A White Paper by the American Academy of Healthcare Interior Designers: There are numerous surfaces in healthcare settings that are cleaned and disinfected multiple times a day to prevent the spread of harmful pathogens. It is noteworthy that flooring is a surface often addressed only as needed, or at the most once a day, despite the fact that it is a surface which almost everyone comes into contact. The American Academy of Healthcare Interior Designers (AAHID) published a white paper titled How Flooring Supports the Healthcare Built Environment that explores how flooring can impact patients, employees, infection prevention and the indoor environment.
Background
The Centers for Disease Control and Prevention (CDC) classifies floors as “low-touch surfaces” in the healthcare environment, which recommends that floors should be cleaned daily, but that a disinfectant is not necessary. This classification often leads to a lack of focus on flooring. Over the past several years, research has begun to inquire whether flooring plays a larger role in germ mitigation. The spread of COVID-19 has sparked research into the rate at which pathogens are transferred from flooring. In a 2020 American Journal of Infection Control and Hospital Epidemiology (AJIC) published study, COVID-19 contamination detected on hospital floors was reduced by increasing the rate of cleaning and disinfection. This change in procedure can have effects on how facilities proceed with flooring installations and the work practices used to maintain them.
Diligent cleaning and disinfection of flooring materials can both reduce infections and maintain lasting durability by preventing reduction of the product’s lifespan. In a 2017 article published in the AJIC, an effort to identify the microorganisms that populate floors in American hospitals discovered 72% of floor sites were positive for Clostridium difficile (C. difficile) and 57% of contaminated objects in contact with the floor transferred pathogens to hands. The results of this study identified pathogens that are often found to be the source of hospital-acquired infections (HAIs) that result in added cost for the facility. Hence, efficient floor cleaning and disinfection not only improves the patient experience, but also reduces surface contamination along with potential risk of HAIs and improves indoor environmental quality.
Design Considerations
Flooring must be properly installed and in good condition to allow for proper cleaning and disinfection. At a minimum, per Facility Guidelines Institute (FGI) “in spaces with high infection-control considerations, the Guidelines for Design and Construction of Hospitals requires that floor assemblies be smooth and monolithic with an integral wall base that extends up the wall a minimum of 6 inches.” A floor that is easy to maintain will be seamless and free of sharp corners, where debris can accumulate. During construction and renovations, the selection of flooring materials is based on a combination of factors such as cost, aesthetics, and functionality. Selections made can impact the cleanability and durability of flooring materials if they are not compatible with a facility’s work practices.
A facility should assess their flooring needs, using a multi-attribute approach, and taking into consideration the following evidence-based design criteria when selecting flooring materials:
- Reducing slips, trips, and falls
- Reducing patient and staff injuries associated with falls
- Reducing noise levels
- Reducing staff fatigue
- Representing best return on investment
Additional product criteria that are significant when making flooring material selection include durability, reducing glare, moisture concerns, sustainability, and ease of cleaning and maintenance. In areas where infection control is a priority, some manufacturers suggest vinyl rolls with heat welded thermal fused seams to create watertight, easy to clean surfaces. Therefore, resilient sheet goods are preferred in most healthcare settings due to the minimal seams and nonporous properties that allows for easy and efficiently cleaning and disinfection. Other flooring types commonly installed in healthcare spaces include rubber tile, homogeneous vinyl tile, and luxury vinyl tile/plank.
How to Care for Flooring
Appropriate selection of flooring materials for each healthcare environment is the first step towards managing a reliable system. The remainder of the work relies on proper installation the product, communication between designers, manufacturers, and healthcare staff, and long-term upkeep and proper maintenance. Once installed, it is ultimately the responsibility of Environmental Services (EVS) personnel to determine which products and equipment are routinely used, as well as the frequency of cleaning and disinfection. As a result of the pandemic, cleaning and disinfection has increased, while buffing and vacuuming floors without HEPA filtration has been reduced to minimize the risk of aerosolizing infectious aerosols.
Initially and when procedures change, it is highly recommended to refer to the manufacturer’s recommendations for cleaning and disinfection to ensure that incompatible products or type of equipment do not cause damage to the flooring and void the floor manufacturer’s warranty. Training may be available from the manufacturer or may be conducted in-house to provide procedures for proper work practices to ensure staff are informed. Training should cover issues surrounding proper use of equipment, dilution rates, and material compatibility.
Conclusion
Attention to flooring is a simple way to reduce the spread of pathogens and lower the rates of reported HAIs. In order to prioritize floor cleaning and disinfection, awareness of the role that floor surfaces play in the chain of infection must be heightened so that both maintenance personnel and administrators are informed on the best work practices and types of products that facilitate efficient cleaning and disinfection. As recommended in AAHID’s white paper it is essential that facilities “focus on infection prevention and control from the ground up.”
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