State of Acute Care: High-performance flooring is required for acute care’s high-demand environment - Oct 2021
By Jessica Chevalier
The acute care market is in an era of transition. While some of the sector’s changes are due to an alteration of needs as a result of the Covid-19 pandemic, major transitions emanate from the trend toward decentralizing some healthcare services and functions from the centralized hospital tower to more community-based providers. Fortunately, to some extent, all these transitions necessitate the need for floorcoverings that are flexible, durable and highly cleanable because demand for beds is high, and hospital systems can’t spare the time, space or dollars required to accommodate flooring that isn’t pulling its weight.
AN EVOLVING SECTOR
There was a time when nearly any injury or surprise illness that required a doctor’s care called for a trip to the emergency room-whether it be a laceration that needed stitching, a severe case of strep throat on a weekend, or a fender bender that resulted in a sore neck. There, less severe patients found themselves shuffled into the care line behind those experiencing more pressing and potentially life-altering medical emergencies, such as cardiac arrests, severe traumatic injuries or anaphylaxis.
Today, urgent care serves as an avenue to take pressure off traditional acute care facilities and offers patients a more streamlined and community-based healthcare experience. Urgent care originated in the 1970s and has proliferated over the last decades; today, there are an estimated 10,000 urgent care facilities in the U.S.
Similarly, outpatient care, surgical, behavioral and mental health, and other specialty care centers have moved patients off the main campus of the hospital into outlying facilities, which has benefits for both the health system and patients, explains Julie Stegeman, Interface’s healthcare segment manager. “Acute care inpatient facilities have more stringent design requirements than outpatient facilities. For acute care outpatient, the costs of the care provided and the buildings themselves are less, which ideally translates to those savings being passed on to patients.”
Mannington Commercial’s Steve Hadrych, co-director of healthcare, explains today’s healthcare operation as a hub-and-spoke system. “We have the hub, the large structure where patient rooms are, offering the very technical aspects of care,” says Hadrych. “A clinic or medical office building is a spoke that guides people through levels of care. Telemedicine is another spoke.”
Today, acute care facilities have pivoted to a focus on caring only for the sickest of the sick, and while the services and specialties spun out of the acute care tower are expected to produce the greatest growth in healthcare in the coming years, acute care remains an active and growing sector in building and renovation.
Acute care is an immense sector, including more than 900,000 staffed hospital beds across the U.S. in more than 6,000 hospitals, according to the America Hospital Association. With the massive Baby Boomer generation now between the ages of 57 and 75, the acute care market will continue to grow.
CURRENT ACTIVITY: RENOVATION
While acute care was already changing when the Covid pandemic hit, Patcraft’s Shannon Cochran, vice president of marketing and design, reports that the enormous load of patients brought into the system by the virus made the sector’s lack of flexibility glaring. And a system running at or over capacity can’t be shut down for renovation.
Amid the pandemic, “there was no ability to remodel, because the hospital was stacked and addressing a much more critical need,” says Earle Jenkins, senior vice president of healthcare/senior living with Mohawk. “As the pandemic started to ease in March and April of this year, pent-up demand came through, creating a surge of business. Acute care facilities had time to address immediate needs. Now that that need has been met, business has stabilized. Our concern now is, as the Delta variant runs rampant and creates another surge, will facilities go back into business lockdown to re-enter the war zone? Right now, it’s too early to tell.”
To some extent, the degree to which flooring manufacturers benefited from the lull in Covid varied. Those who supply flooring that is quick and easy to replace and used in less critical zones, such as LVT and carpet tile, saw business pick up. Those who supply flooring for areas that require more preparation and maneuvering to shut down, such as intensive care and operating room spaces, generally did not see as much business squeezed in during the Covid period.
Hospital systems have different approaches to renovation. A large system with many hospitals in its network may, for instance, renovate all neonatal intensive care units (NICU) across its facilities in one swoop. Another may take the opposite approach, so that it can renovate one NICU in its system and shift patients to another. Yet another may renovate one facility at a time or base its renovation cycle on wear-and-tear. Currently, however, “no one is shutting down a wing of a hospital for renovation,” says Cochran. “We have seen a lot of renovation in discussion, as it relates to adaptive plans. There will be a good deal of pent-up demand when we get through the Delta variant of Covid.”
While renovation was not initiated during the pandemic, many projects already in the hopper moved forward. “Design and construction projects can span multiple years in healthcare,” says Stegman. “Although we saw some impacts due to the pandemic, the healthcare market has maintained a steady pace. Overall, the healthcare segment continues to be one of our strongest. During Q2 2020, some health systems stopped performing elective surgeries, and select facilities took that time to complete longstanding projects.”
Another financial upheaval that acute care systems faced at the onset of Covid was uncertainty regarding Medicaid and Medicare payouts.
Changes in healthcare technology may also drive renovation. Says Paul McKinney, national sales director for Gerflor USA’s healthcare segment, “We are seeing a lot of hybrid spaces, places where the operating room (OR) and radiology co-exist within constraints of procedure and also do imaging.” For instance, a ground-breaking MRI machine used by two departments may call for a reconfiguration of space so that both specialties have ease of access.
“The pandemic taught us so much about what acute care needs,” reports Allison Wolff, director of healthcare and senior living markets for Shaw Contract. “There was no shortage of learning. We are rethinking how acute care is designed: about segregation of populations, waiting room designs and flexibility for surges in service.” Regarding waiting room design, for instance, Cochran points to the long-standing model for pediatrician offices as something that might be applicable in acute care-with separate “well” and “sick” entries and waiting zones utilized to protect patients from transmissible illnesses.
“I listened to a webinar recently that called what hospitals are doing now as ‘future proofing’,” says Kathy Griffel, co-director of healthcare for Mannington Commercial, “looking into the crystal ball and seeing whether the hospital is built for future needs and making it more flexible. They are considering how to employ a modularity format, so that a group of rooms can be flexed into an ICU at the flick of a switch.”
Another unforeseen development that impacts space planning has to do with the minimization of visitors in the hospital space. Having fewer guests to contend with has been a benefit for caregivers. Should the trend continue, it may mean that the square footage of yesteryear’s expansive lobbies-now underutilized space-can be repurposed for another use.
CURRENT ACTIVITY: NEW CONSTRUCTION
The supplier specialists with whom we spoke report that the acute care market was growing prior to the pandemic and continued to grow amid it. “Looking at hospital construction forecasts, we see this segment rebounding from a difficult 2020 and growing more than 35% in 2021,” reports Julie Eno, director of commercial marketing at Armstrong Flooring. “Some of this growth can be attributed to healthcare funding. Rather than focusing on directly fighting the pandemic during the peak of the virus, funds are being used for facility updates.”
McKinney clarifies that new construction underway now is not generally in response to demand generated by the pandemic. When the pandemic hit in early 2020, “much of acute care’s capital budget was in place,” he says. “And any cranes in the sky were already planned. The pandemic response has been more a recognition of the need for flexibility and turning space for pandemic response at a moment’s notice.”
“[The market] has enjoyed a high number of big flagship new construction projects,” reports Griffel. “The pandemic hasn’t eliminated the building pace of those.”
As with senior care, the aging of the Boomer population is a significant factor driving the acute care market toward expansion, and Jenkins expects to continue to see growth within acute care because of the medical care needed by this generation.
Branding has become a more important part of healthcare as the system has moved from individual community hospitals to wide-ranging networks offering an array of services and specialties.
In a time when patients can-to some extent and in some instances-shop around to choose the system that will best serve their needs, healthcare providers lean on their branding as a means of building a connection. In addition, as they expand their reach, healthcare systems want to create a unified feeling across their facilities to create a sense of familiarity in patients utilizing different parts of the same system.
Hospitals achieve this through a variety of means, and flooring can play an important role. As the foundation of any space design, flooring can be used to transmit a specific look or color palette across a system’s facilities.
It can also promote ease of access through wayfinding-utilizing a striping system to lead to particular zones, for instance. Being able to easily navigate a space creates a sense of familiarity and utilizing the same system across multiple assets further reinforces a patient’s comfort.
The repetition of a logo is another important aspect of branding, and hospital systems do utilize flooring in this effort. Tarkett has recreated logos in both Powerbond and walk-off mats.
As one healthcare system acquires another, transitioning the acquired over to the acquirer’s brand is an important part of the process. This may include the specification of new flooring to replace what’s in place, whether or not it has aged out.
As acute care facilities care for the sickest of patients, the materials used within them must stand up to worst-case scenarios, and, for that reason, acute healthcare spaces largely utilize hard surface flooring and are expected to continue trending in that direction, perhaps at an increased rate.
Margaret Bartholomew, marketing manager for Tarkett’s healthcare segment, explains that flooring manufacturers partner with A&D, healthcare clients and flooring contractors to design for the most intense type of care that could take place in a zone. In acute care, soft surface is generally reserved for administration spaces and waiting rooms-sometimes used as an inset within a hard surface installation to create an island of warmth or hominess.
“We are almost going back 15 to 18 years since carpet was used in corridors,” says Hadyrch. “At one point, they considered it as a solution to provide quiet, but that was eliminated with SARS and super bugs because of infection control.” Griffel estimates that today only 5% of acute care square footage is soft surface.
And while hard surface may be a matter of preference for end users within acute care spaces, it is also dictated by the Centers for Disease Control and Prevention (CDC). “The CDC recommends specifying a floor that is cleanable, easy to maintain and repair, seamless and nonporous,” says Eno.
With the exception of some reception zones and corridors where ceramic or terrazzo may be used, the hard surface utilized in acute care is largely resilient-homogeneous and heterogenous sheet vinyl, LVT, rubber and linoleum. McKinney reports that while the percent of hard surface used across acute care has increased, the percent of resilient used has also increased.
Sheet vinyl remains a favorite product for hospital spaces that require a seamless installation, with homogeneous favored for its through-body nature and heat-welded seams. Rubber can also be used “behind the red line,” says McKinney.
Griffel notes that as spaces are created to flex as needed to add ICU or other types of space, sheet products will win, as they can serve in every type of space, whereas LVT, for instance, could not be used in a space that requires sterility, making its application primarily within patient rooms, corridors and office areas.
And linoleum, with its recent updates in technology and aesthetics, is used in many areas, with the exception of the OR, reports McKinney, noting that with its green profile, linoleum is a good choice for healthcare systems that value materials with a good environmental story.
Says Tony Barzycki, vice president of sales for HMTX’s Teknoflor, “Each client will have their own individual goal when selecting flooring. What we do see is that there is a universal importance in selecting a product that offers high performance, longevity, with a healthy ROI [return on investment] and one that will continue to have design appeal for the life of the product.”
The degree to which acute healthcare systems seek green products often varies by their institutional values. It can, of course, also be driven by other stakeholders. “Our customers are more knowledgeable [about sustainability] than ever before,” says Cochran. “Whether personal or firm-driven or prioritized by the healthcare system, the [demand] is coming from different angles.”
That said, in most cases, sustainability will not trump values related to durability or cleanability. If a system wants a PVC-free product but finds that it isn’t as durable as the product with PVC, they will go with the PVC one that will perform.
PRODUCT MUST PERFORM
McKinney reports that the “pandemic has honed the focus of stakeholders onto what is really important with regard to flooring product attributes in acute care-infection control, maintenance, durability.”
This focus has been reinforced by a host of factors coming together in something of a perfect storm; with the patient census high, floors are dirtier, and there simply isn’t time to shut spaces down for replacement or time-consuming cleaning procedures (such as buffing and polishing or steam cleaning). “With tight budgets, health systems need flooring solutions that provide durability and ease of maintenance without sacrificing design aesthetics,” explains Stegeman. “After the pandemic led some health systems to suspend elective surgeries, many had to cut their budgets, including maintenance personnel. So, they still had to clean and disinfect but with less FTEs [full-time equivalents]. They are doing more with less.”
In addition to maintenance departments being short-staffed, turnover is frequent. So while educational sessions on cleaning are helpful, their long-term effects may be clipped as workers come and go. Basic cleaning procedures that can be applied widely are greatly preferred-such as a cleaning with a microfiber mop and an occasional scrub.
When soft surface is utilized, it’s important that the fiber be solution-dyed, so that it can be cleaned with bleach if needed.
Equally important is that cleaning procedures can be completed without the use of odorous cleaners that might disturb an ailing patient. A staff should be able to sanitize a space without disturbing patients in an adjoining space. “Healthcare is driving the movement away from stripping and waxing,” says McKinney. “The VOCs kicked up by the process are high.”
Hospitals have a strong incentive to keep their spaces clean and reduce infection risk. “Creating healthy spaces for patients is key because, should, God forbid, a patient get sick in care, treatment of that illness is covered by the healthcare system, not insurance,” Jenkins explains. “That’s money out of their bottom line.”
Facility Guildelines Institute (FGI) standards dictate what areas of a healthcare facility need to be sterile and offer a minimum standard for how those spaces are designed. States can adopt these or enact more stringent requirements. In addition, ISO (International Organization for Standardization) guidelines certify flooring for factors such as static load, slip resistance and ability to inhibit growth of bacteria and fungus.
At the same time, Barzycki reports that more healthcare entities are looking toward recommendations by organizations like Healthier Hospitals Initiative, Health Care Without Harm and the International Living Future Institute for overall guidelines that support caregiver and patient health.
Flooring manufacturers continue innovating to serve the acute care market even more effectively. Gerflor, for instance, recently rolled out its Clean Corner System, a patent-pending corner coving solution that enables ease of cleaning by eliminating the hard angle, where dirt often gets trapped.
In July, Mannington Commercial launched IdealBase, a 61/4” wall base that extends 2” onto the floor so that it can be welded to the floorcovering to create a sanitary transition up the wall. The installation offers a simplified installation and is more damage resistant.
And Shaw Contract will soon roll out its Sole with Sensfloor Technology, developed for senior living, to the acute care market. The solution, developed with a technology partner, enables users to track movement and activity across a flooring surface. Wolff reports that Shaw Contract’s healthcare partners are advocating for the system, noting that acute care healthcare systems “are a super tech-savvy set of customers and pushing for more technology solutions in driving efficiency, understanding distancing, etc., so customers are bringing us ideas on how the product could be used in their space. They have the ideas already percolating.”
Each of the manufacturers we spoke with utilizes a multi-pronged approach in servicing the acute care market, establishing relationships with A&D, end users and flooring contractors. In a sector so technical and with such regulation, this is very important.
Adds Eno, “To help ensure the right flooring is selected, a decision-making process and policy to guide selection and procurement of finishes, such as flooring, should be developed collaboratively with key stakeholders like purchasing managers, occupational health and safety, infection prevention personnel, building services (maintenance), and environmental services (cleaning staff). This process and policy should be reviewed regularly and amended as needed, and quality improvement elements should be incorporated into the process, including monitoring, audits and feedback.”
Other stakeholders in the acute healthcare space are group purchasing organizations (GPOs), which achieve a cheaper cost for members by purchasing in bulk. Mannington’s Hadrych reports that every hospital system is a member of a GPO-some to more than one. “GPOs are now putting employees in hospital systems to help them reduce costs. They drive savings without end users having to focus on it. We certainly see their role growing,” he reports.
LOOKS THAT CREATE COMFORT
Biophilia remains an important design element within acute care. Surrounding patients with the look and feel of nature is both comforting and healing, and so hospitals have been steadily moving from the clinical and somewhat cold looks of the past to more warm and nurturing aesthetics. Interviewees report that these looks are somewhat cleaner than they were previously, with less rustic, more linear wood looks trending. Woven or linen aesthetics in soft tones are also popular.
On the flip side of that coin, some interviewees report that there has been increased interest in high-tech looks to communicate a system’s cutting-edge approach to medicine. In these cases, McKinney reports that healthcare systems may go for a modern look on the floor, for instance, but will still work in warmer elements in other finishes.
In either case, Stegeman reports that the highest goal aesthetically are products that withstand the test of time, since no acute care inpatient space wants to take up a still-performing floor because it goes out of style or shows signs of wear. Interface recently launched its first vinyl sheet products, which are carbon neutral through the company’s Carbon Neutral Floors program.
“Biophilia is still driving,” says Jenkins. “In sheet, customers look for small-scale nature patterns. If they want to create a design, they often inlay a contrasting color of the same design. Clients don’t want big or bold. They prefer small organics and cross-hatch patterns.”
Adds Eno, “For future healthcare designs, it will be important to continue the trend of creating comforting, anxiety-free spaces. Biophilic design continues to influence color and visuals, and sheet products are prized for their ability to create aseptic areas. Blue and green have always been a staple in healthcare palettes, and we are seeing saturated tones of these hues with a warm tint. These warmer tints make it easy to pair with rich, warm but lighter-toned wood visuals.”
Wolff reports that she has seen a trend of bold color moving from the West Coast to the East. “Just because it’s a clean design doesn’t mean it’s not exciting,” she notes.
While porcelain isn’t commonly used within acute care corridors or care spaces, the material is utilized in bathrooms, which do account for a significant amount of square footage in acute care space, considering that each patient room generally includes a bath space.
Mari Anne Randall, national A&D sales manager for Dal-Tile Corporation, points out that tile has some attributes that make it a natural choice for healthcare, “Tile has no VOCs. [In addition,] facility managers are looking for low-maintenance flooring because of a lack of manpower and budget constraints.” Porcelain floors require no waxing or polishing and can be easily cleaned with simple methods.
In addition, Daltile reports that its StepWise technology makes its porcelain 50% more slip resistant, reducing the risk of slip and fall hazards, which are a significant concern for patient, caregiver and guest health, especially in wet areas.
Porcelain is also sometimes featured in entry or waiting room locations.
Evidence-based design encompasses a broad range of healthcare goals that boil down to looking to data to determine how best to design a healthcare facility and system for the best patient outcomes. While it does relate to the physical design of a space, it also relates to elements like process, safety, efficiency and timelessness as well as the physical and mental wellbeing of caregivers.
One way that a facility can improve both the patient and caregiver experience, for instance, is through duplicating its patient room layouts across its entire facility. That way, a caregiver can enter any room in any facility and know where the items are that they require. This certainty creates a better work experience for the caregiver, who doesn’t have to bungle around trying to find the tool that they need, which in turn gives the patient a feeling of confidence in the care they will receive.
Creating identical spaces also enables a caregiver to easily establish and follow cleanliness protocols and thereby reduce incidents of cross-contamination or infection.
“It’s about creating ultimate efficacy,” says Hadrych. “A lot of it is how the room is designed to function at maximum opportunity.”
McKinney sees evidence-based design as “a long-term approach that drills down to specific outcomes.” With regard to flooring, this includes analysis around material ease of maintenance, weld strength integrity and even adhesive systems. “It’s about getting people to focus on what can affect outcomes outside of what’s pretty and cheap,” he says. “What are the other ramifications of these choices?”
“The more we talk about wellness and wellbeing, the more important they become in the total outcome,” says Cochran, who notes that pursuing evidence-based design is a collaboration between all stakeholders in the process, from manufacturer to designer to end user to flooring contractor. “The education piece is so important,” she says.
Eno notes that evidence-based design doesn’t end with the installation. It’s about “targeting specific improvements, implementing the plan and measuring the results,” she says. “That simple formula has yielded a body of evidence that suggests changes to the physical environment can reduce staff stress and fatigue and increase effectiveness, improve patient safety, reduce patient stress, and improve overall healthcare quality. These advantages can help shorten the length of patient stay, reduce the financial burden of the patient, and improve organizational effectiveness for the facility.”
One way that healthcare systems are currently looking to give back to caregivers is by creating areas in which they can decompress, emote and reflect. For those in the trenches amid the pandemic, days have been hard, with emotions often raw. Creating aesthetically appealing getaway spaces can offer a true escape from the intensity of work’s pressures.
ARMSTRONG: Resilient sheet, homogeneous and heterogeneous, including PVC-free; VCT; PVC-free composition tile; wall base
DAL-TILE: Porcelain tile; large-format porcelain slabs/countertops; mosaics
GERFLOR: Resilient sheet, homogeneous and heterogeneous; LVT; linoleum
INTERFACE/NORA: Rubber sheet and tile; LVT; sheet vinyl; carpet tile
MANNINGTON COMMERCIAL: Resilient sheet, homogeneous and heterogeneous; LVT; liquid linoleum; rubber; wall base; transitions; sanitary base; carpet tile; broadloom
MOHAWK GROUP: Resilient sheet, homogeneous and heterogeneous; LVT; rubber, homogeneous; broadloom; carpet tile
PATCRAFT: Resilient sheet, homogeneous and heterogeneous; LVT, including bio-based; homogenous tile; entry systems and walk-off products; carpet tile; broadloom
SHAW CONTRACT: Resilient sheet, homogeneous and heterogeneous, including PVC-free; LVT, including PVC-free; broadloom, carpet tile
TARKETT: Resilient sheet, homogeneous and heterogeneous; LVT; linoleum; Powerbond 6’ carpet; rubber; carpet tile; broadloom; stairwell rubber and tread systems; walk-off systems; accessories
TEKNOFLOR (HMTX): Resilient sheet and tile, including PVC-free and bio-based options
A UNIQUE INSTALLATION
The demand on installers within the acute care sector differs from other sectors. First of all, installers must understand and adhere to the stringent requirements set forth by both states and systems. This is critical to achieving the safety and sterility needed within certain zones, so these installers must be able to perform time and again to the same consistently high level.
Secondly, because healthcare providers don’t have time to shut down spaces for long periods, renovation work often takes place at night, and expectations are often that the spaces be open for use the next morning. “If you close down an ER for a day, that’s a million dollars lost,” says Jenkins, “so it is very difficult to shut down certain areas.”
“In more than any other segment, the flooring contractor is a key partner,” says Cochran. “Acute care installations are so critical. Systems can’t afford for spaces to be down, so it’s very important to achieve quick turns and have experienced installers that understand the market.”
Because of these specialized needs, not all flooring contractors work in acute care. “There might be three to five dealers in a major metro area that do it,” notes Jenkins. “The others won’t touch it because problems are a fortune to solve.”
Patient satisfaction is not the only way that hospitals judge their success, but it is an important element in the equation. HCAHPS, also known as the CAHPS Hospital Survey, is a tool for measuring patients’ perceptions of their healthcare experience. HCAHPS allows acute care systems to gauge where they are succeeding and where they need to improve-be it in care, facilities, cleanliness, food quality or literally any other aspect of a hospital stay.
Copyright 2021 Floor Focus