Access to health care in rural areas has been a decades-old and ongoing challenge for those who live there. Scopes of health-care services in these areas tend to be more limited and less specialized. Despite these challenges, more than 46 million Americans live in rural areas, and tend to have greater health-care needs than those who live in cities.

After a decade of declining, rural populations in the United States, as an aggregate, are rising again, and their need for health care is growing. Supporting these needs as design professionals first requires understanding rural health-care patients and staff, as well as all the factors influencing how they live and work.

Rural Health-Care Services

Properly designing plumbing systems for rural health care requires not only an understanding of the common services these facilities provide, but also the patients and staff they serve. Now more than ever, rural health-care facilities must be very deliberate in the types of services they offer. Limited finances, lower rates of patient insurance, staffing shortages and lower availability of health-care professionals are challenges they constantly face. 

Consequently, they often focus on a slate of generalized, higher-demand services while leaving more specialized ones to providers in more densely populated areas. Understanding the local populations they serve is also critical to knowing what services to provide and, barring that, having the means to send patients elsewhere to get the care they need.

In clinical settings, the scope of a facility’s services may not be significantly different than those in more urban areas, only on a smaller scale. General family practices and primary care, occupational therapy, dental, cardiology, gastroenterology, wound care, imaging by x-ray and CT, and general laboratory services are common. However, rural areas tend to have higher demands for nutrition counseling, endocrinology (due to higher instances of diabetes) and services for drug and alcohol abuse.

Hospitals and emergency departments in rural areas serve patients who, unfortunately, have lower rates of insurance and less access to health services in general. Thus, these patients are more likely to see health-care providers for emergency services rather than preventative care. 

As such, hospitals and emergency departments serving these patients are often primarily equipped to perform life-saving procedures for common catastrophic events, such as heart attacks, strokes, aneurysms and cancerous tumor removal. Services for labor and delivery, total joint replacement and bariatric procedures are also common. 

Many of these hospitals include helipads for fast transportation from remote areas, but they may also be used to deliver critical patients to other facilities better equipped to treat them. Geographic location and local industry also influence health services, and understanding both can give insight into the services you will need to design for. 

For example, emergency departments in mountain states are equipped to deal with bear attacks and hunting accidents, while those in the northern Great Lakes areas are prepared for hypothermia cases. Likewise, facilities in areas with agricultural and petroleum industries tend to be equipped for fertilizer and other chemical exposure, and farming and automobile accidents.

Considerations for Plumbing Equipment

Several factors should be considered when choosing plumbing materials and equipment for rural health-care facilities. One of the primary factors is the delivery time of materials — consumable materials in particular. The most critical of these for plumbing systems are pressurized medical gas cylinders. During the design phase, it helps to know your client’s medical gas supplier, where the company is located, and what its delivery capabilities are. 

This information, in conjunction with discussions with your client, can help you decide how to size the gas manifolds. Many facilities expect a cylinder delivery once a week, but sizing the manifolds to have capacity for longer is a good idea if supply or delivery disruptions are a concern.

For facilities where medical gas delivery and service is a concern, on-site generation of medical gases is often preferred, if practical. While medical vacuum is always produced by a pump, producing medical air by compressor rather than high-pressure manifolds reduces the risk of supply or delivery issues. In the wake of the COVID-19 pandemic and the supply chain issues that followed, some facilities are even opting to generate oxygen on-site as well.

Another plumbing resource that can be subject to delivery issues is potable water. Most state health departments mandate one primary and one secondary source of domestic water to a hospital. Some designers opt to handle the latter with an emergency potable water connection for a tanker truck, as it tends to have less cost impact on the project than a second water service. 

However, the reality is that many rural areas do not have tanker trucks that can reach the facility in a reasonable amount of time, especially not during natural disasters. Therefore, a secondary water service is often the safer bet. If you opt for an emergency water connection, be prepared to provide your state health department with the name of the water vendor, its location and details of how it will provide service in an emergency.

The number and type of facilities staff play a role in determining best design practices in rural health care. Rural facilities tend to have smaller maintenance contingents that may be less capable of dealing with equipment issues and upkeep than their counterparts in more populated areas. As such, they may be more likely to rely on equipment service technicians and other skilled tradespeople to perform these tasks. 

Even if this is the case with your client, it is still best to consult them on which manufacturers, equipment technologies and fixture types they are most familiar with. This familiarity gives them a better chance to fix things on their own when they can and leverage existing relationships with manufacturer technicians when they cannot.

When selecting equipment needing regular maintenance, it is best to investigate the proximity and availability of those who can do the work. I have heard it said that the best choice of manufacturer is the one that will be on-site on the same day a problem arises; this is especially true in rural health care. 

Many manufacturers of plumbing source equipment offer expanded service packages that put this equipment on regular, monitored maintenance schedules. These packages also provide a service technician to perform the maintenance at given milestones, thereby decreasing the likelihood of a breakdown or other emergency that could equate to lost revenue. While specifying an expanded service package adds cost to the equipment, it often pays for itself if it prevents even one emergency call to a technician or service plumber.

Enhanced equipment monitoring also goes a long way in preventing breakdowns. Trouble signals should, at the very least, be sent to the building monitoring system and facilities staff. More manufacturers now offer remote monitoring, where the manufacturer can detect an issue with the equipment at the same time or earlier than the facilities staff does. This allows them to diagnose an issue early and provide the facility with instructions on resolving it, as well as triaging service technicians when warranted.

Given all the challenges rural health-care facilities face, incorporating design elements that give caregivers and staff as much help as possible is paramount. Keeping your systems simple, maintainable, familiar and resilient helps avoid additional challenges to facilities with limited resources. Designing systems that can handle inevitable delays in material deliveries and maintenance is a must, and building redundancies into equipment where a shutdown means major revenue loss is a good idea. 

Take every opportunity to talk to your client and the facilities staff during the design phase to understand how they work, what kinds of patients they serve, how much maintenance they are willing to perform on their own, their relationships with existing vendors and tradespeople, and what their risk tolerances are. 

Aaron Bock, PE, is a senior plumbing engineer at ERDMAN and has been designing plumbing systems nationwide for the health-care industry for more than 15 years. He is the current vice president-legislative and past president of the Wisconsin American Society of Plumbing Engineers chapter, an advocate of integrated design, and a graduate of the College of Engineering at UW-Madison.