Floorcoverings as a safety factor ... and more.

A manufacturer-financed design council is researching all the implications of an environmental change

The contribution of the physical environment to patient satisfaction, medical outcomes and safety is being investigated by leading healthcare and design researchers. To illustrate some of the issues involved, the evaluation of appropriate floorcoverings for patient and resident rooms points out the role flooring can play in creating a therapeutic setting, in supporting health and safety and in contributing to the health of the provider's bottom line.

Is this a big issue? It is indeed. Beyond the obvious factors of code compliance, room temperature and size, sufficient power supply and an efficient layout of furniture and equipment, room design can have a profound impact on the behavior of the patient, the visitors and the staff. The room also says a lot about the organization providing the care. Most patients cannot accurately evaluate the medications they receive, or the professional care provided, but most people can immediately tell if their rooms look institutional, smell of urine, have harsh echoes or look dirty. We are not talking about design "style." We are talking about the role of the facility, in this case the patient room, in reinforcing the strategic goals of an institution's healthcare program.

With budget constraints creating serious problems in healthcare, it is easy to understand why so many owners and facility managers focus on first-cost and maintenance costs when deciding on products and materials for resident rooms. Cost is obviously very important - but getting the right solution must come first. Once this is done, then the issue of getting the right solution for the most reasonable cost is the appropriate goal.

A safe physical environment is not optional. In healthcare facilities, slip-fall accidents are a major concern and deserve our full attention. Anyone involved in the process of designing, constructing, maintaining or operating a facility will be interested in some recent research relating to a more holistic approach toward safety in healthcare settings.

One research goal has been to learn whether a specific floorcovering in a nursing home is more prone to promote slip-fall accidents than another. Extrinsic factors, such as a slippery or wet surface, extension cords running across a floor, or protruding transition strips where hard and soft flooring meet, can all cause a person to fall and should obviously be minimized or eliminated. The reason for a fall could be intrinsic, however, perhaps caused by a resident's medication, disorientation, spontaneous fracture of a bone or a host of other factors that could cause a resident to fall anyway, no matter what the floorcovering. Therefore, if we cannot eliminate all falls, perhaps it is better to focus attention on flooring that absorbs the impact of falls, so that when they do occur, they are likely to do significantly less harm.

For healthcare facility owners and design professionals, there is so much technical information available that it is often difficult to understand how to apply what you need when you need it. Also, much of the information relating to safety is in engineering or biomechanical terms. How is an owner or designer to use coefficient-of-friction data for responsible decision making when specifying flooring, interior design and planning options?

However, safety evaluation is both a science and an art, and this is where the art comes in. The art of creating a safer environment requires a comprehensive balance of many contributing factors, including floor materials, color, texture, contrast, illumination, acoustics and maintenance. These can support residents, or they can produce potentially hazardous situations. Take, for example, disorientation. For the elderly resident, disorientation is often caused or exacerbated by "environmental noise" - in this sense, defined as acoustical noise, visual noise, glare, optical illusions caused by colors or patterns, etc.

Interior designers are professionally trained to understand the use of design elements, colors, planning and spatial relations as they apply to facility design, but what is further needed in healthcare is additional training and experience in socio-physical design - the relationship between physical environment and human behavior. It is time to start forging the missing link.

A group of professionals, including representatives from interior design, research, architecture, facility management and nursing, have joined together under the name of The Healthcare Design Council, specifically organized by the flooring manufacturer Collins & Aikman, to look at the interaction of science, art and common sense as they relate to healthcare facility design. This group is interdisciplinary and comprehensive; they understand the technical and statistical data that environmental scientists are developing and are very familiar with the design process, materials, products and code issues involved in creating quality healthcare facilities.

Unlike many academic groups conducting scientific research, the Council is committed to developing practical, applied knowledge, directed toward decision makers involved in healthcare operations, design and planning.

For example, at the request of several long-term care facilities in the Northeast, the Council is helping owners evaluate floorcovering options - with both the initial goal of improving safety and the more far-reaching goal of improving resident quality of life. Their challenge was not to find the cheapest, easiest to maintain, or "prettiest" floorcovering, although each of these criteria is important. Their mandate was to work with residents, family members and staff to understand how the environment impacts safety and comfort, and then create a series of recommendations to maximize the benefits of the physical environment to all who live in it.

Our investigation has been operational for only a few months, but we are already identifying significant factors pertaining to floorcovering type that contribute to improved comfort and safety:

Cleanliness 

Enough studies have been done to illustrate that, no matter which floor type or brand is used, thorough maintenance is a must. Both hard and soft surfaces can be thoroughly and economically maintained. The studies we have seen suggest, however, that maintenance of soft flooring is less costly in both dollars and time.

Risk

Residents on units with hard floors sometimes say they do not venture down the hall because it is "too risky." They fear slipping on recently washed or waxed floors, get confused by the glare reflecting from shiny tiles and find the acoustical noise level disorienting. When these same residents are in a soft-floor unit, they report feeling more confident. They believe the floor will help cushion any falls and are, therefore, motivated to be more mobile and social.

Staff members, too, tend to become less fatigued on soft flooring. In one nursing home, insurance claims and incidents of staff complaints of lower back injury are lower than those of comparable facilities in their region. Their insurance company suspects this might have something to do with the soft flooring used throughout this facility, because it provides the necessary traction for better leverage when staff transfer patients from beds to wheelchairs.

The Council's plan is to research this observation further. If soft flooring is a contributing factor to increased staff safety, this would be a significant finding.

Disruption

To most maintenance, environmental services and housekeeping staff, a corridor on a resident floor is a floor to be cleaned. To residents, the corridor is their "main street." Residents object to the obstacle course of mops, waxing machines, extension cords, those "little yellow people holding hands" to keep you from walking on the wet floors, and the constant smell of disinfectant. The noise and disruption caused in most facilities by well-meaning cleaning crews discourages residents from leaving the security of their private rooms and interacting with their neighbors.

In facilities with soft flooring, maintenance techniques and technology are typically perceived as being more residential in scale, and thus significantly less intrusive.

Odor 

Healthcare facilities characteristically have odor problems, often intensified by the lack of effective air handling systems. This has had serious design implications. Several years ago, many healthcare facility owners tried commercial carpeting because they valued the hospitality image that carpet offered. While the carpet did look great, reduce glare and help quiet the environment, there were at least three problems most owners identified:

1. Durability: Commercial carpet used in an office setting for 8 hours a day, 5 days a week was not designed to perform under 24-hour, 7-day-a-week abuse. The commercial carpeting seams did not hold up well. The backing collected dirt, and fluids soaked through the woven backing and penetrated the subfloor, never to be removed.

2. Maintenance: Carpet can look good with only a light vacuuming. Therefore, many environmental services departments did not budget, nor did they follow the manufacturer's directions for, thorough cleaning. Also, since many owners outsource maintenance, the cleaning crews did not always understand how to properly care for carpeting.

3 Odor: With product designed for other uses, and with maintenance less than effective because the materials simply could not be thoroughly cleaned, commercial carpeting held soil and debris, retained body fluids and spills, and trapped odors.

No wonder many owners threw out the commercial carpet and went back to the old hard tile and sheet vinyl flooring. There is, however, a new generation of specialty flooring designed for healthcare settings. It includes or provides for:

* continuous moisture barrier to keep subfloor from contamination

* cushioning to reduce impact of falls

* durability

* density appropriate for easy mobility of wheelchairs, heavy carts and equipment

* slip-resistant, yet not difficult for mobility of elderly patients with walkers

* easy, economical cleaning

* absence of urine odor

* reduced ambient sound

* absence of glare

* aesthetic attractiveness

* quick repairs

* fast installation, with no adhesive odors, solvents or long waits

The Council's research projects in the Northeast involve a series of nursing homes where the directors have chosen to replace their hard tile and sheet vinyl resident room floorcoverings with a 70% cushioned sheet vinyl floorcovering that has a 30% soft carpet-like surface, marketed by Collins & Aikman. Though the original intent was to improve safety, we are rapidly discovering that, in addition to improved safety, the improved environment might contribute significantly to an enhanced quality of life for the residents, as well as a healthier bottom line for owners. These studies are ongoing, however, and data will be collected, analyzed and published as we complete our research.

We would be pleased to share our results with any interested parties. We also are interested in the experiences of others relative to hard and soft flooring in healthcare settings, and would welcome hearing from you.

Judith Yarme, RN, an international healthcare consultant, is the director of the Health Care Facility Research Consortium, a not-for-profit research organization specializing in design and planning issues related to healthcare facility development. For further information or to offer comments, contact Judith Yarme at [phone].