<%BANNER%>

Impact on Carpet Tile in a Hospital Patient Unit Corridor: An Observation Case Study

xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID E20110217_AAAACU INGEST_TIME 2011-02-17T21:55:02Z PACKAGE UFE0014763_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES
FILE SIZE 957024 DFID F20110217_AACEHF ORIGIN DEPOSITOR PATH mitchell_j_Page_030.jp2 GLOBAL false PRESERVATION BIT MESSAGE_DIGEST ALGORITHM MD5
4ff9c56df4c6f13fb1c331c33cbf5bfd
SHA-1
5ef5b1a68482e8314fce7b5d25c32b7ce707a6e2
8304 F20110217_AACEHG mitchell_j_Page_001.pro
52481c2c7f438e8087db8a6e6357e7f0
6438d5a2f1f02dc4d06ccf0e16baa27a158064dd
99830 F20110217_AACEGR mitchell_j_Page_021.jpg
eb9baaa6dc07836ebcaba71d40a0460e
f832773555f93677581923c385ba95046d56ef66
102532 F20110217_AACEHH mitchell_j_Page_069.jpg
8bffceb392352b7873eda9ca5ce73e8e
def8b8e7a9063578cbc8a45c5b4ffee480329466
1842 F20110217_AACEGS mitchell_j_Page_024.txt
2b94fc83ee465fc963919d257c6a6a25
e6dc2dd84bf613f201e3011e62b9f8f1c60dab48
826934 F20110217_AACEHI mitchell_j_Page_099.jp2
945bf741df272009509fabd6681091e0
20cdc04aeacd2a6d586083512913fd5be555586f
20817 F20110217_AACEGT mitchell_j_Page_052.pro
41b0c9d7b902b8ccbef8f53466bd8fbc
0d1f5d30d844bb1c9eb415c5dea93e215a398146
51628 F20110217_AACEHJ mitchell_j_Page_075.jpg
36c54a21c97cb607b4a2c6fa20e7927d
47ed68e1d482cd003f60e121a721fca43c90788f
45078 F20110217_AACEGU mitchell_j_Page_025.pro
d389247f409a53377c6b85ee287d594b
90f8f4e286a1027e2396c8e31057dfd011a967c0
8423998 F20110217_AACEHK mitchell_j_Page_037.tif
2a7cd92f359a43e580ef9ea6f3638c6d
b3507e3c0348a2350b60cb79f230f7f79928ad1b
26426 F20110217_AACEGV mitchell_j_Page_049.QC.jpg
f3bd202fca50ab059cef6572a521e367
daf7d87b8821baa8e6130473f9649c4550637f33
119 F20110217_AACEHL mitchell_j_Page_002.txt
407cdb349eb20fba06a3d0230ceeff35
4918eb36e17698e2e93d9e5cae386caf515bf1ac
2554 F20110217_AACEGW mitchell_j_Page_115.txt
67c25c8528a86bea4c14ee18ed51970c
b59b4a70b886500250bce8c5f5ee14b94b520f33
33302 F20110217_AACEHM mitchell_j_Page_069.QC.jpg
1dc2f4501a3cafb3d494673e15252786
c3feae543196edc8973d9b0d4d263508da445b29
23195 F20110217_AACEGX mitchell_j_Page_058.QC.jpg
e6d20df24b4e379df6f3c8da73ff50de
d966cacc81eeb8850667b9469fe362282ea121fd
4036 F20110217_AACEIA mitchell_j_Page_085thm.jpg
8c54711971368d4ea2211de708e7c811
5e94bb8bf1747140e4dc09a6ffd02d7fca71f997
20706 F20110217_AACEHN mitchell_j_Page_012.QC.jpg
24d491a3aa9444ace8a4a569e946b20f
aa5265ff27e57c8e3617517f0878fc75f49e98d4
6452 F20110217_AACEGY mitchell_j_Page_105thm.jpg
7fceecf3308194329f0a474331647997
b792e013a0946c688a59592e3d45e10999ee8180
74069 F20110217_AACEIB mitchell_j_Page_004.pro
92c3d50e90c48fec1709dd13c3afe326
386b2870cb6869b0d816e0d251c706c44fd77b1b
78000 F20110217_AACEHO mitchell_j_Page_053.jpg
91b7f0ffa3adf15b2dd3adae8b39d3eb
86bf9cf24f0d5f95585eb6d3473bc01a049b3ca3
31588 F20110217_AACEGZ mitchell_j_Page_065.QC.jpg
ac077e70f46505d0f5f65d7deca33763
8bb0577eac5f44baa776b108418460099abc992a
1977 F20110217_AACEIC mitchell_j_Page_064.txt
88bd38a424f207e874e25ef5d4bf2c66
f1fff501c8a28052f746edbc41bc0143c8d4ff2f
95119 F20110217_AACEHP mitchell_j_Page_019.jpg
3d8c677ad3b57cfbffbb7b58bc0f2541
0f719471c9ea74b1d7c8ff9b2815fc4ea89e8909
23929 F20110217_AACEID mitchell_j_Page_032.QC.jpg
f8224b6b757b6986b9e9211278dbd1bc
e6d392bee3b98ca7224fac5cb0b9b4937aab7062
30008 F20110217_AACEHQ mitchell_j_Page_105.QC.jpg
93f4d17f9d5647bc172a4dc9ee26d166
f10fb49031e095565dd6fa1947d4771b5b961cff
23746 F20110217_AACEIE mitchell_j_Page_011.QC.jpg
a8c8502ee4f65f34795582d13aa844c9
6354a2ccf4e17fb2ae463a8b92eb78a377ab431b
7273 F20110217_AACEHR mitchell_j_Page_054thm.jpg
46620390b7430f2f53879d09deab5574
01e877c73d6322f4b4476b129c4812ff5082ba2d
71344 F20110217_AACEIF mitchell_j_Page_103.jpg
66b95ffc88177dce224c763e91903940
f3e46dc9d3b7128cce017beaced826072c72adc8
3027 F20110217_AACEIG mitchell_j_Page_055.txt
6327a85f4ef13faf174f86d067eee2ca
ac839593afc10df9be7f0194afd7c142be9dd98c
30611 F20110217_AACEIH mitchell_j_Page_110.pro
17133335214fe5281168d52cf8ea0d2e
d85764796f11c01746cca1440c775b7fe978dc41
95823 F20110217_AACEHS mitchell_j_Page_024.jpg
93148d4880886d9f71d28b9a28889efa
23f912c92fa7e0872cf08ef15620583a7e5556fa
1675 F20110217_AACEII mitchell_j_Page_095.pro
290f94aa8cdd5cd1c18396e7b495f7d5
1610a6975d6bc6db0c4c6572220e1247c5e74c22
14999 F20110217_AACEHT mitchell_j_Page_085.QC.jpg
d58ad26ea26d177d037bdb1b9cffbc73
d1adac3fd9b23122a7200aa1c82dff4522de448c
F20110217_AACEIJ mitchell_j_Page_024.tif
16eb0349b5eb734ad4ab87ed55fb8678
7577d3d57c51f9627ac2bd8bfa74c74775a40490
3766 F20110217_AACEHU mitchell_j_Page_004thm.jpg
c980c5311ab552f7edf85e3defb500ed
a53fd46e29a834692e1d33a7a8977e8abaa42e0c
26564 F20110217_AACEIK mitchell_j_Page_040.QC.jpg
5d77fb0376dd5a5883ba1c5a3e05da5f
126162f1f34b8740228ba5e31d4a3ca8faf6504d
47967 F20110217_AACEHV mitchell_j_Page_065.pro
77bcc6f0f281ee380fbbb0835db4b698
f4379ca0f7d8ffd9d292206eba62ca91a5a733e9
11071 F20110217_AACEIL mitchell_j_Page_084.QC.jpg
48a7a1192dc5fc6a903ce6c2c17138cb
c959de1e706f1d73b4d5f9572cf0e46aadb43c4b
89445 F20110217_AACEHW mitchell_j_Page_035.jpg
d86872f755965091d88898e1c370f953
9a1029bb6d772e5c902bcdaee692d56b1f8e9063
51036 F20110217_AACEJA mitchell_j_Page_018.pro
7e2ee1b439c22981f5346c6d92ca90b5
88c8b97189ba1538d3d30cc0d6e77efd6356ff1d
1051973 F20110217_AACEIM mitchell_j_Page_100.jp2
7edb6b5d43ddd870750771952c746afd
98f3ffe3300c3fa8f29aa805b2fdda948dffd7dd
F20110217_AACEHX mitchell_j_Page_014.tif
e90efa64dab92d005230862f18eab8a0
ee7ec7a47a4be7b03d0a11482f6c32d030b48cf7
28225 F20110217_AACEJB mitchell_j_Page_035.QC.jpg
44b3e403befd7302114cc2d906c118ea
bd4ffb90d5e8169220ba90c5dc24f4a148afac40
809013 F20110217_AACEIN mitchell_j_Page_041.jp2
015afe1ee52b788d365e1d7b4076a7b0
327fde7f35b4f7185940cded1a3d95c5e50a91e5
53930 F20110217_AACEHY mitchell_j_Page_009.jpg
35ed4abe635ed13a2591a5d785fa3aba
217a108624a8b074f3756b7b0fb8f5b87e7c8b19
8074 F20110217_AACEJC mitchell_j_Page_034thm.jpg
2ae7b64c4c46a6c639d21134c05f54c0
deb671e72470845cdc573af583e0eb34edf2a1cf
40881 F20110217_AACEIO mitchell_j_Page_015.pro
45d0f5787c178964a49a4591fd9b8818
e90307b559f1b92988360727550cf0256ee5f8e7
8194 F20110217_AACEHZ mitchell_j_Page_060thm.jpg
9e39089b2c427cbdd50677aba8db6e6c
4ffd9391d790903583a99c1232e01adf164b3b10
50836 F20110217_AACEJD mitchell_j_Page_059.pro
592e3ae1c4d38bb515e161e5ea58e6ad
1098274fe155718ef8593532d7dd7875d547d35e
44928 F20110217_AACEIP mitchell_j_Page_117.pro
c6d83151ca06b150acfb3d0d349691a6
35bef1892d1479bb997384b1fa5cdef30207bc29
4359 F20110217_AACEJE mitchell_j_Page_110thm.jpg
58d68a133c272d19bec7e8ea3ad98f6b
3b25627673d32bb5ed0be753bb7bb3c632a242c8
8178 F20110217_AACEIQ mitchell_j_Page_027thm.jpg
71537b897364fdf045e625a196c981fe
4eadb5a249f9c2971ec770224fa441ffa89bb7e4
F20110217_AACEJF mitchell_j_Page_007.tif
0afcd2c92fc85cc69191392b32a13414
485f9d3ac6c8771e4d8584102bb2282dbce9d171
1051955 F20110217_AACEIR mitchell_j_Page_055.jp2
d9bf25e233a09ad1beba08ea67550e46
ae263ad39ab64e378c8255e3a3f739f729a84cd3
F20110217_AACEJG mitchell_j_Page_100.tif
82a3cf776c0584c2cf8f07f6cc2bc387
419a4518f157f2b330af326f1b24d1752da36ff5
196461 F20110217_AACEIS mitchell_j_Page_087.jp2
aef2d002582230ff35fff256c10acd8e
6629c050955af7a59acf6b1eed4754e29f02c93d
F20110217_AACEJH mitchell_j_Page_095.tif
672422525f8e66474584feeb4b77746f
ad7a088facaaabf6c0b913791e8c2d6753edd69b
6044 F20110217_AACEJI mitchell_j_Page_058thm.jpg
82b48e5d3c6a8c71c269b86f19367b92
97ea7efa753fae736c90fe4f42e84a812bbc1a2e
33719 F20110217_AACEIT mitchell_j_Page_066.QC.jpg
c1f92c8234a59f091b761c4a7a438676
4eabe42e712d460c65612d77aec0631852803fa6
1789 F20110217_AACEJJ mitchell_j_Page_030.txt
5b2338aa495e0aad9f0353c8652c328d
e9ef0f5d5b4865254136f076ae9a6b9870934a3c
F20110217_AACEIU mitchell_j_Page_058.tif
a353d87dcd2b7442cb74b08fc26b71fa
8f7d5249d4874d5212786d82f1654b0d54de5104
21204 F20110217_AACEJK mitchell_j_Page_077.pro
9cac5acadac76af9af1ae42e22e0da87
1538dda2b9722608115d88fb16e4acfc27fa4969
3333 F20110217_AACEIV mitchell_j_Page_057thm.jpg
a1bd689014dcab8427515cad69b89816
decb8a15ea14e74976bf0bcd213fd8e1cd0280cf
F20110217_AACEJL mitchell_j_Page_070.tif
cb87f53eb2a45c50f003196ace007658
5cf5fa368004ac117b6d5bbb6c3001b1a154b843
4563 F20110217_AACEIW mitchell_j_Page_094thm.jpg
f40003efc178ac5b1ecf90b0aa7f0d2a
502b32822f67fa5106a2eacff3f4e95246071684
F20110217_AACEJM mitchell_j_Page_118.tif
cc72a5a2107c3002a7634b456f545940
b080175e842d395abdbd06051cca38995b502a20
34781 F20110217_AACEIX mitchell_j_Page_084.jpg
23e7958ef56a029f7648e177d2610543
24182aaa3341745f7577542aeaca0f4effcb3695
100265 F20110217_AACEKA mitchell_j_Page_070.jpg
d956cf0278d111cb3407f52ef5e18a7a
b65fcfb98c7dd7cd51383e70fee94eeacbccf102
1307 F20110217_AACEJN mitchell_j_Page_002.pro
9bb5d088857d8f9f40360d84e121b8bc
d96e04499ea234705cf5d3f632e4f469fb22370f
4272 F20110217_AACEIY mitchell_j_Page_005.txt
4d5f5f146f50a874b9d264b277d71521
57928a3800f4d3c173c49f5555cf2fb5ca469134
F20110217_AACEKB mitchell_j_Page_004.tif
53410fd608ed7ca482c0c9ef22a8ab67
0fc284577b58cf163ddcbe1bc9854800019d629b
12859 F20110217_AACEJO mitchell_j_Page_014.jpg
f814e4be3f19dc2e4fd701e2e0851bdf
a6fef510b925a159662a145e0b383872007d51af
8614 F20110217_AACEIZ mitchell_j_Page_115thm.jpg
2f4f4a7a6a4b8654a851cb2b05b86d82
c45241fb99eadfe8ceaf9f901e5bbe4df9a099fb
2201 F20110217_AACEKC mitchell_j_Page_013.txt
d0ef24636d078b90c52135e75cea7462
6b219559148c22bd22a1beb862fd75a444f99e3c
135 F20110217_AACEJP mitchell_j_Page_093.txt
008dadc776f9518fc11cb98a450ae352
1f4816776410f1b50bdc9a41cafcb843a8284a38
8148 F20110217_AACEKD mitchell_j_Page_061thm.jpg
0425a07eef18a7080e93a9636e948a39
006e43835b08e8aad98550c5fe1ff1b6c2bd06cd
F20110217_AACEJQ mitchell_j_Page_020.tif
5bf559b4040382251398978b332f8f09
a743756ee15aa854d97ad81e9d245f49e2151aa3
F20110217_AACEKE mitchell_j_Page_091.tif
336a68d5288b231164eec0a82e142ac9
ba883db81bb0f9db0886d21d77660849242238bc
25426 F20110217_AACEJR mitchell_j_Page_036.pro
4c89b89ffbe6b09f9b5b77551976e801
bdc9a720d5c3b3411c08ac42a14e4b6807fc4614
F20110217_AACEKF mitchell_j_Page_116.tif
0fff88d1f04df353a464721394d562be
c722f5253c5c76b2f0721e5ab626628f22a853e0
690489 F20110217_AACEJS mitchell_j_Page_004.jp2
7ba5c2cbb23f6e5edf2de137d1d94b6f
b5563cb7c0533e06de7d6295dcec39348979a68f
52431 F20110217_AACEKG mitchell_j_Page_061.pro
311695a9495debec95d57d7c3b187b2c
021d5220c92bab99fa310f7e76bd593882f40706
F20110217_AACEJT mitchell_j_Page_114.tif
5b176572fee3765f9826050c93578cd0
db82418fa31d5f8aad5e7bd6aa3faf4ab95b5fda
47837 F20110217_AACEKH mitchell_j_Page_028.pro
eccebf845f4d373c1e6c845cda460c99
9efd3958e88b6c4bb6bd9d1728e359cc373477dc
2239 F20110217_AACEKI mitchell_j_Page_007thm.jpg
a7e82b34eeeecdb1c145dae60314a046
9370b6b8fb6f22d2918b720820eecf8e62774594
15355 F20110217_AACEJU mitchell_j_Page_078.QC.jpg
44c6faa2b7ccfedc4a7ac2a4d99561fc
0a2d7e36efa06c8afcd5b2654f50aff69549b17b
F20110217_AACEKJ mitchell_j_Page_030.tif
06cec39fff3d02f989b86750cae01d5a
be453bffd7eef7f2474fc0f1510e47f719d30422
22312 F20110217_AACEJV mitchell_j_Page_111.jpg
67846a939ef0527144534760b742878d
ed66e18a1b7a440c65aae89c08a118f3fa0f9d28
521731 F20110217_AACEKK mitchell_j_Page_048.jp2
64c0a1df6a2d76736c635d111062c157
5a198717011b48010f9eb87270208f70ca08d6d4
197 F20110217_AACEJW mitchell_j_Page_014.txt
a0a243c5db03a38a3278d51bc0043b2c
5a99149c7ee2c7e0ccc4ea1e9d4c5fff41a81582
45792 F20110217_AACEKL mitchell_j_Page_072.pro
99294ca6cbade7bb0b7480769b754df3
0d4900350b2372ce7e75c3b5b72177ee9ec320ed
1876 F20110217_AACEJX mitchell_j_Page_102.txt
15e093f7612e3b60cf4b7cc0d0b522a3
b4fe62ac5b39013dc57d3b267d410ba01013a2b0
F20110217_AACELA mitchell_j_Page_113.tif
4cc233517365bc99c660ff529ba9b5d7
262c49f6e5d748e5e2e08707353cd381728fa5b3
100290 F20110217_AACEKM mitchell_j_Page_051.jpg
467c9f9243db1457d03cee0255c44b96
c1d40b2f378aa8acc14579f21bbbb2a72859bf1d
54905 F20110217_AACEJY mitchell_j_Page_114.pro
4e66a768f43008b64615e916d6e4607e
bf0d0851457fd64ad9953519e13c72d9396c1191
29890 F20110217_AACELB mitchell_j_Page_023.QC.jpg
7f023a949c4553a7034c59fdd99df0e9
73049a4f04d754a9f0a8f57a220bd4e332317cfb
2302 F20110217_AACEKN mitchell_j_Page_035.txt
efd8cd95bbd1906b51b6a1424af845e9
8fb1eefc1280d1f985b57693a8389194fc2d8ef2
F20110217_AACEJZ mitchell_j_Page_064.tif
3e4bffd4312097c4289d749c292d2735
1f5e288c8024a49205dc30516031a6e99a3eccb1
4511 F20110217_AACELC mitchell_j_Page_080thm.jpg
5ac19779392b43d51667b2b4c8f238cf
48cba2359b1c576acb4971719e37d5a4427085b6
828667 F20110217_AACEKO mitchell_j_Page_032.jp2
776c19d1445b7ec592d846c0086ec335
ac216aa21fd052c58519751f7b951aa52425a39e
6203 F20110217_AACELD mitchell_j_Page_011thm.jpg
b2a091cee2b489fca5412b70a542b173
5b69fe7a4ad3a836850ec3708e0934d1bccc97a1
F20110217_AACEKP mitchell_j_Page_034.tif
c0847474d566092b9ce4df95dcdcfc35
6e6c64b7eeb7ee9c92abe52d12fa26d39d5b9650
1458 F20110217_AACELE mitchell_j_Page_049.txt
fd511e899f0a1bca892609f030c8a179
68944ff5c7dc4995cfefb31bb5c6540e4485cfcc
688 F20110217_AACEKQ mitchell_j_Page_099.txt
246f0edb25df01b049a86edaedf895f6
4f5753d86a98b5b0acb624b2f01585cad23ec198
15047 F20110217_AACELF mitchell_j_Page_090.QC.jpg
7c0cf43f6123dc668022f7aaad0035cc
704d3e795ab097489de9e230280f06e5e1320287
30298 F20110217_AACEKR mitchell_j_Page_019.QC.jpg
e19de9f385a73bc0741602e61cf73c24
7f5629c1b8cb9caea664f1aad11956843a763c95
33024 F20110217_AACELG mitchell_j_Page_034.QC.jpg
a928353e6f0b99be890230dfd019d629
be9826bb3d93379e607076ccde8dd76872f0cf22
469136 F20110217_AACEKS mitchell_j_Page_118.jp2
199b538f9609a2c55368122b384b8071
51d23b9b0b3db345f96e5ca72bf1f3bfe9f779ce
47545 F20110217_AACELH mitchell_j_Page_080.jpg
5180a3ce7423f7e6c65d1a6d2299bda5
7a7a03bc449a9fd5cdaa33f2b6939b64d6b47fff
F20110217_AACEKT mitchell_j_Page_002.tif
4451967ce4366590b4856feaec11ad6f
f1b810689c601f7a8f1d9418d8bf0d83319eeda8
52082 F20110217_AACELI mitchell_j_Page_110.jpg
00cd9cf46df7c152b06aa7ab7894099f
9509c163c3d2d9e32298fc9a839c743cbc8c821d
176 F20110217_AACEKU mitchell_j_Page_078.txt
3d318c21dbf361bf5806dfa32f12e273
f24bd8c0dec14b9600fb6fc0d960d9ff60ac31cc
42793 F20110217_AACELJ mitchell_j_Page_044.pro
ff55117de654ccd268500c7964511acd
3f6d807d9190d992e87d7e73cc93379d9e4b409f
6924 F20110217_AACELK mitchell_j_Page_049thm.jpg
605b41c609b5e77826ddac0e143e5c62
fc7b4379b2db68ede9164726b3612ae599ac101a
50623 F20110217_AACEKV mitchell_j_Page_074.pro
d623fef448d62051403ea917afa6cbfe
f7d710ab30acdc12cf4b5316dd9be5093a7b5995
553697 F20110217_AACELL mitchell_j_Page_076.jp2
c3fcf8a54c660e2e2cf8b36045032309
52f79d6afb4b46fc8b5032b2deecc8ae91243f9e
896 F20110217_AACEKW mitchell_j_Page_086.txt
bfc0f217f18f3aa475622dd9dafdf3d7
5c2f12aa5b29405af8abb127ae3ef1353300dab2
F20110217_AACEMA mitchell_j_Page_078.tif
8d82e59c1d9ffd99d206a0cbabc37f5c
10d603e826ee9655ba03cbf3d347da324cb27643
15434 F20110217_AACELM mitchell_j_Page_004.QC.jpg
86b5e7a3b89f9cf571b62cc92f117332
951d0f0bec265a5e3e0beedf7ced0bba722d3bdc
904548 F20110217_AACEKX mitchell_j_Page_042.jp2
1015d28e9d26ca54d50d7b40964f40cf
084bc00c81f3845788dae5d986465a3e1fc2e119
1051951 F20110217_AACEMB mitchell_j_Page_115.jp2
c56010a6084c611aa4e5c74ea1521b90
09889d364e034eef71935b053672d9b086379472
745 F20110217_AACELN mitchell_j_Page_007.txt
4ebe3499f65710c8c85b38a951bb5d5c
5e7f7d5c45468110216d3882a29206ad5a216aa2
6493 F20110217_AACEKY mitchell_j_Page_010thm.jpg
3121b4058425a218776add1bec2f4db6
8b922f0d8635958bb8be48c51a92b049e69c7a17
6765 F20110217_AACEMC mitchell_j_Page_015thm.jpg
5d600cd10131bee67736e6939255f31a
275d48fce20a0f66abe3fdb8384e36a739d3ac21
F20110217_AACELO mitchell_j_Page_066.tif
bdcc26a09f2918b732f423e9faf7acfe
31295ce27ee1fbe402781f6d0a650968d74c2801
F20110217_AACEKZ mitchell_j_Page_071.tif
8b736b1568908c0279904548cafafc6f
8fee7b84647478dfcef1187ed6c290306db8b10d
47365 F20110217_AACEMD mitchell_j_Page_107.pro
ff3736507a6760c79cda3d57fe7de181
e37ac9aaff5461d9f9b98bafe28ef283951703af
50882 F20110217_AACELP mitchell_j_Page_062.pro
fd670dd53686c384b5aa778aab73025b
52d200e47ff70e8ae84e862703dcf0558072370e
30912 F20110217_AACEME mitchell_j_Page_033.QC.jpg
9d8fbe0bbf603feb24b735eb6ad86f94
1496c94ae7678d083ef53dcf49b04383655253d3
77184 F20110217_AACELQ mitchell_j_Page_050.jpg
62b975a23b25362e3649d350ce49cf7f
a4033fa7490532aae66fc6be1260a112defe144d
7392 F20110217_AACEMF mitchell_j_Page_040thm.jpg
ae423befb18991633e8db7d0895fb7ac
8b29b0e1b1f8c496f1d92ae6dcc6cf6c43a89f31
F20110217_AACELR mitchell_j_Page_055.tif
8e9b3ba443bc322578dec2ce4b679e3b
d0aa636b3d6aed5a75432dddfa5564547dc79cbe
2808 F20110217_AACEMG mitchell_j_Page_100.txt
51d41ad828d1dfd6b1040920ee0dc3aa
12f65bf2c7e118cac99b3a8bfdaf03479123a7f3
F20110217_AACELS mitchell_j_Page_010.tif
caf66bf7226206e2aeec0dbad1180fc6
37261e249f05f0e58dfd8c7f2d053f3448fd83aa
4874 F20110217_AACEMH mitchell_j_Page_113thm.jpg
88786d5973ba22680e7918f3479d7b50
d7021eea1d5974a276c092968391c88b5f460446
26273 F20110217_AACELT mitchell_j_Page_047.QC.jpg
6157d7d0ac5cb6860ae824eb4bb68f5d
690a6de9415b32f197c84af09fe5ab8092c7012f
F20110217_AACEMI mitchell_j_Page_031.tif
3970f908064c4f15b85c4a7bcebf6271
e2cd517ac56d90b693013f9f934aeffef40ff120
84034 F20110217_AACELU mitchell_j_Page_101.pro
8876bef103fcc85d7667c2897ec0e446
ff21d5de0af1dbff57b1e808479b3130140d758f
589245 F20110217_AACEMJ mitchell_j_Page_045.jp2
19fcfb9618ec35cf8d927359157a0907
690eb25bcac7b7eada869cf15495fd2665891423
31452 F20110217_AACELV mitchell_j_Page_071.QC.jpg
efdb98a4f1ed981feaeea4d398453188
7ad01dd7023f8cb99aa9aa7b2192f47c5545b997
1836 F20110217_AACEMK mitchell_j_Page_067.txt
aedb20e6a2d0a38b6f0c960087d4d9f3
8ac3f71f26ab5ebcb639763cee44fc3d561beea3
F20110217_AACEML mitchell_j_Page_003.tif
ced43f247dd1ea9dce59a1f8166ca37a
98d8ce2bbfc4ae5c2212de6d2e508f5ed76280d1
19159 F20110217_AACELW mitchell_j_Page_045.pro
f980308daea8547aa25af4f6783cac05
da10fab62d98fe9333d86227cde7d5910a52924e
49568 F20110217_AACEMM mitchell_j_Page_082.jpg
fbf91b1ae29f941481e9efb787c82fbe
ba14d6e75a4a6a51ce488d9f188a1d68ca990252
413314 F20110217_AACELX mitchell_j_Page_092.jp2
6683c5b252d0d6d8554dcf8340bb6ecc
f9024984187e2261f47721c11b1d920277025f66
64487 F20110217_AACENA mitchell_j_Page_077.jpg
6720f41d7e3796d41a07bf1d8dc802a2
5ec644e34a5c88f69334746a81b38733e87b532e
40529 F20110217_AACEMN mitchell_j_Page_040.pro
49baf33389da2a9e5169fd209d660e85
f6b9fcf2e498194dee1ee593bcad65cb84d30050
2217 F20110217_AACELY mitchell_j_Page_114.txt
8d52d04ac4b0d0f159715850017d5586
47605dcba6a292e27d19c53c3fd560f9d5455d0a
32537 F20110217_AACENB mitchell_j_Page_020.QC.jpg
96620b8146f71d1db5f7e9523fdef5bc
66013b2e13c638964dba703d2a504484070fc96c
1779 F20110217_AACEMO mitchell_j_Page_090.pro
346eaebf9b80b6906b10dfff25b89cd4
84626b16ca652537cd814db7f4727321864ec227
887 F20110217_AACELZ mitchell_j_Page_084.txt
844473b126570797f9652432ceaad6bf
bb8d3c5134f4b2b16efa97f4adb15b016e644162
1012 F20110217_AACENC mitchell_j_Page_081.txt
b180f6634a545c523666f89d591766b6
23e5b289eb0b759897a571508225e105b6750a8a
126 F20110217_AACEMP mitchell_j_Page_095.txt
c559246193adab010376b5ad1c468f5b
73efae362a6702460ecf4f8506fb5e9bc086cae7
102959 F20110217_AACEND mitchell_j_Page_017.jpg
f942a06f0352f9eb80d5bf38eb4c09d4
51242e4003680b569661fe6cd9a29c46c50ab97b
3830 F20110217_AACENE mitchell_j_Page_092thm.jpg
4bc07ad8354f7e1ae9d084a159ff7095
d65b91b772a0ee82959d360315ceea8aa41faed6
2662 F20110217_AACEMQ mitchell_j_Page_098thm.jpg
29a04e21f893d805e66512ee7d08c571
d20f0a579c0f82065b82fb071ecb3131e866448d
818 F20110217_AACENF mitchell_j_Page_045.txt
a33f45ea7b7c927d2ac506a0ba484530
5843bbe6a4e9e61c77c4c8015e24abfb776fd467
901299 F20110217_AACEMR mitchell_j_Page_049.jp2
2d27fb0142c1d390b5c67bf720072511
47d86287e7056bd2e1109c96d732d98848c101ef
66104 F20110217_AACENG mitchell_j_Page_107.jpg
ea4420dd0affdc1b3ab0686aae8c8b85
9b526acfc54de208bb4c484a1119fae4a933000f
4251 F20110217_AACEMS mitchell_j_Page_075thm.jpg
8ecb9b8028ec6f31bdc8c76524424adb
93db683f81a50f32c56fc7eed43ed380c24a00d9
F20110217_AACENH mitchell_j_Page_074.tif
1262ab7d107ab2e8a19481aab5b98457
5d9d33bca3723d5ddaf1f1489592ae99b685699f
1051945 F20110217_AACEMT mitchell_j_Page_034.jp2
4476d91b18253bed150dafc8572a8441
1c7bf0d4aec464c7351092ff0c582a934c37f2d5
98090 F20110217_AACENI mitchell_j_Page_020.jpg
f850ac64bdab74d995840cdb43b41213
1d91673fd15a72b0ba7d2303cf2e52e4b387789e
1051942 F20110217_AACEMU mitchell_j_Page_062.jp2
e605b923872202308926b43e26acbe2f
76ac3db37afacad99214402762043e4d144f824c
F20110217_AACENJ mitchell_j_Page_051.tif
8811adcbfbea4972d290e4417d7d9561
fb58a220839ffb21802ac531de978b67bb4b1f33
69428 F20110217_AACEMV mitchell_j_Page_039.jpg
e4458fd787689d0687210a881669020c
ff0161170e1ebfaeb6753af697bcc14cc274b229
23245 F20110217_AACENK mitchell_j_Page_100.QC.jpg
1f4e28cce2f68a26cc817540f79c50b2
314d3146ce982527f2d6f56a8ac1504df826ef81
1963 F20110217_AACEMW mitchell_j_Page_092.pro
061dc67e38059e76521be5ae93e513a8
dfcd567de0ae226c52e2e36d08dce480e391fb9d
23754 F20110217_AACENL mitchell_j_Page_076.pro
5dfbea13a8be9fb45ed6bcf81605fa8f
a6828daf4184bc496d2f460c32033b97bd7a3a0b
109346 F20110217_AACEOA mitchell_j_Page_014.jp2
7ec2b85feb84e49d44e87392c7dd11e6
6274c14160e8811129e0141dccdab794d20cb977
5828 F20110217_AACENM mitchell_j_Page_012thm.jpg
64488a08e1f39b6e067cdb97ac4e6500
c466ac12d3e88b7c8611e276e1a78f5bd4be47a0
1037533 F20110217_AACEMX mitchell_j_Page_117.jp2
f1b216a3516628729286c26da91e301b
69a34bf84bf8c31f57250577d715a0991e30edf3
32503 F20110217_AACEOB mitchell_j_Page_073.QC.jpg
7539695cdadb5811e0d4f45c3e28c0c0
c4b4671bd963fcbb85ad6fe0886e155265fba24d
4811 F20110217_AACENN mitchell_j_Page_014.QC.jpg
914321c004cd557f7dc105db8a5d23c9
c308fc07b1614c757870f78638c3cc685321488d
122071 F20110217_AACEMY mitchell_j_Page_116.jpg
f9681334460be362dc703a9c15d560ff
53549e61b2c91b32341c065e2c14bba8cc83d97f
1867 F20110217_AACEOC mitchell_j_Page_071.txt
597e1aaeb1bcac38e6092ad6fd9ecbff
3f151f654750a59c1698c0319a96a221650fb4e9
7272 F20110217_AACENO mitchell_j_Page_030thm.jpg
36d902cd4231036ee617a4d0f4c10f84
bb3b50f5bfecb41ad33f35000aa1292f4eacb741
27020 F20110217_AACEMZ mitchell_j_Page_007.jpg
91faf4cc956a6ab9a11135e7e62254da
dcb6bf223550c1721346792917d107f2aadfe064
F20110217_AACEOD mitchell_j_Page_087.tif
0719763ec16a4dbcd220ac69918f85c7
076c612d5ca15409f3208f414253f2dc3360d1c9
F20110217_AACENP mitchell_j_Page_063.tif
33a401cfab8d085c4a5d0cebb0ca69da
028c50edd3ca6925b1adf3b73aeb123a25b6894b
28962 F20110217_AACEOE mitchell_j_Page_046.QC.jpg
8e77e4f9d617a3df98873068df949f5a
a96cb6c3b5f6961cd6c77737651311793199c88a
53917 F20110217_AACENQ mitchell_j_Page_100.pro
355d6cb6fe7a19937ac0ff7741fb3bef
cd2be60085756913ef156a141eaf8de7a6d103c1
101626 F20110217_AACEOF mitchell_j_Page_062.jpg
6cc05bf3dda76a6d0fb419937acf10f8
1cf1c07a1b65c981f2556df82aabd480ed3f179d
332808 F20110217_AACENR mitchell_j_Page_084.jp2
013d669523b0fe5d6c10e23df91553c7
d133052d4abaaccdd6fdc07760749d1ae454d207
12733 F20110217_AACEOG mitchell_j_Page_093.QC.jpg
ed5920ba79f542d7e6c3505ed7d39d80
64722230f930653158ceff45511862272c97dea9
7200 F20110217_AACENS mitchell_j_Page_111.QC.jpg
dea78c4b075541be01bdb52caa3c9502
09d07f1eb74ead8a801ad0d6c147b7a86d5d6ae5
F20110217_AACEOH mitchell_j_Page_045.tif
07026f453e40bc68bb0bd8dddebeb37d
8a5e7bfa1495e6286a7c8b3c8f9e09d39bf4ac00
7720 F20110217_AACENT mitchell_j_Page_020thm.jpg
23c7c471c2abbde2de02cf6801203a95
c1b1ea2db28fc0757e0bf8e395fdb8db85d835eb
F20110217_AACEOI mitchell_j_Page_015.tif
dc52d45712d97711928707bbafd3e65e
80cd1c34b8c931fd619411a79c1df6e8460f51cc
23660 F20110217_AACENU mitchell_j_Page_008.QC.jpg
1a246a31377ad2a2de1647f5b845aaa8
b0d118e31b28c9bd72253faa3c260b0147cfabe7
26430 F20110217_AACEOJ mitchell_j_Page_037.QC.jpg
6c7e9101cece012aed2f3ef8039fa530
5821864e63135dc6b061e97daed20b3ff9575b92
85027 F20110217_AACENV mitchell_j_Page_049.jpg
37c94180431c050acba2da2f6763f962
21130713e703a81905480d18e3293b94e66b40f0
31709 F20110217_AACEOK mitchell_j_Page_075.pro
aa0dfc7ccfe3f34e73d0f05bb77d6c5f
f81270587e602fd1196ca0f5a20db41abb20dcce
23251 F20110217_AACENW mitchell_j_Page_080.pro
ffb50d8922b88955d2281662908afb6a
a574e0c04e4d9fb9defd2e1662ecfe5775cf63a5
81651 F20110217_AACEOL mitchell_j_Page_054.jpg
b332366d7a9966b885aa895836559ad7
8e995e36acc618e1a1c48758d6a83a7597e9d417
1051926 F20110217_AACENX mitchell_j_Page_101.jp2
de0653556e1539dee6080cfce7792ecd
23cc642625f2dc99f200f509698d86d04be25b77
43105 F20110217_AACEOM mitchell_j_Page_051.pro
bcac74a1f6185c9afc4815098beb6f0b
af6099d413f0eb80ec0b4fb556ac5dff8c7a21d3
F20110217_AACEPA mitchell_j_Page_049.tif
0bc6e6fcaa8f272d9c2b3ed411318a24
e357aeb3e96823ee9e25efaa612cc1408769f21b
F20110217_AACEON mitchell_j_Page_080.tif
907d4870decf803af90cc43710569c65
ffa4f169e227afdea158ee688041c4ad0216c53f
25570 F20110217_AACENY mitchell_j_Page_050.QC.jpg
62e798a8eca32e9515e564b79974cf9a
a421da392ff579f1625b26f26742e099927590f0
F20110217_AACEPB mitchell_j_Page_117.tif
547a752304619e6331cf587df4f9ef3b
6c975a08fa7beae8637551ade2d86cf4b56f1063
35363 F20110217_AACEOO mitchell_j_Page_058.pro
55ff89d350c697ad901bdc7b035030a0
2ea0b853041ac6a6b016efa91570b6fa31367e7e
114 F20110217_AACENZ mitchell_j_Page_090.txt
d90748d269710521448c9f5504c21b77
08fc8058a4982a87ee34b7a9144fba8b5fb46d26
F20110217_AACEPC mitchell_j_Page_001.tif
9e2912d6094a1a673ea5bb856786a21f
a6bb8cc581de4a85392cb3670239b3b23536d491
38950 F20110217_AACEOP mitchell_j_Page_095.jpg
ef77609ca6a77f0c0ab18cd046dda4f8
77b4d3eb58f2fe216901ad3606d641762a6b9c2b
6938 F20110217_AACEPD mitchell_j_Page_056thm.jpg
700141de68bc72d20810cde5e680f420
9c3c666909f0bc9e66988866ea2d3d94a1641ba8
58529 F20110217_AACEOQ mitchell_j_Page_009.pro
fa940dc458190adf5278d7b281f93bda
3e004ab5cb4e661edd42b366b561d46589ded5b0
F20110217_AACEPE mitchell_j_Page_013.tif
a61853ed95ca520c87ba9c7ade728b32
71cab7e46fe2f1be606738edd67f4fda18725b44
6342 F20110217_AACEOR mitchell_j_Page_104thm.jpg
950ca5c8dd888091ebfc6f3938ab5a3e
51e4edbc7fbd93873faaa7549b80dd189f9ca964
1051979 F20110217_AACEPF mitchell_j_Page_070.jp2
e1c6ca5b072770729ec50f7e9c09d47f
82f69fcf9c82ef65fb2778aa2c3b1e697592131b
805581 F20110217_AACEOS mitchell_j_Page_109.jp2
7be58873204a7efa0d24114d84f8fe58
fa3b2e12b949b4a9c2eb6891c3c880765314c3e7
F20110217_AACEPG mitchell_j_Page_061.tif
62ff5531dc24fb83215b277673c46843
bc83ca66a323f6ee49626197f6137a0cb48457b7
998199 F20110217_AACEOT mitchell_j_Page_044.jp2
941a16119a1f83f8687b61784356d37b
55b9c119a4e8f9a95478f7ab158e86154e2bc009
808576 F20110217_AACEPH mitchell_j_Page_054.jp2
421b70de59c4845540c7a6a4b441e8ff
3d63a1f5cc5dea843187e7fe8176ee3106728a7f
1048539 F20110217_AACEOU mitchell_j_Page_071.jp2
c7713a03b832191356e5e0394a52b771
815760489f009c930042ff6af1c00e90441bf864
29684 F20110217_AACEPI mitchell_j_Page_072.QC.jpg
55b01e5e4c94c7228b00f4f02dac6977
bc88f97ea56a8a1c7b4a15c72cb099cf6031dc9a
906361 F20110217_AACEOV mitchell_j_Page_005.jp2
960f0de698e5fdf15d547b8cd1819d3e
bc515bf96163440a35fb690ce724cb6125d5bff8
6275 F20110217_AACEPJ mitchell_j_Page_032thm.jpg
31bf5c8a08e56f202c0ce4e02dff5052
bda50abe11090ebff02c308a704fb6218bd7506b
F20110217_AACEOW mitchell_j_Page_054.tif
8e44073b9816ac57de2eb6f766ccea9a
06c8b6cf22c78061c8ece8c8b01e5afafbe901ee
27906 F20110217_AACEPK mitchell_j_Page_015.QC.jpg
28eea8c6f1694f083cfa3282ab833e80
3751e2bf5f37fc4faa1823835f3b2161719e50fe
96674 F20110217_AACEOX mitchell_j_Page_065.jpg
cb44ef453eedf46c30539bcfdea258c4
60240141a43421f4a2fcadc3e920bb832d56c7a1
1051980 F20110217_AACEPL mitchell_j_Page_074.jp2
dad631a2352d775812e1360a7f0a6e7a
f9ecb0617df66ead2dc188f1b69276aafb4c3bd9
5840 F20110217_AACEOY mitchell_j_Page_100thm.jpg
6ffe6209c41d5c5c1cbe495915539578
1b0faf1e9326fff859603bad284ed891e439bcd2
4590 F20110217_AACEQA mitchell_j_Page_089thm.jpg
3183fe313c23a7c9e5b2644638715d51
b334ce53e3f215e94a1728cf91389868aa46f936
53474 F20110217_AACEPM mitchell_j_Page_036.jpg
d6d05645da9b0f788698e29474bb5507
4e89b50b6f1d28b3a329ef947c2c555db57bbe60
78837 F20110217_AACEQB mitchell_j_Page_047.jpg
38148b456089baaa5eb7d1784c7b0674
d7b3f649584f56a282935b23ac88acbe31e73910
812861 F20110217_AACEPN mitchell_j_Page_040.jp2
75d68096ec43fb92645d5287dfc76a08
8aec4b3497a89ca0f55f92ac0452ddc8cf100b14
772 F20110217_AACEOZ mitchell_j_Page_057.txt
235ad08f93fddedb362526a5806c3d07
3645949583aee6128ab75c88ac47a90ecb5c46e2
1217 F20110217_AACEQC mitchell_j_Page_076.txt
b722d653b4ffd8d68266a20aa8bcaf62
f1b059aa180453f1cd146ffbb0b2e27ebaed678b
123 F20110217_AACEPO mitchell_j_Page_097.txt
6b01b171cebaf12737f0c015cc6dbec3
e5ddd7ae4dcc90536d0063fbd5ea9cfa818234b2
471214 F20110217_AACEQD mitchell_j_Page_029.jp2
d3478ea1fd73763d5324d9436966c229
fef7e396e0aace7e7c67980f9585d429784e4b8a
1935 F20110217_AACEPP mitchell_j_Page_046.txt
49180f2583fe1813a73f3b05ed3d5708
27ebeefad316296de107dd2f695286da345b3152
F20110217_AACEQE mitchell_j_Page_108.tif
77d7fd5e29cad98b1fbf928acec4ca16
5f17009276ad9a2618d7e8a94df950500b9cb5ae
1970 F20110217_AACEPQ mitchell_j_Page_027.txt
9955a77e23ddb36548b364ca5bda06f0
a78c637bbe9157e77e2f6a0fc59a90f72d771509
43363 F20110217_AACEQF mitchell_j_Page_094.jpg
813411437b83e4640327437136a93e35
8ab83dc4f244fd10c641cd14d21ea07f6e2b86cb
17629 F20110217_AACEPR mitchell_j_Page_007.pro
a6d38f41765f6a95bbb76aadb4e3d901
00a8239d3034e3025b10db0ff49a550381f6848f
657681 F20110217_AACEQG mitchell_j_Page_091.jp2
1cb9d1364f3524a39bce84c8ed70bd27
04713ee0ddd9f23179f5026910e0990bf6c26210
F20110217_AACEPS mitchell_j_Page_101.tif
34a44b9126b4e59f17145c24f590de74
9c781dc130aa09abb04e9fd4daf25e39773ec831
48564 F20110217_AACEQH mitchell_j_Page_042.pro
8cc8603d2188bb5b1731bae05e2208ed
4fb458a8cf3625da403383bf0bc447948315322f
66972 F20110217_AACEPT mitchell_j_Page_052.jpg
1f5beb6f29687abfed074b722181a328
4fb03ae1b2d2f351a1eefb977fa791392a11e101
50293 F20110217_AACEQI mitchell_j_Page_076.jpg
a9fd26cec241e1c9e674361428fa8527
85079ec3e96b91ab878de57344d3e33aa87f0e6a
1387 F20110217_AACEPU mitchell_j_Page_082.txt
6748ea62deea3347e4bfca8613a70881
43c756dfc3fba476dc0af5bfa11b91c059293c5f
844221 F20110217_AACEQJ mitchell_j_Page_047.jp2
e282ed470ade58fc74c0449521a1a191
66e87bb8040be51588271af827586839d0ac37a9
5869 F20110217_AACEPV mitchell_j_Page_039thm.jpg
b2acb2ef9d75d2e0df6e4981a5dc3d8a
17c8bf2a4d84b9c488373ba89f76de339cd028e5
F20110217_AACEQK mitchell_j_Page_052.tif
bc3458299b8b4d643bbdb03d30331e1d
781b495cf0aac6a119f271ab1b78a7aa45b8ff71
10922 F20110217_AACEPW mitchell_j_Page_088.QC.jpg
6a9074287f5fa767e86a83db7c5abfef
15140e21566917883772c6198c2e2d6b00db8edd
748 F20110217_AACEQL mitchell_j_Page_079.pro
b8b32ae17464a54b05655cb4a015569d
e6798b6d502c962d2746d0f05db2f32c4f621490
97817 F20110217_AACEPX mitchell_j_Page_117.jpg
ac7c6088699d0750e9675d5f958c3795
32aab6cce60125f074e0e139d0ae81872fc3ba88
119419 F20110217_AACERA mitchell_j_Page_104.jpg
1a1b31f434b89145a16912ddc6c3ef23
45e4f882bab199c49675d4f0b78a959f305c9c34
8679 F20110217_AACEQM mitchell_j_Page_007.QC.jpg
115c38e2a09919e01aa233d1e7aa70f6
2be70b05c07aba2f674eb09f8ab331fa51e9f883
102 F20110217_AACEPY mitchell_j_Page_091.txt
66aa008b3074e8e231dd4d82a85896ec
ba0502a008ea9cce51a9561437c47670074223a5
F20110217_AACERB mitchell_j_Page_111.tif
50723c1459f9e196c7cb99f999954713
56728b0b31b2686b7e743e168324a5f4bac46e38
33436 F20110217_AACEQN mitchell_j_Page_064.QC.jpg
af5d5e9df5e6e59e678177b1a225e60a
90d63339cbdf4d051be91935c73e477bb7a8e28b
813117 F20110217_AACEPZ mitchell_j_Page_050.jp2
415960c6b3f40b9c84a93813b878f164
cde4ed2608349ecb9ce4941934c9d03dbd69b742
476429 F20110217_AACERC mitchell_j_Page_095.jp2
889fcf16890ee80328b761bb5bf72106
5bd7edffa7720adb23feacc5ef05ac0f2183a596
744517 F20110217_AACEQO mitchell_j_Page_113.jp2
804b019e0bb84d54abe07b46c1e4900b
9bde7e376ed8021164dc0b678548b492ea109cc6
48426 F20110217_AACERD mitchell_j_Page_021.pro
927f88406bce60f901ab9cb41d5d7745
8091e19d3538afa4485b9f8a29d8c0c340f14602
42287 F20110217_AACEQP mitchell_j_Page_097.jpg
5666f4c48e7cc78ae34495d027f89487
b6a45102b928d1f4f77fbe2448b89d3df8871f7b
F20110217_AACERE mitchell_j_Page_033.tif
a349c9ddd78c0849ed00674f962a1f34
430ce3ca1a176e33ce1fab06eb2ae2821fb27f0f
88153 F20110217_AACEQQ mitchell_j_Page_030.jpg
09ba630d4266c36130f797fd24dd1361
3694b6ada522542f6d97484f8a6571401f7494a3
558780 F20110217_AACERF mitchell_j_Page_097.jp2
33b834660e315b009fc55d2bf696a0dd
2d13138babdd341afc32698ee71d6db5ebf4bada
1766 F20110217_AACEQR mitchell_j_Page_054.txt
3a1d52a2d02b1dd150eb4b89d98bddcf
45c1b49eef76a59960e7d11e4ad1cb226c5b22ad
22428 F20110217_AACERG mitchell_j_Page_085.pro
f64b3c75113b3415bd708f2e55944a89
7f21ec8af1060ee3f17699f54cff22a86cd66646
90321 F20110217_AACEQS mitchell_j_Page_046.jpg
afde2254e36257d430b0f58223dfbb4d
195a11c897ce7298c5f87797b3b7c2e84ab5bd68
1137 F20110217_AACERH mitchell_j_Page_003.txt
d96656694b46e25ce79e525925466946
23a35a7c4579a7f8ec3f35c5137dfefc24452865
1051922 F20110217_AACEQT mitchell_j_Page_028.jp2
13e0bcdf799c0d961ee85b3e92b32177
0c50d5cd0c8f3458f39923ee88dbd22f2229631f
5224 F20110217_AACERI mitchell_j_Page_109thm.jpg
17b6120606b6df0d69369709bd6c21f1
f7c34ea9faec9e59c6692273ba8251d900462c55
74218 F20110217_AACEQU mitchell_j_Page_032.jpg
09fd47a9100f298284692012eb7db055
c40ede34dbc3f6719e990a56409a91803035ca2c
25927 F20110217_AACERJ mitchell_j_Page_031.QC.jpg
8eb5198ef179438c29f2a2f523623e19
71fa99e6fcabbf4634b71122671e392218dc0565
6481 F20110217_AACEQV mitchell_j_Page_041thm.jpg
56fb11279206064fd3ff313debd47360
9e0cc41f3bb1290b82650e6df1251a3c067babf2
4385 F20110217_AACERK mitchell_j_Page_090thm.jpg
21bc92ab845f3a8a455e3cef4235f16a
e9e1cb1ab6d25280cc74c7462d4a5072df537cb1
24042 F20110217_AACEQW mitchell_j_Page_043.QC.jpg
b285ea23e9d2734fa20570502560a780
76f7356071600387b0b46ae6e6d5ad7e2a8f8641
4374 F20110217_AACERL mitchell_j_Page_036thm.jpg
50c793139a9f67381fb6d3290e87d164
f4084e6ec7214048e10433af1976c87486a9bfb2
2161 F20110217_AACEQX mitchell_j_Page_106.txt
675afe53db0707d4df8740240bb458ac
a140be4f0333ef2951d14cf59e843396faa6b27b
4906 F20110217_AACERM mitchell_j_Page_014.pro
b6546a8cf8830dc54ba408e7add3f38a
d7be19929358792a45a6ef73a5d3d5f05148df73
458502 F20110217_AACEQY mitchell_j_Page_093.jp2
a5a28e8edc46981b5197cddf2eff4a57
8c383303e28c8053ad30503027cb2eaa8070d34b
4944 F20110217_AACESA mitchell_j_Page_003thm.jpg
c2780108c9e0057c2a4c5b6d3402ae72
80fe16feb9f4a0380b23bee5846ba4fe1f15b7cd
593362 F20110217_AACEQZ mitchell_j_Page_112.jp2
7aa3358f1035991b8c4893712db108db
c064c8403102510026e1fa8a42d470555bb18e6d
F20110217_AACESB mitchell_j_Page_084.tif
a80de9b909a9329401236a5398fd63d4
9be4b60b8901a9b3e29f1070ccbb35e50ab258b6
2469 F20110217_AACERN mitchell_j_Page_008.txt
185dcdb4b889257dfe1f3101bbbd1973
c3c214aa5adb3d7990158fc549d8155d6d91656b
2020 F20110217_AACESC mitchell_j_Page_038.txt
f4f9c1ebe20c376d6944e93975d89dc7
798adb56e83e17a6f1f495e31fbe07458a628f2a
1051985 F20110217_AACERO mitchell_j_Page_105.jp2
0e813a3e50449ae7409155a7e6cd40d1
704ca10e3dd6a4cb2957fa73d2653619f0845af8
100649 F20110217_AACESD mitchell_j_Page_038.jpg
7d96c4d3e508755296318085c1c0f4d1
d324c0e50b57356cc7eebdaa53d8eee1e6279be7
62928 F20110217_AACERP mitchell_j_Page_115.pro
b5957a3b30cc043d0b8c24a618af46dc
ae87823bb691ba606d083a210a0bf66a9445ffd0
45881 F20110217_AACESE mitchell_j_Page_033.pro
efe4d4a38bc4fe4595e51df8d400dcc3
db3e5b2c3c27aac1bea3d2bd17ea80e81f373627
28161 F20110217_AACERQ mitchell_j_Page_030.QC.jpg
cd7b9908b5a84c17a1c0381fb0f1cd9e
f9d21c8f75f0d56b4f0b7aa6f9ed892dadb7b9c2
904487 F20110217_AACESF mitchell_j_Page_031.jp2
95e30ea3a108ed30e69ad634a6995ce5
c603b294d4073ade40c2ba6c22a3c1ee703c6aea
F20110217_AACERR mitchell_j_Page_065.tif
2e6fe71f0a7a0782c6059df6617d4626
34dc25998eda4c78ba7eca8ebbcb049d80dd3feb
99988 F20110217_AACESG mitchell_j_Page_055.jpg
2d1f9c8e6e2e66d916f88fb48d3d1b54
d2badd180f7d1f5f8e021f0eabc85e3503f024bc
F20110217_AACERS mitchell_j_Page_060.tif
0ea0bdb81d5d3e430600730adb7ac8c4
0c5a413c52c01ce88af156d3b73a0eb9216bf193
33870 F20110217_AACESH mitchell_j_Page_017.QC.jpg
0f3cbb3487ea38f1888ded867ee94eb3
fa5b37da0895e8395736690e9f77dfcd25772608
15461 F20110217_AACERT mitchell_j_Page_076.QC.jpg
6a0d36984be97dba08b09afda616f65e
78f2253f2426946822d252192f2e146243c8aab6
8218 F20110217_AACESI mitchell_j_Page_026thm.jpg
308b541715c92e197b62b7ada095d75b
f38423e4261b621e6ee084e823337ac15f88af21
650104 F20110217_AACERU mitchell_j_Page_102.jp2
8c928ff633d104c0cdf85192b307049e
55f2eb4b034d2a571dc7adbee9fd6c9ddae3643e
2671 F20110217_AACESJ mitchell_j_Page_108.txt
2575e2065c0ae4adb61c234a8e92e451
dde0efa319cc3694faab4cccc3e0fd9e6299dd3c
62732 F20110217_AACERV mitchell_j_Page_106.jpg
69ad06eee267e928ed8d2abce303e3c8
4c43b7bdca0cf8893b78d03fcfc09302f2e7e529
49884 F20110217_AACESK mitchell_j_Page_073.pro
893c2b4ac9d091a2bce0842dca85a9d6
9459a7ab146e6b8f3c2fced57da09d0f9a5295d3
F20110217_AACERW mitchell_j_Page_107.tif
02eae76f9d9d595f00179d66312efd38
7ac445cd8ad751ae8db92baee47b2cb1a018e907
38454 F20110217_AACESL mitchell_j_Page_113.pro
adbae2a550b83564921cbb825a6df8b3
6bebcd85003dd518713000b57c12eb682351dec9
1778 F20110217_AACERX mitchell_j_Page_051.txt
82f69c9b426ca11c58b89df4225b5750
5358423c0cce4595d0fc8545aca9453b22079d30
F20110217_AACETA mitchell_j_Page_028.tif
b4b387418327f3e7242259f1c54cf61c
7eb8ab1ab44b4fa5f1b404210bb9bf3d5405d54d
8399 F20110217_AACESM mitchell_j_Page_022thm.jpg
1e19b36571d282410c13c7bfc3904a62
e63c8caa43ad1f23d5af5a33d1297e37470e6e8f
1043579 F20110217_AACERY mitchell_j_Page_065.jp2
291f4bb7078653f9c22fa187a4c68b2d
4106fd07c3b63343c6ff74ed5dcf601ed0920de1
22636 F20110217_AACETB mitchell_j_Page_039.QC.jpg
a74d9dd872995efbdc7a89857d9cff42
94f27f4d87ddb8ba59dd614da6e86ff20bcacc7d
540114 F20110217_AACESN mitchell_j_Page_009.jp2
3fe056e5b3b6da3869015facae9d42b9
fda8420b4a7a56e12eed4cb91d0588390a87f4b9
7941 F20110217_AACERZ mitchell_j_Page_001.QC.jpg
66b2b2e6ba585a50752abc32034c4007
c08842015c5eeb6421d03ca7b3f615816006446a
63410 F20110217_AACETC mitchell_j_Page_056.pro
586ead03482da917cfec4ba44d807cb4
af8b0f2d67b24d59e173d097f3634b4cefac25b7
F20110217_AACESO mitchell_j_Page_086.tif
e5bfd8340b51ab39a33a7cc56dd9995b
0099d7d4c1a0331f4a105ffb3d15732654979e82
F20110217_AACETD mitchell_j_Page_021.tif
a9ae8ca7d207c78ab5b43b12caea9732
0aa1911d45f9d8725a5ac2fb05ca3b70c4e0f131
F20110217_AACESP mitchell_j_Page_075.tif
77fa71afddd76bee83b2af938873b7df
71bf45c4f625360c0c678982be6bedbf99bdebce
264109 F20110217_AACETE mitchell_j_Page_007.jp2
c47caef88d2331876c161641cc20b136
04cce254eba3d6bdec7f7a24787061377c98ad03
4760 F20110217_AACESQ mitchell_j_Page_077thm.jpg
16acea37646931bdb8ee4634d4ee1e1a
62424d154be589b3d1566f40b255e0b926255aa3
46285 F20110217_AACETF mitchell_j_Page_091.jpg
73c6a42fcdf60eb88327b5b3861e1f21
fed9b55f62c43fa6ec3ae1c43d0f0d1d07c425cb
1328 F20110217_AACESR mitchell_j_Page_075.txt
40d48eddc4e9ca3a8a82f2e9453f9811
bf40b4c730bf517fddc3ba78abe425237f4cc3a5
500916 F20110217_AACETG mitchell_j_Page_082.jp2
33677c719bbb4125f46d6044c283fb35
e8dd0892460d9172e40627544d52b62ba9297989
1051949 F20110217_AACESS mitchell_j_Page_061.jp2
13e90f2c1af61c5156722934701f173b
cdad4b6b04921a6f6e0a102bd17c622b4a0de645
34970 F20110217_AACETH mitchell_j_Page_043.pro
47644df0fc3251cdd9d16ad99436f059
5036e443fff8440c2789b2de54aba28463950088
8229 F20110217_AACEST mitchell_j_Page_018thm.jpg
1cb5cad3c3954ca093d9a44c0a27c717
64ffa155e687be8524cfae79987580bada97aa60
42468 F20110217_AACETI mitchell_j_Page_085.jpg
19f71e4a5d7280f3327658fc0259a7c5
99f15ec71792fb9e46089e957c7868df49ea4cbb
4299 F20110217_AACESU mitchell_j_Page_082thm.jpg
105914fb70173948271168c6e0493a5f
b7d363a05f23a06c6386a06f71e7843d7824972e
3243 F20110217_AACETJ mitchell_j_Page_104.txt
e37701462d69776dfcf1cfa416cedd28
ba920aea602fb041d47647bbf73d6de4f0f113ad
648604 F20110217_AACESV mitchell_j_Page_075.jp2
d87335fa826aa3dde5436af170c16f2b
ca72b9d06af7fa4a8f516c610768e503124ac089
11241 F20110217_AACETK mitchell_j_Page_006.QC.jpg
acf347aa536aa43ad985b2a36660c646
7890a161f4edf4b428d70243d68bd7f1c3ce4f78
2298 F20110217_AACESW mitchell_j_Page_009.txt
3a73cb5ba2181ad73d88197d62378375
eb68f3a43a8410afd723f3832fe22a342f348db0
97505 F20110217_AACETL mitchell_j_Page_028.jpg
f59f28cf18f331a30a6a13a562564b0a
dec8da6e76bd55bf5f7b65aa560eb0562c0fb443
880 F20110217_AACESX mitchell_j_Page_118.txt
9818ebf591b2c06d48358ad978f7ab96
97d0d50f478d17d2282f9cacd39dafb65826130b
1074 F20110217_AACETM mitchell_j_Page_006.txt
7d921afa4e4003b91100c83c2d2d65cf
f7ecaff8b66d017bac8b586729e9b9bbb1f93cb5
101306 F20110217_AACESY mitchell_j_Page_073.jpg
bd6a351ecae97a437009ae4d4b119541
3bc6585b67a0e0ab10e761a8b45c0574d9ec81d0
6895 F20110217_AACEUA mitchell_j_Page_013thm.jpg
22b19397d89284742a833ee6e2d3c1cf
42d9c6ba21ebacce786bcfc201f12c2576c433db
1964 F20110217_AACETN mitchell_j_Page_040.txt
aab51de2f46fd4e3cc730ece6e7ee5d0
a642a05e212bbc7f6415ca56fcbe71d3e1b80ae3
93292 F20110217_AACESZ mitchell_j_Page_067.jpg
8cc2903b30eb1f7e00797567fb6d3252
04e736f8657f86dbcf7d58a22ae430bb406ada88
7669 F20110217_AACEUB mitchell_j_Page_046thm.jpg
86d94ac7558f3985b9df3fefaa0130d5
702b3f7458748bf846d4cf30fd716e9ddbafd16f
7755 F20110217_AACETO mitchell_j_Page_070thm.jpg
a3313f991d95559d83e9e6d0cae8d9b4
9b49b990c5271452dbd71156ed270ef1f5ce6c95
F20110217_AACEUC mitchell_j_Page_026.tif
33fee81fd31913308376242ff9126a60
ef3a6283b47e8a07feba9670cbec53aefcec6438
1051972 F20110217_AACETP mitchell_j_Page_068.jp2
2cf6e2d7f78fd6a7891f49d227787d05
a33cdd6057cc941e7e85d396a64053a27417bb56
4669 F20110217_AACEUD mitchell_j_Page_079thm.jpg
0093eb5f8c0ec4f31e3bc1d23bc55d97
ce439f30e4cceca6c269679e6dd08058fad8981d
F20110217_AACETQ mitchell_j_Page_038.tif
aeb8d1101a492459e3d8ff2057da853b
fb010da56b0d19d554b987a2d3599fea521a4ca8
75114 F20110217_AACEUE mitchell_j_Page_043.jpg
0360384a768ecf57b74d538acab7b1f8
915898cfb3ff0e585f19292a52e95249565a912a
20975 F20110217_AACETR mitchell_j_Page_052.QC.jpg
3cb56ba0bbb33791b166625d1898bacd
0db67c5207433fad8a6948f836893d75160d0bfb
F20110217_AACFAA mitchell_j_Page_023.tif
5f9ffe3da7725676d1ff65331e914367
b2d26ccd3cf223c86ef3f90c9e9b402af24fd84b
781638 F20110217_AACEUF mitchell_j_Page_011.jp2
b9499a5efd2472dfbd239d47543c26c2
a509b15260f06cbe5ccb9d03c4920a1c72d38962
13630 F20110217_AACETS mitchell_j_Page_096.QC.jpg
85566e2fad4bdcf49f2c4455e4b7f675
0ec98140c193766f4864f8fbf7980ef89bf48be7
F20110217_AACFAB mitchell_j_Page_029.tif
75afa3fda6a6f61913241471a78ec97b
0a40a7a4ad41b99cd174a27328e7e72f5e0e98a3
F20110217_AACEUG mitchell_j_Page_103.tif
653709ef773db4a868f7465a219e87b7
7bce4b3863cd984bea233df621cb3321d16f1889
1015624 F20110217_AACETT mitchell_j_Page_025.jp2
4c16dac01098ff7aeae8a75adfd4714b
1fe5f2e219ca88636d592f7ba5a423b2d1a66fe8
F20110217_AACFAC mitchell_j_Page_032.tif
464bdb0c3a1291be0af10059fa655cd2
55e95354fd87454ed42a93c86b4f503a37dcfb16
2255 F20110217_AACEUH mitchell_j_Page_087thm.jpg
6f1b01892d8f0bc3438c5255d3830ae5
4fa42ec7a09f809950d29d9a1cfa96479f33d523
4094 F20110217_AACETU mitchell_j_Page_095thm.jpg
278e85e02966d15470d44505fa5d66b6
d59d001e9fa57e1baf74a634ca20025e0b51d2a2
F20110217_AACFAD mitchell_j_Page_039.tif
5f32c3f8b140ce13bfd9c014957e9d68
565ec117fb694a5f02bad8084965bb195e512147
20590 F20110217_AACEUI mitchell_j_Page_118.pro
a7418a46c31acae8b59efc6affa255d1
edeed469f64b78fcd64d4c0111bda453eefd8387
1044405 F20110217_AACETV mitchell_j_Page_024.jp2
54e0d41cfd14229f8b6dfc317a59b0f5
f276f2bc60ab9435aecca1e1e30085e4605e79cc
F20110217_AACFAE mitchell_j_Page_040.tif
566a7bfb0cc920313d64b51eb0b90f5a
c206d68a7f1a12e8366bcc83ab2900569aed9800
F20110217_AACEUJ mitchell_j_Page_043.tif
b36a5ca6346b8eba4d257dc38767f6d0
eb5891c4ffbecb2a8e9bb5bdb6523ba6bc83b00d
1413 F20110217_AACETW mitchell_j_Page_039.txt
b2a37fcbc848c34feff34e7f92a20ac0
6943481d25c5925e383866487edf838096181534
F20110217_AACFAF mitchell_j_Page_044.tif
caf253cd163f136d84e565e17cecbbc8
d77f30ab577750984df64b2537a4226a457c2517
35099 F20110217_AACEUK mitchell_j_Page_088.jpg
fca3be58b6829cf629607ab6813f5d63
3b661a8c659cb2101b2af2f37b4d2acd88891ced
3328 F20110217_AACETX mitchell_j_Page_056.txt
85dd60219c610f3440b2bde394d290af
c2726526be36915fe871be065f11d0b9160f6846
F20110217_AACFAG mitchell_j_Page_059.tif
15c8d32d846c9fcd1711e0606b888240
d26aa59ed65d466db6ee77ac1634d63bb0a0886c
7166 F20110217_AACEUL mitchell_j_Page_031thm.jpg
a7d3b33a8a3db3bd675d45a5a476d014
99289a03b702cc5d02d9527b034691569c38d55f
17382 F20110217_AACETY mitchell_j_Page_084.pro
2a7f5d56e46fd512fde92dc1a4869d85
70ce9aa8d709ffbcace221177ced4f43aa177ca4
F20110217_AACFAH mitchell_j_Page_081.tif
c18ee47dd7a3296989f4f5eb046aacf2
c73da7e5259ba7a6852b375e08b7777f05d761c7
125 F20110217_AACEVA mitchell_j_Page_092.txt
3206dff12600f488639512f06e4bed50
e82ea02a55d06ca3e7ea2c12c5aedb8d746a2052
50635 F20110217_AACEUM mitchell_j_Page_038.pro
dbe497cdcc59be23bad5d0741ebd9ae5
6ff83d7a7d15d22bc0972055827189f840655e17
1093 F20110217_AACETZ mitchell_j_Page_080.txt
c06e1d6d544f9cf0f7082cf81478a4cb
1d7f1148ce3858db42af436e95eda48777d210e9
F20110217_AACFAI mitchell_j_Page_082.tif
5de332e667988a322b8e16865e4a9f68
800e10808c25f2f0561de69125ac5a31930d111a
7470 F20110217_AACEVB mitchell_j_Page_072thm.jpg
c6e5c3c2f596fabcbddab3fef23e47bf
054b6589660f3c511f82e73abd4eb7d1493ef666
46470 F20110217_AACEUN mitchell_j_Page_067.pro
232345fad044a7bc8273e0fa43996086
38ca658e184f83ab200fe91ae44f9abd01b52cb4
F20110217_AACFAJ mitchell_j_Page_090.tif
c44d74c5cdc40c42b200dcb504ded586
af0c0f2eec868ebb116794c5102c63e1cf83a0f4
41905 F20110217_AACEVC mitchell_j_Page_030.pro
0dc4e3d2d510d9d395e7564216dc46d0
e01a9bd98140031fbf29c3c1526d05724682ebcd
1825 F20110217_AACEUO mitchell_j_Page_019.txt
95f6c03b335b655e01517de53bb2583d
358403a2fa4e1683610fa9f77af54f5ed5cdef05
62540 F20110217_AACEVD mitchell_j_Page_108.jpg
76f1f27085b928a58178282cdf40114d
9f3087e619539f1fcd099ce0390f69d31dd877b5
F20110217_AACEUP mitchell_j_Page_046.tif
1cbebd838bb2a59691456fc71789b3e2
1d1aeaffd42155b000ba68932b3a06f3c0e96c28
F20110217_AACFAK mitchell_j_Page_092.tif
faf3f89c465870816a9ff7a3e72b9695
3cad77e425061ccebe0d692a34a42482b894024e
50241 F20110217_AACEVE mitchell_j_Page_069.pro
a31b27156c7b23585656b71f40b3121e
5b151972f4ad6b2720eb5981b8e0b379b944a7fd
1563 F20110217_AACEUQ mitchell_j_Page_091.pro
9763e6c2c146cb2c01e288533f14d651
19496759d1baac15eb4746b706f533124e2ba787
F20110217_AACFAL mitchell_j_Page_098.tif
c6d6ebdec16cbff8cc42f3bb97dabd95
e55bc8ec10a60666e6e162eb3631e4444c81f306
4796 F20110217_AACEVF mitchell_j_Page_102thm.jpg
974d260e330a992121baf2d50d1c618f
223c3f85d62565eeb1bb27d8c00bfd52ded376f0
8002 F20110217_AACEUR mitchell_j_Page_024thm.jpg
63d702f8ab793d05243a9c45d2c53438
0722a92f711ea0db487be5ea0719cc8cdf1e3835
2064 F20110217_AACFBA mitchell_j_Page_061.txt
c5f04442d565765df552e7a9217d5653
c14fe240b5ecce5963eb4d56564a54af2bbee10b
F20110217_AACFAM mitchell_j_Page_102.tif
9c7486c6ce105cfc9fae3414c858c874
0388d3865d49dcb30a0028cf80af3edcba788540
14904 F20110217_AACEVG mitchell_j_Page_089.QC.jpg
706f72b4392626e9d2d1eca55b797119
15c8289ebc63cf0ab7040d5bd58167a254cfc11d
F20110217_AACEUS mitchell_j_Page_060.txt
a2f0bb2cf61756f48bf7a658ef53b726
cdcb5463acdded7c630744ae88860775a75d9cbb
2021 F20110217_AACFBB mitchell_j_Page_063.txt
39e01c0693d2a2c55ff04e159d229a11
9913d14e5101e5d3c0d64bf1e7280086eec3f56d
F20110217_AACFAN mitchell_j_Page_110.tif
9517053a17be8e95d66a4437b8248d44
34fe90d117f2fb8e934fe0c2abd6fac1bfb2e2e4
1051933 F20110217_AACEVH mitchell_j_Page_056.jp2
1f843ce86c3c702e8c35282db5712ea1
3e58f8a1c45c50b65bfa7102a1759e834a6d8eeb
18226 F20110217_AACEUT mitchell_j_Page_113.QC.jpg
a89f6a7e4bb7839b89c23d59bf4d4414
0fb855572fd34c74589fd458847f81addea294c7
1894 F20110217_AACFBC mitchell_j_Page_065.txt
9ee3bef63594465c7928828ad2f39067
2b66e8ac5f399d2edefcab2fa72d5a700f462531
F20110217_AACFAO mitchell_j_Page_112.tif
a9996f3b5a3feb9a7a768f5c4813dfc0
f50538d4157e16f344209780586df296e21f8018
47134 F20110217_AACEVI mitchell_j_Page_071.pro
098b155b2231d4da18d73226913d0913
e520dae4ff2358a9a6e5d8893902978f1c1ebeb4
44162 F20110217_AACEUU mitchell_j_Page_079.jpg
35d2bd80d2195607ba126b3d163735e2
40feaf6b52113ead5f9ca496b1c8b1a8c18ade87
2050 F20110217_AACFBD mitchell_j_Page_066.txt
f7512f436102639c1b433d34c81d4e58
1ea5aa4e4146c8d0c907fdb3d4425dbc84b9e3ec
F20110217_AACFAP mitchell_j_Page_020.txt
64d87a2fad05038fe1e4339887e66949
536eccb8602c9f2b9cac7f387b7fdfdd4c9a6178
3987 F20110217_AACEVJ mitchell_j_Page_029thm.jpg
4b0b6643a655f1496da36dd8e62e16bd
37290e1b28f06f8e18aa0e501117b58b193b9a00
34289 F20110217_AACEUV mitchell_j_Page_011.pro
93bb5dfe724698faccfeed0e2382e25a
ce9ee53d00d26b4fc1dc6619e9b5576cb8eb90da
1985 F20110217_AACFBE mitchell_j_Page_069.txt
fae85be023c131b058efad97c3208e45
1baeecbec3d74295110284498ad2f3c4415d8533
1847 F20110217_AACFAQ mitchell_j_Page_023.txt
64186040848d6af9143a161a179b4361
f03c562f7daac38bfac24cb7fc6424801b66df1d
6637 F20110217_AACEVK mitchell_j_Page_101thm.jpg
9569f8ee2bfaeb6a9ddf9e8a16907303
643b89ca5154bd9e5269c5b6e7686728fb96de6f
92228 F20110217_AACEUW mitchell_j_Page_072.jpg
8bb6faf35c4ede59cb90d4ce0b9e70d2
098f645882445a52d6cf6d9182ec876c5e0d9b9d
1947 F20110217_AACFBF mitchell_j_Page_070.txt
8b044da7c6207fe3207d61b4e0bc105d
7c255f3402e4dcdd9b29ed8671986f26848a5292
F20110217_AACEWA mitchell_j_Page_076.tif
e2b50388b524997bdb8ad3b61bd81d38
2674d56c429f9c5bfa6380d7bcfaf06d8faed111
1930 F20110217_AACFAR mitchell_j_Page_028.txt
e91e5a5d28059bfc33fae150a4506b69
9d32de0849c143660cd43c709d8d8c5342ce9862
8147 F20110217_AACEVL mitchell_j_Page_064thm.jpg
f439ab2e486194c810cc8ff75e89b046
69bf3b08da53e1c3485a2d69218c5774ba9362c9
33910 F20110217_AACEUX mitchell_j_Page_016.QC.jpg
f43de9419a2c81aa6e8e023abf860a33
fff3fc0b1dcb967d6efadfd55beee0bc72acf4a1
1885 F20110217_AACFBG mitchell_j_Page_072.txt
d7b6102496c59b14866c8b5a25a591b5
10589197ae0f46ce3fe4a386a55247672e6542c6
845 F20110217_AACFAS mitchell_j_Page_029.txt
6be0afaab327052ecb03c20757ed1625
5c3a6a6bb0924c5b34bd3679c60b2b2fdce5a39c
30845 F20110217_AACEVM mitchell_j_Page_068.QC.jpg
03862f418c2e520434883948d42763b7
80b3f22a1d8f40a14b0bcc9e8432e6ee62213258
853254 F20110217_AACEUY mitchell_j_Page_010.jp2
acd6a3e06512d1197130118298fd001a
e6f7335d7c5bebc5d60bb5198767d880ac024bfe
2004 F20110217_AACFBH mitchell_j_Page_073.txt
48420074a5f818f4b2b55142500f39fc
7d168ae28885d12845cfea93221bd256f97c6d82
F20110217_AACEWB mitchell_j_Page_099.tif
2ed370bfd2988ed4d4c62327a945ce4c
75d729d175904d56f7caa89d6b6369618acc5d9b
2002 F20110217_AACFAT mitchell_j_Page_034.txt
7479ab470525757aa01eaaea6d9e37ff
76231a6e0336074c1a4614f154c2491bf7e51773
1901 F20110217_AACEVN mitchell_j_Page_097.pro
5375562ac3dc4cbc755eba27fdecf14e
e17317db5c5c7690014d81e7df1044cdaf22ed57
8175 F20110217_AACEUZ mitchell_j_Page_017thm.jpg
715962bc6ce2a0b958414a59f12491ef
7d654f402cc5479251255465363d3cfc7392ccb5
148 F20110217_AACFBI mitchell_j_Page_079.txt
c4d985072c2768407b1dcd0943dabbf7
9a761821883cb8683b383ff5bfa8301fe52852b8
24251 F20110217_AACEWC mitchell_j_Page_098.jpg
43aec2355db05a6315e52abff0b9f5b4
839f112319b2a27d429772568ee0f95a374c45f6
2182 F20110217_AACFAU mitchell_j_Page_042.txt
405635bddbfe34ce91268238d90f2271
27ec78dff84d04d3c2deef825902f25231860f8b
86851 F20110217_AACEVO mitchell_j_Page_015.jpg
fc9b3ee52bbfd45efaf3a2fc69b7b7d5
a2c4424a1fc1d099d411d99da0b88f8551b3b5aa
718 F20110217_AACFBJ mitchell_j_Page_087.txt
3e494031026028d62d46ec47c608eb72
5c8e28e7f8cdfdb596c4819d5e3dfdca8192149a
2009 F20110217_AACEWD mitchell_j_Page_018.txt
bbbe77f6142a4342ff501652f8459144
0188515dd4a172406cee2e45d7d5924cda42be77
1472 F20110217_AACFAV mitchell_j_Page_043.txt
e856ff8e68b40795b1f0ef1722ee3868
f2c88a96d1ee5a56ab11cca8700c8e215eb3bd09
8651 F20110217_AACEVP mitchell_j_Page_081.QC.jpg
d94843505a173df482495a8f772a03d1
5a2e8ce1ecbdea06b7ff0b553826c59dafae2d29
F20110217_AACFBK mitchell_j_Page_088.txt
980d5d534597cba91196527a730ef86a
4e683a8cca9893748877ae4cecda18cd2139095a
F20110217_AACEWE mitchell_j_Page_105.tif
8277e7bfcbb4c859c55cde0e2de39e7b
4d8e9439800703cebd6d78cb1836acd299131b10
1669 F20110217_AACFAW mitchell_j_Page_048.txt
49f296e471da9310ebcd44b05ae860f7
c33ddcf366031f6d34b42f6343589c43777f1763
1843 F20110217_AACEVQ mitchell_j_Page_037.txt
8c47078d75095fe163a0f992439475c8
e74bf83d946f52c3cce59cac307fab8633a921ca
1868 F20110217_AACEWF mitchell_j_Page_068.txt
271a3cd6139231f89177041c8136db20
5bc88e42dd281d06a9daca578355cd37da9404dc
1444 F20110217_AACFAX mitchell_j_Page_050.txt
16b259daa87b101e0295f3a069e62f49
000cf6b724eb979c5b93c7710c229ba880a1df69
F20110217_AACEVR mitchell_j_Page_089.tif
9571e5c3e335d6b9eb9a9a81c9c8f2a5
3972a0c4b426960e099e912df504723c95898cfc
31561 F20110217_AACFCA mitchell_j_Page_039.pro
9feea69e489993a6fa3aba954edef96f
f315d580e463c0b9df4c2b7a9cb73ac09055f5f0
128 F20110217_AACFBL mitchell_j_Page_094.txt
fd2331e5c17e219f4e43ca3057f7185a
b6f5e7d39a4594040d72e5f8475b464ff3bbe3e2
69188 F20110217_AACEWG mitchell_j_Page_099.jpg
2a1f28262867f25f2eefe5ce0f38f68a
c5580542517178c2673cec3f21270960686c946b
1718 F20110217_AACFAY mitchell_j_Page_053.txt
3d7f06a582c6071c6b5ddbb3cc4dba0d
394ee7e0d5ca0af800046050161de6aed4a06f52
F20110217_AACEVS mitchell_j_Page_094.tif
c0df4d54e526f2c37af0186d42355233
d3b478b455e0c334294b98bf6614c84d5c858e09
25675 F20110217_AACFCB mitchell_j_Page_041.pro
b77e048be9a0280bf0e66e09ba0a7aff
376cd139272af05445f80eacbce1583899154b87
3427 F20110217_AACFBM mitchell_j_Page_105.txt
1b02fc04c45eb5d9e1cfe2ba4ac17fee
28ec947e6153aef1ef0c0addae3eca9a7d96cc31
1848 F20110217_AACEWH mitchell_j_Page_033.txt
a6a531339e903f9a02723427b32f16f0
01339dfeb35deafbc79d0cadcf34110cbecbf98a
1538 F20110217_AACFAZ mitchell_j_Page_058.txt
15656eccf5191b5720744d886b90cde3
d66c920b5bb69bddf592dbf827c07852b96379c2
13241 F20110217_AACEVT mitchell_j_Page_097.QC.jpg
8f93fab448f1988bcaf4125d7ad067c2
5f65edbc1e82e3de96b6e297a78c11ea2e086399
42975 F20110217_AACFCC mitchell_j_Page_046.pro
5b95d793bee6360e19c244cae8f9af0d
9b636da5f50f3d95369e55c760a53b78d832eb47
2287 F20110217_AACFBN mitchell_j_Page_107.txt
df208ebb15cd6137e9a86f53d0d5b815
5b46064c6dc353f966d8a7a5f12c2e67fc0af1b9
40576 F20110217_AACEWI mitchell_j_Page_057.jpg
8e4312a4dc0ae01251d50befd5f825c6
23aa15f6f097c47d2265dccbb1fe48c3356fc899
682659 F20110217_AACEVU mitchell_j_Page_012.jp2
7b777238dc42dff6610644fe585ce9d5
20dfae4caca0ef09add276b81bb99c1d8d5f780b
27037 F20110217_AACFCD mitchell_j_Page_048.pro
87e317c586f3ae60d1785033ece688d5
f43bd3420f9f0c64671b66e59bd0966f07f1bf90
2391 F20110217_AACFBO mitchell_j_Page_109.txt
ac673543d5da85b0c1b12dd093f72ba7
cfe39421cfedd919935ab334e25440dca5ef1e47
380194 F20110217_AACEWJ mitchell_j_Page_006.jp2
d9b69606fad6e2cb6c24eb8d3e94ba01
2ab3814e1266a25de08f1984622f96a19827f77a
F20110217_AACEVV mitchell_j_Page_022.tif
a64d6b61c530edc203ed3aa53df29451
d34e099e73ee1d0725d92c642dd3dbb0011d0318
34481 F20110217_AACFCE mitchell_j_Page_049.pro
26fd64ded99b70ab98ba95c8a024e941
78e729165e91ed38159fe1c04417b90ae3febee2
2084 F20110217_AACFBP mitchell_j_Page_113.txt
36a955caa1769eaf39b35cb8da24d020
751d0a5919ffb59ece17b9b195cd1ae42eeae4cf
F20110217_AACEVW mitchell_j_Page_027.tif
f55a6017c3ae6e7551cf0b1d665a609e
74b37228e0d917026ab8146b7cb53e0210846116
35546 F20110217_AACFCF mitchell_j_Page_050.pro
060d594fe6c979546fff63873f8c4f15
9b7a6e2cc5765246543ae1d641f80002284682b7
2558 F20110217_AACFBQ mitchell_j_Page_116.txt
debe21de20cd9526fd2e610addb718ae
9bfd0eef0667aa382460a14ba64aef7a388217ae
17544 F20110217_AACEWK mitchell_j_Page_048.QC.jpg
0bf0492cfebe4ecaf88ed3ee56f5b56e
c456492377377a6740ca93a389c9e372dddd81f2
5298 F20110217_AACEVX mitchell_j_Page_107thm.jpg
20084626a09e884e50b4e47399ddd637
bbbd30782ef1e244b74bbf54f72684097c716bb9
36835 F20110217_AACFCG mitchell_j_Page_053.pro
2f16aea876cedd65b67c25e8bfc9d570
17ad8aed69fd98ae2f10c91a1857756816238722
467993 F20110217_AACEXA mitchell_j_Page_079.jp2
3aaaad47198194d2713dbe2428f0a9b6
708b760aa94552fea71eb18595508739a0b14bb7
26838 F20110217_AACFBR mitchell_j_Page_003.pro
d4452b7fe764fc9c6cd423b2c3d2fc32
6a3fed06e4d4388d7af9d0786aa2c0fb26fdb0f0
254021 F20110217_AACEWL mitchell_j_Page_081.jp2
b9683c470745e2e3d44a133603a98d65
8212ce56fb7feaac959c217c9f41aad2529cde9b
13103 F20110217_AACEVY mitchell_j_Page_009.QC.jpg
cfde052c52dbe59478c725d8db32ad1c
966d0160a56a50337d8a58d314c1ed95de257c1a
38586 F20110217_AACFCH mitchell_j_Page_054.pro
ca3c93173f1772a8abd341d563b1bb03
eca4c51d661f1d14bbf19e880d4def3c80fe9030
F20110217_AACEXB mitchell_j_Page_047.tif
5256ddb36a05e92351d18ae1c1c885ae
d3a24d4bfdec9460a670c1f30c66fe44993f1317
105176 F20110217_AACFBS mitchell_j_Page_005.pro
d485b2f86f3e05bc1c15ffd3050047c7
fb4cdd4e98b64ffa92979a6b7c3a29255cd93aca
789564 F20110217_AACEWM mitchell_j_Page_107.jp2
45a7f31c02202b6e4331d88121015e35
0ddee4f9a436c69c76eef10fa7f39e49e4fa62b6
F20110217_AACEVZ mitchell_j_Page_096.tif
419b416b75991c29990dcd0aee0caa8a
6958c59807a4959c99361eec35caa89d8aa01f89
51343 F20110217_AACFCI mitchell_j_Page_066.pro
2a41a65c6544f76d02733d92cc9c2d4a
ad7d8ddadaa68422e44ae4b809476546cf239b67
61396 F20110217_AACFBT mitchell_j_Page_008.pro
54b7833378462c2ab159aa6760b8643c
3b621628f13aef0086cfabeb7c4fa369a179d118
F20110217_AACEWN mitchell_j_Page_062.txt
e8f90213c3e29e2a5b29e6386f075db9
69a1eba01333d32f78b6131c288a41e1d76749b0
47203 F20110217_AACFCJ mitchell_j_Page_068.pro
7be7a772e8c87267800cd8c3de622b47
4f158bf3af17a3aa013d7b803e387dbe41ef1e06
1129 F20110217_AACEXC mitchell_j_Page_032.txt
b966f9ea33e3a77101e2fb25da4ca3d7
6932fa767a7833111abb6e618fd997725c7a3678
38247 F20110217_AACFBU mitchell_j_Page_010.pro
8d104b28123b14bf2890603bb1d4a233
f2b373e509601ca30f7cca45af5eecc7dee4acc7
680841 F20110217_AACEWO mitchell_j_Page_096.jp2
58a54e8842eb7c5f5ea2358cea492268
a4ca762bdbe6fa5197d9f6c4a0aab771b9dea8fb
25800 F20110217_AACFCK mitchell_j_Page_082.pro
46d50567d82cf65babc24acc5ff0308e
36cf77ae632a0784cb8687d834aeb224758005d4
31574 F20110217_AACEXD mitchell_j_Page_012.pro
90ab30f26a62481e7dd260159b2a519e
ddedc35e2b4213a3bf935a46bd6ef5e13a468c61
46086 F20110217_AACFBV mitchell_j_Page_019.pro
a80e44735a68db2c2040cf3710570aca
188a48a4628c72a792e87049826b077abeb60898
24437 F20110217_AACEWP mitchell_j_Page_041.QC.jpg
32a54e412d0364736408c04854ae8698
22d711987472cb9ce520ce9e0358a70c3de536da
17551 F20110217_AACFCL mitchell_j_Page_086.pro
5c57f31bf6f76952199260de438af027
844767c0ed2a30369760479fb056f1fd14701106
63312 F20110217_AACEXE mitchell_j_Page_116.pro
5df265e7ce25bbff3c45efa32e773c0e
620e95fea684e97e1244a4c381ab608d4ae39374
47745 F20110217_AACFBW mitchell_j_Page_020.pro
0651bdbc7c36f10b6dec4cb43cda96f3
1b839658082580cc43695ecc38db8bcd88f60661
20594 F20110217_AACEWQ mitchell_j_Page_045.QC.jpg
1fccd385157069e6d67d8c98b872623d
59d9fb43e687e5b6735286df2887493be01cd6e5
26172 F20110217_AACFDA mitchell_j_Page_013.QC.jpg
2af0d8d889a2f8f7c7e6a9c3e731d7cf
effb361a436504e1cef713977a2de2505aa1c588
1051986 F20110217_AACEXF mitchell_j_Page_016.jp2
d23c95210c5d1a261d64141925e50ee8
119ea803f949c637f7e17e02596466e2488e11c7
52597 F20110217_AACFBX mitchell_j_Page_022.pro
d0d466ac2d6e9809c4366037c1cb651a
1b551f648be24b4ded49ca54e4c465b4d7c71acc
F20110217_AACEWR mitchell_j_Page_104.tif
1579b8cceb907f94e296420375a0a047
7153f5bb8b569b1c465aeb14fe3d7213ab43e259
100322 F20110217_AACFDB mitchell_j_Page_016.jpg
d1b775e479eb7bf9e10e75ecf6e923bd
d83299a70f7625aa83a62e75fac9fbbdbc8acaa8
3479 F20110217_AACFCM mitchell_j_Page_088.pro
9fa977d1c5998f445747a9a6b191f71d
98d8c2cdcb3d14772aec51ec686508e8d0d1484f
2011 F20110217_AACEXG mitchell_j_Page_059.txt
a8e75d51f83915e1a5cebfb2305d5222
07dfb5426afc77f146efe7ae938e697e0b1a1618
50693 F20110217_AACFBY mitchell_j_Page_026.pro
c5e176964aec9140d0f9e80d32fbe015
280ae92f41ebb232be8349feadc43da0c267dc9a
F20110217_AACEWS mitchell_j_Page_056.tif
6b3f329693bb93acd3c08d0cc9ad358d
c1cd7adaee106bf12a551faf3fe16c1824ea4ebc
108479 F20110217_AACFDC mitchell_j_Page_022.jpg
85eacf8763d16697e93ff60d95958491
4a2018b3b4a9b0495c74d7ab8129d952b1cd3887
2153 F20110217_AACFCN mitchell_j_Page_094.pro
e607241a04ba986543fe143dfa77104a
46d9051e666c4991234b9119e52bfeb849064ea2
129 F20110217_AACEXH mitchell_j_Page_089.txt
f2b90de3ad964cd34e7a14f9dbc2fbc7
2bb2e533f48ffb63d788fe67cf94c5b3b7d60ae2
45860 F20110217_AACFBZ mitchell_j_Page_035.pro
d825d75b4c9c382b4b0852d521cee00d
1e8cfb12d7459959b100864789a9bf1f6c467e43
49385 F20110217_AACEWT mitchell_j_Page_070.pro
48aac1c7b8a41841bed65ac51db88429
71027a136499589c6ef48979a20e0723819a5a2b
92938 F20110217_AACFDD mitchell_j_Page_025.jpg
8c84a384d0b66068c130871ea126635c
734c005e1f079258641a8fd436e76ab9a8cd9e80
52785 F20110217_AACFCO mitchell_j_Page_103.pro
a011654df92fa3aa695d6f7600ccde1d
6717989ebc59f7f09510aa85a993d2f99e8178b7
7922 F20110217_AACEXI mitchell_j_Page_065thm.jpg
19e71f58d195092d90294f66460bd8d2
3dc1f808005b136bb8b80a833fe88f702e191729
F20110217_AACEWU mitchell_j_Page_088.tif
fdf1d9050cf37e63030a0f51fec4a5e6
847dfb3047b3b901925fb515ff7b735761d42e55
29985 F20110217_AACFDE mitchell_j_Page_025.QC.jpg
fadb1b42f8989a2e94ff91403a415c90
4cdc06049a8d583c220f20fced49b5e9321d1e69
70461 F20110217_AACFCP mitchell_j_Page_105.pro
eeb8615a36a81680eac584e3ad3fdf03
089066d1a6721354408a9a79af5429bcd99225ac
8212 F20110217_AACEXJ mitchell_j_Page_016thm.jpg
6da2337fa7274731915d0f836db88922
d69759f2a4f40b046ca738aae979425ef55477e1
40628 F20110217_AACEWV mitchell_j_Page_106.pro
398f252495b07d6520a151924f8aca03
861a2842786f185d9905ae6f23fabfb00e9139ee
32585 F20110217_AACFDF mitchell_j_Page_026.QC.jpg
c8d027f50cfbcf9e0ba9f3e5d627bcde
a15465b0d9ef821fa80ea97ba9ce9dd6391f74c3
5323 F20110217_AACFCQ mitchell_j_Page_111.pro
b64e0ad45ee0500c58e7c0452fd53697
6d9678dda6767a9ccd703d0c313258b4996a1656
46399 F20110217_AACEXK mitchell_j_Page_024.pro
ae0acc8bb77a7269ffac5839bb50fb9f
7aac7e704bd40473594e8aa43b574fe31fbed189
2031 F20110217_AACEWW mitchell_j_Page_093.pro
ae4be2327de9fa209f8a976d552b2b24
ff64945ad94c38b30490421170c44ff3dff1dd98
33677 F20110217_AACFDG mitchell_j_Page_027.QC.jpg
121217a85d8e1ae1c6daf262f5c56ff2
161a57a90407f94e562e79b3c2d53f743d65f135
38018 F20110217_AACEYA mitchell_j_Page_093.jpg
02a024959c3943ccd85b8d90499b14a1
1292d886289414db61579431f0fb94384b520e91
4872 F20110217_AACFCR mitchell_j_Page_002.jpg
662d0779f0ec17102a91a05f2ddf7b36
c174cba320a813ed341b7e4a264d3760c20415be
F20110217_AACEXL mitchell_j_Page_008.tif
8e95f466763df6a5fdf7a38b98b20bee
c4ea607cd046952a2fd648c6ee4e8987f6bc8657
F20110217_AACEWX mitchell_j_Page_017.txt
79ca444c14d73476dbf82693df719873
07d2641bc4b9c0ac5212f8ee365f1f72a1421113
32755 F20110217_AACFDH mitchell_j_Page_028.QC.jpg
2ebab7d5e829d0cf948eee4461cb121a
efc8d112ca0e0a1a29205e51bde8b42013bd5aa5
F20110217_AACEYB mitchell_j_Page_048.tif
6975bdc58ab8bfaa8c23ffd528d146ad
67d8cf70d6c708cc3b396be149699c564fb8a148
1681 F20110217_AACFCS mitchell_j_Page_002.QC.jpg
a4000f5db89625cf7cbb479e0b8f6dde
291fe570cc7b1c6f5ea469fcb53f8139cee2bf1c
19558 F20110217_AACEXM mitchell_j_Page_107.QC.jpg
6d2bbf2c81610939021168042abb92a6
4dd4c817b74ba9e93b90fbaa2164fc4c2e5c9832
F20110217_AACEWY mitchell_j_Page_114.jp2
1466577011b3c8eb2da93eb85c3d2984
3b1261d40a514fe4da3924d97ff47d5942939cb6
1716 F20110217_AACEYC mitchell_j_Page_015.txt
75ea14ebd06ebe8881d6d18131aea67b
876fbbd83893ec19e5a50e4c0af060bd03a04e72
57361 F20110217_AACFCT mitchell_j_Page_003.jpg
2b7454378a7dc2995496c8eebf0bbfd6
1a3051a07cead2d660f3e025e3df5abc123ad349
32644 F20110217_AACEXN mitchell_j_Page_021.QC.jpg
ea82398f058239e9affc4e798d2517da
0d07b77a6c10f1184032c848d6925e6850cfe443
F20110217_AACEWZ mitchell_j_Page_096.txt
f11d6e473f64c16ba699f3cfeaafcb8e
439595c0efbfd261195691431107dcbbb3735985
14947 F20110217_AACFDI mitchell_j_Page_029.QC.jpg
7feeabd9700c747cccb939ec5add768a
6e67b20bd16611d0315ba5c3360bcb1286de1cb8
89861 F20110217_AACFCU mitchell_j_Page_005.jpg
4148a02054bc3f8c88e73422eeee6e96
2188ce7f8fc0bab488d2a03e1b12f096baba41d7
109741 F20110217_AACEXO mitchell_j_Page_114.jpg
bbe5c25c3fcf4200d3b3755c34ecaa5a
e584cc29c26706b952d1895755d4fb163fd14201
100180 F20110217_AACFDJ mitchell_j_Page_034.jpg
563ad47ce9c6a242302bfac7e7168112
817fb88aba0d736bc3e960e92ecbd798cd48c68e
81210 F20110217_AACEYD mitchell_j_Page_013.jpg
48052ff8d2e7083598669f1bbfc7b78e
d832db4d4e45cfafaf7a67f2536678655a0c6d96
38720 F20110217_AACFCV mitchell_j_Page_006.jpg
29daf57a68310b8fbb6154a1e48751d4
00eb5a35ccdd44802d8724f891c6f9974978a1d6
2563 F20110217_AACEXP mitchell_j_Page_112.txt
6dd44c45999bc0a967db69c26c43d36a
ebc32ff749ad5842e5722578925ec1c228b2c95f
18002 F20110217_AACFDK mitchell_j_Page_036.QC.jpg
a40bdc9c0df263dabbb40afe91ea45e1
4b1b4c3315e6cf7fdfaa015dbf421a91336bfccc
7706 F20110217_AACEYE mitchell_j_Page_071thm.jpg
d4f251ed8686a3f82da8b8ac894752e1
ff2cc36d954c1a3e6a2976e386576330b49ff519
84917 F20110217_AACFCW mitchell_j_Page_008.jpg
70268c2ae0a2be2a9d66fa01e2bcf69b
32ebc0acb557f200176244379b788c43fdaf2e32
F20110217_AACEXQ mitchell_j_Page_053.tif
1b1470a4e52debf08d43ba6e2cf69133
3193a0e845d5e7ffc7d0a5b42f1da7c12496a5db
82773 F20110217_AACFDL mitchell_j_Page_037.jpg
b55c7d5c43b96e70aaf22f6f888626e1
9bbaace27c4e2d2cd85a43ccee7a7567dbf29ea3
38274 F20110217_AACEYF mitchell_j_Page_037.pro
a591eee9dc745404a6b3f84fdd47d670
b4b17e99ae93c56fa73a67a57c91b198b478042f
79392 F20110217_AACFCX mitchell_j_Page_010.jpg
7674d0a7ade41d873504775ac56d6134
a8169c7b51c404d375df70215077a2424284e820
33831 F20110217_AACEXR mitchell_j_Page_070.QC.jpg
62ba7f3a2d3f31cf36679f70d3e212f1
53f1bf321567e17b27862c1131940326f21242e6
34202 F20110217_AACFEA mitchell_j_Page_063.QC.jpg
5c96e6945ff3e61077d148e9d50b566c
74c12bf1867f9038728e3ca853c5d5614e38b4ed
33186 F20110217_AACFDM mitchell_j_Page_038.QC.jpg
82de75bd57a7155ab62408d55c0f66bf
4e8cff56b6d5265d4779773a140ba7df4eaebc9d
1734 F20110217_AACEYG mitchell_j_Page_031.txt
0f2a3ca2804641471853363d62e5c7b1
1ffc8ef96a6913b9e4d643a2d37be3dd8acda9f3
24646 F20110217_AACFCY mitchell_j_Page_010.QC.jpg
65bfcda7c0b6fcfda0afce41f63d5ef6
4249699dbb9be5b7359364ed30281c44961de1c9
8177 F20110217_AACEXS mitchell_j_Page_074thm.jpg
6f97d77d861fbdc617d91089a9e33884
e15838b4bccf10a3b3e20a1117b45216039e8ca3
102118 F20110217_AACFEB mitchell_j_Page_066.jpg
757bc43bc477de44a5e10ec8d87a2c51
d4844f7ce7f11f8b3771aa353b898a95d04230d9
8313 F20110217_AACEYH mitchell_j_Page_063thm.jpg
8efd1e069513da4b74812a36ea643977
ad67a85b24b866995d2ce3bdfba241778d83ee2d
71355 F20110217_AACFCZ mitchell_j_Page_011.jpg
08ca685d21f2d0357bb5aaa6cdc79110
db9119a4be3adccf19c337a013c0c141edb45c95
102874 F20110217_AACEXT mitchell_j_Page_074.jpg
34c778a74f626ab0f96aa28be413c771
c7cb7636f281fac0a293661b42ddae5e83538e3d
95789 F20110217_AACFEC mitchell_j_Page_068.jpg
053945da919688f7005c8ba32fcf0488
a4640c0b7a77d7ebaedf25e29c3eab744fa55835
74460 F20110217_AACFDN mitchell_j_Page_041.jpg
61572675c2ae80857ff65adafd064145
62b04888c2a16f8c7904dd8fdbf2bfffe8624c60
F20110217_AACEYI mitchell_j_Page_097.tif
7ff8d034c9521e392c82040f90ed49ce
389e8d8bfef54b27997de23b1cdccc0bfaa238ee
898016 F20110217_AACEXU mitchell_j_Page_008.jp2
d2a9c55449898debde890fba1fe17ced
85a12415b7321e7fd4313efb2e2b3706257a96f9
33191 F20110217_AACFED mitchell_j_Page_074.QC.jpg
bd9f2a89c8882334dc12d565c503cc70
a5dfd860a62088bb96396b77c3f2f614c784ea31
85198 F20110217_AACFDO mitchell_j_Page_042.jpg
67a4bbb6075814aba2474cd1a9df050f
0bf28d089b399df0ecde555dd064eb1872221bf3
25741 F20110217_AACEYJ mitchell_j_Page_001.jpg
a0b7896ee898f64efefb4a94439ad561
5e313dc97ce3e30d97d31f352c90e35f7fb54f6d
F20110217_AACEXV mitchell_j_Page_085.tif
f8241ff67f9ab51af1f392b52588b30c
ae85b13040e1b227350e1a6daf826df9384a9d27
20485 F20110217_AACFEE mitchell_j_Page_077.QC.jpg
39e89583f54b7aceb8271c2d5dec3912
c7147da1fa3383dd235951e5fad71b5a6a60f3ed
98081 F20110217_AACFDP mitchell_j_Page_044.jpg
8cd31f419d5f66530d8da318ace74f73
5fb04c9d39093bdf9beea65068381f883b0075e0
49443 F20110217_AACEYK mitchell_j_Page_034.pro
3b13a4e5a147c40c21c628f18888037b
afb256bc36cfb05d3834be8150bd05798aefa242
398571 F20110217_AACEXW mitchell_j_Page_057.jp2
2ca97a8fec1fa6070479ca410536453c
3aa83f1678069e9c07ca8576177e07b271630120
15458 F20110217_AACFEF mitchell_j_Page_079.QC.jpg
b44b0894fa26b185050f0c4c870a2493
fa4b1f7a3b42a024681d184bafa98bb77b15ebba
54124 F20110217_AACFDQ mitchell_j_Page_048.jpg
717f83884ba45846cf32aa8f76412699
196835daba4a8910f252dad88f093a2ec9b508b8
F20110217_AACEYL mitchell_j_Page_020.jp2
d385fe3dfd3893ae519c3e41a4ef2edd
e0a929e52a88f86369301115e3686660729fb5aa
60789 F20110217_AACEXX mitchell_j_Page_104.pro
18948197654fff7cd8a95dc9d234e43f
7db58c54e605585d18c07777ac2e4e931b83aca3
7745 F20110217_AACFEG mitchell_j_Page_083.QC.jpg
ba26ffbf129ef011c7228db37e2d475d
84a6e8019d3afa7502ccb4a031d7f731ccd7c547
49782 F20110217_AACEZA mitchell_j_Page_109.pro
447e03455eff2f2cdd0d1c29d98240d1
251d5766564a45ec0b0b80db5357a55c4fea510b
26266 F20110217_AACFDR mitchell_j_Page_054.QC.jpg
85713009329728802ad617b56602246d
d880ca2772fe2fb40dcbb064b9e12c79121d68dc
102956 F20110217_AACEYM mitchell_j_Page_018.jpg
b362d36b577dff37468e0607ee42a59e
07b421118134799a29bec06a245baf24c2d5b38e
1536 F20110217_AACEXY mitchell_j_Page_012.txt
1f7ee9b0f4910db9822ce1ab2e7a6f87
65d5f3813fc5e13eee5d826aab40ecd30274ecda
F20110217_AACEBF mitchell_j_Page_115.tif
716dba6134001b184b7718d8844d110a
5a0dc6771e2eb8599b8aac3f1d422c13dfc646f3
8126 F20110217_AACFEH mitchell_j_Page_087.QC.jpg
a681c0d3a494e839662fb33719c9c3a4
3f1739e37ea95bb219cb6377dfae08da81e8aad2
1703 F20110217_AACEZB mitchell_j_Page_010.txt
46491147efcc2a81dfb1e3fce61f1e39
f152efecbbd9d71a82b0ba982a2edb72ffa961ca
29552 F20110217_AACFDS mitchell_j_Page_055.QC.jpg
177eee3c54f05498f6a93b0ae1a4630f
a58b0f540eb88c25fd62264ae5742b3528961086
45774 F20110217_AACEYN mitchell_j_Page_023.pro
8e306a58362072983bd9ed8b0146a92d
4e117d93443ae7f98e7e2489fe45c51dd5d3e740
32972 F20110217_AACEXZ mitchell_j_Page_018.QC.jpg
48910c40e1c812cf97ec0449273d53a4
2a59121401f49ad78fbd8ed7675455b5cdab3e86
7413 F20110217_AACEBG mitchell_j_Page_025thm.jpg
99e311878a239c3d41c721ee470cec84
4eb910e5684b9935a8bc947d5a7a9b590fbbf671
43997 F20110217_AACFEI mitchell_j_Page_089.jpg
8becdc73caff5b91456c9096ed298248
cd2196e16f888a3d8b77c307cd4eb068a66832a7
1838 F20110217_AACEZC mitchell_j_Page_117.txt
8caf65f79d2ccfb38e9094374d119d8b
67358e75c7c717d74abd0e7eb2188e7b617ad7d5
12773 F20110217_AACFDT mitchell_j_Page_057.QC.jpg
2c4bfc49ae5e5ac254b72009c0836ac7
cbf049cd35d1f5948e247d1ffd68b121b3bfd916
560149 F20110217_AACEYO mitchell_j_Page_036.jp2
7783e1a5576d67f4ec433df475393747
232f5e305419b753c885f9d84c1fdb180b0538c5
4077 F20110217_AACEBH mitchell_j_Page_076thm.jpg
dccfcc55e4592f059fcc80add093ead7
30484dd4f93052f1044ae1fc69181f0dc49a454e
35581 F20110217_AACFEJ mitchell_j_Page_092.jpg
c773f0fad17e7900fbd5e794d409b5a3
2b65f15b4a1a03bcea7dfcbefa13c6f24368c435
5106 F20110217_AACEZD mitchell_j_Page_048thm.jpg
3d5c96ca7b90fa43ebe028ac346bedf7
b61dbb1ecbf4466d90446208ef0cf32f87fe495c
73719 F20110217_AACFDU mitchell_j_Page_058.jpg
af0971a48089665a624c82c2221ca297
370429d6e6ac2bf3e3e2e21212f05b0d884130f1
2270 F20110217_AACEYP mitchell_j_Page_026.txt
62558c35c430291fed60adae935a40fd
0c3084105d074a5f3fb936f8bec27f7fb4939554
11779 F20110217_AACEBI mitchell_j_Page_086.QC.jpg
f623d08a686e12a0bfd8df8a95d16065
3d62b6f8a74a936196a7a45abb48bf73a6f066b0
12019 F20110217_AACFEK mitchell_j_Page_092.QC.jpg
5b894b9246218e28e7988c5f29a7820b
169b4a067a206947c10e84373693d08a6eae6dd5
102962 F20110217_AACFDV mitchell_j_Page_059.jpg
7173007fa198632bb9f0f3418b367e10
8aad31694a92980942c7211d49221974c204ef2a
7967 F20110217_AACEYQ mitchell_j_Page_033thm.jpg
26fa46c23fe6b193e9d0fcfb014a2400
6eb92caa5776aaeda1d72de9b08a7478441da14b
1051975 F20110217_AACEBJ mitchell_j_Page_027.jp2
fe24922a8047883f3cbdbeee0ee4c51a
7e133b2249e63c0debb101248654bcd3ccdfdc7a
14429 F20110217_AACFEL mitchell_j_Page_094.QC.jpg
4c74008b7610e7b3c56fde6b879e2f81
bb5e2ce3587ca2fd7d120ee2a387f6eb59c8d198
17051 F20110217_AACEZE mitchell_j_Page_112.QC.jpg
c28d8ae4b24819255885ea5dd750fb34
83b22a35f5fcc384f0ca73c2d04622766b2f86ce
33464 F20110217_AACFDW mitchell_j_Page_059.QC.jpg
0667da1c3984fa2d705c6b8263410d6a
e6193a97c5d03d28de46270d699093c7ebf87f8a
462 F20110217_AACEYR mitchell_j_Page_001.txt
5a5dfb0599148ef0d946b9047d090775
bb33052a7c22008c09568b4deb71c237b2f06477
34237 F20110217_AACFFA mitchell_j_Page_115.QC.jpg
075cad4d70c95715ec7be60f7b3eb177
1a19c7f414a75281ff8c577e9203235ad3189d49
F20110217_AACEBK mitchell_j_Page_025.tif
559e4da8b1529d787cfc3bfc877000be
77d5ba9421eb833e148cef998acf895b94458d5c
12993 F20110217_AACFEM mitchell_j_Page_095.QC.jpg
146290119c10ce0190bf03d8675235b4
19e31e2c164774478df5e860949a3a307ab5a3d9
7940 F20110217_AACEZF mitchell_j_Page_068thm.jpg
a859b83f48c9bd71601600db48251162
e6b495d4204e23203df904964702625b34c2e642
32545 F20110217_AACFDX mitchell_j_Page_060.QC.jpg
af010e2f71e5dc11310fde643d87c675
aa126bb97281f9d0657d7c2599a03535aba6c4f0
F20110217_AACEYS mitchell_j_Page_083.tif
fc54cb2dc09a3b152b61253fcccabaa1
428848f123462cd93c5c6d7ac6685318c9fd917f
27029 F20110217_AACFFB mitchell_j_Page_117.QC.jpg
e5ed101bb5e0de5efd9b36f1b2bdfb32
37d6eb51760c2478e948dacf6a820ba9dd74e90d
F20110217_AACEBL mitchell_j_Page_006.tif
52004f9a69e4718103877419947bd48b
7692da808af0b15e6b9f06c363c81a8e0992b7b6
21706 F20110217_AACFEN mitchell_j_Page_099.QC.jpg
f2413260f8ea505afecfcf10bbba6ab3
0b13a54792b90f3c151b998b6b8bd40da65c1fb8
7750 F20110217_AACEZG mitchell_j_Page_067thm.jpg
357cc9cd8a80d06452c0172d91594782
4e0cf561fc5663f98658a84d78e224dfdb09c76e
33868 F20110217_AACFDY mitchell_j_Page_061.QC.jpg
cf65e6cb7b3abd7254f9f69e801b0692
cab1c53b05f8cf35fed5c1b545872b84b0c55719
30730 F20110217_AACEYT mitchell_j_Page_024.QC.jpg
33b48c687218c535eb39766790832f17
f92a6a75f2ecbf0c99d05ae89d928db25a70c8cc
50911 F20110217_AACECA mitchell_j_Page_017.pro
4579b4e29cc87ebd9adc4923996ea00f
5c80f7af7f9365056d0e2a917fa7c97853b8caf3
242194 F20110217_AACFFC mitchell_j_Page_001.jp2
221ddca05d1d72f23993fc93be4ad521
9b42b3a602c3f13222788ebccea3efe86ef2d6d1
1051934 F20110217_AACEZH mitchell_j_Page_104.jp2
f9423909987214808762d31f62b8d87d
23e14c6b97aa339a335acffc584f388334c1ba46
32828 F20110217_AACFDZ mitchell_j_Page_062.QC.jpg
2120bcc08b26f1f2910f02942976fd60
c54177f8efa76ab9bf4130480b661b8346327a8c
33752 F20110217_AACEYU mitchell_j_Page_086.jpg
7a6626f8730b8a12fd146b12656f5f78
e521bb320fd1313414cae3907f855dc3ae82eefe
1042 F20110217_AACECB mitchell_j_Page_041.txt
4d2e2f77b843c5f23cf2bb27e3c2af4a
9e00697c5e5dea99e44ad176c96416d89819e9b8
603783 F20110217_AACFFD mitchell_j_Page_003.jp2
627f0e29770421b11ac235e7b14ed1bb
50a51c82076e9d9d8c2f228ea69bd36734f195e2
1863 F20110217_AACEBM mitchell_j_Page_089.pro
c4ccdeac91b5541350a03bcb84f1b24a
6d7d10bbd6d68f6f9c9e7e59cc2afee6e4a8b6c6
84826 F20110217_AACFEO mitchell_j_Page_100.jpg
1364d11243cc59b8c521e658d0485b88
fb6e3c763e621120ac8cac84f98e0c82cdffeaa8
7257 F20110217_AACEZI mitchell_j_Page_047thm.jpg
a90ebe34d93da2863fbc36ac742ea69d
d788176356d261879bf5ac7337a202e2a17a4a38
33652 F20110217_AACEYV mitchell_j_Page_102.pro
67c791b13bf07998a3d9bebbad4fdbc8
7c21373813abf65904abd2db5de1fc2a46881d37
F20110217_AACECC mitchell_j_Page_068.tif
3fc9d7e4e424b56732ec5ee455b47776
c4a01ac35abdcd04485a8dfee9111963122de805
873875 F20110217_AACFFE mitchell_j_Page_013.jp2
2919dad0ed8e759dc1c296f2d1e49cc9
651648dd2dd23a5772fba8c2d84547c070010dda
4964 F20110217_AACEBN mitchell_j_Page_108thm.jpg
bcefe1d872428c1cf131ef99525a2ca6
7eeb1cf7953d52275f3a38c9596ecfce7e0483e7
94442 F20110217_AACFEP mitchell_j_Page_101.jpg
d711cea2af69509bcfd37b5e7b05f9b4
fb0a27d3cb4622037cbbf60ec00cd8de7a1bc5ee
1787 F20110217_AACEZJ mitchell_j_Page_096.pro
79e63b400bcc42dfcfb2d5bbe83dfdbf
dd0e31fd500579d045b4b1449b73edfbda752287
3124 F20110217_AACEYW mitchell_j_Page_088thm.jpg
bf0d88ea2199a1c902893d6531068d94
d72b79bdda7181d768ed863e0d84fdbe7a9cda06
3414 F20110217_AACECD mitchell_j_Page_101.txt
269e4c7cf3720aa268dd7941a2170caa
1c50769136abe71971ed90566db160d0b5c287e4
927795 F20110217_AACFFF mitchell_j_Page_015.jp2
a46e37acb57c19fddca5136bbb2e7b1f
cef31f0b36cf2cf58693d33df1232acdddf4da36
65322 F20110217_AACEBO mitchell_j_Page_012.jpg
f7559c8fa575ad872f03c0ce4a26bed1
0528ca81fea34d87c33c0999af9c7c780f05c7aa
17320 F20110217_AACFEQ mitchell_j_Page_102.QC.jpg
91bb45ad208546fd72e1078be4cf878f
8f682e379e81b47dd78a973290993860eb1dece0
F20110217_AACEZK mitchell_j_Page_057.tif
8ad8b48a22c72a5ae8d22c3bfa06f69d
f354f5036eac89783f0fea2919a4cd723e6e7f81
F20110217_AACEYX mitchell_j_Page_093.tif
6847259fa2e06360a9ea0904f23b2f72
51312a9bb8f4a5bb281b47c7da9613e2f6b36d3d
50112 F20110217_AACECE mitchell_j_Page_060.pro
425306d59050ab761464e11bb0a31cbc
a39aa0daf1bcf5591532dab86e3b10f3c20637d7
1051983 F20110217_AACFFG mitchell_j_Page_017.jp2
7184fc8c7e46253c63cd6b8a7b68e17d
dd4bcf11338aa50aa58e57f81f30073484c54abe
45489 F20110217_AACEBP mitchell_j_Page_096.jpg
4ed3d5d28e3f313583d9be5cc4796086
cd36c0019df5c4f877dfc09c333103c1e172ba93
19890 F20110217_AACFER mitchell_j_Page_103.QC.jpg
de3c6b399ab73be903f5b625bf24cf0e
22cca2f689199002bda58dc17b8cdef1cbfc490f
30516 F20110217_AACEZL mitchell_j_Page_067.QC.jpg
fc0974ab75cfbc5bf1f4c553d8d15695
675ea474d6435bb5d6f92d9821933cd40aff4ca5
50368 F20110217_AACEYY mitchell_j_Page_063.pro
93f7cc9c22d2e3866a2064e0b69516d0
d87cc4dea96c5a7c6648380756f264950fde66db
F20110217_AACECF mitchell_j_Page_042.tif
4521ac41791b2e9c1fb4972256dc9db8
354faa0c392a29293ad0062fda70c74f10fa94d8
1040666 F20110217_AACFFH mitchell_j_Page_019.jp2
ec3786dd81d294fe1ae2a3f43b59b2a9
4d8e196857c691d2d1217275e155f7398bdd3d8d
44631 F20110217_AACEBQ mitchell_j_Page_013.pro
9394445334dcd92801fd2e3464f3f16f
975a40e388f10e46b6567f53037c9d1f348c63a9
28261 F20110217_AACFES mitchell_j_Page_104.QC.jpg
61908fd4b8c219529d4f89983f19bdf0
ec6bdbd3e6896647eb252dfde05a1aad52e22c93
84477 F20110217_AACEZM mitchell_j_Page_040.jpg
e652c2cc4693ab27c14ecbc9c255020c
7631b6497c4f624b30e7de3f7f6bdf5f39eee6c7
27793 F20110217_AACEYZ mitchell_j_Page_081.jpg
b8187dfd9d641991acc460d6c98b72c0
eb4b2198f2ae627e373bdf8d02845dad29dd2289
501447 F20110217_AACECG mitchell_j_Page_078.jp2
08220fc7a492cf7510761f7328cb58bb
43817a9240b7e7c589e091c0b839b5f33e0c4ce8
F20110217_AACFFI mitchell_j_Page_021.jp2
19609a2f3771c3037f27f9a4fd6869fb
f83cb582276bc51ed6d0cf406093644f3f4b9e55
1008 F20110217_AACEBR mitchell_j_Page_036.txt
5e8a274e56edbad506a5ffe3ab51a8c4
524f30bf66e4880bee63b9d28c6e514a082a25ec
128314 F20110217_AACFET mitchell_j_Page_105.jpg
1b36f443647cf4ce543280f948245fdf
ebec3f0295ecf1651eb7db0eca53c92054f7fbf4
15302 F20110217_AACEZN mitchell_j_Page_118.QC.jpg
f4a7794afdf484ff769d76521feb9a52
fb992cfbe30caed0a358309770175e46f7e1ae14
27370 F20110217_AACECH mitchell_j_Page_042.QC.jpg
28961dc038c957a06f7067c818d2c533
84e354df50d102164148e2065d9e9f487c09a5f7
1034038 F20110217_AACFFJ mitchell_j_Page_023.jp2
993a9060082c3fdaebeaa64e0d6db46b
1a9b535077da5e55a62f3e23967cdfd80c17ae1d
8031 F20110217_AACEBS mitchell_j_Page_098.QC.jpg
339fb3925dd009aff85bc6e575e39e39
10f0760265dc60ac7433304b8e23c3045151e0a2
18824 F20110217_AACFEU mitchell_j_Page_108.QC.jpg
cdc9c3c5d2045bbb167f2b709a9a839d
ab9c8ebd34b5e8ae748bcf94540f74b6f409b7be
7501 F20110217_AACEZO mitchell_j_Page_019thm.jpg
129acaa87e12d5b369fb95811fa12b94
6b8804bc55251c9f22a482547bd3795ba07ebbdd
7835 F20110217_AACECI mitchell_j_Page_051thm.jpg
90a2fd368c80f809e5fcad62afc33646
d81bf5016f09cdb7b560a6770fecb03583110d6e
1051978 F20110217_AACFFK mitchell_j_Page_026.jp2
5db813169aa01a93f393bc1baef3d252
edfecd288578412c2b3a9918e682fea1b8b09cf3
1051854 F20110217_AACEBT mitchell_j_Page_018.jp2
2832e00538fba15fc99829d4a6a8f582
e7bafbe95d5c5b49c60091872d7512b84255a34f
20272 F20110217_AACFEV mitchell_j_Page_109.QC.jpg
f4f968b1a4ffbd7a6a1472a9d78d19b9
59930227d47553c15d7ca05196212e707174856b
4187 F20110217_AACEZP mitchell_j_Page_097thm.jpg
a1bcba916c389a59654940ad8d3439f6
fc969dccb249edc15a8766029c9d89ad3fca496a
952219 F20110217_AACFFL mitchell_j_Page_035.jp2
a390ca1c57d6d9ff57df1e02be73bd4c
6f64ed45d48df26c442ca3860dc5286d870f435e
243 F20110217_AACECJ mitchell_j_Page_111.txt
f74b6219462b4108ce364a875569521a
431192674f4ffcf7f497d8249782fabae2ed6c1d
F20110217_AACEBU mitchell_j_Page_109.tif
22973503da5ebf0cd6333b5757b4d430
aafa2b119188a66942111a151147540d81a85b1b
54319 F20110217_AACFEW mitchell_j_Page_112.jpg
4d6866ded5d577a94ef528bf5f5fcd1a
8b9ddad95ec7d6b49772375f42cae7782248e41e
69999 F20110217_AACEZQ mitchell_j_Page_004.jpg
15f35751610e115fbb82e9e414559999
6c247d2956b6da933e45b18cb0ee8dbeb7e0a203
316336 F20110217_AACFGA mitchell_j_Page_083.jp2
3ca18b73d2ad33ed2d7f672e4fcf9bd3
4f61bdc62a56fdb69035f7b32c1a8d1fb6d383c4
815743 F20110217_AACFFM mitchell_j_Page_037.jp2
663e4b75028a445e6ed2daf95b800f7c
5cfbb9973c7faeb8c92cd11eca7c9b0707cb0f0a
15923 F20110217_AACECK mitchell_j_Page_110.QC.jpg
a78e8e7aad9bf72e78822425deaacb14
faaa0b5435db3806326762cf0c34858f3b8ef6e9
F20110217_AACEBV mitchell_j_Page_072.tif
d394ec62128668f238e3ed561b34c0d3
dfbda945b5985781f4937d171522dfcc7ef7662d
62707 F20110217_AACFEX mitchell_j_Page_113.jpg
f364bf6f810541c3f295d4c41f69784d
c1d4a5d78c1b082f529b5458e5a53c769f165085
3314 F20110217_AACEZR mitchell_j_Page_084thm.jpg
6263bfa6a91f5e2c2605209a11ca6723
61bad4d0c543f926364b9b49a42f519800fa01f4
586394 F20110217_AACFGB mitchell_j_Page_089.jp2
bc718fae40ca876ead8a57ccd187a4a2
d89cabeb2428fafa572152f723004f70223494c3
788681 F20110217_AACFFN mitchell_j_Page_043.jp2
d6e2b1f6c475f9b65b74c5f78c86910f
262833cad474d987f1c5f93f6c25e228cedf0cae
1168 F20110217_AACECL mitchell_j_Page_085.txt
f944f9d4f3f2363f0a6288b9c12d2883
567fbea523e7201e82482deaba6d32c1ede529f0
49786 F20110217_AACEBW mitchell_j_Page_027.pro
9e5bf76f34fd062d046f9746dce7b6e8
0258d80d12364dad4d558af5a04107d444127ac9
31514 F20110217_AACFEY mitchell_j_Page_114.QC.jpg
8631c9dbba84bbaf554eb4f467e34afc
35598b4ad6b9127563b1a6716bdb0edfd6f0116d
192516 F20110217_AACEZS UFE0014763_00001.xml FULL
3264030e68f7b02ac30a9042b977fa48
cfefb8d4158730e8e7aa5758dd0a4546cea240d0
531743 F20110217_AACFGC mitchell_j_Page_094.jp2
4a8c88d582e6f9112486f1a71087e113
aa98d619566881a1ef87aeb82b76b65b492a529b
905769 F20110217_AACFFO mitchell_j_Page_046.jp2
3506c0c50951d580662389bf77f9cb52
450c53423185aeac6c2782c79194ff70fd47b012
102561 F20110217_AACECM mitchell_j_Page_026.jpg
7d8b56c6a6bc789432b9ce7c5ab44aaa
7eda5c25680a58476528d28855b001c1aa4e84b8
F20110217_AACEBX mitchell_j_Page_077.txt
86cf37be548bf703e7cdbbce945351fc
cdad5b9f89971482a6c198fc3d36154bc2a40c64
122136 F20110217_AACFEZ mitchell_j_Page_115.jpg
840877e8f21390ac48619c763e9b71ae
5543e95fbdecd12319e96267d2df01bacae66c20
45051 F20110217_AACEDA mitchell_j_Page_029.jpg
7cd1928c31355b2f071895aa2084a3a5
e0b5fb61813e75d3bc57a3d368cb639bddfab1ba
272518 F20110217_AACFGD mitchell_j_Page_098.jp2
b4b5dc1ace9ed6267abe754c54eeba07
75633e2a95423b60cfdc601db3d54c85b93e3cb7
F20110217_AACEBY mitchell_j_Page_067.tif
682617d3f7b94f220e5bfec2aa80c5fa
9c056b3dd2274b0c9622700066a02a48700db680
50154 F20110217_AACEDB mitchell_j_Page_064.pro
1c748b72158d4c5e5970dc5ab16ac3db
271b9e7248d52bb18de8681c53a4844bb1bc25fd
855167 F20110217_AACFGE mitchell_j_Page_103.jp2
d41caa41ad7c8007b13dae61c1bf7862
94e393dfd947f6a3b188ed93b8bafb6f32b29bc4
1025473 F20110217_AACFFP mitchell_j_Page_051.jp2
5e9aa0cf62f5b02cbeb8dc1d72b25644
4fb8eb19ea73a24243e0c53b1dbd8639f5dc7c43
8163 F20110217_AACECN mitchell_j_Page_059thm.jpg
f1de7f1a967e2cbc36b5625b738de41c
da090da3d3ce1c1d12f73f0bc19cbd60c0246d53
67342 F20110217_AACEBZ mitchell_j_Page_109.jpg
f1d7bfba0e589d5084946023c56e0e6f
1474dcb8c7ad1ed228bc8d767f25b783574c9f0b
F20110217_AACEZV mitchell_j_Page_009.tif
3ce7dcacaa0bddcbaba5f0a79fd8e586
dff98dd26d62b9db25c2a67a89933553ff47f46b
12236 F20110217_AACEDC mitchell_j_Page_087.pro
64a5e9a2c2d3952e19aaceee11b7e58f
bfbeb0ab8d54cc9cb4be9ed77706f4a9e6637c3c
681782 F20110217_AACFGF mitchell_j_Page_106.jp2
c425cdec266b2d456d34e6948c3ea6bc
b9ed075b6d048502a010ed109c5bd8b7d9dfbd7d
583218 F20110217_AACFFQ mitchell_j_Page_052.jp2
4fb861d86bf592f08f5357d9539a3b9c
b34b40327b416cc48eabce54ecdf62c7a5e5bae4
F20110217_AACECO mitchell_j_Page_106.tif
ca698f853799933c97c2577adb72d99e
16af61568a03616ed5bc1a52ffce1fc8dcb724f8
F20110217_AACEZW mitchell_j_Page_011.tif
374da21de2392e8c95a4c5ecdf181176
f1f40cd8ae593cfdb8d0eb655b71de0f6e6414a2
102301 F20110217_AACEDD mitchell_j_Page_063.jpg
d9548a45d0759cc0c06f2d6ced9fedb3
fd378b745444483fcb31877f2c3b42b9d5532a5c
269656 F20110217_AACFGG mitchell_j_Page_111.jp2
2f27d44d0db2dc85a602c0a675cba310
61444d573f3388da7664835f7e722adecc5466e9
800386 F20110217_AACFFR mitchell_j_Page_053.jp2
2eb4472b2d01b6b9616f1069d1691988
7d8834c6b5dd4f8606bfdc9e7d907a9177929129
1051974 F20110217_AACECP mitchell_j_Page_038.jp2
589a93a64499be5e04d7321c25f4b156
5191cda19f887606c9be102ddf0290b732c4259e
F20110217_AACEZX mitchell_j_Page_012.tif
6554fd54baed01599ac15482cc5dd919
d0f571cd4a5d85d71babe648deb870c030c76436
4521 F20110217_AACEDE mitchell_j_Page_078thm.jpg
cd54f9e64669d6ba9076072bb42f06d5
549cad90b73472bcc72b79da6f8bf26953118e42
4481 F20110217_AACFGH mitchell_j_Page_005thm.jpg
eb3109015e4c7d316f5a5f3c7bc14189
81ea2307d39b26bc13a1b448a15562bb0c1048ba
784871 F20110217_AACFFS mitchell_j_Page_058.jp2
6c363b13cdb19ce4d4b99ef3570fff6d
b0a7c03746eeb13be15c09f5e7cffdf0f3edd9aa
600651 F20110217_AACECQ mitchell_j_Page_110.jp2
449ed24b8598d0697272cb258df0e5d0
54cb4af0c483d307dce94d08bdc2d3b2c98742da
F20110217_AACEZY mitchell_j_Page_017.tif
090d6b98f775a677aea8bf29cbf98863
d52986dc579790cb69ee5ee4cfd7f050453acf0d
2083 F20110217_AACEDF mitchell_j_Page_111thm.jpg
2ff051a67201429627e24d646aa5243b
bfded0f3ab850e4ba5f1376e3e301bf44b687cca
6042 F20110217_AACFGI mitchell_j_Page_008thm.jpg
58aa1fc6bf4e727d9249ca4314bfb834
d82c4993f816c709d4e2826e39b56560d8a446ab
1051948 F20110217_AACFFT mitchell_j_Page_059.jp2
7a3642452573e07146f9d5ba24cfa447
ac9de82719896c30d20d5b6644e06a4412ed0b11
1373 F20110217_AACECR mitchell_j_Page_011.txt
a027db62867e246ad31d847420f6d7b6
b206da01eba00d6344bf37b3722f18a6151a1fff
F20110217_AACEZZ mitchell_j_Page_018.tif
44f9378f66a55fc0ea06b4f90e6e1fd4
f85be63f696dcd6e04e81905cc9abb4ca56f43e5
18882 F20110217_AACEDG mitchell_j_Page_005.QC.jpg
01af6d07883cefb7e9044d39376f585b
ff3b52359f80e477f3029534dc8f12462b926ed3
7783 F20110217_AACFGJ mitchell_j_Page_021thm.jpg
74cf1f3f6ea0efa56af4808238368007
a44dadce92ef7615aa328228dbddecb7881a577b
1051916 F20110217_AACFFU mitchell_j_Page_063.jp2
015e8f989b3baab2ae82986aaec25bbf
f2c16b4caf3c530cf3b533d99f97d8b0d3872b99
27019 F20110217_AACECS mitchell_j_Page_056.QC.jpg
af2741d191fc5c279e6065bf55b9763f
5f3e38e03d710531e37e5a009422cd2c81fce224
2374 F20110217_AACEDH mitchell_j_Page_103.txt
26dd50a52be126c52abbcf72ec843212
defc8a6c135aa55c7e7afb320508d946d0f19cb5
7963 F20110217_AACFGK mitchell_j_Page_028thm.jpg
b83d8bcc0e188884e26937736bbce38c
6d76d6221c686bbfadeb6e1057c9313807bee1a3
F20110217_AACFFV mitchell_j_Page_064.jp2
e40bfb5d289be27548af7eed09978db7
5073eee0098af35078c5813e58af14cc3c9e8094
18919 F20110217_AACECT mitchell_j_Page_106.QC.jpg
1e14ff36ff8649f741dd3e7c53c301fb
6d11282e4cbd990582cba350fd2cdc0c7cc09311
45387 F20110217_AACEDI mitchell_j_Page_078.jpg
87d23b140afbbd2a48382bf8de89762f
0017484f71f956d353e9a1a357e033a68b18c55c
7152 F20110217_AACFGL mitchell_j_Page_037thm.jpg
cc1f018629561966111bca8c0cb5a50d
0f6ce47261d39d70cceff9d660f1766085598643
F20110217_AACFFW mitchell_j_Page_066.jp2
073585afbaa4b1c4c85454f7f20d7bcc
9cacfe9bda2a8b5635b1d2c96770d58cf5268f10
2029 F20110217_AACECU mitchell_j_Page_074.txt
4c349432ba0bd72c3738da7ac17e6eb6
c1a675d2e8bd84a0859f0f1247ac0420d1fe99ce
1001272 F20110217_AACEDJ mitchell_j_Page_072.jp2
ad64fee2cc232e8e833e1defd8fe0ef0
763c784e163f99a1cdbb11630b0b2e3b0a2bc5d7
8717 F20110217_AACFHA mitchell_j_Page_116thm.jpg
9c6804a520d6e52d6402577563e44b53
d4c0741078b8722a95cf7cfc3951e3a3314b4721
8273 F20110217_AACFGM mitchell_j_Page_038thm.jpg
a87b731f1b59de20c0a620b74b942e58
94b1d35ae57911656f09fffdaf69410cd81b4dc7
1031319 F20110217_AACFFX mitchell_j_Page_067.jp2
a21e64a2a87bdb44502c989c8baa0817
d62f24f6384a8973284a1727ece93a0594e80209
93690 F20110217_AACEDK mitchell_j_Page_033.jpg
788acc1bcc7a6b0c97f59a20f588d790
fe1606e3296f98e52f279066a0475669b0f5ceb1
1051977 F20110217_AACECV mitchell_j_Page_022.jp2
ccb90b325ab3ae3ec1c5cdf180b00b85
02f22af2d8aecf4396bd92ebeee64193ce83270e
6537 F20110217_AACFHB mitchell_j_Page_117thm.jpg
592ed3688809668cabe0fafcf8787cbb
971f2f96c673f4eb4cfb443b32c8a9b3d92267f1
6999 F20110217_AACFGN mitchell_j_Page_042thm.jpg
c761f01d49d6c27c0aebbd319dc21deb
36da1cf095bfbaba4302f31c02306da77b7a1136
1051976 F20110217_AACFFY mitchell_j_Page_069.jp2
8deffcf2e5f3639f292940636fce92e9
4f358b177fcfc259d46d00ae929939d189d21b99
28905 F20110217_AACEDL mitchell_j_Page_044.QC.jpg
219d9da9a9c98b3a27aa56ae1a2bb8f0
ec98bc5392214cea47582cb5b408e725ba4f59f6
F20110217_AACECW mitchell_j_Page_019.tif
2a60b59ac70eff04969136564df93b3d
f134a9e5cebe99008a92eca44aab8542bfac4ec1
9972760 F20110217_AACFHC mitchell_j.pdf
da8d085efc39c520902e1edc0860b6fc
1e65ad0ee6c4fb65dfa63eb1c592e345808ba1bf
5954 F20110217_AACFGO mitchell_j_Page_052thm.jpg
ded3524e0f6be40191665a8c456b243f
415ad5f766fc1bfd5515afa247d5355dd86c2202
508441 F20110217_AACFFZ mitchell_j_Page_080.jp2
79dc8a29d1f6f1d465b101ce4777ad38
b3abe8ce5eb7b10901fb78e6dcc2fc27cdda2cbb
20934 F20110217_AACEEA mitchell_j_Page_081.pro
d6255fe950c26f3d47cf8a52f9973bef
ca8240de66946bb6c1966157bcad030e77295205
97257 F20110217_AACEDM mitchell_j_Page_056.jpg
4749e0553a8a06e6a6b068839c6d7809
bb194f36a0faed5304036cd6c542690ce9067be6
2070 F20110217_AACECX mitchell_j_Page_022.txt
b6709e1950a680796e46468575220215
9224733e332a35f34704873d7429274d18e824ff
140734 F20110217_AACFHD UFE0014763_00001.mets
ae92d20258dd555d46e59048a35e3597
bc5c326e5a3e6a271785b46beedede0ad9fdd743
7787 F20110217_AACFGP mitchell_j_Page_055thm.jpg
01208b69ea763c6b526c046621343e84
acb08926fb30a2ecd9e25542fefb7dc4587a318c
F20110217_AACEEB mitchell_j_Page_079.tif
1e637b4555e69ac6274243e283e06be8
b150b5d33d921bef67bd5d4c4d132e34c59f3f01
35761 F20110217_AACEDN mitchell_j_Page_022.QC.jpg
531244c716e78c370523e04598ee5bf4
43d5a44204a55fd9076e7f2ef718b8ce46483103
5281 F20110217_AACECY mitchell_j_Page_103thm.jpg
a4f2f42aaddd62e5fa5c41a0094a1d08
5f56caa323d18c0b0411589c20645cd0e233c991
413 F20110217_AACEEC mitchell_j_Page_083.pro
6a6a1035b3e6ca972b909d1148f63a78
d1d21dab19a0301aeb847ce5561a738b2e6d0922
7484 F20110217_AACECZ mitchell_j_Page_035thm.jpg
7423e70f0555eae215231d3b3a3c6e5c
c61442792a3655c210c6a996f5671b3e39906606
8490 F20110217_AACFGQ mitchell_j_Page_062thm.jpg
e9b6fb8bac529f6da157d8f72e38205f
d1f2531cc1b1d1f1ebc21ef9ce6bfdd1711c4b5c
674427 F20110217_AACEED mitchell_j_Page_039.jp2
1e2244197aedb7d6b391829142001f4c
a6b1b8f13e0be5beb31cf60ed344c9e0ef0d08d3
100666 F20110217_AACEDO mitchell_j_Page_064.jpg
64faf784ee2e31a4fa961a67e94a049e
b3a13218572e422622032c447e233437c6af7452
8199 F20110217_AACFGR mitchell_j_Page_066thm.jpg
167a912fd1ab04219e7a9ee2823a0c1a
598cea1b3a38b51d1337df9a38997417ea365fda
F20110217_AACEEE mitchell_j_Page_035.tif
028fec4485668c6a7b13a13d21bcfeda
c32dd3949cdc1e507270ee73bb6ec75c28a099af
5989 F20110217_AACEDP mitchell_j_Page_099thm.jpg
b6f820b456530ff1bc44200b704ad6a8
43df8c0013d5cb43262c19a4235bd1da7812ac73
8354 F20110217_AACFGS mitchell_j_Page_069thm.jpg
bab4681282c7566664c2de94ae90f0a9
09be2fcec9889725cd9908372f7a8b3964078a63
F20110217_AACEEF mitchell_j_Page_077.tif
43f9b5cc954a72df7f4aed0141f27808
af0f4e6546c7378e796e071649444f1ced24e465
26948 F20110217_AACEDQ mitchell_j_Page_006.pro
77ca0275cf756ac59d005953049d147d
c9c8cdf10b42393735ba85bb3c573b5cd6b70588
2281 F20110217_AACFGT mitchell_j_Page_081thm.jpg
0c7c166e1635b938e50d7cfc35635958
b62f5d26f9edac0ac4c9455846838408158fcb29
1792 F20110217_AACEEG mitchell_j_Page_044.txt
6b17ccec3472eb8ddddd0fb422ed89ff
b29508cfd13b7ad764289b1885e6072cd8c4e6c3
7046 F20110217_AACEDR mitchell_j_Page_050thm.jpg
1a2bfc34c020bdd8f261126c04cf92b9
ac17d78e9f7b754e3badee7365b3f94db186804b
2022 F20110217_AACFGU mitchell_j_Page_083thm.jpg
63db53b457e774a3aac8919e56ef9b9d
5b2fb32393f740a9e825d10fa4a28a15e1d78c78
3082 F20110217_AACEEH mitchell_j_Page_004.txt
0348618e95a2855b950220fb44bcbcdc
04c47fb1830d36593c698b0579e57b40ad90ba70
104538 F20110217_AACEDS mitchell_j_Page_061.jpg
2282fa1bd7526533aa9a7bd8d159e446
5f6f81e1740fb7d00e46a60f344e9300f55ced01
4297 F20110217_AACFGV mitchell_j_Page_091thm.jpg
475987e37df636d2bb369b3ef4e81507
2cb9dc776dfb52c343e8d4a33493d1ad913a5e6d
1035 F20110217_AACEEI mitchell_j_Page_052.txt
7f0d9948e775954456f45205c5c37872
d1bf4723842dd73344df330b9cfa411b09bd2183
29693 F20110217_AACEDT mitchell_j_Page_002.jp2
0eb1ce3d6e715b02911b2dab292418a9
8adf074d9a213c6b528dcd0fc6b0c2411e456ba2
4024 F20110217_AACFGW mitchell_j_Page_093thm.jpg
f131279013f2fc19d18212d0ef7d8594
06b4716078d3b06e963fa7e4634b83ebd2bc5cfd
5239 F20110217_AACEEJ mitchell_j_Page_106thm.jpg
249fadbbc4535c10731355addefde334
738265f559c184d52734dc70db775e13654995c8
3590 F20110217_AACEDU mitchell_j_Page_009thm.jpg
14d42d67efb12ef5cd7dc6caca63b1e1
3a8524bdcb4801f5e853108543abd256e248ab7c
4188 F20110217_AACFGX mitchell_j_Page_096thm.jpg
7a0ae59c16cc8b2a792e584a5c1ed6b8
71cfdccc00f8e6faea1221b7a1ee78d53fd8c49a
3380 F20110217_AACEEK mitchell_j_Page_078.pro
26f696cd969133a883132200c9f9bc4f
5bd18823299db88ae04e5f39c3e18c304f797b46
57109 F20110217_AACEDV mitchell_j_Page_055.pro
20d6f805dc9bf356c426c2598e687152
38eecdda31c7e283ff9bb19de12508bfc362fd4a
4720 F20110217_AACFGY mitchell_j_Page_112thm.jpg
cedf0b4a7c093b19a869ad08494638d0
ac5dd72e45ac90e3d11a7c0c8a4727f99d4cc280
1251 F20110217_AACEEL mitchell_j_Page_098.pro
3fbc2ffcd179dc505c59d04a63b81dff
8244e207b75b546a096111efda4085a10a3aecdb
578618 F20110217_AACEDW mitchell_j_Page_077.jp2
722594aafdf95617fe2039eeaae58dc6
dd87bfe4b7e7ecd44edd6a98d9f5299fc4c82059
7774 F20110217_AACFGZ mitchell_j_Page_114thm.jpg
434866fdbe8c385140541d281c7a593b
0a31d26141110af26772ae84619bb7806bf07409
90 F20110217_AACEEM mitchell_j_Page_083.txt
4aa0c083f889a5908e4c89e0e2f03aef
9e61d428425acc0bf5cbacffd7ce5785b3870cef
27741 F20110217_AACEDX mitchell_j_Page_032.pro
4529d6d2bcfca11628019c4d269822ae
588b3e61a1d6b52558de578de08a4f09a80bf84d
F20110217_AACEFA mitchell_j_Page_062.tif
5a3be412bbc9d525fd97a87b495ced21
8517d3a21a691b410a7553d2879a1ce0b70e4110
100 F20110217_AACEEN mitchell_j_Page_098.txt
65da4d9b3109d91abaea4a6c999aa0d8
5326df48c6122813c0965ebd79932077a97d8099
16422 F20110217_AACEDY mitchell_j_Page_082.QC.jpg
b503c4ef2ae8935f805c6ae02e5e0604
8ca3414ab14ad03f3fd39d7f0333e86d360589f5
83361 F20110217_AACEFB mitchell_j_Page_031.jpg
a8722a60355e83d9c761787bec635387
bdb3280977c711c9df26ceba485ea5a0b1d1dfba
1999 F20110217_AACEEO mitchell_j_Page_016.txt
2d30ee68a3d5890eaa3d4e3a5ce40172
3c78357c46c5ea62848880095b2414689212b624
5881 F20110217_AACEDZ mitchell_j_Page_045thm.jpg
731d9300a5e79a28a4588119cc9809d4
b1eceb5c8399f46d8fdd2f5a90011ef547970df0
27500 F20110217_AACEFC mitchell_j_Page_101.QC.jpg
cfa459d67cb1105da8788321eb020dbb
a395d18b998e554576896affb19d94c2ec257a5c
497591 F20110217_AACEFD mitchell_j_Page_088.jp2
f078f903d275c6c7ff3e212152e1e30b
1ac22e903fd4149e3121254cdbb89645bb965494
1240 F20110217_AACEEP mitchell_j_Page_014thm.jpg
6b8502c264d1eebd3476038871b06a93
dfeaca25ccab49436c56f9b76159ca6c4725a2f6
35066 F20110217_AACEFE mitchell_j_Page_116.QC.jpg
9d2f7ba752479843a179d623e2189b92
8195bd40b6e9e60468a74590e75883b66b91b39a
6974 F20110217_AACEEQ mitchell_j_Page_043thm.jpg
81169f1c006938ad1391e602c640e0db
0efb4dd3454f9c47f80e0a4cc4befcf0328961a0
1051941 F20110217_AACEFF mitchell_j_Page_116.jp2
03e4a59fa6bbdba9885aeee3f470f470
665d0323a56b6a62c6d1640d4f4e068f57f14fe1
15271 F20110217_AACEER mitchell_j_Page_075.QC.jpg
dc7456d8ef7e48c2a20b137dce55e0c3
46070d3f42b996e891a8941e6094f0c8c68a8c3c
7285 F20110217_AACEFG mitchell_j_Page_044thm.jpg
2f1a84d426ba8e9e4bbd4f3f89192ccf
7019eb77677315871137ca87be09eb233934c519
F20110217_AACEES mitchell_j_Page_060.jp2
eb60aaa0bd9d628a51f448abe052ef65
df8b774df8b3636b78c89b0aa124debe9e7763f5
25767 F20110217_AACEFH mitchell_j_Page_053.QC.jpg
55f208503541cead4b3a86e3a6b97577
9aaf894a05b60ae2b83f367d5b20cb155fa6b0ed
7116 F20110217_AACEET mitchell_j_Page_053thm.jpg
cf1415a0e54c21b1c9fc74417665213c
59ae95fa632bbbc0a8fcf5b286dc0a91d637881f
3287 F20110217_AACEFI mitchell_j_Page_086thm.jpg
d089536f4bd196a2370a19d48a16d39e
059c8563b75f2cb9fc5e1921f2daa6afbd285eec
17640 F20110217_AACEEU mitchell_j_Page_057.pro
1d5a7c913d4b916be44e61f132679a2d
e0bbcf0b9b104a1fc67dc7286de5891c19f5d8e9
F20110217_AACEFJ mitchell_j_Page_073.tif
fe2e91cd8c82853bde661a1255737276
5f3c2fec2c897bf0fbbceb935ca7a250ea778943
2719 F20110217_AACEEV mitchell_j_Page_110.txt
44f6c81ac40cff168fea007e7a9a6f88
da54e892ed05ba6c0cff28480526df7382faac1c
21095 F20110217_AACEFK mitchell_j_Page_029.pro
a1455cea5c9d5fa3ee091f296b6beef7
929c55bc085cf643b2d8dc1df84edae0aef6caab
49949 F20110217_AACEEW mitchell_j_Page_016.pro
a9dad6d48ae3a69b7a448465404f091f
1c0008e31224e913f656d02de766a05989adeb3b
1820 F20110217_AACEFL mitchell_j_Page_025.txt
5b9c193fcf321915c4969be012236708
db9cd4f91b73ca16efe5568118fc24f70aa17f43
28443 F20110217_AACEEX mitchell_j_Page_083.jpg
993a4e59d0a6a818b2ee880341c6e509
7fabd34384262d836aff1e07f2516263baa67cf4
22002 F20110217_AACEGA mitchell_j_Page_087.jpg
3968f4915c03617ec4bf7595dd79fe40
a06c5c581670cf672955be8d0051efb9c092b032
14555 F20110217_AACEFM mitchell_j_Page_091.QC.jpg
9ecca5f7d98b94fd077628958873e5ea
86a5533ccdf33ff64bdff39915a7073089480abc
3974 F20110217_AACEEY mitchell_j_Page_118thm.jpg
4f841531569f9aa71ca63e3bb1685f0a
982b9d6c0ff3251ed1d9e122ea8e976110875a7b
1051912 F20110217_AACEGB mitchell_j_Page_073.jp2
fdb70b4a7d9a0966bfce68cd5d1b0ee8
3858ed485d2c1fcd90238a9aa8788f6cbc467e53
103674 F20110217_AACEFN mitchell_j_Page_027.jpg
8289d1046c45a5255d94e5d621fbb9c1
12af6371ad9320deeba6bc01c877fca838689c24
F20110217_AACEEZ mitchell_j_Page_005.tif
7deb3b2db2bdfc80dab99396f406b2e7
d2c0dd592429cc14a7d799fd5ae4138c333c0925
1918 F20110217_AACEGC mitchell_j_Page_021.txt
c5f67e15865669fb546962ed15f0040c
f6b4f830e8acf4a40b1260c82b690681548c2d56
45419 F20110217_AACEFO mitchell_j_Page_118.jpg
5e17d5828ab2944c4bf9dd25e2516cca
9420c11f6b96f7be37e270f6586da5147ea35880
F20110217_AACEGD mitchell_j_Page_016.tif
757cae97c8009aacc41117e0af66e3c5
5d7aab693e5d04c8be98c9169d2e14b35f26e3c3
2857 F20110217_AACEFP mitchell_j_Page_006thm.jpg
453bd44aab848c59ee6b9d5a90914532
d7f869edbec02bca389493c76a9bc012c267900d
F20110217_AACEGE mitchell_j_Page_069.tif
798174d1a07038b961cd791f08f509ac
5354c5249a577f009cc6642a3fc118491ea6efc7
1032292 F20110217_AACEGF mitchell_j_Page_033.jp2
0c4e3a5994eb4d99d75cc5b267b2de78
2c9af17ee9efd5a0e56a2ac1fd7b82d2b51d7de3
635 F20110217_AACEFQ mitchell_j_Page_002thm.jpg
6e043b99747e7a87b6a041901392884d
aeabea77b20bdec1f8eeb393a91dde1607db8253
99733 F20110217_AACEGG mitchell_j_Page_060.jpg
b681a4a4ff64a9643bb6d882a21bc098
e88cff83e1cbc84aa597bdbd0ed51b1a52724df1
F20110217_AACEFR mitchell_j_Page_050.tif
501a5c2a0a149cd5555ecf1810ff9e5a
47252b7ed2d6c108abe62d6014256886f7d61efa
16053 F20110217_AACEGH mitchell_j_Page_080.QC.jpg
fe294802c9509b3543852ade735973d8
eef6cf56b74edce272ac67d95416931f9c6ef73e
37098 F20110217_AACEFS mitchell_j_Page_112.pro
79b7f08e552a2ab62da5b1cae0fe7d8e
310fa81818052fb0ffe4d1c7f8c40eb3bfdce4c8
7931 F20110217_AACEGI mitchell_j_Page_023thm.jpg
ff1dfeae403bd6ecb999674f55236f08
91ffbfda03e05c654d83ed0fdbbf8862d876a8a6
46484 F20110217_AACEFT mitchell_j_Page_090.jpg
94b10947865b53616bcf4d9371bf8d36
6398a7971519d94b3b589b198b192be29ea0455d
F20110217_AACEGJ mitchell_j_Page_001thm.jpg
a33c4bd5567851be93a5605f548003df
8d860ed208492a70442730c1d6ff1342ab8a6992
F20110217_AACEFU mitchell_j_Page_036.tif
e175b7252d2fb7d6e66f2d990c81e9c7
f4eac687e48c665c3afcb2b7a687e3cf487e30f2
94014 F20110217_AACEGK mitchell_j_Page_023.jpg
bd4b1f2a39df3f0a794c897f70e0428a
de9e517c282757de839622d4802c2a5c32540284
718443 F20110217_AACEFV mitchell_j_Page_108.jp2
7d07e208f674ee111fd784578154cf70
c15363d519214f7b4087ebe1704060327bda558a
620762 F20110217_AACEGL mitchell_j_Page_090.jp2
a86fe422fef835366fe4a95e04ffe739
974b8432644208c68bf8467aa1a72f84c6a99897
F20110217_AACEFW mitchell_j_Page_041.tif
292626b4e7a4ee242410b8aa3d561407
ae23ad3287996acbcf671ba37d50dcf888d5fca7
7900 F20110217_AACEHA mitchell_j_Page_073thm.jpg
56ed967de4baac80d0ecd212e6b36730
e4742acd51637662d226cb25687d0beee3feeae7
425759 F20110217_AACEGM mitchell_j_Page_085.jp2
6934af90bac9b67361ec19db58f9c99f
9c4bbca3ac74fc8a647497dbe0db4704133acd9d
345059 F20110217_AACEFX mitchell_j_Page_086.jp2
1c70965b1999acb910e5479e629fa8f4
718112606492226beffbe32c4867d82dc557b0ca
33536 F20110217_AACEHB mitchell_j_Page_047.pro
f7b8151186aa861d76bc2ef1ca36d57c
7a610b4ef17a0b8423f2e7fa158769ac10582dc1
96238 F20110217_AACEGN mitchell_j_Page_071.jpg
73f33d12d9ae377e6cc95bd7e8e6d583
0503cbdc5f341ffaa59aee182e6428450abf1a4c
30742 F20110217_AACEFY mitchell_j_Page_051.QC.jpg
bcfea8625401068e0fb1011c70debc4a
f3322ef99d6eba9ad70dc23b43127925ac5e4a58
18357 F20110217_AACEHC mitchell_j_Page_003.QC.jpg
e64045a1f93db77fdc6a084ca4481370
7933013e33d7ccfa767d4a4080c28b971dfe5624
57515 F20110217_AACEGO mitchell_j_Page_102.jpg
9d729d8250da4d13f2d2a7c2144d0336
7fb7d637d350651cfb9d4f021e46bf2e03dd3847
47380 F20110217_AACEFZ mitchell_j_Page_108.pro
1880fdfbbdd0d848cb997b4bd7fe39c3
6d2f0d194d711893873fa97a5d7d9a71e0567beb
15907 F20110217_AACEHD mitchell_j_Page_099.pro
9437986754099a3b87eaa5f7f46771ba
b08eb30cd3b077d7771c05f2f19b0ce8ea78f0eb
1615 F20110217_AACEGP mitchell_j_Page_047.txt
623700a038f0cd9ea39739673063fb4b
aa3f136821c65a4f63f63474706e20c59919b5ff
63447 F20110217_AACEHE mitchell_j_Page_045.jpg
54e27b0374ffb818df5088996f311424
d2856399bab4ce531f3080ad00e9b4bab5d9ef81
40089 F20110217_AACEGQ mitchell_j_Page_031.pro
5f2ed7320868b0fbe297a0504ef9b279
a568f49f44f52953349d240749af5a6a63fff6b0



PAGE 1

IMPACT ON CARPET TILE IN A HO SPITAL PATIENT UNI T CORRIDOR: AN OBSERVATIONAL CASE STUDY By JULIANNA M. MITCHELL A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF INTERIOR DESIGN UNIVERSITY OF FLORIDA 2006

PAGE 2

Copyright 2006 by Julianna M. Mitchell

PAGE 3

iii ACKNOWLEDGMENTS I extend my sincere thanks first and fore most to Dr. Debra Harris, whose help, advice, and encouragement have been invaluable She helped to make this endeavor not only possible, but interesting and fun along th e way, and I am grateful for her presence throughout as teacher, mentor, and friend. I would also like to thank Dr. Murray Ct for serving on my thesis committee, as well as Charlotte, Patti, and the staff on the 4th floor of the hospital in which I conducted this study for all of their help and patience. I owe many thanks to my four friends and colleagues in my graduate class. Their caring support, honest criticism, and fun-l oving spirit have been cherished constants throughout our education. I am forever grateful to my incredible support system of friends, super-friends, and family, whose encouragement and pride contin ue to motivate and inspire me. Finally, I wish to thank Conor for his extraord inary understanding and unwavering support throughout this endeavor and always.

PAGE 4

iv TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iii LIST OF TABLES............................................................................................................vii LIST OF FIGURES.........................................................................................................viii ABSTRACT....................................................................................................................... ..x CHAPTER 1 INTRODUCTION........................................................................................................1 Purpose........................................................................................................................ .1 Significance of the Study..............................................................................................2 2 LITERATURE REVIEW.............................................................................................4 Indoor Environmental Quality......................................................................................4 Carpeting and the Hospital Environment.....................................................................5 Indoor Air Quality.................................................................................................5 Infection Control...................................................................................................6 Acoustic Quality....................................................................................................8 Light and Reflected Light......................................................................................9 Personal Comfort...................................................................................................9 Safety Factors......................................................................................................10 Material Composition..........................................................................................11 The Role of Cleaning..................................................................................................12 Cleaning Methods.......................................................................................................14 Preventive Maintenance......................................................................................14 Vacuuming..........................................................................................................14 Spot and Spill Removal.......................................................................................15 Interim Cleaning..................................................................................................16 Restorative Cleaning...........................................................................................17 Summary.....................................................................................................................17 3 RESEARCH METHODOLOGY...............................................................................19 Research Design.........................................................................................................19

PAGE 5

v Methodological Background......................................................................................19 Ethics......................................................................................................................... .20 Research Hypotheses..................................................................................................20 Setting........................................................................................................................ .20 Observation Procedures..............................................................................................22 Analysis......................................................................................................................2 3 4 FINDINGS..................................................................................................................26 Foot Traffic.................................................................................................................26 Type and Frequency............................................................................................26 Patterns................................................................................................................29 Equipment Carts.........................................................................................................34 Type and Frequency............................................................................................34 Patterns................................................................................................................37 Carpet Cleaning Procedures.......................................................................................42 Type and Frequency............................................................................................42 Patterns................................................................................................................43 Contamination Incidents......................................................................................43 Comparison of Cleaning Procedures...................................................................44 5 DISCUSSION.............................................................................................................47 Foot Traffic.................................................................................................................47 Type and Frequency............................................................................................48 Patterns................................................................................................................50 Equipment Carts.........................................................................................................52 Type and Frequency............................................................................................52 Patterns................................................................................................................53 Carpet Cleaning Procedures.......................................................................................55 Preventive Maintenance......................................................................................56 Vacuuming..........................................................................................................56 Spot and Spill Removal.......................................................................................57 Interim Cleaning..................................................................................................58 Restorative Cleaning...........................................................................................58 Carpet Tile Replacement.....................................................................................59 Summary..............................................................................................................59 6 CONCLUSIONS........................................................................................................61 Limitations..................................................................................................................62 Future Directions in Research....................................................................................63 APPENDIX A APPROVAL AND PERMISSION.............................................................................64 B OBSERVATION FORMS..........................................................................................66

PAGE 6

vi C STATISTICAL ANALYSES.....................................................................................69 D EQUIPMENT PHOTOGRAPHS...............................................................................77 E CLEANING EQUIPM ENT SPECIFICATIONS.......................................................88 F MATERIAL SAFETY DATA SHEETS....................................................................91 G HOSPITAL ENVIRONMENTAL SERV ICES POLICY #11: CHEMICALS USED ON HOUSEKEEPERS CART......................................................................99 H HOSPITAL ENVIRONMENTAL SERV ICES POLICY # 27: CARPET CLEANING PROCEDURES...................................................................................101 I TYPICAL PATIENT UNIT CLEANING SCHEDULE..........................................102 LIST OF REFERENCES.................................................................................................103 BIOGRAPHICAL SKETCH...........................................................................................107

PAGE 7

vii LIST OF TABLES Table page 2.1 Commercial carpet clea ning frequency chart...........................................................15 4.1 Total traffic counts observed, by day and time block..............................................26 4.2 Total equipment cart counts observed, by day and time block................................35 4.3 Number of times vacuuming wa s observed, by day and time block........................43 4.4 Contamination incidents and responses...................................................................44 4.5 Comparison of recommended and obser ved carpet cleaning procedures................44

PAGE 8

viii LIST OF FIGURES Figure page 1.1 Relationships between factor s involved in the research.............................................1 1.2 Conceptual framework...............................................................................................2 3.1 Study setting.............................................................................................................2 1 3.2 Factors contributing to the conditi on of flooring finish material.............................24 4.1 Types of users, as percentages of total foot traffic observed...................................28 4.2 Average foot traffic timeline, by time block............................................................28 4.3 Average foot traffic timelines for each user group...................................................29 4.4 Entry/destination locations in the defined corridor area..........................................30 4.5 Most frequently taken foot traffic path s, as percentages of total foot traffic observed...................................................................................................................31 4.6 Locations on study corridor commonly rece iving foot traffic, as percentages of total foot traffic observed.........................................................................................32 4.7 By user group category, locations on study corridor commonly receiving foot traffic, as percentages of total foot traffic observed.................................................33 4.8 Types of equipment carts, as percen tages of total carts/items observed..................36 4.9 Correlation between foot tra ffic and equipment cart counts....................................37 4.10 Most frequently taken paths by equipmen t, as percentages of total equipment carts/items observed.................................................................................................38 4.11 Locations on study corridor commonly receiving equipment cart traffic, as percentages of total equipment carts/items observed...............................................39 4.12 By category of equipment, locations on study corridor commonly receiving equipment cart/item traffic, as percen tages of total carts/items observed................40 4.13 Human-equipment interac tion patterns observed for e ach equipment category......42

PAGE 9

ix D.1 IV Pole.................................................................................................................... ..77 D.2 Typical supply cart...................................................................................................78 D.3 Supply/utility cart.....................................................................................................78 D.4 Supply cart................................................................................................................ 79 D.5 Housekeeping cart....................................................................................................79 D.6 Typical gurneys........................................................................................................80 D.7 Gurney..................................................................................................................... .80 D.8 Food service cart......................................................................................................81 D.9 Small linens cart.......................................................................................................81 D.10 Wheelchair...............................................................................................................8 2 D.11 Portable x-ray machine.............................................................................................82 D.12 Trash bin/large linens cart........................................................................................83 D.13 Emergency crash cart...............................................................................................83 D.14 Treatment cart..........................................................................................................84 D.15 Treatment cart..........................................................................................................84 D.16 Cart used for blood-drawing....................................................................................85 D.17 Portable scale............................................................................................................ 85 D.18 Mobile computer carts..............................................................................................86 D.19 Rolling task chair.....................................................................................................86 D.20 Flatbed maintenance cart..........................................................................................87

PAGE 10

x Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Interior Design IMPACT ON CARPET TILE IN A HO SPITAL PATIENT UNIT CORRIDOR: AN OBSERVATIONAL CASE STUDY By Julianna M. Mitchell August 2006 Chair: Debra D. Harris Major Department: Interior Design Interior designers are generally responsible for the selection a nd specification of flooring materials for healthcare facilities. In turn, flooring ma terials and carpet may have a broad impact on the health, safety, comfort, and confidence level of patients, visitors, and employees. In order to manuf acture and select carpeting that can properly support hospital occupants and ac tivities, it is necessary to consider the factors which impact it. Similarly, a maintenance plan to properly care for carpeting must respond to actual use and wear, in addition to incorpor ating preventive measures for infection control and indoor air quality. This study exam ines use patterns and activities affecting carpet tile in a real-life setting. Observations of a designated portion of a patient unit corridor were made in 2-hour increments between the typical peak hours of 7:00am and 11:00pm. A total of 31 time blocks were randomized over a 6-day peri od. Researchers documented the type and frequency of foot traffic and equipment carts, as well as use patterns in the form of paths

PAGE 11

xi traveled through the corridor area. Additiona lly, cleaning activities were documented in order to compare 1) actual ca rpet cleaning procedures, 2) documented hospital protocol, and 3) infection control guidelines an d industry standard cleaning methods. Results showed that the study corridor carpeting received over 2,900 foot traffic instances per day during peak hours alone, and that average foot tr affic counts varied throughout the day. Further, this particular location within the hospi tal primarily served and supported healthcare professionals charged with patient care. However, unexpected use patterns of the particular spaces allocated to healthcare st aff were revealed. Findings indicate that information such as equipment use and hospital census numbers should be examined when selecting appropriate floor coverings or developing and implementing a maintenance plan. A hospital-wide comprehensive carpet ma intenance program should be developed and documented. Additionally, variation among housekeeping staff members suggests the need for further research regarding c onsistency and quality of regular facility maintenance practices. Further studies shoul d also explore how wear and contamination of carpet tile affect people in the environment, especially with regard to physical health.

PAGE 12

1 CHAPTER 1 INTRODUCTION Interior designers are generally responsible for the selection a nd specification of flooring materials for healthcare facilities. In turn, flooring ma terials and carpet may have a broad impact on the health, safety, comfort, and confidence level of patients, visitors, and employees (Figure 1.1). Speci fying carpeting requires consideration not only of appearance (e.g., color and texture), but of crucial factors such as durability, maintenance, and indoor air quality. In orde r to make appropriate decisions, designers should be informed about how materials are im pacted and maintained by end users. This study examined use patterns and activities th at effect carpet tile in a real-life setting. Figure 1.1: Relationships between fa ctors involved in the research Purpose The purpose of this study is to determin e the human impact on carpet tile in a patient unit corridor, includi ng housekeeping activities, human traffic, and equipment carts. Specific questions answered include 1) what specific users and equipment Hospital Designer Materials ( i.e. car p etin g) Maintenance IEQ (Indoor Environmental Quality) Users

PAGE 13

2 contribute to traffic flow in a patient corridor; and 2) what are the consistency, frequency, and methods of regular cleaning of carpet ti le in an acute care patient corridor? Through this study, occurrences of and r eaction to contamination incidents are isolated and explored. Fu rther, a comparison between 1) actual carpet cleaning procedures, 2) documented hospital protocol and 3) infection control guidelines and industry standard cleaning methods provides valuable information to manufacturers and specifiers of materials for acute care facilities. The conceptu al framework for this study is shown in Figure 1.2. Figure 1.2: Conceptual framework Significance of the Study Interior designersalong with manufactur ers of flooring materials such as carpet continually question whether floo ring finish materials are maintained properly once they are installed in hospitals and other faciliti es. First-hand information about how these products are actually being utili zed and treated in their intend ed setting could lead to the development and selection of better, more suitable floor coverings for healthcare and other environments. Although findings in this case study are not generalizable to other Note: Items in gray are beyond the scope of this research study. Contributing Factors Foot traffic Equipment Air Contamination Impact Type & frequency Use patterns Extent of contamination Response i.e. Maintenance Type & frequency Patterns (schedule) Physical Setting Car p etin g Infection Control Ergonomics IEQ (Indoor Environmental Quality)

PAGE 14

3 hospitals or environments, th ey will provide useful information for the host site and contribute to the body of knowledge for interior design application a nd related industries.

PAGE 15

4 CHAPTER 2 LITERATURE REVIEW Indoor Environmental Quality Concern in recent years about the relati onship between the built environment and the health of occupants has lead to substant ial research and advan ces in indoor air and environmental quality (American Society of Healthcare Engineering, 2004; Luedtke, Scholler, & Kennedy, 2000). In 2003, the Ameri can Journal of Pub lic Health published an entire issue on the subject, signal[ing] a timely recognitio n of the relevance to health and well-being of the indoor environments where people spend most of their time (Samet & Spengler, 2003, p. 1489). Several major organizations, including the U.S. Green Building Council in its Leadership in Energy and Environmental Design Green Building Rating System, the American Societ y of Healthcare Engineering, and the Green Guide for Healthcare list indoor environmental quality as a key contributor to the wellbeing of a buildings occupants (ASHE, 2004; Green Guide for Healthcare, 2005; United States Green Building Council, 2004). The quality of the indoor environmen t has a profound affect on health and productivity. Moreover, risk of diseas e is increased by i ndoor air pollutants, contamination of surfaces by toxins and mi crobes, and contact between people in the environment (Samet & Spengler, 2003). In tu rn, the air and environmental quality of a building are dependent on: 1) the design of th e physical space, 2) the building systems, and 3) the selection and maintenance of ma terials within (ASHE, 2004; Ayliffe, Babb, &

PAGE 16

5 Taylor, 1999; Luedtke et al., 2000). Interior designers make decisions regarding each of these factors and are principally responsible for the specification of interior materials. Carpeting and the Hospital Environment The healthcare sector esp ecially has a collective funda mental mission to protect and enhance individual and community heal th (GGHC, 2005). Fuston and Nadel (1997) assert that the design of healthcare facilities is likely the most critical of all interior spaces because of the extended durations spent in them by patients and employees alike. Hospitals require special consideration with regard to indoor envi ronmental quality due to the susceptible population they serve, as we ll as their need to operate around the clock (McCarthy & Spengler, 2001). Moving into the twenty-first ce ntury, hospitals are becoming more holistically c oncerned with the overall healthfulness (McCarthy & Spengler, 2001, p. 65.14) of their occupants. Beyond treating illness, hospitals must offer non-toxic environments which promote welln ess in addition to healing (Carpman & Grant, 1993; Fuston & Nadel, 1997). Flooring materials in healthcare set tings may have a broad impact on the environmental health of the building and the patients, families, and staff who spend large amounts of time there (Fuston & Nadel, 1997; Harris, 2000). Carpet, in particular, has implications for a range of i ssues critical in a healthcar e setting, including indoor air quality, infection control, acoustic quality, light and reflected light, personal comfort, and safety (Harris, 2000; Radke, 1997; Weinhold, 1988). Indoor Air Quality The quality of the indoor air is one of the key determinants of environmental health (Fisk, 2001; Oliver & Shackle ton, 1998). Indoor air quali ty (IAQ) has a significant influence on incidences of respiratory disease, symptoms of allergies, and asthma,

PAGE 17

6 transmission of infectious diseases, chemical sensitivity, and worker productivity (Fisk, 2001). Poor IAQ is caused by air pollutan ts from indoors and outdoors, which can include volatile organic com pounds (VOCs), dust, and microbial contaminants such as mold, mildew, bacteria, and viruse s (Fisk, 2001; Fuston & Nadel, 1997). Carpet and carpet tiles are of notable c oncern for IAQ. Because carpeting covers an expansive horizontal surface, it is consider ed a sink that can often absorb harmful microbes and settling airborne particles and then re-emit them into the air (Ayliffe et al., 1999; Luedtke et al., 2000). Carpet is known to accumulate and hold soil s and dusts but there is little evidence that higher levels of airborne contaminants exist over carp et than any other interior surface (Anderson, Mackel, Stoler, & Mallison, 1982; Harris, 2000; Luedtke, Stetzenbach, Buttner, Erkenbrecher, & Ke nnedy, 1999). Concern remains, however, largely because carpet dust has been found to contain fungal, bacterial, and other biological debris that could potentially contribute to allerg ies, asthma and infection (Engelhart, Loock, Skutlarek, Sagunski, Lomm el, Farber, 2002; Luedtke et al., 1999). Two separate studies examining carpeting in hospital settings found that carpeted floors had higher levels of surface contamination th an did non-carpeted floors. Levels of airborne contaminants, however, varied less a bove carpet and remained the same or lower over carpeting than over other flooring types (Anderson et al., 1982; Harris, 2000). Infection Control Nosocomial, or hospital-acquired, infectio ns have been identified as a major public health problem and a leading cause of illness and death in hospitals (Dillman, 1996, p. 26). Although the role of the hospital environment in the sp read of nosocomial infection remains controversial, Hota (2004) po ints out that existing data has established

PAGE 18

7 that hospital surfaces can become contaminated after exposure to colonized patients and that specific isolates of nosocomial pa thogens may predominate in the inanimate environment. Martinez, Ruthazer, Hansjo sten, Barefoot, & Snydman (2003) found an epidemiological link between patient room assignment and acquisition of vancomycinresistant enterococci (VRE), establishing contam inated environments as a risk factor for the spread of nosocomial pathogens. Hospital surfaces can be a reservoir for a variety of microorganisms which, when transmitted directly or indirectly to patient s, have the potential to cause nosocomial infections (Dancer, 1999; Hota, 2004; Rutala, 1996; Weber & Rutala, 2003). Recognizing this, hospitals and other healthcar e facilities should take a precautionary and preventive approach when making decisions ab out operations and maintenance as well as materials, furnishings, and equipment, all of which can contribute to transmission of disease and hospital acquired in fection (ASHE, 2004; Ayliffe et al., 1999; Dancer, 1999). As mentioned previously, th e sink effect can cause higher contamination levels of carpeted surfaces as compared with hard or resilient flooring (Anderson et al., 1982; Ayliffe et al., 1999; Harris, 2000; Luedtke et al., 2000). Further, ca rpet and carpet dust have been linked with pathogenic fungi (e.g., species of Aspergillus ), bacteria (e.g., Staphylococcus aureus, Escherichia coli ), viruses (e.g., norovirus es), and molds (e.g., Penicillium, Candida ) (Anderson et al., 1982; Engelhart et al., 2002; Hota, 2004; Luedtke et al., 1999). Despite the potential pres ence of such organisms in carpeting, an epidemiological evaluation of carpeti ng found no association between carpet contamination and nosocomial infection and no statistical difference between infection rates of patients in carpeted rooms and thos e in uncarpeted rooms (Anderson et al., 1982).

PAGE 19

8 Acoustic Quality Hospital noise can interfere with sleep, hinder communication, and cause stress and annoyance for patients, visitors, and staff (Busch-Vishniac, West, Barnhill, Hunter, Orellana, & Chivukula, 2005; Morrison, Haas, Shaffner, Garrett, & Fackler, 2003; Topf, Bookman, & Arand, 1997). Noise levels in h ealthcare settings have been consistently found to exceed acceptable standards (Busch-V ishniac et al., 2005; Harris, 2000). One study measuring noise sources in a six-bed inte nsive care unit reported that highest noise levels were attributable to items (mainl y metallic) falling onto the floor, loud voices, and equipment and stretchers (Tsiou, Eftymiatos, Theodossopoulou, Notis, & Kiriakou, 1998). Topf et al. (1997) recommends im plementing alphanumeric paging systems to replace equipment alarms a nd ringing telephones, designi ng equipment with quieter moving parts, and specifying carpet in high-tra ffic areas as some alterations that could lead to a quieter hospital environment. Carpet can act as an acoustical aid, reducing transmission of sound to the immediate area as well as to floors below (Radke, 1997; Weinhold, 1988). In a comparison of flooring finish materials, Harr is (2000) rates the s ound absorption qualities inherent in carpeting as excellent. Weinhol d (1988) points out that impact sounds from dropped objects are greatly reduced by carpeted flooring. With regard to general noise levels, pile height and pile weight have an effect on the noise reduction coefficient (NRC), or the amount of sound that carp eting will absorb (Weinhold, 1988). An additional acoustical consideration is mainte nance noise, as vacuum-cleaning can create more noise than buffing, sw eeping, or mopping (Weinhold, 1988).

PAGE 20

9 Light and Reflected Light Lighting in healthcare environments must support the functions and activities of medical staff while providing for the sometime s contradictory comfort and lighting needs of patients and their visitors (Horton, 1997; Illuminating E ngineering Society of North America, 1995). Both task performance and visual comfort are affected by perceived brightness (IESNA, 1995). The Illuminati ng Engineering Society of North America (1995) emphasizes the importance of finish materials to luminance ratios, light utilization, and space appearance, all of whic h influence perceptions of brightness. Another issue is glare, whic h is excessive brightness in the visual field that causes annoyance, discomfort, and even loss in vi sual performance and visibility (IESNA, 1995). Because ceilings, walls, and floors can act as secondary light sources, the reflectances of finish material s within a room have a strong influence on luminance levels and can cause glare (IESNA, 1995). Carpet provides a smooth, matte finish on the flooring surface which significantly reduces glare (Carpman & Grant, 1993; Horton, 1997). In a study of patient room flooring materials, carpet slightly exceed ed the recommended refl ectance range (Harris, 2000). However, the reflectance level of vinyl composition tile (VCT), a resilient flooring material, was six times greater than that of carpet (Harris, 2000). The same study found that nurses percepti ons of glare were significant ly less in carpeted patient rooms (Harris, 2000). Personal Comfort Carpeting provides comfort underfoot, psyc hological comfort, and thermal comfort (Radke, 1997; Weinhold, 1988). The cushioned su rface offers some relief from foot and leg fatigue for hospital staff (Radke, 1997; Weinhold, 1988). Weinhold (1988) asserts

PAGE 21

10 that the appearance of carpet suggests quality, warmth, and a home-like atmosphere and stresses the importance of these factors wi th regard to employee and patient morale. Harris (2000) reported that visitors spent significantly more time in patient rooms with carpeting than in non-carpeted rooms. It is im portant to consider the environments role not only in the physical health, but also in the psychological a nd social needs of all of its complex user groups (Carpman & Grant, 1993). Thermal comfort is defined as that cond ition of mind which expresses satisfaction with the thermal environment (ASHRAE, 1997). Harris (2000) found that although flooring material does not directly affect surf ace or room temperature, patients perceive the temperature in carpeted rooms to be mo re comfortable. While patients perceived uncarpeted rooms to be cleaner and have fres her air, they preferre d carpeting overall, due in large part to the perception of thermal comfort (Harris, 2000). Safety Factors Hospital patients typically represent vulnerable user gr oups and are often impaired, disabled, or elderly (Carpman & Grant, 1993). Falls are common among the elderly and can be a concern for all us ers (Guelich, 1999). Willmott (1986) found that elderly patients showed increased gait speed and step length when walking on carpet in comparison with vinyl flooring. Furthermor e, Willmott (1986) repor ted that patients were more confident walking on carpeting a nd expressed fear of falling on resilient flooring. Carpet is a slip-resistant flooring material while resilient and ha rd surface floorings are not, particularly when polished, waxed, or wet (Harris, 2000; Weinhold 1988). Spilled liquids are absorbed into carpet fibers, reducing the danger of slipping and falling as a consequence of a spill (Radke, 1997).

PAGE 22

11 Ergonomic provisions and risk of injury to employees are also important safety considerations in healthcare settings. Studies have shown that tasks that involve pushing and pulling place healthcare workers at higher risk for neck, shoulder, and lower back pain (Hoozemans, van der Beek, Frings -Dresen, van der Woude, & van Dijk, 2002; Smedley, Inskip, Trevelyan, Buckle, Coope r, & Coggon, 2003). Because carpeting has a higher coefficient of friction than hard floor ing surfaces, the force required to push, pull, and turn rolling equipment is greater on carpeted floors (Das, Wimpee, & Das, 2002). Slip-resistance, however, can be a factor in muscle use when pushing and pulling (Lavender, Chen, Li, & Andersson, 1998). Large wheels and pr operly specified, lowpile, dense carpet without padding can help to mitigate the increased effort required to push and pull wheeled carts and equipmen t (Carpman & Grant, 1993; Weinhold, 1988). Material Composition Carpet is becoming an increasingly popular floor covering choice for healthcare facilities (Radke, 1997). Considerations i nvolved in specifying flooring materials for healthcare facilities include health and safe ty factors (flame resistance, electrostatic propensity, biogenic factors, a nd slip resistance), envir onmental factors (acoustics, comfort, ambience, and wheeled vehicle mob ility), and wear-life factors (durability, appearance retention, maintenance, and costs) (Weinhold, 1988). Generally, loop pile nylon fiber with a synthetic, non-permeable backing and low pile height is recommended fo r high-traffic hospital settings such as corridors (Carpman & Grant, 1993; Radke, 1997; Weinhold, 1988) The preferred dyeing method for areas subject to occasional spills is solution dyeing, which takes place at the fiber stage and typically offers excellent colorfastness and cl eanability as well as some degree of stainresistance (Radke, 1997; Weinhold, 1988). Anti microbial agents are considered helpful

PAGE 23

12 in preventing the growth and spread of harmful and infectious microorganisms (Carpman & Grant, 1993; Radke, 1997). Carpeting is not recommended for area s that experience frequent and excessive spills, such as operating rooms, intensive care units, delivery rooms, bathrooms, and laboratories (Ande rson et al., 1982; Sehul ster et al., 2003). The Role of Cleaning Hospital cleaning is an important aspect of infection control and can have a significant impact on patient confidence (Ayli ffe et al., 1999; Dancer, 1999). Cleaning can be defined as the process of removing microorganisms and the organic matter that supports them through the use of water and dete rgents as well as mechanical processes (Ayliffe et al., 1999; Hota, 2004). Zafar, Gaydos, Furlong, Nguyen, & Mennonna (1998, p. 591) state that cleaning is probably the most important method of elim inating environmental reservoir and thus interrupts the spread from [surfaces] to patien ts. However, the quality of institutional cleaning is varied and often goes unmeasured (Hota, 2004). Expert s at the invitationonly Global Consensus Conference on Infection Control Issues Related to Antimicrobial Resistance (1999) identified deteriorating housekeeping practices in healthcare facilities as an assumption that should be made when consider ing infection control recommendations. Studies have shown that cleaning can successfully re duce the presence of known pathenogenic microorganisms on common enviro nmental surfaces in hospitals (Dancer, 1999; Zafar et al., 1998). For in stance, Zafar et al. (1998) re ported a sustained decrease in nosocomial Clostridium difficile with cleaning included as a major part of an aggressive infection control program.

PAGE 24

13 Indoor air quality is also affected by clean ing and quality of maintenance. Franke, Cole, Leese, Foarde, & Berry (1997) reported measurable improvements in indoor air quality attributable to an improved cleani ng program. The study found reduced airborne dust mass, total volatile orga nic compounds, culturable bacter ia and cultural fungi after procedures were implemented including use of high-efficiency vacuum-cleaners and entry mats. Franke et al (1997) points out, however, th at evaluation of cleaning programs should include air quality measur ements before, during, and after cleaning processes because of polluti on and resuspension of dust wh ich can occur during the use of cleaning products. Chemical disinfectants have not been found to be preferable to cleaning with water or detergents alone (Hota, 2004). Disinfect ants eliminate microbes but can shorten the life of some surfaces and can cau se irritation (Ayliffe et al ., 1999). Because of concern that improper use of disinfectants can crea te antibiotic resistance, low-level cleaning strategies are recommended and generally considered sufficient (Global Consensus Conference, 1999; Penna, Mazzola, & Martins, 2001; Rutala, 1996; Sehulster, Chinn, & HICPAC, 2003). Maintenance is consistently mentioned as a crucial factor in the performance, appearance, and safety of carpeting (R adke, 1997; Weinhold, 1988). Radke (1997) suggests that if carpet is prope rly maintained, its ability to act as a sink can allow harmful allergens, dust, and microorganisms to be trapped and removed by vacuuming. Routine vacuuming with a filter bag can coul d reduce the presence of airborne particles that would be redistributed from hard surface flooring into the air by mopping (Radke, 1997).

PAGE 25

14 Cleaning Methods In order to resist the growth of pathoge nic microorganisms, flooring in patient-care areas should be clean, dry, and well-ventilated (Ayliffe et al., 1999; Sehulster et al., 2003). Hospitals should ensure this by k eeping a routine cleaning schedule and developing a maintenance plan based on car eful consideration of manufacturer recommendations (Radke, 1997). As a genera lly accepted practice, manufacturers derive their recommendations from infection cont rol guidelines and industry standards. Five key elements should be components of a thorough maintenance program: preventive maintenance, vacuuming, spot and spill removal, interim cleaning, and restorative cleaning (Carpet a nd Rug Institute, 2004; Institu te of Inspection Cleaning and Restoration, 2002; Radke, 1997). Preventive Maintenance Preventive maintenance is intended to mi nimize the impact of soiling on carpet. Walk-off mats placed at entrances and major in terior traffic areas control the amount of soil that enters carpeted areas (CRI, 2004; IICRC, 2002). Outside mats serve to scrape dirt and debris off shoes before entering th e building (CRI, 2004). Inside mats serve the dual purpose of removing small soil particle s and absorbing moisture from entrants shoes (CRI, 2004). Vacuuming For carpeting, the Guidelines for Environm ental Infection Control in Health-Care Facilities, set forth by the Centers fo r Disease Control and Prevention (CDC), recommends regular vacuuming with well-maintained equipment designed to minimize dust dispersion (Sehulster et al., 2003, p. 135). The CRI (2004) recommends upright vacuum sweepers with top loading soil ba gs and separate motors for suction and

PAGE 26

15 brushing. Vacuums should be equipped with an enclosed high-effici ency particulate air filter (HEPA) bag and adjustable brushes or be ater bars to lift trapped particles to the flooring surface (CRI, 2004; IICRC, 2002; Radke, 1997; Sehulster et al., 2003). Effective daily vacuuming removes soil in addition to lifting and restoring carpet pile (IICRC, 2002). Actual vacuum-cleaning frequency depends on the amount of foot traffic the area receives, as shown in Table 2.1 (IICRC, 2002). Vacuuming should be performed once or more daily with sl ow and methodical movements (CRI, 2004). Table 2.1: Commercial carpet cleaning frequency chart Traffic Soil Rating Vacuuming Spot and Spill Removal Interim Cleaning Restorative Cleaning Light <500 foot traffics per day 1 2 times weekly Daily or when spots are noticed 1-3 times yearly 1-2 times yearly Medium 500-1000 foot traffics per day Traffic areas: Daily Overall: 3-4 times weekly Daily or when spots are noticed 3-6 times yearly 2-4 times yearly Heavy 1000-2500 foot traffics per day Traffic areas: Daily Overall: 4-7 times weekly Daily or when spots are noticed 6-12 times yearly 3-6 times yearly Very Heavy >2500 foot traffics per day Traffic areas: 1-2 times daily Overall: 7 times weekly Daily or when spots are noticed 12-52 times yearly 6-24 times yearly (IICRC, 2002) Spot and Spill Removal Spills, especially involving blood or body fl uids, require prompt spot-cleaning (CRI, 2004; Radke, 1997; Sehulster et al., 2003). Radke (1997) cautions against overwetting during treatment of a spill or stain and stresses that spills should be blotted rather than rubbed. Blotting s hould always be performed from the outside to the center of the spot in order to reduce further co ntamination or stai ning (CRI, 2004).

PAGE 27

16 If water alone does not remove a spot, sp ecific solutions can be applied to the carpeting dependent upon the nature of the spill (CRI, 2004). CRI (2004) suggests solutions that can be made by diluting mild de tergent, ammonia, or vinegar in water or by using a fast-evaporating dry cl eaning fluid such as rubbi ng alcohol (CRI, 2004). Once the proper solution is selecte d, it should be applied to a clean, white cloth and blotted (CRI, 2004). Remaining residue from the spil l or cleaning solution can be flushed out using clean water. Finally, the carpet s hould be blotted dry ( CRI, 2004; IICRC, 2002). For carpet tile specifically, the CDC s uggests replacement of any contaminated individual tiles (Sehulster et al., 2003). Once a contaminated tile is pried up and removed from the floor, it can be discarded or cleaned in a less obtrusive location for re-use at a later time. Interim Cleaning Interim cleaning is performed primarily because it can prolong the duration between restorative cleanings and does not require extended drying time (IICRC, 2002). Usually referred to as dry extraction or soil suspension, the intenti on is to dislodge and disperse accumulated soil to allow for rem oval by vacuuming (CRC, 2004; Radke, 1997). Soil suspension uses a combination of chem ical action, elevated temperature (heat), agitation, and time (CRC, 2004; IICRC, 2002). Chemical action, also called pre-cond itioning, works by reducing surface tension and dissolving certain soils (CRC, 2004; IICRC, 2002). Time is fundamental to this process because chemicals often need prol onged contact time in or der to adequately dislodge and dissolve impacted soils (CRC, 2004; IICRC, 2002). The process can be accelerated by agitation using a common brush or mechanical equipment to enhance and accelerate chemical action on soils (CRC, 2004; IICRC, 2002). Dry foam and absorbent

PAGE 28

17 compounds are two commonly used methods fo r low-moisture interim cleaning (IICRC, 2002). Vacuuming must be performed following these procedures in order to remove dislodged soil particles and residue from ch emical solutions (CRC, 2004; IICRC, 2002). Restorative Cleaning The CDC recommends periodic deep clean ing with minimal aerosols or residue (Sehulster et al., 2003). Hot water extracti on is another soil suspension method designed to remove embedded soils not removed by re gular vacuuming or dry extraction methods (CRC, 2004; IICRC, 2002). It is generally considered the best method for deep or restorative carpet cleaning (Radke, 1997). The process involves applying a detergent pre-spray to the carpet and using a low moisture applicator to agitate the pre-condi tioner. In hot water extraction, warm water (not exceeding 120F) is inject ed into the carpet, suspending contaminants in the solution to allow for removal by a vacuum system (IICRC, 2002; Radke, 1997; Sehulster et al., 2003). The elevated temperature of the wa ter or solution empl oyed in the cleaning process can help to reduce surface tension, speeding up the process of soil suspension (CRC, 2004; IICRC, 2002). Wet carpeting shou ld be allowed to dry completely, followed by a thorough vacuuming before use (CRC, 2004; IICRC, 2002). If carpet remains wet for a period of time over 72 hours it should be replaced (Ayliffe et al., 1999; Sehulster et al., 2003). Summary The quality of the indoor environment is of growing importance to hospitals and the healthcare and design industr ies. A more holistic approach to the overall health of all users within a healthcar e setting includes careful atten tion to the physical environment, including interior materials. The selecti on and maintenance of flooring materials and

PAGE 29

18 carpet, in particular, can have a broad im pact on the health, safety, comfort, and confidence level of patients, vi sitors, and employees alike. In order to manufacture and select carpeting that can prope rly support hospital occupants a nd activities, it is necessary to consider the factors which impact it. Similarly, a maintenance plan to properly care for carpeting must respond to actual use and wear, in addition to incorporating preventive measures for infection control and indoor air quality. Proper cleaning removes harmful cont aminants and microorganisms and maintains the appearance of carpeting. The necessary frequency and degree of routine, interim, and rest orative cleaning measures are dependent upon quantity and patterns of foot traffic and wear f actors such as equipment carts.

PAGE 30

19 CHAPTER 3 RESEARCH METHODOLOGY Research Design The study design was a cross-sectional cas e study utilizing observation as a research methodology. This cross-sectional st udy design was chosen for its effectiveness in exploring a phenomenon or situ ation at a particular point in time. Kumar (2005) states that cross-sectional studies can be useful in obtaining an ove rall picture as it stands at the time of the study. Non-participant obs ervation provides an obj ective, first-hand look at behavior in a natural setting, whereas a self-report method such as a questionnaire relies on the subjects to be accurate and unbiased (Sommer & Sommer, 2002). In this situation, where the aim was to explore wh at actually happens in comparison with existing minimum standards, the obse rvation method was a logical choice. Methodological Background Observation involves systematically watc hing and recording how people use their environments (Kumar, 2005; Ze isel, 1990). Unobtrusive obser vation is ideal for studying commonplace behavior in natural surroundings, generating useful data for design and other professionals concerned with the relationships betw een people and their physical settings (Sommer & Sommer, 2002; Zeisel, 1990). Systematic, non-participant observation requir es that the research er not be involved in any observed activities and involves a c oding system with prearranged categories (Kumar, 2005; Sommer & Sommer, 2002). Categor ies are limited to items and behavior that occur naturally in the setting and can be observed and recorded (Sommer & Sommer,

PAGE 31

20 2002). Use of more than one observer or me thod can improve the reliability of this methodology (Sommer & Sommer, 2002). Observing and recording behavior provide s information about precisely how the physical setting is used by its occupants, but explanations about behavior require further research (Kumar, 2005; Somm er & Sommer, 2002). Ethics The research study was approved by the Institutional Review Board of the University of Florida and listed as exempt (A ppendix A). This research conforms to the ethical principles and guidelines for the prot ection of human subjects as set forth in The Belmont Report written by The National Commissi on for the Protection of Human Subjects of Biomedical and Behavioral Research (Dept. of Health, Education, and Welfare, 1979). In addition, the researcher completed training in HIPAA for Researchers at the University of Florida. Research Hypotheses Hypotheses tested are as follows: 1. Actual carpet cleaning procedures ar e concurrent with documented hospital protocol. 2. Actual carpet cleaning proce dures are concurrent with infection control guidelines and industry standards. 3. Documented hospital protocol is concurrent with infection control guidelines and industry standards. Setting The research setting was a hospital in-pat ient medical/surgical unit in a community medical center. The study took place in a co rridor with access to the nursing station, patient rooms, utility closet, staff and public elevators, as well as a nursing POD in

PAGE 32

21 which healthcare providers document patient charts electronically (Figure 3.1). In addition, the corridor accessed a lounge and re stroom area generally reserved for visitor use but temporarily serving as a staff-only break area during renovation of the permanent break room. Figure 3.1: Study setting The carpeting in the setting for this st udy is comprised of a primary fill and secondary border carpet tile, each tile m easuring 19.69 inches square. The construction of both types consists of nylon fiber with a protective, stai n-resistant coating and a nonpermeable backing, incorporated with an anti-m icrobial agent. The primary carpet tile is a tufted textured loop, using 71% soluti on dye and 29% yarn dye. Two notable measurements that effect carpet performance ar e pile yarn weight and pile density. Pile yarn weight is a measurement of the amount of yarn in a given area of carpet face (Weinhold, 1988). Pile density is the weight of pile yarn in a unit volume of carpet and

PAGE 33

22 calculated based on pile yarn weight and pile height (Weinhold, 1988). Higher tuft density generally yields better performance (Weinhold, 1988). The tufted yarn weight for the primary carpet tile is 23 oz. per square yard and pile density is 7,886 oz. per cubic yard. The secondary carpet til e is tufted tip-sheared and the dye method is 100% solution dye. The tufted yarn weight for the secondary carpet tile is 24 oz. per square yard with a pile density of 6,545 oz. per cubic yard. Observation Procedures Observation was limited to the documentation of factors impacting carpeting in the corridor. Two observers utilized observati on forms to record foot traffic, equipment carts, and housekeeping activities (Appendix B). The documentation was anonymous, unidentifie d data with no information about schedules or names of employees, patients, or visitors. Observations were made in twohour increments between th e hours of 7:00am and 11:00pm, during which the vast majority of hospital activity occurs. Four observations of each 2-hour increment were randomized over a six-day period, using Research Randomizer (Social Psychology Network, 2005). The number and locations of empty patient rooms were documented at each observation period using a diagram of the patie nt wing. Researchers used a field study observation form to record foot traffic and ro lling cart incidences. A separate form was used to detail cleaning procedures and not e chemicals and equipment used. The form included a diagram on which the specific lo cations of each cleaning activity, along with unplanned contamination incidents such as spills or debris, were described and documented. All observation forms utilized can be found in Appendix B.

PAGE 34

23 One foot traffic count was considered to be any movement by a person within the defined corridor until the person reversed di rection. A new instance was recorded once the person retraced his or her footstep(s). For each instance, the locations from and to which the user traveled were documented using a system of codes for each access point on the corridor. Users were identified based on employee badge, or lack thereof, along with uniform, hospital gown, or other forms of dre ss. Any staff member coming in contact with patients was considered healthcare st aff. Environmental services personnel were identifiable by distinct uniform and were considered housekeeping staff. Construction personnel, contractors (e.g., plumbers), and f acilities staff not invol ved in housekeeping were identified as maintenance staff. The classification of visitor was reserved for family, friends, or clergy there solely to visi t patients or the facil ity as non-employees. Volunteers and employees of th e hospital who did not fall into the previously mentioned categories, or who were not identifiable as such, were classified as staff. Equipment carts, transport vehicles, supply carts, treatment carts, and so on were documented in conjunction with the foot traffi c count of the person pushing or pulling the cart. Specific codes as well as more deta iled notes were recorded on the observation form, and researchers attempted to photograph each type of equipment or cart. Any additional contact with the corridor flooring was noted, such as bags or equipment being dragged across the carpet surface. Analysis This study identified factors contributing to the contamination and wear of carpet tile in an acute care patient wing corridor (Figure 3.2). Human impact on carpeting and response to said impact are reported in terms of type and frequency as well as patterns.

PAGE 35

24 Figure 3.2: Factors contribut ing to the condition of flooring finish material Type and frequency of impact were meas ured by foot traffic and equipment cart counts as well as contamination incidents. Data was examined for differences between days of the week and times of the day to provide further information about traffic frequencies. Patterns of impact were meas ured by path taken and by human-equipment interaction. Type and frequency of respons e to impact on carpeting were measured by observations of cleaning activit ies, chemicals and cleaning equipment used, and location of activity. Response patterns were measur ed by schedule, consistency, and lag time between contamination incidences and subseque nt treatment. Differences were identified between 1) actual carpet cleaning procedures ; 2) documented hospital protocol; and 3) infection control guidelines and industry standards. In order to analyze the effect of day of the week and time of the day on human foot traffic and equipment counts, a two-way Anal ysis of Variance (ANOVA) was performed using an additive model at level alpha=0.05. The independent variables in both cases were time blocks (time) and days of a week (d ay). The response variables were (Y)= foot Contributing Factors Foot traffic Equipment Impact Responsei.e. Maintenance Physical Setting Carpeting T y pe & frequenc y Foot traffic counts Equipment cart counts Spill incidents Patterns Paths Human-equipment interaction Pushing/pulling Stopping/starting T y pe & frequenc y Cleaning activity Chemicals Equipment Location Patterns Schedule Consistency Lag time (spills)

PAGE 36

25 traffic count and (Y)= equipment cart count. Since the response variables were count data, a square root transformation was require d in order to ensure a normal distribution for the data. Thus the actu al response variables were (foot traffic count) and (equipment). Bonferronis multiple comparison test was used to identify specific differences between means for each time block. Foot traffic data was re-tested due to an unusually high traffic count duri ng a time block in which an emergency code occurred on the unit. The same tests were performed re moving that particular time block from the data set. Pearson correlation was used to te st for a relationship between foot traffic and equipment cart counts, again utilizing a squa re root transformation to ensure normal distribution for count data. Ou tput from statistical analyses can be found in Appendix C. All other statistical data reporte d is entirely descriptive in orde r to assist in interpretation.

PAGE 37

26 CHAPTER 4 FINDINGS The intent of this study was to examine f actors specifically impacting carpeting in a defined portion of a hospital corridor. Foot traffic, equipment car ts, and carpet cleaning procedures were observed and analyzed. The type, frequency, and patterns of impact on the corridor carpeting are reported here. Foot Traffic Type and Frequency Based on mean traffic counts for each time block, average daily foot traffic between the hours of 7:00am and 11:00pm ( 16 hours) was approximately 2,900. Table 4.1 shows total traffic counts for each time bloc k observed (n=31). Blank cells indicate an increment of time that was not observed, as determined by a randomization of the 31 time blocks to be studied. Table 4.1: Total traffic counts observed, by day and time block 1: 7-9am 2: 9-11am 3: 11-1pm 4: 1-3pm 5: 3-5pm 6: 5-7pm 7: 7-9pm 8: 9-11pm 1 Sun 256 218 272 187 2 Mon 559 354 383 399 307 383 3 Tues 440 518 320 410 298 236 4 Wed 348 409 351 430 370 5 Thurs 720 353 499 354 318 6 Fri 347 384 325 223 288 Testing for effect of day and time toge ther on traffic counts, there was strong evidence that the means for the 31 time bl ocks were significantly different (F=4.08, p <0.05). Further, day of the week alone did not have a significant effect on number of

PAGE 38

27 foot traffic incidents. Time of day, howe ver, did significantly impact traffic counts (F=3.17, p <0.05). Bonferronis multiple comparison test showed a significant difference between the means of the first (7-9am ) and eighth (9-11pm) time blocks ( p <0.05). The data was tested again to see if a patien t coding during one of the 7-9am time blocks influenced the results. Testing for effect of time of day on foot traffic counts without data from the aforementioned time block reve aled a significant di fference between mean foot traffic counts (F=3.87, p <0.05). Bonferronis multiple comparison test did not reveal a significant difference at alpha le vel 0.05 between any 2 particular time blocks. Hospital census data tracks the number of patients in beds on the unit, which fluctuates throughout the day. In this case, the number of empty beds was considered a co-variate in testing for possible effect on f oot traffic. The number of empty beds on the unit, taken from official hospital census data, had a significant effect on foot traffic in the study corridor (F=8.37, p <0.05). Users fell into one of eight user groups: 1) healthcare staff, 2) housekeeping staff, 3) maintenance staff, 4) food se rvice staff, 5) other staff, 6) visitors, 7) patients, or 8) dogs (present as part of the hospitals Anim al-Assisted Therapy program). The categories of specific users are shown in Figure 4.1, expres sed as percentages of total foot traffic observed (n=11,249). Healthcare staff represented close to 80% of all foot traffic in the defined corridor area (Figure 4.1). Visitors were the second highest repres ented user group, making up 8% of all foot traffic observed. Housekeeping staff comprised 6.4% of all foot traffic observed. The remaining user groups (maintenance st aff, food service staff, other staff, patients, and dogs) each made up less than 3% of all foot traffic observed.

PAGE 39

28 Dogs, 0.2% Patients, 1.0% Visitors, 8.0% Healthcare Staff, 78.9% Housekeeping, 6.4% Maintenance, 2.3% Staff (other), 0.6% Food Service, 2.7% Figure 4.1: Types of users, as percen tages of total foot traffic observed Figure 4.2 shows average foot traffic c ounts for each time block both with and without data from the time block during wh ich an emergency code occurred. Both timelines show a slightly decreasing trend. 257 294 305 355 438 366 517 378 0 100 200 300 400 500 600 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm A 257 294 305 355 438 366 449 378 0 100 200 300 400 500 600 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm B Figure 4.2: Average foot traffic timeline, by tim e block. Part A shows a regression line all time blocks observed; part B shows means taken without data from the time block during which an emergency code occurred Figure 4.3 shows foot traffic timelines for each user group, based on the mean traffic counts observed for each time block. Healthcare staff averages remained more

PAGE 40

29 consistent than those of the other user group categories. Visitor tr affic peaked during the 1-3pm and 5-7pm time blocks. Patient and f ood service traffic both varied considerably throughout the day. Maintenance staff a nd housekeeping staff traffic both dropped drastically after the 1-3pm and 3-5pm time blocks, respectively. Healthcare Staff0 50 100 150 200 250 300 350 400 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm A Visitors0 10 20 30 40 50 60 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm B Patients0 1 2 3 4 5 6 7 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm C Housekeeping Staff0 5 10 15 20 25 30 35 40 45 50 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm D Maintenance Staff0 5 10 15 20 25 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm E Food Service Staff0 5 10 15 20 25 7-9am9-11am11-1pm1-3pm3-5pm5-7pm7-9pm9-11pm F Figure 4.3: Average foot traffic timelines for ea ch user group. A) healthcare staff, B) visitors, C) patients, D) housekeeping staff, E) mainte nance staff, and F) food service staff Patterns Traffic patterns were observed and recorded in the form of actual paths walked by the various user groups on the study corridor. Fourteen unique loca tions were identified in the defined corridor area as entry/destination points (Figure 4.4). An additional

PAGE 41

30 category was assigned for any location not sp ecifically defined within the corridor, yielding over 100 possible paths. Figure 4.4: Entry/destina tion locations in the defined corridor area Of the over 100 possible paths through the corridor area, the 6 most frequently taken are shown in Figure 4.5, expressed as the percentage of total foot traffic observed (n=11,249) who took one of the 6 particular paths. Approximately 1 out of every 6 people who traveled through the study corridor walked from point A to point B or from point B to point A. Nearly as many traveled between points A and C. The path between point C and the breakr oom space was taken by 6.6% of all foot traffic observed. The path between point A and the nursing st ation entrance received 4.4% of all foot traffic observed. Paths between the nursing POD and point A and between the nursing POD and point B each received close to 4% of all foot traffic observed.

PAGE 42

31 The remainder of foot traffic followed various other paths through the corridor, each path receiving less than 3% of all traffic observed. Figure 4.5: Most frequently take n foot traffic paths, as percentages of total foot traffic observed Thirty-two percent of all traffic obser ved during the study can be considered through-traffic, passing through the corridor w ithout coming from or going to a room or space located on the corridor in the defined area for the research study. Locations on the corridor accounted for the remainder of foot traffic incidences. While Figure 4.5 showed particular paths taken within the corridor Figure 4.6 highlights destination/entry points on the study corridor and shows th e percentages of total foot tr affic observed that traveled to or from these locations. Almost half (47%) of all foot traffic inst ances observed passed through point A. Points B and C were each involved in n early 30% of all foot traffic. Approximately 1 out of every 4 people tr aveling through the study corridor walked from or to the nursing station or the area just outside of it. Close to 1 in 5 people traveled from or to the nursing POD.

PAGE 43

32 17% of all foot traffic observed visited the 4 patient rooms direct ly adjacent to the defined study corridor area. The room serving as staff breakroom accounted for just over 10% of all foot traffic observed. The utility closet and the handwashing sink accounted for 6% and 3% of foot traffic, respectively. 32% 24% 18% 17% 11% 6% 3% 0% 5% 10% 15% 20% 25% 30% 35% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash Sink Figure 4.6: Locations on study co rridor commonly receiving f oot traffic, as percentages of total foot traffic observed Figure 4.7 details destination/entry loca tions frequented by specific user group categories. Thirty percent of healthcare staff traffi c was through-traffic. The remaining twothirds of healthcare staff mainly fre quented the areas in and around the nursing station, the nursing POD, and patient rooms. The room serving as a temporary staff breakroom received 12% of healthcare staff traffic. Visitors, of whom nearly 60% were throughtraffic, also frequented patient rooms and the nursing station area. The utility closet and handwashing sink area s received no traffic from visitors or patients. Patients primarily passed through the defined st udy corridor area as through-traffic.

PAGE 44

33 Fourteen percent of housekeeping staff tra ffic was through-traffic. Half of the traffic from housekeeping staff was concen trated around the utility closet area and almost 20% was in and around patient rooms. Forty-two percent of mainte nance workers were through-traffic. The remaining third of maintenance staff traffic was re latively evenly divided among locations on the corridor, the breakroom receiving slight ly more traffic from maintenance staff than other locations. One quarter of food service staff traffic was through-traffic, while over half traveled to and from patient rooms. Dogs visiting as part of the hospitals Animal-Assisted Therapy program traveled largely to and from patient rooms. A pproximately one third of dog traffic was through-traffic. Dogs also visited the nursing station area, but none were observed traveling to or from any other lo cation in the study corridor area. 30% 27% 22% 20% 12% 3% 3% 0% 5% 10% 15% 20% 25% 30% 35% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkHealthcare Staff A 57% 16% 5% 23% 4% 0% 0% 0% 10% 20% 30% 40% 50% 60% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkVisitors B 74% 10% 1% 8% 3% 0% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkPatients C 14% 11% 1% 19% 12% 50% 4% 0% 10% 20% 30% 40% 50% 60% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkHousekeeping Staff D Figure 4.7: By user group categ ory, locations on study corrid or commonly receiving foot traffic, as percentages of total foot tr affic observed. A) healthcare staff, B) visitors, C) patients, D) housekeeping st aff, E) maintenance staff, F) food service staff, G) sta ff (other), and H) dogs

PAGE 45

34 42% 9% 9% 11% 17% 3% 5% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkMaintenance Staff E 25% 13% 2% 51% 1% 1% 0% 0% 10% 20% 30% 40% 50% 60% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkFood Service Staff F 44% 32% 6% 6% 3% 6% 3% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkStaff (other) G 30% 17% 0% 43% 0% 0% 0% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkDogs H Figure 4.7. Continued. Equipment Carts Type and Frequency Based on mean equipment counts for each time block, the average daily equipment cart/item count between the hours of 7:00a m and 11:00pm was approximately 240. Table 4.2 shows total equipment cart counts for each time block observed (n=31). Blank cells indicate an increment of time that was not observed, as determined by a randomization of 31 time blocks to be studied.

PAGE 46

35 Table 4.2: Total equipment cart counts observed, by day and time block 1: 7-9am 2: 9-11am 3: 11-1pm 4: 1-3pm 5: 3-5pm 6: 5-7pm 7: 7-9pm 8: 9-11pm 1 Sun 31 18 23 15 2 Mon 36 21 36 38 32 24 3 Tues 41 33 22 39 18 14 4 Wed 34 39 37 54 21 5 Thurs 24 40 45 19 24 6 Fri 18 44 31 23 36 There was no significant difference between mean equipment counts for the 31 time blocks. Further, day of the week alone did not have a significant effect on number of foot traffic incidents. Time of day al one also did not signif icantly impact traffic counts. A wide range of types of equipment carts were observed. Figure 4.9 shows types of equipment carts, expressed as percentage s of total carts/items observed (n=928). Supply/utility carts, treatment carts, non-wh eeled items, and the other category all include multiple varieties of carts or items, grouped together for ease of identification and description. Non-wheeled items observed incl uded plastic and linen bags, chairs, and oxygen tanks. The other categor y consisted of equipment that contributed to less than 1% of all foot traffic observed and included patient tray tables rolling bags/purses, trash cans, rolling walkers, patient beds, scales and computer carts. The most commonly observed equipment included IV poles, supply/ utility carts, housekeeping carts, gurneys (with and without patients), and food service carts. Photographs of commonly observed equipment carts can be found in Appendix D.

PAGE 47

36 Other, 3.3% Flatbed Maint. Cart, 3% Wheelchair (w/ patient), 3.4% Non-wheeled Items (dragging), 3.7% Treatment Cart, 3.8% Trash Bin, 4.5% Wheeled Task Chair, 2% Vacuum, 1.4% Wheelchair (w/o patient), 4.7% Supply/Utility, 12.9% Housekeeping Cart, 12% Gurney (w/ patient), 6.6% Small Linens Cart, 4.8% X-ray 4.6% Gurney (w/o patient), 8.1% Food Service/Meal Cart, 8.1% IV Pole, 13.9% Figure 4.8: Types of equipment carts, as pe rcentages of total carts/items observed In the case of equipment carts/items, th e number of empty beds on the unit did not significantly affect the number of equipment carts traveling th rough the defined area of the study corridor. However, testing did show a significant co rrelation between foot traffic counts and equipment cart counts, both with (r=0.49, p<0.05) and without (r=0.65, p <0.05) data from the time block during which the emergency code occurred. Figure 4.9 shows regression lines for the data including all time blocks (n=31) and for the data with the time block including the emergency code removed (n=30). A stronger correlation exists between between foot traffic and equipment cart counts when the time block during which the emergency code occurred is removed from the data set.

PAGE 48

37 7.00 6.00 5.00 4.00 equipment carts (sq rt) 27.50 25.00 22.50 20.00 17.50 15.00 12.50 foot traffic (sq rt) all data (n=31) A 7.00 6.00 5.00 4.00 equipment carts (sq rt) 24.00 22.00 20.00 18.00 16.00 14.00 12.00 foot traffic (sq rt) without emergency code time block (n=30) B Figure 4.9: Correlation between f oot traffic and equipment cart counts. Part A shows a regression line for all time blocks obser ved (n=31); part B shows a regression line for all time blocks except the time block during which an emergency code occurred (n=30) Patterns Observations of actual paths taken by equipment carts and items on the study corridor were documented. Of the more than 100 possible paths, the 5 most frequently taken paths through the corridor are shown in Figure 4.10, expressed as percentage of total equipment carts observed (n=928).

PAGE 49

38 Figure 4.10: Most frequently taken paths by equi pment, as percentages of total equipment carts/items observed Approximately 1 in 3 equipment carts m oving through the study corridor traveled from point A to point C or from point C to point A. Fifteen percent of all equipment carts obser ved traveled between points A and B. The path between points B and C was ta ken by just over 6% of all equipment carts/items observed. The path between point C and the utility closet received approximately 5% of all equipment carts/items observed. The path between point C and the outside of the nursing station received close to 4% of all equipment carts/items observed. The remainder of equipment cart traffic followed various other paths through the corridor, each path receiving less th an 3% of all traffic observed. Fifty percent of all equipment carts/ite ms observed during the study were throughtraffic, passing through the corridor without coming from or going to a room or space located on the corridor. Locations on the co rridor accounted for the remaining half of equipment observed. Figure 4.11 highlights dest ination/entry points on the study corridor

PAGE 50

39 and shows the percentages of total equipment cart traffic obs erved traveling to or from these locations. Approximately 1 out of every 4 equipmen t carts moving through the study corridor traveled to or from a patient room. 12% of all carts observed traveled from or to the utility closet. 10% of all carts observed visited the ar ea in and around the nursing station. The nursing POD, breakroom, and handwashing sink each accounted for less than 2% of all equipment carts/items observed. 50% 25% 12% 10% 2% 2% 1% 0% 10% 20% 30% 40% 50% 60% Through Traffic Patient Rooms Utility Closet Nursing Station Nursing POD BreakroomHandwash Sink Figure 4.11: Locations on study corridor common ly receiving equipment cart traffic, as percentages of total equipment carts/items observed Figure 4.12 details the destination/entry points frequented by specific equipment carts/items. Three out of every 4 IV poles were thr ough-traffic. Of the remainder, most traveled to or from patient rooms. Over half of all supply/u tility carts observed were through traffic, one fourth traveling to or from th e nursing station area. One quarter of all housekeeping cart tra ffic was through-traffic. The remaining 75% was concentrated mainly around the utility closet and patient room areas, with some activity in and around the nursing station.

PAGE 51

40 Half of the linen carts obse rved were through-traffic, and much of the remainder moved to or from patient rooms. Only 1 of every 10 food service carts was thr ough-traffic, while half traveled to and from patient rooms. Close to two-thirds of all treatment car ts observed were through-traffic, with patient rooms receiving most of the re mainder of treatment cart activity. Gurneys, both with and without patients, showed similar trends with regard to destination/entry points. All observed wheelchairs with pa tients were through-traffic. Of wheelchairs without patients, only ha lf were through-traffic. The nursing station, nursing POD, and patient room areas received the remaining traffic. Trash bins traveled almost exclusively to and from the utility closet. Just 6% passed through the corridor area as through-traffic. 77% 5% 1% 11% 0% 1% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkIV Poles A 54% 25% 1% 13% 4% 3% 0% 0% 10% 20% 30% 40% 50% 60% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkSupply/Utility Carts B 23% 11% 0% 23% 4% 35% 2% 0% 5% 10% 15% 20% 25% 30% 35% 40% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkHousekeeping Carts C 51% 3% 0% 36% 0% 5% 5% 0% 10% 20% 30% 40% 50% 60% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkLinen Carts D Figure 4.12: By category of equipment, lo cations on study corrido r commonly receiving equipment cart/item traffic, as percenta ges of total carts/items observed. A) IV poles, B) supply/utility Carts, C) housekeeping carts, D) linen carts, E) food service carts, F) treatment carts, G) gurney (with patient), H) gurney (without patient), I) wheelchair (with pa tient), J) wheelchair (without patient), and K) trash bins

PAGE 52

41 10% 11% 0% 47% 0% 2% 0% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkFood Service Carts E 63% 9% 3% 24% 0% 0% 1% 0% 10% 20% 30% 40% 50% 60% 70% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkTreatment Carts F 79% 4% 2% 13% 0% 2% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkGurney (with patient) G 59% 4% 7% 29% 0% 0% 2% 0% 10% 20% 30% 40% 50% 60% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkGurney (without patient) H 100% 0% 0% 0% 0% 0% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkWheelchairs (with patient) I 51% 16% 14% 16% 0% 0% 5% 0% 10% 20% 30% 40% 50% 60% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkWheelchairs (without patient) J 6% 0% 0% 0% 0% 94% 0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Through Traffic Nursing Station Nursing POD Patient Rooms BreakroomUtility Closet Handwash SinkTrash Bins K Figure 4.12. Continued.

PAGE 53

42 Figure 4.13 illustrates the human-equipmen t interaction patterns of pushing, pulling, or a combination of both. The vast majority of equipment carts observed was largely pushed. Trash bins were an excep tion, with 9 out 10 being pulled, not pushed. Wheelchairs with or without patients and lin en carts were pushed exclusively. Users combined pushing and pulling gurneys with patients and housekeeping carts 8% and 5% of the time, respectively. 020406080100120140Number Observed IV Pole Gurney (with patient) Gurney (without patient) Linens Cart Housekeeping Food Service Treatment Wheelchair (with patient) Wheelchair (without patient) Supply/Utility Trash Bin Vacuum Flatbed Maintentance Wheeled Task Chair Other Pushed Pulled Combination Figure 4.13: Human-equipment interaction patterns observed for each equipment category Carpet Cleaning Procedures Type and Frequency The only carpet cleaning ac tivity observed not directly in response to a contamination incident was vacuuming. V acuuming of the defined corridor area was observed 3 times during the observation periods (n=31). Table 4.3 shows the occurrences of vacuuming observed. Blank cells indicate an increment of time that was not observed, as determined by a randomization of 31 time blocks to be studied.

PAGE 54

43 Table 4.3: Number of times vacuuming was observed, by day and time block 1: 7-9am 2: 9-11am 3: 11-1pm 4: 1-3pm 5: 3-5pm 6: 5-7pm 7: 7-9pm 8: 9-11pm 1 Sun 0 0 0 0 2 Mon 1 0 0 0 0 0 3 Tues 0 0 0 0 0 0 4 Wed 0 1 0 0 0 5 Thurs 0 0 0 1 0 6 Fri 0 0 0 0 0 In each case, the vacuuming performed is considered overall vacuuming, not confined to a particular location within th e corridor area. Vacuuming movements were not necessarily performed in a consistent, me thodical pattern, with some portions of the carpeting receiving more thorough cleaning than others. However, vacuuming did cover the entire area of the defined corridor. The vacuum equipment used was an upri ght vacuum with a top loading soil bag and a separate motor for brushing. Details a bout the specific vacuum equipment used can be found in Appendix E. No chemicals were used in the cleaning process. Patterns Vacuuming did not occur at a consistent time. Vacuuming was observed on three separate days at approximately 8:30a m, 9:20am, and 3:00pm, respectively. Contamination Incidents Three contamination incidents were obser ved during the study. Table 4.4 details each incident and response by hospital staff. Material Safety Data Sheets (MSDS) for the specific chemicals used can be found in Appendix F.

PAGE 55

44 Table 4.4: Contamination incidents and responses Type of Contamination Time of Incident Response Time Chemicals Used Procedure Followed Coffee spill 7:10am Immediate QuickSpot (<1% hydrogen peroxide) Blotted spill dry with cloth, sprayed area with QuickSpot, let stand for approx. 15 minutes, blotted. Followed up 2 hours later with vacuum Swept dust from patient room into corridor 10:00am Immediate None Swept carpet with small brush and dustpan Dust from construction work 2:00pm Approx. 18 hours None Used masking ta pe to remove dust from carpet surface (performed by maintenance staff) Comparison of Cleaning Procedures Table 4.5 presents findings regarding 1) infection control guidelines and industry standard cleaning methods, 2) documented hospital protocol, and 3) actual carpet cleaning procedures. Documentation rega rding hospital protocol can be found in Appendices E-I. Refer to Chapter 2, p. 13-16 for information regarding infection control guidelines and industry standards. Table 4.5: Comparison of recommended and observed carpet cleaning procedures Infection Control Recommendations/ Industry Standards Hospital Protocol Actual Carpet Cleaning Procedures Preventive Maintenance Walk-off mats at entrances and major interior traffic areas. Walk-off mats at entrances. Contracted service for entrance mats. No written documentation available. Walk-off mats observed at entrance to hospital. No walk-off mats observed at elevator entrance to unit or elsewhere on corridor. Vacuuming Traffic areas: 1-2 times daily. Overall: 7 times weekly. Upright vacuum sweeper with top loading soil bags and separate motors for suction and brushing. Daily in the elevator area, in the hall and behind doors. Daily final overall vacuum. Included as part of the daily cleaning schedule (Appendix I). Upright vacuum sweeper with top loading soil bags and separate motors for suction and brushing. Observed on 3 occasions. Regular schedule not observed.

PAGE 56

45 Table 4.5. Continued. Spot & Spill Removal Daily or when spots are noticed. Blot or scrape spills off of carpet. If water alone does not remove spot, solutions can be made by diluting mild detergent, ammonia, or vinegar in water (dependent on spill type). Dry cleaning solvent can be used (apply standard rubbing alcohol to clean cloth and blot). Flush out spotting solutions with clean water after spot has been treated. Once weekly or bi-weekly checks for spots and spills, dependent on staffing. Carpet spot-remover listed with chemicals to be kept on housekeeping carts: QuickSpot, containing less than 1% hydrogen peroxide (refer to Hospital Environmental Services Policy Number 11, Appendix G). Label instructions are to spray carpet until wet, allow to sit 5-10 minutes, scrub or blot soil away, vacuum when dry. No other written documentation available. 3 contamination incidents observed. Response times ranged from immediate to 18 hours. Proper application of cleaning solution. Interim Cleaning 12-52 times yearly. Dry extraction or dry foam method (use low moisture applicator to brush dry extraction compound into carpet fibers). As needed between deep cleanings. Host dry extraction carpet cleaning system. Label instructions are to apply dry powder to carpeting, brush through fibers with Dry-Clean Machine, vacuum. No written documentation available. None observed. Restorative Cleaning 6-24 times yearly. Hot water extraction. Detergent pre-spray agitated with low moisture applicator. Warm water (not exceeding 120F). Allow to dry thoroughly and vacuum before use. Twice Yearly (spring and fall). Hot water extraction. Twice yearly in carpeted corridors, generally in spring and fall seasons. Hospital Environmental Services Policy Number 27 (Appendix H). None observed. Must make arrangements with individual units rather than follow an established written timetable. Carpet Tile Replacement As needed. Replace severely damaged or stained tiles with shelf stock. No written documentation available. None observed. Environmental Services intends to replace damaged or spilled-on tiles immediately, clean backof-house, and re-use cleaned tiles if possible.

PAGE 57

46 This research tested the following hypotheses: 1. Actual carpet cleaning procedures ar e concurrent with documented hospital protocol. 2. Actual carpet cleaning proce dures are concurrent with infection control guidelines and industry standards. 3. Documented hospital protocol is concurrent with infection control guidelines and industry standards. Evidence from observation data did not unequivocally support or reject the stated hypotheses. Observation and documentation of vacuuming procedures for the most part support all 3 hypotheses, but information about other types of carpet cleaning procedures does not directly prove or disprove the hypotheses.

PAGE 58

47 CHAPTER 5 DISCUSSION The well-being of hospital patients, visito rs, and staff may be influenced by the quality of the environment within the hospita l building, including interior materials. Discussions and recommendations regarding proper selection and maintenance of flooring materialsand carpeting in partic ularcommonly mention traffic and wear factors. These issues are assumed to ex ist and to have some degree of impact on carpeting, but little has been studied about the actual type, fre quency, and patterns of traffic, wear and the role of maintenance on carpeting. The purpose of this research was to iden tify particular wear factors impacting carpeting in an acute care patien t corridor. Further, patterns of wear as well as regular and incidental maintenance were explored. This study specifically sought to answer the questions: 1) what specific users and equipm ent contribute to traffic flow in a patient corridor; and 2) what are th e consistency, frequency, and me thods of regular cleaning of carpet tile in an acute care patient corridor? Foot Traffic Each foot traffic incidence or count does not necessarily mean a different person; once a person changed direction or retrac ed steps, a new incidence was counted. Therefore, foot traffic numbers should be cons idered as paths or in cidences rather than individuals.

PAGE 59

48 Type and Frequency Observations showed that the average traffic count was approximately 2,900 during the peak hours of 7:00am to 11:00pm. Thus, daily traffic counts for a 24-hour period number well above this average for peak hours. In other words, over 2,900 paths are walked daily across the defined area studied w ithin this carpeted hospital corridor. This greatly exceeds the minimum number of daily foot traffics for the very heavy traffic soil rating in the IICRCs Commercial Carpet Cleaning Frequency Chart of 2,500 traffic incidences or more (refer to Table 2.1, p. 15). This chart is typically the basis for carpet manufacturer recommendations It suggests, based on num eric foot traffic counts, specific minimum frequencies for various levels of crucial carpet cleaning practices. The average daily foot traffic count from this study establishes definitively that the traffic soil rating for this corridor is very heavy. Statistical testing showed that day of the week had no significant effect on traffic counts. Mean traffic counts were virtually the same whether observed on a weekend or weekday and whether it was early or late in the week. Foot traffic counts did significantly differ depending on the time of day, specifically between the first time block (7-9 am) and the last time block (9-11pm). This could potentially be explained by a particular ly high traffic count during one of the 7-9am time blocks due to a patient coding on the unit. The code brought an influx of healthcare staff through the study corridor in response to the emergency. However, quantities of foot traffic di ffered throughout the day regardless of extenuating circumstances. When the tim e block during which a patient coded was removed from the data set, testing still showed a significant difference between mean traffic counts depending on time of day. The 7-9a m time block sees a change in shift for

PAGE 60

49 nursing and other healthcare staff as we ll as the beginning of the workday for housekeeping staff. Meals were served t ypically during the 7-9am, 11am-1pm, and 57pm time blocks, signaling a rise in food servic e staff traffic. Visitor traffic mainly occurred between the hours of 1pm and 7pm. The 9-11pm interval occurs after the evening shift change for healthcare staff and the typical workday for most other hospital staff members. Additionally, normal meals were not typically served after this time and visitor traffic generally decreased as well, so most foot traffic dropped off noticeably before the beginning of this time block. Thus many factors contributed to the variation in mean traffic counts between time blocks. The vast majority of foot traffic throu gh the study corridor was healthcare staff. Four out of five instances of foot traffic occurring on this partic ular corridor involved healthcare staff. Aside from rare occurrences of foot traffic by dogs and unidentifiable or miscellaneous staff members, patients repr esented the lowest number of foot traffic instances at just 1% of all traffic. While visi tors contributed to 8% of the traffic in this corridor, employees of the hospital still comp rised over 90% of all foot traffic observed. Although hospitals exist to provide for patients, this research shows that this particular location within the hospital (a patient unit co rridor) primarily serves and supports the activities of the healthcare professi onals charged with patient care. Since most of the traffic through the st udy corridor was attributable to staff involved with patient care, it follows that fewer patients on the unit may lead to lower foot traffic counts. Thus, hos pital census information could act as a predic tor of foot traffic levels for the fabrication and selecti on of flooring materials or the development of a maintenance plan.

PAGE 61

50 Patterns Twelve patient rooms on the unit lie be yond the portion of th e corridor under observation and are only accessible by passing thr ough the corridor at point A. Thus, it is not surprising that nearly half of all foot traffic observed passed through that point. In fact, close to 33% of foot traffic observed was entirely through-traffic, passing through the corridor without coming from or going to a room or space located on the corridor in the defined area for the research study. It is also unsurprising that approximately 1 out of 5 foot traffic incidences involved patient rooms and 1 out of 4 involved the nur sing station area, give n the prevalence on the unit of healthcare staff connected with patient care. More notable, however, are proportions of overall traffic as well as speci fic healthcare staff tr affic frequenting the nursing POD. Even though the nursing station is considerably larger and accommodates more staff and a greater variet y of activities, the small nursi ng POD received close to the same proportion of foot traffic. The nursi ng POD has 21 square feet (SF) and room enough for only one task chair, yet 1 in 5 h ealthcare staff member s traveling through the corridor walked to or from the POD. Observers noted anecdotally that at times a staff member approaching the nursing POD f ound it full and had to choose another destination. This could mean that charting and work stations that are conveniently accessible from patient rooms are insufficient fo r the intended use by the healthcare staff. Given the patient-centered focus of hospita ls, it follows that patient rooms would be the destination for a large por tion of foot traffic. As st ated previously, patient rooms received 20% of all healthcare staff traffic. Predictably, visitors also frequented patient rooms, with 23% traveling to or from 1 of the 4 patient rooms located on the study corridor area. Over 50% of food service st aff traffic involved patient rooms due to

PAGE 62

51 activity pertaining to the deliver y and pick-up of meal trays. Housekeeping staff traffic involved patient rooms 20% of the time. Only 8% of patient traffic is attributable to patient rooms. This is not unexpected, however considering that just 4 of the 33 patient rooms were located directly on the de fined study portion of the corridor. It should be noted that the space referr ed to as breakroom was temporarily serving as such during most of the research st udy. It was returned to its typical capacity as visitor lounge on the final day of the observation period. Construction/maintenance activity was therefore involved in returning breakroom furnishings to their permanent location and in the installation of the visitor lounge furniture. This explains the 4% of visitor traffic and the 17% of ma intenance staff traffic to and from that location. The fact that 12% of healthcare staff traffic involved th is space remains useful in that this traffic will likely shift to the new breakroom but not change much in proportion. It is not atypical for hospital units to undergo c onstruction and/or maintenance projects periodically. Thus, foot traffic by maintenan ce workers may be more variable than that of other user groups, but occurs during the nor mal course of business within the hospital environment. The handwashing sink and utility closet ar eas received the lowest foot traffic counts. Just over 3% of healthcare staff traffic involved the handwashing sink. Several similar handwashing stations ar e located elsewhere on the unit, so it is possible that staff members were utilizing other ha ndwashing sinks in addition to this particular location. Although the utility closet received only 6% of all foot traffic observed, the overwhelming majority of traffic to and from this location was attributable to housekeeping staff. In fact, half of all housek eeping staff traffic was concentrated in and

PAGE 63

52 around the utility closet area. In light of this the location and design of the utility closet area may play an important role in the daily housekeeping procedures. Equipment Carts Type and Frequency Observations showed that the average equipment cart count was approximately 240 during the peak hours between 7:00am and 11: 00pm. The average equipment cart count during observed hours indicates that daily tr affic counts for a 24-hour period exceeds the average number of counts for peak hours. It is not surprising that a significan t correlation exists between equipment cart counts and foot traffic counts, since people transporting equipment carts/items were coun ted as foot traffic. Since the emergency code brought an influx of foot traffic but did not notably incr ease equipment cart counts, the correlation is stronger when data from the time block in cluding the emergency code is removed. The number of equipment carts/items did not differ significantly between days of the week or between time blocks. Furthe r, equipment cart counts were not affected significantly by the number of empty beds on the unit. Generally speaking, equipment carts seem to be present due to operati onal aspects of the un it and are necessary regardless of patient load. Of the mo st commonly observed equipment carts, supply/utility, housekeeping, and food service cart s were observed to be part of daily operations and therefore present on a regular basis. One-third of all carts/items traveling through the corridor be longed to one of these 3 categories. Multiple computer carts were available on the unit for healthcare professionals to use as mobile charting stations within patie nt rooms. It should be noted that these computer carts fell into the other category because they contribute d to less than 1% of all equipment traffic observed. When coupled with the frequent use of the nursing POD

PAGE 64

53 area by healthcare staff, this fact takes on adde d importance. The observed lack of use of these mobile computers in the corridor study area and the relatively high use by healthcare staff of the small nursing POD ma y be an indicator of healthcare staff preference for the nursing POD. Another notable observation was the dr agging of non-wheeled items across the carpeted floor, contributing to nearly 4% of all equipment traffica relatively small amount, but unexpected altogether. The impli cations of this largely depend on the item being dragged. A heavy, sharp, or roughly te xtured item could cause damage to the carpeting and even compromise the installation of the carpet tiles. The tendency to drag items could be an important new consideration in the fabrication of carpet tiles and for hospital facilities decisions and policies. Patterns Considering the high proportion (25%) of e quipment carts observed traveling to or from one of the 4 patient rooms located on the study corridor, it is no t surprising that half of all carts passed through the corridor area to reach the patient rooms beyond. Unlike in the case of foot traffic, equipment carts t ook the three particular through-traffic paths (points A to B, points A to C, and points B to C) more than any ot her paths within the corridor. Because of the wi de variety of carts/items observed, it is more useful to examine the traffic patterns of individual equipment cart categories. IV poles, gurneys (with and without patient s), and treatment cart s traveled almost exclusively as through traffic or in and out of patient rooms. These types of equipment were primarily observed to be associated dire ctly with patients, so paths to and from patient rooms within and beyond the study area of the corridor were not surprising. Small linen carts showed a similar tendency to gravitate toward patient rooms or move

PAGE 65

54 through the corridor as through-tr affic. Again, these carts were observed to be directly related to patient rooms. Small linen carts were generally positioned in the corridor just outside of the rooms and were taken periodically when full to be emptied in a separate location. Every wheelchair observed with a patient was through-traffic, while wheelchairs with no patients took more varied paths thr ough the study corridor ar ea. No patient in one of the 4 rooms located on the study corrido r left or entered a room in a wheelchair during the observation time blocks. Since 12 patient rooms are located beyond the area of the corridor under observation, it is not surprising that patients traveled through the corridor to or from the rooms beyond. More notable, visits to th e nursing station and nursing POD were common for wheelchairs wit hout patients but not observed at all for wheelchairs with patients. Likely, healthcar e workers charged with transporting patients from this unit arrive with an empty wheelch air and check with staff on the unit before moving on to individual rooms. Food service carts were also observed to be of direct service to patients. Just under half of all food service carts observed frequented the areas in and around patient rooms. Food service cart traffic attributed to the nur sing station and the utility closet (11% and 2%, respectively) were positioned just outside of those locations. Approximately 30% of all food service cart traffic wa s not accounted for by any spec ific location on the corridor, due to movements between various, non-specified locations in the middle of the corridor. Of food service carts observe d, only 10% were through-traffic. This, in conjunction with the fact that 30% traveled to or from uns pecified points throu ghout the corridor area,

PAGE 66

55 shows a tendency by food service carts, in part icular, to take short paths and to start and stop frequently. Housekeeping carts showed more variability in traffic patterns than most other categories of equipment carts. Only 23% of housekeeping carts were through-traffic, while the same number frequented patient room s. As expected, a large portion (35%) of housekeeping carts traveled to or from the u tility closet area. Si milar to food service carts, housekeeping carts were observed servic ing virtually all spaces within the unit, rather than passing through without st opping or concentrating in one location. Rolling carts are directly linked with the people utilizing them, as evidenced by the significant correlation between foot traffic a nd equipment carts. Carts are either pushed or pulled over the floor surface, causing not only wear on the carpeting, but physical effort and sometimes strain on the person doi ng the pushing or pulling. For the most part, the equipment observed was pushed through the corridor. Food serv ice, supply/utility, and flatbed maintenance carts were observed being pulled 20-30% of the time, although they were still pushed the majority of the ti me. Trash bins were the exception, with 91% being pulled through the corridor area. While these findings do not necessarily impact the carpeting directl y, they are useful in examini ng ergonomic factors related to carpeting, especially from a risk management standpoint. Carpet Cleaning Procedures As stated previously, the results of this study did not explicitly support or reject the stated hypotheses that: 1) act ual carpet cleaning procedur es are concurrent with documented hospital protocol, 2) actual carpet cleaning procedures are concurrent with infection control guidelines and industry sta ndards, and 3) documented hospital protocol is concurrent with infection control guidelines and industry standards. The reason for this

PAGE 67

56 is that differences varied among the six key components of carpet maintenance programs. While some aspects of carp et cleaning, such as vacuum ing, did show concurrence between actual carpet cleaning procedures, documented hospital protocol, and infection control guidelines and industry standards, others did not. Additionally, very little written documentation of hospital protocol was availa ble, so in some cases a comparison cannot be made. Preventive Maintenance As part of infection control guidelines and industry standard cleaning protocol, preventive maintenance involves utilization of walk-off mats at entrances and major interior traffic areas. Although there is no written documentation available concerning the hospitals walk-off mat program, hospital Envi ronmental Services stated that there is one in place and that hospital policy includes walk-off floor mats at entrances. While walk-off mats were, in fact, present at the ho spital entrance, none were observed at major interior traffic areas, as sugge sted by guidelines. The unit is accessed by elevator, yet no floor mats were located at this common entrance location. Vacuuming On the commercial carpet cleaning freque ncy chart (refer to Table 2.1, p. 15 ) developed by the Institute of Inspection Cl eaning and Restoration (2002), the hospital in this study falls into the very heavy foot traffic category, with over 2,500 foot traffics per day. As a result, industry standards call for vacuuming 1 to 2 times daily. The daily cleaning schedule provided for housekeepi ng staff by the hospitals Environmental Services department includes vacuuming in specific corridor areas as well as an additional final vacuuming. Evidence from observation data suggests that overall

PAGE 68

57 vacuum cleaning occurred once daily, but is not sufficient to assume two daily vacuumings. Observers noted that, while vacuuming wa s occurring regularly in the defined area of the study corridor, it was not observed at any time elsewh ere in the co rridor within view of the observers. The lack of evid ence regarding vacuuming within the unit indicates the variability of cleaning practices among housekeeping staff members on the unit. A clearly documented policy regarding vacuuming could help to promote a higher degree of consistency among hospi tal housekeeping staff members. Spot and Spill Removal Standard recommendations require spill and spot removal daily or when spots are noticed. The hospitals Envir onmental Services department aims for once weekly or biweekly spot or spill checks, although there is no written docum entation to that effect, and no obvious investigations were observed. A dditionally, response times were varied and ranged from immediate to 18 hours. Under hos pital protocol, carpet spots are considered special projects, yet spills are not often re ported and records of special projects are inconsistent and largely missing. Aside fr om a list of chemicals to be kept on housekeeping carts (refer to Hospital Environmental Serv ices Policy #11, Appendix G), no documentation could be found regarding either the protocol for treatment of spots or recorded past incidents. Hospital documentation does include Quic k Spot, a carpet spot-remover made by Envirox LLC, on a list of chemicals to be kept on housekeeping carts (Appendix G). Label instructions for this product, which are to spray carpet until wet, allow to sit five to ten minutes, scrub or blot soil away, and vac uum when dry, are in keeping with infection control guidelines.

PAGE 69

58 Two out of the 3 contamination inci dents observed received a response by housekeeping staff within approximately 5 mi nutes. The only liquid spill observed was treated immediately in accordance with guide lines. The third incident, however, was not noticed or treated until some 18 hours later, at which time a maintenance staff member used masking tape to remove dust/debris fr om the carpet surface. This cleaning method is not in line with infection control guidelin es, industry standards, or hospital protocol. The delay in attending to this contamination incident and the improper treatment of it emphasizes the need for policy concerning fre quent and consistent spill checks. Though Environmental Service aims for weekly or bi -weekly spill checks, observation data shows that this may not be sufficient. Interim Cleaning Interim cleaning should be performed in this corridor 12 to 52 times annually, according to the IICRC commercial carpet cleaning frequency chart (refer to Table 2.1, p. 15). Aside from data on the chemicals used in the procedure, the hospital has no written protocol for interim cleaning or the dry extract ion method typically used in this facility. Environmental Services reports that the Host Dry Extraction system is performed as needed between deep cleanings. Label instru ctions are consistent with guidelines, and are to apply dry powder to the carpeting, br ush through fibers with a Dry-Clean Machine (made by Host), and follow with vacuuming. No policy exists concerning the frequency with which this process is to be performed, and no documentation of past applications of the procedure was available. This proce dure was not observed dur ing the study period. Restorative Cleaning Guidelines and hospital protocol both speci fy hot water extraction as the method of restorative carpet cleaning and both agree on the way in which this process is to be

PAGE 70

59 performed. However, while the IICRCs co mmercial carpet cleaning frequency chart recommends restorative cleaning 6 to 24 times per year, Hospital Environmental Services Policy #27 (Appendix H) specifi es deep carpet cleaning just 2 times per year, once in spring and once in fall. This discrepancy is substantial yet difficult to rectify because the same high traffic volume that causes the need for frequent deep cleaning makes closing the corridor for the process extremely inc onvenient. This procedure was not observed during the study period. Carpet Tile Replacement Infection control guidelines and indu stry recommendations suggest replacing contaminated or damaged individual carpet tile s as needed. Since the recent installation of carpet tile in place of broadloom carpe t, a new hospital protocol has not been established or documented, but is under deve lopment. In accordance with guidelines, Hospital Environmental Services intends to replace carpet tiles found to be damaged or stained. Further plans include immediately removing tiles on which spills have occurred in order to carry out proper treatment in a less conspicuous locati on. One contamination incident observed involved a liquid spill, but the cleaning was performed at the site on which it occurred and the tile was not remove d or replaced during the study period. It should be noted, however, that this particul ar incident involved a food product and no other opportunity occurred to carry out the requisite repla cement of a carpet tile. Summary Hypothesis 1 was that actual carpet clean ing procedures are concurrent with documented hospital protocol. Findings from this study support this hypothesis with regard to preventive maintenance. Observ ation data indicates that vacuuming was performed once daily, not twice daily as require d by hospital protocol. In this case, the

PAGE 71

60 hypothesis is not supported. Due to the li mited documentation of hospital protocol available and the lack of observation of pa rticular cleaning methods there is not enough evidence to support the first hypothesis regarding spot and spill treatment, interim cleaning, restorative cleaning, a nd carpet tile replacement. Hypothesis 2 was that actual carpet clean ing procedures are concurrent with infection control guidelines and industry sta ndards. Observations of vacuuming as well as spot and spill treatment support this hypothe sis. However, preventive maintenance practices were not concurrent with guidelin es because floormats were not present at major interior traffic locations. Findings regarding carpet tile replacement do not support the second hypothesis, although only one inci dent that called for this action was observed. Since no interim cleaning or restor ative cleaning procedures were observed, there is not sufficient evidence of thes e activities to suppor t this hypothesis. Hypothesis 3 was that documented hospital protocol is concurrent with infection control guidelines and industry standards. This hypothesis is supported by findings concerning vacuuming, since hos pital protocol calls for twice daily vacuuming and guidelines suggest 1-2 times daily. Findings regarding restorative cleaning, however, do not support the third hypothesis. Though th ey agree on the appropriate method for restorative cleaning, hospital policy requires it twice yearly, compared to the industry standard recommendation of 6-24 times per year. Due to lack of documentation of hospital protocol regarding preventive main tenance, spot and spill treatment, interim cleaning, and carpet tile replacement, hypothe sis 3 cannot be accepted or rejected based on evidence collected.

PAGE 72

61 CHAPTER 6 CONCLUSIONS With growing interest in th e indoor environmental quality of healthcare settings, it is important to consider impact factors on interior finish materi als such as flooring. Little has been studied about particular factors c ontributing to the wear and maintenance of flooringspecifically carpeti ngin a hospital environment. As a result, those responsible for the manufactur ing, selection, and care of such materials are left guessing as to what happens to carpe ting in its intended setting. This study established definitively that the f oot traffic in this particular patient unit corridor numbered over the 2,500 required to be considered a heavy traffic area by the IICRC. Further, foot traffic was effected by the number of patients being cared for on the unit, and was correlated with equipment cart traffic, which adds to the impact on carpeting. Equipment carts were consistently observed regardless of day of the week, time of the day, or patient load. In light of this, information such as equipment use and hospital census numbers should be examined when selecting appropr iate floorcoverings or developing and implementing a maintenance plan. Healthcare staff contributed to 80% of all foot traffic dur ing the study, evidence that this particular location within the hospita l primarily serves and supports the activities of the healthcare professionals charged with pati ent care. In fact, observations of areas in the study corridor alloca ted to healthcare staff revealed unexpected patterns. The heavy use of the small nursing POD along with anecdotal observations by researchers of overcrowding in this space point to a pref erence among the staff for a charting space that

PAGE 73

62 is more convenient and accessible than th e larger nursing station. These findings, coupled with the observed lack of use of com puter carts provided to healthcare staff for the purpose of convenient charting, suggest a need for a reassessmen t of the types of spaces and tools required by current and future healthcare professionals. This research brought to light the ho spitals lack of a documented carpet maintenance program. Most of the intenti ons and activities of hospital Environmental Services were generally in lin e with infection control guidel ines and industry standards. However, the lack of documented policy may cause inconsistencies and complications in carrying out proposed maintenance activities. For example, a policy exists requiring deep cleaning twice yearly, yet re cent high census numbers ha ve compelled the hospitals Environmental Services to make arrangeme nts with each individual unit in order to schedule this procedure, resulting in possi ble untimely cleanings. Written documentation of a comprehensive carpet maintenance program, reviewed and approved by hospital administration, could call atte ntion to the frequency and consistency of cleaning procedures necessary to mainta in the appearance and sanitary condition of the carpet tile. In this way, hospital administration and Enviro nmental Services could work together to ensure that cleanings are scheduled and pe rformed with regularity despite operational obstacles and that housekeeping staff has a clear understanding of expected carpet cleaning procedures. Limitations While systematic observation does not rely on self-reporting by participants, it can still be subject to bias and human error on the part of the observer(s). Obstructed views, unexpected distractions, or excessive activity may have led to inaccuracies in traffic counts and identification of user and equipment types.

PAGE 74

63 Additionally, cross-sectiona l observation methods do littl e to explain the findings or determine how the observed behaviors and patterns effect the environment and its users. This research is prim arily exploratory in nature. As this was a case study, findings cannot be generalized to other hospitals or environments. A larger study including mo re hospitals would have obtained more universal information about this type of loca tion. In addition, this was not a longitudinal examination of hospital activities. While one week is representational of typical activity, it did not allow for the observation of infreque nt activities such as spill incidents and interim and restorative cleaning processes. Further information about off-peak hours could also be gathered by 24-hour observations. Future Directions in Research Further studies should explor e how wear and contaminati on of carpet tile affect people in the environment, especially with regard to physical health (i.e., infection control and ergonomics). Studies explori ng the relationship between carpeting and infection control (including allergies and asthma ) in healthcare settings are few in number and rarely examine the role and impact of variable maintenance practices. Future research should also include ergonomic evalua tions of the role ca rpeting and carpet tile play in injuries from pushing and pulling equipment carts. Further research should also focus on maintenance programs and their practical implementation. The quality and consistency of actual cleaning procedures in healthcare settings and their potential to impact occupants should be examined more closely by researchers in the future. A better unders tanding of how carpet and carpet tile are maintained in their intended setting could c ontribute not only to a long wear life and healthy environment, but to appropriate a nd safe carpet selection at the outset.

PAGE 75

64 APPENDIX A APPROVAL AND PERMISSION

PAGE 76

65

PAGE 77

66 APPENDIX B OBSERVATION FORMS

PAGE 78

67

PAGE 79

68

PAGE 80

69 APPENDIX C STATISTICAL ANALYSES The following is the statistal analysis testi ng for effect of time of day and day of the week on foot traffic counts. The GLM Procedure Class Level Information Class Levels Values day 6 1 2 3 4 5 6 time 8 1 2 3 4 5 6 7 8 Number of observations 48 NOTE: Due to missing values, only 31 observations can be used in this analysis. ####################################################################### Dependent Variable: sqrtfoot Sum of Source DF Squares Mean Square F Value Pr > F Model 12 164.0657648 13.6721471 4.08 0.0037 Error 18 60.3453900 3.3525217 Corrected Total 30 224.4111548 R-Square Coeff Var Root MSE sqrtfoot Mean 0.731095 9.705333 1.830989 18.86581 Source DF Type III SS Mean Square F Value Pr > F day 5 37.91095997 7.58219199 2.26 0.0922 time 7 74.30927664 10.61561095 3.17 0.0230

PAGE 81

70 Bonferronis multiple comparison test: Least Squares Means for effect time Pr > |t| for H0: LSMean(i)=LSMean(j) Dependent Variable: sqrtfoot i/j 1 2 3 4 5 6 7 8 1 0.6906 1.0000 1.0000 0.7830 0.2744 0.1568 0.0186 2 0.6906 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 3 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.1284 4 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 5 0.7830 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 6 0.2744 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 7 0.1568 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 8 0.0186 1.0000 0.1284 1.0000 1.0000 1.0000 1.0000

PAGE 82

71 The following is the statistical analysis tes ting for effect of time of day and day of the week on foot traffic count s after removing data from the time block during which an emergency code occurred. The GLM Procedure Class Level Information Class Levels Values day 6 1 2 3 4 5 6 time 8 1 2 3 4 5 6 7 8 Number of observations 48 NOTE: Due to missing values, only 31 observations can be used in this analysis. ####################################################################### Dependent Variable: sqrtfoot Sum of Source DF Squares Mean Square F Value Pr > F Model 12 116.2908109 9.6909009 3.87 0.0057 Error 17 42.5776858 2.5045698 Corrected Total 29 158.8684967 R-Square Coeff Var Root MSE footcount Mean 0.731994 8.508360 1.582583 18.60033 Source DF Type III SS Mean Square F Value P-value day 5 30.9679642 6.19359285 2.47 0.0739 time 7 48.41685591 6.91669370 2.76 0.0412

PAGE 83

72 Bonferronis mulitiple comparison test: Least Squares Means for effect time Pr > |t| for H0: LSMean(i)=LSMean(j) Dependent Variable: sqrtfoot i/j 1 2 3 4 5 6 7 8 1 1.0000 1.0000 1.0000 1.0000 1.0000 0.7442 0.1766 2 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 3 1.0000 1.0000 1.0000 1.0000 0.7218 0.4010 0.0528 4 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 5 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 6 1.0000 1.0000 0.7218 1.0000 1.0000 1.0000 1.0000 7 0.7442 1.0000 0.4010 1.0000 1.0000 1.0000 1.0000 8 0.1766 1.0000 0.0528 1.0000 1.0000 1.0000 1.0000 Least Squares Means for effect day Pr > |t| for H0: LSMean(i)=LSMean(j) Dependent Variable: sqrtfootcount i/j 1 2 3 4 5 6 1 0.0718 0.3729 0.6803 0.2558 1.0000 2 0.0718 1.0000 1.0000 1.0000 1.0000 3 0.3729 1.0000 1.0000 1.0000 1.0000 4 0.6803 1.0000 1.0000 1.0000 1.0000 5 0.2558 1.0000 1.0000 1.0000 1.0000 6 1.0000 1.0000 1.0000 1.0000 1.0000

PAGE 84

73 The following is the statistal analysis testi ng for effect of number of empty beds on foot traffic counts. Dependent Variable: sqrtfoot Sum of Source DF Squares Mean Square F Value Pr > F Model 1 50.2526737 50.2526737 8.37 0.0072 Error 29 174.1584811 6.0054649 Corrected Total 30 224.4111548 R-Square Coeff Var Root MSE sqrtfoot Mean 0.223931 12.98966 2.450605 18.86581 Source DF Type III SS Mean Square F Value Pr > F beds 1 50.25267374 50.25267374 8.37 0.0072 Standard Parameter Estimate Error t Value Pr > |t| Intercept 21.05678340 0.87601136 24.04 <.0001 beds -0.60106447 0.20778528 -2.89 0.0072

PAGE 85

74 The following is the statistal analysis testi ng for effect of time of day and day of the week on equipment cart counts. The GLM Procedure Class Level Information Class Levels Values day 6 1 2 3 4 5 6 time 8 1 2 3 4 5 6 7 8 Number of observations 48 NOTE: Due to missing values, only 31 observations can be used in this analysis. ####################################################################### Dependent Variable: sqrtcount Sum of Source DF Squares Mean Square F Value Pr > F Model 12 12.62580915 1.05215076 1.38 0.2615 Error 18 13.74287472 0.76349304 Corrected Total 30 26.36868387 R-Square Coeff Var Root MSE sqrtcount Mean 0.478818 16.18693 0.873781 5.398065 Source DF Type III SS Mean Square F Value Pr > F day 5 2.56589195 0.51317839 0.67 0.6498 time 7 7.83755528 1.11965075 1.47 0.2409

PAGE 86

75 The following is the statistal analysis testi ng for effect of number of empty beds on equipment cart counts. Dependent Variable: sqrtequip Sum of Source DF Squares Mean Square F Value Pr > F Model 1 1.76560055 1.76560055 2.08 0.1598 Error 29 24.60308333 0.84838218 Corrected Total 30 26.36868387 R-Square Coeff Var Root MSE sqrtequip Mean 0.066958 17.06309 0.921077 5.398065 Source DF Type III SS Mean Square F Value Pr > F beds 1 1.76560055 1.76560055 2.08 0.1598 Standard Parameter Estimate Error t Value Pr > |t| Intercept 5.808745362 0.32925486 17.64 <.0001 beds -0.112664657 0.07809752 -1.44 0.1598

PAGE 87

76 The following is the statistal analysis testing for correlation between foot traffic and equipment cart counts. Correlations sqrtfootcount sqrtequip Pearson Correlation 1 .490(**) Sig. (2-tailed) .005 sqrtfootcount N 31 31 Pearson Correlation .490(**) 1 Sig. (2-tailed) .005 sqrtequip N 31 31 ** Correlation is significant at the 0.01 level (2-tailed).

PAGE 88

77 APPENDIX D EQUIPMENT PHOTOGRAPHS Figures D.1-D.20 are photographs of commonly observed equipment. Figure D.1: IV Pole

PAGE 89

78 Figure D.2: Typical supply cart Figure D.3: Supply/utility cart

PAGE 90

79 Figure D.4: Supply cart Figure D.5: Housekeeping cart

PAGE 91

80 Figure D.6: Typical gurneys Figure D.7: Gurney

PAGE 92

81 Figure D.8: Food service cart Figure D.9: Small linens cart

PAGE 93

82 Figure D.10: Wheelchair Figure D.11: Portable x-ray machine

PAGE 94

83 Figure D.12: Trash bin/large linens cart Figure D.13: Emergency crash cart

PAGE 95

84 Figure D.14: Treatment cart Figure D.15: Treatment cart

PAGE 96

85 Figure D.16: Cart used for blood-drawing Figure D.17: Portable scale

PAGE 97

86 Figure D.18: Mobile computer carts Figure D.19: Rolling task chair

PAGE 98

87 Figure D.20: Flatbed maintenance cart

PAGE 99

88 APPENDIX E CLEANING EQUIPMEN T SPECIFICATIONS

PAGE 100

89

PAGE 101

90

PAGE 102

91 APPENDIX F MATERIAL SAFETY DATA SHEETS

PAGE 103

92

PAGE 104

93

PAGE 105

94

PAGE 106

95

PAGE 107

96

PAGE 108

97

PAGE 109

98

PAGE 110

99 APPENDIX G HOSPITAL ENVIRONMENTAL SERVICES POLICY #11: CHEMICALS USED ON HOUSEKEEPERS CART

PAGE 111

100

PAGE 112

101 APPENDIX H HOSPITAL ENVIRONMENTAL SERVICES POLICY # 27: CARPET CLEANING PROCEDURES

PAGE 113

102 APPENDIX I TYPICAL PATIENT UNIT CLEANING SCHEDULE

PAGE 114

103 LIST OF REFERENCES Anderson, R. L., Mackel, D. C., Stoler, B. S., & Mallison, G. F. (1982). Carpeting in hospitalsan epidemiological evaluation. Journal of Clinical Microbiology 15(3), 408-415. American Society of Healthcare Engineering. (2004). Green Healthcare Construction Guidance Statement Chicago, IL: American Society of Healthcare Engineering. American Society of Heating, Refrigerat ing, and Air-Conditioning Engineers, Inc. (1997). ASHRAE Handbook: Fundamentals (I-P ed.). Atlanta, GA: American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Inc. Association for Professionals in Infecti on Control and Epidemiology, Community and Hospital Infection Control AssociationC anada, & Infection Control Nurses Association. (1999). Global Consensu s Conference: Final Recommendations. American Journal of Infection Control 27(6), 503-13. Ayliffe, G. A. J., Babb, J. R., & Taylor, L. J. (1999). Hospital-Acquired Infection: Principles and Prevention (3 ed.). Boston: Butterworth Heinemann. Busch-Vishniac, I. J., West, J. E., Barnhill, C., Hunter, T., Orellana, D., & Chivukula, R. (2005). Noise levels in Johns Hopkins Hospital. Journal of the Acoustical Society of America 118(6), 3629-3645. Carpet and Rug Institute. (2004). Carpet Maintenance Guidelines for Commercial Applications Dalton, GA: The Carpet and Rug Institute. Carpman, J. R., & Grant, M. A. (1993). Design that Cares: Planning Health Facilities for Patients and Visitors (2nd ed.). Washington DC: Am erican Hospital Association. Dancer, S. J. (1999). Mopping up hospital infection. Journal of Hospital Infection 43(2), 85-100. Das, B., Wimpee, J., & Das, B. (2002). Ergonom ics evaluation and redesign of a hospital meal cart. Applied Ergonomics 33(4), 309-318. Department of Health, Edu cation, and Welfare. (1979). The Belmont Report (OPPR Publication No. 9-12065). Washington, DC: US Government Printing Office. Dillman, C. (1996). Epidemiology of nosocomia l infections: 10-month experience in one hospital. Current Therapeutic Research 52(Suppl. A), 26-29.

PAGE 115

104 Engelhart, S., Loock, A., Skutlarek, D., Sa gunski, H., Lommel, A., Farber, H., et al. (2002). Occurrence of toxigenic Aspergillus versicolor isolates and sterigmatocystin in carpet dust from damp indoor environments. Applied and Environmental Microbiology 68(8), 3886-3890. Fisk, W. J. (2001). Estimates of potential na tionwide productivity and health benefits from better indoor environments: An update. In J. D. Spengler, J. M. Samet & J. F. McCarthy (Eds.), Indoor Air Quality Handbook New York: McGraw-Hill. Franke, D. L., Cole, E. C., Leese, K. E., Foarde, K. K., & Berry, M. A. (1997). Cleaning for improved indoor air quality: An initi al assessment of effectiveness. Indoor Air 7, 41-54. Fuston, A., & Nadel, K. P. (1997). Creating no ntoxic, health-enhancing environments. In S. O. Marberry (Ed.), Healthcare Design New York: John Wiley & Sons, Inc. Green Guide for Healthcare. (2005, August 2005). Green Guide for Healthcare: A B est Practices Guide for Healthy and Sust ainable Building Design, Construction and Operations Version 2.0 pilot. Retrieved October 14, 2005. Guelich, M. M. (1999). Prevention of falls in the elderly: A literature review. Topics in Geriatric Rehabilitation 15(1), 15-25. Harris, D. (2000). Environmental quality and healing environments: a study of flooring materials in a healthcare telemetry unit. Dissertation Abstracts International 4202(00), DAI-A61/11. (University Digital no. AAT 9994253). Hoozemans, M. J. M., van der Beek, A. J., Frings-Dresen, M. H. W., van der Woude, L. H. V., & van Dijk, F. J. H. (2002). Push ing and pulling in association with low back and shoulder complaints. Occupational and Environmental Medicine 59(10), 696-702. Horton, J. G. (1997). Lighting. In S. O. Marberry (Ed.), Healthcare Design New York: John Wiley & Sons, Inc. Hota, B. (2004). Contamination, disinfecti on, and cross-colonization: Are hospital surfaces reservoirs for nosocomial infection? Clinical Infectious Diseases 39(8), 1182-1189. Illuminating Engineering Societ y of North America. (1995). Lighting for Hospitals and Health Care Facilities New York: Illuminating Engi neering Society of North America. Institute of Inspection Cleaning and Restoration Certification. (2002). Standard and Reference Guide for Professional Carpet Cleaning Vancouver, WA: Institute of Inspection Cleaning and Rest oration Certification.

PAGE 116

105 Kumar, R. (2005). Research Methodology: A Step-by-Step Guide for Beginners London: Sage Publications. Lavender, S. A., Chen, S. H., Li, Y. C., & Andersson, G. B. J. (1998). Trunk muscle use during pulling tasks: Effects of a li fting belt and footing conditions. Human Factors 40(1), 159-172. Luedtke, A. E., Scholler, D. M., & Kennedy, G. (2000). Designing for good indoor air quality. Presented at NeoCon World's Trade Fair Chicago, IL. Luedtke, A. E., Stetzenbach, L., Buttner, M., Erkenbrecher, C., & Kennedy, G. (1999). Relationships between floorcoverings a nd airborne particles. Presented at Indoor Environment '99 Austin, TX. Martinez, J. A., Ruthazer, R., Hansjosten, K., Barefoot, L., & Snydman, D. R. (2003). Role of environmental contamination as a risk factor for acquisition of vancomycin-resistant enterococci in patie nts treated in a medical intensive care unit. Archives of Internal Medicine 163(16), 1905-1912. McCarthy, J. F., & Spengler, J. D. (2001). Indoor environmental quality in hospitals. In J. D. Spengler, J. M. Samet & J. F. McCarthy (Eds.), Indoor Air Quality Handbook New York: McGraw-Hill. Morrison, W. E., Haas, E. C., Shaffner, D. H ., Garrett, E. S., & Fackler, J. C. (2003). Noise, stress, and annoyance in a pediatric intensive care unit. Critical Care Medicine 31(1), 113-119. Oliver, L. C., & Shackleton, B. W. (1998). The indoor air we breathe. Public Health Reports 113(5), 398-409. Penna, T. C. V., Mazzola, P. G., & Martins, A. M. S. (2001). The efficacy of chemical agents in cleaning and disinfection programs. BioMed Central Infectious Diseases 1(16). Radke, R. (1997). Carpet. In S. O. Marberry (Ed.), Healthcare Design New York: John Wiley & Sons, Inc. Rutala, W. A. (1996). APIC guideline fo r selection and use of disinfectants. American Journal of Infection Control 24(4), 313. Samet, J. M., & Spengler, J. D. (2003). Indoor environments and h ealth: Moving into the 21st century. American Journal of Infection Control 93(9), 1489-1493. Sehulster, L., Chinn, R. Y. W., & HICPAC (2003). Guidelines for environmental infection control in health-care facili ties. Recommendations of CDC and the healthcare infection control practic es advisory committee (HICPAC). MMWR. Recommendations And Reports: Morbid ity And Mortalit y Weekly Report. Recommendations And Reports / Centers For Disease Control 52(RR-10), 1.

PAGE 117

106 Smedley, J., Inskip, H., Trevelyan, F., Buckle, P., Cooper, C., & Coggon, D. (2003). Risk factors for incident neck and s houlder pain in hospital nurses. Occupational and Environmental Medicine 60(11), 864-869. Sommer, R., & Sommer, B. (2002). A Practical Guide to Beha vioral Research: Tools and Techniques. New York: Oxford University Press. Topf, M., Bookman, M., & Arand, D. (1996). Ef fects of critical ca re unit noise on the subjective quality of sleep. Journal of Advanced Nursing 24(3), 545-551. Tsiou, C., Eftymiatos, D., Theodossopoulou, E ., Notis, P., & Kiriakou, K. (1998). Noise sources and levels in the evgeni dion hospital intensive care unit. Intensive Care Medicine 24(8), 845-847. United States Green Building Council. (2004). LEED-NC(Leadership in Energy and Environmental Design) Green Building Rating System for New Construction Version 2.1. Weber, D. J., & Rutala, W. A. (2003). The environment as a source of nosocomial infections. In R. P. Wenzel (Ed.), Prevention and Control of Nosocomial Infections New York: Lippincott Williams & Wilkins. Weinhold, V. B. (1988). Interior Finish Faterials for Health Care Facilities Springfield, IL: Charles C. Thomas Publisher. Willmott, M. (1986). The effect of a vinyl floor surface and a carpeted floor surface upon walking in elderly hospital inpatients. Age and Ageing 15(2), 119-120. Zafar, A. B., Gaydos, L. A., Furlong, W. B ., Nguyen, M. H., & Mennonna, P. A. (1998). Effectiveness of infection control program in controlling nosocomial Clostridium difficile. American Journal of Infection Control 26(6), 588-593. Zeisel, J. (1990). Inquiry by Design: Tools for Environment-Behavior Research New York: Cambridge University Press.

PAGE 118

107 BIOGRAPHICAL SKETCH Julianna M. Mitchell was born in New Jersey and grew up with her two sisters in Jupiter, Florida. She graduated from hi gh school in 1998 in Tarpon Springs, Florida, where she met and later married her husband in 2003. Juli attended the University of Florida as a vocal music major and graduated with honors in 2002, receiving a Bachelor of Music with a minor in business. One year later, she returned to UF to pursue a Master of In terior Design. She studi ed abroad during the summer of 2004 at the Vicenza Institute of Architecture in Vicenza, Italy. Following the completion of her degree, Ju li plans to relocate to Seattle, Washington where she will apply her skills and energies to creating beautiful, sensitive, and healthy architectural environments.


Permanent Link: http://ufdc.ufl.edu/UFE0014763/00001

Material Information

Title: Impact on Carpet Tile in a Hospital Patient Unit Corridor: An Observation Case Study
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0014763:00001

Permanent Link: http://ufdc.ufl.edu/UFE0014763/00001

Material Information

Title: Impact on Carpet Tile in a Hospital Patient Unit Corridor: An Observation Case Study
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0014763:00001


This item has the following downloads:


Full Text












IMPACT ON CARPET TILE IN A HOSPITAL PATIENT UNIT CORRIDOR:
AN OBSERVATIONAL CASE STUDY













By

JULIANNA M. MITCHELL


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF INTERIOR DESIGN

UNIVERSITY OF FLORIDA


2006

































Copyright 2006

by

Julianna M. Mitchell















ACKNOWLEDGMENTS

I extend my sincere thanks first and foremost to Dr. Debra Harris, whose help,

advice, and encouragement have been invaluable. She helped to make this endeavor not

only possible, but interesting and fun along the way, and I am grateful for her presence

throughout as teacher, mentor, and friend.

I would also like to thank Dr. Murray C6te for serving on my thesis committee, as

well as Charlotte, Patti, and the staff on the 4th floor of the hospital in which I conducted

this study for all of their help and patience.

I owe many thanks to my four friends and colleagues in my graduate class. Their

caring support, honest criticism, and fun-loving spirit have been cherished constants

throughout our education.

I am forever grateful to my incredible support system of friends, super-friends, and

family, whose encouragement and pride continue to motivate and inspire me. Finally, I

wish to thank Conor for his extraordinary understanding and unwavering support

throughout this endeavor and always.
















TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ................................................................................................. iii

LIST OF TA BLE S .............................. ....... ...... .. .............. .. vii

LIST OF FIGURES ...................................................... ................... viii

A B STR A C T ................................................. ..................................... .. x

CHAPTER

1 IN TR OD U CTION ............................................... .. ......................... ..

P u rp o se ............................................................................ 1
Significance of the Study .............................................................................. ...... .2

2 LITERA TURE REVIEW .......................................................... ..............4

Indoor Environm ental Q quality ............................................................ ...............4.
Carpeting and the H hospital Environm ent ........................................ .....................5
Indoor A ir Q quality .............................................................5
Infection Control ............................... ............... ... .........6
Acoustic Quality ................................ ................................ .. .......8
L ight and R elected L ight........................................................... ............... 9
Personal Comfort................. .. ................................9
Safety Factors ............................................................... .. ... ............. 10
M material Com position ...................................................... ..... ............... 11
The R ole of Cleaning .................. ...................................... .......... .... 12
Cleaning M methods .................................................................... .. ... .... 14
Preventive M maintenance ............................................... ............ ............... 14
V acu u m in g ................................................................14
Sp ot an d Spill R em ov al ............................................................ ..................... 15
Interim Cleaning .................. ............................ .. ..... ................. 16
R estorative C leaning ..................... .. .......................... ...... .......... 17
S u m m ary ...................................... .................................................. 17

3 RESEARCH M ETHODOLOGY ........................................ .......................... 19

R research D esig n ....................................................... ................ 19









M ethodological B background ........................................ .........................................19
E th ic s .............................................................2 0
R research H ypotheses ................................................................ ............. .... 20
S e ttin g .................................................................................................................... 2 0
O observation Procedures ............................................................................22
A n a ly sis ..............................................................................2 3

4 F IN D IN G S ................................................................................ 2 6

F oot T traffic ...................................................................................................... .......26
Type and Frequency ................................................ ............... 26
P atte rn s ................................................................2 9
E q u ip m en t C arts .................................................................................................... 3 4
Type and Frequency ................................................ ............... 34
P atte rn s ................................................................3 7
C arpet C leaning P procedures .................................................................................. 42
Type and Frequency ......................................................... 42
P atte rn s .................. .............................. .................................... ....... ..... .. 4 3
Contam nation Incidents ............................................................. .. ............. 43
Comparison of Cleaning Procedures ...................... ..............44

5 D ISC U S SIO N ................. ............................................ ............. ........... ....47

F o o t T ra ffic ............................................ .............................................................. 4 7
Type and Frequency ............................................. ................................ 48
P patterns ................................................... .......... .. ..... 50
E quipm ent C arts .............. ................................................................... ... 52
Type and Frequency ................................................ ............... 52
P atte rn s ................................................................5 3
C arpet Cleaning Procedures ............. ......................................... ............... 55
Preventive M maintenance ...................................................... 56
V acuum ing ................................................................... .... .... .. ........ .. .. 56
Spot and Spill R em oval .......................................................................57
Interim Cleaning ............................................ ... .. .......... 58
R estorative C leaning ........................ .. ................ ............ .... ............58
Carpet Tile Replacement ......................... ............ 59
S u m m ary ............. ......... ................................................................ ..... 5 9

6 C O N C L U SIO N S ...........................................................................................6 1

L im stations ................. ........................ ........... ............. .......... 62
Future D directions in R research ............................................................................. 63

APPENDIX

A APPROVAL AND PERMISSION......................................... .......................... 64

B OBSERVATION FORMS.......................................................... ...............66


v









C STATISTICAL ANALYSES .................................. .....................................69

D EQUIPM ENT PHOTOGRAPHS ........................................ .......................... 77

E CLEANING EQUIPMENT SPECIFICATIONS ....................................................88

F M ATERIAL SAFETY DATA SHEETS......................................... .....................91

G HOSPITAL ENVIRONMENTAL SERVICES POLICY #11: CHEMICALS
USED ON HOUSEKEEPER'S CART ...... .... ............. ......................................99

H HOSPITAL ENVIRONMENTAL SERVICES POLICY # 27: CARPET
CLEANING PROCEDURES .............................. .......... .............................101

I TYPICAL PATIENT UNIT CLEANING SCHEDULE ............... ....................102

L IST O F R E F E R E N C E S ......... ................. ................................................................. 103

BIOGRAPHICAL SKETCH ...... ........ ................... ............................ 107
















LIST OF TABLES


Table page

2.1 Com m ercial carpet cleaning frequency chart................................... ... ..................15

4.1 Total traffic counts observed, by day and time block ........................................... 26

4.2 Total equipment cart counts observed, by day and time block.............................35

4.3 Number of times vacuuming was observed, by day and time block......................43

4.4 Contamination incidents and responses ....................................... ............... 44

4.5 Comparison of recommended and observed carpet cleaning procedures ...............44
















LIST OF FIGURES


Figure pge

1.1 Relationships between factors involved in the research ....................................

1.2 C onceptu al fram ew ork ................................... ..................................... .................... .... 2

3.1 Study setting ............................................................... ... .... ......... 21

3.2 Factors contributing to the condition of flooring finish material...........................24

4.1 Types of users, as percentages of total foot traffic observed .............................. 28

4.2 Average foot traffic timeline, by time block ...........................................................28

4.3 Average foot traffic timelines for each user group..........................................29

4.4 Entry/destination locations in the defined corridor area .......................................30

4.5 Most frequently taken foot traffic paths, as percentages of total foot traffic
o b se rv e d ........................................................................... 3 1

4.6 Locations on study corridor commonly receiving foot traffic, as percentages of
total foot traffic ob served .............................................................. .....................32

4.7 By user group category, locations on study corridor commonly receiving foot
traffic, as percentages of total foot traffic observed.............................................. 33

4.8 Types of equipment carts, as percentages of total carts/items observed..................36

4.9 Correlation between foot traffic and equipment cart counts.............. .................37

4.10 Most frequently taken paths by equipment, as percentages of total equipment
carts/item s observed ......................... ....... .... .. ..... .......... .....38

4.11 Locations on study corridor commonly receiving equipment cart traffic, as
percentages of total equipment carts/items observed..............................................39

4.12 By category of equipment, locations on study corridor commonly receiving
equipment cart/item traffic, as percentages of total carts/items observed ...............40

4.13 Human-equipment interaction patterns observed for each equipment category......42









D .1 IV P o le ............................................................................... 7 7

D .2 Typical supply cart ........... ................ .. .............. ........ .......... 78

D .3 Supply/utility cart............. ...... ...................................................... .. ....... . ...... 78

D .4 S u p p ly c a rt.......................................................................................................... 7 9

D .5 H housekeeping cart ........................................................... .... ............... 79

D.6 Typical gurneys ............ ... ................. ................. 80

D.7 Gurney .................................... .... ............... 80

D .8 F ood service cart ............................................................... 8 1

D .9 Sm all linens cart ................................................... ............. ......... ... 81

D .10 W h e elch air ............................................................................................................... 8 2

D 11 P portable x-ray m achine..................................................................... .................. 82

D 12 T rash bin/large linens cart.......................................................................... .... 83

D 13 E m ergency crash cart ...................................................................... ...................83

D .14 T reatm ent cart ........................ .. ........................ .. .... ........ ........ 84

D .15 T reatm ent cart ........................ .. ........................ .. .... ........ ........ 84

D 16 Cart used for blood-drawing ............................................................................. 85

D.17 Portable scale.................. ...................................85

D .18 M obile com puter carts............................................ ....................................... 86

D.19 Rolling task chair ............................... .......... ...... ............... 86

D .20 F latbed m maintenance cart............................................................... .....................87















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Interior Design

IMPACT ON CARPET TILE IN A HOSPITAL PATIENT UNIT CORRIDOR:
AN OBSERVATIONAL CASE STUDY

By

Julianna M. Mitchell

August 2006

Chair: Debra D. Harris
Major Department: Interior Design

Interior designers are generally responsible for the selection and specification of

flooring materials for healthcare facilities. In turn, flooring materials and carpet may

have a broad impact on the health, safety, comfort, and confidence level of patients,

visitors, and employees. In order to manufacture and select carpeting that can properly

support hospital occupants and activities, it is necessary to consider the factors which

impact it. Similarly, a maintenance plan to properly care for carpeting must respond to

actual use and wear, in addition to incorporating preventive measures for infection

control and indoor air quality. This study examines use patterns and activities affecting

carpet tile in a real-life setting.

Observations of a designated portion of a patient unit corridor were made in 2-hour

increments between the typical peak hours of 7:00am and 11:00pm. A total of 31 time

blocks were randomized over a 6-day period. Researchers documented the type and

frequency of foot traffic and equipment carts, as well as use patterns in the form of paths









traveled through the corridor area. Additionally, cleaning activities were documented in

order to compare 1) actual carpet cleaning procedures, 2) documented hospital protocol,

and 3) infection control guidelines and industry standard cleaning methods.

Results showed that the study corridor carpeting received over 2,900 foot traffic

instances per day during peak hours alone, and that average foot traffic counts varied

throughout the day. Further, this particular location within the hospital primarily served

and supported healthcare professionals charged with patient care. However, unexpected

use patterns of the particular spaces allocated to healthcare staff were revealed. Findings

indicate that information such as equipment use and hospital census numbers should be

examined when selecting appropriate floorcoverings or developing and implementing a

maintenance plan.

A hospital-wide comprehensive carpet maintenance program should be developed

and documented. Additionally, variation among housekeeping staff members suggests

the need for further research regarding consistency and quality of regular facility

maintenance practices. Further studies should also explore how wear and contamination

of carpet tile affect people in the environment, especially with regard to physical health.















CHAPTER 1
INTRODUCTION

Interior designers are generally responsible for the selection and specification of

flooring materials for healthcare facilities. In turn, flooring materials and carpet may

have a broad impact on the health, safety, comfort, and confidence level of patients,

visitors, and employees (Figure 1.1). Specifying carpeting requires consideration not

only of appearance (e.g., color and texture), but of crucial factors such as durability,

maintenance, and indoor air quality. In order to make appropriate decisions, designers

should be informed about how materials are impacted and maintained by end users. This

study examined use patterns and activities that effect carpet tile in a real-life setting.



Users Hospital


IEQ (Indoor Designer
Environmental
Quality)


Maintenance Materials
(i.e. carpeting)

Figure 1.1: Relationships between factors involved in the research

Purpose

The purpose of this study is to determine the human impact on carpet tile in a

patient unit corridor, including housekeeping activities, human traffic, and equipment

carts. Specific questions answered include 1) what specific users and equipment










contribute to traffic flow in a patient corridor; and 2) what are the consistency, frequency,

and methods of regular cleaning of carpet tile in an acute care patient corridor?

Through this study, occurrences of and reaction to contamination incidents are

isolated and explored. Further, a comparison between 1) actual carpet cleaning

procedures, 2) documented hospital protocol, and 3) infection control guidelines and

industry standard cleaning methods provides valuable information to manufacturers and

specifiers of materials for acute care facilities. The conceptual framework for this study

is shown in Figure 1.2.



Contributing Factors Impact
* Foot traffic Impact Physical Setting IEQ
* Equipment a Type & frequency Carpeting (Indoor
Air Contamination Use patterns Environmental
SExtent of contamination Quality)


Response
i.e. Maintenance Infection
Type & frequency Control
Patterns (schedule)
Ergonomics
Note: Items in gray are beyond the scope of this research study.


Figure 1.2: Conceptual framework

Significance of the Study

Interior designers-along with manufacturers of flooring materials such as carpet-

continually question whether flooring finish materials are maintained properly once they

are installed in hospitals and other facilities. First-hand information about how these

products are actually being utilized and treated in their intended setting could lead to the

development and selection of better, more suitable floor coverings for healthcare and

other environments. Although findings in this case study are not generalizable to other









hospitals or environments, they will provide useful information for the host site and

contribute to the body of knowledge for interior design application and related industries.














CHAPTER 2
LITERATURE REVIEW

Indoor Environmental Quality

Concern in recent years about the relationship between the built environment and

the health of occupants has lead to substantial research and advances in indoor air and

environmental quality (American Society of Healthcare Engineering, 2004; Luedtke,

Scholler, & Kennedy, 2000). In 2003, the American Journal of Public Health published

an entire issue on the subject, "signal[ing] a timely recognition of the relevance to health

and well-being of the indoor environments where people spend most of their time"

(Samet & Spengler, 2003, p. 1489). Several major organizations, including the U.S.

Green Building Council in its Leadership in Energy and Environmental Design Green

Building Rating System, the American Society of Healthcare Engineering, and the Green

Guide for Healthcare list indoor environmental quality as a key contributor to the well-

being of a building's occupants (ASHE, 2004; Green Guide for Healthcare, 2005; United

States Green Building Council, 2004).

The quality of the indoor environment has a profound affect on health and

productivity. Moreover, risk of disease is increased by indoor air pollutants,

contamination of surfaces by toxins and microbes, and contact between people in the

environment (Samet & Spengler, 2003). In turn, the air and environmental quality of a

building are dependent on: 1) the design of the physical space, 2) the building systems,

and 3) the selection and maintenance of materials within (ASHE, 2004; Ayliffe, Babb, &









Taylor, 1999; Luedtke et al., 2000). Interior designers make decisions regarding each of

these factors and are principally responsible for the specification of interior materials.

Carpeting and the Hospital Environment

The healthcare sector especially has a "collective fundamental mission to protect

and enhance individual and community health" (GGHC, 2005). Fuston and Nadel (1997)

assert that the design of healthcare facilities is likely the most critical of all interior

spaces because of the extended durations spent in them by patients and employees alike.

Hospitals require special consideration with regard to indoor environmental quality due

to the susceptible population they serve, as well as their need to operate around the clock

(McCarthy & Spengler, 2001). Moving into the twenty-first century, hospitals are

becoming more holistically concerned with the "overall healthfulness" (McCarthy &

Spengler, 2001, p. 65.14) of their occupants. Beyond treating illness, hospitals must offer

non-toxic environments which promote wellness in addition to healing (Carpman &

Grant, 1993; Fuston & Nadel, 1997).

Flooring materials in healthcare settings may have a broad impact on the

environmental health of the building and the patients, families, and staff who spend large

amounts of time there (Fuston & Nadel, 1997; Harris, 2000). Carpet, in particular, has

implications for a range of issues critical in a healthcare setting, including indoor air

quality, infection control, acoustic quality, light and reflected light, personal comfort, and

safety (Harris, 2000; Radke, 1997; Weinhold, 1988).

Indoor Air Quality

The quality of the indoor air is one of the key determinants of environmental health

(Fisk, 2001; Oliver & Shackleton, 1998). Indoor air quality (IAQ) has a significant

influence on incidences of respiratory disease, symptoms of allergies, and asthma,









transmission of infectious diseases, chemical sensitivity, and worker productivity (Fisk,

2001). Poor IAQ is caused by air pollutants from indoors and outdoors, which can

include volatile organic compounds (VOCs), dust, and microbial contaminants such as

mold, mildew, bacteria, and viruses (Fisk, 2001; Fuston & Nadel, 1997).

Carpet and carpet tiles are of notable concern for IAQ. Because carpeting covers

an expansive horizontal surface, it is considered a "sink" that can often absorb harmful

microbes and settling airborne particles and then re-emit them into the air (Ayliffe et al.,

1999; Luedtke et al., 2000).

Carpet is known to accumulate and hold soils and dusts but there is little evidence

that higher levels of airborne contaminants exist over carpet than any other interior

surface (Anderson, Mackel, Stoler, & Mallison, 1982; Harris, 2000; Luedtke,

Stetzenbach, Buttner, Erkenbrecher, & Kennedy, 1999). Concern remains, however,

largely because carpet dust has been found to contain fungal, bacterial, and other

biological debris that could potentially contribute to allergies, asthma and infection

(Engelhart, Loock, Skutlarek, Sagunski, Lommel, Farber, 2002; Luedtke et al., 1999).

Two separate studies examining carpeting in hospital settings found that carpeted floors

had higher levels of surface contamination than did non-carpeted floors. Levels of

airborne contaminants, however, varied less above carpet and remained the same or lower

over carpeting than over other flooring types (Anderson et al., 1982; Harris, 2000).

Infection Control

Nosocomial, or hospital-acquired, infections have been identified as a "major

public health problem" and a leading cause of illness and death in hospitals (Dillman,

1996, p. 26). Although the role of the hospital environment in the spread of nosocomial

infection remains controversial, Hota (2004) points out that existing data has established









that hospital surfaces can become contaminated after exposure to colonized patients and

that specific isolates of nosocomial pathogens may predominate in the inanimate

environment. Martinez, Ruthazer, Hansjosten, Barefoot, & Snydman (2003) found an

epidemiological link between patient room assignment and acquisition of vancomycin-

resistant enterococci (VRE), establishing contaminated environments as a risk factor for

the spread of nosocomial pathogens.

Hospital surfaces can be a reservoir for a variety of microorganisms which, when

transmitted directly or indirectly to patients, have the potential to cause nosocomial

infections (Dancer, 1999; Hota, 2004; Rutala, 1996; Weber & Rutala, 2003).

Recognizing this, hospitals and other healthcare facilities should take a precautionary and

preventive approach when making decisions about operations and maintenance as well as

materials, furnishings, and equipment, all of which can contribute to transmission of

disease and hospital acquired infection (ASHE, 2004; Ayliffe et al., 1999; Dancer, 1999).

As mentioned previously, the "sink" effect can cause higher contamination levels

of carpeted surfaces as compared with hard or resilient flooring (Anderson et al., 1982;

Ayliffe et al., 1999; Harris, 2000; Luedtke et al., 2000). Further, carpet and carpet dust

have been linked with pathogenic fungi (e.g., species ofAspergillus), bacteria (e.g.,

Staphylococcus aureus, Escherichia coli), viruses (e.g., noroviruses), and molds (e.g.,

Penicillium, Candida) (Anderson et al., 1982; Engelhart et al., 2002; Hota, 2004; Luedtke

et al., 1999). Despite the potential presence of such organisms in carpeting, an

epidemiological evaluation of carpeting found no association between carpet

contamination and nosocomial infection and no statistical difference between infection

rates of patients in carpeted rooms and those in uncarpeted rooms (Anderson et al., 1982).









Acoustic Quality

Hospital noise can interfere with sleep, hinder communication, and cause stress and

annoyance for patients, visitors, and staff (Busch-Vishniac, West, Bamhill, Hunter,

Orellana, & Chivukula, 2005; Morrison, Haas, Shaffner, Garrett, & Fackler, 2003; Topf,

Bookman, & Arand, 1997). Noise levels in healthcare settings have been consistently

found to exceed acceptable standards (Busch-Vishniac et al., 2005; Harris, 2000). One

study measuring noise sources in a six-bed intensive care unit reported that highest noise

levels were attributable to items (mainly metallic) falling onto the floor, loud voices, and

equipment and stretchers (Tsiou, Eftymiatos, Theodossopoulou, Notis, & Kiriakou,

1998). Topf et al. (1997) recommends implementing alphanumeric paging systems to

replace equipment alarms and ringing telephones, designing equipment with quieter

moving parts, and specifying carpet in high-traffic areas as some alterations that could

lead to a quieter hospital environment.

Carpet can act as an acoustical aid, reducing transmission of sound to the

immediate area as well as to floors below (Radke, 1997; Weinhold, 1988). In a

comparison of flooring finish materials, Harris (2000) rates the sound absorption qualities

inherent in carpeting as excellent. Weinhold (1988) points out that impact sounds from

dropped objects are greatly reduced by carpeted flooring. With regard to general noise

levels, pile height and pile weight have an effect on the noise reduction coefficient

(NRC), or the amount of sound that carpeting will absorb (Weinhold, 1988). An

additional acoustical consideration is maintenance noise, as vacuum-cleaning can create

more noise than buffing, sweeping, or mopping (Weinhold, 1988).









Light and Reflected Light

Lighting in healthcare environments must support the functions and activities of

medical staff while providing for the sometimes contradictory comfort and lighting needs

of patients and their visitors (Horton, 1997; Illuminating Engineering Society of North

America, 1995). Both task performance and visual comfort are affected by perceived

brightness (IESNA, 1995). The Illuminating Engineering Society of North America

(1995) emphasizes the importance of finish materials to luminance ratios, light

utilization, and space appearance, all of which influence perceptions of brightness.

Another issue is glare, which is excessive brightness in the visual field that causes

annoyance, discomfort, and even loss in visual performance and visibility (IESNA,

1995). Because ceilings, walls, and floors can act as secondary light sources, the

reflectances of finish materials within a room have a strong influence on luminance levels

and can cause glare (IESNA, 1995).

Carpet provides a smooth, matte finish on the flooring surface which significantly

reduces glare (Carpman & Grant, 1993; Horton, 1997). In a study of patient room

flooring materials, carpet slightly exceeded the recommended reflectance range (Harris,

2000). However, the reflectance level of vinyl composition tile (VCT), a resilient

flooring material, was six times greater than that of carpet (Harris, 2000). The same

study found that nurses' perceptions of glare were significantly less in carpeted patient

rooms (Harris, 2000).

Personal Comfort

Carpeting provides comfort underfoot, psychological comfort, and thermal comfort

(Radke, 1997; Weinhold, 1988). The cushioned surface offers some relief from foot and

leg fatigue for hospital staff (Radke, 1997; Weinhold, 1988). Weinhold (1988) asserts









that "the appearance of carpet suggests quality, warmth, and a home-like atmosphere"

and stresses the importance of these factors with regard to employee and patient morale.

Harris (2000) reported that visitors spent significantly more time in patient rooms with

carpeting than in non-carpeted rooms. It is important to consider the environment's role

not only in the physical health, but also in the psychological and social needs of all of its

complex user groups (Carpman & Grant, 1993).

Thermal comfort is defined as that condition of mind which expresses satisfaction

with the thermal environment (ASHRAE, 1997). Harris (2000) found that although

flooring material does not directly affect surface or room temperature, patients perceive

the temperature in carpeted rooms to be more comfortable. While patients perceived

uncarpeted rooms to be cleaner and have fresher air, they preferred carpeting overall, due

in large part to the perception of thermal comfort (Harris, 2000).

Safety Factors

Hospital patients typically represent vulnerable user groups and are often impaired,

disabled, or elderly (Carpman & Grant, 1993). Falls are common among the elderly and

can be a concern for all users (Guelich, 1999). Willmott (1986) found that elderly

patients showed increased gait speed and step length when walking on carpet in

comparison with vinyl flooring. Furthermore, Willmott (1986) reported that patients

were more confident walking on carpeting and expressed fear of falling on resilient

flooring.

Carpet is a slip-resistant flooring material, while resilient and hard surface floorings

are not, particularly when polished, waxed, or wet (Harris, 2000; Weinhold 1988).

Spilled liquids are absorbed into carpet fibers, reducing the danger of slipping and falling

as a consequence of a spill (Radke, 1997).









Ergonomic provisions and risk of injury to employees are also important safety

considerations in healthcare settings. Studies have shown that tasks that involve pushing

and pulling place healthcare workers at higher risk for neck, shoulder, and lower back

pain (Hoozemans, van der Beek, Frings-Dresen, van der Woude, & van Dijk, 2002;

Smedley, Inskip, Trevelyan, Buckle, Cooper, & Coggon, 2003). Because carpeting has a

higher coefficient of friction than hard flooring surfaces, the force required to push, pull,

and turn rolling equipment is greater on carpeted floors (Das, Wimpee, & Das, 2002).

Slip-resistance, however, can be a factor in muscle use when pushing and pulling

(Lavender, Chen, Li, & Andersson, 1998). Large wheels and properly specified, low-

pile, dense carpet without padding can help to mitigate the increased effort required to

push and pull wheeled carts and equipment (Carpman & Grant, 1993; Weinhold, 1988).

Material Composition

Carpet is becoming an increasingly popular floor covering choice for healthcare

facilities (Radke, 1997). Considerations involved in specifying flooring materials for

healthcare facilities include health and safety factors (flame resistance, electrostatic

propensity, biogenic factors, and slip resistance), environmental factors (acoustics,

comfort, ambience, and wheeled vehicle mobility), and wear-life factors (durability,

appearance retention, maintenance, and costs) (Weinhold, 1988).

Generally, loop pile nylon fiber with a synthetic, non-permeable backing and low

pile height is recommended for high-traffic hospital settings such as corridors (Carpman

& Grant, 1993; Radke, 1997; Weinhold, 1988). The preferred dyeing method for areas

subject to occasional spills is solution dyeing, which takes place at the fiber stage and

typically offers excellent colorfastness and cleanability as well as some degree of stain-

resistance (Radke, 1997; Weinhold, 1988). Antimicrobial agents are considered helpful









in preventing the growth and spread of harmful and infectious microorganisms (Carpman

& Grant, 1993; Radke, 1997). Carpeting is not recommended for areas that experience

frequent and excessive spills, such as operating rooms, intensive care units, delivery

rooms, bathrooms, and laboratories (Anderson et al., 1982; Sehulster et al., 2003).

The Role of Cleaning

Hospital cleaning is an important aspect of infection control and can have a

significant impact on patient confidence (Ayliffe et al., 1999; Dancer, 1999). Cleaning

can be defined as the process of removing microorganisms and the organic matter that

supports them through the use of water and detergents as well as mechanical processes

(Ayliffe et al., 1999; Hota, 2004).

Zafar, Gaydos, Furlong, Nguyen, & Mennonna (1998, p. 591) state that cleaning is

"probably the most important method of eliminating environmental reservoir and thus

interrupts the spread from [surfaces] to patients." However, the quality of institutional

cleaning is varied and often goes unmeasured (Hota, 2004). Experts at the invitation-

only Global Consensus Conference on Infection Control Issues Related to Antimicrobial

Resistance (1999) identified "deteriorating housekeeping practices" in healthcare

facilities as an assumption that should be made when considering infection control

recommendations.

Studies have shown that cleaning can successfully reduce the presence of known

pathenogenic microorganisms on common environmental surfaces in hospitals (Dancer,

1999; Zafar et al., 1998). For instance, Zafar et al. (1998) reported a sustained decrease

in nosocomial Clostridium difficile, with cleaning included as a major part of an

aggressive infection control program.









Indoor air quality is also affected by cleaning and quality of maintenance. Franke,

Cole, Leese, Foarde, & Berry (1997) reported measurable improvements in indoor air

quality attributable to an improved cleaning program. The study found reduced airborne

dust mass, total volatile organic compounds, culturable bacteria and cultural fungi after

procedures were implemented including use of high-efficiency vacuum-cleaners and

entry mats. Franke et al. (1997) points out, however, that evaluation of cleaning

programs should include air quality measurements before, during, and after cleaning

processes because of pollution and resuspension of dust which can occur during the use

of cleaning products.

Chemical disinfectants have not been found to be preferable to cleaning with water

or detergents alone (Hota, 2004). Disinfectants eliminate microbes but can shorten the

life of some surfaces and can cause irritation (Ayliffe et al., 1999). Because of concern

that improper use of disinfectants can create antibiotic resistance, low-level cleaning

strategies are recommended and generally considered sufficient (Global Consensus

Conference, 1999; Penna, Mazzola, & Martins, 2001; Rutala, 1996; Sehulster, Chinn, &

HICPAC, 2003).

Maintenance is consistently mentioned as a crucial factor in the performance,

appearance, and safety of carpeting (Radke, 1997; Weinhold, 1988). Radke (1997)

suggests that if carpet is properly maintained, its ability to act as a "sink" can allow

harmful allergens, dust, and microorganisms to be trapped and removed by vacuuming.

Routine vacuuming with a filter bag can could reduce the presence of airborne particles

that would be redistributed from hard surface flooring into the air by mopping (Radke,

1997).









Cleaning Methods

In order to resist the growth of pathogenic microorganisms, flooring in patient-care

areas should be clean, dry, and well-ventilated (Ayliffe et al., 1999; Sehulster et al.,

2003). Hospitals should ensure this by keeping a routine cleaning schedule and

developing a maintenance plan based on careful consideration of manufacturer

recommendations (Radke, 1997). As a generally accepted practice, manufacturers derive

their recommendations from infection control guidelines and industry standards.

Five key elements should be components of a thorough maintenance program:

preventive maintenance, vacuuming, spot and spill removal, interim cleaning, and

restorative cleaning (Carpet and Rug Institute, 2004; Institute of Inspection Cleaning and

Restoration, 2002; Radke, 1997).

Preventive Maintenance

Preventive maintenance is intended to minimize the impact of soiling on carpet.

Walk-off mats placed at entrances and major interior traffic areas control the amount of

soil that enters carpeted areas (CRI, 2004; IICRC, 2002). Outside mats serve to scrape

dirt and debris off shoes before entering the building (CRI, 2004). Inside mats serve the

dual purpose of removing small soil particles and absorbing moisture from entrants'

shoes (CRI, 2004).

Vacuuming

For carpeting, the "Guidelines for Environmental Infection Control in Health-Care

Facilities," set forth by the Centers for Disease Control and Prevention (CDC),

recommends regular vacuuming with "well-maintained equipment designed to minimize

dust dispersion" (Sehulster et al., 2003, p. 135). The CRI (2004) recommends upright

vacuum sweepers with top loading soil bags and separate motors for suction and









brushing. Vacuums should be equipped with an enclosed high-efficiency particulate air

filter (HEPA) bag and adjustable brushes or beater bars to lift trapped particles to the

flooring surface (CRI, 2004; IICRC, 2002; Radke, 1997; Sehulster et al., 2003).

Effective daily vacuuming removes soil in addition to lifting and restoring carpet

pile (IICRC, 2002). Actual vacuum-cleaning frequency depends on the amount of foot

traffic the area receives, as shown in Table 2.1 (IICRC, 2002). Vacuuming should be

performed once or more daily with slow and methodical movements (CRI, 2004).

Table 2.1: Commercial carpet cleaning frequency chart
Traffic Soil Spot and Spill Interim Restorative
Rating Vacuuming Removal Cleaning Cleaning
Light Daily or when 1-3 times 1-2 times
1-3 times 1-2 times
<500 foot 1 2 times weekly spots are
traffics per day noticed
Medium Traffic areas: Daily Daily or when 6 times 2-4 times
500-1000 foot Overall: 3-4 times spots are yea ye
traffics per day weekly noticed
Heavy Traffic areas: Daily Daily or when 6-12 times 3-6 times
1000-2500 foot Overall: 4-7 times spots are y
traffics per day weekly noticed
Traffic areas: 1-2
Very Heay times daily Daily or when 12-52 times 6-24 times
>2500 foot spots are
traficsperday Overall: 7 times noticed yearly yearly
traffics per day noticed
weekly
(IICRC, 2002)

Spot and Spill Removal

Spills, especially involving blood or body fluids, require prompt spot-cleaning

(CRI, 2004; Radke, 1997; Sehulster et al., 2003). Radke (1997) cautions against

overwetting during treatment of a spill or stain and stresses that spills should be blotted

rather than rubbed. Blotting should always be performed from the outside to the center of

the spot in order to reduce further contamination or staining (CRI, 2004).









If water alone does not remove a spot, specific solutions can be applied to the

carpeting dependent upon the nature of the spill (CRI, 2004). CRI (2004) suggests

solutions that can be made by diluting mild detergent, ammonia, or vinegar in water or by

using a fast-evaporating dry cleaning fluid such as rubbing alcohol (CRI, 2004). Once

the proper solution is selected, it should be applied to a clean, white cloth and blotted

(CRI, 2004). Remaining residue from the spill or cleaning solution can be flushed out

using clean water. Finally, the carpet should be blotted dry (CRI, 2004; IICRC, 2002).

For carpet tile specifically, the CDC suggests replacement of any contaminated

individual tiles (Sehulster et al., 2003). Once a contaminated tile is pried up and removed

from the floor, it can be discarded or cleaned in a less obtrusive location for re-use at a

later time.

Interim Cleaning

Interim cleaning is performed primarily because it can prolong the duration

between restorative cleaning and does not require extended drying time (IICRC, 2002).

Usually referred to as dry extraction or soil suspension, the intention is to dislodge and

disperse accumulated soil to allow for removal by vacuuming (CRC, 2004; Radke, 1997).

Soil suspension uses a combination of chemical action, elevated temperature (heat),

agitation, and time (CRC, 2004; IICRC, 2002).

Chemical action, also called pre-conditioning, works by reducing surface tension

and dissolving certain soils (CRC, 2004; IICRC, 2002). Time is fundamental to this

process because chemicals often need prolonged contact time in order to adequately

dislodge and dissolve impacted soils (CRC, 2004; IICRC, 2002). The process can be

accelerated by agitation using a common brush or mechanical equipment to enhance and

accelerate chemical action on soils (CRC, 2004; IICRC, 2002). Dry foam and absorbent









compounds are two commonly used methods for low-moisture interim cleaning (IICRC,

2002). Vacuuming must be performed following these procedures in order to remove

dislodged soil particles and residue from chemical solutions (CRC, 2004; IICRC, 2002).

Restorative Cleaning

The CDC recommends periodic deep cleaning with minimal aerosols or residue

(Sehulster et al., 2003). Hot water extraction is another soil suspension method designed

to remove embedded soils not removed by regular vacuuming or dry extraction methods

(CRC, 2004; IICRC, 2002). It is generally considered the best method for deep or

restorative carpet cleaning (Radke, 1997).

The process involves applying a detergent pre-spray to the carpet and using a low

moisture applicator to agitate the pre-conditioner. In hot water extraction, warm water

(not exceeding 120F) is injected into the carpet, suspending contaminants in the solution

to allow for removal by a vacuum system (IICRC, 2002; Radke, 1997; Sehulster et al.,

2003). The elevated temperature of the water or solution employed in the cleaning

process can help to reduce surface tension, speeding up the process of soil suspension

(CRC, 2004; IICRC, 2002). Wet carpeting should be allowed to dry completely,

followed by a thorough vacuuming before use (CRC, 2004; IICRC, 2002). If carpet

remains wet for a period of time over 72 hours it should be replaced (Ayliffe et al., 1999;

Sehulster et al., 2003).

Summary

The quality of the indoor environment is of growing importance to hospitals and

the healthcare and design industries. A more holistic approach to the overall health of all

users within a healthcare setting includes careful attention to the physical environment,

including interior materials. The selection and maintenance of flooring materials and









carpet, in particular, can have a broad impact on the health, safety, comfort, and

confidence level of patients, visitors, and employees alike. In order to manufacture and

select carpeting that can properly support hospital occupants and activities, it is necessary

to consider the factors which impact it.

Similarly, a maintenance plan to properly care for carpeting must respond to actual

use and wear, in addition to incorporating preventive measures for infection control and

indoor air quality. Proper cleaning removes harmful contaminants and microorganisms

and maintains the appearance of carpeting. The necessary frequency and degree of

routine, interim, and restorative cleaning measures are dependent upon quantity and

patterns of foot traffic and wear factors such as equipment carts.














CHAPTER 3
RESEARCH METHODOLOGY

Research Design

The study design was a cross-sectional case study utilizing observation as a

research methodology. This cross-sectional study design was chosen for its effectiveness

in exploring a phenomenon or situation at a particular point in time. Kumar (2005) states

that cross-sectional studies can be "useful in obtaining an overall picture as it stands at

the time of the study." Non-participant observation provides an objective, first-hand look

at behavior in a natural setting, whereas a self-report method such as a questionnaire

relies on the subjects to be accurate and unbiased (Sommer & Sommer, 2002). In this

situation, where the aim was to explore what actually happens in comparison with

existing minimum standards, the observation method was a logical choice.

Methodological Background

Observation involves systematically watching and recording how people use their

environments (Kumar, 2005; Zeisel, 1990). Unobtrusive observation is ideal for studying

commonplace behavior in natural surroundings, generating useful data for design and

other professionals concerned with the relationships between people and their physical

settings (Sommer & Sommer, 2002; Zeisel, 1990).

Systematic, non-participant observation requires that the researcher not be involved

in any observed activities and involves a coding system with prearranged categories

(Kumar, 2005; Sommer & Sommer, 2002). Categories are limited to items and behavior

that occur naturally in the setting and can be observed and recorded (Sommer & Sommer,









2002). Use of more than one observer or method can improve the reliability of this

methodology (Sommer & Sommer, 2002).

Observing and recording behavior provides information about precisely how the

physical setting is used by its occupants, but explanations about behavior require further

research (Kumar, 2005; Sommer & Sommer, 2002).

Ethics

The research study was approved by the Institutional Review Board of the

University of Florida and listed as exempt (Appendix A). This research conforms to the

ethical principles and guidelines for the protection of human subjects as set forth in The

Belmont Report, written by The National Commission for the Protection of Human

Subjects of Biomedical and Behavioral Research (Dept. of Health, Education, and

Welfare, 1979). In addition, the researcher completed training in HIPAA for Researchers

at the University of Florida.

Research Hypotheses

Hypotheses tested are as follows:

1. Actual carpet cleaning procedures are concurrent with documented hospital
protocol.

2. Actual carpet cleaning procedures are concurrent with infection control guidelines
and industry standards.

3. Documented hospital protocol is concurrent with infection control guidelines and
industry standards.

Setting

The research setting was a hospital in-patient medical/surgical unit in a community

medical center. The study took place in a corridor with access to the nursing station,

patient rooms, utility closet, staff and public elevators, as well as a nursing "POD" in









which healthcare providers document patient charts electronically (Figure 3.1). In

addition, the corridor accessed a lounge and restroom area generally reserved for visitor

use but temporarily serving as a staff-only break area during renovation of the permanent

break room.







m Study Corridor
Observer Location














Figure 3.1: Study setting

The carpeting in the setting for this study is comprised of a primary fill and

secondary border carpet tile, each tile measuring 19.69 inches square. The construction

of both types consists of nylon fiber with a protective, stain-resistant coating and a non-

permeable backing, incorporated with an anti-microbial agent. The primary carpet tile is

a tufted textured loop, using 71% solution dye and 29% yam dye. Two notable

measurements that effect carpet performance are pile yarn weight and pile density. Pile

yarn weight is a measurement of the amount of yarn in a given area of carpet face

(Weinhold, 1988). Pile density is the weight of pile yarn in a unit volume of carpet and









calculated based on pile yam weight and pile height (Weinhold, 1988). Higher tuft

density generally yields better performance (Weinhold, 1988). The tufted yarn weight for

the primary carpet tile is 23 oz. per square yard and pile density is 7,886 oz. per cubic

yard. The secondary carpet tile is tufted tip-sheared and the dye method is 100% solution

dye. The tufted yarn weight for the secondary carpet tile is 24 oz. per square yard with a

pile density of 6,545 oz. per cubic yard.

Observation Procedures

Observation was limited to the documentation of factors impacting carpeting in the

corridor. Two observers utilized observation forms to record foot traffic, equipment

carts, and housekeeping activities (Appendix B).

The documentation was anonymous, unidentified data with no information about

schedules or names of employees, patients, or visitors. Observations were made in two-

hour increments between the hours of 7:00am and 11:00pm, during which the vast

majority of hospital activity occurs. Four observations of each 2-hour increment were

randomized over a six-day period, using Research Randomizer (Social Psychology

Network, 2005).

The number and locations of empty patient rooms were documented at each

observation period using a diagram of the patient wing. Researchers used a field study

observation form to record foot traffic and rolling cart incidences. A separate form was

used to detail cleaning procedures and note chemicals and equipment used. The form

included a diagram on which the specific locations of each cleaning activity, along with

unplanned contamination incidents such as spills or debris, were described and

documented. All observation forms utilized can be found in Appendix B.









One foot traffic count was considered to be any movement by a person within the

defined corridor until the person reversed direction. A new instance was recorded once

the person retraced his or her footstep(s). For each instance, the locations from and to

which the user traveled were documented using a system of codes for each access point

on the corridor.

Users were identified based on employee badge, or lack thereof, along with

uniform, hospital gown, or other forms of dress. Any staff member coming in contact

with patients was considered healthcare staff. Environmental services personnel were

identifiable by distinct uniform and were considered housekeeping staff. Construction

personnel, contractors (e.g., plumbers), and facilities staff not involved in housekeeping

were identified as maintenance staff. The classification of visitor was reserved for

family, friends, or clergy there solely to visit patients or the facility as non-employees.

Volunteers and employees of the hospital who did not fall into the previously mentioned

categories, or who were not identifiable as such, were classified as staff.

Equipment carts, transport vehicles, supply carts, treatment carts, and so on were

documented in conjunction with the foot traffic count of the person pushing or pulling the

cart. Specific codes as well as more detailed notes were recorded on the observation

form, and researchers attempted to photograph each type of equipment or cart. Any

additional contact with the corridor flooring was noted, such as bags or equipment being

dragged across the carpet surface.

Analysis

This study identified factors contributing to the contamination and wear of carpet

tile in an acute care patient wing corridor (Figure 3.2). Human impact on carpeting and

response to said impact are reported in terms of type and frequency as well as patterns.











Factors I t|| ---- Semtting
Foot ;il, ,C .,. ,,
Equipment
Type & frequency
Foot traffic counts Response
Equipment cart i.e. Maintenance
counts
Spill incidents
Patterns Type & frequency
Paths Cleaning activity
Human-equipment Chemicals
interaction Equipment
Pushing/pulling Location
Stopping/starting Patterns
Schedule
Consistency
Lag time (spills)


Figure 3.2: Factors contributing to the condition of flooring finish material

Type and frequency of impact were measured by foot traffic and equipment cart

counts as well as contamination incidents. Data was examined for differences between

days of the week and times of the day to provide further information about traffic

frequencies. Patterns of impact were measured by path taken and by human-equipment

interaction. Type and frequency of response to impact on carpeting were measured by

observations of cleaning activities, chemicals and cleaning equipment used, and location

of activity. Response patterns were measured by schedule, consistency, and lag time

between contamination incidences and subsequent treatment. Differences were identified

between 1) actual carpet cleaning procedures; 2) documented hospital protocol; and 3)

infection control guidelines and industry standards.

In order to analyze the effect of day of the week and time of the day on human foot

traffic and equipment counts, a two-way Analysis of Variance (ANOVA) was performed

using an additive model at level alpha=0.05. The independent variables in both cases

were time blocks (time) and days of a week (day). The response variables were (Y)= foot









traffic count and (Y)= equipment cart count. Since the response variables were count

data, a square root transformation was required in order to ensure a normal distribution

for the data. Thus the actual response variables were /(foot traffic count) and

\(equipment). Bonferroni's multiple comparison test was used to identify specific

differences between means for each time block. Foot traffic data was re-tested due to an

unusually high traffic count during a time block in which an emergency code occurred on

the unit. The same tests were performed removing that particular time block from the

data set. Pearson correlation was used to test for a relationship between foot traffic and

equipment cart counts, again utilizing a square root transformation to ensure normal

distribution for count data. Output from statistical analyses can be found in Appendix C.

All other statistical data reported is entirely descriptive in order to assist in interpretation.















CHAPTER 4
FINDINGS

The intent of this study was to examine factors specifically impacting carpeting in a

defined portion of a hospital corridor. Foot traffic, equipment carts, and carpet cleaning

procedures were observed and analyzed. The type, frequency, and patterns of impact on

the corridor carpeting are reported here.

Foot Traffic

Type and Frequency

Based on mean traffic counts for each time block, average daily foot traffic

between the hours of 7:00am and 11:00pm (16 hours) was approximately 2,900. Table

4.1 shows total traffic counts for each time block observed (n=31). Blank cells indicate

an increment of time that was not observed, as determined by a randomization of the 31

time blocks to be studied.

Table 4.1: Total traffic counts observed, by day and time block
1: 2: 3: 4: 5: 6: 7: 8:
7-9am 9-1lam 11-lpm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm
1 Sun 256 218 272 187
2Mon 559 354 383 399 307 383
3 Tues 440 518 320 410 298 236
4 Wed 348 409 351 430 370
5 Thurs 720 353 499 354 318
6 Fri 347 384 325 223 288

Testing for effect of day and time together on traffic counts, there was strong

evidence that the means for the 31 time blocks were significantly different (F=4.08,

p<0.05). Further, day of the week alone did not have a significant effect on number of









foot traffic incidents. Time of day, however, did significantly impact traffic counts

(F=3.17, p<0.05). Bonferroni's multiple comparison test showed a significant difference

between the means of the first (7-9am) and eighth (9-1 1pm) time blocks (p<0.05). The

data was tested again to see if a patient coding during one of the 7-9am time blocks

influenced the results. Testing for effect of time of day on foot traffic counts without

data from the aforementioned time block revealed a significant difference between mean

foot traffic counts (F=3.87, p<0.05). Bonferroni's multiple comparison test did not

reveal a significant difference at alpha level 0.05 between any 2 particular time blocks.

Hospital census data tracks the number of patients in beds on the unit, which

fluctuates throughout the day. In this case, the number of empty beds was considered a

co-variate in testing for possible effect on foot traffic. The number of empty beds on the

unit, taken from official hospital census data, had a significant effect on foot traffic in the

study corridor (F=8.37, p<0.05).

Users fell into one of eight user groups: 1) healthcare staff, 2) housekeeping staff,

3) maintenance staff, 4) food service staff, 5) other staff, 6) visitors, 7) patients, or 8)

dogs (present as part of the hospital's Animal-Assisted Therapy program). The categories

of specific users are shown in Figure 4.1, expressed as percentages of total foot traffic

observed (n=l 1,249).

* Healthcare staff represented close to 80% of all foot traffic in the defined corridor
area (Figure 4.1).

* Visitors were the second highest represented user group, making up 8% of all foot
traffic observed.

* Housekeeping staff comprised 6.4% of all foot traffic observed.

* The remaining user groups (maintenance staff, food service staff, other staff,
patients, and dogs) each made up less than 3% of all foot traffic observed.












Healthcare Staff,
78.9%


Dogs, 0.2%
Patients, 1.0%
Visitors, 8.0%


Housekeeping, 6.4%

Maintenance, 2.3%
Food Service, 2.7%

Staff (other), 0.6%


Figure 4.1: Types of users, as percentages of total foot traffic observed


Figure 4.2 shows average foot traffic counts for each time block both with and


without data from the time block during which an emergency code occurred. Both


timelines show a slightly decreasing trend.


600
517
500438
438
400 366 378 355
400
300- 305 294 257

200

100

0
0 -----------------------------
7-9am 9-11am 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm

600

500 449 438
400 366 378 355
400

300- 294 257

200

100

0 -
7-9am 9-11am 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm

Figure 4.2: Average foot traffic timeline, by time block. Part A shows a regression line all
time blocks observed; part B shows means taken without data from the time
block during which an emergency code occurred

Figure 4.3 shows foot traffic timelines for each user group, based on the mean


traffic counts observed for each time block. Healthcare staff averages remained more













consistent than those of the other user group categories. Visitor traffic peaked during the


1-3pm and 5-7pm time blocks. Patient and food service traffic both varied considerably


throughout the day. Maintenance staff and housekeeping staff traffic both dropped


drastically after the 1-3pm and 3-5pm time blocks, respectively.


Healthcare Staff Visitors


7-9am 9-11am 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm A

Patients











7-9am 9-11am 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm C

Maintenance Staff


50
40
30
20
10
0
7-9amn 9-11am 11-1pmr 1-3pmr 3-5pmr 5-7pmr 7-9pm 9-11pm B

Housekeeping Staff
50
45
40
35
30
25
20
15
10
5 -
0 --
7-9am 9-11am 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm D

Food Service Staff


25 25

20 20

15 /\ 15

10 10

5 5

0 0
7-9am 9-11am 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm E 7-9am 9-11am 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm F

Figure 4.3: Average foot traffic timelines for each user group. A) healthcare staff, B)
visitors, C) patients, D) housekeeping staff, E) maintenance staff, and F) food
service staff


Patterns


Traffic patterns were observed and recorded in the form of actual paths walked by


the various user groups on the study corridor. Fourteen unique locations were identified


in the defined corridor area as entry/destination points (Figure 4.4). An additional


W









category was assigned for any location not specifically defined within the corridor,

yielding over 100 possible paths.


Figure 4.4: Entry/destination locations in the defined corridor area

Of the over 100 possible paths through the corridor area, the 6 most frequently

taken are shown in Figure 4.5, expressed as the percentage of total foot traffic observed

(n=l 1,249) who took one of the 6 particular paths.

* Approximately 1 out of every 6 people who traveled through the study corridor
walked from point A to point B or from point B to point A. Nearly as many
traveled between points A and C.

* The path between point C and the breakroom space was taken by 6.6% of all foot
traffic observed.

* The path between point A and the nursing station entrance received 4.4% of all foot
traffic observed.

* Paths between the nursing POD and point A and between the nursing POD and
point B each received close to 4% of all foot traffic observed.










* The remainder of foot traffic followed various other paths through the corridor,
each path receiving less than 3% of all traffic observed.





404 a & b:16.4%
S a & c: 13.0%
I 403 c & breakroom: 6.6%
Sa & nursing station: 4.4%
402 a & nursing POD: 3.8%
b & nursing POD: 3.6%














Thirty-two percent of all traffic observed during the study can be considered


through-traffic, passing through the corridor without coming from or going to a room or

space located on the corridor in the defined area for the research study. Locations on the

corridor accounted for the remainder of foot traffic incidences. While Figure 4.5 showed
particular paths taken within the corridor, Figure 4.6 highlights destination/entry points
elevatorstexit









Figuon the 4.5study corridor and shows taken foot traffic paths, as percentages of total foot traffic observed that traveled
to or from theserved locations.

SAlmost half percentt of all foot traffic instances observed during the study can be considerednt A.
through-traffic, passing through the corridor without coming from or going to a room or

space located on the corridor in the defined area for the research study. Locations on the

corridor accounted for the remainder of foot traffic incidences. While Figure 4.5 showed

particular paths taken within the corridor, Figure 4.6 highlights destination/entry points

on the study corridor and shows the percentages of total foot traffic observed that traveled

to or from these locations.

* Almost half (47%) of all foot traffic instances observed passed through point A.

* Points B and C were each involved in nearly 30% of all foot traffic.

* Approximately 1 out of every 4 people traveling through the study corridor walked
from or to the nursing station or the area just outside of it.

* Close to 1 in 5 people traveled from or to the nursing POD.










* 17% of all foot traffic observed visited the 4 patient rooms directly adjacent to the
defined study corridor area.

* The room serving as staff breakroom accounted for just over 10% of all foot traffic
observed.

* The utility closet and the handwashing sink accounted for 6% and 3% of foot
traffic, respectively.


18%


Through Nursing Nursing
Traffic Station POD


17%


Patient
Rooms


Breakroom Utility Handwash
Closet Sink


Figure 4.6: Locations on study corridor commonly receiving foot traffic, as percentages
of total foot traffic observed

Figure 4.7 details destination/entry locations frequented by specific user group

categories.

* Thirty percent of healthcare staff traffic was through-traffic. The remaining two-
thirds of healthcare staff mainly frequented the areas in and around the nursing
station, the nursing POD, and patient rooms. The room serving as a temporary staff
breakroom received 12% of healthcare staff traffic.

* Visitors, of whom nearly 60% were through-traffic, also frequented patient rooms
and the nursing station area.

* The utility closet and handwashing sink areas received no traffic from visitors or
patients.

* Patients primarily passed through the defined study corridor area as through-traffic.


35% -<


30%-

25%-

20%-

15%-

10%-










* Fourteen percent of housekeeping staff traffic was through-traffic. Half of the
traffic from housekeeping staff was concentrated around the utility closet area and
almost 20% was in and around patient rooms.

* Forty-two percent of maintenance workers were through-traffic. The remaining
third of maintenance staff traffic was relatively evenly divided among locations on
the corridor, the breakroom receiving slightly more traffic from maintenance staff
than other locations.

* One quarter of food service staff traffic was through-traffic, while over half
traveled to and from patient rooms.

* Dogs visiting as part of the hospital's Animal-Assisted Therapy program traveled
largely to and from patient rooms. Approximately one third of dog traffic was
through-traffic. Dogs also visited the nursing station area, but none were observed
traveling to or from any other location in the study corridor area.


Healthcare Staff


Visitors


Through Nursing Nursing Patient Breakroom Utility Handwash
Traffic Station POD Rooms Closet Sink A

Patients


Through Nursing Nursing Patient Breakroorn Utility -bndwash


Through Nursing Nursing P ti n Breakroorn UtIIity -andwash


Traffic Station POD Rooms Closet Sink C Traffic Station POD Rooms Closet Sink D

Figure 4.7: By user group category, locations on study corridor commonly receiving foot
traffic, as percentages of total foot traffic observed. A) healthcare staff, B)
visitors, C) patients, D) housekeeping staff, E) maintenance staff, F) food
service staff, G) staff (other), and H) dogs











Food Service Staff


Through Nursing Nursing Patient Breakroom Utility Handwash
Traffic Station POD Rooms Closet Sink

Figure 4.7. Continued.


Through Nursing Nursing Patient Breakroon Utility -indwash
Traffic Station POD Rooms Closet Sink


Equipment Carts

Type and Frequency

Based on mean equipment counts for each time block, the average daily equipment


cart/item count between the hours of 7:00am and 11:00pm was approximately 240. Table


4.2 shows total equipment cart counts for each time block observed (n=31). Blank cells


indicate an increment of time that was not observed, as determined by a randomization of


31 time blocks to be studied.


Maintenance Staff









Table 4.2: Total equipment cart counts observed, by day and time block
1: 2: 3: 4: 5: 6: 7: 8:
7-9am 9-1lam 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm
1 Sun 31 18 23 15
2Mon 36 21 36 38 32 24
3 Tues 41 33 22 39 18 14
4 Wed 34 39 37 54 21
5 Thurs 24 40 45 19 24
6Fri 18 44 31 23 36

There was no significant difference between mean equipment counts for the 31

time blocks. Further, day of the week alone did not have a significant effect on number

of foot traffic incidents. Time of day alone also did not significantly impact traffic

counts.

A wide range of types of equipment carts were observed. Figure 4.9 shows types

of equipment carts, expressed as percentages of total carts/items observed (n=928).

Supply/utility carts, treatment carts, non-wheeled items, and the "other" category all

include multiple varieties of carts or items, grouped together for ease of identification and

description. Non-wheeled items observed included plastic and linen bags, chairs, and

oxygen tanks. The "other" category consisted of equipment that contributed to less than

1% of all foot traffic observed and included patient tray tables, rolling bags/purses, trash

cans, rolling walkers, patient beds, scales, and computer carts. The most commonly

observed equipment included IV poles, supply/utility carts, housekeeping carts, gurneys

(with and without patients), and food service carts. Photographs of commonly observed

equipment carts can be found in Appendix D.












IV Pole, 13.9%


Supply/Utility, 12.9%


Vacuum, 1.4%
Wheeled Task Chair,
2%
Flatbed Maint. Cart, 3%

Other, 3.3% 1

Wheelchair
(w/ patient), 3.4%
Non-wheeled Items
(dragging), 3.7%
Treatment Cart, 3.8%

Trash Bin, 4.5%

X-ray, 4.6%

Wheelchair
(w/o patient), 4.7%


Housekeeping Cart,
12%





Gurney (w/o patient),
8.1%



Food Service/Meal Cart,
8.1%
Gurney (w/ patient),
6.6%
Small Linens Cart,
4.8%


Figure 4.8: Types of equipment carts, as percentages of total carts/items observed

In the case of equipment carts/items, the number of empty beds on the unit did not

significantly affect the number of equipment carts traveling through the defined area of

the study corridor.

However, testing did show a significant correlation between foot traffic counts and

equipment cart counts, both with (r=0.49, p<0.05) and without (r=0.65, p<0.05) data

from the time block during which the emergency code occurred. Figure 4.9 shows

regression lines for the data including all time blocks (n=31) and for the data with the

time block including the emergency code removed (n=30). A stronger correlation exists

between between foot traffic and equipment cart counts when the time block during

which the emergency code occurred is removed from the data set.













all data (n=31)

2750-
0

2500-
0
S2250- O o



0
S20 000-


0 1750- O_ A 0
o
15 00- 0 0 0
0
o0o
1250-

400 500 600 700
equipment carts (sq rt)
A



without emergency code time block (n=30)

2400-
O
O
2200- 0

S20 00- _
oP oo o
2o o oooo o
S18 00-4 O O
0
0
0 16 00- 0
o
12
0 0
1400- 0


1200-

400 500 600 7 00
equipment carts (sq rt) B

Figure 4.9: Correlation between foot traffic and equipment cart counts. Part A shows a

regression line for all time blocks observed (n=31); part B shows a regression
line for all time blocks except the time block during which an emergency code

occurred (n=30)


Patterns


Observations of actual paths taken by equipment carts and items on the study


corridor were documented.


Of the more than 100 possible paths, the 5 most frequently taken paths through the


corridor are shown in Figure 4.10, expressed as percentage of total equipment carts


observed (n=928).































Figure 4.10: Most frequently taken paths by equipment, as percentages of total equipment
carts/items observed

* Approximately 1 in 3 equipment carts moving through the study corridor traveled
from point A to point C or from point C to point A.

* Fifteen percent of all equipment carts observed traveled between points A and B.

* The path between points B and C was taken by just over 6% of all equipment
carts/items observed.

* The path between point C and the utility closet received approximately 5% of all
equipment carts/items observed.

* The path between point C and the outside of the nursing station received close to
4% of all equipment carts/items observed.

* The remainder of equipment cart traffic followed various other paths through the
corridor, each path receiving less than 3% of all traffic observed.

Fifty percent of all equipment carts/items observed during the study were through-

traffic, passing through the corridor without coming from or going to a room or space

located on the corridor. Locations on the corridor accounted for the remaining half of

equipment observed. Figure 4.11 highlights destination/entry points on the study corridor


- a & c: 28.9%
a & b: 15.0%
- b&c: 6.1%
c & utility closet: 5.2%
Sc & outside of nursing
station: 3.7%









and shows the percentages of total equipment cart traffic observed traveling to or from

these locations.

* Approximately 1 out of every 4 equipment carts moving through the study corridor
traveled to or from a patient room.

* 12% of all carts observed traveled from or to the utility closet.

* 10% of all carts observed visited the area in and around the nursing station.

* The nursing POD, breakroom, and handwashing sink each accounted for less than
2% of all equipment carts/items observed.


Figure 4.11: Locations on study corridor commonly receiving equipment cart traffic, as
percentages of total equipment carts/items observed

Figure 4.12 details the destination/entry points frequented by specific equipment

carts/items.

* Three out of every 4 IV poles were through-traffic. Of the remainder, most
traveled to or from patient rooms.

* Over half of all supply/utility carts observed were through traffic, one fourth
traveling to or from the nursing station area.

* One quarter of all housekeeping cart traffic was through-traffic. The remaining
75% was concentrated mainly around the utility closet and patient room areas, with
some activity in and around the nursing station.


Through Patient Utility Nursing Nursing Breakroom Handwash
Traffic Rooms Closet Station POD Sink










* Half of the linen carts observed were through-traffic, and much of the remainder
moved to or from patient rooms.

* Only 1 of every 10 food service carts was through-traffic, while half traveled to and
from patient rooms.

* Close to two-thirds of all treatment carts observed were through-traffic, with
patient rooms receiving most of the remainder of treatment cart activity.

* Gurneys, both with and without patients, showed similar trends with regard to
destination/entry points.

* All observed wheelchairs with patients were through-traffic.

* Of wheelchairs without patients, only half were through-traffic. The nursing
station, nursing POD, and patient room areas received the remaining traffic.

* Trash bins traveled almost exclusively to and from the utility closet. Just 6%
passed through the corridor area as through-traffic.


IV Poles


Supply/Utility Carts


Housekeeping Carts Linen Carts


Through Nursing Nursing Paient Breakroom Utility Handwash Through Nursing Nursing Patient Breakroom Utility Handwash
Traffic Station POD Rooms Closet Sink C Traffic Station POD Rooms Closet Sink D

Figure 4.12: By category of equipment, locations on study corridor commonly receiving
equipment cart/item traffic, as percentages of total carts/items observed. A)
IV poles, B) supply/utility Carts, C) housekeeping carts, D) linen carts, E)
food service carts, F) treatment carts, G) gurney (with patient), H) gurney
(without patient), I) wheelchair (with patient), J) wheelchair (without patient),
and K) trash bins
















Food Service Carts


10% 11%

lOoBllo


2%
0% 0%o


Through Nursing Nursing Patient Brearoom Utility Handwash
Trdfic Staton POD Rooms Closet Sink


100% Wheelchairs (with patient) Wheelchairs (without patient)


100%
90%

80%
70%

60%
50%

40%
30%

20%
10% ,,0, 0% 0%
0%
Through Nursing Nursing Padent Breakroom Utility Handwash
Traffic Station POD Rooms Closet Sink


Closet Sink


Trash Bins


ioj 6%
10 0% 0% 0% 0% 0%
0
Through Nursing Nursing Patient Brealooom Utility Handwash
Traffic Station POD Rooms Closet Sink


Figure 4.12. Continued.


Treatment Carts


Traffic Station POD Rooms











Figure 4.13 illustrates the human-equipment interaction patterns of pushing,


pulling, or a combination of both. The vast majority of equipment carts observed was


largely pushed. Trash bins were an exception, with 9 out 10 being pulled, not pushed.


Wheelchairs with or without patients and linen carts were pushed exclusively. Users


combined pushing and pulling gurneys with patients and housekeeping carts 8% and 5%


of the time, respectively.


0 20 40 60 80 100 120 140
Number Observed

Figure 4.13: Human-equipment interaction patterns observed for each equipment
category

Carpet Cleaning Procedures

Type and Frequency

The only carpet cleaning activity observed not directly in response to a


contamination incident was vacuuming. Vacuuming of the defined corridor area was


observed 3 times during the observation periods (n=31). Table 4.3 shows the occurrences


of vacuuming observed. Blank cells indicate an increment of time that was not observed,


as determined by a randomization of 31 time blocks to be studied.


IV Pole
Gurney (with patient)
Gurney (without patient)
Linens Cart
Housekeeping
Food Service
Treatment
Wheelchair (with patient)
Wheelchair (without patient)
Supply/Utility
Trash Bin
Vacuum
Flatbed Maintentance
Wheeled Task Chair
Other


* Pushed
o Pulled
o Combination


Wheeed ask hai Plle









Table 4.3: Number of times vacuuming was observed, by day and time block
1: 2: 3: 4: 5: 6: 7: 8:
7-9am 9-1lam 11-1pm 1-3pm 3-5pm 5-7pm 7-9pm 9-11pm
1Sun 0 0 0 0
2Mon 1 0 0 0 0 0
3 Tues 0 0 0 0 0 0
4 Wed 0 1 0 0 0
5 Thurs 0 0 0 1 0
6 Fri 0 0 0 0 0

In each case, the vacuuming performed is considered overall vacuuming, not

confined to a particular location within the corridor area. Vacuuming movements were

not necessarily performed in a consistent, methodical pattern, with some portions of the

carpeting receiving more thorough cleaning than others. However, vacuuming did cover

the entire area of the defined corridor.

The vacuum equipment used was an upright vacuum with a top loading soil bag

and a separate motor for brushing. Details about the specific vacuum equipment used can

be found in Appendix E. No chemicals were used in the cleaning process.

Patterns

Vacuuming did not occur at a consistent time. Vacuuming was observed on three

separate days at approximately 8:30am, 9:20am, and 3:00pm, respectively.

Contamination Incidents

Three contamination incidents were observed during the study. Table 4.4 details

each incident and response by hospital staff. Material Safety Data Sheets (MSDS) for the

specific chemicals used can be found in Appendix F.










Table 4.4: Contamination incidents and responses
Type of Time of Response Chemicals Procedure
Contamination Incident Time Used Followed
Coffee spill 7:10am Immediate QuickSpot Blotted spill dry with cloth, sprayed
(<1% area with QuickSpot, let stand for
hydrogen approx. 15 minutes, blotted.
peroxide) Followed up 2 hours later with
vacuum
Swept dust from 10:00am Immediate None Swept carpet with small brush and
patient room into dustpan
corridor
Dust from 2:00pm Approx. 18 None Used masking tape to remove dust
construction work hours from carpet surface (performed by
maintenance staff)


Comparison of Cleaning Procedures

Table 4.5 presents findings regarding 1) infection control guidelines and industry

standard cleaning methods, 2) documented hospital protocol, and 3) actual carpet

cleaning procedures. Documentation regarding hospital protocol can be found in

Appendices E-I. Refer to Chapter 2, p. 13-16 for information regarding infection control

guidelines and industry standards.

Table 4.5: Comparison of recommended and observed carpet cleaning procedures
Infection Control Hospital Actual Carpet Cleaning
Recommendations/ Protocol Procedures
Industry Standards
Preventive Walk-off mats at entrances Walk-off mats at entrances. Walk-off mats observed at
Maintenance and major interior traffic Contracted service for entrance to hospital.
areas, entrance mats. No walk-off mats observed
No written documentation at elevator entrance to unit
available. or elsewhere on corridor.
Vacuuming Traffic areas: 1-2 times Daily in the elevator area, Observed on 3 occasions.
daily. in the hall and behind Regular schedule not
Overall: 7 times weekly. doors, observed.
Upright vacuum sweeper Daily final overall vacuum.
with top loading soil bags Included as part of the daily
and separate motors for cleaning schedule
suction and brushing. (Appendix I).
Upright vacuum sweeper
with top loading soil bags
and separate motors for
suction and brushing.











Table 4.5. Continued.


Spot & Spill
Removal


* Daily or when spots are
noticed.
* Blot or scrape spills off of
carpet.
* If water alone does not
remove spot, solutions can
be made by diluting mild
detergent, ammonia, or
vinegar in water (dependent
on spill type).
* Dry cleaning solvent can be
used (apply standard
rubbing alcohol to clean
cloth and blot).
* Flush out spotting solutions
with clean water after spot
has been treated.


* 3 contamination incidents
observed.
* Response times ranged
from immediate to 18
hours.
* Proper application of
cleaning solution.


Interim 12-52 times yearly. As needed between deep None observed.
Cleaning Dry extraction or dry foam cleaning.
method (use low moisture Host dry extraction carpet
applicator to brush dry cleaning system.
extraction compound into Label instructions are to
carpet fibers). apply dry powder to
carpeting, brush through
fibers with Dry-Clean
Machine, vacuum.
No written documentation
available.
Restorative 6-24 times yearly. Twice Yearly (spring and None observed.
Cleaning Hot water extraction, fall). Must make arrangements
Detergent pre-spray Hot water extraction, with individual units rather
agitated with low moisture Twice yearly in carpeted than follow an established
applicator, corridors, generally in written timetable.
Warm water (not exceeding spring and fall seasons.
1200F). Hospital Environmental
Allow to dry thoroughly Services Policy Number 27
and vacuum before use. (Appendix H).
Carpet Tile As needed. No written documentation None observed.
Replacement Replace severely damaged available. Environmental Services
or stained tiles with shelf intends to replace damaged
stock. or spilled-on tiles
immediately, clean back-
of-house, and re-use
cleaned tiles if possible.


* Once weekly or bi-weekly
checks for spots and spills,
dependent on staffing.
* Carpet spot-remover listed
with chemicals to be kept
on housekeeping carts:
QuickSpot, containing less
than 1% hydrogen peroxide
(refer to Hospital
Environmental Services
Policy Number 11,
Appendix G).
* Label instructions are to
spray carpet until wet,
allow to sit 5-10 minutes,
scrub or blot soil away,
vacuum when dry.
* No other written
documentation available.






46


This research tested the following hypotheses:

1. Actual carpet cleaning procedures are concurrent with documented hospital
protocol.

2. Actual carpet cleaning procedures are concurrent with infection control guidelines
and industry standards.

3. Documented hospital protocol is concurrent with infection control guidelines and
industry standards.

Evidence from observation data did not unequivocally support or reject the stated

hypotheses. Observation and documentation of vacuuming procedures for the most part

support all 3 hypotheses, but information about other types of carpet cleaning procedures

does not directly prove or disprove the hypotheses.














CHAPTER 5
DISCUSSION

The well-being of hospital patients, visitors, and staff may be influenced by the

quality of the environment within the hospital building, including interior materials.

Discussions and recommendations regarding proper selection and maintenance of

flooring materials-and carpeting in particular-commonly mention traffic and wear

factors. These issues are assumed to exist and to have some degree of impact on

carpeting, but little has been studied about the actual type, frequency, and patterns of

traffic, wear and the role of maintenance on carpeting.

The purpose of this research was to identify particular wear factors impacting

carpeting in an acute care patient corridor. Further, patterns of wear as well as regular

and incidental maintenance were explored. This study specifically sought to answer the

questions: 1) what specific users and equipment contribute to traffic flow in a patient

corridor; and 2) what are the consistency, frequency, and methods of regular cleaning of

carpet tile in an acute care patient corridor?

Foot Traffic

Each foot traffic incidence or count does not necessarily mean a different person;

once a person changed direction or retraced steps, a new incidence was counted.

Therefore, foot traffic numbers should be considered as paths or incidences rather than

individuals.









Type and Frequency

Observations showed that the average traffic count was approximately 2,900 during

the peak hours of 7:00am to 11:00pm. Thus, daily traffic counts for a 24-hour period

number well above this average for peak hours. In other words, over 2,900 paths are

walked daily across the defined area studied within this carpeted hospital corridor. This

greatly exceeds the minimum number of daily foot traffics for the "very heavy" traffic

soil rating in the IICRC's Commercial Carpet Cleaning Frequency Chart of 2,500 traffic

incidences or more (refer to Table 2.1, p. 15). This chart is typically the basis for carpet

manufacturer recommendations. It suggests, based on numeric foot traffic counts,

specific minimum frequencies for various levels of crucial carpet cleaning practices. The

average daily foot traffic count from this study establishes definitively that the traffic soil

rating for this corridor is "very heavy."

Statistical testing showed that day of the week had no significant effect on traffic

counts. Mean traffic counts were virtually the same whether observed on a weekend or

weekday and whether it was early or late in the week.

Foot traffic counts did significantly differ depending on the time of day,

specifically between the first time block (7-9am) and the last time block (9-11pm). This

could potentially be explained by a particularly high traffic count during one of the 7-9am

time blocks due to a patient coding on the unit. The code brought an influx of healthcare

staff through the study corridor in response to the emergency.

However, quantities of foot traffic differed throughout the day regardless of

extenuating circumstances. When the time block during which a patient coded was

removed from the data set, testing still showed a significant difference between mean

traffic counts depending on time of day. The 7-9am time block sees a change in shift for









nursing and other healthcare staff as well as the beginning of the workday for

housekeeping staff. Meals were served typically during the 7-9am, 1 lam-lpm, and 5-

7pm time blocks, signaling a rise in food service staff traffic. Visitor traffic mainly

occurred between the hours of 1pm and 7pm. The 9-11pm interval occurs after the

evening shift change for healthcare staff and the typical workday for most other hospital

staff members. Additionally, normal meals were not typically served after this time and

visitor traffic generally decreased as well, so most foot traffic dropped off noticeably

before the beginning of this time block. Thus, many factors contributed to the variation

in mean traffic counts between time blocks.

The vast majority of foot traffic through the study corridor was healthcare staff.

Four out of five instances of foot traffic occurring on this particular corridor involved

healthcare staff. Aside from rare occurrences of foot traffic by dogs and unidentifiable or

miscellaneous staff members, patients represented the lowest number of foot traffic

instances at just 1% of all traffic. While visitors contributed to 8% of the traffic in this

corridor, employees of the hospital still comprised over 90% of all foot traffic observed.

Although hospitals exist to provide for patients, this research shows that this particular

location within the hospital (a patient unit corridor) primarily serves and supports the

activities of the healthcare professionals charged with patient care.

Since most of the traffic through the study corridor was attributable to staff

involved with patient care, it follows that fewer patients on the unit may lead to lower

foot traffic counts. Thus, hospital census information could act as a predictor of foot

traffic levels for the fabrication and selection of flooring materials or the development of

a maintenance plan.









Patterns

Twelve patient rooms on the unit lie beyond the portion of the corridor under

observation and are only accessible by passing through the corridor at point A. Thus, it is

not surprising that nearly half of all foot traffic observed passed through that point. In

fact, close to 33% of foot traffic observed was entirely through-traffic, passing through

the corridor without coming from or going to a room or space located on the corridor in

the defined area for the research study.

It is also unsurprising that approximately 1 out of 5 foot traffic incidences involved

patient rooms and 1 out of 4 involved the nursing station area, given the prevalence on

the unit of healthcare staff connected with patient care. More notable, however, are

proportions of overall traffic as well as specific healthcare staff traffic frequenting the

nursing POD. Even though the nursing station is considerably larger and accommodates

more staff and a greater variety of activities, the small nursing POD received close to the

same proportion of foot traffic. The nursing POD has 21 square feet (SF) and room

enough for only one task chair, yet 1 in 5 healthcare staff members traveling through the

corridor walked to or from the POD. Observers noted anecdotally that at times a staff

member approaching the nursing POD found it full and had to choose another

destination. This could mean that charting and work stations that are conveniently

accessible from patient rooms are insufficient for the intended use by the healthcare staff.

Given the patient-centered focus of hospitals, it follows that patient rooms would

be the destination for a large portion of foot traffic. As stated previously, patient rooms

received 20% of all healthcare staff traffic. Predictably, visitors also frequented patient

rooms, with 23% traveling to or from 1 of the 4 patient rooms located on the study

corridor area. Over 50% of food service staff traffic involved patient rooms due to









activity pertaining to the delivery and pick-up of meal trays. Housekeeping staff traffic

involved patient rooms 20% of the time. Only 8% of patient traffic is attributable to

patient rooms. This is not unexpected, however, considering that just 4 of the 33 patient

rooms were located directly on the defined study portion of the corridor.

It should be noted that the space referred to as "breakroom" was temporarily

serving as such during most of the research study. It was returned to its typical capacity

as visitor lounge on the final day of the observation period. Construction/maintenance

activity was therefore involved in returning breakroom furnishings to their permanent

location and in the installation of the visitor lounge furniture. This explains the 4% of

visitor traffic and the 17% of maintenance staff traffic to and from that location. The fact

that 12% of healthcare staff traffic involved this space remains useful in that this traffic

will likely shift to the new breakroom but not change much in proportion. It is not

atypical for hospital units to undergo construction and/or maintenance projects

periodically. Thus, foot traffic by maintenance workers may be more variable than that

of other user groups, but occurs during the normal course of business within the hospital

environment.

The handwashing sink and utility closet areas received the lowest foot traffic

counts. Just over 3% of healthcare staff traffic involved the handwashing sink. Several

similar handwashing stations are located elsewhere on the unit, so it is possible that staff

members were utilizing other handwashing sinks in addition to this particular location.

Although the utility closet received only 6% of all foot traffic observed, the

overwhelming majority of traffic to and from this location was attributable to

housekeeping staff. In fact, half of all housekeeping staff traffic was concentrated in and









around the utility closet area. In light of this, the location and design of the utility closet

area may play an important role in the daily housekeeping procedures.

Equipment Carts

Type and Frequency

Observations showed that the average equipment cart count was approximately 240

during the peak hours between 7:00am and 11:00pm. The average equipment cart count

during observed hours indicates that daily traffic counts for a 24-hour period exceeds the

average number of counts for peak hours. It is not surprising that a significant correlation

exists between equipment cart counts and foot traffic counts, since people transporting

equipment carts/items were counted as foot traffic. Since the emergency code brought an

influx of foot traffic but did not notably increase equipment cart counts, the correlation is

stronger when data from the time block including the emergency code is removed.

The number of equipment carts/items did not differ significantly between days of

the week or between time blocks. Further, equipment cart counts were not affected

significantly by the number of empty beds on the unit. Generally speaking, equipment

carts seem to be present due to operational aspects of the unit and are necessary

regardless of patient load. Of the most commonly observed equipment carts,

supply/utility, housekeeping, and food service carts were observed to be part of daily

operations and therefore present on a regular basis. One-third of all carts/items traveling

through the corridor belonged to one of these 3 categories.

Multiple computer carts were available on the unit for healthcare professionals to

use as mobile charting stations within patient rooms. It should be noted that these

computer carts fell into the "other" category because they contributed to less than 1% of

all equipment traffic observed. When coupled with the frequent use of the nursing POD









area by healthcare staff, this fact takes on added importance. The observed lack of use of

these mobile computers in the corridor study area and the relatively high use by

healthcare staff of the small nursing POD may be an indicator of healthcare staff

preference for the nursing POD.

Another notable observation was the dragging of non-wheeled items across the

carpeted floor, contributing to nearly 4% of all equipment traffic-a relatively small

amount, but unexpected altogether. The implications of this largely depend on the item

being dragged. A heavy, sharp, or roughly textured item could cause damage to the

carpeting and even compromise the installation of the carpet tiles. The tendency to drag

items could be an important new consideration in the fabrication of carpet tiles and for

hospital facilities decisions and policies.

Patterns

Considering the high proportion (25%) of equipment carts observed traveling to or

from one of the 4 patient rooms located on the study corridor, it is not surprising that half

of all carts passed through the corridor area to reach the patient rooms beyond. Unlike in

the case of foot traffic, equipment carts took the three particular through-traffic paths

(points A to B, points A to C, and points B to C) more than any other paths within the

corridor. Because of the wide variety of carts/items observed, it is more useful to

examine the traffic patterns of individual equipment cart categories.

IV poles, gurneys (with and without patients), and treatment carts traveled almost

exclusively as through traffic or in and out of patient rooms. These types of equipment

were primarily observed to be associated directly with patients, so paths to and from

patient rooms within and beyond the study area of the corridor were not surprising.

Small linen carts showed a similar tendency to gravitate toward patient rooms or move









through the corridor as through-traffic. Again, these carts were observed to be directly

related to patient rooms. Small linen carts were generally positioned in the corridor just

outside of the rooms and were taken periodically when full to be emptied in a separate

location.

Every wheelchair observed with a patient was through-traffic, while wheelchairs

with no patients took more varied paths through the study corridor area. No patient in

one of the 4 rooms located on the study corridor left or entered a room in a wheelchair

during the observation time blocks. Since 12 patient rooms are located beyond the area

of the corridor under observation, it is not surprising that patients traveled through the

corridor to or from the rooms beyond. More notable, visits to the nursing station and

nursing POD were common for wheelchairs without patients but not observed at all for

wheelchairs with patients. Likely, healthcare workers charged with transporting patients

from this unit arrive with an empty wheelchair and check with staff on the unit before

moving on to individual rooms.

Food service carts were also observed to be of direct service to patients. Just under

half of all food service carts observed frequented the areas in and around patient rooms.

Food service cart traffic attributed to the nursing station and the utility closet (11% and

2%, respectively) were positioned just outside of those locations. Approximately 30% of

all food service cart traffic was not accounted for by any specific location on the corridor,

due to movements between various, non-specified locations in the middle of the corridor.

Of food service carts observed, only 10% were through-traffic. This, in conjunction with

the fact that 30% traveled to or from unspecified points throughout the corridor area,









shows a tendency by food service carts, in particular, to take short paths and to start and

stop frequently.

Housekeeping carts showed more variability in traffic patterns than most other

categories of equipment carts. Only 23% of housekeeping carts were through-traffic,

while the same number frequented patient rooms. As expected, a large portion (35%) of

housekeeping carts traveled to or from the utility closet area. Similar to food service

carts, housekeeping carts were observed servicing virtually all spaces within the unit,

rather than passing through without stopping or concentrating in one location.

Rolling carts are directly linked with the people utilizing them, as evidenced by the

significant correlation between foot traffic and equipment carts. Carts are either pushed

or pulled over the floor surface, causing not only wear on the carpeting, but physical

effort and sometimes strain on the person doing the pushing or pulling. For the most part,

the equipment observed was pushed through the corridor. Food service, supply/utility,

and flatbed maintenance carts were observed being pulled 20-30% of the time, although

they were still pushed the majority of the time. Trash bins were the exception, with 91%

being pulled through the corridor area. While these findings do not necessarily impact

the carpeting directly, they are useful in examining ergonomic factors related to

carpeting, especially from a risk management standpoint.

Carpet Cleaning Procedures

As stated previously, the results of this study did not explicitly support or reject the

stated hypotheses that: 1) actual carpet cleaning procedures are concurrent with

documented hospital protocol, 2) actual carpet cleaning procedures are concurrent with

infection control guidelines and industry standards, and 3) documented hospital protocol

is concurrent with infection control guidelines and industry standards. The reason for this









is that differences varied among the six key components of carpet maintenance programs.

While some aspects of carpet cleaning, such as vacuuming, did show concurrence

between actual carpet cleaning procedures, documented hospital protocol, and infection

control guidelines and industry standards, others did not. Additionally, very little written

documentation of hospital protocol was available, so in some cases a comparison cannot

be made.

Preventive Maintenance

As part of infection control guidelines and industry standard cleaning protocol,

preventive maintenance involves utilization of walk-off mats at entrances and major

interior traffic areas. Although there is no written documentation available concerning

the hospital's walk-off mat program, hospital Environmental Services stated that there is

one in place and that hospital policy includes walk-off floor mats at entrances. While

walk-off mats were, in fact, present at the hospital entrance, none were observed at major

interior traffic areas, as suggested by guidelines. The unit is accessed by elevator, yet no

floor mats were located at this common entrance location.

Vacuuming

On the commercial carpet cleaning frequency chart (refer to Table 2.1, p. 15 )

developed by the Institute of Inspection Cleaning and Restoration (2002), the hospital in

this study falls into the "very heavy" foot traffic category, with over 2,500 foot traffics

per day. As a result, industry standards call for vacuuming 1 to 2 times daily. The daily

cleaning schedule provided for housekeeping staff by the hospital's Environmental

Services department includes vacuuming in specific corridor areas as well as an

additional final vacuuming. Evidence from observation data suggests that overall









vacuum cleaning occurred once daily, but is not sufficient to assume two daily

vacuumings.

Observers noted that, while vacuuming was occurring regularly in the defined area

of the study corridor, it was not observed at any time elsewhere in the corridor within

view of the observers. The lack of evidence regarding vacuuming within the unit

indicates the variability of cleaning practices among housekeeping staff members on the

unit. A clearly documented policy regarding vacuuming could help to promote a higher

degree of consistency among hospital housekeeping staff members.

Spot and Spill Removal

Standard recommendations require spill and spot removal daily or when spots are

noticed. The hospital's Environmental Services department aims for once weekly or bi-

weekly spot or spill checks, although there is no written documentation to that effect, and

no obvious investigations were observed. Additionally, response times were varied and

ranged from immediate to 18 hours. Under hospital protocol, carpet spots are considered

special projects, yet spills are not often reported and records of special projects are

inconsistent and largely missing. Aside from a list of chemicals to be kept on

housekeeping carts (refer to Hospital Environmental Services Policy #11, Appendix G),

no documentation could be found regarding either the protocol for treatment of spots or

recorded past incidents.

Hospital documentation does include Quick Spot, a carpet spot-remover made by

Envirox LLC, on a list of chemicals to be kept on housekeeping carts (Appendix G).

Label instructions for this product, which are to spray carpet until wet, allow to sit five to

ten minutes, scrub or blot soil away, and vacuum when dry, are in keeping with infection

control guidelines.









Two out of the 3 contamination incidents observed received a response by

housekeeping staff within approximately 5 minutes. The only liquid spill observed was

treated immediately in accordance with guidelines. The third incident, however, was not

noticed or treated until some 18 hours later, at which time a maintenance staff member

used masking tape to remove dust/debris from the carpet surface. This cleaning method

is not in line with infection control guidelines, industry standards, or hospital protocol.

The delay in attending to this contamination incident and the improper treatment of it

emphasizes the need for policy concerning frequent and consistent spill checks. Though

Environmental Service aims for weekly or bi-weekly spill checks, observation data shows

that this may not be sufficient.

Interim Cleaning

Interim cleaning should be performed in this corridor 12 to 52 times annually,

according to the IICRC commercial carpet cleaning frequency chart (refer to Table 2.1, p.

15). Aside from data on the chemicals used in the procedure, the hospital has no written

protocol for interim cleaning or the dry extraction method typically used in this facility.

Environmental Services reports that the Host Dry Extraction system is performed "as

needed" between deep cleaning. Label instructions are consistent with guidelines, and

are to apply dry powder to the carpeting, brush through fibers with a Dry-Clean Machine

(made by Host), and follow with vacuuming. No policy exists concerning the frequency

with which this process is to be performed, and no documentation of past applications of

the procedure was available. This procedure was not observed during the study period.

Restorative Cleaning

Guidelines and hospital protocol both specify hot water extraction as the method of

restorative carpet cleaning and both agree on the way in which this process is to be









performed. However, while the IICRC's commercial carpet cleaning frequency chart

recommends restorative cleaning 6 to 24 times per year, Hospital Environmental Services

Policy #27 (Appendix H) specifies deep carpet cleaning just 2 times per year, once in

spring and once in fall. This discrepancy is substantial yet difficult to rectify because the

same high traffic volume that causes the need for frequent deep cleaning makes closing

the corridor for the process extremely inconvenient. This procedure was not observed

during the study period.

Carpet Tile Replacement

Infection control guidelines and industry recommendations suggest replacing

contaminated or damaged individual carpet tiles as needed. Since the recent installation

of carpet tile in place of broadloom carpet, a new hospital protocol has not been

established or documented, but is under development. In accordance with guidelines,

Hospital Environmental Services intends to replace carpet tiles found to be damaged or

stained. Further plans include immediately removing tiles on which spills have occurred

in order to carry out proper treatment in a less conspicuous location. One contamination

incident observed involved a liquid spill, but the cleaning was performed at the site on

which it occurred and the tile was not removed or replaced during the study period. It

should be noted, however, that this particular incident involved a food product and no

other opportunity occurred to carry out the requisite replacement of a carpet tile.

Summary

Hypothesis 1 was that actual carpet cleaning procedures are concurrent with

documented hospital protocol. Findings from this study support this hypothesis with

regard to preventive maintenance. Observation data indicates that vacuuming was

performed once daily, not twice daily as required by hospital protocol. In this case, the









hypothesis is not supported. Due to the limited documentation of hospital protocol

available and the lack of observation of particular cleaning methods, there is not enough

evidence to support the first hypothesis regarding spot and spill treatment, interim

cleaning, restorative cleaning, and carpet tile replacement.

Hypothesis 2 was that actual carpet cleaning procedures are concurrent with

infection control guidelines and industry standards. Observations of vacuuming as well

as spot and spill treatment support this hypothesis. However, preventive maintenance

practices were not concurrent with guidelines because floormats were not present at

major interior traffic locations. Findings regarding carpet tile replacement do not support

the second hypothesis, although only one incident that called for this action was

observed. Since no interim cleaning or restorative cleaning procedures were observed,

there is not sufficient evidence of these activities to support this hypothesis.

Hypothesis 3 was that documented hospital protocol is concurrent with infection

control guidelines and industry standards. This hypothesis is supported by findings

concerning vacuuming, since hospital protocol calls for twice daily vacuuming and

guidelines suggest 1-2 times daily. Findings regarding restorative cleaning, however, do

not support the third hypothesis. Though they agree on the appropriate method for

restorative cleaning, hospital policy requires it twice yearly, compared to the industry

standard recommendation of 6-24 times per year. Due to lack of documentation of

hospital protocol regarding preventive maintenance, spot and spill treatment, interim

cleaning, and carpet tile replacement, hypothesis 3 cannot be accepted or rejected based

on evidence collected.














CHAPTER 6
CONCLUSIONS

With growing interest in the indoor environmental quality of healthcare settings, it

is important to consider impact factors on interior finish materials such as flooring. Little

has been studied about particular factors contributing to the wear and maintenance of

flooring-specifically carpeting-in a hospital environment. As a result, those

responsible for the manufacturing, selection, and care of such materials are left guessing

as to what happens to carpeting in its intended setting.

This study established definitively that the foot traffic in this particular patient unit

corridor numbered over the 2,500 required to be considered a "heavy traffic" area by the

IICRC. Further, foot traffic was effected by the number of patients being cared for on the

unit, and was correlated with equipment cart traffic, which adds to the impact on

carpeting. Equipment carts were consistently observed regardless of day of the week,

time of the day, or patient load. In light of this, information such as equipment use and

hospital census numbers should be examined when selecting appropriate floorcoverings

or developing and implementing a maintenance plan.

Healthcare staff contributed to 80% of all foot traffic during the study, evidence

that this particular location within the hospital primarily serves and supports the activities

of the healthcare professionals charged with patient care. In fact, observations of areas in

the study corridor allocated to healthcare staff revealed unexpected patterns. The heavy

use of the small nursing POD along with anecdotal observations by researchers of

overcrowding in this space point to a preference among the staff for a charting space that









is more convenient and accessible than the larger nursing station. These findings,

coupled with the observed lack of use of computer carts provided to healthcare staff for

the purpose of convenient charting, suggest a need for a reassessment of the types of

spaces and tools required by current and future healthcare professionals.

This research brought to light the hospital's lack of a documented carpet

maintenance program. Most of the intentions and activities of hospital Environmental

Services were generally in line with infection control guidelines and industry standards.

However, the lack of documented policy may cause inconsistencies and complications in

carrying out proposed maintenance activities. For example, a policy exists requiring deep

cleaning twice yearly, yet recent high census numbers have compelled the hospital's

Environmental Services to make arrangements with each individual unit in order to

schedule this procedure, resulting in possible untimely cleaning. Written documentation

of a comprehensive carpet maintenance program, reviewed and approved by hospital

administration, could call attention to the frequency and consistency of cleaning

procedures necessary to maintain the appearance and sanitary condition of the carpet tile.

In this way, hospital administration and Environmental Services could work together to

ensure that cleaning are scheduled and performed with regularity despite operational

obstacles and that housekeeping staff has a clear understanding of expected carpet

cleaning procedures.

Limitations

While systematic observation does not rely on self-reporting by participants, it can

still be subject to bias and human error on the part of the observerss. Obstructed views,

unexpected distractions, or excessive activity may have led to inaccuracies in traffic

counts and identification of user and equipment types.









Additionally, cross-sectional observation methods do little to explain the findings

or determine how the observed behaviors and patterns effect the environment and its

users. This research is primarily exploratory in nature.

As this was a case study, findings cannot be generalized to other hospitals or

environments. A larger study including more hospitals would have obtained more

universal information about this type of location. In addition, this was not a longitudinal

examination of hospital activities. While one week is representational of typical activity,

it did not allow for the observation of infrequent activities such as spill incidents and

interim and restorative cleaning processes. Further information about off-peak hours

could also be gathered by 24-hour observations.

Future Directions in Research

Further studies should explore how wear and contamination of carpet tile affect

people in the environment, especially with regard to physical health (i.e., infection

control and ergonomics). Studies exploring the relationship between carpeting and

infection control (including allergies and asthma) in healthcare settings are few in number

and rarely examine the role and impact of variable maintenance practices. Future

research should also include ergonomic evaluations of the role carpeting and carpet tile

play in injuries from pushing and pulling equipment carts.

Further research should also focus on maintenance programs and their practical

implementation. The quality and consistency of actual cleaning procedures in healthcare

settings and their potential to impact occupants should be examined more closely by

researchers in the future. A better understanding of how carpet and carpet tile are

maintained in their intended setting could contribute not only to a long wear life and

healthy environment, but to appropriate and safe carpet selection at the outset.

















APPENDIX A
APPROVAL AND PERMISSION


UNIVERSITY OF
FLORIDA


Institutional Review Board


98A Psychology Bldg.
PO Box 112250
Gainesville, FL 32611-2250
Phone: (352) 392-0433
Fax. (352) 392-9234
E-mail: irb2@ufl.edu
http://irb.ufledu


December 8, 2005


TO:




FROM:


Debra D. Harris, PhD
PO Box 115705
Campus


Ira S. Fischler, PhD, Chair,
University of Florida Institutional Review Board 02


SUBJECT: UFIRB Protocol #2005-U-1117
Flooring in acute care facilities: carpet tile seam penetration field study

FUNDING: Interface Flooring Systems, Inc.


Because this protocol does not involve the use of human participants in research, it is exempt
from further review by this Board in accordance with 45 CFR 46. Human participants are
defined by the Federal Regulations as living individuals) about whom an investigator
conducting research obtains (1) data through intervention or interaction with the individual; or
(2) identifiable private information.

Should the nature of your study change or you need to revise this protocol in any manner,
please contact this office before implementing the changes.


IF/dl


Eqtul Opporunity/AfirmatLvc Action Inslitulon












UF Health Science Center

Certificate of Completion

This is to certify that

Julianna Mitchell

has successfully completed the

HIPAA for Researchers
at the University of Florida

on 11/17/2005

This HIPAA Training Completion has been recorded. Print a copy of this certificate for
your records. It will print black and white, not in color.
If you have trouble printing this certificate, please close this window and return to the
Privacy Homepage. Click on Get Your CerM iate and print your certificate from there.
Print


If you have any questions, contact Everall Peele, HIPAA training Coordinator in the
Privacy Office at 352-273-5096 or epeele@ufl.edu
You may now close this browser window.

If you used get your certificate link and the name on the certificate appears to be Incorrect, please go back
using the browser back button and enter your correct name.

























APPENDIX B

OBSERVATION FORMS


FIELD STUDY OBSE
Corridor, 4th floor, B
Date
Time Block
Observer
No. of Empty Beds


RVATION FORM
STower H Heathcare staff
P Patient
V Vistor
S Staff(other)
M Maintenanoc
F Food Sevice Staff
HK Houeekeeping Staff


NSI Nursing station (inside)
N50 Nursig station (outside)
CH Charting
CL Closet
BR Breakroom
S Sink


WC Wheeldair
G Gurney
BD Blood Drawing
IV IVPole
MT Medical Treatment
LC Unensart
FSC Food Servic Cart
HKC Housekeeping Cart


Ref. # Foot Trafllc From/To Equipment Pull /Push Stop/"Start Notes Spill
















i i :
--- --- t-- : -------- ----- -






-- --- i ---- i r- -----






: i i


















DAILY CENSUS DIAGRAM
Corridor, 4th Floor, Bed Tower
Date
Time Block
Observer
No. of Empty Beds


START or END




















































K





AiE






uU


30
2 z















APPENDIX C
STATISTICAL ANALYSES

The following is the statistal analysis testing for effect of time of day and day of the

week on foot traffic counts.

The GLM Procedure
Class Level Information

Class Levels Values

day 6 123456

time 8 12345678


Number of observations 48

NOTE: Due to missing values, only 31 observations can be used in this analysis.
#######################################################################


Dependent Variable: sqrtfoot

Sum of
Source DF Squares Mean Square F Value Pr > F

Model 12 164.0657648 13.6721471 4.08 0.0037

Error 18 60.3453900 3.3525217
Corrected Total 30 224.4111548

R-Square CoeffVar Root MSE sqrtfoot Mean

0.731095 9.705333 1.830989 18.86581

Source DF Type III SS Mean Square F Value Pr> F

day 5 37.91095997 7.58219199 2.26 0.0922
time 7 74.30927664 10.61561095 3.17 0.0230








70



Bonferroni's multiple comparison test:

Least Squares Means for effect time
Pr > |t| for HO: LSMean(i)=LSMean(j)
Dependent Variable: sqrtfoot

i/j 1 2 3 4 5 6 7 8

1 0.6906 1.0000 1.0000 0.7830 0.2744 0.1568 0.0186
2 0.6906 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000
3 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.1284
4 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000
5 0.7830 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000
6 0.2744 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000
7 0.1568 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000
8 0.0186 1.0000 0.1284 1.0000 1.0000 1.0000 1.0000







71



The following is the statistical analysis testing for effect of time of day and day of


the week on foot traffic counts after removing data from the time block during which an


emergency code occurred.

The GLM Procedure
Class Level Information

Class Levels Values

day 6 1 2 3 4 5 6

time 8 1 2 3 4 5 6 7 8


Number of observations 48

NOTE: Due to missing values, only 31 observations can be used in this
analysis.
#######################################################


Dependent Variable: sqrtfoot


Source DF Squares
Value Pr > F
Model 12 116.2908109
3.87 0.0057
Error 17 42.5776858
Corrected Total 29 158.8684967

R-Square Coeff Var Root MSE footco
0.731994 8.508360 1.582583

Source DF Type III SS Mean Squa:

day 5 30.9679642 6.19359285
0.0739
time 7 48.41685591 6.9166937(
0.0412


Sum of
Mean Square

9.6909009

2.5045698


unt Mean
18.60033

re F Value

2.47

0 2.76


F











P-value











































able:








73



The following is the statistal analysis testing for effect of number of empty beds on


foot traffic counts.

Dependent Variable: sqrtfoot


Squares
50.2526737

174.1584811
224.4111548


Root MSE

2.450605


Type III SS

50.25267374


Sum of
Mean Square
50.2526737

6.0054649


F Value Pr > F
8.37 0.0072


sqrtfoot Mean

18.86581


Mean Square

50.25267374


F Value

8.37


Pr > F

0.0072


Estimate
21.05678340
-0.60106447


Standard
Error
0.87601136
0.20778528


DF
1

29
Total 30


Coeff Var

12.98966


Source
Model

Error
Corrected


R-Square

0.223931




Source

beds


Parameter
Intercept
beds


t Value
24.04
-2.89


Pr > Itl
<.0001
0.0072








74



The following is the statistal analysis testing for effect of time of day and day of the


week on equipment cart counts.


The GLM Procedure
Class Level Information

Class Levels Values

day 6 1 2 3 4 5 6

time 8 1 2 3 4 5 6 7 8



Number of observations 48

NOTE: Due to missing values, only 31 observations can be used in this
analysis.
#######################################################################



Dependent Variable: sqrtcount


Source

Model

Error

Corrected Total


R-Square

0.478818


Squares

12.62580915

13.74287472

26.36868387


Coeff Var

16.18693


Root MSE

0.873781


Source

day
time


Sum of
Mean Square

1.05215076

0.76349304


sqrtcount Mean

5.398065


Type III SS

2.56589195
7.83755528


Mean Square

0.51317839
1.11965075


F Value

1.38


Pr > F

0.2615


F Value

0.67
1.47


Pr > F

0.6498
0.2409












The following is the statistal analysis testing for effect of number of empty beds on


equipment cart counts.

Dependent Variable: sqrtequip


Source DF

Model 1

Error

Corrected Total


Squares

1.76560055

29

30


Mean Square

1.76560055

24.60308333

26.36868387


Sum of
F Value Pr > F

2.08 0.1598

0.84838218


sqrtequip Mean

5.398065


Source DF

beds 1


Parameter

Intercept
beds


Type III SS

1.76560055


Estimate

5.808745362
-0.112664657


Mean Square

1.76560055


Standard
Error

0.32925486
0.07809752


F Value Pr > F

2.08 0.1598


t Value

17.64
-1.44


Pr > Itl

<.0001
0.1598


R-Square

0.066958


Coeff Var

17.06309


Root MSE

0.921077











The following is the statistal analysis testing for correlation between foot traffic

and equipment cart counts.


Correlations


sqrtfootcount sqrtequip
sqrtfootcount Pearson 1
Correlation
Sig. (2-tailed) .005
N 31 31
sqrtequip Pearson
Correlation .490(**)
Sig. (2-tailed) .005
N 31 31
** Correlation is significant at the 0.01 level (2-tailed).















APPENDIX D
EQUIPMENT PHOTOGRAPHS

Figures D. 1-D.20 are photographs of commonly observed equipment.


Figure 1: IV Pole



































.2: Typical supply cart


nlgure ).j: Supply/utility cart





























Figure D.4: Supply cart


figure Li.: nouseKeeping can


























Figure D.6: Typical gurneys


Figure D.7: Gurney































Figure D.8: Food service cart


Figure U.9: Small linens cart



































figure U. iu: wneeicnair


Figure D. 11: Portable x-ray machine





























.12: Trash bin/large linens cart


t gure u. 1: Emergency crash cart





































.14: Treatment cart


Figure u. 13: Ireatment cart



































.16: Cart used for


.17: Portable scale


ood-drawing






























.18: Mobile computer carts


figure U. 19: Rolling task chair
































lgure u).2U: Flatbed maintenance cart
















APPENDIX E
CLEANING EQUIPMENT SPECIFICATIONS


____I___I_ yy u- sI


WINDSOR


VtII ~SAMIAflC

electrnic contol ZII


VSE1-3


A) Vacuum Extention Hose 1087
Optional

B) VSM-Tool Kit Optional
1 Straight Tube 1084
2 Crevice Nozzle 1092
3 Clip 1081
4 Dusting Brush 1094
5 Upholstery Nozzle 1090
6 Watl- and Upholstery
Brush 1095
C) Bags and Filters
1 Paper ag Pkg of 10) 2003
2 Cloth Bag 1079
(only use with Micro-Filter)
3 Exhaust Fitter 1534
4 VacMotor Filter 1044
5 Micro-Hospital-Filter <







89



WINDSOR warrants to the original purchaser/user that this product is
unconditionally guaranteed free from defects in workmanship and
materials under normal use and service for a period of one year.
WINDSOR will, at its option, repair or replace without charge, except
for transportation costs, parts that fail under normal use and service
when operated and maintained in accordance with the Instructions
Manual. This warranty does notapplyto normal wear orto items whose
life is dependent on their use and care.
This warranty is in lieu of all other warranties, expressed orimpliad, and
releases WINDSOR from all other obligations and liabilities. It is
applicable only in the USA. and Canada, and is extended only to the
original user/purchaser of this product WINDSOR is not resoonsible
for costs for repairs performed by persons otherthan those specifically
authorized by WINDSOR. Thiswarranty does not apply to damagefrom
transportation, alterations by unauthorized persons, misuse orabuse of
the equipment, use of noncompatible chemicals, or damage or loses of
income due to malfunctioning of the product.
If a difficulty develops with this product, you should contact the dealer
from whom it was purchased.









Technical Details Wiring Diagram

Voltage .... 120 volt, 60 hz
Vacuum motor .. 6.4 amp, ," "'*" .". -
Water lift. . 89 indies
Air flow ... 91cfm -f i _
Brush motor . 1.4amp.
Dust bag capacity 1.3 gal.
Brush width .. 12. inches
Brush strip .. . replaceable
Brush drive .. nonslip drie belt with .
electronic overload protection
Height . 48 Inches
Width . 14 inches
Weight . 16 Ibs
W WARNING! lectric stck could occur
it sed amirs or o on wet suaces!

Approvals:
INWINDSOR INDUSTRIES, INC.
1351 west Standlod Ave.
Englewod, Colorado 8110 USA
800-444-7654
OM UL-2 303-762-1800
FAX: 303-7682-R1