loss Measurements of Installed Multimode Fiber Cable Plant; IEC 612
80-4-1 Edition 2, Fibre-Optic Communications Subsystem Test Procedure – Part 4-1: Installed Cable Plant
– Multimode Attenuation Measurement
• ANSI/TIA-568.2-D, Balanced Twisted-Pair Telecommunications Cabling and Components Standard
• ANSI/TIA-568.3-D, Optical Fiber Cabling and Components Standard
• ANSI/TIA-569-D, Telecommunications Pathways and Spaces
• ANSI/TIA-758-B, Customer-Owned Outside Plant Telecommunications Cabling Standard
• ANSI/TIA-862-B, Structured Cabling Infrastructure Standard for Intelligent Building Systems
• ANSI/TIA-1152-A, Requirements for Field Test Instruments and Measurements for Balanced Twisted-Pair
Cabling
• ANSI/TIA-1179-A, Healthcare Facility Telecommunications Infrastructure Standard

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4 Definitions, Acronyms, Abbreviations, and Units of Measurement

4.1 Definitions
For the purposes of this document, the following terms and definitions apply. Some terms and definitions may also be
represented by an acronym as listed in Section 4.2

annunciator An electrical signaling device used to indicate the sources of calls or alarms on a
switchboard or control panel (e.g., as used in hotels or offices).
backbone (1) A facility (e.g., pathway, cable, conductors) between any of the following
spaces: telecommunications rooms (TRs), common TRs, floor-serving terminals,
entrance facilities, equipment rooms, and common equipment rooms (CER). (2) In
a data center, a facility (e.g., pathway, cable, conductors) between any of the
following spaces: entrance rooms or spaces, main distribution areas, intermediate
distribution areas, horizontal distribution areas, and TRs.
backbone cabling See backbone.
critical power A subsystem of the emergency system that supplies energy to task illumination,
special power circuits, and selected receptacles serving areas and functions related
to patient care and that is connected to alternate power sources by one or more
transfer switches during the interruption of the normal power source.
cross-connect A facility enabling the termination of cabling elements and their interconnection or
cross-connection.
distributed antenna system A system that transmits or relays radio frequency signals (e.g., signals from
cellular/personal communications system telephones, text pagers, wireless local
area networks) within buildings, structures, tunnels, or other areas where wireless
services cannot be otherwise provided.
equipment room An environmentally controlled centralized space for telecommunications and data
(telecommunications) processing equipment with supporting communications connectivity infrastructure.
horizontal cabling (1) The cabling between and including the telecommunications outlet and
connector and the horizontal cross-connect. (2) The cabling between and including
the building automation system outlet or the first mechanical termination of the
horizontal connection point and the horizontal cross-connect. (3) Within a data
center, horizontal cabling is the cabling from the horizontal cross-connect (in the
main distribution area or horizontal distribution area) to the outlet in the equipment
distribution area or zone distribution area.
horizontal cross-connect A cross-connect of horizontal cabling to other cabling (e.g., backbone cabling,
active equipment).
internet protocol The Open Systems Interconnection Reference Model Layer 3 (Network layer)
protocol most commonly used for internetworking. Required for communications
over the Internet.
media Wire, cable, or conductors used for telecommunications.
(telecommunications)
panel An electrical device consisting of an enclosure, box or surface that may contain
switches, dials, displays or meters for controlling or monitoring other electrical
devices.
patch panel A connecting hardware system that facilitates cable termination and cabling
administration using patch cords.

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pathway A facility for the placement of telecommunications cable.

(telecommunications)
proprietary A characteristic of a technique, technology, or device which is owned and
controlled by a company or other party and is thereby only usable or adaptable as
allowed by that party and not deemed to achieve interoperability.
redundancy The provision of secondary components or other elements that either become
operational or allow continuous operation so that failure of a specified primary
component does not result in mission failure.
space (telecommunications) An area whose primary function is to house the installation and termination of
telecommunications equipment and cable (e.g., equipment room,
telecommunications room, entrance facility).
telecommunications Any transmission, emission, and reception of information (e.g., signs, signals,
writings, images, sounds) by cable, radio, optical, or other electromagnetic systems.
telecommunications outlet An assembly of which consists of a faceplate, body, housing, or supporting bracket,
and one or more receptacles or jacks of a telecommunication connector.
Telecommunications outlets are typically located to provide ease connection for
communication and data equipment (e.g., computer, phone).
telecommunications room A telecommunications space that differs from equipment rooms and entrance
facilities in that this space is generally considered a floor-serving or tenant-serving
(as opposed to building- or campus-serving) space that provides a connection point
between backbone and horizontal cabling.
termination The physical connection of a conductor or fiber to connecting hardware.
topology The physical or logical arrangement of a system.
uninterruptible power A system that provides a continuous supply of power to a load, utilizing stored
supply energy when the normal source of energy is not available or is of unacceptable
quality. A UPS will provide power until the stored energy of the system has been
depleted, or when the acceptable quality of either an alternative source of power
(e.g., generator) or the normal source of power becomes available.
zone cabling A design methodology that utilizes a connection point centrally located within areas
with higher densities of telecommunications outlets and devices being served.

4.2 Acronyms and Abbreviations

Abbreviations and acronyms, other than in common usage, are defined as follows:

ADA American Disabilities Act CT computed tomography

AHJ authority having jurisdiction DAS distributed antenna system
AV audio visual DR digital radiology
AWG American wire gauge EF entrance facility
BAS building automation system EHR electronic health record
BMS building management system ESS electronic safety and security
CATV community access television HIPAA Health Insurance Portability and
CCTV closed circuit television Accountability Act
CfC condition for coverage HVAC heating ventilation and air conditioning
CIA confidentiality, integrity, and availability ICT information communication technology
CoP condition of participation ICU intensive care unit
CR computerized radiology IP internet protocol

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IV intravenous RTLS real time locating system

LAN local area network TO telecommunication outlet
LED light emitting diode TCP/IP transmission control protocol/internet
MRI magnetic resonance imaging protocol
NM nuclear medicine TR telecommunications room
OR (medical) operating room UPS uninterruptible power supply
PACS picture archival and communications US ultrasound
systems UTP unshielded balanced twisted-pair
PET positive emission tomography VGA video graphics array
PoE power over Ethernet VoIP voice over internet protocol
RF radio frequency WLAN wireless local area network
RFID radio frequency identification XA x-ray angiography
RT radiation therapy

4.3 Units of Measurement

The units of measurement used in this standard are metric. Approximate conversions from metric to U.S. customary
units are provided in parentheses; e.g., 100 millimeters (4 inches).
Units of measurement used in this standard are defined below:

bit binary digit

C Celsius
cfm cubic foot per minute
dBm decibel milliwatt
F Fahrenheit
ft foot; feet
ft2 square foot
Gb/s gigabit per second
Hz hertz
in inch
m meter
m2 square meter
m3/min cubic meter per minute
Mb megabit
MB megabyte
Mb/s megabit per second
MHz megahertz
mil 1/1000 of an inch
mm millimeter
V volt
VAC volt alternating current
VDC volt direct current

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5 Regulatory Bodies and Regulations

5.1 Authorities Having Jurisdiction (AHJ’s)

Several regulating bodies may have authority over the installation and maintenance of information technology system
devices, infrastructure, spaces, etc. As such all designs, installation and maintenance of information technology system
equipment shall be completed in such a manner as to meet the appropriate AHJ standard for the facility or program. The
facility licensing and provider type identifies the acceptance requirements for the AHJ which could include and may
not be limited to: Government Agencies (i.e. Ministry of Health or Centers for Medicare & Medicaid Services, or
Department of Health by State), and Accrediting Organizations (i.e. Joint Commission). The AHJ considers collectively
Healthcare Facilities codes (i.e. NFPA 99), National Electrical Codes, state and local building codes, and Healthcare
Facility Guidelines to form acceptance requirements.
5.1.1 Centers for Medicare & Medicaid Services (CMS)
Many Healthcare facilities depend on receiving monetary payments from government programs. In the United States,
Healthcare organizations that receive payment from Medicare or Medicaid programs must be certified as complying
with the federal Conditions of Participation (CoPs), and Conditions for Coverage (CfCs). The CMS is the agency within
the United States Department of Health and Human Services that administers the Medicare program and works with
state governments to administer Medicaid, the State Children's Health Insurance Program (SCHIP), and health insurance
portability standards. CMS responsibilities include stipulating compliance with quality standards in long-term care
facilities through its survey and certification process, and maintaining clinical laboratory quality standards under the
Clinical Laboratory Improvement Amendments. CMS ensures that the standards of any Accrediting Organizations
recognized by CMS through a process called "deeming" meet or exceed the Medicare standards set forth in the CoPs &
CfCs.
5.1.2 Department Of Health, Ministry Of Health
Each State has the responsibility for certifying healthcare facilities CMS compliance or noncompliance in that state. A
State Department of Health Survey Agency evaluates and certifies each participating healthcare facility for compliance
with state laws, CoPs & CfCs requirements and then certifies it as a provider institution. Be aware states conduct
standard surveys and complete them on consecutive workdays, whenever possible. The State’s certification for a facility
is subject to CMS’ approval. The CMS regional office determines a facility’s eligibility to participate in the Medicare
program based on the State’s certification of compliance and a facility’s compliance with civil rights requirements;
however, “Certification of compliance” means that a facility’s compliance with Federal participation requirements is
ascertained. In addition to certifying a facility’s compliance or noncompliance, the State recommends appropriate
enforcement actions to the State Medicaid agency for Medicaid and to the regional office for Medicare. A hospital
accredited by a CMS-approved accreditation program may substitute accreditation under that program for survey by the
State Survey Agency. Healthcare facility new construction or renovation plans and specifications often need approval
by the state Department of Health prior to construction.
5.1.3 Accrediting Organizations
In the United States if a national accrediting organization, such as the Joint Commission, has and enforces standards
that meet the federal CoPs, CMS may grant the accrediting organization "deeming" authority and "deem" each health
care facility accredited by that organization as meeting the Medicare and Medicaid certification requirements. The health
care facility would have "deemed status" and would not be subject to the Medicare survey and certification process
because it has already been surveyed by the Accrediting Organization. Accreditation is voluntary and seeking deemed
status through accreditation is an option, not a requirement. Healthcare facilities seeking CMS approval may choose to
be surveyed either by an accrediting body, such as Joint Commission, DNV Healthcare, a subsidiary of Det Norske
Veritas (DNV), The Healthcare Facilities Accreditation Program (HFAP), or by state surveyors on behalf of CMS.
Joint Commission is the United States oldest and largest standards-setting and accrediting body in healthcare with
deeming authority from the Centers for Medicare & Medicaid Services (CMS). Joint Commission Accreditation is
recognized within the United States as a symbol of quality which indicates that an organization meets Joint Commission
performance standards. Surveyors assess hospital's compliance with the Medicare CoP for all services, areas and
locations covered by the hospital's provider agreement under its CMS Certification Number (CCN). The Joint
Commission publishes its own accreditation standards.

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In the limited context of this standard, the Accrediting Organization is a unique AHJ within the United States which has
authority over the installation and maintenance of information technology system devices, infrastructure, spaces, etc.
As such, all designs, installation and maintenance of information technology system equipment shall be completed in
such a manner as to meet the appropriate accrediting organization’s standard for the facility or program.
5.2 Patient Information Privacy
5.2.1 Health Insurance Portability and Accountability Act (HIPAA)
The American Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a set of rules to be followed by
health plans, doctors, hospitals and other health care providers. HIPAA took effect on April 14, 2003. In the health care
and medical profession, the great challenge that HIPAA has created is the assurance that all patient account handling,
billing, and medical records are HIPAA compliant.
The goals and objectives of this legislation are to reduce industry inefficiencies, reduce paperwork, make it easier to
detect and prosecute fraud and abuse, and enable workers of all professions to change jobs, even if they (or family
members) had pre-existing medical conditions.
Compliance with the Health Insurance Portability and Accountability Act (HIPAA) is more complex than simply using
products that claim to be “HIPAA-compliant.” HIPAA compliance entails an organized set of secure, monitored, and
documented practices within and between covered entities. Though products cannot ensure compliance, some products
may contain elements or features that allow them to be operated in a HIPAA-compliant way.
Some provisions of the HIPAA involve patient hospital interaction. For example, patients must be able access their
record and correct errors and must be informed of how their personal information will be used. Other provisions involve
confidentiality of patient information and documentation of privacy procedures. It is these provisions that have led to
regulation-specific software updates, specialist consulting, and in some cases complete overhauls of medical billing and
records systems.
5.3 Disability Access
5.3.1 Americans with Disabilities Act (ADA)
Within the United Sates, the Americans with Disabilities Act provides requirements for the access and use of public
accommodations and telecommunications by those with disabilities. As such, designers of healthcare facilities in the
United States need to ensure that all systems under their purview meet these requirements. Designers for facilities
outside of jurisdiction of the United States should check with the applicable national and local AHJ(s) to ensure that all
relevant regulations concerning disability access are met.
5.3.2 Disability Discrimination Act [Australia]
The Federal Disability Discrimination Act 1992 (DDA) provides protection for everyone in Australia against
discrimination based on disability. The DDA makes it against the law to discriminate against someone if they have a
disability in different area of life, including:
• Access to premises used by the public.
• Provision of goods, services and facilities.
• Administration of Commonwealth Government laws and programs
Access considerations include:
• All areas within places used by the public should be accessible to people with a disability.
• Facilities should be accessible (e.g., wheelchair-accessible toilets, lift buttons within reach, tactile and audible
lift signals for people with vision impairments)
• Required information is available and accessible by all users of the premises.

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5.4 Other Organizations

The following organizations provide additional information concerning regulatory requirements that may be
encountered:
• Academy of Architecture for Health (AAH)
• American Hospital Association (AHA)
• American Institute of Architects (AIA)
• American Society for Healthcare Engineering (ASHE)
• California Office of Statewide Healthcare Planning and Development (OSHPD)
• Centers for Disease Control (CDC)
• Centers for Medicare & Medicaid Services (CMS)
• Department of Health and Human Services (HHS)
• Health Information Management Systems Society (HIMSS)
• National Fire Protection Administration (NFPA)

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6 Communications Infrastructure

6.1 Overview
Healthcare pathways and spaces require additional space consideration to support systems unique to the healthcare
environment. In addition to the supporting systems the communications infrastructure needs to accommodate other
factors, such as:
• Security considerations
Physical security of systems which process, transmit, and store data may require special treatment under the
Health Insurance Portability and Accountability Act (HIPAA). This should be coordinated with the owner.
NOTE: See ANSI/TIA-5017 for information on securing the physical network.
• Redundancy considerations
Because of the critical nature of services provided in the healthcare environment, consideration should be given
to providing redundant carrier services and entrance facilities serving the facility.
• Pathway considerations
Pathway design and space assignment shall be coordinated with the mechanical, electrical, plumbing, and
pneumatic tube systems designers.
Pathways and spaces shall be designed in accordance with the requirements of the AHJ following the relevant cabling
and implementation standards (e.g., ISO/IEC 14763-2, ANSI/TIA-1179-A, ANSI/TIA-569-D, ANSI/TIA-758-B).
6.2 OSP Pathways and Spaces
6.2.1 Requirements
The design of outside plant pathways and spaces should be consistent with standards such as ANSI/TIA-758-B and
ISO/IEC 14763-2.
If multiple service pathways are used, they shall have a minimum separation of 6 m (20 ft).
6.2.2 Recommendations
Utility companies installing service via underground conduit should maintain redundant pathways for maintenance
purposes. In the case of customer owned outside plant providing pathways for utility services, then the designer should
provide enough space for multiple service providers and maintain redundant pathways for maintenance.
Diversely routed pathways should be physically separated by at least 20 m (66 ft) at all points along their routes.
6.3 Entrance Facilities
The entrance facility (EF) consists of the pathways, spaces, cables, connecting hardware, protection devices, and other
passive and active equipment that support the service provider (SP) and access provider (AP).
6.3.1 Location
[Link] Requirements
The EF shall be located:
• As close as practicable to communications service entry point.
• Above the highest known flood level.
• Away from exterior curtain walls
• As close as practical to the electrical service ground to minimize bonding conductor lengths between the ICT
electrical grounding infrastructures.
In multi-story buildings, the EF shall not be located on the top or highest floor.
[Link] Recommendations
EF should be located on floors above grade and where possible, above the level known to be at risk for flood. EFs should
not be located in areas subject to water intrusion from external sources (e.g., fountains, utility services).
In multi-story buildings, the EF should be located above grade and within the bottom 33% (1/3) of the building.
If multiple EFs are used, they should have a minimum separation of 15 m (50 ft).

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6.3.2 Cabling Entrance

[Link] Requirements
To reduce the risk of injury or damage to the building or its occupants, the maximum length of outside plant cable that
may enter the facility is determined by the AHJ and applicable codes. Beyond this length, the cable must be transitioned
and connected to cable with an allowed rating and/or placed within an allowed pathway.
For critical care facilities, multiple entrance points and route diversity shall be provided.
When the primary data center serving the facility is located remote from the facility, two entrance facilities with
redundant communications services shall be provided.
[Link] Recommendations
Diverse entrance cabling pathways should have route separation as great as practical.
Where not otherwise required, redundant cabling entrance points or an equivalent strategy to provide redundant data
services should be provided.
6.3.3 Design Requirements
The EF shall be designed in accordance with the requirements of the standard being followed, such as ANSI/TIA-569-
D or ISO/IEC 14763-2.
If the EF is to support additional systems (e.g., building automation, nurse call, security, CATV, clinical systems), the
EF shall be increased in size to provide adequate space for these additional systems. If the EF cannot be increased in
size the additional systems shall be installed in the equipment room or telecommunications room.
The minimum size of the EF shall be the larger of the AHJ requirements or 4 m x 4.5 m (12 ft by 14 ft)
6.4 Equipment Rooms
NOTE: To minimize confusion in this document, the acronym “ER” will not be used because of the confusion between
“Equipment Room” and “Emergency Room”.
6.4.1 Requirements
The equipment room shall be located above the highest known flood level. The main cross-connect (MC) of a healthcare
facility shall be located within the equipment room.
The equipment room shall be designed in accordance with the requirements of the standard being followed (e.g.,
ANSI/TIA-569-D, ISO/IEC 14763-2). The floor dimensions of an equipment room shall be at least 3 m × 4 m (10 ft
×12 ft).
A growth factor of 100% should be considered when determining room size. This growth can be accommodated by
dedicating space adjacent to the equipment room that can be claimed in the future (e.g., storage room).
If the equipment room is to support additional systems (e.g., building automation, nurse call, security, CATV, or clinical
systems) the equipment room shall be increased in size to provide adequate space for these additional systems. If the
equipment room cannot be increased in size the additional systems shall be installed in a telecommunications room
(TR).
If the equipment room is required to perform as a data center, the design of this space and the supporting infrastructure
shall be in accordance ANSI/BICSI 002.
Primary equipment room power shall be backed up with UPS or other system(s) allowing uninterrupted service for the
longer duration of AHJ requirements or 30 minutes from the time of the primary power failure.
Working space in front and behind racks, cabinets and equipment shall be at least 0.9 m (3 ft).
Entry to an equipment room shall be restricted to authorized personnel
6.4.2 Recommendations
Equipment rooms should not be located in areas subject to water intrusion from external sources (e.g., fountains, utility
services).
For equipment access, locating the equipment room on the floor nearest prevailing grade level (ground floor) is often
the most advantageous.
Entrances to an equipment room should be controlled through the use of electronic access control (e.g., credential
reader).

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6.4.3 Additional Information

An intermediate cross-connect (IC) may be located in an equipment room.
6.5 Telecommunications Rooms
6.5.1 Requirements
Where not otherwise specified in this standard, the TR shall be designed in accordance with the requirements of the
standards being followed (e.g., NFPA 99, ANSI/TIA-1179-A, ISO/IEC 14763-2, FGI Guidelines)
A minimum of one TR shall be placed on each floor.
TRs shall be located outside of surgery suites and other sterile area (before the “redline”) to allow TR maintenance
without requiring personnel to dress out in protective clothing in the sterile areas. TRs shall be directly accessible from
a corridor without passing through another space (e.g., electric closet, mechanical room).
A TR may not serve an area exceeding 1860 m2 (20,000 ft2). TR shall be located as close as practical to the center of
the area served.
The minimum floor dimensions of a TR shall meet the requirements of the AHJ (e.g., NFPA 99). Where AHJ
requirements are not present, the minimum floor dimensions shall be 4 m × 4.5 m (12 ft ×14 ft). If the TR is to support
additional systems (e.g., building automation, nurse call, security, CATV, paging, intercom, or clinical systems), the
TR’s physical size shall provide adequate space for these additional systems. This may require additional physical space.
NOTE: A growth factor of 50% of the systems and services being supported by the TR should be considered when determining
the final physical size of the TR.
NOTE: Some facilities do not allow placing medical or building systems in the TR. Where this restriction applies, medical
and building systems shall be placed within a dedicated space adjacent to the TR. The space shall be designed in accordance
with the requirements of applicable standards (e.g., ANSI/TIA-569-D, ISO/IEC 14763-2). Room sizing shall take into
consideration the wall mounting area required of each system (e.g., building automation, nurse call, security, CATV, paging,
intercom, or clinical systems).
When placing a TR below grade level, water infiltration issues and mitigation shall be considered during the design,
including:
• Height below surrounding drainage systems
• Water detection systems
• Secure and continuous vapor barriers
• Water and vapor extraction systems
• Main building systems that might create damage
• Hazardous materials stored or utilized in the basement
• Flooding potential during and following severe weather events
Working space in front and behind racks, cabinets and equipment shall be at least 0.9 m (3 ft).
Entry to TR shall be restricted to authorized personnel
6.5.2 Recommendations
In multi-story buildings, TRs on each floor should be located so that the TR’s physical footprint matches or is contained
within or encompasses the physical footprint of the TR directly above and below, as applicable. This “stacking”
minimizes the length of pathway required to connect TRs on adjacent floors.
The TR should be located on the same floor as the work areas served. TRs should be located away from MRI rooms
and other imaging modalities to minimize electric and magnetic field interference.
No other equipment should be mounted above the equipment within the TR.
Where systems, applications and other requirements are not defined, TRs should be at least 4 m × 4.9 m (12 ft × 16 ft).
Entrances to a TR should be controlled through the use of electronic access control (e.g., credential reader).

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6.5.3 Additional Information

Healthcare facilities may have many types of electronic systems sharing the same pathways and spaces. The list below
is a sampling of those systems:
• Voice
• Data
• Overhead paging
• Closed circuit security system
• Access control
• Audio visual
• Distributed antenna system
• Nurse call system
• Intercom system
• Integrated operating system
• Patient monitoring system
• Infant protection system
• Patient education/entertainment systems
Each of these and other related systems will have specific dedicated space requirements for maintainability that must
be considered when designing the facilities TR such as:
• Size
• Location
• Quantity
For example, a nurse call system typically has spacing and other requirements such as:
• Allow 1.2 m × 2.4 m (4 ft × 8 ft) area of wall space for the central equipment and associated power supplies
and amplifiers per floor.
• The nurse call system must be connected to emergency power, or to an UPS on normal (commercial) power.
• The equipment room must have secured access.
The standards for a commercial building may not work in a typical hospital environment. A 3 m (10 ft) × 3 m (10 ft)
room for every 930 m2 (10,000 ft2) will in most cases not provide sufficient space.
See Figure 6-1 and Figure 6-2 for a sample comparison.
Many hospitals do not allow combining traditional voice/data spaces with medical or building spaces. This would
increase the above requirements by requiring side-by-side rooms or "split" rooms. See Figure 6-3 for an example.

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Voice and Data Network Racks

Conduit Risers

Wall Mounted
Systems (e.g.,
security,
overhead paging)

Future
Equipment
Rack

Wireless
Systems
Devices

Electrical Power Panel

Figure 6-1
Typical TR Layout

Voice and Data Network Racks

Conduit Risers

Wall Mounted Systems

(e.g., nurse call,
security, overhead
paging)

Specialty Systems
(e.g., biomedical,
patient monitoring)

Future Racks
and Systems

Wireless Systems
Devices

Electrical Power Panel

Figure 6-2
Typical Healthcare TR

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Rack Mounted Conduit Risers

Specialty Systems
(e.g., biomedical,
patient monitoring)

Electrical Power
Panel

Wall Mounted Systems

(e.g., nurse call, security,
overhead paging)
Medical Equipment TR

Conduit Risers

Future Racks Voice and Data

and Systems Network Racks

Cable Slack
Electrical Power Storage
Panel

Voice/Data TR Wireless Systems

Devices

Figure 6-3
Typical Healthcare TR (Split Rooms)

6.6 Cabling Pathways

6.6.1 Requirements
All applicable codes, standards (e.g., ANSI/TIA-569-D, ISO/IEC 14763-2, EN 50174-2) and requirements of the AHJ
shall be met.
6.6.2 Recommendations
Protected distribution systems (PDSs) protect sensitive cabling from unauthorized access outside of secure areas by
enclosing the cabling in a sealed raceway or conduit system. If used, PDSs should be located in common areas where
they can be inspected on a regular basis for unauthorized access. Refer to ANSI/TIA-5017 for other measures that can
be taken to improve the physical network security of telecommunications cabling infrastructure.

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6.7 Work Areas

6.7.1 Telecommunication Outlets
To ensure proper system performance for high performance cabling, the designer shall use outlet boxes capable of
maintaining the proper bend radius of telecommunications cable media (e.g., category 6A cable, multimode optical fiber
cable) used.
6.7.2 Patient Care Areas
Designers shall consult with the applicable electrical and building codes, as well as all AHJs for equipment ground
required in patient care areas, critical care areas, and procedure areas. In areas where patients are treated surfaces such
as faceplates may be contacted by the staff or patient accidently or through instrumentation. To control electric shock
hazard low potential differences between exposed surfaces shall be maintained. Codes may require work area outlets in
these areas even those not employing PoE to be installed with a metal raceway system meeting the requirements for an
effective ground-fault path.
6.7.3 Water and Wet Areas
As work areas within healthcare facilities frequently include water and wet applications and systems, designers shall
consult with the applicable electrical and building codes, as well as all AHJs.
Requirements and restrictions may vary greatly between regions and nations. For example, within the United States,
NFPA 70 provides a distinction between power (electrical) and low-voltage (telecommunication), whereas within
Europe for wet areas, low-voltage cabling must adhere to the same requirements as electrical wiring.
6.8 Cabling
6.8.1 Requirements
Backbone and horizontal cabling used for data networks shall conform to applicable standards (e.g., ANSI/TIA-1179-
A, ISO/IEC 11801-1). Horizontal cabling used for wireless networks (e.g., WLAN, DAS) shall also conform to the
requirements listed in Section 6.10. Horizontal cabling used for building and facility systems (e.g., access control,
building automation, low-voltage lighting) shall also conform to applicable standards for the specific systems (e.g.,
ANSI/BICSI 007, ANSI/TIA-862-B, ISO/IEC 11801-6).
6.8.2 Recommendations
Where balanced twisted-pair cabling is used, Category 6A/Class EA or higher performing cabling should be used for all
applications. Class FA or higher performance cabling should be considered for applications that have EMI/RFI immunity
concerns, current high bandwidth requirements (e.g., PACS) or are expected to support 8k or equivalent video
resolution.
6.9 Transmission Performance Field Testing
6.9.1 Introduction
Field testing of installed cabling is typically conducted after balanced twisted-pair and optical fiber cabling links are
installed. These cabling links may be pre-terminated or field terminated.
6.9.2 Requirements
Installed cabling shall be tested according to the cabling manufacturer’s or project’s testing plan to verify the installed
cabling performance meets the requirements of applicable standards (e.g., ANSI/TIA-568.2-D, ANSI/TIA-568.3-D,
ISO/IEC 11801-1, ISO/IEC 14763-2).
Field test instruments used to test installed cabling shall meet the requirements of applicable standards (e.g., ANSI/TIA-
1152-A, ANSI/TIA-526-7-A, ANSI/TIA-526-14-C). Test instrument documentation shall include certification of
calibration performed to manufacturer’s requirements as well as the date and time of the tester’s current calibration.
6.9.3 Recommendations
All installed cabling (e.g., balanced twisted-pair, optical fiber, coaxial cabling) should be tested or certified with the
appropriate field-test instrument, in accordance with applicable standards. Testing of the permanent link in the horizontal
cabling should be performed using permanent link requirements from the first connection at the horizontal cross-connect
(floor distributor) to the service outlet, or the HCP if a service outlet is not present.

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6.10 Wireless Networks

6.10.1 Overview
The active wireless spectrum found in a modern hospital is broad and diverse. Typically, wireless systems supporting a
hospital must accommodate many users, utilize a greater density of antennas, and require higher reliability. Typical uses
for wireless networks include:
• Regulated and/or licensed wireless networks
– Wireless medical telemetry
– First responders (police/fire)
– Aeronautical radios (helicopters)
– Customer-owned radio systems
– 2-way radio, private wireless paging
– Wireless service providers (e.g., cellular and/or wireless paging)
• Medical grade applications of typical business systems
– Patient records
o Electronic medical record
o Mobile medical computing
o Imaging
– Wireless telephony for caregivers
– Electronic medical equipment networks
o Pumps
o Transport monitors
o Patient beds
• Other common healthcare applications
– Physiological monitoring
– Real time location systems
o Equipment
o Patients
o Staff
– RFID
o Supply chain management
o Surgical instruments
– Safety and security
o Infant protection
o Patient elopement / wandering patient
o Behavioral health
– Timekeeping
– Patient queuing / waiting
6.10.2 General Design Considerations
The medical facility may be a complex ecosystem with multiple types of users, functional areas and departments, and
myriad wireless services that range from legacy wireless deployments to new implementations which may employ
emerging technologies.
[Link] Structural Environment
Complicating the ability to deploy robust wireless infrastructure throughout the facility are differences in construction
methods and materials from that of most other buildings. Because of constant occupancy and equipment loads, the
hospital building must be of sufficient structural strength to support this loading from the people it takes to run the
enterprise, patients and visitors as well as the systems and building materials required. Further, hospital construction
above the ceiling is a system-dense environment with mechanical, medical gas distribution, ventilation, and chilled
water plumbing all contributing to the complexity of planning a wireless network. Smoke compartments, fire rated walls
with multiple layers of sheetrock, sprinkler systems, and lead lined rooms add further complication to wireless design.

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[Link] Electrical Environment

The electrical power needs of hospitals are greater than most other typically sized buildings and may be thought of in
industrial terms. The electromagnetic environment is the complex result of the many varied electrical systems in the
facility. Power is more robust with the requirement for standby emergency generators. As IT and wireless
communications systems expand, so too grows the need for additional emergency backup.
[Link] Area Specific Requirements
• Office and Patient Areas: (resemblance to office buildings)
– Impact of Low-E glass
– Varying “tenant” requirements
– Restriction of certain networks, devices and antennas
– Age of building and presence of hazardous building materials
– Use of metal in walls, window frames, and door opening
– Telecommunications, data, and security requirements
• Diagnostic equipment and operating areas (resemblance to industrial)
– High voltage
– Extensive shielding
– EMI/RFI
– Hazardous/flammable substances
– Controlled substances
– Security
• Teaching areas
– Restrictions on use of personal communications devices
– Varying needs for telecommunications services, (e.g., streaming video)
• Reception, hospitality and food service areas
– Greater exposure to general public
– Expanded use of personal communications services
– Entertainment systems
– Point of sale systems
• Parking structures
– Unique structural characteristics
– High density of metal objects (vehicles)
– Likely greater exposure of mechanical, electrical, and plumbing services
– Security requirements
[Link] Placement of Equipment
Wireless antennas and access points should be placed within enclosures or “surface” mounted in locations that provide
access without disturbing the surrounding environment.
6.10.3 Distributed Antenna Systems
[Link] Overview
A distributed antenna systems (DAS) is commonly used to support cellular and other regulated/licenses radio systems.
A DAS consists of a network of antenna nodes connected to a common head-end fed by multiple signal sources, using
coaxial cable, optical fiber or balanced twisted-pair. There are three categories of DAS architecture:
• Passive–A passive DAS distributes RF energy over coaxial cables and through signal combiners and filters to
coverage antennas. Between the RF sources and the coverage antennas, there are only losses. Passive solutions
are often desirable in small to medium areas with less than 11,150 m2 (120,000 ft2) of floor space when there
is a good signal on the outside, but assistance is needed to penetrate the building.
• Active — An active DAS is characterized by a main hub (located in a headend) that bidirectionally downlinks
RF signals into media signals and uplinks media signals into RF signals. An active DAS is mostly deployed
using an optical fiber cabling backbone and dedicated base transceiver stations (BTS’s).
• Hybrid — A hybrid DAS combines the use of both active and passive components and system architectures.
While a hybrid DAS is configured primarily as an active DAS, passive DAS components are used between the
optical-to-RF signal converter and the antennas.

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[Link] Requirements
The designer shall comply with all codes and regulations that apply to the installation and use of a DAS and the
implemented services.
NOTE: Systems used for some critical services may require emergency power, UPS/battery service, special cable, and alarm
monitoring. Refer to the NEC and NFPA 99 for requirements and restrictions to the use of emergency power within medical
facilities.
“Right to retransmit” laws may not exist in some jurisdictions (e.g., United States). Where applicable, the facility shall
obtain a letter of authorization from each licensee to operate the DAS for each frequency not owned (licensed) by the
facility. Designers shall check with the appropriate AHJ and applicable service providers for any required authorizations.
Any DAS implemented shall operate seamlessly with the other systems, and not cause interference to those services.
DAS systems shall comply with the requirements of ANSI/BICSI 006.
Donor antenna placement and cable pathways shall be coordinated with the service provider, architect and other
disciplines (e.g., electrical, mechanical). Head-end equipment shall be located in a secure space (e.g., equipment room,
TR, building systems support space).
[Link] DAS Design Considerations
Because of the highly specialized nature of RF engineering and design, designers and other involved personnel should
have experience in DAS and are qualified to provide system engineering, design, and licensing services for the DAS.
It is recommended that a spectrum analyzer be used to provide data on ambient signal levels of all existing services
present at the facility location. For new systems, the designer shall calculate (path-loss software recommended) the
amount of loss anticipated in each system, and the anticipated signal coverage throughout the facility. From
manufacturer’s data, the receiver sensitivity for each system (typically -95 dBm for radio equipment, -85 dBm for
cellular, and -65 dBm for wireless data) can be established. This data will identify whether each specific system requires
any form of signal modification.
There are technical conditions that can make DAS systems either unnecessary or non-functional:
• If sufficient isolation between supported frequencies cannot be achieved, the system may not be stable.
• If the existing service signal level (ambient signal strength) throughout the facility is higher than the signal
level of the DAS, the use of a DAS system will not improve that wireless service.
• If the signal from any particular donor service outside the building is at a level lower than the receiver
sensitivity, it is not possible to amplify the signal without introducing unacceptable noise and interference.
NOTE: In this instance, extending service to the facility may not be possible if the facility is located outside of the
authorized service area for that particular licensee.
• Donor signals arrive at the facility from different directions and at different signal levels. These must be
individually processed to be effectively utilized by the DAS. Within larger facilities, it is possible these signals
may require distribution in separated or partial sections of the facility.
• It is common that some of the services considered for installation on the DAS may not require or function
properly with a DAS because of signal levels, distribution requirements, or legal restrictions.
Some internal healthcare systems may carry information subject to privacy or security policies or other regulations. The
transmission of this data could require the restriction of any transmission external to the facility.
6.10.4 Discrete Antenna Systems
[Link] Overview
Discrete antenna systems are associated with unlicensed radio deployments, such as WLAN (IEEE 802.11) and smaller
personal area networks (IEEE 802.15). Discrete antenna systems are commonly used to enable data transmission over
small, defined areas.
[Link] Requirements
Discrete antenna system infrastructure shall meet the requirements of Section 6 as well as ANSI/BICSI 008.

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6.10.5 Wireless System Grades of Service

[Link] Overview
Within a healthcare facility, there are typically three grades of service:
• Medical Grade — Life Critical
Medical grade services support clinical devices and applications that exist to collect and share life critical medical
information with providers of medical care.
• Enterprise Grade — Mission Critical
Enterprise grade services support health devices and applications that collect medical information and are
intended to “inform and direct”. They are considered mission critical but not life critical.
• Consumer Grade — Inform
Generally for use by the public, consumer grade wireless service supports consumer devices and applications that
make no medical claim and are meant to “inform”.
Table 6-1 provides examples of each grade as applied to healthcare environments

Table 6-1 Example of Applied Service Grades

Life-critical, clinical patient care devices like wireless medical monitoring and telemetry systems, infusion
Medical
pumps and future technologies such as MBAN (mobile body area network) devices and diagnostics

Physician and nurse-deployed work stations, smart phones and tablets for secure wireless access to
Enterprise
electronic health records, nurse call systems, asset management and first-responder communications

Consumer Shared guest Internet access for consumer devices like cellular phones, tablets and laptop computers

[Link] Assurance Measures and Performance

Assurance describes the availability of a wireless network for its intended use. It includes five key components:
• Coverage — The percentage of the clinical space that has acceptable wireless signal and is accomplished by the
proper placement of antennas and wireless access points.
• Signal quality — Usability of a received signal at a device. Signal quality is comprised of both received signal
strength and signal to noise ratio available to the client devices.
Affecting strength are power, the distance between the antenna and client device, and wireless propagation
characteristics. Signal to noise refers to the desired signal in the presence of other wireless protocols.
• Capacity — The ability to support a required number of simultaneous users/devices in conducting voice and or
data transfers within each coverage area. Capacity is implemented by using a combination of radio channels and
technologies sufficient to support the required traffic.
• Security — Physical and cyber protection of the physical components, as well the confidentiality, integrity and
availability of RF signals through digital encryption and other means. At the highest level, all communications
devices are physically secured to prevent tampering, encryption is WPA2 or equivalent and equipment is
compatible with the facility’s authentication server(s).
NOTE: See Appendix B for further information on network security.
• Certainty — The ability of a protocol to operate in an associated RF environment and to deliver the required
communications performance, as defined by relevant parameters (throughput, latency, jitter), without impact to
other applications/devices.
The three grades of service are differentiated by their assurance requirements, with medical grade being the most
stringent, as shown in Table 6-2.
[Link] Recommendations
The minimum levels shown in Table 6-2 should be met for wireless systems implemented within healthcare facilities.

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Table 6-2 Service Assurance Requirements

Coverage Signal Capacity Security Certainty
Medical 100% 100% 100% Maximum 100%
Enterprise 95% 95% 95% High 95%
Consumer 90% 90% Best Effort Limited 90%

6.11 Passive Optical Networks

[Link] Overview
A passive optical network (PON) implements a point-to-multipoint architecture (i.e., tree topology), in which an
unpowered optical splitter is used to enable a single optical fiber to serve multiple end-points. PONs commonly utilize
a zone-based cabling solution from a ceiling or floor zone box with pre-terminated simplex single mode optical fiber
cabling to the actual work area outlets.
A PON consists of an optical line terminal (OLT) at the source or transmission and one or more optical network units
(ONUs) or Optical Network Terminals (ONTs) located near the area to be served. An ONT will typically have from 2
to 24 ports, most commonly configured for the modular connector of balanced twisted-pair cabling.
[Link] Requirements
The design and deployment of PON systems, including the cabling infrastructure, shall follow applicable standards
(ANI/TIA-568.3-D, ANSI/TIA-569-D, ISO/IEC 11801-1, EN 50173-1) and the requirements of Section 6.
While the majority of PON designs have no power requirements when placed in a TR, accommodation shall be made
to provide cooling and power within the TRs should powered equipment (e.g., LAN switches) be installed in the future.
[Link] Recommendations
While a PON may function with single optical fiber cabling connections, two strands of optical fiber should be provided
to each work area outlet to allow for any future growth or potential desktop optical network terminal redundancy options.
NOTE: ANSI/TIA-1179-A requires the installation of two strands as a minimum.
PON devices may require additional or backup power that is not available through a PON. The combined use of optical
fiber and copper cables (e.g., electrical conductor, balanced twisted-pair) may allow critical devices (e.g., IP phones) to
continue functioning during a power outage, when the copper cable is properly connected between an UPS and the PON
device.
Within a PON supporting a building, the passive elements are usually located in the TRs where the access switches are
typically installed. Because of the extended distance reach of a PON because of the use of optical fiber media, the need
for multiple TRs per floor to support network connectivity can be reduced to a single TR containing the optical fiber
patch panels. However, it is recommended that a TR or TE be provisioned wherever horizontal cable lengths exceed 90
meters.
The recommendations found within the Telecommunications Distribution Methods Manual (TDMM) and the Outside
Plant Design Reference Manual (OSPDRM) should be used with all PON designs and implementations.
[Link] Additional Information
PON architecture may not be suitable for all applications. However, PON architecture, because of its use of optical fiber
and tree topology, may be an acceptable method when designing systems:
• Supporting building applications over long distances
• Within areas with increased levels of EMI/RFI
• Where existing pathways and spaces do not have the capacity for additional cabling.
• Where the number of devices/connections is not distributed evenly around the TR (e.g., patient room floors of
a multistory facility)

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7 General Design Considerations

7.1 Architectural
7.1.1 Overview
In addition to the architectural pathways and spaces required for any communications system in any type of facility,
additional considerations are needed for healthcare facilities. Telecommunications rooms, equipment rooms, cable tray
pathways, riser pathways, etc. are required for any facility, but because of the nature of specific areas of a hospital and
its designed spaces, additional considerations may be required.
7.1.2 NFPA 99, Healthcare Facilities Code
Per NFPA, “NFPA 99 establishes criteria for levels of health care services or systems based on risk to the patients, staff,
or visitors in health care facilities to minimize the hazards of fire, explosion, and electricity.” There are numerous
references in NFPA 99 regarding cable distances, telecom room sizes, telecom room quantities, and clearances from
other Systems. Detailed care should be made in reviewing this code, especially Chapter 7, Information technology and
Communications systems.
Additionally, NFPA 99 stipulates diverse backbones, telecom room sizes, square footage of areas served per TR, and
working spaces and equipment clearances. Since NFPA 99 requires redundant, diverse backbones; for buildings with a
single “stack” of TRs, additional chase pathways may be required. NFPA 99 also prohibits other systems traversing
through telecom rooms so other design trades may be affected. Requirements for other systems such as nurse call
systems are also addressed.
7.1.3 FGI Guidelines
Accepted as code in many states, the Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of
Hospitals and Outpatient Facilities outline many telecommunications and low voltage requirements related to low
voltage systems design and architecturally-impacted spaces. Requirements include device placement, TR room sizing,
and sound-masking. Care should be given by the designer in assuring the guidelines are reviewed and incorporated as
required.
7.1.4 Ceilings
While ceiling coordination is required on just about every project design, healthcare facility ceilings should take special
consideration and review. There are many more systems in hospitals ceilings compared to other facility types. These
systems include:
• Wireless access points
• Distributed antenna system antenna
• Telemetry system antenna
• Overhead paging system speakers
• Nurse call dome lights
• Real-time locating system (RTLS) sensors
• CCTV cameras
These are all in addition to other trades devices’, including lights, mechanical air supply and return grills, medical gas
valve access, and fire alarms.
Hospital ceilings are becoming more complex with multiple dropped bulkheads, increasing the chances that camera
line-of-sight may be impaired for some or all intended targets. The risk of coverage gaps from ceilings interfering with
line-of-sight has also increased with the practice of using a fewer multi-lensed cameras to observe the same area as
compared to a larger number of single lens cameras. Ceiling soffits and other decorative ceiling elements should also
be considered, as these can block camera and nurse call light views and degrade signals from ceiling antennas.
7.1.5 Patient Rooms
The patient room itself is becoming more and more complex and cramped with devices. For example, headwalls may
contain one or more power outlets, light switches, nurse call devices, bed interfaces, and medical gas connections. The
devices that connect to these outlets and their physical size should be accounted for when placing communications
devices.

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NOTE: Communications/IT devices include charting PCs, physiological monitors, label printers, barcode scanners, medical
device integration PCs (or interface boxes), telephones, tablet charging stations, and wireless telephone charging stations.
Therefore, proper coordination should be made with:
• All other trades for the location of devices, including wall elevation and floorplan, and
• Clinical staff to assure the proper personnel movement and workflow requirements are maintained.
In some cases, space for an additional PC or laptop cart in the room may be required.
7.1.6 Controlled and Sterile Environments
[Link] Introduction
A controlled environment is a space which requires a controlled low level of environmental contaminants and pollutants
such as dust, airborne microbes, aerosol particles, and chemical vapors. A sterile environment is a type of controlled
environment that is considered free of microorganisms. Controlled and sterile environments are most often associated
with surgical or operating rooms but may also be found in patient and treatment areas, material storage, and other areas
as part of a larger risk mitigation strategy.
[Link] Environment and Conditions
Unless specified stated, a controlled environment is not sterile. Depending on the size and requirements of the area, a
controlled environment may:
• Maintain a positive pressure inside of the controlled space to keep unfiltered air out.
• Perform numerous air changes per hour of the air inside of them.
• Have a utility mezzanine with access points external to the controlled space, lowering risk of contamination
when performing routine service or maintenance.
• Require use of equipment or items designed to produce minimal air contamination, such as airborne particles
and off gasses (out gasses).
Sterile environments can be found outside of a controlled environment. However, all sterile environments will utilize
methods and materials to resist or prevent microorganism contamination.
[Link] Planning
Because of rigorous decontamination procedures required prior to entering maintained controlled and sterile
environments, ICT project managers and technicians will need to carefully plan out all tasks and have all materials,
tools, and test equipment on hand in advance of the initial entry to avoid multiple reentries during the particular
installation or repair assignment visit. Each reentry typically will require performing personnel and materials/tools/test
equipment decontamination procedures again.
During early planning, meet with and obtain from the architectural design team and the client, a list of all equipment,
its locations and the type(s) of environments that may need ICT cabling infrastructure or wireless connectivity.
As a controlled environment’s HVAC system(s) is typically monitored by building automation systems (BAS) for any
operational problems or failures. Consult with project HVAC and BAS designers or the facility’s operational and
mechanical personnel regarding any ICT cabling infrastructure needs their systems may require.
Most controlled and sterile environments have access and security requirements. Consult with the project’s security
consultants regarding any ICT cabling infrastructure needs that any specified access control, fire detection and
suppression, intrusion detection, contamination detection, emergency evacuation, and surveillance systems may require.
Plan and recommend ICT telecommunication outlet (TO) boxes for future client needs. If the initial project’s funding
is an issue, recommend empty ICT TO boxes with conduits containing pulling line for future ICT TO additions. Adding
ICT TOs and conduits into maintained controlled and sterile environments can be cost prohibitive, because of additional
labor, decontamination and impact to normal operations.
In maintained controlled and sterile environments, be prepared to conduct design and pre-installation site surveys and
telecommunications installation tasks by undergoing a client required personnel and materials/tools/test equipment
decontamination process, and dress in client-provided attire moments prior to entering those environments.
[Link] Requirements
Specify and install metallic ICT TO boxes and conduits for ICT cabling infrastructure. These conduits are to end outside
of the controlled environment, such as in a utility mezzanine, consolidation point, or telecommunications room.
Label the conduits at their end outside of the controlled environment according to their associated TO box number,
location, and use.

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Produce and update accurate ICT TO location and associated conduit/pathway as-built prints. The prints can then be
used for planning future cabling additions or TO repairs and modifications without having to enter the controlled
environment.
ICT cable jacket outgassing is a common occurrence. If it is necessary to restrict the ICT cables from mixing with
environmental air because of the ICT cable jacket outgassing, then a sealed ICT cabling pathway shall be used.
[Link] Recommendations
The project design and contractor specifications should stipulate that prior to installing cabling into the controlled
environment’s conduits, each conduit is to be cleaned out by introducing clean air under pressure into the conduit’s
controlled environment side. On the other end of the conduit, the exiting air should be filtered, and any debris captured
by a collection system, such as a shop-type vacuum equipped with discharge air filtering.
Care needs to be taken when selecting materials and products for controlled and sterile environments. Contaminants
related to telecommunications systems installations include:
• Off gas (also referred to as out gas) - the release of a gas into the air which was dissolved, trapped, frozen, or
absorbed in a material into the air.
• Particulate - the release of fine particles from a material into the air.
As an example, specify and install stainless steel faceplates for telecommunications outlet/connectors as stainless steel
does not outgas, easily generate particulates, and is easier to sterilize.
The use of open top or sided cable tray (e.g., ladder tray, basket tray) within a controlled or sterile space is not
recommended as these types of:
• Do not prevent cable jacket outgassing from mixing with environmental air
• With the addition of cabling, provide an irregular surface where particulates or microorganisms may
accumulate (e.g., create dirt traps)
• Zinc electroplated products may allow for the production of particulate contaminates, commonly known as
“whiskers”.
The faceplates are to contain the exact amount of jack openings corresponding to the amount of cables and jacks to be
initially installed. Do not try to future proof TO boxes by specifying and installing faceplates containing extra ports then
install blank inserts into those extra ports. Controlled and sterile environment entry in order to remove a faceplate to
reinsert an accidently pushed through blank insert can be avoided by not specifying and installing faceplates containing
extra ports. Blank inserts can be a place for contaminants to gather and then be released when those inserts are removed.
The installation of telecommunications outlet/connector dust covers is not recommended. Dust covers can be a place
for contaminants to gather and then be released when those covers are removed to make a connection.
To minimize potential issues, leave minimal cable slack inside of TO boxes and place the slack at the opposite end of
the TO boxes’ conduit.
Specify and seal both ends of TO box conduits with a closed cell foam that does not off gas or particulate.
Specify and install sealed, hands-free telephones that are designed for use in the appropriate environment.
7.2 Redundancy
7.2.1 Space Redundancy
The high demands on uptime and reliability in the data and voice networks that support healthcare facilities today creates
a need for equipment redundancy. This need can be met internally within the hardware itself or by providing additional
backbone cabling installed in a redundant method. The latter will require a designed series of redundant pathways
consisting of conduits, sleeves, cable trays and other supports.
Figure 7-1 shows some basic redundancy options for spaces and connecting pathways. Depending on the site location
or other specific needs, implementing redundancy may be more complex or be achieved by other pathway configurations
and connectivity methods than what is displayed.
NOTE: The addition of core and edge switching may not achieve or increase redundancy, diversity or expandability.

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ANSI/BICSI 004-2018

Backbone A
2nd Floor 2nd Floor 2nd Floor 2nd Floor
TR-A TR-B TR-A TR-B
Backbone B
Backbone Backbone
A A
Backbone Backbone Backbone A Backbone B
B B

Backbone A
1st Floor 1st Floor 1st Floor 1st Floor
TR-A TR-B TR-A TR-B
Backbone B

Backbone Backbone
A A
Backbone Backbone Backbone A Backbone B
B B

Main Backbone A Main Main Backbone A Main

Equipment Equipment Equipment Equipment
Room A Room B Room A Room B
Backbone B Backbone B

Redundancy Example 1 Redundancy Example 2

Backbone A Backbone A
2nd Floor 2nd Floor 2nd Floor 2nd Floor
TR-A TR-B TR-A TR-B
Backbone B Backbone B

Backbone Backbone
A A
Backbone A Backbone B Backbone Backbone
B B

Backbone A
1st Floor 1st Floor 1st Floor 1st Floor
TR-A TR-B TR-A TR-B
Backbone B

Backbone Backbone Backbone

Backbone
A A A
A
Backbone Backbone Backbone Backbone
B B B B

Main Main Main Main

Equipment Equipment Equipment Equipment
Room A Room B Room A Room B

Redundancy Example 3 Redundancy Example 4

Figure 7-1
Redundancy Examples for ICT Spaces and Cabling Backbone

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7.2.2 Network and System Redundancy

Increasingly, network architecture must not only be designed to support all the applications and anticipated bandwidth
requirements in a scalable manner to accommodate future growth in applications, hosts, and data storage, but also
accommodate all these requirements with the level of redundancy that is in alignment with the business objectives.
Network and system redundancy reduces the risk of downtime caused by human-error, natural disasters, planned
maintenance, and repair activities. Network services and systems can be provided with redundant links throughout the
network and can also be provided with redundant equipment and components.
Network and system redundancy may also be required by the AHJ because of specific site or jurisdictional requirements.
Further information concerning network redundancy can be found in Appendix C and standards such as ANSI/BICSI
002.
7.3 Electrical Power
7.3.1 Overview
The telecommunications industry has traditionally used DC to power communications equipment. With a DC-powered
system, it is not necessary to invert the battery voltage to the load (change to AC) when batteries are used as an
emergency or reserve power medium.
7.3.2 Power Supply Units
[Link] Overview
Power supply units typically convert the commercial AC power supply to DC operating voltages. DC voltages range
from 12 to 48 VDC for carrier modulation and 5 to 12 VDC for circuit board logic voltage.
[Link] Requirements
If the equipment is operating from the power supply directly without using batteries, both the positive and negative
leads to the supply shall be fused with the proper fuse size. This will prevent the equipment from becoming the return
path for the system ground should the main ground fail.
If using a rectifier system to charge the batteries as well as operate equipment, the system shall be sized to fully charge
batteries within 24 hours while allowing operation of equipment during charging.
NOTE: The charging system also should be able to equalize the battery system to extend the battery system life. The charge
current is normally 1/10 of the capacity of the battery.
If using a battery and rectifier system, a DC distribution system with a low-voltage disconnect shall be included as part
of the designed system. A low-voltage disconnect will prevent damage to the equipment or battery system by
disconnecting the load either fully or in stages from the batteries to prevent the batteries from being fully discharged or
damaged.
[Link] Recommendations
A designer should take into account the power requirements of all the equipment involved. This may entail
uninterruptible power supply (UPS) systems that will generate 120/240 VAC at 50/60 Hz, battery rectifiers that will
operate the equipment as well as recharge the battery banks after a power failure, and wind and solar power generation
systems for remote areas. Power requirements for equipment located outside of the equipment room (e.g., amplifiers
used within distributed antenna systems) should also be included.
7.3.3 Uninterruptible Power Supplies
[Link] Overview
While there are different types of UPS systems, a static UPS is commonly used within ICT and building systems. A
static UPS unit is a solid-state device designed to protect critical loads from most types of power fluctuations. There are
three primary types of static UPS units, as listed below.
• Offline or Standby UPS Units
Offline or passive standby UPS units are devices that power the load directly from the utility and only provide
backup power when the utility power goes below preset tolerances. Offline or passive standby UPS units
provide limited line conditioning and often have transfer times that exceed system tolerances. It is not
recommended that standby power systems be used to support critical communications loads.

List continues on the next page

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• Line-Interactive UPS Units

Line-interactive UPS units are basically offline UPS units with line conditioning included. Electronic or
magnetic energy storage is used to sustain the load during transfer to the inverter.
These units work well in most circumstances, but they have the following limitations:
– There is no frequency regulation.
– Battery reserve time and recharge time may be limited.
– May not be suitable for use with some generators.
– The isolation of power source to load in a line-interactive UPS unit is less than that available with an
online double conversion UPS unit.
• Online Double-Conversion Uninterruptible Power Supply UPS Units
Online double-conversion UPS units completely rectify the ac line from ac to dc and use this dc to both charge
the battery and power a dc to ac inverter.
Under normal circumstances, the full UPS unit:
– Is always online and provides isolation, regulation, filtering, and frequency control.
– Does not involve any switching time to transfer to battery.
Online double-conversion UPS units exist in different designs. For ICT and building systems utilizing the data
network for power (e.g., PoE), the online double-conversion UPS system is the most frequently used.
[Link] Requirements
For the UPS requirements of the equipment needed, determine the full load power required in both watts and volt/amps.
Determine how long the UPS should support the required load as well as any future growth.
Refer to local codes regarding the potential need to de-energize equipment connected to UPS’s when water/fire
suppression systems are activated.
[Link] Recommendations
For critical systems, both standby power (e.g., emergency generator) as well as short-term battery backup should be
planned and provided. This allows equipment to be minimally affected by power fluctuations during short outages. If it
is a longer duration outage, the standby power source will power the system for a limited time until facilities can be
restored.
There may be advantages to providing an UPS system to supply power to all building systems, rather than specifying
individual UPS units for each building system. UPS systems utilizing single-module UPS units are the easiest systems
to design. However, if the critical load is large or if a high level of redundancy or reliability is required, multiple UPS
units, operating in parallel, may be necessary. Refer to standards, such as ANSI/BICSI 002, for recommendations when
designing parallel UPS systems.
[Link] Additional Information
An important item to include within design considerations is when the power goes out, unless the entire facility is on a
backup generator, the air-conditioning system will no longer operate. In most facilities, the room air temperature will
quickly rise to unsafe levels for both the equipment and personnel. While some configurations allow fans to continue
functioning to slow the rate of heat increase, the power to run the fans will also be coming from the UPS system.
7.4 Security Control Frameworks
7.4.1 Introduction
There are a number of security control frameworks that organizations use to build, assess, and document their security
programs and achieve regulatory compliance. While they vary in structure and level of detail, they are all built on the
commonly accepted three pillars of information security: confidentiality, integrity, and availability, known together as
the CIA triad.
Below are descriptions of five widely used frameworks and the controls or sections in each framework that may be most
relevant to ICT.
7.4.2 HIPAA Security Rule
The HIPAA Privacy Rule addresses protected health information (PHI) in general, while the HIPAA Security Rule
addresses the protection and handling of electronic protected health information (ePHI). The HIPAA security standards
are organized into three safeguard categories: administrative, physical, and technical.
The physical safeguards may be the most applicable, although some of the contingency planning controls in the
administrative section may also apply.

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The sections and specifications of the HIPAA physical security safeguards are:
• Facility access controls
– Contingency operations
– Facilities security plan
– Access control and validation procedures
– Maintenance records
• Workstation use
• Workstation security
• Device and media controls
– Disposal
– Media reuse
– Accountability
– Data backup and storage
7.4.3 National Institute of Standards and Technology (NIST) Cybersecurity Framework
The NIST framework is a comprehensive, well-organized framework that can be used to establish an organization-wide
security management program and assess the effectiveness of an existing security program. This framework is based on
industry standard best practices for managing risk and is aligned with other governance frameworks. It’s been widely
adopted across a variety of industries.
This framework is organized around four “tiers”, which provide context on how an organization views cybersecurity risk
and the processes in place to manage that risk. The four tiers reflect a progression from informal, reactive security
programs to programs that are agile and risk-informed.
The framework is organized into five core security functions for continuous and effective cybersecurity risk
management. These five functions are:
• Identify — Develop the organizational understanding to manage cybersecurity risk to systems, assets, data, and
capabilities.
• Protect — Develop and implement the appropriate safeguards to ensure delivery of critical infrastructure
services.
• Detect — Develop and implement the appropriate activities to identify the occurrence of a cybersecurity event.
• Respond — Develop and implement the appropriate activities to take action regarding a detected cybersecurity
event.
• Recover — Develop and implement the appropriate activities to maintain plans for resilience and to restore any
capabilities or services that were impaired because of a cybersecurity event.
The protect function is commonly the most relevant to ICT Systems. Each function is divided into categories to group
related security activities, and further divided into subcategories of suggested activities for achieving security in the
function.
Subcategories within the Protect function that may be relevant include:
• Physical access to assets is managed and protected.
• Network integrity is protected, incorporating network segregation where appropriate
• Data-in-transit is protected
• Adequate capacity to ensure availability is maintained
• Communications and control networks are protected
7.4.4 NIST Special Publication (SP) 800-53
This publication is called Security and Privacy Controls for Federal Information Systems. It is a comprehensive catalog
of security controls widely used by government agencies and contractors, but also adopted by many organizations in a
variety of industries. The controls are organized into 18 families, each of which has multiple controls.
The families that may be most applicable to ICT are:
• Physical and environmental protection
• Systems and communications protection
• Access control

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7.4.5 ISO/IEC 27001:2013 and 27002:2015

ISO/IEC 27001 is made up of 18 sections of security controls. The section most relevant to ICT systems are physical
and environmental security, although controls in the asset management and access control sections may also be
considered. The physical and environmental security controls cover topics such as physical security perimeter, entry
controls, protection against external and environmental threats, equipment siting and protection, supporting utilities, and
cabling security.
7.4.6 Center for Internet Security (CIS) Critical Security Controls (aka “Top Twenty”)
This is a prioritized framework of twenty technical security controls, each of which is subdivided into detailed
recommendations for specific security tools, settings, and activities. The following controls are relevant to ICT systems.
• CSC11: Security Configurations for Network Devices
• CSC12: Boundary Defense
• CSC14: Controlled Access Based on the Need to Know

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8 Healthcare Systems

8.1 Nurse and Code Call Systems

8.1.1 Overview
Traditionally, the nurse call system is to request attention of the nursing staff. However, the term “nurse call” can be
misleading because most systems are not limited to this function. The nurse call system may be used to notify doctors,
nurses, or any other clinical staff. A system may provide notification to staff using designated tones, lights, voice
communication, text messaging, or other communication methods. A nurse call system may be interfaced with other
systems to annunciate code calls, page specific staff, or to provide secondary fire alarm annunciation.
The design and installation of a nurse call system shall comply with all governing codes and regulations. The system
shall be Listed, and the system’s device types shall meet AHJ requirements. Additionally, operational and staffing
requirements should be considered when locating alarming/annunciating systems (e.g., 24/7 staffed systems, coding
systems).
8.1.2 System Architecture
There are two types of system architecture: tone/visual type architecture and audiovisual type architecture. The type of
system architecture to be selected is determined by the types of care provided at the health care institution, and specific
owner needs.
[Link] Tone/Visual Nurse Call System
A tone/visual nurse call system is typically used in facilities where supervision is required without the need for
emergency medical attention. Examples are:
• Supervised care facility — patients need only supervision
• Clinical area — no sophisticated voice communications are necessary, or requested
A tone/visual architecture provides only basic level service and does not support voice communications. Notification is
provided using:
• A special tone (or pattern of tones)
• A solid or flashing light at the supervising station and the entrance or door of the room or area where the
incident occurred. This directs staff to the area where supervision is necessary.
Notification devices are typically located at the supervising station and the entrance of the room or area where the
incident occurred.
[Link] Audiovisual (AV) Nurse Call System
An audiovisual (AV) nurse call system typically is used in locations where supervision is required along with the need
for emergency medical attention. Most areas of an acute care hospital meet this description.
AV nurse call systems provide an opportunity for medical staff or the patients to notify the supervising staff if there is a
problem or emergency. Notification is provided using the methods noted under a tone/visual system, with the optional
capability of a prerecorded or live voice messaging.
Notification devices are typically located at the supervising station and the entrance of the room or area where the
incident occurred.
Voice communication allows health care practitioners to gather additional information and perform their duties in a
more efficient and personal manner.

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8.1.3 Devices
[Link] Overview
Nurse call system devices can be separated into three categories: initiation devices, central or head-end equipment, and
notification devices including master stations:
• Initiation devices primarily are used to generate a signal that is sent to the central equipment, notification
devices, or to initiate an alarm/event at the nurse station or a duty station.
• Head-end equipment primarily is used for electric or electronic processing and routing of the alarm and
signaling between initiation devices and notification devices. Head-end equipment may also store data and
generate reports.
• Notification devices primarily function to convert the electronic signal into an audible or visual alarm to notify
the appropriate supervising staff of an alarm/event.
The designer shall refer to applicable federal, state, and local codes for initiation and notification device placement
requirements.
[Link] Initiation Devices
[Link].1 Staff Emergency Station
A staff emergency station is a device that is used by staff to request additional assistance. This may also be called a staff
assist station.
[Link].2 Bathroom Station
A bathroom station is a wall- or ceiling-mounted device that is used if a patient needs to alert the supervising staff while
using the bathroom and/or shower. Typically, there is one push button or pull cord station located next to the toilet and
one pull cord station mounted inside or above the shower. When the bath station is to be mounted in a shower, a shower
station Listed for installation in a shower shall be used. The shower station should be mounted high on the wall, where
it will not receive direct shower spray. Bathroom stations shall have a pull cord from the station faceplate to the required
distance above the floor, typically 150 mm (6 in).
[Link].3 Pillow Speaker
A pillow speaker is a device that connects to the bedside station or bed to provide controls for a patient to contact the
nurse call system. Pillow speakers may have controls for a television or other audio entertainment, and may provide a
nurse call intercom. Some pillow speakers have switches for the control of additional devices (e.g., window shade, radio,
lighting). Pillow speakers shall have the capability of use by disabled persons so that simple actions such as blowing
into a tube or squeezing a bulb can initiate a call.
NOTE: Pillow speaker functional capacity may be limited and require additional hardware or vendor support.
[Link].4 Bedside Station
A bedside station is a wall mounted device at the head of a patient’s bed that provides call buttons and tone speakers.
The bedside station provides the ability for the patient to request help and receive acknowledgment. The bedside station
also may have interfaces for televisions, patient monitors, or additional auxiliary devices (e.g., intravenous [IV] pump
alarms) to the nurse call system.
[Link].5 Code Call Station
A code call station is a device that has one or more buttons that initiate a code call to the staff. The alarm signal can be
silenced only from the activated code call station to ensure proper supervision and inspection.
[Link].6 Staff Station
A staff station is a wall-mounted device that is used by the staff to make an intercom call to additional staff located at a
main nurse station. They are typically placed in rooms where staff may be working, such as laundry, kitchen, locker room, and
lounges.
[Link].7 Staff Register Station
A staff registration station is a wall-mounted device that alerts the nurse call system that a staff member is present in the
room and may indicate the type of respondent.
[Link].8 Bed Interface
A bed interface is a device that allows connection of the pillow speaker, and associated controls, directly to the patient
bed. The patient bed must be designed to utilize this interface.

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[Link].9 Tamper Resistant Ceiling Microphone

A tamper resistant ceiling microphone is typically used in psychiatric wards or detention center patient rooms. The
primary use for this device is to provide audio monitoring of a room.
[Link].10 Tamper Resistant Hall Station
A tamper resistant hall station typically is used in psychiatric wards or detention center corridors. This device is designed
to allow staff to monitor a ceiling microphone. This device can also alert staff of a problem before entering a high-
security patient room.
[Link] Head-End Equipment
[Link].1 Cabling
For traditional systems, cabling consists of various types of balanced twisted-pair cabling for device power and
signaling. Termination is completed on blocks in a terminal cabinet.
For end-to-end Internet protocol (IP)-based systems, a minimum category 5e UTP cable shall be used. Termination
hardware shall match the performance rating of the horizontal UTP cable installed.
[Link].2 Electrical Interfaces
Nurse call systems shall be electrically isolated from all other systems. Nurse call systems have interfaces that allow the
system both to remain electrically isolated and communicate with other systems.
The system shall have a secondary electrical power source. The secondary power source shall comply with federal,
state, and local codes.
[Link].3 Central Equipment
Control panels and associated hardware shall be housed in a secure space (e.g., TR, building systems support space).
[Link] Notification Devices
[Link].1 Master Station
A master station functions as the main interface between the nurse call system and the supervising staff. These stations
can be touch screen, push button, or computer based. They are typically located at nursing stations. The master station
may also serve as a secondary annunciator for the patient room fire alarm smoke detectors.
[Link].2 Mini-Master Station
A mini-master station has less functionality, or less priority/control than a master station. Mini-master stations typically
are located in smaller, secondary nurse stations or alcoves.
[Link].3 Annunciator Panel
An annunciator panel is similar to a mini-master station but typically is wall mounted with little or no control over the
system. Annunciator panels are used when the only requirement is notification of the alert location.
[Link].4 Overhead Paging Systems
Overhead paging systems can be used for voice notification, if it is integrated with a nurse call system.
[Link].5 Corridor Light
A corridor light is a notification light that is wall or ceiling mounted. It consists of several lights and may be capable of
displaying various flash rates. A corridor light may also be integrated with the fire detection system.
[Link].6 Zone Light
A zone light is a device that shares the overall functionality and design of a corridor light. The function of a zone light
is to provide staff with a summary of multiple corridor light rooms or areas. Zone lights display and sound an alarm if
any one, or a multiple of, the programmed rooms have an alarm condition. In multiple corridor nursing units, zone lights
shall be installed at the intersections of corridors.

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8.1.4 Communications Interface

[Link] Overview
Many nurse call systems have the capability of communicating externally from their system to increase the efficiency
and level of care that providers can give. Patients can have the ability to communicate directly with their assigned care
giver, which may have a positive impact on the overall satisfaction rating for the healthcare facility. Common interface
methods include:
• Pocket pagers — routes nurse call events to text or numeric pager system.
• Wireless communication devices — offer the messaging and notification capability of pocket pagers with the
added advantage of dialing back to the patient for a two-way audio conversation.
• Real time locating systems (RTLS) — systems that use infrared or RFID badges and sensors to ascertain the
location of a person or asset within a healthcare facility.
Other systems which may have an interface include:
• Feature beds
• IV pumps
• Private branch exchange (PBX) or VoIP systems
• Bed management systems
• Code blue systems
• Patient entertainment (television)
8.1.5 Wireless Nurse Call Systems
NOTE: Wireless nurse call devices may not be permitted, or permitted only as a temporary solution, by the AHJ.
[Link] Overview
A recent development in the nurse call field is the use of wireless nurse call systems. Care should be used to select a
system using frequencies that will not interfere with other hospital systems. The system shall be Listed, and the system’s
device types and placement shall meet AHJ requirements.
If the wireless system is for a senior residence facility, corridor lights are not required. Compliance with UL 2560 is
required.
Acute care facilities/skilled nursing facilities require each patient room to have a corridor light. The wireless nurse call
system supervises the wireless initiation devices every 90 seconds.
Senior residence facilities do not require a corridor light for resident rooms. The wireless initiation devices are
supervised once every 24 hours.
Wireless technologies typically integrated to nurse call systems are:
• Wireless hands-free voice recognition communication
• Wireless telephone technology
• Wireless asset tracking and staff locating
8.1.6 Code Call Systems
[Link] Overview
Code call systems are used in healthcare facilities to give staff members the ability to request assistance in critical
emergency situations. They can be integrated into a nurse call system or installed as a stand-alone system. A stand-alone
application is common in out-patient facilities.
Code blue systems are the most prevalent code call system. It requests a team of specialists to respond to a life
threatening cardiac situation. When activated, the system sends a signal to an audio/visual master station or ancillary
annunciator. Code call monitoring stations must be monitored 24 hours per day, seven days per week. Code call systems
may also notify response teams by use of pocket pager or public-address systems. All code calls require a priority
response at the associated calling station before clearing the call. Supervised wiring methods are required.
[Link] Integration
Healthcare facilities with traditional nurse call systems typically have the option to expand these systems to provide
code call functionality. Each type of code call will have its own distinct call classification and response from the system
and staff members.
Code call systems may be interfaced with elapsed timers in procedure rooms (e.g., operating rooms, catheterization
labs).

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[Link] Design
Federal, state, and local codes shall be consulted for determining placement of code stations. Common areas for code
blue stations are the emergency department (ED), operating rooms (OR), treatment rooms, intensive care unit (ICU)
rooms, and critical care unit (CCU) rooms.
[Link] Implementation
Code call stations are wall mounted stand-alone switches, or one of several programmable call buttons. In a nurse call
system application, the functionality can be built into nurse master stations, duty/staff stations, or patient stations. These
buttons are designed to be used by staff. Corridor lights identify which corridor the call came from, and lights above the
door indicate the room the call originated from. Specific colored lamps (e.g., LED), and the flash rate of the lamps, are
used to identify the type of code call.
8.2 Connected Medical Imaging
8.2.1 Overview
Medical imaging systems are used to view the human body in order to diagnose, monitor, or treat medical conditions.
These technologies are in turn based on different physical principles like acoustics, magnetism, nuclear and particle
physics. Each type of technology gives different information about the area of the body being studied or treated, related
to possible disease, injury, or the effectiveness of medical treatment.
8.2.2 Imaging Modalities
[Link] Types
The following is a list of common types of imaging modalities.
• X-ray
• Fluoroscopy
• Computed tomography (CT)
• Ultrasound
• Mammography
• Nuclear imaging
• Radiation therapy (RT)
• Magnetic resonance imaging (MRI)
[Link] Computerized and Digital Radiography
In the medical imaging industry, there are several definitions used for the various modes of digital imaging.
Computerized radiology (CR) is used to describe digital imaging achieved by the use of photo sensitive plates placed
in a cassette. Digital radiology (DR) is used to describe digital imaging in which the image receptor is non-cassette
based. DR is either charged-couple device (CCD) or flat panel based, and the x-ray exposure is made directly to the
image receptor.
Many hospitals initially converted from film screen to CR and CR is frequently used as an interim step to DR technology.
8.2.3 Imaging Infrastructure and Communication Systems
[Link] Picture Archival and Communications System (PACS)
[Link].1 Overview
Figure 8-1 shows a typical PACS configuration. PACS consists of various electronic components and connects to a
computer network to facilitate the management of medical images from various imaging modalities. Other functions
include the storage, retrieval, manipulation and display of medical images on a network. It also integrates the image
management system with radiology and clinical information systems.
The proliferation of multiple imaging modalities and their associated dedicated storage systems has driven healthcare
organizations to make the transition to PACS. PACS form the core portion of medical image management system and
consists of a cluster of integrated application, database, and web servers. PACS systems are expected to:
• Maintain patient privacy and system security
• Ensure patients are protected from planned and unplanned downtime with reliable backup and high availability.
The PACS architecture requires high availability, typically greater than 99.99%, which translates to a maximum
of 50 minutes of downtime per year.
• Contain costs by reducing long-term storage expense

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Image Acquisition

CT, MRI, US, NM, XR Technologist reviews

modalities images
Physician Viewing

Radiologist reading and

dictation of report

Web client referring

PACS physician viewing

Medical Image Long Term

Archive Archive

Figure 8-1
Main PACS Functions

[Link].2 Components
The typical PACS consists of the five components:
• Image acquisition
• Communication network
• Image display and interpretation
• Image store and retrieval
• Patient data interface
The PACS archive should include a long-term storage, short-term storage, and an image management database that
makes use of hierarchical storage management (HSM). Most PACS employ a hierarchical storage strategy where new
images are stored on a local archive of on-line hard disk and older images on a distant archive of off-line tape library
for long-term storage; and the HSM manages the migration of stored images and data between the high-speed hard disk
subsystem for short-term storage and the lower-speed tape subsystem for long-term storage.
The selection of archiving technology depends upon archiving media and architectures. Archiving media may be in the
form of magnetic discs, a redundant array of inexpensive discs (RAID), optical discs, or magnetic tape. Archiving
architectures could be local, centralized, or distributed. The direction of archiving is toward centralized archiving, digital
imaging and communications in medicine (DICOM) and Health Level Seven (HL-7) interfaces, digital linear tape (DLT)
media, and structured query language (SQL) databases. Other issues in archiving technology include availability,
scalability, security, backup, fault tolerance, recovery, and knowledge discovery.

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[Link] Digital Imaging and Communications in Medicine (DICOM)

DICOM is a standard for handling, storing, printing, and transmitting information in medical imaging. DICOM uses
TCP/IP to enable the integration of various imaging modalities, servers, workstations, printers, and network hardware
from multiple manufacturers into a PACS.
The following are the three main areas that DICOM addresses:
• Network communications — A set of protocols for devices to allow the exchange of information over the
communication or data network infrastructure.
• Commands— Specifically, the syntax and semantics of the commands and associated information that is
shared between connected DICOM-enabled devices.
• Media communication — The set of media storage services, file format and directory structure that provides
access to stored images and related information.
[Link] Health Level Seven (HL-7)
Health Level Seven (HL-7) defines protocol for the exchange, management and integration of varied data in electronic
health records. The application level interfaces directly to and performs common application services for the application
processes. Its goal is to provide a comprehensive framework and related standards for the exchange, integration, sharing,
and retrieval of electronic health information that supports clinical practice and the management, delivery and evaluation
of health services.
[Link] Integrating the Healthcare Enterprise (IHE)
Integrating the Healthcare Enterprise (IHE) promotes integration within and across all units of the healthcare enterprise.
The currently active IHE domains are:
• Anatomic pathology
• Cardiology
• Eye care
• Information technology infrastructure
• Laboratory
• Patient care coordination
• Patient care devices
• Quality, research and public health
• Radiation oncology
• Radiology
8.2.4 Network Bandwidth and Service Level Agreement Considerations
The expectations of the user should be managed, especially if the implementation of the PACS link is over the wide
area network (WAN).
Consider a single study of a CT scan of thirty 512 x 512 x 16-bit images; each examination is approximately 15
megabytes. For a digital mammography study of four 4K x 6K x 12-bit images, the amount of data grows to 200
megabytes per examination. For the clinical center, it is estimated that approximately 8 million individual image slices
are generated per year. This is equivalent to four terabytes of image data assuming a typical individual image size is 0.5
MB.
Computing bandwidth requirements is complicated by the fact that some PACS systems will compress their images
before they send them to a diagnostic workstation, and the workstation will decompress the image. Some modalities
will do the same as they send images to the PACS systems. In general, bandwidth calculation is a tedious process pre-
implementation. However, post implementation the network engineer will be able to produce some benchmark for each
modality. Table 8-1 shows the typical images size and study size for various modalities. A compression factor of two is
used for lossless images and twenty for lossy.
As one will expect the transmission time will vary by the transport media. Table 8-2 shows the typical transmission
times assuming a network utilization rate of 30% and an efficiency of 70%.

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Table 8-1 Typical Study Size for Differing Image Modalities

Modality Number of Images Image Size (MB) Compression Factor Study Size (MB)
CT-16 200 0.5 2 50.00
CT-64 2000 0.5 2 500.00
MRI 160 0.125 2 10.00
US 1600 0.9 20 72.00
XA (1024) 2000 1.0 2 1000.00
XA (512) 2000 0.25 2 250.00
NM 100 0.031 2 1.56

Table 8-2 Example Transmission Times of Image Modalities for Differing Transmission Technologies
Assume 30% Network Utilization and 70% Efficiency

Transmission Transmission time in minutes

Technology CT-16 CT-64 MRI US XA (1024) XA (512) NM
10BaseT 1.36 13.61 0.27 1.96 27.21 6.80 0.04
100BaseT 0.14 1.36 0.03 0.20 2.72 0.68 0.00
1000BaseT 0.01 0.14 0.00 0.02 0.27 0.07 0.00
10GBaseT 0.001 0.014 0.00 0.002 0.027 0.007 0.00
T1/DS-1 8.81 88.12 1.76 12.69 176.24 44.06 0.28
Dual T1/DS-1 4.41 44.06 0.88 6.34 88.12 22.03 0.14
Quad T1/DS-1 2.20 22.03 0.44 3.17 44.06 11.01 0.07
T3/DS-3 0.30 3.04 0.06 0.44 6.08 1.52 0.01
10Mb MetroE 1.36 13.61 0.27 1.96 27.21 6.80 0.04
OC-3 0.09 0.87 0.02 0.13 1.75 0.44 0.00
OC-12 0.02 0.22 0.00 0.03 0.44 0.11 0.00
DSL 9.07 90.70 1.81 13.06 181.41 45.35 0.28
Cable Modem 3.40 34.01 0.68 4.90 68.03 17.01 0.11

For a typical medical image of 50 MB, it will take approximately four seconds for transmission plus overhead or
approximately one minute to retrieve a 500 MB study.
As digital imaging is implemented as part of the electronic health record requirements, there will be a major implication
on the enterprise network. With study sizes ranging from 50 MB to 1 Gigabyte digital imaging over time will change
the primary source of traffic in the health care network. Table 8-3 shows the typical transmission of single studies for
various modalities and the typical load during a year in a medium size hospital system.

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Table 8-3 Example of Study Size and Expected Annual Load

Bits Image MB / Image Image / MB / Exams /
Modality Matrix MB / Year
Stored Capture captured Exam Exam year
Nuclear Medicine 256 x 24 24 DICOM 0 10 2 30,000 58,982
Ultrasound 512 x 16 16 DICOM 1 30 60,000 943,718
MRI 256 x 256 16 DICOM 0.125 160 21 90,000 1,887,437
Computerized
2048 x 2560 16 DICOM 10 3 26 600,000 15,728,640
Radiology (CR)
CT 16-Slice 512 x 512 16 DICOM 1 200 105 80,000 8,388,608
CT 64-Slice 512 x 512 16 DICOM 1 2,000 1,049 40,000 41,943,040
PET 512 x 512 16 DICOM 1 90 47 20,000 943,718
Digital
4096 x 5624 16 DICOM 46 4 184 30,000 5,528,617
Mammography
Cath Lab 1,024 16 DICOM 2 70 147 20,000 2,936,013
Special
1,024 16 DICOM 2 15 31 10,000 314,573
Procedures
Echo's 512 16 DICOM 1 130 68 20,000 1,363,149

8.3 Patient Monitoring (Telemetry)

8.3.1 Overview
Patient monitoring, also known as physiological monitoring, is a dedicated system which monitors patients breathing,
heartbeat and other vital signs, and alarms if they exceed certain parameters. In some jurisdictions, patient telemetry is
used to indicate wired patient monitoring.
These systems are used to monitor and/or record patient’s vital health information including:
• Electrocardiogram (ECG)
• Electroencephalogram (EEG)
• Blood pressure
• Respiration
• Temperature
• Pulse oxygen
• Other vital signs specific to a nursing unit or hospital department
8.3.2 System Connections
Typically, individual monitors (one per bed) are connected to the nurses’ station and may also be connected to a central
monitoring center located elsewhere in the hospital or off-site. More sophisticated versions include CCTV style video
to allow visual observation of patients. This allows the constant monitoring of the most critically ill patients in the
hospital.
Patient monitoring typically requires a dedicated Ethernet jack at every bed in the emergency department, intensive care
units, cardiac care units, and post-anesthesia units. Typically, several monitoring-capable beds are setup in multiple
inpatient units, with the plan they will roll up a cart when one is needed. It is recommended to install an additional
Ethernet jack wherever one is required for patient monitoring. Patient monitoring systems can be either networked or
stand-alone.
When a workstation alcove is present between multiple rooms that contain monitoring, they may be equipped with
remote observation capability. This may require an additional cable to be installed between the remote observation
device and main monitor within the patient room. See Figure 8-2 for an example of a stand-alone patient monitoring
station.

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Balanced twisted-pair cable

Balanced twisted-pair cable

Figure 8-2
Example of a Stand-Alone Patient Monitoring Station

8.3.3 Cabling
[Link] Proprietary
The cabling is typically a home run to a central location, with specific requirements varying by system manufacturer.
[Link] Backbone Distribution
If optical fiber is used, a minimum of six (6) multimode strands or single mode optical fiber cabling shall be provided
from each TR to equipment room.
[Link] Horizontal Distribution
[Link].1 Requirements
For master stations, a minimum of four (4) balanced twisted-pair cables from the TR to the faceplate serving the master
station shall be provided
For standard and secondary stations, a minimum of two (2) balanced twisted-pair cables from the TR to the faceplate
serving the station shall be provided
Where balanced twisted-pair cabling is used, a dedicated patch panel shall be used within each TR serving the telemetry
system.
[Link].2 Recommendations
Cabling color for the stations should be different than the color for data and voice applications.

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8.3.4 Power Recommendations

All patient monitoring devices should be on critical power depending on the application, based on the room it is serving.
Verify with all national and local codes and regulations.
All devices should have battery back-ups
8.3.5 Monitors
Most devices can visually display many different vital signs on one monitor. Monitors can be controlled:
• Locally
– Touch screen
– Push button control
• Remotely via master station
A large, wall or ceiling mounted central display monitor(s) may be placed in a highly visible location within a nursing
unit to provide a quick, visual overview of all the patients within the unit. Secondary monitors can also be placed outside
of a patient room (e.g., isolation, decontamination, secure holding rooms) for remote monitoring. A central patient
monitor server and storage devices will record and monitor the entire patient monitoring system.
NOTE: When placing monitors, patient privacy requirements need to be addressed. Documents such as HIPAA may have
specific requirements when determining the field of view, maximum distance allowed for legibility and other visual properties.
8.3.6 Additional Information
[Link] Alarms
Units will alarm:
• Locally
• At the master station
• At secondary monitors, if applicable
[Link] Locations
Patient monitoring devices are found in many areas, including:
• Emergency department (ED) and traumatology
• Anesthesia
• Cardiology
• Internal medicine
• Intensive care units
• Neurology
• Pediatrics
• Pulmonology
• Surgery (e.g., surgical room, prep/recovery areas)
The following is a list of locations where monitoring devices are typically mounted:
• Ceiling
• Wall
– On a rail
– Stationary
• Mobile
– On a pole with wheels
– Portable
– Handheld
• Column (e.g., perfusion, nursing, anesthesia)
– On a rail
– Stationary
Master stations are usually located at each central nurse’s station.
[Link] Stand-Alone Devices
Stand-alone devices may:
• Store information in its local memory that can be downloaded at a later date
• Print to a paper recorder

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8.3.7 Wireless Medical Telemetry System (WMTS)

WMTS is the remote monitoring of a patient's health. The use of wireless medical telemetry gives patients greater
mobility and increased comfort by freeing them from the need to be connected to hospital equipment that would
otherwise be required to monitor their condition. Wireless medical telemetry also serves the goal of reducing health care
costs because it permits the remote monitoring of several patients simultaneously. In the USA, these usually require
dedicated radio frequency space with facility registration by The American Society for Healthcare Engineering (ASHE).
8.4 Physician Dictation
8.4.1 Overview
This system can either be a PC/web-based application or a service which provides a telephone number. Practitioners
can either logon or call the dictation service and dictate patient record information, medication instructions and any
other information to be placed in the patients’ health record.
8.5 At-Risk Human Perimeter Systems
8.5.1 Overview
At-risk human perimeter systems are designed to alert medical staff when a sensor attached to a patient passes outside
the allowed area. The system design and advancement closely mimic that of loss prevention systems because of the
similarity in technical and functional design.
These systems can be categorized into two major groups with completely different risks:
• Infant abduction / baby alert systems are designed for use in nursery and birthing medical units to protect
patients.
• Supervised care facilities utilize systems designed to protect patients from wandering or elopement.
8.5.2 Infant Abduction Prevention
[Link] Overview
Infant abduction systems are similar to the senior elopement systems. Both systems use similar products and principles
of design. Many manufacturers include solutions for both systems because of this similarity. Although the systems
function in the same manner, senior elopement systems are not always designed with the risk of malicious intent. Unlike
the senior elopement system, infant abduction prevention systems are intended to deter persons with mal-intentions.
Typically, these systems are combined with a badge system where mother and baby are matched for ID and security
purposes. Radio frequency technology can be used for tracking infants and mothers. The tag is affixed to the child/infant
in one of several different ways but is not easily removable without specialized tools. Sensors are located at all unit exits
to prevent the unwanted exit of babies from the maternity department. In more encompassing deployments the sensors
cover all the units completely and detect and alarm if a tag is removed without the system being properly informed,
telling security what child and where the tag was cut and in the unit the tag was removed.
In the event of an undesired exit, the system can be interfaced with the access control system and/or door hardware to
create a delayed egress and prevent the immediate exit from the unit. Delayed egress must be coordinated with security
systems, door hardware, AHJ, and requirements for path of egress.
[Link] System Options
Infant abduction systems include additional options specifically driven by its purpose, such as:
• Real time tracking and locating of assets, patients and staff
• Intelligent software capable of recognizing trends
• Loitering recognition
• Multiple programmable security levels
• Ability to lock doors when a risk is present
• Logging
• Network/computer integration
• Fall detection
• Paging
• Elevator deactivation
• Multiple display/annunciator
• Voice, tone or visual alarms

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The software used can include mother/infant matching options; this is convenient during the patients stay and vital at
check-out. Systems designed for infant protection use many of the optional features available on the senior elopement
system as part of their basic design. Elevators, doors, staff only areas and all points of egress can be designed to
automatically lock and prevent access when the transmitter device enters a predetermined area.
[Link] Design
[Link].1 Requirements
Ensure compliance with the AHJ.
This system is usually located in the maternity or labor and delivery (LDR) unit, the nurseries of a hospital, and often
pediatric units.
Consoles shall be placed at all nurse stations within the protected area. Head-end equipment shall be located in a secure
space (e.g., equipment room, TR, building systems support space)
Alert devices shall be placed at all perimeter exits from the protected area. Keypads shall be installed to allow staff to
temporarily bypass the system to transport patients in and out of the unit.
System requirements and integration options shall be discussed and defined in programming meetings with the owner,
nursing, security, facility, and information technology departments.
[Link].2 Recommendations
It is highly recommended that any information technology system designer of an infant protection system consults with
the National Center for Missing and Exploited Children for the following:
• Abductor profile
• Specific case histories
• Recommended design parameters
• Recommended communications protocols (procedures)
8.5.3 Supervised Care Elopement Prevention
Supervised care facilities are dedicated to patients that cannot care for themselves. The nature of the illness and
disabilities of patients of this type make it necessary to protect them from elopement.
ESS systems have been designed to alert staff when a patient attempts to cross a predetermined boundary. The
sophistication and options available on these systems can vary, but the main function is to provide perimeter security
for at-risk patients while allowing free access and egress for select populations, visitors, and staff. These systems also
can help a facility present a more open and inviting environment by decreasing the requirement for locked doors and
other types of architectural security.
[Link] System Options
At-risk human perimeter systems include options such as:
• Real-time tracking and locating of assets, patients, and staff
• Intelligent software capable of recognizing trends
• Loitering recognition
• Multiple programmable security levels
• Ability to lock doors when a risk is present
• Logging
• Network and computer integration
• Fall detection
• Paging
• Elevator deactivation
• Multiple display and annunciator
• Voice, tone, or visual alarms

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8.6 Interactive Patient Television System

8.6.1 Overview
An interactive patient television system uses the patient’s in-room television as a two-way interactive device. Ideally,
the system leverages a facility’s existing network and televisions to transform the television from a mere screen into a
patient portal — a two-way interactive communication channel that lets the patient enjoy premium satellite channels
(including high-definition channels), on demand movies, patient education content, video games, and more.
Beyond merely providing the patient with expanded entertainment options, an interactive patient television system can
serve as a conduit for many facility-specific tasks. With staffing shortages and shorter hospital stays placing greater
demands on nurses and caregivers, efficiency improvement is more critical than ever. The system can reduce the number
of non-clinical requests for nursing staff by empowering patients to access information and entertainment on demand;
keeping them informed, entertained and comfortable in their beds.
An interactive patient television system can empower patients to make non-clinical requests such as ordering meals,
scheduling a case worker or spiritual counselor visit or even requesting blankets, pillows and other items using their
television remote or pillow speaker. Relieving medical staff from these non-clinical requests allows caregivers to focus
on providing quality care, maximizes nursing staff productivity and facilitates timely attention to priority clinical issues.
The system can also enable patients to view educational programs, including those specifically prescribed for their
medical conditions, on demand and without cumbersome video equipment carts or video libraries. A robust system can
even record the patient’s participation and provide reporting that meets the joint commission’s requirements to confirm
the patient has viewed and understood the educational content.
Since patients can use the system for a wide range of non-clinical needs, there is less reason for them to leave their beds
or rooms, which, as discussed, may help reduce the risk of patient falls and the associated liability implications.
Interactive patient television system helps healthcare facilities increase patient satisfaction and improve quality of care
while boosting overall process and staff efficiencies.
8.6.2 System Description
System hardware shall include but not be limited to:
• Content server(s)
• Signal transmission and decoding hardware
• Internet, cable television, nurse call, and hospital LAN interface hardware
• Required user interface equipment, such as wired or wireless keyboards, integrated pillow speakers
• System displays, monitors, or televisions
• Any other equipment required to meet the intent of these specifications, whether enumerated within these
specifications, to provide a complete and operating patient entertainment system.
System operation shall include full patient and family interaction via wired or wireless keyboard, and integrated pillow
speaker. Services to consider for implementation are:
• Cable and satellite television service
• Broadcast radio channels
• Movies in video-on-demand format
• Music
• Patient education with a “verification of completion” page
• Patient education, including discharge instructions and testing for patients and families
• Patient satisfaction surveys
• Dietary orders in dining-on-demand format
• Email
• Internet
• Secure web-based patient status information for families and friends
• Service recovery tools (real time notification to appropriate departments regarding specific patient complaints)
• Patient itinerary both in room and web-based
• Games
• Non-clinical staff calls and requests, including integration with existing pocket page system for staff response
• Gift shop shopping and other amenities
• Web link to donation sites
• Additional functions as deemed appropriate by hospital staff

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8.6.3 Design with Coaxial Cabling Systems

The traditional interactive patient television system may utilize the existing or new television distribution system. The
addition of twisted pair distribution to outlets currently served by coaxial distribution lends itself to be retrofitted later
in the project, as funds may become available to support the system and its programming needs. See Figure 8-3 for a
sample layout for the basic infrastructure to support this system.
The following is a list of material that may be included in the design of this system.
• Backbone riser cable
– Optical fiber cable
– Coax: RG-11, 13 mm (0.5 in) hard-line
• Distribution amplifier
• Miscellaneous taps and splitters
• Cable rack for data cable
• Patch panel for data cable

Balanced Twisted-
Pair Cable

Coaxial Cable

Outlet

Patch Panel

Cable
Management

Output

Input

Coaxial Cable
Splitter

Figure 8-3
Example Interactive Patient Television System Infrastructure

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8.6.4 Design with Balanced Twisted-Pair Cabling Systems

[Link] Broadband Video Transmission
One of the most demanding applications on the market today is broadband video, commonly known as CATV or cable
television. It carries a broad range of signals extending from 54 MHz to 860 MHz. Coaxial cable (series-59 or series-6)
is commonly used for these applications. In addition, balanced twisted-pair cabling can also support broadband video.
CATV companies provide high speed Internet service through cable modems, as defined in the Data Over Cable Service
Interface Specification, commonly known as DOCSIS. DOCSIS 3.0 and its earlier versions allows downstream
communications from a head-end site using one or more 6 MHz channels between 88 MHz and 860 MHz and upstream
communications at frequencies between 5 to 42 MHz. DOCSIS 3.0 enabled modems support channel bonding, which
allows a maximum downstream throughput of 1200-1600 Mb/s depending on location. In comparison, DOCIS 3.1 offers
a minimum ability of 10 Gb/s downstream and 1 Gb/s upstream throughput capability.
Figure 8-4 illustrates how broadband video can be distributed in a hospital environment. Potential applications would
include cable television/satellite newscasts, stored or live video broadcast, distance learning, security monitoring, and
video conferencing.
Category 6A cabling is recommended for broadband video distribution because of the lower insertion loss (stronger
signal) and better noise immunity.

Satellite, Antenna
Horizontal
or CATV Input Patch Panel Cabling

Combiner
Distribution Hub
Analog (e.g., NTSC)
and Digital Video Signal
Outlet
Broadband
Modulator Video Balun

DVD Player
Video Camera

Figure 8-4
Broadband Video Distribution Over Balanced Twisted-Pair Cabling

[Link] Internet TV / Internet Protocol Television (IPTV)

Internet TV and IPTV use the internet and other digital means to transmit television and other media content. The
transmission infrastructure is similar to broadband video distribution; the key difference is that displays connect directly
to the outlet through the use a single patch cord, avoiding the need for a balun and other related coaxial cabling.
With the development of digital transmission, additional applications such as HDBaseT have been developed to allow
power to be provided through the horizontal cabling to the display, potentially removing the need for the display to
connect to the primary electrical system.
Cabling design and infrastructure requirements for Internet TV / IPTV are similar to other intelligent buildings systems
specified in standards such as ANSI/BICSI 007, ANSI/TIA-862-B and ISO/IEC 11801-6.

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8.7 Alarm Management

8.7.1 Overview
An acute healthcare facility has numerous systems that provide alarm notification. The management of these alarms is
determined by evaluating and documenting the needs, processes, and procedures of the facility. This evaluation should
identify and document all systems, signaling protocols, alarm types, code mandated response method and priority, and
how each alarm is to be processed.
Example of systems that can generate alarm data are:
• Air handling unit controllers
• Boiler system controllers
• Emergency generator control panels
• Chiller unit controllers
• Fuel oil system controllers
• Refrigerator temp alarms
• Fire alarm systems
• Elevator control systems
• Smoke control systems
• Medical gas systems
• Access control systems
• Intrusion detection systems
• Surveillance systems
• Infant abduction systems
• Patient flow systems
• Bed management systems
• Patient monitoring systems
• Nurse call systems
• Code call systems
• On-call scheduling systems
• Infusion pump systems
• Ventilator systems
• Temperature monitoring
8.7.2 Devices
Devices are typically classified as one of the following:
• Input Appliance (e.g., sensors, cameras, manual initiation devices)
• Actuator (e.g., motors for valve or damper)
• Notification appliance (e.g., visual and audible annunciators and monitoring stations)
• Controller/processor (with associated inputs, outputs, and supervisory connection points)
• Relay (with associated inputs and outputs points)
8.7.3 Design Overview
Consult with federal, state, and local codes for specific power requirements (e.g., secondary power source requirements).
Controllers shall be placed with consideration for environment and physical security needs.
Typical system monitoring locations are:
• BMS monitor — facilities control room
• Fire alarm system — 24-hour monitoring location and remote annunciators at main entrance
• Elevator control system — facilities or fire command room (FCR)
• Smoke control system — facilities or fire command room (FCR)
• Medical gas system — 24-hour monitoring locations, unit corridors and nurse stations
• Access control system — security station
• Surveillance system — security station

List continues on the next page

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• Infant abduction system — security station and nurse station

• Patient monitoring systems — serving nurse station
• Nurse call systems — serving nurse station
• Code call system — serving nurse station and 24-hour monitoring location
• Infusion pump systems — serving nurse station
• Ventilator systems — serving nurse station
8.7.4 Building Automation and Management Systems
A building automation system (BAS) is a system of distributed micro-processor-based controllers to automate any
combination of building system operations. BAS data is typically managed and monitored through a building
management system (BMS). These systems are typically designed and specified by the heating, ventilation, and air
conditioning (HVAC) engineer. Coordination with the BAS/BMS designer will be required for any systems selected to
interface with the BMS.
8.7.5 Medical Systems
Medical systems have traditionally utilized dedicated, system specific, alarms for notification. They are traditionally
proprietary in nature and are designed by manufacturers with the assistance of medical equipment consultants.
Because of the potential for overloading staff with alarm notifications from multiple sources, there has been interest in
using middleware systems to process alarm input data from multiple systems, prioritize the alarms, and notify the
appropriate staff via onsite paging, smart phones, and in-building wireless phones. Though Federal Drug Administration
regulations (21 CFR Part 880) for Medical Device Data Systems (MDDS) do not currently apply to alarm monitoring
systems, some connected devices may be regulated. Some middleware systems can also process building alarm data
(via interface with the BMS) and route notification to the appropriate response staff.
The designer of middleware solutions should confirm that all connected devices falling under 21 CFR Part 880 are
compliant with regulations, and the respective vendors are able to provide a connection point for the middleware system.
Compatibility of signaling protocols shall be confirmed with each vendor.
8.7.6 Electronic Safety and Security (ESS) Systems
Fire alarm systems shall not use a sub-system for any type of fire alarm notification. The fire alarm system can provide:
• Monitoring data to the BMS system
• Action commands to access control systems (e.g., door release)
• Action commands to elevator control systems (e.g., recall command)
• Action commands to mass notification systems (e.g., alert command)
Access control systems can provide alarm data to sub-systems. The access control system can provide:
• Data to the BAS/BMS system (e.g., notification and/or integration with lighting and HVAC systems)
• Action commands to surveillance systems (e.g., activate camera)
• Action commands to elevator control systems (e.g., provide floor access rights)
• Response from fire alarm system input (e.g., door release)
• Response from infant abduction systems and patient elopement systems (e.g., door locks)
8.8 Emergency Medical Services Radio
8.8.1 Overview
Radio supporting emergency medical services operates within a subset of the frequency bands designated for land
mobile radio. Typical frequency bands encountered include 35, 43, 152-163, and 462-468 MHz supporting functions
including telemetry, voice communication between EMS and hospitals, and medical dispatch.
8.8.2 Requirements
Land mobile radio frequencies and emergency medical services radio frequencies, are governed by an AHJ, typically
the national government body overseeing radio communications. All deployment shall meet applicable AHJ
requirements, including licensing.
DAS systems used to support emergency medical services radio shall also meet the requirements of Section 6.10
8.8.3 Recommendations
The installation of emergency medical services radio should meet the requirements of applicable standards (e.g., NFPA
1221).

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8.9 Telemedicine, Communication and Notification Suites

8.9.1 Telemedicine
Telemedicine refers to the provision of remote clinical services, via real-time two-way communication between the
patient and the healthcare provider, using electronic audio and visual means.
There are three main types of telemedicine:
• Store-and-forward telemedicine solutions
Sometimes called asynchronous telemedicine, store-and-forward solutions enable healthcare providers to
forward and share patient medical data (e.g., lab results, images, videos, records) with a provider at a different
location. Store-and-forward telemedicine works best for interprofessional medical services where a provider
needs to outsource diagnosis to a specialist. For instance, teleradiology allows technicians and healthcare
professionals at smaller hospitals to share patient x-rays for diagnosis by a specialist at another location.
Asynchronous telemedicine is also commonly used for teledermatology and teleophthalmology.
• Remote patient monitoring
Remote patient monitoring (RPM) allows healthcare providers to track a patient’s vital signs and other health
data from a distance and is sometimes also called telemonitoring or home telehealth.
Many RPM solutions record and transmit a patient’s medical data automatically, generating a regular report
for the physician. In some cases, this medical data is transmitted to a team of health monitoring professionals
who are responsible for flagging any warning signs and sending them on to the physician, if needed.
• Real-time telehealth
Also called synchronous telemedicine, real-time telemedicine requires a live interaction between either a health
professional and patient, or between health professionals, using audio and video communication.
In addition to synchronous video and audio, real-time telemedicine systems may also incorporate a variety of
diagnostic tools and systems within the remote unit, allowing the performance of a variety of test, with the
results being transmitted to the health professional as they occur.
[Link] Requirements
Telemedicine solutions shall meet AHJ and patient privacy (e.g., HIPAA) requirements.
NOTE: In addition to the telemedicine system, ICT infrastructure and equipment, as well as providers, patients, and staff using
the tool may also have to comply with AHJ and patient privacy requirement.
[Link] Recommendations
Healthcare providers should create a dedicated space for telemedicine visits to ensure privacy, proper lighting and audio,
and avoid interruptions. When possible, providers should place their camera on a level stand and position the camera at
eye-level.
Systems used to support video applications within telemedicine should be designed to effectively support high resolution
image files and 4k synchronous video, with consideration for supporting 8k or higher synchronous video.
8.9.2 Communication and Notification Suites
A healthcare facility may provide a room for private communication accessible by healthcare personnel, patients and
visitors. These rooms are similar to rooms for telemedicine applications, but often do not require the need to support
high resolution synchronous video transmission. These rooms may support additional connectivity (e.g., LAN, WLAN,
Bluetooth low energy) for an occupant’s equipment, dependent of specified room and occupant requirements.

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9 Other Information Communication Technology Systems

9.1 Notification Systems

9.1.1 Overview
Information that is intended to reach multiple individuals in a building or is necessary to be sent to an individual or
group whose exact whereabouts in a building may not be readily apparent, can be successfully communicated via a
notification system. Additionally, notification systems allow audio information to be sent to the entire premise, selected
rooms/floors/sections, and provide reinforcement (i.e., amplification) to ensure that information is intelligible, and has
sufficient volume to overcome any noise or attenuation factors.
Uses of notification systems include:
• Time and facility schedule information
• Organization information
• Paging (e.g., personnel location/direction)
• Environmental and ambient sound control
• Building and facility status
9.1.2 System Types
• Distributed — utilizes an engineered number of speakers located within a space to provide uniform coverage
of the space. Distributed systems are typically either:
– Constant voltage outputs from central amplifiers to speakers
– VoIP connections to individual integrated amplifier/speaker units
• Standalone Audio/Visual — speakers can be associated/integrated with individual visual display locations
• Integrated Audio/Visual — combines characteristics of both Distributed and Standalone systems into an
integrated system
[Link] IP Addressable Speaker
IP addressable speakers can be used for zoned systems, multiple buildings, or remote locations.
Each loudspeaker or group of loudspeakers has its own IP address. The digital signal is sent to distributed amplifiers or
amplified loudspeakers with the selected IP address. As the IP signal alone will not power the loudspeakers, additional
power will need to be supplied to the loudspeaker location.
Cabling for IP addressable speakers may be either balanced twisted-pair or optical fiber cable, with local media
conversion as applicable. IP addressable speakers can be powered utilizing Power over Ethernet (PoE).
Variable delays between input and delivery can cause audio quality problems and need to be considered in the network
design.
[Link] Centrally Amplified Systems
A centrally amplified system places the amplifier at the central distribution point for the system. Cabling is extended
from this amplifier to the loudspeakers.
Two types of amplifiers and loudspeakers can be used in a centrally amplified system:
• Constant voltage
• Constant current
Constant voltage systems are typically used for distributed paging systems. A constant voltage, typically 25, 70, or 100
V, is tapped in the field to adjust the loudspeaker volume and load.
Constant current systems are typically used within small installations. These systems require loudspeakers to be
balanced, based on load rating. A constant current system is typically driven into a 4 or 8-ohm loudspeaker system.
In both constant current and constant voltage systems, the cable is typically 18 AWG [1.0 mm (0.039 in)] or larger and
is often shielded. Additionally, the AHJ may have additional requirements based on the voltage or current within the
system (e.g., use of conduit).

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[Link] Distributed Amplified Systems

A distributed amplified system places amplifiers away from the central distribution point. Small amplifiers are placed
directly on the loudspeaker mounting frame (e.g., ceiling loudspeakers) or inside the housing (e.g., horn-type
loudspeakers). Distributed amplified system designs and the number of speakers they can support are affected by speaker
wattage, amplifier power, conductor size/gauge and signal source.
9.1.3 Notification System Inputs
A notification system may use one or more input sources. Common input sources include
• Microphone — This circuit conducts the signal from a microphone to a preamplifier or audio mixer. The cable
should have two conductors with a shield. The typical connector on this cable is called an X series (X latching
resilient rubber compound [XLR]), although conductors may be directly terminated on other types of
terminating devices. The typical signal levels for this circuit are -80 dBm to -20 dBm
• Line-level — This circuit connects the output of a microphone preamplifier, tape player, compact disc (CD)
player, or telephone common equipment to an audio mixer or amplifier. The cable may have one or two
conductors with an overall shield. The typical signal levels are -20 dBm to 0 dBm
• Local on-site computers and/or servers
– Centrally located servers within premises — can include interfaces from other local building systems (e.g.,
fire-life safety, audio/visual) to sound system signal processors/mixers and amplifiers
• Remote data/audio feeds:
– Off-site Commercial or Organizational Broadcast feeds via wired or wireless connectivity (e.g., AM/FM
radio, background music)
9.1.4 Connectivity Arrangements
Common connectivity requirements of notification may include:
• Ethernet (typically 10/100/1000BaseT by communication cabling)
Ethernet can be used in conjunction with VoIP to provide common audio and control inputs and outputs to
most of the components of a sound system, including integrated amplifier/speaker assemblies.
• Analog audio inputs from audio sources to signal processors and amplifiers
– Telephone grade (300-3400 Hz)
– Voice audio grade (300-5000 Hz)
– Mono audio grade (300-8000 Hz)
– High fidelity stereo audio grade (20-20,000 Hz)
• Analog audio outputs between amplifiers and speakers:
– 8-ohm
– Constant voltage (typically 25 or 70 volts)
9.1.5 Design Considerations
[Link] General Requirements
The necessary pathways for notification systems shall conform to applicable codes, requirements of the AHJ and Section
6 of this document. Additionally, the location and mounting of power supplies or amplifiers shall conform to applicable
codes and requirements of the AHJ.
NOTE: In many jurisdictions, audio output circuits cannot share pathways with other power-limited or communication circuits
and must be installed in dedicated pathways.
Notifications systems intended for use as primary mass notification systems (MNS) for building emergency notification
purposes must meet applicable AHJ and Code requirements (e.g., NFPA 72, National Fire Alarm and Signaling Code).
AHJ or Code requirements may require that notification systems utilizing constant-voltage distribution methodologies
utilize separate pathway/raceway systems for audio output wiring (between amplifiers and speakers) from those utilized
for other building ICT functions.
Shielded cable shall be used when running higher voltage level speaker lines in close proximity to voice or data cabling.

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[Link] General Recommendations

Microphone and line-level cables should not be run in close proximity to audio output cables because crosstalk may
occur.
Loudspeakers may be flush mounted in the ceiling, suspended from the ceiling, or wall mounted. Horns are often
mounted on walls, racks, poles, or I-beams or suspended from ceilings.
The audio paging cable runs typically return to the nearest TR or equipment room, which allows for easier maintenance,
trouble- shooting, and system changes.
[Link] Audibility
Effective audibility can be compromised in many ways, including:
• Alarm level — If output levels are not sufficient, occupants will be unaware of alarm events
• Alarm clarity — If alarm tones and patterns are not clearly recognizable, occupants may misinterpret the nature
of the alarm
• Alarm reliability — Excessive false alarms can create mistrust and doubt, which can lead to ignoring alarm
events
The AHJ, codes and standards contain extensive rules and guidelines to address these issues.
[Link] Other Considerations
• Degree of environmental control in coverage area (e.g., habitable indoor space, industrial space subject to
temperature or humidity ranges outside of those of a typical habitable indoor space, outdoor areas)
• Speaker mounting locations, number of coverage areas and zoning requirements
• Acoustic Considerations:
– Amount of ambient noise in coverage area
– Physical dimensions of coverage area
– Architectural finishes and surface conditions in coverage area
9.1.6 Integration
Integration between notification systems and other intelligent building systems can include:
• Building clock and time distribution systems
• Building telephone systems
• Fire detection and alarm/life safety systems, including hazardous material detection systems
9.2 Intercom Systems
9.2.1 Overview
Intercoms can incorporate connections to landlines, cellular telephones, and other intercom systems over telephone or
data lines. Intercoms may also utilize both audio and video transmissions to identify visitors who seek access to limited-
access or secure rooms and areas.
9.2.2 Components
The primary components of an intercom system are the master station and one or more remote stations. The master
station receives calls from the remote stations and is typically staffed with an operator. Types of remote stations include:
• Substation — Unit that is capable of only initiating a call to a master station but is not capable of initiating a
call to other stations (sometimes called slave units)
• Door station — Unit that is capable of only initiating a call to a master station. It is typically weatherproof
• Intercom station — Full-featured remote unit that is capable of initiating and receiving party line conversation,
individual conversation, and signaling
• Wall mount station — Fixed-position intercom station with a built-in loudspeaker. May have a flush-mounted
microphone, handheld push-to-talk microphone, or telephone-style handset
• Portable — Mobile intercom, sometimes called a belt pack
• Handset — Permanent or portable telephone-style connection to an intercom station. Holds both an earpiece
and a push-to-talk microphone
• Headset — Portable intercom connections from a belt pack to one or both ears via headphones with an
integrated microphone on a boom arm

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9.2.3 System Types

[Link] Analog Voice Only
An analog voice only intercom system typically consists of:
• Master station
– Home-run cabling to each secondary device
– Selectable call control
– All call button
– Privacy button
– Extension devices to add on more points of communications
– Integrated speaker and microphone to allow 2-way voice communications
– Power supplies
• Secondary devices
– Another master station
– Secondary master stations
– Door stations
o Wall or surface mounted
o Push to call button or hands-free
o Integrated speaker and microphone to allow 2-way voice communications
o Light to designate that call has been placed
o Ancillary access control and video surveillance points
 Allow for remote release of controlled doors
 Allow for CCTV cameras to “wake up” and start recording
[Link] Analog Voice and Video
An analog voice and video intercom system typically consists of:
• Master station
– The elements of an analog voice only system
– Video monitor to display connected call
– Video and audio outputs to allow 3rd party recording
• Secondary devices
– The elements of an analog voice only system
– Door stations
o The door station elements of an analog voice only system
o Integrated video camera
[Link] IP-based, Voice Only
An IP-based, voice only intercom systems typically consists of:
• Master station
– The elements of an analog voice only system
– Networked cabling to central switching unit
• Secondary devices
– The elements of an analog voice only system
– Networked cabling to central switching unit for each secondary device
[Link] IP-based, Voice and Video
An IP-based, voice and video intercom system typically consists of:
• Master station
– The elements of an analog voice and video system
– Networked cabling to central switching unit
• Secondary devices
– The elements of an analog voice and video system
– Networked cabling to central switching unit for each secondary device
• Central switching unit (CSU)
– Networked appliance used as central core for all intercom call processing

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9.2.4 Healthcare Applications

The following areas have additional considerations when designing and implementing an intercom system.
[Link] Operating Room (OR)
• Master station at the main nurse station and the OR control room, and if applicable, any OR stations
– Hands-free
– Weatherproof
• Communications to other hospital specific departments
[Link] Emergency Room (EmR)
• Master station at reception desk
• Secondary master station at each nurse station
• Door station at each entrance to EmR
– Provide relay to control entrance door
• Communications to main OR nurse’s station
• Communications to ambulance entry
• Communications to security office
• Communications to other hospital specific departments
[Link] Mortuary
• Door station outside of autopsy room
• Door station inside of autopsy room
– Hands-free
– Weatherproof
[Link] Radiology
• Communications to OR communications and the EmR
• Communications to pathology
• Communications to histology
• Communications to central sterile
• Communications to other hospital specific departments
[Link] Procedure Rooms (e.g., Cath Labs, MRI rooms)
• Control Room
– Master station
– Amplifier
– Technician headset
o Wired
o Wireless
• Procedure room
– Ceiling mounted speakers
– Ceiling mounted microphone
9.2.5 Operation
The voice communication channel is normally initiated at the substation. By pressing the push button at the substation,
a voice channel is opened to an assigned control station. The voice channel can be programmed to forward to an alternate
control station if the assigned primary control station fails to answer the call within a set duration of time.
[Link] Infrastructure and Protocols
Control Stations and substations support either the TCP/IP protocol or a manufacturer's proprietary serial protocol.
TCP/IP systems are designed to use Category 5e or higher performing balanced twisted-pair cable.
A serial communications-based system typically uses a 2 or 4 conductor cable and is wired point-to-point between the
control station/substation and communication server.

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9.2.6 Integration
Integration of intercom systems is typically with security systems, such as video surveillance and access control.
In integrating Intercom with video surveillance, the system will typically monitor the voice channels between control
stations and substations. It will then call up associated video surveillance cameras for audio/visual verification of the
calling party. The video and audio content could also be recorded for forensic review at a later time.
For access control, when a card reader is associated with a substation it can display a stored badge photograph and
unlock an access control door using a control station function key.
Communication or device failure alarms can be programmed at the security management system (SMS) to detect a
failure within the intercom system.
Intercom substations can be shown on the security management system's graphical user interface.
The icon for the intercom station could be interactive and open a voice channel between the selected substation and its
associated master station.
9.2.7 Wireless Intercoms
The use of wireless intercom systems within healthcare application is not recommended. Additionally, many AHJs
prohibit the use of these systems within healthcare environments. Issues when implementing a wireless intercom system
include:
• Interference and signal loss conflicting carrier frequencies and signal power from other wireless devices and
systems (e.g., digital enhanced cordless telecommunications devices, wireless data networks, remote audio
speakers)
• Privacy and confidentiality requirements of patient and facility information
• Interference with other hospital systems
9.3 Sound and Acoustical Systems
Information that is intended to reach multiple individuals in a building or is necessary to be sent to an individual or
group whose exact whereabouts in a building may not be readily apparent, can be successfully communicated via a
sound system. Additionally, sound systems allow audio information to be sent to the entire premise, selected
rooms/floors/sections, and provide reinforcement (i.e., amplification) to ensure that information is intelligible, and has
sufficient volume to overcome any noise or attenuation factors.
9.3.1 Purposes of Sound Systems:
• Time and facility schedule information (e.g., class periods, shift changes)
• Organization and commercial information (e.g., advertisements, promotions, news).
• Paging (e.g., personnel location/direction, general announcements)
• Environmental and ambient sound control (e.g., background music)
• Presentation and training (e.g., meeting /conference rooms, classroom facilities).
• Building/facility status/emergency information (e.g., incident notification, egress, condition/status of
infrastructure)
9.3.2 Sound Systems
[Link] Types
• Distributed — utilizes an engineered number of speakers located within a space to provide uniform coverage
of the space. Distributed systems are typically:
– Constant voltage outputs from central amplifiers to speakers
– VoIP connections to individual integrated amplifier/speaker units
• Standalone Audio/Visual — speakers can be associated/integrated with individual visual display locations
• Integrated Audio/Visual — combines characteristics of both distributed and standalone systems into an
integrated system
[Link] Modes of Operation
• Automated (e.g., pre-recorded, scheduled)
• Ad-hoc (e.g., via user microphone or telephone set)

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[Link] Information Sources

• Local on-site computers and/or servers
– Centrally located servers within premises — can include interfaces from other local building systems (e.g.,
fire-life safety, audio/visual) to sound system signal processors/mixers and amplifiers
• Remote Data/Audio Feeds:
– Off-site commercial or organizational broadcast feeds via wired or wireless connectivity (e.g., AM/FM
radio, background music)
[Link] Typical Connectivity Arrangements
• Ethernet (typically 10/100/1000BaseT by communication cabling)
Ethernet can be used in conjunction with VoIP to provide common audio and control inputs and outputs to
most of the components of a sound system, including integrated amplifier/speaker assemblies.
• Analog audio inputs from audio sources to signal processors and amplifiers
– Telephone grade (300-3400 Hz)
– Voice audio grade (300-5000 Hz)
– Mono audio grade (300-8000 Hz)
– High fidelity stereo audio grade (20-20,000 Hz)
• Analog audio outputs between amplifiers and speakers:
– 8-ohm
– Constant voltage (typically 25 or 70 volts)
9.3.3 Sound System Design Conditions:
• Degree of environmental control in coverage area (e.g., habitable indoor space, industrial space subject to
temperature or humidity ranges outside of those of a typical habitable indoor space, outdoor areas)
• Speaker mounting locations, number of coverage areas and zoning requirements
• Acoustic Considerations:
– Amount of ambient noise in coverage area
– Physical dimensions of coverage area
– Architectural finishes and surface conditions in coverage area
9.3.4 Integration
Integration between sound systems and other intelligent building systems can include:
• Building clock and time distribution systems
• Building telephone systems
• Fire detection and alarm/life safety systems, including hazardous material detection systems
9.3.5 Code and AHJ Requirements
Sound systems intended for use as primary mass notification systems (MNS) for building emergency notification
purposes must meet applicable AHJ and code requirements (e.g., NFPA 72).
AHJ/code requirements may require that sound systems utilizing constant-voltage distribution methodologies utilize
separate pathway/raceway systems for audio output wiring (between amplifiers and speakers) from those utilized for
other building ICT functions.
9.4 Sound Masking/Privacy Systems
9.4.1 Overview
When designing an optimal acoustic environment, architects consider a variety of elements to address noise control and
speech privacy. These elements are collectively called the ABC's of acoustic design, and are:
• Absorb — Acoustic wall panels, carpet, and ceiling tiles help absorb excess sound
• Block — Solid barriers, partitions, and walls help block excess sound
• Cover — Sound masking helps cover up excess sound
These elements can be used together or individually to achieve the desired acoustic environment. Absorbing and
blocking materials are considered part of a facility’s architectural requirements, with covering materials typically
considered as an audio system.

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Sound masking systems consist of three elements: emitters (e.g., speakers), control equipment, and the requisite cabling.
A common indirect method is to mount one or more speakers above a suspended ceiling or below an access floor, with
the speakers positioned to emit the masking noise towards a building element. When operational, the noise reflects off
the building element and into the ceiling (or access floor), where it travels through the ceiling or floor and into the space
to be masked.
Within a healthcare facility, sound masking systems are commonly used where privacy is required. Other areas include:
• Offices and counseling areas
• Pharmacies / dispensaries
• Patient rooms
• Reception areas
• Outside of conference rooms
9.4.2 Requirements
IP-Based sound masking systems are considered an intelligent building system. Cabling and pathways supporting these
systems shall meet the requirements of Section 6 and ANSI/BICSI 007.
9.4.3 Recommendations
The use of zone area coverage allows for flexibility in design, as ceiling architecture, ceiling height, other sound related
systems (e.g., paging, ambient music) can affect final speaker placement.
NOTE: A speaker’s coverage areas can vary from can range from approximately 9.3 m2 (100 ft2) to 1,115 m2 (12,000 ft2).
Each speaker of a sound masking system should be individual controllable to account for speaker location differences
that could affect performance (e.g., ceiling plenum construction and materials)
9.5 Emergency Communication Telephone
9.5.1 Overview
Emergency communication telephones provide a quick and dedicated way to notify the appropriate personnel of an
emergency. Emergency telephones are often a purpose-built device dedicated to this function.
Emergency communication telephones may be integrated into the telecommunications network using the existing
telephone infrastructure, wireless communication, or may be IP based.
9.5.2 Components
Besides the phone assembly, an emergency communication telephone may include:
• A strobe light at the telephone to identify the location of the call
• Surveillance cameras to remotely observe the caller
• External speakers to communicate with the caller
9.5.3 Location
Emergency communication telephones can be located on the interior or exterior of a building. They also can be mounted
on freestanding towers. Location, mounting, and necessary pathways for emergency communication telephones shall
conform to applicable codes, requirements of the AHJ and Section 6 of this document.
9.6 Digital Signage and Wayfinding
9.6.1 Overview
Information can be provided to persons within the facility through the use of digital and video displays. Common
applications include:
• Wayfinding, such as building/tenant location information (directory), event/meeting information (location,
time), transportation mode information (schedules, arrivals/departures, status, alternate routes).
• Organization and commercial information (e.g., advertisements, promotions, news).
• Visual paging and message boards.
• Presentation and training (e.g., meeting /conference rooms, classroom facilities).
• Building/facility status/emergency information (e.g., incident notification, egress, condition/status of
infrastructure)

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9.6.2 Digital Displays

[Link] Types
• Front/rear projection
• Flat panel
– Liquid crystal display (LCD)
– Light emitting diode (LED)
[Link] Modes of Operation
• Static display (basic text or still image)
• Animation (e.g., flashing, scrolling, reversing text/background)
• Full-motion video
[Link] Information Sources
• On-Site computers and servers — can include interfaces to other local building systems (e.g., fire-life safety,
audio/visual)
• Integral to display (pre-programmed or programmed remotely via a network connection)
• Centrally located servers within premises — includes interfaces to other local building systems (fire-life safety,
audio/visual, etc.)
• Remote data/video feeds (e.g., off-site commercial or organizational broadcast feeds. network television, local
CCTV feeds)
[Link] Typical Connectivity Arrangements
• Ethernet (typically 10/100/1000BaseT)
• High-definition multimedia interface (HDMI)
• VGA
• Red, green, blue (RGB) video
• RF digital video
9.6.3 Usage Conditions
• Degree of environmental control in installation area (e.g., indoor versus outdoor)
• Mounting location — mounting arrangements can include wall, ceiling or floor
• Field of view — will influence the size of the display, the mounting arrangements and legibility of the
information presented
• Lighting and visibility conditions — natural or artificial lighting can affect visibility and legibility, also
visibility can be affected by items such as smoke, fog, mist, or rain. Dust or other particulate matter collecting
on a display can also reduce visibility.
[Link] Viewing Distance
[Link].1 Overview
Viewing distance is a concept used to capture attention for an image on display. Viewing distance is also closely related
with the resolution and size of an image.
The concept of viewing distance requires an understanding of perspective theory as the resolution of the image, and its
detail, is always taken from where the viewer is positioned and whether the viewer is standing, walking, sitting or
viewing from a moving vehicle. The clarity of atmospherics such as light and shade and weather conditions also plays
a part in viewing distance.
The perception of the human eye varies from person to person, and some people are vision impaired, so the only true
viewing distance comparison is the distance at which most people can see the image or sign.
[Link].2 Recommendations
For general applications, a 50 mm (2 in) minimum letter height provides visual legibility to a maximum of 15 m (50 ft).
Other recommended minimum letter heights for various applications include:
• Vehicular direction signs, internal roads, carparks and service areas: 60 mm (2.4 in)
• External pedestrian direction signs: 60 mm (2.4 in)
• Internal direction signs: 30 mm (1.2 in)
• Building directory listings: 20 mm (0.75 in)
• Door signs: 17 mm (0.7 in)

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[Link] Readability
The following recommendations can assist in the optimal readability of signage:
• Utilize contrasting colors.
NOTE: The use of black and white negates color related readability issues for all types of color vision deficiency
• Provide a lighting contrast between the background and the letters and graphics.
• Use a combination of uppercase and lowercase letters is easier to read than all uppercase.
• The size, type and layout of lettering on signs should be clearly legible and easily understood.
NOTE: Typefaces that are Sans Serif (e.g., Arial, Tahoma, Geneva) are preferable.
• The size and spacing between letters and words should be in proportion to the size of the display and amount
of information provided.
• Displays should have low or non-reflective surfaces.
• Position lighting to reduce glare on displays with reflective surfaces.
• For wayfinding systems, maintain a consistent form and layout.
9.6.4 Design Considerations
[Link] Requirements
The location, pathways required, and installation of all digital signage and displays shall conform to applicable codes,
requirements of the AHJ, standards, and regulatory documents (e.g., ADA).
Displays used for wayfinding shall have a consistent physical placement and installation relative to the floor and other
building features (e.g., doors, hallway intersections).
Displays which may present private or confidential information or other materials which are governed by codes, the
AHJ or other regulatory documents (e.g., ADA) shall be located and installed per all applicable requirements.
NOTE: This may include displays that are located in secure or limited access areas, such as healthcare procedure rooms.
[Link] Recommendations
Displays showing the same content should have the same screen aspect ratio.
When locating the display,
• The person closest to the display should not be closer than the width of the video image.
• Viewers should have no more than 15 degrees of eye rotation to the center and 30 degrees to the top of the
image.
9.6.5 Wayfinding Recommendations
Displays should be placed in transition areas or where multiple paths intersect.
The maximum distance between information or directional signs in long corridors should be no greater than 30 m
(100 ft).
Maps may be used to supplement directional information at key decision points to reduce the amount of directional
displays needed.
9.7 Clock and Time Systems
9.7.1 Master Clock System
[Link] Overview
A master clock system provides for accurate time to be distributed from a head-end device to remote clocks throughout
a healthcare facility. The system head-end typically utilizes global positioning satellite (GPS) signaling, or another
atomic source, for reference. The remote clocks synchronize with the head-end reference signal at periodic intervals.
Master clock systems are available in both wired and wireless configurations.
Equipment, programming, wiring methods, integration options, and inter-connects for master clocks are manufacturer
specific. A manufacturer should be selected prior to the design effort.
[Link] Wired Systems
Wired systems typically utilize a centralized clock head-end device. This device maintains atomic time via a source
signal. The timing source and updates are typically received via roof mounted GPS antenna, local area network, wide
area network, or Internet. The head end device then distributes the time signal to remote clocks via copper signal cable.

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Distance between the central unit and the remote clock is manufacturer and cable dependent. Power for the remote
devices may be provided by AC, DC, or PoE.
Remote clocks are available in analog or digital display format and have a variety of clock face and vandal resistant
options to meet the needs of the facility.
[Link] Wireless Systems
Wireless systems typically consist of a centralized satellite clock transmitter attached to a GPS receiver antenna or a
network time protocol (NTP) source. The transmitter receives the clock signal from the GPS receiver, or NTP source,
and retransmits the signal out through a wireless antenna (typically built into the transmitter unit) to the remote clocks.
Large facilities may require remote satellite transmitters to extend signaling distances between the centralized satellite
transmitter and the clock.
Remote clocks will synchronize with the nearest satellite transmitter at periodic intervals.
Remote clocks can be powered locally or use battery power. They are available in analog or digital display format and
have a variety of clock face and vandal resistant options to meet the needs of the facility.
[Link] Design Considerations
Clocks are typically located in patient rooms, ORs, ICUs, laboratories, and wash stations, nurse stations, and other
locations where the measuring of time is essential or desired.
Consideration should be given to integrating the central clock system with elapsed time clocks.
Head-end equipment shall be located in a secure space (e.g., equipment room, TR, building systems support space).
9.7.2 Elapsed Time Clock
[Link] Overview
An elapsed time clock provides the ability to accurately count time, either by counting-up or counting-down. Elapsed
timers typically have a locally placed switch or button that initiates, pauses, and resets the timer function. When not in
use the clock may display current time.
Elapsed time clocks are available in analog or digital display format. Digital display is the most common.
Equipment, programming, wiring methods, integration options, and inter-connects for elapsed time clocks are
manufacturer specific. A manufacturer should be selected prior to the design effort.
[Link] Design Considerations
Elapsed time clocks are typically located in ORs, ICUs, laboratories, hand wash stations, and other locations where the
measuring of time is essential.
When used for timing applications at hand wash stations, consideration should be given to the integrated elapsed timer
options offered by the sink manufacturer.
Elapsed time clocks are typically integrated with the code system in procedure rooms (e.g., operating rooms and
intensive care units). When code status is initiated, a signal is sent to the elapsed timer, which commences a counting
up function on the elapsed time clock.
9.7.3 Time and Attendance System
[Link] Overview
Time and attendance systems are typically software-based solutions processing employee time and scheduling data
received from specialized time clocks, bio-metric readers, card readers, or web-based employee input. Some systems
are designed for healthcare and incorporate features specific to the market sector.
The time and attendance system may interface with, or be a software module for, other applications such as:
• Healthcare information system
• HR database
• Payroll system
[Link] Design
The designer shall consult with the owner to determine the preferred solution, including all optional application modules
or integration requirements needed to meet the facility needs.
Time and attendance system servers shall be placed in a secure telecom space (e.g., equipment room).
Placement of employee input devices and management consoles shall be coordinated with the owner.

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9.8 Electronic Safety and Security Systems

9.8.1 Overview
Electronic safety and security (ESS) systems are focused on the protection of life, property and assets. ESS devices and
systems include, but are not limited to:
• Safety systems (e.g., fire detection and suppression, emergency mass notification)
• Physical access control
• Video surveillance
• Intrusion detection systems
The design and installation of systems are often under the governance of an AHJ and may require the inclusion of
authorized personnel through some of all facets of the project.
9.8.2 Requirements
ESS systems shall be designed and installed per applicable codes (e.g., NFPA 72, NFPA 101) and standards (e.g.,
ANSI/BICSI 005).
9.9 Radio Frequency Identification (RFID)-Based Systems
9.9.1 Overview
RFID denotes technologies that use radio waves for automatic identification and data collection. Among the various
methods of RFID object identification, the most common is storing the serial number that identifies the object and other
information on a microchip that is attached to an antenna.
Although many applications use this technology, it is typically used for retail/asset management systems and at-risk
human perimeter systems (e.g., supervised care, hospitals) within healthcare.
9.9.2 Retail/Asset Management
[Link] Overview
Tracking, identifying, and counting merchandise and equipment can offer efficiency to healthcare facilities. The use of
electronic tagging in this environment has grown as the cost and advantages have become more appealing.
Uses of RFID in healthcare applications may include:
• Inventory management.
• Patient real-time location services.
• Operational efficiency.
9.10 Real Time Locations System (RTLS)
9.10.1 Overview
Real time locating systems are just as they are titled. They are systems which are used to locate people or devices in
real time. These differ from RFID (radio frequency identification) systems which are often used to identify if a person
or device crosses a certain threshold or portal. Oftentimes these two systems are referenced interchangeably, but they
are not the same.
9.10.2 Active vs Passive Systems
There are two types of RTLS system, active and passive. Active systems are “Locate-able”, while passive systems are
“Track-able”. Locate-able is when the real time location of the device is always known and in continuous contact. Track-
able systems use sensors to determine last known location or choke point. The tag location is only known when it is
close proximity of the sensor.
Active systems use battery powered devices tags that continuously (or intermittently) broadcast a signal. These active
“tags” (also commonly referred to as “beacons”) are used to accurately track the real-time location of assets (such as
wheelchairs in a hospital). Active tags provide a much longer read range than passive tags, but they are also much more
expensive.
Passive systems use tags are powered by the electromagnetic energy transmitted from an RFID reader. Passive tags are
used for applications such as access control cards, theft protection, pharmaceutical tracking, file tracking, event (race)
timing, and more. The lower price point per tag makes employing passive systems economical for many industries.

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9.10.3 Common Methods of Transmission

RTLS systems use the following technologies:
• RF — Tags transmit a signal every few seconds and RF receivers/antennas receive the signals and by using
RF triangulation between multiple receivers, the device is located.
• Wireless fidelity (WiFi) — Similar to RF, a wireless Ethernet signal is transmitted from the device and the
Wireless access points receive and locate the device via triangulation.
• Infrared — Infrared RTLS technology uses Infrared light to transmit and receive line-of-sight infrared light.
Whereas RF and WIFI signals can pass through walls and thus potentially falsely locate devices in adjacent
rooms, infrared (IR) technology provides a positive location within a room using only line-of-sight light waves.
In many systems, both IR and RF (or WiFi) is combined to provide a more accurate system.
• Ultrasonic — Another technology uses ultrasound signals instead of RF or IR signals. Similar to IR, ultrasound
waves do not penetrate walls the way RF signals do so positive room location can be achieved.
• Bluetooth / BLE — Bluetooth or Bluetooth Low Energy (BLE) systems use the Bluetooth transceiver build
into devices such as smartphones and triangulate similar to WiFi or RF. The potential use of this includes the
fact that many smartphones already have this technology, so the devices/tag are essentially already deployed.

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10 Integration of Systems

10.1 Overview
Because of the nature of different systems which can be integrated, additional requirements and considerations may be
encountered that would not be present within a “stand-alone” implementation. While many of these considerations focus
on patient privacy, consult with all applicable AHJs to ascertain the totality of requirements to be met.
10.2 Integrated Operating Rooms
10.2.1 Overview
The term integrated operating room or “integrated OR” refers to an operating room that has been equipped with
equipment which will provide the staff, including doctors, with the information they need. Information that is necessary
during an operation can be as varied as electronic health records (EHR), radiology images and status of operations in
other rooms, buildings or even countries.
Other technologies that can be useful in the OR include video conferencing, broadcasting procedures live, video
allowing nurses outside the room to view room status to assist in scheduling.
Integrated ORs allow surgeons to confer with peers or specialists around the world while performing a procedure. They
can also provide teaching experiences for medical students many miles away by providing video and audio conferencing
10.2.2 Devices
There are many devices that may be present in an integrated OR including:
Documentation station
• Desk typically located in the OR where a nurse is stationed. The nurse will control the flow of information to
the monitors within the OR
• Has control of the video switcher which may be located in another room
• Equipment is in area that regularly is scrubbed; equipment/cabinets need to be rated for the environment
• May need multiple computers for access to multiple networks/systems
– PACS
– Hospital network
– Video conference
Touch panel control
• Typically located at central position as room status monitor
Video monitors
• Mounted on booms, arms, walls and desk
• Video source controlled through documentation station
Video switcher
• Possibly located in centralized equipment room
• Provides switching capability for multiple sources to multiple monitors
• Controlled at documentation station or through centralized control
Room status camera
• Typically viewed at nurse station for progress of procedure
• Assists in scheduling of cleaning, next procedure, assistance, etc.
Pan/tilt/zoom camera
• Typically used for video conferencing
• Control of camera can be through video conference system or centralized control

Device list continues on the next page

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Video switcher
• Accepts feeds from and provides outputs to multiple sources and signal types including:
– Component video
– Composite video
– Display port (DP)
– Digital visual interface (DVI)
– HDMI 1.4A and B
– Mini display port
– S-video
– Ultra-extended graphics array (UXGA)
– VGA
• Controlled by documentation station and possibly a centralized control system
Video conference equipment
• Connectivity for either broadcasting or receiving video conferences
– Internet connections
– Integrated services digital network (ISDN)
Microphones
• Ceiling microphones
• Boom microphones
• Lapel microphones
• Boundary microphones
Room speakers
• Typically flush mounted in ceiling
Audio switcher
• Provide multiple inputs
– Conference bridge
– Intercom system
– Microphones
– Portable communication and music devices (e.g., cellular phones, tablets)
– Miscellaneous equipment
Audio amplifiers
• Multi-channel devices work best
• Outputs are typically 4, 8, or 16 ohms
Audio bridge
• Needed for audio conferencing
Camera controller
• Documentation station control
• Video conference control
Lighting control
• Controlled at documentation station
10.2.3 Design Considerations
[Link] General
Many systems are purchased by the owner through a medical equipment provider; audiovisual equipment can be
provided by an experienced AV integrator.
Medical equipment providers typically provide a complete package, including:
• Pathways and cabling by construction personnel
• Termination and equipment installation by equipment manufacturer
Components shall be compatible and tested with each other.

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[Link] Connectivity
The following is a list of connections which are often made to existing systems:
• Connection to the hospital network
• Connection to hospital PACS system
• Connection to the Internet
• ISDN lines
• POTS lines
[Link] Cabling
Cabling is dependent on the equipment provided.
• AV connectivity
– Coaxial type
– HDMI
– Proprietary cable
– Shielded twisted pair
– Balanced twisted-pair communications cabling
• Network and telecommunication connectivity
[Link] Pathways
Pathways typically include conduits from the corridor to:
• Booms
• Documentation station
• Ceiling speakers
• Cameras
• Wall mounted monitors
• Ceiling microphones
Access panels may be required when equipment is to be located in “hard-lid” areas
For individual devices, trade size 21 (3/4) conduit can be used for most applications.
Conduit to documentation station may be 50 mm (2 inch) or larger depending on cabling required. At the documentation
station, provide flush mounted pull boxes for AV wiring, lighting wiring and communications
Provide pathway for required video connections between the documentation station AV equipment and the PC at the
documentation station. For monitors, cable and connector type must be considered.
For cable trays in the corridors (assuming accessible ceilings), route cable tray to centralized equipment room and
provide rated penetrations through rated walls
[Link] Coordination
Items that require coordination with other trades include:
• Power requirements at documentation desk must be identified and provided to electrical engineer
• Heat load at documentation desk must be calculated and provided to the mechanical engineer
• Power requirements at central equipment must be identified and provided to electrical engineer
• Heat load at central equipment must be calculated and provided to the mechanical engineer
• Power supply for lighting
• All power for equipment must be on critical power
[Link] Environmental Requirements
• Documentation station
• Central equipment

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10.3 Procedure Rooms

10.3.1 Overview
This section details the minimum requirements for an integrated procedure room. Procedure rooms include but are not
limited to operating rooms, catheterization labs and endoscopy rooms. Because of the variances found in different
healthcare facilities and different healthcare providers, the requirements of a given facility may vary from those given
below. The designer will be tasked with determining the requirements from the owner and the users for the integrated
procedure room.
The term integrated procedure room refers to a room where medical procedures are performed and that has been
equipped with equipment which will provide the staff, particularly surgeons, with the information they need, when they
need it and without having to leave the room. Information that is required during a medical procedure can be as varied
as calling up EHRs, radiology images through the PACS system, the status of procedures being conducted in another
procedure room such as coordinating transplant surgeries or allowing personnel outside the OR to determine the progress
of a procedure for scheduling of the next procedure.
Physicians are now able to have the most current x-ray, CT scan or MRI displayed on a PACS screen for their reference
during procedures in the procedure room. Multiple monitors are utilized and positioned to allow the surgical team to
view the information they need without leaving their station, which improves patient safety and procedure efficiency.
One of the assisting nurses typically controls multiple monitors to provide images from diverse sources including:
• PACS
• Anesthesiology
• Physiology monitors
• Video feeds to another procedure room
• Video conferencing
• Information available on the hospital's network
The control is typically located at a documentation station within the procedure room.
This system can also be used as a teaching tool by using high definition cameras to allow remote students to view a
procedure through video conferencing. In a reverse situation, an experienced physician in a remote location can provide
'over-the-shoulder' advice to a less-experienced colleague while a procedure is underway.
The heart of an integrated procedure room is an audio/video switching system. The controls must be easy to operate,
and all controls must be located in one area, typically considered a documentation station.
10.3.2 Operational Requirements
A truly integrated procedure room must allow easy access to information and content from diverse sources including:
• Hospital network
• PACS system
• EHR access
• Video conference system
• Room status cameras
• Room microphones
• Music sources including MP3/MP4 players
• Imaging equipment
• Anesthesiology boom
• Patient monitor
• Document cameras
Once the information has been received, it must be disseminated to a variety of devices to make it useful. These devices
include:
• Monitors mounted on the walls or booms (from 1 to 5 or more monitors)
• Documentation station
• Amplified room speakers
• Recording devices (if required)
Control of these devices is a critical element and can determine the success or failure of a project in the user's eyes.
Careful documentation and follow-through is required for a successful project.

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10.3.3 Devices
[Link] Procedure Room Equipment
[Link].1 Documentation Station
This is a desk typically located in the OR where a nurse is stationed. The nurse will control the flow of information to
the monitors within the OR. If the OR needs to conference or monitor a facility outside the room, this would also be
handled at the documentation station.
The documentation station typically has full control of the audio/video switcher which may be located in another room.
Equipment located in an area that regularly is scrubbed or washed down must be rated for the environment in which it
is installed.
The documentation station may need to house multiple central processing units (CPUs) for access to multiple
networks/systems including PACS, hospital network and video conference equipment. A keyboard, video and mouse
(KVM) switcher would likely be used to minimize the amount of desk space needed to control multiple CPUs.
[Link].2 Room Status Camera
The room status camera(s) are used by personnel outside the procedure room to monitor activities without having to
enter a sterile space. This allows the facility to monitor progress of a procedure and schedule the room for cleaning, so
the next procedure can begin. Healthcare facilities have significant resources invested in the procedure room so the
faster they can turn them around for the next procedure, the more efficiently they can run.
The room status camera may be a fixed camera, or it could be pan-tilt-zoom (PTZ). Using analog cameras for the room
status camera would be a simple system as the analog cameras make it easy to go from a camera to a monitor. IP cameras
may be complicated to implement but provide advantages in the resolutions available and control of the camera from a
remote desktop.
[Link].3 Video Conference Camera
The video conference camera(s) should be a PTZ camera with controls accessible at the documentation station and
remotely. This camera or cameras are positioned to view the medical procedure to allow either remote teaching
opportunities or telemedicine.
Camera controls must be compatible with the video conferencing equipment selected as well as the control system for
the documentation station.
[Link].4 Sound Reinforcement System
The sound reinforcement system will be comprised of several components. An audio amplifier is required to provide
sufficient signal level to flush-mounted ceiling mounted speakers. An alternative to the audio amplifier is to provide
powered speakers.
There will be multiple inputs to the amplifier system. The video conference system will utilize the speakers to allow the
far end to be heard throughout the surgical theater. The speakers can also be used to provide music during a procedure
which can be done through a docking station, CD player, radio receiver or any number of devices. Each device should
have the capability of being controlled by the documentation system, so all devices can be controlled within the
procedure room.
Microphones will be needed for a true conference to take place. Microphones may be ceiling mounted to pick up all the
audio in the general area, lapel microphones to pick up a single person, boom microphone to localize the audio to be
picked up or even boundary microphones in the right situation. The proper mix of microphones will need to be
determined to meet the needs of the integrated procedure room.
[Link] Central Control Equipment
[Link].1 Video Conference Equipment
Video conferencing equipment may be needed for telemedicine, for remote learning or for monitoring the progress of
another procedure room in the case of a transplant. The video conferencing equipment may be controlled through the
documentation station, using PC controls, or through a touch screen device.
Connectivity for the video conference equipment can be through Internet Protocol (IP) or through ISDN lines. This
manual will not make a distinction between the two types of transport; this is merely to note the different methods of
connectivity.
The video conferencing equipment must also be able to transport the audio portion of the conference. The requirements
of the video conferencing system are outside the scope of this document.

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[Link].2 Audio/Video Switcher

The heart of the integrated procedure room is the audio/video (AV) switcher. This may be called a router by some
manufacturers, but the function is that of a switching device. The switcher will typically be located in a central location
which can support multiple procedure rooms. Locating it outside the sterile environment of the procedure suite may be
advantageous for servicing the equipment without having to “gown-up.”
The AV switcher has inputs from multiple audio and video devices and routes them to multiple audio and video outputs.
The AV switcher is typically software controlled and the interface can either be through a networked PC or a touch
screen device that may or may not be connected wirelessly.
The video switcher must receive and provide signals with varying formats. These formats include:
• Component video
• Composite video
• Display port (DP)
• DVI
• HDMI, up to and including 1.4 A and B
• Mini display port
• S-video
• UXGA
• VGA
Through the video switcher and attached peripherals, the format of the video inputs must be converted to the format
required by the device attached to the output. In some cases, the same input will need to go to multiple devices and some
of the devices may not have the same input requirements. In this case, it would be necessary to provide multiple
conversions of the same signal simultaneously. The video switcher chosen for a project must take these sometimes-
competing requirements into consideration.
10.3.4 Coordination
The electrical requirements of the documentation station must be coordinated with the electrical engineer. Coordinate
the grounding requirements at the same time.
For the central equipment location, coordinate the expected heat loads with the mechanical engineer and the electrical
loads with the electrical engineer. Security of this room is also essential, so it is recommended that this room have a
card reader and video surveillance installed to control and document who has accessed the equipment.
10.3.5 Procedure Room Integration
The most critical piece of the system is the interface that will be used to control the system. Without a straightforward
control system, many features may be unused or worse the system could be deemed a failure. Careful documentation of
the system requirements and interface requirements are needed to ensure that needs have been met upon completion.
10.3.6 Procedure Room Pathways
Special consideration is needed for the pathways associated with the integrated procedure room. Since many of the
devices use cables other than the traditional category 6 cable, sizing becomes a much larger consideration. Also, since
some of the integrators prefer to install their own cables, the pathways may need to be sized for connectorized cables.
All cabling routed in the vicinity of a procedure room shall be installed in conduit. Installed conduit may require
additional shielding (e.g., copper wire wrap) or a drain wire. It is recommended that conduit installation be coordinated
with the AHJ, as there may be additional requirement, such as needing to ground each junction box.
The conduit from the ceiling of the procedure room to the documentation station may need to be metric designator 53
(trade size 2) to provide space for all the cables needed at the documentation station. Between the control cables, video
cables, multiple CPUs, multiple networks and communication devices, there is a large amount of cabling that needs to
have a pathway. Provide a properly sized pull box in the wall for the metric designator 53 (trade size 2) conduit to allow
access to the cables.
Since some of the cables are video grade cables, some are audio cables, and some are data cables, the separation of
cabling can become a very large consideration. Audio cables containing microphone level signals are especially
susceptible to noise and must be separated from other types of cables.
Many devices may be located on booms. Coordinate pathways and faceplates needed with the boom manufacturer and
other trades located in the booms.

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10.3.7 Grounding
Grounding of the equipment in procedure rooms is particularly important as stray voltage can create very hazardous
conditions for the team and for the patient. Coordinate all grounding with the electrical engineer to ensure all equipment
is grounded and that all equipment shares the same ground potential.
10.3.8 Commissioning
Once a system has been installed, commissioning must be completed to verify compliance with system and interface
requirements previously documented in the design phase. Without verification there is no assurance the system will
meet the needs of the users.
10.3.9 System Training
Once the commissioning of systems is complete, end users should be trained in the operation and maintenance of the
systems. Operations and maintenance documentation created during the design, installation and commissioning phases
should be used for user training.

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Appendix A Infectious Control Risk Assessment (ICRA) (Informative)

This appendix is not part of the requirements of this standard, but it is included to provide additional information related
to this standard.

DISCLAIMER NOTE: This section is included to inform the reader of infectious control issues and work plans. It is
not intended to provide the reader with the total knowledge needed to produce a complete working document and should
not be used as the sole source of information for these matters.

A.1 Overview
The healthcare industry has seen a rapid growth over the past few years in both new construction and renovations. Each
presents itself to different infection control environments and methods. Contractors want to keep their employees
healthy so they can finish the work, and the existing facility wants to keep their existing patients from becoming further
infected. There are many considerations in the design and construction or renovation of the health care facility.
Poorly designed and maintained construction environments pose numerous risks for patients and workers from
contaminated air, water or environmental surfaces. For example, improper ventilation design during a renovation project
has been associated with an outbreak of infections such as aspergillosis. Airborne infections, such as tuberculosis, have
caused outbreaks among patients, workers and even visitors. The threats related to terrorism have dramatically
highlighted the importance of facility design for enhancing the control of infectious agents.
Professional, accreditation and oversight agencies have provided guidance for new construction and major renovations
in health care facilities for the deployment of infectious control methods.
When planning for new construction or major renovation, the designer should coordinate with architects, risk and safety
professionals, infection control professionals (typically employed by the facility) and environment of care managers to
ensure that infection control methods are included in the design process. A critical step is to establish if the owner has
an "infection control risk assessment" (ICRA) in place. This assessment provides the foundation for planning of the
project regardless of size or scope of the project.
A.2 Background
Construction and maintenance activities in and near healthcare facilities may increase airborne concentrations of dust
and potentially pathogenic organisms. One pathogen of concern includes the fungus Aspergillus. Patients with weak
immune systems are typically at risk for acquiring aspergillosis, an infection caused by Aspergillus. The mortality rate
for aspergillosis can be as high as 100%, depending on the status of the patients’ immune systems. Aspergillus species
(spp.) are ubiquitous organisms that survive well in air, dust and moisture present in healthcare facilities. Construction
and maintenance activities can disturb Aspergillus-contaminated dust and produce bursts of airborne spores. If patients
with weak immune systems come in contact with these airborne spores (i.e., inhalation), Aspergillosis may develop.
There are numerous documented cases in medical journals and other literature sources of construction-associated
aspergillosis. Aspergillus is not the only pathogenic fungus of concern. Construction-associated infections may also be
caused by Penicillium, Rhizopus, Fusarium and other fungi.
Patients are also at risk of developing infections from waterborne pathogens, such as Legionella. Legionella spp. are
commonly found in natural and man-made aquatic environments. Potable water systems in healthcare facilities may
also contain Legionella. Several factors have been identified as promoting the growth of Legionella in healthcare potable
water systems, including water temperatures in the range of 25 to 42 C (77 to 108°F) and stagnation. Patients with weak
immune systems, people who smoke, and elderly patients are susceptible to Legionellosis, an infection caused by
Legionella. In documented healthcare outbreaks of Legionellosis, patient exposure was traced to contaminated aerosols
generated by cooling towers, showers, faucets, respiratory therapy equipment, and humidifiers. Mortality rates for
Legionellosis have ranged from 12 to 34%.
A.3 Policy
Most faculties are committed to protecting the health and safety of their patients, staff and visitors during construction
and maintenance activities. They recognize that construction and maintenance projects may introduce health and safety
risks into the healthcare environment.

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When performing these activities, contractors and maintenance personnel shall take the appropriate steps to minimize
such risks. Maintenance and contractor personnel shall follow the procedures outlined below. Contractors shall adhere
to provisions listed in their project-specific infection control work plan.
A.4 Products
The following is a gathering of the different material that may be required to fulfill a facilities ICRA plan:
• High-efficiency particulate air (HEPA) / ultra-low penetration air (ULPA) vacuum cleaners — HEPA/ULPA
vacuum cleaners shall trap 99.999% of particles 0.12 microns and larger. Vacuum shall have a minimum air
flow of 2.5 m3/min (90 cfm).
• Polyethylene — 0.15 mm (6 mil) or 0.2 mm (8 mil) thick reinforced laminated polyethylene film and shall
meet the requirements of NFPA 701, large scale flammability test, and ASTM E84 Class A, including
compatible fire-retardant tape.
• Adhesive-faced contamination control mats (sticky walk-off mats) — size of mats shall be the width of the
opening and have a minimum 760 mm (30 in) depth.
• Negative air machine: a machine with a fan or blower, typically with HEPA/ULPA filters, which can negatively
pressurize a room or area for a continuous period of time. Provide unit sized to meet room requirements. If unit
does not exhaust air to the outside of the building, see Class III.4a. Units shall include prefilters, final filters,
HEPA/ULPA-filters and filter static pressure gauges. HEPA/ULPA filters shall be 99.997% efficient at 0.3
micron particle size.
• Zipper lock entrance — fire retardant, reinforced vinyl construction with reinforced stitching.
• Temporary prefabricated enclosure unit — provide the enclosure with an inspection window and pressure
differential porthole.
• Airflow direction indicator
NOTE: This product is for drywall or other "hard" or non-plastic partitions; where plastic dust barriers are used, the
plastic barrier will serve this purpose)
• Dust catching device, disposable, dry, electrostatic cloths or mitts — for dust removal
• Disposable, wet cloths, presoaked with cleaning solution — for dust removal.
• Contractor health form — this is mandatory for anyone working around patients and requires proof of specific
vaccinations and current TB test.
• Personal identification information.
A.5 Infection Control Training
All contractor personnel shall attend infection control training sponsored by the owner. No contractor employee shall
be permitted to work on site until he/she has attended such training.
Contractor superintendents, managers, supervisors, and foremen shall attend a four-hour infection control seminar
provided by the owner.
Other contractor personnel shall attend a thirty-minute infection control seminar. Such training shall be provided as
often as necessary to accommodate the needs of the contractor; however, no more than one seminar shall be provided
per week.
A.6 Contractor Work Schedule
The contractor may be required to schedule certain activities at times that are convenient with the owner’s schedule.
Such activities may include those that produce excessive amounts of noise or vibration.
The contractor should also be prepared to schedule the following activities at times that are convenient with the owner’s
schedule:
• Connection of existing utility systems to new utility systems
• Temporary shutdowns of existing utility systems
• Load-in of building materials through occupied areas
• Pile driving
These activities have potential for disrupting patient care activities. The contractor shall schedule such work with the
facilities director.

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A.7 Storage of Building Materials

The contractor shall store building materials (e.g., plyboard, ceiling tiles, floor tiles, etc.) in a location and manner that
protects them from exposure to rain and exterior dust. Prior to being moved into the building, building materials shall
be stored in an enclosed, protective environment or they shall be wrapped in a water-resistant material.
If building materials become wet, they shall be discarded or dried within forty-eight hours of first becoming wet to
prevent mold growth.
A.8 Protective Clothing for Contractors
Contractors shall wear prescribed protective clothing, when entering clean, restricted areas, such as the surgical suite.
Prescribed protective clothing includes coveralls, shoe covers, and head covers. Contractors shall don, doff, and dispose
of protective clothing in accordance with posted instructions at the entrances to such areas.
When accessing occupied indoor areas, contractors shall wear protective clothing if their street clothes are visibly
contaminated with dust. Such clothing shall be donned before contractors enter the building or exit an interior work
zone.
A.9 Contractor’s Access to Occupied Areas
The contractor shall not be permitted in occupied areas unless permission is obtained from the appropriate personnel or
otherwise listed in this work plan. Contact between contractors and staff/patients shall be minimized. Specific paths of
travel for each phase have been carefully selected to minimize such interaction between contractors and staff/patients.
It is anticipated that contractors will need access to mechanical and electrical rooms located in occupied areas. Access
to these areas shall be scheduled in advance with the appropriate personnel.
During times when contractors must access occupied areas, their clothes shall not be visibly soiled with dust.
A.10 Construction of Short Duration Barriers
Short duration barriers shall be constructed of 0.1 mm (4 mil), flame-retardant polyethylene (or similar) sheeting. Short
duration barriers shall run from the floor to acoustical ceiling, unless otherwise specified. Duct tape shall be used to
hang the polyethylene sheeting. Openings (entries) for short duration barriers shall be constructed with overlapping
sheeting or an adhesive zipper that attaches to adjacent polyethylene sheets (e.g., Zipwall zipper). Contractors may use
pre-fabricated, non-combustible plastic barriers (e.g., environmental containment unit) instead of flame-retardant
polyethylene sheeting.
Prior to dismantling the short duration barriers, the contractor shall clean the floors and wall surfaces in the short
duration work zone. The contractor shall use a HEPA-filtered vacuum to clean such surfaces.
A.11 Construction of Long Duration Barriers
Unless otherwise noted, long duration barriers shall be constructed of 1 layer of 16 mm (0.625 in) thick Type X gypsum
wallboard applied on each side of noncombustible studs spaced 610 mm (24 in) on center. Seams on the occupied side
of the barriers shall be taped and/or caulked. The occupied side of the barriers shall be painted. Long duration barriers
shall run from the floor to upper deck, unless otherwise specified.
Unless otherwise noted, openings for long duration barriers shall be constructed with 44 mm (1.75 in) thick, solid-
bonded core wood doors set in non-combustible frames. Such door openings shall have a minimum clear width of at
least 710 mm (28 in). Doors shall be in good condition, with no holes or cracks. Doors shall be equipped with positive
latching hardware.
The contractor shall construct a short duration barrier to enclose any construction or dismantling of a long duration
barrier (to minimize the release of dust into occupied areas during construction/demolition of the long duration barrier).
Such short duration work enclosures shall be negatively pressurized with respect to adjacent occupied areas. The
contractor shall use HEPA-filtered fan unit(s) to generate negative pressure within these work enclosures. The short
duration barrier may be dismantled after construction of the long duration barrier is complete. For the dismantling and
removal of a long duration barrier, the short duration barrier shall be erected prior to dismantling activities and shall not
be removed until all components of the long duration barrier are removed from the building.
A.12 Negative Pressurization of Work Zone
No construction activity may take place in a work zone until the work zone is placed under negative pressure with
respect to adjacent occupied areas.

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A.13 HEPA-Filtered Fan Units and HEPA-Filtered Vacuums

HEPA (high efficiency particulate air) filtered fan units are specified in select areas to generate negative pressure within
work zones. HEPA-filtered fan units typically have volumetric flow rates of 1.4 to 56.6 m3/min (50 to 2,000 cfm).
HEPA-filtered fan units may have 2 or 3 filters, including at least one pre-filter and one final HEPA filter. The HEPA
filter within the fan unit shall be capable of removing 99.97% of particles with a diameter of 0.3 microns from the air
stream.
HEPA-filtered vacuums are specified for cleaning operations. The HEPA filter within the vacuum shall be capable of
removing 99.97% of particles with a diameter of 0.3 microns from the air stream.
The contractor shall be responsible for providing power to HEPA filtered fan units and vacuums.
A.14 Construction in Occupied Areas
The contractor is prohibited from performing indoor construction activities outside of designated work zones (including,
but not limited to, roof penetration, above-ceiling, and corridor work in occupied areas), unless permission has been
granted by the facilities director.
When contractors do perform construction activities in occupied areas, the contractor shall erect a short duration barrier
around the work zone. Such barriers shall remain in place until the work is complete and ceiling tile(s) replaced. The
work zone within the short duration barrier shall remain under negative pressure with respect to adjacent occupied areas.
In order to generate negative pressure within these work zones, the contractor shall use HEPA-filtered fan units. The
HEPA-filtered fan units shall be exhausted to an indoor location deemed appropriate by facilities personnel.
The contractor shall establish an ante area within the work enclosure. The contractor shall make available the following
items for personal and equipment decontamination:
• HEPA-filtered vacuum
• Spray bottle with hospital-grade cleaning solution
• Disposable towels
• Protective clothing (coveralls, shoe covers, and head covers)
Peel-off adhesive mats shall be placed at the entrances to these work zones. Adhesive mats shall be replaced at least
once per work day or as often as needed to remove dust from shoe bottoms.
Demolition debris and other waste shall be loaded into covered wheeled containers. Such containers shall be transported
directly to the building exterior for disposal of waste. The containers’ wheels and exterior shall be wiped with a wet
towel before transport (to remove surface dust).
The contractor may be required to schedule such work at times convenient to facilities personnel.
A.15 Enforcement
The facilities safety officer and director will be responsible for ensuring that contractors follow the provisions of the
infection control work plans and facility personnel follow basic maintenance infection control measures.
NOTE: The safety officer and facilities director have the authority to stop work within a construction or maintenance work
zone if such activities are endangering the lives of patients, staff or visitors.
For maintenance projects, the safety officer and facilities director shall make periodic visits to maintenance work zones
to verify that facility personnel are following basic maintenance infection control measures.
For construction projects, the safety officer or facilities director shall make at least one documented visit per week to
each construction work zone. During the zone visits, the safety officer or facilities director shall verify that contractors
are following the provisions of the infection control work plan. The safety officer or facilities director shall record their
observations on an infection control evaluation form.

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Appendix B Network Security (Informative)

This appendix is not part of the requirements of this standard, but it is included to provide additional information related
to this standard.

B.1 Overview
This section provides a broad overview of threats and countermeasures for network security as it relates to IP-based
Healthcare system design. It is not intended to be a comprehensive or detailed source on the subject of logical security,
which is a rapidly evolving discipline. After reading this section, the reader should be familiar with the terminology
necessary to intelligently discuss the specific requirements for network security with competent professionals.
Historically, Healthcare systems were physically isolated and relied upon point-to-point (PTP) communications. To
gain improvements in efficiency, Healthcare systems began to migrate to network-based communications and grow
external connections. Many were designed prior to the wide-scale adoption of network security products and practices,
and unfortunately, most lacked adequate consideration of and protection from network attack. This trend has evolved
for myriad reasons, and now healthcare systems are often connected to the Internet.
Connecting a healthcare system to any external network, either a corporate network or the Internet, whether directly or
indirectly through a corporate LAN and its firewalls, makes it vulnerable to network attack. Security measures are
necessary to mitigate and manage these vulnerabilities but often cannot totally eliminate them. Along with this
connectivity, some level of risk must be accepted. Total isolation from non-Healthcare networks is the only means of
making a Healthcare system impervious to network attack. Admittedly, such isolation comes with a high price and may
be unworkable. Therefore, it is necessary for the designer to understand the risks in interconnecting the network and to
discuss those risks and potential countermeasures with competent professionals before finalizing a design.
The primary objectives of network security are the confidentiality, integrity, and availability (CIA) of the protected
assets. Threats against CIA can create risk. Risks are determined by factoring the threats and vulnerabilities along with
impact as shown in Equation B-1:

Threat × Vulnerability × Impact

Risk = (B-1)
Control Measures

Control measures are applied to mitigate risks. The perception of risk varies based on the importance of the data or
function of the network. The acceptable level of risk that can be tolerated is explicitly determined by the organization.
The definition of acceptable risk levels and appropriate controls is typically outlined in a security policy.
A security policy should normally address the following issues:
• Privacy — Guidance to users on the importance of limiting information to individuals who need to know.
• Acceptable use — Network activities that are considered acceptable within the organization at a user,
department, office, or organizational level.
• User and network node authentication — Definition of systems responsible for identifying validation
credentials. This typically is part of the operating system supporting the network and can be augmented by
additional security measures as required.
• Data protection — Virus, spyware controls, encryption, and portable storage device management (e.g.,
universal serial bus thumb drives, portable drives, handheld mobile devices, laptops).
• Internet usage — Definition of what constitutes proper business use of Internet resources.
• Data access — Assignment of appropriate access to data based upon function within the organization.
• Policy compliance — Consequences of the failure to comply with all network policies and definition of steps
taken to ensure compliance.

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Each of these policies is intended to address a specific set of risks. These policies also incur a cost to the organization
that must be recognized and balanced against the potential impact of a realized risk. Additional hardware and software
required for implementing policies, associated labor to maintain systems, and operational constraints impacting potential
customer interaction must be considered when designing network security policies.
B.2 Risks
B.2.1 Overview
The purpose of ESS systems is to reduce risk in the physical and logical environments and improve cyber security. If
the underlying components are compromised, the overall system does not fulfill its purpose. Several scenarios could
undermine ESS systems as illustrated by the following threats and associated organizational impacts.
B.2.2 Denial of Service
As a function of resiliency, an IP-based access control system (ACS) may operate under cached information in the event
of a network outage. If a network outage is forced by a denial of service (DoS) attack, this could allow an individual
with revoked access to enter the facility.
In an effort to reduce costs, some facilities have reduced the number of security personnel in favor of IP-based cameras,
centralized monitoring, and digital video recordings. If IP-based video cameras cannot be reached, activity in those
areas is not monitored, and the data could be lost, physical breaches are virtually invisible.
Such risks are not limited to IP-based camera networks. Nearly all modern video surveillance systems (including ones
that do not support IP cameras) offer remote monitoring from a user’s handheld or desktop device over the Internet.
Some of these systems can be compromised by a relatively modest DoS attack, allowing hackers time to gain physical
access to a location while the camera images are not being recorded.
DoS attacks are often distributed across hundreds or thousands of computers, often part of a botnet, in a distributed
denial of service attack. Such attacks are more difficult to defend against because they can originate from so many
sources.
B.2.3 Replay Attacks
If logical access to the network is available, transmitted data can be captured, manipulated, and replayed. The data could
be a system authentication, the addition of an access card, approval for access into a restricted area, or pausing of a
surveillance recording. Any of these events could provide access to an unauthorized entity.
B.2.4 Spoofing
Closely related to replay attacks are spoof exploits where a hacker impersonates a device or user who has authorized
access. Such attacks are easier on systems with weak or nonexistent authentication or ones relying on security through
obscurity; the hope that attackers will overlook or not be aware of a particular vulnerability because a system is not
widely used.
B.2.5 Backdoors
Systems often are shipped with service or administrator accounts with easily guessed (or nonexistent) passwords. Such
easy backdoor access is often overlooked, particularly in physical security systems that are assumed to be inaccessible
from the outside world.
B.2.6 Malicious Codes
Malicious codes, including viruses, worms, or Trojan horses, can disrupt services and undermine CIA. The result is an
ESS system that does not meet its design intent. In the context of the ESS system, the devices are typically application
specific and on an isolated network. This significantly limits the exposure to malicious codes, but the risk still exists.
B.2.7 System Control
If physical access to equipment or network connections (including wireless) is available, new hardware could be
introduced or the system compromised. This includes remote access to maintenance modems discovered by war dialers.
War dialers allow an attacker to discover open modems by entering a telephone number range and allowing the tool to
systematically call each number.

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With physical access, keystroke loggers can be installed to capture passwords and transmit them wirelessly or over the
Internet. Several websites are dedicated to listing default passwords for any device imaginable, including security
systems. With the correct password, an attacker can redirect video cameras, delete data or security log files, add new
access cards, and perform other functions normally protected by security control processes.
Even changing the default password of a device is no guarantee. Brute-force attacks or dictionary attacks guess
thousands of passwords a second until the correct one is found. On devices that do not limit password retries (e.g., three
attempts before lockout), there may be few or no indications that an attack is in progress.
Spoofing or impersonation of legitimate devices (e.g., wireless access points) also can be used to compromise a security
system. Such man-in-the-middle attacks might occur at a shared resource, such as a fake coffeehouse wireless fidelity
connection, where user credentials might be scanned as they are entered by an unsuspecting user.
Logs can be interrupted when another device claims the IP address of the log server.
B.2.8 Social Engineering
Humans have a built-in mechanism to be friendly and trusting. Social engineering is the use of pretext to exploit this
cooperative nature and obtain information or influence action. Social engineers also may employ intimidation and
impersonation as well as snooping and eavesdropping.
An example of social engineering is a telephone call to a user from a person falsely identifying himself or herself as a
network support person needing the user’s identification and password to troubleshoot a network issue. In many cases,
the user will provide the data without a second thought.
B.2.9 Phishing and Spear Phishing
Another type of social engineering is phishing, where unsuspecting users might receive apparently legitimate requests
to validate their login credentials and that offer a convenient button to do so. Phishing attacks are often seen as fraudulent
e-mails or entire websites, which often appear legitimate to the victim. Phishing attacks tend to be fairly widely targeted
(e.g., customers of a particular bank, government agency, private company). As security systems become more
commoditized, it is not unreasonable to expect such attacks to target them as well.
Spear phishing refers to specifically targeted attacks against a small group or a single individual, often with detailed
information to make the message or website look even more trustworthy. Such attacks are usually one in a series of
measures to gain access to high-value assets such as company financial systems.
B.2.10 Mobile Devices
Increasingly, users are requesting access to security networks from their handheld and portable devices. Inexpensive
security camera systems advertise that they can be monitored from handheld devices. Such distributed access also
represents a distributed threat, introducing the potential for many more attack risks, particularly if clients store their
access credentials on the device.
B.2.11 Insider Threats
The most damaging impact often comes from authorized users that abuse their access. The system administrator can
start maintenance and shut down important systems at an opportune time to allow accomplices to breach the perimeter
unseen. Either scenario can negate the expensive ESS infrastructure and bypass the expected controls.
B.3 Control Measures
B.3.1 Overview
The practice of securing information has many parallels to the primary domain of this manual, physical security. In
physical security, countermeasures serve to deter, delay, or detect attacks on assets. Physical security designers may
deploy various countermeasures intended to discourage potential attackers, slow them down, or detect the attacks in real
time before the assets have been compromised.
The equivalent of physical security’s countermeasures in the logical security world is security controls or control
measures. As discussed in this section, control measures are put in place to provide layers of protection for the
information assets they are intended to shield from vulnerability and compromise of CIA from cyber-attacks.

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It is important to understand that just like a physical structure (e.g., home, business), the architecture of the network,
computing, or storage device will invariably affect its vulnerability. As terminal server and mainframe systems have
been shifted to client/server architecture, data has been exposed to risk in increasing levels. Client/server environments
create more data in motion that can be stolen, delayed, or damaged. Cloud computing, software-as-a-service, and
service-oriented architecture (SOA) systems provide even more potential for risk since the computing assets may not
be under the control of the purchaser.
Data being stored or processed on systems outside of the security of the computer room or data center is subject to
hacking or unauthorized access. Because sensitive files are stored on workstations and laptops, the physical theft of a
central processing unit or laptop often can allow an attacker to browse and decrypt files containing business or personal
information without much risk of discovery.
The protection of information assets is not simple. Even more than physical security countermeasures, logical security
is the interaction between people, processes, and technology. In contrast to physical countermeasures, logical security
is the adaptability of the attack on data assets. Control measures are required to be pervasive and must involve an
ongoing process of evaluation and revision.
B.3.2 Firewalls
A firewall is hardware or software designed to keep unwanted and unauthorized traffic from entering a network or any
computer attached to a network from an unauthorized device or network. A firewall’s decision on what traffic to permit
to enter a network or computer system is based upon the IP address of the device or network sending the traffic. Firewalls
can protect stand-alone networks (see Figure B-1) or enterprise networks (see Figure B-2).
In an enterprise network, these decisions typically are based on policies implemented by the firewall administrator. The
security policies implemented within a firewall can restrict what services are allowed to be accessed, specific IP
addresses and ranges of IP addresses, and even what logical ports the firewall will permit network packets to access.
Firewalls also can offer extensive reporting and tracing functionality.

Internet

Firewall

Router

LAN

Server Workstation

Figure B-1
Stand-Alone Network

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Internet

Partner Network

Firewall

Antivirus Server Proxy Server

LAN

Router

Wide / Metropolitan
Area Network

Router Router

LAN LAN

Server Workstation Server Workstation

Figure B-2
Enterprise Network

Firewalls are types of gateways that can be housed in servers, routers, specialized hardware devices, or software loaded
on a computer. They work by examining network packets as they enter and exit the network. Those packets that do not
pass the requirements configured in the firewall are filtered out and are not permitted to pass.
Modern firewalls filter traffic based on several network packet attributes, including:
• Source IP address.
• Source port.
• Destination IP address or port.
• Applications.
• Protocols (e.g., file transfer protocol, hypertext transfer protocol).
• Domain name of the source.

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In general, firewalls can be grouped into the following three categories:

• A packet filter firewall examines each network datagram and uses an access control list (ACL) to determine if
an inbound or outbound datagram should be discarded (filtered) or allowed to pass through the firewall. This
type of firewall inspects addresses to determine what to filter.
• A circuit gateway firewall permits an inbound or outbound connection to take place on the basis of
authentication and authorization criteria. This type of firewall does not inspect each datagram; once the user or
device is granted access to the communications channel, it can send and receive any type of data.
• A proxy server firewall takes the place of another network device and initiates all communications on its behalf.
The proxy server inspects all incoming and outgoing messages before they are forwarded to the destination. The
devices at both ends of the connection never communicate directly; each communicates with the proxy server,
which represents itself as one of the devices when communicating with the other.
Firewalls can be used to create security zones (see Figure B-3). Each zone is associated with a level of trust such as:
• Untrusted — May include the Internet or other hostile networks.
• Semitrusted — May include a demilitarized zone (DMZ) or partner networks.
• Trusted — May include the corporate or enterprise network.

External / Internet

DMZ

Internal
Network

Remote FTP
Access Servers Web
Internal Servers Internet
Application
Users Resources
Servers
Trusted
Zone

Semitrusted Zone

Untrusted Zone

Figure B-3
Example of Security Zones

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A DMZ is a network segment that operates as a neutral zone between a company’s private network and the outside
public network. It is intended to avoid direct communication between devices in untrusted zones with devices in a
trusted zone. ESS devices (e.g., credential databases) should normally be in a trusted zone.
Users of the public network can only access devices in the DMZ. If an outside user compromised a device in the DMZ,
only that device might be compromised, but other assets would not be directly at risk.
There are many threats for which firewalls do not provide effective control measures. Malware, ransomware, viruses,
Trojan horses, and insider attacks are typical weaknesses of this type of control.
B.3.3 Intrusion Detection and Prevention Systems
While firewalls prevent potentially harmful traffic from entering the network, an intrusion detection system (IDS)
detects an unauthorized use or attack upon a network. Once an IDS detects a security breach, a number of actions are
possible to mitigate the threat. Where the IDS can simply watch for attacks and report breaches, the intrusion prevention
system (IPS) can protect system files. The IPS also is capable of working in concert with firewalls to reconfigure ACLs
to actively block a subsequent attack (active IDS).
An IDS consists of three components:
• Sensors that collect traffic
• Analyzers that look for suspicious activity
• Administrator interface that collects output from the analyzer
There are two primary IDS types:
• A host-based IDS monitors activity within a specific computer
• A network IDS monitors activity on the network where it is attached
B.3.4 Network Segregation with Virtual LANs (VLANs)
To reduce the total cost of ownership, many facilities use the same network infrastructure for office automation purposes
as well as security systems and industrial control. To follow the principle of isolation, it is important to provide some
separation between these systems. One way to provide this separation without the need for additional LAN equipment
is the use of VLANs.
B.3.5 Virtual Private Networks (VPNs)
Rather than purchasing PTP circuits for dedicated and protected bandwidth between locations, many organizations use
virtual private networks (VPNs). Similarly, VPN point-to-multipoint arrangements allow one or many individuals to
connect to an organization securely and privately, usually involving software on the client end and hardware on the
enterprise end.
B.3.6 Access Control Lists (ACLs)
For facilities that do not have firewalls or the budget to add firewalls, it is possible to set up some restrictions using
ACLs on routers and switches to limit traffic crossing these devices. The restrictions can be configured based on source
and destination IP addresses as well as port numbers. The functionality is similar to firewalls, but without some of the
deeper functionality or specific security design. Because these devices are not specifically designed for this feature, there
may be an impact on throughput.
B.3.7 Network Admission Control and Network Access Protection Systems
Variously called network admission control and network access protection, these technologies are intended to scan
endpoint devices for vulnerabilities and patch levels before they are allowed to connect to a trusted network. Network
admission systems or ACS typically address the ability of an unauthorized network device to attach to the LAN and
obtain an IP address or communicate with other network devices. Many of these systems operate on the basis of IEEE
802.1X authentication with port access controls.
B.3.8 Dial-Back Modems
Dial-back modems mitigate the risk of unauthorized remote access by disconnecting from inbound calls and dialing
back only numbers that have been preprogrammed. As modem use mostly has been replaced with Internet-based access,
such devices tend to be rarer, although they act as a valuable control option during DoS attacks.

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B.3.9 Network Behavior Analysis

Network behavior analysis systems capture information from traffic flowing over the network to determine the source
and destination as well as the protocol and any anomalies in the traffic that might indicate malicious traffic. These
systems can use direct packet capture or more often use NetFlow or sFlow data streams as input for the traffic
information.
B.3.10 Vulnerability Scanners
Vulnerability scanners send specially crafted network traffic to devices on the network to determine the operating
system, configuration, and patch status of each device. Sometimes, a login is used to determine additional information
from the registry. These scanners identify vulnerabilities on the device (e.g., easily guessed passwords, missing security
patches). Many systems include workflow software for follow-up of patching or configuration changes.
B.3.11 Server Hardening
Server hardening can be used to shut down any unused processes or irrelevant software modules on a device. The
presence of these processes may introduce vulnerabilities, and by removing the processes, the vulnerabilities are also
eliminated. This precludes the application of some specific patches and can make applying the patches unnecessary.
B.3.12 Authentication Methods
Authentication uses one or more of the following three factors to validate identity:
• Something you know — Usually a user name and password
• Something you have — A security token, access card, or proximity detection device
• Something you are — Physical attributes (e.g., fingerprint, retinal scan)
Some methods are biometric based (something you are), including fingerprint readers, iris scanners, and voice
recognition. These factors can be combined into a stronger authentication model (two factor authentication).
B.3.13 Software Patching
All software has flaws. Many of these flaws can be exploited to obtain access, elevate privileges, or leak information.
When software developers become aware of these vulnerabilities, they typically create patches to the original software.
These patches alter the original software in order to eliminate the vulnerability. Sometimes, these patches introduce
additional flaws that may be more serious than the original flaw or may interrupt the normal function of the original
software.
If the risk of poor quality patches is graphed over time in comparison with the risk of exploits against the vulnerability,
there is an ideal point where the risk of applying new software intercepts the introduction of exploits targeting the
originally flawed software. Because of the decreasing time to exploit releases, this time frame continually decreases.
For the reasons stated above, it is critical that all service packs, hotfixes, and other patches are tested on a nonproduction
test network prior to implementation to ensure their predictable impact and adequate security.
Zero-day attacks (attacks that are exploited on or before the release of patches) are potentially the most serious as
systems are effectively unprotected against them.
B.3.14 Antivirus
Antivirus software (and all anti-malware software) typically detects threats by comparison of files or behaviors to
signatures or actions of known malicious code. As such, it is necessary not only to install the software but also to ensure
continued updates to the virus signature database. This requires access to the Internet or to an internal system that
maintains copies of all the updates.
B.3.15 Encryption
Encryption obfuscates the actual data to make it unreadable to anyone but the authorized users of the data. Data
encryption is applied to data in transport through secure protocols (e.g., Internet protocol security, applicability
statement 2, transport layer security, secure sockets layer). Data encryption also can be applied to data at rest with
specific software for whole disk encryption or encrypted folders. Access to the login credentials or an open system can
undermine the use of encryption.

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B.3.16 Security Information and Event Management

Security information and event management systems coordinate input from firewalls, network IDS, antivirus software,
activity logs, and other security feeds to create a view of any security incident. This coordinated approach can provide
better intelligence during an IDS alert. With improved information, it is possible to verify target system(s) are patched
and immune to the perceived threat.
B.3.17 Awareness Training
One valuable control tool against social engineering (e.g., phishing attacks) is awareness training. This training should
target system users as well as administrators so they know what data or processes are sensitive and could undermine the
overall system security.
This will assist in recognizing attempts to gather important information and detect pretexts.
B.3.18 Background Checks
People who operate and maintain networks should be scrutinized as carefully as the design of the ESS systems. As part
of the employment process, it is important to include background checks to ensure that authorized access is appropriately
given to employees who are expected to be trustworthy.
B.3.19 Segregation of Duties
The principle of least privilege should be assigned to the functions of individuals. By carefully designing processes, it
is possible to ensure that no individual has the ability to bypass control measures. For example, one person could be
responsible for monitoring video feeds while another person is responsible for archiving the video and changing tapes.
This would require collusion or cooperation between the two individuals to bypass the capability of identifying activity
covered by the video.
B.3.20 Audits
One of the most valuable tools in maintaining network security is performing frequent, irregularly scheduled security
audits. This involves reviewing the log data that most
ESS and network elements create in routine operation for signs of unusual, unexplained, or unauthorized activity. Since
these system logs can be quite voluminous, a variety of automated tools often are used to assist in their review. Audits
should not be performed by the same individuals who are responsible for the routine operation and administration of
the system under review.
Audits are also useful in a multi-tenant or shared user physical environment. ACS provide rapid access when clients
want to know what employee visited a site or utilized a shared resource during certain time frames.
B.4 General Security Recommendations
The following are general network security recommendations and practices for ESS systems:
• Develop a security policy.
• Establish physical security.
• Lockdown perimeter security.
• Enable existing security features.
• Secure operational traffic.
• Secure management traffic.
• Manage configuration.
• Eliminate security deficiencies.
• Provide continuous security training.
• Perform security audits.
B.4.1 Develop a Security Policy
A security policy defines the controls, behaviors, and expectations of users and processes and lays the groundwork for
securing ESS assets. Since the acceptable range of use of ESS systems is narrower and they have more demanding
operational requirements than ICT, they also demand their own security policy.
B.4.2 Establish Physical Security
Establish effective physical security to protect ESS equipment from physical damage and unauthorized access.

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B.4.3 Lockdown Perimeter Security

Eliminate all external connections to the perimeter of the ESS network that are not necessary. For necessary connections,
authenticate, authorize, and monitor any use over those connections, including:
• Understand, document, and periodically review the necessity for each external connection.
• Consider the use of security products for perimeter protection that meet published, well-known, and accepted
security standards.
• Allow only authorized users of devices to reach authorized destinations during authorized time periods and log
the details of the activity.
B.4.4 Enable Existing Security Features
Effectively utilize security features of current ESS and infrastructure devices, including:
• Configure all available user access controls.
• Change the defaults, and use strong passwords that expire regularly.
• Eliminate or protect any paths over which plaintext access control cannot be avoided.
• Do not reuse or share user identifications or passwords among systems or personnel.
• Keep operational security in mind — do not reveal valuable information about the network through sign-on
banners, device names, or other means.
• Configure router ACLs to restrict network protocols and connectivity.
• Use switch VLANs to isolate like traffic, making ACLs easier to apply and manage.
• Use media access control (MAC) filtering to block out unauthorized devices.
Guides on the secure configuration of network devices are available from various sources, including manufacturers and
user groups.
B.4.5 Secure Operational Traffic
Eliminate any unnecessary operational traffic by:
• Disabling nonessential features on ESS network devices.
• Putting like devices on the same VLAN and then using router and switch security features to allow only
authorized devices, their required protocols, and their specific network connectivity on those VLANs.
B.4.6 Secure Management Traffic
Use dedicated hosts for device management. Use router and switch security features to allow only these hosts, using
specific management protocols, to access infrastructure and ESS devices. Isolate and protect management traffic from
operational traffic in any of the following ways:
• Manage devices through direct local connection.
• Manage devices using an out-of-band network or serial connection. This requires both dedicated
communications bandwidth and a dedicated management interface on each device.
• Manage devices using a protected in-band remote connection. Use VLANs for in-band isolation, ACLs for
traffic control, and VPNs, where available, for integrity.
B.4.7 Manage Configuration
Good configuration management starts with good documentation, which requires the following:
• Map out and document the entire ESS network, infrastructure, and device configurations.
• Prepare and configure new equipment off-line.
• Sanitize old equipment before disposal by clearing configuration information and user data from memory and
disks, restoring factory defaults, and removing nonfactory labels.
• Keep infrastructure security features current with device moves, additions, and decommissions.
• Enable auditing features, and periodically examine the resulting logs for signs of unusual activity.
• Synchronize to a common time reference so that audit logs become more useful during security incident
response.
• Develop a disaster recovery plan for the ESS system and test it periodically.
B.4.8 Eliminate Security Deficiencies
Identify security deficiencies (using established ESS security policy), and develop a plan to proactively eliminate them.

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B.4.9 Continuous Security Training

Recommend that all security personnel receive comprehensive and relevant security training with refreshers on a periodic
basis.
B.4.10 Perform Security Audits
Verify the effectiveness of security measures by performing frequent, irregularly scheduled security audits.
B.5 Trends
A trend in network security is the concept of deperimeterization. The idea is that a perimeter is no longer sufficient to
provide a trusted zone, and all devices and protocols used on the network should be robust enough to exist in a hostile
environment. This concept makes use of inherently secure protocols that authenticate communications partners before
allowing any transfer of data, secure operating systems and applications, and host-based intrusion prevention.
Threats and trend reports are periodically published (e.g., Cisco Systems’ annual security report and IBM’s X-Force
trend and risk report). This data shall be considered when managing potential risk.
B.6 Network Security for Facility and IT Networks
B.6.1 Overview
There are several networks within the data center beyond the core computer room Ethernet local area or Fiber Channel
storage area network. Networks within the data center are made up of discrete IT and facility system networks. Often,
the implementation of these networks are planned, designed, installed, and managed by individual departments with
little or no communication between the groups, resulting in a lack of coordination and a common set of guidelines or
standards.
The networks can be categorized into three main systems:
• Computer room networks:
– Server and NAS Ethernet LAN
– Storage Fiber Channel SAN
• Building desktop networks:
– Desktop PCs
– VoIP Telephones
• Facility building automation system (BAS) networks:
– HVAC controls
– Fire alarm
– Physical security
– Computer room power monitoring
– Electrical distribution control
– Lighting
Although these network categories are discrete in their topology, they do interface through BMS or Data center
infrastructure management (DCIM) tools to provide key management functionality for data center facility managers,
computer operators, and network administrators. It is important that networks are planned and designed in a coordinated
effort to ensure:
• It is clearly understood which staffing roles require access to each network
• Who is responsible to manage each network
• Who is responsible to manage the interfaces between the networks and what levels of security are required at
each network interface
• Who is responsible to manage each network, hardware platforms, and operating systems
• Who is responsible to install each network cabling infrastructure pathways
Once these questions have been answered the data center designer can begin to identify where the hardware and core
network components should be located, how they are interconnected (if required), and how logical security will be
provided.
B.6.2 Requirements
The configuration of the non-computer room networks shall have logical security that isolates each of these non-
computer room networks from each other and from the critical and data sensitive computer room network.

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B.6.3 Recommendations
Each of the discrete systems may have server based control logic which raises the question, “Where should non-IT
servers be physically located?” If the non-IT servers are not managed by the IT department, it is not recommended they
be located within the computer room. A separate secure room, or area, within the data center should be provided for
non-IT servers. It is recommended that non-IT servers be supported by a dedicated facility UPS, separate from the UPS
that supports the computer room, which meets the Class redundancy of the data center.
The IT network team should be engaged early in the facility design process so that each of these non-computer room
networks are clearly understood by the IT network administrators enabling them to plan a suitable firewall design to
isolate and protect each of the networks.
B.6.4 Additional Information
Figure B-4 shows an example of a facility & IT network topology with these types of systems.

Internet
(Remote Monitoring)

HVAC System Physical Security

TCP/IP Ethernet

Programmable
Logic
Controller PDU CCTV Access
HMI Control HMI
System System
Server Server

LonTalk / ModBus / BACNet Fire Alarm System

TCP/IP

Plant Sensors Actuators Fan VAV

Sensors & Valves Controls

FACP Remote
FACP
Electrical Distribution Control
TCP/IP

Programmable Supervised
Logic
Devices
Controller
HMI
System
Lighting System
Server
Operations TCP/IP
LonTalk / ModBus / BACNet
TCP/IP
Lighting
Controller
I/O Breaker Power Generator UPS HMI
System
Sensors Control Meters Status Status Server
HMI
BMS
Server Communication Protocols

NOTE: Conceptual illustration only and may not show all Ballast Occupancy Switch Dimmer Light
required system components for applicable code Driver Sensors Fixture

Figure B-4
Example of Facility & IT Network Topology

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Appendix C Network Design Principles (Informative)

This appendix is not part of the requirements of this standard, but it is included to provide additional information related
to this standard.

C.1 Overview
Generally, networks are implemented to enable the sharing of resources and the exchange of information between users.
As the number of resources, users, and connections increases, networks must be routinely modified to accommodate the
growth, making network design a dynamic and continual process. Physically, a network can be as small as two connected
computers and the media used to enable the connections, which can be physical or wireless.
A network cabling infrastructure is a combination of products, design principles, physical configuration, functional
organization, operational procedures, and data formats used as the basis for the design, construction, modification, and
operation of an information and communications technology (ICT) network.
The structured grouping of hardware (e.g., network cabling equipment), software, and applications creates the network
architecture that allows for the transport of voice, data, and video signals between network devices in a building or
campus or across a geographic area. The successful integration of these three elements allows the exchange of
information and data and the sharing of resources among users, administrators, and devices.
C.2 Systems Integration and Interfacing
Systems integration is a major advantage of network-based systems that integrate disparate systems together and provide
interfaces designed to achieve interoperability, seamless communication, and operational efficiency. The integration of
data systems allows diverse systems to share or access information across functional or system boundaries. See standards
such as ANSI/BICSI 005 and ANSI/BICSI 007 for additional information.
C.3 Scalability
IP-network technology makes it possible for an organizational network to easily and economically scale beyond the
physical boundaries of a building or campus to suit any size installation and support growth after the initial deployment.
For example, access control systems (ACS) could be expanded across multiple facilities by adding new devices to the
existing network infrastructure.
All networks that are intended to scale over time for a specific application or that share network resources with other
applications should be designed with quality of service (QoS) in mind.
C.4 Resource Sharing
In many instances, it is difficult to justify the purchase of costly devices, services, or software if only one computer can
access them at a time. IP networks allow for the sharing of these resources. Resource sharing also makes building a
highly reliable network more cost- effective than multiple single-use networks.
Based on control measures established by the network administrator, users may access various types of resources
connected to the network through the server. The types of resources include:
• Software applications.
• Peripheral devices
• User-created files.
• Internet access.
• Management tools.
Multiple network users can access a peripheral if the device is connected to the network either directly or indirectly:
• Direct connection — The peripheral device can be equipped with a network interface card (NIC) and software
compatible with the type of network in use.
• Indirect connection — The peripheral device is connected to a station or a server on the network, and its
resources are made available through the network operating system software.

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Without networks, each computer stores data locally, unlike mainframes or minicomputers, both of which use centralized
storage. As a result, faulty reporting and decision making can occur if the same data is updated on some computers but
not on others. Information sharing and data exchange are also problematic in this area. A network makes it possible to
centralize data. All files shared by users are stored in a central location, which guarantees consistency and simplifies the
update process.
In addition to user-created files, software applications can be installed on a centralized storage device accessible from
any computer connected to the network locally or remotely. This accelerates the deployment process since any
application or update only needs to be installed once on the network.
Examples of network resources that can be utilized by devices include:
• Printers.
• Storage and archiving equipment.
• CD/DVD writers.
• Servers.
A network must be equipped with services designed for resource sharing, including:
• Access control — Necessary in cases where two or more devices attempt to use a shared resource at the same
time (e.g., telecommunications circuit between two sites, a printer).
• Synchronization — Ensure that a receiving device is listening when a sending device is transmitting to that
device.
• Flow control — Monitor and adjust the rate at which data is transferred from a sender to a receiver in order to
minimize transfer time and data loss. For example, if a receiving device is occupied with other tasks, it will use
flow control to ask the sending device to pause transmission.
• Error control — Necessary to verify that a message was transferred successfully between a sender and a
receiver or to request a retransmission if the transfer was not successful as determined by error checking.
C.5 Reliability
Reliability is the predictable behavior of a system or a group of integrated systems during operation. As building systems
become more integrated and complex, they become less reliable. Reliability is cumulative in a system and decreases as
significant or critical components are added.
Reliability is an important attribute in distinguishing one IP security solution from another. For example, choosing
cameras with a built-in memory buffer captures video in the event of a loss of connectivity. When the network becomes
available again, the data can be recaptured as if the network was never down. The size of the buffer determines how long
the camera can reliably capture data without the supporting network.
C.6 Resiliency
The primary reason for designing resilience into a network is to avoid single points of failure that can have a devastating
impact on mission-critical business functions. Today’s networks allow for layers of resilience, so even if a network
component fails, backup telecommunications paths can reroute the event transmissions around the problem component.
To adequately protect the exchange, transfer, and storage of data across a network, both network resilience and service
resilience must be incorporated into the design:
• Network resilience is accomplished through the design of alternate data paths between two IP network
switches. This allows the network to maintain operation in the event of a cable fault.
• Server resilience is accomplished by locating a duplicate server in a remote location to achieve a “hot”
resilience. Service resilience protects a network against significant disruption and costs in terms of time,
resources, and money in the event of a single storage device failure.
Backups may not exist for critical data if users do not duplicate their files on a regular basis. A network can be equipped
with a backup system that runs at specific intervals, ensuring that critical data is mirrored and stored, making it available
from a secondary source if needed.
Power supply resilience allows for uninterrupted service in the event of a loss of primary power. This important
component of the system resilience plan makes use of power loss detection, power distribution, power quality
monitoring, battery backup, uninterruptible power supply (UPS), and emergency power generators to ensure reliable
and continuous line voltage power to equipment.

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C.7 Standardization
The standardization of technologies, processes, architectures, infrastructure, installation practices, and other related
network hardware results in a high level of interoperability. The flexibility of standardized network hardware used in IP-
based security systems gives users more options for equipment integration, acquisition, maintenance, upgrade, and
replacement.
IP system design, installation, and testing methods are well defined because of generally accepted standards and
practices for the data networking industry. Additionally, standardized network hardware is widely available and cost
effective.
Telecommunications cabling standards are developed to provide compatibility with existing and future network
technologies. These standards make it possible to implement a cabling infrastructure using a structured approach where
a common set of design and performance guidelines ensures compatibility between cabling systems and network
technologies. The term structured cabling system is often used to describe a standards-based cabling infrastructure.
C.8 Network Management and Administration
Network management is the combination of planning, procedures, hardware, software, and personnel needed to maintain
network operations at maximum efficiency at all times.
Because changes in hardware and software are routine on most networks, network administrators must be able to perform
multiple network-related tasks.
Networked devices make it easier for a network administrator to monitor, control, and change the configuration of any
station from a centralized location using management software. The network replaces the need for physical access to a
station for management tasks such as:
• Taking inventory of the hardware and software components in specific stations across the network.
• Installing or updating station software, including the station’s operating system (OS). Update configurations
may be in response to vendor initiatives (e.g., installing patches or upgrades).
• Identifying and tracking new network components and their relationships to existing components. Maintain or
change the configurations of network components as needed (e.g., when a device needs to be relocated).
• Scanning for viruses and other undesirable software.
• Copying all new or modified files from the station to a network backup device.
• Powering on or powering off the station. For instance, after configuration changes, the shutdown and restart of
the device is required.
• Updating the basic input output system.
Management software also can be used to notify network administrators of component failure in a station. In some cases,
the software can detect and report any attempt to remove components, reducing the possibility of theft or unauthorized
modifications. This can be of significant importance when applied to devices as they are frequently the target of
vandalism.
Network management software plays an additional role in monitoring the network to ensure its desired operation. For
example, a managed switch can be monitored and controlled using network management software. A network
administrator can observe traffic conditions and collect operational status information on the switch as well as on all
devices connected to the switch.
If needed, diagnostic routines can be initiated to discover the cause of a fault condition. All of these actions can be
performed remotely through a centralized management console, which saves time by eliminating the need to physically
inspect the units. This is most applicable if ESS systems are spread over larger geographic areas, making on-site repairs
difficult, if not impossible (e.g., remote mounted cameras, motion detectors, other access control and monitoring devices
installed in remote or hazardous locations).
C.9 Bandwidth and Quality of Service (QoS)
Bandwidth, commonly referred to as the transmission capacity of a network, is the amount of data that can be passed
along a communication channel in a given period of time. Inadequate bandwidth can cause bottlenecks, retransmissions,
failed transmissions, and inadequate system performance.
When a voice or video packet needs to be transported over a network, it is critical for the network to deliver all fragments
in order and with minimum loss, error, or delay. Failure to do so subjects the receiver to a noticeable degradation in the
quality of speech. This type of traffic is characterized as both loss sensitive and delay sensitive.

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Because of these factors, digital transmission is not always compatible with networks originally designed for traditional
data traffic between devices. To provide an acceptable level of service, an organizational network must be able to
identify, prioritize, and dedicate resources to the traffic generated by voice and other network intense, mission-critical
applications. Networks designed to support these applications can be described as IP QoS capable.
The term QoS describes any technology developed to manage network traffic. In all cases, the role of QoS is to provide
a guaranteed minimum data transfer rate, latency level, or both to any network application for specified users. QoS is a
set of resource reservation control mechanisms that are put in place to ensure that a transmission channel has a minimum
amount of bandwidth dedicated to a device or application along with a maximum delay in transmission that can be
tolerated. This is important, for example, in IP voice traffic or
when streaming real-time multimedia applications (e.g., video surveillance), which require fixed bit rates and are delay
sensitive. When data packets are transmitted over a network, QoS mechanisms give higher priority to real-time data than
non-real-time data (e.g., file downloads).
The planner must consider the integration and implementation of the following three QoS tools throughout the network:
• Classification — Identification of the application and marking its precedence.
• Prioritization — Giving priority to the voice or video services over any other. To improve performance, a
technique known as traffic prioritization can be used. Prioritization makes it possible to assign different levels
of priority to the applications running simultaneously on a station. For example, a NIC can be configured to
transfer data to and from an IP camera before processing messages from any other application.
• Policing or shaping — Dropping or decreasing the priority of high volumes of traffic.
C.10 Intelligence to the Edge Devices
As intelligence and functionality migrate to edge devices, such as cameras and card readers, implementations will be
able to integrate and control most aspects of a business, including ICT; network and Internet access; heating, ventilation,
and air-conditioning control; lighting control; fire detection and alarm systems (FDAS); elevator control; physical
access; and video surveillance.
Embedding analytics technology in devices can create “smart” devices, which are capable of reducing bandwidth and
storage requirements. These intelligent devices provide two-way communication, are interactive, and can act
independently as decision makers, thereby increasing the accuracy of alarms, preventing false positives, and increasing
the effectiveness of security resources.
Additionally, because intelligent edge devices analyze captured data in real time as events are detected, an alert can be
sent immediately to the appropriate parties, thereby dramatically reducing response time.

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Best Practices for Healthcare Institutions and Facilities

Appendix D Related Documents (Informative)

This appendix is not part of the requirements of this standard, but it is included to provide additional information related
to this standard.

The following standards and documents are related to, or have been referenced within recommendations of this standard,
and provide additional information which may be of use to the reader.

BICSI
• ANSI/BICSI 003, Building Information Modeling (BIM) Practices for Information Technology Systems
• ANSI/BICSI N2, Practices For The Installation of Telecommunications and ICT Cabling Intended to Support
Remote Power Applications
• Outside Plant Design Reference Manual, 6th edition
• Telecommunications Distribution Methods Manual, 13th edition

Canadian Standards Association

• Z8000-11, Canadian Health Care Facilities
NOTE: Exclude clauses 12.6, 12.7 and 12.8, as this document provides more detailed guidance

Facility Guidelines Institute

• FGI 2018 Guidelines for the Design and Construction of Health Care Facilities

Institute of Electrical and Electronics Engineers (IEEE)

• IEEE 602-2007 (the IEEE White Book), Recommended Practice for Electric Systems in Health Care Facilities

International Code Council

• International Building Code (IBC)

National Electrical Manufacturers Association (NEMA)

• NEMA Installation Guide for Nurse Call Systems

National Fire Protection Association (NFPA)

• NFPA 70E, Standard for Electrical Safety in the Workplace
• NFPA 72®, National Fire Alarm Code
• NFPA 101®, Life Safety Code®
• NFPA 241, Safeguarding Construction, Alteration, and Demolition Operations
• NFPA 1221, Standard for the Installation, Maintenance, and Use of Emergency Services Communications
Systems
• NFPA 1600, Standard on Disaster/Emergency Management Business Continuity Programs
• NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems
• NFPA Fire Protection Handbook

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Telecommunication Industry Association (TIA)

• ANSI/TIA-568.0-D, Generic Telecommunications Cabling for Customer Premises
• ANSI/TIA-568.1-D, Commercial Building Telecommunications Cabling Standard
• ANSI/TIA-606-C, Administration Standard for Telecommunications Infrastructure
• ANSI/TIA-607-C, Generic Telecommunications Bonding and Grounding (Earthing) for Customer Premises
• ANSI/TIA-5017, Telecommunications Physical Network Security Standard

Verband der Elektrotechnik, Elektronik und Informationstechnik

• DIN VDE 0834-1:2000-04, Rufanlagen in Krankenhäusern, Pflegeheimen und ähnlichen Einrichtungen
- Teil 1: Geräteanforderungen, Errichten und Betrieb (Call Systems in Hospitals, Nursing Homes and Similar
Institutions-Part 1: equipment requirements, construction and operation)
• DIN VDE 0834-2:2000-04, Rufanlagen in Krankenhäusern, Pflegeheimen und ähnlichen Einrichtungen
- Teil 2: Umweltbedingungen und Elektromagnetische Verträglichkeit (Call systems in hospitals, nursing
homes and similar facilities -Part 2: Environmental conditions and electromagnetic compatibility)

Other Standards and Documents

• American Health Insurance Portability and Accountability Act, United States Department of Health & Human
Services
• Americans with Disabilities Act, United States Department of Justice
• California Code of Regulations, Title 24; California Building Standards Code, California Building Standards
Commission
NOTE: Section 1224.4.1 details Communication Site Underground Essential Utilities
• Disability Discrimination Act, Australian Human Rights Commission

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