Trends in Acute Care: Design and flooring must address big-picture challenges in acute care settings – Oct 2023
By Jessica Chevalier
While the acute healthcare sector may be past the worst of the pandemic hurdles, it faces a collection of big-picture challenges for which there are no simple or single-source solutions. The aging of Baby Boomers continues to squeeze the healthcare system, and, paired with the current and growing nurse and staff shortage, the acute care space finds itself with more needs than hands to manage it all.
At the same time, post-Covid, hospital systems continue to analyze their use and design of space, seeking materials that address their practical needs for cleanability, acoustic mitigation and safety while also providing respite for staff, patients and their families. Designers serving the acute care sector are addressing components of these with intentional interior design that leans on finishes offering multifaceted solutions and aesthetic appeal, and it is important that manufacturers have a strong handle on the sector’s trends, so that they can build products that serve its needs now and in the future.
ACUTE CARE EVOLUTION
Jocelyn Stroupe, principal and director of health interiors for CannonDesign in Chicago, notes that in the early days of her career, “hospitals weren’t really thought about as places that needed to be designed, but the realization that a hospital is an environment for healing changed that.”
With that change, some of the nice-to-haves became have-to-haves. “We used to have to do some convincing with providers in advocating for more daylight into buildings, as well as acoustic mitigation efforts,” reports Brenda Smith, Atlanta-based health principal for HDR. “Those have become givens. Today, it’s a question of how much the budget can afford.”
Flexibility of space is an important trend that emerged from the pandemic. “A lot of facilities are creating a controlled environment for infectious diseases through their mechanical systems-creating whole wings or units that could be transformed as needed,” says Stroupe.
She views many of the physical changes occuring within the acute care space today as an exercise in rightsizing. The Facilities Guidelines Institute sets standards for the built environment of the healthcare system. However, Stroupe notes, “For years, we have seen patient rooms built much larger than they needed to be, leading to a lot of square footage that wasn’t as functional as it could be. Today, we are seeing things tighten up, and I don’t see a lot being built above the standard.”
And while some of these changes are building in flexibility in preparation for the next pandemic, Ashlee Washington, senior associate at Ankrom Moisan, which has offices in Portland and Seattle, Washington, notes that, even now, “some facilities are still seeing high census numbers. Given that, our designs are often expected to be more around stringent cleaning protocols or providing additional mechanical/electrical/plumbing (MEP) infrastructure to allow for flexibility.”
MAKING SPACE
Designers report that both the renovation and new construction sides of acute care are active at present. Some projects may call for replacement of an aged facility with a totally new one, others call for an addition of a tower, while still others may be adding room for 12 new beds to an existing wing.
Smith is aware of several expansions underway to address the pressure on emergency departments. She says, “Administrators are looking at what drives revenue-surgery, cardiology, cancer centers, orthopedics can-and seeing how they can expand specialties. It isn’t a greed thing; they are asking, ‘Can we drive enough profit in those areas to keep our ER, critical care and behavioral health departments afloat?’ These are pressing every health system and are a cost to most systems.”
On the cost side, more behavioral health space is in high demand. “I don’t know of a health system that isn’t making modifications to their ER to provide a designated pod for behavioral health or holding, maybe creating bays where anywhere from six to 20 patients can be stabilized and observed until an open bed is identified,” says Smith.
For Washington’s firm, which specializes in renovation work, there is always a need to make more of less. She notes, “The reality of most existing facilities is that there is finite space and an infinite need for additional space. Because our team specializes in renovation work, we are consistently working within existing boundaries and footprints.We are consistently seeing a need for more storage space as fewer items are stored in the room to reduce waste when unused.” Amid the pandemic, the need for easily accessible PPE grew significantly, and today, acute care designers are building solutions to that need into the physical landscape.
Hospital waiting rooms are part of the cultural landscape, but are they the best solution for patients, families or institutions? Increasingly, the answer is that there are better solutions available.
The pandemic effectively forced the closure of waiting rooms and brought to light another way of managing guests. “It opened our eyes to see that we need to deal with flow differently,” explains Smith. Amid the pandemic, patients generally waited in their car until providers were ready to address their needs, when they were contacted via phone and told the procedure for entry. This system was used to reduce the spread of the Covid virus and, of course, other viruses as well.
In this new era, smaller waiting rooms are generally being created, and technology is being used to keep patients moving through the care process and eliminate buildups of individuals.
Some systems are providing real-time monitoring online so that patients can schedule their arrival for less hectic times. This is generally employed in urgent care or emergency settings. In addition, some patients are asked to wear monitoring devices that provide the healthcare system with an overall view of how patients are processing through the care process and where back-ups are occurring. Cameras are also being employed to enable caregivers to monitor waiting areas and rooms at a glance. Using these tools, systems may be able to adjust staffing to alleviate a bottleneck.
In addition to providing less opportunity for hospital visitors to spread illness, Smith notes that sitting in a room full of patients waiting for care generates anxiety in many people, and eliminating this anxiety is beneficial to patients, their waiting loved ones and staff.
Cutting back on waiting room space allows acute care systems to dedicate more square footage to clinical space.
THE FLOORING STORY
Acute care spaces are 95% hard surface today, reports Beverley Spencer, senior associate and senior interior designer at FCA in New York City. This may not come as much of a surprise, since the performance demands on flooring in acute care settings are many. Flooring has to stand up to harsh cleaning but be supportive underfoot. It needs to support wheeled traffic without joints or texture that will generate excess noise. In clinical spaces, it must be a uniform, seam-free monolithic surface but be swiftly replaceable if, or when, it is damaged. It needs to create a warm, natural aesthetic without being natural.
In addition, cleaners got more caustic in the pandemic and their use is expected to continue. “Everyone has maintained a high degree of focus on disinfectants and has continued using harsh chemicals,” reports Stroupe. “Where I have seen the most flooring damage is when alcohol gel drops on the floor and removes color. We have also definitely seen degradation of finish materials from the use of chemical cleaners. Training staff continues to be a hurdle. It’s hard to recruit for these positions, and everyone wants things to be cleaned quickly and efficiently. Everyone is using floor scrubbing machines.”
Just as importantly, flooring manufacturers must offer aesthetics that will hold up over time. “We have a project right now that is 1.3 million square feet, and it won’t be completed until 2028,” says Franne Stewart, studio practice leader of health interiors for HKS, who frequently looks to Gerflor, Shaw Contract, and Interface’s Nora for acute care design needs. She adds, “We don’t want to set ourselves up for a dated look, so we have to forecast on that.”
RESILIENT
Hospitals utilize many types of resilient flooring today: sheet, rubber, linoleum and LVT.
In patient care spaces, Stroupe says that whether or not the sheet vinyl is welded often comes down to the preference of the facility. “Some want the code minimum, while others prefer welded sheet in all clinical space,” she notes. “However, there are a couple of challenges with resilient welded sheet. The ability to get a really good installation depends on skilled labor availability in the area you’re working in. Lots of areas don’t have that expertise, particularly if you need integral cove.”
In addition, managing failures with sheet can be a huge undertaking, as sheet vinyl can’t be easily repaired. And that provides LVT an inroad. “You can replace plank or tile more easily than sheet, and it doesn’t take the same installer skill,” says Stroupe. “I’m still a fan of a seamless floor because it is a little better choice for cleanliness and maintenance.” Stroupe notes that she has seen a huge increase in the use of LVT as of late and virtually no use of VCT.
Stewart likes utilizing resilient tile that can be heat welded on acute care projects. “As far as I know, there is only one manufacturer-Patcraft-doing this with its AdMix line,” she says, adding that Shaw Contract may be also offering it. Stewart likes the option, which allows her to continue the same look into a zone where heat welding is not required.
Similarly, she likes same-height products that enable her designs to transition from LVT to sheet products seamlessly to connect different zones. On a recent cancer center project, this allowed her to transition from sheet in the patient rooms to a cost-saving LVT in the corridors. “We like to lead with lifecycle cost, but upfront cost is the driver for sure,” the designer says. “It always trumps.” She praises Gerflor, Shaw and Tarkett for their efforts to be competitive cost-wise with their sheet products.
Spencer notes an increase in the use of acoustic-backed resilient tile as of late, especially in corridors as a means of reducing noise that may disturb patient sleep, and reports that in the early days after the pandemic, “there was a greater focus on seamless flooring, but this is decreasing. We are still specifying the same types of resilient tile and sheet that we did before the pandemic, but our research to determine whether products will hold up to withstand harsher chemicals and cleaning protocols has increased.”
She notes that for acute care, “We specify a lot of Shaw, Patcraft, Mannington and Nora products. We use manufacturers that are reputable and will stand by their products.”
Rubber is a popular choice for zones where acoustic mitigation is of high importance. “Many facilities prefer 3mm rubber flooring for its comfort underfoot, cleanability and acoustic properties,” notes Washington. “But it is also very expensive compared to other products on the market. So, we do often have to explore other resilient sheet goods to use in tandem with rubber or in lieu of rubber flooring.”
On the plus side, Stewart reports, “The cost of rubber has gotten more competitive due to the varied thicknesses available today. If we can get a thinner rubber and use it throughout, it will help the staff with fatigue and also help manage acoustics.”
Smith reports that she is intrigued by the concept of poured linoleum but hasn’t yet used it due to its cost. She frequently uses sheet linoleum in inpatient units and sometimes in patient rooms as well. She also utilizes Forbo’s Marmoleum tile in corridors.
While some hospital systems, such as Kaiser Permanente, are standardized on non-PVC products, these are few and far between. In addition, some design firms prioritize PVC-free products as a matter of internal policy.
“As a healthcare designer, we are making sure to create safe and healthy environments in terms of material health,” explains Smith. “Part of that is understanding that vinyls aren’t the best or safest materials for humans. I have tried to move away from these and use non-vinyls like linoleum and rubber. Some end users buy into that. Others have resisted because they don’t have the staff to clean these materials differently. Linoleum can get ruined if it isn’t cleaned correctly. Rubber needs to be buffed. In a climate where cost is a major consideration, we need environments promoting infection control, and more caustic cleaners are being used by staff that is less trained or turning over frequently. As such, I have become less resistant to using vinyl products. I am specifying more homogenous vinyl resilient sheet today for durability and performance with a variety of cleaning products.”
Smith adds that the challenge of using non-PVC options often comes back to education. She frequently facilitates test areas before utilizing a material unfamiliar to the facilities, noting, however, that “once something goes sideways, it is very hard to recover, and that has been the challenge with non-PVC.”
Stroupe adds, “Everyone is really interested in the elimination of PVC. Within our firm, it is a priority, but the performance isn’t often as reliable as standard sheet-though it’s getting better.”
CARPET TILE
Some acute care systems today continue to use carpet tile in administrative spaces and conference rooms. Others are opposed to its use anywhere, which Stroupe feels is extreme.
While noting the big-picture move away from carpet, Washington also believes it can be useful. “As designers, we try to utilize carpets fastidiously and in a way that is easiest for facilities to maintain,” she says. “Soft surfaces can help imbue a more residential or comfortable environment, so we try to prioritize their use in waiting areas and conference spaces. Luckily, manufacturers are beginning to release some highly durable fused woven resilient carpet products that can give the aesthetic of carpet but with more durability.”
When Stewart utilizes carpet tile on any part of an acute care project, it is always solution-dyed.
HARD SURFACE
Both ceramic and terrazzo are popular choices for acute care public spaces and corridors.
When ceramic is specified, it is generally large format and rectified, so that the grout joints do not produce a click under wheeled objects. Smith also appreciates the monolithic aesthetic this produces.
Stewart says she is seeing lots of large-format porcelain used on both floors and walls. “The nice thing about porcelain is that it doesn’t stain or fade,” she adds. “There is no sealing, and it isn’t susceptible to bacterial buildup.”
Spencer notes the following trends have emerged in the post-Covid world, adding, “It is difficult to plan and design for the future because we do not know what is around the corner-but one thing the pandemic taught us is that spaces need to be flexible, adaptable and resilient. We need to plan for technological integration early in the process to create a cohesive design aesthetic and plan for adequate wall space and millwork that will accommodate larger screen sizes. When selecting and detailing materials, we have to consider the possibility of another future pandemic.”
• Flexible and adaptable spaces, such as patient rooms that have the ability to convert to ICUs if needed
• Integrated smart technology and larger TVs in patient rooms
• A simplified design aesthetic and details that are easier to clean and maintain
• An increase in respite rooms for staff and greater attention to the design of these spaces with the goal of increasing staff retention
• The re-emergence of anterooms as part of isolation rooms and an increased quantity of isolation rooms
• Increased accommodation for PPE
STAFF SUPPORT
“One of the biggest impacts on acute care currently, which we knew was coming but was accelerated by the pandemic, is staff shortages,” says Smith. “Amid the pandemic, many nurses retired out, and the data suggests that this will get worse.”
Indeed, according to Nurse Journal, “… 17% of nurses expect to retire by 2030. The report shows that 4.7 million nurses are needed to maintain the current workforce. To address the global nursing shortage, 10.6 million more nurses must replace retiring nurses.”
In fact, Smith reports that she has seen healthcare systems build new units to fulfill existing needs but then find that they are unable to open them (in part or fully) because they are unable to staff them.
While this may seem like a problem outside design’s purview, that isn’t the case, according to Spencer. “A well-laid-out, functional floor plan that provides caregivers with clear visibility to patients, limits their travel distances, and includes space where they can relax and take a moment to themselves naturally reduces stress,” says Spencer. In today’s short-handed acute care environments, stress and burnout are significant factors to retaining staff. Therefore, creating intentional spaces where nurses can decompress helps them feel supported, offering a healthy getaway when things become intense.
“Nurses don’t have to cry in the bathroom anymore,” says Stroupe. Indeed, having a dedicated space with access to the outdoors or natural lighting and finishes that support calm and wellbeing can serve to recharge the staff member.
Smith reports, “The first time I included one of these spaces in a design was four to five years ago. Now, they are a mantra.”
Another strategy for dealing with the staff shortage is using robotics, and this can mean designing circulation differently in an acute care setting, reports Smith. Healthcare systems that are constructing new facilities may create back-of-house passages and lobbies for the robotics to utilize. Smith reports that Chicago’s RUSH University System for Health built a new patient tower that is served by robots that travel across the street through an underground tunnel to a supply facility to retrieve what the staff needs, then park in a back-of-house lobby where staff collect their materials.
If an existing facility chooses to utilize robots, these must often share corridors with humans. In this case, says Smith, it is important that there be a dedicated lane for the unit.
In either case, these robots present a new challenge for flooring, which must hold up to the wear and tear of a unit that is programmed to run the exact same path hour after hour, day after day. Smith reports that it is yet too early in the use of robotics to see how already installed flooring will hold up, but this is an area of concern for both A&D and administration.
Additionally, efforts are being made to provide nurses and other caregivers with the ability to monitor patients in a timelier manner. This includes gaining visibility to patients within their rooms without making entry, which is also useful in minimizing germ transmission and promoting rest for the patients. Stroupe reports, “Every time a staff member goes into a room, they need PPE. So, if they can monitor from outside the room and only go in as needed, there is less chance of infection, and it is timesaving.”
Lastly, in some cases, the nurses’ station is getting a reboot, becoming more of an off-stage space where staff can gather and discuss patients more openly. “Where do tough conversations take place?’ asks Smith. “We create neighborhoods where staff can gather and work through their stresses and concerns. This can be done in many ways-art integration, materials, texture-but you have to create a hospitality feel.”
BIOPHILIC INFLUENCE
Biophilia continues to have an important role in acute care, where mental comfort and well-being are importance factors to both healing and optimal performance in the workplace. This often includes utilizing wood-look flooring and natural tones, shapes and forms. “We are paying more attention to how a space can be formed to help people feel sheltered and safe,” says Stroupe. “We all have an innate response to sitting under a tree-it gives us a feeling of protection, and in design, we can emulate that with lowered ceilings in certain spaces, for instance.”
“Additional biophilic strategies include introducing softer millwork edges that mimic natural forms in patient rooms and at nurse stations, and specifying lighting that mimics natural light or helps regulate circadian rhythms,” notes Spencer.
Biophilic design principles also include designing spaces that reflect the natural environment within which the facility exists. Washington utilizes “art and graphic elements that represent nature within the context of the specific location we’re designing for and utilizing color palettes that are rich and support the regional graphics, as well. We also use natural wayfinding patterns with key features meant to serve as directional landmarks and prioritize views of nature as much as possible.”
Similarly, because healthcare spaces can be triggering for many individuals, Washington and her team often use trauma-informed design, “providing autonomy, clear wayfinding, soothing lighting, quieter spaces and a keen understanding of the people who visit and work within the spaces we design.”
COSTS & TIMELINES
Supply chain costs are still high, so end users are looking for alternatives to their usual vendors or resources, says Smith, noting that many projects underway are coming in significantly over budget-often 30% to 50%-and some are now pausing on new work because borrowing is expensive presently. Cost increases are due to a blend of supply, material and labor cost inflation.
“When working on renovations of aging facilities, there are many mechanical/electrical/plumbing and infrastructure upgrades that take priority over finishes,” says Washington. “We always try to design with the longest product life in mind, but every decision is balanced with the overall project needs. Most often, cleaning and durability are the non-negotiables. Acoustical performance and softness underfoot are typically sacrificed for a lower-cost product alternative.”
Indeed, although healthcare systems do not want to shut down a floor or wing to repair or upgrade flooring, upfront costs still rule, says Smith. “Our most informed clients will look at performance characteristics and lifecycle cost. But we are at a moment when priorities have shifted in that clients are trying to get spaces built to take care of patients-that is their main objective. And with the cost increases they are managing, that is the bottom line. If they can meet their performance criteria and it costs less, that’s what they will do.”
Stroupe adds, “Even clients with rigorous standards have strayed from these due to cost,” adding, however, that her clients are increasingly interested in utilizing U.S.-made materials, especially if using something domestic means shorter lead times.
Spencer notes that planning for longer lead times is simply a given in today’s planning and construction process.
“Labor is now a moving target,” adds Washington. “It remains absolutely critical to work closely with our construction partners to track the supply chain and labor costs of the products we specify.”
The needs for behavioral healthcare are increasing, and facilities serving these clients have their own requirements. For designers, that means thinking about every flooring seam, connection and joint, says Smith. For patient rooms, finishes must be completely tamper resistant. This includes being ligature resistant, eliminating anything that can be pulled away or broken to be used as a weapon, and considering opportunities for a patient to create a pocket or hiding spot for contraband. “How the flooring meets the wall and base is really important,” says Smith. “And we must use tamper-resistant caulk.”
Copyright 2023 Floor Focus
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