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

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