Imagine a busy emergency department forced to divert ambulances; not because of a sudden influx of patients, but due to a burst water pipe. In January of 2025, a ruptured ceiling pipe in a UK hospital collapsed parts of the roof and stopped ambulances access for seven hours. The employees had no choice but to reroute ambulances until the crisis was stabilized.

This incident is far from an outlier. While generators tend to be the main focus for many people when it comes to emergency preparation in healthcare facilities, plumbing failures are equally as urgent. In the words of the CDC, “The resilience of a community depends on the ability of its critical infrastructure sectors to reliably respond to its needs, particularly during emergency events.”

According to Christoph Lohr, vice president of technical services and research at IAPMO, “Emergency preparedness for plumbing systems in healthcare facilities is critical because these systems must remain operational and hygienic during both everyday use and crisis scenarios. Water availability, pressure and quality directly impact infection control, patient safety, and facility resilience."

To put it simply, when water stops flowing, hospitals stop functioning.

For that reason, ensuring that a healthcare facility is able to withstand whatever life throws at it – from global pandemics to burst pipes – is critical to maintaining smooth and safe operation where it matters most.

What hospitals are preparing for, and how infrastructure makes the difference

Emergency preparedness in healthcare is more than a regulatory checkbox; it’s a critical operational priority. From natural disasters and utility failures to internal system breakdowns, the threats to hospital infrastructure are diverse, disruptive and increasingly frequent. While much of the focus in emergency planning centers on staffing, communications and clinical protocols, the true backbone of hospital resilience lies in mechanical and plumbing systems. These unseen systems (circulating water, managing waste, ventilating air and controlling temperature) are what allow hospitals to remain safe, sanitary and – most importantly – operational during a crisis.

Natural disasters are a leading threat to these systems. Floods can overwhelm drainage infrastructure, infiltrate backflow preventers and destroy mechanical equipment housed at or below grade. During hurricanes, rooftop HVAC systems are especially vulnerable to wind damage, while associated power outages often lead to loss of water pressure and compromised air quality inside. Even extreme temperatures can push systems to their limits: chillers (which are used to keep equipment running smoothly) can become overloaded in high-heat conditions, while frozen pipes can rupture and cut off access to potable water, flooding interior spaces during extended cold snaps.

Facilities that navigate these hazards successfully often do so through design foresight: elevating mechanical rooms, integrating freeze protection for plumbing systems and building redundancy into both HVAC and domestic water infrastructure. That redundancy is critical not just for weather events, but also for utility failures, which can be equally paralyzing.

As Bancroft Architects + Engineers explains, “Redundant systems are designed to provide an uninterrupted water supply, ensuring that healthcare services continue without any unforeseen hitches.”

Loss of potable water halts absolutely critical functions like sterilization, handwashing, HVAC makeup water and patient hygiene. Power outages can disable pumps and ventilation systems, and failure in a medical gas system can be life-threatening in ICUs and operating rooms. HVAC system loss, meanwhile, impacts pressure-controlled rooms and indoor air quality; both essential to infection prevention. To mitigate these risks, engineers design systems with overlapping protections: dual water mains, onsite water storage tanks, emergency generators, cross-connected piping and building automation systems capable of initiating emergency protocols.

Hugo Aguilar, vice president of codes and standards at IAPMO, also noted that the COVID-19 pandemic highlighted the vulnerabilities in the way that hospitals manage water and air systems, and standards have been changed because of it. "Public health emergencies have absolutely influenced updates to both the Uniform Plumbing Code (UPC) and the Uniform Mechanical Code (UMC)." The UPC discusses the safe operation, closure and reopening of buildings to address risk management practices for potable and nonpotable water supply systems and provides risk management practices for preparing water systems every step of the way: prior to shutdown, during shutdown and how to reopen a building properly. The UMC has also updated their ventilation and air purification requirements.

But, not all emergencies come from outside. Internal mechanical failures are among the most common — and potentially costly — threats hospitals face. A burst pipe can flood an entire care unit or damage vital infrastructure. Equipment leaks or backflow events can introduce contaminants into sterile environments, triggering infection control risks and forcing service shutdowns. Waterborne pathogens such as Legionella pose another serious threat, often proliferating in stagnant or underused piping systems. Biofilm accumulation (or sticky layers of bacteria, fungi, and microorganisms) can adhere to pipe interiors, while cross-connections between potable and non-potable water systems can introduce chemical contamination.

In these cases, prevention and rapid response are key. Many facilities now deploy advanced leak detection systems, real-time pressure sensors, automated shut-off valves, and monitoring dashboards that alert facility teams to anomalies before they escalate into emergencies. According to Healthcare Market Manager at Zurn Elkay, Jana Summey, “Data is king. Healthcare facilities want a continual line of sight to monitor water—whether it’s daily risk mitigation for waterborne pathogens or responding to an emergency.”

Summey adds that smart plumbing systems capable of remote flow monitoring, automated flushing, and real-time alerting are quickly becoming baseline infrastructure. “Zurn’s plumbSmart technology allows hospitals to track water flow at the individual fixture level, even across multi-building campuses,” she explains. “If a fixture fails to meet preset water volume thresholds, it can be automatically flushed, with the activity recorded and integrated into a facility’s water safety documentation.” This level of insight supports compliance with infection prevention policies and helps mitigate the risk of stagnation that can lead to microbial growth.

Supporting all of this work is a framework of codes and standards that define not only the technical requirements of emergency preparedness, but the legal and financial consequences. The Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Rule ties facility-specific risk assessments and contingency plans — covering power, gas and water systems — to reimbursement eligibility.

The Joint Commission mandates that all accredited healthcare facilities maintain a written Emergency Operations Plan that includes utility system reliability and response, and the Facility Guidelines Institute (FGI) outlines minimum design requirements for mechanical and plumbing systems in both new construction and renovations. NFPA 99 further classifies systems by risk category and defines mitigation strategies for failure scenarios.

Ultimately, the ability of a hospital to remain functional during an emergency comes down to what’s behind the walls and beneath the floors. Redundant water systems, pressure-regulated drainage infrastructure, ventilated isolation rooms and smart controls for valves and fixtures are no longer optional; they are the foundational elements of 21st-century healthcare resilience.

Risk management and maintenance

No emergency response plan is complete without a long-term maintenance and testing strategy. Even the best-designed systems can become a liability if not routinely inspected, after all!

According to IAPMO, working hand in hand with architects during the building process will be paramount to preparing for disasters. In the words of Lohr, "That's why the Construction Practices for Potable Water Manual is so important: it outlines actionable steps installers can take during construction—grounded in scientific research—to reduce the risk of waterborne pathogen growth."

IAPMO was also asked to lead the FGI Plumbing Task Group, where they contributed guidance to improve emergency preparedness in healthcare plumbing. According to Lohr, they're looking into how to "better integrate plumbing design decisions earlier in the architectural process."

Recently, language was added to the 2023 Water Efficiency and Sanitation Standard (WE-Stand) to help architects better understand that that the distance between fixtures and equipment can affect water quality and sustainability; increasing water age and system volume. "These types of proactive code considerations—combined with IAPMO’s broader efforts in training, research, and technical standards—are helping to ensure that plumbing systems in healthcare settings can remain resilient, safe, and responsive even during emergencies," said Lohr.

Organizations like the American Society for Health Care Engineering (ASHE) recommend regular testing of utility systems, including scheduled water flushing, leak detection and emergency switchovers. These routines should include both preventative and predictive maintenance practices. Many facilities also conduct table-top or full-scale exercises to verify that backup systems activate properly and that staff know how to respond when mechanical systems falter.

As mentioned earlier, smart monitoring systems add a critical layer of risk mitigation. With tools that log pressure, flow rates and usage patterns, facility teams can detect anomalies before they become critical. This data supports operational decision-making and provides a documented history that can help reduce liability in the event of a waterborne illness or mechanical failure.

The next generation of healthcare plumbing and mechanical systems is being shaped by modularity, digital integration and climate resilience. As hospitals plan for the long term, they are increasingly seeking solutions that offer adaptability, predictive capabilities and protection against extreme weather events.

Modular construction techniques are gaining traction because they enable faster installation, standardized quality control, and easier replacement or expansion of system components. Modular mechanical racks, pre-plumbed fixture systems and factory-assembled valve stations are helping facilities streamline both construction timelines and future upgrades.

Digital tools are also transforming emergency planning. Technologies like IoT-connected devices (or nonstandard computing hardware such as sensors, actuators or appliances) allow teams to simulate emergencies, predict failure points and test system responses virtually before any real-world issue arises. These simulations help inform not just design decisions, but also maintenance planning and staffing strategies. The CDC emphasizes “facilities should not only develop a written emergency water supply plan (EWSP), but also test it through tabletop exercises and update it after real-world disruptions.”

Climate adaptation is another critical frontier. Mechanical and plumbing systems must now account for stronger storms, hotter summers, colder winters and longer utility outages. That means elevating mechanical rooms, insulating piping against freeze conditions, reinforcing stormwater drainage systems and ensuring emergency water supply and HVAC systems can operate independently for extended periods.

Thankfully, organizations like IAPMO are constantly working on creating new training and certification programs that are focused solely on healthcare plumbing infrastructure. Programs like the ASSE 12000, for example: "These programs are designed to give professionals the tools they need to address water quality, Legionella mitigation and infection control—key concerns in any healthcare setting." This, Vice President of Engineering Tony Zhou, says, is because IAPMO is "seeing growing demand from healthcare facilities that want trained, certified personnel who understand the critical nature of these systems."

Hospitals of the future will need to be more adaptable, self-monitoring, and environmentally responsive than ever before. That preparedness starts with what lies behind the walls and beneath the floors.

When a hospital prepares for the worst, the focus often turns to what’s most visible: beds, staff and supplies. But, when a real emergency strikes, it’s what’s behind the walls and beneath the floors that often determines whether care can continue.

Picture a nurse reaching for an eyewash station after a chemical spill, only to find no water pressure. Or, imagine an ICU relying on stable airflow to protect immunocompromised patients, just as a ventilation system fails. These moments don’t make headlines, but they are critical failures that can be the difference between life and death.

If the recent COVID pandemic taught us anything, it’s that we’re entering an era where healthcare infrastructure must do more than just function: it must anticipate, adapt and respond. Facilities are investing in technologies that not only alert teams to problems, but prepare for them well before they happen. They’re elevating mechanical spaces, cross-connecting water supplies and reinforcing drainage systems to do more than meet code standards. They’re being designed for the worst case-scenario.

As the climate changes and systems grow more interconnected, the hospitals that will stand strongest aren’t just the ones with the best emergency plan, they’re the ones with infrastructure that’s ready to act on it.

Because, in a moment of crisis, it’s not just about having power or personnel. It’s about whether water still flows, air still circulates and systems still hold. That’s the quiet, critical promise of good design. And, most importantly, it’s what will keep the next emergency from becoming a disaster.