It’s No Nordic Myth: Scandinavian Hospitals Use Half the Energy as Those in the U.S.

In certain sustainability circles in healthcare, it’s common to hear the claim that hospitals in Scandinavia (Denmark, Norway, and Sweden) use dramatically less energy than hospitals in the United States. Is this just another urban legend, akin to the old Nordic myths of Thor and Valhalla? If not, what is it about these hospitals that make them such light energy consumers compared to U.S. facilities? Is it technology, operations, occupant behavior, or are there other reasons that explain this apparent difference?

To begin to learn the answers, I spoke with Richard Beam, Director of Energy Management Services at Providence Health & Services, a not-for-profit Catholic health care ministry based in Washington State and 2009 winner of the U.S. Environmental Protection Agency’s ENERGY STAR® Partner of the Year award for Sustained Excellence. Beam recently joined a group of administrators, architects and engineers on a study tour of high performance Scandinavian hospitals, sponsored by the Integrated Design Lab and International Sustainable Solutions. After leading efforts to save over $13 million in energy since 2004, Beam told me Providence was interested in looking abroad for ideas and lessons as well.

Author: The average Energy Use Intensity (EUI) for an acute care hospital in the United States ranges from around 220 to 270 kBtu/ft2/yr site energy, depending upon size and other factors. What is the range of EUIs for the hospitals you toured?

Beam: The sponsors of the tour calculated that the Norwegian and Swedish hospitals we visited use between 70 to 127 kBtu/ft2/yr site energy, which suggests that Norwegian hospitals use about half and Swedish hospitals use about a quarter of the energy consumed in U.S. hospitals. The Scandinavian officials we spoke with told us these figures didn’t include plug load because they cannot accurately predict them. But even factoring that in, these hospitals seem to be using significantly less energy.

Author: How do Scandinavian hospitals benchmark energy performance?

Beam: We learned that the European Union requires buildings to be rated on a scale of A through G and that these ratings were to be publicly posted but we did not see any certificates in the hospitals. This rating is apparently their equivalent to EPA’s national rating system, but top performing hospitals and other buildings aren’t recognized with an award like the ENERGY STAR. They just get an “A”. It would have been interesting to know the ratings of the hospitals we toured - to see actual performance data - but it was easy to believe these facilities were consuming less energy than ours back home.

Author: Why is that? Are Scandinavian hospitals comparable with U.S. hospitals?

Beam: The Scandinavians live in a very different environment than we do, and I don’t just mean geographically. Energy costs are tremendous over there. Electricity costs 27 cents/kWh in Denmark. Gasoline is $10 per gallon in Norway. That kind of price signal really pushes energy conservation. In Norway, where hydro-electric power costs 7 cents/kWh, the price signal is much less but they still consume very little oil and natural gas because of their concerns about climate change and about conserving their limited fuel reserves in the North Sea. The Nordic countries also provide healthcare for everyone. The state expects their hospitals to last upwards of a hundred years so their new designs aren’t constrained by first cost issues like U.S. hospitals. We were told their payback periods for energy related investments are as high as 17 years or more in some cases because it’s state money. They aren’t beholden to the bond market by having to repay their investments back in five years, like U.S. hospitals. What an enormous advantage!

Author: How did the high latitudes influence their building designs?

Beam: Well, daylight up there is either in short supply during the winter or over abundant in the summertime. For health reasons, regulation says that everyone has to have access to daylight wherever they are in a building, even in the basement. That drives the design. Architects design hospitals to be more horizontal than vertical, and narrow with lots of glass. Pavilions and courtyards were predominant everywhere we went because the hospitals wanted their patients and staff to have access to daylight and natural views. Scandinavians prize being outdoors in all seasons – we heard parents place their babies in trams outside for naps even in cold weather – so access to outside air is a strong cultural value and expectation. Not surprisingly, we saw operable windows in practically every space throughout the hospital, including patient rooms.

Author: Yes, low rise buildings can use less energy than taller ones because not as much energy is needed to get the conditioned air up to the top floors. Nor do you need as much energy to move people for that matter. But how are they able to meet indoor air temperature and humidity targets with open windows?

Beam: Engineers in Scandinavia seem to have more flexibility in meeting their targets than we do. Their target is a comfort range spanning from 68 to 78 degrees, whereas we design and operate to a 3-degree target in the U.S. The air handling systems we saw delivered filtered and slightly tempered air at 64-65 degrees. Our target in the U.S. is to deliver that air at 52-54 degrees to ensure that we meet requirements for humidity and thermal comfort levels. Scandinavians save big because their geography gives them free cooling and they save again because building occupants accept broader temperature ranges. That cultural tolerance allows them to design much smaller ventilation systems than what we are able to do back here.

Author: What kind of ventilation systems do they use?

Beam: In patient rooms and atriums, we saw some use of displacement ventilation which is much better for energy savings than conventional mixing ventilation. For a given amount of energy, displacement ventilation can supply a larger quantity of air than a conventional mixing system because the air flow is as direct as possible - from the floor to the ceiling. But to supply that same quantity of air with an overhead mixing system, it would require greater velocity of air, more fan power, and more energy. Another advantage they have is reduced air change rates. Their patient rooms have two to three mechanical air changes per hour while ours in Washington and Oregon are required to have six. Scandinavian hospitals are mechanically moving 2/3 less air than we are and using 2/3 less fan horse power with little or no chiller associated with it.

Author: Mechanical ventilation uses 21% of electricity in a typical U.S. hospital, the second largest end use after lighting, according to the U.S. Energy Information Administration. What a goldmine of opportunity if hospitals could mine it over here. But what about infection control? Why do Scandinavian infection control officers support natural ventilation and operable windows in hospitals?

Beam: Their view is that most hospital infections come from physical contact, not from airborne vectors. Pressurization between patient rooms and hallways wasn’t a concern but hand washing and disinfecting surfaces was. If patients have infectious airborne diseases, they have special isolation rooms for them that are pressurized. A real eye opener for us was when we compared infection rates: 8% of their patients get infections, compared to 9% - 12% back here. Granted, these are anecdotes between a handful of hospitals - not rigorous national studies - but clearly there seems to be a story here. Better data will help us get to the facts. Wouldn’t it be the best of both worlds if we could lower our infection rates and energy consumption by increasing natural ventilation?

Author: How were the Scandinavians heating and cooling their buildings? Did you see any innovative technologies or strategies?

Beam: Geothermal heat pumps were very common in all the hospitals we visited. By utilizing the earth’s constant temperature below the frost line, these hospitals were able to heat and cool their buildings with great efficiency. The largest system we saw had 800 wells dug 300 feet deep. Of their total energy budget, most of their money went towards heating and ventilation. Decentralization was another strategy I found interesting. Rather than combining all HVAC into one centralized four-pipe system like we do, the systems over there are completely decoupled. Heating was separate and typically consisted of radiators under the windows. If a space needed extra cooling, they would provide a spot cooler at a nursing station or they’d pipe in chilled water or chilled beam as needed. It makes sense to decentralize if everyone has some limited ability to control their own space.

Author: What lessons can we learn from Nordic hospitals?

Beam: A lot of us came back from the trip impressed with how the Scandinavians had adapted to their environment. The northern latitudes can be harsh with temperature extremes and lack of daylight but the Scandinavians have designed their buildings to maximize exposure to essential elements like daylight and fresh air. They’ve tapped into geothermal heat and have evolved a culture that not only survives but thrives. The lesson for us back here is to ask, how can we best adapt to our own local environment with all its inherent benefits and challenges?

Clark Reed is the Director of the Healthcare Facilities Division for ENERGY STAR at the U.S. EPA. In 2008, ENERGY STAR helped Americans save enough energy to avoid greenhouse gas emissions equivalent to that of 29 million cars—all while saving consumers $19 billion. To join, visit energystar.gov/healthcare or contact the author at the U.S. Environmental Protection Agency - MC 6202J, 1200 Pennsylvania Ave NW, Washington, D.C. 20460. Email: reed.clark@epa.gov Phone: 202-343-9146.