Cleanliness and Controlling Infection

Healthcare acquired infections (HAIs) affect an estimated 2 million people in the U.S. each year, and an estimated 99,000 lives are lost, resulting in healthcare costs of nearly $20 billion a year.¹⁵

Although some types of HAI are declining, new strains of antibiotic-resistant bacteria are causing infections that are more difficult to cure. In 2015, hospitals experienced reimbursement reductions—about $330 million—for infection rates that exceed federal standards.

There is general consensus and increasing evidence that the design of the built environment plays an important role in preventing HAIs in healthcare facilities. As with other aspects of patient safety, much of the effort to reduce infection centers on protocols and process. Preventing HAIs involves procedures as well understood as hand washing and as high-tech as hydrogen peroxide vapor systems and UV light systems on wheels. But flooring materials are a major component in every healthcare space. Older flooring materials like carpet can absorb moisture and are difficult to disinfect. Older vinyl, vinyl composition tile (VCT), and linoleum floors require continuous applications of finish to clean, disinfect, and preserve the floor.

New types of resilient flooring eliminate the need for field-applied polishes and finishes, and these surfaces support an effective cleaning regimen requiring less labor and minimal chemicals. Dirt tends to stay on top of dense materials like rubber and does not permeate the material, so it is easier to keep clean and disinfected. Safety flooring that contains antimicrobial agents, including products that have been independently tested for the ability to inhibit the growth of MRSA, is particularly important on flooring that might be wet or exposed to fluids. Vulcanized rubber flooring with heat-welded seams is ideal for sterile applications, such as operating rooms.

The Healing Effect of Beauty and Comfort

The patient experience has garnered much attention in recent research, particularly since ACA tied reimbursements and incentives to patient experience as measured by HCAHPS scores. Providers are also reacting to the rapidly evolving ease of comparing, reviewing, and discussing hospitals and other facilities online as patients research their options when planning elective procedures or hospital stays. Failure to meet the patient's expectations now directly impacts the provider's bottom line.

Multiple studies over the years have confirmed that the healing effect of beauty in the physical environment is a result of many factors, from the layout of the room to the artwork on the walls. A Cornell University study¹⁶ assessed one aspect of the relationship between the physical attractiveness of outpatient facilities on patients' perceived quality of care, noting, “In no other type of facility has design been shown, through systematic research, to have such a significant effect on outcomes considered essential to the long-term survival and performance of the organization.”

The study collected data from 750 patients in six outpatient practices where the facilities varied significantly in physical attractiveness. The results showed that patients' perceived quality of care was higher in more attractive rooms, and their perceived waiting times were shorter than the actual times. Their ratings on the quality of their interaction with staff—considered the most important factor influencing the perception of quality of care—were also consistently higher in more attractive settings.

As previously discussed, floors can help reduce stress, provide comfort, and improve sleep by reducing noise. The aesthetic value of attractive flooring can also evoke positive psychological perception. Resilient flooring is available in a wide range of colors, patterns, and textures, and can be custom designed with high-definition printing and embossing technology and computer-aided water-jet cutting. Different textures and surfaces of resilient flooring can be used for transitions between spaces while still being a part of a comprehensive design.

For example, the importance of a happy, welcoming, colorful environment is a high priority at St. Vincent Children's Hospital in Indianapolis, Indiana. This is reflected in their installation of recycled rubber flooring in vibrant patterns in the lobby area, emergency department, and corridor. The look is kid-friendly. The floor has the required performance requirements of resistance; but, just as importantly, it has an inviting quality intended to make every patient entering the facility feel comfortable and at ease.

In spaces especially designed for people with reduced acuity due to age, disease, or injury, wayfinding is critical. Returning veterans, young people with special needs, and a large aging population can all be helped when design and materials are used carefully to define the physical environment. In these spaces, flooring like recycled rubber or no-wax sheet vinyl with many available colors, patterns, and textures can be used to create pathways, environmental cues, and “decision” points.

Often high-gloss flooring finishes are not the best choice. This can be surprising, since in the past, shiny floors were often considered to be a sign of cleanliness. In reality, glare can be a significant stressor and a constant visual annoyance that is tiring for patients and staff. The Facility Guidelines Institute's Guidelines for Design & Construction of Healthcare Facilities recommend that highly polished flooring or flooring finishes that create glare should be avoided.

Flooring selection also directly affects the creation of a positive healing environment by supporting healthy indoor air quality. Hospitals go to great effort and expense to create a healing environment that is protected from outside pollutants, allergens, and toxic chemicals. Sophisticated filtration and state-of-the-art HVAC systems are the first line of defense. At the same time, products used within the space, from equipment to finishes, can also release harmful substances.

Chemicals used in cleaning are a particular challenge in healthcare settings, where patients are especially vulnerable and may have compromised immune systems, allergies, or sensitivities to certain odors. Cleaning can be very disruptive for the staff and patients. Eliminating the strip/wax/buff maintenance cycle eliminates chemical fumes and also lowers operation costs.

Rubber floors are dense and dimensionally stable, so they can be kept clean without finishes, coatings, or waxes to seal the surface. Advanced vinyl products are manufactured with high-performance flooring surfaces that eliminate the need for harsh chemicals and disruptive processes.

The adhesives used when installing a floor also affect indoor air quality. For example, two-part urethane or epoxy adhesives with a long curing time are often used to prevent indentations in soft vinyl and linoleum flooring. Some manufacturers offer a solvent-free one-part urethane adhesive that meets stringent zero-VOC standards and other benefits, such as very low odor, improved tack properties for easier application, and flat, concealed seams for easy cleaning and disinfecting. An impact-resistant bond with high peel strength makes it a good addition to behavioral health settings or other units requiring extra safety measures. The adhesive is moisture-cured and permanently elastic, providing excellent adhesion to elastomers, concrete, and wood.

All floorcovering, adhesives, and sealants in healthcare settings should meet the stringent VOC standards of the Collaborative for High Performance Schools (CHPS) criteria, as described in the State of California's Department of Health Services Standard Practice. Products should also meet USGBC LEED for the Building Design and Construction-Healthcare standards (LEED, 2014), and contribute to points for low-emitting materials under the Indoor Environmental Quality category. All cleaning products specified should met Green Seal GS-37 and GS-40 standards (Green Seal, 2011).

Resilient flooring that meets high environmental standards throughout the entire manufacturing process, including raw material supplies, is available. Flooring products that are manufactured by companies committed to sustainable materials and processes, and that meet the evidence-based criteria in this course, are likely to contribute to points in all LEED versions under two categories: Material & Resources dealing with conservation, purchasing and waste management, and Indoor Environmental Quality, which includes conditions inside a building, such as air quality, lighting, thermal conditions, ergonomics, acoustics, and their effect on occupants. Manufacturers should provide detailed support in the use of their products to help achieve LEED certification.

Types of Resilient Flooring for Different Applications

As discussed, resilient flooring meets the increasingly exacting standards of performance required in healthcare settings. But the range of resilient flooring products available is extremely wide, offering different performance profiles for different applications.

There are three basic categories of resilient flooring that are effective in healthcare settings:

► Rubber (both flooring and underlayments), including vulcanized rubber and recycled rubber

► No-wax vinyl, including homogenous (solid) and heterogeneous (composed of more than one layer). This includes new solid vinyl tile (sometimes called “luxury vinyl tile” or LVT) and decorative solid vinyl tile (SVT)

► Safety flooring

Although most of these flooring types have been used for decades, recently new technologies are significantly expanding the options.

Each category has different strengths. The following is a summary of some common applications and recent innovations.

Rubber Flooring

Vulcanized rubber sheet flooring with heat welded seams is the only rubber flooring product suitable for a sterile environment or an area where bodily fluids might be present, including operating rooms, laboratories, and procedure rooms. Vulcanized rubber is not porous and does not have seams, so dirt and germs cannot penetrate the floor.

Vulcanized rubber tiles, on the other hand, are suitable for most non-sterile areas, and are often used in lobbies, waiting rooms, and stair treads.

Recycled rubber is an extremely sustainable product that also provides specific acoustic, ergonomic, and fall protection benefits. Some manufacturers create unique performance surfacing from reclaimed waste, such as tires and post-industrial and post-consumer waste. Solid recycled floors are available in a virtually limitless range of colors and patterns and can be custom designed and cut.

The most advanced recycled rubber surfaces offer force reduction, energy return, durability, and sustainability. They can typically be recycled at the end of use and made into new flooring. Available in sheets or tiles, recycled rubber flooring can be selected for virtually any non-sterile area. The inherent sound-reducing quality of rubber helps to minimize the sound of footfalls, making it the preferred choice for large public areas like lobbies, waiting rooms, hallways, and cafeterias. Its ergonomic properties make it effective in all areas where staff is standing for long periods.

Specialized recycled rubber flooring (along with some vinyl products) is often specified for technical medical spaces, such as server and other computer rooms, imaging rooms or diagnostic centers, because it protects sensitive equipment from damage caused by electrostatic discharge.

Acoustic underlayments composed of recycled rubber can be used with other types of floors to provide sound dampening and cushioning. Recycled rubber is also an essential layer in the combination floors discussed in this course, where a no-wax vinyl flooring surface is fused to a recycled rubber backing.

No-Wax Vinyl Flooring with PUR Coatings

Traditional vinyl, used in many institutional buildings and hospitals in the past, came in a wide range of color and thicknesses and had the basic attraction of low cost. Otherwise, it was not the most effective and sustainable product—a hard, unforgiving surface, reverberating all sounds, and requiring frequent labor-intensive waxing and maintenance with harsh chemicals. The high maintenance required was disruptive to patient care areas and overall workflow, and introduced odors that worked against the indoor air quality required in healthcare settings.

New technologies and product development utilize certified greener manufacturing, eliminate harmful substances, and use recycled and recyclable components.

Perhaps the most significant development is PUR, a UV-cured polyurethane reinforcement coating now available for a wide range of vinyl floors and flooring surfaces, including no-wax sheet vinyl and safety floors. The very low-VOC coating is applied during manufacturing. Its properties facilitate soil release and preserve appearance. Other coatings incorporate aluminum oxide particles, a mineral with exceptional hardness, to further increase resistance to scratches and abrasion.

The dramatic reduction of maintenance also saves energy, chemical usage, water consumption, and the disposal of caustic stripping solutions during re-coating.

Solid sheet vinyl flooring with heat-welded seams is used in sterile areas, such as operating rooms. Sheets are used because the seams between tiles are difficult to keep sterilized.

Two product categories in particular are experiencing rapid growth in healthcare settings:

Solid vinyl tile, particularly luxury vinyl tile (LVT), is the fastest growing product category in the commercial flooring industry. Originally designed for the retail market and residential application, these products are now readily specified in all commercial market segments. Ease of installation, ease of replacement, and design flexibility have driven this growth.

LVT today utilizes new high-definition printing and embossing to create vinyl flooring that closely mimics the look of natural wood, stone, metal, fabric, and other designs. As facilities work to increase patient satisfaction, the look of natural materials is highly desirable, but few of them offer the ergonomic and acoustic characteristics of resilient surfaces. They are also difficult to clean and maintain in healthcare settings. High-performance LVT adds a wide range of new options.