Creating Safer Spaces in Healthcare

Impacts, performance, and outcomes of rubber flooring
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Sponsored by nora systems, Inc.

Patient Perception, HCAHPS, and TPS

In the HCAHPS survey, question #8 asks, “During the hospital stay, how often was your room and bathroom kept clean?” The patient’s perception of cleanliness has an important impact on a facility’s TPS, and thus on payments.

The dimensional stability and resilience of rubber does not trap dirt or bacteria in specific rubber products. Rubber has an inherent resistance to bacteria and fungi without any chemicals or additives. Rubber allows for non-welded seams, as they contribute to a more hygienic environment, with the exception of the OR. The Centers for Disease Control (CDC) survey, based on a large sample of U.S. acute-care hospitals, found that one in 25 hospital patients had at least one HAI. There were an estimated 722,000 HAIs in the United States in 2011. About 75,000 hospital patients with HAIs died during their hospitalizations. A separate CDC study of medical costs estimates that the overall annual direct medical costs of HAI to U.S. hospitals ranges from $35.7 billion to $45

HAIs, along with falls and 30-day readmit, are non-reimbursable “never events” (also called “sentinel events”): events that should never happen. Their occurrence has direct impact on the facility’s bottom line. Although there is no existing evidence that links flooring to HAIs, the use of carpet in patient areas is perhaps its most controversial consideration. A number of studies establish the role of carpet as a reservoir for fungi and bacteria.vii One study proposes that new carpeting becomes contaminated very quickly, and the effect of cleaning carpet is transient—bacterial levels soon return to pre-cleaning levels.viii Moreover, bacterial contamination increases with higher levels of activity, and soiled carpet that is damp or wet provides the ideal setting for bacteria to proliferate. Wet carpets are a slip/trip/fall hazard and can propagate microorganism growth.ix

Regarding infection control, the FGI SRA recommendations on infection prevention include: “Select interior finish materials for patient care areas, especially high touch surfaces (e.g., floor, wall, ceiling, furniture covering, door handles) that are easy to clean, disinfect, and maintain or contain antibacterial characteristics in order to minimize the risk of surface contamination. Research shows that the contamination of environmental surfaces may serve as a link in the chain of infection transmission. Certain surface materials have been reported to be easier to clean, disinfect, and maintain and are associated with lower risk of contamination.”x

As noted above, there are specific rubber flooring products that do not act as media to micro-organisms, meaning these products do not encourage or produce bacteria. Relevant standards include:
    • ASTM E 2180: Standard Test Method for Determining the Activity of Incorporated Antimicrobial Agent(s) in Polymeric or Hydrophobic Materials
    • ASTM G 21: Standard Practice for Determining Resistance of Synthetic Polymeric Material to Fungi

Rubber flooring products should not contain any of the 15 antimicrobial chemicals and elements as additives that leading healthcare organization Kaiser Permanente has recently banned as additives to fabrics, furnishings, and finishes in its building projectsxi:
    • Benzisothiazolin 3-one
    • Didecyldimethylammonium chloride (DDAC)
    • Diiodomethyl p-tolyl sulfone
    • Hexamethylenetetramine
    • Kathon 886 (CIT/MIT mixture)
    • Methylchloroisothiazolinone (CIT, CMIT)
    • Methylisothiazolinone (MIT)
    • N-octadecyldimethyl [3-(trimethyoxsilyl) propyl] ammonium chloride
    • Silver (nano)
    • Silver sodium hydrogen zirconium phosphate
    • Silver zinc zeolites
    • Triclosan
    • Zinc pyrithione
    • 4,4-dimethyloxazolodine
    • Quaternary ammonium compounds, benzyl-C8-16-alkyldimethyl, chlorides

Creating Safer Spaces

Falls have been identified by CMS as an event that is preventable and should never occur. Yet falls are the most common adverse event reported in hospitals. Reviews of observational studies in acute care hospitals show that fall rates range from 1.3 to 8.9 falls per 1,000 patient days. Between 30 to 35 percent of patients who fall sustain an injury. Each of these injuries, on average, adds on 6.3 days to the hospital stay, and the cost for a fall with injury is about $14,056. (Joint Commission Prevent Falls Project). A single nurse fall is estimated to cost a hospital approximately $33,000. Rubber flooring cannot provide a measurable effect, but it can have an actionable impact on slips/trips/falls (STF).

Baystate Medical Center/Baystate Health, Springfield, Massachusetts

Photo courtesy of nora systems, Inc.

Baystate Medical Center/Baystate Health, Springfield, Massachusetts

“Staff members really like the flooring because it has a little bit of cushion to it,” says Stanley Hunter, project executive at Baystate Medical Center.

Falls in healthcare have far-reaching negative impacts on the patient’s recovery and quality of life, but also on the bottom line of the hospital, and because costs associated with the treatment of a fall are no longer reimbursable. CMS has identified 14 categories for HACs (the complete list is available at “Falls and trauma” is the category on the list that can be directly attributed to flooring.

Flooring-Related Issues Impacting Fall Protection

For healthcare applications, the following issues are paramount to understand when evaluating specific flooring products to create safer spaces; these include the floor material, the floor finish, type of maintenance, and the coefficient of friction. Other factors include the ageing eye, change in height due to floor transitions, and floor pattern (color value, light reflectance value, glare, and the texture of the surface). Flooring selection must weigh these factors of fall prevention against closely related priorities, such as preventing staff fatigue (which has been shown to contribute to slips, trips, and falls) and enabling heavy equipment to be moved safely and efficiently.

Slip Resistance

Coefficient of Friction (COF) is the ratio between the tangential force needed to start or maintain uniform relative motion between two contacting surfaces and the perpendicular force holding them in contact. COF is often considered the only relevant component of slip resistance, but multiple factors contribute to the slip resistance of a floor, and even COF can be complicated to measure effectively.

The option considered most useful for comparing the COF of resilient flooring is to test using a modified version of ASTM D2047 without polish (unless the flooring requires it) and using a dry neolite (material of most of today’s shoe soles) sensor. This test method is currently being developed by the ASTM F06 committee. Most resilient flooring manufacturers already use this method and publish the values. The flooring manufacturer should provide testing reports, including the test method and the machine and sensors used, and if possible testing information on pre-aged samples of the product that will indicate long-term performance.


The average age of the typical inpatient population is 65; a caregiver’s average age is 55. Glare can alter cognitive perception, and visual acuity with the ageing eye can be a trip hazard. “Shiny” does not equal clean. By correcting this frequent misperception, a non-glare, finish-free product installation will impact HCAHPS scores not only for noise, indoor air quality, and cleanability, but also for safety related to mobility. The SRA recommendation to “Design to minimize glare on floor (e.g., flooring material, lighting, windows)” cites research demonstrating a number of reasons why shiny floors contribute to falls. When a surface is perceived as slippery, patients may change their step length, walking speed, or the surface contact.xii

Light Reflectance Value

Light reflectance value (LRV) has variables as it relates to lighting, daylighting, and flooring color. Gloss Value is measured by an instrument at different angles and is not related to color. If a flooring material requires a finish, this often results in high gloss due to layers of wax, and impairment and visual acuity become a concern.xiii


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Originally published in Architectural Record