Identifying and exploring 9 factors that should be considered when specifying for healthcare facilities.

Before specifying flooring for healthcare facilities, there are several aspects that need to be thoroughly explored. Healthcare environments are unique and as such have stringent requirements – all the more so when it comes to their flooring. There are several floor types ideally suited to these facilities, which is why the continuous innovations in this area, be it technological or aesthetic, make it exciting to monitor as a source of inspiration for future installations.

1.    Acoustics
Sound affects individuals on a physiological and psychological level, which is why unwanted noise can increase blood pressure, heart rate, respiration rate and blood cholesterol levels.

The World Health Organization (WHO) recommends that the average sound level in general hospital and healthcare areas should not exceed 30 dB(A) for daytime levels or 35 dB(A) as the upper limit for daytime sound levels. However research indicates that it is not uncommon for measurements of 65-83 dB to be found in intensive care units. In the market today there are flooring options available with acoustic solutions that achieve an impact sound reduction of up to 20dB.

Several floor types are considered ideal for healthcare environments, from vinyl to hardwood flooring. Advancements in technology has led to these floor types being able to offer very specialised services with regards to acoustics, maintenance, hygiene etc. Before making a decision, it’s advisable to speak with your flooring supplier to find out everything you need to know and to ensure your flooring choice matches each of the space’s numerous needs.

2.    Colour and demarcation
The quality of the visual environment can have a positive or negative effect on the occupant’s feeling of wellbeing and in hospitals and healthcare buildings, this can affect staff performance and patient recovery.

The cost of hospital staff and patient treatment is considerable; therefore, measures to maximise performance as well as healing through improved environments will generally be cost-effective. For these reasons, it is essential to consider colour design at the early stages of specifying, renovating and/or designing a building. Only then can a truly integrated approach to the visual environment be pursued.

As noted above, the colour and pattern of the floor should be carefully considered during the design stage, as they can provide healthcare facilities with both practical and aesthetic benefits.

A bright, interesting and attractive interior that does not feel ‘institutional’ can help to create a calming environment that ultimately helps the healing process by reducing the patient’s stress levels. Even though warm, neutral colours can create a comfortable and cosy environment, a splash of colour here-and-there can add a sense of ‘fun’ to an otherwise serious setting.

Colours can also be used for functional purposes, by designating different zones and by creating navigational signage that helps patients find their way around the building and also assists staff in moving around the hospital complex via the most efficient routes.

Simply put, when selecting your choice of colour, the end goal is to create a space that is functional but doesn’t feel cold or clinical, and perhaps this is easier said than done, however as a designer it’s critical to keep the needs of the patient in mind while balancing it with the needs of the facility.

3.    Hygiene and air quality
According to WHO guidelines for indoor air quality, indoor air pollution plays a significant role in the general state of health of people who spend a considerable amount of time indoors.

Hospitals and healthcare facilities, therefore, have a particular duty to protect patients, staff and visitors, from air pollution, bio particles and airborne infection; especially when the WHO identifies children, elderly people and other vulnerable groups as being particularly at risk from biological and chemical indoor pollutants.

The choice of flooring in the hospital environment can play a vital role in improving patient healthcare and, similar to colour, good air quality can assist in ensuring the psychological and physical wellbeing of inhabitants.

With healthcare and facilities managers understanding the importance of improving Indoor Air Quality (IAQ), specifying flooring with low Volatile Organic Compounds (VOC) emissions to meet current standards is a priority. VOCs are used in most products and are a large group of carbon-based chemicals that easily evaporate at room temperature into the air we breathe, the implications on patient healthcare being of potential concern. It is, therefore, imperative that any flooring specified has a low VOC emissions rate.

When it comes to hygiene, specifiers need to consider flooring that can withstand thorough, daily cleaning with specific chemicals to disinfect the area. However, The Centre for Disease Control & Prevention (CDC) in America states: “Studies have demonstrated that disinfection of floors offers no advantage over regular detergent/water cleaning and has minimal or no impact on the occurrence of healthcare acquired infections.”

Their studies go on to show that large surfaces such as floors and walls have not been directly associated in the spread of staph and methicillin-resistant Staphylococcus aureus (MRSA), but should these surfaces be exposed to such infections, two commonly used disinfectants namely sodium hypochlorite and quaternary ammonium salts, would be effective in containing such infections.

There are flooring products on the market that boast wonderful anti-microbial properties, which is also a factor to consider when it comes to hygiene.

Most flooring options for healthcare environments are unique in that they are comprised of materials that are resistant to fungus and mould, or their composition is such that they are made to be exposed to daily chemical use, for example. Once again, it’s critical to know what your floor has to offer you before selecting it as your final choice.

4.    Traffic and Durability
Hospitals are exposed to heavy traffic, whether it is a daily influx of foot traffic or the wheeling of carts or beds in and out of surgical rooms. For this reason, the selected flooring has to be extremely durable and offer excellent flexibility. Flooring that does not require wax or polish for life is ideal for high-traffic areas since these areas typically require more intensive and frequent cleaning.

Over a 10-year period, only around 10% of the cost incurred in the specification of flooring is the cost of the flooring product itself. The majority of the expense comes from the labour, energy, water and cleaning materials required for maintenance. Manufacturers offering easy low-cost maintenance flooring ultimately provide significant cost and time benefits. By installing a floor with advanced coatings at a higher initial cost, money can be saved in the long term by avoiding complex maintenance regimes, frequent repairs and early refurbishments as well as any compensation costs that stem from the inevitable organisational disruption of fixing a faulty finish. Instead the facility’s floor budget can divide the cost of a more expensive but long-lasting floor into many years of reliable service.

With the right manufacturer it is reasonable to expect flooring in a heavy traffic healthcare environment to maintain its appearance and properties well over a decade after application.

5.    Maintenance
There are several factors that need to be considered; ease of maintenance, speed of maintenance and the cost implications of a maintenance routine. To ensure that any floor lasts for the duration it was intended for, a suitable maintenance regime for that specific floor needs to be implemented and followed. This will inevitably minimise costs as it will dramatically delay the need for any refurbishments or replacements ion the short-term.

Any maintenance plan needs to be quick and easy to follow. A healthcare environment is usually a busy space and as such, time can’t be wasted on waiting for cleaning duties to happen, not to mention the increased risks that arise from waiting for wet floors to dry, which could increase the possibility of slips and falls.

Certain flooring products, as mentioned before, are comprised of technologically advanced materials which make them conducive to specific cleaning agents. It’s important to follow the maintenance programme specified by the specific flooring’s manufacturer to avoid damaging the floor, which contributes to additional unforeseen costs which could have been avoided.

The time, effort and money it takes to care for a floor are not only worthwhile, but a must! The investment results in a floor that performs to expectation, which is critical, both from a functional and aesthetic point of view.

6.    Sustainability
Key concepts of sustainability and ‘green’ practises are being incorporated into flooring specifications and have become key decision making factors in determining the type of flooring to be installed in healthcare environments. While much of sustainability focuses on the carbon footprint of material, this emphasis tends to undervalue another vital aspect of sustainability; namely toxic and hazardous chemical compounds contained in the flooring itself, in associated materials and used during installation.

The potential for hazardous emissions of chemicals and their effect on indoor air quality are a key concern and should be a major factor in any flooring decision. While parts of the sustainability criteria focus on hazardous chemicals in the material itself, installation practises and associated compounds (glues etc.) can also have an impact on the final overall quality.

It is also important to investigate production specifications within each category of flooring material. The quality standards of each material can vary considerably between flooring manufacturers. In addition, differences in the coatings applied to the same flooring material may result in very different performance and chemical emissions.

Volatile Organic Compounds (VOCs) are one of the main substances to be aware of as they are a popular construction ingredient and yet exposure to these can constitute a significant health risk. To safeguard the air quality, floor products should be low-VOC emitting, non-toxic and chemically inert.

Furthermore, consideration of the environmental impact of disposal at the end of the useful life of the flooring can influence the choice, with some materials being inherently more difficult and hazardous to deal with. Decision makers in healthcare environments need to look for the right balance between reasonable installation and maintenance costs and low environmental impact, including low toxicity.

7.    Safety
Floor sanitation is not the only health and safety factor that needs to be considered when specifying flooring, as many aspects of the floor can influence the likelihood of slips, trips and falls.

Most in-patient falls result from a confluence of factors that include intrinsic factors such as patient age and types of medications administered to the patient, as well as extrinsic or environmental factors such as glare, clutter and spills that are not properly addressed by maintenance staff. Flooring decisions can help to mitigate several environmental factors associated with in-patient fall rates.

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 project.

Floor finishes that enhance traction underfoot can be used in areas likely to be wet or slippery. Healthcare sites can incorporate anti-slip aggregates into resin floor systems to provide extra grip underfoot. In areas where still water is likely to be present during normal daily operations and where standard footwear is being worn it is advisable to install a friction filled non-profiled material with macro-roughness (roughness comprising an aggregate).

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 build-up of moisture levels. Proper maintenance practices are a must in any healthcare environment, which requires a proper cleaning schedule and the availability of staff to quickly and efficiently clean spills as they happen.

8.    Staff requirements
Heel spurs (plantar fasciitis) are a repetitive stress injury caused by repeated impact of the foot against a surface. It is a common lower extremity injury suffered by bedside care providers. Nurses with heel spurs may have difficulty walking to a patient’s bedside and delivering optimal care.

Specifying flooring with anti-fatigue properties can help to prevent and minimise repetitive stress injuries. An anti-fatigue surface dissipates foot pressure whereas a surface lacking anti-fatigue properties does not absorb energy, putting greater pressure on feet.

A study carried out by Redfern and Cham in 2001 stated the following: “Investigations of the influence of flooring characteristics on discomfort suggests that elasticity, stiffness and thickness play roles,” in the effect of flooring on the musculoskeletal systems of healthcare workers (be it good or bad).

Taking the needs of staff into consideration is crucial, as it affects their ability to carry out their job successfully, failing which can result in long-term cost implications if said staff have to take longer periods of sick leave more frequently.

9.    Lifespan
Several factors influence the specified floorings lifespan; from cleaning and maintenance, traffic and durability to material construction. To optimise its lifespan, all the above factors should be considered and ideally implemented, as each of these ultimately affect the installed floor’s ability to withstand very unique conditions specific to the healthcare environment.

The specified floor will be deemed a failure if it starts to fade or deteriorate or has to be replaced long before it has served its purpose. Each of these nine considerations are therefore critical to the success of a flooring installation.

A healthcare setting has very stringent requirements and as such requires flooring that performs well beyond expectation, but just because the environment may be considered clinical, does not mean that the installation has to follow suit. In fact, healthcare settings should encourage specifiers to introduce a bit of flair and warmth to counteract the stereotypical idea of such a facility, turning it into a welcoming environment that encourages healing.

Acknowledgement and thanks go to the following for the information contained in this article: FloorworX; Polyflor SA; http://www.buildingbetterhealthcare.co.uk/; http://www.jjflooringgroup.com; https://www.linkedin.com/pulse/flooring-specification-considerations; http://www.wales.nhs.uk; http://www.natureplus.org; http://www.ergoworld.com/pdf/slipstripshealthcare.pdf; http://mcmorrowreports.com