When installing floors in healthcare facilities, one cannot stress the importance of health and safety enough, not only for patients but also visitors and staff. 

Healthcare facilities have very specific needs, not only for patients, but visitors and staff alike. Several years back the technology we have today was not available, which is why some healthcare facilities are still making use of old, corroded and unsightly floors that require a lot of extra labour to ensure that they remain hygienic and safe.

This article takes a look at four key factors that need to be taken into consideration when specifying flooring for healthcare facilities in order to ensure the health, safety and wellbeing of everyone within these facilities. These factors include but are not limited to:
•    The Evidence-based approach;
•    Managing contamination;
•    The prevention of moisture; and
•    Anti-slip treatments.

The Evidence-based approach

An increasing amount of research has shown that the physical environment in which patients are cared for, and caregivers work, has a measurable impact on them. It is estimated, after more than 1 000 research studies, that healthcare design can improve patient care, enhance medical outcomes and reduce medical errors and waste.

Consequently, the use of this research in the design of healthcare environments is of great interest to the industry. According to the Centre of Health Design, this process, referred to as evidence-based design (EBD), calls for design decisions about the built environment to be based on credible research to achieve the best possible outcomes.

According to an article written by Dr. Carolyn Clancy, US Director of the Agency for Healthcare Research and Quality, and published in the American Journal of Medical Quality, hospital leaders continue to seek ways to improve quality and reduce errors, which is why it is critical that they look around their own physical environments with the goal of ensuring the hospital contributes to, rather than impedes, the process of healing.

This change in attitude has encouraged significant changes in the design of healthcare environments. These EBD principles should ideally be embraced by everyone involved with the project, offering them a guide to help them do more with less. Today, a multi-disciplinary team has to first identify the project’s mission, goals and objectives, and then blend available research with practical knowledge in order to create a meaningful and financially sound design and construction plan.

Preferably, the team should examine how the desired evidence-based design objectives may impact design decisions regarding the built environments – from programming and planning down to the selection of finishes and furnishings. It is critical that the client supports this process. Additionally, the project team should include professionals overseeing all issues relating to cost, aesthetics and performance from the beginning of the project. The ultimate team would be comprised of hospital leadership, architects and interior designers, staff and family representatives, as well as infection control maintenance staff.

However, one of the primary obstacles in incorporating EBD principles is additional upfront costs but, when evaluated over the long term, EBD solutions can offer an advantageous return on investment by improving service efficiency, improving staff satisfaction and retention, increasing patient safety and satisfaction, as well as increasing a hospital’s market share. Flooring within this environment is an especially important design element. Not only is it found in all spaces, but the type of flooring specified greatly influences the outcome of each space.

A South African Perspective

Evidence-based policies have gained significant momentum, with several books hitting the shelves on this topic. This approach has been widely employed in Europe. Sub-Saharan Africa has three evidence-based medicine institutions, South Africa has two, and the other branch is in Nigeria.

In South Africa, Evidence-based Health Care (EBHC) is a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values. Research literature is constantly changing and therefore, to provide optimal care, healthcare professionals need to keep abreast of new developments to be able to offer care that works and eliminate the use of that shown to be harmful or ineffective.

This information is invaluable, as noted above with the employment of Evidence-based Design in Healthcare facilities. The Evidence-based principles involves five essential steps, and elaborates on the above:
1.    Ask – converting information leads to answerable questions;
2.    Access – finding the best evidence with which to answer the questions;
3.    Appraise – critically appraising the evidence for its validity and usefulness;
4.    Apply – applying the results of the appraisal into clinical practise; and
5.    Audit: evaluating performance.

Developed in the early 1990s, EBHC has expanded greatly over the past twenty years and has been shown to be an efficient and much needed practise worldwide. These resources are able to give all parties involved in the specification of flooring for healthcare facilities greater insight into what is needed in order to ensure the health and wellbeing of patients, staff and visitors alike.

Managing Contamination

Healthcare facilities need to adhere to strict protocols to ensure there is no contamination. The floor of nearly any facility can quickly become a breeding ground for microbes as it is walked on, can be exposed to spills, and is the recipient of airborne microbes that settle on the floor in the form of dust. This why it is crucial to manage the level of contamination and make it a top priority, especially in healthcare facilities.

Traditionally contamination is controlled by cleaning the floor regularly with an antibacterial, antimicrobial solution. However, the number of times this can be carried out in one day is limited  as the floor cannot be wet all day long, which in turn makes it a challenge for facilities to remain fully compliant.

Fortunately, protective floor coatings with antimicrobial properties have been developed that provide an extra layer of defence against contamination. However, this solution isn’t always foolproof. It is crucial to select the right coating, as certain flooring that are porous and can retain and transmit moisture, making it an ideal breeding ground for a number of microbes, including bacteria, fungi and various moulds and spores.

Over time, cracks may appear due to wear, impact, repeated exposure to chemicals, or even settling of the building’s foundations, and the most determined swabbing can’t control microbe growth below the floor surface. Traditional treatments may not be able to penetrate deep into these areas, while bacteria continue to live for extended periods, posing health threats.

Selecting a coating specifically manufactured to provide solutions to these challenges will drastically minimise health risks. It is advised to carry out pre-treatment of the substrate with products that have antimicrobial properties. Pre-treatment products can penetrate deep into the substrate and antimicrobial joint fillers, coatings and overlays can increase total system thickness. The result is a long-lasting, durable floor system that will contribute to the hygienic requirements of a healthcare facility.

The prevention of moisture

As already noted, moisture levels within or on a floor play a significant role in both the safety and hygiene of a healthcare facility. Within every medical facility, there are several different tasks taking place, yet all of them have one thing in common – they are all taking place on top of a floorcovering material glued down to a concrete slab beneath it.

Floorcovering material bond failures over concrete represent an extremely hefty price tag. If a floorcovering fails, the healthcare facility will have to shut down and patients will need to be moved to another location, all objects need to be removed and then the construction process needs to remedy and replace everything.

The question then arises: why does this happen? All concrete slabs emit moisture in the form of water-vapour from the surface. If the volume of moisture exceeds the dissipation ability of the floorcovering placed over it, moisture becomes entrapped between the slab and the flooring. In time, the volume of moisture and the chemistry of the substance will destroy the bond of the adhesive, resulting in bubbles, seam splits, curling and other physical signs that ultimately result in trip hazards, breach of sterility, and aesthetic and performance loss.

The type of floor specified needs to be hygienic and impervious to water to prevent any seeping below the floorcovering. It may be advisable to treat the screed with a moisture barrier to prevent any moisture trapped in the slab from reaching the floorcovering and effecting the adhesive bond. The moisture originates from the water mixed with the concrete or cement at installation and should evaporate through the surface of the floor during the drying period before floorcovering installation. The correct evaporation rate is needed to ensure it is a well cured screed with no cracks occurring.

Changes in design and the construction of concrete and additional additives can slow down the curing rate, and all too often fast-track building programmes can contribute to the challenges associated with moisture levels which results in the subfloor not performing to expectation. To counteract this, moisture tests should be carried out, not only on the surface but also deeper down in the slab.

To manage this risk, no self-levelling compounds should be laid unless a moisture test of 40% below the slab has been carried out. Consequently, when specifying a screed, it is important to ensure that it has a good moisture barrier. Self-levelling flooring compounds provide smooth horizontal surfaces and are used to level the substrates (mainly concrete slabs) before floorcoverings are applied.

Furthermore, the level of the floor adds to its safety, as indentations that occur as a result of an uneven floor can pose risks to both staff and clients. Simply put, the chosen screed should result in a surface that is level and smooth.

The only way to address the problems mentioned is to be proactive in the specification process and to understand the time lines, the environmental conditions, and to have a plan to remediate the moisture condition prior to floorcovering installations should test results come back high or unsafe. If the level is low, the allocated funds will need to be spent.

Other factors that need to be taken into consideration is interior temperature, relative humidity, and pressure control at the beginning of the project. Indoor air quality also plays a critical role as it affects moisture levels which, if too high, facilitate the growth of mould and fungi.

Anti-slip Treatments

The safety of staff and visitors in healthcare facilities is an important topic to consider when specifying floors that function efficiently in this unique environment. Even though the facilities in a healthcare environment are designed for the treatment and wellbeing of its patients, staff and visitors, the question remains, are these facilities indeed safe?

A clear systematic approach should be taken in order to provide a complete care solution. There are several anti-slip treatments, non-slip coatings and multi-use slip prevention products available, designed specifically to prevent slips and falls. For prevention of slips and falls, it is paramount to understand how these types of accidents occur as well as how to put procedures in place so that they do not re-occur and also to understand that you require sustained slip resistance and to know the ratings for both wet and dry slip tests to ensure you get the right solution for your requirement.

With the wide range of products available today, there really should be no excuse for slippery floors. However, these treatments and coatings cannot be effective on floors that are wet, albeit as a result of poor maintenance practices or a buildup of moisture levels.

Proper maintenance practices, the reduction of moisture levels and good anti-slip treatments and/or coatings will directly impact the safety of everyone in a healthcare facility, be it a hospital, clinic or care facilities.

When discussing healthcare and safety, it becomes evident that all of the above needs to be viewed comprehensively and holistically. None of the points can be isolated or viewed separately, as each one has an effect on the other. Hygiene can be affected by moisture levels, moisture levels can affect contamination and safety, and in the end all of these combined determine whether a flooring installation is successful with regards to ensuring the health and safety of patients of those that inhabit a healthcare facility.

Acknowledgement and thanks go to the following for the information contained in this article: www.interiorsandsources.com; http://facilitymanagement.com; Floors International SA; FloorworX; Polyflor SA; www.protectiveindustrialpolymers.com; www.mcdmag.com; http://www.cebhc.co.za/ and http://www.elsevier.com.