Informed Flooring Specifications Designed to Last

Informed Flooring Specifications | Designed to Last | Healthcare Market

For most people, 2020 was their first experience with a pandemic that can endanger lives and cripple economies across the globe, and it has certainly increased awareness and diligence when it comes to all things that can affect human health, including material ingredient management.

Prior to Covid 19, material health was already a hot topic among many industry professionals, but we can reasonably expect those conversations to become more prevalent and the hunt for healthy, sustainable building materials to expand as we seek out ways to protect ourselves in various environments.

Designers play a huge roll in this conversion to healthier and more sustainable product solutions. They are looked upon by their clients as expert guides that can inform them of advances in technology and help them make the best possible choices for finish selections.

Today we are going to discuss the tools that are available to help designers make these recommendations and accurately compare flooring products based on a number of different criteria.

AIA CES best practices Credit(s) earned on completion of this course will be reported to AIA CES for AIA members. Certificates of Completion for both AIA members and non-AIA members are available upon request.

Approved for 1 AIA Learning Unit (LU) for continuing education. AIA provider: 40119203 Course: AIACES112420

This course is registered with AIA CES for continuing professional education. As such, it does not include content that may be deemed or construed to be an approval or endorsement by the AIA of any material of construction or any method or manner of handling, using, distributing, or dealing in any material or product. 

Questions related to specific materials, methods, and services will be addressed at the conclusion of this presentation. 6/9/2021 approved certifications: AIA: AIACES112420 1 LU | HSW   IDCEC: CEU-114038 Designation: HSW-Barrier Free GBCI: 920024113

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©2021 Roppe Holding Company

Roppe Holding Company, U.S.A., 1602 North Union Street, Fostoria, Ohio 44830-1158 | 1.800.537.9527

Architects and designers face specific challenges when selecting flooring products for healthcare facilities. For most people, 2020 was their first experience with a pandemic that can endanger lives and cripple economies across the globe, and it has certainly increased awareness and diligence when it comes to all things that can affect human health, including material ingredient management.

Prior to the recent pandemic, material health was already a hot topic among many industry professionals. We can reasonably expect those conversations to become more prevalent and the hunt for healthy, sustainable building materials to expand as we seek out ways to protect ourselves in various environments.

Designers play a huge roll in this conversion to healthier and more sustainable product solutions. They are looked upon by their clients as expert guides that can inform them of advances in technology and help them make the best possible choices for finish selections.

Today we are going to discuss the tools that are available to help designers make these recommendations and accurately compare flooring products based on several different criteria.

After this session you will be able to:

• Develop an understanding for various ASTM standards that can help with product comparisons
• Explore which types of resilient flooring are most appropriate for a variety of occupied spaces
• Explain a range of available documentation and the relevance to material health
• Discover the impact that choosing healthy, sustainable products can have on building occupants

Every environment is now treated as if it were a healthcare setting. COVID has been that equalizer There is certainly more awareness about the necessity of thorough evaluation regarding things that can affect human health, including material ingredient management and maintenance protocols.

Prior to 2020, material health was already a hot topic among industry professionals, but we can reasonably expect those conversations to become more prevalent as the hunt for healthy, sustainable building materials that do not negatively impact critical functions of the human body expands and we seek out ways to protect and fortify ourselves in various environments.

While all market segments have felt the impact of COVID-19, nothing compares to the toll it has taken on the healthcare industry.

Even before the pandemic, healthcare market segments were looking for ways to improve patient outcomes and minimize risks of infection, (Hospital Acquired Conditions, known as HAC’s), and exposure to harmful substances for both patients and caregivers alike. With the rise of the pandemic, and the near-exhaustive efforts of staff to reduce these risks in their facilities, this has become more important than ever.

Like it or not, health systems are a business and patient outcomes are their financial drivers.

When the Affordable Care Act was passed in 2010, the model of care changed from volume-based to value-based, patient centered care. This healthcare reform for Medicare and Medicaid, simply put, means health systems are reimbursed on measures of clinical quality, safety, efficiency, and patient satisfaction. Much of this reimbursement is determined by HCAHPS scores, which are grades provided by the very patients they have served.

Healthcare is about protecting people and flooring is the foundation of the healing environment.

Why is that? At its most basic level, aesthetics, they are so very important. As consumers, we make decisions in the first 30 seconds.

Specific to health systems, aesthetics shape consumers’ perception of the health system’s ability to provide safe, quality care. In this slide, you see four categories, with their associated connections for flooring decisions which can either positively or negatively affect both perceptions and outcomes. While these four categories will be key to so much of what to what we will cover in this CEU, there are two bullet points worthy of mention at the outset. Under operational issues, you see ‘impact on never events’ and HCAHPS scores.

The National Patient Safety Agency, NPSA, defines a never event as ‘A serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers.” The pain point for healthcare facilities is - the potential for litigation aside - insurance companies won’t provide reimbursement should they occur. There are two never events that flooring can have an actionable impact on: slips, trips and falls (STF), and Hospital Acquired Conditions (HAC), or secondary infections that occur during the patient’s hospital stay. HCAHPS scores are calculated from a patient satisfaction survey which, upon discharge from the healthcare facility, is their perception of how their care was.

Flooring too plays a role in this, since two of the question categories deal with cleanliness and the noise levels in and around the patient’s room. HCAHPS scores also play a huge role in the level of reimbursement the hospital receives.

Designers play a huge role in this conversion to healthier and more sustainable product solutions.

They act as expert guides that inform end users about advances in technology that should be utilized on as many projects as possible. Today we are going to discuss the tools that are available to help designers make these recommendations and accurately compare products based on several different criteria.

As the bar continues to move when it comes to performance and expectation, we will look at documentation and testing standards available to designers to help them navigate the world of flooring selection.

Welcome to RHC University Medical Center.

Although located in a remote area of the state, the hospital was built with health and performance in mind.

They wanted to create spaces that encouraged wellness both on a visual level and a molecular level. One of their many objectives was to select durable, made in the USA flooring options that would support their investment and health-conscious goals as they transitioned away from traditional high maintenance flooring options and embraced easier to maintain, safer options for both the patients and the staff.

Let’s start in the lobby.

As with so many different facilities, the lobby can set the tone for the entire experience throughout the building. Since hospitals tend to be stressful places to begin with, RHC wanted the Lobby to feel inviting, warm, and safe with a material that performs at high levels to handle the constant stream of traffic. Equally important, was flooring that wasn’t coated, thus preventing the access disruptions that are associated with stripping and finish applications. For this, they knew they wanted the pleasing aesthetics a high-performance luxury vinyl plank.

Large scale windows wrap around the lobby allowing natural light to fill the space and creating a connection with the trees, gardens and the water feature out front.

This connection with natural elements is a premise of the Biophilic design movement and current research has shown that the inclusion of natural elements like sunlight and water can improve patient outcomes, reduce the need for pain medication, reduce stress, and improve the working environment for those caring for patients (Green, 2018). To this end, the windows were a must for the design of the lobby and for the health of the living wall, so the hospital knew that whatever flooring they chose in the entry had to exceed the ASTM F1515 Light Stability test.

The technology for this testing method originated in the automotive industry. Obviously, the paint on cars needs to be exceptionally light stable, so why not ask the same of flooring? To pass this test. flooring is installed in a closed box and exposed to high intensity light for 400 hours (NTS, 2018). After the 400 hours, the color change is measured and should be less than ∆E8. As with all ASTM standards, the manufacturer is only required to publish whether they pass those minimum performance requirements. They do not have to provide their actual ∆E values, but you can always ask!

Those big windows were not the only concern for the lobby.

RHC University Medical Center is in a unique geographical area of the United States. It experiences a wide range of weather from rain, to snow, to dust storms and extreme heat, so there were several additional considerations that needed to be considered, like slip resistance for the rain and snow, and abrasion resistance for the dust storms. Permanent walk off material in vestibules is always a fantastic idea for front line defense, but not even the best walk off mat can catch it all.

Slip resistance is a serious concern for building owners and occupants, regardless of market segment, not only because people can be litigious, but also simply because no one wants to create spaces where people can get hurt. ASTM D2047 Static Coefficient of Friction (COF) is one of the most often-cited references when relating floor materials to their slip resistance. It’s important to note that maintenance processes and commonly utilized site applied finishes, polishes and other sealers to maintain resilient flooring products will change the walking surface and ultimately the Static Coefficient of Friction.

Since the selected LVT does not contain, nor require a finish, the potential for this issue was minimized. In the next couple of slides, we’ll go into greater detail about COF. Fair warning, this a topic that even national and international testing standards have a hard time agreeing on.

ASTM D2047 is the current predominant slip resistance test method in the United States utilized on resilient flooring. Be aware that many manufacturers still report ratings from ASTM C1028 which was thrown out as invalid in 2014. The topic of slip resistance is controversial and can vary in requirement widely from state to state depending on which version of the International Building Code the state last adopted. Every three years, the building code is updated. Most of the sections outlining slip resistance for flooring refer only to ceramic tile. The ADA accessibility requirements do not overrule state or local laws that impose higher accessibility standards. When federal, state, or local codes differ, is best to follow the one that has the most stringent requirements. (OK.gov, 2021)

Making this trickier for specifiers, the actual ADA standards do not specify a minimum level of slip resistance (coefficient of friction) because an industry wide consensus surrounding the method for rating slip resistance remains elusive. (ADA, 2010) For decades, it was widely believed the Americans with Disabilities Act (ADA) required a static coefficient of friction, dry or wet, of 0.60 or higher for level floors and 0.80 for ramps. (Sotter & Sotter, 2016) In fact, that rating came from a research project sponsored by the Architectural and Transportation Barriers Compliance Board. (Access Board) They conducted tests with people with various disabilities and concluded that a higher coefficient of friction was needed to safely accommodate them. A SCOF of 0.6 was recommended for accessible routes and 0.8 for ramps. The ADA adopted this for a time but withdrew the recommendation in 2010 (McGee, 2017) because the recommendation was missing one important thing: it failed to specify a means of measurement. Even the Access Board of the U.S. Department of Justice has also disavowed any responsibility for this rating. (Sotter & Sotter, 2016)

OSHA, however, has long recommended a minimum coefficient of friction of 0.50 for workplace safety, but, once again, without specifying how the coefficient of friction is to be determined. (Sotter Engineering Corporation, 2020) Written verbiage in ANSI standards addressing DCOF refer to tile without including other types of flooring. In the 2012 edition of the IBC, ANSI 137.1 was included as a guide for DCOF.

In 2014, (ANSI) A137.1, American National Standard Specifications for Ceramic Tile, was revised to read: “[DCOF] does not predict the likelihood a person will or will not slip on a tile surface.” It goes on to recommend a minimum of .42 for a tile floor based on the ASTM D2047 testing method, but then adds “The specifier shall determine tiles appropriate for specific project conditions, considering by way of example, but not in limitation, type of use, traffic, expected contaminants, expected maintenance, expected wear, and manufacturers’ guidelines and recommendations” TCNA added to this essentially explaining that there are many different factors that can further impact slip resistance possibly in efforts to limit the statement of liability of the specifiers, but neither ANSI nor TCNA offer any method to evaluate those additional variables. This goes back to central challenge with rating slip resistance in flooring. (Sotter & Sotter, 2016)

While different measurement devices and protocols have been developed over the years for use in the laboratory or the field, a widely accepted method still has not emerged (US Access Board , n.d.) and different slip resistance test methods will give different results, particularly under wet conditions. A key challenge with all the testing methodologies is that the tests cannot consider important variables like the age of the person walking on the floor, their physical/mental health, their choice of shoes or their specific gait. All the factors contribute heavily to the overall likelihood that someone might or might not safely traverse an area. Section 302.1 of the current ADA Guidelines (2010) states that “floor and ground surfaces shall be stable, firm, and slip resistant”. It goes on to say, i.e. no loose gravel.

Key considerations:

Flooring to be nonporous and smooth

Added texture can increase maintenance challenges and provide grooves that harbor and protect dirt and bacteria

Surface texture can impact slip resistance depending on conditions

There is a lack of correlation between the surface roughness and the dynamic coefficient of friction under the wet environment

This LVT also selected because of the lack of heavy embossing or micro beveled edges. The Facilities Guidelines Institute spearheaded by Johns Hopkins outlines several criteria flooring must meet in order to be considered appropriate for use in healthcare. Among these criteria are recommendations for the flooring to be nonporous and smooth. (Facilities Guidelines Institute, 2010) Similarly, RHC recognized that added texture can increase maintenance challenges and provide grooves that harbor and protect dirt and bacteria, but they also looked at the way the product would wear under the abrasive dirt that blows in when the door opens. Higher ridges have the potential to wear faster and white out as people walk across the floor and grind that dirt into the wear layer.

Smooth LVT or LVT with little or no texture has a better chance of resisting showing such wear and tear longer. Currently, there is no test available to evaluate what levels of embossing will wear better than others. Since luxury vinyl plank and tile does not have its own ASTM flooring classification, it falls under the ASTM F1700 category encompassing solid vinyl tile. The D3389 abrasion test is designed to calculate the abrasion resistance of fabrics coated with rubber or plastic is not a requirement for the products that fall under ASTM F1700. Both reputably manufactured LVT and solid vinyl tile will cause excessive wear on the testing machine before they get a usable rating because the products are inherently hard.

Staircase safety & aesthetics

Another major consideration for the space was the featured staircase. Product selection: High-performance luxury vinyl stair tread.

The lobby staircase is visually prominent, and this is a consideration when coordinating the lobby flooring selection with safety and durability As it is so prominent in the space, they wanted to make sure that it coordinated well with the flooring choice but also provided a safe and durable option that wouldn’t detract from the “resimercial” feel they wanted to help make occupants feel more at home. They arrived at a unique solution in a luxury vinyl stair tread that coordinates with the flooring selection for the lobby. As this staircase is not a technical means of egress and all the riser heights and tread depths are uniform, visual strips were not required, but to be safe, they felt like it would be a good idea to include them.

The latest version of the International Building Code (IBC),section 1029.14.2.3 designates that stairs considered to be in assembly spaces with a capacity to hold 300 or more people should have “a solid and continuous stripe … applied to the horizontal leading edge of each step… outlining stripes shall have a minimum horizontal width of 1” and a maximum of 2”” (International Building Code, 2020). There is no definition for what light reflective value or percentage of contrast these stripes should be and there is no exact recommendation from the ADA about this either aside from the recommendation that a dark stripe should be used on a light surface and a light stripe on a dark surface. There is also no requirement of differentiating texture in the stripes. In section 1025.2.1 the same designations are required for stairs that are considered a means of egress but in this case, the stripes are required to be photoluminescent. (International Building Code, 2020)

At the outset of this CEU, it was stated how a large amount of hospitals insurance reimbursements are based on patient outcomes. Mention was made of never-events, and that an STF (slips, trips and falls) is one of them.

RHC was already sold on rubber flooring because of its acoustic properties and maintenance benefits of being a non-coated floor, but what further caught their eye was that rubber flooring has a distinct advantage over other resilient flooring in that its Co-efficient of Friction (COF) wet or dry, is closer to the same result or without as much variation. We touched upon the applicable standard, ASTM D2047, in an earlier slide, when we were discussing surface textures, but rubber flooring offers a huge work-around for those choices, since its COF is unaffected, whether it is smooth or has a texture.

Areas most vulnerable to STF never-events such as OR’s, corridors and patient rooms should find this virtue alone very appealing. Rubber flooring is heat weldable, comes in sheet or tile form, and some manufacturers offer an integral flash cove which eases in installation and maintenance. Rubber flooring has a wide color line, already shown to contrast and complement the LVT in RHC’s cafeteria application.

Flooring finishes for administration offices.

The pandemic caused RHC to look very closely at the finishes they have been using in all areas of the hospital to public and sanitary spaces

According to EPA definitions, a disinfectant cannot legally claim on its label or in any advertising that it can disinfect carpet.

After some research, RHC further learned that there is no way to truly disinfect porous surfaces, (Starcher, 2020) so they decided to make a concerted effort to remove as much carpet as possible from their facility, including the carpet that would traditionally have been used in the administration and office areas, as well as the lecture spaces.

Almost all carpet is anionic or negatively charged. Unfortunately, disinfectants are cationic or positively charged,. And what do we know about opposites? They attract! So, when you add a cationic disinfectant to an anionic carpet, it creates a gummy residue that will hold and attract more dirt and bacteria instead of effectively neutralizing germs and viruses.

Depending on the carpet manufacturer, using a disinfectant or sanitizing product may completely void any warranties the product carries. Some disinfectant and sanitizing products can also affect the performance of mill-applied stain resistance properties. Lastly, there is no realistic “on the job” way to test, verify or validate that what has been done to disinfect or sanitize carpeting has been effective.

The cafeteria – a main gathering space for patients, staff and visitors. The risk of contaminants and slip hazards is high in food serving areas. Cleanliness vs. the perception of cleanliness:

The old “Shiny is clean” myth still prevails in some design and facilities services circles. Actually, the reverse is arguably true. Glare on surfaces makes spills or subtle changes in subfloor flatness virtually undetectable. The term in play here is known as Light Reflectance Value, LRV. It is a calculation which indicates how much a color reflects, and conversely, how much that color absorbs.

Measured on a scale of 0-100, black is 0 and white is 100. It is generally accepted that an LRV below the midpoint of 50 absorbs light, while higher than 50 reflects. Paint manufacturers pioneered this measurement and LRV is a commonplace listing on their paint swatches and samples. Flooring manufacturers are moving in this direction of likewise labeling their samples, but it might require a quick call or email to your rep to get this information.

According to FGI (Sec A2.1-7.3.1), “floor reflectivity with gloss values further can cause glare that may compromise patient vision, disturbing balance. A non-wax floor which eliminates glare, or a matte finish is recommended.” To further remind specifiers of which way to go with their selections, there is a new saying emerging in healthcare design: ‘matte is where it’s at.’ When it comes to this cafeteria’s flooring specifications, the choice was made to go with a rubber flooring and LVT combination in colors with LRV’s of less than 50.

In healthcare, cleanliness should be a top priority in order to help control the occurrence of hospital acquired infections. Just like any other business, healthcare facilities cannot operate at a loss and both Medicare and Medicaid do not reimburse hospitals for costs related to them, as previously mentioned.

Maintenance is the #1 pain point with health systems and RHC feels no differently. RHC did not want their EVS teams getting bogged down with unnecessary flooring maintenance when there are so many surfaces in the facility that also need attention.

Studies have found that the strip and wax process takes about 81% longer than simply cleaning and disinfecting resilient flooring, and costs about 90% more in labor hours. 99% more in chemistry used, resulting in 70% more in supply costs. Because the strip and wax process takes so much longer, it diverts focus from cleaning other surfaces, causes cleaning equipment to depreciate faster and use more electricity.

There is also no proof that applied sacrificial wear layers offer extra protection against germs, viruses, and bacteria.

For every 10,000 sf of flooring that must be stripped, approximately 250 gallons of water is used depending on the dilution recommendation of the stripping agent. Much of the discarded and removed finish will end up down drains, clogging plumbing and creating costly repair situations and blockages. RHC found that although flooring solutions like LVT or rubber flooring initially cost two to eight times more to install than a flooring that requires the application of a sacrificial wear layer, they could recover those costs within 2-5 years in maintenance dollars and labor savings. This is not new information.

In 1998, “Life-Cycle Benefits of Flooring Surfaces in Health Care – Our Methodology Was All Wrong?” published findings from a 15-year study conducted in a busy hospital in Orlando, Florida that concluded, of the 15 hard surfaces and 12 carpet options evaluated, the average cost to maintain the most initially expensive floors like rubber and ceramic tile over their lifetime were ultimately less expensive than the original installation cost of the floors. The study also found that the flooring types offering the most initial installation cost savings like VCT ended up costing 9 – 15xs the initial cost of installation over the course of the products’ life cycle. This extreme cost difference was so high from the initial cost “savings” that had been anticipated, that the hospital immediately changed their methodology of value engineering to include a maintenance factor. Adding this factor is something rarely done in most VE cases, but incredibly impactful when cost savings are imperative.

With overwhelming evidence supporting their decision to move forward with low maintenance flooring options, RHC decided to create a flooring pattern that integrated the LVT from the lobby and the rubber flooring they utilized in some of the sanitary spaces. Rubber was used around the serving line where risk of spills was greater, and people would be standing for longer periods of time. They found a manufacturer that offered both materials and could verify that the different rates of expansion and contraction for each would not be a problem when installed adjacent to each other without transitions. They also wanted to ensure that maintenance requirements would not drastically change between the 2 surfaces so that their technicians could move through the entire facility without having to switch chemistry products or cleaning equipment. 

While the physical safety and health of building occupants is a primary concern for RHC, they also wanted to address mental health and safety as much as possible by making many potentially stressful aspects of needing hospitalized care easier on patients.

RHC decided to provide complimentary daycare services for patients receiving various treatments and undergoing outpatient procedures to help alleviate that potential worry of a parent needing to find alternate childcare. RHC also realized that the anxiety would not be limited to the parents. Children whose parents are critically ill or injured may be feeling stressed, confused or even angry, so RHC wanted the space to be an escape from that. A place that could inspire creativity or that could allow the child to distract and relax.

Colors are the most used tool by children to express their emotions and thoughts.

Although the preferences of children show a general commonality based on age group, their color choices can differ based on their moods, the way they express themselves and their feelings. (Renk Etkisis, 2017) Researchers at the University of California determined that young children chose bright colors to represent positive feelings and dark colors for negative feelings. (Parent Co , 2016)

For younger children, who lack the ability to properly communicate their needs to unfamiliar caregivers, the colorful rainbow acts as a means of alternate communication. Institutions like the American Red Cross, St. Jude’s Hospital, Boston Children’s Hospital, and Scholastic incorporate this ability to connect feelings to colors to better understand the emotions of young children.

So, if the children can point to or tell the caregivers that they feel gray or blue, are seeing red, or feel green with envy, the caregivers will know what they are talking about and can better guide them through their emotions. (Parent Co , 2016) The goal was for the daycare to be bright and inviting without becoming so over stimulating that the child might become more anxious while waiting on mom or dad. RHC created a space inspired by color that is easily adaptable to children of different ages while keeping everyone connected with a central rainbow theme.

The other side of the visual coin, was, of course, the ability to keep the space clean. It is estimated that 1 in every 12 children have asthma (AAFA, 2018) and clusters of children are known “germ factories”, so the decision to remove carpet that can be a reservoir for allergy-causing substances that trigger asthma (Li, n.d.) in favor of flooring that can be easily disinfected was an easy one.

The lecture spaces across the hall were similarly addressed.

Lecture Spaces

For the lecture spaces, RHC looked at higher education to see what was working in that market segment.

Especially with the proximity to the cafeteria right outside and the morgue directly below, sound control became a new consideration on top of easy maintenance requirements. Rubber flooring has similar sound deadening characteristics to that of certain vinyl or backed carpet tiles, but without the challenge of not being able to disinfect it.

Sound ratings of flooring

As they started comparing sound ratings on flooring, they noticed that some ratings were substantially higher than others but were expressed differently. After consulting an industry expert, the difference between a ∆IIC value and a standard IIC value was explained. The IIC, or Impact Isolation Class, rating essentially measures the floor's ability to absorb impact sound. For this a taping machine bangs on the flooring and decibels are measured from below. There are many ways to skew an IIC rating toward higher numbers. A manufacturer can create an installation with a 12” concrete slab or a drop ceiling installed below it. Both these things would elevate an IIC number.

So, when considering the effectiveness of a flooring material at controlling noise in this way, it is best to look for the ∆IIC rating. This test is more heavily controlled. The taping machine bangs on 6” thick concrete slab and the decibels are measured from below. The flooring is then installed on that slab, the machine taps again, decibels are recorded and the difference between the two is the ∆IIC rating.

This is different from STC ratings, but no less important particularly for areas above other occupied spaces. Sound Transmission Class represents a material or product’s ability to block sound from travelling through a wall, ceiling, floor or other building assembly – in other words, to stop airborne noise transferring from place to place. (Wilkinson, n.d.) Rubber scored much higher than vinyl flooring options or other hard surfaces in both categories and became the top flooring choice for the lecture spaces.

source Acoustical Data - Impact Insulation Class (IIC) (force.com)

Third-party verification

RHC really focused on making educated decisions throughout their facility and utilizing all the available reports and documentation available to them to help guide them in this journey. 

As we find ourselves in one of the meeting halls or lecture spaces RHC has available to residents and guest lecturers, we are going to look at some of those reporting methods and what they mean.

EPDs, HPDs and Declare labels have become standard issue documentation for industry professionals, but they are costly for the manufacturer and the data they present is not always as complete as manufacturers make it out to be.

Third-party verification does not even guarantee full transparency in these documents. Verification companies can only verify that what the manufacturers tell them matches what is on the label or in the report. There is not someone going to individual manufacturing facilities and looking over their shoulders during the production process like some aggressive chemical hall monitor.

Hospitals have some of the heaviest, most aggressive rolling loads

In addition to battling some of the most dangerous viruses and germs daily, healthcare facilities have some of the heaviest and most aggressive point and rolling loads of any market segment particularly in and around their operating rooms. These rolling loads can dent or even tear certain types of flooring which goes back to both patient perception of cleanliness and actual cleanliness. Damaged flooring is the perfect place for bacteria to snuggle up in and spread out.

RHC was pleased to find out the flooring they selected also performed well under ASTM F970 testing. ASTM F970 measures indentation resistance in flooring. A weight is placed on the flooring for a 24-hour period, then the indentation is measured. To pass, the residual indentation must not exceed .005” in depth from a 250 lb. weight. A standard Hill-Rom bed exerts 583lbs of pressure per wheel on the floor without a person in it. (Tarkett, 2017) Some of these beds are designed to hold up to 995lbs. (Hill-Rom, 2019) A manufacturer can choose to conduct modified ASTM F970 testing that continues to increase the weight until the flooring can no longer resist the indentation. Manufacturers can report these findings to help the specifier have a better idea of quality.

There is a lot of debate surrounding this test because there is no allowance for the type of adhesive used in an installation assembly and this can greatly affect indentations in the flooring. In the case of sheet vinyl or LVT/ LVP flooring installed in a healthcare facility, a traditional pressure sensitive adhesive that remains in a “tacky” state even after installation would be a poor choice as it could lead to adhesive bed displacement and the perception of flooring indentation when really, the adhesive just moved out of the way of the heavy point or rolling load causing the product to “fail”. ASTM F970 is also only measuring indentation resistance, it does not measure recovery or rebound. Once a vinyl plank or sheet dents, it is very unlikely to recover, but rubber flooring might over time. There is not really a test for that though. It is also important to know that ASTM F970 is for static load resistance only and is not an indicator for rolling loads. There is no industry-wide accepted method to evaluate dynamic loads (Armstrong Flooring ) and this is again partially due to how much of an effect the adhesive selection will have on the overall assembly.

When evaluating the considerable weight of many machines, furniture, and those Hill-Rom beds, it might seem to make more sense to go with a flooring option that is rigid or hard like polished concrete, terrazzo or epoxy coatings. However, healthcare facilities have support staff and caregivers that are on their feet for an incredible number of hours during a single shift or worse, connecting shifts. That can take a huge toll on the human body. Disorders of the musculoskeletal system account for one third of all occupational illnesses and work-related injuries. The costs resulting from workers comp claims and missed time are considerable – but selection of the right ergonomic floor covering can help counteract this. (Nora By Interface )

According to Newton's third law, the ground reaction force (GRF) is the force exerted by the ground on a body in contact with it. When a person is just standing, the GRF corresponds with the person’s weight. When the body is moving, the GRF increases due to accelerated forces. For example, while running, the GRF increases to up to two or three times the body weight. (Kistler )

There is a balancing act here. RHC realized that it would be ideal to install flooring that had some “give” to it in order to limit the ground reaction force impact on the people standing and walking on the flooring all day in areas like ERs, ORs, ICUs and Labs, but since it is not feasible to install anti-fatigue mats all over the hospital, they had to find a flooring selection that would not make pushing or moving heavy equipment more difficult for staff by being too soft. Flooring that is too soft would increase the risk of injury far beyond the risks of using those harder flooring choices. Rubber flooring was the only Red List Chemical Free option available that could offer extreme durability, excellent chemical resistance and high indentation resistance while still offering moderate ergonomic comfort. They looked at various thicknesses of material but found that there was no correlation with ergonomic comfort and thicker rubber flooring. Thicker rubber flooring only increased costs and created more need for transitions to and from other flooring types, so RHC moved forward with installing standard rubber flooring in all their high-risk patient areas as well as any area where hospital staff would be on their feet for long periods of time. The average caregiver is 50+, they walk up to five miles per 12-hour shift!

Investing in material health

Where there is the greatest risk for patients and caregivers

While flooring is not considered a high-touch surface, it is still the largest, most interacted with finish in each area, and germs could easily land on the floor, hang out for a bit and then get transferred to other possibly high touch surfaces.

They wanted a Red List chemical free flooring option that would be durable enough to handle the aggressive levels of traffic and continuous disinfection these spaces also require:

• Operating rooms
• Emergency rooms
• ICUs, NICUs, and burn units

Environmental Impact

For specifiers wishing to select flooring for its overall environmental impact, they can ask for an Environmental Product Declaration (EPD).

EPDs present transparent, verified, and comparable information about the life-cycle environmental impact of products. (The International EPD System , n.d.) In order to create an EPD, a Life Cycle Assessment must be conducted by the manufacturer for each type of product..

HPDs

Health Product Declarations (HPDs) provide a full disclosure of the potential chemicals of concern in products by comparing product ingredients to a set of priority “hazard” lists based on the GreenScreen for Safer Chemicals and additional lists from other government agencies.

In a standard HPD, the chemical inventory of the product must be characterized and screened to at least 0.1% (1000 ppm). (Blank, 2018) However, in order to have your HPD qualify for LEED v 4, product contents must be disclosed by chemical name and CAS number to at least 100 ppm (0.01%), with few exceptions allowed.

This level of transparency is detailed enough that other manufacturers could absolutely figure out how to poach proprietary technology, so it understandably makes many manufacturers nervous.

This is the same level of transparency that ILFI’s Declare labels demand.

The 3 compliance levels are:

1. LBC Red List free – which means that the product is free of all red list ingredients
2. LBC compliant – which means that the product contains some chemicals that ILFI has designated as temporary red list exceptions
3. Declare– which means that the product is compliant with the omission of Red List ingredients, or its temporary exceptions

A Declare label answers 3 main questions: Where does the product come from? What is it made of? And where does it go at the end of its life?

Not surprisingly, a Declare Label requires compliance with the California Department of Public Health (CDPH) for all interior building products that have the potential to emit VOCs. (International Living Futures Institute , 2020) Much like an HPD, Declare labels also take a hard look at the inclusion of Red List Chemicals that may be among a product’s list of raw material ingredients. So, can a product be Red List Chemical Free and not have a Declare label attached to it? Absolutely, the same information about material ingredients can be found on an HPD.

HPDC Builder (roppe.com)

Here are examples of a Declare label and an HPD, in the event you are not familiar with them.

By now everyone should be at least somewhat familiar with the Red List from International Living Future Institute.

The Red List is considered the worst of the worst when it comes to chemicals and compounds commonly found in building materials that negatively affect the human body. As awareness of the harmful nature of Red List Chemicals has grown over the last several years, many manufacturers are responding by choosing healthier or, at the very least, less harmful material ingredients for a range of products.

One of the 22 categories found on the Red List is VOCs. We have probably all heard the statistics about indoor air toxicity. The levels of some hazardous pollutants in indoor air have been found to be up to 70 times greater than in outdoor air. Chemical compounds that have a carbon basis and evaporate easily into the air are known as Volatile Organic Compounds. Caregivers continually exposed to a range of viruses, bacteria and other contaminants cannot afford to have their immune systems compromised either. Yet there are no clear guidelines to ensure good air quality is available in buildings.

The average person will use typically 33lbs of air a day by simply breathing compared with 2.5lbs of food and 4.5lbs of water (Ramaswamy, Al-Jahwari, & Al-Rajhi, 2010), so it just stands to reason that especially in a healthcare facility, limiting as many Red List Chemicals and VOCs as possible would just make sense.

Volatile organic compounds (VOCs)

Operating Room Corridors

For the spaces where patients would be the most vulnerable, they investigated several types of flooring that claimed to limit the spread of infectious bacteria, germs, and viruses. RHC set out to invest heavily in material health where patients and caregivers would be at the greatest risk; Operating rooms, emergency rooms, ICUs, NICUs and burn units. They wanted a Red List Chemical Free flooring option that would be durable enough to handle the aggressive levels of traffic and continuous disinfection these spaces also require.

For the spaces where patients would be the most vulnerable, they also investigated several types of flooring that claimed to limit the spread of infectious bacteria, germs, and viruses. While flooring is not considered a high touch surface, it is still the largest most interacted with finish in each area, and germs could easily land on the floor, hang out for a bit and then get transferred to other possibly high touch surfaces. RHC found a US manufacturer who provides 6-foot-wide rubber sheet flooring with a heat weldable integral cove base which ticked all the boxes for them. This allowed for a virtually seamless floor for their 8-foot-wide corridors.

A product cannot be both Red List Chemical free and include antimicrobials with marketed health claims.

Healthcare facilities have been trying to balance the use of antibacterial and antimicrobial finishes with the fear that aggressive use of these materials will encourage the mutation of super bugs that are largely antibiotic resistant. In the U.S., antimicrobials are classified as pesticides, and since they are designed to kill organisms, they can have some undesirable effects of living beings. (Earlham College, n.d.)

Most pesticides are at minimum, mutagens and teratogens. Mutagens are substances that change the genetic information of an organism, usually by changing DNA. Mutagens can also be carcinogens. Common mutagens include formaldehyde, dioxane, and nicotine. Teratogens are substances that cause harm to the fetus or embryo during pregnancy, causing birth defects even when the mother shows no signs of toxicity. Common teratogens include ethanol, mercury compounds, lead compounds and xylene. It should be noted that mutagenic and teratogenic effects can and do occur at much lower exposure levels than those required to exhibit outwardly toxic effects like illness or impaired bodily functions. (Earlham College, n.d.) Antimicrobials were frequently used in soaps until the FDA banned them in 2016, but they are increasingly popular in building materials, including countertops, paints, doorknobs, and certain types of flooring. (International Living Future Institute, 2021) Antimicrobials and antibacterials are also one of the 22 categories on the Red List.

As COVID-19 surged and took the world hostage, many people were hoarding products with antimicrobial claims thinking that using these products were more likely to keep them safe. So, regardless of negative side effects, are antimicrobials incorporated into things like flooring truly effective against viruses? Well, like anything else, it depends. Claims for antimicrobial effectiveness are determined in laboratory testing by their performance against ‘test organisms’ that are assumed to be harder to kill, but usually less pathogenic or likely to cause disease, than the germs, bacteria and viruses, the antimicrobials are intended to kill in real-life situations.

For a novel pathogen such as COVID-19, governments and researchers are doing additional studies now on what effectively sterilizes and kills the virus, but they’ve yet to make extensive claims for antimicrobials.

Because of the wide range for only potential efficacy of antimicrobials on the market combined with the risk of negative side effects on human health, many facilities like RHC decided to look for material finishes that are “naturally” and inherently effective at controlling the spread of bacteria, fungi and viruses.

In general, infectious viruses prefer the human body first, followed by hard surfaces at room temperature. The smallpox virus, for example, can easily live for months – even years – on a tabletop. That’s why it caused a devastating epidemic before the smallpox vaccine.

Some viruses survive for shorter periods outside the body, although “shorter” is often still long enough to infect other people. Hepatitis B and C can live between 16 hours and 1 week. Cold viruses can survive 1 week while flu viruses die after about 24 hours. HIV is an example of a virus that dies almost instantly outside the body. (Service Master Commercial Cleaning , n.d.). The infectivity window for COVID-19 is still under some debate. The most widely accepted range for infectious activity on various hard surfaces is 72 hours adopted from a research letter published at the beginning of the pandemic in the New England Journal of Medicine. Although, some hard surfaces like copper and cardboard were found to have shorter windows. An even more disturbing publication that came from the Australian Centre for Disease Preparedness suggested that COVID-19 can survive on surfaces for up to 28 days. (Labos, 2020) Flooring is not considered a critical surface, so RHC decided to skip products that included EPA-graded pesticides in favor of Red List Chemical free options. If a product passes ASTM G-21, this means it has inherent resistance to fungi without any chemicals or additives. RHC chose that ASTM as a ready resource and qualifier in selecting flooring products for their interiors.  

Many facilities like RHC decided to look for material finishes that are “naturally” and inherently effective at controlling the spread of bacteria, fungi and viruses. In general, infectious viruses prefer the human body first, followed by hard surfaces at room temperature. The smallpox virus, for example, can easily live for months – even years – on a tabletop. That’s why it caused a devastating epidemic before the smallpox vaccine.

Some viruses survive for shorter periods outside the body, although “shorter” is often still long enough to infect other people. Hepatitis B and C can live between 16 hours and 1 week. Cold viruses can survive 1 week while flu viruses die after about 24 hours. HIV is an example of a virus that dies almost instantly outside the body. (Service Master Commercial Cleaning , n.d.). The infectivity window for COVID-19 is still under some debate. The most widely accepted range for infectious activity on various hard surfaces is 72 hours adopted from a research letter published at the beginning of the pandemic in the New England Journal of Medicine. Although, some hard surfaces like copper and cardboard were found to have shorter windows. An even more disturbing publication that came from the Australian Centre for Disease Preparedness suggested that COVID-19 can survive on surfaces for up to 28 days. (Labos, 2020) Flooring is not considered a critical surface, so RHC decided to skip products that included EPA-graded pesticides in favor of Red List Chemical free options.  

While hard surfaces are the better choice for areas where disinfection is key, it is not that simple.

Using harsh disinfectants in or around occupied spaces that are not properly ventilated can lead to a host of irritation issues in the short term and larger health concerns in the long term.

As we move into in the patient rooms, sanitation and disinfection protocols look a little different as most of these spaces have a continuous stream of new patients entering them.

Patient Rooms

How many people in this room feel like they have a good understanding of the differences between cleaning and disinfecting and the order in which they must be carried out? Cleaning is the process of removing dust, dirt, debris, and organic matter from various surfaces, but not necessarily killing anything. Disinfecting destroys or inactivates both the bacteria and viruses identified on the product’s label (like influenza and rhinovirus) but only on hard, nonporous surfaces. Disinfection without cleaning is pointless since most disinfectants lose their effectiveness rapidly in the presence of organic matter. (Tarkett) Flooring is considered a noncritical surface when it comes to disinfection protocols.

Noncritical surfaces may come in contact with skin, but not with mucus membranes. This is different than the now popularly coined phrase “high touch” surfaces. For example, bed rails, bedside tables, and countertops are considered both “noncritical” and yet, they are prime high touch culprits, so noncritical surfaces can still require a lot of attention when it comes to cleaning and disinfection practices.

While hard surfaces are the better choice for areas where disinfection is key, it is not that simple. Using harsh disinfectants in or around occupied spaces that are not properly ventilated can lead to a host of irritation issues in the short term and larger health concerns in the long term.

How many people in this room feel like they have a good understanding of the differences between cleaning and disinfecting and the order in which they must be carried out?

Cleaning is the process of removing dust, dirt, debris, and organic matter from various surfaces, but not necessarily killing anything. Disinfecting destroys or inactivates both the bacteria and viruses identified on the product’s label (like influenza and rhinovirus) but only on hard, nonporous surfaces. Disinfection without cleaning is pointless since most disinfectants lose their effectiveness rapidly in the presence of organic matter. Flooring is considered a noncritical surface when it comes to disinfection protocols. Noncritical surfaces may come in contact with skin, but not with mucus membranes. This is different than the now popularly coined phrase “high touch” surfaces. For example, bed rails, bedside tables, and countertops are considered both “noncritical” and yet, they are prime high touch culprits, so noncritical surfaces can still require a lot of attention when it comes to cleaning and disinfection practices.

While hard surfaces are the better choice for areas where disinfection is key, it is not that simple. Using harsh disinfectants in or around occupied spaces that are not properly ventilated can lead to a host of irritation issues in the short term and larger health concerns in the long term. There are some manufacturers that advocate for steam cleaning as an effective, chemical free way to sanitize a space around a patient.

“While the use of steam will kill what it has touched, given the operator gets the equation correct, it can also act as a propellant to move microorganisms out of its path and redistribute them throughout the air without killing them first. Most resilient flooring will not respond well to prolonged contact with an object that is pumping out those kinds of temperatures. Even if the flooring itself can resist dimensional stability issues, the adhesive underneath the flooring may break down and cause secondary issues.” 

UV Light Sanitation is also gaining popularity because of the lack of harmful chemicals and the ability to completely mechanize the sterilization process. Automated UV-C units can be introduced into spaces and sterilize the whole room without requiring human intervention at all. Even stubborn C-Diff is eliminated with exposure to UV-C rays within 10ft of the unit after only 15 minutes. (Hospital News ) This is of course, assuming the room has been thoroughly cleaned first. UV light sanitation cannot condense the necessary 2 steps into one. With the utilization of powerful UV Light in mind, let’s all take a minute to reflect on ASTM F1515, light stability testing. While the UV-C is safe and effective at eliminating harmful bacteria, germs, and viruses, it will absolutely change the color of various finishes, and it can do that very quickly.

Products without polyurethane wear layers may resist yellowing slightly longer, but they will also eventually turn dull and dingy in appearance. Since publicly reported patient satisfaction scores, or HCAHPS, include patient perception of cleanliness (Centers for Medicare and Medicaid Services, 2020), dull, yellowed and cracked finishes throughout a patient room is unlikely to promote the perception of clean environment even if it is sterilized. This can also lead to increased repair and replacement costs for the hospital as the testing methods that interior finishes are required to comply with simply do not account for this level of repeated, aggressive UV light exposure. While vinyl and urethane finishes are known to be especially sensitive to this type of sanitation, most finishes and flooring will experience some level of degradation; even incredibly durable, homogenous flooring options like rubber.

Labs & specialty testing spaces

A sudden jolt of electrical current can fry circuits inside the device, and it’s critical to determine the type of footwear people will use in the space

Labs | Rubber ESD flooring

For areas where high-sensitivity equipment is frequently used

Some manufacturers offer rubber flooring in an ESD formulation to accommodate areas where highly sensitive equipment is frequently used. With the successful implementation of rubber flooring in so many other areas, there was never any debate as to what RHC would be installing in their labs.

This may surprise specifiers, since rubber flooring is known for its durability in areas like pathology labs where staining agents, harsh chemicals and waxes are prevalent in use. Rubber has better chemical and stain resistance properties than most other resilient flooring categories.

Rubber can only be dissipative as rubber has natural insulating characteristics which makes sense given the ergonomic and sound controlling qualities that come with it. Vinyl can be either conductive or dissipative, so it is important to accurately communicate which one is necessary in each space. Certain vinyl ESD flooring options on the market require a finish to be added as the final step of installation. This adds time, money and labor dollars to the budget plus it will no longer be considered a low maintenance floor. Given, how costly and sensitive much of the equipment used in state-of-the-art laboratories can be, RHC decided that rubber ESD flooring was the best choice.

Rehabilitation Center

RHC also has a state-of-the-art rehabilitation center. This space is used for everything from teaching people who have suffered terrible injuries to walk again to assisting with various therapies designed to increase motor function and dexterity in patients with specific handicaps.

The Rehab Center needed to be comfortable and of course, promote patient health. RHC knew that they needed a flooring with a suitable Fall rating as many of the patients pose a fall risk, but they also needed the floor to be firm enough that it would not create a stability issue by being too soft like certain mat flooring you might find in a rock-climbing facility.

The ASTM F2772 test for sports flooring was designed by a collaboration of the US Olympics, the NBA, the MLB, and the USTA. For flooring to be considered “sports flooring” it must pass four individual tests.

SHOCK ABSORPTION

First is shock absorption that measures the floor’s ability to reduce the force of impact.

Increased shock absorption translates to a safer floor capable of reducing the risk of long-term injuries. Class 1 is the ideal rating for flooring in a facility like this. Classes 2-5 absorb more force, but the higher the number, the harder the floor will be to walk on, like the rock-climbing fall mat. Next, vertical deformation is measured to determine the floor’s ability to deform or “give” when a person jumps or falls on it. It is associated with flooring comfort and the reduction of immediate injuries. Too much “give” is like running on the beach and can be extremely unstable, while too little give increases the risk of injuries on impact if someone should fall in the space.

The ball bounce test measures the accuracy of the vertical ball behavior. The higher and more uniform the ball rebounds, the better for flooring designed to have games like basketball or tennis played on them. Again, if the flooring has too much give to it, this will absorb force and limit the ball’s ability to bounce. Finally, the Sliding Effect is calculated. This is also referred to as coefficient of friction, but the unlike ASTM D2047 that uses the James machine, the British Pendulum is used. This test has also been said to produce unreliable results in “wet” testing, but it is credited by certain manufacturers with highlighting the floor’s optimal level of grip and slide in all directions and allows for safe and easy movement or pivoting. (Gerflor)

While there are many floors that pass these 4 tests, RHC wanted something that looked less like a competition gym and more like a space with physical growth in mind, like a traditional work out space. In the interests of keeping the materials in the space as healthy as possible, they chose to stay away from recycled tire content. Recycling tires into crumb rubber for use in things like flooring or playground material diverts millions of tires from ending up in landfills. It saves energy and resources.

There are also some serious negatives involved in utilizing old tires. Scientists are raising alarms about distillate aromatic extract, also called “aromatic process oils,” used as softeners in tires. These oils can make up to 30 percent of a tire’s mass. They contain some of the world’s most harmful chemicals. The European Chemicals Bureau says this can be regarded as “a substance with persistent bioaccumulative toxicity (PBT).”

LEAD The concern with tires and material health does not end there. Lead is another concern that has been identified in crumb rubber.

Lead compounds have been part of tire formulations since 1839, when Charles Goodyear heated a mix of natural rubber, sulfur and white lead, and created the world’s first melt-proof rubber blend. Three independent sources have identified levels of lead in tires above the U.S. legal limit for lead in children’s products. Obviously, tires are not designed to be toys for children, but when these tires are being ground up into flooring that children will be in contact with, the concern is real. Lead is not only included in the initial production of certain tire formulations; it is also absorbed as tires run over highway paint formulated anywhere from 1930 – 1990 or from crushing lead balancing weights that fall off tires onto the road. (Healthy Building Network , 2013) The material hazards of tires are so concerning that companies like Michelin have spent more than $800 million in a single year researching sustainability so they can make tires out of root vegetables. (Berendsohn, 2018) Luckily, RHC was able to find a flooring from a manufacturer that removed the use of recycled tire content and replaced it with scrap material from the rest of the red list chemical free flooring they were already producing!

At this point, there are probably a few people who are wondering why RHC would make material health such a priority and then continue to use vinyl flooring in large areas of their facility. RHC felt that a great way to create a comfortable “at home” ambience was using commercially rated products that mimicked finishes people might want in their homes. The high-definition print films coupled with the coordinating stair treads allowed them to pursue this vision. However, since there are some health concerns associated with utilizing vinyl flooring, RHC wanted to research the topic before moving forward with this selection. They found that push back about luxury vinyl plank comes from a few different factors; the potential inclusion of phthalates, organotin compounds, potential for the inclusion of contaminated recycled content as well as vinyl chloride among the raw materials, and dioxin production from burning polyvinyl chloride. While these may sound extremely prohibitive, when you break it down, responsibly manufactured vinyl products are not the villains they are often made out to be and LVT/LVP is extremely durable and cost effective which often outweighs the negatives.

Phthalates and organotin compounds appear on ILFI’s Red List. Mounting evidence from animal studies show that phthalates, particularly orthophthalates, interrupt the functioning of the endocrine system which can have implications for childhood and reproductive development, as well as presenting as a potential carcinogen. Phthalates are prevalent in a wide variety of vinyl and plastic products and are exceedingly difficult to avoid, but certain manufacturers of luxury vinyl plank and tile have found safe alternatives, known as non-phthalate plasticizers, to the use in place of these orthophthalates.

Organotin compounds are used in the production of PVC, silicone rubber, and polyurethane. Exposure can cause memory loss, eye irritation, and liver damage. Certain organotin compounds are neurotoxins and acute exposure can be lethal. Organotin compounds can most often be found in the wear layers of certain products, but these are few and far between anymore especially when working with reputable manufacturers. Phthalates and Organotin compounds may find a way back into an otherwise clean product with the utilization of recycled content that is not properly screened. Recycled content can also increase the likelihood of dimensional stability issues, so products with recycled content backings are best avoided. (International Living Future Institute, 2021)

DIOXINS A particularly important yet concerning component of LVT is the use of vinyl chloride during the manufacturing process of polyvinyl chloride.

Vinyl chloride in its raw form poses several threats to human health from dizziness all the way to lung and kidney irritation. Vinyl chloride is not produced in LVT plants, but it is brought in as a raw material. Most LVT is produced in a closed loop system that keeps factory workers completely safe from the health effects associated with coming in contact with vinyl chloride during the manufacturing process. And finally, Dioxin.

Dioxins are a group of highly toxic chemicals that can cause problems with reproduction, development, and the immune system. They can mess with a person’s hormones and lead to cancer. Dioxin production has been ruthlessly connected to PVC by a variety of green building standards, but dioxin is the unintended byproduct of all industrial processes that contain chlorine. More specifically, dioxins are produced when chloride matter is burned. (Johnsen) Essentially, any process involving combustion in the presence of a small amount of chlorine can lead to the formation of dioxins under certain temperature and oxygen conditions. So, burning trash in your backyard or a building fire will lead to dioxin emissions. Forest fires produce dioxins because trees and other living matter contain chlorine ions. Diesel engines, the production of zinc, aluminum, iron & steel, bricks, cement and ceramics, timber kilns and many other industrial processes can be sources of dioxin formation.

In 2004, The Australian Federal Government undertook an inventory on dioxin emission sources. They found that uncontrolled combustion processes, like burning trash and accidental fires comprised mostly of grass and brush fires - contribute approximately 75 percent of all dioxin emissions in Australia. Metal production like aluminum, zinc, and steel accounted for nearly 9 percent of total emissions in Australia, while local PVC manufacturing was negligible (less than 0.001 percent of the total). (Vinyl Council Australia ) Currently the European PVC industry accounts for around 0.1 % of the total dioxins emitted by human activities. (Johnsen) In the United States, federal regulation of waste incinerator emissions and incinerator closures have significantly reduced dioxin and furan releases to the air from those sources, but forest fires, house fires, and people illegally burning trash is much harder to control and therefor a larger problem when it comes to dioxin production.

PVC

PVC is not only found in flooring. In healthcare situations, PVC is used in about 75% of building materials as well as miscellaneous items like PVC-based IV bags, blood bags, urine bags, tubing, oxygen masks, catheters, and disposable gloves.

While many of these items are one use items destined for the landfill, flooring can absolutely be recycled and does not need to end up in the incinerator or landfill. After reviewing the data, RHC choose a reputable USA-based manufacturer to work with and moved forward with their designs.

The result is a facility that embraces and fosters health and is filled with finishes that offer a calculable return on investment based on their long-life cycles. Flooring is the largest, most interacted with surface in a building and not all flooring, even within a specific category, is not created with the same levels of care and attention to material ingredients. While not all testing and reporting methods are as strenuous or straight forward as some would prefer, when there is understanding about what they mean, it allows the specifier to make more accurate recommendations about the selections.

All the research RHC invested into understanding the ramifications of their specifications paid off. Patient satisfaction scores went up as a direct result of installing materials built to handle the aggressive demands of a healthcare environment. EVS ended up with more time to focus on other surfaces in the facility instead of spending a lot of time and energy trying to maintain waxed flooring throughout. Hospital staff productivity increased, and the number of sick days taken by hospital staff went down. The rate of costly and dangerous hospital acquired infections decreased as well in the spaces that not only look clean but are safe and hygienic. While flooring is a non-critical surface, that does not mean it is unimportant. When flooring is carefully selected based on a variety of metrics, not just habit or visual appeal, it can and will enhance a space in ways that pay off in both the short term and the long term!

Flooring sets the stage for all healthcare activity.

It covers every square inch of any built environment. It is not just a design feature, but an investment in health and safety. With the right flooring solution, you can provide a pleasing aesthetic, ease the cost and time of maintenance, reduce harmful noise and provide added comfort underfoot, not only for patients, but for the provider and their staff.

The impact of a flooring product on the patient experience plays a key role also, because those patient outcomes ultimately affect the hospital’s bottom line. Hopefully this CEU has provided you fresh insights and resources.

Thank you for your time.

Thank you

This concludes the Informed Flooring Specificationscontinuing education module for healthcare.

Bibliography

Bibliography

Bibliography