Acute Care Amid Covid-19: Flooring must provide a state atop which healthcare may transform - Oct 2020
By Jessica Chevalier
The COVID-19 pandemic has been an unprecedented crisis for modern medicine. Certainly the U.S. healthcare system has faced widespread challenges before, but as we’ve recently been reminded, it has been more than 100 years since a novel airborne virus swept indiscriminately through the population. At present, within the U.S. alone, the virus has played a role in the deaths of 200,000 individuals, and the physical space within acute care facilities has been forced to evolve rapidly, both to treat Americans suffering from the virus and to the minimize its spread to front-line workers and other patients.
In this battle, the functionality and adaptability of acute care space is paramount, and flooring serves a purpose in many ways: signaling wayfinding and social distancing between individuals, offering ease of cleanability, and most importantly, providing a flexible and effortless stage on which the important work of virus-fighting may take place. Put simply, if the floor creates any impediment to the larger goal of making people well, it is not doing the job that it should.
Perkins + Will’s Brenda Smith was a nurse before returning to school to pursue a career in design. Although she never intended to return to healthcare, she found that her background made her uniquely suited to serve as “an interpreter between clinical and design.”
Based out of Perkins + Will’s Manhattan office, in the early days of the pandemic when New York City was under the virus’ siege, Smith was part of the Greater New York Hospital Association task force seeking to identify available space for COVID patients and evaluate non-healthcare facilities that might serve as makeshift acute care space if need be. The task force units-each consisting of an architectural firm, a mechanical engineer and a construction manager-operated in partnership with the governor’s office, getting regular briefings on the status of the virus’ spread and what space was needed where.
In addition, Smith reports that Perkins + Will’s healthcare practice was meeting once weekly to discuss what clients were requesting and what solutions were being created. This covered everything from the development of a software platform to help a Seattle-based healthcare system track bed status to the development of shields to prevent spread of the disease during ventilation procedures for a client in the Southwest.
ADAPTABILITY IS PARAMONT
As the healthcare community learned how easily the novel coronavirus is spread between individuals, one of the highest goals of the healthcare system became minimizing its transmission within hospital walls. That meant reconfiguring space for a variety of emerging needs, such as creating triage areas to screen patients for COVID; establishing split flows for COVID positive and negative patients as well as staff donning and doffing personal protective equipment (PPE); creating infection wings with negative pressure, which prevents the virus from being spread through the hospital’s mechanical systems; and altering or eliminating gathering spaces.
Of course, these alterations were, for the most part, swiftly retrofitted to existing structures, not enacted in permanent means, and one big question mark for the flooring industry is whether healthcare systems will seek out permanent finishes to support these needs. While there is great hope that a vaccine will minimize the COVID pandemic in the next couple of years, that is unlikely to mean full eradication of the disease immediately and certainly won’t inhibit future novel virus outbreaks.
With so many unknowns, one requirement rises to the top: the need for malleability in the acute care space. And the importance of that may become critically important this fall and winter, should flu and COVID outbreaks collide. While Marie Lukaszeski, director of planning/design/property management at Lafayette General Health, is hopeful that the preventive measures taken for COVID-such as hand-washing, mask-wearing, social distancing-will help minimize flu spread, she reports, “When we go into October and get very full of patients with the regular flu, to add COVID atop that would be close to unmanageable.”
With the shifting sands of outbreaks afoot, flooring manufacturers must continue focusing on the fundamentals of
healthcare flooring-providing a safe surface upon which workers and patients may move, minimizing disease transmission, eliminating slips and falls, and providing the acoustic benefits necessary for enabling patients to rest and recuperate-while also allowing hospital systems to transform atop them as needed. Of course, for the design teams making decisions about finishes, this balancing act will no doubt prove challenging. “While design responses and finish selections directly related to COVID-19 materialize, it’s important for designers to balance this priority with other longer-term priorities so we can continue to be adaptable in an ever-changing market sector,” notes Eric Koffler, senior associate at NBBJ Design. “This will allow us to continue to be ready to respond to future [pandemics].”
Referencing what could be the future of hospital design, Brenda Smith, associate principal and healthcare design leader with Perkins + Will, says, “We have had a couple of hospitals proactively design universal rooms for patients that can shift from an acute setting to an intensive care setting. They did it anticipating that they might need it someday and were so relieved that they did.”
While a good deal of healthcare work has always been intense and demanding, the pandemic shined a much-needed light on just how hard it can be on both the body and the mind. Due to that, some healthcare systems are integrating respite spaces into their designs. These places offer a quiet and nurturing spot for healthcare workers seeking a few minutes of calm and rest. Smith explains that these needn’t be large or grandiose, and they can often be created in already existing locations that are underutilized. On one recent project, Perkins + Will didn’t have a corner for such a space in the hospital, so it made use of a roof area overlooking the river, adding porch swings and a dining space. Smith believes that accessibility to daylight and nature views is key, adding, “This is possible to do without a whole lot of financial investment, but it takes a commitment and intention from the organization.”
ACUTE CARE SQUARE FOOTAGE
Prior to the pandemic, there was a move to shift many inpatient procedures and elective surgeries toward outpatient settings, leaving acute care settings for the “sickest of the sick,” as Koffler puts it. “We are seeing more acuity-adaptable rooms in our projects-ones that can accommodate medical surgical patients on day one but are sized to adapt to all higher acuity levels,” he reports. “This takes additional square footage, but there are lifecycle cost benefits to consider, as well. Special attention is needed to ensure that all auxiliary spaces and mechanical systems are designed for this future change.” In short, the adaptability desired in contemporary acute care spaces requires more square footage per individual space.
However, overall, Lukaszeski reports that the big-picture goal of having more patients recovering outside of the hospital is likely to reduce square footage in acute care overall nationally.
To complicate this discussion is the fact that the COVID crisis accelerated a trend already in place that may ultimately minimize the need for square footage: telehealth. During the quarantine, the healthcare industry utilized Internet-based remote medicine as a means of limiting exposure. Smith explains that, prior to the pandemic, the insurance companies had, to some extent, curbed the practice by reimbursing telehealth visits at a lower rate than in-person ones. However, “when COVID hit, the federal government said it would reimburse at the same rate, and insurance companies followed suit,” Smith reports. As of yet, there is no indication whether reimbursement will remain as-is post-pandemic or revert to the lower rates of prior days. However, it is important to note that the percent of visits being done through a telehealth portal has decreased as the pandemic has progressed, and this, too, remains an important trend to keep an eye on. “We did a master planning project with a Canadian hospital system three years ago,” recalls Smith. “They asked us to look at various percentages of care handled through telemedicine and what the implications were for the space. We provided scenarios about the reduction in needed office space by percentage of telehealth visits.”
Again, because the current move to telehealth was reactionary-necessitated by COVID, rather than strategic-the current situation may not provide an accurate picture of what the implications of regularized telehealth practice might be on hospital space. Right now, healthcare professionals are squeezing telehealth visits in between physical ones-sometimes utilizing offices or hallways, sometimes grabbing empty exam rooms. A more thoughtful approach would involve “carving out the right space,” explains Smith. “You don’t need as much of a footprint, but you do need good acoustics and lighting, a good Internet connection and privacy.”
Adds Koffler, “Overall, telehealth may offer opportunities to reduce onsite needs, so designers will need to think about total parking spaces, fewer exam rooms, and smaller waiting spaces. A telehealth room would take up less space than an exam room.”
With adaptability behind an important component of the future of acute care, some elements of wayfinding may need to be permanent, while others will require changeability. Amid COVID, Lukaszeski employed adhesive decals on the floor to provide direction and reports that they have adhered surprisingly well.
However, she sometimes employs more permanent means. For a new surgical platform comprised of 12 operating rooms, the designer worried that the staff might get lost and enter the wrong surgery suite-a frightening prospect-so she utilized waterjet cutting to create giant room numbers in the floor in front of the rooms.
Lukaszeski anticipates that, moving forward, she may utilize a similar strategy, with waterjet-cut design elements to signify the need for social distancing between those waiting in line.
Koffler notes that the best strategy may be creating subtle but intuitive symbolism that “in times of need, can be used to identify and separate flows of traffic, seating areas, and draw attention to social distanced furniture arrangements. We are currently working on a rehabilitation hospital and are using floor patterns and architectural wall surfaces as a way to identify a patient’s gait pattern and distance. I can see these same subtle cues in floor or ceiling elements that can be used by the staff to reorganize furniture layouts into pandemic configurations. Permanent architectural features that align to the current pandemic’s social distancing recommendations should be weighed against potential future pandemics that may have different measures to mitigate transmission and exposure.”
CLEANABILITY AMID COVID
There is no doubt among interviewees that the use of carpet is on the decline in acute care spaces, and COVID has only served to reinforce that trend. The fact is, designers and end users do not see carpet as being as cleanable as hard surface flooring, regardless of what manufacturers say. Koffler reports that carpet-generally tile-is primarily reserved for administrative areas or large, open waiting areas, where acoustics and comfort underfoot are prioritized.
“We see a reduction in the amount of carpet allowed in acute healthcare facilities,” Koffler says. “A decade ago, we had frequent conversations related to carpet (for acoustics) or resilient surface flooring (for cleanability) located in inpatient corridors. Today, flooring conversations for these same corridors are primarily focused on using resilient tile or resilient sheet.”
Smith and Lukaszeski report similar trends. Says Smith, “We have had very few clients who put soft surface flooring into their care spaces. We see more of it in clinic environments and waiting rooms. There have been a few exceptions from clients who carpeted clinical corridors and even inpatient bed units-more often in the Midwest. The shift [away from using carpet] has been taking place for the last 15 years. We’ve sat in meetings with epidemiologists who have been very anti-soft surface and have had to balance what is appropriate from a hospitality perspective and cleanability.” When Smith does specify carpet, it is always solution-dyed tile with patterns that have the ability to “sort of blur” in case a tile or group of tiles is damaged and needs to be changed out. She turns to Shaw frequently due to its non-PVC backing and has also used Interface, Tarkett and Mannington products.
Lukaszeski reports that Ochsner Medical Center, with which Lafayette General just merged, pulled out all carpet across its entire hospital system and says that only 10% of the products she specifies for Lafayette are soft surface. In fact, the designer notes that the only COVID-related flooring complaint she has received during the pandemic was in relation to a hospital call center in which a worker had tested positive, and the individual’s coworkers were concerned that space could not be thoroughly sanitized due to the soft surface flooring in place. She believes that the concerns raised right now about the proper sanitization of carpet will remain in designers’ minds for a long time and further sway them away from its use in acute care.
Unlike, say, retail locations or schools, hospitals have always been a place where cleanliness and sanitation were of the highest priority. Hospitals have long been fighting the spread of illness within their walls, with the most serious of these battles in recent years waged on diseases spread through contact, such as MRSA and staph. As such, strict cleaning and sanitation practices for surfaces, including flooring, were in place prior to the onset of the novel coronavirus within the U.S.; however, as patients rarely touch flooring with their hands, it isn’t considered as critical a touch point for germ-spreading as, say, countertops or handholds.
In response to COVID, Lafayette General has employed housekeeping staff as a constant presence to wipe down touch points. For surfaces, the hospital utilizes a spray-on Clorox product that kills bacteria within seconds and employs a fogger system in public areas daily.
Within patient rooms, procedures have had an even more significant overhaul wherein the nurses, rather than the housekeepers, are now charged with cleaning and prepping each space between patients, thereby limiting exposure to a smaller number of hospital staff. This obviously puts more responsibility on the nursing staff, and Lukaszeski notes that “anything that can clean itself or that a robot can zap” for cleaning is in great demand.
Some of the systems with which Smith works are managing cleaning differently. Housekeeping remains in charge of cleaning patient rooms but only enters after a certain number of air exchange cycles have been completed. “Coronavirus is actually easier to kill than bacterial-based infections like staph and MRSA,” says Smith, “but we need to be making sure that the staff is trained in the contact time that a cleaner needs to do its job.”
She continues, “The places that seem to have the highest impact from the cleaning agents are coated textiles and surfaces. Harmful pathogens aren’t as prevalent on the floor as on other touch points. Robotic misting systems or those that use UV light have their own impact on degrading finishes. We don’t know whether those will degrade flooring to the point where it isn’t performing or just negatively impact the aesthetic.”
With regard to the aesthetics of flooring, Koffler reports, “We are finally reaching a point where shiny does not mean clean; it means the wrong cleaner was used. The low-maintenance costs and reductions in solar and light fixture glare make this an enticing incentive for our clients.”
If there is one sector where sheet vinyl still has strong standing, it is in acute healthcare, where seams are the enemy due to their ability to trap grime and germs. In fact, Facility Guidelines Institute protocols require the use of monolithic flooring and integral cove base in areas where patient populations are more susceptible to hospital-acquired infections, including operating rooms, isolation rooms and sterile processing facilities, according to Koffler, who adds that “emergency department treatment rooms and ICU/intermediate/medical surgical patient rooms do not have these same requirements and are the very same rooms that are reaching capacity with both infected and non-infected patients.”
While sheet goods used to dominate pathways, today that is changing, according to Koffler. He notes, “On recent projects, resilient tile reigns supreme in corridors due to its ease of repair and overall install cost savings as compared against sheet. It’s growing ever more important that manufacturers look to align LVT and sheet pattern and color offerings so that facilities can have a cohesive and uniform aesthetic.”
Also important to Koffler’s clients are solutions that are healthy for the patient and the environment, though these, too, need to offer high-quality aesthetics. He says, “In our academic work, we see an uptick in the use of rubber tile. Flooring surfaces that do not have plasticizers limit or otherwise zero-out shrinkage after installation, which means seams do not need to be sealed. In instances where monolithic flooring is needed, the ability to cold weld the seams allows for more intensive and heightened hygienic regimens.”
Smith also believes that creating spaces that are holistically beneficial to human health is highly important in acute care and she relies heavily on the Perkins + Will transparency site to vet the products that she specifies within the sector. She notes that the first go-to products are linoleum, rubber and PVC-free resilient from companies like Gerflor, Forbo and Ecore.
Lukaszeski also likes rubber but reports that it is better in some application than others: in corridors, where it can be easily buffed, it looks great, but in smaller spaces, where buffing is more of a challenge, the aesthetics suffer.
While ceramic may seem like a natural choice for acute care due to its cleanability and durability, the designers with whom we spoke generally reserve it for bathroom spaces due to its grout joints, which both dirty and work poorly under wheels-of which there are many in acute care. Smith sometimes uses it in entrance or lobby spaces-with carpet insets under seating groups-but notes that the acoustic reverberation is always a challenge.
Terrazzo is a revered material among acute care designers. It is low maintenance (no waxing required), easy to clean, incredibly durable and aesthetically appealing. It also offers good opportunity for branding. While terrazzo and epoxy floors easily withstand frequent cleaning, they “often come at a price that limits their use in acute settings,” says Koffler.
However, while they are costly, Koffler notes that, in some systems, terrazzo is the go-to. “I’ve worked with institutions where terrazzo flooring/integral terrazzo base is the standard in operating spaces and others, where a solid surface wainscot [is specified] down inpatient corridors in lieu of typical sheet/bumper rail/crash rail protection,” he says. “Their ROI [return on investment] showed that repairable and durable surfaces outlast the performance of traditional materials. Designers must continue to look at materials for their practical characteristics-like durability, cleanability and maintenance-in addition to inherent qualities that are sensitive to patient needs.”
Lukaszeski believes that creating a smooth flooring surface is of utmost important in acute care. “Flooring that has a good visual pattern with a smooth surface is required; there should be no ticking on the surface,” she says. “Floors must be seamless and have no transitions. Everything in a hospital rolls-bed, telemetry, IV poles; everything is on casters, and so transition strips don’t belong in a healthcare setting. If you have a patient with a terrible headache or some other kind of pain, they need a seamless ride through the hospital.”
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